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28,056
| 180,856
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33080+57831
|
Discharge summary
|
report+addendum
|
Admission Date: [**2172-1-30**] Discharge Date: [**2172-2-27**]
Date of Birth: [**2107-11-27**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Back pain,emergent transfer from [**Hospital3 **] Hosp.
Major Surgical or Invasive Procedure:
s/p Replacement Asc Ao-resuspension of Ao valve/Exlporatory
Laparotomy([**1-30**])
s/p Tracheostomy([**2-17**])
History of Present Illness:
64 yo F transferred from OSH for Type A dissection. Presented to
OSH with hypotension after collapsing while in the bathroom.
Past Medical History:
HTN, hypothyroidism
Social History:
Lives with family
Family History:
unable to obtain
Physical Exam:
Admission
NAD
NCAT
Lungs CTAB
RRR
+ BS
mottled toes
decreased rectal tone
Discharge
VS T99.4 HR 80SR BP 104/52 RR 26 O2sat 98% on 50% TM
Gen NAD
Neuro A&Ox3, MAE-lower extremity weakness(L>R)
Pulm CTA-bilat
CV RRR, no murmur. Sternum stable, incision CDI.
Abdm firm, slightly distended, +BS. Upper abdm incision w/VAC
dressing/lower incision CDI
Ext wasrm with trace edema. palpable pulses
Pertinent Results:
[**2172-1-30**] 08:58PM GLUCOSE-155* LACTATE-2.9* K+-3.6
[**2172-1-30**] 07:58PM UREA N-15 CREAT-1.0
[**2172-1-30**] 01:02PM ALT(SGPT)-71* AST(SGOT)-121* LD(LDH)-444* ALK
PHOS-44 AMYLASE-41 TOT BILI-1.8*
[**2172-1-30**] 01:02PM WBC-4.9 RBC-2.74* HGB-8.7* HCT-23.3* MCV-85
MCH-31.7 MCHC-37.3* RDW-14.7
[**2172-1-30**] 01:02PM PLT COUNT-183
[**2172-1-30**] 01:02PM PT-14.7* PTT-54.6* INR(PT)-1.3*
[**2172-1-31**] 03:19AM BLOOD ALT-175* AST-398* LD(LDH)-1223*
CK(CPK)-[**Numeric Identifier 76897**]* AlkPhos-58 TotBili-2.0*
[**2172-2-26**] 03:34AM BLOOD WBC-12.1* RBC-3.25* Hgb-9.9* Hct-29.9*
MCV-92 MCH-30.4 MCHC-33.1 RDW-15.7* Plt Ct-464*
[**2172-2-26**] 03:34AM BLOOD Plt Ct-464*
[**2172-2-26**] 03:34AM BLOOD PT-12.9 PTT-28.3 INR(PT)-1.1
[**2172-2-26**] 03:34AM BLOOD Glucose-133* UreaN-21* Creat-0.5 Na-135
K-4.3 Cl-100 HCO3-28 AnGap-11
[**2172-2-24**] 02:00AM BLOOD AlkPhos-236*
[**2172-2-20**] 02:22AM BLOOD ALT-76* AST-73* LD(LDH)-292* AlkPhos-284*
Amylase-65 TotBili-0.4
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2172-2-25**] 12:49 PM
CHEST (PORTABLE AP)
Reason: check dophoff placement
[**Hospital 93**] MEDICAL CONDITION:
64 year old woman s/p asc ao replacement and dophoff placement
REASON FOR THIS EXAMINATION:
check dophoff placement
HISTORY: For dobbhoff placement.
FINDINGS: In comparison with the study of [**2-21**], there has been
placement of a Dobbhoff tube that extends to the lower body of
the stomach, then coils upon itself and extends further into the
stomach. There is increasing opacification at the left base
consistent with some combination of pleural fluid, atelectasis,
and even pneumonia.
DR. [**First Name8 (NamePattern2) 1569**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11006**]
Approved: TUE [**2172-2-25**] 3:45 PM
CHEST (PORTABLE AP)
Reason: dropping HCT r/o effusion
[**Hospital 93**] MEDICAL CONDITION:
64 year old woman with
REASON FOR THIS EXAMINATION:
dropping HCT r/o effusion
SINGLE AP PORTABLE VIEW OF THE CHEST
REASON FOR EXAM: Dropping hematocrit, assess for effusion.
Comparison is made with prior study performed a day earlier.
Cardiac size is normal. The mediastinum is not widened.
Tracheostomy tube is in the standard position. NG tube tip is
out of view below the diaphragm. Small right and
small-to-moderate left pleural effusions have increased, as are
adjacent bibasilar atelectasis.
jr
DR. [**First Name (STitle) 3901**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3902**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**]
Approved: FRI [**2172-2-21**] 10:38 PM
RADIOLOGY Final Report
CT HEAD W/O CONTRAST [**2172-2-3**] 11:19 PM
CT HEAD W/O CONTRAST
Reason: assess for infarcts
Field of view: 25
[**Hospital 93**] MEDICAL CONDITION:
64 year old woman s/p replacement of asc ao/resuspention of avr.
post-op weakness l>r
REASON FOR THIS EXAMINATION:
assess for infarcts
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 64-year-old woman status post replacement of
ascending aorta/resuspension of aortic valve. With postoperative
weakness, left greater than right.
COMPARISON: There are no prior studies of this area for
comparison.
TECHNIQUE: Non-contrast head CT.
FINDINGS: There are confluent areas of hypodensity involving the
parietal regions bilaterally, in a somewhat watershed-type
distribution between the middle cerebral and posterior cerebral
arteries, concerning for hypoperfusion. In addition, there are
smaller areas of low density involving the white matter of both
frontal lobes, predominantly in a subcortical location. There is
no evidence of hemorrhage, shift of normally midline structures
or hydrocephalus. There is local effacement of sulci in the
parietal lobes bilaterally. Mild mucosal thickening is noted
within the left sphenoid air cell as well as within a few
ethmoid air cells. The patient is currently intubated. The
mastoid air cells appear clear. Soft tissues are unremarkable.
There appears to be a calcification of the left distal vertebral
artery.
IMPRESSION: Findings consistent with subacute bilateral parietal
lobe infarctions, which appears to be within watershed
distribution, most suspicious for ischemia related to
hypoperfusion, although given the other abnormalities in the
white matter of both frontal lobes, embolic infarcts are also
within the differential.
Findings were discussed with [**First Name8 (NamePattern2) 402**] [**Last Name (NamePattern1) **] of the primary team
at 11:40 p.m. on [**2172-2-3**].
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) 15097**] L. [**Doctor Last Name **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Approved: TUE [**2172-2-4**] 10:52 AM
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 76898**] (Complete)
Done [**2172-1-30**] at 1:36:02 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **]
[**Street Address(2) 15115**]
[**Location (un) 15116**], [**Numeric Identifier 15117**] Status: Inpatient DOB: [**2107-11-27**]
Age (years): 64 F Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Ascending aortic dissection
ICD-9 Codes: 402.90, 440.0, 441.00, 423.3, 424.1, 424.0
Test Information
Date/Time: [**2172-1-30**] at 13:36 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 #: 2008AW-:1 Machine: b2009
Echocardiographic Measurements
Results Measurements Normal Range
Findings
LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum.
LEFT VENTRICLE: Low normal LVEF.
RIGHT VENTRICLE: Mild global RV free wall hypokinesis.
AORTA: Ascending aortic intimal flap/dissection.. Descending
aorta intimal flap/aortic dissection.
AORTIC VALVE: Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+)
MR.
TRICUSPID VALVE: Mild [1+] TR.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. The TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. No TEE related
complications.
Conclusions
Pre-[**Last Name (NamePattern4) **]: The patient was in shock, being resuscitated, so only a
few images were obtained prior to Fem-Fem bypass. A dissection
is noted from the STJ across the arch and continuing down the
full length of the visible aorta. Extensive clots in the false
lumen. Trace AI. Mild MR.
[**First Name (Titles) **] [**Last Name (Titles) **]: The patient is AV paced, on Epi and Milrinone
infusions. There is good biventricular systolic fxn.
A graft of the ascending aorta is seen. Descending aorta
dissection with flap and clot in false lumen are noted.
Trace AI, mild MR.
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) **] [**2172-1-30**] 13:54
Brief Hospital Course:
She was intubated in the emergency room. She was seen by
vascular surgery as she has numbness and weakness as well as
mottled lower extremitites. She was taken emergently to the
operating room on [**1-30**] where she arrested, was placd emergently
on bypass and underwent a replacement of ascending aorta and
hemiarch and aortic valve resuspension. She developed an acute
abdomen and underwent an exploratory laparotomy and repair of
large liver laceration. Her abdomen was left open and she was
transferred to the ICU in critical but stable condition. She was
taken back to the operating room later that same day for
abdominal washout and VAC placement as her abdomen was unable to
be closed due to edematous bowel. She remained intubated. She
was seen by neurology as she awoke but was not moving her left
arm. CT head showed subacute bilateral parietal lobe
infarctions, which appears to be within watershed distribution,
most suspicious for ischemia related to hypoperfusion. She
continued on TPN. She remained intubated and on ancef while her
abdomen was open. She was aggressively diuresed to assist with
abdominal closure and her abdomen was closed on [**2-7**]. She was
started on a lasix drip to diuresis. Tube feeds were started.
She developed a fever and was pancultured, sputum grew H. Flu
for which she was started on cipro. She continued to have
difficulty weaning from the vent and on [**2-17**] she underwent
tracheostomy. She began to tolerate trach collar during the day,
and remained on the ventilator overnight. She continued to
improve. The top of her incision was opened and VAC'd and she
was started on 1 week of ampicillin. She continued to slowly
improve and she was ready for discharge to rehab with a dobhoff
tube on POD #29.
Medications on Admission:
antihypertensive, ? synthroid
Discharge Medications:
1. Acetaminophen 500 mg/5 mL Liquid [**Month/Year (2) **]: Five Hundred (500) mg
PO Q4H (every 4 hours) as needed for temperature >38.0.
2. Atorvastatin 10 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY
(Daily).
3. Paroxetine HCl 10 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY
(Daily).
4. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
5. Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: 5000 (5000)
units Injection TID (3 times a day).
6. Aspirin 325 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
7. Potassium Chloride 20 mEq Packet [**Last Name (STitle) **]: Forty (40) mEq PO once
a day.
8. Metoprolol Tartrate 50 mg Tablet [**Last Name (STitle) **]: 1.5 Tablets PO TID (3
times a day).
9. Lorazepam 0.5 mg Tablet [**Last Name (STitle) **]: 0.5 mg PO Q8H (every 8 hours) as
needed.
10. Amlodipine 5 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY (Daily).
11. Furosemide 80 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **] hospital
Discharge Diagnosis:
s/p Replacement Asc Ao-resuspension of Ao valve/Exploratory
Laparotomy([**1-30**])
s/p Tracheostomy([**2-17**])
subacute parietal watershed CVA
PMH:HTN, Hypothyroid
Discharge Condition:
stable
Discharge Instructions:
Keep wounds clean and dry. OK to shower, no bathing or swimming.
Take all medications as prescribed.
Call for any fever, redness or drainage from wounds
change abdominal VAC dressing Q3days
Followup Instructions:
Dr [**Last Name (STitle) 7772**] 2 weeks after discharge from rehab [**Telephone/Fax (1) 1504**]
Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **](General Surgery)in [**1-1**] weeks [**Telephone/Fax (1) 3618**]
Dr [**Last Name (STitle) 63251**] [**Name (STitle) 63252**](PCP) after discharge from rehab
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2172-2-26**] Name: [**Known lastname **],[**Known firstname 2803**] Unit No: [**Numeric Identifier 12508**]
Admission Date: [**2172-1-30**] Discharge Date: [**2172-2-27**]
Date of Birth: [**2107-11-27**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 265**]
Addendum:
Patient sent to rehab at [**Hospital1 12509**] [**Hospital **]
Hospital in [**Hospital1 2314**], MA. on [**2-26**].
Brief Hospital Course:
Abdominal wound vac discontinued and changed to wet to dry
dressings twice a day. She remained ready for discharge to rehab
on [**2-27**].
Medications on Admission:
antihypertensive, ? synthroid
Discharge Medications:
1. Acetaminophen 500 mg/5 mL Liquid [**Month/Year (2) 1649**]: Five Hundred (500) mg
PO Q4H (every 4 hours) as needed for temperature >38.0.
2. Atorvastatin 10 mg Tablet [**Month/Year (2) 1649**]: One (1) Tablet PO DAILY
(Daily).
3. Paroxetine HCl 10 mg Tablet [**Month/Year (2) 1649**]: One (1) Tablet PO DAILY
(Daily).
4. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) 1649**]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
5. Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (STitle) 1649**]: 5000 (5000)
units Injection TID (3 times a day).
6. Aspirin 325 mg Tablet [**Last Name (STitle) 1649**]: One (1) Tablet PO DAILY (Daily).
7. Potassium Chloride 20 mEq Packet [**Last Name (STitle) 1649**]: Forty (40) mEq PO once
a day.
8. Metoprolol Tartrate 50 mg Tablet [**Last Name (STitle) 1649**]: 1.5 Tablets PO TID (3
times a day).
9. Lorazepam 0.5 mg Tablet [**Last Name (STitle) 1649**]: 0.5 mg PO Q8H (every 8 hours) as
needed.
10. Amlodipine 5 mg Tablet [**Last Name (STitle) 1649**]: Two (2) Tablet PO DAILY (Daily).
11. Furosemide 80 mg Tablet [**Last Name (STitle) 1649**]: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **] hospital
Discharge Diagnosis:
s/p Replacement Asc Ao-resuspension of Ao valve/Exploratory
Laparotomy([**1-30**])
s/p Tracheostomy([**2-17**])
subacute pareital watershed CVA
PMH:HTN, Hypothyroid
Discharge Condition:
stable
Discharge Instructions:
Keep wounds clean and dry. OK to shower, no bathing or swimming.
Take all medications as prescribed.
Call for any fever, redness or drainage from wounds
Followup Instructions:
Dr [**Last Name (STitle) 4012**] 2 weeks after discharge from rehab [**Telephone/Fax (1) 2092**]
Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **](General Surgery)in [**1-1**] weeks [**Telephone/Fax (1) 12510**]
Dr [**Last Name (STitle) 12511**] [**Name (STitle) 12512**](PCP) after discharge from rehab
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 266**]
Completed by:[**2172-2-27**]
|
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46,911
| 103,125
|
42442
|
Discharge summary
|
report
|
Admission Date: [**2198-2-13**] Discharge Date: [**2198-2-22**]
Date of Birth: [**2119-4-4**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4765**]
Chief Complaint:
cardiopulmonary arrest
Major Surgical or Invasive Procedure:
pulmonary intubation
central line placement
History of Present Illness:
78yo male with history of COPD found by nursing home staff to be
unresponsive.
.
The patient was in his usual state of health until yesterday
when he went into atrial fibrillation with shortness of breath.
He was treated with propanolol, digoxin, prednisone, and
azithromycin but looked somewhat worse this morning. Shortly
afterwards, he was found to be unresponsive. A code blue was
called and CPR was initiated at 1035am. It is unclear if he was
wearing is oxygen prior to this event. AED applied and delivered
a shock at 1038am with CPR afterwards. EMS arrived at 1040am
and CPR was stopped, patient with agonal breathing and
bradycardic rhythm. Patient intubated, given epinephrine and
atropine, and taken to the ambulance at 1044am, which
transported him to [**Hospital 8125**] Hospital. He was thought to be down for
about 10 minutes before ACLS was initiated.
.
On arrival to OSH, central line was placed and he was started on
levophed and given amiodarone load and hydrocortisone 100mg IV.
He was then transferred to [**Hospital1 18**] for further management.
.
On arrival to [**Hospital1 18**] ED, patient was intubated and sedated.
Post-arrest team consulted and ArticSun protocol was initiated.
Head CT demonstrated no acute process. Patient transferred to
CCU for further management.
Past Medical History:
1. CARDIAC RISK FACTORS: (-)Diabetes, (-)Dyslipidemia,
(+)Hypertension
2. CARDIAC HISTORY:
- CABG:
- PERCUTANEOUS CORONARY INTERVENTIONS:
- PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
-Atrial fibrillation (? if this is accurate)
-COPD- on home oxygen
-Pulmonary hypertension
-CKD- stage III (baseline Cr 1.5-1.6)
-GERD
-Hypothyroidism
-Psoriasis
-Renal cysts
-Hyperlipidemia
-Hx of diverticulitis
Social History:
Widower, quit smoking cigarettes 6 years ago. Smoke rare
tobacco pipe. Does not drink alcohol. Lives with a nephew.
[**Name (NI) **] ADLs. Has daughter [**Name (NI) **] who is very involved in his care.
Family History:
Positive for COPD secondary to smoking and asbestos exposure.
- No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death; otherwise non-contributory.
Physical Exam:
PHYSICAL EXAMINATION ON ADMISSION:
VS: T=90.5 BP= 109/46 HR= 68 RR= 15 O2 sat=100% (intubated)
GENERAL: Intubated, sedated.
HEENT: Pupils 2+ and sluggish.
NECK: Supple with JVP of 16 cm.
CARDIAC: RRR, normal S1, S2. No m/r/g.
LUNGS: Bilateral wheezes, scattered crackles, wheezes or
rhonchi.
ABDOMEN: Soft, non-distended. Cooling pads in place
EXTREMITIES: 2+ edema bilaterally, cool to touch.
SKIN:
PULSES: Right DP/PT- dopplerable
.
Discharge exam:
Vitals - Tm 97.9/97.9 BP: 99-122/60-69 P: 58-89 RR 20 SaO2
88-94% 4L NC
Weight: 82 (82.9)
.
Tele: run or AF, RVR at 0600, lasting 10 minutes. Otherwise SR.
.
GENERAL: 78 yo M in no acute distress
HEENT: mucous membs moist, JVD at 12 cm
CHEST: faint crackles BB, tubular BS overall.
CV: S1 S2 Normal in quality but distant. RRR
ABD: soft, non-tender, non-distended, BS normoactive.
EXT: wwp, 2+ pitting edema 1/2 up calf.
NEURO: Memory impaired with short term events but clearer today.
Speech clear. 4/5 strength in U/L extremities.
SKIN: no rash, PIV OK
PSYCH: A/O
Pertinent Results:
Labs on Admission:
[**2198-2-13**] 12:57PM BLOOD WBC-8.6 RBC-5.15 Hgb-15.5 Hct-46.6 MCV-91
MCH-30.1 MCHC-33.2 RDW-13.3 Plt Ct-158
[**2198-2-13**] 12:57PM BLOOD Neuts-85.3* Lymphs-7.7* Monos-4.8 Eos-1.0
Baso-1.3
[**2198-2-13**] 12:57PM BLOOD PT-13.4* PTT-28.2 INR(PT)-1.2*
[**2198-2-13**] 12:57PM BLOOD Glucose-129* UreaN-53* Creat-2.1* Na-137
K-4.6 Cl-109* HCO3-16* AnGap-17
[**2198-2-13**] 12:57PM BLOOD ALT-218* AST-231* AlkPhos-58 TotBili-1.2
[**2198-2-13**] 12:57PM BLOOD Albumin-2.8* Calcium-7.0* Phos-7.3*
Mg-2.0
Cardiac Enzymes:
[**2198-2-13**] 06:45PM BLOOD CK-MB-11* MB Indx-13.1* cTropnT-0.26*
[**2198-2-14**] 12:52AM BLOOD CK-MB-13* MB Indx-15.9* cTropnT-0.23*
[**2198-2-14**] 12:12PM BLOOD CK-MB-15* MB Indx-20.5*
[**2198-2-14**] 06:34PM BLOOD CK-MB-16* MB Indx-22.9*
[**2198-2-15**] 12:32AM BLOOD CK-MB-14* MB Indx-24.1*
[**2198-2-15**] 05:28AM BLOOD CK-MB-13* MB Indx-24.1*
TTE [**2-13**]:
The left atrium is elongated. The right atrium is moderately
dilated. No atrial septal defect is seen by 2D or color Doppler.
The estimated right atrial pressure is at least 15 mmHg. Left
ventricular wall thicknesses and cavity size are normal. There
is severe global left ventricular hypokinesis (LVEF = 15-20 %).
There is no ventricular septal defect. The right ventricular
cavity is moderately dilated with severe global free wall
hypokinesis. The aortic valve leaflets are mildly thickened
(?#). There is no aortic valve stenosis. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Trivial mitral regurgitation is seen. Moderate [2+]
tricuspid regurgitation is seen. There is moderate to severe
pulmonary artery systolic hypertension. There is an anterior
space which most likely represents a prominent fat pad.
IMPRESSION: Biventricular systolic dysfunction. Dilated RV. Mild
AR. Mild TR. At least moderate to severe pulmonary artery
systolic hypertension.
CT Head [**2-13**]:
IMPRESSION:
1. No acute intracranial process.
2. Region of encephalomalacia in the left frontal lobe,
subjacent to the
craniotomy site
3. Bilateral proptosis.
LENI [**2-14**]:
IMPRESSION: Normal Doppler evaluation of both lower extremities.
No evidence of deep venous thrombosis.
TTE [**2-16**]:
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. Left ventricular wall thicknesses are
normal. The left ventricular cavity size is normal. Overall left
ventricular systolic function is mildly depressed (LVEF= 40 %).
No masses or thrombi are seen in the left ventricle. There is no
ventricular septal defect. The right ventricular cavity is
moderately dilated with moderate global free wall hypokinesis.
There is abnormal septal motion/position consistent with right
ventricular pressure/volume overload. The diameters of aorta at
the sinus, ascending and arch levels are normal. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. No aortic regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. Severe [4+] tricuspid
regurgitation is seen. There is severe pulmonary artery systolic
hypertension. There is no pericardial effusion.
.
ECG [**2198-2-21**]:
Sinus rhythm. Atrial ectopy. Left axis deviation. Right
bundle-branch block with left anterior fascicular block.
Compared to the previous tracing of the same day there is no
significant change.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
85 160 158 386/429 56 -107 56
.
Labs at discharge:
[**2198-2-22**] 06:45AM BLOOD WBC-13.3* RBC-5.64 Hgb-16.1 Hct-48.5
MCV-86 MCH-28.6 MCHC-33.2 RDW-14.2 Plt Ct-206
[**2198-2-22**] 06:45AM BLOOD Glucose-88 UreaN-60* Creat-1.8* Na-138
K-4.2 Cl-95* HCO3-34* AnGap-13
[**2198-2-22**] 06:45AM BLOOD Calcium-9.8 Phos-3.8 Mg-2.1
Brief Hospital Course:
ASSESSMENT AND PLAN- 78yo male with history of COPD found to be
unresponsive s/p cardiopulmonary arrest.
.
# Cardiopulmonary arrest- Unclear etiology at this time but
thought [**2-8**] severe hypoxia at rehabilitation causing a possible
VF or PEA event. Patient with no known coronary artery disease
and extensive history of COPD. EKG on arrival to hospital
demomstrated LAD, RBBB, STD V1-V4, TWI aVL, V4-V5. Previous EKG
([**1-18**]) revealed RBBB and left axis deviation. Other contributing
factors are new medications (digoxin, propanolol) and
bradycardic-induced VT/VF is also possible in this situation.
Given history of COPD and pulmonary hypertension, cor pulmonale
is a definite possibility. He had no further episodes of
bradycardia or arrhythmia on telemetry and was aggressively
diursed to prevent further severe hypoxia. At discharge, he
would desat to the mid 80's on 4L NP. He underwent an artic sun
protocol and his mental status has improved greatly over his
hospital course. OT evaluated pt and felt he had mild short term
memory defecits only.
.
# Acute on Chronic Systolic CHF with right heart failure: Pt was
aggressively diuresed over his hospital stay and transitioned to
PO lasix today. His dry weight is 180 pounds. IV furosemide has
been added prn for use with weight gain more than 3 pounds in 1
day or 5 pounds in 3 days. Despite apparant dry weight, pt
continues to have 2+ pitting edema [**1-8**] way up LE that is thought
[**2-8**] right heart failure. TEDS stockings and leg elevation is
recommended. Consider repeat ECHO as an outpt. Should also
consider ACEi or [**Last Name (un) **] for CHF once kidney function is improved as
it has been held for a high creatinine here.
.
#Atrial fibrillation: He has had 3 spisodes of AF/RVR. This
appears to be a new rhythm for him and he was started on
warfarin 4mg daily. His tachycardia was treated wtih increasing
doses of metoprolol.
.
# HLD- continue home statin
.
# COPD- patient with extensive smoking history and known COPD
s/p recent exacerbation in [**1-18**]. His medical regimen was
optimized with increased dose of Advair, slow prednisone taper
and nebulizeer treatement. He currently has a non productive wet
sounding cough. Azithromycin course has been completed. He will
need continuing monitoring of his oxygen level, especially with
ambulation. As his cardiac arrest is thought [**2-8**] hypoxia,
treatment for his COPD and CHF is paramount.
.
# Hypothyroidism
- continue home levothyroxine
.
# Acute on Chronic Kidney disease- baseline Cr 1.5-1.6. His
Creatining high was 2.7 thought [**2-8**] ATN, now 1.8.
.
#Transaminitis. LFTs stably elevated. Likely [**2-8**] right heart
failure.
Medications on Admission:
1. Digoxin 0.125mg daily (recently initiated for episode of RVR
a few days prior to presentation)
2. Propanolol 20mg [**Hospital1 **]
3. Trazadone 25mg qHS
4. Liquid antacid 30ml PO q4h prn
5. Milk of magnesia- 30ml PO daily prn
6. Albuterol 2.5mg neb via INH q6hr prn SOB
7. Azithromycin 500mg daily x 3 days (day 1- [**2-12**])
8. Levothyroxine 75mg daily
9. Calcitriol 0.25mg daily
10. Spiriva INH 1puff daily
11. Advair 250/50 1 puff q12hr
12. Simvastatin 10mg qHS
13. Guaifenisin q12hr
14. Lasix 40mg daily x 2 days (day 1- [**2-12**])
15. Prednisone 10mg q8hr x 5 days (day 1- [**2-12**])
16. MVI daily
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. fluticasone 50 mcg/actuation Spray, Suspension Sig: One (1)
Spray Nasal DAILY (Daily).
3. Milk of Magnesia 400 mg/5 mL Suspension Sig: Ten (10) cc PO
at bedtime as needed for constipation.
4. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
5. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) vial Inhalation Q6H (every 6 hours).
6. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
7. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO once a
day.
8. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO once a
day.
9. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
11. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q8H (every 8
hours) as needed for pain.
12. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day: Stop once
prednisone is finished.
13. furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): give pm dose at 1500.
14. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
15. prednisone 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
for 2 days.
16. prednisone 10 mg Tablet Sig: Two (2) Tablet PO once a day
for 3 days: [**2-26**], 21 and 22.
17. prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day
for 3 days: [**3-1**], 24 and 25, then d/c.
18. furosemide in 0.9 % NaCl 100 mg/100 mL (1 mg/mL) Solution
Sig: Forty (40) mg Intravenous twice a day as needed for for
weight gain of more than 3 pounds in 1 day or 5 pounds in 3
days.
19. warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day for 3
days: Then check INR and adjust dose.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 5503**] [**Hospital **] Hospital - [**Location (un) 5503**]
Discharge Diagnosis:
Acute on chronic systolic congestive heart failure
Sudden cardiac death
Chronic Obstructive pulmonary disease on home O2
Acute on Chronic kidney injury
Atrial fibrillation with rapid ventricular response
Pulmonary hypertension
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Your heart stopped and you needed to be shocked to restore a
normal heart rhythm. You were transferred to [**Hospital1 18**] for treatment
and was placed on a cooling protocol to help you recover. You
were on a ventilator and medicines to keep your blood pressure
up. We have given you medicine to get rid of extra fluid, we
think that may be why you became so sick. You continued to have
episodes of atrial fibrillation at a rapid rate and we have
adjusted your medicines to keep your heart rate low and help
your heart pump better.
.
We made the following changes to your medicines:
1. START taking furosemide 40 mg twice daily to prevent fluid
from building up again. IV furosemide may be needed if your
weight is increasing. You should wear TEDS stockings every day
as well.
2. STOP taking digoxin and propanolol
3. INCREASE the Advair to 500/50 dosing
4. INCREASE Furosemide to 40 mg twice daily
5. TAPER prednisone as noted
6. START aspirin to prevent a stroke in the setting of atrial
fibrillation
7. START omeprazole to protect your stomach from the prednisone.
You can stop this once the prednisone is finished
8. START Metoprolol to lower your heart rate and help your heart
pump better.
9. START warfarin to prevent a stroke because of your atrial
fibrillation. You will need to have this monitored closely by
your primary care doctor after you get out of rehabilitation.
.
Weigh yourself every day once you are home. Your goal weight is
180 pounds.
Followup Instructions:
Name: [**Last Name (LF) 3321**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Address: [**Doctor Last Name 37166**], [**Location (un) **],[**Numeric Identifier **]
Phone: [**Telephone/Fax (1) 5315**]
*Please schedule an appointment to see Dr. [**Last Name (STitle) 3321**] within 2
weeks.
|
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67,527
| 177,837
|
36305
|
Discharge summary
|
report
|
Admission Date: [**2156-8-15**] Discharge Date: [**2156-8-27**]
Date of Birth: [**2070-4-17**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Erythromycin Base / Neosporin
Scar Solution / Ampicillin / Tobrex
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Placement of a R IJ dialysis catheter
CVVH
History of Present Illness:
Ms. [**Known lastname 82252**] is an 86yoF with history of severe aortic stenosis,
CAD s/p CABG in [**2154**] and RCA stents x3 in [**2148**] recently
hospitalized here from [**Date range (1) 52084**] for acute pulmonary edema who
now is TF from OSH for management of recurrent pulmonary edema.
For details of her initial presentation see Dr.[**Name (NI) 62137**] admission
note from [**2156-8-12**]. Briefly, she presented to OSH with 10/10
chest pain not relieved by nitro x4 and SOB that developed at
rest. She was transferred to [**Hospital1 18**] and had an echo which showed
severe aortic stenosis ([**Location (un) 109**] <0.8cm2) with preserved systolic
function, AR (1+), MR (2+), TR (2+) and severe PAH. Unclear
whether she was evaluated as inpatient by CT surgery but was to
follow up with Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) 5076**] as outpatient re need
for open AVR vs TAVI.
.
On the evening she was discharged to her ALF, she again
developed acute chest pain and SOB. She described the pain as
[**10-11**] and radiating to her L arm, and associated with
diaphoresis. She notes that the chest pain was the same as the
chest pain that she initially presented with, but the SOB was
more severe. She did not use NG as advised by the medical team
on discharge. She called EMS and she was transported back to
OSH. When she arrived she was noted to be in severe respiratory
distress and was started on BiPAP. She received IV lasix 20mg
x1. Labs were notable for Creat 3.35 (up from 2.31 on [**8-11**]), BNP
702, CK 153, trop 0.64. EKG showed sinus tach. She was admitted
to the ICU. After further diuresis her O2sats improved to 94% on
3L. Cards was c/s and felt that CP was likely related to aortic
stenosis and not ACS. She was transferred to [**Hospital1 18**] for further
treatment and surgical evaluation.
.
On transfer, she feels well w/o complaints. She states that her
chest pain has resolved and her breathing is comfortable on the
BiPAP. She notes orthopnea c/w her baseline (requires 2
pillows), denies worsening peripheral edema. She believes she
is 3lbs over her dry weight.
Past Medical History:
1. CARDIAC RISK FACTORS: + Diabetes (Insulin-dependent for 27
years), + Dyslipidemia, + Hypertension
2. CARDIAC HISTORY:
-CABG: off-pump CABG x 2: Saphenous vein grafted to LAD and
saphenous vein graft to PDA
-PERCUTANEOUS CORONARY INTERVENTIONS:
PCI and stentx3 (?BMS) to RCA ([**2145**])
PTCA to LAD ([**2138**])
Aortic stenosis
Carotid stenosis status post right carotid endarterectomy [**2137**]
Chronic kidney disease (unknown baseline Creat)
Left subclavian steal syndrome
Glaucoma
Sleep apnea (no longer uses CPAP)
Past surgical history: Tonsillectomy, Left ankle repair, Right
carpal tunnel release, Total abdominal hysterectomy, Laser eye
surgery, CABG as above
Social History:
Non-smoker, rare brandy, no drugs.
Lives in [**Hospital3 **] in [**Hospital1 487**].
Three sons, local.
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory. Mother and
father died from cancer. Brother passed away from GI bleed and
PUD and another with liver cirrhosis. One sister passed away
from cancer, another sister passed as a child.
Physical Exam:
Admission Physical Exam:
VS on transfer: T= 96.1 BP= 152/61 HR=88 RR=19 O2 sat= 95% on
CPAP (50% FIO2)
GENERAL: Pleasant, comfortable-appearing, in no acute distress.
Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK: Supple with 10cm JVP . surgical scar s/p right
endartrectomy
CARDIAC: s/p CABG, RRR, 4/6 systolic crescendo murmur loudest at
LUSB radiating to carotids, No r/g.
LUNGS: Bibasilar crackles to mid lung, faint expiratory wheezes.
Resp were unlabored, no accessory muscle use.
ABDOMEN: Hysterectomy scar, abd is Soft, non-tender,
non-distended.
EXTREMITIES: WWP, no clubbing/cyanosis, trace pedal edema.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Right: Carotid 2+ Femoral 2+ DP 1+ PT 1+
Left: Carotid 2+ Femoral 2+ DP 1+ PT 1+
Discharge Physical Exam:
Patient delirious, not oriented.
On high flow face mask with good oxygen saturations
Cardiac exam unchanged.
Lungs continue to be wheezy on exam with elevated JVP
Pertinent Results:
Admission labs:
WBC 5.6 Hgb 9.6 Hct 27.5 Plts 211
PT 11.4 PTT 25.7 INR 0.9
Na 140 K 4.7 Cl 99 CO2 23 BUN 70 Cr 4.2 Gluc 209 Ca 8.4 Mag 2.2
Phos 5.2
CK 164 CKMB 12 Trop-T 0.53
ALT 17 AST 32 Alk phos 133 T bili 0.4
Admission studies:
CXR: Moderate pulmonary edema, worsened in comparison to prior
study from
[**2156-8-12**]. Otherwise, no significant change.
EKG: Sinus rhythm, LVH, 1-2mm ST depressions in I, II
TTE [**2156-8-16**]:
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. There is mild focal LV systolic dysfunction with
antero-lateral hypokinesis. The remaining segmetns are
hyperdynamic and thus overall left ventricular ejection fraction
is preserved (LVEF>55%). There is no ventricular septal defect.
The right ventricular cavity is mildly dilated with normal free
wall contractility. 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. 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. At least moderate (2+)
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. Moderate [2+] tricuspid regurgitation is seen.
There is moderate pulmonary artery systolic hypertension. There
is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2156-8-12**], no
change (the [**Location (un) 109**] was slightly underestimated and regional
antero-lateral hypokinesis was present but not commented on for
the prior study).
CXR [**2156-8-24**]: Diffuse hazy opacification with cardiomegaly are
consistent with pulmonary edema, unchanged in appearance from
the prior examination. A small left pleural effusion is not
significantly changed. No pneumothorax is seen. A previously
seen right central venous line has been removed with no
resulting hematoma or mediastinal widening. Median sternotomy
wires are unchanged.
Pertinent Labs:
Renal function pre-CVVHD:
[**2156-8-18**] 07:08PM BLOOD UreaN-98* Creat-6.4*
Renal function Post-CVVHD:
[**2156-8-20**] 09:59AM BLOOD UreaN-23* Creat-2.0*
[**2156-8-21**] 05:15AM BLOOD UreaN-33* Creat-3.0*
[**2156-8-23**] 03:57AM BLOOD UreaN-55* Creat-3.7*
[**2156-8-24**] 05:16AM BLOOD UreaN-65* Creat-4.0*
[**2156-8-25**] 05:45AM BLOOD UreaN-78* Creat-4.6*
[**2156-8-26**] 04:59AM BLOOD UreaN-86* Creat-5.0*
Brief Hospital Course:
Primary Reason for Hospitalization:
83yoF with h/o severe aortic stenosis and [**Hospital **] transfered from
OSH for SOB [**2-4**] flash edema from AS.
# Acute on chronic diastolic heart failure - Due to both severe
aortic stenosis and mitral regurgitation. She was initially
requiring BiPAP to maintain O2sats >90%, but this improved and
by discharge she was maintaining O2 sats >90% on NC at 15L/min,
with occasional episodes of SOB requiring face mask. She was
continued on her home BP meds to reduce afterload, with her
metoprolol tartrate increased to 100mg [**Hospital1 **]. Her Imdur was
initially increased to 90mg daily but then decreased to her home
dose of 60mg daily. She was diuresed with IV lasix and
metolazone. She was also treated with IV morphine to increase
pulmonary venodilation and improve her sensation of dyspnea.
This was later changed to IV dilaudid due to concern for poor
clearance in setting of renal failure. She was evaluated by CT
surgery, who felt that she was not an appropriate candidate for
open AVR given her comorbidities. She was then considered for
TAVI, but there was concern that she may not be a candidate for
the procedure given her known atherosclerosis of femoral vessels
and h/o difficult access for cardiac cath. Patient opted to
start CVVH to optimize her renal function, in order to pursue
balloon valvuloplasty. Review of her echo demonstrated that her
MR was more significant than AS and she would likely get little
benefit from intervention on her aortic valve. Patient clearly
expressed her wishes to not pursue further invasive treatments
and to focus on her comfort at a hospice facility. A family
meeting was held with the patient's sons, palliative care,
social work, and the primary team, and it was agreed that the
patient's expressed wishes could best be served in a hospice
house. The following day, however, she appeared to be very
uncomfortable and it was thought that interventions at hospice
may not be enough to keep her breathing more comfortably. She
died at 11:40 PM on [**8-27**], family was contact[**Name (NI) **] and autopsy was
offered and declined.
.
# CAD - On admission pt c/o chest pain, thought most likely [**2-4**]
demand ischemia, low suspicion for ACS given history and absence
of ischemic changes on EKG. She was initially continued on
aspirin 325mg, metoprolol, atorvastatin and clopidrogel. ACEi
was held in the setting of renal failure. Her isosorbide
mononitrate CR was initally increased to 90mg daily, then
reduced to 60mg daily as above. Chest pain did not recur.
# Acute on chronic RF: Creat increased from 2.2 on previous
admission to 4.2, and continued to increase to 6.4. Patient was
started on CVVH on HD3 and tolerated this well. On HD5 CVVH was
held when her dialysis line malfunctioned and renal function did
not improve. Creatinine continued to trend upwards and patient
continued to have poor urine output. She did respond to bolus
doses of 200 mg IV lasix and metolazone with some improvement in
respiratory status. The renal service discussed the possibility
of resuming dialysis with the patient, but she elected not to
continue as she did not want to be on dialysis long-term.
# Hypertension: BP stable on home amlodipine, and metoprolol.
Imdur dose modified as described above. These meds were
continued after goals of care transitioned to CMO in hopes of
improving patient's respiratory status.
# Hypercholesterolemia: Atorvastatin was initially continued
throughout hospitalization but discontinued on changing goals of
care to CMO.
# Diabetes Mellitus: Patient's blood sugar was well controlled
throughout admission on home lantus and insulin sliding scale.
She was contined on ISS in hopes that glucose control would
improve her mental status and quality of life.
Patient passed at 11:40pm on [**2156-8-27**]. Family was notified.
Medications on Admission:
1. Lantus 100 unit/mL Solution Sig: As directed units
Subcutaneous at bedtime: Please take 14 - 16 units at bedtime. .
2. Humalog 100 unit/mL Solution Sig: As directed units
Subcutaneous Before meals: As directed by your primary care
doctor: 4-6 units prior to meals.
3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
5. furosemide 40 mg Tablet Sig: One (1) Tablet PO As directed:
Take 40 mg daily on sunday, tuesday, thursday, and saturday.
Take 40 mg twice a day on monday, wednesday, and friday.
6. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
7. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1)
Tablet PO once a day.
8. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
9. isosorbide mononitrate 60 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
10. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Medications:
N/A
Discharge Disposition:
Expired
Facility:
Hospice of the [**Location (un) 1121**]
Discharge Diagnosis:
Critical aortic stenosis
Coronary artery disease s/p CABG
Anemia
Moderate Mitral Reguritation
Acute on chronic renal failure
Hypertension
Discharge Condition:
Expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
|
[
"396.2",
"428.33",
"250.00",
"583.9",
"518.4",
"V49.86",
"428.0",
"V45.82",
"518.81",
"585.9",
"584.9",
"285.9",
"041.89",
"E947.8",
"272.0",
"V66.7",
"403.90",
"V45.81",
"414.00",
"790.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"39.95",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
12407, 12467
|
7388, 11255
|
368, 412
|
12649, 12658
|
4786, 4786
|
12710, 12716
|
3406, 3703
|
12379, 12384
|
12488, 12628
|
11281, 12356
|
12682, 12687
|
3141, 3269
|
3743, 4578
|
2716, 3118
|
321, 330
|
440, 2573
|
4802, 6936
|
6953, 7365
|
2595, 2696
|
3285, 3390
|
4603, 4767
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,985
| 120,390
|
7808
|
Discharge summary
|
report
|
Admission Date: [**2168-1-2**] Discharge Date: [**2168-1-4**]
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 11344**]
Chief Complaint:
Seizures
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The pt is a 83 year-old Spanish speaking only man with a PMH
of dementia, strokes and seizures who presented from [**Hospital 100**]
Rehab
today after having had 2 witnessed GC. He has a prior history of
GC seizures per the NH, and they his last seizure was in [**2165**].
He
had been treated with Depakote, however this was stopped last
year after he was felt to be too sedated on the medication. He
is
currently being treated with Ativan 05.mg PO BID for
"combativeness and agitation", and this medication has been
longstanding. His last dose was at 6am this morning.
This morning around 10am he had a GC seizures lasting about 30
seconds without incontinence, tongue biting or gaze preference.
Afterwards he was "post-ictal" for less than 5 minutes. The RN
noted possible L leg weakness at that time. Per her report, he
was then back to his usual state of health, however his baseline
is somewhat difficult to discern. Per the NH records and RN
report, they are unsure of his mental status as he only speaks
Spanish. He does not speak usually and when he does, they do not
understand him. He also does not follow commands. The NH does
not
know if this is due to a language barrier or not as they do not
have Spanish speaking staff to help with this issue.
He was noted to be masturbating around 11am, which is typical
for
him. Then at 12 or 12:30pm he had another GC lasting 30 seconds.
No focality was noted at that time again, however afterwards the
RN and physician noted [**Name Initial (PRE) **] arm and leg weakness but no facial
droop. He was then transferred to [**Hospital1 18**] for further evaluation
and called as a code stroke due to the history of L sided
weakness.
On review of systems per the [**Name8 (MD) **] RN, he has not had any fevers,
rashes, diarrhea or recent illnesses.
In the ED he had a witnessed GC seizure lasting 12 minutes and
broken with Ativan. He had a R gaze deviation and tonic
posturing
of the L arm and then the left leg followed by tonic movements
of
all extremities. He received 2mg of Ativan x 2 as well as
Dilantin 1.5g IV x 1, and thiamine 10mg IV. His NCHCT did not
show evidence of an acute infarct and his deficits were felt to
be from his seizures, therefore no further code stroke
interventions were pursued.
After speaking to the NH twice ([**Telephone/Fax (1) 28223**]) I attempted to
contact his nieces: Ms. [**Last Name (Titles) 28224**] ([**Telephone/Fax (1) 28225**]) and Ms. [**Last Name (Titles) 1661**]
([**Telephone/Fax (1) 28226**] and [**Telephone/Fax (1) 28227**]) however the first and 3
numbers provided have been disconnected and the second is a
dental office which is currently closed.
Past Medical History:
-dementia, w/ questionable hx of head trauma
-prior strokes
-seizures (last per NH is [**2165**], reportedly GC, had been tx w/
depakote 750 [**Hospital1 **])
-psychosis
-stasis dermatitis
-Anemia of chronic dz
-lichen simplex
-cholecystectomy
-chronic venous stasis w/ PVD
-dysphagia
-chronic entroion
-latent TB
-old healed incision over L-spine as well as scars on R leg and
L
arm, suggestive of surgery however NH has no record of these
surgeries
Social History:
unknown, NH unable to provide further information
beyond that he is Spanish speaking only, mostly wheel-chair
bound
and has 2 nieces that rarely visit
Family History:
unknown
Physical Exam:
Vitals: T: 97.6 P: 60-80's R: 14 BP: 126-172/65-90 SaO2: 100% on
2L NC
General: initially awake with eyes open, then somnolent after
seizure
HEENT: NC/AT, no scleral icterus noted, unable to fully evaluate
oropharynx however no lesions noted
Neck: Supple. No nuchal rigidity
Pulmonary: wheezing bilaterally
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: L leg swollen and hyperpigmented but not warm
Skin: several skin tags with mild breakdown, no sacral ulcers
Neurologic:
-Mental Status: initially eyes open, not verbal and not
following
commands, despite translator and maximal cues. After witnessed
GC, somnulant but groans with sternal rub.
-Cranial Nerves: Olfaction not tested. Surgical pupils but
reactive bilaterally. No oculocephalic reflex R gaze
preference,
no blink to treat on L. There is no ptosis bilaterally. Unable
to
obtain funduscopic exam due to patient attempting to hit
examiner. No facial droop, facial musculature symmetric.
-Motor: Normal bulk throughout. Increased tone in upper
extremities noted during sz. Moves arms and legs antigravity
bilaterally.
-Sensory: withdraws to nox stim in all extremities w/ some
localization
-Coordination: unable to access
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 1 0
R 2 2 2 1 0
Plantar response was flexor bilaterally.
-Gait: unable to access
Pertinent Results:
CT-Head [**2168-1-2**]
IMPRESSION: No evidence of acute intracranial hemorrhage. Right
frontal encephalomalacia again seen. MRI with diffusion-weighted
images is more sensitive in the evaluation for acute
ischemia/infarct and for vascular detail.
CXR [**2168-1-2**]
IMPRESSION: No acute cardiopulmonary process.
ECG [**2168-1-3**]
Baseline artifact. Sinus rhythm. P-R interval prolongation.
Leftward axis. Late R wave progression. T wave abnormalities.
Since the previous tracing of [**2164-5-15**] no significant change.
EEG [**2168-1-3**]
Official Read Pending.
Unofficial read - no electrographic evidence of ongoing
seizures.
[**2168-1-3**] 08:45AM BLOOD WBC-4.3 RBC-4.28* Hgb-12.5* Hct-37.9*
MCV-89 MCH-29.3 MCHC-33.1 RDW-16.1* Plt Ct-191
[**2168-1-3**] 08:45AM BLOOD Neuts-58.8 Lymphs-34.7 Monos-6.2 Eos-0.1
Baso-0.1
[**2168-1-2**] 01:20PM BLOOD PT-12.8 PTT-30.3 INR(PT)-1.1
[**2168-1-3**] 08:45AM BLOOD Glucose-142* UreaN-6 Creat-0.6 Na-143
K-4.0 Cl-107 HCO3-27 AnGap-13
[**2168-1-2**] 01:20PM BLOOD ALT-18 AST-25 CK(CPK)-40 AlkPhos-83
TotBili-0.4
[**2168-1-3**] 08:45AM BLOOD CK(CPK)-60
[**2168-1-2**] 01:20PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2168-1-3**] 08:45AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2168-1-3**] 08:45AM BLOOD Calcium-9.1 Phos-3.3 Mg-2.0 Cholest-95
[**2168-1-2**] 01:20PM BLOOD calTIBC-278 Ferritn-90 TRF-214
[**2168-1-3**] 08:45AM BLOOD VitB12-539 Folate-GREATER TH
[**2168-1-3**] 08:45AM BLOOD Triglyc-79 HDL-37 CHOL/HD-2.6 LDLcalc-42
[**2168-1-3**] 08:45AM BLOOD TSH-2.4
[**2168-1-3**] 08:45AM BLOOD Phenyto-15.6
[**2168-1-2**] 01:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2168-1-2**] 02:29PM URINE RBC-0 WBC-0-2 Bacteri-RARE Yeast-NONE
Epi-<1
[**2168-1-2**] 02:29PM URINE Blood-TR Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
[**2168-1-2**] 02:29PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.008
MICRO:
RPR negative
Blood cultures No growth to date
Urine Culture negative.
Brief Hospital Course:
On admission, a head CT was not indicative of a stroke or
hemorrhage. The patient was admitted to the ICU. The patient
had no clinical seizures after his admission. He was initially
treated with dilantin. Keppra was subsequently added for dual
therapy and the ultimate intention to transition to Keppra
monotherapy. After discharged dilantin should be weaned as
ordered and keppra should be titrated. The geriatrics service
consulted and assured us that he will have neurology follow-up
for further dose adjustments at [**Hospital1 5595**].
There was no provoking cause identified that might of set off
this flurry of seizures, TSH was normal, UA was clean,
chest-x-ray was without evidence of pneuomnia, blood cultures
and urine cultures were negative, and serum tox was negative.
As such this series of seizure were felt likely related to the
patients prior seizure disorder and simple under treatment.
Medications on Admission:
-ASA 81mg
-Calcium
-Vitamin D
-Ativan 05.mg PO BID
-Senna
-Tylenol PRN
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
3. Keppra 500 mg Tablet Sig: One (1) Tablet PO twice a day:
Increase to 500mg qam and 750qm in three days, then increase to
750mg [**Hospital1 **] for three days, then increase to 750mg qam and 1000mg
qpm for three days, then increase to 1000mg po bid thereafter.
4. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO twice a day for 3 days: Give 100mg po bid for three days,
then decrease to 100mg daily for three days, then discontinue.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - LTC
Discharge Diagnosis:
Seizure
Dementia
Discharge Condition:
Stable. Examination at stated baseline.
Discharge Instructions:
Please attend all follow-up appointments. Please take all
medications as prescribed. If you experience a prolonged seizure
or other concerning symptoms, please report to the emergency
dept for evaluation.
Followup Instructions:
Please follow-up with your primary care doctor as arranged.
Please follow-up with neurology at [**Hospital1 5595**].
Completed by:[**2168-1-4**]
|
[
"434.90",
"294.8",
"298.9",
"459.81",
"285.29",
"345.10",
"V58.66",
"787.29",
"V12.59"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8875, 8940
|
7157, 8070
|
271, 277
|
9001, 9043
|
5125, 7134
|
9296, 9444
|
3627, 3636
|
8192, 8852
|
8961, 8980
|
8096, 8169
|
9067, 9273
|
4402, 5106
|
3651, 4213
|
223, 233
|
305, 2967
|
4228, 4385
|
2989, 3442
|
3458, 3611
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,073
| 175,184
|
48002
|
Discharge summary
|
report
|
Admission Date: [**2144-1-20**] Discharge Date: [**2144-1-27**]
Service: Trauma
HISTORY: This was an 89-year-old man who entered via the
Emergency Room after choking on his food at home and having a
witnessed cardiopulmonary arrest by his wife. [**Name (NI) **] was
intubated emergently at the scene by the medics and
transferred to our hospital with pulseless electrical
activity. However, with resuscitation, he regained a normal
rhythm and a pulse.
PAST MEDICAL HISTORY: Felty syndrome with leukemia, coronary
artery disease, status post myocardial infarction,
cerebrovascular accident times three.
HOSPITAL COURSE: The patient underwent CT scanning of the
head showing no focal injury. An extensive neurological
evaluation revealed what was thought to be a profound anoxic
brain injury. Ultimately after consultation with the family,
the patient was allowed to expire on the 7th hospital day.
DISPOSITION: Deceased.
CONDITION ON DISCHARGE: Deceased.
[**First Name11 (Name Pattern1) 518**] [**Last Name (NamePattern4) **], [**MD Number(1) 17554**]
Dictated By:[**Last Name (NamePattern4) 17555**]
MEDQUIST36
D: [**2144-2-23**] 15:26:20
T: [**2144-2-23**] 16:16:53
Job#: [**Job Number **]
|
[
"348.1",
"807.02",
"958.7",
"714.1",
"204.90",
"518.84",
"E888.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"96.6",
"38.91",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
638, 944
|
491, 620
|
969, 1249
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,026
| 170,102
|
30502
|
Discharge summary
|
report
|
Admission Date: [**2122-5-24**] Discharge Date: [**2122-5-28**]
Date of Birth: [**2049-11-29**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
[**2122-5-24**] Exploratory Laparotomy, Small Bowel Resection, Right
Femoral Hernia Repair
History of Present Illness:
72 year old female with history significant only for
hypothyroidism, who has been experiencing abdominal pain, nausea
and vomiting since about 1 pm on [**5-23**]. The emesis worsened as did
the groin pain over the course of the next several hours and
patient decided to come to the ED. She reports last bowel
movement at greater than 24 hours ago and denies passing any
flatus since the pain began, approximately 12 hours ago. Patient
has never experienced this before. She denies any fevers,
chills,
hematemesis.
Past Medical History:
Hypothyroidism
Family History:
Noncontibutory
Physical Exam:
Upon admission to [**Hospital1 18**]:
Temp: 97.7 HR: 63 BP: 132/55 Resp: 16 O(2)Sat: 100 Normal
Constitutional: Comfortable
HEENT: Extraocular muscles intact, Normocephalic,
atraumatic
Oropharynx within normal limits
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, Nontender, firm 5 cm mass in the right
inguinal area, nontender.
GU/Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing or edema
Skin: No rash, Warm and dry
Neuro: Speech fluent
Psych: Normal mood, Normal mentation
Pertinent Results:
[**2122-5-24**] 02:16PM GLUCOSE-157* UREA N-9 CREAT-0.6 SODIUM-139
POTASSIUM-3.6 CHLORIDE-105 TOTAL CO2-24 ANION GAP-14
[**2122-5-24**] 02:16PM CALCIUM-8.3* PHOSPHATE-3.1 MAGNESIUM-1.7
[**2122-5-24**] 02:16PM WBC-12.6* RBC-3.95* HGB-12.2 HCT-35.3* MCV-89
MCH-31.0 MCHC-34.7 RDW-13.1
[**2122-5-24**] 02:16PM PLT COUNT-298
[**2122-5-24**] 09:10AM CALCIUM-8.6 PHOSPHATE-2.8 MAGNESIUM-1.9
[**2122-5-23**] 10:10PM ALT(SGPT)-31 AST(SGOT)-24 ALK PHOS-78 TOT
BILI-0.6
[**2122-5-23**] 10:10PM LIPASE-25
[**2122-5-23**] 10:10PM ALBUMIN-3.9
CT Abd/pelvis:
IMPRESSION:
1. Right femoral hernia with mild dilatation of bowel loops
proximal and
collapse of bowel loops distally consistent with mechanical
small bowel
obstruction.
2. Significant dilatation of the stomach.
3. Sigmoid colon diverticulosis without diverticulitis.
4. Small segment VII liver lesion might be further worked up
with ultrasound.
Brief Hospital Course:
She was admitted to the Acute Care Service where she underwent
CT imaging of her abdomen and pelvis showing right femoral
hernia with mild dilatation of bowel loops proximal and collapse
of bowel loops distally consistent with mechanical small bowel
obstruction. She was taken to the operating room for repair of
her hernia. There were no complications. Postoperatively her NG
tube remained in place for a little over 24 hours. Her serial
abdominal exams were followed very closely and remained stable.
She had little NG output and began passing flatus and the NG was
removed.
Overnight on [**5-25**] she reported feeling "heart racing" but denied
chest pain or shortness of breath. She was found to be in atrial
fibrillation. 5mg Lopressor x2 and 5mg diltiazem x3 did not
break the rhythm, however she remained hemodynamically stable.
EKG showed rapid afib with RVR, 1st set of cardiac enzymes with
negative troponin. She was transferred to the ICU and placed on
a Diltiazem drip; the drip was turned off when she converted to
NSR. She was started on 2.5mg Lopressor q6h but became
hypotensive and the Lopressor was stopped. She remained in the
ICU for 24 hours and in NSR. Her TSH was checked and was 5.1;
at home she takes 50 mcg levothyroxine. She was given IV
Levothyroxine while NPO and later changed back to her oral home
dose. We are recommending that she follow up with her primary
care doctor within the next week for ongoing evaluation of this.
Once stable she was transferred back to the regular nursing
unit.
Once back to the regular nursing unit her diet was advanced for
which she was able to tolerate. She was passing flatus and had a
bowel movement on day of discharge. Her pain was well controlled
and she was ambulating independently.
Medications on Admission:
levothyroxine 50 mcg daily
Discharge Medications:
1. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Tylenol 325 mg Tablet Sig: Two (2) Tablet PO every 4-6 hours
as needed for pain.
3. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
4. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
5. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation.
Discharge Disposition:
Home
Discharge Diagnosis:
Right femoral hernia with incarcerated small bowel
Atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with an incarcerated hernia in
your right groin which required an operation to repair.
Following your operation you experienced an irregular heart
rhythm called atrial fibrillation whcih was felt likley a
reflection of your fluid volume status associated with your
surgery. You were given medications to correct this irregularity
which has now resolved. It is improtnat that you follow up with
your PCP within the next week for ongoing follow up of this.
You may resume your home medications as prescribed.
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.
Please call your doctor or return to the emergency room if you
have any of the following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
Activity:
No heavy lifting of items [**10-3**] pounds for 6 weeks. You may
resume moderate
exercise at your discretion, no abdominal exercises.
Wound Care:
You may shower, no tub baths or swimming.
If there is clear drainage from your incisions, cover with
clean, dry gauze.
Your steri-strips will fall off on their own. Please remove any
remaining strips 7-10 days after surgery.
Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
Followup Instructions:
Follow up in Acute Care Surgery clinic in [**1-22**] weeks, call
[**Telephone/Fax (1) 600**] for an appointment.
Follow up with your primary care doctor in the next 1-2 weeks
for a general physical and for follow up of the irregular heart
rhythm you experienced while in the hospital.
Provider: [**Name10 (NameIs) **] DENSITY TESTING Phone:[**Telephone/Fax (1) 4586**]
Date/Time:[**2122-8-20**] 9:00
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2164**], MD Phone:[**Telephone/Fax (1) 1803**]
Date/Time:[**2122-8-20**] 10:00
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) 13532**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2122-8-20**] 11:20
Completed by:[**2122-5-28**]
|
[
"427.31",
"789.59",
"E942.6",
"551.00",
"244.9",
"458.29"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.62",
"53.21"
] |
icd9pcs
|
[
[
[]
]
] |
4883, 4889
|
2574, 4334
|
319, 411
|
5004, 5004
|
1641, 2551
|
7271, 7986
|
1009, 1025
|
4413, 4860
|
4910, 4983
|
4360, 4390
|
5154, 6901
|
1040, 1622
|
265, 281
|
6913, 7248
|
439, 955
|
5019, 5130
|
977, 993
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,288
| 125,243
|
39348
|
Discharge summary
|
report
|
Admission Date: [**2106-9-14**] Discharge Date: [**2106-9-17**]
Date of Birth: [**2030-9-17**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6075**]
Chief Complaint:
aphasia, unresponsive
Major Surgical or Invasive Procedure:
none
History of Present Illness:
75 y/o male iwth PMHx including HTN, CHF, chronic A fib and
previous hx of stroke presents with and episode of
unresponsiveness at OSH at ~4am. History was obtained via
telephone from his wife and OSH records provided. Patient was
at
his baseline when on Friday ([**9-10**]) while being bathed by his
home
health aid, he had an episode of unresponsiveness and "glassy
eyes". BP at this time was 253/114. He was taken to [**Hospital3 86998**] where his symptoms almost completely resolved over 45
minutes save for mild slurred speech. He was subsequently
admitted for evaluation.
This evaluation included a head CT which initially was reported
as normal but later was found to have an area of infarction in
the L post-parietal area. MRI was unsuccessful. Other
evaluation included a CXR with possible pneumonia vs aspiration,
carotid US with 0-40% stenosis bilaterally and an ECHO reported
as normal including LV funtion and no vegetations seen.
According to his wife, he continued to remain at his baseline
for
the duration of his OSH admission when today at ~4am he slumped
over in his chair and was aphasic. He was able to follow simple
commands per report (i.e. squeeze fingers, wiggle toes). His
NIHSS was also reported to be 28-29. [**Hospital1 2025**] tele-stroke was
contact[**Name (NI) **] who recommended arterial TPA. But due to lack of
beds,
[**Hospital1 18**] was contact[**Name (NI) **] and he was med-flighted here.
Past Medical History:
-H/o stroke several years ago
-HTN
-s/p AVR and MVR
- CHF
-LE cellulitis
-h/o MRI (10-20 years ago)
-psoriasis
-kyphosis
-osteroarthritis
-A fib on coumadin
-lymphedema
Social History:
Lives with wife. [**Name (NI) **] 4 children. H/o tobacco usage but none
currently, no EtOH. Has a home health aid to assist with ADLs.
Uses a walker at baseline. Per wife, full code.
Family History:
No h/o strokes, migraines
Daughter with childhood epilepsy
Family h/o cancersn and DM
Physical Exam:
Physical Examination:
- VS: HR 80 BP 140/81
- General: Awake, alert, NAD, says "yes" to almost all
questions
- HEENT: NCAT, mucous membranes moist and pink, sclera
non-icteric
- Neck: Supple, no thyromegaly, no lymphadenopathy, no bruits
- Lungs: Clear bilaterally, good aeration, no wheezing/crackles
- Cardiac: Normal S1 and S2, faint [**1-30**] murmur
- Abdomen: S/NT/protuberant, normoactive BS, no masses, no HSM
- Extremities: no C/C/E, LE with lymphedema
Neurologic Examination:
- MS: Able to say "yes" to almost all questions, unable to
speak
in full sentences.
- Cranial Nerves:
I: not tested
II: Blinks to visual threat in all quadrants, PERRL both
directly and consensually
III, IV, VI: EOMI without nystagmus or ptosis
VII: Facial movements symmetric, slight left facial droop
VIII: Turns head towars appropriate side
IX, X: Palate elevates midline and symmetrically, gag intact
XII: Tongue protrudes midline, no fasciculations
- Motor: Normal bulk and tone, no tremor, rigidity or
bradykinesia, no pronator drift.
[**Doctor First Name **] Tri Bic WE FF FE IP Quad Ham AF AE TF TE
C5 C7 C6 C6 C7 C7 L2 L3 L4-S1 L4 S1 S2 L5
R 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
- Coordination: No dysmetria with FTN
- Reflexes: No clonus, toes downgoing bilatrally
[**Hospital1 **] Tri [**Last Name (un) 1035**] Pat Ach
C5-6 C7-8 C5-6 L3-4 S1-2
Right 2 2 2 2 2
Left 2 2 2 2 2
- Sensation: Withdrawals to noxious stimulation bilaterally
- Gait: Not assessed
Pertinent Results:
[**2106-9-14**] 08:10AM BLOOD WBC-17.7* RBC-4.35* Hgb-12.8* Hct-37.7*
MCV-87 MCH-29.4 MCHC-33.8 RDW-14.6 Plt Ct-243
[**2106-9-17**] 05:05AM BLOOD WBC-12.6* RBC-3.98* Hgb-11.6* Hct-35.6*
MCV-90 MCH-29.2 MCHC-32.6 RDW-14.3 Plt Ct-240
[**2106-9-15**] 02:27AM BLOOD PT-34.6* PTT-32.8 INR(PT)-3.5*
[**2106-9-17**] 05:05AM BLOOD PT-26.8* PTT-30.2 INR(PT)-2.6*
[**2106-9-15**] 02:27AM BLOOD Fibrino-564*
[**2106-9-14**] 08:10AM BLOOD Glucose-142* UreaN-21* Creat-1.3* Na-144
K-3.3 Cl-102 HCO3-28 AnGap-17
[**2106-9-17**] 05:05AM BLOOD Glucose-121* UreaN-17 Creat-1.0 Na-141
K-3.4 Cl-103 HCO3-28 AnGap-13
[**2106-9-17**] 05:05AM BLOOD Calcium-8.9 Phos-3.4 Mg-2.1
Cholest-127
Triglyc-85 HDL-33 CHOL/HD-3.8 LDLcalc-77
[**2106-9-14**] 12:54PM BLOOD Digoxin-0.3*
[**2106-9-14**] 01:05PM BLOOD Type-ART pO2-190* pCO2-52* pH-7.35
calTCO2-30 Base XS-2
[**2106-9-14**] 08:15AM BLOOD Lactate-2.5*
[**2106-9-14**] 01:05PM BLOOD freeCa-1.15
[**2106-9-14**] 03:04PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-TR
UCX <10K ORGANISMS
IMAGING:
CT STROKE PROTOCOL (CT/A/P)
1. Acute left MCA territory ischemia with occlusion of left MCA,
M1/M2
segment.
2. No evidence of intra- or extra-axial hemorrhage. The above
findings were
discussed with Dr. [**First Name4 (NamePattern1) 11923**] [**Last Name (NamePattern1) 33038**] at 9:08 a.m.
CXR
1. Bibasilar atelectasis with more focal opacity in the left
lung base which
may represent atelectatic change versus underlying infection.
Clinical
correlation is recommended.
2. Moderate cardiomegaly.
TRANSTHORACIC ECHO
The left atrium is moderately dilated. The right atrium is
markedly dilated. There is mild symmetric left ventricular
hypertrophy with normal cavity size. Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Overall left ventricular systolic function is normal
(LVEF>55%). Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). The aortic root is
mildly dilated at the sinus level. The ascending aorta is
moderately dilated. A bioprosthetic aortic valve prosthesis is
present. The transaortic gradient is normal for this prosthesis.
No aortic regurgitation is seen. A bioprosthetic mitral valve
prosthesis is present. The gradients are higher than expected
for this type of prosthesis. Trivial mitral regurgitation is
seen. The estimated pulmonary artery systolic pressure is
normal. Significant pulmonic regurgitation is seen. There is no
pericardial effusion.
IMPRESSION: Suboptimal image quality. No apparent cardiac source
of embolism, but view technically limited. Bioprosthetic AVR/MVR
which are not well-visualized. Mitral prosthesis with higher
than expected gradients. Preserved global left ventricular
systolic function. Markedly dilated atria.
CAROTID U/S (PRELIM REPORT)
BILATERAL <40% STENOSIS
Brief Hospital Course:
NEURO:
Patient was transferred to [**Hospital1 18**] after becoming unresponsive and
aphasic at [**Hospital3 **] during an admission for L parietal stroke.
Per report, NIHSS 28-29 mostly for aphasia. Patient was not
given tPA for multiple reasons:
- patient had some prefusion of the area of infarction already
- minimal neurologic deficit for the occlusion of M1 segment of
the MCA
- Patient is on Coumadin with high INR
- Expected difficulties with passing of microcatheter to the
area
of artery block, which in circumstances of high INR can result
in
bleeding
Patient was then transferred to [**Hospital1 18**]. CT stroke protocol
revealed L MCA M1-2 infaract. Patient was already improving, so
likely had a proximal L MCA stroke that broke up on its own and
had lodged distally (temporal region), leaving him with only
minimal deficits.
Neurologic examination in the Neuro ICU revealed 4+/5 symmetric.
Good naming, No dysarthria, Able to read. Right field cut.
Workup for etiology of stroke was negative. Carotids were <40%
stenosis bilaterally, and TTE revealed no thrombus or PFO.
Patient was treated with continued anticoagulation with
coumadin, and the addition on Aggrenox for antiplatelet effect.
Patient's neurologic exam improved significantly and he had no
defecits other than R field cut.
For treatment of stroke, patient was continued on coumadin and
started on Aggrenox for antiplatelet effect. He will follow up
in the stroke clinic.
CV: No active issues. Patient has chronic AF, rate controlled
and on coumadin. Coumadin was became supratherapeutic when given
antibiotics so was held for 2 days, then restarted for goal INR
2.5-3.5 given AVR and MVR.
Digoxin level was 0.3, current dose was continued as there was
no clinical evidence of toxicity.
Home antihypertensives were initially held to allow
autoregulation, and restarted prior to discharge.
RESP:
CXR showed bibasilar atelectasis, there was no clinical evidence
of PNA.
ID:
Patient had been on levaquin for UTI at [**Hospital3 **] which was
continued to complete 7 day course.
UA was positive and UCx was neg, though it was after several
days abx.
GENETCS:
Patient was noted to have blue sclera, dark urine, and [**Doctor Last Name 352**]/blue
patches of skin discoloration. There was high suspicion for
alkaptonuria, especially given history of heart valve disease
and repair. Urine/serum homogentisic acid could not be sent
while inpatient.
Patient was discharged to home with home PT.
Medications on Admission:
-lasix 20mg daily
-digoxin 0.125mg daily
-enalapril 40mg daily
-atenolol 25mg daily
-coumadin 6mg Sunday & Thursday; 3mg Monday, Tuesday, Wednesday,
Friday and Saturday
Discharge Medications:
1. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Warfarin 3 mg Tablet Sig: Two (2) Tablet PO once a day: Sun
Thurs.
3. Warfarin 3 mg Tablet Sig: One (1) Tablet PO once a day:
except Sun Thurs.
4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Dipyridamole-Aspirin 200-25 mg Cap, Multiphasic Release 12 hr
Sig: One (1) Cap PO BID (2 times a day).
Disp:*60 Cap(s)* Refills:*2*
6. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
7. Enalapril Maleate 20 mg Tablet Sig: Two (2) Tablet PO once a
day.
8. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day
for 4 days.
Disp:*4 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 6136**] Home Care
Discharge Diagnosis:
left MCA infarct
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure taking care of you. You were admitted after an
episode of unresponsivess and difficulty speaking. You were
found to have a stroke on the left side. You were started on a
new medication to prevent strokes called Aggrenox.
You improved significantly. You will receive physical therapy at
home.
Followup Instructions:
You will appointment with Dr. [**Last Name (STitle) 1693**] in the stroke clinic.
Tuesday [**2106-10-26**]
10:00 am
[**Hospital Ward Name 23**] Clinical Center [**Location (un) **]
You will be placed on a waiting list for a closer appointment
|
[
"427.31",
"457.1",
"428.0",
"737.10",
"438.83",
"599.0",
"784.3",
"401.9",
"270.2",
"V58.61",
"V42.2",
"414.01",
"434.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"87.03"
] |
icd9pcs
|
[
[
[]
]
] |
10300, 10361
|
6934, 9406
|
338, 344
|
10422, 10422
|
4014, 6911
|
11033, 11280
|
2229, 2317
|
9626, 10277
|
10382, 10401
|
9432, 9603
|
10699, 11010
|
2332, 2332
|
2354, 2803
|
277, 300
|
372, 1815
|
2931, 3995
|
10563, 10675
|
2827, 2915
|
1837, 2007
|
2023, 2213
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,597
| 167,458
|
7908
|
Discharge summary
|
report
|
Admission Date: [**2139-6-19**] Discharge Date: [**2139-7-3**]
Date of Birth: [**2069-9-11**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
obstructive jaundice w/pancreatic mass
Major Surgical or Invasive Procedure:
ERCP
Staging laparoscopy
Exploratory laparotomy
Reduction of internal hernia
Cholecystostomy tube placement
History of Present Illness:
69 y/o male with ankylosing spondylitis and hypertension
presented w/new onset of obstructive jaundice. Pt. referred
from hospital in [**State 531**]. Upon arrival pt. had been found to
have bilirubin on 40. Pt. had undergone ERCP at [**Hospital 531**]
hospital without relief of symptoms. On exam pt. was very
jaundiced, itchy, and weak.
Past Medical History:
Ankylosing spondylitis
hypertension
anemia
proteinuria
Social History:
lives in [**State 531**]
Family History:
sister treated by Dr. [**Last Name (STitle) 468**] for pancreatic process
Physical Exam:
Gen: WD, WN, NAD
HEENT: PERRL&A, NCAT, non-icteric sclera
Chest: CTAB no w/c/r appreciated
CV: RRR, nl s1s2, no m/r/g appreciated
Abd: soft, mildly distended, incision clean, dry, and intact,
drain site w/ostomy bag, non-tender to palpation, normal active
bowel sounds
Ext: mild edema bilat lower extrem, no clubbing, no cyanosis, L
groin w/resolving hematoma
GU: scrotal swelling --> improved
Pertinent Results:
[**2139-6-19**] 10:13PM URINE Color-DkAmb Appear-Clear Sp [**Last Name (un) **]-1.010
[**2139-6-19**] 10:13PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-LG Urobiln-4* pH-6.5 Leuks-NEG
[**2139-6-19**] 10:13PM URINE RBC-0 WBC-0 Bacteri-NONE Yeast-NONE Epi-0
[**2139-6-30**] 10:00AM BLOOD Cortsol-28.8*
[**2139-6-30**] 01:10PM BLOOD Cortsol-38.9*
[**2139-6-23**] 12:15PM BLOOD CK-MB-3 cTropnT-<0.01
[**2139-6-23**] 07:40PM BLOOD CK-MB-4 cTropnT-0.01
[**2139-6-24**] 04:00AM BLOOD cTropnT-0.02*
[**2139-6-19**] 09:05PM BLOOD Lipase-27
[**2139-6-20**] 08:46AM BLOOD Lipase-132*
[**2139-7-2**] 04:45AM BLOOD Lipase-118*
[**2139-6-26**] 06:40AM BLOOD ALT-76* AST-116* LD(LDH)-232 AlkPhos-263*
TotBili-15.9*
[**2139-6-25**] 07:10AM BLOOD TotBili-17.1*
[**2139-6-23**] 12:15PM BLOOD ALT-113* AST-249* CK(CPK)-200*
AlkPhos-331* TotBili-20.5*
[**2139-6-22**] 05:21AM BLOOD ALT-79* AST-106* AlkPhos-393* Amylase-76
TotBili-27.0*
[**2139-6-20**] 06:11PM BLOOD CK(CPK)-83
[**2139-6-20**] 08:46AM BLOOD CK(CPK)-66 Amylase-69
[**2139-6-20**] 03:53AM BLOOD ALT-64* AST-84* AlkPhos-333*
TotBili-23.4*
[**2139-6-19**] 11:38PM BLOOD CK(CPK)-77
[**2139-6-19**] 10:13PM BLOOD ALT-71* AST-92* AlkPhos-378* Amylase-84
TotBili-27.2* DirBili-21.3* IndBili-5.9
[**2139-6-19**] 09:05PM BLOOD Amylase-82
[**2139-7-2**] 04:45AM BLOOD Glucose-85 UreaN-14 Creat-0.7 Na-140
K-3.1* Cl-104 HCO3-27 AnGap-12
[**2139-7-2**] 04:45AM BLOOD Plt Ct-536*
[**2139-6-29**] 04:55AM BLOOD Plt Ct-388
[**2139-6-24**] 07:00PM BLOOD PT-11.5 PTT-26.1 INR(PT)-0.9
[**2139-6-19**] 12:50PM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-NORMAL
Macrocy-NORMAL Microcy-NORMAL Polychr-OCCASIONAL Target-1+
[**2139-6-19**] 12:50PM BLOOD Neuts-66 Bands-0 Lymphs-22 Monos-10 Eos-2
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2139-6-29**] 04:55AM BLOOD WBC-14.1* RBC-3.37* Hgb-10.0* Hct-29.8*
MCV-89 MCH-29.6 MCHC-33.4 RDW-18.4* Plt Ct-388
[**2139-6-28**] 06:45AM BLOOD WBC-13.5* RBC-3.34* Hgb-9.7* Hct-29.7*
MCV-89 MCH-29.1 MCHC-32.8 RDW-18.1* Plt Ct-368
[**2139-6-26**] 06:40AM BLOOD WBC-18.2* RBC-3.38* Hgb-9.7* Hct-29.0*
MCV-86 MCH-28.8 MCHC-33.5 RDW-17.9* Plt Ct-386
Brief Hospital Course:
Pt. was admitted to [**Hospital1 18**] s/p ERCP on [**2139-6-19**]. Post ERCP pt. was
hypotensive with other vital signs WNL. Pt. was afebrile with
adequate urine output. A CXR [**6-20**] showed no free air effectively
ruling out the possibility of a perforation during the ERCP.
Also [**6-20**] the pt underwent an MRCP that showed dilitation of
intrahepatic ducts, nodular wall enhancement in the distal
pancreas, a mass in the neck of the pancreas, and a large cystic
lesion on the right kidney. Furthermore, there appeared to be
ductal dilation in the uncinate region as well as gross side
branching in the distal part of the pancreatic duct. This was
all consistent with intraductal papillary mucinous tumor. We
knew from a pre-hospital brushing from [**State 531**] that he had
adenocarcinoma harbored in this. On [**2139-6-23**] hospital day 4 the
pt. was taken to the OR and scheduled for a staging laparotomy
with subsequent whipple procedure. However, upon opening the
abdomen it was discovered that the pt. had a small bowel
obstruction w/a clear transition point. When the whipple was
initiated with the open cholecystectomy anesthesia indicated
that the pt. had become tachycardic and hypotensive. This
continued and it was felt that the pt. was becomming septic.
The procedure was abondanded, a cholecystostomy tube was placed,
a central line placed in the L groin, and the pt. was taken to
the PACU. Pt. was hemodynamically stable upon transport to the
PACU after receiving fluids, blood, and pressors in the OR.
Post-op the pt. developed a hematoma at the site of the central
line. An ultrasound was performed that showed no evidence of a
pseudoaneurysm or AV malformation. POD 1 the pt. had stable
crits. and was extubated in the evening and did well through the
night. The pt. did well for the rest of his hospital course.
On pod 3 he developed hiccoughs that gradually resolved on their
own. He remained afebrile with stable vital signs. Antibiotics
were discontinued after five days of therapy. On POD 8 pt. was
tolerating a regular diet and had complete return of bowel
function. On POD 10 pt. was deemed ready for rehab and
discharged to a skilled nursing facility for continued care and
recouperation.
Medications on Admission:
prinivil 10 [**Hospital1 **]
atenolol 50 qday
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 3 days.
Disp:*3 Tablet(s)* Refills:*0*
3. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
Two (2) Tab Sust.Rel. Particle/Crystal PO once a day for 3 days.
Disp:*6 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
4. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day: -
while taking pain medication
- hold for diarrhea.
Disp:*40 Capsule(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 5481**] TCU
Discharge Diagnosis:
Pancreatic cancer
Intraductal papillary mucinous tumor
Incarcerated inguinal hernia with small bowel obstruction
hypertension
anemia
ankylosing spondylitis
Discharge Condition:
good
Discharge Instructions:
- Pt. may eat a reguar diet.
- Pt. to resume home medications.
- Pt. may sponge bath or cover ostomy bag and shower. No baths
or soaking in tub.
- no heavy lifting - anything more that a gallon of milk
- Pt. to call clinic or return to ED if T>101.5, chills, nausea,
vomitting, severe pain, erythema or purulent drainage from wound
sites, or any other concern.
Followup Instructions:
- Please follow-up with Dr. [**Last Name (STitle) **] in 2 weeks. Please call his
clinic to arrange an appointment [**Telephone/Fax (1) 1231**].
Completed by:[**2139-7-3**]
|
[
"038.9",
"397.0",
"157.0",
"720.0",
"995.93",
"998.59",
"401.9",
"V64.1",
"396.8",
"E878.8",
"998.12",
"576.2",
"550.10"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.11",
"51.04",
"96.27",
"51.10",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
6538, 6593
|
3615, 5857
|
351, 461
|
6793, 6799
|
1473, 3592
|
7209, 7385
|
969, 1044
|
5953, 6515
|
6614, 6772
|
5883, 5930
|
6823, 7186
|
1059, 1454
|
273, 313
|
489, 833
|
855, 911
|
927, 953
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,136
| 176,661
|
9646+56050
|
Discharge summary
|
report+addendum
|
Admission Date: [**2166-12-25**] Discharge Date: [**2167-1-17**]
Date of Birth: [**2100-11-15**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 826**]
Chief Complaint:
Infected right AV graft
Major Surgical or Invasive Procedure:
Excision of right arm AV graft
Placement of right IJ permacath on [**2166-12-28**]
Placement of a right groin temporary HD catheter
Placement of a right tunneled HD line on [**2167-1-9**]
History of Present Illness:
66 year-old male with multiple medical problems including CAD
status post CABG, HTN, PAF not on anticoagulation [**1-21**] history of
GI bleed, and ESRD on hemodialysis who has had multiple RUE AV
access procedures. He was found to have an exposed RUE AV
fistula/graft in clinic on [**2166-12-25**], and was sent to Pre-Op for
a planned repair where he became febrile to 103.0, with chills.
No headache, sore throat, cough, chest pain, shortness of
breath, N/V, rash or abdominal pain. Mr. [**Known lastname **] does not void.
Past Medical History:
1. Coronary artery disease s/p MI in [**12/2164**], status post 2
stents to the LAD. Cath in [**1-/2165**] revealed re-stenosis of both
stents. He is status post 3-vessel CABG on [**2165-2-20**] with LIMA to
LAD, saphenous vein to RCA, saphenous vein to OM.
2. ESRD x 5 years on HD (MWF), felt secondary to HTN
3. Status post CVA in [**2149**] with residual left-sided hemiparesis
4. Hypertension
5. UGIB after cardiac cath on [**12/2164**]
6. Gout
7. Pancreatitis
8. Diverticulosis
9. History of multiple E coli bacteremias
10. Anemia of chronic disease
11. Hypercholesteremia
12. COPD
13. Afib/Aflutterm, not on anticoagulation secondary to history
of GI bleed.
Social History:
The patient lives at home with his wife & daughter in a [**Location (un) 6332**] apartment with an elevator. No VNA care was necessary
prior to admission, and the patient could attend to all of his
own ADLs.
Family History:
Mother with hypertension
No history of no strokes, seizures, or heart disease
Physical Exam:
Per transplant surgery admission note on [**2166-12-25**]:
VITALS: T 193, HR 99, BP 130/59, RR 18
GEN: In NAD. Alert and oriented X 3.
HEENT: No icterus. Clear OP.
LN: No cervical or axillary LAD
RESP: Chest CTA bilaterally. No wheezes.
CVS: RRR.
GI: BS normoactive. Abdomen soft and non-tender. No hernia. No
mass.
EXT: No pedal edema. Calves non-tender.
INTEGUMENT: No rash.
Pertinent Results:
Admission labs [**2166-12-25**]:
WBC-11.5*# HGB-11.8* HCT-35.2* PLT COUNT-166
GLUCOSE-139* UREA N-56* CREAT-9.3*# SODIUM-135 POTASSIUM-4.2
CHLORIDE-90* TOTAL CO2-31* ANION GAP-18
ALT(SGPT)-9 AST(SGOT)-20 ALK PHOS-145* TOT BILI-0.4
ALBUMIN-4.3 CALCIUM-11.2* PHOSPHATE-4.4 MAGNESIUM-1.9
PT-13.9* PTT-27.7 INR(PT)-1.2
[**2166-12-25**] EKG: Afib, rate 104. Lateral ST-T wave changes.
[**2166-12-25**] CXR: No acute disease
Relevant studies in hospital:
[**2166-12-30**] CT HEAD: FINDINGS: There is an area of decreased
attenuation involving the white and [**Doctor Last Name 352**] matter of the posterior
left frontal lobe. This could be consistent with an evolving
infarct. Diffuse areas of low attenuation in the periventricular
white matter is consistent with chronic microvascular
angiopathy. No intracranial mass lesion, hydrocephalus, or shift
of normally midline structures is apparent. There is no evidence
of intracranial hemmorage. Numerous calcifications are noted in
the sulci, brain parenchyma and ventricles.
Osseous and soft tissue structures are unremarkable.
IMPRESSION:
1. Likely evolving infarct of the left posterior frontal lobe,
which would be consistent with the patient's history of new
expressive aphasia.
2. Numerous intracranial scattered calcifications, which could
represent prior cystercercosis infection. Clinical correlation
is recommended.
3. No evidence of intracranial hemorrhage.
[**2166-12-30**] MRI HEAD: There is a wedge-shaped area of slow
diffusion in the ventral portion of the left pons, consistent
with an acute infarction. There is also slow diffusion involving
the posterior aspect of the insular cortex, operculum, and
anterior aspect of the left parietal lobe consistent with an
acute infarction. There are multiple areas of increased T2
signal in the periventricular subcortical white matter
consistent with chronic small vessel infarctions. There is also
a region of magnetic susceptibility artifact in the posterior
right thalamus, consistent with sequela from a prior
intraparenchymal hemorrhage. There is associated Wallerian
degeneration in the right cerebral peduncle. There are multiple
areas of magnetic susceptiblity artifact throughout both
cerebral hemispheres, which correspond to the multiple
intraparenchymal calcifications, consisent with sequela from
prior cystercercosis infection. On the postcontrast images,
there is no abnormal enhancement in the brain parenchyma.
In the MRA images, there is no evidence of a vascular occlusion,
stenosis, or aneurysm involving the arteries in the circle of
[**Location (un) 431**]. There is some motion artifact which limits the study. We
do not have a good evaluation of the distal smaller branches of
the intracerebral vasculature. The vertebral arteries, basilar
arteries, intracranial internal carotid arteries, and the middle
and anterior cerebral arteries are patent.
There is a small T1- and T2-hyperintense mass in the soft
tissues of the left frontal scalp. This may represent a small
sebaceous or proteinaceous cyst.
IMPRESSION: Acute infarctions involving the left ventral pons
and the posterior left insular cortex, left temporal operculum,
and left anterior parietal lobe.
[**2166-12-31**] U/S carotids: Bilateral < 40% stenosis
[**2166-12-31**] TTE: The left atrium is elongated. The right atrium is
moderately dilated. There is moderate 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 aortic valve leaflets (3)
are mildly thickened. There is no aortic valve stenosis. Mild
(1+) aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Trivial mitral regurgitation is seen. There is
no pericardial effusion.
Compared with the prior study (tape reviewed) of [**2165-3-4**],
there is no
significant change.
[**2167-1-6**] TEE: The left atrium is mildly dilated. No spontaneous
echo contrast or thrombus is seen in the body of the left
atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. The interatrial septum is
aneurysmal with a very small superior left-to-right shunt color
Doppler at rest. There is mild symmetric left ventricular
hypertrophy with normal cavity size and systolic function
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. There are complex (>4mm non-mobile) atheroma in the
descending thoracic aorta. The aortic valve leaflets are
moderately thickened but severe aortic stenosis is not suggested
and no discrete vegetations are seen. Mild to
moderate ([**12-21**]+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened but no discrete vegetations are
seen. Trivial mitral
regurgitation is seen. There is no pericardial effusion.
Brief Hospital Course:
66 year-old male with multiple medical problems including CAD
s/p CABG, PAF on no anticoagulation [**1-21**] history of GU bleed,
HTN, and ESRD on HD, admitted with an exposed and infected AV
graft. His hospital course will be reviewed by problems.
1) Exposed/infected AV graft and MSSA bacteremia: Mr. [**Known lastname **] was
initially admitted to the transplant surgery service and taken
to the OR on [**2166-12-25**] for the emergent removal of his
exposed/infected RUE AV graft. The infected portions were
removed. A temporary right groin HD catheter was placed. He was
initially started on empiric Vancomycin, Levofloxacin and
Flagyl. Blood cultures drawn on [**2166-12-25**] eventually all grew
methicillin-sensitive Staph aureus, 6/6 bottles. Flagyl was
D/C'd, and Vancomycin was eventually switched to Linezolid PO,
which unfortunately was ordered but never approved. He received
a short course of Oxacillin ([**2166-12-30**]), and ID was consulted on
[**2166-12-31**], at which time antibiotics were switched to Cefazolin
2gm IV with hemodialysis ([**2166-12-31**]). Blood cultures from [**12-26**]
grew MSSA 1/4 bottles. Surveillance blood cultures on [**12-27**] and
[**12-31**] negative.
Given his Staph aureus bacteremia, a TTE was performed on
[**2166-12-31**] which was negative for vegetations. A TEE was
subsequently performed on [**2167-1-6**], which was also negative for
vegetations, although it revealed a small ASD. Nonetheless, per
ID, given his high-grade staphylococcus aureus bacteremia on
admission, removal of only the infected portions of the AV graft
(? ends), negative TEE but possibly in the setting of having
already thrown a vegetation, decision was taken to complete 6
weeks of antibiotherapy. Hence, plan is to continue Cefazolin 2
gm IV with hemodialysis, counting from [**2166-12-27**] (first negative
blood cultures). Last dose on
[**2167-2-7**].
2) CVA: Mr. [**Known lastname **] has a known history of PAF, and was not on
anticoagulation on admission given a prior history of GI bleed.
He also has a prior history of CVA, with residual left
hemiparesis. On [**2166-12-30**], Mr. [**Known lastname **] was noted to have new
expressive aphasia, with a left sided mouth droop. CT head and
MRI head were consistent with an acute infarct involving the
left ventral pons and the posterior left insular cortex, left
temporal operculum, and left anterior parietal lobe. Neurology
was consulted, and Mr. [**Known lastname **] was started on anticoagulation
with Coumadin, as well as aspirin. Goal MAP>90. Of note, given
his poor vascular access, Heparin could not be given. Lovenox
was also not an option in the setting of his ESRD. Coumadin was
temporarily held on [**2167-1-9**] for line placement.
The etiology of his CVA was felt most likely cardioembolic in
the setting of known PAF (in atrial fibrillation in hospital)
and no anticoagulation. Septic embolus was also a concern given
his MSSA bacteremia. Hence, he underwent a TTE on [**2166-12-31**],
which was negative for vegetations. A carotid ultrasound
revealed bilateral <40% stenosis of his carotids. A TEE was also
performed on [**2167-1-6**], which was also negative for vegetations,
although it revealed a small ASD.
He is to remain on anticoagulation with goal INR [**1-22**], as well as
ASA. He will need follow-up of his INR. INR 1.3 at discharge.
Follow-up to be arranged with the [**Hospital3 **].
3) ESRD: Mr. [**Known lastname **] was followed by the renal service throughout
his stay. He was continued on hemodialysis 3 times per week.
Meds were renally dosed. Of note, while in hospital, he was
noted to have persistent hyperkalemia despite hemodialysis,
which was felt secondary to dietary indiscretions and food
brought by family. He was kept on a low potassium diet, with
good results. He will need continued close monitoring of his
electrolytes, especially phosphate with possible up titration of
his meds.
Of note, Mr. [**Known lastname **] has extremely poor vascular access.
Temporary lines were placed in his right groin and right IJ. A
tunneled HD line was placed on [**2167-1-9**]. Permanent vascular
access should be delayed until after completion of 6 weeks of IV
antibiotics and documentation of sterile blood cultures 3 days
after discontinuation of antibiotics.
4) CAD: Mr. [**Known lastname **] has known CAD, and is status post CABG. No
acute issues in hospital. He was continued on ASA, statin, ACE
inhibitor. It is unclear why he is not on a beta-blocker as an
out-patient.
5) Anemia: Mr. [**Known lastname 32641**] hematocrit was between 28-34 while in
hospital. Iron studies on [**2167-1-6**] revealed Fe 43, TRF 148,
Ferritin [**2142**], TIBC 192. He was transfused a single unit of
PRBCs on [**2166-12-29**], and remained fairly stable afterwards.
Hematocrit 28.8 at discharge.
6) FEN: Cardiac heart healthy ([**2-20**] gm Na)/ Renal diet. Ensure
low potassium.
Medications on Admission:
Lipitor 10mg qd
Nephrocaps 1 [**Hospital1 **]
Protonix 40mg qd
Renagel 1200mg tid
ASA 325mg qd
Norvasc 5mg qd
Clonidine 0.1mg [**Hospital1 **]
Enalapril 20mg qd
Discharge Medications:
1. Clonidine HCl 0.1 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
2. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Amlodipine Besylate 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Enalapril Maleate 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Cefazolin Sodium 10 g Recon Soln Sig: Two (2) grams Injection
Q HEMODIALYSIS ().
7. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Sevelamer HCl 400 mg Tablet Sig: Five (5) Tablet PO TID (3
times a day).
10. Coumadin 5 mg Tablet Sig: One (1) Tablet PO at bedtime for 2
days: Please give Coumadin 5 mg PO QHS on [**2167-1-10**] and [**2167-1-11**]
and check INR daily. Please adjust subsequent Coumadin dose for
goal INR [**1-22**]. INR on [**2167-1-10**] 1.3.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Infected right arm AV graft
Staphylococcus aureus bacteremia
Atrial fibrillation
Cerebrovascular accident
End-stage renal disease
Secondary diagnoses:
Coronary artery disease
Discharge Condition:
Patient stable at discharge.
Discharge Instructions:
Please see below for recommended follow-up appointments.
Please take all medications as prescribed.
Please return to the ED if you develop recurrent temperature
>101.5, weakness, slurred speach, confusion, chest pain,
shortness of breath, redness or drainage from right groin
catheter, increased redness or drainage from right arm,
persistent pain, or any other worrisome symptoms.
Followup Instructions:
With Dr. [**First Name (STitle) **] in one week. Please call for appt.
[**Telephone/Fax (1) 673**]
Please call your nephrologist and schedule an appointment to see
him within 1 week of discharge. You will continue HD 3 times per
week.
Please call your PCP and schedule and appointment to see him/her
withinh 2 weeks of discharge.
We will call the neurology clinic at [**Hospital1 18**] and schedule an
appointment. We will call you with the appointment date and
time.
You will need follow-up in the [**Hospital3 **]. We will
notify you with your appointment date and time.
Completed by:[**2167-1-10**] Name: [**Known lastname 5644**],[**Known firstname 5645**] Unit No: [**Numeric Identifier 5646**]
Admission Date: [**2166-12-25**] Discharge Date: [**2167-1-17**]
Date of Birth: [**2100-11-15**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3435**]
Addendum:
The patient was not discharged on [**2167-1-10**] as had been
anticipated due to difficulties with the rehabilitation facility
placement.
.
The patient's hct dropped to 26.6 on [**2167-1-14**] and he had guaiac
positive stool. He anticoagulation was stopped and he was
transfused 2u pRBCs on [**2167-1-15**]. The patient's hct recovered
after the transfusion and remained stable for the remainder of
his hospitalization.
.
He was discharged to [**Hospital 5662**] Hospital on [**2167-1-17**]
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 14**] & Rehab Center - [**Hospital1 15**]
[**Name6 (MD) 116**] [**Last Name (NamePattern4) 1531**] MD [**MD Number(1) 1532**]
Completed by:[**2167-1-17**]
|
[
"434.91",
"041.19",
"070.30",
"427.32",
"275.3",
"996.62",
"790.7",
"276.7",
"403.91",
"414.00",
"V45.81",
"E879.8",
"496",
"285.9",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"38.95",
"39.95",
"39.43"
] |
icd9pcs
|
[
[
[]
]
] |
15818, 16041
|
7416, 12321
|
340, 530
|
13842, 13872
|
2505, 2973
|
14304, 15795
|
2014, 2093
|
12532, 13520
|
13643, 13774
|
12347, 12509
|
13896, 14281
|
2108, 2486
|
13795, 13821
|
277, 302
|
558, 1086
|
2982, 7393
|
1108, 1773
|
1789, 1998
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,376
| 183,181
|
30580+57675
|
Discharge summary
|
report+addendum
|
Admission Date: [**2170-10-5**] Discharge Date: [**2170-10-8**]
Date of Birth: [**2138-12-19**] Sex: F
Service: SURGERY
Allergies:
Aspirin
Attending:[**First Name3 (LF) 301**]
Chief Complaint:
She was admitted to [**Hospital1 18**] [**10-4**] overnight, after spending
several days at an outside hospital with suspected viral
syndrome. She remained afebrile (Tmax 99.0), mildly tachycardic
(HR 96-105), vitals otherwise wnl. Laboratory findings detailed
below, but is significant for leukocytosis, thrombocytosis,
acute
renal failure. A CT of the abd/pelvis demonstrated T tube in
place, mild high attenuation free fluid in upper abdomen and
pelvis consistent with hemoperitoneum, mod-severe gastric
distention (gastroparesis vs outlet obstruction).
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms [**Known lastname 732**] is a 31-year old woman with a history of
[**Known lastname 72564**]-Danlos admitted to [**Hospital1 18**] [**Date range (1) 28235**] for cholecystitis,
requiring open cholecystectomy CBD exploration & t-tube
placement
and concurrent Small Bowel Resection for parastomal hernia at
site of previous ileostomy (?[**2160**]) created after her Total
Abdominal Colectomy? for spontaneous bleeding during child
labor.
Yesterday AM, she was admitted to [**Hospital **] Hospital for nausea &
vomiting. Earlier CT scan suggested free fluid, likely to be
hemoperitoneum. had a CT [**Location (un) 1131**] of a repeat study (for
abdominal pain) that demonstrated "increased free fluid
suggestive of worsening hemoperitoneum... findings suggestive of
'pelvic congestion syndrome,' and possible free air.'"
Additionally, her hemoglobin has dropped from 14.3 to 11.1,
and
her leukocytosis persists @16.7 from 18.5. She is also now
tachycardic with a heart rate of 100 but her SBP has remained
within normal parameters per the hospitalist. Transfered to
[**Hospital1 18**]
for eval and amanagement.
Past Medical History:
PAST MED HX:
[**Hospital1 72564**]-Danlos syndrome
Bipolar disorder
Anxiety disorder
h/o car accident
h/o migraines
? Hypothyroidism per her report
? Stroke during delivery [**2159**]
.
PAST [**Doctor First Name 147**] HX:
Ileostomy [**1-20**] to obstetric trauma [**2159**]
Hand surgery x3
Bilateral knee surgeries
R shoulder surgery
Social History:
Lives in [**Hospital1 **] with her 10-year old son. Smoked 1pack a day
from age 15 to recently (15 pack year history). Does not drink
EtOH or use illicit drugs.
Family History:
Mother also had [**Name (NI) 72564**] Danlos but was murdered in [**2154**].
Several other family members died of "alcoholism, drugs, stroke,
heart attacks" but no specifics known
Physical Exam:
T 98.9, HR 103, BP 93/62-->106/54, RR 15, POx 100%
Gen: NAD; thin/emaciated, but appears well
ENT: conj wnl.
Pulm: CTA all fields
Card: borderline tachy, regular, no murmurs; perfusing all 4
extremities well
Abd: stoma is pink with light brown loose stool; drain with
minimal amount of discharge around drain site (yellow) but
bilious material in drain. BS +/nl/active, soft, non-tende,r no
masses
Joints: well-healed post [**Doctor First Name **] changes bilat knees; no acute
joint
findings
Derm: no eruption, multiple tattoos noted
Other: PIV
Pertinent Results:
[**2170-10-5**] 07:39AM BLOOD WBC-10.3 RBC-3.19* Hgb-9.4* Hct-27.0*
MCV-85 MCH-29.4 MCHC-34.7 RDW-13.9 Plt Ct-331
[**2170-10-6**] 12:00AM BLOOD WBC-5.5 RBC-2.72* Hgb-8.3* Hct-23.3*
MCV-86 MCH-30.6 MCHC-35.7* RDW-13.5 Plt Ct-272
[**2170-10-6**] 10:20AM BLOOD WBC-7.3 RBC-3.82*# Hgb-11.7*# Hct-33.2*
MCV-87 MCH-30.7 MCHC-35.3* RDW-13.8 Plt Ct-263
[**2170-10-7**] 06:05AM BLOOD WBC-5.9 RBC-4.09* Hgb-12.4 Hct-35.0*
MCV-86 MCH-30.5 MCHC-35.6* RDW-13.8 Plt Ct-341
[**2170-10-8**] 05:40AM BLOOD Hct-32.4*
[**2170-10-5**] 07:39AM BLOOD PT-13.4 PTT-24.0 INR(PT)-1.1
[**2170-10-6**] 12:00AM BLOOD PT-13.5* PTT-25.7 INR(PT)-1.2*
[**2170-10-7**] 06:05AM BLOOD Plt Ct-341
[**2170-10-7**] 06:05AM BLOOD Glucose-77 UreaN-7 Creat-0.5 Na-136 K-4.0
Cl-103 HCO3-27 AnGap-10
[**2170-10-5**] 07:39AM BLOOD Albumin-3.5 Calcium-9.2 Phos-2.4* Mg-1.5*
UricAcd-3.7 Iron-18* Cholest-132
[**2170-10-7**] 06:05AM BLOOD Calcium-8.4 Phos-4.2# Mg-1.5*
[**2170-10-5**] 07:39AM BLOOD calTIBC-319 Ferritn-188* TRF-245
Brief Hospital Course:
This is a 31 year old female with [**Month/Day/Year 72564**]-Danlos syndrome (type
4) who presented at outside hospital with nausea and vomiting
and a questionable CT scan concerning for free air and
hemoperitoneum.
The patient was admitted to the surgical intensive care unit
where serial abdominal exams and hcts were closely monitored.
She was transfused with two units of packed cells and
Ampicillin-sulbactam was given intravenously. Patient continued
to complain of intermittent left lower quadrant pain with
radiation to the back.
[**2170-10-6**] Patient transferred to floor. Hematocrit 35 after 2
units of packed cells. Advanced diet to sips. Vital signs
remained stable and afebrile.
[**2170-10-7**] Patient's diet advanced to a regular, low fat diet.
Tolerated diet well without nausea or vomiting. Overnight,
systolic blood pressure noted to be in 70's with heartrate in
70's. Bolused x 3 with 500 cc. with increase in to 84 systolic.
[**2170-10-8**] Labs wbc 5.9 and hct of 32.4. Tolerating a regular diet
and feeling well. We will discharge her home today with follow
up with Dr. [**Last Name (STitle) **] in 3 weeks, with her primary care Dr. [**Last Name (STitle) 21454**]
in 2 weeks, and with Interventional radiology on Monday [**12-10**] at 10 am to remove her t-tube.
Medications on Admission:
lamictal 100mg', klonopin 1mg qid prn, seroquel 100mg' prn
insomnia, topamax 25mg''
Discharge Medications:
1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
2. Lamotrigine 100 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
3. Quetiapine 100 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
4. Topiramate 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
6. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed.
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Primary Diagnois: Nausea/vomiting, anemia, and high white count.
Discharge Condition:
Stable
Discharge Instructions:
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.
Please call your doctor or return to the emergency room if you
have any of the following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 304**], MD Phone:[**Telephone/Fax (1) 274**]
Date/Time:[**2170-10-26**] 1:30
Please call your primary care provider for [**Name Initial (PRE) **] follow up
appointment in one to two weeks.Dr. [**Last Name (STitle) 21454**] Phone ([**Telephone/Fax (1) 72565**].
Interventional Radiology: Dr [**Last Name (STitle) **] [**Name (STitle) 1096**]
Completed by:[**2170-10-8**] Name: [**Known lastname **],[**Known firstname **] Unit No: [**Numeric Identifier 12025**]
Admission Date: [**2170-10-5**] Discharge Date: [**2170-10-8**]
Date of Birth: [**2138-12-19**] Sex: F
Service: SURGERY
Allergies:
Aspirin
Attending:[**First Name3 (LF) 559**]
Addendum:
Please note updated appointment time with Dr. [**Last Name (STitle) 12026**] for T-tube
cholangiogram, [**2170-12-10**] at 10:30.
Discharge Disposition:
Home With Service
Facility:
[**Company 720**]
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 560**], MD Phone:[**Telephone/Fax (1) 5721**]
Date/Time:[**2170-10-26**] 1:30
Please call your primary care provider for [**Name Initial (PRE) **] follow up
appointment in one to two weeks.Dr. [**Last Name (STitle) 12027**] Phone ([**Telephone/Fax (1) 12028**].
Provider: [**Name10 (NameIs) 12029**] LOWER GI (TCC) RADIOLOGY Phone:[**Telephone/Fax (1) 491**]
Date/Time:[**2170-12-10**] 10:30 with Dr. [**Last Name (STitle) 12026**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 560**] MD [**MD Number(1) 561**]
Completed by:[**2170-10-8**]
|
[
"V44.2",
"288.60",
"296.80",
"V12.04",
"300.00",
"305.1",
"V45.89",
"756.83",
"285.9",
"346.90",
"787.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
8512, 8560
|
4306, 5600
|
829, 836
|
6465, 6474
|
3298, 4283
|
8583, 9249
|
2533, 2715
|
5734, 6284
|
6377, 6444
|
5626, 5711
|
6498, 7554
|
2730, 3279
|
230, 791
|
864, 1979
|
2001, 2338
|
2354, 2517
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,227
| 142,958
|
33464
|
Discharge summary
|
report
|
Admission Date: [**2127-5-23**] Discharge Date: [**2127-6-18**]
Date of Birth: [**2052-2-15**] Sex: F
Service: SURGERY
Allergies:
Dilaudid / Morphine / Flagyl / Latex / Percocet
Attending:[**First Name3 (LF) 3376**]
Chief Complaint:
She was discharged home on [**5-20**] following a sigmoidectomy.
While at home she noticed gradually increasing abdominal
distension, and persistent [**5-17**] abdominal pain, worse on the
right. She continued to tolerate regular diet though her
appetite decreased. She had a normal bowel movement 2 days
after discharge but subsequently had no BMs until she had 2
watery bowel movements this evening. She presented to the ED at
an outside hospital in [**Hospital3 **] this evening, where her WBC was
found to be 27. A KUB was done which revealed diffuse free air,
and she had a CT scan with PO contrast which revealed a very
large diffuse fluid collection with contrast layering.
Major Surgical or Invasive Procedure:
[**2127-5-23**] exploratory laparotomy, washout and loop colostomy
[**6-11**] - pleural tap
History of Present Illness:
Ms. [**Known lastname **] is a 75 year old woman who recently underwent
sigmoid colectomy for a sigmoid stricture on [**2127-5-12**]. Her
hospital course was prolonged by diarrhea and esophagitis.
Repeated Cdiffs were negative and she was started on Imodium,
and
she underwent an EGD which revealed esophageal candidiasis. She
was discharged home on [**5-20**]. While at home she noticed
gradually
increasing abdominal distension, and persistent [**5-17**] abdominal
pain, worse on the right. She continued to tolerate regular
diet
though her appetite decreased. She had a normal bowel movement
2
days after discharge but subsequently had no BMs until she had 2
watery bowel movements this evening. She presented to the ED at
an outside hospital in [**Hospital3 **] this evening, where her WBC was
found to be 27. A KUB was done which revealed diffuse free air,
and she had a CT scan with PO contrast which revealed a very
large diffuse fluid collection with contrast layering. She
denied any nausea/vomiting prior to today but has had some
nausea
after the CT scan. She was never febrile at home. She denies
any chest pain, but does complain of mild shortness of breath
starting this AM.
Past Medical History:
PMH: diverticulitis, htn, hypothyroid, hyperchol, gerd,
esophagitis, panic d/o, hemorrhoids, osteo, B12 def
PSH: hemmorhoid, urethral sling, bladder suspension ,tah,
cholecystectomy, Lumbar fusion, L rotator cuff
Social History:
Married. Lives with supportive husband and son. Denies use if
tobacco products, illicit drugs, and ETOH.
Family History:
noncontributory
Physical Exam:
On admission
VS: 98.4 97 140/P 22 98% on 2L, 170 lbs
GEN: NAD, AAOx3
HEENT: PERRLA, EOMI, Oropharynx pink/moist
CHEST: CTA B/L, no crackles, wheezes, ronchi
HEART: S1S2 RRR, 2/6 SEM loudest at aortic
ABD: Soft, distended, + BS, midline incision intact. Tender to
palpation diffusely but especially right upper and lower
quadrants. No rebound, guarding, or tenderness to percussion.
No hernias/masses.
EXT: No C/C/E
.
At Discharge:
Vitals:
GEN:
CV:
RESP:
ABD:
Incision:
Extrem:
Pertinent Results:
[**2127-6-16**] 04:53AM BLOOD WBC-12.5* RBC-2.57* Hgb-7.9* Hct-23.7*
MCV-92 MCH-30.6 MCHC-33.2 RDW-15.6* Plt Ct-315
[**2127-6-12**] 04:44AM BLOOD WBC-19.3* RBC-3.14* Hgb-9.5* Hct-28.0*
MCV-89 MCH-30.2 MCHC-33.9 RDW-16.9* Plt Ct-300
[**2127-6-10**] 06:50AM BLOOD WBC-21.8* RBC-3.33*# Hgb-10.2*# Hct-28.4*
MCV-85 MCH-30.6 MCHC-36.0* RDW-17.0* Plt Ct-239
[**2127-6-5**] 05:35AM BLOOD WBC-20.3* RBC-1.60*# Hgb-4.8*# Hct-14.6*#
MCV-91 MCH-29.8 MCHC-32.8 RDW-15.2 Plt Ct-498*
[**2127-5-30**] 06:25AM BLOOD WBC-15.6* RBC-3.27* Hgb-9.9* Hct-30.2*
MCV-92 MCH-30.3 MCHC-32.8 RDW-15.5 Plt Ct-522*
[**2127-5-25**] 02:09AM BLOOD WBC-32.4* RBC-3.41* Hgb-10.3* Hct-30.6*
MCV-90 MCH-30.2 MCHC-33.6 RDW-17.1* Plt Ct-634*
[**2127-5-24**] 01:13AM BLOOD WBC-28.7*# RBC-2.77* Hgb-8.6* Hct-26.0*
MCV-94 MCH-31.1 MCHC-33.1 RDW-14.7 Plt Ct-678*#
[**2127-6-10**] 06:50AM BLOOD PT-12.3 PTT-31.7 INR(PT)-1.0
[**2127-6-3**] 09:47AM BLOOD PT-14.5* PTT-43.6* INR(PT)-1.3*
[**2127-6-16**] 04:53AM BLOOD Glucose-104 UreaN-34* Creat-1.1 Na-143
K-4.7 Cl-112* HCO3-23 AnGap-13
[**2127-6-1**] 08:00AM BLOOD Glucose-105 UreaN-11 Creat-1.3* Na-143
K-3.5 Cl-113* HCO3-25 AnGap-9
[**2127-5-24**] 01:13AM BLOOD Glucose-108* UreaN-42* Creat-0.8 Na-146*
K-3.6 Cl-110* HCO3-20* AnGap-20
[**2127-6-6**] 06:49AM BLOOD ALT-6 AST-11 LD(LDH)-248 AlkPhos-40
TotBili-0.3
[**2127-6-16**] 04:53AM BLOOD Calcium-8.5 Phos-4.1 Mg-2.1
[**2127-6-6**] 06:49AM BLOOD Albumin-2.2* Calcium-7.5* Phos-3.2 Mg-1.9
[**2127-5-24**] 01:13AM BLOOD Calcium-7.6* Phos-4.3# Mg-2.6
[**2127-6-4**] 04:55PM BLOOD calTIBC-134* Ferritn-317* TRF-103*
[**2127-6-4**] 04:55PM BLOOD Triglyc-114
[**2127-6-4**] 04:55PM BLOOD Triglyc-114
[**2127-6-7**] 11:29AM BLOOD Vanco-16.6
[**2127-6-2**] 05:51AM BLOOD Vanco-51.8*
[**2127-5-27**] 08:15AM BLOOD Vanco-7.2*
.
[**2127-6-12**] 10:45 am PLEURAL FLUID N.
GRAM STAIN (Final [**2127-6-12**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2127-6-15**]): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
.
Time Taken Not Noted Log-In Date/Time: [**2127-6-10**] 8:05 am
SEROLOGY/BLOOD CHEM # 00899I-[**6-10**] 8:04AM.
**FINAL REPORT [**2127-6-11**]**
HELICOBACTER PYLORI ANTIBODY TEST (Final [**2127-6-11**]):
NEGATIVE BY EIA.
(Reference Range-Negative).
.
[**2127-6-5**] 8:01 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT [**2127-6-6**]**
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2127-6-6**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
(Reference Range-Negative).
.
[**2127-5-24**] 6:00 am SWAB Site: ABDOMEN
**FINAL REPORT [**2127-6-1**]**
GRAM STAIN (Final [**2127-5-24**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
.
[**2127-5-24**] 1:47 am BLOOD CULTURE
**FINAL REPORT [**2127-5-30**]**
Blood Culture, Routine (Final [**2127-5-30**]):
BACTEROIDES FRAGILIS GROUP. BETA LACTAMASE POSITIVE.
Anaerobic Bottle Gram Stain (Final [**2127-5-26**]):
REPORTED BY PHONE TO [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 77615**] @ 7:05A [**2127-5-25**].
GRAM NEGATIVE RODS.
.
RADIOLOGY Final Report
PLEURAL ASP BY RADIOLOGIST LEFT [**2127-6-12**] 9:24 AM
PLEURAL ASP BY RADIOLOGIST LEF
Reason: please tap Left pleural effusion - please send fluid for
gr
[**Hospital 93**] MEDICAL CONDITION:
75 year old woman with left pleural effusion
REASON FOR THIS EXAMINATION:
please tap Left pleural effusion - please send fluid for gram
stain, culture, LDH, pH, glucose, albumin, amylase, creatinine,
protein
PLEURAL ASPIRATE BY RADIOLOGIST:
INDICATION: 75-year-old woman with left pleural effusion.
PROCEDURE: Informed and signed written consent was obtained from
the patient. A preprocedure timeout was performed with two
patient identifiers. Under ultrasound guidance, distance and
trajectory to a fluid collection in the right hemithorax was
performed. The area was cleansed, local anesthesia was
administered and subsequently a 16-gauge [**Last Name (un) 11097**] catheter was
placed within the fluid with approximately 700 cc of clear fluid
removed. There is no evidence of residual effusion on ultrasound
after the procedure. The patient tolerated the procedure well.
Post-procedure chest x-ray did not show evidence of
pneumothorax. Samples were sent for microbiology and chemistry
evaluation.
Brief Hospital Course:
On admission the patient was prepared for surgery and started
empirically on vanc/zosyn.
Following surgery she was kept intubated, sedated, with an NG
tube, JP drain and foley catheter in place. She was transferred
to the ICU for intense, continued monitoring.
[**5-24**] - vasopressors weaned down as tolerated to minimal volumes.
[**5-25**] - Patient extubated, vasopressors weaned off,
levofloxacin, flagyl added to antibiotic coverage.
[**5-26**] - [**5-28**] - d/c levofloxacin and flagyl, started cipro, oxygen
requirements weaned down, OOB to chair
[**5-29**] - transferred to the floor for continued monitoring,
central line removed
[**5-30**] - PICC line placed, diet advanced to a regular diet
[**5-31**] - nutrition supplements added TID, continued work with
physical therapy
[**6-1**] - CT scan performed demonstrating interval development of
four loculated fluid collections within the peritoneal cavity,
which are located anterior to the stomach, near the anterior
abdominal wall on the right side, in the right lower quadrant
area
and within the pelvis.
[**6-3**] - IR percutaneous drainage of fluid collections. Lasix
started prn for lower extremity edema
[**6-4**] continued gentle diuresis, regular diet with supplements,
transfused 2 units of RBC for hct of 24.3.
[**6-5**] ID consulted - recommended continued therapy on zosyn only
[**6-7**] Picc line removed due to clot formation, placed on
pre-mixed peripheral nutrition.
[**6-8**] - PICC line placed, resumed on TPN.
[**6-9**] - transfused a total of 4 units of RBC for a hematocrit of
18. GI consulted for guiaic positive output. EGD demonstrated
a shallow cratered ulcer with a visible vessel was seen on the
superior wall of the duodenal bulb. [**Hospital1 **]-CAP Electrocautery was
applied at the visible vessel for hemostasis successfully. The
patient was treated with a proton pump inhibitor [**Hospital1 **].
[**6-10**] - continued TPN, gentle diuresis, monitor hct
[**6-11**] - rising white cell count, CT scan demonstrated decreasing
fluid collections, no need for drainage
[**6-12**] - Interventional radiology tapped right sided pleural
effusion for 700cc, no drain left in place. Fluid was negative
for PMNs, microorganisms. Continued abx, TPN, encourage PO
intake
[**6-13**] - cont abx, reg diet, TPN
[**6-14**], [**6-15**] - cont abx, reg diet, cycled TPN overnight
[**6-16**]: Hct decreasing slightly, 2 units of RBC given
[**6-17**]: EGD performed demonstrating a shallow ulcer but no visible
bleeding. GI recommends H.Pylori treatment empirically including
PO Protonix indefinitely, and Clarithromycin & Amoxicillin for
2 weeks.
[**6-18**]- Continues to require encouragement with PO intake.
Continue strict Calorie counts. Tolerating REgular diet and
Ensure drinks three times per day. TPN weaned, blood sugar 114
at 2:45pm. Continue to monitor blood sugars closely. Treat
accordingly. Continue with empiric H. Pylori treatment for 2
weeks. Vitals stable. Urine output adequate. Stoma viable with
loose brown stool. Continue with rehabilitation. Follow-up with
Dr. [**Last Name (STitle) 1120**] in [**2-9**] weeks for both staple and tension suture
removal.
Medications on Admission:
Sucralfate 1g''''; Synthroid 125', Metoprolol 25'', Lotrel
[**5-27**]', Sertraline 100', Torsemide 5', Loperamide 2'''PRN,
Tylenol
325 PRN, Nystatin 5ml'''', Pantoprazole 40', [**Doctor First Name **] ',
Temazepam
15'PRN, Crestor 5', Fioricet PRN, MVI, Os-Cal 500'', Ocuvite
1tab'', Vitamin B12 250'
Discharge Medications:
1. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for groin for 2 weeks.
3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): Hold SBP<100, HR<60.
4. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) for 2 weeks.
5. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Hold SBP<100, HR<60.
6. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Enalapril Maleate 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): Hold SBP<100, HR<60.
8. Torsemide 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
9. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
10. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H
(every 8 hours) as needed for pain: Do not exceed 4000mg/24hour.
11. Rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
13. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
14. Megestrol 400 mg/10 mL Suspension Sig: One (1) PO BID (2
times a day).
15. Normal Saline Flush 0.9 % Syringe Sig: One (1) 10mL
Injection every eight (8) hours: via PICC.
16. Clarithromycin 250 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day) for 2 weeks: Started on [**2127-6-18**].
17. Amoxicillin 250 mg Capsule Sig: Four (4) Capsule PO Q12H
(every 12 hours) for 2 weeks: Started on [**2127-6-18**].
18. Reglan 10 mg Tablet Sig: One (1) Tablet PO QID and HS.
19. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection Before meals and bedtime for 1 weeks: Refer to Sliding
Scale.
20. Regular Insulin Sliding Scale
Insulin SC (per Insulin Flowsheet)
Sliding Scale
Fingerstick q6Insulin SC Sliding Scale
Q6H
Regular
Glucose Insulin Dose
0-60 mg/dL [**1-8**] amp D50
61-120 mg/dL 0 Units
121-160 mg/dL 2 Units
161-200 mg/dL 4 Units
201-240 mg/dL 6 Units
241-280 mg/dL 8 Units
281-320 mg/dL 10 Units
321-360 mg/dL 12 Units
> 361 mg/dL Notify M.D.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Primary:
Splenic flexure colonic perforation
Malnutrition
Post-op anemia
Post-op low urine output
Post-op multiple abdominal abscesses
Right brachial venous blood clot
.
Secondary:
diverticulitis, htn, hypothyroid, hyperchol, gerd, esophagitis,
panic d/o, hemorrhoids, osteo, B12 def
Discharge Condition:
Stable
Tolerating a regular diet
Adequate pain control with oral medication
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting, diarrhea
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or becoming
progressively worse, or inadequately controlled with the
prescribed pain medication.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
.
Incision Care:
* Your retention sutures and staples will be removed at your
follow-up appointment with Dr. [**Last Name (STitle) 1120**].
*You may shower. Pat incision dry.
*Avoid swimming and baths until further instruction at your
followup appointment.
*Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
.
Monitoring Ostomy Output / Prevention of Dehydration:
*Keep well hydrated.
*Replace fluid loss from ostomy daily.
*Avoid only drinking plain water. Include Gatorade and/or other
vitamin drinks to replace fluid.
*Try to maintain ostomy output between 1000mL per day.
*If Ostomy output exceeds 1 liter, take 4mg of Imodium, repeat
2mg with each episode of loose stool. Do not exceed 16mg in 24
hours.
Followup Instructions:
1. Please call the office of Dr. [**Last Name (STitle) 1120**] to make a follow up
appointment in [**2-9**] weeks at [**Telephone/Fax (1) 29433**].
2. Please call PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 77614**] [**Telephone/Fax (1) **] for a
follow-up in 1 week.
THIS SUMMARY NEITHER DICTATED NOR READ BY ME
Completed by:[**2127-6-18**]
|
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icd9cm
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[
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[]
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[
"46.03",
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icd9pcs
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13607, 13679
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7828, 11012
|
992, 1085
|
14006, 14083
|
3225, 5223
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15727, 16127
|
2690, 2707
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11363, 13584
|
6795, 6840
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13700, 13985
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|
2722, 3145
|
3159, 3206
|
268, 954
|
6869, 7805
|
1113, 2314
|
5259, 6758
|
2336, 2551
|
2567, 2674
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,055
| 129,828
|
10750
|
Discharge summary
|
report
|
Admission Date: [**2200-9-18**] Discharge Date: [**2200-9-22**]
Date of Birth: [**2141-2-17**] Sex: M
Service: VASCULAR SURGERY
CHIEF COMPLAINT: Acute occlusion of right femoral to
peroneal bypass [**Year (4 digits) **]
HISTORY OF PRESENT ILLNESS: A 59-year-old non diabetic white
male with coronary artery disease, SPMI, SB coronary artery
bypass [**Year (4 digits) **], with hypertension, emphysema, rheumatoid
arthritis and peripheral vascular disease with multiple
revascularizations, had undergone a right femoral to peroneal
bypass [**Year (4 digits) **] with composite right arm [**Year (4 digits) 5703**] by Dr. [**Last Name (STitle) 1391**] on
[**2200-8-18**].
On the night prior to admission, the patient noted new onset
of right calf claudication. No rest pain. The patient was
seen the following morning by Dr. [**Last Name (STitle) 1391**] in the office and
admitted for further care.
PAST MEDICAL HISTORY:
1. Coronary artery disease: History of angina, myocardial
infarction in [**2191**], coronary artery bypass [**Year (4 digits) **] [**2197**]
2. Hypertension
3. Emphysema
4. Rheumatoid arthritis
5. Renal artery stenosis
6. Pneumonia in the past, never hospitalized
7. Peripheral vascular disease
PAST SURGICAL HISTORY:
1. Coronary artery bypass [**Year (4 digits) **] x5 with left saphenous [**Last Name (LF) 5703**],
[**2197-9-12**] at [**Hospital 4415**].
2. Aortobifemoral bypass [**Hospital **], [**2192**] at [**Hospital3 35151**]
3. Left leg bypass [**Hospital3 **] with right saphenous [**Hospital3 5703**], [**2197**]
(after coronary artery bypass [**Year (4 digits) **])
4. Right femoral popliteal [**Doctor Last Name 4726**]-Tex bypass [**Last Name (LF) **], [**2200-5-13**]
at [**Hospital3 8834**], failed one month later
5. Right femoral to peroneal bypass [**Hospital3 **] with composite
right arm [**Hospital3 5703**] on [**2200-8-18**] by Dr. [**Last Name (STitle) 1391**].
6. Left hip repair, [**2199-5-13**]
7. Inguinal hernia repair
FAMILY HISTORY: Mother had diabetes. Heart disease and
stroke have occurred in his immediate family.
SOCIAL HISTORY: The patient is a chief court officer. He
lives with his wife. [**Name (NI) **] smokes approximately a half a pack
of cigarettes per day after a history of one and a half packs
per day. Wife is also a smoker. The patient does not drink
alcohol. He ambulates with a cane.
ALLERGIES: Morphine causes severe nausea.
ADMISSION MEDICATIONS:
1. Lopressor 50 mg p.o. b.i.d.
2. Folic acid 1 mg p.o. q.d.
3. Plaquenil 200 mg p.o. q.d.
4. Lipitor 40 mg p.o. q hs
5. Ambien 10 mg p.o. q hs prn
6. Combivent 2 puffs qid
7. Celebrex q.d., dose unknown
8. Ecotrin 325 mg p.o. q.d.
9. Megace 4 teaspoons q.d.
10. Sublingual nitroglycerin prn
PHYSICAL EXAM:
VITAL SIGNS: Pulse 80, respirations 20, blood pressure
110/60
GENERAL: Alert, cooperative white male in no acute distress
HEAD, EARS, EYES, NOSE AND THROAT: Normocephalic. Pupils
equal, round and reactive to light and accommodation.
Extraocular motions intact. Tongue in midline. Pharynx
clear.
NECK: Supple.
CHEST: Lungs clear.
HEART: Regular rate and rhythm without murmur.
ABDOMEN: Soft, nontender. Bowel sounds present. No bruits.
RECTAL: Deferred.
EXTREMITIES: Arthritic changes hands. Right foot pale,
bluish and cold. No capillary refill. Sensory and motor
function intact.
PULSE EXAM: Carotid, brachial, radial and femoral pulses all
2+. Right popliteal, DP and PT pulses absent. Left
popliteal pulse 2+. Left DP and PT pulse dopplerable.
NEUROLOGIC: Nonfocal.
ADMISSION LABS: White blood cells 16.6, hemoglobin 13.7,
hematocrit 40.6, platelets 365,000. PT 12.5, PTT 22.1, INR
1.0. Sodium 137, potassium 4.1, chloride 106, CO2 20, BUN
10, creatinine 0.4, glucose 96.
IMAGING: Chest x-ray not ordered. Electrocardiogram not
ordered.
HOSPITAL COURSE: The patient was admitted to the hospital on
[**2200-9-18**]. He underwent an urgent arteriogram which showed an
occluded right femoral peroneal bypass [**Date Range **]. TPA was
started. Repeat arteriogram on [**2200-9-19**] after TPA overnight
showed the proximal anastomosis of the right femoral to
peroneal bypass [**Date Range **] wide open all the way down to the level
of the distal anastomosis. A small amount of blood clots
were noted in the distal [**Date Range **]. No outflow was identified.
A guidewire could not be passed into the peroneal artery.
TPA was continued.
Post angiogram, the patient developed bleeding and small
hematoma of the right groin around the sheath. This was
treated by compression by the interventional radiology team.
TPA and heparin were discontinued. It was felt that the
[**Date Range **] would reocclude without further thrombolytic treatment.
The patient was treated with fresh frozen plasma,
cryoprecipitate and packed red blood cells. Admission
hematocrit had been 40. His post transfusion hematocrit was
32. His fibrinogen level returned to [**Location 213**]. After the
sheaths were pulled, there was no further bleeding. The
right groin hematoma was stable. Ultrasound of the right
groin on [**2200-9-19**] showed no pseudoaneurysm.
The patient had severe pain in his right leg which required
oral Dilaudid for control. He also received several doses of
intravenous Toradol with good effect. The patient was
advised that his only option was a right below the knee
amputation. He reluctantly agreed, but wanted to be
discharged home to take care of family issues. The patient
agreed to return for surgery in approximately one to two
weeks after discharge. He was given a prescription for
Percocet for pain control at time of discharge.
At time of discharge, the patient had an ecchymotic right
groin with a stable hematoma. Femoral pulses were palpable
bilaterally. He had a dopplerable right PT pulse. There was
no dopplerable right DP pulse. The patient had diminished
capillary refill of his toes. His right fifth metatarsal
ulceration was dry and stable.
DISCHARGE MEDICATIONS:
1. Combivent 2 puffs q.i.d. prn
2. Lipitor 40 mg p.o. q hs
3. Folic acid 1 mg p.o. q.d.
4. Lopressor 50 mg p.o. b.i.d.
5. Ambien 10 mg p.o. q hs prn
6. Percocet 1 to 2 tablets p.o. q4h prn pain
7. Lorazepam 0.5 mg p.o. q6h prn
DISCHARGE CONDITION: Stable
DISPOSITION: Home
DISCHARGE DIAGNOSIS:
1. Acute occlusion, right femoral peroneal bypass [**Date Range **] with
discontinuation of thrombolysis secondary to right groin
hematoma
SECONDARY DIAGNOSES:
1. Post angio-coagulopathy, treated with fresh frozen plasma
and cryoprecipitate
2. Coronary artery disease
3. Hypertension
4. Emphysema
5. Rheumatoid arthritis
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4417**]
Dictated By:[**First Name3 (LF) 15535**]
MEDQUIST36
D: [**2200-9-22**] 12:23
T: [**2200-9-22**] 12:46
JOB#: [**Job Number 13295**]
|
[
"V45.81",
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] |
icd9cm
|
[
[
[]
]
] |
[
"99.10"
] |
icd9pcs
|
[
[
[]
]
] |
6294, 6322
|
2032, 2119
|
6037, 6272
|
6343, 6484
|
3883, 6014
|
2479, 2780
|
1275, 2015
|
2795, 3587
|
6505, 6940
|
167, 243
|
272, 926
|
3604, 3865
|
948, 1252
|
2136, 2456
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,601
| 193,271
|
20234
|
Discharge summary
|
report
|
Admission Date: [**2187-12-25**] Discharge Date: [**2188-1-4**]
Date of Birth: [**2112-4-11**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
[**Hospital 7792**] transfer from OSH
Major Surgical or Invasive Procedure:
Cardiac catheterization x 2
History of Present Illness:
75 yo male with PMH of CHF, hyperlipidemia , ESRD (on HD), HTN,
GERD, DM-II, PAF, and PVD who is transferred from [**Hospital 16186**] for NSTEMI. The patient was recently discharged from
[**Hospital1 18**] for gastroparesis, and presented to [**Hospital3 **] from
his home for respiratory distress and chest pain. On
presentation there, cardiac enzymes were cycled and his troponin
1.424 -> 5.116 -> 6.993 -> 4.905. He was thought to have
pulmonary edema in the setting of NSTEMi, and required 6L O2 to
maintain O2 sats. He was admitted to the ICU there. Prior to
transfer, it was reported that he brady'ed to the 30s, but after
further investigation, realized this did not happen. On arrival
to our CCU, he was satting well on 2L NC. He was transferred for
NSTEMI and cardiac catheterization. At Sturdy, he was continued
on his ASA, plavix, and placed on a heparin gtt. He was also
hyperkalemic, and was dialyzed prior to transfer. On arrival, he
was chest pain free and without complaints. He only would like
to eat something.
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He reports exertional buttock and calf pain thought does not do
much activity. All of the other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope. He reports recently
worsening dyspnea
Past Medical History:
1. CARDIAC RISK FACTORS: (+)Diabetes, (+)Dyslipidemia,
(+)Hypertension
2. CARDIAC HISTORY:
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: none
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
CHF (most recent documented EF 50% on [**2187-12-6**])-patient on 2-3L
oxygen at home
ESRD (HD qM,W,F)
Type 2 DM
HTN
Hypercholesterolemia
GERD
Lymphangiectasia and erosions of prox colon
PVD s/p LE percutaneous intervetions
Paroxysmal atrial fibrillation
.
PAST SURGICAL HISTORY:
.
Ex-lap for ruptured appendectomy many years ago
10 years ago - R 1st toe amp
[**7-/2184**] - L radiocephalic AVF
[**9-/2184**] - Ligation of L radiocephalic AVF/creation left brachial
basilic AVF
[**2-/2185**] - Superficialization of left upper arm AVF
[**2187-12-5**] - LLE angioplasty, stenting of SFA
[**2187-12-10**] - L 3rd toe amputation
Social History:
The patient had been living with his wife in an in-law apartment
attached to his daughter's home up until his last admission
earlier this month for his vascular surgeries and he was then
discharged to a rehab/NH facility. He has a prior 30 pack-year
tobacco history but states he quit 35 yrs ago. No ETOH use and
no IVDA/illicit drug history. At home, the patient had been very
functional according to his daughter and he was using a cane and
walker to ambulate.
Family History:
No family history of early MI, otherwise non-contributory
Physical Exam:
VS: T=97.8 BP=144/56 (131/144) HR=76 (75-82) RR=23 O2sat= 100%2L
GENERAL: WDWN in NAD lying in bed. Oriented x1.5. Mood, affect
appropriate but sleepy.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 8 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. few bibasilar crackles
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 1+ Femoral 1+ Popliteal could not palpate DP
dressings in place
Left: Carotid 1+ Femoral 1+ Popliteal could not palpate DP
dressings in place
Pertinent Results:
Labs:
.
[**2187-12-25**] 10:02PM BLOOD WBC-5.8 RBC-3.55* Hgb-10.3* Hct-32.6*
MCV-92 MCH-29.0 MCHC-31.6 RDW-16.4* Plt Ct-197
[**2187-12-26**] 03:46AM BLOOD WBC-6.7 RBC-3.52* Hgb-10.5* Hct-32.8*
MCV-93 MCH-29.8 MCHC-32.0 RDW-17.4* Plt Ct-203
[**2187-12-27**] 04:32AM BLOOD WBC-6.5 RBC-3.24* Hgb-9.7* Hct-29.7*
MCV-92 MCH-29.8 MCHC-32.6 RDW-17.1* Plt Ct-217
.
[**2187-12-25**] 10:02PM BLOOD PT-14.2* PTT-52.4* INR(PT)-1.2*
[**2187-12-26**] 03:46AM BLOOD PT-14.1* PTT-53.7* INR(PT)-1.2*
[**2187-12-26**] 10:12PM BLOOD PT-14.6* PTT-82.3* INR(PT)-1.3*
[**2187-12-27**] 05:19AM BLOOD PT-16.7* PTT->150* INR(PT)-1.5*
.
[**2187-12-25**] 10:02PM BLOOD Glucose-133* UreaN-39* Creat-5.0*# Na-137
K-5.3* Cl-95* HCO3-34* AnGap-13
[**2187-12-26**] 03:46AM BLOOD Glucose-136* UreaN-48* Creat-5.2* Na-137
K-5.6* Cl-94* HCO3-33* AnGap-16
[**2187-12-27**] 04:32AM BLOOD Glucose-173* UreaN-65* Creat-6.9*#
Na-132* K-5.5* Cl-89* HCO3-31 AnGap-18
.
[**2187-12-25**] 10:02PM BLOOD CK(CPK)-21*
[**2187-12-25**] 10:02PM BLOOD CK-MB-NotDone cTropnT-1.06*
.
[**2187-12-25**] 10:02PM BLOOD Calcium-9.6 Phos-5.1*# Mg-2.4
[**2187-12-26**] 03:46AM BLOOD Calcium-9.5 Phos-5.6* Mg-2.6
.
[**2187-12-27**] 01:35PM BLOOD Type-ART pO2-73* pCO2-44 pH-7.46*
calTCO2-32* Base XS-6
.
Imaging/Studies:
EKG: at OSH afib with STD in I, aVL and <1mm in II, V5, V6. TWI
in I, aVL, II, III, aVF, V4-V6
.
ECG [**12-25**] -
Atrial fibrillation. Left ventricular hypertrophy with ST-T wave
abnormalities. The ST-T wave changes are diffuse. Clinical
correlation is
suggested. Since the previous tracing of [**2187-12-17**] no significant
change.
TRACING #1
Read by: [**Last Name (LF) **],[**First Name3 (LF) 177**] W.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
78 0 100 368/399 0 41 -173
CXR [**12-25**]:
FINDINGS: In comparison with study of [**12-15**], there is persistent
enlargement
of the cardiac silhouette with tortuosity of the aorta and
calcification in
the transverse arch. The pulmonary vessels are minimal engorged.
The left
costophrenic angle has been excluded from the image. On the
right _____ there
is opacification along the lower chest wall with blunting of the
costophrenic
angle. This could represent pleural fluid or thickening. No
evidence of
acute focal pneumonia.
IMPRESSION: Little overall change
ECG [**2187-12-26**]:
Atrial fibrillation. Left ventricular hypertrophy with ST-T wave
abnormalities. The ST-T wave changes are diffuse. Clinical
correlation is
suggested. Since the previous tracing of [**2187-12-25**] no significant
change.
TRACING #2
Read by: [**Last Name (LF) **],[**First Name3 (LF) 177**] W.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
71 0 98 376/395 0 42 -151
.
2D-ECHOCARDIOGRAM [**2187-12-6**]:
The left atrium is moderately dilated. Left ventricular wall
thicknesses and cavity size are normal. There is mild regional
left ventricular systolic dysfunction with apical akinesis.
Overall left ventricular systolic function is mildly depressed
(LVEF= 50%). 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. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Trivial mitral
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Mild regional left ventricular systolic dysfunction,
c/w CAD. Moderate pulmonary hypertension.
.
ETT: none
.
CARDIAC CATH [**2184-5-6**]:
COMMENTS:
1. Coronary angiography of this right dominant system revealed
two
vessel coronary artery disease. The left main coronary artery
was short and had no angiographically apparent flow limiting
stenoses. The LAD had a 60% stenosis in the mid vessel followed
by a severely diffusely diseased and small caliber vessel
leading to a distal total occlusion. The LCX had diffuse disease
up to 50% stenosis with an OM1 with a distal 70% stenosis and a
very small AV groove branch with severe disease. The RCA had a
distal 50% stenosis with the rest of the vessel being diffusely
diseased up to 50%.
2. Resting hemodynamics were performed. Right sided filling
pressures were normal (mean RA pressure was 5 mm Hg and RVEDP
was 6 mm Hg). Pulmonary artery pressures were normal (PA
pressure was 28/14 mm Hg). Left sided filling pressures were
normal (mean PCW pressure was 12 mm Hg). Central arterial
pressures were moderately elevated (aortic pressure was 163/69
mm Hg). Cardiac index was normal (at 2.8 L/min/m2).
FINAL DIAGNOSIS:
1. Severe diffuse two vessel and branch disease not amenable to
PCI or CABG.
2. Well-compensated congestive heart failure
.
Brief Hospital Course:
75 yo male with ESRD on HD, CAD, PVD, DM2, HTN, Hyperlipidemia,
PAF, who is transferred from OSH for NSTEMI and respiratory
distress
.
# CORONARIES: Patient has known 2V CAD by prior angiography; has
diffuse disease that was not intervenable on prior cath. During
the OSH course, patient was found to have NSTEMI with positive
biomarkers and ECG with ST depressions in inferolateral leads.
Pt. was continued on asa, statin, plavix, lisinopril and
b-blocker. Heparin gtt was also continued, for atrial
fibrillation and NSTEMI. His CKs remained flat at 24 - 20
throughout admission. His troponin on [**12-25**] was 1.06. On HD2,
pt underwent HD with improvement of O2 requirement from 6LNC to
2LNC. He underwent cardiac catheterization on [**12-27**] that showed
3 vessel coronary artery disease with biventricular diastolic
dysfunction, severe PAH, and he received a DES in the mid-RCA.
There were no changes in sx after catheterization and he
continued to have STc in the aterolateral leads. He was
trasferred to the floor on [**12-28**]. He continued to have
paroxysmal SOB at rest and w/ with minimal exertion. Patient
underwent another catheterization on [**1-1**] with POBA to left
circumflex. This was tolerated without complications. Patient
was continued on ASA 325, Lisinopril was changed to 40mg on non
HD days (please see below), metoprolol xl 100mg QD, Lipotor
80mg, Plavix 75mg and Isosorbide Mononitrate 60mg daily.
Patient had no episodes of chest pain during hospitalization at
[**Hospital1 18**]. His heparin was continued through until completion of
the second catheterization for NSTEMI and atrial fibrillation
(see below).
.
# PUMP: Patient has had history of CHF exacerbation with
previously depressed EF but most recent ECHO with EF about 50%
with moderate PAH. It was felt that he had pulmonary congestion
in the setting of NSTEMI and CXR with a suggestion of volume
overload. His BBk and ACEI was continued and dosing was changed
(see below ESRD). He was mildly hypervolemic in exam on CCU day
2 and underwent HD on CCU day 2. The new oxygen requirement
resolved by HD3 after hemodialisis. Patient underwent HD MWF w/
volume removal sufficient to prevent LE edema and pulmonary
edema. He was discharged on Metoprolol and Lisnopril.
.
# RHYTHM. Pt. found to be in afib on arrival, rate controlled.
Pt. was not on coumadin at OSH or outpatient, was on ASA and
plavix and was treated with heparin gtt for NSTEMI and atrial
fibrillation. Given [**Country **] score of 4, it was unclear why he was
not anticoagulated. Pt was continued on heparin gtt and
transitioned to warfarin PO. At time of discharge, pt's INR was
2.0. He was discharged with 5 warfrain mg PO. He will have his
INR checked by VNA and followed up by his PCP. [**Name Initial (NameIs) **] follow up with
cardiologist was arranged.
# HTN. On admission to CCU, patient was hypertensive w/ SBP 140
- 170s. He was continued on BBK, and his nifedipine was changed
to diltiazem on CCU day 2. Due to relative bradycardia o/n on
CCU d2-3, pt's BBK and CCB were held. BBK was restarted on HD4
as HR improved to 60s -70s and diltiazem was discontinued.
Patient's SBPs improved w/ repeated HD sessions, 120s - 140s.
Pt. experienced episodes of hypotension while in HD, to 90s (see
below). Thus his lisinopril was changed to 40mg on non HD days
and Metoprolol to s/p HD on HD days.
# Respiratory Distress: Initially required 6L O2 with hypoxia
and tachypnea. Possible causes considered were pulm edema [**2-24**]
NSTEMI, PNA (recently treated with cipro), PE. Patient is on
2-3L O2 at home. CXR showed mild pulmonary congestion. His O2
sats improved to 100% on 2LNC after first HD session at [**Hospital1 18**].
Patient reported continued SOB at rest and with exertion. This
was fluctuating throughout the hospitalization, did not change
with catheterization, but did improve with repeated HD sessions.
At time of discharge, patient's SOB was improved overall.
# ESRD on HD. Pt was followed by renal while hospitalized. He
underwent HD MWF. He received Epogen and Zemplar. He had
transient hypotensive episodes during HD, thus Lisinopril was
changed to 40mg on non-HD days and Metoprolol was changed to be
given after HD. Pt. PO4 increased to maximum of 7.8. His
Sevelamer was increased to 2400 TID w/ meals with resultant PO4
of .............. on day of discharge. Pt. was continued on
Nephrocaps. On [**1-2**] pt. was noted to have an episode of
hypotension and diaphoresis in setting of physical therapy
session, w/ SBP down to 87mmHg, s/p HD volume removal of 3.5L
that day. ECG showed the lateral ST segment depressions
somewhat more pronounced from prior day, but otherwise unchaged.
This was felt to be [**2-24**] hypovolemia and patient responded to
250cc NS bolus w/ BPs 110s.
# Anemia. HCT of 32 on admission remained stable throughout
hospital stay 28-33. Fe studies were consistent w/ ACD, w/
TIBC/Ferritin of 168* 859* and Fe of 29. Given Fe/TIBC - 17%
suggestive of Fe defficiency component, he was thus started on
Fe 325 [**Hospital1 **].
# PVD, periphearal neuropathy. Patient has had multiple
amputations in the past, s/p L femoral artery stenting and has
pain on movement of LE b/l with history of peripheral
neuropathy. Pt was noted to have a 3 LLE toe amputation site w/
stable eschar and skin ulcerations. On exam there was no
erythema or fluctuance. Pt also has R first toe amputation. He
is followed by Dr. [**Last Name (STitle) **]. He was evaluated by vascular
surgery and was noted to have biphasic DP/PT. DSD dressings
were applied to this site. Due to LE pain, patient was started
on Gabapentin 300mg PO QHD, with moderate relief of his pain.
It is suggested that this dose be adjusted upon discharge to
optimize pain control. Patient received APAP 500-1000mg Q6h prn
for pain with moderate effect.
# DM c/b vasculopathy, retinopathy, nephropathy and gastropathy.
Pt's glipizide was held and he was placed on ISS for BG control.
BG ranged between 100 - 200. Pt was started on gabapentin as
above. He was also continued Reglan 10mg QIACH for
gastroparesis with no episodes during the hospitalization.
There was no tremor or cogwheeling noted on exam throughout the
hospitalization.
FEN: Patient was given diabetic/low Na diet. He received heparin
gtt for NSTEMI and afib, and started on PPI given ASA, Plavix
and Heparin.
Patient was discharged to home in hemodynamically stable
contidion, free of chest pain, stable oxygen requirement and
improved SOB. PT had recommended rehab, but the patient and his
family refused to have him placed in rehab.
Issues requiring optimization on OP basis include:
- Coumadin dosing w/ INR goal of [**2-25**]
- HTN regimen optimization
- Pain regimen titration for LE neuropathic pain
- Podiatry follow up for LE toe amputation
- Vascular surgery follow up.
Medications on Admission:
1. Atorvastatin 80 mg PO DAILY
2. Digoxin 125 mcg PO EVERY OTHER DAY
3. Lorazepam 0.5 mg PO Q8H
4. Metoprolol Succinate 100 mg PO DAILY
5. Nifedipine 90 mg Sustained Release PO DAILY
6. Lisinopril 40 mg PO DAILY
7. Isosorbide Mononitrate 60 mg PO DAILY
8. Metoclopramide 10 mg Tablet PO QIDACHS
9. Glipizide 10 mg PO qam.
10. Glipizide 7.5 mg at bedtime.
11. Aspirin 325 mg PO DAILY
12. Clopidogrel 75 mg PO DAILY
13. Nitroglycerin 0.3 mg Sublingual PRN
14. Senna 8.6 mg PO BID PRN
15. Nephrocaps PO DAILY (Daily).
16. Docusate Sodium 100 mg [**Hospital1 **] PRN
17. Sevelamer Carbonate 1600 mg PO TID W/MEALS
18. Acetaminophen 325 mg PO Q6H as needed
Discharge Medications:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for agitation.
3. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
4. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
5. Glipizide 10 mg Tablet Sig: One (1) Tablet PO qam.
6. Glipizide 5 mg Tablet Sig: 1.5 Tablets PO qpm.
7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: [**1-24**] Sublingual
every four (4) hours as needed for chest pain.
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
11. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
13. Sevelamer HCl 800 mg Tablet Sig: Three (3) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*270 Tablet(s)* Refills:*2*
14. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
15. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
16. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO QHD (each
hemodialysis).
Disp:*15 Capsule(s)* Refills:*2*
17. Miconazole Nitrate 2 % Cream Sig: One (1) application
Topical twice a day: Apply to wound on his coccyx.
Disp:*1 tube* Refills:*1*
18. 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*
19. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
20. Warfarin 1 mg Tablet Sig: Five (5) Tablet PO once a day:
Please call Dr.[**Name (NI) 23247**] office at [**Telephone/Fax (1) 17753**] prior to your
next dose for adjustment after your blood work is checked.
Disp:*150 Tablet(s)* Refills:*0*
21. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO on
non-hemodialysis days (Tues, Thurs, Sat, Sun).
Disp:*30 Tablet(s)* Refills:*2*
22. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day: take
after dialysis on [**Telephone/Fax (1) **], wednesday and friday.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Primary -
Acute on chronic systolic heart failure
Non ST elevation myocardial infarction
Secondary -
Atrial fibrillation
End stage renal disease on dialysis
Hypertension
Peripheral vascular disease
Peripheral neuropathy
Diabetes
Hypercholesterolemia
Discharge Condition:
afebrile, hemodynamically stable
Discharge Instructions:
You were transferred to this hospital because you had a heart
attack for cardiac catheterization. During this procedure you
had a stent placed to open a blockage in one of your coronary
arteries. You underwent a second cardiac catheterization during
which angioplasty was preformed (breaking apart a block in the
artery). While you were hospitalized here you continued to
undergo dialysis every [**Company 766**], Wednesday, and Friday. Your
heart rate was irregular (in atrial fibrillation) and was
controlled with medication and you were started on coumadin (an
anticoagulant which can help prevent strokes).
Changes to your medications
1. Your digoxin were stopped.
2. Your nifedipine was stopped.
3. Your lisinopril was decreased to 20 mg daily on non-dialysis
days. Do not take lisinopril on days you undergo dialysis.
4. Your sevelamer was increased to 2400 mg three times a day
with meals.
5. You were started on ferrous sulfate (iron) for anemia 325 mg
twice a day.
6. You were started on gabapentin at 300 mg after every
dialysis session for pain in your legs caused by nerve damage.
7. You were also started on coumadin 5 mg daily. You will need
to be followed closely while on this medication and have labs
drawn by your visiting nurse [**First Name (Titles) **] [**Last Name (Titles) 766**] and faxed to Dr.[**Name (NI) 23247**]
office at [**Telephone/Fax (1) 21596**].
8. You were started on pantoprazole 40 mg daily to protect your
stomach while taking anticoagulation.
9. Your Metoprolol was decreased to 50mg by mouth once a day.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1500 ml
Please call your doctor or come to the emergency room for any
fevers > 100.4, chills, night sweats, chest pain, shortness of
breath, nausea and vomiting, leg swelling, blood in your bowel
movements or any other symptoms that concern you. If you notice
any bleeding with bowel movements, gum bleeding or vomiting
blood you should contact your doctor immediately.
Followup Instructions:
You will need to follow up with a coumadin clinic at [**Hospital3 **]
[**Location (un) 620**] - [**Telephone/Fax (1) 10413**]. Dr.[**Name (NI) 23247**] office is working on
setting this up for you. Until then you will have your labs
drawn by the visiting nurse and sent to Dr.[**Name (NI) 23247**] office. It
is very important that you check with Dr.[**Name (NI) 23247**] office for a
dose adjustment prior to taking your coumadin after having your
blood work checked.
An appointment was made for you to follow up with your
cardiologist Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 5315**]) at his [**Location (un) 3320**]
office ([**Last Name (un) 54343**] [**Location (un) 3320**] MA in the [**Location (un) 3320**] industrial
park) on Wednesday [**1-9**] at 1 pm.
An appointment was made for you to follow up with your primary
doctor, Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 17753**]), on Friday [**1-24**] at
11:30 am.
It is important that you keep all of your follow up
appointments. If you cannot make any of the appointments,
please call and reschedule.
Please keep your previously scheduled appointment:
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2188-1-10**] 1:10
Completed by:[**2188-1-6**]
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icd9cm
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,752
| 193,554
|
27023
|
Discharge summary
|
report
|
Admission Date: [**2169-9-4**] Discharge Date: [**2169-9-11**]
Date of Birth: [**2091-3-26**] Sex: M
Service: MEDICINE
Allergies:
Ceftriaxone
Attending:[**Doctor First Name 2080**]
Chief Complaint:
Rigors
Major Surgical or Invasive Procedure:
Transthorasic echocardiogram
Transesophageal echocardiogram
History of Present Illness:
78 yo man with a history of Afib, bradycardia with pacemaker,
HTN, hyperlipidemia, and chronic fungal nailbed infections
admitting from the ED with rigors. Patient was in his usual
state of health until yesterday afternoon, when he suddenly
developed rigors while driving his car. He called his PCP and
was told to go to the ED. Additionally, he reports confusion
while in the ED. He had no associated symptoms of fatigue, night
sweats, change in weight or appetite. No recent history of
infection, sick contacts, new sexual contacts, travel, surgical
or dental procedures, IV drug use, or pets in the home. No HA,
SOB, cough, chest pain or discomfort, nausea, vomiting,
diarrhea, consitipation, dysuria, change in bladder or bowel
habits, rash, or new joint or muscle aches. He has not
experienced this before.
.
In the ED, his vitals were Temp:101.1 HR:66 BP:141/82 Resp:18
O(2)Sat:100 RA. Spiked temp to 102.8 and given tylenol. CXR,
KUB, CT head, and U/A wnl. [**Doctor First Name **] and urine cultures pending. LP
attempted, but aborted due to significant kyphosis.
.
Upon transfer to the medicine floor, he remained febrile to
101.5. He was started on ceftriaxone and vancomycin.
.
ROS:
(+) Per HPI. Pateint also reports recurrent rhinitis and sinus
infection with sore throat and dry cough, a chronic history of
decreased neck mobility s/p fall, and polyuria [**2-14**] enlarged
prostate.
(-) Per HPI. Additionally, denies numbness or parasthesia. No
feelings of depression or anxiety.
Past Medical History:
#Atrial fibrillation
#Tricuspid regurgitation: Noted on echo 1 week ago during pre-op
work up for spinal surgery.
#HTN: Mild, nanaged with diet
#Hyperlipidemia: Managed with lipitor, follows a low salt/low
fat diet
#Enlarged prostate: Most recent PSA last year, reportedly low.
#Arthritis: Most prominant in his spine
#Onychomycosis: Present in nailbeds of fingers and toes.
#GERD
#Scoliosis: Occasionally wears a back brace.
#[**Last Name (un) 8061**]
.
PSH:
- Pacemaker: Placed 4-5 years ago after syncopal episode [**2-14**]
bradycardia to the 30s.
- Tonsillectomy
Social History:
Distant smoking history ([**1-14**] pack/day for 10 years and
occasional cigars, quit 40 years ago). Has 8 glasses of
wine/week, occasional pints of alcohol with dinner. Denies
illicit drug use. Retired scientist, now volunteers with the
elderly. Originally from [**Country 4754**], immigrated in the [**2119**] and
travels to Europe 4-5x/year. Lives at home alone, never married.
Exercises regularly and follows a low salt/low fat diet.
Family History:
No known history of heart disease, DM, HTN. Sister was a smoker
with TB (uncertain if latent of active) and lung cancer. Father
with h/o stroke died at 82.
Physical Exam:
Physical Exam at admission:
Vitals: Tc=101.5 Tm=98.8 107/ HR=65 RR=18 O2sat 100%RA
General: Resting comfortably in bed, NAD. Pleasant and
interactive.
HEENT: Submandibular LAD noted R>L. Small cold sore on L upper
lip. PERRL, EOMI, sclera anicteric, conjunctiva pink w/o
injections, MMM, oropharnyx pink w/o injections or exudates, no
lesions or sores in mouth, neck supple without masses, no nuchal
rigidity.
LUNGS: CTAB, no accessory muscle use, no wheezing, rhonci, or
rales
CV: RRR, nl S1+S2, no m/r/g. Placememaker pocket non-tender to
palpation
Abdomen: Soft, NTND, +BS, no rebound or gaurding, no HSM.
Ext: +Inguinal LAD on L. Warm and well perfused, with no
clubbing, cyanosis, or edema. +DP and PT pulses. No evidence of
splinter hemorrhages, [**Doctor Last Name **] spots, or [**Last Name (un) **] lesions
MSK: Erythematous rash with small papules on abdomen and lower
extremities. Nailbed changes consistent with chronic fungal
infection. No vertebral tenderness.
.
Physical Exam at discharge:
Vitals: afebril 97.5 138/82 HR=68 RR=18 O2sat 98%RA
General: Resting comfortably in bed, NAD. Pleasant and
interactive.
HEENT: PER, EOMI, sclera anicteric, conjunctiva pink w/o
injections, MMM, oropharnyx pink w/o injections or exudates, no
lesions or sores in mouth, neck supple without masses, no nuchal
rigidity.
LUNGS: CTAB, no accessory muscle use, no wheezing, rhonci, or
rales
CV: RRR, nl S1+S2, don't appreciate murmur, no r/g. Placememaker
in place. no pocket tenderness or redness
Abdomen: Soft, NTND, +BS, no rebound or gaurding, no HSM.
Ext: previously +Inguinal LAD on L which was tender, improved;
Left foot red decreased swelling w/elevation, tenderness
improved but still mild erythema. Warm and well perfused, with
no clubbing, cyanosis, or edema. +DP and PT pulses. No evidence
of splinter hemorrhages, [**Doctor Last Name **] spots, or [**Last Name (un) **] lesions. Pt
wearing TEDS
MSK: rash resolved. Nailbed changes consistent with chronic
fungal infection. No vertebral tenderness.
Pertinent Results:
IMAGING:
1) CXR AP& LAT ([**2169-9-4**]): IMPRESSION: No focal consolidation.
Persistent blunting of the left costophrenic angle, more likely
secondary to pleural thickening or changes of COPD versus less
likely a trace left effusion.
.
2) CT Head W/O CONTRAST ([**2169-9-4**]): IMPRESSION: No acute
intracranial process. Chronic atrophy. Fluid opacification of a
couple right mastoid air cells. Correlate clinically for
inflammatory process.
.
3) ECHO ([**2169-9-6**]): Please see OMR for full report. IMPRESSION:
There is a small (1cm) mobile echodensity attached to one of the
pacemaker wires (probably the atrial lead). This is best seen on
image #31. This could be a thrombus, fibrous tissue or a
vegetation. There is moderate to severe tricuspid regurgitation
but the valve itself does not appear to have a vegetation. The
right ventricle is mildly dilated with borderline systolic
function. The inferior septum is mildly hypokinetic. The mitral
and aortic valves are well seen without vegetation. Both have
mild regurgitation.
.
4) BILATERAL LOWER EXTREMITY VEINS ([**2169-9-7**]): FINDINGS:
Grayscale and Doppler son[**Name (NI) 1417**] of bilateral common femoral,
superficial femoral, and popliteal veins were performed. There
is normal compressibility, flow, and augmentation. IMPRESSION:
No evidence of DVT.
.
5) TEE ([**2169-9-8**]): See OMR for full report. CONCLUSIONS: 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. The pacing leads are identified
in the right atrium with no associated discrete
vegetation/thrombus. Right atrial appendage ejection velocity is
good (>20 cm/s). No atrial septal defect is seen by 2D or color
Doppler. There are simple atheroma in the aortic arch. There are
complex (>4mm, non-mobile) atheroma in the descending thoracic
aorta to 52 cm from the incisors. The aortic valve leaflets (3)
are mildly thickened. No masses or vegetations are seen on the
aortic valve. Trace aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. No mass or vegetation is
seen on the mitral valve. Mild to moderate ([**1-14**]+) mitral
regurgitation is seen. Moderate [2+] tricuspid regurgitation is
seen. There is borderline pulmonary artery systolic
hypertension. There is a very small pericardial effusion.
IMPRESSION: No discrete vegetation/thrombus identified on the
pacer wires or valvular vegetations. Complex non-mobile plaque
in the descending aorta. Mild to moderate mitral regurgitation.
.
LABS:
[**2169-9-10**] 06:50AM [**Month/Day/Year 3143**] WBC-4.7 RBC-3.40* Hgb-11.8* Hct-34.7*
MCV-102* MCH-34.6* MCHC-33.9 RDW-12.5 Plt Ct-245
[**2169-9-8**] 06:14AM [**Month/Day/Year 3143**] WBC-5.5 RBC-3.48* Hgb-12.4* Hct-34.7*
MCV-100* MCH-35.6* MCHC-35.7* RDW-12.7 Plt Ct-179
[**2169-9-7**] 06:40AM [**Month/Day/Year 3143**] WBC-5.6 RBC-3.29* Hgb-11.4* Hct-33.4*
MCV-102* MCH-34.6* MCHC-34.0 RDW-12.5 Plt Ct-185
[**2169-9-6**] 06:20PM [**Month/Day/Year 3143**] WBC-6.3 RBC-3.63* Hgb-13.1* Hct-37.2*
MCV-102* MCH-35.9* MCHC-35.1* RDW-12.9 Plt Ct-164
[**2169-9-6**] 06:07AM [**Month/Day/Year 3143**] WBC-6.6 RBC-3.00* Hgb-10.8* Hct-30.4*
MCV-101* MCH-36.0* MCHC-35.5* RDW-13.1 Plt Ct-139*
[**2169-9-5**] 06:50AM [**Month/Day/Year 3143**] WBC-12.2* RBC-3.37* Hgb-11.8* Hct-34.4*
MCV-102* MCH-35.0* MCHC-34.2 RDW-12.6 Plt Ct-184
[**2169-9-4**] 05:40PM [**Month/Day/Year 3143**] WBC-12.0*# RBC-3.56* Hgb-12.5* Hct-36.2*
MCV-102* MCH-34.9* MCHC-34.4 RDW-12.6 Plt Ct-201
[**2169-9-5**] 06:50AM [**Month/Day/Year 3143**] Neuts-79* Bands-6* Lymphs-6* Monos-6
Eos-0 Baso-0 Atyps-3* Metas-0 Myelos-0
[**2169-9-4**] 05:40PM [**Month/Day/Year 3143**] Neuts-90.3* Lymphs-6.0* Monos-3.3 Eos-0.2
Baso-0.2
[**2169-9-6**] 06:07AM [**Month/Day/Year 3143**] Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL
Macrocy-2+ Microcy-OCCASIONAL Polychr-NORMAL Burr-OCCASIONAL
[**2169-9-5**] 06:50AM [**Month/Day/Year 3143**] Hypochr-NORMAL Anisocy-NORMAL
Poiklo-OCCASIONAL Macrocy-1+ Microcy-NORMAL Polychr-NORMAL
[**2169-9-10**] 06:50AM [**Month/Day/Year 3143**] Plt Ct-245
[**2169-9-8**] 06:14AM [**Month/Day/Year 3143**] Plt Ct-179
[**2169-9-7**] 06:40AM [**Month/Day/Year 3143**] Plt Ct-185
[**2169-9-6**] 06:20PM [**Month/Day/Year 3143**] Plt Ct-164
[**2169-9-6**] 06:07AM [**Month/Day/Year 3143**] Plt Ct-139*
[**2169-9-5**] 06:50AM [**Month/Day/Year 3143**] Plt Smr-NORMAL Plt Ct-184
[**2169-9-5**] 06:50AM [**Month/Day/Year 3143**] PT-14.2* PTT-30.5 INR(PT)-1.2*
[**2169-9-4**] 05:40PM [**Month/Day/Year 3143**] Plt Ct-201
[**2169-9-4**] 05:40PM [**Month/Day/Year 3143**] PT-12.8 PTT-25.1 INR(PT)-1.1
[**2169-9-10**] 06:50AM [**Month/Day/Year 3143**] Glucose-89 UreaN-10 Creat-0.8 Na-137
K-4.1 Cl-102 HCO3-28 AnGap-11
[**2169-9-8**] 06:14AM [**Month/Day/Year 3143**] Glucose-96 UreaN-11 Creat-0.7 Na-137
K-4.1 Cl-105 HCO3-26 AnGap-10
[**2169-9-7**] 06:40AM [**Month/Day/Year 3143**] Glucose-102* UreaN-12 Creat-0.6 Na-133
K-3.7 Cl-104 HCO3-26 AnGap-7*
[**2169-9-6**] 06:20PM [**Month/Day/Year 3143**] Glucose-83 UreaN-15 Creat-0.7 Na-132*
K-4.1 Cl-100 HCO3-28 AnGap-8
[**2169-9-6**] 06:07AM [**Month/Day/Year 3143**] Glucose-95 UreaN-16 Creat-0.7 Na-130*
K-3.7 Cl-100 HCO3-24 AnGap-10
[**2169-9-5**] 06:50AM [**Month/Day/Year 3143**] Glucose-88 UreaN-22* Creat-0.9 Na-133
K-3.7 Cl-98 HCO3-26 AnGap-13
[**2169-9-4**] 05:40PM [**Month/Day/Year 3143**] Glucose-78 UreaN-19 Creat-0.9 Na-133
K-4.2 Cl-97 HCO3-26 AnGap-14
[**2169-9-7**] 06:40AM [**Month/Day/Year 3143**] ALT-36 AST-39 AlkPhos-52 TotBili-1.0
[**2169-9-6**] 06:07AM [**Month/Day/Year 3143**] ALT-40 AST-47* LD(LDH)-207 AlkPhos-49
TotBili-1.0
[**2169-9-5**] 06:50AM [**Month/Day/Year 3143**] ALT-24 AST-27 AlkPhos-52 TotBili-1.7*
DirBili-0.4* IndBili-1.3
[**2169-9-10**] 06:50AM [**Month/Day/Year 3143**] Calcium-9.3 Phos-3.4 Mg-2.0
[**2169-9-8**] 06:14AM [**Month/Day/Year 3143**] Calcium-8.7 Phos-3.5 Mg-2.0
[**2169-9-7**] 06:40AM [**Month/Day/Year 3143**] Calcium-8.6 Phos-3.1 Mg-2.0
[**2169-9-6**] 06:20PM [**Month/Day/Year 3143**] Calcium-8.6 Phos-3.3 Mg-2.2
[**2169-9-6**] 06:07AM [**Month/Day/Year 3143**] Calcium-8.5 Phos-2.6* Mg-2.0
[**2169-9-5**] 06:50AM [**Month/Day/Year 3143**] Calcium-8.3* Phos-3.9
[**2169-9-6**] 06:07AM [**Month/Day/Year 3143**] Hapto-161
[**2169-9-5**] 09:10PM [**Month/Day/Year 3143**] VitB12-655 Folate-14.7
[**2169-9-5**] 09:10PM [**Month/Day/Year 3143**] TSH-1.7
[**2169-9-7**] 06:40AM [**Month/Day/Year 3143**] Vanco-11.1
[**2169-9-4**] 05:40PM [**Month/Day/Year 3143**] LtGrnHD-HOLD
[**2169-9-4**] 05:55PM [**Month/Day/Year 3143**] Lactate-1.0
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to [**Hospital1 18**] from [**2169-9-4**] to [**2169-9-11**]. His
hospital course was as follows:
.
# GBS Bacteremia: Patient was admitted to the hospital c/o
rigors. [**Month/Day/Year **] cultures grew Group B streptococcus sensitive to
PCN, clindamycin, and vancomycin. He was started empirically on
vancomycin and ceftriaxone, followed by the development of a
urticarial rash as described below. Ceftriaxone was discontinued
and the patient was maintained on 1000 mg IV vancomycin. CXR and
head CT showed no acute process. LP attempted, but aborted due
to significant kyphosis. TTE revealed vegetation on one of his
pacemaker leads, which was initally concerning for endocarditis,
but this finding was not reporoduced with TEE. Given the
patients bengin clinical picture and concurrent cellulits, we
felt that his bacteremia was likly [**2-14**] to cellulitis and his
medications were changed to IV ceftriaxone 2mg q24h x14 days s/p
MICU desensitization. A Midline was placed. Upon discharge,
[**Month/Day (2) **] cultures showed on growthfor 48 hours.
.
# Cellulits: Patient developed swelling and non-blaching
erythema on dorsal aspect of L foot on [**9-5**] concerning for
cellulitis vs DVT. Lower extremity Doppler showed no evidence of
DVT. With the absence of vegetation found on TEE, cellulits was
thought to be the next most likely source. He was treated with
CTX as described above and treated symptomatically with Teds and
elevation. Upon discharge, cellulitis was improved and pt will
complete IV CTX as outpt at [**Hospital1 18**] East.
.
#Drug rash: Patient was started on ceftriaxone and vancomycin in
the ED and shortly after developed a urticarial rash that
responded to Benadryl 25 mg IV. Ceftriaxone was thought to be
the likely cause and was discontinued. Ceftriaxone was restarted
successfully after desensitization per ID reccs for treatment of
bacteremia secondary to cellulitis.
.
#Anemia: Found to have macrocytic anemic with HCT 36.2 on
admission. B12, folate, T. Bili, haptoglobin, and LDH wnl. In
the absence of other sources, chronic alcohol consumption is a
likely cause. He is anemia was monitored and remained stable.
.
The patient was continued on home medications of atorvastatin,
omeprazole, calcium carbonate, and econazole for hyperlipidemia,
GERD, and onychomycosis, respectively. His home medications of
tolterodine, tamsolusin, and finestride were continued for BPH.
He was maintained on a cardiac/heart healthy diet. Bowel regimen
consisted of Colace and senna. His code status was presumed
full. He was discharged home with a Midline for medication
administration. Pt received antibiotics prior to discharge on
[**2169-9-11**] with outpt follow-up w/PCP and completion of antibiotic
course on [**2169-9-19**] (see below).
.
The patient was discharged in good condition with plans to
follow up with PCP as described below. Also he will recieve his
antibioitics at [**Hospital1 18**] Infusion Pharesis Unit, [**Hospital1 18**] [**Hospital Ward Name **],
Grzymish 5 Office: [**Telephone/Fax (1) 14067**] Time slot: 2pm on weekdays.
Medications on Admission:
-Liptor 40 mg daily
-Omeprazole 20 mg daily
-Lorantidine
-Calcium carbonate
-ASA 325mg
-Iron 325 mg
-Fish oil
-Glucosamine and condroitin
-MVI
-Calcium and Vitamin D supplements
-Annual flu shot
-Sunblock daily
Discharge Medications:
1. Ceftriaxone 2 gram Recon Soln Sig: Two (2) grams Intravenous
every twenty-four(24) hours for 2 weeks: Completion of a two
week course, last day on [**2169-9-19**].
Disp:*qs qs* Refills:*0*
2. Heparin Lock Flush 10 unit/mL Syringe Sig: One (1) syringe
Intravenous once a day.
Disp:*50 syringes* Refills:*0*
3. Sodium Chloride 0.9 % 0.9 % Parenteral Solution Sig: One (1)
10cc syringe Intravenous once a day.
Disp:*50 syringes* Refills:*0*
4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Calcium-Vitamin D Oral
9. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
10. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
11. Loratadine 10 mg Tablet Sig: One (1) Tablet PO daily ().
12. Tolterodine 4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO once a day.
13. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Econazole 1 % Cream Sig: One (1) Topical daily ().
15. Tums Oral
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Bacterimia w/cultures positive for GBS
Cellulitis of the foot
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You came to the hospital because you were experiencing
significant fever and chills and were instructed to come to the
ED by your PCP. [**Name10 (NameIs) **] cultures showed that you had a bacterial
infection. There was concern that this infection had also spread
to your heart. Several imaging studies were performed to access
whether or not there was an infectious process in your heart.
While in the hospital you were found to have a cellulitis in
your left lower leg and foot. This was thought to be the source
of your bacterial infection. You were treated with antibiotics
and your fever and other symptoms improved. In order to ensure
full treatment of the infection and prevent spread to your pace
maker and heart, you will need to complete a 2 week course of IV
antibiotics that you will complete as an outpatient. It has been
arranged that you will come to [**Hospital1 18**] [**Hospital Ward Name **] to receive you
IV antibiotics each day until you have finished the 14 day
course on [**2169-9-19**].
.
The following changes were made to your medications:
- Please START taking IV Ceftriaxone 2 gm daily; you will need
to go to the special [**Year (4 digits) **] for receiving this antibiotic daily
for a total course of two weeks with the last day on [**2169-9-19**].
- Please continue to take all of your other home medications as
prescribed.
Please be sure to take all medication as prescribed.
.
Please be sure to keep all follow-up appointments with your PCP
and cardiologist.
.
It was a pleasure taking care of you and we wish you a speedy
recovery.
Followup Instructions:
Please be sure to keep all follow-up appointments with your PCP
and cardiologist.
.
Please be sure to attend a special [**Date Range **] at [**Hospital1 18**] [**Hospital Ward Name **]
to receive your IV antibiotics everyday with the last dose on
[**9-19**] unless otherwise instructed by your doctors. [**First Name (Titles) **] [**Last Name (Titles) **]
information is as follows:
[**Hospital1 18**] Infusion Pharesis Unit
[**Hospital1 18**] [**Hospital Ward Name **], Grzymish 5
Office: [**Telephone/Fax (1) 14067**]
Time slot: 2pm on weekdays
(NOTE: on the weekends or holidays you will have your infusion
of antibiotics on [**Hospital Ward Name 1826**] 7 outpatient unit ([**Telephone/Fax (1) 447**]),
this information will also be provided during your first visit
to the [**Telephone/Fax (1) **].)
.
Name: [**Last Name (LF) 66436**],[**First Name3 (LF) **] P.
Location: MEDICAL CARE AFFILIATES
Address: [**Location (un) 31127**], PLAZA 1, [**Location (un) **],[**Numeric Identifier 31128**]
Phone: [**Telephone/Fax (1) 31124**]
Appointment: Tuesday [**2169-9-19**] 3:30pm
.
We are working on a follow up appointment in Cardiology with Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] within 9-15 days of discharge. The office will
contact you at home with an appointment. If you have not heard
or have any questions please call [**Telephone/Fax (1) 62**].
Completed by:[**2169-9-13**]
|
[
"693.0",
"272.0",
"790.7",
"V07.1",
"E930.5",
"427.31",
"530.81",
"401.9",
"285.9",
"397.0",
"600.00",
"110.1",
"682.7",
"041.02"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"99.12",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
16410, 16416
|
11731, 14844
|
279, 340
|
16531, 16531
|
5129, 11708
|
18274, 19689
|
2925, 3083
|
15105, 16387
|
16437, 16510
|
14870, 15082
|
16682, 18251
|
3098, 4089
|
4103, 5110
|
233, 241
|
368, 1863
|
16546, 16658
|
1885, 2454
|
2470, 2909
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,987
| 122,480
|
34032
|
Discharge summary
|
report
|
Admission Date: [**2200-9-9**] Discharge Date: [**2200-9-11**]
Service: SURGERY
Allergies:
Penicillins / Procardia
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
Cold Right Foot
Major Surgical or Invasive Procedure:
Thrombectomy of right femoral-popliteal
polytetrafluoroethylene graft and thrombectomy of native
popliteal/tibial vessels.
History of Present Illness:
[**Age over 90 **] yoF well known to Dr. [**Last Name (STitle) 1391**] who was most recently
discharged after R Femoral to Above knee Popliteal Bypass graft
with PTFE which was initially complicated by thrombus and
treated
with [**Doctor Last Name 18096**] emobolectomy. She now comes in with a 9 hour
history of cold right foot. She states she was in USOH at rehab
facility until last night when she noticed Right lateral thigh
pain. It was managed with pain control until this afternoon
until she noticed that her R foot was cold. She was taken to
[**Hospital3 26615**] hospital where she was emergently transferred to
[**Hospital1 18**] for management.
Here she is in NAD but has a cool R foot. She has F/R/O/M but
no
sensation in the R foot. It is cool to just below the knee. It
is pale in comparison to the Left leg, but not discolored. She
has a palpable femoral pulse, but no dopplerable signals distal
to that.
Past Medical History:
R FEM/AK [**Doctor Last Name **] with PTFE as above. Cardiac testing - stress
[**4-6**] pmibi EF 65%, no reversible ischemia, dysrhythmia afib
pacer
placed, MI [**4-6**], HTN, aorto-bifem bypass '[**75**], venous stasis LLE,
atrophic L kidney dz, chronic renal insuff, pancreatitis,
carcinoma soft palate, s/p cholecystectomy, hyperlipidemia,
hypothyroid 2' to amiodarone
Social History:
n/c
Family History:
n/c
Physical Exam:
On admission:
AAO x 3, NAD
RRR no MRG
CTA B/L no MRG
Soft, NT, ND, +BS, midline scar c/w aorto bifem in '[**75**]
Left: Palpable femoral Pulse, warm well perfused, dopplerable
DP and PT.
Right: cool R foot. She has F/R/O/M but no
sensation in the R foot. It is cool to just below the knee. It
is pale in comparison to the Left leg, but not discolored. She
has a palpable femoral pulse, but no dopplerable signals distal
to that.
Discharge:
Expired
Pertinent Results:
admission
[**2200-9-9**] 10:30PM BLOOD WBC-6.8 RBC-3.92* Hgb-12.3 Hct-38.1
MCV-97# MCH-31.3 MCHC-32.2 RDW-17.5* Plt Ct-121*
[**2200-9-9**] 10:30PM BLOOD Neuts-66.4 Lymphs-26.7 Monos-5.1 Eos-1.1
Baso-0.7
[**2200-9-9**] 10:30PM BLOOD PT-15.1* PTT-30.0 INR(PT)-1.3*
[**2200-9-9**] 10:30PM BLOOD Glucose-117* UreaN-68* Creat-2.5* Na-139
K-4.2 Cl-103 HCO3-25 AnGap-15
[**2200-9-9**] 10:45PM BLOOD Hgb-13.2 calcHCT-40
discharge
[**2200-9-11**] 02:21AM BLOOD WBC-10.1 RBC-3.64* Hgb-11.2* Hct-35.8*
MCV-98 MCH-30.8 MCHC-31.3 RDW-17.3* Plt Ct-135*
[**2200-9-11**] 02:21AM BLOOD Plt Ct-135*
[**2200-9-11**] 02:21AM BLOOD Glucose-87 UreaN-52* Creat-2.0* Na-136
K-4.5 Cl-107 HCO3-21* AnGap-13
[**2200-9-11**] 02:21AM BLOOD CK(CPK)-522*
[**2200-9-11**] 02:21AM BLOOD CK-MB-16* MB Indx-3.1 cTropnT-0.03*
[**2200-9-11**] 02:21AM BLOOD Calcium-8.3* Phos-5.3* Mg-2.4
[**2200-9-11**] 02:30AM BLOOD Type-ART pO2-86 pCO2-37 pH-7.36
calTCO2-22 Base XS--3
[**2200-9-11**] 12:46AM BLOOD Type-ART pO2-85 pCO2-42 pH-7.33*
calTCO2-23 Base XS--3
Brief Hospital Course:
[**Age over 90 **]F with a prior aortobifemoral bypass and a femoral-popliteal
bypass. This
femoral-popliteal bypass has already occluded in the early
postoperative period. She now presents with at least 48 hours of
ischemia. Dr. [**Last Name (STitle) 1391**], her surgeon, had a long discussion with
her and the family regarding the fact that this may not
be a salvageable situation and she may be better off with
amputation. She wanted another attempt at removing a clot from
the graft and seeing if we could reestablish flow. She
understood that this was not likely but we would make an
attempt. Patient was taken to the OR for thrombectomy of right
femoral-popliteal polytetrafluoroethylene graft and thrombectomy
of native popliteal/tibial vessels on [**9-10**]. Surgery was
unsuccessful. Patient taken to SICU for recovery. Patient was
extubated on off pressors. Patient did not want further
surgery. Family and Patient desired CMO on [**9-11**]. Patient
expired on [**9-11**].
Medications on Admission:
Simvastatin 20 mg PO DAILY, Travoprost *NF* 0.004 % Left Eye
QD HS, Pilocarpine 2% 1 DROP BOTH EYES Q6H, Timolol Maleate 0.5%
1 DROP LEFT EYE [**Hospital1 **], Brimonidine Tartrate 0.15% Ophth. 1 DROP
LEFT EYE Q8H, Quixin *NF* 0.5 % left eye QOD, Aspirin 325 mg PO
DAILY, Docusate Sodium 100 mg PO BID, Olanzapine 2.5 mg PO HS,
Metoprolol Tartrate 100 mg PO BID, Levothyroxine Sodium 75 mcg
PO
DAILY, Pantoprazole 40 mg PO Q24H, Acetaminophen 650 mg PO
Q6H:PRN, Bisacodyl 10 mg PO/PR DAILY:PRN, Ipratropium Bromide
Neb
1 NEB IH Q6H, Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN, Milk
of
Magnesia 30 mL PO Q6H:PRN, Mesalamine DR 800 mg PO TID, Lasix
40mg QDAY.
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary: Right lower extremity ischemia with
thrombosed femoral-popliteal prosthetic graft
Secondary: dysrhythmia afib pacer placed,
MI [**4-6**],
h/o HTN,
h/o aorto-bifem bypass '[**75**],
h/o venous stasis LLE,
h/o atrophic L kidney dz,
h/o chronic renal insuff,
h/o pancreatitis,
h/o carcinoma soft palate,
s/p cholecystectomy,
h/o hyperlipidemia,
h/o hypothyroid 2' to amiodarone
Discharge Condition:
stable
Discharge Instructions:
none
Followup Instructions:
none
Completed by:[**2200-12-2**]
|
[
"401.9",
"444.22",
"577.1",
"584.9",
"V45.01",
"996.74"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.49",
"38.08"
] |
icd9pcs
|
[
[
[]
]
] |
5045, 5054
|
3317, 4307
|
245, 370
|
5483, 5491
|
2273, 3294
|
5544, 5579
|
1761, 1766
|
5016, 5022
|
5075, 5462
|
4333, 4993
|
5515, 5521
|
1781, 1781
|
190, 207
|
398, 1328
|
1795, 2254
|
1350, 1724
|
1740, 1745
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,179
| 196,823
|
2143+55356
|
Discharge summary
|
report+addendum
|
Admission Date: [**2184-9-29**] Discharge Date: [**2184-10-4**]
Date of Birth: [**2146-1-16**] Sex: F
Service: NEUROSURGERY
Allergies:
Erythromycin Base / Oxacillin / Oxycodone / Penicillins
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
persistent HA in the setting of pseudotumor cerebri s/p VPS
and Chiari Type 1
Major Surgical or Invasive Procedure:
Suboccipital craniotomy with C1 laminectomies for decompression
of chiari malformation
History of Present Illness:
Patient is a 38 year old female with a history of multiple VP
shunts for pseudotumor cerebri. She was also diagnosed with a
Chiari type 1 malformation. She underwent new VP shunt placement
in [**2184-4-30**] with Dr [**Last Name (STitle) **]. Pre-op her symptoms were
intractable headaches and neck pain. She represents to clinic
for
follow up today with a new CT scan of the brain for review. She
reports her symtpoms have not significantly improved since
surgery , with tussive HA and problems when straining;
occasional
neck paresthesias are noted; but these HA also have not
worsened.
Her shunt is easily palpable and is able to be pumped and
refills
readily.
Of note previous notes state she complained of short term memory
issues. She denies that she has any memory impairment at this
time. Other than her headache and neck pain she denies nausea,
vomiting, dizziness, difficulty ambulating, changes in vision,
hearing, or speech, or changes inbowel or bladder function.
Past Medical History:
Pseudotumor cerebri with prior opening pressure of 35 s/p
lumboperitoneal shunt and revisions complicated by MSSA shunt
infection in [**8-/2175**] s/p LP shunt removal, depression, PTSD,
eczema, asthma, small ASD vs. stretched PFO, obesity s/p lap
band
surgery at [**Hospital1 11485**] in [**2181**]
Social History:
lives with family, Currently on disability, no tobacco or ETOH
Family History:
non-contributory
Physical Exam:
Gen: WD/WN, obese, comfortable, NAD.
HEENT: Pupils: PERRL EOMs intact without nystagmus
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused. No C/C/E.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
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, 4mm to
2mm 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 finger rub bilaterally.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**6-3**] throughout. No pronator drift
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger bilaterally
On Discharge:
non-focal
Pertinent Results:
CT head stable ventricular catheter placement
and ventricular size.
Last MRI: Chiari 1 malformation with >7mm tonsillar ectopia
[**2184-9-29**]: CT head IMPRESSION: Status post suboccipital
craniectomy with dural flap with expected post-operative change.
[**2184-9-30**]: MRI Brain- post operative changes, good decompression.
final read pending
Brief Hospital Course:
38 y/o F with persistent headache and multiple shunts for
pseudotumor cerebri presents with a chiari malformation type I.
She was taken to the OR electively on [**9-29**] for a suboccipital
craniotomy for decompression of chiari malformation.
Intraoperative course was uncomplicated and patient was
transferred to PACU for recovery. Postoperative CT head
demonstrated decompression of the cerebellar tonsils with normal
postoperative changes. She experienced postoperative nausea
that was treated with PRN IV Zofran and Compazine. On POD 1 she
underwent a postop MRI and was transferred to the floor.
Throughout her hospital stay she remained neurologically intact.
She was seen and evaluated by Physical therapy. On [**10-1**] she was
cleared by PT and OT for discharge home.
At the time of discharge she is tolerating a regular diet,
ambulating without difficulty, afebrile with stable vital signs.
Medications on Admission:
fluticasone, acetazolamide
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) as needed for spasm.
Disp:*30 Tablet(s)* Refills:*0*
3. Robaxin 500 mg Tablet Sig: 1-2 Tablets PO every eight (8)
hours.
Disp:*30 Tablet(s)* Refills:*2*
4. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
Discharge Disposition:
Home with Service
Discharge Diagnosis:
Chiari Malformation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
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 wash your hair 5 days after surgery. Your wound
closure uses dissolvable sutures, do not leave wet dressings or
wet towels on wound.
?????? 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.
?????? Do not take any anti-inflammatory medicines such as Motrin,
Aspirin, Advil, and Ibuprofen etc.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit. Do not drive until cleared by
your physician.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
- Wear your cervical collar for comfort.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please return to the office in [**8-8**] days(from your date of
surgery) for a wound check. This appointment can be made with
the Nurse Practitioner. Please make this appointment by calling
[**Telephone/Fax (1) 1669**].
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in 6 weeks.
You will need an MRI of the brain with and without gadolinium
contrast with a CSF flow study.
Completed by:[**2184-10-1**] Name: [**Known lastname 1632**],[**Known firstname 511**] Unit No: [**Numeric Identifier 1633**]
Admission Date: [**2184-9-29**] Discharge Date: [**2184-10-4**]
Date of Birth: [**2146-1-16**] Sex: F
Service: NEUROSURGERY
Allergies:
Erythromycin Base / Oxacillin / Oxycodone / Penicillins
Attending:[**First Name3 (LF) 599**]
Addendum:
see brief hospital course addendum
Major Surgical or Invasive Procedure:
Suboccipital craniotomy with C1 laminectomies for decompression
of chiari malformation
Brief Hospital Course:
The pts hospitalization was prolonged due to c/o headache as
well as low grade temperature. Medications were adjusted.
Fever workup was negative. She was cleared by PT for home with
assist of adl's with family. The pt and parents agree with this
plan.
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Robaxin 500 mg Tablet Sig: 1-2 Tablets PO every eight (8)
hours.
Disp:*30 Tablet(s)* Refills:*2*
3. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Valium 5 mg Tablet Sig: One (1) Tablet PO three times a day
for 2 days.
Disp:*6 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
[**Name6 (MD) **] [**Last Name (NamePattern4) 603**] MD [**MD Number(2) 604**]
Completed by:[**2184-10-4**]
|
[
"278.00",
"348.4",
"V45.2",
"V45.86",
"784.0",
"780.62",
"348.2",
"V85.42",
"787.02",
"493.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.09",
"01.39",
"02.12"
] |
icd9pcs
|
[
[
[]
]
] |
9023, 9166
|
8134, 8390
|
8022, 8111
|
5318, 5318
|
3245, 3595
|
7037, 7984
|
1916, 1934
|
8413, 9000
|
5275, 5297
|
4551, 4580
|
5469, 7014
|
1949, 2172
|
3215, 3226
|
281, 361
|
516, 1495
|
2424, 3201
|
5333, 5445
|
1517, 1819
|
1835, 1900
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,846
| 195,641
|
24004
|
Discharge summary
|
report
|
Admission Date: [**2133-4-6**] Discharge Date: [**2133-4-26**]
Date of Birth: [**2096-8-28**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Vancomycin / Rocephin / Reglan / Compazine
Attending:[**Last Name (NamePattern1) 1561**]
Chief Complaint:
multiple resp issues, now w/ tracheal stent placement [**11-21**], w/
good results. Here for trachealplasty by [**Doctor Last Name 952**]. Referral from
[**State **]
Major Surgical or Invasive Procedure:
Trachealplasty
History of Present Illness:
37y/o w/ episode of viral encephalitis at age 19, w/ some
neuromuscular comprimise post illness w/ increasing episodes of
bronchitis, unable to clear secretions, inpatient x2 months,
progressing to self suctioning. Ongoing w/ multiple pna,
bronchitis, resp arrests, placed on vent mult times, antibiotics
q2-3 months in past 6-8 years. Trach placed [**2125**], in place x4
months. Changed [**Name8 (MD) 61113**] MD, referred to Interventional
Pulmonologist, stent placed [**11-21**] w/ significant immediate
improvement. IP MD [**First Name (Titles) **] [**Last Name (Titles) **] Conference @ [**Hospital1 18**], referred pt to
[**Hospital1 **] Center for trachealplasty surgery by [**Name8 (MD) 952**] MD
Past Medical History:
viral encephalitis, pna, bronchitis, trach, HTN, reflus, anemia,
RA vs Lupus,? seixure disorder, L chest portacath.
Social History:
Full- time ICU RN in [**State **].
Lives w/ parents, primary care givernot well M- CAD, F-CAD,
parkinsons disease
non- smoker, [**12-21**] etoh/month, no rec drugs
Family History:
M- CAD, F-CAD, parkinsons
5 siblings alive and well
Pertinent Results:
[**2133-4-6**] 09:34PM BLOOD WBC-12.9* RBC-3.48* Hgb-9.1* Hct-29.0*
MCV-83 MCH-26.2* MCHC-31.4 RDW-13.9 Plt Ct-414
[**2133-4-7**] 07:38PM BLOOD WBC-11.4* RBC-3.16* Hgb-8.3* Hct-25.9*
MCV-82 MCH-26.4* MCHC-32.2 RDW-14.1 Plt Ct-390
[**2133-4-8**] 02:21AM BLOOD WBC-14.1* RBC-3.26* Hgb-8.6* Hct-26.4*
MCV-81* MCH-26.3* MCHC-32.4 RDW-14.2 Plt Ct-386
[**2133-4-17**] 05:40AM BLOOD WBC-6.3 RBC-3.13* Hgb-8.2* Hct-25.5*
MCV-82 MCH-26.1* MCHC-32.1 RDW-14.0 Plt Ct-516*
[**2133-4-6**] 09:34PM BLOOD PT-12.7 PTT-23.7 INR(PT)-1.0
[**2133-4-6**] 09:34PM BLOOD Plt Ct-414
[**2133-4-7**] 07:38PM BLOOD PT-13.0 PTT-24.5 INR(PT)-1.1
[**2133-4-7**] 07:38PM BLOOD Plt Ct-390
[**2133-4-8**] 02:21AM BLOOD PT-13.2 PTT-24.6 INR(PT)-1.1
[**2133-4-17**] 05:40AM BLOOD Plt Ct-516*
[**2133-4-17**] 08:36PM BLOOD PT-12.6 PTT-24.7 INR(PT)-1.0
[**2133-4-22**] 10:50AM BLOOD Plt Ct-497*
[**2133-4-22**] 10:50AM BLOOD PT-12.5 PTT-26.0 INR(PT)-1.0
[**2133-4-6**] 09:34PM BLOOD Glucose-109* UreaN-10 Creat-0.8 Na-139
K-3.7 Cl-101 HCO3-25 AnGap-17
[**2133-4-7**] 07:38PM BLOOD Glucose-96 UreaN-8 Creat-0.7 Na-137 K-4.0
Cl-106 HCO3-25 AnGap-10
[**2133-4-8**] 02:21AM BLOOD Glucose-130* UreaN-10 Creat-0.8 Na-137
K-4.2 Cl-105 HCO3-25 AnGap-11
[**2133-4-9**] 02:55AM BLOOD Glucose-118* UreaN-11 Creat-0.7 Na-139
K-5.3* Cl-100 HCO3-28 AnGap-16
[**2133-4-17**] 05:40AM BLOOD Glucose-97 UreaN-7 Creat-0.7 Na-138 K-4.9
Cl-102 HCO3-28 AnGap-13
[**2133-4-22**] 10:50AM BLOOD Glucose-102 UreaN-3* Creat-0.7 Na-137
K-4.4 Cl-98 HCO3-33* AnGap-10
[**2133-4-6**] 09:34PM BLOOD Calcium-9.0 Phos-2.7 Mg-2.0
[**2133-4-7**] 07:38PM BLOOD Calcium-8.7 Phos-3.8 Mg-1.9
[**2133-4-8**] 02:21AM BLOOD Calcium-8.8 Phos-3.9 Mg-1.9
[**2133-4-17**] 05:40AM BLOOD Calcium-9.4 Phos-4.7* Mg-1.9
[**2133-4-22**] 10:50AM BLOOD Calcium-9.5 Phos-3.9 Mg-1.7
CXR ([**4-7**])--There has been interval partial reexpansion of the
atelectatic changes at the right base and in the left mid lung
field, but new atelectasis is now seen in the retrocardiac left
lower lobe.
CXR ([**4-8**])--IMPRESSION: Improving right lower lobe opacity.
Satisfactory position of lines and tubes.
CXR ([**4-9**])--1) Tiny right apical pneumothorax following right
chest tube removal.
2) Satisfactory tracheostomy tube placement.
3) Improving bibasilar atelectasis, left greater than right.
CXR ([**4-12**])--Worsening left retrocardiac opacity as well as
development of
patchy right lower lobe opacity. The fluctuating nature of these
opacities on serial films favors atelectasis or recurrent
aspiration as the likely
etiology.
CXR ([**4-18**])--No pneumonia or pneumothorax.
CXR ([**4-24**])--Mild bilateral subsegmental atelectasis.
Brief Hospital Course:
Pt admitted [**2133-4-6**] for pre-op of trachealplasty done [**4-7**].
Immediately post op...
Post-Op course in CSRU c/b resp failure requiring intubation,
sedation, and fever 102 for which she was cultured.
POD#1- Temp 100.4. Bronch done w/ good results of surgical
site, minimal secretions. Sedation weaned, pt stable, good cuff
leak present, followed by extubation. Pt immediately developed
stridor unresponsive to recemic epinephrine and albuterol nebs
over 5 minutes w/o improvement. Sats remained over 93%. Pt
re-intubated w/ plan of continued recemic epinephrine, diuresis,
HOB elevated.
Patient remained in ICU w/ qd x3 attempted extubations all
requiring re-intubation for stridor. Started on linezolid and
levofloxacin for MRSA in sputum 3 week course until [**2133-4-30**].
Flex and rigid bronchoscopies done indicate superior tracheal
malacia above trachealplasty.
Tracheostomy done [**4-10**] and remained in place for secretion
clearance, [**Month/Year (2) 46569**] maintenance, resting of tracheal tissue edema,
independence of activity post-op with plan for re-evaluation in
1 week.
Patient required aggressive pulmonary toilet with
humidification, albuterol nebs, CPT, hydration to liquify
secretions for clearance.
POD#11- To OR for Cervical trachealplasty, tolerated procedure
well, trach removed, transferred to SICU intubated. Overnighted
x2 in SICU for observation of [**Month/Year (2) 46569**] maintenance and secretion
clearance w/ daily bronchoscopies to assist and maintain
secretion clearance. Failed extubation x1, then successful on
POD #14/3.
Transferred to floor on POD#15/4 w/ aggressive pulmonary toilet,
CPT, ambuation and hydration. Nausea intermittently controlled
w/ anzemet somewhat limiting hydration efforts.
Patient stable on floor and preparing for discharge POD# 16/6
when experienced significant secretions w/ inability to clear
secretions, O2 sat 80%, requiring emergent bronchoscopy and
transfer to SICU for bronch and observation.
Pt bronched am POD#17/7, clearance mod amt secretions, stable
and transferred to floor. She was ambulating comfortably,
eating a regular diet with controlled pain on POD#19/9, and was
considered stable for discharge with follow-up within the week.
Medications on Admission:
Keppra 500'', Albuterol neb'', mucomyst neb'', protonix 40 mg',
valium, ambien, tylenol#3
Discharge Medications:
1. Hydroxychloroquine Sulfate 200 mg Tablet Sig: Two (2) Tablet
PO DAILY (Daily).
2. Diclofenac Sodium 25 mg Tablet, Delayed Release (E.C.) Sig:
Three (3) Tablet, Delayed Release (E.C.) PO BID (2 times a day).
3. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
4. Albuterol Sulfate 0.083 % Solution Sig: [**12-21**] Inhalation Q6H
(every 6 hours) as needed.
5. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
6. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
7. Ferrous Sulfate Oral
8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
10. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed for wheeze.
11. Zolpidem Tartrate 5 mg Tablet Sig: 1-2 Tablets PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*0*
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
13. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed.
14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID
(3 times a day).
15. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
16. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
Disp:*8 Tablet(s)* Refills:*0*
17. Guaifenesin 600 mg Tablet Sustained Release Sig: Two (2)
Tablet Sustained Release PO BID (2 times a day).
Disp:*120 Tablet Sustained Release(s)* Refills:*2*
18. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours).
Disp:*4 Tablet(s)* Refills:*0*
19. Hydromorphone HCl 2 mg Tablet Sig: 1-2 Tablets PO Q2H (every
2 hours) as needed.
Disp:*35 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Tracheobronchial malacia
Discharge Condition:
Good, stable
Discharge Instructions:
Discharge to hotel until follow-up visit with Dr. [**Last Name (STitle) 952**], then
D/C back to home.
If you experience unremitting abdominal or throat pain,
shortness of breath, stridor or fever >101.5 as well as any
other symptoms of concern to you please seek medical evaulation
at a convenient ER.
You may resume your usual activities
You may resume your regular diet
You should resume your regular medication regimen with the
additions started on this admission. Be sure to finish your
course of antibiotics.
You may shower, but not bath, and be sure to dry the incision
sites carefully. The paper strips will fall off of their own
[**Location (un) **].
Please follow-up with Dr. [**Last Name (STitle) 952**] for further instructions.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 170**] Call to schedule
appointment at a time convenient for you on Thursday.
***Dr.[**Name (NI) 1816**] private pager# is [**Numeric Identifier 58797**]. To access this, call
the hospital operator at [**Telephone/Fax (1) 8717**] and request this # to be
paged to a number where you can be reached.
Provider: [**Last Name (LF) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 612**] Call to schedule
appointment
|
[
"518.5",
"V12.09",
"478.74",
"519.1",
"780.2",
"V09.0",
"482.41",
"401.9",
"V55.0",
"478.6",
"279.4",
"996.59"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.48",
"00.14",
"97.23",
"98.15",
"33.22",
"96.04",
"31.79",
"96.05",
"96.71",
"34.04",
"31.1"
] |
icd9pcs
|
[
[
[]
]
] |
8596, 8602
|
4315, 6546
|
483, 499
|
8671, 8685
|
1643, 4292
|
9476, 10042
|
1571, 1624
|
6686, 8573
|
8623, 8650
|
6572, 6663
|
8709, 9453
|
277, 445
|
527, 1234
|
1256, 1373
|
1389, 1555
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
43,392
| 145,700
|
47490+59007
|
Discharge summary
|
report+addendum
|
Admission Date: [**2107-6-30**] Discharge Date: [**2107-7-15**]
Date of Birth: [**2044-7-6**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1390**]
Chief Complaint:
s/p trauma, struck by car
Major Surgical or Invasive Procedure:
[**7-1**] ORIF pubic symphysis, L anterior column, SI screw
[**7-3**] washout, IVC filter
[**7-6**] washout, VAC change
[**7-9**] washout, VAC change
[**2107-7-1**]: ORIF pubic symphsysis, fixation L ant column, SI screw
[**2107-7-3**]: Inferior vena cava filter to the right femoral
approach
[**2107-7-3**]: Irrigation and debridement of Morel-[**Last Name (un) **] lesion
right flank skin soft tissue muscle 50 cm x 30 cm; Application
of negative pressure to Morel-[**Last Name (un) **] lesion.
[**2107-7-6**]: Washout and debridement of back and drainage of
hematoma. Application of vacuum-assisted closure sponge.
[**2107-7-9**]: Irrigation and debridement open deep abscess/hematoma
posterior lumbar spine. Application vacuum-assisted closure
sponge less than 50 sq cm.
[**2107-7-11**]: Open treatment thoracic fracture dislocation,
posterior. Posterolateral fusion T5-T9. Posterolateral
instrumentation T5-T9.
[**2107-7-14**]: Vacuum exchange and debridement down to local
exposed muscle.
History of Present Illness:
62M helmeted bicyclist, struck by vehicle. There was +LOC that
resolved by the time ALS arrived on scene. He was alert &
oriented x3, moving all extremities but was repetitive upon
arrival to ED. He was taken to CT scanner but became hypotensive
& brought back to trauma bay for resuscitation. He stablized,
but was intubated for return to CT in the setting of hemodynamic
instability, requiring 2U pRBC. He had an open wound to right
temperoparietal head, R back wound w/ lg hematoma s/p IR embo,
T7 vert body fx, b/l pubic rami fx, b/l acetab fx, b/l rib
fx/PTX
Past Medical History:
h/o DVT
Social History:
Occupational Profile: Works full time in finance.
Performance Patterns: Lives with wife. [**Name (NI) **] 2 supportive sons.
Family History:
non-contributory
Physical Exam:
On admission:
O(2)Sat: 100
Constitutional: Vital signs within normal limits- patient
boarded and collared with repetitive questioning
HEENT: Large abrasion and hematoma/depression of the skin
of the right parietal region, Pupils equal, round and
reactive to light
Dentition and midface intact
Chest: chest wall diffusely tender to palpation but without
crepitus and good breath sounds bilaterally
Cardiovascular: Regular Rate and Rhythm
Abdominal: Soft, Nontender
Extr/Back: Left flank with a large puncture wound
approximately T12 level with surrounding large hematoma with
significant amount of blood on the underlying sheets
Neuro: Reveal 4 extremities symmetrically, rectal tone
reported mildly decreased
On discharge:
Vitals: 98.4 75 113/77 18 100% RA
GEN: A&O, NAD, +MAE
HEENT: Small scalp laceration 4 cm x 2 cm, healing well, skin
slightly macerated
Chest: LS CTAB. CV: RRR
Abdomen: Soft, nontender, nondistended.
EXTR/BACK: Suprapubic horizontal incision well healed with
steristrips intact. Posterior vertical incision well healed with
steristrips. Lower back wound with wound vac and small amount
serosangineous drainage.
Pertinent Results:
On admission:
[**2107-6-30**] 01:40PM WBC-15.7* RBC-3.45* HGB-10.8* HCT-32.4*
MCV-94 MCH-31.4 MCHC-33.4 RDW-13.6
[**2107-6-30**] 01:40PM PT-12.2 PTT-26.9 INR(PT)-1.1
[**2107-6-30**] 01:40PM PLT COUNT-147*
[**2107-6-30**] 01:40PM FIBRINOGE-175*
[**2107-6-30**] 01:47PM GLUCOSE-152* NA+-143 K+-4.0 CL--111* TCO2-17*
[**2107-6-30**] 01:40PM UREA N-14 CREAT-1.2
[**2107-6-30**] 01:40PM LIPASE-74*
Labs on discharge:
[**2107-7-14**] 04:31AM BLOOD WBC-10.6 RBC-3.12* Hgb-9.2* Hct-28.0*
MCV-90 MCH-29.6 MCHC-33.0 RDW-15.1 Plt Ct-265
[**2107-7-14**] 04:31AM BLOOD Glucose-126* UreaN-14 Creat-0.7 Na-138
K-4.0 Cl-101 HCO3-27 AnGap-14
[**2107-7-14**] 04:31AM BLOOD Calcium-8.3* Phos-2.6* Mg-2.1
Imaging:
CT HEAD W/O CONTRAST Study Date of [**2107-6-30**] 1:44 PM
Small amount of intraventricular hemorrhage within the left
lateral ventricle. Right scalp hematoma and laceration. No
evidence of
calvarial fracture.
CT C-SPINE W/O CONTRAST Study Date of [**2107-6-30**] 2:43 PM
IMPRESSION:
1. Nondisplaced C7 left superior articular process and
transervse process
fracture. Possible 3rd left rib fracture. Nondisplaced left T3
transverse
process fracture.
2. 8-mm left thyroid nodule with coarse calcification.
Recommend followup ultrasound on a non-emergent basis if
clinically indicated.
CT ABD & PELVIS/CHEST WITH CONTRAST Study Date of [**2107-6-30**] 2:44
PM
IMPRESSION:
1. Massive right buttock hematoma with active extravasation.
2. Retroperitoneal hematoma mainly on the right and involving
the right psoas muscle.
3. Small to moderate right anterior and small posterior
pneumothoraces. Small loculated left hemopneumothorax with
adjacent atelectasis or contusion.
4. Displaced transverse process fractures of T12 through L4
transverse
process on the right. Fracture of the L4 transverse process on
the left. T6 through T12 minimally displaced spinous process
fractures and displaced spinous process fractures of L4 and L5.
5. Bilateral anterior acetabular column fractures. Bilateral
inferior pubic ramus fractures. Pubic symphysis diastasis of
1.3 cm and right SI joint diastasis and a minimally displaced
right iliac bone fracture.
6. Multiple rib fractures, most of which are segmental, as
described above.
[**2107-7-2**] 3:23 PM
MR THORACIC SPINE W/O CONTRAST; MR CERVICAL SPINE W/O CONTRAST
IMPRESSION: There is no evidence of spinal cord compression or
signal
abnormality throughout the cervical spinal cord to indicate
spinal cord edema or cord expansion.
Mild posterior disc bulge is identified at C6/C7 level, causing
mild anterior thecal sac deformity.
The fracture of the transverse process of C7 is better depicted
in the
corresponding CT of the cervical spine dated [**2107-6-30**].
Significant soft tissue edema is noted in the posterior
paravertebral
musculature and along the ligamentum nuchae as described above.
No fluid
collections are detected.
Limited examination due to patient motion and respiratory
movement. Within this limitation, there is high signal
intensity throughout the anterior aspect of the T7 vertebral
body, consistent with a nondisplaced fracture. There is no
evidence of spinal cord compression or epidural hematoma.
ECG Study Date of [**2107-7-5**] 2:25:04 AM
Sinus tachycardia and sinus arrhythmia. Normal ECG. No previous
tracing
available for comparison.
Brief Hospital Course:
He was admitted to the TSICU for stablization and close
monitoring. His injuries include: scalp laceration, R
buttock/retroperitoneal hematoma, L rib fractures of [**7-21**], R 7th
rib fracture, bilat acetabular column fracture, bilateral pubic
rami fractures, R iliac fracture, bilateral PTX, L posterior
lung laceration, T6-T12 spinous process fractures, T12-L4
transverse process fracture, R scapular fracture, T7 vertebral
body fracture.
Neuro: Post-operatively, was intubated and sedated. When
sedation was weaned, he was appropriately responsive. HIs pain
was controlled with narcotic medication. He had a scalp
laceration for which he received [**Hospital1 **] WTD dressing changes.
CV: On admission, the patient was hypotensive and placed on
pressors. He was actively bleeding from his flank wound and
there was concern from pelvic bleeding. He went to IR for
coiling of his obturator and inferior gluteal arteries. Vital
signs were routinely monitored. He was transfused pRBCs as
needed. Bedside echo showed signs of hypovolemia, no pericardial
effusion, fluid around spleen.
Pulmonary: The patient was stable from a pulmonary standpoint
and he was weaned from the vent, extubated on [**7-6**]. He did well
on NC and eventually room air post-extubation. vital signs were
routinely monitored.
GI/GU: Post-operatively, he was started on tube feeds and
advanced to goal. Speech and swallow evaluated him and he was ok
for nectar thickened liquids. His NGT was removed and TFs
stopped,he continued to tolerate PO. He was given lasix for
diuresis and responded well. He had a foley in place.
ID: He was kept on cefazolin due to his wound on his back. He
was also febrile to 101.4 and had a sputum culture that grew
MSSA. He had a PICC placed on [**7-8**].
Heme: He underwent multiple RBC, FFP, and cryo transfusions due
to continued bleeding and downward trending hematocrit. He
received up to 22u of RBC from his ED to ICU course.
MSK: Patient went to OR for repair of pelvic fracture and
acetabular fracture. THere was a large fascial defect around
sacrum with clot in the area, and a wound VAC was placed, with
multiple VAC changes. He also had a T7 vertebral body fracture.
He was kepts on logroll precautions. He had ligamentous edema
within his c-spine and he was kept in a c-collar.
Prophylaxis: The patient received an IVC filter. He was kept on
GI ulcer prophylaxis.
Dispo: The patient was transfered from ICU to floor on [**7-9**]. He
was hemodynamically stable, without transfusion requirements. He
was saturating well on RA and tolerating nectar thickened
liquids PO. His pain was under control.
Floor course:
Neuro: He remained alert and oriented with adequate pain control
with PO medications. No changes in neurological status were
noted while on the floor.
CV: Vital signs were monitored routinely and he remained
hemodynamically stable.
PULM: He remained afebrile with normal oxygen saturations on
room air.
GI: He was re-evaluated by speech and swallow and his diet was
upgraded to a regular diet. He was placed on a bowel regimen and
having bowel movements regularly.
GU: His foley catheter was removed postoperatively on [**7-14**] at
which time he voided without difficulty.
ID: He was continued perioperatively on IV cefazolin which was
changed to PO Keflex for 10 days at discharge per
recommendations of spine surgery given the hardware and risk for
infection. His WBC was within normal limits prior to discharge
and he remained afebrile without active signs of infection. His
PICC line was removed prior to discharge.
Heme: His hematocrit remained stable throughout his floor course
and he required no further blood transfusions. An IVC filter was
placed on [**7-3**] for PE prophylaxis and he was started on 40 mg
enoxaparin daily for 2 weeks at the time for discharge per
orthopedics recommendations.
MUSK: On [**7-11**] he was taken to the operating room with spine for a
posterior fusion with instrumentation T5-T9. He remained
nonweightbearing on bilateral lower extremities. He continued to
work with physical and occupational therapy and progressed his
mobility status to transfer with the slideboard from bed to
wheelchair.
On [**7-15**] he is afebrile with stable vital signs. He is tolerating
a regular diet and making adequate amounts of urine. His pain is
well controlled with an oral regimen. He is neurologically
stable and without signs of infection. His respiratory status is
stable without compromise. Both the patient and his family have
undergone teaching with PT/OT, nursing and the surgical staff
and the patient is being discharged home with services in place.
Follow up is scheduled with spine, ortho, ACS and the patient's
PCP.
Medications on Admission:
none
Discharge Medications:
1. Hospital Bed
Fully electric
2. App/Pump Pad
Diagnosis: Deep abscess hematoma lumbar spine
3. Wheelchair
4. Commode
Drop Arm
5. Slideboard
6. Hoyerlift
7. Acetaminophen [**Telephone/Fax (1) 1999**] mg PO Q6H:PRN pain
8. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
9. Cephalexin 500 mg PO Q6H Duration: 10 Days
RX *cephalexin 500 mg 1 Capsule(s) by mouth four times a day
Disp #*40 Capsule Refills:*0
10. Diazepam 2-5 mg PO QHS:PRN insomnia
RX *diazepam 5 mg 0.5-1 tablets by mouth at bedtime Disp #*30
Tablet Refills:*0
11. Docusate Sodium (Liquid) 100 mg PO BID
12. Enoxaparin Sodium 40 mg SC DAILY
RX *enoxaparin 40 mg/0.4 mL 1 syringe once a day Disp #*14
Syringe Refills:*0
13. Multivitamins 1 TAB PO DAILY
14. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 0.5-1 Tablet(s) by mouth every four (4) hours
Disp #*50 Tablet Refills:*0
15. Senna 1 TAB PO BID:PRN constipation
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
s/p bicyle vs. car: polytrauma
Injuries:
1. Scalp laceration
2. large gluteal Morelle [**Last Name (un) 66188**] lesion with hematoma
3. Left rib fractures of [**7-21**]
4. Right 7th rib fracture
5. Bilateral acetabular column fractures
6. Bilateral pubic rami fractures
7. Right iliac fracture
8. Bilateral pneumothoraces
9. Left posterior lung laceration
10. T6-T12 spinous process fractures
11. T12-L4 transverse process fracture
12. Right scapular fracture
13. T7 vertebral body fracture
Other associated diagnoses:
Acute blood loss anemia
MSSA ventilator-associated pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to the hospital after suffering an accident on
your bicycle. You sustained multiple injuries including rib
fractures, collapse in your lung, lung lacerations, and injuries
to your spine, scapula and pelvis. You required multiple
procedures in the operating room to repair your injuries, a stay
in the intensive care unit, and multiple blood transfusions
during the earlier part of your hospital course. You are
recovering very well from your accident are now being discharged
home with services to continue your recovery. Multiple follow up
appointments have been scheduled for you (see below).
Activity:
Do NOT smoke.
You should remain nonweightbearing on both of your legs. Please
discuss your weightbearing status with the orthopedic surgeons
at your follow up appointment. You have been started on an
anticoagulation medication called lovenox. Please administer
this medication daily as prescribed. You will be given a two
week supply. Please discuss future anticoagulation at your
orthopedic surgery follow up appointment.
You may bear full weight as tolerated on your arms and range of
motion your arms as tolerated.
You should remain in the soft cervical collar as instructed by
the spine surgeons until your follow up appointment. Please
discuss with the spine [**Date Range 5059**] at your follow up how long you
will need to wear the collar. You may remove the collar briefly
to perform daily hygeine to your neck but do not move your head
up or down when the collar is off.
No pulling up, lifting more than 10 lbs, or excessive
bending/twisting.
Keep your wounds clean and dry. No tub baths or pool swimming.
Please discuss when you may resume these at your follow up
appointments. It is okay to take a shower/let water run over the
incisions. Gently pat them dry afterward.
Have a friend/family check your incisions daily for signs of
infection.
PAIN:
Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your [**Name2 (NI) 5059**].
You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. Do not
take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
Your pain medicine will work better if you take it before your
pain gets too severe.
Talk with your [**Name2 (NI) 5059**] about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
[**Name2 (NI) 5059**] has said its okay.
If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
Constipation is a common side effect of medicine such as
Percocet or codeine. If needed, you may take a stool softener
(such as Colace, one capsule) or gentle laxative (such as milk
of magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
If you go 48 hours without a bowel movement, or have pain moving
the bowels, call your [**Name2 (NI) 5059**].
MEDICATIONS:
You will receive a prescription for pain medication as discussed
above. You should continue to take over-the-counter stool
softeners with the pain medication to prevent constipation.
You will receive a prescription for lovenox to prevent blood
clots in your legs.
You will receive a prescription for 10 more days of antibiotics
to be taken by mouth at home.
Followup Instructions:
Department: Primary Care
Name: Dr. [**First Name4 (NamePattern1) 2411**] [**Last Name (NamePattern1) 12997**]
When: Monday [**2107-7-25**] at 10:00 AM
Location: [**Location (un) 2274**]-[**University/College **]
Address: [**Hospital1 3470**], [**University/College **],[**Numeric Identifier 3471**]
Phone: [**Telephone/Fax (1) 86132**]
Department: ORTHOPEDICS
When: THURSDAY [**2107-7-28**] at 11:20 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 [**2107-7-28**] at 11:40 AM
With: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], NP [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
When: THURSDAY [**2107-8-4**] at 1 PM
With: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in the 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
Notes: You will need a chest x-ray prior to this appointment.
Please go to [**Hospital1 7768**], [**Hospital Ward Name 517**] Clinical Center, [**Location (un) 3202**] Radiology 30 minutes prior to your appointment.
Department: ORTHOPEDICS
When: WEDNESDAY [**2107-7-27**] at 9:25 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: SPINE CENTER
When: WEDNESDAY [**2107-7-27**] at 9:45 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 8603**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2107-7-15**] Name: [**Known lastname 16135**],[**Known firstname **] Unit No: [**Numeric Identifier 16136**]
Admission Date: [**2107-6-30**] Discharge Date: [**2107-7-15**]
Date of Birth: [**2044-7-6**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4216**]
Addendum:
This addendum is to clarify Mr. [**Known lastname 16137**] final diagnosis to
include the prior stated diagnoses in addition to traumatic
shock and respiratory failure.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 197**] [**Name (NI) 198**]
[**First Name11 (Name Pattern1) 499**] [**Last Name (NamePattern4) 4218**] MD [**MD Number(2) 4219**]
Completed by:[**2107-7-21**]
|
[
"E879.8",
"876.1",
"805.2",
"873.0",
"599.71",
"958.4",
"808.2",
"285.1",
"860.0",
"922.32",
"868.04",
"808.41",
"839.42",
"861.22",
"922.2",
"808.0",
"041.11",
"811.00",
"853.02",
"958.7",
"518.81",
"997.31",
"807.08",
"E813.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.53",
"79.39",
"88.51",
"86.04",
"38.7",
"78.59",
"81.05",
"39.79",
"86.28",
"88.49",
"96.6",
"96.72",
"86.22",
"83.44",
"77.79",
"81.63",
"99.29"
] |
icd9pcs
|
[
[
[]
]
] |
19364, 19593
|
6666, 11368
|
328, 1331
|
13053, 13053
|
3305, 3305
|
16659, 19341
|
2115, 2133
|
11423, 12332
|
12447, 13032
|
11394, 11400
|
13229, 16636
|
2148, 2148
|
2875, 3286
|
263, 290
|
3734, 6643
|
1359, 1924
|
3320, 3714
|
13068, 13205
|
1946, 1955
|
1971, 2099
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,723
| 193,691
|
214
|
Discharge summary
|
report
|
Admission Date: [**2182-1-19**] Discharge Date: [**2155-2-24**]
Service:
HISTORY OF PRESENT ILLNESS: The patient is an 88-year-old
female with a history of coronary artery disease now with
bradycardia. He had an episode of dizziness when walking
today. His wife took his pulse and noticed it was "slow."
The patient reportedly had some relief from his symptoms
after his wife gave him a sublingual nitroglycerin. He
subsequently had a second episode of dizziness at rest and
went to the Emergency Department.
There, he was found to have a pulse of 30 without P waves.
External pacing was attempted and unsuccessful capturing.
Atropine was given without effect. He was started on
dopamine 10 mcg per minute and noted to revert to sinus at 50
beats per minute then hypertension to the 200s.
The patient was reportedly still complaining of dizziness
while in sinus. He denied chest pain, shortness of breath,
abdominal pain, and palpitations.
He had an exercise treadmill test on [**2181-1-5**] which
was stopped for shortness of breath with no ST segment
changes. Rhythm was sinus with rare isolated AEA and VEA
with blood pressure responsive flat. Nuclear images with
moderate defects, apex with ejection fraction of 65% and mild
apical hypokinesis.
PAST MEDICAL HISTORY:
1. Coronary artery disease; in [**2179-5-27**] with 20% left
main coronary artery, a DV left anterior descending with
noncritical stenosis and widely patent stent in the proximal
segment. First obtuse marginal with critical lesion. Left
circumflex with mild luminal irregularities and 40% proximal
right coronary artery. Mild diastolic function with ejection
fraction of 60% with a normal wall motion.
2. Hepatitis C virus.
3. Hypertension.
4. Nocturia.
5. Osteoarthritis.
6. Ventral hernia.
7. Cholelithiasis; status post endoscopic retrograde
cholangiopancreatography.
8. Colon cancer; status post colectomy in [**2165**].
9. Positive purified protein derivative.
10. Cervical degenerative joint disease.
ALLERGIES: He has no known drug allergies.
MEDICATIONS ON ADMISSION:
1. Aspirin 325 mg p.o. q.d.
2. Atenolol 50 mg p.o. q.d.
3. Atorvastatin p.o. q.d.
4. Doxazosin p.o. q.h.s.
5. Zoloxafed 200 p.m.
6. Tolterodine 200 mg p.o. b.i.d.
7. Losartan 80 mg p.o. q.d.
8. Diphenhydramine 50 mg p.o. q.h.s.
9. Glucosamine 500 mg p.o. q.d.
PHYSICAL EXAMINATION ON PRESENTATION: On physical
examination, his pulse was 35, blood pressure was 100/42,
respiratory rate was 22. He was 91% on room air. In
general, he was lying with the head of the bed at 20 degrees,
in no acute distress. His pupils were equally round and
reactive to light and accommodation. Extraocular motions
were intact. Oral mucous membranes were dry. Jugular venous
distention was difficult to assess secondary to constant head
and oral movement. He was bradycardic with a normal S1 and
S2. No murmurs, rubs, or gallops. His lungs were clear to
auscultation anteriorly. His abdomen with a prominent
ventral hernia was soft, nontender, and nondistended. Normal
active bowel sounds. His extremities showed 2+ dorsalis
pedis pulses bilaterally with no pitting edema.
PERTINENT LABORATORY VALUES ON PRESENTATION: White blood
cell count was 7.8, hematocrit was 42.6, and platelets were
180. Prothrombin time was 12.9, partial thromboplastin time
was 24.2, INR was 1.1. Sodium was 145, potassium was 5.1,
chloride was 109, bicarbonate was 27, blood urea nitrogen was
22, creatinine was 1.2, and blood glucose was 115. CK was
63. Troponin was less than 0.3. Calcium was 9.9, magnesium
was 1.9, phosphate was 5.2.
RADIOLOGY/IMAGING: Electrocardiogram showed junctional
bradycardia at 36 beats per minute with left axis with waves
in III and aVF and inverted T waves in III with no ST segment
changes.
Electrocardiogram after dopamine showed a normal sinus rhythm
at 61 beats per minute, a left axis, high-normal P-R
interval, Q waves in III and aVF, T wave flattening in III,
and no ST segment changes.
HOSPITAL COURSE: He was admitted to the Coronary Care Unit
as a percutaneous wire was unable to capture and v-pace.
His heart rate was maintained on dopamine. His rhythm was
found to be an atrial exit block, likely the cause of his
dizziness. He was evaluated by Electrophysiology and was
sent for pacemaker placement.
On the second night of admission he was complaining of
insomnia and was given Ambien and became very agitated. At
that time, he pulled out his right internal jugular Cordis.
Two hours after replaced, he received 2 mg of intravenous
haloperidol for the confusion and seemed to calm down. It
was thought to be secondary to the Ambien which was
discontinued. He had no further episodes of hallucinations
or agitation at that time.
His creatinine improved with hydration to his baseline of
around 0.8. He was maintained on his outpatient medications
for BPH and osteoarthritis.
He received a pacemaker on [**2182-1-21**] without
complications. His hematocrit remained stable. He had
received three doses of vancomycin perioperatively. His beta
blocker and angiotensin receptor blocker were resumed as they
had previously been held while on dopamine and also with his
tendency for bradycardia. These were resumed without issue.
The only complicating factor was he was slightly nauseated
with vomiting after returning from his procedure. It was
thought this was likely due to the sedation. He was given
antiemetics, and it resolved the following day when the
sedation wore off.
He was able to eat and ambulate without dizziness or concern.
Therefore, he was discharged home in good condition.
MEDICATIONS ON DISCHARGE:
1. Aspirin 325 mg p.o. q.d.
2. Atenolol 50 mg p.o. q.d.
3. Atorvastatin p.o. q.d.
4. Doxazosin p.o. q.h.s.
5. Zoloxafed 200 p.m.
6. Tolterodine 200 mg p.o. b.i.d.
7. Losartan 80 mg p.o. q.d.
8. Diphenhydramine 50 mg p.o. q.h.s.
9. Glucosamine 500 mg p.o. q.d.
Of note, it should be noted that the patient should not be
given Ambien as it causes agitation and delirium.
DISCHARGE INSTRUCTIONS/FOLLOWUP: He was to follow up with
the Electrophysiology Clinic.
[**First Name8 (NamePattern2) 2064**] [**Last Name (NamePattern1) **], M.D. [**MD Number(2) 2139**]
Dictated By:[**Last Name (NamePattern1) 2140**]
MEDQUIST36
D: [**2182-1-22**] 14:14
T: [**2182-1-22**] 19:23
JOB#: [**Job Number 2141**]
|
[
"600.0",
"721.0",
"E937.9",
"070.51",
"427.89",
"401.9",
"553.20",
"298.9",
"414.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.72",
"37.83"
] |
icd9pcs
|
[
[
[]
]
] |
5663, 6043
|
2093, 4011
|
4029, 5637
|
6077, 6407
|
111, 1270
|
1293, 2067
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,633
| 113,066
|
35198
|
Discharge summary
|
report
|
Admission Date: [**2129-11-20**] Discharge Date: [**2129-11-23**]
Date of Birth: [**2074-5-7**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
s/p ?Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
55 yo male found down with GCS13, taken to an area hospital with
ETOH level 316 and was intubated for combativeness. Was
reportedly found to have bilateral traumatic SAH then
transferred to [**Hospital1 18**] for further care. On arrival patient moving
all extremities; he received propofol for agitation.
Past Medical History:
Unknown
Social History:
Lives alone; family in [**State 531**]
Family History:
Noncontributory
Physical Exam:
Upon admission:
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 2->1 b/l EOM unable to assess. +corneal reflex
+gag reflex
Neck: collar
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Intubated, sedated
Orientation: unable to assess.
Language: Unable to assess.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to 2->1
mm bilaterally.
III - XII: Unable to assess
Motor: Withdrawal to noxious stimuli in left UE and b/l lower
extremities. Right UE does not withdrawal to noxious stimuli
Sensation: see above.
Toes downgoing bilaterally
Coordination: unable to assess
Pertinent Results:
[**2129-11-20**] 05:26AM GLUCOSE-98 UREA N-11 CREAT-1.0 SODIUM-145
POTASSIUM-3.6 CHLORIDE-107 TOTAL CO2-27 ANION GAP-15
[**2129-11-20**] 05:26AM CALCIUM-8.7 PHOSPHATE-2.3* MAGNESIUM-2.2
[**2129-11-20**] 05:26AM WBC-10.4 RBC-4.36* HGB-13.8* HCT-37.1* MCV-85
MCH-31.6 MCHC-37.1* RDW-13.3
[**2129-11-20**] 05:26AM NEUTS-78.8* LYMPHS-17.3* MONOS-3.2 EOS-0.5
BASOS-0.1
[**2129-11-20**] 05:26AM PLT COUNT-200
[**2129-11-20**] 05:26AM PT-13.9* PTT-23.6 INR(PT)-1.2*
[**2129-11-20**] 02:10AM ASA-NEG ETHANOL-289* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
Head CT [**2129-11-20**]
IMPRESSION:
1. Bilateral parietal subarachnoid hemorrhage.
2. Partially visualized fracture of the right mandibular ramus.
Please refer to the concurrent facial bone CT for further
detail.
C-spine CT [**2129-11-20**]
IMPRESSION:
1. No fracture or malalignment in the cervical spine.
2. Ossification of the posterior longitudinal ligament with
moderate to
severe spinal canal stenosis. This places the spinal cord at
risk for
contusion during trauma. If the patient has neurologic symptoms,
MR of the
cervical spine is suggested for further evaluation.
3. Fracture of the right mandibular ramus. Please refer to the
concurrent
facial bone CT for further detail.
Facial CT [**2129-11-20**]
IMPRESSION:
1. Fracture of the right mandibular ramus as described above.
2. Possible fractures of the anterior nasal bones. Clinical
correlation is suggested.
Repeat head CT [**2129-11-20**]
IMPRESSION:
1. Small foci of bilateral parietal subarachnoid hemorrhage have
become less dense. No new hemorrhage.
2. New fluid in the left sphenoid sinus, which may be related to
intubation.
Brief Hospital Course:
He was admitted to the Trauma service. Neurosurgery and OMFS
consults were placed. His subarachnoid hemorrhages were managed
non operatively. Serial head CT scan was followed and remained
stable. He was loaded with Dilantin and will continue for a
total of 10 days on this.
He will follow up as an outpatient with OMFS for his jaw
fracture. He was placed on a soft diet.
He was evaluated by Physical therapy for gait assessment and by
Occupational therapy for cognitive evaluation given the head
injury. After careful evaluation it was assessed that he could
be discharged to home.
Social work was consulted for coping and EtOH; he was provided
with information on alcohol and drug counseling in the [**Hospital1 487**]
area.
Instructions for follow up were provided to patient.
Medications on Admission:
Unknown
Discharge Medications:
1. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
3. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day) for 8 days.
Disp:*24 Capsule(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
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).
Discharge Disposition:
Home
Discharge Diagnosis:
s/p ?Fall
Bilateral subarachnoid hemorrhages
Right mandibular fracture
Discharge Condition:
Hemodynamically stable, tolerating a regular diet, pain
adequately controlled.
Discharge Instructions:
Continue Dilantin for another 8 days.
Ahere to a soft diet because of your jaw fracture.
Return to the Emergency room if you develop any fevers, chills,
headache, dizziness, seizures, increased jaw pain, shotness of
breath, nausea, vomitng, diarrhea and/or any other symptoms that
are concerning to you.
Followup Instructions:
Follow up in 4 weeks with Dr. [**First Name (STitle) **], Neurosurgery. Call
[**Telephone/Fax (1) 1669**] for an appointment. Inform the office that you will
need a repeat head CT scan for this appointment.
Follow up this Friday in [**Hospital 40530**] clinic with Dr. [**First Name (STitle) **] for your jaw
fracture; call [**Telephone/Fax (1) 274**] for an appointment.
Completed by:[**2129-12-6**]
|
[
"802.20",
"303.91",
"780.60",
"E928.9",
"852.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
4768, 4774
|
3186, 3970
|
325, 331
|
4888, 4968
|
1475, 3163
|
5322, 5725
|
772, 789
|
4028, 4745
|
4795, 4867
|
3996, 4005
|
4992, 5299
|
804, 806
|
276, 287
|
359, 669
|
1132, 1456
|
820, 1022
|
1037, 1116
|
691, 700
|
716, 756
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,973
| 147,126
|
9813
|
Discharge summary
|
report
|
Admission Date: [**2180-10-27**] Discharge Date: [**2180-10-31**]
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 14936**] is a [**Age over 90 **]yo woman with h/o COPD, pectus carinatum,
moderate AS, and chronic diastolic heart failure who presents
with a [**1-19**] week history of dyspnea.
.
She reports increasing shortness of breath such that she was
having difficulty with her daily activities (such as using her
walker to get down the [**Doctor Last Name **] at her independent living facility).
+cough, but no fevers. No hemoptysis. Per family's report, a CXR
was obtained 2 weeks ago, and they were told there was a
pneumonia, so she was given a 1 week course of levofloxacin
(last dose 2 days ago). Nevertheless, she has continued to feel
weak and out of breath. Over the last 3-4 days, she has had
increasing LE edema. She denies orthopnea or PND. No chest pain
or back pain. She did have a nosebleed a few days ago.
.
In the ED, initial VS were: 97.8 90 129/73 20 100% NRB. She
received ASA 162mg and a dose of lasix 20mg IV for presumed
heart failure. LE ultrasound was negative for DVT, and a CTA was
performed to rule out PE. Although there was no evidence of PE,
a large hematoma was found surrounding the thoracic aorta with a
5mm focal defect in the aortic wall suggestive of tear. She was
seen by CT surgery, who felt that surgery would be needed to
repair the tear, but that given her age and comorbidities,
conservative management with BP control was indicated. CT
surgery discussed this with the patient and her family. Of note,
the ED nurse felt that she might be aspirating while eating.
.
Upon arrival to the MICU, she denied any difficulty breathing.
She asked for ice cream, stating that she was very hungry.
Past Medical History:
COPD--spirometry included below
Pectus carinatum
Scoliosos
Moderate aortic stenosis on TTE from [**2-/2180**]
Chronic diastolic CHF per DC summary [**2-/2180**]
Depression
Colon CA and small bowel CA s/p resection in [**2160**] and [**2169**]
GERD w/ h/o Barrett's esophagus
History of falls
Hypothyroidism
Glaucoma
Cataracts
Short term memory loss
Hospitalized [**2-/2180**] with SBO that required lysis of adhesions,
was transiently intubated and on pressors; required lasix for
diuresis because of acute on chronic heart failure; also noted
to have episodes of sinus tachycardia.
? h/o C diff: during [**2-25**] admission, had leukocytosis to 26 and
treated empirically for C diff.
Social History:
.
Soc Hx:
60 pack year h/o smoking, quit in [**2157**]. No alcohol use. Lives at
independent living with a 24 hr aide. Uses a walker or
wheelchair. Has a son in NJ and a daughter in the area. Children
report that she is normally alert and oriented, quite sharp,
although she can get confused at times.
Family History:
Fam Hx: no h/o lung disease, no h/o AAA. Father died of MI.
Physical Exam:
97.8 84 Left 83/56, Right 98/61 25 97% 4L
Elderly woman sleeping in bed, wakes easily, somewhat hard of
hearing
EOMI, MMM, face symmetric, OP clear
Neck supple, no carotid bruits. JVP to angle of jaw while at 45
degrees
S1, S2, regularly irregular (PACs every 3rd beat) with 2/6
systolic murmur at LLSB.
Slightly short of breath with talking. +Chest wall deformity.
Lungs with diffuse crackles throughout, decreased BS at bases
b/l.
Abdomen protuberant with well-healed midline scar. +BS, soft,
NT.
Skin with chronic changes of LE b/l; very thin, fragile skin.
LE with L>R pitting edema, somewhat weepy. Radial and DP pulses
are 2+ b/l and equal.
Alert and oriented. Strength is intact in UE b/l, both proximal
and distal.
Brief Hospital Course:
[**Age over 90 **]yo woman with COPD and pectus carinatum who presented with
dyspnea and was found to have tear in thoracic aorta.
1. Dyspnea: Most likely multifactorial due to underlying chest
wall deformity (from pectus carinatum, scoliosis and compression
fractures), COPD, and acute on chronic diastolic heart failure.
Although pneumonia is also a possibility, she did not have
fevers, a productive cough, or evidence of infiltrate on CXR.
Aortic stenosis may contribute to her propensity to develop
pulmonary edema/pleural effusions. Continued afterload control
with home meds (diltiazem, lisinopril) and added metoprolol for
HR control, management of AFIB as below. Continued home inhalers
(advair, spiriva, albuterol). She received occasional low doses
of lasix for gentle diuresis to help with breathing. She was
discharged on 10 mg PO lasix. She was also discharged with home
oxygen which she should use during transfers and as needed.
2. Tear in Thoracic Aorta: Unclear why this developed as patient
does not have poorly controlled HTN or family history of
dissection. She has been coughing more lately, which could have
contributed. Regardless of cause, she was evaluated by CT
surgery, who did not feel that she was an operative candidate
because of her age and comorbidities. The patient and family
communicated understanding of her diagnosis and consensus about
the decision regarding medical management only. BP maintained at
goal SBP < 120-130.
3. Leukocytosis: She has not had fever to suggest infection.
Cultures sent with no evidence to suggest pulmonary infection.
4. Compression fractures: Started Ca/Vit D. Consider fosamax as
outpatient.
5. Hypothyroidism: Continued levothyroxine
6. Depression: Continued mirtazapine and trazodone
7. Glaucoma, cataracts: Comtinued on dorzolamide eye drops
8. GERD: PPI
9. FEN: low salt diet with 1:1 supervision/aspiration
precautions.
10. PPx: PPI, pneumoboots, bowel reg
11. Access: PIV x 2
12. Code: DNR/DNI, confirmed with patient and family.
13. Comm: with daughter [**Name (NI) **] [**Name (NI) **] (h) [**Telephone/Fax (1) 33029**]; (c)
[**Telephone/Fax (1) 33030**].
14. Dispo: Patient was discharged to home hospice
Medications on Admission:
ASA 81mg on Sun, Wed, Fri
Diltiazem 180mg daily
Lisinopril 5mg daily
Levothyroxine 88mcg daily
Mirtazapine 30mg HS, 7.5mg QAM
Trazodone 25mg QHS
Megace 40mg/ml [**1-19**] tsp QOD
MVI daily
Senna 1 tab [**Hospital1 **] prn
Docusate 100 [**Hospital1 **]
Bisacodyl 10mg daily PRN
Milk of magnesia 8% 15ml daily prn
Miralax 17g daily
Dorzolamide 2% drops OU TID
Cyanocobalamin 1000mcg qmonth
Spiriva 18mcg daily
Advair 250/50 [**Hospital1 **]
Albuterol inh 2 puffs TID PRN
Discharge Medications:
1. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Mirtazapine 15 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
4. Mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO QAM (once a day
(in the morning)).
5. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
6. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
7. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) puff Inhalation DAILY (Daily).
8. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q6H (every 6 hours) as needed.
9. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Dorzolamide 2 % Drops Sig: One (1) Drop Ophthalmic TID (3
times a day).
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
13. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Fifteen (15)
ML PO Q6H (every 6 hours) as needed.
14. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
15. Polyethylene Glycol 3350 100 % Powder Sig: Seventeen (17)
grams PO DAILY (Daily) as needed.
16. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
17. DILT-XR 120 mg Capsule,Degradable Cnt Release Sig: One (1)
Capsule,Degradable Cnt Release PO once a day.
18. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
19. Lasix 20 mg Tablet Sig: 0.5 Tablet PO once a day.
20. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed.
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] [**Location (un) **] hospice care
Discharge Diagnosis:
Primary diagnoses:
Shortness of breath
Thoracic aortic aneurysm
Atrial fibrillation
Leukocytosis
Secondary diagnoses:
Compression fracture
Hypothyroidism
Depression
Glaucoma
GERD
Cataracts
Discharge Condition:
Stable
Discharge Instructions:
1)You were admitted to the hospital with shortness of breath.
You had a CAT scan of your chest which showed no evidence of a
blood clot in your lungs but did show a small tear in your
thoracic aorta. After discussion with you and your family the
decision was made to focus on medical management.
2)Please take all medications as listed in the discharge
instructions.
3)Please schedule a follow-up appointment with your primary care
physician [**Name Initial (PRE) 176**] 1-2 weeks after being discharged from the
hospital.
4)If you experience any fevers, chills, chest pain, shortness of
breath, dizziness, abdominal pain, or any other concerning
symptoms, please seek immediate medical attention.
Followup Instructions:
Please schedule a follow-up appointment with your primary care
physician [**Name Initial (PRE) 176**] 1-2 weeks after being discharged from the
hospital.
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
|
[
"707.03",
"244.9",
"738.3",
"428.33",
"365.9",
"427.31",
"707.21",
"V10.05",
"441.01",
"496",
"401.9",
"428.0",
"424.1",
"V10.09",
"366.9",
"733.13",
"427.89",
"733.09"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8300, 8380
|
3781, 5991
|
229, 236
|
8614, 8623
|
9372, 9659
|
2957, 3018
|
6511, 8277
|
8401, 8499
|
6017, 6488
|
8647, 9349
|
3033, 3758
|
8520, 8593
|
182, 191
|
264, 1910
|
1932, 2619
|
2636, 2940
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,714
| 164,454
|
12657+56386
|
Discharge summary
|
report+addendum
|
Admission Date: [**2159-4-25**] Discharge Date: [**2159-5-5**]
Date of Birth: [**2100-1-12**] Sex: F
Service: MICU
HISTORY OF THE PRESENT ILLNESS: This is a 59-year-old female
with an extensive recent past medical history including
Pseudomonas abdominal abscess, vancomycin-resistant
Enterococcal bacteremia, and severe right heart failure
well-healed presented from her nursing home with five to six
days of malaise and confusion.
On [**2159-4-21**], she was noted to be confused, had a cough
with brown sputum and complained of a sore throat. A chest
x-ray was performed as an outpatient that reportedly showed
pulmonary edema and bilateral effusions. Still, the
patient's oxygen saturations were said to be in the mid 90s
on 4 liters nasal cannula which is her baseline. Her Lasix
and Zaroxolyn doses were increased with good diuretic
response.
She spiked a temperature to 101.6. On [**2159-4-23**], she
began refusing food and became increasingly disoriented and
confused. She reportedly complained of epigastric pain,
nausea, and back pain. She denied chest pain, melena, and
diarrhea. Because of her mental status changes and fever,
she was sent to the Emergency Room for further evaluation.
In the Emergency Room, she was found to be disoriented and
confused. Her systolic blood pressure was in the 70s and
dopamine was started with good response; the blood pressure
increased to the 100s. She was given 3 liters of normal
saline IV. Her INR was found to be 16 for which she was
given 4 units of FFP and 5 mg of vitamin K p.o. Her chest
x-ray showed a right lower lobe infiltrate and she was given
vancomycin, levofloxacin, and Flagyl and admitted to the
Intensive Care Unit.
PAST MEDICAL HISTORY:
1. Intra-abdominal abscess from ceftazidime-resistant
Pseudomonas.
2. Question of cryptogenic cirrhosis.
3. Abdominal wall cellulitis.
4. Diabetes mellitus type 2.
5. Hypertension.
6. Umbilical hernia repair.
7. Atrial fibrillation, chronic, on Coumadin.
8. VRE bacteremia.
9. DVT/PE.
10. Chronic renal insufficiency with a baseline creatinine of
2.0 to 3.0.
11. Gentamicin-induced acute tubular necrosis.
12. Decubitus ulcer in the right hip, stage IV.
13. Gastroparesis.
14. Depression.
15. GERD.
16. Hypoglycemia causing unresponsiveness in the past.
ALLERGIES: Imipenem causes seizure.
ADMISSION MEDICATIONS:
1. Protonix 40 mg p.o. q.d.
2. Digoxin 0.125 mg p.o. q.o.d.
3. Zestril 2.5 mg p.o. q.d.
4. Effexor 100 mg p.o. b.i.d.
5. Lasix 60 mg p.o. b.i.d. recently increased to 80 mg p.o.
b.i.d.
6. Zaroxolyn 5 mg p.o. q.d. increased to 5 mg p.o. b.i.d. on
[**2159-4-23**].
7. Coumadin 4 mg p.o. q. Monday through Saturday, 2 mg p.o.
q. Sunday.
8. Zinc sulfate 220 mg p.o. q.d.
9. Duragesic patch 50 micrograms per hour to be changed q.
72 hours.
10. Neomycin 1 gram p.o. b.i.d.
11. Metoclopramide 5 mg p.o. b.i.d.
12. Ativan 0.5 mg p.o. b.i.d.
13. Vitamin C 500 mg p.o. b.i.d.
FAMILY HISTORY: Positive family history for diabetes
mellitus and no family history for cirrhosis.
SOCIAL HISTORY: She lives at [**Hospital 1475**] Nursing Home where
she has been for the last year since her admission in [**2158**]
for Pseudomonal abscess. She walks across the room
independently but remains chronically debilitated from her
prior severe illness. The closest relative is her brother,
Mr. [**First Name4 (NamePattern1) **] [**Known lastname 39094**]. She has a positive history of tobacco use
but details are unclear. [**Name2 (NI) **] history of ethanol or drug use.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature
101.0, heart rate 92, blood pressure 96/34, respirations 18,
oxygen saturation 95% on 4 liters and 90% on room air.
General: She was inattentive but verbal, disoriented, frail,
and chronically ill appearing, and in no acute distress.
HEENT: The pupils were equal, round, and reactive to light.
She had a dense cataract in the right eye. Extraocular
motions were intact. There was no scleral icterus. No
nystagmus. Neck: No lymphadenopathy. JVD was seen 10 cm
above the sternal angle at 30 degrees. Pulmonary: The
patient was not compliant with examination. There were
decreased breath sounds and expiratory wheezes at the right
base and rales at the left base. Cardiovascular: Normal S1,
loud S2, regular rate and rhythm, no S3 or S4. Abdomen:
Soft, nontender, nondistended, positive bowel sounds. The
patient refused Guaiac in the Emergency Room. She had a
large surgical scar in the left abdomen that was nontender
and well healed. Extremities: No peripheral edema, 2+
dorsalis pedis pulses. Neurologic: She moves all four
extremities. She was oriented to self only, inattentive.
She had asterixis. Skin: There was mild skin breakdown of
the sacrum. There was a stage IV decubitus ulcer at the
right hip. Back examination was notable for a completely
nontender spine examination.
LABORATORY DATA ON ADMISSION: White count 12.7. The
differential revealed 86% neutrophils, 8% lymphocytes, 4%
monocytes, hematocrit 31.6, platelets 413,000, mean cell
volume 79. PT 49.2, PTT 71.5, INR 16.0. Chem-7: Sodium
139, potassium 5.2, chloride 99, bicarbonate 22, BUN 160,
creatinine 5.3, glucose 85. Albumin 2.8, calcium 9.9,
phosphate 6.2, magnesium 2.5, ALT 40, AST 48, amylase 68,
total bilirubin 1.5. CK 39, MB 4, troponin less than 0.3.
The urinalysis showed a specific gravity of 1.012, moderate
blood, negative nitrates, trace protein, negative glucose,
negative ketones, negative bilirubin, pH 5.0, small leukocyte
esterase. Cell count 0-2 red blood cells, 0-2 white blood
cells, occasional bacteria, no yeast.
RADIOLOGY: Chest x-ray showed increased heart size with
prominent pulmonary vasculature, likely represented CHF, no
evidence of pneumothorax or large pleural effusions. There
was an infiltrate in the left lower lobe.
KUB showed no evidence of obstruction.
Abdominal ultrasound showed no evidence of ascites.
CAT scan of the head showed no intracranial hemorrhage.
EKG showed atrial flutter at 85 beats per minute with an old
Q wave in lead III, T wave inversions in V2 to V6 and II,
III, and aVF, and [**Street Address(2) 4793**] depression in lead V2. There was
poor R wave progression.
An echocardiogram from [**2158-5-8**] had revealed an ejection
fraction of greater than 55% and severe global right
ventricular hypokinesis with 4+ tricuspid regurgitation and
moderate pulmonary hypertension.
IMPRESSION: This is a 59-year-old female with a history of
pseudomonal intra-abdominal abscess and known right
ventricular failure who presented with deteriorating mental
status at her nursing home, fever, chest x-ray consistent
with CHF, coagulopathy, and acute on chronic renal failure.
HOSPITAL COURSE: 1. CHANGE IN MENTAL STATUS: The patient's
change in mental status is felt to be multifactorial. The
patient had acute renal failure with a significant uremia.
This was treated as discussed below. Once her uremia was at
its baseline, the patient remained confused and disoriented
suggesting an additional etiology or etiologies to her
persistent neurologic impairment. Because she carried a past
history of hepatic encephalopathy and was being treated as an
outpatient with Neomycin, we initiated treatment with
Lactulose. Additionally, we felt an infectious etiology was
likely contributing to her delirium.
2. INFECTIOUS DISEASE: Given the patient's hypotension,
fever, and history of Pseudomonal abscess, the Surgery
Service was consulted in the Emergency Room to assess whether
there could be an intra-abdominal source of infection. They
felt that this was unlikely given the examination and
radiographic findings.
We next turned our attention to the possibility of a
pulmonary source of infection. She was started on
levofloxacin which was immediately changed to meropenem given
her history of ceftazidime-resistant pseudomonal infection.
A bedside thoracic ultrasound was performed which revealed
low likelihood of effusion.
A chest CT performed on [**2159-4-27**] revealed a loculated
right pleural effusion whose appearance was most consistent
with hemothorax, although empyema could not be excluded.
There was dense atelectasis of the right lower lobe with a
potential superimposed pneumonia. There was a smaller left
loculated pleural effusion.
Given these findings, the patient underwent thoracentesis on
[**2159-4-30**] by ultrasound guidance. The fluid was
exudative and highly cellular with predominantly neutrophils.
Cytology was negative for malignancy. The fluid was red to
brown in color and was felt to likely represent infected
empyema with coagulated blood.
The Thoracic Surgery Service was consulted and on [**2159-5-2**] the patient underwent video-assisted thoracoscopic
surgery with evacuation of the hematoma without
decortication. Her pleural fluid grew ceftazidime-resistant
and meropenem-resistant pseudomonas. The strain of
Pseudomonas was sensitive to cefepime and her antibiotics
were switched to cefepime.
At the time of this dictation summary, the patient remains
with three chest tubes to suction.
Additional sources of fever were also considered. An LP was
performed which was negative. Blood cultures and urine
cultures were drawn, all of which were negative.
3. PULMONARY: The patient was not more hypoxic than her
baseline upon admission. In fact, she was briefly called out
to the floor on hospital day number two after she had been
weaned off of dopamine. However, she was increasingly
agitated on the floor and had an increasing oxygen
requirement of unclear etiology. A chest x-ray was performed
that showed no change from previous.
Due to increasing oxygen needs and questionable ability to
protect her airway, she was brought back to the Intensive
Care Unit and intubated. During her thoracoscopic surgery,
and intraoperative bronchoscopy was performed that showed
narrowing of a segmental right lower lobe bronchus. This was
suspicious for obstruction.
Upon return to the Intensive Care Unit, she was bronchoscoped
again and a biopsy was taken. The pathology is pending.
Question of whether her empyema/pneumonia could have arisen
secondary to obstruction.
The patient remained on mechanical ventilation at the time of
this dictation summary and the goal is to extubate as soon as
mechanics demonstrate sufficient improvement.
4. ACUTE ON CHRONIC RENAL FAILURE: The Renal Service was
consulted given her history of renal failure. The urinalysis
was consistent with ATN but there was also a significant
prerenal component suspected. With fluid resuscitation, the
patient's creatinine returned to as low as 2.4 and her BUN
was 44. This was felt to be her baseline. The Renal Service
signed off and recommended outpatient renal follow-up.
5. ANEMIA: This was felt likely to be secondary to chronic
disease and she was initiated on Epogen three times a week.
Her hematocrit was stable and she did not require
transfusion.
6. COAGULOPATHY: This was likely secondary to vitamin K
deficiency in this patient on Coumadin. Vitamin K was
provided with adequate reversal of her INR to 1.2. She was
heparinized while in the Intensive Care Unit in order to
provide stroke prophylaxis given her atrial fibrillation, and
also because of her history of DVT and PE.
7. ATRIAL FLUTTER/FIBRILLATION: The patient's rate is well
controlled off rate-controlling medications. As mentioned
above, the patient was anticoagulated for stroke prophylaxis.
8. NUTRITION: Tube feeds were initiated while the patient
remained intubated.
9. PROPHYLAXIS: The patient was on heparin and famotidine.
10. CODE STATUS: This was discussed with the patient's
brother and the patient is full code.
The remainder of the summary of this admission will be
dictated as an addendum.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4561**]
Dictated By:[**Name8 (MD) 2734**]
MEDQUIST36
D: [**2159-5-5**] 12:57
T: [**2159-5-6**] 20:14
JOB#: [**Job Number 39095**]
Name: [**Known lastname 7066**], [**Known firstname **] Unit No: [**Numeric Identifier 7067**]
Admission Date: [**2159-4-25**] Discharge Date: [**2159-5-14**]
Date of Birth: [**2100-1-12**] Sex: F
Service:
HOSPITAL COURSE:
1. Change in mental status: The patient's altered mental
status improved slightly after extubation in the Intensive
Care Unit. She had recovered from her acute renal failure,
therefore, it was felt by her ongoing infection was causing
her mental status to be unclear. However, the patient was
able to converse briefly, but was often disoriented to place
and time. She continued in this way until she became more
obtunded on the day of death.
2. Infectious disease: The patient was given three chest
tubes to suction, to drain ceftriaxone resistant and
meropenem resistant Pseudomonas empyema. She had undergone
evacuation of the hematoma without decortication on [**2159-5-2**]. She was transferred to the floor with two chest tubes
to drainage and one chest tube for irrigation and then
eventually the two chest tubes were put to water-seal. She
appeared to be oxygenating at about her baseline of 94-96% on
[**6-12**] liters of nasal cannula oxygen. She also had right
internal jugular central line which had been placed on
admission that was a risk for infection, but the patient was
not manifesting fever or elevated white count, and the line
was watched and was attempted to be changed on the day prior
to death.
On the day of death, the patient became hypothermic to 93.3
tympanic despite some warming blankets. After instituting
bear hugger, the patient's temperature rose to approximately
94. She also had dropping urine output over the 24 hours
prior to death. An Infectious Disease consult was obtained
for management of multidrug resistant empyemas as well as to
consider other sources of infection. They recommended
Vancomycin for possible line sepsis causing the clinical
picture of hypothermia as well as oliguria.
In addition, fungal cultures and blood cultures were obtained
to try to elucidate the mechanism of sepsis and fluconazole
was administered for concern of fungal sepsis. On the
evening of [**5-14**], the patient became bradycardic to about
the 30s and remained unresponsive. A code blue was called,
and the Code Blue Team attempted to resuscitate the patient.
The rhythm varied from bradycardia to asystole to pulseless
electrical activity.
Attempts at resuscitation were unsuccessful in restoring
pulse and rhythm, and the patient was pronounced dead on the
evening of [**5-14**]. The patient's brother was notified and
a postmortem examination was declined. The mechanism of
death was felt to be sepsis due to unknown source of
infection.
The patient had been planned to undergo decortication on
[**5-15**], but became too unstable to plan for the
decortication. She had been continued on cefepime throughout
her entire hospital course on the medical floor.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(2) 3954**]
Dictated By:[**Name8 (MD) 74**]
MEDQUIST36
D: [**2159-5-16**] 19:56
T: [**2159-5-17**] 07:26
JOB#: [**Job Number 7075**]
|
[
"707.0",
"427.31",
"428.0",
"397.0",
"584.5",
"510.9",
"496",
"486",
"571.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.09",
"38.93",
"34.91",
"03.31",
"00.14",
"33.22",
"34.04",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
2957, 3041
|
12320, 12333
|
2363, 2940
|
4933, 6735
|
12349, 15286
|
1738, 2340
|
3058, 3553
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,424
| 118,940
|
2284
|
Discharge summary
|
report
|
Admission Date: [**2132-11-5**] Discharge Date: [**2132-11-6**]
Date of Birth: [**2065-2-2**] Sex: F
Service: MEDICINE
Allergies:
Sulfonamides / Daypro / Glucosamine/Chondroitin
Attending:[**First Name3 (LF) 7934**]
Chief Complaint:
67 yo F w/ drop in hct noted by cardiologist on routine labs.
Major Surgical or Invasive Procedure:
none
History of Present Illness:
67 yo F w/ h/o CAD s/p mid LAD cypher stent [**2132-10-16**], critical
left carotid disease w/ h/o amaurosis fugax, and recently dx
cecal mass ([**2132-9-26**]) thought to be infectious who was referred
to ED by her cardiologist who noted a drop in hct from 31.5
([**2132-10-17**]) -> 21.8. Patient denies noticing BRBPR or black stools
but in ED was noted to have black guiac + stool on rectal exam.
NG lavage was negative. Patient denies h/o hemorrhoids 30 yrs
ago but no h/o GIB. She had heartburn several years ago but
nothing recently. She does c/o severe fatigue since her stent.
Of note, a CT from [**2132-9-26**] done for c/o right sided abdominal
burning with nausea and palpable fullness showed mass-like
thickening of the cecal tip with adjacent regional LAD
concerning for invasive colon cancer. Her sx resolved on
doxycycline and apparently her abdominal distension improved as
well. Patient has never had a c-scope. Her MDs were deferring
this following CT until carotids were intervened on. Of note,
patient denies c/o weight loss. She denies any back pain. She
denies any CP or significant SOB. No DOE noted because she has
been too fatigued to be active. + LH x a few days. Instead, she
is sleeping more than ever. She denies h/o NSAID use (except
ASA). She has no h/o PUD.
Past Medical History:
# htn
# hypercholesterolemia
# critical left carotid disease w/ left amaurosis fugax, surgery
deferred due to abnml EKG
# CAD s/p cypher stent [**2132-10-16**]
# asthma
# OA
# frequent sinus infections
# recently dx abd mass (noted on CT from [**2132-9-26**])
# herniated disc
.
PSHx:
# s/p appy
# s/p C-sxn x 2
# s/p TH-ectomy for goiter
# bladder and uterine suspension
Social History:
+ tob: 1 ppd x 35 yrs
rare etoh
Divorced. Lives alone. Retired office worker x 5.5 yrs. 3 kids
([**Last Name (LF) 3786**], [**First Name3 (LF) 2251**], and [**State 12000**])
Family History:
F w/ h/o angina in 50s, deceased due to MI in 70's
brother w/ h/o esophageal CA (h/o tob and etoh)
PGM w/ h/o RA
Physical Exam:
T 98.2 bp 136/67 hr 94 rr 16 O2 98% RA
genrl: in nad, laying in bed
heent: perrla (4->3mm), MMM, OP clear
cv: rrr, no m/r/g
pulm: cta bilaterally
abd: nabs, soft, nt/nd, no masses/hsm
rectal: black, guiac positive stool
extr: no [**Location (un) **]
Pertinent Results:
[**2132-11-5**] 08:40PM PT-12.8 PTT-23.9 INR(PT)-1.1
[**2132-11-5**] 08:40PM PLT COUNT-694*#
[**2132-11-5**] 08:40PM HYPOCHROM-2+
[**2132-11-5**] 08:40PM NEUTS-62.9 LYMPHS-25.6 MONOS-5.4 EOS-5.6*
BASOS-0.4
[**2132-11-5**] 08:40PM WBC-10.2 RBC-2.38*# HGB-7.1*# HCT-21.8*#
MCV-92 MCH-29.8 MCHC-32.5 RDW-14.6
[**2132-11-5**] 08:40PM CEA-23*
[**2132-11-5**] 08:40PM CALCIUM-9.0 PHOSPHATE-4.2 MAGNESIUM-2.0
[**2132-11-5**] 08:40PM CK-MB-NotDone cTropnT-<0.01
[**2132-11-5**] 08:40PM CK-MB-NotDone cTropnT-<0.01
[**2132-11-5**] 08:40PM GLUCOSE-95 UREA N-13 CREAT-0.7 SODIUM-140
POTASSIUM-4.8 CHLORIDE-104 TOTAL CO2-25 ANION GAP-16
Brief Hospital Course:
Patient Hct bumped and stabalized with PRBC. She got tired of
being in the hospital and refused to be seen or examined by
anybody in the hositpal including GI. Patient left AMA. Before
she left she was told to follow up with her PCP and take her
protonix twice a day instead of once.
Medications on Admission:
altace 5 mg po qd, synthroid 100 mcg po qd, zyrtec 10 mg po qd,
lipitor 80 mg po qd, protonix 40 mg po qd, plavix 75 mg po qd,
ASA 325 mg po qd, albuterol prn, toprol 25 mg po qd
Discharge Medications:
Left AMA
Discharge Disposition:
Home
Facility:
Left AMA
Discharge Diagnosis:
left AMA
Discharge Condition:
Left AMA
Discharge Instructions:
Left AMA
Followup Instructions:
Left AMA
|
[
"496",
"401.9",
"272.0",
"244.9",
"414.01",
"578.9",
"V45.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
3920, 3946
|
3370, 3658
|
369, 375
|
3998, 4008
|
2701, 3347
|
4065, 4076
|
2300, 2415
|
3887, 3897
|
3967, 3977
|
3684, 3864
|
4032, 4042
|
2430, 2682
|
268, 331
|
403, 1695
|
1717, 2091
|
2107, 2284
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,728
| 125,910
|
2966
|
Discharge summary
|
report
|
Admission Date: [**2145-3-18**] Discharge Date: [**2145-3-30**]
Date of Birth: [**2113-8-27**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Morphine / Codeine / Rifampin / Quinolones / Steri-Strip /
Iodine; Iodine Containing
Attending:[**First Name3 (LF) 64**]
Chief Complaint:
Infected L femur reconstruction
Major Surgical or Invasive Procedure:
[**2145-3-18**]: OPERATION: Removal of cement spacers from left femur
and
left tibia. Removal of left proximal femur and prosthetic
reconstruction (revision of proximal femur) and revision
total knee prosthesis (total femur replacement using [**Initials (NamePattern4) **]
[**Last Name (NamePattern4) 3389**] Howmedica nodular reconstruction system using a 47 mm
bipolar head, an 80 mm plus two 50 mm body segments and a
small rotating hinged knee with a 205 mm x 12 mm stem).
[**2145-3-18**]: Repair of left popliteal vein and ligation of
anterior tibial artery.
[**2145-3-18**]: Left lower extremity arteriogram with
contralateral second-order catheterization, left superficial
femoral artery to posterior tibial bypass graft with a
contralateral reverse saphenous vein.
History of Present Illness:
This was a planned procedure for removal of cement spacer and
tranisition to an allograft reconstruction vs. total femur
prosthesis based on bone stock.
Past Medical History:
She has a history of osteosarcoma diagnosed in childhood.
She had an allograft prosthetic composite left distal femur used
for limb salvage reconstruction in [**2126**].
Revision surgery with a titanium endoprosthesis [**2144-3-2**].
I&D for coag-negative staph infection [**2144-3-17**]
Removal of prosthesis and spacer placement [**2144-7-27**]
Currently on vancomycin therapy s/p 8 weeks (levels 14-20)ending
[**2144-9-21**].
Incomplete resolution of inflammatory markers with resurgence of
SCN infection.
[**2144-10-26**]: Removal of cement spacer, debridement of cement
from proximal femoral canal, excision of 10 cm of residual
infected femur, tibial osteotomy, and removal of tibial
component from prior total knee and patellar button from
prior total knee.
[**2144-10-29**]: Complex open reduction internal
fixation of left pathologic subtrochanteric periprosthetic
femur fracture.
On daptomycin, levaquin, rifabutin from [**2144-10-26**]; levaquin
stopped on [**2144-11-18**].
History of alcohol and cocaine abuse, currently in recovery.
History of Adriamycin toxicity
History of abnormal PAP smears in the past.
Social History:
Unemployed. Currently living with her mom who lives in the area
and has plans to move to the [**State 4565**] area after her surgery.
She is divorced.
Tobacco: Ten cigarettes a day x15 years. History of alcohol
and cocaine abuse, currently in recovery.
Family History:
Mother with osteoporosis and arthritis. Father with
hypertension. Siblings: Brother with bipolar disorder.
Physical Exam:
On day of DC:
Wounds to B LE clean, dry, intact. NO purulence or excessive
erethyma. Palpable DP pulse LLE. [**Last Name (un) 938**], FHL, G, TA intact.
AF, VSS
Pertinent Results:
All intraop, blood and urine CX's to date: no growth
Brief Hospital Course:
The pt was admitted for inpatient surgery. Intraoperatively, it
was determined that her bone stock was insufficient for an
allograft reconstruction. Intraoperative gram stains and WBC's
per HPF were not consistent with infection. Plans for a total
femru prosthesis were initiated. During creation of the tibial
plateau cut, and injury was sustained to vasculature surrounding
the knee. An intra-op vascular surgery consult was made. They
repaired a vein and ligated an artery . She had good
intraoperative doppled signals distal to the repair. Placement
of her total femur psothesis continued without further
difficulty. Post operatively, she had intermittently
dopplerable DP and PT signals. Vascular surgery was reconsulted
and the decision to proceed to arteriogram and possibel bypass
was made. [**Name (NI) **] pt was awoken and her and her family were
informed of her condition and the decision to proceed with the
vascular procedure was made. Her LLE arterial bypass was
completed and the pt remained intubated in the PACU. She was
extubated and pain management helped with her pain medication
optimization. She had easily palpable DP and PT pulses in her
LLE. She sustained low grade fevers, believed to be related to
atelectasis. Her intraop Cx were negative. Blood Cx and
urinary Cx's were negative. CXR's showed resolving atelecatasis
and effusion. Her fevers resolved. She mobilized well with PT.
her pain regimen was optimized. Her Cx's were all negative.
She was deemd appropriate for DC home with services.
Medications on Admission:
Clonazepam [Klonopin]
1 mg Tablet
1 Tablet(s) by mouth as directed 1 in am, 2 in pm 90 Tablet 2
(Two) [**Last Name (LF) **], [**First Name7 (NamePattern1) 1022**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Gabapentin [Neurontin]
300 mg Capsule
1 Capsule(s) by mouth three times a day 90 Capsule 6 (Six)
[**Last Name (LF) **], [**First Name7 (NamePattern1) 1022**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Mom[**Name (NI) 6474**] [Nasonex]
50 mcg Spray, Non-Aerosol
1 puff IN twice a day 1 Bottle 3 (Three) [**Last Name (LF) **], [**First Name7 (NamePattern1) 1022**]
[**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Omeprazole [Prilosec]
20 mg Capsule, Delayed Release(E.C.)
1 Capsule(s) by mouth twice a day 60 Capsule 6 (Six)
[**Last Name (LF) **], [**First Name7 (NamePattern1) 1022**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Prochlorperazine Edisylate [Compazine]
5 mg Tablet
[**12-2**] Tablet(s) by mouth q8 90 Tablet 3 (Three)
[**Last Name (LF) **], [**First Name7 (NamePattern1) 1022**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Sertraline
100 mg Tablet
1 Tablet(s) by mouth once a day 45 Tablet 1 (One)
[**Last Name (LF) **], [**First Name7 (NamePattern1) 1022**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Tizanidine
2 mg Tablet
2 Tablet(s) by mouth three times a day 180 Tablet 6 (Six)
[**Last Name (LF) **], [**First Name7 (NamePattern1) 1022**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Valacyclovir
500 mg Tablet
1 Tablet(s) by mouth twice a day Take for 3 days for each
episode 18 Tablet 2 (Two) [**Last Name (LF) **], [**First Name7 (NamePattern1) 1022**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Vancomycin
250 mg Capsule
1 Capsule(s) by mouth three times a day Take 1 tablet PO TID x 4
weeks; then [**Hospital1 **] x 2 weeks; qd x 2 week; then qod x 2 week 150
Tablet 0 (Zero) [**Last Name (LF) **], [**First Name7 (NamePattern1) 803**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
OTC Aspirin
(Prescribed by Other Provider: [**Name Initial (NameIs) **])
325 mg Tablet
1 Tablet(s) by mouth twice a day
Calcium
(OTC)
500 mg Tablet
one Tablet(s) by mouth daily
Magnesium
(Prescribed by Other Provider)
84 mg Tablet Sustained Release
two Tablet(s) by mouth twice a day
Multivitamin,Tx-Minerals [Vitamins & Minerals]
(OTC)
Tablet
Tablet(s) by mouth
Discharge Medications:
1. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) 30 mg
Subcutaneous Q12H (every 12 hours).
Disp:*60 30 mg* Refills:*2*
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
6. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. Tizanidine 2 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
9. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
DAILY (Daily) as needed.
10. Supplies
CPM machine for L knee: PRN, no hip flexion past 90 degrees
11. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours).
Disp:*120 Capsule(s)* Refills:*2*
12. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO
Q6H (every 6 hours) as needed.
13. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: Three
(3) Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
Disp:*100 Tablet Sustained Release 12 hr(s)* Refills:*0*
14. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: One
(1) Tablet PO Q8H (every 8 hours) as needed.
Disp:*80 Tablet(s)* Refills:*1*
15. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
16. CALCIUM 500+D 500 (1,250)-200 mg-unit Tablet Sig: One (1)
Tablet PO QD ().
17. Hydromorphone 4 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours).
Disp:*100 Tablet(s)* Refills:*0*
18. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Osteosarcoma L femur, s/p failed allograft and infected
prosthesis.
Discharge Condition:
improved
Discharge Instructions:
Partial weight bearing L leg, full weight bearing R leg
Strict posterior hip percautions: no ADDuction across midline,
no flexion past 90 degrees, no internal rotation.
No active ABDuction.
[**Male First Name (un) **] hose to LLE when possible
PRN CPM L leg
Keep incisions clean and dry
Physical Therapy:
Activity: Ambulate
Right lower extremity: Full weight bearing
Left lower extremity: Partial weight bearing
Avoid active ABduction L hip<br>Active assist ROM L knee<br>Work
on L calf strengthening<br>Posterior hip precautions<br>NO hip
flexion greater than 90 degrees<br>NO hip ADDuction beyond
midline<br>NO hip internal rotation
Treatments Frequency:
PRN dressing changes with dry sterile gauze to surgical
incisions if irritated
Staples will be removed in clinic on follow up
elevate L leg when in bed
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5866**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2145-4-9**] 10:30
Provider: [**Name10 (NameIs) **], Vascular surgery: FOllow up in [**3-7**] weeks
with arterial duplex. This will be arranged for you. Please
call ([**Telephone/Fax (1) 9393**] to confirm this appointment
Provider: [**Name10 (NameIs) **],[**First Name3 (LF) 251**] C. [**Telephone/Fax (1) 1228**] Call to schedule
appointment
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 1228**] Call to schedule
appointment
|
[
"518.0",
"998.2",
"E878.1",
"736.6",
"V10.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.32",
"00.80",
"84.57",
"39.29",
"88.48",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
8965, 8971
|
3165, 4711
|
379, 1157
|
9083, 9094
|
3088, 3142
|
9958, 10590
|
2777, 2889
|
7217, 8942
|
8992, 9062
|
4737, 7194
|
9118, 9405
|
2904, 3069
|
9424, 9760
|
9782, 9935
|
308, 341
|
1185, 1339
|
1361, 2487
|
2503, 2761
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,054
| 130,998
|
26751
|
Discharge summary
|
report
|
Admission Date: [**2134-2-1**] Discharge Date: [**2134-2-11**]
Date of Birth: [**2093-11-27**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Ethyl Alcohol / Erythromycin Base / Latex Gloves
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Chest pain/Acute type A dissection
Major Surgical or Invasive Procedure:
[**2134-2-1**] - 1. Aortic root replacement with a Bentall procedure
using St. [**Male First Name (un) 923**] 27 mm composite valve graft with coronary button
reimplantation. 2. Total arch replacement with a combination of
a 24 mm Vascutech Dacron tube graft and a 16 x 8 x 8 mm
aortobifemoral graft to the LCCA and the innominate artery. 3.
Coronary artery bypass grafting times one with a reverse
saphenous vein graft from the neo ascending aorta to the left
anterior descending coronary artery.
[**2134-2-4**] - Closure of open chest following previous
dissection repair.
History of Present Illness:
40 yo Spanish Speaking F with known Marfan's Syndrome and
history of Type B dissection who presented to ED this morning
with chest pain radiating to the back [**7-31**]. Bilateral UE BPs
unequal left 140 and R 60 systolically with
equal femoral pulses. Pt mentating. CT showed Type A aortic
dissection. Pt going straight to OR for Repair of Ascending
Aorta dissection/?AVR
Past Medical History:
Past Medical History:
Hypertension
Marphan's Syndrome
Asthma
Hashimoto's thryoiditis
Hyperprolactinemia
Loss of vision R eye
Arthritis
HA
dizzy
Past Surgical History:
s/p D&C with left salpingo-oophorectomy
HSC polypectomy - [**Hospital 8**] Hospital
Abd MMY - [**Hospital1 756**]
Social History:
non drinker
non smoker
Family History:
n/c
Physical Exam:
Pulse:68 Resp:12 O2 sat: 99%
B/P Right:60/ Left: 146/69
Height: Weight:
General: Well nourished female in mild distress
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 IV/VI holosystolic murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None []
Neuro: Grossly intact
Pulses:
Femoral Right:2+ Left:2+
DP Right:1+ Left:2+
PT [**Name (NI) 167**]:1+ Left:2+
Radial Right:2+ Left:2+
Carotid Bruit Right:transmitted murmur Left:
Pertinent Results:
[**2134-2-1**] - ECHO
Pre-bypass:
The left atrium is normal in size. No mass/thrombus is seen in
the left atrium or left atrial appendage. No atrial septal
defect is seen by 2D or color Doppler. Left ventricular wall
thickness, cavity size, and global systolic function are normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The aortic root is moderately dilated at the sinus
level. The ascending and descending aorta are mildly dilated. A
mobile density is seen in the ascending aorta, aortic arch, and
descending aorta consistent with an intimal flap/aortic
dissection. The number of aortic valve leaflets cannot be
determined due to the aortic dissection. There is no aortic
valve stenosis. Severe (4+) aortic regurgitation is seen. The
aortic regurgitation jet is eccentric, directed toward the
anterior mitral leaflet. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no
pericardial effusion.
Post bypass
Patient is in sinus rhythm. LVEF is globally depressed . LVEF=
35%. Mild RV hypokinesis. Mechanical valve seen in the aortic
position. Leaflets move well and the valve appears well seated.
Washing jets typical for this type of valve seen. Graft material
seen in the ascending aorta and arch.
[**2134-2-1**] CTA
1. New type A aortic dissection involving the aortic root and
extending to
the level of the descending thoracic aorta.
2. Extension of previously noted type B dissection, which now
extends to the level of the common iliacs bilaterally.
[**2134-2-11**] 05:25AM BLOOD WBC-15.1* RBC-4.79 Hgb-14.0 Hct-42.3
MCV-88 MCH-29.2 MCHC-33.1 RDW-14.4 Plt Ct-245
[**2134-2-11**] 05:25AM BLOOD PT-28.2* INR(PT)-2.8*
[**2134-2-10**] 05:00AM BLOOD PT-26.1* PTT-37.5* INR(PT)-2.5*
[**2134-2-9**] 12:50PM BLOOD PT-28.8* PTT-34.3 INR(PT)-2.8*
[**2134-2-10**] 05:00AM BLOOD Glucose-93 UreaN-15 Creat-0.8 Na-137
K-4.2 Cl-101 HCO3-28 AnGap-12
[**2134-2-11**] 05:25AM BLOOD Mg-2.1
Brief Hospital Course:
Mrs. [**Known lastname 15785**] was admitted to the [**Hospital1 18**] on [**2134-2-1**] for management
of her acute type A dissection. She was taken immediately to the
operating room where she underwent a bental procedure, total
arch replacement and coronary artery bypass grafting to one
vessel. Please see operative report for details. Postoperatively
she was taken to the intensive care unit with an open chest due
to swelling. She was transfused for postoperative anemia. Over
the next few days, she was diuresed. On [**2134-2-4**], she returned to
the operating room where she underwent sternal washout and
closure. Coumadin was started for her mechanical aortic valve.
On [**2134-2-6**], Mrs. [**Known lastname 15785**] awoke neurologically intact and was
extubated. On [**2134-2-8**] she was transferred to the step down unit
for further recovery. The physical therapy service was consulted
for assistance with her postoperative strength and mobility.
She was discharged to home on POD 10. By the time of discharge
the patient was ambulating freely, the wound was healing and
pain was controlled with oral analgesics.
Medications on Admission:
Acyclovir ?
Albuterol PRN
Fluoexetine
Hydrocortisone ?
Amlodipine 5mg
Lipitor 40
HCTZ 25
Isosorbide 30
Labetolol 200mg po BID
Losartan 50
Discharge Medications:
1. Outpatient Lab Work
INR goal for mechanical aortic valve is [**2-24**]. Her INR will be
followed by the office of Dr. [**Last Name (STitle) 23903**], phone ([**Telephone/Fax (2) 65891**].
Plan confirmed by Liula of Dr.[**Name (NI) 65892**] office. INR to be
drawn on [**2134-2-12**] with results sent to the office of Dr. [**Last Name (STitle) 23903**].
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
5. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*0*
6. Losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
7. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
Disp:*180 Tablet(s)* Refills:*0*
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
3 days.
Disp:*3 Tablet(s)* Refills:*0*
9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for 3
days.
Disp:*3 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
10. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day:
dose will change daily for goal INR [**2-24**].
Disp:*30 Tablet(s)* Refills:*2*
11. Triamterene-Hydrochlorothiazid 37.5-25 mg Capsule Sig: One
(1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*0*
12. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
2-4 Puffs Inhalation Q4H (every 4 hours) as needed for wheezing.
Disp:*qs * Refills:*0*
13. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
14. Outpatient Physical Therapy
outpatient physical therapy
dx: type A aortic dissection, s/p Bental procedure
evaluate and treat for improved strength and conditioning
Discharge Disposition:
Home With Service
Facility:
TBA
Discharge Diagnosis:
Type A dissection
Hypertension
Marfan's Syndrome
Asthma
Hashimoto's thryoiditis
Hyperprolactinemia
Loss of vision R eye
Arthritis
HA
dizzy
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with percocet prn
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
Please call to schedule appointments
Surgeon Dr. [**Last Name (STitle) 914**] in 4 weeks [**Telephone/Fax (1) 170**]
Primary Care Dr. [**Last Name (STitle) 23903**] in [**1-23**] weeks [**Telephone/Fax (1) 17826**]
Wound check appointment - [**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse
will schedule
INR goal for mechanical aortic valve is 2.5-3. Her INR will be
followed by the office of Dr. [**Last Name (STitle) 23903**], phone ([**Telephone/Fax (1) 65893**]. Plan confirmed by Liula of Dr.[**Name (NI) 65892**] office.
Completed by:[**2134-2-11**]
|
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"518.5",
"401.9",
"285.9",
"E878.8",
"414.01",
"493.90",
"759.82",
"245.2",
"716.90",
"369.70",
"424.1",
"998.0",
"441.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.2",
"34.79",
"38.45",
"36.11",
"96.6",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
7707, 7741
|
4403, 5531
|
363, 941
|
7924, 8020
|
2425, 4380
|
8645, 9231
|
1706, 1711
|
5720, 7684
|
7762, 7903
|
5557, 5697
|
8044, 8622
|
1533, 1649
|
1726, 2406
|
289, 325
|
969, 1344
|
1388, 1510
|
1665, 1690
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,274
| 133,526
|
43287
|
Discharge summary
|
report
|
Admission Date: [**2190-3-15**] Discharge Date: [**2190-4-5**]
Service: MEDICINE
Allergies:
Iodine; Iodine Containing / Penicillins
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Fever and change in mental status.
Major Surgical or Invasive Procedure:
Intubation and mechanical ventilation
Central line placement
Tracheostomy
PEG Tube placement
History of Present Illness:
This is an 88 y.o. woman with multiple medical problems who
presents to the MICU with UTI/?urosepsis, and PNA vs CHF. The
patient resides at [**Hospital3 **] Center and today was
noted to have increased confusion, fevers, decreased SaO2. Two
weeks ago, pt noted to have influenza B virus for which she was
treated supportively. She was evaluated by the covering doctor
at [**Hospital 100**] rehab who noted that she was not awake enough to eat
this morning. He noted fevers despite scheduled tylenol
administration and a cough and increasing congestion. At
[**Hospital 100**] Rehab, the patient's PE was notable for a temp of 102.8,
a heart rate of 105, and a sat of 80% on 3L which increased to
90% on same. At this point the decision was made to transfer
the patient to [**Hospital1 18**] for further evaluation and treatment.
In the ED, the pt was initially afebrile, but tachycardic at a
rate of 105. Pt was also breathing at a rate of 30 on a NRB
satting at 94%. Exam was notable for diffuse rhonchi and
decreased breath sounds in the LUL. CXR was notable for diffuse
PNA. Labs were notable for WBC=15.4 and worsenening renal
function with creatinine of 1.9 from a baseline level of 1.3.
Pt received albuterol(2) and combivent(1) nebs. Pt also
received ceftriaxone, azithromycin, and vancomycin. Pt
dropped her pressure to the 80s systolic and was started on
peripheral levophed. The patient was intubated and a RIJ was
placed. The patient was brought to the MICU intubated and
sedated and was therefore not able to provide additional hx.
Past Medical History:
HTN
hypercholesterolemia
diastolic CHF EF 60%
COPD/asthma
paroxysmal afib
sick sinus syndrome s/p pacemaker
Diabetes Mellitus (when she was in former rehab hospital)
DVT
?CAD
Nephrolithiasis
cataracts
CRI w/ baseline Cr 1.3 on [**10-16**] (per H&P from [**8-2**] Heb Reb
baseline 2)
dementia
CVA [**92**] yrs ago, periods of confusion since then
poor balance with frequent falls (coumadin stopped)
urinary incontinence
s/p left mastectomy for breast ca
anemia (unknown baseline)
Past Surgical History:
Left radical mastectomy
appendectomy.
Social History:
Non-smoker, no EtOH. Former nurse. Lives at [**Hospital 100**] Rehab.
Family History:
Noncontributory
Physical Exam:
HEENT:NCAT, intubated
COR:nl s1, s2, JVP obscured by IJ
LUNG:diffuse rhonchi most prominent at bases
ABD: obese, multiple raised hyperpigmented
EXT: No clubbing or cyanosis, 2+ edema
Neuro: intubated and sedated.
Pertinent Results:
ADMISSION LABS:
===============
[**2190-3-15**] 11:20AM PT-50.7* PTT-48.6* INR(PT)-5.8*
[**2190-3-15**] 11:20AM PLT COUNT-276#
[**2190-3-15**] 11:20AM NEUTS-79* BANDS-14* LYMPHS-5* MONOS-2 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2190-3-15**] 11:20AM WBC-15.4*# RBC-3.73* HGB-11.1* HCT-33.9*
MCV-91 MCH-29.6 MCHC-32.6 RDW-15.0
[**2190-3-15**] 11:20AM ASA-NEG ETHANOL-NEG ACETMNPHN-6.5
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2190-3-15**] 11:20AM CALCIUM-7.9* PHOSPHATE-3.5 MAGNESIUM-2.1
[**2190-3-15**] 11:20AM proBNP-7426*
[**2190-3-15**] 11:20AM GLUCOSE-121* UREA N-62* CREAT-1.9* SODIUM-143
POTASSIUM-4.0 CHLORIDE-100 TOTAL CO2-38* ANION GAP-9
[**2190-3-15**] 11:32AM LACTATE-1.1
[**2190-3-15**] 11:55AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2190-3-15**] 11:55AM URINE RBC-0-2 WBC-[**12-16**]* BACTERIA-MOD
YEAST-NONE EPI-0-2
[**2190-3-15**] 03:08PM LACTATE-1.7
STUDIES:
========
CT HEAD W/O CONTRAST [**2190-3-15**]
IMPRESSION:
1. No evidence of acute intracranial hemorrhage.
2. Evidence of old left frontal infarct.
CHEST (PORTABLE AP) [**2190-3-15**]
IMPRESSION: Moderate CHF. Underlying pneumonia cannot be
entirely excluded.
EKG [**2190-3-15**]
Atrial mechanism is unclear. Possibly sinus tachycardia, at rate
102 with left bundle-branch block but cannot exclude slow atrial
flutter, at rate 204 with 2:1 A-V block and slight variability
of A-V conduction. Even atrial fibrillation with high degree A-V
block and junctional pacemaker with left bundle-branch block
conduction cannot be altogether excluded (though much less
likely). Compared to the previous tracing of [**2189-11-3**] at 12:51,
ventricular demand pacing is no longer in evidence. The rhythm
in the former tracing is clearly atrial fibrillation with slower
but variable ventricular response, at rate 74.
TRACING #1
CHEST (PORTABLE AP) [**2190-3-16**]
IMPRESSION:
1. Persistent low position of the endotracheal tube.
2. Improving pulmonary edema with unchanged atelectasis versus
infiltrate in the right lung.
Portable TTE (Complete) Done [**2190-3-16**] at 2:00:00 PM
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size is normal. with
normal free wall contractility. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) are mildly thickened.
There is no aortic valve stenosis. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is mild functional mitral stenosis (mean
gradient XXmmHg) due to mitral annular calcification. 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.
Compared with the report of the prior study (images unavailable
for review due to technical difficulties) of [**2189-10-30**], findings
are similar.
CHEST (PORTABLE AP) [**2190-3-26**]
IMPRESSION:
1. In the interim, the lung volumes have improved.
2. Slight improvement in the multifocal airspace pneumonic
consolidations particularly in the right mid lung.
CHEST (PORTABLE AP) [**2190-3-27**]
FINDINGS: A single portable image of the chest was obtained and
compared to the prior examination dated [**2190-3-26**]. Allowing for
slight differences in technique, there is no significant
interval change. There is a right basilar hazy opacity likely
secondary to underlying small effusion. There is a left
retrocardiac opacity again noted likely secondary to underlying
atelectasis and a small to moderate-sized effusion, difficult to
exclude pneumonia. There is persistent perihilar fullness
associated with indistinct bronchopulmonary markings reflecting
underlying pulmonary venous congestion and interstitial edema.
The cardiac silhouette is within normal limits. A calcified
tortuous thoracic aorta is noted. The supporting lines are
stable and in satisfactory position.
CHEST (PORTABLE AP) [**2190-3-30**]
IMPRESSION:
1. Status post placement of a tracheostomy tube in a
satisfactory location.
2. Worsening of effusion on the right side; fluid is now seen in
the right minor fissure.
3. Stable Left pleural effusion.
4. Persistent cardiomegaly and moderate pulmonary edema
indicative of congestive heart failure.
CHEST (PORTABLE AP) [**2190-3-31**]
IMPRESSION:
1. Lung volume along with patient's body habitus and volume
overload might explain the worsening opacification in the left
lower lung. However, there is a definite left pleural effusion.
2. The right minor effusion has resolved.
3. The opacification seen in both lungs could either represent
edema or pneumonia or a combination of both, as well as an
element of volume overload, especially that the azygos vein
today is distended.
CHEST (PORTABLE AP) [**2190-4-1**]
Tracheostomy is at the midline with its tip 6 cm above the
carina. The right pacemaker leads terminate in the right atrium
and right ventricle. There is slight interval worsening of
pulmonary edema with unchanged bilateral pleural effusions, left
more than right in bibasilar atelectasis. Small amount of
subdiaphragmatic air is demonstrated on the left and most likely
related to insertion of the recent PEG.
The right internal jugular line was removed and replaced by
right PICC line with its tip terminating at the junction of the
right brachiocephalic vein and SVC.
CT TORSO [**2190-4-1**]:
#CHEST: Lung bases with bilateral lower lobe atelectasis,
slightly more extensive than on previous study. Moderate-sized
bilateral pleural effusions, incompletely evaluated, of simple
fluid attenuation, whose size on the right appears slightly
decreased from that study, and whose size on the left appears
stable. There is extensive mitral annular calcification,
unchanged.
#ABDOMEN: Because study is limited by no contrast, no liver
abnormalities are identified. The adrenal glands, spleen and
markedly atrophic pancreas appear unremarkable. The gallbladder
is distended, however demonstrates no wall thickening or
surrounding stranding to suggest acute process. The kidneys are
symmetric, somewhat atrophic, without evidence of
hydronephrosis. Loops of small and large bowel are normal in
caliber. Contrast has reached to the rectum. A PEG tube is in
place in the left upper quadrant, terminating within the lumen
of the stomach. There is a moderate amount of free air within
the abdomen noted. No lymphadenopathy is appreciated. There is
atherosclerotic calcification of the aorta in the proximal
branches, however no aneurysmal dilation. A small fat-containing
umbilical hernia is noted, and some of the air free in the
intraperitoneal cavity has tracked into it. Impression: No
evidence of bowel obstruction. Fat-containing umbilical hernia
unchanged in size, into which some of the free intraperitoneal
air has tracked.
#PELVIS: The uterus and rectum are unremarkable. There is no
free fluid in the pelvis nor is there lymphadenopathy. There is
sigmoid diverticulosis without evidence of diverticulitis.
Incidental note of flank calcified injection granulomas.
#OSSEOUS STRUCTURES: Multiple unchanged compression deformities
in the visualized lower thoracic and lumbar spines.
ABDOMINAL PLAIN FILM [**2190-4-4**]
Nonspecific bowel gas pattern without signs of bowel
obstruction.
Brief Hospital Course:
ALTERED MENTAL STATUS:
Likely secondary to pneumonia and UTI. Head CT negative for new
pathology. Toxicology screen negative. After treating pt's
infections, per family, she was at her baseline mental status.
RESPIRATORY FAILURE / PNEUMONIA:
Patient's respiratory failure was thought to be secondary to
MRSA pneumonia as well as component of CHF. She was intubated
and placed on the ventilator. She was diuresed with IV lasix and
treated for a full course of IV vancomycin and ceftriaxone. Her
WBC count normalized. She has been since treatment. Continued
atrovent and albuterol nebulizers. Due to prolonged need for
ventilator, she had tracheostomy and continues to be on the
ventilator, tolerating it well.
URINARY TRACT INFECTION:
The patient was found to have a UTI susceptible to ceftriaxone.
She completed a full course of antibiotics. Repeat UA and UCx
were negative.
ATRIAL FIBRILLATION:
On admission, pt's INR supratherapeutic while on coumadin. Held
and then heparin gtt started for anticoagulation. Had
intermittent episodes of atrial fibrillation with RVR. This was
controlled with IV lopressor.
HYPERTENSION:
Relatively controlled with metoprolol 12.5 mg. Pt was on 25 mg
TID at home, but had borderline pressures, so was decreased
while in ICU.
CHRONIC RENAL INSUFFICIENCY:
Cr elevated upon admission. Responded to IVFs and is now at
baseline.
ABDOMINAL PAIN / INCARCERATED UMBILICAL HERNIA:
Complained of pain after PEG placement. Abdominal XR did not
show any bowel obstruction or perforation. Most likely seconday
to PEG. Tolerated feeds without high residuals.
HYPERCHOLESTEROLEMIA:
Continued simvastatin.
DIABETES:
Montiored FS. While in hospital, pt was on insulin gtt. Switched
to sliding scale insulin and fixed dose insulin with relative
control of sugars.
F/E/N: Replete lytes PRN. Tube feeds. Pt s/p PEG placement.
PPX: Bowel regimen, PPI, heparin gtt
ACCESS: PICC
CODE: Full
----
TO DO:
[ ] tube feeds
[ ] transition heparin gtt to coumadin (PTT goal 60-80, INR
goal [**2-28**] for afib)
[ ] monitor blood pressures
[ ] if rapid Afib, try lopressor 5 mg IV x 1
Medications on Admission:
1. Acetaminophen 500 mg Tablet [**Month/Day (3) **]: One (1) Tablet PO Q4H (every
4 hours) as needed.
2. Ferrous Sulfate 325 (65) mg Tablet [**Month/Day (3) **]: One (1) Tablet PO
DAILY (Daily).
3. Fluticasone 110 mcg/Actuation Aerosol [**Month/Day (3) **]: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
4. Simvastatin 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day.
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Aspirin 325 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
8. Lactulose 10 gram/15 mL Syrup [**Hospital1 **]: Thirty (30) ML PO Q8H
(every 8 hours) as needed.
9. Docusate Sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO DAILY
(Daily) as needed.
10. Insulin Lispro 100 unit/mL Solution [**Hospital1 **]: One (1) injection
Subcutaneous ASDIR (AS DIRECTED): per insulin sliding scale.
11. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution [**Hospital1 **]: One (1)
neb treatment Inhalation Q2H (every 2 hours) as needed for
shortness of breath.
12. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) neb
treatment Inhalation Q6H (every 6 hours) as needed.
13. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol [**Hospital1 **]: [**1-27**]
Puffs Inhalation Q4H (every 4 hours).
14. Warfarin 3 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO once a day.
15. Metoprolol Tartrate 25 mg Tablet [**Month/Day (2) **]: 1.5 Tablets PO TID (3
times a day).
16. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
17. Furosemide 10 mg/mL Solution [**Month/Day (2) **]: [**3-1**] mL Injection once a
day: as directed by rehab physician.
Discharge Medications:
1. Chlorhexidine Gluconate 0.12 % Mouthwash [**Month/Day (3) **]: Fifteen (15) ML
Mucous membrane [**Hospital1 **] (2 times a day).
2. Simvastatin 10 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY
(Daily).
3. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day).
4. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: Ten (10) mL PO BID (2
times a day).
5. Lactulose 10 gram/15 mL Syrup [**Hospital1 **]: Thirty (30) ML PO TID (3
times a day).
6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
7. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Hospital1 **]: Six (6)
Puff Inhalation QID (4 times a day).
8. Albuterol 90 mcg/Actuation Aerosol [**Hospital1 **]: Six (6) puffs
Inhalation Q4H (every 4 hours) as needed for SOB.
9. Miconazole Nitrate 2 % Powder [**Hospital1 **]: One (1) Appl Topical TID
(3 times a day) as needed.
10. Acetaminophen 160 mg/5 mL Solution [**Hospital1 **]: Twenty (20) mL PO
Q4H (every 4 hours).
11. Aspirin 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
12. Fentanyl 75 mcg/hr Patch 72 hr [**Hospital1 **]: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
13. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
14. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID
(3 times a day).
15. Ondansetron HCl (PF) 4 mg/2 mL Solution [**Last Name (STitle) **]: Two (2) mL
Injection Q8H (every 8 hours) as needed for nausea/vomiting.
16. Insulin Regular Human 300 unit/3 mL Insulin Pen [**Last Name (STitle) **]: as per
sliding scale sliding scale Subcutaneous four times a day: as
per sliding scale.
17. Fentanyl Citrate (PF) 50 mcg/mL Solution [**Last Name (STitle) **]: [**1-27**] mL
Injection Q4H (every 4 hours) as needed.
18. Medication
Heparin gtt; titrate for PTT 60-80.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary Diagnosis:
1. Respiratory failure
2. Pneumonia
3. Urinary tract infection
4. Atrial Fibrillation
Secondary Diagnosis:
1. Abdominal pain secondary to incarcerated hernia
2. Acute on chronic kidney injury
Discharge Condition:
Stable. On ventilator with tracheostomy. Afebrile.
Discharge Instructions:
You were admitted for altered mental status and fever. You were
found to have a pneumonia and a urinary tract infection. You
were treated with a full course of antibiotics. You were
intubated due to respiratory distress and then extubated. You
had a tracheostomy and a PEG tube placement. You also got a
PICC for IV access.
Please continue the medications as prescribed. Please follow up
with your medical doctors.
If you have any of the following symptoms, please call your
doctor or go to the nearest ER: fever>101, chest pain, shortness
of breath, abdominal pain, altered mental status, or any other
concerning symptoms.
Followup Instructions:
Please follow up with your primary care physician [**Last Name (NamePattern4) **] [**1-27**] weeks.
Follow up with General Surgery Clinic at [**Hospital1 18**] [**Telephone/Fax (1) 21370**]
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
Completed by:[**2190-4-5**]
|
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"V45.01",
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icd9cm
|
[
[
[]
]
] |
[
"38.93",
"31.1",
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"96.04",
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] |
icd9pcs
|
[
[
[]
]
] |
16594, 16660
|
10524, 10532
|
281, 376
|
16916, 16971
|
2902, 2902
|
17651, 17998
|
2637, 2654
|
14605, 16571
|
16681, 16681
|
12672, 14582
|
16995, 17628
|
2493, 2533
|
2669, 2883
|
207, 243
|
404, 1968
|
16808, 16895
|
2918, 10501
|
16700, 16787
|
10547, 12646
|
1990, 2470
|
2549, 2621
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,679
| 185,313
|
46046
|
Discharge summary
|
report
|
Admission Date: [**2161-12-15**] Discharge Date: [**2161-12-24**]
Date of Birth: [**2107-7-26**] Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Vioxx
Attending:[**First Name3 (LF) 36695**]
Chief Complaint:
dyspnea and vaginal bleeding
Major Surgical or Invasive Procedure:
Dilation and Curretage
IUD removal
operative hysteroscopy
Polypectomy
13 units PRBC transfusion
History of Present Illness:
Patient is a 54 yo F with a history of dysfunctional uterine
bleeding presents with increasing dyspnea. Patient was admitted
to GYN [**2076-11-24**] with uterine bleeding. A Mirena IUD was placed
with some difficulty and uterine tissue revealed uterine polyps.
Per patient the bleeding has continued and she has used [**4-9**] pads
daily since discharge. The bleeding was somewhat better after
the IUD placement, but started having clots and cramping again
in the last 3-4 days (both were severe prior to IUD placement).
With the continued bleeding she has began to feel more
symptomatic with dizziness and dyspnea on exertion. She reports
that the symptoms became significant approximately 4 days ago.
She denies any history of chest pain or dyspnea at rest. She
does have occasional palpitations similar to her previous
episodes of atrial fibrillation.
.
In the ED initial vitals were t 98.5 Hr 79 BP 139/52 RR 26 O2
100% 5L
She was seen by the OB/GYN consult resident who recommended
evaluation of the IUD placement. It was not seen on pelvic u/s
but pelvic CT showed proper placement of the IUD. Additionally
gyn recommended treatment with provera to allow Mirena IUD to
help decrease the bleeding. In the ED she received ativan 1 mg
IV, provera 20 mg PO and received 1 U PRBCs.
.
Currently she has back pain. It is a [**7-14**] and is located in her
lower back. It radiates to her legs but is not associated with
any weakness or incontenence.
.
ROS: Positive for nocturia (takes lasix at night), Denies chest
pain, syncope, presyncope, dysuria, headache, blurry vision. Has
had elevated glucose to 400s in the last few days, no diarrhea,
constipated. No edema, no orthopnea, no PND. Has had decreased
appetite but drinking lots of water.
Past Medical History:
GynHx: LMP [**2157**], age 50. Denies h/o abnl paps, last pap [**2155**].
No h/o fibroids or polyps. No h/o STDs. Has not been sexually
active since [**2155**].
ObHx:
-FT SVD x 2, no complications
PMH:
- Moderate restrictive lung disease and severely impaired
diffusion capaciy. On 4 liters home O2 at baseline Last PFTS
[**3-11**]: FVC 1.37 33% predicted
FEV1 1.09 35% predicted
- CHF - diastolic dysfunction, EF >55%
- Atrial fibrillation/Aflutter, s/p cardioversion [**2-9**] and [**5-9**],
on anticoagulation (Neg holter [**5-9**])
- DM type 2, on insulin followed at [**Last Name (un) 387**], last HbA1C 9.8%
10/07
- HTN
- Morbid obesity
- Low back pain
- Depression/anxiety - stable, no suicidal ideation
- Hyperlipidemia
- GERD
Social History:
Pt present in ED with her sister, [**Name (NI) **]. [**Name2 (NI) **] two daughters.
Separated from husband. [**Name (NI) **] t/e/d. Ex-husband [**Name (NI) **] [**Name (NI) 76430**] is
the [**Hospital 228**] health care proxy.
Family History:
Mother: [**Name (NI) 430**] and neck ca, breast ca, colon CA and
myelodysplasia; Father: MI 49yo ([**Month (only) **]), ETOH; healthy siblings.
Physical Exam:
T 99.1 BP 150/52 HR 81 RR 22 O2 sat 98% 5L
Gen - Morbidly Obese, alert, oriented x 3, in NAD
HEENT - OP clear, pale mucous membranes. neck obese without
lymphadenopathy
CV - distant HR, regular rate
Lungs - clear bilaterally
Abd - obese, soft, non-tender
Back - no tenderness
Rectal - deferred
Ext - no edema, 2+ pulses
Neuro - intact strength and sensation bilaterally UE/LE,
reflexes 2+
Skin - no rashes, pale
Pertinent Results:
HCT: 25.3 on admission, 24.1 post 1st unit PRBC, 23.1 post 2nd
unit PRBC,
WBC
Cr
.
.
RADS:
.
US Pelvis [**2161-12-15**]: There is no hydronephrosis in either kidney.
The endometrium measures 10 mm. The uterus measures 10.3 x 5.7
x 6.2 cm. The right ovary is not definitely seen. Intrauterine
device is not definitely seen. Cystic structure measuring 3.7 x
3.0 cm is seen adjacent to the left adnexa, likely representing
paraovarian cyst. IMPRESSION: 1. IUD not definitely seen. 2.
Probable left paraovarian cyst. 3. Right ovary not seen.
.
CT Pelvis [**2161-12-15**]: Intrauterine device is present within the
uterus.There is left paraovarian cyst as seen on the ultrasound.
The rectum and visualized sigmoid colon are unremarkable. There
is no free pelvic fluid. Urinary bladder is distended.
IMPRESSION: 1. Intrauterine device within the uterus. 2. Left
paraovarian cyst as seen on the ultrasound.
.
CXR [**2161-12-15**]: In comparison with the study of [**2161-8-14**], there is
little change. Enlargement of the cardiac silhouette with
dilatation of pulmonary vessels persists. No evidence of acute
focal pneumonia.
Brief Hospital Course:
54 yo F with h/o atrial fibrillation, uncontrolled diabetes
mellitus, morbid obesity, restrictive lung disease, with vaginal
bleeding s/p IUD placement on prior hospitalization, admitted
with symptomatic blood loss anemia, treated with blood
transfusions and Provera.
# Dysfunctional uterine bleeding: Bleeding likely secondary to
excess estrogen in the setting of high peripheral conversion. In
addition, INR supra therapeutic on Coumadin. On prior
hospitalization for DUB, the patient had suction D&C with
endometrial biopsy negative for cancer, as well as placement of
Mirena IUD for long-term control of bleeding. On presentation,
GYN service was consulted. The patient was initially admitted
the Medicine with GYN consult because of her complex medical
issues. CT pelvis confirmed IUD well placed. Provera 20mg PO
daily x10days was started on [**2161-12-15**]. The patient was
transfused 6 units of PRBC's without complication. The patient
was also maintained on iron supplementation and a bowel regimen.
The patient's HCT improved from 25.3 on admission to 31.7 prior
to 6th unit.
Patient continued to bleed heavily. She was transferred to the
GYN service. On [**2161-12-19**] patient was noted to have weakness,
dizziness, and lightheadedness. Patient became hypotensive to
103/57 with a heart rate of 95. EKG showed normal sinus rhythm.
Hematocrit decreased from 31.7 to 22.6. Given the rapid
bleeding, decision was made to go to the operating room
emergently. Patient underwent a dilation and curettage and an
operative hysteroscopy with a polypectomy. The IUD was removed.
Please see the Operative note on [**2161-12-19**] for further detail. At
the time of this discharge, the pathology report is pending. The
surgery was uncomplicated. The patient received 2 units of blood
intraoperatively.
She was transferred to the ICU for continuous monitoring, and
received 4 more units in the ICU with the hematocrit improvement
to 28. Provera was also increased to 40mg PO daily. Vaginal
bleeding had improved dramatically. Patient was transferred to
the floor. However, the hematocrit trended down to 26, and she
received 1 more unit PRBC while on the floor. Follow up
hematocrits remained stable, increasing to 31.
In summary, patient received 6 units pre-operatively, and 7
units post-operatively. On discharge, she was no longer
bleeding, and hemodynamically stable.
# Mild Leukocytosis: On HD2, the patient's WBC increased to 12.4
and the patient had a low grade temperature of 100.1. The
patient had not received blood products in several hours. No
localizing symptoms. UA was negative. WBC decreased to 8.
# Dyspnea: The patient has restrictive lung disease with a home
O2 requirement. Symptoms of dyspnea likely secondary to blood
loss anemia. Chest x-ray was showed little change, without acute
focal pneumonia, though cardiac silhouette increased and
pulmonary vessels were dilated. Dyspnea was treated with O2 to
maintain sats and HCT correction with transfusions, Provera and
IUD as described above. If the patient remains dyspneic,
consider ECHO.
# Chronic diastolic heart failure: Currently the patient is
compensated. Lungs clear without signs of volume overload. Lasix
was continued. Beta-blocker was resumed the evening of
admission. The patient was monitored for signs and symptoms of
fluid overload.
# Atrial fibrillation: The patient has a history of AF with
three cardioversions. The patient reports last episode of
palpitations the Sunday prior to admission. On telemetry, the
patient was in sinus rhythm and her rate was well controlled
throughout the hospitalization. She was maintained on her
outpatient Norpace and beta-blocker. Admission INR was supra
therapeutic. Coumadin was held. When bleeding did not decrease,
anticoagulation was reversed with vitamin K. The patient's
cardiologist, Dr. [**Last Name (STitle) **] was consulted. Decision to hold
Coumadin indefinitely was made as the risk of hemorrhage was
felt to be greater than the risk of clot formation, given
patient was in normal sinus rhythm throughout her entire
hospitalization. The INR was reversed to 1.0 Patient's PCP [**Last Name (NamePattern4) **].
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1007**], will be following the patient closely, with the plan
of potentially restarting Coumadin as needed should the patient
revert to atrial fibrillation.
# Diabetes: The patient has poorly controlled diabetes with a
very high insulin requirement. [**Last Name (un) **] was consulted. Lantus was
increased to 90 Units [**Hospital1 **], and sliding scale was aggressive, but
FSG remained in the 200-300's. The patient had glucosuria on UA.
# HTN: The patient was continued on lisinopril and Lasix. She
was restarted on her beta-blocker the evening of admission. It
was initially held in the setting of symptomatic anemia.
# L toe Paronychia: The patient complained of ongoing L great
toe pain, redness. Podiatry was consulted, and removed the L toe
paronychia. Daily dressing changes were initiated. Patient was
started on a 10 day course of antibiotics. She initially
received Unasyn IV, and was transitioned to Augmentin. Foot Xray
did not reveal evidence of osteomyelitis. Patient is to follow
up with Podiatry in one week after discharge.
# Depression/anxiety: The patient said she felt safe and that
she felt reassured knowing the plan. She was continued on
venlafaxine.
# Gastroesophageal reflux: The patient was continued on
pantoprazole for GERD.
# FEN/GI: The patient remained euvolemic. Electrolytes were
repleted PRN. She tolerated a diabetic cardiac diet.
Medications on Admission:
-ASA 325 QD
-Furosemide 120 [**Hospital1 **]
-Glyburide-Metformin 5/500 (2 tabs QD)
-Humalog sliding scale
-Vicodin (up to 6 tabs per day prn back pain)
-Lantus 100 U QD
-Lipitor 40 QD
-Lisinopril 20 QD
-Magnesium OTC
-Norpace 100 mg (2 tabs [**Hospital1 **])
-Omeprazole 20 QD
-Toprol XL 50 QD
-Venlafaxine 75 QD
-Warfarin 5 mg
- Ferrous sulfate 325 mg daily
- colace [**1-6**] daily
Discharge Medications:
1. Home oxygen
O2 at 5-6 L/min continuous
2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Disopyramide 100 mg Capsule, Sustained Release Sig: Two (2)
Capsule, Sustained Release PO Q12H (every 12 hours).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
7. Furosemide 40 mg Tablet Sig: Three (3) Tablet PO BID (2 times
a day).
8. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily) as needed for anemia.
Disp:*60 Tablet(s)* Refills:*3*
9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
10. Clotrimazole 1 % Cream Sig: One (1) Appl Topical DAILY
(Daily).
Disp:*QS 2 month supply * Refills:*2*
11. Medroxyprogesterone 10 mg Tablet Sig: Two (2) Tablet PO
DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
12. Amoxicillin-Pot Clavulanate 875-125 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
13. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
14. Sterile Gauze Pad 4 X 4 Bandage Sig: QS 2 months Topical
change dressing q day.
Disp:*QS 1 month * Refills:*2*
15. Bacitracin 500 unit/g Ointment Sig: QS 1 month Topical once
a day.
Disp:*QS 1 month * Refills:*2*
16. Saline Solution [**1-5**] % Solution Sig: QS 1 month
Miscellaneous qs 1 month.
Disp:*QS 1 month * Refills:*2*
17. Insulin Glargine 100 unit/mL Solution Sig: One (1) mL
Subcutaneous twice a day.
Disp:*QS 1 mon supply * Refills:*2*
18. Syringe with Needle (Disp) 1 mL 26 x [**1-6**] Syringe Sig: QS 1
month supply Miscellaneous once a day.
Disp:*QS 1 mo supply * Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Dysfunctional uterine bleeding
.
Secondary:
Diabetes mellitus, type two
Chronic diastolic congestive heart failure
Gastroesophageal reflux disease
Hyperlipidemia
Hypertension
Depression
Anxiety
Anemia
Chronic lower back pain
Morbid obesity
Atrial fibrillation/flutter requiring anticoagulation
Moderate restrictive lung disease requiring home oxygen
Discharge Condition:
Stable, satting at her baseline, ambulatory.
Discharge Instructions:
You were admitted to the hospital because of vaginal bleeding
and symptomatic anemia. It is thought that the bleeding was
related to high levels of the hormone estrogen in the setting of
obesity. You had an intrauterine device placed to reduce the
bleeding during uour previous hospitalization. The position of
this device was confirmed. You were taken to the operating room
to get a sample of the endometrial lining, as well as remove a
polyp. At the time of your discharge the pathology report is
pending. The IUD was removed during this procedure. You were
given Provera for a continuous course until told otherwise. Your
symptomatic anemia was likely the result of chronic vaginal
bleeding. You were given blood transfusions to improve your
symptoms and correct your anemia. You were also treated for your
other medical conditions.
.
You should follow your pre-admission congestive heart failure
regimen. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3
lbs. Adhere to 2 gm sodium diet. You should restrict your fluid
intake as described by your physician.
.
You should follow up with your Gynecologist and Primary Care
Provider as instructed.
.
You should continue daily dressing changes of the left big toe.
Please wash the toe with Saline, dry in, and apply bacitracin
covered with sterilze gauze. Continue doing so until you see
podiatry. You will also need to finish a 10 day course of
Augmentin (antibiotics). You have received 3 days of antibiotics
in the hospital and will have 7 more days at home.
.
Return to the emergency room if you have a return of your
symptoms, worsening of your vaginal bleeding, persistent
bleeding after discontinuation of your Provera, dizziness,
lightheadedness, shortness of breath, palpitations, chest pain,
fever, chills or any other concerning symptoms.
Followup Instructions:
Please call [**Telephone/Fax (1) 543**] to set up a follow up podiatry
appointment for an appointment 1 week after your discharge
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 10491**], MD Phone:[**Telephone/Fax (1) 142**]
Date/Time:[**2162-2-9**] 9:30
Provider: [**Name Initial (NameIs) 703**] (C4) TCC RADIOLOGY Phone:[**Telephone/Fax (1) 327**]
Date/Time:[**2162-2-3**] 10:15
Provider: [**First Name8 (NamePattern2) 3130**] [**Last Name (NamePattern1) 3131**], MD Phone:[**Telephone/Fax (1) 2664**]
Date/Time:[**2162-2-3**] 2:30
Please call to set up a follow up appointment with [**Last Name (un) **] ([**Telephone/Fax (1) 17256**]
|
[
"300.4",
"250.02",
"681.11",
"427.31",
"428.0",
"455.0",
"401.9",
"278.01",
"288.60",
"V58.67",
"621.0",
"518.89",
"280.0",
"530.81",
"428.32",
"627.1",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.26",
"69.59",
"68.29",
"69.09"
] |
icd9pcs
|
[
[
[]
]
] |
12821, 12827
|
4944, 10540
|
311, 409
|
13230, 13277
|
3795, 4921
|
15143, 15814
|
3203, 3348
|
10975, 12798
|
12848, 13209
|
10566, 10952
|
13301, 15120
|
3363, 3776
|
243, 273
|
437, 2182
|
2204, 2942
|
2958, 3187
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,591
| 137,197
|
45830
|
Discharge summary
|
report
|
Admission Date: [**2131-8-20**] Discharge Date: [**2131-8-26**]
Service: [**Location (un) **] MICU
HISTORY OF PRESENT ILLNESS: An 85-year-old male with a
history of CAD, MR, and hypertension presented with dyspnea
and left flank pain for two days. He awoke one day prior to
admission with shortness of breath at rest. The shortness of
breath increased with exertion (climbing stairs). Patient
denied palpitations, chest pain, fever, chills, nausea,
vomiting, diarrhea. Patient also complained of right flank
pain that was intermittent and dull. The patient denied
hematuria or dysuria.
In the Emergency Department, the patient's blood pressure was
90/50 with no response with fluid bolus. He got dobutamine
which was discontinued as his blood pressure rapidly returned
to systolic of 127.
PAST MEDICAL HISTORY:
1. CAD status post inferior MI in [**2118**] with a RCA stent in
[**2119**].
2. MR with mitral valve prolapse.
3. Hypertension.
4. Alzheimer's.
5. Restrictive lung disease.
6. CVA with right uvula deviation and right lower extremity
weakness.
7. DVT complicated by pulmonary embolus.
8. Positive PPD.
9. Gout.
10. Osteoarthritis.
11. Cholelithiasis.
12. Abdominal aortic aneurysm.
13. Hematuria status post TURP.
ALLERGIES: Aspirin.
MEDICATIONS ON ADMISSION:
1. Allopurinol 300 mg p.o. q.d.
2. Colchicine 600 mg p.o. q.d.
3. Furosemide 40 mg p.o. b.i.d.
4. Nitroglycerin sublingual prn.
5. Metoprolol 50 mg p.o. b.i.d.
6. Micro-K 10 mEq b.i.d.
7. Zantac 150 mg p.o. b.i.d.
8. Lisinopril 10 mg p.o. q.d.
9. Finasteride 5 mg p.o. q.d.
10. Lac-Hydrin b.i.d.
PHYSICAL EXAM ON ADMISSION: Temperature 96.0, pulse 70,
blood pressure 127/102, respirations 18, and 100% on 2 liters
O2. General: Thin, African American male lying on a
stretcher in no acute distress. Neck: Positive JVD at
jawline with no bruits. Heart: S1 and S2 normal, regular,
rate, and rhythm, holosystolic murmur loudest at apex
radiating to axilla. Lungs: Crackles bilaterally [**1-22**] of the
way up. Abdomen: Thin with normoactive bowel sounds, soft,
nontender, and nondistended, 3 cm pulsatile abdominal mass.
Extremities: 1+ pedal edema bilaterally. Back: Positive
right CVA tenderness.
LABORATORY STUDIES ON ADMISSION: White blood cell count 11.3
with 83% polys, 0 bands, 8 lymphocytes, 7 monocytes, 2
eosinophils, 0 basophils, hematocrit 37.0, platelets 215.
Sodium 145, potassium 4.1, chloride 112, bicarb 22, BUN 52,
creatinine 2.9 (2.3 in [**2131-1-20**]). Glucose 120,
calcium 8.6, magnesium 2.8, phosphorus 2.9. CK 209, troponin
0.01.
CT of the abdomen without contrast showed an abdominal and
thoracic aortic aneurysm without evidence of rupture,
pulmonary fibrosis, and renal cyst. Coarsened trabeculae in
the right femoral head with question osteopenia.
EKG: Initially in rapid AFib, then with PVCs, left
ventricular hypertrophy, no ST-T wave changes.
Echocardiogram in [**4-/2125**]: EF of 40%, mild dilatation
positive MR.
BRIEF SUMMARY OF HOSPITAL COURSE: Patient was initially
admitted to the [**Hospital Unit Name 196**] service, where he was diuresed with
Lasix, but continued to have intermittent shortness of
breath. On [**2131-8-21**], his oxygen requirements increased with
decreased oxygen sats, satting 86% on 100% nonrebreather. He
was placed on a Heparin drip for AFib and question of
pulmonary embolus. We were unable to do a CTA/PE protocol
secondary to chronic renal failure; V/Q scan was felt to be
unlikely to be helpful given the patient's underlying lung
disease. Patient was transferred to the MICU for worsening
pulmonary status. Upon transfer, his blood pressure held
fairly well, however, he required dopamine and multiple fluid
boluses. He was noted to have runs of AFib with rapid
ventricular response in the 130s.
A second echocardiogram was performed which showed mild
regional left ventricular systolic dysfunction, abnormal
inferior wall motion, 4+ MR, 2+ TR, right ventricular [**Last Name (LF) 16089**],
[**First Name3 (LF) **] of greater than 60%. His cardiac enzymes continued to
rise.
He had a chest CAT scan on [**2131-8-22**] that showed severe
coronary calcification, moderately enlarged heart with an
enlarged PA that was unchanged from prior studies. There
were scattered paratracheal lymph nodes up to 1 cm, small
dilatation of the aorta and bilateral pleural effusions that
were new compared to a study from [**2131-8-20**] with an
increased density and severely fibrotic parenchyma. A CAT
scan of his abdomen showed a small amount of air in the
biliary tree, the liver, pancreas, spleen, and adrenals, and
bowels were unremarkable. There was enumerable simple renal
cysts bilaterally, dilated infrarenal aorta, and a small
amount of fluid around the liver. There is a right inguinal
hernia noted that was not obstructed.
Patient developed a metabolic acidosis with elevated lactate.
A Renal consult was obtained, who recommended bicarbonate for
lactic acidosis. They felt his acute renal failure and
chronic renal failure was likely secondary to ischemic ATN
with underlying on chronic renal failure likely secondary to
hypertension nephropathy. Recommended holding further
diuresis at this time and continue on bicarbonate drip.
On [**2131-8-23**], the patient into sustained AFib with a rate into
140s and no response to vagals. Patient was changed to
Neo-Synephrine from dopamine given concern for
arrhythmogenicity of dopamine. However, on Neo-Synephrine
drip his hypotension became more pronounced with systolic
blood pressures in the 80s. Patient was placed back on
dopamine and the Neo-Synephrine was weaned off. He continued
to experience hypotension and vasopressin was added.
Cardioversion was attempted with 100 jolts, however, he has
continued on AFib with rapid ventricular rate and
hypotension.
On the evening of [**2131-8-23**] patient did well, however, weaning
off all pressors including dopamine and vasopressin.
However, patient again developed hypotension with several
episodes of SVT.
On [**2131-8-26**], he had deterioration on his condition and was on
three pressors with continued hypotension and acidosis with
increased lactate and decreased urine output. Per discussion
with the family and the [**Hospital 228**] health care proxy, the
decision was made to make the patient comfort measures only
and to discontinue the ventilator. Shortly after
discontinuation of the ventilator, the patient underwent
asystole with fixed pupils, no spontaneous respirations, or
palpable pulses.
Time of death: 1:55 p.m. His family was notified and
declined a postmortem.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3795**]
Dictated By:[**Last Name (NamePattern1) 14605**]
MEDQUIST36
D: [**2131-11-7**] 14:14
T: [**2131-11-8**] 08:36
JOB#: [**Job Number 97619**]
|
[
"410.71",
"518.82",
"403.91",
"428.0",
"584.9",
"276.2",
"427.31",
"515",
"492.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.6",
"38.91",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
1292, 1603
|
2997, 6865
|
138, 808
|
2238, 2968
|
830, 1266
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,265
| 170,620
|
13279
|
Discharge summary
|
report
|
Admission Date: [**2144-7-3**] Discharge Date: [**2144-7-14**]
Date of Birth: [**2100-7-13**] Sex: M
Service: [**Last Name (un) **]
SERVICE: Transplant Surgery
HISTORY OF PRESENT ILLNESS: This is a 43-year-old patient
who presents to the [**Hospital1 69**]
today on [**2144-8-2**] for cadaveric pancreatic transplant.
The patient's past medical history is significant for living
related renal transplant in [**2136**]. The patient also has a
history of diabetes mellitus. The patient is consented and
preopped for transplant at this time and the plan is to
proceed with the operation and admit to the Transplant
Surgery Service.
PHYSICAL EXAMINATION: All vital signs were within normal
limits. The patient was alert and oriented times three, in
no apparent distress. The pupils were equally round and
reactive to light. The extraocular movements were intact.
The oropharynx was clear and moist with no signs of erythema.
The neck was supple with no lymphadenopathy or jugular venous
distention. The heart revealed a regular rate and rhythm
with no murmurs, rubs, or gallops. The lungs were clear to
auscultation bilaterally with no wheezes, rales, or rhonchi.
The abdomen was nondistended with normoactive bowel sounds,
nontender throughout, revealing a well-healed scar from
previous kidney transplant in [**2136**]. The pulses were 2+ with
no edema in all extremities.
HOSPITAL COURSE: The patient tolerated the procedure well in
the Operating Room and was admitted to the Transplant Surgery
Service at this time. The patient was placed on q.i.d.
fingersticks during this time to follow the control of his
glucose levels and all vital signs were stable in the
immediate postoperative period. On postoperative day number
one, [**2144-7-4**], the patient received 9,100 milliliters
fluid IV and put out over 4,000 milliliters of urine. The
[**Location (un) 1661**]-[**Location (un) 1662**] drain put out 305 milliliters and the
nasogastric tube put out 250 milliliters. The patient's
glucose level was 131 on postoperative day number one after
being 288 prior to the transplant and glucose levels were
noted to stay well controlled with levels on the following
days drawn showing a range between 96 and 177 with a median
of 141 between postoperative day number one and the day of
discharge, [**2144-7-14**]. The patient was afebrile
throughout the rest of his stay at the [**Hospital1 190**] and had a relatively unremarkable
postoperative course.
Ultrasounds were done of the pancreas on postoperative day
number three, [**2144-7-6**], which showed the pancreas to be
within normal limits and receiving an excellent flow.
Another ultrasound was performed on [**2144-7-7**],
postoperative day number four, and on [**2144-7-8**],
postoperative day number five. These studies all showed no
ductal dilatation, normal wave forms, no difficulties with
the anastomosis with only a small fluid collection anterior
to the pancreas and the ultrasound on [**2144-7-8**],
postoperative day number five, was a completely normal
Doppler study.
The patient was discharged on [**2144-7-14**] on the following
medications.
DISCHARGE MEDICATIONS:
1. Tacrolimus 4 mg b.i.d.
2. Rapamune 3 mg q.d.
3. Valcyte 450 mg p.o. q.d.
4. Bactrim one tablet p.o. q.d.
5. Nystatin.
6. Protonix 40 mg q.d.
7. Colace 100 mg b.i.d.
8. Aspirin 81 mg q.d.
9. Toprol 100 mg q.d.
10. Sotalol 120 mg q.d.
11. Coumadin 3 mg q.d.
12. Wellbutrin 150 mg q.d.
13. Digoxin 0.125 mg q.d.
14. Zocor 20 mg q.d.
DISCHARGE INSTRUCTIONS: The patient was to follow-up with
the Transplant Service at the clinic as directed and to have
weekly laboratories drawn. The patient was instructed to
[**Name8 (MD) 138**] M.D. if he had increasing fever, chills, drainage or
redness around the wound site or if there were any other
questions.
CONDITION ON DISCHARGE: The patient was stable and
discharged to home.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 3432**]
Dictated By:[**Last Name (NamePattern1) 15912**]
MEDQUIST36
D: [**2144-8-11**] 09:33:38
T: [**2144-8-11**] 09:55:55
Job#: [**Job Number 40422**]
|
[
"998.12",
"427.31",
"V42.0",
"401.9",
"414.01",
"V45.82",
"250.01",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"52.80",
"54.12"
] |
icd9pcs
|
[
[
[]
]
] |
3175, 3535
|
1424, 3152
|
3560, 3856
|
679, 1406
|
212, 656
|
3881, 4197
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,484
| 121,703
|
17473
|
Discharge summary
|
report
|
Admission Date: [**2146-1-20**] Discharge Date: [**2146-1-26**]
Service: CCU
HISTORY OF PRESENT ILLNESS: This is an 83 year old male with
a past medical history significant for hypertension, coronary
artery disease, status post inferior myocardial infarction,
gastroesophageal reflux disease, mild chronic obstructive
pulmonary disease, paroxysmal atrial fibrillation, who was
transferred to the CCU from the Cardiac Catheterization
Laboratory with a pericardial tamponade. The patient was
admitted to an outside hospital with supraventricular
tachycardia and treated with a calcium channel blocker which
led to complete heart block at which time a dual chamber
pacemaker implant was placed. The patient was discharged
[**2146-1-14**]. The patient returned to the outside hospital on
[**2146-1-18**], with chest pain, and was ruled out for myocardial
infarction. A transthoracic echocardiogram at that time was
without evidence of pericardial effusion on [**2146-1-19**]. The
patient did have a positive stress test, went to the Cardiac
Catheterization Laboratory there and was transferred to CMI
service at [**Hospital1 69**] for left
circumflex intervention. On [**2146-1-20**], the patient underwent
cardiac catheterization which demonstrated left main 30%,
left anterior descending 50% proximal, pressure determined to
be insignificant, left circumflex 70% which was stented with
2.5 by 13 millimeters. The patient was transferred to the
C-Medicine service with an original blood pressure of 128/42.
At 11:30 p.m., on [**2146-1-20**], the patient complained of chest
pain, heaviness which radiated to his back and neck.
Nitroglycerin was given, and systolic blood pressure dropped
to 105. He was given fluid. The systolic blood pressure
during that night was in the 70s to 80s. The patient was
taken back to the Cardiac Catheterization Laboratory. There
was a patent left circumflex stent with a new moderately
severe stenosis in the proximal left anterior descending.
Proximal and distal left anterior descending were
percutaneous transluminal coronary angioplastied. The
patient had ventricular tachycardia and was treated with
Amiodarone. Right heart catheterization showed right atrial
pressure of 23, right ventricle 28/23, pulmonary artery 28/23
and a wedge pressure of 24. Echocardiogram demonstrated
tamponade. Pericardiocentesis at that time removed 650cc of
bloody fluid. Intra-aortic balloon pump was placed, then
later pulled in the CCU.
MEDICATIONS ON TRANSFER:
1. Aspirin.
2. Plavix.
3. Integrilin.
4. Protonix.
5. Lopressor 25 mg twice a day.
PHYSICAL EXAMINATION ON ADMISSION TO CCU: Temperature is 91,
heart rate 60 and paced, blood pressure 88/54, oxygen
saturation 98% on AC ventilation, 800 by 18, FIO2 of 100%,
PEEP of 5. Generally, the patient is intubated, sedated but
frowning, moving arms. The pupils were 2.0 millimeters,
sluggishly reactive bilaterally, no scleral icterus. The
patient was pale. The oropharynx was dry. Decreased tongue
vesiculations. Neck - jugular venous distention to ear while
supine. Lungs - bilateral breath sounds without wheezing or
crackles anteriorly or laterally. Pericardial drain in place
oozing on bandage and actively bleeding. Heart with distant
sounds. Groin - left femoral Swan, right IUBP site, all
pulses dopplerable except left dorsalis pedis.
LABORATORY DATA: At 8:00 a.m., arterial blood gases revealed
pH 7.36/16/312, lactate 12.1. INR 1.6. Partial
thromboplastin time 81.9. White blood cell count 16.9,
hematocrit 31.9, platelet count 313,000. Sodium 139,
potassium 4.0, chloride 106, bicarbonate 9, blood urea
nitrogen 16, creatinine 1.4. It was 1.1 at the outside
hospital. Glucose 247 by fingerstick, anion gap 24.
Urinalysis - specific gravity 1.010, large blood, positive
nitrite, positive leukocyte esterase, greater than 300
protein, 250 glucose.
Chest x-ray showed endotracheal tube in good position, left
pleural effusion, question of right middle lobe infiltrate.
Electrocardiogram was ventricular paced with a left bundle
branch block.
HOSPITAL COURSE: The patient was an 83 year old man with
coronary artery disease, hypertension, status post PCI with
pericardial tamponade and 650cc pericardiocentesis. The
patient was on Integrilin, Aspirin and Plavix so bleeding
persisted in the setting of dysfunctional platelets. The
patient was transferred to the CCU from the catheterization
laboratory for closer monitoring. Coagulopathy was corrected
with platelet transfusions, DDAVP, Vitamin K and fresh frozen
plasma. The patient was also transfused packed red blood
cells. Since the patient was status post a left circumflex
stent and a left anterior descending percutaneous
transluminal coronary angioplasty times two, the patient's
enzymes were continued to be cycled especially in the setting
of the discontinuation of Integrilin, Aspirin and Plavix. On
presentation, the patient remained paced at 60 beats per
minute. The acidosis was thought to be secondary to the
setting of hypotension, lactic acid buildup. The patient was
also started on insulin drip. Electrolytes were monitored
closely for stabilization. Overall, the patient received
four units of packed red blood cells, three units of
platelets and one pack of fresh frozen plasma the first
night. In addition, blood cultures were sent and there were
gram negative rods in one out of four bottles. He was
started on Levaquin while awaiting identification and
sensitivities. The patient otherwise remained stable with
acidosis improving and improved glucose control, no longer
requiring an insulin drip. In addition, his creatinine
improved with improved perfusion. The following day the
patient had a repeat bedside echocardiogram which showed that
the right atrium and right ventricle were filling well. In
addition, the patient was starting to be weaned off the
ventilator. Thus from the standpoint of the tamponade, there was
minimal drainage and the preceding echocardiogram showed no
reaccumulation of fluid. At that point, an Aspirin and low
dose beta blocker were added. The patient did well and was
extubated later on [**2146-1-23**]. Overnight on [**2146-1-23**], the
patient was transfused one unit of packed red blood cells.
The pericardial drain was removed and as noted previously the
patient was extubated. He did have an event of
supraventricular tachycardia to the 120s, and was given 5 mg
of Lopressor with an appropriate response of his heart rate
back to the 90s. The patient continued to improve and he was
continued on Aspirin. The beta blocker was titrated up, and
ace inhibitor was added. Repeat transthoracic echocardiogram
was to be obtained and if no evidence of reaccumulation, the
patient was to be restarted on Plavix. Concern was that the
patient was coagulopathic, and laboratories were consistent
with DIC. Since he remained stable, it was determined just
to give blood products as needed for reversal. The patient
continued on levofloxacin for the gram negative rod
bacteremia. The patient was transferred to the floor on
[**2146-1-24**]. While on the floor, the patient had an additional
episode of tachycardia to the 130s with a decrease in his
systolic blood pressure at 100 to 110. The patient was given
5 mg of intravenous Lopressor with a decrease in his heart
rate to the 120s and systolic blood pressure increased to
120s. He was given a repeat dose of 5 mg of intravenous
Lopressor with a quick return of his heart rate to the 60s
and 70s and the blood pressure remained stable. The patient
remained asymptomatic throughout this period. On [**2146-1-25**],
the patient was increased on his standing beta blocker. A
transthoracic echocardiogram was obtained, without evidence
of tamponade. The patient continued to do well without
evidence of tamponade physiology and remained hemodynamically
stable. He was on his Captopril 6.25 mg three times a day,
Metoprolol 50 mg twice a day and restarted on his Plavix 75
mg for a goal of nine months of treatment. The patient was
also started on Atorvastatin 10 mg once daily.
MEDICATIONS ON DISCHARGE::
1. Nitroglycerin p.r.n..
2. Aspirin 325 mg once daily.
3. Protonix 40 mg q24hours.
4. Atorvastatin 10 mg once daily.
5. Levofloxacin 500 mg once daily.
6. Plavix 75 mg once daily times nine months.
7. Robitussin p.r.n.
8. Metoprolol 50 mg SR q24hours.
9. Lisinopril 10 mg once daily.
DISCHARGE DIAGNOSES:
1. Pericardial tamponade.
2. Stent of left circumflex coronary.
3. Percutaneous transluminal coronary angioplasty of left
anterior descending times two.
4. Myocardial infarction.
5. Enterobacter bacteremia, sepsis.
FOLLOW-UP: The patient is to follow-up with his primary care
physician in one to two weeks, follow-up with Device Clinic
[**2146-3-8**], at 1:30 p.m. and with Dr. [**Last Name (STitle) **] [**2146-3-8**], at
2:00 p.m.
CONDITION ON DISCHARGE: Improved, stable.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 5214**]
Dictated By:[**Name8 (MD) 17134**]
MEDQUIST36
D: [**2146-5-4**] 10:28
T: [**2146-5-7**] 08:02
JOB#: [**Job Number 48805**]
|
[
"410.91",
"423.0",
"414.01",
"411.1",
"785.51",
"997.1",
"496",
"790.7",
"276.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"97.44",
"96.04",
"88.55",
"88.56",
"37.61",
"99.29",
"36.06",
"36.01",
"96.71",
"37.22",
"37.21",
"37.0"
] |
icd9pcs
|
[
[
[]
]
] |
8440, 8881
|
8124, 8419
|
4092, 8098
|
116, 2482
|
2507, 4074
|
8906, 9152
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,961
| 188,674
|
31727
|
Discharge summary
|
report
|
Admission Date: [**2126-10-15**] Discharge Date: [**2126-10-22**]
Date of Birth: [**2064-2-5**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
unstable angina
Major Surgical or Invasive Procedure:
[**2126-10-16**] CABG X 5 (LIMA to LAD, SVG to DIAG, SVG to OM, SVG to
PDA with Y graft to PLV)
History of Present Illness:
Patient had new onset angina x 3 weeks. While undergoing stress
test she had angina and referred for cardiac cath which revealed
severe three vessel disease and left main disease. She was then
transferred to [**Hospital1 18**] for surgical management.
Past Medical History:
Hypertension, Hypercholesterolemia
Social History:
Lives with husband. Denies tobacco use. +ETOH use (1glass
wine/day).
Family History:
Non-contributory
Physical Exam:
VS: 79 158/86 14
Gen: Lying in bed in NAD
HEENT: NCAT, EOMI, PERRL, anicteric
Neck: Supple, FROM -JVD
Neuro: A&O x 3, MAE, non-focal
Pulm: CTAB
CV: RRR -c/r/m/g
Abd: Soft, NT/ND NABS
Ext: Warm, well-perfused, mild varicosities
Pertinent Results:
[**10-16**] CNIS: Minimal plaque with bilateral less than 40% carotid
stenosis. [**10-16**] Echo: Pre Bypass: The left atrium is mildly
dilated. No thrombus is seen in the left atrial appendage. No
atrial septal defect is seen by 2D or color Doppler. Left
ventricular wall thicknesses are normal. The left ventricular
cavity size is normal. There is mild to moderate global left
ventricular systolic dysfunction. Right ventricular chamber size
and free wall motion are normal. There are simple atheroma in
the aortic arch. There are complex (>4mm) atheroma in the
descending thoracic aorta. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion. There are
filamentous strands on the aortic leaflets consistent with
Lambl's excresences (normal variant). There is no aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened, but appear structurally normal.
Mitral regurgitation varied dramatically throughout the
prebypass period.. High Mild to Moderate([**1-29**]+)/low Moderate (2+)
mitral regurgitation is seen with provactive manuvers. With
application of nitroglycerin, mitral regurgitation became trace
to absent. Vena contracta was 0.5-0.6 cm at worst. Mitral
annulus averages 3.1 cm in diameter. Post Bypass: Patient is on
phenylepherine with atrial pacing. LV function is improved to
50-55% with no wall motion abnormalities. RV function remains
normal. Mitral Regurgitation is now trace to mild. Remaining
exam is unchanged. All findings discussed with surgeons at the
time of the exam.
[**10-21**] CXR: Resolved left apical pneumothorax and decreasing right
atelectasis. Increasing pleural fluid on the left.
[**2126-10-15**] 08:40PM BLOOD WBC-10.9 RBC-3.80* Hgb-12.1 Hct-34.4*
MCV-90 MCH-31.9 MCHC-35.2* RDW-13.1 Plt Ct-209
[**2126-10-21**] 06:40AM BLOOD WBC-8.2 RBC-2.76* Hgb-8.7* Hct-25.5*
MCV-92 MCH-31.4 MCHC-34.1 RDW-13.5 Plt Ct-250
[**2126-10-15**] 08:40PM BLOOD PT-12.9 PTT-101.9* INR(PT)-1.1
[**2126-10-19**] 06:00AM BLOOD PT-11.9 PTT-23.5 INR(PT)-1.0
[**2126-10-15**] 08:40PM BLOOD Glucose-117* UreaN-10 Creat-0.7 Na-142
K-3.6 Cl-112* HCO3-22 AnGap-12
[**2126-10-20**] 05:20AM BLOOD Glucose-110* UreaN-12 Creat-0.7 Na-144
K-4.3 Cl-109* HCO3-29 AnGap-10
[**2126-10-20**] 05:20AM BLOOD Calcium-7.8* Phos-2.5* Mg-2.3
Brief Hospital Course:
As mentioned in the HPI, Ms. [**Known lastname 74520**] was transferred to [**Hospital1 18**]
for surgical management of her coronary disease. She underwent
all pre-operative testing prior to surgery and on [**10-16**] was
brought to the operating room where she underwent a coronary
artery bypass graft x 5. Please see operative report for
surgical details. Following surgery she was transferred to the
CVICU for invasive monitoring in stable condition. Within 24
hours she was weaned from sedation, awoke neurologically intact
and extubated. On post-op day one she was started on beta
blockers and diuretics. She was gently diuresed towards her
pre-op weight. Later on this day she was transferred to the SDU
for further management. Chest tubes and epicardial pacing wires
were removed on post-op day two. On post-op day three she
required a blood transfusion for low HCT. She continued to do
well and worked with physical therapy for strength and mobility.
Early on post-op day five she had an episode of atrial
fibrillation and was started on amiodarone. She was discharged
the following day (post-op day six) in sinus rhythm with VNA
services and the appropriate follow-up appointments.
Medications on Admission:
At home: Zocor 40mg qd
At Transfer: Toprol XL 50mg qd, Aspirin 325mg qd, Heparin gtt,
Zocor 20mg qd, Actonel, Niacin, Calcium, Vit E,D, MVI
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day
for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
2. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO twice
a day for 7 days.
Disp:*14 Packet(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 1 months.
Disp:*60 Tablet(s)* Refills:*0*
5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
7. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Ferrous Gluconate 300 (35) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
CAeCod VNA
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 5
Post-op Atrial Fibrillation
PMH: Hypertension, Hypercholesterolemia
Discharge Condition:
good
Discharge Instructions:
please shower, no bathing or swimming for 1 month
no lotions, creams, or powders, to any incisions
no driving for 1 month
no lifting greater than 10 pounds for 10 weeks
call for fever greater than 100.5, redness, or drainage
Followup Instructions:
with Dr. [**Last Name (STitle) 14522**] in [**3-2**] weeks
with Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
Completed by:[**2126-10-22**]
|
[
"411.1",
"493.20",
"E878.2",
"512.1",
"E849.7",
"272.0",
"401.9",
"414.01",
"424.0",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.14",
"36.15",
"39.61",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
6090, 6131
|
3491, 4684
|
338, 436
|
6303, 6309
|
1157, 3468
|
6582, 6746
|
877, 895
|
4874, 6067
|
6152, 6282
|
4710, 4851
|
6333, 6559
|
910, 1138
|
283, 300
|
464, 717
|
739, 775
|
791, 861
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,517
| 174,684
|
3401
|
Discharge summary
|
report
|
Admission Date: [**2117-12-14**] Discharge Date: [**2117-12-20**]
Date of Birth: [**2058-5-11**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
shortness of breath/PE
Major Surgical or Invasive Procedure:
None
History of Present Illness:
59 yo man w/ hx DM Type II, HTN, obesity who presented to the ED
with acutely worsening SOB, lightheadedness, diaphoresis
following BM. Pt describes 3 days of DOE of 10 feet that he
first noticed ambulating while at work without noticable
precipitants. Pt noted no other symptoms until the day of
admission, when he felt diaphoretic, lightheaded and nauseated
while moving his bowels. He required assisstance to leave the
bathroom and subsequently contact[**Name (NI) **] EMS. He noted severe SOB
and a sensation of vomiting during this episode. On admission to
the ED, he reported no CP, V/D, F/C/M, orthop, PND, dysuria,
incontinence, recent travel or sick contacts.
Vitals on presentation were 958-99-128/82-16-100% on NRB (100%).
A CXR was unremarkable and a CT was obtained in the setting of
continued SOB. CT chest demonstrated large PEs in the left main
and right main with invasion into the segmental/sub-segmental
branches. Pt was started on heaprin gtt with improvement to
hemodynamic status. He was admitted to the [**Hospital Unit Name 153**] for 24 hour
observation (following that, spent 1 day awaiting transfer to
medicine). Since admission to the unit, pt notes no SOB, F/C/M,
N/V/D, CP. He has been hemodynamically stable is transferred for
further evaluation and observation.
Past Medical History:
1. hypertension
2. NIDDM
3. Gout
Social History:
married with 4 children
denies tobacco/alcohol/IVDA
Family History:
father died of MI at 58
no history of clots/cancers
Physical Exam:
T97.7 R24 SpO2 90% on NC BP122/78 P98
Gen-NAD, pleasant
HEENT-anicteric, oral mucosa moist, neck supple
CV-rrr, no r/m/g, faint heart sounds
resp-CTAB, faint breath sounds due to body habitus, no wheezes,
no accessory muscle use, speak in full sentences
[**Last Name (un) 103**]-soft, active BS, nontender, obese abdomen
neuro-A+O x3, PERL, EOMI, CNII-XII intact, moves all 4 limbs
symmetrically
extremities-DP 2+ bilaterally, no pitting edema, no swelling, no
calf tenderness, no palpable cords
Pertinent Results:
EKG [**12-14**]:
sinus with LAD, Q in II, III, aVF(old), no ST changes
CTA [**12-14**] :There is a large pulmonary embolus within the
left main pulmonary artery and multiple left segmental and
subsegmental branches.There is also a large pulmonary embolus
in the right
main pulmonary artery and multiple segmental and subsegmental
branches.
In the right middle lobe,there is a more nodular density
measuring approximately 7 mm, but this is adjacent to a
vessel, and not clearly separate from it. In both lower
lobes,there are peripheral opacities which are more linear as
opposed to wedge-shaped, more likely atelectasis, although
infarcts cannot be excluded in this setting.
Echo ([**12-15**]): Probably normal LV systolic function (due to poor
imager quality, a regional wall motion abnormality cannot be
excluded). Mild to moderate tricuspid regurgitation with
moderate pulmonary hypertension.
EKG ([**12-15**]): Sinus rhythm with slowing of the rate as compared to
the previous tracing of [**2117-12-14**]. Ventricular ectopy is no
longer recorded. There is prior inferior myocardial infarction
and probable anterior myocardial infarction as well. Diffuse
non-specific ST-T wave abnormalities. There is slight Q-T
interval prolongation. Compared to the previous tracing of
[**2117-12-14**] ventricular ectopy has abated and the rate has slowed.
Otherwise, no diagnostic interim change.
[**2117-12-14**] 07:30PM PT-13.6 PTT-23.3 INR(PT)-1.2
[**2117-12-14**] 07:30PM PLT COUNT-166
[**2117-12-14**] 07:30PM WBC-6.3 RBC-5.26 HGB-15.5 HCT-46.0 MCV-87
MCH-29.5 MCHC-33.7 RDW-13.5
[**2117-12-14**] 07:30PM CALCIUM-9.2 PHOSPHATE-3.4 MAGNESIUM-1.7
[**2117-12-14**] 07:30PM CK-MB-8 cTropnT-<0.01
[**2117-12-14**] 07:30PM LIPASE-34
[**2117-12-14**] 07:30PM ALT(SGPT)-60* AST(SGOT)-62* LD(LDH)-583*
CK(CPK)-1008* ALK PHOS-61 AMYLASE-41 TOT BILI-0.4
[**2117-12-14**] 07:30PM GLUCOSE-268* UREA N-11 CREAT-1.0 SODIUM-137
POTASSIUM-4.6 CHLORIDE-102 TOTAL CO2-24 ANION GAP-16
[**2117-12-15**] 02:00PM BLOOD CK-MB-8 cTropnT-<0.01
[**2117-12-15**] 08:23AM BLOOD CK-MB-8 cTropnT-<0.01
[**2117-12-14**] 07:30PM BLOOD CK-MB-8 cTropnT-<0.01
[**2117-12-20**] 07:10AM BLOOD WBC-5.7 RBC-4.95 Hgb-14.5 Hct-42.4 MCV-86
MCH-29.2 MCHC-34.1 RDW-13.8 Plt Ct-269
[**2117-12-20**] 07:10AM BLOOD Plt Ct-269
[**2117-12-20**] 07:10AM BLOOD PT-18.4* PTT-76.8* INR(PT)-2.1
Brief Hospital Course:
59 yo man w/ hx of HTN, DM II who presents with large bilateral
pulmonary emboli of unknown source treated successfully with
anticoagulation. He has been hemodynamically stable since
admission and notes no new complaints on transfer.
B/L PULM EMBOLI ?????? Large bilateral PE unaccounted for by hx ?????? no
hx long travel, coagulopathy. It is interesting, however, that
pt notes brother and sister (for a total of 3 out of 9 siblings)
that have presented to their respective physicians with clots. A
full set of studies (Factor V, homocysteine, lupus,
anti-cardiolipin ab, anti-thrombin, Protein C, S, etc) should be
considered ?????? will discuss w/ PCP as this may be best followed as
an outpt. He received coumadin 10mg yesterday w/ no change in
INR (1.4) and 15mg this AM prior to transfer. His warfarin dose
was titrated up secondary to body mass and non-response on 10mg
and heparin gtt continued until INR was between 2 and 3. On the
day of discharge, his INR was therapeutic at 2.1 on 12.5mg
coumadin; however, given that he was therapeutic for less than
2days and he was adamant about leaving, lovenox 120mg SC Q12 x2
days was prescribed. He will need close follow-up as an outpt
for furter titration of warfarin. He will likely require
lifelong anticoagulation.
HTN: Anti-hypertensives were withheld as pt was normotensive in
the setting of massive bilateral PEs. Pt will follow-up with his
PCP to restart antihypertensives as an outpatient.
DMII: Pt's serum glucose was high on admission, but reasonably
well controlled on his home meds, pioglitazone 30' and glyburide
10" with RISS coverage. He was on a dibetic diet.
ELEVATED TRANSAMINASES : On admission, pt's transaminases were
noted to be elevated. This was thought secondary to increased
load in the right heart s/p PE. LFTs trended down during his
stay.
PRESYNCOPE: Likely a vasovagal response secondary to valsalva
during BM in combination with developing PEs. Remained
asymptomatic during this admission. Pt also has hx of elevated
creatinine (nl MB fraction) and ruled out for MI; no evidence of
another acute muscular condition.
PROPHY: receiving heparin, ambulating as tolerated
FEN: Diabetic diet
CONTACT: wife: [**Telephone/Fax (1) 15752**], [**Name2 (NI) **]r: [**Telephone/Fax (1) 15753**]
DISPO ?????? Upon successful transition to warfarin and development
of appropriate outpatient therapeutic strategy, pt was
discharged home. He will follow-up with Dr.[**First Name (STitle) 1313**] on Thursday
[**12-23**] and have an INR check Wed [**12-22**].
Medications on Admission:
norvasc
glyburide
actos
diovan 160/12.5
ASA
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
3. Pioglitazone HCl 30 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*60 Tablet(s)* Refills:*0*
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
6. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
injection Injection ASDIR (AS DIRECTED).
7. Enoxaparin Sodium 120 mg/0.8 mL Syringe Sig: One (1)
injection Subcutaneous Q12H (every 12 hours) for 2 days.
Disp:*4 injection* Refills:*0*
8. Coumadin 2.5 mg Tablet Sig: Five (5) Tablet PO at bedtime.
Disp:*150 Tablet(s)* Refills:*2*
9. Outpatient [**Name (NI) **] Work
PT/INR
Please fax results to ([**Telephone/Fax (1) 15754**].
ATTN: Dr.[**First Name8 (NamePattern2) 1312**] [**Last Name (NamePattern1) 1313**]
Discharge Disposition:
Home
Discharge Diagnosis:
Bilateral pulmonary emboli
HTN
Diabetes
Discharge Condition:
Good
Discharge Instructions:
Please call your doctor and return to the hosiptal for any
increasing shortness of breath, chest pain, or any other
concerning symptoms you may have.
Please continue lovenox injections for 2 days amd follow-up with
Dr.[**First Name (STitle) 1313**] later this week for check of INR.
Followup Instructions:
Please follow-up with Dr.[**First Name (STitle) 1313**] in 1 week after discharge.
Please call for appointment: [**Telephone/Fax (1) 7318**].
Please have your bloodwork checked on Thursday, [**2117-12-23**] and faxed
to Dr.[**First Name (STitle) 1313**] for possible titration of your coumadin dose.
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
|
[
"790.4",
"415.19",
"250.00",
"274.9",
"780.2",
"401.9",
"278.00"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8583, 8589
|
4811, 7351
|
339, 346
|
8674, 8680
|
2401, 4788
|
9012, 9410
|
1817, 1870
|
7445, 8560
|
8610, 8653
|
7377, 7422
|
8704, 8989
|
1885, 2382
|
277, 301
|
374, 1676
|
1698, 1732
|
1748, 1801
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,603
| 141,895
|
39524
|
Discharge summary
|
report
|
Admission Date: [**2103-10-26**] Discharge Date: [**2103-11-2**]
Date of Birth: [**2048-4-13**] Sex: F
Service: NEUROSURGERY
Allergies:
Erythromycin Base
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
right leg numbness
Major Surgical or Invasive Procedure:
Left Craniotomy for resection of Left parietal mass
History of Present Illness:
Ms. [**Known lastname 46**] is a 55 year-old female with stage IIIC melanoma
(T4bN3bM0) who has completed surgical management and adjuvant
radiation therapy as well as surgical management of a second
primary, stage IB melanoma, currently on week 32 of interferon
therapy. However, her therapy has been hold due to tachycardia
possibly from volume depletion. She has had intermittent right
hand tingling and numbness for the past one or two years.
However, in the afternoon of [**2103-10-26**], she had a acute onset of
numbness of right [**Doctor Last Name **] that only lasted for 15 mins. After she
arrived at our ED, a head CT was taken and showed "2.3 x 1.7 x
1.5 cm lesion in the high left frontoparietal region with
surrounding vasogenic edema. adjacent small 0.4 cm focus of
hyperdensity=hemorrhage. additional 1 cm rounded lesion in the
right parietal lobe with mild surrounding edema". The neurology
team saw her and recommended an MRI of head and starting Keppra
and steroid. She denied focalized weakness, tingling, fecal and
urine incontinence.
Review of Systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies blurry vision, diplopia, loss of vision,
photophobia. Denies sinus tenderness, rhinorrhea or congestion.
Denies chest pain or tightness, palpitations, lower extremity
edema. Denies cough, shortness of breath, or wheezes. Denies
nausea, vomiting, diarrhea, constipation, abdominal pain,
melena, hematemesis, hematochezia. Denies rashes or skin
breakdown. No numbness/tingling in extremities. All other
systems negative.
Past Medical History:
Oncology history:
Ms. [**Known lastname 46**] noted a "pimple" on her mid back
which began to bleed intermittently, and increased in size. On
[**2102-8-8**] an excisional biopsy was performed with pathology
revealing an at least 14.5 mm deep, ulcerated and invasive
melanoma, which was classified as type non-specific, but clearly
contained a nodular component. There was a small focus of
epidermal involvement of MMIS and the tumor extended to at least
[**Doctor Last Name 10834**] level IV. Additionally, a PET/CT scan showed a 3 cm
FDG-avid mass in her right axilla without other disease. On
[**10-5**],
she underwent a wide local excision, sentinel lymph node
evaluation with selective left axillary lymphadenectomy, and a
right axillary lymph node dissection. There was no residual
disease found in the wide excision nor disease in the four left
axillary sentinel lymph nodes, however, five of twenty-seven
lymph nodes were involved in the right axilla, as well as
evidence of extracapsular spread. She completed a course of
adjuvant radiation therapy to her right axilla on [**2102-12-5**].
On [**2103-1-3**], she was preparing to commence a year of adjuvant
interferon when a suspicious lesion was identified on her right
leg above the ankle and was biopsied, with pathology showing a
1.2 mm deep, non-ulcerated invasive melanoma with at least two
mitoses per square millimeter.
On [**2103-2-1**], she underwent a wide local excision with sentinel
lymph node sampling with pathology revealing no evidence of
disease in the wide excision specimen or any of the three right
inguinal sentinel lymph nodes.
Ms. [**Known lastname 46**] began adjuvant interferon therapy on [**2103-3-13**]. In
early
[**Month (only) 116**], her chest x-ray revealed a new, ill-defined opacity in the
right apex projecting over the posterior third rib. On follow
up
CT performed [**6-15**], an area of most likely scarring was seen in
the right apex without features consistent with neoplasm seen.
In addition, a suspected stone at the level of papilla of Vater
with dilatation of common bile duct up to 11 mm. On [**6-19**], I
called to inform her of the results of her imaging. At that
time, she noted increased abdominal bloating, reduced energy and
appetite. She was referred to the [**Hospital1 18**] ED, underwent an ERCP
with sphincterotomy on [**6-20**] and a laparoscopic cholecystectomy
on
[**6-21**]. She was discharged on [**6-22**], and restarted interferon on
[**2103-7-4**].
PMH: obesity, hyperlipidemia
PSH: appendectomy, uterine myomectomy
Social History:
She lives alone and is currently unemployed. She has previously
worked doing secretarial work. She is a lifetime nonsmoker and
rarely drinks alcohol. She has no children.
Family History:
Her father died at age 58 from complications of colon cancer and
her mother died at age 88 from complications of an intracranial
hemorrhage. She has a 50-year-old sister who suffers from
epilepsy and multiple sclerosis. There is no family history of
melanoma.
Physical Exam:
Vitals: T 97.4 bp 160/90 HR 88 RR 18 SaO2 96% on RA
General: Comfortable, NAD
HEENT: NC/AT, EOMI, anicteric, slightly dry MM, chin-to-chest
normal motion and not painful
CV: RRR, nl s1/s2, no m/r/g
Lungs: clear to auscultation bilaterally without rales or
rhonchi
Abdomen: + bowel sounds, nondistended, no tenderness to
palpation, no organomegaly appreciated
Extremities: no edema or rash
Neurologic: A&OX3, CN II-XII grossly intact
Psych: appropriate, pleasant, cooperative
Pertinent Results:
[**2103-10-26**] 06:55PM GLUCOSE-115* UREA N-7 CREAT-0.6 SODIUM-144
POTASSIUM-3.3 CHLORIDE-108 TOTAL CO2-25 ANION GAP-14
[**2103-10-26**] 06:55PM estGFR-Using this
[**2103-10-26**] 06:55PM CALCIUM-8.9 PHOSPHATE-4.0 MAGNESIUM-2.0
[**2103-10-26**] 06:55PM WBC-7.2 RBC-4.22 HGB-11.9* HCT-35.3* MCV-84
MCH-28.2 MCHC-33.8 RDW-17.9*
[**2103-10-26**] 06:55PM NEUTS-83.1* LYMPHS-13.5* MONOS-3.0 EOS-0.3
BASOS-0.2
[**2103-10-26**] 06:55PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-OCCASIONAL
STIPPLED-OCCASIONAL
[**2103-10-26**] 06:55PM PLT COUNT-193
CT of the head:
2.3 x 1.7 x 1.5 cm lesion in the high left frontoparietal region
with
surrounding vasogenic edema. adjacent small 0.4 cm focus of
hyperdensity=hemorrhage. additional 1 cm rounded lesion in the
right parietal lobe with mild surrounding edema. findings highly
suggestive of metastatic dz. no midline shift or herniation.
MRI HEAD [**2103-10-27**]:Multiple parenchymal enhancing lesions,
consistent with
metastases. The largest lesion in the left paracentral lobule is
hemorrhagic and demonstrates moderate surrounding edema, but no
significant shift of midline structures and no herniation.
CT C/A/P [**2103-10-27**]: 1. Right axillary postoperative seroma and
radiation changes. 2. Scarring in mid-back at site of primary
melanoma lesion. 3. No evidence of additional disease in the
torso.
EEG [**2103-10-28**]
This is an abnormal awake and sleep EEG due to the presence
of occasional sharp wave discharges and spike and slow wave
discharges
in the bilateral frontal central regions, phase reversing at F3
and F4,
indicative of an area of epileptogenic cortex in these regions.
Additionally, intermittent bursts of theta frequency slowing was
seen in
the bilateral frontal central regions indicative of subcortical
dysfunction. Otherwise, the waking background reached a normal 9
Hz
alpha frequency rhythm. No clear electrographic seizures were
seen.
MRI brain [**2103-10-31**]
Stable appearance to multifocal peripheral parenchymal enhancing
lesions, with a large amount of edema surrounding the left
parietal lesion.
CT head [**2103-10-31**]
1. Expected postoperative changes in the left parietal resection
bed,
including minimal hemorrhage and pneumocephalus.
2. No large quantity of intracranial hemorrhage.
3. No acute large vascular territorial infarction.
4. No shift of normally midline structures or central
herniation.
Brief Hospital Course:
Ms. [**Known lastname 46**] is a 55 year-old female with stage IIIC melanoma
(T4bN3bM0) who has completed surgical management and adjuvant
radiation therapy as well as surgical management of a second
primary, stage IB melanoma, currently on week 32 of
interferon therapy(however, His therapy has been hold due to
tachycardia possibly from volume depletion), presenting with
right sided numbness and tingling and weakness. Head CT
revealed a new mass.
# Brain Mass: neuro was consulted for patient's numbness and
brain mass on CT. MRI was done which revealed hemorrhagic
lesion, likely metastatic melanoma in left parietal lobe which
would correspond to symptom distribution. EEG was also done
which showed epileptogenic cortex in frontal lobes bilaterally
but no seizures, as well as subcortical dysfunction. Pt was
started on Keppra for seizure prophylaxis as well as decadron
for management of cerebral edema. Pt's symptoms of tingling
improved without further intervention but did not completely go
away. Her primary oncologist recommended surgery to remove
largest brain met, followed by XRT. Due to hemorrhage
associated with lesion, anticoagulation and antiplatalet
therapies were avoided (DVT prophylaxis with pneumoboots) and pt
was placed on captopril to maintain SBP goal <160. On [**2103-10-31**]
the patient was transfered to the Neurosurgery service for Left
sided craniotomy for resection of left parietal lesion.
Postoperatively she was extubated and transfered to the PACU.
She remained there overnight without any issues. CT head showed
no hemorrhage. She was transfered to the floor. She was
transitioned OOB and her cathter was removed. Her diet was
advanced.
# anemia: this was likely secondary to underlying cancer and/or
medication or IV fluids. HCT was followed by remained stable.
Medications on Admission:
lorazepam 0.5 mg Tab
One - Two Tablet(s) by mouth Every 4-6 hours as needed for
nausea
naproxen 375 mg Tab
One Tablet(s) by mouth Two-Three times per day. as needed for
Fever, achiness, pain.
Simvastatin 20 mg Tab
1 Tablet(s) by mouth each night
prochlorperazine maleate 10 mg Tab
One Tablet(s) by mouth Three times per day as needed for nausea
Intron A 18 million unit (1 mL) Solution for Injection
self inject subcutaneously 18 miu three times a week M-W-F
Discharge Medications:
1. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for nausea.
2. naproxen 375 mg Tablet Sig: One (1) Tablet PO every twelve
(12) hours as needed for pain.
3. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
Q8H (every 8 hours) as needed for N/V.
4. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Keppra 750 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*0*
6. dexamethasone 2 mg Tablet Sig: Taper PO Taper for 5 days:
Take 2 tablets by mouth twice a day for 2 days. Then take 1
tablet twice a day for 2 days. Then take 1 tablet for 1 day.
Then discontinue.
Disp:*7 Tablet(s)* Refills:*0*
7. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for Pain.
Disp:*40 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Metastatic melanoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
General Instructions/Information
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures 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.
?????? If you are being sent home on steroid medication, make sure
you are taking a medication to protect your stomach (Prilosec,
Protonix, or Pepcid), as these medications can cause stomach
irritation. Make sure to take your steroid medication with
meals, or a glass of milk.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: increasing redness,
increased swelling, increased tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2103-10-31**] at 9:15 AM
With: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP [**Telephone/Fax (1) 19462**]
Building: [**Hospital6 29**] [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2103-10-31**] at 9:30 AM
With: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 14688**], RN [**Telephone/Fax (1) 22**]
Building: [**Hospital6 29**] [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: FRIDAY [**2103-11-2**] at 9:30 AM
With: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 14688**], RN [**Telephone/Fax (1) 22**]
Building: [**Hospital6 29**] [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: NEURO-ONCOLOGY
When: MONDAY [**2103-11-5**] at 1 PM
With: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 4861**], MD [**Telephone/Fax (1) 1844**]
Building: [**Hospital6 29**] [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Please obtain a referral for Dr. [**Last Name (STitle) 724**] from your primary care
physician. [**Name10 (NameIs) **] referral can be faxed to [**Telephone/Fax (1) 14669**].
Follow-Up Appointment Instructions
??????Please return to the office in 10 days (from your date of
surgery) for a wound check. This appointment can be made with
the Nurse Practitioner. Please make this appointment by calling
[**Telephone/Fax (1) 1669**].
??????You have an appointment in the Brain [**Hospital 341**] Clinic on [**2103-11-5**] at 1pm. The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 5074**] of [**Hospital1 18**], in the [**Hospital Ward Name 23**] Building, [**Location (un) **]. Their phone
number is [**Telephone/Fax (1) 1844**]. Please call if you need to change your
appointment, or require additional directions.
|
[
"196.3",
"348.5",
"198.3",
"278.00",
"431",
"285.9",
"272.4",
"729.89",
"172.7",
"782.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.59"
] |
icd9pcs
|
[
[
[]
]
] |
11161, 11167
|
8014, 9832
|
302, 356
|
11231, 11231
|
5549, 7991
|
13592, 15736
|
4763, 5027
|
10346, 11138
|
11188, 11210
|
9858, 10323
|
11382, 13569
|
5042, 5530
|
1466, 1975
|
244, 264
|
384, 1447
|
11246, 11358
|
1997, 4556
|
4572, 4747
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,755
| 127,592
|
4414
|
Discharge summary
|
report
|
Admission Date: [**2188-7-30**] Discharge Date: [**2188-8-5**]
Date of Birth: [**2125-3-28**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
Fevers at dialysis
Major Surgical or Invasive Procedure:
Removal of tunneled dialysis catheter
Intubation.
Central Line Placement.
History of Present Illness:
63 y/o female with h/o Diabetes Mellitus Type II, End Stage
Renal Disease on dialysis, HTN, unknown pulmonary condition on
3L 02 by nasal canula at home, presents from the [**Location (un) **]
Dialysis with fevers occuring during dialysis. [**Name (NI) **]
husband reports that she has been mildly lethargic for the past
week and has been having fevers following dialysis. Husband
reports patient was slightly confused on the day prior to
admission. Patient repots that she was feeling "fine" prior to
hospitilization. She went to dialysis on the morning of
admission as per her usual routine and developed a temperature
during the procedure. She was given IV Vancomycin at dialysis
and was transferred to the ED for evaluation of infection
concerns. During ambulance transfer, patient vomited and there
was a question that she may have aspirated gastric contents.
Patient recalls being placed in the ambulance but does not
recall anything from that moment until after she arrived in the
MICU.
.
Patient had previously had a right tunneled hemodialysis
catheter which was placed in [**9-2**]. Six months prior to
admission patient had a fistula for hemodialysis created in the
right arm. This fistula was seeded with bovine material.
Tunneled catheter was left in place because patient reported
signficiant pain with blood draws.
.
[**Hospital1 18**] ED Course: VS- T 100.5; HR 98; BP 161/64; RR 22; O2 100%
RA. ED notes indicate that the patient had labored breathing
upon arrival with tachypnea. Given the clinical apperance of
the patient, she was intubated to protect her airway. A Left IJ
central line was placed for access. Patient was given
Vancomycin/Ceftriaxone, Metronidazole, and Levaquin. She was
admitted to the MICU.
.
ROS:
General: Patient notes that she has felt tired for approximately
three weeks. She denies feeling feverous and notes that her
husband takes her temperature regularly. She denies any chills.
Patient reports that she has had good appetite and has not had
any recent dietary changes. She denies any changes in her sleep
pattern.
Skin: Patient reports that she regularly has ulcers on her legs.
Patient's daughter reported away from the presence of her
mother that she regularly witnesses her mother picking at the
scabs on her arms with a tweezers. Patient reports that her
legs are always red and swollen.
HEENT: Patient denies any vision changes. She does not
remember when her last eye exam was conducted. Patient denies
headaches or changes in her hearing. She denies allergies or
nasal drainage.
Cardiac: S/p 5 Vessel CABG in [**2179**]. Patient reports that she
was dancing with her son in-law at her sister's birthday party
in [**2179**]. She said that she felt short of breath and needed to
sit down. She then went to her PCP who recommended cardiology
f/u which resulted in cardiac catherization. Patient any other
episodes of chest pain or pressure.
Resp: Patient reports that she has been evaluated for sleep
problems but nothing was found on these studies. She says that
she cannot use CPAP machine. She is on 3L O2 by nasal canula at
all times at home. She reports that she sleeps in bed with only
one pillow at night. She denies any PND.
GI: Patient denies any diarrhea, constipation or recent changes
in the stool. She notes that she feels her abdomen is slight
distended.
GU: Patient reports that she has been on hemodialysis since
[**2184**]. She says that she produces very little urine and denies
pain or burning with urination.
ENDO: Patient reports that she is hypothyroid and is medically
managed.
EXT: Patient reports that she has sores on her feet that are
very slow to heal. She reports that she fell and broke her hip
requiring surgical correction.
NEURO: Patient reports that she does not feel her feet or her
hands. She notes that she does not feel pain from the ulcers.
She is unsteady on her feet and gets tired when she tries to use
her arms to push herself up from a chair. Most recently she has
been primarily using her wheelchair in the home.
Past Medical History:
1. DM2 since her 40s, dialysis since [**2-3**]
2. ESRD [**2-1**] DMII, on MWF HD, followed by Dr. [**First Name (STitle) 805**]. RIJ
tunneled cath placed on [**2185-12-13**] for peritoneal dialysis.
Fistula created in [**1-6**] but RIJ tunneled cath left in place for
access.
3. h/o MRSA cellulitis of bilateral LE
4. HTN
5. Hyperlipidemia
6. Hypothyroidism
7. PD cath placement on [**2185-12-13**] with RIJ tunneled cath
8. CAD s/p CABG [**2179**], NSTEMI in [**9-2**] during admission; echo [**3-4**]
with EF 35-40%
9. Anemia
10. Osteoporosis
11. Depression
12. h/o right hip fx s/o ORIF
13. On Home 3L O2, PFTs [**2186**] with restrictive pattern, pulmonary
HTN
14. R Charcot Foot
15. Restless Leg Syndrome
Social History:
The patient lives with her husband who is her primary caregiver.
She denies past or present tobacco use. She denies alcohol or
IV drug use. Patient previously worked as a secretary. She
endorses carbohydrate counting to control her diabetes and eats
a renal and cardiac friendly diet.
Family History:
Father - Deceased with MI at 60
Sister - Breast cancer diagnosed at age 56.
Mother - 60s, CAD; diagnosed with breast cancer in her 30s.
Son with DM
Physical Exam:
VS- T: 97.1 BP: 131/67 P: 85 RR: 22 O2 Sat: 95% on 3L
Fingerstick: 103 Weight: 94.0 kg
GEN: Patient is ill-appearing woman who appears much older than
her stated age of 63. She appears very pale and has thinning of
her hair. She was being fed dinner by her husband. She is in
no acute distress on 3L O2 by nasal canula.
SKIN- Scabs were noted on the extremeties.
HEENT: NC, AT. MMM, No oral sores noted. PERRLA. Midline
nasal septa. Opthalmoscopic exam revealed red reflux, no
diabetic changes noted (no cotton wool spots or hemorrages).
LIJ in place with slight ooze.
HEART: RRR. Systolic ejection murmur was heard best at the LUSB,
grade II/VI. No gallops or rubs noted.
LUNGS: Diffuse crackles were noted over both lung fields.
ABD: Bowel sounds were noted in all four quadrants. Abdomen was
distended with no tenderness. Right-sided abdominal hernia
noted which was easily reducable.
EXT: An ulcer was noted on the left malleolus which measures
approx. 1.5 x 0.8 cm. There is undermining from [**5-8**] oclock,
0.5 cm. The wound bed is 100% nonviable tissue and the bone is
palpable in the center of the wound bed. The wound edges are
macerated and defined. The periwound tissue is macerated and
erythemic, slight edema. There is no induration, fluctuance or
crepitus. R ankle is significant for displaced calcaneus bone.
+1 Ankle edema was noted on the right ankle. Patient has had an
amputation of the right fifth toe. Erythema is noted on both
shins extending from the ankle until 2 in below the knee. +1
DT/PT pulses. Palpable thrill over left arm AV fistula.
NEURO: PERRLA. CN II - XII intact. Decreased vibration and
temperature sensation in stocking glove distribution.
Pertinent Results:
Admission Labs:
[**2188-7-30**] 07:21PM WBC-13.7* RBC-3.09* HGB-9.4* HCT-31.6*
MCV-102*# MCH-30.5 MCHC-29.9* RDW-21.5*
[**2188-7-30**] 07:21PM NEUTS-91.9* BANDS-0 LYMPHS-5.1* MONOS-1.9*
EOS-1.0 BASOS-0.2
[**2188-7-30**] 07:21PM HYPOCHROM-2+ ANISOCYT-2+ POIKILOCY-OCCASIONAL
MACROCYT-3+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL
[**2188-7-30**] 07:21PM PLT SMR-NORMAL PLT COUNT-324
[**2188-7-30**] 07:21PM PT-15.0* PTT-28.6 INR(PT)-1.3*
[**2188-7-30**] 07:21PM GLUCOSE-142* UREA N-21* CREAT-3.1* SODIUM-138
POTASSIUM-3.9 CHLORIDE-94* TOTAL CO2-31 ANION GAP-17
[**2188-7-30**] 07:21PM ALT(SGPT)-17 AST(SGOT)-20 ALK PHOS-237*
AMYLASE-36 TOT BILI-0.6
[**2188-7-30**] 07:29PM LACTATE-2.7*
[**2188-7-30**] 09:02PM TYPE-ART TEMP-38.1 PO2-237* PCO2-51* PH-7.45
TOTAL CO2-37* BASE XS-10
.
Discharge Labs:
[**2188-8-5**] 05:25AM BLOOD WBC-7.2 RBC-2.78* Hgb-8.6* Hct-29.2*
MCV-105* MCH-30.8 MCHC-29.3* RDW-21.9* Plt Ct-312
[**2188-8-4**] 06:07AM BLOOD Neuts-81.0* Lymphs-10.6* Monos-4.2
Eos-3.9 Baso-0.3
[**2188-8-5**] 05:25AM BLOOD Glucose-82 UreaN-24* Creat-4.1*# Na-139
K-4.5 Cl-99 HCO3-30 AnGap-15
.
Imaging:
CXR An endotracheal tube and nasogastric tube are in unchanged
positions. A Portable chest radiograph is obtained. A right IJ
central line is again noted with its tip in the approximate
location of the caval atrial junction. Midline sternotomy wires
are again noted. The ET tube tip is seen approximately 2 cm
above the carina. The OG tube tip descends below the diaphragm,
with its tip excluded from view. Low lung volumes limits
evaluation. Small amount of linear atelectasis is seen in the
left mid and lower lung. No large effusions are present. There
is no pneumothorax. Stable mild cardiomegaly is again noted.
There is no evidence of CHF. Mediastinal and hilar configuration
is grossly unremarkable. The visualized osseous structures are
intact.
IMPRESSION:
1. Lines and tubes in good position.
2. Stable cardiomegaly, with linear atelectasis involving the
left mid-to- lower lung.
.
Transthoracic Echo: IMPRESSION: No vegetations or abscess seen,
but the study is technically suboptimal for full assessment of
valvular structure. Moderate biventricular systolic dysfunction.
Moderate mitral regurgitation. Moderate to severe tricuspid
regurgitation. Moderate pulmonary hypertension.
.
Compared with the prior study (images reviewed) of [**2187-3-29**],
severity of
tricuspid regurgitation may have slightly increased. Severity of
pulmonary hypertension has decreased. The other findings are
similar.
.
Transesophageal Echo:
IMPRESSION: Aneurysmal interatrial septum with small secundum
ASD/right-to-left flow. Moderate mitral regurgitation. Moderate
tricuspid
regurgitation. Complex atheroma in the aortic arch. Rigth
ventricular cavity
enlargement with free wall hypokinesis. No discrete valvular
vegetations
identified.
.
Left Ankle X-ray:
There are no findings to suggest osteomyelitis such as bony
destruction or
soft tissue defects. However, of note there is significant
demineralization of the osseous structures, which decreases the
sensitivity for detection of such findings. Small plantar and
posterior calcaneal spurs are also seen. Marked vascular
calcifications are present.
Brief Hospital Course:
[**Hospital1 18**] ED Course: VS- T 100.5; HR 98; BP 161/64; RR 22; O2 100%
RA. ED notes indicate that the patient had labored breathing
upon arrival with tachypnea. Given the clinical apperance of
the patient, she was intubated to protect her airway. A Left IJ
central line was placed for access. Patient was given
Vancomycin/Ceftriaxone, Metronidazole, and Levaquin. She was
admitted to the MICU.
.
MICU Course: VS- T 101.3; BP 116/37; HR 70; RR 18-20; O2 100% AC
FIO2 0.5 TV 500 RR 18 PEEP 5. Removal of tunneled hemodialysis
catheter was performed by Radiology on [**2188-7-31**]. Patient extubated
with out event. Patient was treated in MICU given indwelling
line and leukocytosis with left shift with vancomycin dosed per
level and ceftriaxone 1g IV q24h for gram negative coverage.
.
FLOOR Course:
.
Mrs. [**Known lastname 5395**] was admitted to the floor from the MICU in stable
condition. During the course of her stay, she had [**6-6**] blood
cultures taken on [**2188-7-30**] positive for coagulase negative
staphlococcus. There was no growth in [**4-2**] blood cultures taken
on [**2188-8-1**] and [**2188-8-2**]. Patient's indwelling catheter tip was
negative for growth. Wound in the patient's foot was positive
for Coagulase positive Staph Aureus. MRSA swab of the nares was
negative; patient has past history significant for MRSA positive
bilateral lower extremity cellulitis. Stool culture was
negative for for C. Difficile. CBC was significant for
leukocytosis with left shift throught the duration of stay. TTE
and TEE were negative for valvular involvement. Patient denied
any pain or burning with urination though she notes that she
does not produce much urine. Patient had a potential witnessed
aspiration event in the ambulance, CXR did not show any evidence
of consolidation, cough, or chest pain throughout the duration
of her stay. Patient was dosed Vancomycin IV with her dialysis.
Trough goals were 15-20 mg.
.
Patient had 2 episodes of shortness of breath which were
temporally linked to episodes of hypoglycemia. Patient denied
cough productive of sputum, chest pain, or recurrent shortness
of breath following hypoglycemic events. Mild diffuse crackles
were noted on physical exam; CXR was clean. Previous PFTs from
[**2186**] note a restrictive lung process. Patient was increased to
4L oxygen by nasal canula. 02 sats were stable at 97% on 4L at
the time of discharge.
.
Patient was seen by podiatry and wound care for an open wound of
her left malleolus. X-ray of the foot showed no findings of
osteomyelitis such as bony deformation of soft tissues. Patient
was noted to have significant demineralization of the bone which
decreases the efficacy of x-ray for osteoperosis diagnosis.
Wound swab grew coagulase positive Staphlococcus Aureus.
Patient has palpable pulses in both feet. Wet to dry dressings
were applied to foot by wound care. Vancomycin was dosed with
dialysis.
.
Patient is hemodialysis dependant secondary to ESRD. She
received dialysis on MWF as well as an additional day of
dialysis on Tu ([**2188-8-5**]) for concern of volume overload.
Continued Sevelmar Hydrochloride, Nephrocaps, Calcium Acetate
dosing at dialysis. Vancomycin was dosed at dialysis.
.
Patient has long standing Diabetes Mellitus. She had 2 episodes
of hypoglycemia (BS - 40s) occuring in the early morning
(04:00). Patient was given juice and 1 amp D50 which she
responded with blood glucose to 200. Her Lantus dose was
decreased to 30 mg daily; her sliding scale insulin was
decreased at bedtime. Blood sugars remained stable on this
regimen.
.
Patient was maintained on Clopidogrel 75 mg daily, Asprin 81 mg
daily, and Metoprolol 50 mg [**Hospital1 **] for her CAD and hypertension.
Hypothyroidism was maintained on Levothyroxine Sodium 50 mcg
daily. Depression was treated with home Sertraline 100 mg
daily. Patient received Carbidopa-Levodopa (25-100) 2 tablets
at bedtime for known restless leg syndrome.
.
Left central IJ line was removed prior to discharge by medicine
team.
Medications on Admission:
AMBIEN 10 mg--1 tablet(s) by mouth at bedtime
AMOXICILLIN 500 mg--4 capsule(s) by mouth 1 hr before dental
work
ASPIRIN 81 mg--1 tablet(s) by mouth once a day
B COMPLEX --1 capsule(s) by mouth daily
COZAAR 50 mg--1 tablet(s) by mouth 4 times a week
DAYPRO 600MG--2 by mouth every day with food
DIGOXIN 125 mcg--[**1-1**] alternating with 1 tab tablet(s) by mouth
q4days 2 tabs po initially, then [**1-1**] alternating with 1 tab
every 4 days.
Humalog Pen 100 unit/mL (75-25)--use as directed twice a day as
needed for high sugars
KLONOPIN 1 mg--1 tablet(s) by mouth 0 1 po qhs and 2 po before
hd
LANTUS 100 unit/mL--30-50 unit once a day as directed
LIPITOR 10 mg--1 tablet(s) by mouth at bedtime
MIRAPEX 0.125 mg--[**1-1**] tablet(s) by mouth at 6pm and again at
bedtime
NEPHROCAPS 1 mg--1 capsule(s) by mouth once a day
NORVASC 5 mg--1 tablet(s) by mouth once a day
PHOSLO 667 mg--2 capsule(s) by mouth as directed
PLAVIX 75 mg--1 tablet(s) by mouth q am
RENAGEL 800 mg--1 tablet(s) by mouth as directed
SYNTHROID 50 mcg--1 tablet(s) by mouth once a day
TOPROL XL 100 mg--1 tablet(s) by mouth at bedtime
ZOLOFT 100 mg--1 tablet(s) by mouth q am
Discharge Medications:
1. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. Sevelamer 800 mg Tablet Sig: Three (3) Tablet PO TID (3 times
a day).
6. Vancomycin in Dextrose 1 g/250 mL Solution Sig: Three (3)
grams Intravenous with HD for 36 days: please treat for a total
of 6 weeks starting [**2188-7-31**] and ending [**2188-9-11**].
7. Ambien 10 mg Tablet Sig: One (1) Tablet PO at bedtime.
8. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
9. B Complex Capsule Sig: One (1) Capsule PO once a day.
10. Daypro 600 mg Tablet Sig: Two (2) Tablet PO once a day: with
food.
11. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO at bedtime.
12. Lipitor 10 mg Tablet Sig: One (1) Tablet PO at bedtime.
13. Norvasc 5 mg Tablet Sig: One (1) Tablet PO once a day.
14. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day.
15. Mirapex 0.125 mg Tablet Sig: [**1-1**] Tablet PO once at 6pm then
at bedtime.
16. Digoxin 125 mcg Tablet Sig: [**1-1**] alternating with 1 Tablet PO
every 4 days 2 tabs po initially, then [**1-1**] alternating with 1
tab every 4 days.
17. Klonopin 1 mg Tablet Sig: One (1) Tablet PO at bedtime: and
2 tablets before hemodialysis
.
18. Humalog Mix 75-25 100 unit/mL (75-25) Suspension Sig: use as
directed Subcutaneous twice a day as needed for for high
sugars.
19. Lantus 100 unit/mL Solution Sig: Thirty (30) units
Subcutaneous once a day: at lunchtime.
Disp:*1 10 mL* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Primary Diagnosis:
- Coagulase Negative Staphlococcus Bactermia
Secondary Diagnosis:
- Diabetes Mellitus Type II
- End Stage Renal Disease
- Open Wound on Left Malleolus
- Restrictive Pulmonary Process
- Restless Leg Syndrome
- Hypertension
- Hypercholesterolemia
- Coronary Artery Disease
- Hypothyroidism
- Anemia
- Osteoperosis
- Depression
Discharge Condition:
Stable.
Discharge Instructions:
You were admitted to the hospitals for fevers which were noted
at your dialysis center. While in the hospital you received an
antibiotic, Vancomycin, at your inpatient dialysis appointments.
You will continue to receive this antibiotic at dialysis for
six weeks because you had bacteria in your blood and in your
foot that are being treated with this antibiotic. You are no
longer showing any clinical signs of infection.
.
In the emergency room your physician was concerned about your
ability to breath and you were intubated. You were taken off
the ventilator one day after admission. You have been short of
breath a few times since admission and your oxygen settings have
been increased to 4L. Please continue to use 4L of oxygen at
home.
Please follow the attached medication list. Your home
medications are all being continued except for Cozaar. Please
have the staff at hemodialysis check your blood pressure and if
it is high speak with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5781**] about adding your
Cozaar. You will also be receiving a new medication, Vancomycin,
with hemodialysis.
.
If you experience any fevers, chills, nausea, vomiting,
shortness of breath, increasing fatigue, or any other concern,
please call your primary doctor. If you cannot reach your
primary doctor or still have concerns, please return to the
Emergency Room or call 911.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2188-8-21**] 12:20
Provider: [**First Name11 (Name Pattern1) 5445**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5446**], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2188-8-28**] 2:50
Provider: [**Name10 (NameIs) 6821**] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 1971**] Date/Time:[**2188-8-28**]
10:15
Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 128**] Date/Time:[**2188-9-2**]
2:00
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 1401**], M.D. Phone:[**Telephone/Fax (1) 2386**]
Date/Time:[**2188-9-2**] 3:00
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21,388
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15242
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Discharge summary
|
report
|
Admission Date: [**2105-3-24**] Discharge Date: [**2105-4-18**]
Date of Birth: [**2038-4-12**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Chest pain, shortness of breath, NSTEMI
Major Surgical or Invasive Procedure:
Cardiac catheterization
Intubation
Transfusion of packed RBC
Bronchoscopy with BAL
Central line placement
History of Present Illness:
Patient is a 66 yo woman with PMH DM (poor compliance) who was
initially admitted to [**Location (un) **] [**2105-3-21**] with c/o "high blood
sugars". Also noted to have CP and SOB. Patient is poor
historian, but states chest pain located in center of chest,
unable to characterize or identify strength of pain, came on at
rest while she was at home, associated with SOB. She denies
having this chest pain before, denies recent angina or DOE
symptoms, LE edema, PND, orthopnea. However, per daughter, she
states that the patient has been c/o SOB x past month, described
as DOE. Daughter denies that patient has been having chest
pain.
.
Patient was admitted to ICU at [**Location (un) **] for management of her
hyperglycemia(Glucose = 1200). On admission, she also ruled for
NSTEMI with Trop=7.46, and was also noted to have ARF with
elevated Cr=4, which was thought [**2-19**] hypovolemia from diuresis
from elevated blood sugars. She was started on an insulin drip
with good control of blood sugars, started on plavix, aspirin,
heparin, statin and beta blocker for her NSTEMI. She was not
started on an ACE I due to her ARF. She was given stress dose
steroids, as she was on prednisone as an outpatient and ?found
to be adrenally insuffiecient. During her [**Hospital3 **]
course, her peak Trop=28.72, CK 647, MB 82.1. Patient was noted
to have elevated LFTs during hospital course, and therefore
lipitor was d/ced (although thought elevated LFTs could also
have been [**2-19**] shock liver as patient was hypotensive on initial
admission). Patient underwent ECHO on [**2105-3-23**] that demonstrated
inferior ischemia, EF=40%. She had episode of SOB on floor for
which she received 40mg IV lasix with good UOP and resolution of
symtpoms. On [**2105-3-24**] patient underwent dobutamine stress test
that was stopped due to SOB and CP, decreased O2 sat to 85%, TWI
in lead II and III. She was started on nitro gtt and
transferred to [**Hospital1 18**] for cardiac catheterization. On transfer,
patient's labs notable for Cr decreased to 1.3, glucose 245, WBC
12.6, Hct 34.3.
.
On arrival to cath lab, patient noted to have diffuse b/l
crackles, increased O2 requirement, inablitity to lay flat. She
was therefore transferred to CCU for diuresis prior to cath.
.
Currently patient denies CP/pressure, SOB, feels "tired", no
other complaints.
Past Medical History:
DM
COPD, steroid dependent
Lung CA s/p rescection (LUL lobectomy)
anxiety
GERD
Social History:
smokes 1ppd x 40years, no EtOH, no drug use, lives with son in
[**Name (NI) 1157**] per patient. Per OSH notes, ?EtOH, ?lives with
daughter.
Family History:
NC
Physical Exam:
Vitals - HR 91, BP 141/97, O2 94% on 3L NC
General - awake, alert, NAD, hear crackles at bedside
HEENT - small pupils b/l, MMM
Neck - + JVD to earlobe, could not appreciate carotid bruits b/l
CVS - RRR, normal S1, S2, could not appreciate M/R/G due to loud
breath sounds
Lungs - diffuse crackles and rhonci b/l posteriorly and
anteriorly
Abd - soft, diffusely mildly tender to palpation w/out
rebound/gaurding, enlarged liver to 4 cm below costophrenic
angle
Groin - + femoral bruit ascultated on R side, no bruit on L
Ext - 1+ LE edema b/l to level of knee, faintly palpable DP b/l
Pertinent Results:
[**2105-3-24**] 10:00PM BLOOD WBC-13.2* RBC-3.94*# Hgb-12.1# Hct-34.5*#
MCV-88 MCH-30.6 MCHC-35.0 RDW-17.3* Plt Ct-157
[**2105-3-24**] 10:00PM BLOOD Neuts-88* Bands-9* Lymphs-1* Monos-2
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2105-3-24**] 10:00PM BLOOD Glucose-179* UreaN-27* Creat-1.1 Na-138
K-2.8* Cl-102 HCO3-23 AnGap-16
[**2105-3-24**] 10:00PM BLOOD ALT-32 AST-21 LD(LDH)-499* AlkPhos-87
TotBili-0.5
Brief Hospital Course:
Assessment/Plan: Patient is a 66 yo woman with longstanding DM,
lung ca s/p resection presents with NSTEMI, [**Hospital 27810**] transferred to
[**Hospital1 18**] for cardiac cath.
.
# Respiratory: Patient presented w/ evidence of CHF, with
crackles on exam, CXR c/w CHF. Also w/ hx of COPD, steroid
dependent. However, on admission, patient was diuresed > 5L but
continued to be hypoxic and eventually required intubation.
Therefore other etiologies were considered for hypoxia. Chest
CT [**3-27**] demonstrates interstitial septal thickening and ground
glass opacities in R lung c/w pulm edema vs pulm hemorrhage vs
acute interstitial pna vs lymphegenic carcinomatosis, L hilar
finding ?recurrent ca vs scar. Patient was treated empirically
for pna (sputum cx from [**3-27**] w/ MSSA and H.Flu) with broad
spectrum abx (vanc, aztreonam) and was extubated on [**2105-3-31**].
Post extubation, she remained tenuous in her respiratory status.
On night of [**2105-4-5**] pt underwent respiratory arrest, causing
code (7 minutes), and was intubated. Again, unclear etiology of
her underlying pulmonary process, as no clinical evidence of
volume overload or apparent cause of flash pulmonary edema, on
broad spectrum abx w/ vanc, aztreonam and clindamycin, and on
[**Date Range 3782**] steroid dose of pred 10mg qd for COPD. Patient was
started empirically on bactrim 200mg IV q6hr for PCP coverage,
as LDH has remained high throughout hospitalization. Resp
status continues to be tenuous. Urine legionella negative.
Bronch [**4-7**] BAL for cytology + for highly atypical cells,
suspicious for sq cell carcinoma, remainder of micro negative
(PCP, [**Last Name (NamePattern4) **]/Cx, AFB, fungal, legionella, nocardia). Pulm service
questioned lymphagetic spread of carcinoma. Patient was
evaluted for IP thoracentesis of R sided effusion to confirm
malignant effusion. There was also a possibilty of VATS vs
trans-bronchial bx in future. Patient also underwent 14 day
course abx with vanc, aztreonam, also transiently on bactrim
empirically for PCP (micro negative from BAL). Patient was also
continued on her home dose of prednisone 10 mg QD as well as
inhalers. She continued to require high PEEPs and close to 100%
FiO2. Patient subsequently underwent another hypoxia induced
PEA arrest (12 minutes) on [**4-13**] requirement brief dopamine
infusion. The etiology of her PEA arrests remained uncertain
with hypoxia being most likely diagnosis. Patient's mental
status also continued to worsen. Patient was subsequently
started on morphine drip for comfort as she became bradycardic
and hypotensive on AM of [**2105-4-18**]. Patient subsequently expired
after she became asystolic due to presumed cardiac failure and
superimposed renal failure on 9:56 am on [**2105-4-18**]
.
# Lung ca s/p resection: Is possible ?recurrent lung ca
contributing to SOB sxs. CXR on admission demonstrates L hilar
mass c/w recurrent lung ca vs adenopathy vs scar from radiation.
Chest CT as above - repeat Chest CT demonstrates diffuse
consolidation, per pulm w/ BAL results, likely represents
lymphagenic spread of ca, likely contributing/causing pt's
respiratory issues.
.
# Renal: Patient had ARF at outside hosptial, thought pre-renal
given elevated glucose at 1200 and osmotic diuresis. On
presentation to [**Hospital1 18**], Cr had normalized to 1.0. Throughout
hospital course thus far, pt developed contrast induced
nephropathy following first cath, with Cr peak = 3.5. Cr then
resolved to 1.2, but then had code on [**4-5**] with repeat cardiac
cath (although small amount of dye was used), and Cr now
trending back up. Patient also w/ continued hematuria w/ blood
tinged urine - was on CBI, now d/ced per urology recs. Her UO
continued to decrease and her Cr continued to rise.
.
# Cardiac:
A. Ischemic: Patient initially presented to OSH with CP, r/i
for NSTEMI, started on heparin gtt, underwent dobutamine stress
test and developed CP, SOB, TWI in inferior leads (II, III,
avF), transferred to [**Hospital1 18**] for cardiac cath. Cardiac cath on
[**2105-3-25**], w/ 3x stent to RCA. CK peak for NSTEMI was 647. During
code on [**2105-4-5**], pt developed ST elevations diffusely which
quickly resolved. Was taken back to cath lab that demonstrated
clean coronary arteries. She was continued on ASA, plavix,
statin and amiodarone.
.
B. Pump: Patient presented with clinical evidence of CHF, with
bilateral crackles, LE edema, EF=40% per OSH ECHO. Likely
ischemic cardiomyopathy. Initially MUCH improved lung exam on
IV lasix. Initially on admission, diuresed > 5L off pt, but pt
w/ worsening lung fxn leading to intubation, as above. Swan
placed during hospital course, and readings were non-consistent
w/ CHF, with PCWP=15. Recent ECHO showed no change in EF at
45%. ? component of diastolic dysfxn. Intra cath following
code on [**4-5**], PCWP=16, mildly elevated L and R filling
pressures.
.
C. Rhythm: Patient in NSR throughout early hospital course.
However, pt became increasingly tachycardic, sinus tachy. O/n
[**4-1**] pt transiently went into AFib - started amio load and gtt,
and pt remains in and out of atrial fibrillation/atrial flutter.
.
Patient went into PEA arrest while down in IR having her PICC
line repositioned on [**2105-4-13**]. Pulse and blood pressure returned
after being coded for >10 minutes. Patient brought back to
MICU, echo revealed increasing right-sided dysfunction, however,
EKG not consistent with right heart strain. Patient's
creatinine >3, unable to tolerate chest CTA.
.
D. Pericardial rub: pericardial rub appreciated on ascultation
on [**3-29**] - cardiac enzymes sent that demonstrated no elevation.
EKG demonstrates diffuse ST elevation and PR depression c/w
pericarditis. Likely [**2-19**] uremia, although per renal stating [**2-19**]
Dressler's syndrorme. ECHO demonstrates no pericardial
effusion.
.
# Anemia: Pt presented with Hct = 31. Since that time, has
continued to trend down, requiring tfns PRN to keep > 28.
Likley [**2-19**] ICU setting, renal failure. hemolysis labs - WNL.
She received on epo 8000 units TIW (M,W,F).
.
# Elevated Alk phos and LDH: Unclear etiology. Have remained
stable-y elevated throughout hospital course. Improved once
lipitor was d/c
.
# DM: Patient w/ long history of DM, apparently non-compliant
w/ insulin as outpatient. Presented to OSH w/ hyperglycemia,
glucose=1200. Since admission has been on ISS w/ intermittent
long acting insulin. Patient FS were controlled with insulin
gtt
.
# ?Adrenal insufficiency: Patient started on fludricort and
hydrocort (stress dose steroids) at OSH - per notes, believed to
be adrenally insufficient due to hypotension despite IVF
boluses. No record of cortisol level at OSH. Unclear adrenal
insufficiency. Plan to:
- will attempt to contact [**Name (NI) 3782**] provider for more information
regarding this diagnosis - on fludricort as [**Name (NI) 3782**] for
orthostatic hypotension, on 10mg pred QD as [**Name (NI) 3782**], No hx of
adrenal insufficiency. Therefore, steroids as above.
.
# GERD: Continue protonix
.
# Depression: continue citalopram
.
# hyponatremia - likely SIADH in setting of pulmonary process.
Stable with fluid restriction
.
Pt expired on [**2105-4-18**] 9:56 am
Medications on Admission:
Outpatient medications:
florinef
citalopram
trazadone
lescol
prednisone
protonix
insulin
.
Medications on transfer:
Albuterol INH q4hr PRN
RISS
Metoprolol 12.5mg TID
Nystatin PO PRN
Protonix 40mg QD
Trazadone 50mg qhs
Citalopram 40mg QD
Fludricortisone 0.2mg QD
Hydrocortisone 100mg IV q8hr
Heparin gtt at 550
Plavix 75mg QD
Nitro gtt
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
Completed by:[**2105-4-18**]
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20,656
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46390
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Discharge summary
|
report
|
Admission Date: [**2200-10-23**] Discharge Date: [**2200-11-8**]
Date of Birth: [**2131-12-18**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Compazine / Protamine
Attending:[**First Name3 (LF) 2932**]
Chief Complaint:
nausea/vomiting
Major Surgical or Invasive Procedure:
GJ tube placement
exploratory laparotomy with surgical GJ tube placement
History of Present Illness:
68 year old female w/ ESRD on dialysis, gastroparesis, and Type
II diabetes presents with 1 week of increased nausea, vomiting
and generalized weakness. She was recently hospitalized in [**9-22**]
with a MSSA bacteremia (TEE negative for vegetations), for which
she was treated with 2 weeks of vancomycin. Since then, she has
felt generally weak, but this has worsened over the last [**11-18**]
weeks to the point that she is having difficulty ambulating,
although she has not had any falls. She has chronic
nausea/vomiting, which is attributed to gastroparesis, however
this has been worse over the last week, with minimal PO intake.
The vomiting can occur at any time and is not only associated
with eating. No hemetemesis or coffee grounds emesis. She notes
reflux symptoms which have worsened over the last 1-2 weeks, but
denies abdominal pain. She has chronic diarrhea (1 loose
BM/day), but has noted increased frequency of BM ([**12-20**]/day) over
the last week. (+) 5 lb weight loss over the last 2 weeks. (+)
sensation of solids occasionally "getting stuck," which she has
had for several months, but which has been worsening over the
last several weeks. No difficulty swallowing liquids. No
coughing after meals. She was seen in the ED [**10-11**] c/o N/V and
weakness, at which time a CXR was negative and 2 sets of CE were
negative; she underwent dialysis and was d/c'd home. She saw a
physician at [**Name9 (PRE) 191**] [**10-23**] after dialysis, at which time she was
noted to be dehydrated and referred to the emergency room. Of
note, she had a GJ tube placed in [**4-22**], which was removed during
her recent hospitalization given that she was eating by herself.
Since its removal, the patient's daughter reports that the
patient has eaten minimally.
ROS: as above, in addition: No fevers. (+) occasional sweats.
Gradual decline in vision over the last several years, but no
recent change. (+) dry mouth. No sinus pain or sore throat. No
chest pain, palpitations, LE edema, DOE, SOB. (+) mild cough X 1
week, minimally productive. No focal weakness, no headache. (+)
generalized pruritis since starting dialysis, no focal rash.
Minimal urine production at baseline, no dysuria. No
bleeding/bruising.
Past Medical History:
1. Diabetes mellitus type 2 with retinopathy, nephropathy and
neuropathy
2. End-stage renal disease, on hemodialysis Tu, Th, Sat.
3. Hypertension
4. Non-ischemic cardiomyopathy. Last echo [**2199**] with EF
<30%. Clean coronaries on cath 06/[**2197**].
5. Sickle cell trait
6. Chronic anemia
7. Hepatitis C
8. Fibroids status post hysterectomy
9. Status post right nephrectomy
10. Genital warts.
11. s/p CCY
12. celiac artery stenosis
13. Gastroparesis with chronic n/v
Social History:
Ms [**Known lastname 5749**] lives alone in [**Location (un) 686**], has some services including
Meals
on Wheels and housecleaning assistance; denies
tobacco/EtOH/drugs; 2 daughters and 1 son in the area. Most
recently she has been in a rehabilitation hospital after a
recent admission.
Family History:
noncontributory
Physical Exam:
Physical exam on admission
VITAL SIGNS: Temperature is 96, BP 152/70 81 20 97%RA
GENERAL: cachectic appearing; NAD
HEENT: Mucous membranes were dry. There was otherwise no
erythema in the posterior oropharynx.
CVS: s1 s2 rrr no m/r/g
Chest: CTA b/l
ABDOMEN: Soft, nontender, and nondistended with normoactive
bowel sounds and no hepatosplenomegaly.
ext: warm; +2 dp pulses;
neuro: alert and oriented
Pertinent Results:
Laboratory studies on admission
[**2200-10-23**]
WBC-4.3 HGB-15.4 HCT-45.6 MCV-87 RDW-18.8 PLT COUNT-206
NEUTS-57 BANDS-0 LYMPHS-27 MONOS-15* EOS-1
GLUCOSE-89 UREA N-5 CREAT-2.6 SODIUM-136 POTASSIUM-7.1 (recheck
3.2) CHLORIDE-92 TOTAL CO2-31
ALT(SGPT)-24 AST(SGOT)-115* ALK PHOS-59 AMYLASE-13 TOT BILI-0.7
LIPASE-23
ALBUMIN-4.4
EKG: Sinus rhythm. Since the previous tracing of [**2200-10-12**] the
axis is more leftward. The Q-T interval is longer. Otherwise, as
previously described.
Radiology
[**10-24**] KUB: No evidence of obstruction.
[**10-24**] CXR PA/lateral: There is mild-to-moderate cardiomegaly. The
aorta is noted to be tortuous and calcified. The mediastinal and
hilar contours are stable and normal in appearance. The
pulmonary vascularity is normal. The lungs are clear. There are
no pleural effusions. There is no pneumothorax. The soft tissues
and osseous structures are unremarkable.
[**10-31**] CXR: Moderate free intraperitoneal air. Clinical
correlation is recommended. Hyperinflated lungs and stable
cardiomyopathy. No evidence of pneumonia, CHF.
[**10-31**] CT Abd/pelvis: Free intraperitoneal air could be
consistent with recent percutaneous gastrostomy tube placement.
Intrahepatic vascular calcifications are again identified. There
is probable mild intrahepatic biliary ductal dilatation, not
significantly changed from previous study. Previously described
low-attenuation lesion in segment 6 is not visualized on this
noncontrast- enhanced study. The spleen is unremarkable. The
pancreas is unremarkable. The patient is status post right
nephrectomy, and multiple surgical clips are again noted within
the abdomen. The left kidney again demonstrates multiple
low-attenuation lesions, which allowing for differences in
technique are not significantly changed in size or appearance
from previous study. No free fluid is present within the
abdomen. No evidence of intraabdominal abscess or fluid
collection.
[**11-2**] CXR: Compared to the film from 2 days ago, there continues
to be free air under the hemidiaphragm. There is increased
opacity in the retrocardiac region suggesting volume
loss/infiltrate. The right lung is clear.
[**11-3**] MRI Head: The study is somewhat degraded by motion. There
are stable T2 and FLAIR hyperintensities within the
periventricular and deep white matter of both cerebral
hemispheres consistent with chronic microvascular ischemia.
There is no restricted diffusion to suggest an acute infarct.
The ventricles are normal. There is no shift of normally midline
structures, enhancing mass, or osseous/soft tissue
abnormalities. The signal intensities of the brain parenchyma
are normal.
[**11-4**] EEG: This was abnormal EEG due to the slow and
disorganized
background and bursts of generalized slowing, consistent with a
mild to
moderate encephalopathy. The most common causes include
infection,
vascular disease, toxic/metabolic disturbances, or medications.
[**11-5**] KUB: GJ tube in place with free intra-abdominal air,
likely unchanged from [**10-31**] CT.
[**11-7**] right hip plain film: No fracture or dislocation. Mild
degenerative changes within both hips. Diffuse osteopenia.
Extensive vascular calcifications.
[**11-7**] CT Head: There is no intracranial hemorrhage, shift of
normally midline structures, major vascular territorial infarct,
or hydrocephalus. There are stable low attenuations in the
periventricular white matter consistent with chronic
microvascular ischemia. There is also stable evidence of atrophy
with prominence of the bifrontal CSF spaces. There are dense
calcifications in the cavernous internal carotid arteries
bilaterally as well as the vertebral arteries bilaterally. There
is no acute fracture or sinus opacification. The [**Doctor Last Name 352**]-white
matter differentiation is preserved
[**11-8**] Head CT: No acute intracranial process. Unchanged from
prior study dated [**2200-11-7**]
Brief Hospital Course:
68 year old female admitted with nausea, vomiting, weight loss,
likely secondary to gastroparesis. Hospital course complicated
by hemetemesis and peritonitis following GJ tube placement.
1) Gastroparesis: Following admission, the patient was placed on
reglan with meals and the gastroenterology service was
consulted. Given minimal PO intake (calorie count <200
calories/day), the IR service was consulted for a GJ tube
placement. As mentioned in HPI, pt had GJ tube placed in [**4-/2200**],
which was removed in [**9-/2200**] given concern for infection and the
fact that she was no longer using it. She underwent a GJ tube
placement on [**2200-10-30**], course complicated by peritonitis
requiring GJ tube (see below).
2) Hemetemesis: On [**2200-10-28**], the patient had an episode of
hemetemesis (approximately 1 cup of bright red blood). She
underwent an EGD, which showed pill esophagitis (the likely
source of bleeding), multiple non-bleeding duodenal ulcers, an
non-obstruction ring at the GE junction. Her hematocrit remained
stable and she did not require transfusion. She received several
days of [**Hospital1 **] sucralfate and was started on PPI in the morning and
H2 blocker in the evening; she had no further hemetemesis during
the course of her hospital stay. Given her duodenal ulcers, she
should have an outpatient breath test to rule-out persistent H.
pylori infection (had been antibody positive in the past,
treated).
3) Peritonitis: The day following her GJ tube placement by IR on
[**2200-10-30**], she was noted to have increased abdominal pain, with
wbc 23 (up from 4 the day before). KUB showed free air under the
diaphragm, which the IR service felt was in excess of what was
to be expected from the procedure. She underwent an Abdomen CT
with contrast through GJ tube, which showed no evidence of
extravasation. Surgery was consulted, and she underwent an
exploratory laparotomy on [**2200-10-31**], which showed that the G tube
balloon was inflated in the first portion of the duodenum, and
thus, not able to be pulled up to the intra-abdominal wall to
provide a seal with G-tube, resulting in a leak. The old GJ tube
was removed and the site repaired; a new surgical GJ tube was
placed. The patient was monitored in the ICU for 2 nights prior
to return to the general medical floor [**2200-11-2**]. Her staples
were removed on [**2200-11-7**], and she will follow-up in surgery
clinic 2 weeks following discharge. At time of discharge, she is
tolerating tube feeds (through J tube) at goal and taking some
in by mouth. She is receiving her medications through the G
tube. She will complete a 14 day course of
levofloxacin/metronidazole for peritonitis. At time of
discharge, her wbc is 13.4; this should be monitored to ensure a
downward trend. Further infectious work-up included blood
cultures (now growth to date) and C. diff toxin stool assays
(negative X 2, pending X 1).
4) Change in mental status: On admission, the patient was noted
to be somewhat sleepy, answering questions appropriately but
falling asleep during the interview. Following surgery on
[**2200-10-31**], her mental status was markedly worsened, with minimal
responsiveness. Head CT was without acute change, MRI was
without acute infarct, EEG was consistent only with moderate
encephalopathy, and metabolic work-up (TSH, vitamin B12, RPR,
ammonia, LFTs) was negative except for hypercalcemia (treated
with IVF and cinacalcet). A neurologic consult was obtained, who
felt that her change in mental status was likely due to delirium
(delayed clearance of drugs/anesthesia in the setting of renal
failure, acute illness). Her mental status gradually improved
over the course of her hospital stay, although she continues to
wax and wane.
5) ESRD: The patient was continued on Tuesday, Thursday,
Saturday dialysis, and the renal service followed her throughout
her hospital stay. She was continued on nephrocaps.
6) Hypercalcemia: The patient had previously been diagnosed with
hyperparathyroidism, and had been prescribed Sensipar, which she
had not been taking regularly. This was restarted following
admission. Her calcium will need to continue to be closely
monitored. A vitamin D level is pending at time of discharge.
7) HTN: The patients blood pressure remained well controlled on
metoprolol; Cozzar and Norvasc have been held, but can be
restarted as an outpatient if needed for blood pressure control.
8) Type II DM: The patient is currently on NPH 5 units [**Hospital1 **] with
a RISS; this can be adjusted as needed as an outpatient.
9) Pneumonia: Following surgery, a retrocardic opacity was noted
on chest X-ray, although she did not have cough or respiratory
symptoms. She will continue a 14 day course of levo/flagyl for
now.
10) Transaminitis: The patient's ALT/AST normalized over the
course of her hospital stay. There was no TBili elevation to
suggest obstruction. Serum ETOH was negative. The patient has a
known history of hepatitis C (antibody positive, viral load
[**Numeric Identifier 7310**]). She should follow-up in liver clinic as an outpatient.
Hepatitis B panel was negative
11) Fall: On the evening of [**2200-11-6**], the patient had a
mechanical fall from her bed. She reported that she had woken up
from a dream and tried to get up from bed and tripped. She
complained of mild right hip pain; a plain film was negative,
and she reported her hip pain resolved. She had a head CT which
was without acute change/bleed; a follow-up head CT (to rule out
chronic subdural) on [**2200-11-8**] was also negative.
Medications on Admission:
per OMR note by PCP [**Name Initial (PRE) **] [**10-17**], pt non-compliant with meds
ASA 325 mg PO daily
Celexa 10- mg PO daily
Cozaar 50 mg PO daily
Prilosec 20 mg PO BID
Toprol XL 50 mg PO daily
Flonase 1 spray [**Hospital1 **]
Lipitor 80 mg PO daily
Remeron 15 mg PO qhs
Zelnorm 6 mg PO BID
Lomotil prn
Norvasc 7.5 mg PO daily
Sensipar 30 mg PO daily
NPH 10 units [**Hospital1 **]
Discharge Medications:
1. Camphor-Menthol 0.5-0.5 % Lotion [**Hospital1 **]: One (1) Appl Topical
PRN (as needed).
2. Famotidine 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO QPM (once a
day (in the evening)): through G tube.
3. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] [**Name (STitle) 4962**] (once a day (in the morning)):
through G tube.
4. Levofloxacin 250 mg Tablet [**Name (STitle) **]: One (1) Tablet PO Q48H (every
48 hours) for 6 days: through G tube.
5. Metoprolol Tartrate 25 mg Tablet [**Name (STitle) **]: One (1) Tablet PO BID
(2 times a day): through G tube.
6. B Complex-Vitamin C-Folic Acid 1 mg Capsule [**Name (STitle) **]: One (1) Cap
PO DAILY (Daily): through G tube.
7. Metronidazole 500 mg Tablet [**Name (STitle) **]: One (1) Tablet PO BID (2
times a day): through G tube.
8. Polyvinyl Alcohol 1.4 % Drops [**Name (STitle) **]: 1-2 Drops Ophthalmic PRN
(as needed).
9. Insulin NPH Human Recomb 100 unit/mL Suspension [**Name (STitle) **]: Five (5)
units Subcutaneous twice a day.
10. Insulin Lispro (Human) 100 unit/mL Solution [**Name (STitle) **]: sliding
scale Subcutaneous before each meal and at bedtime: If FS <70
give juice and recheck in 1 hours. If 70-150 give 0 units, if
151-200 give 2 units, if 201-250 give 4 units, if 251-300 give 5
units, if 301-350 give 6 units, if 351-400 give 7 units, if >400
give 8 units and [**Name8 (MD) 138**] MD.
11. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [**Name8 (MD) **]: Five (5)
ML PO Q6H (every 6 hours) as needed.
12. Reglan 5 mg Tablet [**Name8 (MD) **]: One (1) Tablet PO with meals.
13. Cinacalcet 30 mg Tablet [**Name8 (MD) **]: One (1) Tablet PO DAILY
(Daily).
14. Dolasetron Mesylate 12.5 mg IV Q8H:PRN
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary: gastroparesis
Secondary: end stage renal disease, hemetemesis, hypercalcemia,
hypertension, anemia, peritonitis, change in mental status
Discharge Condition:
Stable
Discharge Instructions:
Please follow-up as indicated below.
Please see your primary care physician or come to the emergency
room if you develop abdominal pain, fevers, chills, or other
symptoms that concern you.
Followup Instructions:
1) Surgery:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2200-11-20**] 2:00 p.m.
2) Primary Care:
Provider: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 3512**]
Date/Time:[**2200-11-12**] 11:30
- please follow-up with your primary care physician [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 250**]) within 1-2 weeks following discharge.
3) Psychiatry
Provider: [**Name10 (NameIs) 19240**],[**First Name3 (LF) **] PSYCHIATRY OPD Date/Time:[**2200-11-14**]
9:00
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2937**]
Completed by:[**2200-11-8**]
|
[
"403.91",
"578.0",
"588.81",
"998.59",
"362.01",
"567.89",
"536.42",
"250.52",
"536.3",
"V45.73",
"282.5",
"357.2",
"070.70",
"287.5",
"250.62",
"250.42",
"425.4",
"428.20",
"583.81",
"276.51",
"787.2",
"428.0",
"V58.67",
"285.21",
"585.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"39.95",
"96.6",
"43.11"
] |
icd9pcs
|
[
[
[]
]
] |
15613, 15692
|
7839, 10763
|
314, 389
|
15882, 15891
|
3909, 7114
|
16129, 16981
|
3452, 3469
|
13825, 15590
|
15713, 15861
|
13416, 13802
|
15915, 16106
|
3484, 3890
|
259, 276
|
417, 2638
|
7123, 7725
|
7735, 7816
|
10778, 13390
|
2660, 3131
|
3147, 3436
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,125
| 141,642
|
34929
|
Discharge summary
|
report
|
Admission Date: [**2135-11-29**] Discharge Date: [**2135-12-8**]
Date of Birth: [**2088-5-18**] Sex: M
Service: PLASTIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 26411**]
Chief Complaint:
s/p MVC
Major Surgical or Invasive Procedure:
1. Open reduction and internal fixation of bilateral Le
Fort 1 comminuted fracture.
2. Open reduction and internal fixation of right maxillary
alveolar fracture.
3. Placement of interdental fixation.
4. Repair of intraoral gingival periosteal laceration
approximately 1 cm in length
History of Present Illness:
The patient is a 47 yo M s/p MVC where he was found outside
of his car. There were teeth marks noted on the dash. The
patient was transported to the [**Hospital1 18**] ED where a head, sinus,
mandible, maxillofacial CT were performed. The patient was in
pain & aggitated during the exam, so he was given fentanyl.
Staffed by trauma and plastic surgery in the ED and admitted to
the TICU for airway management.
Past Medical History:
None
Social History:
EtOH abuse
Family History:
NC
Physical Exam:
On initial exam by plastic consult:
Rate:87 BP:139/80 RR:16 P02:100% on [**Name (NI) 597**]
The pt was highly sedated during initial interview. Able to
open
eyes for short periods of time, but unable to follow commands.
Upon re-examination, the patient was still intoxicated, but able
to follow directions to a certain degree and able to move all
extremities.
HEENT: EOMI, PERRL, mild edema peri-orbital b/l, teeth not
aligned when clenched, unable to examine nasal passageways
without a nasal speculum, tenderness with palpation
infraorbitally b/l
Pertinent Results:
[**2135-11-29**] 07:35PM WBC-11.5* RBC-4.22* HGB-12.9* HCT-36.5*
MCV-87 MCH-30.7 MCHC-35.4* RDW-12.4
[**2135-11-29**] 07:35PM PLT COUNT-247
[**2135-11-29**] 07:35PM PT-13.6* PTT-27.0 INR(PT)-1.2*
[**2135-11-29**] 12:13PM CK(CPK)-1542*
[**2135-11-29**] 12:13PM CK-MB-21* MB INDX-1.4 cTropnT-<0.01
[**2135-11-29**] 04:03AM GLUCOSE-121* UREA N-14 CREAT-1.0 SODIUM-140
POTASSIUM-3.9 CHLORIDE-103 TOTAL CO2-25 ANION GAP-16
[**2135-11-29**] 04:03AM CK(CPK)-898*
[**2135-11-29**] 04:03AM CK-MB-17* MB INDX-1.9 cTropnT-<0.01
[**2135-11-29**] 04:03AM CALCIUM-8.9 PHOSPHATE-2.9 MAGNESIUM-2.0
[**2135-11-29**] 04:03AM WBC-16.6* RBC-4.44* HGB-14.1 HCT-37.7* MCV-85
MCH-31.8 MCHC-37.5* RDW-12.4
[**2135-11-29**] 04:03AM PLT COUNT-242
[**2135-11-29**] 04:03AM PT-12.6 PTT-25.0 INR(PT)-1.1
[**2135-11-29**] 02:22AM WBC-17.8* RBC-4.65 HGB-14.7 HCT-39.7* MCV-86
MCH-31.7 MCHC-37.0* RDW-12.4
[**2135-11-29**] 02:22AM PLT COUNT-227
[**2135-11-29**] 01:30AM URINE RBC-0 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-0
[**2135-11-29**] 12:02AM TYPE-ART PO2-116* PCO2-39 PH-7.38 TOTAL
CO2-24 BASE XS--1
[**2135-11-29**] 12:02AM GLUCOSE-132* LACTATE-2.8* NA+-143 K+-3.7
CL--102
[**2135-11-29**] 12:01AM cTropnT-<0.01
Brief Hospital Course:
40 y/o M presented to the ED on [**2135-11-28**] s/p rollover MVC. He
was found to have multiple midface fx's (B maxillary sinuses all
walls, R lat & inf orbital wall fx's w/ fat protrusion thru inf
portion, vomer fx) , Fracture of the medial and inferior wall of
the right orbit. No evidence of intraocular muscle entrapment.
Multiple fractures of maxilla. No mandibular fx. He also had L
rib fx's (2,3,[**7-17**]) and avulsed teeth R 7,8 and a deep palate
laceration. A plastic surgery consult was called the pt was
admitted for airway management, pain control, and definitive
treatment. Ophthalmology was consulted, who deferred to plastics
for operative management of the orbital fractures. A dental
consult was called and recommended OMFS intervention. The pt was
placed on sinus precautions and prepared for the OR. Prior to
going to the OR, PT evaluated the patient. The pt ambulated
well. Social work counseled the pt about his alcohol abuse. The
pt was taken to the OR with plasics and OMFS on [**2135-12-2**].
Medications on Admission:
None
Discharge Medications:
1. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML
Mucous membrane TID (3 times a day): Use until follow up
appointment.
Disp:*1000 ML(s)* Refills:*2*
2. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment Sig: One
(1) Appl Ophthalmic PRN (as needed).
Disp:*1 tube* Refills:*2*
3. Oxycodone 5 mg/5 mL Solution Sig: [**6-18**] mL PO Q3H (every 3
hours) as needed.
Disp:*300 mL* Refills:*0*
4. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed.
Disp:*1 bottle* Refills:*0*
5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): Crush tablet and mix with water.
Disp:*60 Tablet(s)* Refills:*2*
6. Haloperidol 5 mg Tablet Sig: One (1) Tablet PO BID:PRN as
needed for agitation for 7 days.
Disp:*14 Tablet(s)* Refills:*1*
7. Clindamycin HCl 300 mg Capsule Sig: One (1) Capsule PO four
times a day for 7 days.
Disp:*28 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
S/p MVC
1. Bilateral Le Fort 1 comminuted maxillary fracture.
2. Right maxillary alveolar fracture.
3. Intraoral gingival periosteal open wound, laceration.
Discharge Condition:
Hemodynamically stable on Full liquid diet, Able to ambulate
without assistance
Discharge Instructions:
Please follow the nutrition recommendations provided to you in
the hospital. You are only to eat full liquids. If you are
short of breathe or feel or are about to vomit, proceed directly
to the ED. If you cannot wait that long, use wire cutters to
open your jaw. You should keep these with you at all times.
Return to the ER if:
* If you are vomiting and cannot keep in fluids or your
medications.
* If you have shaking chills, fever greater than 101.5 (F)
degrees or 38 (C) degrees, increased redness, swelling or
discharge from incision, chest pain, shortness of breath, or
anything else that is troubling you.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds as ordered.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 79924**] in clinic on [**12-16**] at 2:30
PM in the [**Hospital Ward Name 23**] building [**Location (un) 470**] at [**Telephone/Fax (1) 5343**].
Completed by:[**2135-12-13**]
|
[
"E816.0",
"285.9",
"599.70",
"802.4",
"E928.9",
"873.64",
"293.0",
"276.3",
"802.8",
"305.00",
"518.5",
"802.0",
"867.2",
"873.65",
"807.05"
] |
icd9cm
|
[
[
[]
]
] |
[
"27.61",
"76.77",
"27.52",
"76.74",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
4974, 4980
|
2968, 3990
|
324, 621
|
5181, 5263
|
1726, 2945
|
6408, 6634
|
1136, 1140
|
4045, 4951
|
5001, 5160
|
4016, 4022
|
5287, 6385
|
1155, 1707
|
277, 286
|
649, 1064
|
1086, 1092
|
1108, 1120
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,766
| 153,709
|
17700
|
Discharge summary
|
report
|
Admission Date: [**2127-3-20**] Discharge Date: [**2127-3-22**]
Service: CARDIOTHORACIC
HISTORY OF PRESENT ILLNESS: This is an 85 year-old patient
who was transferred to [**Hospital1 69**]
from [**Hospital3 3583**] presenting with a three day history of
chest pain. She had gone from her primary care physician's
to [**Hospital3 3583**], which showed electrocardiogram changes.
Chest x-ray was negative. She received aspirin, nitropaste,
Lopressor and heparin. Her CKs rose to 1057. She was
transferred to [**Hospital1 69**] for
immediate cardiac catheterization, which showed an index of
1.74, wedge 21, 70% osteo vein, 70% left anterior descending
coronary artery, 70% circumflex, 80% right coronary artery
and an occluded diagonal one, diagonal two and obtuse
marginal two. In the holding area after catheterization the
patient had chest pain with ST depressions and went back to
the catheterization laboratory for intraaortic balloon
placement emergently. Also noted when IVP was placed at the
catheterization laboratory. The iliac artery was noted to
have a severe occlusion and was stented.
On examination blood pressure 112/64, sating 100% on 2 liters
nasal cannula. She was a pleasant elderly lady who was in no
distress at the time. Her lungs were clear. Her heart
sounds were obscured by the intraaortic balloon pump. Her
abdominal examination was benign. She had 1+ lower extremity
edema with a right groin dressing that was clean, dry and
intact. Neurologically she was alert and oriented and her
examination was otherwise nonfocal.
MEDICATIONS ON ADMISSION:
1. Indocin.
2. Suldinec.
3. Midamor, which is Amiloride.
ALLERGIES: No known drug allergies.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Gout.
PREOPERATIVE LABORATORIES: White blood cell count 9.2,
hematocrit 37.0, platelet count 184,000. PT 10.9, PTT 23.9,
INR 1.0, sodium 131, K 4.6, chloride 97, CO2 25, BUN 30,
creatinine 2.2. Those were laboratories from [**Hospital3 3583**]
at 1:00 p.m. on the day of admission. Multiple serial
electrocardiograms all showed ST depressions and elevations
in precordial leads. ALT 26, AST 109, alkaline phosphatase
99, CPK 1096, amylase 46, total bilirubin 0.9. A second
round of laboratories at 5:00 p.m. at [**Hospital1 190**] showed BUN slightly up at 32 and a creatinine
drop slightly to 1.8.
HOSPITAL COURSE: She continued on heparin drip, aspirin and
nitroglycerin drip and she was referred to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1537**]
from cardiothoracic surgery. She continued with her
intraaortic balloon pump in the Coronary Care Unit. She was
also given the next morning 2 units of packed red blood
cells, nitroglycerin was weaned off with a blood pressure of
102/41 and heart rate in the 60s in sinus rhythm. BUN came
down slightly to 29 with a creatinine still at 1.8 and
hematocrit rose to 31.9. She remained NPO. Echocardiogram
was done on [**3-21**] that showed 2+ mitral regurgitation and
a depressed ejection fraction of approximately 35% with an
akinetic inferior wall. She was seen by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], also
her attending cardiologist who recommended that she have
surgery. The patient also had an episode of chest discomfort
on the 25th, which lasted approximately an hour on balloon
pump. Her heparin was running as well as her intravenous
nitroglycerin with a balloon on one to one and it was
determined she had a very labile unstable angina and with a
plan to take her to the Operating Room that morning and on
the morning of the 26 the patient went to the Operating Room
with Dr. [**Last Name (STitle) 1537**] and had a mitral valve repair with a 26 mm
[**Doctor Last Name **] anuloplasty band and coronary artery bypass grafting
times three with a left internal mammary coronary artery to
the left anterior descending coronary artery, vein graft to
the posterior descending coronary artery, vein graft to
posterior descending coronary artery and vein graft to the
obtuse marginal. The patient went through the operation
without a vent. The chest was closed and as the patient was
being transferred to bed the patient had a cardiovascular
collapse. The patient was emergently started on CPR with
protocol. Dr. [**Last Name (STitle) 1537**] immediately opened the chest and placed
the patient back on cardiopulmonary bypass. He did several
more vein grafts to try get her heart additionally
revascularized. It was not determined at that time what was
the cause of the acute demise, but the patient appeared to
have no cardiac reserve and expired in the Operating Room on
[**2127-3-22**].
DISCHARGE DIAGNOSES:
1. Status post mitral valve repair and coronary artery
bypass grafting times three with reemergent cardiopulmonary
bypass and repeat coronary artery bypass grafting.
2. Hypertension.
3. Gout.
4. Mitral regurgitation.
Again the patient expired in the Operating Room on [**2127-3-22**].
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern1) 76**]
MEDQUIST36
D: [**2127-5-21**] 02:28
T: [**2127-5-28**] 08:28
JOB#: [**Job Number 49238**]
|
[
"443.9",
"414.01",
"410.41",
"411.1",
"424.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.15",
"88.55",
"37.61",
"35.33",
"39.50",
"36.12",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
4684, 5256
|
1597, 1696
|
2365, 4663
|
127, 1571
|
1718, 2347
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,561
| 157,758
|
33928
|
Discharge summary
|
report
|
Admission Date: [**2139-7-15**] Discharge Date: [**2139-7-28**]
Date of Birth: [**2079-4-30**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 473**]
Chief Complaint:
air in the retroperitoneum s/p ERCP
Major Surgical or Invasive Procedure:
ERCP with sphinceterotomy and stent
PICC
Exploratory laparotomy
Transduodenal incision and exploration for control of ampullary
hemorrhage.
Duodenorrhaphy for closure of periampullary duodenal endoscopic
retrograde cholangiopancreatography - related perforation.
Enterotomy for evacuation of intestinal hematoma with primary
closure.
Combined gastrostomy jejunostomy tube placement.
History of Present Illness:
This is a 60 year old female s/p lap chole OSH for symptomatic
cholelithiasis. Had ERCP today due to abd pain and elevated
LFTs. ERCP showed stricture at distal CBD. Sphincterotomy for
distal CBD stricture done and free air seen after on scout
images. She reported mild abdominal pain
Past Medical History:
PSH:Lap CCY [**7-12**]
carpal tunnel release
bladder suspension
PMH: asthma, hypothyroid, chronic back pain,
Physical Exam:
98, 76, 122/71, 16, 100% 2L
Gen: NAD
CV: RRR
Lungs: CTA bilat.
Abd: soft, mild diffuse tenderness, no peritoneal signs, ND
Pertinent Results:
[**2139-7-15**] 11:20AM BLOOD WBC-12.0* RBC-4.02* Hgb-12.2 Hct-37.2
MCV-93 MCH-30.4 MCHC-32.8 RDW-13.4 Plt Ct-429
[**2139-7-16**] 06:15AM BLOOD WBC-9.1 RBC-3.77* Hgb-11.5* Hct-33.6*
MCV-89 MCH-30.4 MCHC-34.2 RDW-13.8 Plt Ct-415
[**2139-7-16**] 06:15AM BLOOD Glucose-96 UreaN-6 Creat-0.7 Na-142 K-3.7
Cl-106 HCO3-25 AnGap-15
[**2139-7-16**] 06:15AM BLOOD ALT-65* AST-23 AlkPhos-261* Amylase-438*
TotBili-0.3
[**2139-7-16**] 06:15AM BLOOD Lipase-898*
[**2139-7-16**] 06:15AM BLOOD Calcium-8.9 Phos-3.4 Mg-2.0
.
ERCP [**2139-7-16**]
The intrahepatic ducts were dilated. Partial pancreatogram
revealed normal PD. Following biliary sphincterotomy, a small
amount of free air was noted in the RUQ.
Impression: Normal pancreatic duct
Distal biliary stricture compatible with inflammatory stricture
vs occult neoplasm
Successful biliary sphincterotomy
Decision was made to place self expanding covered metal stent
placement. This stent will relieve the obstruction and
hopefully tamponade the [**Last Name (un) **] and occlude any possible
perforation.
The stent can easily be removed at a later date
.
CT ABDOMEN W/CONTRAST [**2139-7-15**] 6:55 PM
IMPRESSION:
1. Small collection of simple fluid as well as air in the
retroperitoneum consistent with duodenal perforation.
2. Pneumobilia consistent with recent sphincterotomy.
2. CBD stent in place.
3. Mild peripancreatic stranding and peri-hepatic inflammation.
.
EGD
Red blood was seen in the first part of the duodenum and second
part of the duodenum.
Impression: Blood in the stomach body and antrum
Blood in the first part of the duodenum and second part of the
duodenum
Recommendations: Severe bleeding noted in second portion of
duodenum not amenable to endoscopic intervention.
.
[**7-24**]
Abd Fluoro - IMPRESSION: No evidence of extraluminal
extravasation from the duodenum.
.
[**2139-7-24**] 04:44AM BLOOD WBC-9.4 RBC-3.43* Hgb-10.5* Hct-31.5*
MCV-92 MCH-30.6 MCHC-33.3 RDW-14.4 Plt Ct-311
[**2139-7-22**] 05:20AM BLOOD Glucose-129* UreaN-12 Creat-0.5 Na-137
K-3.9 Cl-96 HCO3-32 AnGap-13
[**2139-7-27**] 03:46AM BLOOD ALT-162* AST-66* AlkPhos-357* Amylase-70
TotBili-0.2
[**2139-7-27**] 03:46AM BLOOD Lipase-143*
[**2139-7-27**] 03:46AM BLOOD Albumin-3.2*
Brief Hospital Course:
This is a 60 year old female who was admitted s/p Lap CCY and
now s/p ERCP with evidence of free air.
On ERCP is was noted that there was moderate post-obstructive
dilation. These findings are suggestive of an inflammatory
stricture vs malignancy. A sphincterotomy was performed in the
12 o'clock position using a sphincterotome over an existing
guidewire. Following sphincterotomy, patient developed moderate
amount of bleeding from sphincterotomy site. This was controlled
with balloon tamponade. Fluoroscopy suggested small amount of
free air in the right upper quadrant, possibly a small
perforation. Given these finding's decision made to place self
expanding covered metal stent. A 10mm by 6cm self expanding
covered wall stent biliary stent was placed successfully.
Abd/GI: She was NPO with NGT and IVF.
She was started on Unasyn. A PICC was obtained and she was
started on TPN.
Post-ERCP Pancreatitis: Her Amylase/Lipase were increased to
[**Telephone/Fax (1) 78377**] on [**2139-7-17**]. She also complained of more epigastric
tenderness. She continued with bowel rest and TPN.
Melena and GI Bleed: She was having melena on HD 3 and then
bloody NGT output. She decompensated on the floor and was
brought to the ICU. She was tachycardic and hypotensive. Her HCT
went from 35 -> 30 ->23. She received 6 units of blood for acute
blood loss anemia s/p ERCP. She was intubated without
difficulty. She was identified as having a biliary bleed and
went urgently to the OR on [**2139-7-17**].
She remained in the ICU and was NPO with a NGT.
She still required some fluid boluses for hypotension and her
HCT on POD 1 was 36 and was then stable at 28.
Trophic tubefeedings were started on POD 3. The NGT was removed
on POD 5 and the G-tube was left to gravity.
Her tubefeedings were advanced to goal and she was tolerating
these. On POD 7, a fluoroscopy SBFT to assess her duodenum
showed No evidence of extraluminal extravasation from the
duodenum.
Her PO diet was advanced and she was tolerating a regular diet
at time of discharge. Her tubefeedings were cycled at night.
Her drain was removed. Her abdomen was soft and nontender. Her
staples were removed and steri strips placed.
Medications on Admission:
wellbutrin, levothyroxine, omeprazole, compazine, cipro/flagyl
(started after lap chole). need to get her doses
Discharge Medications:
1. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
2. Magnesium Hydroxide 400 mg/5 mL Suspension [**Last Name (STitle) **]: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
3. Miconazole Nitrate 2 % Powder [**Last Name (STitle) **]: One (1) Appl Topical TID
(3 times a day).
4. Bisacodyl 10 mg Suppository [**Last Name (STitle) **]: One (1) Suppository Rectal
DAILY (Daily) as needed.
5. Senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day).
6. Docusate Sodium 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO BID (2
times a day).
7. Oxycodone-Acetaminophen 5-325 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO
Q6H (every 6 hours) as needed.
8. Levothyroxine 25 mcg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
Life Care Center of [**Location (un) 3320**]
Discharge Diagnosis:
Air in the retroperitoneum consistent with duodenal perforation.
Post-ERCP Pancreatitis
Abdominal Pain
Biliary Hemorrhage
Hemorrhagic shock.
Malnutrition
Partial bile duct obstruction.
Discharge Condition:
Good
Tolerating a diet
Tolerating tube feedings
Discharge Instructions:
You were admitted s/p ERCP and concern for free air.
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting, diarrhea
or other reasons.
* Signs of dehydration include dry mouth, rapid heartbeat or
feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
.
* Please resume all regular home medications and take any new
meds
as ordered.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
* Continue to increase activity daily
* No heavy lifting (>[**11-18**] lbs) for 6 weeks.
* You may shower and wash.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 468**] on [**2139-8-31**] at 10:30. Call
[**Telephone/Fax (1) 2835**] with questions or concerns.
Please follow-up with Dr. [**Last Name (STitle) **], for repeat ERCP and stent
removal.
His office will call to set this up.
Completed by:[**2139-7-28**]
|
[
"263.9",
"E870.8",
"998.11",
"998.2",
"996.59",
"998.12",
"577.0",
"285.1",
"998.0",
"576.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"46.71",
"44.39",
"51.85",
"51.10",
"38.93",
"51.87",
"99.15",
"96.6",
"45.02",
"39.98"
] |
icd9pcs
|
[
[
[]
]
] |
6838, 6909
|
3578, 5770
|
349, 734
|
7139, 7189
|
1339, 3555
|
8726, 9028
|
5932, 6815
|
6930, 7118
|
5796, 5909
|
7213, 8703
|
1196, 1320
|
274, 311
|
762, 1048
|
1070, 1181
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,854
| 180,162
|
12959
|
Discharge summary
|
report
|
Admission Date: [**2115-1-18**] Discharge Date: [**2115-1-23**]
Date of Birth: [**2034-9-3**] Sex: M
Service: MEDICINE
Allergies:
Aspirin
Attending:[**First Name3 (LF) 7055**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Pacemaker update
History of Present Illness:
80M with a history of CAD s/p 5 vessel CABG in [**2098**], STEMI in
[**2111**] multiple interventions the most recent being [**2113-8-22**] with
PCI and BMS of native Lcx. He underwent implantation of dual
chamber [**Company 1543**] pacemaker in [**2113-2-16**] due to Wenchebach
Mobits type I heart block. Initially, he noted improvement in
exercise tolerance with the pacer noting that he was able to
walk [**2-17**] block without becoming fatigued or SOB. In the last two
months he has had progressive worsening of DOE and SOB such that
he is home bound and becomes dyspneic when walking from one room
to another. He currently has LV dysfunction, with an EF of
20-25%, which is down from when the pacemaker was placed. He has
class III heart failure symptoms with DOE with minimal exertion.
On the day of admission, he was electively admitted for upgrade
to a biventricular pacemaker. Unfortunately placement of the biV
leads was unsuccessful, the previous RV pacer wires remain and
his generator was up graded and changed to DDI-55. He was
admitted to the CCU for post proceedural monitoring.
.
On arrive in the CCU his vitals were 97.0 67 100/70 95% 2L. EKG
Prolonged PR interval AV conduction delay with rate of 80bpm a
non conducted P and diffuse twave inversions.
Past Medical History:
1. CARDIAC RISK FACTORS: + Dyslipidemia, + Hypertension +
Diabetes
2. CARDIAC HISTORY:
- CABG: 5 vessel, [**2098**]: LIMA to LAD, SVG to Diag, SVG to RCA,
SVG
to OMI, SVG to Ramus
- PERCUTANEOUS CORONARY INTERVENTIONS:
1) [**11-22**] STEMI with BMS x 2 to the SVG to the OM at B&W.
2) [**4-23**] PCI 80% LAD, patent LIMA, total occlusion of the OM and
total Occlusion of the saphenous vein graft to the RCA.
3) [**8-24**] PCI with BMS to the native circumflex.
- PACING/ICD: [**Company 1543**] dual chamber V-pacer, placed in [**2-/2113**]
for asymptomatic AV Wenckebach with bradycardia
3. OTHER PAST MEDICAL HISTORY:
- Mitral valve prolapse with mild MR
- 5 vessel CABG [**2098**]
- Hypertension
- Hyperlipidemia
- ESRD on HD M W F via Left arm [**Hospital3 39763**]dialysis in [**Location (un) 7661**]- Dr. [**Last Name (STitle) 39764**]
- Celiac Sprue-not following gluten free diet currently
- GI bleed on aspirin requiring transfusion [**5-24**] and [**9-23**]
- ? arrhythmia, s/p EP study that was negative [**2112**]
- Legally blind [**3-20**] macular degeneration
Social History:
Married, does not work. Retired from the radio Broadcast and
sales. One glass of wine once weekly.
-Tobacco history: Never smoker
Family History:
MOther: Diabetes
Denies history of heart failure, early MI
Physical Exam:
GENERAL: Elderly cachectic male appearing tired.
HEENT: Temporal wasting, Sclera anicteric.
NECK: Supple with JVP of 8cm.
CARDIAC: Cachectic appearing, prominant ribs, s/p CABG, II/VI
SEM at LUSB, Visable heave at 5th intercostal space,
midclavicular line.
LUNGS: CTABL, no crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. BS normoactive.
EXTREMITIES: warm, wel perfused, no edema.
PULSES:
Right: DP 2+ PT 2+
Left: DP 2+ PT 2+
Pertinent Results:
[**2115-1-20**] 06:02AM BLOOD WBC-10.3# RBC-3.68* Hgb-11.6* Hct-38.4*
MCV-104* MCH-31.6 MCHC-30.2* RDW-15.3 Plt Ct-114*
[**2115-1-18**] 12:15PM BLOOD WBC-4.9 RBC-4.05* Hgb-12.5* Hct-40.3
MCV-100* MCH-30.9 MCHC-31.1 RDW-15.6* Plt Ct-151
[**2115-1-18**] 12:15PM BLOOD PT-13.5* INR(PT)-1.2*
[**2115-1-18**] 12:15PM BLOOD Plt Ct-151
[**2115-1-18**] 12:15PM BLOOD Glucose-91 UreaN-43* Creat-4.9* Na-138
K-6.0* Cl-95* HCO3-29 AnGap-20
[**2115-1-20**] 06:02AM BLOOD Glucose-87 UreaN-30* Creat-3.8*# Na-140
K-5.2* Cl-99 HCO3-33* AnGap-13
[**2115-1-20**] 06:02AM BLOOD Calcium-8.9 Phos-5.3* Mg-2.1
[**2115-1-19**] 05:22AM BLOOD Calcium-9.6 Phos-5.3* Mg-2.2
[**2115-1-20**] 09:42PM BLOOD Type-ART pO2-98 pCO2-119* pH-7.10*
calTCO2-39* Base XS-3 Intubat-NOT INTUBA
[**2115-1-20**] 09:42PM BLOOD Lactate-1.1
CXR [**2115-1-18**]
FINDINGS: In comparison with the study of [**6-12**], the right
ventricular
pacemaker lead has apparently been repositioned. Little change
in the
appearance of the cardiac silhouette. No definite pneumothorax
is
appreciated. The degree of pulmonary vascular congestion appears
to be
somewhat less than on the previous study.
Brief Hospital Course:
A 80 yoM with PMH NYHA Stage III heart failure and mobitz I
block admitted for upgrade of pacer.
.
# Pacemaker: Patient went for revision of pacer with plan for
BiV pacer placement which was unsuccessful due to anatomy. In
the proceedure, patient was noted to have sinus rhythm with
narrow complex. It was determined tat patient would benefit from
setting to only pace below ventricular rate of 55 rather than
continuous pacing between 60-120. The previous RV pacer wires
were left in place and his generator was upgraded and changed to
DDI-55. He was admitted to the CCU for post proceedural
monitoring. He was maintained on telemetry for 48 hours and
remained in sinus rhythm with occasional ventricular pacing.
.
# Congestive heart failure with systolic dysfunction: NYHA
class IV heart failure. Between [**2112**] and [**2114**] patient's EF
decreased 50% 20-25%. On admission, patient noted worsening
dyspnea on exertion prior to admission. After the pacemaker
upgrade proceedure, patient developed new O2 requirement related
to decompensated congestive heart failure. Chest xray did not
show pulmonary edema or effusion. Immediately following the
proceedure, the patient was responsive to questions, answering
appropirately. Over the course of the following night, he became
progressively unresponsive. After a discussion with the family
detailing the low chance of a successful resuscitation effort,
the patient's code status was changed to DNR/DNI. He was treated
with a trial of BIPAP with improved responsiveness however
patient found the mask uncomfortable and it was discontinued
after 2 hours. The patient again became unresponsive. The
patient remained unresponsive and another family meeting was
held in which the decsion was made to transition care to comfort
measures only. On hospital day 5 the patient expired with the
family at the bedside.
.
# Coronary artery disease: Patient with significant CAD s/p CABG
and multiple stents, most recenly BMS to Circumflex in [**2113**].
Cardiac ischamia likey contributed to development of heart
failure. Clopidogrel 75mg was continued throughout admission.
.
#ESRD: patient receives dialysis MWF and missed dialysis for EP
proceedure. Dialysis was attempted on HD 2, only 1L was removed
due to low blood pressure. No further dialysis was performed in
the course of this hospitalization.
Medications on Admission:
clopidogrel 75 mg Tablet Daily
Vitamin B12 1,000 mcg/mL Solution Q month
Darbepoetin alfa 25 mcg/mL Solution q friday at dialysis- every
3 weeks
folic acid 5 mg/mL Solution monthly at pcp
iron sucrose Dosage uncertain
metoprolol succinate 12.5mg daily
paricalcitol Dosage uncertain (at dialysis MWF)
bisacodyl 5 mg Daily ,
calcium carbonate 500 mg TID
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Deceased
Discharge Condition:
Deceased
Discharge Instructions:
Deceased
Followup Instructions:
Deceased
|
[
"412",
"V45.82",
"403.91",
"459.2",
"272.4",
"414.00",
"V45.81",
"276.7",
"369.4",
"V49.86",
"426.13",
"410.71",
"250.00",
"362.50",
"799.4",
"V45.11",
"428.0",
"428.22",
"579.0",
"585.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"37.75"
] |
icd9pcs
|
[
[
[]
]
] |
7343, 7352
|
4562, 6911
|
287, 305
|
7404, 7414
|
3395, 4539
|
7471, 7482
|
2871, 2931
|
7314, 7320
|
7373, 7383
|
6937, 7291
|
7438, 7448
|
2946, 3376
|
1718, 2220
|
228, 249
|
333, 1608
|
2251, 2707
|
1630, 1698
|
2723, 2855
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,756
| 129,438
|
3626
|
Discharge summary
|
report
|
Admission Date: [**2138-1-14**] Discharge Date: [**2138-1-22**]
Date of Birth: [**2076-6-27**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
Lethargy, Hypotension, Hypothermia
Major Surgical or Invasive Procedure:
Debridement of right foot wound
History of Present Illness:
61 yo male w/ pmh significant for DM II, HTN, CKI, colon CA,
anemia, PVD with recent right great toe amputation in [**2137-11-6**]
who presents with lethargy and hypotension. Pt was feeling
lethargic at home for the last day and had his daughter check
his BP which his SBP was 90s from baseline of (120s) and he felt
cold. He was recently discharged from rehab (~2 weeks ago). He
states that he was doing well at home. He notes associated
lightheadedness but denies any chest pain, shortness of breath,
abdominal pain, palpitations, fevers, chills, nausea or
vomiting.
.
In the ED, initial vs were: Temp 93F rectally, 76, 105/46, 11,
95% on RA. His SBP was down to 90s he was given 1 L of IV fluids
for which he responded w/SBP in low 100s. He was also
hypothermic with temp down to 93 and was placed on bearhuger
with temp improving to 96 F. He was also found to be bradycardic
with HR in the 40s (baseline in 60s-70s). K 5.9 and EKG showed
peaked T waves, increase in QRS to 134 (baseline of 132)w/ known
RBBB that is unchanged. Given kayexalate. He was also given 2
units of PRBC for hct 23 and started on Vanc and Zosyn.
.
On the floor, he states that he is feeling better. He denies any
lightheadedness and feels less fatigued. He denied any pain or
discomfort.
Past Medical History:
-Type I Diabetes (on insulin since age 18), A1C 8.9 [**2137-10-15**]
-Chronic Kidney Disease (not on dialysis but reportedly only 17%
kidney function, per patient)
-Hypertension
-Peripheral Vascular Disease
-Anemia of Chronic Disease
-Obstructive sleep apnea (on CPAP at night)
-Colon cancer s/p resection ([**2132**])
-Erectile dysfunction
.
PAST SURGICAL HISTORY:
-R great toe amputation ([**11/2137**])
-Right Carotid Artery Stent (?)
-Balloon angioplasty of right anterior tibial artery.
-Balloon angioplasty of right dorsalis pedis artery
-Rectosigmoid cancer - Low anterior resection ([**2132**])
-Decompression of right ulnar nerve and anterior transposition
of
right ulnar nerve about the medal epicondyle.
-Cubital tunnel release and anterior transposition of left ulnar
nerve.
Social History:
The patient is married and lives with his wife and daughter in
the [**Name (NI) 86**] area. He returned home from rehab 2 weeks prior to
admission. He is a trained minister and devotes his time to
theological research in the Seventh Day [**Hospital1 14911**] faith. He
denies all past and current tobacco, alcohol, and
street/recreational drug use/abuse.
Family History:
Father: Diabetes, CAD. Died of prostate cancer at age 58.
Mother: [**Name (NI) 3495**] disease (died from MI at age 51)
Physical Exam:
Admission Physical Exam:
Vitals: T: 98.8 BP: 118/52 P: 72 R: 18 O2: 93 RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, 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
Right Foot: 1st toes amputation, appears to be healing well,
nice granulation tissue.
.
Discharge Physical Exam:
Vitals: T: 96.1 BP: 168/86 P: 64 R: 20 O2 % Sat: 99& on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, 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+ radial pulses b/l, 1+ PT b/l no
clubbing, cyanosis or edema
Right Foot: dressing in place over great toe amputation wound;
clean/dry/intact
Pertinent Results:
CBC:
[**2138-1-20**] 06:40AM BLOOD WBC-7.1 RBC-3.28* Hgb-9.2* Hct-27.3*
MCV-83 MCH-28.0 MCHC-33.6 RDW-17.7* Plt Ct-138*
[**2138-1-19**] 07:44AM BLOOD WBC-7.5 RBC-3.16* Hgb-8.8* Hct-26.0*
MCV-82 MCH-27.8 MCHC-33.8 RDW-18.5* Plt Ct-167
[**2138-1-18**] 06:15AM BLOOD WBC-8.4 RBC-3.08* Hgb-8.7* Hct-25.6*
MCV-83 MCH-28.2 MCHC-33.9 RDW-18.4* Plt Ct-143*
[**2138-1-16**] 06:48AM BLOOD WBC-7.4# RBC-3.28* Hgb-9.3* Hct-27.1*
MCV-83 MCH-28.5 MCHC-34.5 RDW-18.2* Plt Ct-129*
[**2138-1-15**] 12:16AM BLOOD WBC-4.8 RBC-3.29* Hgb-9.5* Hct-27.3*
MCV-83 MCH-28.8 MCHC-34.7 RDW-17.9* Plt Ct-138*
[**2138-1-14**] 08:57AM BLOOD WBC-4.2 RBC-3.31* Hgb-9.3* Hct-28.2*
MCV-85 MCH-28.2 MCHC-33.0 RDW-17.7* Plt Ct-120*
[**2138-1-14**] 12:50AM BLOOD WBC-3.5* RBC-2.89* Hgb-8.0* Hct-23.7*
MCV-82 MCH-27.8 MCHC-33.8 RDW-17.8* Plt Ct-136*#
.
CHEM:
[**2138-1-22**] 06:35 UreaN-59 Creat-3.2* Na-136
K-4.1 Cl-108 HCO3-18*.
[**2138-1-20**] 06:40AM BLOOD Glucose-201* UreaN-67* Creat-3.9* Na-136
K-4.2 Cl-108 HCO3-14*
[**2138-1-19**] 07:44AM BLOOD Glucose-112* UreaN-68* Creat-4.0* Na-136
K-4.6 Cl-111* HCO3-13*
[**2138-1-17**] 06:45AM BLOOD Glucose-93 UreaN-61* Creat-4.6* Na-141
K-4.8 Cl-114* HCO3-12*
[**2138-1-15**] 05:41AM BLOOD Glucose-140* UreaN-54* Creat-4.2* Na-139
K-4.7 Cl-115* HCO3-12*
[**2138-1-14**] 02:38PM BLOOD Glucose-210* UreaN-54* Creat-3.8* Na-137
K-5.2* Cl-117* HCO3-10*
[**2138-1-14**] 12:50AM BLOOD Glucose-170* UreaN-56* Creat-3.7* Na-136
K-6.4* Cl-117* HCO3-10*
.
BLOOD GASES:
[**2138-1-16**] 07:24AM BLOOD Type-[**Last Name (un) **] pO2-70* pCO2-28* pH-7.29*
calTCO2-14* Base XS--11
[**2138-1-14**] 03:02PM BLOOD Type-[**Last Name (un) **] pO2-52* pCO2-27* pH-7.19*
calTCO2-11* Base XS--16
.
LFTs:
[**2138-1-20**] 06:40AM BLOOD ALT-25 AST-17 AlkPhos-117 TotBili-0.3
[**2138-1-19**] 07:44AM BLOOD ALT-31 AST-16 AlkPhos-119 TotBili-0.5
[**2138-1-17**] 06:45AM BLOOD ALT-51* AST-33 AlkPhos-138* TotBili-0.4
[**2138-1-16**] 06:48AM BLOOD ALT-67* AST-48* AlkPhos-137* TotBili-0.4
[**2138-1-14**] 08:57AM BLOOD ALT-117* AST-175* LD(LDH)-268*
AlkPhos-184* TotBili-0.4
.
CEs:
[**2138-1-14**] 08:57AM BLOOD cTropnT-0.04*
[**2138-1-14**] 12:50AM BLOOD cTropnT-0.01
.
MISCELLANEOUS:
[**2138-1-14**] 08:57AM BLOOD TSH-3.7
[**2138-1-15**] 05:41AM BLOOD Cortsol-18.7
[**2138-1-15**] 12:16AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
[**2138-1-15**] 12:16AM BLOOD HCV Ab-NEGATIVE
[**2138-1-18**] 06:57AM BLOOD pO2-85 pCO2-25* pH-7.32* calTCO2-13* Base
XS--11
[**2138-1-14**] 09:49PM BLOOD Glucose-80 Lactate-1.4 Na-140 K-5.0
Cl-120* calHCO3-12*
[**2138-1-14**] 12:54AM BLOOD Glucose-156* Lactate-1.0 K-5.9*
[**2138-1-14**] 08:57AM BLOOD Lipase-35
.
ECG:
[**2138-1-18**]: Sinus rhythm. Right bundle-branch block. Probable
prior anterior myocardial infarction. Compared to the previous
tracing of [**2138-1-15**] the findings are similar.
.
[**2138-1-14**]: The rhythm is sinus bradycardia with right
bundle-branch block and low limb lead voltage. Prior
anteroseptal myocardial infarction. Compared to the previous
tracing of [**2137-11-16**] the rate has slowed. The Q-T interval is
prolonged.
.
XRAY:
[**2138-1-19**]: PA & LAT CHEST XRAY FINDINGS: As compared to the
previous radiograph, there is a marked improvement. The
pre-existing parenchymal opacities have markedly decreased in
extent. There is no newly appeared parenchymal opacity. The old
opacities, predominating in both upper lobes as well as at the
lung bases and in the retrocardiac lung areas are still clearly
visible. Moreover, moderate bilateral pleural effusions are
still seen. The size of the cardiac silhouette is unchanged and
normal.
.
[**2138-1-15**]: PORTABLE AP CHEST XRAY IMPRESSION: Pulmonary vascular
engorgement has improved and perihilar opacification decreased,
consistent with resolving edema. The right lower lobe is more
densely consolidated medially. Whether this represents
atelectasis and residual edema or pneumonia requires
radiographic and clinical followup. The heart is normal size.
Pleural effusion is minimal if any along the imaged pleural
surfaces. The right lateral pleural sulcus is excluded from the
examination. No pneumothorax.
.
[**2138-1-14**]: PA & LAT CHEST XRAY IMPRESSION: No acute intrathoracic
abnormality.
.
OTHER IMAGING:
[**2138-1-15**]: LIVER/GALLBLADDER U/S CONCLUSIONS: 1) Normal-appearing
liver and no bile duct dilatation. 2) Ascites and bilateral
effusions. 3) Mild edema in the gallbladder wall which may be a
reflection of the clinical suspicion of hepatitis. Acalculous
cholecystitis is not excluded and HIDA scan could be performed
if this becomes a clinical suspicion. 4) Dilated pancreatic
duct and small cyst in the head and uncinate process suggestive
of IPMN. When clinically able, an MR of the pancreas is
recommended.
.
[**2138-1-14**]: RENAL U/S IMPRESSION:
1. Echogenic small kidneys consistent with chronic renal
parenchymal disease. 2. No evidence for hydronephrosis. 3. No
evidence for renal artery stenosis.
.
Brief Hospital Course:
ISSUES REQUIRING FOLLOW-UP:
-Consider repeat ECHOcardiogram as an outpt
-Consider CT with contrast vs MRCP to further evaluate elevated
LFTs, abnormal RUQ U/S
-Please follow-up bicarbonate level, and adjust sodium
bicarobonate dose accordingly
61 yo male w/ pmh significant for DM II, HTN, CKI, colon cancer,
anemia, PVD with recent right great toe amputation in [**2137-11-6**]
who presents with hypothermia, hypotension, and lethargy, found
to be bradycardic, hypoxic with acute renal failure requiring
admission to MICU for stablization prior to transfer to floor.
.
# Hypothermia: Etiology unclear, but thought that hypothermia
resulted in bradycardia and myocardial stunning with subsequent
hypotension, decreased renal perfusion, and acute kidney
failure, also accounting for hyperkalemia at time of
presentation. See below for problem-by-problem review. Pt
warmed with bear hugger in ED and MICU with hypothermia resolved
at time of transfer to the floor (HD2).
.
# Hypotension and bradycardia: With hypothermia and hypotension,
the initial concern was for sepsis and the pt had a complete
infectious workup with blood and urine cultures sent. He did
fulfill SIRS criteria with Temp < 35C and WBC <4 at initial
presentation. Pt denied any cough, dysuria, diarrhea or fevers.
He had a recent right big toe amputation which appeared to be
healing well. Vascular saw patient and recommended foot x-ray,
which was unremarkable. Blood pressures were supported with
fluids. However, pt became hypoxic with fluid rescusitation
(see below). Once pt rewarmed and heart rate stable, pressures
also normalized. He was initially put on Vancomysin and Zosyn
for sepsis, which were discontinued after transfer to the floor
since lab work was negative for infection and pt had no systemic
signs or symptoms of infection. After transfer to the floor,
the patient's hypotension resolved.
.
# Hypoxia: In the setting of fluid resuscitation for hypotension
and acute renal failure, patient had flash pulmonary edema with
O2 sats in the 70s. He responded well to lasix and supplemental
oxygen. It was felt that his poor urine output could not
compensate for the volume of fluids required to stabilize his
blood pressures. A cardiac ECHO was obtained showing a decreased
LVEF from ECHO on [**11-15**]. Troponins negative. Consider repeat
ECHO as outpt. Chest x-ray was improved after he diuresed and
pt was weaned off O2 and achieved good O2 sats when ambulating.
Pt was seen by PT who felt that any difficulty breathing at time
of discharge was likely related to deconditioning.
.
# Fatigue: Pt has chronic anemia with Hct in mid-upper 20s at
baseline. At time of presentation pt's Hct was in low 20s. He
received 2 units of blood with good response. He has been
receiving Aranecp for years as well as iron supplement.
Hypothyroid etiology was entertained and TSH measured, which was
within normal limits. Pt's fatigue resolved after receiving
pRBCs and his hematocrit returned to baseline. He remained
hemodynamically stable on the floor. Guaiac negative.
.
# Acute on Chronic Renal Failure (baseline Cre ~2.5): Urine
lytes and FeNa consistent with a prerenal etiology. Most likely
due to decreased kidney perfusion in setting of hypotension. Pt
initially had poor UOP which later improved. [**Month (only) 116**] be that pt had
prerenal insult to kidney, and extended hypotension resulted in
ATN picture. Cr rose, pleateued, and began to decline while on
floor. Pt was discharged in stable condition with steadily
decreasing Cr values. Renal consult team followed pt while
hospitalized. Per renal recs sodium bicarb supplementation was
initiated and pt??????s calcitriol continued. Pt??????s lytes, magnesium
and phosphate were trended and urine output monitored and he
appeared to improve while on floor with slight increase in
bicarb and downtrending Cr (3.2 on day of discharge).
.
# Non-Anion Gap / Anion Gap Metabolic Acidosis: At admission
patient was noted to have NAG metabolic acidosis with
respiratory compensation. Given hx of DMII, RTA was
entertained. Met acidosis became anion gap over his stay here
and it was thought that pre-renal azotemia evolved into
intrarenal pathology with resulting ATN in setting of
hypotension. Nephrology service was consulted and recommended
sodium bicarbonate to replete low serum HCO3 and pt will be
discharged with new prescription for daily supplementation. Pt
will need Chem7 checked every 3-4 days, with results faxed to
PCP for [**Name9 (PRE) 702**].
.
# Elevated LFTs: Elevated LFTs on admission. Pt was
asymptomatic throughout. Pt without medication or supplement
changes. RUQ U/S showed mild GB edema, Dilated pancreatic duct
and small cyst in the head and uncinate process suggestive of
IPMN. [**Month (only) 116**] be related to hypotensive insult to hepatic and
biliary systems. Hepatitis serologies were negative. Abd/pelvis
CT or MRCP is recommended as outpt to follow-up.
.
# Hyperkalemia: Pt found to have elevated potassium at
presentation, most likely due to renal failure. Electrolytes
were closely monitored daily. He received calcium gluconate and
kayexalate in the ED. Thought that EKG showed concerning changes
initially however subsequent EKGs normalized once hyperkalemia
resolved in MICU and pt's potassium has remained within normal
limits on the floor.
.
# DM: Pt was put on his home standing insulin and insulin
sliding scale per protocol with freq blood glucose fingerstick
monitoring. His FSG levels were rising with increased PO
intake, so his Lantus dose was increased to 10U each morning.
Pt also has insulin sliding scale.
.
# HTN: After resolution of hypotension, patient's
antihypertensive medications were resumed. However, patient
continued to have systolic BP above 160, so his amlodipine dose
was increased to 10mg daily.
.
# Right great toe amputation wound: Wound appeared to be healing
w/o signs of active infection. Podiatry and Vascular were
consulted. Wound was debrided at bedside by podiatry and pt had
excessive bleeding. Subcutaneous heparin for DVT prophylaxis was
discontinued and replaced with pneumoboots. Pt??????s aspirin and
prasugrel were continued. Surgicel packed in wound. Pt spiked
fever of 101.0 evening after wound debridement but was
asymptomatic. This was thought to be acute stress response to
wound debridement and abx were held, fever resolved overnight.
Vascular recommended Doppler u/s of LEs showing peripheral
vascular disease with poor circulation R>L. A PT consult was
obtained while on floor and recommended rehab to improve
strength and mobility.
.
# Code Status: Confirmed Full
Medications on Admission:
- amlodipine 5 mg Tablet once a day
- atorvastatin 20 mg once a day
- calcitriol 0.25 mcg Capsule by mouth once a day
- darbepoetin alfa in polysorbat [Aranesp (polysorbate)] 40
mcg/0.4 mL Syringe inject s/c once a week [**2138-1-2**]
- famotidine 20 mg Tablet every twenty-four(24) hours
- Humalog Pen 100 unit/mL Insulin Pen
- insulin glargine [Lantus] 5 units sc in the mornong
- lovastatin 20 mg Tablet by mouth daily
- metoprolol tartrate 25 mg Tablet twice a day
- omeprazole 20 mg Capsule, Delayed Release(E.C.) mouth once a
day
- oxycodone 5 mg Capsule, 1 Capsule(s) by mouth every four (4)
hours pain
- tramadol 50 mg Tablet 0.5 (One half) Tablet(s) by mouth twice
a day
- aspirin 325 mg Tablet 1 Tablet(s) by mouth DAILY (Daily)
- docusate sodium 100 mg Capsule 1 Capsule(s) by mouth once a
day
- ferrous sulfate 325 mg (65 mg Iron) Tablet
1 (One) Tablet(s) by mouth once a day (OTC) [**2136-10-24**]
- sennosides [Senokot] 8.6 mg Tablet 1 Tablet(s) by mouth once a
day
Discharge Medications:
1. darbepoetin alfa in polysorbat 40 mcg/0.4 mL Syringe Sig:
40mcg Injection once a week.
2. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
3. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
4. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
5. insulin glargine 100 unit/mL Cartridge Sig: Ten (10) units
Subcutaneous every morning.
6. prasugrel 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
8. omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
9. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
12. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
13. insulin lispro 100 unit/mL Insulin Pen Sig: As directed
Subcutaneous three times a day prior to meals per sliding scale:
per sliding scale.
14. sodium bicarbonate 650 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
15. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 533**] [**Last Name (NamePattern1) **] for Extended Care - [**Location 1268**]
Discharge Diagnosis:
Primary:
-Acute on Chronic Renal Failure
-Hypothermia
-Non-anion gap metabolic acidosis
.
Secondary:
-Hypertension
-Type 2 Diabetes Mellitus
-Anemia
-Peripheral Vascular Disease with right great toe amputation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. [**Known lastname **],
It was a pleasure taking care of you at [**Hospital1 18**]. You were admitted
because you had a low body temperature (hypothermia), low blood
pressure (hypotension), and were very tired with decreased
energy levels. We also discovered that your kidneys weren't
working properly (acute kidney injury). You were admitted to
the Medical Intensive Care Unit where you were warmed, given
intravenous fluids and a blood transfusion to help correct your
hypothermia and low blood pressure, as well as to alleviate your
decreased energy levels. When you were well enough to come to
the medical floor we continued to monitor you. You were less
fatigued by the end of your stay, and your labwork tells us that
your kidney function is returning to baseline. However, you
still have low levels of bicarbonate in your blood, and we're
giving you bicarbonate supplements. Your blood pressure, heart
rate, and body temperature have all been stable since you left
the ICU.
While you were here, we also managed your chronic diabetes. The
podiatry and vascular specialists came to check on your foot,
and thought it was healing nicely. The podiatry doctor debrided
your foot twice in order to maintain good healing.
The following changes to your medication regimen:
-STOP lovastatin
-STOP oxycodone
-STOP tramadol
-START sodium bicarbonate 1300mg two times a day with meals
-INCREASE amlodipine to 10mg daily
-INCREASE Lantus to 10units each morning
When you leave rehab, you will need to call to make an
appointment to see your prmary physician (Dr. [**Last Name (STitle) **] at
[**Telephone/Fax (1) 250**].
Followup Instructions:
When you leave rehab, you will need to call to make an
appointment to see your prmary physician (Dr. [**Last Name (STitle) **] at
[**Telephone/Fax (1) 250**].
--> You can call to reschedule the appointment with the
infectious disease doctors (listed below)
Department: INFECTIOUS DISEASE
When: THURSDAY [**2138-1-30**] at 11:30 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10000**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
[
"707.03",
"285.9",
"780.65",
"250.61",
"327.23",
"276.2",
"250.41",
"443.9",
"585.9",
"V49.71",
"518.0",
"V10.05",
"458.9",
"583.81",
"V58.67",
"403.90",
"276.7",
"584.9",
"707.22",
"799.02",
"357.2"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
18207, 18342
|
9270, 15889
|
339, 373
|
18596, 18596
|
4303, 9247
|
20438, 21044
|
2869, 2991
|
16926, 18184
|
18363, 18575
|
15915, 16903
|
18779, 20415
|
2057, 2480
|
3031, 3633
|
265, 301
|
401, 1669
|
18611, 18755
|
1691, 2034
|
2496, 2853
|
3658, 4284
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,205
| 104,569
|
3914+55526
|
Discharge summary
|
report+addendum
|
Admission Date: [**2169-4-30**] Discharge Date: [**2169-5-5**]
Date of Birth: [**2123-11-17**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This is a 45 year-old man wtih a
history of narcotic and benzodiazepine abuse status post
multiple attempts to detox who decided three days ago to stop
all of his narcotics and benzodiazepines, because he was
tired of being dependent on these medications. The patient
[**Hospital6 17459**] on [**4-28**] who
placed him on a combination of medications for withdraw. The
patient saw this physician again on the day of admission in
his office, checked a tox screen with a urine screen negative
for narcotic and gave him a test dose of Naltrexone by mouth
[**2-22**] of a 50 mg tablet at 1:00 p.m. Twenty minutes later the
patient became acutely confused, agitated, hypertensive,
without back pain and without headache. On further
questioning the patient admitted to taking one Percocet
earlier on the day of admission. In the Emergency Room the
patient's blood pressure was 220/100 with a pulse of 127,
respirations 28, very agitated and placed on four point
restraints. The patient received 8 mg of Ativan and 111 mg
of morphine over a several hour period with improvement in
his mental status and diminishment of his blood pressure to
166/110 and his pulse was diminished to 97.
SOCIAL HISTORY: One half pack per day of smoking times 17
years, occasional alcohol, history of intravenous drug abuse,
no cocaine. The patient was disabled with past profession as
a boxer. He lives with his fiance.
MEDICATIONS AT ADMISSION PRIOR TO [**4-28**]: The patient was
taking Percocet 7.5 mg tablets prn roughly 120 tablets per
month, Fentanyl patch 100 micrograms for the last seven
years, Xanax 1.5 mg b.i.d. for the last seven years, Prozac
and Tums. After seeing the withdraw specialist the patient
was on Neurontin 1600 mg q.i.d., Robaxin 750 mg t.i.d.,
Celebrex 200 mg q.d., Quinine 260 mg b.i.d., Baclofen 20 mg
b.i.d., Ambien 10 to 20 mg q.h.s., Librium 25 mg q.i.d.,
Valium 10 mg q.o.d., Risperdal 1 mg prn, Clonidine 0.1 mg
patch q week, Doxepin 100 mg q.h.s., Tizanidine 4 mg q.h.s.
PHYSICAL EXAMINATION ON ADMISSION: Blood pressure 166/110.
Heart rate 97. The patient is [**Age over 90 **]% on room air. Pupils were
3 mm equal and reactive to light. Extraocular movements
intact. Oropharynx was clear. JVP was difficult to
evaluate. Neck was supple. The patient had a regular rate
and rhythm with no murmurs, rubs or gallops. Lungs were
clear to auscultation bilaterally. Abdomen was obese, well
healed midline scar, diffuse tenderness, no edema. 2+ pedal
pulses. The patient had a nonfocal cranial nerves examination
with cranial nerves II through XII intact.
HOSPITAL COURSE: The patient was initially observed in the
MICU for signs of acute withdraw and management of the
patient's hypertension. The patient was started on 60 mg of
intravenous morphine prn signs of withdraw q 6 hours. The
patient was also given up to 4 mg of po Ativan q 4 to 6
hours. The patient was weaned aggressively off these
narcotics and was followed by the toxicology service who
recommended keeping him on short acting agents for 72 hours
after his ingestion due to the 72 hour duration of
Spironolactone in the circulation. Therefore long acting
agents were discouraged and not used in this patient although
the patient did get one dose of methadone prior to this
decision being made. The patient was weaned off of his
intravenous medications and switched to oral. At the time of
discharge the patient was receiving 30 mg of MSIR q 6 hours
prn and 2 mg po Ativan q 6 hours prn. On the day prior to
discharge the patient got 10 mg total of po Ativan and
roughly 120 mg po of MSIR. The plan was to continue to wean
these medications completely off with acute inpatient detox
patient. The patient had been followed by social work,
psychiatry, toxicology and general medicine. All services
agreed that the patient would require inpatient
detoxification. An outpatient taper was discussed, however,
the patient's narcotic requirements were too high for any of
the physicians involved in his care to feel comfortable
prescribing him with medications. Also it was thought that
he should be receiving these medications and this
detoxification under an observed setting with administration
of these medications by a third party. The patient was
agitated throughout his hospitalization, but on the last 48
hours of his hospitalization showed no objective signs of
withdraw. The patient was normotensive. The patient had no
signs of tachycardia. The patient's pupils remained normal
with normal reactivity at the last day of admission. The
patient was afebrile throughout his hospitalization. The
patient was combative at times, but was never physically
aggressive or threatening.
PLEASE SEE OMR NOTE DATED [**2169-5-12**] BY DR. [**Last Name (STitle) **] FOR DETAILS
OF THE REMAINDER OF THIS HOSPITALIZATION.
DISCHARGE DIAGNOSES:
1. Acute narcotic withdraw.
2. Narcotic dependence.
3. Benzodiazepine dependence.
4. Depression.
5. Anxiety.
6. Complex regional pain syndrome.
7. Chronic low back pain.
8. Gastroesophageal reflux disease.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 2506**]
Dictated By:[**Last Name (NamePattern1) 7942**]
MEDQUIST36
D: [**2169-5-5**] 11:08
T: [**2169-5-5**] 11:18
JOB#: [**Job Number 17460**]
Name: [**Known lastname 1385**], [**Known firstname 126**] Unit No: [**Numeric Identifier 2788**]
Admission Date: [**2169-4-30**] Discharge Date: [**2169-5-12**]
Date of Birth: [**2123-11-17**] Sex: M
Service:
THIS IS A DISCHARGE SUMMARY ADDENDUM FROM EVENTS OF [**2169-5-5**] TO [**2169-5-12**].
Narcotics withdrawal: The patient was continued on a
narcotics taper 20% per day. He was evaluated by the best
team and was deemed not to be a candidate for inpatient
detoxification due to his chronic pain syndrome. On day of
discharge, he was on 10 mg of OxyContin twice a day with a
plan to taper him to 10 mg of OxyContin once a day and then
off. He was discharged with two OxyContin pills of 10 mg.
He was tapered off of his benzodiazepines during this
hospitalization and has required none since the finish of his
taper on [**2169-5-12**]. He is to follow-up with the [**First Name4 (NamePattern1) 2789**]
[**Last Name (NamePattern1) 2790**] Clinic on [**2169-5-16**] at 8:20 a.m. He will also
follow-up with his primary care physician, [**Last Name (NamePattern4) **]. >.....<, on
[**2169-5-15**]. The patient will continue Neurontin 1200 mg
t.i.d. and Tylenol around the clock in addition to his Paxil
for his ill-defined chronic pain syndrome which may be due to
RSV. The patient is encouraged to follow-up with the Pain
Clinic who may be able to provide alternative measures for
controlling his pain. He has been discouraged to use
narcotics as a means to control his pain as an outpatient.
CONDITION OF DISCHARGE: Stable to home.
DISCHARGE MEDICATIONS:
1. OxyContin 10 mg tablets for two doses only.
2. Paxil 40 mg po q.d.
3. Tylenol around the clock.
4. Neurontin 1200 mg t.i.d.
5. Senna 1 tablet b.i.d.
DISCHARGE DIAGNOSIS: Same as above.
[**First Name4 (NamePattern1) 77**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 1977**]
Dictated By:[**Doctor First Name 2791**]
MEDQUIST36
D: [**2169-5-12**] 05:36
T: [**2169-5-14**] 18:25
JOB#: [**Job Number 2792**]
|
[
"401.9",
"337.29",
"E969",
"305.1",
"300.00",
"292.0",
"304.71",
"724.2",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"94.65"
] |
icd9pcs
|
[
[
[]
]
] |
5008, 7091
|
7114, 7272
|
7295, 7580
|
2762, 4987
|
159, 1344
|
2190, 2744
|
1361, 2175
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,984
| 176,631
|
39364
|
Discharge summary
|
report
|
Admission Date: [**2199-7-24**] Discharge Date: [**2199-9-12**]
Date of Birth: [**2139-6-17**] Sex: M
Service: NEUROSURGERY
Allergies:
Morphine Sulfate
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
IPH
Major Surgical or Invasive Procedure:
[**2199-8-21**]: PEG placement
History of Present Illness:
60 yo old male with unknown history found in his car
unresponsive. Was brought to OSH and was not following
commands, aphasic, and hypertensive at 198/126. CT demonstrated
IPH. Patient was given 20 mg of Labetalol and loaded with 1
gram of phosphenytoin and transfered to [**Hospital1 **]. upon arrival
here his BP
was 160/90. He was given 4 mg of MS and went into bradycardia
down to 43 and BP fell to 70/43. Patient was given 0.5 mg of
atropine and pressures returned to 131/83. Patient remained
saturating 95%.
Past Medical History:
gout, ETOH
Social History:
ETOH
Family History:
unknown
Physical Exam:
On Admission:
O: T:98.2 BP: 160/90 HR:82 R18 O2Sats 95%
Gen: comfortable, NAD.
HEENT: Pupils: 4->3 BL
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, not following commands,
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
3 mm bilaterally. Visual fields are full to confrontation. No
gross visual field cut
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: mile VIII: unable to assess
IX,X, [**Doctor First Name 81**], XII:unable to asses.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**4-3**] throughout. No pronator drift
Sensation: withdraws all 4 extremities
Reflexes: B T Br Pa Ac
Right 2 2 2 2 2
Left 2 2 2 2 2
crossed adduction
toes upgoing on the right. Down on Left
Coordination: unable to assess
PHYSICAL EXAM UPON DISCHARGE:
Alert, interactive, oriented to himself and place. [**Last Name (LF) 2994**], [**First Name3 (LF) 2995**].
Ambulating steadily.
On discharge:
Patient awake and alert, generally oriened to self and place,
disoriented to time. Expressive aphasia, some receptive aphagia.
Ambulates with good strength and balance with minimal
assistance.
Pertinent Results:
CTA HEAD W&W/O C & RECONS [**2199-7-24**]
1. Intracranial hemorrhage in the left frontoparietal lobe
having mass effect on the left lateral ventricle, change is
difficult to ascertain between the prior study three hours ago
due to differences in technique, but the hemorrhage may be
slightly larger on this study.
2. Punctate area of high attenuation anterior to the primary
hemorrhage,
which may represent a secondary subarachnoid hemorrhage or a
thrombosed vein.
3. No stenosis, occlusion or aneurysm seen on CT. Underlying
mass lesion
cannot be ruled out by this study.
CT HEAD W/O CONTRAST [**2199-7-26**]
1. Unchanged appearance of intraparenchymal hemorrhage in the
left
frontoparietal lobe and mass effect on the left lateral
ventricle.
2. Punctate area of high attenuation anterior to the primary
hemorrhage which may represent secondary subarachnoid hemorrhage
or thrombosed vein.
3. Non-contrast CT is unable to determine if there is an
underlying mass
lesion.
CT Head [**7-29**]: IMPRESSION: Stable size and appearance of large
left frontal intraparenchymal hemorrhage with surrounding edema.
No new areas of intracranial hemorrhage or increased mass
effect.
MRI Head [**7-29**]: IMPRESSION: 1. Multiple chronic, superfically
located cerebral microhemorrhages, which could be related to
unusual early-onset amyloid angiopathy or multiple cavernomas.
While it is unusual for numerous cavernomas to spare the deeper
cerebral structures, the presence of two developmental venous
anomalies favors the diagnosis of cavernomas. The left frontal
cerebral hematoma is likely caused by the same process as these
chronic microhemorrhages.
2. Linear rim of enhancement surrounding the left frontal
hematoma is likely related to granulation tissue. Follow-up to
resolution is recommended.
3. Edema or fluid adjacent to left atlanto-occipital joint may
represent
ligamentous injury. Recommend CT of the cervical spine to
evaluate for a
fracture.
4. No evidence of arteriovenous malformation or arterial
aneurysm.
[**2199-7-31**] Chest Xray: FINDINGS: As compared to the previous
radiograph, the patient has received a Dobbhoff tube. The tube
should be advanced by approximately 10 cm, the tip of the tube
now projects over the gastroesophageal junction.
[**2199-8-2**] Xray: IMPRESSION: Successful replacement of a Dobhoff
tube with an 8-French [**Location (un) 2174**]-[**Doctor First Name 1557**] nasointestinal tube in
the third part of the duodenum.
[**2199-8-3**] Xray: Dobbhoff tube reaches the fourth portion of the
duodenum but is coiled back and the tip is not clearly
visualized. Recommended new film without respiratory motion for
better evaluation of the tip of the Dobbhoff tube.
[**2199-8-4**] Xray: FINDINGS: The feeding tube tip is at the fourth
portion of the duodenum.
[**8-9**] Cerebral Angiogram: IMPRESSION: [**Known firstname **] [**Known lastname **] underwent
cerebral arteriography which failed to reveal any evidence of
aneurysm, ateriovenous malformation or AV fistula.
[**8-15**] EEG: IMPRESSION: This EEG monitoring showed a mildly slow
background rhythm indicative of an encephalopathy. There were no
areas of prominent focal slowing, but recording over the right
hemisphere was markedly degraded after the first several hours.
There were no epileptiform features or electrographic seizures.
[**8-19**] LENIS: IMPRESSION: No evidence of acute deep venous
thrombosis bilaterally.
[**8-19**] Head CT: IMPRESSION: Continued evolution of left frontal
intraparenchymal hemorrhage with associated significant
vasogenic edema, greater in proportion than expected from the
initial hematoma. Continued close surveillance is recommended.
No new foci of hemorrhage.
[**8-20**] Echo: The left atrium is mildly dilated. No atrial septal
defect is seen by 2D or color Doppler. Left ventricular wall
thicknesses and cavity size are normal. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%). Doppler parameters are
indeterminate for left ventricular diastolic function. There is
no ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve appears
structurally normal with trivial mitral regurgitation. Trivial
mitral regurgitation is seen. The left ventricular inflow
pattern suggests impaired relaxation. The pulmonary artery
systolic pressure could not be determined. There is no
pericardial effusion.
[**8-23**] Brain Scan: IMPRESSION: Small focal areas of increased
perfusion immediately anterior and immediately posterior to the
left frontal intraparenchymal hemorrhage and edema, which may
serve as seizure foci.
[**2199-9-4**] MRI/MRA Brain:
IMPRESSION:
1. Interval decrease in size of the previously noted left
frontal lobe
intraparenchymal hemorrhage, continued followup is recommended
until a
complete resolution of the hematoma to rule out underlying
pathology.
2. Multiple unchanged foci of magnetic susceptibility,
suggesting amyloid
deposits versus small cavernomas. No other new lesions are
identified. After the administration of gadolinium contrast, no
evidence of large vessels are demonstrated to suggest an
arteriovenous vascular malformation.
3. Unchanged MRA of the head with no evidence of flow stenotic
lesions or aneurysms, there is no evidence of enlarged vessels
to suggest an arterial vascular malformation.
[**2199-9-10**]: LENIS
IMPRESSION: No evidence of deep vein thrombosis in either leg.
Dilantin [**2199-9-9**]: 11.9
Brief Hospital Course:
60 y/o M with unknown past medical history was found
unresponsive in car. He was taken to OSH aphasic, following no
commands, and hypertensive. Head CT reveals a large L IPH. He
was transferred to [**Hospital1 18**] for further neurosurgical care. He was
admitted to the TSICU. Patient was agitated on exam and he was
started on a CIWA scale. Repeat head CT was stable. On [**7-27**],
patient's exam was EO to loud voice and spontaneous movement of
all extremities, no commands. MRI was recommended to rule out
underlying mass.
[**7-28**]: Dilantin reloaded.
[**7-29**]: Agitated overnight, leading to respiratory distress and
hypoxia. Re-intubated at 0400hrs. A CT head was performed and
stable. MRI brain was also performed which showed multiple
lesions in the cerebellum likely small cavernoma's and
indicating that larger left frontal lesion is also a Cavernoma.
A follow up Angiogram has been scheduled for [**2199-8-2**].
[**7-30**]: patient was successfully extubated. A Doboff tube was
placed for feeding.
Patient will be evaluated by Speech Therapy to see if he can
resume a P.O. diet.
Transfer orders were written for patient to transfer out of the
ICU to the Step down unit on [**7-31**].
[**Date range (1) 30965**] Pt seen by speech and swallow and initially failed for
PO diet with plan to reevaluate on [**8-2**]. Pt seen on [**8-2**] and felt
to be improving and DHT placed by IR. Tube feeds were started
when post pyloric placement confirmed. Plan to re-evaluate on
[**8-5**].
On [**8-6**] the patient was seen by speech and swallow and he was
cleared for puree diet and nectar thick liquids. He would be
re-evaluated later in the week. Nutrition recommended starting
PPN and calorie counts while pt initiates PO diet. Angiogram
scheduled and preop'ed for [**8-7**].
[**8-7**] Angio rescheduled for [**8-9**] due to scheduling conflict. Pt
changed to TPN and diet restarted. His neurological exam is
improving slightly with some verbalization therefore he was
cleared for transfer to the floor.
[**8-8**] pt was again seen by speech therapy and nutrition. His diet
was advanced to thin liquids and soft solids with sips.
[**Date range (1) 78217**] pt remained neurologically stable and was followed by
nutrition. He continued to require TPN [**1-1**] poor po intake.
[**Date range (1) 87018**] Pt remained on TPN for poor nutritional intake. His PO
intake did increase over this time but still remained below his
nutritional needs. Plan was to discuss PEG tube placement with
his daughter and stop the TPN. Pt had a question of syncopal
event vs seizure on [**8-15**]. He was found on the floor by nursing
staff and was incontinent of his bowels. Upon exam he remained
awake and alert, following simple commands and saying simple
words. He had no extremity pain to movement or palpation and a
CT head was obtained. CT head showed no change from his previous
exams and EEG monitoring was ordered. EEG monitoring showed
mildly slow waveforms but no epileptogenic activity. Syncope
work up was initiated including an echo, cardiac enzymes, TSH &
HgB A1c.
On [**8-18**] the cardiac enzymes resulted negative times 3. Pt
remained neurologically stable without other incident.
On [**8-19**] the patient complained of bilateral lower extremity pain
(pain with passive movement). Due to the difficulty examining
the patient LENI's were ordered but found to be negative for
DVT. In the afternoon the patient was ambulating with physical
therapy and became unresponsive with dilated pupils and stiff
flexion of upper extremities. Issues resolved within 2 minutes
and the patient was neurologically back to his baseline. vitals
remained stable. A head CT was obtained and revealed more
resolution of the previous hemorrhage, otherwise stable. The
event was a presumed seizure therefore the Keppra was increased
and a Neurology consult was requested.
On [**8-20**] a family meeting took place. The patient's elder
daughter obtained guardianship in the AM from the court. The
patient's nutrition status was discussed and it was decided to
proceed with PEG placement. A consult with general surgery was
then placed for the PEG.
On [**8-22**]: This patient had PEG placed and was not able to be
extubated following procedure. The PaO2 was 99 on FiO2 60 and
PEEP of 10 with 1 hour of tachypnea to 30s. The cause of this
was unknown. CXR showed pneumoperitoneum and small LLL pleural
effusion. He required a dilantin load on [**8-23**]. On [**8-26**] he
exhibited global aphasia and was given a Dilantin load of 500mg
per neurology recomendations. On [**8-27**], he was reloaded with
fosphenytoin and the corrected level was 13.6.
On [**8-29**] his dilantin was corrected to 15.1. There was a family
meeting and the son was obtaining conservaship.
[**Date range (1) 33651**]: Patient remained stable. Awaiting Guardianship.
[**9-10**]: LENIS were negative.
on [**9-12**], the day of discharge, patient has returned to his
hospital baseline. He is awake and alert on exam although
generally confused. He ambulates in the halls with minimal
assistance. He is taking a P.O. diet and his Peg is minimally
used. As discussed with the daughter he will need to have the
PEG in for 4 weeks before removal can be considered as discussed
with General Surgery.
Medications on Admission:
None
Discharge Medications:
1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
3. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain, fever.
4. allopurinol 100 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
6. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for discomfort.
7. diphenoxylate-atropine 2.5-0.025 mg Tablet Sig: One (1)
Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
8. levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
9. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
10. phenytoin sodium extended 100 mg Capsule Sig: One (1)
Capsule PO QAM (once a day (in the morning)).
11. phenytoin sodium extended 100 mg Capsule Sig: One (1)
Capsule PO QPM (once a day (in the evening)).
12. phenytoin sodium extended 100 mg Capsule Sig: Two (2)
Capsule PO QHS (once a day (at bedtime)).
13. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
14. HydrALAzine 10-20 mg IV Q6H:PRN HTN, SBP >160
15. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 1459**] Care and Rehabilitation Center
Discharge Diagnosis:
L IPH
Protien/calorie malnutrition
Right upper extremity hemiparesis
Non verbal
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
?????? You have been prescribed Dilantin and Keppra for seizures. You
must remain on this medication until your follow-up with
Neurology. Please check a Dilantin level one week from
discharge. Please call ([**Telephone/Fax (1) 2528**] with any questions
regarding your seizure medication.
?????? You have a feeding tube and it may be removed after 8
weeks of insertion as it is no longer needed for nutrition.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion, lethargy or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? New onset of the loss of function, or decrease of function on
one whole side of your body.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 2102**] to schedule an appointment with Dr.
[**First Name (STitle) **], to be seen in 4 weeks. You will need a CT scan of the
brain without contrast prior to your appointment. This can be
scheduled when you call to make your office visit appointment.
?????? Please follow-up with Neurology - Dr. [**First Name (STitle) **] regarding
your seizures. Please call ([**Telephone/Fax (1) 2528**] to schedule this
appointment.
?????? Please follow-up with General Surgery to discuss your
PEG and removal 8 weeks after insertion ([**2199-8-21**]) ([**Telephone/Fax (1) 14957**]
Completed by:[**2199-9-12**]
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27,326
| 140,743
|
46396
|
Discharge summary
|
report
|
Admission Date: [**2126-5-13**] Discharge Date: [**2126-5-15**]
Date of Birth: [**2052-11-29**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Demerol / Phenobarbital / Nsaids
Attending:[**Last Name (NamePattern1) 1572**]
Chief Complaint:
Nausea/EKG changes
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 93019**] is a 73 year-old man with DMII, HTN and extensive CAD
s/p multiple PCIs including at least 11 stents, most recently
[**5-/2125**], and capsule endoscopy last week for a history of anemia,
who presents with 1 week of nausea, loose stools, diaphoresis
and dizziness. He presented to his PCP today who found lower
abdominal pain and referred him to the ED, where he was found to
have EKG changes.
.
He was in his USOH until 6 days ago when he underwent capsule
endoscopy as part of a continuing GI investigation of previous
anemia and guaiac positive stools, despite a recently normal
hematocrit. He began to have loose stools the day before the
procedure, while on a liquid-only diet for the procedure, and
after the procedure noted nausea, diaphoresis and dizziness that
has persisted until this admission. He reports loose stools
about 3x per week. The "dizziness" is described as feeling faint
when he would stand up. The symptoms waxed and waned during the
course of each day. He also reports insomnia and anorexia. Of
note, he reports that these symptoms are very different from any
prior episodes of CP, GERD or esophageal spasm.
.
His recent GI workup is for a h/o low Hct on prior admissions
(to 34) and guaiac positive stools. Per patient, colonoscopy
([**Hospital1 112**]), abdominal MRI and capsule endoscopy have all been
unremarkable.
.
He denies CP, palpitations, syncope, SOB or edema. He also
denies vomiting, abdominal pain, black or bloody stools or
urine, cough, fever, chills or night sweats. All of the other
review of systems were negative. Denies prior history of stroke,
TIA, DVT or PE. He notes regular use of stool softeners at home
but no recent constipation. He also notes recent extensive
dental work and antibiotic treatment due to an abscess.
.
His PCP noted [**Name9 (PRE) 25714**] abdominal pain on deep palpation, which the
patient says was reproduced in the ED. In the ED, he was
hemodynamically stable, NAD with no CP. Initial vitals showed
hypertension to SBP 190. He received Ondasetron 2mg, ASA 325 mg,
Heparin, Nitroglycerin SL 0.4mg. EKG changes were concerning for
STE in the inferior leads, over a territory of a known old
infarct. CXR in the ED was negative for PNA. Cardiology was
involved because of a question of ACS.
Past Medical History:
1. CAD s/p MI, with h/o 11 stents - Two recent admissions in
late [**Month (only) 547**]: the first admission the patient was taken to cath
for CP and stented in the LAD and LCX. He was discharged, then
came back 1 day later with recurrent symptoms, stable cardiac
enzymes (peak toponin 0.04), and was taken for a repeat cath on
[**3-21**]. The cath showed patent stents and an 80% OM2 lesion to
which a new DES
was successfully placed. The patient experienced an improvement
in frequency and severity of symptoms after stent placement.
2. Hypertension
3. Hypercholesterolemia
4. DM type II with peripheral neuropathy
5. Obstructive sleep apnea - uses CPAP occasionally; states he
does not need it this admission
6. Esophageal spasm
7. GERD - experiences symptoms 3-5 times per week
8. Chronic back pain secondary to spinal stenosis s/p cervical
laminectomy, s/p L3-5 laminectomy and L4-5 in situ fusion [**12-6**]
9. Overactive bladder
10. Restless leg syndrome
11. s/p cholecystectomy
Social History:
Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse. Worked as a medical
research consultant. Currently retired.
Family History:
No early history of heart disease. Brother with MI in 50s, died
in 70s of MI. Both brothers underwent CABG in their mid 50s to
60s. No family history of sudden cardiac death. Father died of
prostate cancer at 51.
Physical Exam:
VS: T= 98.6 BP= 154/73 HR= 72 RR= 14 O2 sat= 100% 2L NC
GENERAL: WDWN male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 4 cm at 20 degrees.
CARDIAC: RR, normal S1, S2, 2/6 systolic murmur. No thrills,
lifts. No S3 or S4.
LUNGS: No chest wall deformities. Resp were unlabored, no
accessory muscle use. Some crackles at L base, otherwise CTAB.
ABDOMEN: Soft, ND. No HSM. Abd aorta not enlarged by palpation.
No abdominial bruits. Tenderness in midline lower abdomen to
deep palpation, but without guarding or peritoneal signs.
-murphys.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ DP 2+
Left: Carotid 2+ DP 2+
Pertinent Results:
[**2126-5-13**] 07:00PM GLUCOSE-154* UREA N-23* CREAT-1.4* SODIUM-135
POTASSIUM-4.7 CHLORIDE-100 TOTAL CO2-22 ANION GAP-18
[**2126-5-13**] 07:00PM estGFR-Using this
[**2126-5-13**] 07:00PM ALT(SGPT)-24 AST(SGOT)-21 CK(CPK)-205* ALK
PHOS-67 TOT BILI-0.2
[**2126-5-13**] 07:00PM LIPASE-54
[**2126-5-13**] 07:00PM cTropnT-0.07*
[**2126-5-13**] 07:00PM CK-MB-9
[**2126-5-13**] 07:00PM WBC-9.7 RBC-4.72 HGB-14.6 HCT-42.6 MCV-90
MCH-30.9 MCHC-34.2 RDW-15.0
[**2126-5-13**] 07:00PM NEUTS-50.8 LYMPHS-39.5 MONOS-6.5 EOS-2.6
BASOS-0.7
[**2126-5-13**] 07:00PM PLT COUNT-325
[**2126-5-13**] 07:00PM PT-14.3* PTT-26.3 INR(PT)-1.2*
[**2126-5-14**] 01:16AM BLOOD WBC-8.5 RBC-4.48* Hgb-14.0 Hct-39.8*
MCV-89 MCH-31.2 MCHC-35.1* RDW-14.9 Plt Ct-336
[**2126-5-14**] 07:52AM BLOOD PT-15.0* PTT-74.4* INR(PT)-1.3*
[**2126-5-13**] 07:00PM BLOOD ALT-24 AST-21 CK(CPK)-205* AlkPhos-67
TotBili-0.2
[**2126-5-14**] 01:16AM BLOOD CK(CPK)-192*
[**2126-5-14**] 07:52AM BLOOD CK(CPK)-211*
[**2126-5-13**] 07:00PM BLOOD cTropnT-0.07*
[**2126-5-14**] 01:16AM BLOOD CK-MB-8 cTropnT-0.09*
[**2126-5-14**] 07:52AM BLOOD CK-MB-8 cTropnT-0.08*
[**2126-5-14**] 01:16AM BLOOD %HbA1c-7.5*
[**2126-5-15**] 05:00AM BLOOD WBC-7.0 RBC-4.56* Hgb-13.9* Hct-42.3
MCV-93 MCH-30.5 MCHC-33.0 RDW-14.6 Plt Ct-318
[**2126-5-15**] 05:00AM BLOOD PT-14.8* PTT-25.4 INR(PT)-1.3*
[**2126-5-15**] 05:00AM BLOOD Glucose-127* UreaN-19 Creat-1.3* Na-140
K-5.2* Cl-104 HCO3-30 AnGap-11
[**2126-5-15**] 05:00AM BLOOD Glucose-127* UreaN-19 Creat-1.3* Na-140
K-5.2* Cl-104 HCO3-30 AnGap-11
Echo [**5-14**]: The left atrium is normal in size. Left ventricular
wall thicknesses are normal. There is mild regional left
ventricular systolic dysfunction with severe hypokinesis of the
inferior and inferolateral walls with an overall EF of 40%.
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. There is no
pericardial effusion.
IMPRESSION: Mildly depressed left ventricular systolic function
with an EF of 40% and regional dysfunction with inferior,
inferolateral hypokinesis consistent with CAD.
KUB:
IMPRESSION:
1. No bowel obstruction, however, there is marked fecal loading
throughout
the colon.
2. L4 laminectomy with possible transitional anatomy at L5.
Brief Hospital Course:
This is a 73 yo man with DMII, HTN and an extensive cardiac
history including known 3VD and multiple PCIs including 11
stents who now presents with 1 week of nausea, lightheadedness,
diaphoresis and loose stools in the setting of recent capsule
endoscopy for h/o anemia, found to have ST elevations in an area
of prior ischemia.
# CORONARIES: EKG findings are nonspecific because of known
prior inferior infarct. The ST changes may represent a
collateral vessel territory given known RCA occlusion. Given no
CP and low enzymes, not ACS or cardiac strain in the setting of
hypovolemia and likely tachycardia from diarrhea and nausea, c/w
lightheadedness. Pt was on heparin overnight which was d/c'd.
EKG was unchanged in AM. Cardiac enzymes were unchanged. From a
cardiac standpoint there are no acute issues. He was however,
changed from simvastatin 40mg to lipitor 80mg given his prior
coronary history.
# PUMP: EF of 30% in [**2124**]. Clinically slightly hypovolemic,
perhaps related to recent episodes of diarrhea. Pt was given 1L
NS overnight to replete volume. Echo today showed mildly
depressed left ventricular systolic function with an EF of 40%
and regional dysfunction with inferior, inferolateral
hypokinesis consistent with CAD. No evidence of vegitations on
TTE given recent dental work.
# RHYTHM: NSR follow on tele
.
# Abdominal Pain and symptoms: No abd pain at home but c/o
nausea, loose stools. [**Month (only) 116**] be residual discomfort from endoscopy,
possibly with a subacute viral enteritis. Given territory of
pain, differential includes prostatitis or UTI, diverticulitis,
infectious colitis or enteritis, UTI. Low suspicion for
appendicitis or PUD given clinical picture. Recent endoscopy and
colonoscopy were negative for sources of bleeding or diverticula
(per patient). Normal WBC and normal temps not suggestive of an
acute infectious process. KUB negative and showed constipation.
He was started on a bowel regimen. Additionally, the patient
will follow-up with his GI (Dr. [**Last Name (STitle) 10794**] for further outpatient
management.
.
# ARF. Cre slightly up from baseline of 1.2. In the setting of
diarrhea and lightheadedness, likely prerenal related to mild
hypovolemia. On Admission his Cr was 1.4. Given 1L IVF
overnight. Cr on discharge 1.3 on discharge and trending down.
.
# Diabetes - Hold home glucophage and glyburide; continue home
lantus and add SSI.
# Dyslipidemia - atorva 80 mg daily, as above
.
# GERD - Continue outpatient regimen of sucralfate and
ranitidine. Holding prilosec due to potential interaction with
plavix.
.
# Chronic back pain secondary to spinal stenosis s/p L3-L5
laminectomy and an L4-L5 in situ fusion- PRN APAP for pain.
.
# Neuropathy - Continue home nortriptyline. Decreasing neurontin
dose to 300 q12h due to increased creatinine. Considered
neurontin toxicity as underlying cause of mild renal failure,
nausea, diarrhea, but less likely.
.
# Overactive bladder - Continue home hytrin.
.
# Depression - Continue home effexor.
Medications on Admission:
ASA 325 mg PO daily
Clopidogrel 75 mg PO daily
Terazosin 1 mg PO qhs
Ranitidine 150 mg PO daily
Nortriptyline 10 mg PO qhs
Sucralfate 1g PO qid
Nitroglycerin 0.4 mg SL PRN
Simvastatin 40 mg PO daily
Lopressor 100 mg PO bid
Glucophage 1000 mg PO tid
Prilosec EC 40 mg PO bid
Effexor 75 mg PO daily
Neurontin 800 mg PO bid
Glyburide 5 mg PO daily
Lantus 30 units SQ
Zestril 5 mg PO daily
Multivitamin PO daily
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Terazosin 1 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. Nortriptyline 10 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime) as needed for insomnia.
6. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
7. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1)
Sublingual prn as needed for chest pain.
8. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO
twice a day.
9. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO three times
a day.
10. Venlafaxine 75 mg Tablet Sig: One (1) Tablet PO once a day.
11. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H
(every 12 hours).
Disp:*60 Capsule(s)* Refills:*2*
12. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
13. Glyburide 5 mg Tablet Sig: One (1) Tablet PO once a day.
Tablet(s)
14. Lantus 100 unit/mL Solution Sig: Thirty (30) Subcutaneous
at bedtime.
15. Zestril 5 mg Tablet Sig: One (1) Tablet PO once a day.
16. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
17. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
Disp:*60 Tablet(s)* Refills:*0*
18. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Constipation
Secondary:
DM2 with peripheral neuropathy
Dyslipidemia
Hypertension
CAD with h/o MI and multiple interventions
OSA
Esophageal spasm
GERD, symptomatic
Chronic back pain secondary to spinal stenosis s/p cervical
laminectomy, s/p L3-5 laminectomy and L4-5 in situ fusion [**12-6**]
Restless leg syndrome
Discharge Condition:
stable, chest pain free, ambulating, sat >95% on RA
Discharge Instructions:
It was a pleasure taking care of you while you were in the
hospital. You were admitted to [**Hospital1 18**] because of abdominal pain.
You were initially sent to the ICU because of concern regarding
your heart. However, you did NOT have a heart attack and
remained stable. Additionally, your abdominal pain improved and
a x-ray of your abdomen showed constipation.
Please follow the medications prescribed below.
- You were started on a bowel regimen to help move your bowels
(Senna and Docusate).
- Please STOP your omeprazole given you are also on plavix and
they can interact.
- DECREASE your gabapentin to 300mg twice a day
- STOP your simvastatin and START atorvastatin 80mg daily
- There were not changes made to your medications, please
continue your medication prior to admission
Please follow up with the appointments below.
- you should follow-up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]. He is aware
of your admission. Additionally, you should also follow-up with
your GI doctor, Dr. [**Last Name (STitle) 10794**].
Please call your PCP or go to the ED if you experience chest
pain, palpitations, shortness of breath, nausea, vomiting,
fevers, chills, or other concerning symptoms.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction
Followup Instructions:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 43**], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 541**]
Date/Time:[**2126-5-29**] 2:30
Please follow-up with your PCP [**Name Initial (PRE) 176**] 1-2 weeks. Dr. [**Last Name (STitle) **]
already spoke with him regarding your admission and you agreed
to call and make an appointment.
PCP: [**Name10 (NameIs) 903**],[**First Name3 (LF) 251**] J. [**Telephone/Fax (1) 24396**]
Please follow-up with your GI doctor, Dr. [**Last Name (STitle) 10794**] within the next
1-2 weeks. You agreed to give him a call and follow-up. If you
have difficulty making an appointment you can follow-up with GI
here at [**Hospital1 18**]. GI: ([**Telephone/Fax (1) 2233**]
Completed by:[**2126-5-15**]
|
[
"596.51",
"530.81",
"285.9",
"357.2",
"333.94",
"414.01",
"008.8",
"276.52",
"V45.4",
"250.60",
"584.9",
"412",
"401.9",
"V45.82",
"311",
"789.00",
"724.2",
"338.29",
"530.5"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
12423, 12429
|
7469, 10485
|
335, 341
|
12797, 12851
|
4977, 7446
|
14252, 15030
|
3884, 4099
|
10944, 12400
|
12450, 12776
|
10511, 10921
|
12875, 14229
|
4114, 4958
|
277, 297
|
369, 2665
|
2687, 3679
|
3695, 3868
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,570
| 107,406
|
34268
|
Discharge summary
|
report
|
Admission Date: [**2153-10-23**] Discharge Date: [**2153-10-29**]
Date of Birth: [**2104-5-1**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain, shortness of breath
Major Surgical or Invasive Procedure:
[**2153-10-23**] Coronary Artery Bypass Graft x 2 (LIMA to LAD, SVG to
OM)
History of Present Illness:
49 y/o spanish speaking female with h/o chest discomfort with
shortness of breath. She had a abnormal stress test and was
referred for a cardiac cath. Cath revealed multi-vessel disease
and she was then referred for surgical revascularization.
Past Medical History:
Hypertension, Anxiety
Social History:
Denies tobacco or ETOH use. Spanish speaking. Lives alone.
Family History:
Non-contributory
Physical Exam:
Admission
VS: 75 18 178/85 5'2" 112#
Gen: NAD
Skin: Unremarkable
HEENT: NCAT, EOMI, PERRL
Neck: Supple, FROM -JVD
Chest: CTAB -w/r/r
Heart: RRR -c/r/m/g
Abd: Soft, NT/ND +BS
Ext: Warm, well-perfused -edema
Neuro: A&O x 3, MAE, non-focal
Discharge
T 97.1 BP 102/65 HR 97 RR 18 97% RA 51.4KG
General: spanish speaking, no acute distress
Pulmonary: lungs clear to asucultation bilaterally
Cardiac: tachycardia, normal S1S2. No murmurs, rubs, gallops
appreciated.
Sternal incision: sternum stable. No erythema or drainage.
Abdomen: soft and nontender without rebound or guarding
Extremities: warm with trace edema
Pertinent Results:
[**2153-10-23**] Echo: PREBYPASS: 1. The left atrium is normal in size.
No atrial septal defect or PFO is seen by 2D or color Doppler.
2. There is hypokinesis of the midpapillary anterior segment
with left ventricular systolic dysfunction with 45%. 3. Right
ventricular chamber size and free wall motion are normal. 4. The
ascending, transverse and descending thoracic aorta are normal
in diameter and free of atherosclerotic plaque. 5. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion. 6. The mitral valve leaflets are structurally normal.
Trivial mitral regurgitation is seen. POSTBYPASS: 1. Patient is
on phenylephrine infusion. 2. The anterior midpapillary segment
has improved function, EF is now 60%. 3. Mitral regurgitation is
unchanged.
[**2153-10-23**] 02:21PM WBC-12.5*# RBC-2.59*# HGB-8.2*# HCT-23.0*#
MCV-89 MCH-31.6 MCHC-35.4* RDW-12.5
[**2153-10-23**] 02:21PM PLT COUNT-247
[**2153-10-23**] 02:21PM PT-16.6* PTT-38.2* INR(PT)-1.5*
[**2153-10-23**] 02:21PM GLUCOSE-126* LACTATE-2.6* NA+-135 K+-3.4*
CL--104
[**2153-10-26**] 05:32AM BLOOD WBC-11.5* RBC-2.71* Hgb-9.0* Hct-24.7*
MCV-91 MCH-33.2* MCHC-36.4* RDW-13.6 Plt Ct-220
[**2153-10-26**] 05:32AM BLOOD Plt Ct-220
[**2153-10-26**] 05:32AM BLOOD Glucose-97 UreaN-9 Creat-0.6 Na-135 K-4.0
Cl-101 HCO3-30 AnGap-8
[**Hospital 93**] MEDICAL CONDITION:
49 year old woman with
REASON FOR THIS EXAMINATION:
s/p cabg falling hct, Is there a hemothorax.
Final Report
INDICATION: Status post CABG, decreasing hematocrit. Left
pneumothorax.
COMPARISON: [**2153-10-24**].
PORTABLE CHEST RADIOGRAPH: Right-sided central venous sheath and
mediastinal
wires are in unchanged position. Cardiac and mediastinal
contours appear
unchanged. Increasing bibasilar atelectasis is present. Lung
volumes are
lower compared to prior study. Possible small bilateral pleural
effusions are
identified; however, there is no evidence of large hemothorax.
IMPRESSION: Increasing bibasilar atelectasis. Possible small
bilateral
pleural effusions; however, no evidence of large hemothorax.
[**2153-10-28**] 06:55AM BLOOD WBC-10.1 RBC-3.34* Hgb-10.7* Hct-31.0*
MCV-93 MCH-32.2* MCHC-34.7 RDW-13.7 Plt Ct-404#
[**2153-10-23**] 02:21PM BLOOD WBC-12.5*# RBC-2.59*# Hgb-8.2*#
Hct-23.0*# MCV-89 MCH-31.6 MCHC-35.4* RDW-12.5 Plt Ct-247
[**2153-10-28**] 06:55AM BLOOD Glucose-90 UreaN-8 Creat-0.6 Na-135 K-4.5
Cl-101 HCO3-27 AnGap-12
[**2153-10-24**] 03:08AM BLOOD Glucose-92 UreaN-10 Creat-0.6 Na-136
K-3.4 Cl-106 HCO3-24 AnGap-9
Brief Hospital Course:
Ms. [**Known lastname 78888**] was a same day admit after undergoing pre-operative
evaluation for her cardiac cath on [**10-15**]. On [**10-23**] she was brought
directly to the operating room where she underwent a coronary
artery bypass graft x 2. Please see operative report for
surgical details. Following surgery she was transferred to the
CVICU in stable condition for invasive monitoring. She did well
in the immediate post-op period, was weaned from sedation, awoke
neurologically intact and extubated. She remained
hemodynamicaaly stable and on POD1 was transferred to the step
down floor for continued post-operative care/recovery. Once on
the floor she had an uneventful post-operative course and was
discharged home with visiting nurses on POD 6.
Medications on Admission:
HCTZ 25mg qd, Lisinopril 5mg qd, Aspirin 81mg qd, Vit E, C, and
B, Propanolol 40mg [**Hospital1 **]
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
4. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
Disp:*270 Tablet(s)* Refills:*0*
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
3 days.
Disp:*3 Tablet(s)* Refills:*0*
7. Potassium Chloride 10 mEq Tablet Sustained Release Sig: Two
(2) Tablet Sustained Release PO once a day for 3 days.
Disp:*6 Tablet Sustained Release(s)* Refills:*0*
8. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q6H (every 6 hours) as needed.
Disp:*1 1* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x
2(LIMA to LAD, SVG to OM)[**10-23**]
PMH: Hypertension, Anxiety
Discharge Condition:
Good
Discharge Instructions:
shower daily , no baths or swimming
no lotion, creams, or powders on any incision
no driving for one month and until off all narcotics
no lifting greater than 10 pounds for 10 weeks
call for fever greater than 100.5, redness, or drainage of
incisions
take all medications as directed
Followup Instructions:
[**Hospital 409**] clinic in 2 weeks
Dr. [**Last Name (STitle) **] in 4 weeks
Dr. [**First Name (STitle) **] in [**1-24**] weeks
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2153-11-28**]
9:00
Completed by:[**2153-10-29**]
|
[
"E878.2",
"285.1",
"300.00",
"414.01",
"401.9",
"276.8",
"413.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.11",
"36.15",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
5994, 6052
|
4045, 4804
|
354, 430
|
6219, 6225
|
1510, 2831
|
6557, 6863
|
840, 858
|
4954, 5971
|
2871, 2894
|
6073, 6198
|
4830, 4931
|
6249, 6534
|
873, 1491
|
283, 316
|
2926, 4022
|
458, 703
|
725, 748
|
764, 824
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,353
| 163,126
|
17827+56893+56894
|
Discharge summary
|
report+addendum+addendum
|
Admission Date: [**2177-6-9**] Discharge Date: [**2177-6-19**]
Date of Birth: [**2113-12-27**] Sex: M
Service: [**Hospital Unit Name 196**]
HISTORY OF PRESENT ILLNESS: This is a 63-year-old Kenyan man
with a past medical history significant for insulin
dependent-diabetes mellitus, hypertension,
hypercholesterolemia, and no known coronary artery disease,
who presents complaining of substernal chest pain and chest
pressure that was nonradiating, intermittent, occurred in
brief episodes at rest, and was new, along with diaphoresis
and shortness of breath, and general weakness, and fatigue
for about two days, feeling somewhat worse today. The
patient states that he was visiting from [**Country 16465**] for a
conference. He denies fever, chills, nausea, vomiting, and
diarrhea.
In the Emergency Department, the patient arrived pain free.
He was given aspirin in route. He was given Lopressor 5 mg
IV x1, 25 mg po x1, and Lasix 20 mg IV x1, as well as
nitropaste. He was initially in mild apparent failure, but
was having good urine output.
PAST MEDICAL HISTORY:
1. Insulin dependent-diabetes mellitus.
2. Hypertension.
3. Hypercholesterolemia.
4. Negative exercise tolerance test last year as per patient.
5. No known renal disease.
SOCIAL HISTORY: Prior smoking history, but remote. The
patient is from [**Country 16465**] and is a farmer and coffee exporter.
He has no known HIV risk factors, but had a negative HIV test
in [**Month (only) 1096**]. He is sexually active in a monogamous
relationship with his wife.
ALLERGIES: No known drug allergies.
MEDICATIONS:
1. NPH 30 units am and 20 units pm.
2. Glucophage 500 mg po q day.
3. Aspirin 81 mg po q day.
4. Unknown antihypertensive medication.
5. Unknown cholesterol medication.
PHYSICAL EXAMINATION: Vital signs: Temperature 99.8, heart
rate 80, blood pressure 175/53, respiratory rate 24, and
oxygen saturation is 99%. In general, in no apparent
distress, comfortable obese man. HEENT: Normocephalic,
atraumatic. Mucous membranes moist. No jugular venous
distention. Cardiovascular: Regular, rate, and rhythm,
decreased heart sounds, no murmurs appreciable. Lungs are
clear to auscultation bilaterally. No rales, rhonchi, or
wheezing. Abdomen is soft, obese, nontender, and
nondistended, and normal bowel sounds. Extremities: 1+
pitting edema in bilateral lower extremities. Rectal
examination was guaiac negative.
PERTINENT LABORATORIES AND DIAGNOSTICS ON ADMISSION: The
patient had a Chem-7 which revealed a sodium of 135,
potassium of 5.2, chloride of 102, bicarbonate of 21, BUN of
34, creatinine of 1.7, and a glucose of 245. Patient's
complete blood count revealed a white count of 7.7,
hematocrit of 33.6, normal differential, MCV of 89.
Patient's cardiac enzymes: First set CK 453, CK MB 5,
troponin 1.8. Second set CK 357, CK MB 4, troponin 1.8.
Third set: CK 224, CK MB 4, troponin 2.2. Fourth set: CK
257, CK MB 4, troponin 2.4. Patient's calcium was 8.3,
phosphorus 2.9, magnesium 3.2. Coagulation profile revealed
a PT of 13.6, PTT of 29.6, and an INR of 1.2. Fractional
excretion of sodium was 3.4%, creatinine clearance was 80.
Urinalysis revealed moderate blood and moderate protein.
Chest x-ray was consistent with cardiomegaly and diffuse
bilateral pulmonary vasculature enlargement consistent with
congestive heart failure.
Abdominal KUB revealed no free air, no obstruction, and
positive stool.
Electrocardiogram revealed normal sinus rhythm at 66 beats
per minute, left axis deviation, P-R interval of 206, Q's in
III and aVF, T-wave flattening in I and aVL, and no ST-T
changes.
ASSESSMENT: This is a 63-year-old male with a history of
insulin dependent-diabetes mellitus, hypertension,
hypercholesterolemia, and no known coronary artery disease
who presents complaining of intermittent episodes of
substernal chest pain x2 days associated with diaphoresis,
shortness of breath, and fatigue concerning for unstable
angina. He was admitted continued symptoms to rule out
myocardial infarction as well as workup for his increased
creatinine of 1.7.
HOSPITAL COURSE:
1. Procedures: The patient underwent a cardiac
catheterization on [**2177-6-9**], which revealed a right
dominant coronary vasculature, no significant obstructive
disease with normal flow, a pulmonary capillary wedge
pressure of 30 mm Hg, and systolic hypertension.
The patient underwent an echocardiogram on [**6-10**], which
revealed mild left atrial dilatation, mild symmetric left
ventricular hypertrophy, mild regional left ventricular
systolic dysfunction, a resting basal to mid inferior
akinesis and basal to mid inferolateral hypokinesis and
akinesis, RVH, right ventricular cavity dilatation, mild
global right ventricular free wall hypokinesis, abnormal
septal motion consistent with right ventricular pressure and
volume overload, mild aortic and mitral and tricuspid valve
thickening, mild-to-moderate AR, mild MR, moderate TR, left
ventricular inflow consistent with pseudonormal pattern with
increased left sided filling pressures and impaired left
ventricular relaxation, severe pulmonary artery hypertension,
and an ejection fraction of 55%.
The patient underwent a VQ scan on [**6-12**] which was negative
for embolic disease and was suggestive of central airway
disease. The patient underwent a chest CT scan on [**2177-6-12**] which was suggestive of congestive heart failure,
although there was a mention of very mild enlargement of
hilar lymph nodes to a nonpathologic degree as well as
mention of a small nodule measuring several mm in the lung
fields.
The patient underwent a cardiac MR [**First Name (Titles) **] [**6-13**], which revealed
mild global ventricular dysfunction with regional dysfunction
of the distal anterolateral and septal walls as well as the
apex. There is no evidence of myocardial scarring. There is
no significant intercardiac shunt.
The patient underwent a right heart cardiac catheterization
on [**2177-6-16**]. During this procedure, a right ventricular
biopsy was attained. The patient's pulmonary artery
pressures had decreased from the previous cardiac
catheterization from 111 to 59, but the pulmonary capillary
wedge pressure was still at around 30. Preliminary studies
on the right ventricular biopsy had been negative for any
infiltrative disease. Further studies were pending at the
time of this dictation.
2. Narrative of hospital course by problem:
1. Chest pain/rule out myocardial infarction: The patient
was started on aspirin, beta blocker, Heparin and Integrilin
given the fact that he had active chest pain. However,
cardiac catheterization showed no coronary artery disease.
As a result, Heparin and Integrilin were discontinued. His
troponin, however, did reach a peak of greater than 2.
2. Pulmonary artery hypertension: The workup mentioned above
under the procedure section was performed to elicit a cause
of the patient's pulmonary hypertension. At the time of this
dictation, the leading candidate for a cause is the patient's
left heart disease and a restrictive cardiomyopathy secondary
to diabetes, hypertension, and excessive salt intake. The
patient is being transferred to the Coronary Care Unit for
monitoring and testing.
3. Diabetes: The patient was taken off Glucophage given his
acute on chronic renal failure. He was placed on a regular
insulin-sliding scale, and was given NPH insulin. The
patient's insulin was titrated up in order to meet his
diabetic needs. He was also placed on [**First Name8 (NamePattern2) **] [**Doctor First Name **] diet. The
patient was started on Glipizide 5 mg po q day.
4. Hypertension: The patient was optimally managed with
metoprolol, lisinopril, and diltiazem. These were titrated
up as needed.
5. Acute renal failure versus chronic renal insufficiency:
The patient's fractional excretion of sodium was greater than
3% suggesting that the patient had intrinsic renal disease.
He was given Mucomyst around the time of his first cardiac
catheterization. He was started on lisinopril for renal
protection. His creatinine improved from 1.9 on admission to
1.2 the day prior to transfer to the CCU. His creatinine did
start to increase slightly with further diuresis throughout
the hospital stay.
6. Congestive heart failure: The patient had a good ejection
fraction by echocardiogram, but there was mention of several
wall motion abnormalities. Documentation of high pulmonary
capillary wedge pressures on cardiac catheterization prompted
the team to aggressively diurese the patient with Lasix. At
the time of this dictation, the patient had been diuresed
about [**1-24**] pounds during his hospital stay.
7. Infectious Disease: An Infectious Disease consult was
requested to try to elucidate whether or not there was an
infectious role being played in his pulmonary artery
hypertension. They were asked to investigate the possibility
that Infectious Disease may be causing the hilar
lymphadenopathy and ground-glass opacities found on high
resolution CT scan.
Infectious Disease recommendations included ruling out the
patient for tuberculosis, which he did. They also included
looking into the possibility that the patient was drinking
bark teas that could have tryptophan which can cause
pulmonary artery hypertension. Lastly, the consultant
recommended HIV testing, which the patient declined given the
fact that he had negative tests results in [**Month (only) 1096**].
8. Hypercholesterolemia: The patient was treated with
atorvastatin while in-house.
9. Anemia: The patient's anemia was worked up extensively.
Iron studies were not significant for iron deficiency. B12
and folate levels were normal. Hemolysis panel was negative.
A malaria smear was obtained and it too was negative.
At the time of dictation, the patient was moved to the
Coronary Care Unit for placement of a Swan-Ganz catheter and
further hemodynamic testing.
The rest of this dictation will be covered by Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **].
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 4786**]
Dictated By:[**Last Name (NamePattern1) 1595**]
MEDQUIST36
D: [**2177-6-19**] 02:04
T: [**2177-6-19**] 06:36
JOB#: [**Job Number 49473**]
Name: [**Known lastname 9169**], [**Known firstname **] Unit No: [**Numeric Identifier 9170**]
Admission Date: [**2177-6-9**] Discharge Date: [**2177-6-20**]
Date of Birth: [**2113-12-27**] Sex: M
Service: [**Hospital Unit Name 319**]
The patient was transferred to the CCU for a brief stay for a
Swan-guided diuresis. His P.A. pressures were initially
99/37, but after aggressive IV diuresis, they were reduced to
37/12 with a wedge pressure between [**11-23**]. The patient's
blood pressure is also now better controlled with systolic
blood pressure running less than 130.
The patient's dry weight upon discharge is 103.3 kg.
DISCHARGE MEDICATIONS:
1. Lisinopril 20 mg q day.
2. Lasix 60 mg [**Hospital1 **].
3. NPH 35 units q am, 20 units q pm.
4. Metoprolol 50 mg tid.
5. Glipizide 5 mg q day.
6. Lipitor 10 mg q day.
7. Aspirin 325 mg q day.
DISCHARGE DIAGNOSES:
1. Restrictive cardiomyopathy with reactive pulmonary
hypertension.
2. Type 2 diabetes mellitus.
3. Hypertension.
4. Hypercholesterolemia.
DISCHARGE STATUS: The patient was discharged in good
condition to home. He will fly back to his homeland, [**Country 8876**]
in the next few days. There he is to have close medical
followup. His physician needs to monitor his blood sugars
and adjust his insulin regimen as needed. His blood
pressures will also need to be monitored on a regular basis
and his antihypertensives to be adjusted as needed. His
creatinine upon discharge had risen to 1.6, most likely due
to all the aggressive diuresis he received. His renal
function will also need to be monitored over a close basis
over the next few weeks, and his medications adjusted as
needed.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1095**]
Dictated By:[**First Name (STitle) 7614**]
MEDQUIST36
D: [**2177-6-20**] 12:02
T: [**2177-6-20**] 12:05
JOB#: [**Job Number 9171**]
Name: [**Known lastname 9169**], [**Known firstname **] Unit No: [**Numeric Identifier 9170**]
Admission Date: [**2177-6-9**] Discharge Date: [**2177-6-20**]
Date of Birth: [**2113-12-27**] Sex: M
Service: [**Hospital Unit Name 319**]
This is an addendum to the discharge dictation for the
purpose of recording patient's dry weight and hemodynamics.
The patient was transferred to the CCU, and had a Swan-Ganz
catheter placed for aggressive diuresis. His dry weight was
found to be approximately 103 kg. At this weight, he had a
systolic blood pressure of 128/50. A right atrial pressure
of approximately 12, right ventricular pressure of 40/10, a
pulmonary capillary wedge pressure of 12, pulmonary artery
pressure of 34/8, central venous pressure of 13, cardiac
output of 5.6 with a cardiac index of 2.37, and a SVR of 843,
and a pulmonary vascular resistance of 171.
DR [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] 12.661
Dictated By:[**Last Name (NamePattern1) 580**]
MEDQUIST36
D: [**2177-6-19**] 14:21
T: [**2177-6-23**] 13:21
JOB#: [**Job Number 9172**]
|
[
"593.9",
"272.0",
"397.0",
"584.9",
"250.00",
"416.8",
"428.0",
"401.9",
"425.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.23",
"37.25",
"89.64",
"89.68",
"99.20",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
11264, 13503
|
11046, 11243
|
4118, 6413
|
1799, 2469
|
2790, 4101
|
6441, 11023
|
190, 1073
|
2484, 2772
|
1095, 1267
|
1284, 1776
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,644
| 108,088
|
14843
|
Discharge summary
|
report
|
Admission Date: [**2197-11-14**] Discharge Date: [**2197-11-24**]
Date of Birth: [**2133-12-13**] Sex: M
Service:
ADMISSION DIAGNOSIS: Rectal cancer.
DISCHARGE DIAGNOSIS: Rectal cancer, status post
abdominoperineal resection.
HISTORY OF PRESENT ILLNESS: The patient is a 63 year old man
with a known history of right colon adenocarcinoma, staging
T3 N0, rectal adenocarcinoma staging T1 N0, status post
chemotherapy and radiation therapy in [**Month (only) 216**] and [**2197-9-3**]. The patient had had previous resections for the known
cancers. He now has a recurrence of a rectal cancer at the
suture line. The patient comes for further surgical
resection of the recurrent cancer.
PHYSICAL EXAMINATION: In general, the patient is in no acute
distress. Chest is clear to auscultation bilaterally.
Cardiovascular is regular rate and rhythm, without murmurs,
rubs or gallops. The abdomen is soft, nontender,
nondistended. Incisional scars consistent with previous
surgery. Extremities - The patient does have some mild
pitting edema of the bilateral lower extremities. Otherwise,
the extremities are warm, noncyanotic, nonedematous.
Neurologically, the patient is grossly intact.
PAST MEDICAL HISTORY:
1. Right colon adenocarcinoma, T3 N0.
2. Rectal adenocarcinoma, T1 N0.
3. Status post chemotherapy and radiation treatment in
[**Month (only) 216**] and [**2197-9-3**].
4. Hypertension.
5. History of atrial fibrillation.
6. History of Clostridium difficile infection.
7. Status post right colectomy and sigmoid resection in
[**2194-12-3**].
8. Transurethral resection of prostate [**2197-10-3**].
9. Port-a-cath placement [**2197-8-3**].
MEDICATIONS ON ADMISSION:
1. Lasix 40 mg once daily.
2. Diltiazem extended release 120 mg once daily.
3. Accupril 10 mg once daily.
4. Potassium Chloride 10 meq once daily.
5. Albuterol inhaler two puffs four times a day.
6. Atrovent inhaler two puffs four times a day.
7. Digoxin 250 mcg once daily.
8. Warfarin 1 mg once daily, has been off Warfarin
preoperatively.
9. Azmacort inhaler p.r.n.
HOSPITAL COURSE: The patient was admitted for further
surgical therapy of his recurrent rectal cancer. In the
operating room, the decision was made to proceed with
abdominoperineal resection. The patient seemed to tolerate
the procedure well without complication.
Postoperatively, the patient was recovering nicely on bedrest
until the morning of [**2197-11-16**], postoperative day number two.
The patient on postoperative day number two had some mental
status changes and was initially somewhat lethargic and
became agitated and intermittently violent. The patient
became disoriented although he was alert. Initial workup
including cardiac and metabolic workups proved to be
negative. The patient did have some crackles on physical
examination throughout his lung fields. After speaking with
the family, the patient had a history of some altered mental
status changes preceding a previous episode of pneumonia that
he had had. Working diagnosis at that time was pneumonia
versus hospital psychosis. The patient's mental status did
not improve over the course of the following two days with
some intermittent agitation. The patient was medicated with
Haldol and Ativan. This had some success.
On the evening of postoperative day number four, the patient
had an acute episode of respiratory distress and required
intubation on the floor. Subsequent to this, the patient was
transferred to the Intensive Care Unit for closer monitoring
and ventilatory management. In the Intensive Care Unit, the
patient did well and was extubated postoperative day number
six. The patient was empirically covered for a probable
aspiration pneumonia with Levaquin, a seven day course. The
patient was transferred back to the floor on postoperative
day number six. His mental status was normal at that time.
Throughout the rest of his hospital course, the patient did
quite well. His diet was advanced as tolerated. The patient
was discharged on postoperative day number ten tolerating a
regular diet and having regular ostomy output, good pain
control on p.o. pain medications.
CONDITION ON DISCHARGE: Good.
DISPOSITION: To home.
DIET: Ad lib.
MEDICATIONS ON DISCHARGE:
1. Lasix 40 mg once daily.
2. Diltiazem extended release 120 mg once daily.
3. Accupril 10 mg once daily.
4. Potassium Chloride 10 meq once daily.
5. Albuterol inhaler two puffs four times a day.
6. Atrovent inhaler two puffs four times a day.
7. Digoxin 250 mcg once daily.
8. Warfarin 1 mg once daily, has been off Warfarin
preoperatively.
9. Azmacort inhaler p.r.n.
10. Amiodarone 400 mg twice a day.
11. Percocet 5/325 mg one to two tablets q4hours p.r.n.
FOLLOW-UP: The patient is to follow-up with Dr. [**Last Name (STitle) **] on
[**2197-11-27**]. He is being sent home with VNA for ostomy care and
[**Known lastname 1661**]-[**Location (un) 1662**] teaching. [**Known lastname 1661**]-[**Location (un) 1662**] will likely be
discontinued at subsequent office visit with Dr. [**Last Name (STitle) **].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 6066**]
Dictated By:[**Last Name (NamePattern1) 5745**]
MEDQUIST36
D: [**2197-11-24**] 08:21
T: [**2197-11-26**] 09:18
JOB#: [**Job Number **]
|
[
"154.1",
"790.01",
"553.21",
"507.0",
"998.2",
"427.31",
"780.09",
"492.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.23",
"38.93",
"96.71",
"48.5",
"53.51",
"96.6",
"46.75",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
190, 246
|
4266, 5360
|
1708, 2087
|
2105, 4168
|
732, 1212
|
152, 168
|
275, 709
|
1234, 1682
|
4193, 4240
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,636
| 133,237
|
50966
|
Discharge summary
|
report
|
Admission Date: [**2135-4-26**] Discharge Date: [**2135-6-13**]
Date of Birth: [**2053-2-22**] Sex: F
Service: SURGERY
Allergies:
Reglan
Attending:[**First Name3 (LF) 3376**]
Chief Complaint:
Enterovaginal Fistula
Major Surgical or Invasive Procedure:
Cystoscopy [**2135-5-4**]
exlap, LOA, SBR, internal bypass [**2135-5-20**]
History of Present Illness:
Ms. [**Known lastname 13014**] is an 82 year old female with history of rectal cancer
s/p open [**Month (only) **] with partial posterior wall vaginectomy [**2133**] with
several ostomy revisions, most recently in [**2135-1-14**] who was
admitted in [**2135-3-14**] with an enterovaginal fistula. While in
house she underwent an exam under anesthesia by Gyn and the
Colorectal service and a Foley catheter was placed in the
vagina.
She was discharged to rehab in [**2135-4-5**] and since that time,
the patient reports new development of vulvar pain and worsening
hematuria.
Her hematocrit was monitored at [**Hospital6 459**] and was
found to decrease from 25-> 23 and she received 2 units of
packed red blood cells on [**2135-4-19**]. Her hematocrit rose
appropriately to 30 and remained stable on recheck on [**2135-4-24**].
Per nursing report at [**Hospital 100**] Rehab the bladder foley was
re-inserted on [**2135-4-26**] days ago and required multiple
attempts.
With regard to the vaginal foley catheter, she endorses leaking
around the catheter and that the catheter has fallen out
multiple times requiring replacment. She now endorses vulvar
irritation that she describes a burning sensation and erythema.
of note, there has also been a significant decrease in the
ostomy output.
She denies any fever, chills, nausea, vomiting or abdominal
pain.
Past Medical History:
1. Idiopathic pulmonary fibrosis.
2. Rectal/colon cancer, followed by Dr. [**Last Name (STitle) 1120**].
3. Labial agglutination secondary to lichen sclerosus and
radiation, followed by Dr. [**First Name (STitle) **].
4. Bilateral pulmonary embolism in [**2133**].
5. History of PSVT in [**2126**]. The patient is status post
ablation.
6. Hypertension.
7. Status post fall with left hip fracture, [**2129**].
PAST SURGICAL HISTORY:
1. Left hip replacement.
2. Bilateral total knee replacements.
3. Cesarean section x3.
4. Hysterectomy.
5. Colonoscopy and ileostomy with subsequent two revisions of
ostomy.
Social History:
Lives with daughter, usually quite functional and does housework
on her own. Worked as cook in high school cafeteria.
Tob: 3ppd for 15 years, quit35 years ago
EtOH: none
Drugs: none
Family History:
Mother died of heart dx in 90s, father died at age 89. Sister
died at age 86 with heart failure. Brother with MI s/p bypass,
age 60s. Brother died from bronchiectasis from ? lung infection.
Physical Exam:
Vitals: T: 97.7 T: 97.3 HR: 79 BP: 103/54 RR: 20 Sat: 98RA
Gen: Alert and Oriented x 3, NAD
Card: Regular Rate and Rhythm, no murmur/rub/gallop/click
Pulm: scattered crackles auscultation posteriorly. Coarse breath
sounds. She tends to be tachypneic for over a month unchanged
despite continued diuresis. Patient is not short of breath.
Abdomen: mildly distended. Ostomy pink: stool and flatus in
bag. Staples removed with intervening steri-strips. Stable
erythema around wound x 5 days. Trace drainage at lower aspect
of incision. +BS minimal and appropriate tenderness to
palpation. No rebound or gaurding
Ext: warm, no edema
Pertinent Results:
[**2135-5-30**] 06:00AM BLOOD WBC-12.4* RBC-2.90* Hgb-8.2* Hct-26.6*
MCV-92 MCH-28.4 MCHC-30.9* RDW-15.4 Plt Ct-506*
[**2135-5-31**] 04:49AM BLOOD Glucose-121* UreaN-28* Creat-0.7 Na-137
K-4.9 Cl-102 HCO3-26 AnGap-14
[**2135-5-27**] 11:30 am FLUID,OTHER Site: ABDOMEN
ABDOMEN FLUID COLLECTION.
GRAM STAIN (Final [**2135-5-27**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final [**2135-5-30**]): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
[**2135-5-16**] 6:30 am BLOOD CULTURE
**FINAL REPORT [**2135-5-22**]**
Blood Culture, Routine (Final [**2135-5-22**]):
ENTEROCOCCUS SP..
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
296-5698F
[**2135-5-15**].
Anaerobic Bottle Gram Stain (Final [**2135-5-17**]):
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
[**2135-5-26**] 4:50 pm BLOOD CULTURE 2 OF 2.
**FINAL REPORT [**2135-6-1**]**
Blood Culture, Routine (Final [**2135-6-1**]): NO GROWTH.
[**2135-5-26**] 9:34 pm CATHETER TIP-IV Source: PICC.
**FINAL REPORT [**2135-5-29**]**
WOUND CULTURE (Final [**2135-5-29**]): No significant growth.
[**2135-5-15**] 11:35 pm URINE Source: CVS.
**FINAL REPORT [**2135-5-19**]**
URINE CULTURE (Final [**2135-5-19**]):
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
WORK UP OF SELECTED ORGANISMS REQUESTED BY DR. [**Last Name (STitle) 105906**]
#[**Numeric Identifier 22887**] [**2135-5-17**].
INTERPRET RESULTS WITH CAUTION.
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
PSEUDOMONAS AERUGINOSA. 10,000-100,000 ORGANISMS/ML..
STAPHYLOCOCCUS, COAGULASE NEGATIVE. 10,000-100,000
ORGANISMS/ML..
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
| PSEUDOMONAS AERUGINOSA
| |
STAPHYLOCOCCUS, COAGULASE N
| | |
AMIKACIN-------------- <=2 S
AMPICILLIN------------ <=2 S
CEFEPIME-------------- 2 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R 8 I
LEVOFLOXACIN---------- =>8 R
MEROPENEM------------- 8 I
NITROFURANTOIN-------- 32 S 32 S
OXACILLIN------------- =>4 R
PIPERACILLIN/TAZO----- 16 S
TETRACYCLINE---------- =>16 R 8 I
TOBRAMYCIN------------ 8 I
VANCOMYCIN------------ 1 S 1 S
[**2135-5-15**] 11:11 pm BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT [**2135-5-20**]**
Blood Culture, Routine (Final [**2135-5-19**]):
ENTEROCOCCUS FAECALIS. FINAL SENSITIVITIES.
HIGH LEVEL GENTAMICIN SCREEN: Susceptible to 500 mcg/ml
of
gentamicin. Screen predicts possible synergy with
selected
penicillins or vancomycin. Consult ID for details.
HIGH LEVEL STREPTOMYCIN SCREEN: Resistant to 1000mcg/ml
of
streptomycin. Screen predicts NO synergy with
penicillins or
vancomycin. Consult ID for treatment options. .
SENSITIVE TO Daptomycin (0.38 MCG/ML).
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS FAECALIS
|
AMPICILLIN------------ <=2 S
DAPTOMYCIN------------ S
PENICILLIN G---------- 8 S
VANCOMYCIN------------ 1 S
Anaerobic Bottle Gram Stain (Final [**2135-5-16**]):
REPORTED BY PHONE TO [**First Name8 (NamePattern2) 105907**] [**Last Name (NamePattern1) 13613**] @ 1724 ON [**5-16**] -
12R.
GRAM POSITIVE COCCI.
IN PAIRS AND CHAINS.
HISTORY: 82-year-old woman with multiple prior surgeries,
history of rectal
cancer with now large fluid collection in the abdomen. Please
drain and send
for Gram stain and culture.
COMPARISON: CT from the night before.
FINDINGS: Ultrasound again reveals the large anterior abdominal
fluid
collection.
PROCEDURE: After the risks and benefits of the procedure were
explained to
the patient, written informed consent was obtained. A
preprocedure timeout
was performed using three forms of patient identification.
The overlying skin was prepped and draped in the usual sterile
fashion. The
skin and subcutaneous tissues were anesthetized with 1% buffered
lidocaine
solution. Then, using direct ultrasound guidance, an 18-gauge
[**Last Name (un) 4300**] needle
was advanced into the fluid collection. A small amount of
straw-colored fluid
was obtained. Then, [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 7648**] wire was advanced through the
needle. After
sequential dilation, an 8 French pigtail catheter was left in
place and
approximately 120 cc of straw-colored fluid was obtained. This
was sent for
culture and Gram stain. The catheter was fastened to the skin.
This was left
to gravity drainage.
The patient tolerated the procedure well. There were no known
complications.
Dr. [**Last Name (STitle) **] supervised the procedure.
IMPRESSION:
Ultrasound-guided 8 French pigtail catheter placement into
anterior abdominal
fluid collection, yielding 120 cc of straw-colored fluid.
Specimen was sent
for culture and Gram stain.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **]
DR. [**First Name8 (NamePattern2) 7722**] [**Last Name (NamePattern1) 7723**]
Approved: MON [**2135-5-30**] 11:28 AM
CT A/P [**2135-5-26**]:
MPRESSION:
1. Increasing large anterior abdominal fluid collection with
foci of gas
measuring 16 x 16 cm. This is amenable to ultrasound-guided
drainage.
2. No change in the presacral fluid collection measuring 2.7 x
2.4 cm.
3. Status post small bowel bypass with no evidence of oral
contrast
extravasation or small-bowel obstruction. The matted loops of
small bowel,
deep in the pelvis do not fill with oral contrast, consistent
with a bypass.
4. Slightly improving bilateral hydroureteronephrosis.
5. Right lower lobe airspace disease, incompletely visualized on
this study
but findings are suspicious for pneumonia or aspiration.
6. Cholelithiasis.
[**2135-4-26**] 12:35PM GLUCOSE-127* UREA N-23* CREAT-0.6 SODIUM-135
POTASSIUM-4.5 CHLORIDE-102 TOTAL CO2-25 ANION GAP-13
[**2135-4-26**] 12:35PM ALT(SGPT)-20 AST(SGOT)-20 LD(LDH)-155 ALK
PHOS-466* TOT BILI-0.5
[**2135-4-26**] 12:35PM ALBUMIN-2.6* CALCIUM-9.0 PHOSPHATE-3.6
MAGNESIUM-1.9 IRON-20*
[**2135-4-26**] 12:35PM calTIBC-200* FERRITIN-195* TRF-154*
[**2135-4-26**] 12:35PM TRIGLYCER-68
[**2135-4-26**] 12:35PM WBC-9.5 RBC-3.37* HGB-9.6* HCT-30.0* MCV-89
MCH-28.4 MCHC-32.0 RDW-14.1
[**2135-4-26**] 12:35PM PLT COUNT-538*
[**2135-4-26**] 12:35PM PT-13.4 PTT-31.5 INR(PT)-1.1
[**2135-4-26**] 12:12PM URINE BLOOD-LG NITRITE-POS PROTEIN->300
GLUCOSE-100 KETONE-15 BILIRUBIN-LG UROBILNGN-1 PH-9.0* LEUK-LG
Brief Hospital Course:
The patient was seen in the ED and admitted to the surgical
service for further management. She was made NPO and was seen by
Nutrition for initiation of TPN and by gynecology for initial
management of her vaginitis and assistance with pain control. A
PICC line was placed. Additionally the wound/ostomy nurse [**First Name (Titles) **] [**Last Name (Titles) 17037**]d for assistance with her ostomy. The patient was
observed to have hematuria, c/w her known entero vaginal
fistuala and was started on Cipro. Gastroenterology was
consulted for this and agreed with plan to optimize nutrition
and use diverting ostomy with goal of resolution of fistula. CT
a/p was obtained on [**4-30**] that demonstrated her enterovaginal
fistula. On HD 6 the patient was progressing well and given no
clear infection in the existing mesh on CT, abx were dc'd.
Because of persistent hematuria and palpable mass, GU elected to
take the patient for cystoscopy which was performed and did not
show any clear lesions. Because of persistent hematuria, the
patient was restarted on abx (bactrim). Her E-V fistula failed
to resolve and an MRI was obtained on [**5-14**] c/w with this as well
as possible involvement of the bladder, and the patient was
planned for the OR for closure on [**2135-5-20**]. She was medically
optimized for this during the next several days.
On [**2135-5-20**], the patient went to the OR for surgical revision of
her entero-vaginal fistula. An ex-lap was performed with lysis
of adhesions and resection of small bowel, as well as a bypass
of the small bowel involved in the fistula. No evidence of
recurrent rectal ca was found. EBL was 150cc and pt received
approximately 3 L of IVF intra-op. Pt remained hemodynamically
stable. An epidural was placed for pain control. She was
successfully extubated in the PACU and was admitted to the ICU
for post-operative monitoring. She was treated with a warming
blanket for post-operative hypothermia. On the morning following
her operative, the patient did have some hypotension. She was
treated initally with a 3L LR fluid bolus followed by LR
maintenance fluids. She was also given albumin. Additionally,
she was noted to have clots in her urine, for which a 3-way
foley was placed and CBI was briefly initiated. The patient
remained hemodynamically stable thereafter and was transferred
out of the ICU on the 2nd day after her surgery.
Following transfer from the unit the patient was taken to the
floor for further managment. She was continued her TPN, was seen
by PT who indicated she would require continued rehab on DC. On
POD five she was tried on a regular diet but req'd replacement
of her NG tube after nausea/vomiting. On POD 6 she was triggered
for tachypnea and required treatment for underlying CHF. Her
symptoms resolved with diuresis. Her postoperative abx
(Vanc/Zosyn) were dc'd without complication on POD 6 as well.
She continued to have postoperative abdominal pain and was found
to have a fluid collection that required IR drainage, with
removal of 100cc serous fluid. Additionally, her wound staples
had to be removed [**2-15**] serous drainage. On POD 11 IR drain was
removed. By HD 11 she was tolerating a regular diet after NG
tube removal and was oob to chair and working with PT. On HD 13
she was again triggered for tachypnea and this resolved with
diuresis. She also required consult by Geriatrics for delirium,
and it was determined to be hypoactive delirium, aggravated by
the presence of a yeast UTI, which was treated with fluconazole.
On HD47 she was noted to have positive urinalysis. When urine
cultures returned positive for klebsiella on HD48 POD 39/23, she
was started on ciprofloxacin for 5 days. By HD49 POD 40/24 the
patient was OOB and walking and was planned fo discharge to home
with instructions to follow up in the clinic in [**1-15**] weeks as
well as with home care services per DC instructions below.
Patient will have 24 hour care provided by her daughter [**Name (NI) **].
[**Name2 (NI) 105908**] has 2 rolling walkers, cane and walk-in shower with
bench. She will also recieve [**Name2 (NI) 269**] services for ostomy/incision
care and PT.
Medications on Admission:
TPN, Mirtazapine 7.5 QHS, Octrotide 100 IV Q8, Omeprazole 20 QD,
metoprolol 25 [**Hospital1 **], propafenone 150 TID, Lidocaine Jelly
Discharge Medications:
1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. Propafenone 150 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
5. Dronabinol 2.5 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
6. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
7. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO at bedtime.
Discharge Disposition:
Home With Service
Facility:
All Care [**Hospital1 269**] of Greater [**Location (un) **]
Discharge Diagnosis:
Enterovaginal Fistula
Discharge Condition:
Vital signs stable
Mental status: Alert and oriented x 3
Ambulating with assistance
Discharge Instructions:
Incision Care:
-Your steri-strips will fall off on their own.
-You may shower, and wash surgical incisions.
-Avoid swimming and baths until your follow-up appointment.
-Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
Monitoring Ostomy output/Prevention of Dehydration:
-Keep well hydrated.
-Replace fluid loss from ostomy daily.
-Avoid only drinking plain water. Include Gatorade and/or other
vitamin drinks to replace fluid.
-Try to maintain ostomy output between 1000mL to 1500mL per day.
-If Ostomy output >1 liter, take 4mg of Imodium, repeat 2mg with
each episode of loose stool. Do not exceed 16mg/24 hours.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) 1120**] in [**1-15**] weeks. Call for an appointment:
[**Telephone/Fax (1) **]
|
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icd9cm
|
[
[
[]
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] |
[
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] |
icd9pcs
|
[
[
[]
]
] |
16466, 16557
|
11265, 15418
|
288, 365
|
16623, 16642
|
3473, 4112
|
17432, 17555
|
2611, 2803
|
15602, 16443
|
16578, 16602
|
15444, 15579
|
16733, 16733
|
16748, 17409
|
2216, 2396
|
2818, 3454
|
227, 250
|
393, 1753
|
4148, 11242
|
16657, 16709
|
1775, 2193
|
2412, 2595
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,453
| 126,696
|
19696
|
Discharge summary
|
report
|
Admission Date: [**2189-2-23**] Discharge Date: [**2189-2-27**]
Date of Birth: [**2134-7-25**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 943**]
Chief Complaint:
Transfer From an outside hospital with hepatic encephalopathy
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
54 year old man w/ Hep C cirrhosis, h/o multiple admissions for
hepatic encephalopathy, CRI, Type II DM, pancytopenia initially
admitted to OSH [**2189-2-22**] with melena and mental status change. He
was found by his [**Last Name (un) **], unconscious, in his house on [**2189-2-22**].
Over the last week he had 3 episodes of black, tarry stools and
increased weakness. At the time he denied hematemesis, although
he did report epigastric pain. At that time, HCT notable for
29.8 (baseline 24-32). Pt was treated with lactulose, and his
HCT remained relatively stable without further episodes of
melena noted.
Past Medical History:
1. HCV cirrhosis, genotype 1A (c/b h/o portal htn/
ascites/encephalopathy/ sbp)
2. History of spontaneous bacterial peritonitis
3. Chronic Renal Insufficiency (baseline Cr = 1.3)
4. Diabetes Type II
5. Pancytopenia likely d/t hypersplenism
6. Chronic hyperkalemia
7. Hypertension
8. Methadone maintenance
9. DVT s/p IVC filter placement
Social History:
Lives with sister in [**Name (NI) 4310**] ([**Telephone/Fax (1) 53279**]).Tobacco abuse 22
[**Telephone/Fax (1) 53278**], quit 6 months ago3.History of IVDU, quit 7yrs ago on
methadone maintenance.History of ETOH abuse, quit 23 yrs ago.
Family History:
Father died at 55 CAD.
Mother died at 82 lung cancer.
Physical Exam:
96.4, 140/70, 60, 18, 100%RA
Finger stick 164
Gen: Cachectic man, eating breakfast, NAD, non-toxic
HEENT: NCAT, PERRL, EOMI, anicteric, MMM
Neck: supple, no LAD
Resp: CTAB
Card: RRR, nl S1 S2, no m/g/r
Abd: soft, nl BS, NT/ND, no HSM appreciated
Ext: +2 DP/PT, no edema
Neuro: A&O3, CNs intact, MAE, normal gait, no asterixis
Pertinent Results:
[**2189-2-24**] AM on admission
CBC: WBC-2.5* Hgb-8.6* Hct-24.0* MCV-89 MCH-32.0 MCHC-35.8*
RDW-18.2* Plt Ct-64*
Diff: Neuts-72.3* Bands-0 Lymphs-19.6 Monos-2.2 Eos-5.2*
Baso-0.7
Smear: Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL Macrocy-1+
Microcy-NORMAL Polychr-1+
Coags: PT-14.4* INR-1.3
Chem7: Glucose-131* BUN-42* Cr-1.2 Na-147* K-3.5 Cl-115* HCO3-23
AnGap-13
ALT-48* AST-44* AlkPhos-156* TotBili-0.6
Lipase-59
CK-MB-NotDone cTropnT-<0.01
Albumin-3.0* Calcium-8.5 Phos-3.9 Mg-1.3*
TSH-1.5
.
[**2189-2-24**] 05:20AM BLOOD Type-ART pO2-94 pCO2-34* pH-7.44
calHCO3-24 Base XS-0 Intubat-NOT INTUBA
.
CT head: No acute intracranial abnormality visualized.
CXR: No acute cardiopulmonary process.
Brief Hospital Course:
The patient was initially admitted to [**Hospital **] [**Hospital 1459**] hospital
on [**2189-2-22**] where he had A negative nexk CXR, CXR, and head CT.
A CTA chest showed cirrhosis with ascites but no pulmonary
embolus. While at the OSH he was seen by 4 consult services
(neuro, heme, pulmonary, and ?liver or GI).
.
He was tranferred to [**Hospital1 18**] [**2189-2-23**] for further management. On
[**2189-2-24**] 12 a.m., he was noted by nursing staff to be conversant,
alert and oriented X 2, although confused. He was found at 4
a.m. that same night unresponsive. The patient was transferred
to the ICU and intubated for airway protection. His lactulose
was administered via an NG tube. On [**2189-2-24**] the patient self
extubated himself did not require re-intubation given improved
mental status and no respiratory distress. He required 1 unit
of pRBC on [**2189-2-24**] for an hct of 24.3 (down from 26.9). He was
guaiac negative during his hospital stay though he was
reportedly guaiac positive at the OSH. His hematocrit responded
well to the transfusion and remained stable for the rest of his
hospital stay. He was transferred back to the floor on [**2189-2-25**]
and his mental status quickly returned to his baseline. He was
followed by hepatology throughout the course of his
hospitalization and put on rifaximin 400mg po tid.
.
His blood sugars were chronically high (150-250) but according
to his primary N.P. he has confusion with blood sugars <200.
His home dose of glipizide 5mg po q day was not adjusted, but he
did receive RISS while in hospital.
.
He was continued on his home medications of lactulose (titrated
to goal of [**6-5**] bowel movements per day), Cipro (for SBP
prophylaxis), propranolol (for portal HTN), hydralazine,
amlodopine, ferrous sulfate, and protonix. His lasix and epogen
were initially held but were restarted while in hospital.
Medications on Admission:
Propranolol HCl 20 mg PO TID
Hydralazine HCl 10 mg PO Q6H
Amlodipine 5 mg PO DAILY
Lactulose 30 ml PO QID
Glipizide 5 mg PO DAILY
Pantoprazole 40 mg PO Q24H
Ciprofloxacin HCl 250 mg PO Q12H
Ferrous Sulfate 325 mg PO DAILY
Furosemide 40 mg PO DAILY
Insulin SC Sliding Scale
Discharge Medications:
1. Glipizide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO tid ().
Disp:*90 Tablet(s)* Refills:*2*
4. Propranolol HCl 20 mg Tablet Sig: One (1) Tablet PO TID (3
times a day). Tablet(s)
5. Hydralazine HCl 10 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours).
6. Amlodipine Besylate 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
8. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
9. Lancets Misc Sig: One (1) Miscell. four times a day.
Disp:*80 * Refills:*2*
10. Glucometer Elite Classic Kit Sig: One (1) Miscell.
once.
Disp:*1 * Refills:*0*
11. Glucometer Encore Test Strip Sig: One (1) bottle
Miscell. once.
Disp:*1 bottle* Refills:*2*
12. Epoetin Alfa 10,000 unit/mL Solution Sig: Four (4) ml
Injection once a week.
13. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q4H (every
4 hours).
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Hepatic encepalopathy
Discharge Condition:
good
Discharge Instructions:
Take your medications as prescribed.
Call your doctor or come to the ER is you are having fevers to
101.4, confusion, vomitting, abdominal pain, shortness of
breath, or any other worrisome symptoms.
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Where: LM [**Hospital Unit Name 5628**]
Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2189-3-4**] 2:20
Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Where: LM [**Hospital Unit Name 3126**] CENTER Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2189-7-20**] 1:20
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13,664
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|
51176
|
Discharge summary
|
report
|
Admission Date: [**2200-8-7**] Discharge Date: [**2200-9-5**]
Date of Birth: [**2132-5-6**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 297**]
Chief Complaint:
SOB, hypoxia
Major Surgical or Invasive Procedure:
intubation
arterial line
colonoscopy
EGD
Left subclavian line
tracheostomy [**8-26**]
PEG tube [**9-3**]
History of Present Illness:
68yo man with h/o HIV/AIDS (last CD4 211 [**2200-8-9**], vl <50 [**6-/2200**]
on HAART), CAD s/p CABG [**2194**], PCI RCA [**2198**], CHF (EF >55%,
diastolic dysfunction), admitted [**2200-8-7**] with SOB and fever. He
has been intubated previously for recurrent pneumonia and CHF
exacerbations. The patient was evaluated in the ED [**2200-8-4**] after
noting fever of 101 at home. CXR at that time showed no change
from prior, UA was negative, and other labs were essentially
unremarkable, and he was discharged to home. He was evaluated by
his PCP [**2200-8-5**] and started on Azithromycin for concern of
atypical pneumonia. On the morning of admission [**2199-8-7**] he
developed a fever to 101.8 and worsening shortness of breath. He
denied cough and chest pain. On presentation to the ED T 99.1,
HR 61, BP 146/44, RR 24 93%RA. CXR showed new bilateral patchy
opacities. He was started on azithromycin, ceftriaxone, and
vancomycin. He was transferred to the MICU that night with
worsening tachypnea and decreasing O2 saturation on 100% NRB.
Oxygentation improved after diuresis with torsemide, and he was
transferred back to the floor on Zosyn, vancomycin, and
azithromycin for treatment of pneumonia. Since that time he has
continued to spike fevers, today to 100.7. Renal function has
declined with creatinine rising 3.0 to 4.4 between [**2200-8-11**] and
today, [**2200-8-13**]. On the night of [**2200-8-11**] he was diuresed after
developing pulmonary edema with iv fluid boluses for treatment
of acute renal failure, thought to be prerenal in etilogy.
[**Hospital 106213**] hospital course has been complicated by recurrent
diarrhea, C. diff negative x1.
*
On [**8-8**] patient desaturated to 88% on 100%NRB, RR 26, BP
120/70, HR 75. ABG 7.31/41/63 on NRB. CXR showed diffuse patchy
infiltrates unchanged since last CXR [**2200-8-10**] and small bilateral
effusions. Patient was alert and conversive. He was SOB, denies
chest pain, abdominal pain, headache, dizziness. Prior to
transfer to the MICU he received torsemide 20mg iv x1.
Past Medical History:
1. HIV, diagnosed in [**2185**]. Last CD4 273, VL<50 on [**2200-12-30**].
Patient has history of KS, CMV esophagitis. Source of
transmission unknown.
2. CAD, s/p 2-vessel CABG in [**2194**] and RCA stent in 10/[**2198**].
Patent stents on last cath in 10/[**2198**].
3. Diastolic CHF
4. History of large cell lymphoma (liver and periaortic Lymph
nodes) s/p 6 rounds of chemotherapy in [**2189**]
5. Peripheral vascular disease.
6. DM type 2
7. Hypertension
8. GERD
9. CRI with history of hyperkalemia. Baseline creatinine
variable. Last 0.8 in 11/[**2199**].
10. Lipodystrophy
11. History of TIA [**4-/2199**] with left hemiplegia that resolved.
12. Status post anterior disc excision and fusion C7-Ti in [**2189**].
13. h/o resp failure requiring intubation [**7-7**] (x7 days) with
"double PNA" and resp failure in [**State 33977**] in [**5-7**]
14. Probable HIV encephalopathy
15. Severe arthritis involving both shoulders and cervicle spine
Social History:
He lives with his wife in [**Name (NI) 1562**]. He is a lifelong non-smoker.
No EtOH consumption and no history of illicit drug use. + flu
shot this year.
Family History:
Sister died of CAD and CVA
Brother has h/o CAD
Mother has h/o CAD
Physical Exam:
On admission:
PE: T 97.3 Tm 100.7 HR 78 BP 154/45 RR 38 90% NRB
Gen: cachectic appearing, in moderate respiratory distress with
use of accessory muscles
HEENT: PERRL, anicteric, MM dry,
Neck: neck supple, JVP elevated to jaw
CV: RRR, no mrg, nml s1s2
Resp: diffuse crackles to apices, decreased bibasilar breath
sounds R>L, no egophany, RLL dullness to percussion
Abd: +BS, soft, NT, ND
Ext: no edema, decreased DP's B, warm
Neuro: alert and oriented, CN II-XII intact with decreased
hearing B (R>L), motor and sensation intact grossly
On Transfer to MICU:
PE: T 97.3 Tm 100.7 HR 78 BP 154/45 RR 38 90% NRB
Gen: cachectic appearing, in moderate respiratory distress with
use of accessory muscles
HEENT: PERRL, anicteric, MM dry,
Neck: neck supple, JVP elevated to jaw
CV: RRR, no mrg, nml s1s2
Resp: diffuse crackles to apices, decreased bibasilar breath
sounds R>L, no egophany, RLL dullness to percussion
Abd: +BS, soft, NT, ND
Ext: no edema, decreased DP's B, warm
Neuro: alert and oriented, CN II-XII intact with decreased
hearing B (R>L), motor and sensation intact grossly
Pertinent Results:
CT chest ([**8-24**]):
Diffuse ground-glass opacifications and septal thickening
bilaterally. There is an associated right pleural effusion. This
could be due to an element of CHF. There is also more patchy
airspace opacifications seen at both lung bases.
*
Left Upper Ext U/S ([**8-22**]): to eval to swelling
There is flow throughout all the veins of the upper extremity.
There is compressibility of the subclavian and axillary veins.
Compressibility of the smaller upper extremity veins is limited
due to technical factors on the current exam.
*
ECHO ([**8-14**]):
The left atrium is mildly dilated. Left ventricular wall
thicknesses are
normal. The left ventricular cavity size is normal. Overall left
ventricular systolic function is normal (LVEF 70%). No masses
or thrombi are seen in the left ventricle. There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The right ventricular free wall is
hypertrophied. The right ventricular cavity is mildly dilated.
Right ventricular systolic function appears depressed. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Trivial mitral regurgitation is seen. There is
severe pulmonary artery systolic hypertension. There is no
pericardial effusion.
.
Renal U/S [**2200-8-9**]:
No evidence of hydronephrosis. Normal renal ultrasound.
.
EGD [**8-15**]:
Friability and erythema in the first part of the duodenum
compatible with duodenitis. Erosions in the second part of the
duodenum
.
GI Bleeding Study [**8-15**]:
No evidence of intra-abdominal extravasation of tracer to
indicate
a GI bleed. However, lateral delayed images show abnormal tracer
uptake within the region of the rectum. The rectal area could be
further evaluated by direct inspection.
.
EGD [**8-20**]:
Stricture of the distal bulb
Blood in the fundus
Mucosa suggestive of Barrett's esophagus
Otherwise normal egd to mid-jejunum
.
Colonoscopy [**8-20**]:
There was no blood in the colon or terminal ileum.
Otherwise normal colonoscopy to terminal ileum
.
Video Swallow [**9-3**]:
Aspiration and penetration of thin and nectar-thickened liquids.
Please refer to speech pathologist report for further
evaluation.
Brief Hospital Course:
67 yo man with HIV/AIDS, CAD s/p CABG, HTN, DM2 admitted with
fever and shortness of breath, transferred to MICU with hypoxic
respiratory failure requiring intubation.
#) Hypoxic resp failure requiring intubation. Trach placed on
[**8-26**].
Pt initially with multifocal PNA and likely fluid overload (PCWP
of 27). He received 10 days of azithromycin for atypical PNA
coverage and 21 days of Vanco/Zosyn. 1st bronch did not reveal
a great deal of sputum in his airways thus assumed initial PNA
had resolved.
He was then placed on a lasix gtt for aggressive diuresis. He
was thought to have right heart failure secondary to pulm HTN
(CVP of 13, PA pressure of 69/28). His Swan was d/c'ed on [**8-17**].
An echo done on [**8-14**] revealed an EF of 70%, normal E/A ratio,
moderate PA HTN and RV hypokinesis. His lasix gtt was
eventually d/c'ed on [**8-25**] for acute on chronic renal failure.
A 2nd Bronch was performed on [**8-19**] to evaluate a RLL opacitiy;
BAL gram stain revealed 1+ GPC but negative culture, negative
PCP/AFB cultures, positive yeast. A third bronch done on [**8-26**];
BAL w/o WBC's, Gram Stain negative, Cultures NG. A sputum Cx on
[**8-31**] revealed OP flora and yeast. He was treated with 3 days of
Caspofungin for yeast in his sputum, urine, and on his skin.
Yeast was then noted to be [**Female First Name (un) **].
He then developed ARDS (increased Vd/Vt ratio with decreased
compliance) which subsequently resolved. He was able to be
weaned off ventilator support; he tolerated a trach mask for 4
days prior to discharge. His trach was changed to a 6 portex
cuffless nonfenestrated trach prior to discharge with plan to
decanulate at rehab.
#) GI bleed: Melena and hct drop to 18 on [**8-15**]. EGD on [**8-15**]
revealed duodenitis and duodenal erosions without active
bleeding. A bleeding scan revealed abnormal tracer uptake
within the region of the rectum. He received 5 units of PRBCs on
[**8-15**], with Hct rise to 32.2. C-scope on [**8-20**] revealed no
bleeding source, a repeat enteroscopy showed clot in fundus and
stricture in duodenal bulb. No further workup was performed.
He received intermittent transfusions from [**Date range (1) **]. His GI
bleed did not recur and his hct remained stable throughtout the
remainder of his hospital course.
#) Acute on chronic renal failure (basline Cr 1.6-1.9).
Etiology thought to be secondary to ATN from GI bleed
superimposed on CRI secondary to HTN and DM. HAART regimen was
not thought to be the cause of acute failure. His creat again
increased after aggressive diuresis (no casts on urine sediment
at that time). His creatinine improved to 1.5 after lasix gtt
d/c'ed and fluid goals changed to even. His daily fluid goal
was even prior to discharge. He was given lasix prn. Of note
his home regimen includes Lasix 40 mg daily.
#) HIV: Last CD4 count pre-hospitalization >300, 211 during
illness. On Bactrim prophylaxis. HAART initially held
secondary to inability to pass NGT/OGT/Dob-Hoff. Restarted on
[**8-16**]. Received HAART meds intermittently until [**8-22**], but then
held as per ID as pt had to be NPO for various GI and pulm
procedures. HAART meds again restarted on [**8-25**]. HIV genotype
ordered. Viral load noted to be <50 on [**8-29**].
#) Hypernatremia. New on [**8-16**], presumed secondary to
aggressive diuresis with Lasix. He was continued on free water
boluses (250 cc q 6 hrs). Hypernatremia resolved on [**8-23**].
#) HTN. BP well controlled during hospital stay. He was
maintained on his outpatient regimen of metoprolol, hydralazine,
and amlodipine.
#) DM type 2: He was on an insulin drip from [**8-15**] - [**8-17**] for
tighter blood sugar control. Prior to discharge his blood
sugars were well controlled on an increased dose of NPH (27
units [**Hospital1 **]) and a regular insulin sliding scale.
#) Mid back pain; etiology likely musculoskeletal secondary to
prolonged bedrest. Pain was well controlled with tylenol and
morphine prn. He was discharged on prn oxycodone. He was seen
by PT and OT during his stay.
#) Psych. He developed a delirium thought to be secondary to
his prolonged ICU stay. It resolved prior to discharge. He was
continued on olanzipine and paroxetine.
#) CAD s/p CABG - Continued on B-B. ASA and [**Hospital1 4532**] restarted
after GI bleed resolved. He is not on an ACEI likely secondary
to h/o hyperkalemia. Unclear why his is not on a statin. LFT's
noted to be WNL's.
#) FEN: Pt with NGT; tube feeds at goal throughout most of
hospital course. A Video swallow evaluation was performed; it
was determined that Mr [**Known lastname 106212**] could take his po meds however
will not likely maintain caloric intake without tube feeds. PEG
placed at bedside by GI on [**2200-9-4**].
#) Ppx: SC heparin, PPI. Elevate HOB. Bactrim QOD.
#) Access: swan ganz (pulled on [**8-17**]), Left a line pulled [**8-30**],
Right PICC placed [**8-22**] - pulled prior to discharge.
Medications on Admission:
Medications on Admission:
ABACAVIR SULFATE 300MG--One twice a day
BACTRIM 200-40MG/5--20 ml
CRIXIVAN 333MG--3 three times a day
EPIVIR 150MG--One twice a day
HYDRALAZINE HCL 100 mg TID
Insulin sliding scale
KLONOPIN 0.25MG--One at bedtime
LOPRESSOR 50MG--One twice a day
NEURONTIN 400/800/800
NEVIRAPINE 200MG--One tablet by mouth twice a day
Zantac 150mg [**Hospital1 **]
NORVASC 5MG--2 every day
PAXIL 20MG--One tablet every day
PERIDEX 1.2MG/ML--Swish and spit twice a day as needed
[**Hospital1 **] 75MG--1qd
TORSEMIDE 60 mg [**Hospital1 **]
ZYPREXA 5MG--One at bedtime
*
Meds on Transfer from floor to ICU:
Abacavir 300mg [**Hospital1 **]
Amlodipine 10mg daily
Azithromycin 500mg iv q24hr
Zosyn 2.25mg iv Q8hr
Vancomycin 1000mg iv q48hr
Ativan prn
Oxycodone 5mg prn
[**Hospital1 **] 75mg daily
Hydralazine 100mg tid
Indinavir 1000mg tid
Insulin 20units NPH [**Hospital1 **] +RISS
Lamivudine 100mg daily
Metoprolol 50mg tid
Nevirapine 200mg [**Hospital1 **]
Olanzapine 5mg qHS
Paroxetine 20mg daily
Ranitidine 150mg daily
Bactrim 20mL QOD
Triamcinolone TP
ASA 81mg daily
Discharge Medications:
1. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Epoetin Alfa 2,000 unit/mL Solution Sig: One (1) Injection
QMOWEFR (Monday -Wednesday-Friday).
3. Chlorhexidine Gluconate 0.12 % Liquid Sig: Five (5) ML Mucous
membrane [**Hospital1 **] (2 times a day).
4. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
5. Nevirapine 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
6. Indinavir 200 mg Capsule Sig: Five (5) Capsule PO three times
a day.
7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
8. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
10. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
11. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO Q
AFTERNOON AND PM ().
12. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO Q AM ().
13. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
14. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO three times
a day.
15. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
16. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
18. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO QHS (once a day (at bedtime)).
19. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
20. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
21. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**6-15**]
Puffs Inhalation Q6H (every 6 hours).
22. Bactrim 400-80 mg Tablet Sig: One (1) Tablet PO every other
day.
23. Abacavir 300 mg Tablet Sig: One (1) Tablet PO twice a day.
24. Epivir 150 mg Tablet Sig: One (1) Tablet PO once a day.
25. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for SOB, wheezing.
26. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**6-15**]
Puffs Inhalation Q4H (every 4 hours) as needed.
27. NPH Insulin
27 Units in the morning and evening.
28. Regular Insulin Sliding Scale
Please refer to Insulin Sliding Scale.
29. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day as
needed for Signs and Symptoms of fluid overload: Pt has been
doing well with a daily fluid goal of even Please give lasix
based on clinical exam. Normal regimen includes 40 mg daily. .
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Cape & Islands
Discharge Diagnosis:
Pneumonia
CHF exacerbation
ARDS
GI bleed
s/p intubation, tracheostomy, and PEG
Discharge Condition:
Fair
Discharge Instructions:
Please call your primary care physician or return to the
hospital if you experience worsening shortness of breath, chest
pain, cough, fever, or have any other concerns.
Followup Instructions:
You have the following appointment scheduled:
1. Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Where: [**Hospital6 29**]
CARDIAC SERVICES Phone:[**Telephone/Fax (1) 6197**] Date/Time:[**2200-9-10**] 11:00
2. Provider: [**Name10 (NameIs) 1412**] [**Name Initial (NameIs) **] [**Name12 (NameIs) 1413**], M.D. Where: LM [**Hospital Unit Name 4341**] DISEASE Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2200-9-15**] 1:30
|
[
"428.30",
"486",
"518.81",
"250.40",
"276.2",
"403.91",
"263.9",
"276.5",
"428.0",
"584.5",
"537.3",
"707.03",
"276.0",
"112.2",
"416.8",
"042",
"285.9",
"535.61",
"355.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"43.11",
"96.6",
"96.72",
"45.23",
"38.91",
"96.04",
"89.64",
"99.04",
"33.24",
"31.1"
] |
icd9pcs
|
[
[
[]
]
] |
15898, 15956
|
7212, 12187
|
324, 430
|
16079, 16086
|
4858, 7189
|
16303, 16797
|
3662, 3729
|
13313, 15875
|
15977, 16058
|
12239, 13290
|
16110, 16280
|
3744, 3744
|
272, 286
|
458, 2503
|
3758, 4839
|
2525, 3472
|
3488, 3646
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,741
| 164,445
|
51251
|
Discharge summary
|
report
|
Admission Date: [**2173-11-2**] Discharge Date: [**2173-11-5**]
Service: MEDICINE
Allergies:
Penicillins / lisinopril / simvastatin
Attending:[**First Name3 (LF) 4765**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname **] is a [**Age over 90 **] yom w/ CAD s/p CABG and stenting, diastolic
dysfunction, with multiple admissions for pneumonia, pleural
effusions and empyemas who was admitted to ICU for hypotension
and hypoxic respiratory distress. Patient developed acute
shortness of breath, unproductive cough, and fever that began
earlier this evening. He has dyspnea on exertion at baseline,
but does not require home O2. Patient has had difficulty with
thin liquids in past resulting in reported aspiration pneumonia.
His last choking episode was over 2 weeks ago. He also reports
some middle back pain which had started over the weekend, and
was worse when walking per patient. Patient currently denies any
back pain. He has not had any chest pain, recent illness or
trauma. He denies abdominal pain, nausea, vomiting, or diarrhea.
Of note, patient has been "unsteady" for past few weeks with
walker at home. Last BM was [**11-1**], and was normal.
Patient was 92% on RA when seen by EMS and started on 2L NC.
ED Course:
initial vitals: 100.4 HR 94 152/56 RR 20 sat 100% 2L NC
Tmax: 103.8
Systolics to mid 80's
satting 97% on 3L NC at 5am
-Fluids: 1.5L NS
-triggered for RR of 33
-ceftriaxone 1g
-levaquin 750mg
-tylenol 500mg
-ipratropium & albuterol nebs
On arrival to MICU, patient's VS: 95/46 HR 94 RR 28 sat 95%
3LNC
Review of systems: no chest pain, abdominal pain, nausea,
vomiting, or diarrhea.
Past Medical History:
-admission for septic shock [**7-/2172**] of unclear etiology,
requiring intubation and pressors
-CAD status post CABG in [**2162**] with a LIMA to the LAD and SVG
to the PDA, SVG to the OM.
-Subsequent cardiac catheterization in [**2164-5-24**] with
Hepacoat stent of the SVG-OM. The SVG to the PDA was noted to be
occluded at this time.
-Most recent Persantine MIBI in [**2170-2-25**]
demonstrating a mild inferior fixed defect with an ejection
fraction of approx 61%.
-Peripheral neuropathy
-Diastolic dysfunction
-Chronic exertional shortness of breath
-Hyperlipidemia
-HTN
-BPH s/p TURP in '[**53**]
-Cataracts s/p surgery
Social History:
Lives at home with his wife, daughter and son. 60 pack-year
smoking hx. Quit in [**2133**]. Previous social alcohol use. No
illicits.
Family History:
No significant family medical history that the patient is aware
of.
Physical Exam:
Admission Physical:
Gen: NAD
Neck: no JVD, no masses
Pulm: bibasilar crackles, no wheezes
CV: holosystolic murmur, NR, regular rhythm
Abd: NT, ND, soft
Ext: 1+ bilateral lower ext edema
Skin: no lesions noted
Neuro: alert, orientation not assessed, no gross deficits, EOMI
Discharge Physical:
Gen: NAD, sitting on side of bed
CV: RRR, no M/R/G
Chest: crackles left base, [**Month (only) **] bibasilar
ABD: soft, NT, BM overnight
Extremeties: 1+ edema bilat
Neuro: oriented x3, good recall of distant events.
O2 sat 95% RA, Afeb, BP 108-137/54-60, HR 65
Pertinent Results:
Admission Labs:
[**2173-11-2**] 01:20AM BLOOD WBC-11.3* RBC-4.36* Hgb-14.0 Hct-41.1
MCV-94 MCH-32.1* MCHC-34.1 RDW-13.6 Plt Ct-145*
[**2173-11-2**] 01:20AM BLOOD Neuts-88.5* Lymphs-4.9* Monos-3.7 Eos-2.6
Baso-0.3
[**2173-11-2**] 01:20AM BLOOD Glucose-121* UreaN-31* Creat-1.4* Na-137
K-4.9 Cl-101 HCO3-26 AnGap-15
[**2173-11-2**] 01:20AM BLOOD cTropnT-<0.01
[**2173-11-2**] 01:40AM BLOOD Lactate-2.2*
Microbiology:
Blood culture [**2173-11-2**]: pending x2
Urine culture [**2173-11-2**]: negative
Imaging:
CXR [**2173-11-2**]:
IMPRESSION: Clear, well-expanded lungs with the exception of
minimal left
Preliminary Reportgreater than right basilar atelectasis.
MRI T-spine
THORACIC SPINE: The thoracic spinal canal is capacious. The
thoracic spinal cord is normal in signal intensity and
morphology. There are no significant degenerative changes in
the thoracic spine. There is no abnormal enhancement to suggest
epidural abscess, osteomyelitis, discitis or metastasis. There
are several T1-bright and T2-bright lesions in the vertebral
bodies, compatible with benign intraosseous hemangiomas.
The cervical spine is only partially visualized, which
demonstrates various degrees of disc bulges and spinal canal
narrowing, but no evidence of infection or metastasis.
IMPRESSION: No evidence of infection or metastasis. Multiple
intraosseous
hemangiomas.
Echo [**11-2**]
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is mild
regional left ventricular systolic dysfunction with focal basal
inferior hypokinesis. The remaining segments contract normally
(LVEF = 50%). Right ventricular chamber size and free wall
motion are normal. The ascending aorta is mildly dilated. The
aortic valve leaflets are moderately thickened. There is a
minimally increased gradient consistent with minimal aortic
valve stenosis. Mild to moderate ([**1-25**]+) mitral regurgitation is
seen. The estimated pulmonary artery systolic pressure is
normal. There is no pericardial effusion.
IMPRESSION: Mild regional left ventricular systolic dysfunction,
c/w CAD. Mild to moderate mitral regurgitation.
Compared with the report of the prior study (images unavailable
for review) of [**2169-8-15**], mild regional LV systolic dysfunction
is apparent. The other findings appear similar.
Discharge Labs:
[**2173-11-5**] 07:26AM BLOOD WBC-6.3 RBC-4.00* Hgb-12.3* Hct-38.1*
MCV-95 MCH-30.8 MCHC-32.3 RDW-13.8 Plt Ct-153
[**2173-11-4**] 05:58AM BLOOD PT-10.2 PTT-46.5* INR(PT)-0.9
[**2173-11-5**] 07:26AM BLOOD Glucose-106* UreaN-23* Creat-1.4* Na-140
K-4.6 Cl-103 HCO3-31 AnGap-11
[**2173-11-5**] 07:26AM BLOOD Calcium-8.7 Phos-3.7 Mg-2.0
[**2173-11-3**] 02:19AM BLOOD %HbA1c-5.6 eAG-114
[**2173-11-3**] 02:19AM BLOOD Triglyc-111 HDL-35 CHOL/HD-4.2 LDLcalc-91
LDLmeas-103
Brief Hospital Course:
Brief Course:
Mr. [**Known lastname **] is a [**Age over 90 **] yom w/ CAD, diastolic dysfunction, hx
multiple admissions for pneumonia, pleural effusions and
empyemas presenting with acute onset shortness of breath and
fever with mild leukocytosis and CXR without focal opacity
admitted to MICU for hypoxic respiratory distress concerning for
pneumonia, later transferred to CCU for NSTEMI which was likely
due to demand in setting acute illness.
Acute issues:
# Hypotension: Concern for sepsis initially, with concern for
pulmonary source given pt was complaining of cough and dyspnea,
however no focal infiltrate on CXR. Pt was admitted to the MICU
and required no pressors. He was volume-resuscitated and started
on Ceftriaxone and Azithromycin initially for community-acquired
PNA. Cultures were sent and there has been no growth to date.
Given pt's acute onset back pain, epidural abscess vs
osteomyelitis was also considered. ESR and CRP were elevated.
MRI showed no osteomyelitis or epidural abscess; just revealed
multiple intraossesous hemangiomas.
TTE showed mild regional left ventricular systolic dysfunction,
consistent with CAD. This finding was expected given known
inferior wall disease on previous P-MIBI study (fixed defect
inferiorly) and occluded SVG-PDA during [**2164**] cath study.
Pt's troponins found to be elevated and uptrending and was
transferred to the CCU for further workup and management of
presumed NSTEMI. Pt was received by CCU team on HD1 with pt on
heparin gtt, statin, and beta blocker. Pt remained
hemodynamically stable during stay in CCU without pressors. In
addition, antibiotics were stopped on HD2 as leukocytosis
resolved, pt remained afebrile and hemodynamically stable and
demonstrated no source of infection.
#NSTEMI: Troponins elevated to peak of 1.2, likely due to demand
NSTEMI in setting of acute hypotension. Troponins were elevated
and intially uptrending. Patient started on heparin drip and
transferred to the CCU. Troponins stabilized and trended down,
and patient was persistantly asymptomatic. He remained
hemodynamically stable after transfer to the CCU and serial ECGs
showed no ST changes or TWI. Decision was made to pursue medical
management and he was kept on heparin drip for 48 hours. Patient
was discharged on aspirin, clopidogrel, atorvastatin and
metoprolol.
# Hypoxic Respiratory Distress: Pt presented with O2 sat of 92%
on RA, and was placed on NRB in the ED. Differential included
pulmonary edema [**2-25**] acute diastolic heart failure vs. pneumonia
or viral bronchitis. Infectious etiology thought to be most
likely given fever, leukocytosis and cough. No evidence of
volume overload on exam, making acute diastolic heart failure
unlikely. CXR was without acute process. He required 2L nasal
cannula O2 during stay in MICU and CCU. Upon arrival to CCU, pt
was thought to be euvolemic and did not require diuresis.
# Back Pain: Reportedly acute onset. Considered pleuritic
irritation from pulmonary process (see above), chronic
musculoskeletal pain or spondylosis, or myalgias from possible
viral infection, or epidural abscess. MRI showed only
intraosseal hemangiomas. Back pain remained stable throughout
course and felt to be MSK in etiology.
Chronic issues:
# CKD: Baseline creatinine 1.3, with Cr 1.4 on admission.
Medications were renally dosed.
# Chronic Diastolic dysfunction: Last EF 60%. No evidence of
acute exacerbation. His beta blocker was initially held in the
ICU given hypotension but restarted when NSTEMI suspected. Pt
remained stable on metoprolol.
# CAD s/p CABG & Stenting: He was continued on home clopidogrel.
When troponins were uptrending, pt started on ASA and
metoprolol. Risk stratification: HgbA1c and lipid panel within
normal limits.
# Peripheral Neuropathy: Continued home gabapentin
# Depression: Continued home citalopram
# BPH: Continued home finasteride
Transitional issues:
-f/u chem 10 in one week
-blood cultures from [**2173-11-2**] still pending (no growth at 4 days)
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Finasteride 5 mg PO DAILY
2. Citalopram 10 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. Gabapentin 200 mg PO TID
5. Metoprolol Tartrate 25 mg PO BID
6. Tolterodine 4 mg PO DAILY
7. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Vitamin D 1000 UNIT PO DAILY
2. Citalopram 10 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. Finasteride 5 mg PO DAILY
5. Gabapentin 200 mg PO TID
6. Tolterodine 4 mg PO DAILY
7. Aspirin 81 mg PO DAILY
8. Atorvastatin 80 mg PO DAILY
9. Metoprolol Succinate XL 50 mg PO DAILY
Hold SBP< 100, HR <55
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
Non ST elevation myocardial infarction
Fever
Back Pain
Chronic Kidney Disease
Chronic Diastolic heart failure
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 had trouble breathing and was admitted to the hospital.
Initially you received antibiotics for a presumed pneumonia but
you were diagnosed with a heart attack. You have been started on
medicines to help your heart recover and to prevent future heart
attacks.
Followup Instructions:
Department: CARDIAC SERVICES
When: FRIDAY [**2173-12-3**] at 2:20 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2173-11-6**]
|
[
"585.9",
"428.0",
"311",
"600.00",
"403.90",
"V45.81",
"410.71",
"V45.82",
"414.00",
"724.5",
"458.8",
"V49.86",
"518.82",
"356.9",
"428.32"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10744, 10829
|
6051, 9281
|
267, 273
|
10983, 10983
|
3205, 3205
|
11453, 11805
|
2547, 2616
|
10421, 10721
|
10850, 10962
|
10080, 10398
|
11166, 11430
|
5561, 6028
|
2631, 3186
|
9954, 10054
|
1662, 1726
|
207, 229
|
301, 1642
|
3221, 5545
|
10998, 11142
|
9298, 9933
|
1748, 2379
|
2395, 2531
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,488
| 152,399
|
12519
|
Discharge summary
|
report
|
Admission Date: [**2123-4-21**] Discharge Date: [**2123-4-26**]
Date of Birth: [**2057-8-29**] Sex: M
Service: Cardiothoracic
CHIEF COMPLAINT: Chest pain.
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 38817**] is a 65-year-old male
who, on routine examination, had an abnormal
electrocardiogram. This prompted a stress test which was
markedly positive.
He underwent a catheterization on the day of admission
revealing a 100% occluded right coronary artery and 95%
occluded left main with preserved left ventricular ejection
fraction.
The patient denies any history of general symptoms. He has
had a left carotid endarterectomy in the past. He had a
Duplex last week which revealed a normal left carotid artery
and an 80% stenosed right internal carotid artery. He has no
history of cerebrovascular accidents or transient ischemic
attacks. He does have right calf claudication at greater
than one mile which is relieved with rest. He denies any
orthopnea, paroxysmal nocturnal dyspnea, or lower extremity
edema.
The patient was transferred to [**Hospital1 188**] for coronary artery bypass graft by Dr. [**Last Name (STitle) **].
PAST MEDICAL HISTORY: (Past Medical History significant for)
1. Hyperlipidemia.
2. Attention deficit disorder.
PAST SURGICAL HISTORY: (Past Surgical History is significant
for)
1. Status post left carotid endarterectomy.
2. Status post removal of pilonidal cyst.
3. Status post tonsillectomy and adenoidectomy.
4. Status post basal cell carcinoma excision.
MEDICATIONS ON ADMISSION: His medications on admission
included aspirin 325 mg p.o. q.d., Ritalin 20 mg p.o. b.i.d.,
multivitamin p.o. q.d., atenolol 25 mg p.o. q.d.,
Lipitor 10 mg p.o. q.d., sublingual nitroglycerin p.r.n.,
Viagra p.r.n.
ALLERGIES: He has no known drug allergies.
PHYSICAL EXAMINATION ON PRESENTATION: On physical
examination, the patient was in no acute distress.
Temperature was 97.9, heart rate of 68 (sinus), blood
pressure was 123/72, and 93% on room air. His heart was
regular in rate and rhythm with no murmurs. His respiratory
examination showed good breath sounds, clear bilaterally.
His had positive bowel sounds, with a soft, nontender, and
nondistended abdomen. His extremities showed positive
dorsalis pedis and posterior tibialis pulses bilaterally. He
had no cyanosis or edema in extremities. His neck was
supple. He had a right carotid bruit.
PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories on
admission included a white blood cell count of 9.1,
hematocrit of 42.1, platelets of 187. PT of 13.8, PTT
of 51.9, INR of 1.3. Sodium of 139, potassium of 4.2,
chloride of 103, bicarbonate of 27, blood urea nitrogen
of 12, creatinine of 1.1, glucose of 98.
RADIOLOGY/IMAGING: Electrocardiogram was significant for
normal sinus rhythm, rate of 60, left shift of the axis. Q
waves in II, aVL, and V1. No acute ischemia on
electrocardiogram.
HOSPITAL COURSE: On hospital day two, the patient went to
the operating room with Dr. [**Last Name (STitle) **] and underwent a coronary
artery bypass graft times four. Grafts were left internal
mammary artery to left anterior descending artery, saphenous
vein graft to first obtuse marginal, saphenous vein graft to
second obtuse marginal, and saphenous vein graft to posterior
descending artery.
The patient tolerated the procedure well and was transferred
to the Intensive Care Unit, intubated, on Neo-Synephrine
drip, and a propofol drip. In the Intensive Care Unit, the
patient was extubated on postoperative day one without
incident. He received pulmonary toilet. He had an episode
of hypotension when he was placed on Neo-Synephrine. He was
bolused with intravenous fluids, and his mean arterial
pressure was greater than 60. He was awake, alert and
oriented times three. He remained stable over the first
postoperative night. He was weaned off all drips.
Respiratory status was stable. The patient's diet was
advanced, and he was transferred to the floor for the
remainder of his recovery.
On the floor, the patient remained hemodynamically stable.
His chest tubes were discontinued on postoperative day two
without incident. His wires were discontinued on
postoperative day three without incident. Physical Therapy
worked with the patient, and he is currently an activity
level V. He is tolerating a regular diet. His wounds are
clean, dry, and intact.
DISCHARGE DISPOSITION: He is in stable condition and is
ready for discharge with follow up with Dr. [**Last Name (STitle) **] in four
weeks.
DISCHARGE DIAGNOSES:
1. Coronary artery disease, status post coronary artery
bypass graft times four.
2. Hypercholesterolemia.
3. Attention deficit disorder.
MEDICATIONS ON DISCHARGE:
1. Lasix 20 mg p.o. b.i.d. times seven days.
2. Potassium cholesterol 10 mEq p.o. b.i.d. times seven
days.
3. Colace 100 mg p.o. b.i.d.
4. Enteric-coated aspirin 325 mg p.o. q.d.
5. Ritalin 20 mg p.o. b.i.d.
6. Multivitamin 1 tablet p.o. q.d.
7. Lopressor 25 mg p.o. b.i.d.
8. Lipitor 10 mg p.o. q.d.
9. Percocet 5/325 one to two tablets p.o. q.4h. p.r.n.
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE FOLLOWUP: The patient was to follow up with
Dr. [**Last Name (STitle) **] in four weeks and with Dr. [**First Name (STitle) 807**] (his primary
care physician) in two weeks.
DISCHARGE STATUS: He was discharged to home with [**Hospital6 3429**] services for wound checks.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Last Name (NamePattern1) 3835**]
MEDQUIST36
D: [**2123-4-26**] 12:05
T: [**2123-4-27**] 09:44
JOB#: [**Job Number 38818**]
|
[
"272.4",
"458.2",
"414.01",
"413.9",
"433.10",
"314.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.15",
"36.13"
] |
icd9pcs
|
[
[
[]
]
] |
4428, 4547
|
4568, 4709
|
4735, 5111
|
1557, 2925
|
2943, 4404
|
1302, 1530
|
5126, 5162
|
161, 174
|
5183, 5725
|
203, 1163
|
1186, 1278
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,492
| 196,674
|
27979
|
Discharge summary
|
report
|
Admission Date: [**2121-6-26**] Discharge Date: [**2121-7-24**]
Date of Birth: [**2056-2-12**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 949**]
Chief Complaint:
Elevated creatinine
Major Surgical or Invasive Procedure:
Intubation and transfer to ICU, paracentesis
History of Present Illness:
This is a 65 year old male with PMH of alcohol-related cirrhosis
complicated by esophageal varices, h/o portal vein thrombosis,
refractory ascites s/p TIPS which is stenosed, h/o hepato-renal
syndrome requiring admission to [**Hospital1 18**] from [**4-18**] to [**4-30**], and h/o
SBP on Bactrim ppx, DM, pituitary mass, and hypothyroidism with
recent admission to [**Hospital1 18**] in [**5-/2121**] for hepatic encephalopathy
who presents today with a creatinine of 3.5 from 2.6 prior
(baseline mid 2s) from daycare clinic after a 6.75L
paracentesis. The patient's wife reports that Mr. [**Name13 (STitle) 68123**] has
had increased fatigue recently, but denies any confusion. No
sick contacts and reports good adherance with all medications
including lactulose regimen.
.
In daycare, he had a paracentesis which removed 6.75L of ascitic
fluid, with a sample sent to rule out SBP. He received 62.5g of
albumin, vitals were stable: BP 161/75, hr 64, sat 99% on RA.
Labs were significant for a HCT of 28, creatinine of 3.5,
negative EtOH.
.
Review of sytems: Patient denies CP, palp, SOB, recent URI Sx,
cough, fever, N/V/D. No change in appetite, dysuria or change in
stool. Otherwise as per HPI.
Past Medical History:
Alcoholic cirrhosis known varices
portal vein thrombosis
s/p TIPS
DM
Hypothyroid
Pituitary mass
h/o nephrolithiasis
h/o +PPD
Social History:
Lives w/ wife at home. Independent in ADLs and ambulation.
Smokes [**12-22**] cigars per day. No alcohol for the last 5 months.
Denies IVDU. No ETOH since [**10-28**].
Family History:
Mother deceased, age 50, CVA. Father deceased, age 62, stomach
problems. One brother living and in good health. Two sisters,
both living and in good health
Physical Exam:
On Admission:
Vitals: 98.1 133/49 53 20 100%RA
General: Appears fatigues, lying in bed.
HEENT: PERRLA, EOMI, anicteric, MMM, OP clear
Neck: Supple, no JVD or LAD
Heart: RRR, S1 and S2 appreciated, no m/r/g
Lungs: CTAB
Abdomen: Soft, NT. Moderately distended. LVP site without
bleeding and covered by bandage.
Extremities: 1+ edema in LE, 2+ pulses
Neurological: Fatigued. A&Ox3. CN II-XII grossly intact.
discharge:
Vitals:temp 98.2(98.2) 125-157/63-70 -78-20-100%RA.
I/O: 0 + 100/475 + 4 stool 24hrs: 1220+[**Telephone/Fax (1) 68124**]+ 17BM
GENERAL: NAD. Somnolent.
HEENT: mmm, PERRL.
CARDIAC: RRR, 1/6 systolic ejection murmur.
LUNGS: Clear but lll with decreased bs
ABDOMEN: Soft but distended with ascites worsening distention,
BS present
EXTREMITIES: pedal edema +1. no asterixis
Pertinent Results:
Labs on Admission:
[**2121-6-26**] 08:10AM BLOOD WBC-4.2 RBC-3.13* Hgb-9.8* Hct-28.5*
MCV-91 MCH-31.4 MCHC-34.5 RDW-16.0* Plt Ct-123*
[**2121-6-26**] 08:10AM BLOOD PT-15.4* INR(PT)-1.3*
[**2121-6-26**] 08:10AM BLOOD Glucose-183* UreaN-57* Creat-3.5* Na-140
K-4.7 Cl-111* HCO3-18* AnGap-16
[**2121-6-27**] 06:00AM BLOOD ALT-21 AST-40 LD(LDH)-178 AlkPhos-222*
TotBili-0.3
[**2121-6-28**] 04:33AM BLOOD WBC-5.7# RBC-2.84* Hgb-9.0* Hct-25.3*
MCV-89 MCH-31.5 MCHC-35.4* RDW-15.6* Plt Ct-123*
[**2121-6-28**] 08:31AM BLOOD WBC-6.5 RBC-3.06* Hgb-9.7* Hct-27.8*
MCV-91 MCH-31.9 MCHC-35.1* RDW-15.7* Plt Ct-149*
[**2121-6-28**] 08:00PM BLOOD WBC-6.7 RBC-2.89* Hgb-9.2* Hct-26.1*
MCV-90 MCH-32.0 MCHC-35.4* RDW-15.7* Plt Ct-109*
LABS ON DISCHARGE:
[**2121-7-22**] 05:30AM BLOOD WBC-5.2 RBC-2.81* Hgb-8.9* Hct-25.9*
MCV-92 MCH-31.5 MCHC-34.2 RDW-18.7* Plt Ct-106*
[**2121-7-23**] 05:45AM BLOOD WBC-4.5 RBC-2.66* Hgb-8.4* Hct-24.8*
MCV-93 MCH-31.5 MCHC-33.8 RDW-18.8* Plt Ct-110*
[**2121-7-24**] 05:50AM BLOOD WBC-4.1 RBC-2.63* Hgb-8.3* Hct-23.6*
MCV-90 MCH-31.7 MCHC-35.4* RDW-18.7* Plt Ct-98*
[**2121-7-24**] 05:50AM BLOOD PT-16.1* PTT-30.5 INR(PT)-1.4*
[**2121-7-24**] 05:50AM BLOOD Plt Smr-LOW Plt Ct-98*
[**2121-6-27**] 06:00AM BLOOD Glucose-143* UreaN-57* Creat-3.2* Na-140
K-4.5 Cl-111* HCO3-19* AnGap-15
[**2121-7-1**] 04:24PM BLOOD Glucose-216* UreaN-92* Creat-5.2* Na-145
K-3.6 Cl-112* HCO3-19* AnGap-18
[**2121-7-4**] 04:39AM BLOOD Glucose-146* UreaN-92* Creat-5.0* Na-149*
K-3.4 Cl-116* HCO3-19* AnGap-17
[**2121-7-20**] 07:00AM BLOOD Glucose-250* UreaN-47* Creat-2.6* Na-143
K-3.8 Cl-110* HCO3-23 AnGap-14
[**2121-7-24**] 05:50AM BLOOD Glucose-198* UreaN-41* Creat-2.6* Na-141
K-3.7 Cl-109* HCO3-21* AnGap-15
[**2121-6-28**] 04:33AM BLOOD ALT-22 AST-41* LD(LDH)-186 AlkPhos-196*
TotBili-0.8
[**2121-7-24**] 05:50AM BLOOD ALT-21 AST-35 LD(LDH)-192 AlkPhos-178*
TotBili-1.3
[**7-19**] Liver U/S
IMPRESSION:
1. Large differential between the peak systolic velocities of
the proximal and distal segments of the TIPS consistent with
known TIPS stenosis, though patency of the TIPS is maintained.
2. The left portal and anterior right portal veins are patent,
however,
directionality of flow cannot be assessed due to limitations of
patient's
respiratory rate and inability to comply with breath-hold.
3. Stable moderate ascites.
4. Cirrhotic liver.
[**7-20**]: CHEST CT:
IMPRESSION:
1. New small left pleural effusion.
2. Stable appearance of peribronchial opacities in the left
lower lobe may
represent acute infection or sequela of aspiration.
3. Stable multifocal bronchiectasis, likely due to recurrent
infection.
4. Large amount of ascites with cirrhotic liver.
5. Atherosclerotic disease.
.
[**7-13**]
peritoneal fluid cytology:
NEGATIVE FOR MALIGNANT CELLS.
.
[**7-19**] LIVER ULTRASOUND:
IMPRESSION:
1. Large differential between the peak systolic velocities of
the proximal and distal segments of the TIPS consistent with
known TIPS stenosis, though patency of the TIPS is maintained.
2. The left portal and anterior right portal veins are patent,
however,
directionality of flow cannot be assessed due to limitations of
patient's
respiratory rate and inability to comply with breath-hold.
3. Stable moderate ascites.
4. Cirrhotic liver.
Brief Hospital Course:
Mr. [**Name13 (STitle) 68123**] is a 65 year old male with PMH of alcohol-related
cirrhosis complicated by esophageal varices, encephalopathy, h/o
portal vein thrombosis, refractory ascites s/p TIPS on LTPX list
who presented to [**Hospital1 18**] following a Cr of 3.5 following large
volume paracentesis and concern for HRS.
ACTIVE ISSUES:
#. ARF/HRS: The patient was seen in clinic [**6-26**] for an LVP during
which 6.5L of fluid were removed. Labs drawn before the LVP
revealed a Cr of 3.5 up from patient's baseline of low 2s.
Immediate concern was for HRS and the patient was admitted. He
was initially given an albumin challenge during which his Cr
dropped minimally to 3.2. He was started on midodrine/ocreotide
on [**6-27**]. Patient's kidney function did not improve and
midodrine/octreotide was stopped. Creatinine than began to fall
without intervention and patient was discharged with creatinine
at baseline of 2.6.
#. Encephalopathy: The patient has a h/o EtOH Cirrhosis and was
most recently admitted in early [**Month (only) **] for mgmt of encephalopathy.
At that time, the patient admitted to missing doses of
lactulose and having <3 BMs daily. On this asmission, the
patient confirmed adherance to lactulose/rifaximin regimen and
was not confused on admission. Overnight on [**6-26**], the patient's
wife reports that he became increasingly confused. An extra
dose of lactulose was given and the patient had a BM. The
following AM, the patient was somnolent and could not be roused.
Triggered for nursing concern regaring AMS. ABG on RA showed
pO2 of 63 and the pt was satting in the low 90s. Placed on NRB,
CXR, ECG and suction performed. SICU consulted and patient was
transferred for a brief stay until mental status improved with
increased lactulose dosing. He returned to the floor with
improved mental status and though had some day-to-day waxing and
[**Doctor Last Name 688**] of mental status, was managed well on lactulose and
rifaximin titrated to 3-4BM/day. RUQ u/s showed stenotic, but
patent TIPS and patency of the visualized portal vasculature.
Pts mental status remained stable and he took in adequate PO
intake. He was discharged on lactulose 60mL PO q6hrs and
rifaximin 550mg [**Hospital1 **].
3. LLL pneumonia/pleural effusion:
Patient completed a course of Zosyn for LLL pneumonia seen on
[**6-29**]. He showed interval improvement with less coughing, but
worsening of an associated pleural effusion was seen on repeat
CXR on [**7-16**] in the setting of decreased breath sounds and
increased coughing. He was re-started on Vanc/zosyn emprically
and chest CT showed resolution of PNA. He completed a 8 day
course of zosyn and PNA had resolved by time of discharge.
INACTIVE/Chronic ISSUES:
#. Diabetes mellitus: The patient has a h/o DMII and is on a
home regimen of 28 units glargine with humalog sliding scale.
Continued on HISS and 20 units glargine in house with good sugar
control.
#. Hypothyroidism. The patient has a h/o hypothyroidisim.
Continued home regimen of levothyroxine 100mcg daily.
Transitional ISSUES:
Please check daily weight
Encourage PO intake, do calorie counts and please give sugar
free carnation breakfast TID
Transfusion parameters: one U PRBC if crit is under 23 and
notify transfusion center
Please give pt lactulose 60ml PO q6hrs and titrate up if not
have >3 BM/day. Can give PRN at night if pt having >2BM/8hr
Medications on Admission:
1. lactulose 10 gram/15 mL Solution: 30ml PO TID
2. levothyroxine 100 mcg Tab: 1 Tab PO once a day.
3. propranolol 20 mg Tab: 1 Tab PO twice a day.
4. magnesium oxide 400 mg Tab: 1 Tab PO once a day.
5. Calcium 500 500 mg calcium (1,250 mg) Tab: 1 Tab PO once a
day.
6. clotrimazole 10 mg Troche: 1 troche QID
7. omeprazole 20 mg Cap: 1 Cap, PO once a day
8. insulin glargine 100 unit/mL Solution: 28 units SQ HS
9. insulin lispro 100 unit/mL Solution: Per sliding scale SQ
QACHS
10. ergocalciferol (vitamin D2) 50,000 unit Cap: 1 Cap PO once a
week.
11. Bactrim 400-80 mg Tablet: 1 Tab PO once a day.
12. midodrine 5 mg Tablet: 3 Tab PO three times a day
Discharge Medications:
1. lactulose 10 gram/15 mL Syrup Sig: Sixty (60) ML PO Q6H
(every 6 hours): If under three BM/24 hr titrate dose up until
having at least three BM.
2. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. lactulose 10 gram/15 mL Solution Sig: 1000 (1000) MLs PO Q12H
(every 12 hours) as needed for hepatic encephalopathy.
4. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. Heparin Flush (10 units/ml) 1 mL IV PRN line flush
Temporary Central Access-Floor: Flush with 10 mL Normal
Saline followed by Heparin as above daily and PRN.
8. insulin glargine 100 unit/mL Solution Sig: Twenty Eight (28)
Units Subcutaneous at bedtime.
9. insulin lispro 100 unit/mL Solution Sig: per sliding scale
units Subcutaneous QACHS.
10. Calcium 500 500 mg calcium (1,250 mg) Tablet Sig: One (1)
Tablet PO once a day.
11. magnesium oxide 400 mg Tablet Sig: One (1) Tablet PO once a
day.
12. spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
13. Bactrim 400-80 mg Tablet Sig: One (1) Tablet PO once a day.
14. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO once a week.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital - [**Hospital1 8**]
Discharge Diagnosis:
Hepatorenal syndrome
Hepatic encephalopathy
Pneumonia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. [**Known lastname 16651**],
It was a pleasure taking care of you. You were admitted to the
hospital because your kidneys began to fail. After close
monitoring, your kidney function improved and currently they are
working at their baseline function. You also had mental status
changes during your admission secondary to your liver failure.
We treated you with lactulose and you improved. Finally, you
were found to have a pneumonia and we have treated it with
antibiotics.
We have made the following changes to you medications.
medications discontinued: propanolol
medications changed: lactulose 30ml by mouth three times a day
to 60mL by mouth every 6 hours.
Medications started: rifaximin 550mg tab take one tab twice a
day
spironolactone 50 mg tablet take one by mouth daily
sevelamer Carbonate 800mg take one tablet by mouth three times
per day with meals
Followup Instructions:
You will need to follow up in the transplant clinic for a
paracentesis and appointment. It will be on [**2121-7-30**] at 7:30 am
at RCU ([**Location (un) 453**] of [**Hospital Ward Name 121**] Building at [**Hospital1 18**]).
|
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icd9cm
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48,103
| 135,324
|
8600
|
Discharge summary
|
report
|
Admission Date: [**2166-6-15**] Discharge Date: [**2166-6-20**]
Date of Birth: [**2088-3-6**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4057**]
Chief Complaint:
weakness, unsteady gait, and hemoptysis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
78 y/o M with PMHx significant for metastatic melanoma
(currently at the end of a 10-week experimental regimen), who
presented to the ED after 3 episodes of hemoptysis, 1 episode
yesterday and 2 episodes this morning. Reports that amount of
hemoptysis was approximately 4 inches x 4 inches. Per report,
the patient also has had worsening confusion, unsteadiness of
gait, and generalized weakness over the past few weeks. In the
ED, the patient had a CTA chest that showed no PE, increasing
mets and new mets in the lungs, and no gross bleeding. CT head
showed large mets everywhere (significantly worse from prior).
There was no midline shift or mass effect, but there was some
surrounding edema around one of the metastatic lesions. Oncology
was [**Name (NI) 653**], who recommended transfer to the unit for
observation overnight. IP was also [**Name (NI) 653**], with plans for
bronchoscopy in the morning. Prior to transfer to the floor, the
patient's VS were 97.8 124/71 79 18 97% on RA. He had not had
any further episodes of hemoptysis.
.
On the floor, the patient's VS were T: 98.1 BP: 114/72 P: 81 R:
13 O2: 93% on RA. He complained of abdominal pain that has been
occurring for some time. He reported that his shortness of
breath has been occurring for some time and is currently
resolved. He also reported recent unsteadiness of gait and
weakness. He denied any headaches, visual changes, chest pain,
or lightheadedness. He denied any current shortness of breath.
Per the patient's family, he has also had recent loss of
appetite and confusion.
.
Review of sytems:
(+) Per HPI
(-) Denies headache, sinus tenderness, rhinorrhea or congestion.
Denied shortness of breath. Denied chest pain or tightness,
palpitations. Denied nausea, vomiting, diarrhea, constipation.
No recent change in bowel or bladder habits. No dysuria. Denied
arthralgias or myalgias. Denied focal numbness or weakness.
Past Medical History:
Past Medical History:
- metastatic melanoma (priamry melanoma resected from tip of
nose in [**2147**])
- varicose vein surgery in the [**2115**]
- ear surgery in [**2152**] for what was felt to be a basal cell;
additional basal cell on the left shin
- ?hypertriglyceridemia
.
Detailed Oncologic History:
- shave biopsy of a left midback lesion on [**2163-9-29**], revealing
an at least 2.4 mm thick [**Doctor Last Name **] level IV melanoma without
ulceration, margins were positive
- reexcision on [**2163-10-3**], revealing residual invasive 1.8
mm thick melanoma with questionable regression
- left shin lesion revealing a nodular basal cell carcinoma with
positive margins; subsequent reexcision showed a dermal scar and
no residual basal cell carcinoma
- wide local excision of a left back melanoma and axillary
sentinel lymph node biopsy on [**2163-10-27**]; primary site revealed
only a dermal scar without residual melanoma; no melanoma in 3
examined sentinel lymph nodes
- [**10-7**] - noted a firm mass in the right axilla; FNA on [**11-25**]
revealed melanoma
- CT chest showed right axillary nodule and multiple bilateral
pulmonary nodules
- [**2166-2-11**] - initiated DTIC therapy with disease progression
documented after 2 cycles
- [**2166-4-3**] - MRI head with small right posterior parietal and left
cerebellar lesions c/w metastatic disease
- [**2166-4-8**] - began compassionate use ipilimumab protocol
(currently C1W10 of this therapy)
Social History:
He lives alone. He has a history of alcohol abuse but has been
sober for 18 years. Used to smoke cigarettes, but quit ~30 years
ago.
Family History:
Father with some form of cancer (does not recall primary).
Mother with breast cancer. ?brother with metastatic colon
cancer.
Physical Exam:
ADMISSION EXAM:
Vitals: T: 98.1 BP: 114/72 P: 81 R: 13 O2: 93% on RA
General: Alert, oriented x 3 with some slight confusion, no
acute distress
HEENT: Sclera anicteric, dry MM, OP clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, spme TTP in the upper abdomen, non-distended,
bowel sounds present, no rebound tenderness or guarding, no
organomegaly noted
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: PERRL, CN II-XII grossly intact (aside from some slight
anisocoria R>L), 5/5 strength throughout, sensation to LT intact
throught, 2+ patellar, biceps, and brachioradialis reflexes,
wide unsteady gait, mild dysmetria on the L on finger-to-nose
Pertinent Results:
CTA [**2166-6-15**]:
1) Progression of multiple bilateral pulmonary metastases.
2) No acute PE or hemothorax.
3) Increased splenic, right adrenal, right posterior
infradiaphrammatic
lesions consistent with progression of metastatic disease.
Evidence of
osseous metastatic disease again seen.
CT head:
Multiple hyperdense intracranial lesions with surronding edema,
significantly increased size and number from prior MRI,
consistent with
progression of metastatic melanoma, some of which may contain
internal
hemorrhage.
Brief Hospital Course:
78 y/o M with known metastatic melanoma, presents with 3
episodes of hemoptysis and worsening confusion and gait
disturbance, now with imaging showing worsening metastatic
disease.
.
Hemoptysis: Given imaging findings, likely related to worsened
pulmonary metastases with endobronchial involvement. Metastases
do appear close to right PA on CT; however, if tumor had invaded
PA, would expect more massive hemoptysis. Pt only reports a
small amount of hemoptysis (with the largest amount being approx
5cm x 5cm). Of note, the patient's hematocrit is currently 34
(from 39 5 days prior). However, he is hemodynamically stable
(normotensive and not tachycardic). IP was contact in the [**Name (NI) **]
with plans for possible bronch in AM. Pt. did well during his
hospitalization and the hemoptysis resolved. He was transfered
from the MICU to the oncology floor. The patient was
hemodynamically stable during his stay on the oncology [**Hospital1 **].
.
Metastatic Brain disease: Pt. received an MRI during his
hospital stay that showed metastatic disease in the brain. He
was seen by Radiation Oncology and he was started on
Dexamethasone. They completed two radiation treatments during
his admission and he will continue these treatments for a full
course of 5 treatments.
.
Metastatic Melanoma: Pt with worsening pulmonary, intracranial,
splenic, adrenal, osseous, and other metastatic disease. Pt
recently completed 10 weeks of experimental treatment with
ipilimumab with progression of disease. Onc is aware of
admission and recommended ICU admission for overnight
observation. Pt currently full code after discussion on
admission; however, will need ongoing goals of care discussion
in AM (family wishes to involve primary oncologist in these
discussions). Patient recovered well during her admission and
was tranferred to the oncology floor.
.
Transaminitis: Most likely related to metastatic disease vs.
toxicity from chemo drugs.
.
Goals of Care: Family discussion with son and daughter re
planning for goals of care. We were awaiting Dr[**Name (NI) 30161**] input
but prior to Dr [**Last Name (STitle) 1729**] being able to see the patient, the family
was anxious about discussing course, etc. Relayed poor prognosis
and unlikely helpful interventions.
Medications on Admission:
LORAZEPAM - 0.5 mg Tablet - 0.5 (One half) Tablet(s) by mouth
twice a day as needed for anxiety or insomnia
MEGESTROL - 400 mg/10 mL (40 mg/mL) Suspension - 800mg/20ml by
mouth daily for appetite stimulation
ONDANSETRON HCL - 8 mg Tablet - 1 Tablet(s) by mouth every 8 hrs
as needed for nasuea/vomiting
OXYCODONE - 5 mg Tablet - [**11-30**] Tablet(s) by mouth every 4-6 hrs
as
needed for pain
PROCHLORPERAZINE MALEATE - 5 mg Tablet - [**11-30**] Tablet(s) by mouth
every 6 hrs as needed for nausea/vomiting
VALACYCLOVIR [VALTREX] - 500 mg Tablet - 1 Tablet(s) by mouth
once a day
.
Medications - OTC
ASPIRIN [ADULT LOW DOSE ASPIRIN] - (Prescribed by Other
Provider; OTC) - 81 mg Tablet, Delayed Release (E.C.) - 1
Tablet(s) by mouth once a day
MULTIVITAMIN - (OTC) - Tablet - 1 Tablet(s) by mouth once a
day
Discharge Medications:
1. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet, Rapid
Dissolve PO BID (2 times a day) as needed for agitation for 2
weeks.
Disp:*28 Tablet, Rapid Dissolve(s)* Refills:*0*
2. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for pain.
Disp:*2 Adhesive Patch, Medicated(s)* Refills:*1*
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Valacyclovir 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO four times a
day for 1 weeks.
Disp:*28 Tablet(s)* Refills:*0*
6. Metoclopramide 5 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for hiccups for 1 weeks.
Disp:*28 Tablet(s)* Refills:*1*
Discharge Disposition:
Extended Care
Facility:
[**Doctor Last Name **] Nursing & Rehabilitation Center - [**Location (un) **]
Discharge Diagnosis:
Primary Diagnosis: Hemoptysis
Secondary Diagnosis: Brain metastases
Discharge Condition:
Activity Status: Ambulatory - Independent.
Level of Consciousness: Alert and interactive.
Mental Status: Confused - sometimes.
Discharge Instructions:
It was a pleasure working with you during your hospitalization.
You were admitting after coughing up blood. We believe that a
lesion in your lung is related to your presenting symptom. We
completed an MRI on your admission that found two metastatic
foci. Radiation-oncology was consulted and recommended whole
brain radiation therapy. We started your treatment as an
inpatient and encourage you to keep your outpatient appointment
with the Radiation Oncologist to complete your treatment course.
Please continue all your home medications in addition to several
medications that we recently added.
Followup Instructions:
Please follow up with Radiation Oncology to complete your 5 day
course of radiation therapy.
In addition to your appointment with radiation oncology, you
should follow-up with the following physicians:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5387**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2166-6-24**] 3:00
Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 30162**], RN Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2166-6-24**] 3:00
Provider: [**First Name11 (Name Pattern1) 3750**] [**Last Name (NamePattern4) 3751**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2166-6-24**] 3:00
|
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|
3788, 3922
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46,462
| 170,474
|
36040
|
Discharge summary
|
report
|
Admission Date: [**2163-1-27**] Discharge Date: [**2163-2-3**]
Date of Birth: [**2098-1-2**] Sex: M
Service: MEDICINE
Allergies:
Ace Inhibitors / Ambien
Attending:[**First Name3 (LF) 13541**]
Chief Complaint:
Transfer from [**Hospital **] Rehab w/ SVC syndrome for planned IR
intervention
Major Surgical or Invasive Procedure:
Flexible bronchoscopy
Pleurocentesis
History of Present Illness:
Mr. [**Known lastname **] is a 65 y/o man, long-time smoker, recently diagnosed
w/ SCC of lung w/ SVC syndrome, who presents for scheduled SVC
recannalization w/ IR.
The patient was diagnosed w/ SCC in [**11-22**] at NWH, when he
presented w/ SVC syndrome. CT chest revealed large R lung mass
which is 6cm in maximal dimension & paratracheal/RUL/RML in
location. The mass encases the patient's SVC. (CT chest also
showed R main pulm artery narrowed by mass and R pleural
effusion). The pt underwent bronchoscopy [**2162-12-1**], lesions in
right and left lobe biopsied & established dx of SCC. Head MRI
[**2162-12-2**] reportedly negative for mets. He was started on chemotx
(Decadron, Taxotere, & Cisplatin) on [**2162-12-29**] plus radiation. He
subsequently developed worsening SOB & on [**2163-1-4**] was admitted
to ICU at NWH w/ post-obstructive PNA (sputum grew MRSA &
Acinetobacter Baumannii, which was tx'd w/ tigecycline &
doxycycline). He underwent R sided thoracentesis, results not
available in paperwork w/ pt. He also had a bronchscopy, which
showed significant airway edema above the vocal cords & complete
obstruction of R bronchial tree due to edema & extrinsic
compression. He was started on steroids for airway edema. In the
setting of steroids, he was noted to have elevated Bld glucose &
was started on Lantus & ISS. He had a bout of pre-renal [**Last Name (un) **] w/
crt peaking at 2.4 (BL reportedly 1.6-1.7). Echo done showed EF
>65% w/ mild concentric LVH. Bilateral LENIs (done b/c of edema)
were negative for thrombus as was RUE u/s. Pt was discharged to
[**Hospital1 **] [**Hospital1 **] on [**2163-1-14**].
During rehab stay at [**Name (NI) **], pt noted increasing swelling of
b/l arms, neck, face, & LEs. Pt also occasionally c/o SOB. (Of
note, he has been on 02 via NC over the last month--likely b/c
of CA, underlying COPD & pl effusion. He is currently requiring
2-3L O2 by NC.) He has been noted to have declining counts in
all cell lines: WBC 2.8, plt 77, Hct 23 on [**2163-1-25**]. Per email
from Dr. [**Name (NI) **], who spoke w/ MD at rehab, the pt's
primary oncologist, Dr. [**Last Name (STitle) 23509**], does not think drop in cell
counts is secondary to chemo at this point, and reportedly
thought bone marrow suppression might be cause. ASA & Fragmin
(DVT ppx) were stopped due to the thrombocytopenia. There were
repotedly no signs of acute bleeding. Pt transfused 2 units
PRBCs [**2163-1-25**] last night. He has reportedly had periods of
hypernatremia (as high as 152 per notes). Additionally, his
prednisone taper (for airway edema) ended [**2162-12-25**]; however, on
[**2162-12-27**] he was given a dose of 40mg prednisone for unclear
reasons. It appears that he has had persistent sinus
tachycardia, possibly [**1-17**] decreased cardiac filling from SVC
syndrome. His last chemo was [**12-29**] & XRT was [**12-31**].
On arrival to [**Hospital1 18**] wards, pt is w/o complaints. He says he is
not SOB, unless he exerts himself. He gets SOB w/ ambulating a
few feet. He denies all pain, including CP.
ROS: He endorses occas cough. Denies fever, chills, night
sweats, headache, vision changes, rhinorrhea, sore throat, chest
pain, hemoptysis, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
-SCC dx'd [**11-22**], c/b SVC syndrome. Per pt, not metastatic. Brain
MR reportedly w/o mets.
-HTN
-Hypercholesterolemia
-COPD -- pt unaware of this as a dx, though he has been on
spiriva as oupt
-Shingles [**9-22**]
-Right arm keratosis excision;
-Benign laryngeal polyp excision [**2131**]
Social History:
Married, supportive spouse, who is [**Name8 (MD) **] RN. Worked for town of
[**Hospital1 **] as "Parts Manager" until he was dx'd w/ CA. Quit smoking
~4mo ago, 80-100pack-year hx. No ETOH/ilicits.
Family History:
Brother with cancer (unknown kind). NC
Physical Exam:
VS: 98.2, 128, 138/80, 94% on 3L
GEN: sitting up in bed, appears older than stated age, appears
sl uncomfortable, though pt states that he is comfortable.
Plethoric facies. A&0X3.
HEENT: EOMI, PERRL, sclera anicteric, conjunctivae clear, OP
moist and without lesion
NECK: swollen appearing b/l, JVP elevated above jaw, no masses
felt
CV: Distant hrt sounds. Tachy but Reg rate, normal S1, S2. No
m/r/g.
CHEST: Resp appeared labored, occas w/ purse mouth breathing.
Some accessory muscle use. Scatter wheezes, rhonchi & crackles.
Decreased Breath sounds about [**12-18**] way up R back..
ABD: Soft, NT, ND, no HSM.
EXT: [**1-18**]+ dependent edema in UEs (R>L), 1+ dependent edema in
LEs. Muscles are atrophied in LEs.
SKIN: Skin tear on R hand, ecchymosis on abd ([**1-17**] insulin injx
per pt). Reported stage II pressure ulcer on buttock.
Neuro: CN 2-12 intact. Sensation intact to light touch
throughout. 5/5 strength in upper & lower extremities except for
hip & knee flex/ext which is ~5(-)/5.
Pertinent Results:
[**2163-1-27**] 11:35PM GLUCOSE-99 UREA N-41* CREAT-1.2 SODIUM-143
POTASSIUM-3.8 CHLORIDE-106 TOTAL CO2-27 ANION GAP-14
[**2163-1-27**] 11:35PM CALCIUM-8.3* PHOSPHATE-2.1* MAGNESIUM-1.5*
[**2163-1-27**] 11:35PM WBC-1.6* RBC-3.38* HGB-9.9* HCT-29.4* MCV-87
MCH-29.3 MCHC-33.7 RDW-17.8*
[**2163-1-27**] 11:35PM NEUTS-78* BANDS-2 LYMPHS-8* MONOS-12* EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2163-1-27**] 11:35PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-OCCASIONAL
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL
[**2163-1-27**] 11:35PM PLT SMR-LOW PLT COUNT-90*
[**2163-1-27**] 11:35PM PT-12.5 PTT-25.1 INR(PT)-1.1
Discharge labs:
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC
RDW Plt Ct
[**2163-2-3**] 05:10AM 29.0*#1 3.46* 10.3*# 30.6* 89 29.8 33.7
18.1* 54*
BASIC COAGULATION PT PTT INR
[**2163-2-3**] 05:10AM 13.6* 30.2 1.2*
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3
[**2163-2-3**] 05:10AM 113* 78* 2.2* 144 4.3 112* 20*
CHEMISTRY TotProt Calcium Phos Mg
[**2163-2-3**] 05:10AM 8.4 5.6* 2.3
[**2-1**] pleural fluid cytology: ATYPICAL.
Rare atypical epithelioid cells in a background of
lymphocytes and macrophages; cannot exclude involvement by
carcinoma.
CXR [**1-30**]: Compared to the film from earlier the same day, there
is some new hazy opacity at the right heart border that could
represent small area of infiltrate, volume loss. Otherwise,
there is no change.
Brief Hospital Course:
65 yo man w/ SVC syndrome due to malignant compression of SVC
and continued respiratory distress.
# Respiratory distress: Pt stable while at rest, with
considerable SOB with movement. Likely due to R-sided pleural
effusion, known emphysema, RUL mass, as well as airway edema.
Therapeutic thoracentesis performed on [**1-28**]. Flex bronch on
[**1-28**] demonstrated considerable airway obstruction with no
possibility for endobronchial stent placement, as well as a
posterior wall defect in the right bronchus intermedius. He was
treated symptomatically with Spiriva and Atrovent nebulizers,
steroids, as well as low-dose morphine PRN to decrease air
hunger. He was evaluated by IR for possible SVC stent placement
as a palliative measure for his respiratory distress, however
given his respiratory distress and inability to lie flat, a
stent was not attempted.
# Neutropenic fever/hospital-acquired PNA: Pt developed fever to
104 with sBPs in 70s and HR 150s. He was given 2L bolus of NS,
Tylenol, Vanc & Cefepime for neutropenic fever. He was then
noted to develop worsening tachypnea and increased oxygen
requirement. Pt was rigorring mildly on the floor when an EKG
was obtained he appeared to be in sinus tach. ABG revealed
7.45/36/109. Pt was transferred to ICU, where CXR ([**1-30**])
revealed some new hazy opacity at the right heart border that
could represent small area of infiltrate, volume loss. Pt was
presumed to have post-obstructive pneumonia process for which he
was started on vancomycin and cefepime. He will need to
complete a 7-day course (ends on [**2-4**]). His neutropenia
resoloved shortly after recieving neupogen and he was not
neutropenic at discharge.
# Pancytopenia: Likely late response to chemotherapy and
radiation. CBC on admission demonstrated WBC 1.6, Hct 29.4 (s/p
transfusion of 2 units PRBCs on [**2163-1-25**]), and Plt 90. Pt
treated with filgrastim, which resulted in a bump in WBC to 15.1
on [**2-2**]. Hct dropped to 24.7, prompting transfusion of 2 units
PRBCs on [**2-2**] to maximize oxygen-carrying capacity of blood to
minimize SOB. His WBC has risen greatly in response to neupogen
and his platelets have stabilized in the 50's. His Hct
reposonded appropriately to the 2 units of PRBC and was in the
30's on discharge.
# SVC syndrome: Due to SCC mass encasing SVC. Edema worsening
s/p chemo and radiation treatments, for which these have been
held. SVC stent placement was considered, but after discussion
with the patient, his wife and IR, it was felt that the risks of
anesthesia would outweigh the potential benefits of the
procedure. The head of his bed was kept elevated, and lasix was
given, if blood pressure permitted, to minimize fluid retention.
# Sinus tachycardia: Ongoing issue--noted on hospitalization at
NWH in [**Month (only) 404**] as well as at rehab. [**Month (only) 116**] be related to decreased
cardiac filling b/c of SVC syndrome. Low Hct may also be
contributing--baseline Hct unknown. He is high risk for PE,
which was considered, but pt is unable to lay flat for CTA. His
HR remained in the 100's to 110's at discharge.
# Lung cancer: Dx'd [**11-22**]. S/p Decadron, Taxotere, & Carboplatin
on [**12-29**] & XRT on [**12-31**]--none since. Followed by primary
oncologist, Dr. [**Last Name (STitle) 23509**], and Radiation Oncologist, Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] (per chart). Palliative care was consulted and discussed
goals with pt and wife for pt to return to rehab and potentially
home with hospice, if condition permits.
Rehab Contact info:
[**Hospital3 105**] Northeast - [**Hospital1 **]
[**Telephone/Fax (1) 81789**] or [**Telephone/Fax (1) 69892**]
Fax: [**Telephone/Fax (1) 81790**]
# CODE: DNR/DNI, confirmed with the patient and his wife.
Medications on Admission:
Acetaminophen 650 mg PO Q6H:PRN
Allopurinol 150 mg PO DAILY
Cyanocobalamin 100 mcg PO DAILY
Furosemide 40 mg PO DAILY
Guaifenesin
HydrALAzine 10 mg PO Q8H
Multivitamins 1 TAB PO DAILY
Nicotine Patch 21 mg TD DAILY
Nystatin 500,000 UNIT PO Q8H
Paroxetine 20 mg PO DAILY
Pantoprazole 40 mg PO Q24H
PredniSONE 40 mg PO DAILY
Simvastatin 80 mg PO DAILY
Tamsulosin 0.4 mg PO HS
Discharge Medications:
1. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed.
3. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
4. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
5. Levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig:
One (1) ML Inhalation q4hr () as needed for wheeze.
6. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
7. Insulin Lispro 100 unit/mL Solution Sig: 2-12 units
Subcutaneous ASDIR (AS DIRECTED).
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Polyethylene Glycol 3350 100 % Powder Sig: One (1) PO DAILY
(Daily).
10. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
11. Morphine 2 mg/mL Syringe Sig: 1-5 mg Injection Q3-4H () as
needed for shortness of breath or wheezing.
12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
Mid-line, heparin dependent: Flush with 10 mL Normal Saline
followed by Heparin as above, daily and PRN per lumen.
14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
15. Cefepime 2 gram Recon Soln Sig: Two (2) grams Injection Q12H
(every 12 hours) for 2 days: Last day is [**2-4**].
16. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
gram Intravenous Q 24H (Every 24 Hours) for 2 days: Last day is
[**2-4**]. .
17. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Hospital1 **]
Discharge Diagnosis:
Non-small cell lung cancer
Superior vena cava syndrome
Pneumomediastinum secondary to bronchus wall defect
Resolved febrile neutropenia
Acute on chronic renal failure
Bacterial pneumonia, probable post-obstructive
Anemia of chronic disease
Discharge Condition:
Critical, transitioning to hospice care.
Discharge Instructions:
You were admitted to the hospital for complications pertaining
to your squamous cell lung cancer, including SVC syndrome and
pneumonia. The SVC syndrome is the cause of the edema in your
arms and neck. We were not able to place a stent in your
superior vena cava (SVC) due to the current risks of the
procedure, so we advise you to keep your head and arms elevated
when possible. Also, you developed a fever while in the
hospital which is presumably due to pneumonia. You were started
on two antibiotics which should cover the bacteria responsible
for your pneumonia. You will need to finish a 7 day course of
these antibiotics which ends on [**2-4**].
You are being discharged back to [**Hospital1 **]. Some of your
medications have been stopped. Please see the discharge
medication list for changes.
Followup Instructions:
Please follow-up with your oncologist Dr. [**Last Name (STitle) 23509**] and your
radiation oncologist Dr. [**Last Name (STitle) **] as needed.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 13546**]
Completed by:[**2163-2-3**]
|
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"284.1",
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icd9cm
|
[
[
[]
]
] |
[
"38.93",
"33.22",
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] |
icd9pcs
|
[
[
[]
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12711, 12786
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4071, 4269
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,391
| 122,123
|
54430
|
Discharge summary
|
report
|
Admission Date: [**2188-11-12**] Discharge Date: [**2188-11-17**]
Date of Birth: [**2104-12-31**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Doctor First Name 3290**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
83 y/o F with PMH severe dementia (nonverbal at baseline),
chronic UTIs, stage III-IV sacral decubitus ulcers, p.afib and
recurrent DVTs on coumadin p/w fevers at a nursing home.
.
Per nursing home, patient was recently started on PO bactrim DS
[**Hospital1 **] for wound infection and uses bactroban IN for MRSA
colonization. was running temps of 101.2 axillary to 102.6 since
0200 that could not be brought down with tylenol. At 1130am
patient had a BS of 500 and was found moaning and shaking. her
HR was 112 and her BP 107/47 Her O2 sat was 93% on RA.
.
She was taken by EMS at 1255 with BP of 90/60-100/60 and a HR of
80-84. In the the ED, she triggered for hypotension. She was was
found to be in Afib with RVR to 140-180 per report. UA was
grossly positive for infection. Started abx (vanc and zosyn),
received 3L - the first 2 L brought her to 110 systolic. The
patient was started on neo on the elevator up to the ICU.
.
In the ICU, she quickly received 500cc bolus with uptitration of
her neo. A CVO2 sat was 73 and her lactate was 1.6
Past Medical History:
- Recurrent UTIs with MDR organisms (ecoli,
pseudomonas-?colonizer)with chronic foley
- cholilithiais and choledocholithiasis with recurrent
admissions for ascending cholangitis s/p [**Hospital1 **]/stents, perc
chole.
- recurrent C.diff [**3-21**] and [**4-20**]
- paroxysmal Afib on coumadin
- DVT on coumadin, dx [**3-21**]
- DM2 on insulin
- HTN
- Recurrent admission for dehydration/hypernatremia
- Dysphagia-dx [**4-20**], on pureed diet with nectar thicks
- Osteochondroma of L knee as a child
- MVP
- Alzheimer's disease - severe nonverbal
- Sacral decub (stage IV) and bilateral heel (stage III)
pressure and deep tissue wounds
- severe knee arthitis-bed bound
- Anemia-?ACD, baseline H/H [**9-11**]
- s/p right ORIF of hip fracture at age 75
Social History:
Lives at nursing home. No alcohol or drugs.
Family History:
Daughter with arthritis, father died of hepatitis C from a blood
transfusion. Mother died at age 86 of a myocardial infarction.
Son with hypertension.
Physical Exam:
VS: T 102.0, HR 120-150, BP 90-100/40-55, 94% on 2L
GEN: Extremely frail appearing elderly woman lying in bed
HEENT: PERRL, anicteric, MM extremely dry appearing, pt will not
open mouth for full exam, no jvd
RESP: CTA Bilaterally with good air movement
CV: Tachy, irregular, normal S1 and S2, holosystolic
cres/descres murmur throughout precordium
ABD: Soft, NT, ND, BS+, no organomegaly
EXT: No clubbing, cyanosis, edema, faint pulses
SKIN: no rashes/no jaundice/no splinters
NEURO: Babbling a small amount nonsensically, moving all four
extremities, no facial droop or other obvious focal deficits.
Pertinent Results:
[**2188-11-12**] 02:10PM BLOOD WBC-7.6 RBC-4.65 Hgb-12.0 Hct-37.0
MCV-80* MCH-25.7* MCHC-32.3 RDW-19.3* Plt Ct-238
[**2188-11-13**] 03:41AM BLOOD WBC-6.3 RBC-3.81* Hgb-9.9* Hct-30.6*
MCV-80* MCH-26.0* MCHC-32.3 RDW-19.3* Plt Ct-239
[**2188-11-14**] 03:48AM BLOOD WBC-7.0 RBC-3.65* Hgb-9.1* Hct-28.8*
MCV-79* MCH-24.8* MCHC-31.4 RDW-19.2* Plt Ct-183
[**2188-11-15**] 03:30PM BLOOD WBC-4.1 RBC-2.59* Hgb-6.7* Hct-20.8*
MCV-80* MCH-26.0* MCHC-32.5 RDW-18.9* Plt Ct-204
[**2188-11-16**] 04:03AM BLOOD WBC-5.7 RBC-3.62*# Hgb-9.8*# Hct-29.0*#
MCV-80* MCH-27.0 MCHC-33.6 RDW-18.0* Plt Ct-227
[**2188-11-16**] 02:26PM BLOOD WBC-4.3 RBC-3.30* Hgb-8.9* Hct-26.5*
MCV-80* MCH-27.2 MCHC-33.8 RDW-17.9* Plt Ct-182
[**2188-11-17**] 06:28AM BLOOD WBC-6.1 RBC-3.46* Hgb-9.3* Hct-27.9*
MCV-80* MCH-26.9* MCHC-33.5 RDW-18.1* Plt Ct-236
[**2188-11-12**] 02:10PM BLOOD Neuts-94.8* Lymphs-2.6* Monos-1.2*
Eos-1.1 Baso-0.2
[**2188-11-13**] 03:41AM BLOOD Neuts-86.2* Lymphs-10.5* Monos-1.5*
Eos-1.2 Baso-0.6
[**2188-11-13**] 10:00AM BLOOD PT-51.7* PTT-60.6* INR(PT)-5.7*
[**2188-11-15**] 08:10AM BLOOD PT-21.2* PTT-35.1* INR(PT)-2.0*
[**2188-11-17**] 06:28AM BLOOD PT-27.8* INR(PT)-2.7*
[**2188-11-12**] 02:10PM BLOOD Glucose-285* UreaN-35* Creat-1.2* Na-128*
K-9.1* Cl-102 HCO3-18* AnGap-17
[**2188-11-12**] 08:54PM BLOOD Glucose-175* UreaN-27* Creat-1.0 Na-139
K-4.0 Cl-113* HCO3-17* AnGap-13
[**2188-11-17**] 06:28AM BLOOD Glucose-145* UreaN-13 Creat-0.7 Na-142
K-4.0 Cl-112* HCO3-23 AnGap-11
[**2188-11-12**] 08:54PM BLOOD ALT-75* AST-117* CK(CPK)-225*
[**2188-11-13**] 03:41AM BLOOD ALT-76* AST-105* AlkPhos-209*
[**2188-11-15**] 08:10AM BLOOD LD(LDH)-188 TotBili-0.6
[**2188-11-12**] 08:54PM BLOOD CK-MB-6 cTropnT-0.02*
[**2188-11-13**] 03:41AM BLOOD proBNP-7284*
[**2188-11-12**] 08:54PM BLOOD Calcium-7.3* Phos-2.1* Mg-1.5*
[**2188-11-13**] 03:41AM BLOOD Calcium-8.3* Phos-2.5* Mg-2.8*
[**2188-11-15**] 08:10AM BLOOD Calcium-7.6* Phos-2.5* Mg-1.6
[**2188-11-17**] 06:28AM BLOOD Calcium-8.0* Phos-2.6* Mg-1.5*
[**2188-11-15**] 08:10AM BLOOD Hapto-153
[**2188-11-16**] 07:25AM BLOOD Vanco-20.7*
[**2188-11-13**] 04:16AM BLOOD Type-ART Temp-39.0 O2 Flow-2 pO2-143*
pCO2-37 pH-7.28* calTCO2-18* Base XS--8 Intubat-NOT INTUBA
[**2188-11-12**] 02:10PM BLOOD Lactate-2.4*
[**2188-11-12**] 05:01PM BLOOD Lactate-1.9
[**2188-11-12**] 09:27PM BLOOD Lactate-1.6
[**2188-11-13**] 04:16AM BLOOD Lactate-0.6
[**2188-11-12**] 02:40PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.017
[**2188-11-12**] 02:40PM URINE Blood-NEG Nitrite-POS Protein-NEG
Glucose-100 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD
[**2188-11-12**] 02:40PM URINE CastGr-0-2
[**2188-11-15**] 2:19 pm CATHETER TIP-IV Source: femoral [**Doctor First Name **].
**FINAL REPORT [**2188-11-17**]**
WOUND CULTURE (Final [**2188-11-17**]): No significant growth.
[**2188-11-12**] 9:01 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT [**2188-11-13**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2188-11-13**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
Time Taken Not Noted Log-In Date/Time: [**2188-11-13**] 2:08 am
URINE Site: NOT SPECIFIED 62288O.
**FINAL REPORT [**2188-11-16**]**
URINE CULTURE (Final [**2188-11-16**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Piperacillin/tazobactam sensitivity testing available
on request.
PROVIDENCIA STUARTII. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| PROVIDENCIA STUARTII
| |
AMIKACIN-------------- <=2 S
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN--------- =>4 R =>4 R
GENTAMICIN------------ <=1 S <=1 I
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- <=16 S 256 R
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S <=1 I
TRIMETHOPRIM/SULFA---- =>16 R <=1 S
[**2188-11-12**] 2:10 pm BLOOD CULTURE #1.
Blood Culture, Routine (Pending):
Brief Hospital Course:
**MICU Course**
83 y.o. female w/advanced AD, history of DVT, PAF, severe
decubitus ulcers, reccurrent UTI, presents with urosepsis and
afib w/RVR.
.
# Shock. Patient was initially admitted to the MICU for septic
shock, with fever, hypotension and UTI suggesting urosepsis.
Mildly elevated liver enzymes and [**Last Name (un) **] implied that the patient
was found relatively early in her decompensation. Pt was started
on Zosyn, Vanc and was briefly on pressors for the first night
of admission but quickly weaned off with fluid boluses.
# Atrial fibrillation, rapid rate: Pt's afib quickly improved
with fluid boluses and low dose metoprolol for rate control
.
**WARDS Course**
83 y.o. female w/advanced AD, history of DVT and PAF (on
coumadin), severe decubitus ulcers, reccurrent UTI, who presents
with urosepsis and afib w/RVR.
.
# Sepsis: Resolved on transfer to floor. Pt was afebrile during
her wards course. She was transitioned from vancomycin and zosyn
when culture data available for urine - growing ecoli and
providencia stuartii. Continued on vancomycin for HAP and
changed to ceftriaxone for UTI. Broadly covered given her
history of MRSA. Discontinued bactrim for decubitus ulcers that
was started prior to admission. Do not suspect this is nidus for
her sepsis and concerned for potential antibiotic resistance
with long term abx therapy. Blood culture have been negative to
date. Her femoral line was removed and cultured and no growth to
date as well. R picc line was placed for antibiotic
administration, please discontinue after abx completed. She
appears clinically stable for dc to rehab at this time. Plan to
continue antibiotic coverage until [**2188-11-21**] for planned 8 day
coverage.
.
# Afib: Afib w RVR on admission and noted to be in pAfib during
her stay. Was not admitted on any nodal or antihypertensive
agents, currently on coumadin for CHADS of 5. Was
supratherapeutic on admission. TFTs wnl on admission - not cause
of sinus tach. Hemodynamically stabilized in MICU with volume
resuscitation. She was then started on metoprolol tartrate 25mg
[**Hospital1 **] for rate control on [**11-14**] w good result.
*INR is currently therapeutic (goal 2.0-3.0) off coumadin.
Elevated level likely [**1-15**] to cephalosporin interaction. After
discussion with family/HCP daughter decision was made to
continue anticoagulation for recurrent dvts and afib. Plan to
follow with daily INR levels and restart coumadin when INR<2.0.
.
# Sacral decub infections: Present on admission - this has been
chronic problem for her. Listed initially as possible nidus of
infection, although currently appears to be stable. Wound
consult followed pt and made recommendations during her stay -
plan to continue per PAGE1 included in dc planning papers. Pt
was admitted on bactrim therapy for treatment of decubitus ulcer
however this was held during her stay while being treated w
other antibiotics. Do not believe that patient requires
antibiotic coverage at this time for her ulcers.
.
#. Anemia: pt's baseline is unclear but likely around 28-30. She
was guaiac negative during her stay. Post-MICU Hct was noted to
downtrend from 37 (thought to be hemoconcentrated and
artificially elevated) to 20. Unclear etiology for anemia
however it is possible that guaiac screenings did not detect
slow occult bleed. Pt did not exhibit abd pain that would lead
us to suspect RP bleed. She was transfused 2u pRBCs on [**11-15**] for
anemia and responded appropriately. Hct stable at time of
discharge. Plan to check Hct in 5 days or sooner if restarting
coumadin.
.
# DM: continued on insulin ss (humalog).
.
# Aortic Stenosis: TTE was obtained during her stay showing
worsening aortic stenosis. Pt can be followed as an outpt. Felt
to be euvolemic on evaluation after volume resuscitation in MICU
and 1 day of maintenance fluids on wards. Please discuss w PCP.
.
# Advanced AD: severe nonverbal/babbles at baseline. Never
oriented to person, place, or time. She was noted to be a MS
baseline on transfer to the floor, confirmed with HCP.
.
# Goals of care: discussed with daughter on [**11-17**] via phone (HCP
unable to come into hospital). She wishes to treat all acute
medical issues for her mother including anticoagulation for
recurrent DVTs and coumadin ppx for afib.
.
# Recurrent DVTs: Currently holding anticoagulation given
anemia, therapeutic INR and increased risk for bleeding. Pt had
been on anticoagulation for recurrent DVTs and afib (CHADS 5).
Discussed goals of care w her daughter who would "like
everything done if possible except for CPR and intubation." She
prefers to continue coumadin even with increased bleeding risk.
Plan to restart coumadin when INR<2.0 with goal 2.0-3.0.
.
# Urinary incontinence: Pt had foley placed for volume
monitoring while inpt - plan to dc at rehab and monitor UO. To
avoid delirium, infection (given multiple admissions for
urosepsis) and atonic bladder complications would recommend
straight catheterizing twice daily at rehab.
.
FEN: Diabetic diet with thickened liquids as at rehab
Access: R Picc
PPx: pneumoboots, therapeutic INR
Comm: daughter and HCP [**Name (NI) **] [**Name (NI) 111409**] ([**Telephone/Fax (1) 111416**], cell
[**Telephone/Fax (1) 111408**]). Alternate is [**First Name4 (NamePattern1) **] [**Known lastname 4027**] [**Telephone/Fax (1) 111417**].
Code: DNR/DNI (pressors ok)
Medications on Admission:
-Bactrim DS [**Hospital1 **], last dose 12/14
-Lantus 20 U qHS with humulog SS
-Coumadin 6mg qHS
-Omeprazole 20 mg daily
-Ferrous Sulfate 325 mg
-Trazodone 12.5 mg PO QHS
-Vitamin D 400
-Vitamin C 500
-Zinc sulfate 220 daily
-BIsacodyl 10mg PR, Milk of Mag, PEG.
Discharge Medications:
1. miconazole nitrate 2 % Powder [**Hospital1 **]: One (1) Appl Topical TID
(3 times a day) as needed for yeast infection.
2. insulin lispro 100 unit/mL Solution [**Hospital1 **]: One (1) sliding
scale Subcutaneous ASDIR (AS DIRECTED): For FS 150-200 give 2u
humalog. FS 201-250 give 4u humalog. FS 251-300 give 6u humalog.
FS 301-350 give 8u humalog. FS 351-400 give 10u.
[**Name8 (MD) **] MD [**First Name (Titles) **] [**Last Name (Titles) **] <70 or >400.
3. metoprolol tartrate 25 mg Tablet [**Last Name (Titles) **]: One (1) Tablet PO BID
(2 times a day): hold for sbp<100 or HR <55.
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Last Name (Titles) **]: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. vancomycin 1,000 mg Recon Soln [**Last Name (Titles) **]: 1000 (1000) MG
Intravenous every twenty-four(24) hours for 4 days.
6. heparin, porcine (PF) 10 unit/mL Syringe [**Last Name (Titles) **]: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
7. ceftriaxone in dextrose,iso-os 1 gram/50 mL Piggyback [**Last Name (Titles) **]:
One (1) gram Intravenous Q24H (every 24 hours) for 4 days.
8. Coumadin 2 mg Tablet [**Last Name (Titles) **]: One (1) Tablet PO once a day: Do
not start this medication until INR<2.0. Please uptitrate dose
with INR goal 2.0-3.0 per daily labs. .
9. ferrous sulfate 325 mg (65 mg Iron) Tablet [**Last Name (Titles) **]: One (1)
Tablet PO once a day.
10. trazodone 50 mg Tablet [**Last Name (Titles) **]: one fourth Tablet PO at bedtime.
11. Vitamin D 400 unit Capsule [**Last Name (Titles) **]: One (1) Capsule PO once a
day.
12. Vitamin C 500 mg Tablet [**Last Name (Titles) **]: One (1) Tablet PO once a day.
13. zinc sulfate 220 mg Tablet [**Last Name (Titles) **]: One (1) Tablet PO once a
day.
14. bisacodyl 5 mg Tablet [**Last Name (Titles) **]: One (1) Tablet PO once a day as
needed for constipation.
15. Milk of Magnesia 400 mg/5 mL Suspension [**Last Name (Titles) **]: One (1)
suspension PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Senior Healthcare of [**Location (un) 1439**]
Discharge Diagnosis:
PRIMARY:
Urosepsis
HAP
SECONDARY:
sacral decubitis ulcers
Discharge Condition:
Mental Status: Confused - always. Babbles, occasionally
responsive to questions. Never oriented to self, place, time.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
You were admitted to the hospital and ICU for low blood pressure
and rapid heart rate that we attribute to a urine infection. You
were give IVF hydration to increase your blood pressure. You
were also found to have a possible pneumonia. We started you on
antibiotics to treat these infections.
For your atrial fibrillation we started a medication to help
control your heart rate.
An cardiac echocardiogram was done in the ICU which showed
worsening aortic stenosis. Please discuss these results with
your primary care doctor.
Additionally you have decubitus skin ulcers for which our wound
team continued to follow. These appear stable.
.
You received a blood transfusion for anemia with an appropriate
response in your hematocrit level. Your stool does not have
positive blood in it.
.
The following changes were made to your medications:
START omeprazole 20mg daily, to decrease acid and protect your
stomach mucosa
START Vancomycin, these were initiated on [**11-13**] and should be
continued for 8 days to treat pneumonia, stop date [**2188-11-21**]
START Ceftriaxone, these cover your UTI and should be continued
for 8 days, day 1 was [**11-13**]; stop date [**2188-11-21**].
START metoprolol tartrate 25mg twice daily to control heart rate
from your atrial fibrillation
HOLD Coumadin, your INR was supratherapeutic on admission (your
goal is 2.0-3.0) and while you are on antibiotics your INR will
be elevated. This will be restarted if your INR starts to
downtrend. STOPPED Bactrim therapy for decubitus ulcers
Followup Instructions:
Department: ENDO SUITES
When: THURSDAY [**2188-11-27**] at 10:00 AM
Department: DIGESTIVE DISEASE CENTER
When: THURSDAY [**2188-11-27**] at 10:00 AM
With: [**Name6 (MD) 1948**] [**Last Name (NamePattern4) 1949**], MD [**Telephone/Fax (1) 463**]
Building: [**First Name8 (NamePattern2) **] [**Hospital Ward Name 1950**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 1951**]
Campus: EAST Best Parking: Main Garage
|
[
"599.0",
"427.31",
"707.03",
"V12.51",
"250.00",
"276.1",
"275.2",
"707.24",
"041.4",
"995.92",
"294.10",
"486",
"V58.67",
"788.30",
"285.29",
"041.85",
"038.9",
"331.0",
"041.12",
"427.32",
"785.52",
"V58.61",
"584.9",
"293.0",
"707.04",
"V49.86",
"424.1",
"401.9",
"507.0",
"V13.02"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
15296, 15385
|
7608, 12970
|
320, 327
|
15487, 15487
|
3046, 7549
|
17249, 17719
|
2257, 2410
|
13284, 15273
|
15406, 15466
|
12996, 13261
|
15707, 17226
|
2425, 3027
|
7585, 7585
|
269, 282
|
355, 1403
|
15502, 15683
|
1425, 2179
|
2195, 2241
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,159
| 178,096
|
8626
|
Discharge summary
|
report
|
Admission Date: [**2103-10-14**] Discharge Date: [**2103-10-23**]
Date of Birth: [**2042-6-26**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest pain, Transfer from [**Hospital3 3583**]
Major Surgical or Invasive Procedure:
Coronary artery bypass graft ( LIMA-LAD, SVG -diagonal, Obtuse
marginal, diagnonal RCA)
History of Present Illness:
61M with PMH of CAD s/p AMI in [**2094**], multiple PCI, HLP, HTN, [**Hospital **]
transferred from [**Hospital3 3583**] where he presented with chest
pain.
Patient states he had approximately 30 minutes of substernal
chest pressure this afternoon at 3:45pm while watching football.
It felt like an elephant was sitting on his chest,
non-radiating. Stated it felt the same as when he had his heart
attack in [**2094**]. Not associated with SOB, diaphoresis or nausea.
He and his wife left to go to the hospital, but the pain
continued so they stopped at a local fire station where he
received 2 SLNG and an ASA and was brought to [**Hospital3 3583**].
There his EKG showed slight STD in 1 and AVL. He was chest pain
free by the time he arrived at [**Hospital1 46**].
In the ED here, VSS, was chest pain free. EKG unchanged from
prior. Trop here was 0.03 with CK of 46. CXR clear by my read.
Admitted from ROMI.
Upon transfer to the floor, patient is still chest pain free. He
feels back to his baseline. Denies any current CP, SOB, N/V/D,
HA or vision changes.
Past Medical History:
1. CARDIAC RISK FACTORS: (+)Diabetes, (+)Dyslipidemia, (+)HTN
2. CARDIAC HISTORY: AMI in [**2094**] with RCP thrombectomy
-CABG: None
-PCI: Has had 5 caths here at [**Hospital1 18**], last one in [**2100**]:
[**2100**]:
COMMENTS:
1. Selective coronary angiography showed a right dominant system
with
patent but mildly disease LMCA. The LAD had moderate diffused
disesae
proximally and was totally occluded within the old [**Doctor First Name 10788**] stent.
the distal vessel was diffusely diseased and filled via R->L
collaterals. LCX had mild diffuse disease and the RCA stent had
only mild ISR but were otherwise patent.
2. Left ventriculography was deferred.
3. Limited hemodynamics showed normal aortic systemic pressures.
4. Successful placement of two overlapping Cypher drug-eluting
stents
(2.5 x 28 mm distally and 3.0 x 18 mm proximally) in the
proximal to
mid-LAD to treat in-stent restenosis and a total occlusion. A
high
pressure inflation was performed with a 3.0 mm balloon. Final
angiography demonstrated no residual stenosis, no
angiographically
apparent dissection, and normal flow (See PTCA Comments).
FINAL DIAGNOSIS:
1. One vessel coronary disease.
2. Successful placement of drug-eluting stents in the LAD.
-PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
HTN
Hyperlipidemia
DM - on po meds
Obesity
Social History:
He is married with three children, currently not working (worked
previously as a [**Doctor Last Name 9808**] operator) - supposed to start again on
Tuesday. Moderate amount of stress because he hasn't worked in 6
months. No current or prior tobacco use. Has rare alcohol use.
Family History:
Mother died at 59 of an myocardial infarction. Father alive and
in good health. Brother, question of an myocardial infarction at
age 45.
Physical Exam:
VS: T=98 BP=150/82 HR= 80 RR=15 O2 sat=RA
GENERAL: Well appearing middle aged male in NAD. Oriented x3.
Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with no JVD
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: NABS, obese. Soft, NTND. .
EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: radial and DP 2+ bilaterally
Pertinent Results:
CCath:
COMMENTS:
1. Selective coronary angiography of this right dominant system
revealed
three vessel CAD. The LMCA was angiographically normal. The LAD
had a
90% stenosis proximal to the prior series of stents, and was
occluded in
the mid portion of the stent. The distal LAD fills by faint left
to left
collaterals with an apparently good caliber vessel. The LCX had
progression of disease up to 70% in the proximal vessel. The RCA
had a
tight 90% in stent restenosis within the proximal vessel. The
remaining
RCA was of large caliber.
2. Limited resting hemodynamics demonstrated mild systemic
arterial
hypertension with BP of 142/80mmHg. LVEDP was modestly elevated
at
25mmHg. There was no gradient on pullback of catheter from LV to
aorta.
3. Left ventriculography demonstrated anterolateral and apical
hypokinesis with preserved wall motion of the basal segments.
Overall EF
was estimated to be 50%. There was no mitral regurgitation.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Anterolateral LV hypokinesis with low normal ejection
fraction.
3. LV diastolic dysfunction.
4. Systemic arterial hypertension.
Echo:
The left atrium and right atrium are normal in cavity size.
There is mild symmetric left ventricular hypertrophy with normal
cavity size. There is mild to moderate regional left ventricular
systolic dysfunction with severe hypokinesis of the distal half
of the anterior septum and anterior walls. The apex is mildly
aneurysmal and hypokinetic. The remaining segments contract
normally (LVEF = 45 %). No masses or thrombi are seen in the
left ventricle. Right ventricular chamber size and free wall
motion are normal. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no mitral valve prolapse. There is an anterior space which most
likely represents a fat pad.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
regional systolic dysfunction c/w CAD (mid-LAD distribution).
Carotid U/S:
Impression: Right ICA stenosis <40% .
Left ICA with stenosis <40% .
Vein Mapping:
FINDINGS: The greater saphenous veins are patent bilaterally
from the level of the ankle through to the saphenofemoral
junction. Please see digitized images on PACS for formal
sequential measurements. There is an element of varicose
dilatation involving the right greater saphenous vein.
ECG:
Sinus rhythm. Q waves in the inferior leads consistent with
prior infarction. Late transition with tiny R waves in the
anterior leads consistent with possible prior anterior wall
myocardial infarction. Non-specific ST-T wave changes. Compared
to the previous tracing possible anterior wall myocardial
infarction is new.
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2103-10-22**] 05:40AM 12.0* 3.50* 10.2* 30.8* 88 29.3 33.2 14.4
242
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2103-10-22**] 05:40AM 176* 11 0.9 137 4.4 101 28 12
Brief Hospital Course:
Mr [**Known lastname 30222**] is a 61 year old male with known coronary artery
disease s/p stenting in the past who presented to an OSH with
chest pain. Was transffered to [**Hospital1 **] for evaluation for
revasularization. On [**2103-10-15**] Mr. [**Known lastname 30222**] had a cardiac
catheterization, which showed three vessel disease. He was taken
to the OR on [**2103-10-19**] for for coronary artery by
grafting(LIMA-LAD, SVG- [**Last Name (LF) **], [**First Name3 (LF) **], dRCA)- see operative note for
details. Post operatively, Mr. [**Known lastname 30222**] was transferred to the
intensive care unit for ongoing hemodyanmic monitoring and
mechanical ventilation in stable condition. On the evening of
his surgery he was weaned and extubated. His statin and beta
blocker were resumed and diuresis was begun. The following day
he was transferred from the ICU to the step down floor for
ongoing postoperative care. His chest tubes and temporary pacing
wires were removed per protocol. He was evaluated by physical
therapy for strength and conditioning and was cleared for
discharge to home on POD#4 in stable condition.
Medications on Admission:
Metformi n500mg [**Hospital1 **]
Januvia
Toprol 200 mg qd
Fish Oil
Aspirin 325 mg qd
Hydrochlorothiazide 12.5 mg qd
Enalapril 2.5 mg qd
Isosorbide Mononitrate (Extended Release) 30 mgqd
Atorvastatin 20 mg
Clopidogrel 75 mg PO qd
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Glimepiride 2 mg Tablet Sig: One (1) Tablet PO qhs ().
Disp:*30 Tablet(s)* Refills:*2*
5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
6. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO BID (2 times a day)
for 7 days.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
7. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7
days.
Disp:*14 Tablet(s)* Refills:*0*
8. Janumet 50-500 mg Tablet Sig: One (1) Tablet PO bid ().
Disp:*60 Tablet(s)* Refills:*2*
9. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
10. Enalapril Maleate 5 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
Disp:*20 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] [**Location (un) 5087**]
Discharge Diagnosis:
s/p Coronary artery bypass graft x4
Hypertension
hyperlipdemia
Diabetes
Neuropathy
coronary artery disease with multiple stents
S/P RCA thrombectomy and stenting
IMI [**2094**]
Gout
head injury s/p traumatic fall [**2102**]
right hand surgery
tonsillectomy
Discharge Condition:
good
Discharge Instructions:
no lotions, creams, powders or ointments on any incision
shower daily and pat incisions dry
no lifting greater than 10 pounds for 10 weeks
no driving for one month AND off all narcotics
call for fever greater than 100, redness, drainage, or weight
gain of 2 pounds in 2 days or 5 pounds in one weeks
Followup Instructions:
Please schedule the folllowing appointments:
Dr. [**First Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
Dr. [**Last Name (STitle) 30223**] [**Name (STitle) 30224**] [**Doctor Last Name **] (primary care) in 2 weeks [**Telephone/Fax (1) 13687**]
Dr. [**Last Name (STitle) 3321**] in [**2-13**] weeks.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2103-10-23**]
|
[
"458.29",
"412",
"401.9",
"V45.82",
"274.9",
"272.4",
"414.01",
"355.9",
"411.1",
"996.72",
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icd9cm
|
[
[
[]
]
] |
[
"37.22",
"39.61",
"36.15",
"36.13",
"88.56",
"88.53"
] |
icd9pcs
|
[
[
[]
]
] |
9845, 9917
|
7221, 8357
|
369, 459
|
10218, 10225
|
4079, 5022
|
10573, 11007
|
3201, 3339
|
8637, 9822
|
9938, 10197
|
8383, 8614
|
5039, 7198
|
10249, 10550
|
3354, 4060
|
1655, 2695
|
283, 331
|
487, 1551
|
2847, 2892
|
1573, 1635
|
2908, 3185
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,183
| 130,212
|
20079
|
Discharge summary
|
report
|
Admission Date: [**2117-6-7**] Discharge Date: [**2117-6-19**]
Date of Birth: [**2048-7-14**] Sex: M
Service: MEDICINE
Allergies:
Amoxicillin / Bactrim / Keflex
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Hypercarbic respiratory failure
Major Surgical or Invasive Procedure:
bronchoscopy (x3) / tracheostomy placement
History of Present Illness:
HPI: 68yoM with CAD s/p CABG, MVR, s/p PPM/ICD, esophageal ca
who presented to OSH on [**2117-6-3**] with respiratory distress. He was
noted to be more lethargic and dyspneic on admission to OSH. It
was felt that the pt was in CHF. He was also noted to be
bradycardic at the time of admission (HR 40) and concern for 2nd
degree type I heart block per notes. His BP was 80/60 on
admission. He was given low dose dopamine and diuretics for his
CHF and brady/relative hypotension. According to OSH notes, the
pt's PPM was checked and had back-up rate at 39 bpm and was
functioning properly. TTE at OSH showed EF 50% with mild MR. [**Name13 (STitle) **]
was also noted to be somnolent with PCO2s (79-91) in the prior
48hrs before tx. He was placed on BiPAP and did well with
improvement in pCO2 to 49. He was transitioned to nasal cannula
and transferred to [**Hospital1 18**] for futher care.
At [**Hospital1 18**], the pt was found to be afebrile with stable vs but
somnolent on appearance. ABG was 7.25/90/111 on 3L NC. Given the
hypercarbic respiratory failure and somnolent appearance, the pt
was transferred to the ICU for further care.
In the ICU the pt was intubated for impending respiratory
failure and hypersomnulance. At that time ABG was 7.09/137/385.
He was then noted to be bradycardic to the 40s and SBPs dropped
to the 60s. He was bolused 250 cc of IVF and started on dopamine
and continuous IVFs. His SBPS trended up to the 120s on
dopamine.
Past Medical History:
1. CAD s/p CABG 3v in 11'[**13**]
---LIMA --> LAD, SVG --> OM, and SVG --> RCA
---Ischemic cardiomyopathy (LVEF = 40%), s/p ICD placement in
[**Month (only) 958**]
[**2114**]
2. s/p mitral valve replacement (Carbomedics mechanical
prosthesis) in [**10/2114**]
3. Atrial fibrillation
4. Hypertension
5. Diabetes
6. Idiopathic pulmonary fibriosis s/p Pulmonary Rehab at New
[**Hospital1 13199**] Rehab in '[**15**]
---severe restriction on his pulmonary function testing, which
is markedly worse than his preoperative TLC of 75% predicted.
Some of this restriction may reflect worsened fibrotic lung
disease or it may be due to some element of pleural thickening
releated to his previous problems with pleural effusions as per
his pulmonologist.
7. ?Amiodarone Pulmonary Toxicity
8. Stage II esophageal cancer T3, N0, MO, status post XRT,
chemotherapy and esophagectomy.
---s/p J-tube and Port-A-Cath placement on [**2115-8-13**] by
[**Doctor First Name **] [**Doctor Last Name **].
---Concurrent radiation therapy and chemotherapy on [**2115-8-19**]
with infusional 5-FU and cisplatin, completed [**2115-9-26**].
---s/p esophagectomy, [**2115-11-14**] by Dr. [**Last Name (STitle) **].
Social History:
SOCIAL HISTORY:
The patient is married and lives in [**Location 5110**], MA. He has three
children and is a former engineer. He has never smoked and
denies ever drinking alcohol. He does not use recreational
drugs.
Family History:
FAMILY HISTORY:
Denies any h/o cancer, CAD. Parents died when he was young,
unsure of causes.
Physical Exam:
PHYSICAL EXAMINATION:
VS: T 99.1 HR 71 BP 120/64 RR 19 O2 sat 100% AC 400 x 22 FI02
0.5 PEEP 5 ABG 7.43/51/173
GEN: intubated male in NAD
HEENT: anicteric sclera, intubated
NECK: supple
CARDIO: RRR, nl S2, loud click heard during S1
PULM: CTA b/l
ABD: soft, NT, ND + BS
EXT: 1+ pitting edema b/l, cool extremities, unable to palpate
[**Doctor Last Name **] extremity pulses
Pertinent Results:
OSH STUDIES:
most recent ABG 7.30/78/120 ([**6-7**] at 1350)
Bicarb 34
BUN 94
Cr 1.7 (from notes)
Dig 1.0 ([**6-3**])
BNP 3700 ([**6-3**])
WBC 9.4 (from 13.6)
Hct 36
Plt 155
[**Month/Day (4) 263**] 2.0
.
Labs here: pls see below
.
ECG: Anterolateral TWI that were present in previous EKGs,
bradycardia with rate of 40, appears to have high grade AV block
with a junctional rhythm
.
TTE [**2116-6-2**]:
LA: elongated.
LV: wall thicknesses and cavity size are normal. There is mild
regional left ventricular systolic dysfunction with severe
hypo/akinesis of the distal third of the left ventricle. The
remaining walls contract well. No masses or thrombi are seen in
the left ventricle.
RV: chamber size and free wall motion are normal.
Aortic valve: leaflets (3) appear structurally normal with good
leaflet excursion and no aortic regurgitation.
Mitral Valve: A bileaflet mitral valve prosthesis is present.
The mitral prosthesis appears well seated, with normal
leaflet/disc
motion and transvalvular gradients. No mitral regurgitation is
seen. [Due to acoustic shadowing, the severity of mitral
regurgitation may be significantly
UNDERestimated.]
Pulm Artery Pressure: The estimated pulmonary artery systolic
pressure is top normal.
Pericardium: there is no pericardial effusion.
.
cardiac cath [**2113**]:
1. Selective angiography of this right-dominant system revealed
three-vessel and LMCA disease. The LMCA had a distal 40-50%
distal
stenosis. The LAD had severe ostial and proximal diffuse
diseased and was totally occluded after D1. The distal LAD
filled via left-to-left and right-to-left collaterals. The D1
branch had a 70% stenosis at its ostium. The LCX had a 40%
stenosis at the origin of a large OM1. The OM1 branch had serial
70% lesions proximally and mid vessel with distal luminal
irregularities. The RCA had a mid-vessel tubular 60% stenosis
and a 70% stenosis just before the RPDA. There were luminal
irregularities in the PDA and RPL.
2. Entry hemodynamics revealed a central aortic pressure of
140/81
mmHg. The LVEDP was 16 mmHg.
3. Left ventriculography revealed an ejection fraction of 29%.
Imaging was suboptimal due to ejection of the pigtail catheter
back into the aorta. There was anterobasal hypokinesis,
anterolateral akinesis, apical dyskinesis/akinesis, inferior and
posterobasal hypokinesis. There was mild to moderate ([**12-28**]+)
mitral regurgitation.
Brief Hospital Course:
A/P: 68 yo male with h/o CAD s/p CABG, idiopathic pulmonary
fibrosis, esophageal cancer, MVR and bradycardia s/p PPM/ICD who
presented with somnolence, hypercarbic respiratory failure,
bradycardia, hypotension and likely urosepsis.
Pt ultimately developed worsening tracheal secretions, resulting
in repeated bronchoscopy, then on [**6-19**] developed severe tracheal
obstruction, c/b bleeding, resulting in worsening hypoxemia and
ultimately PEA. ACLS x 30 min, without recovery. Pt pronounced
dead [**6-19**] at ~10:45 AM.
* Respiratory failure: Patient was transferred from an OSH for
possible pacemaker replacement and had significant respiratory
distress at presentation. He had been on Bipap at the OSH but
had worsening hypercarbic respiratory failure upon arrival here.
His gas of 7.09/137/385 led to him being intubated. The patient
had a h/o of severe idiopathic pulmonary fibrosis, but it was
unclear what the underlying insult was. Initially cardiogenic
vs. septic process was debated. He was covered broadly with
vancomycin, levaquin and flagyl to cover for a PNA. He was ruled
out for MI with three sets of CEs. Echo was done to evaluate
cardiac function and showed nl EF with ? RV strain. CTA was then
done and was negative for PE. Pt was continued on ventilator
but did not tolerate PSV very well. He also had episodes of
tachypnea and tachycardia but these improved with sedation.
After d/w the pt and his family he had a trach placed on [**6-16**].
He completed 8 days of levaquin to cover for a PNA and had
sputum cx that had rare growth of coag + staph, but this was
thought to be colonization.
.
.
Pt continued to have difficulty with tracheal secretions,
resulting in repeat bronchoscopy on [**6-18**], and again on [**6-19**]. On
the monring of [**6-19**] pt was noted to have decreased tidal volumes
and found to be in respiratory distress with O2 sats of 97% on
100% O2. Manual bagging was commenced, an an emergent
bronchoscopy was performed which revealed ball-valve
clot/soft-tissue obstruction at distal trach with complete
luminal occlusion during exhalation. Attempts to clear clot
with suction or forceps were unsucessful. A Cook catheter was
passed via trach distal to obstruction allowing ventilation with
improvement in O2 sats from 70%->96%, but tidal volumes remained
low. An urgent thoracic surgery consult was placed, and
collective decision was made to intubate from above. Pt
subsequently developed progressive hypoxemia and bronch then
revealed diffuse bleeding from above and below. Pt progresively
decompensated, resulting in PEA resulting in ACLS x 30 minutes
without recovery of signs of life. Case was discussed with wife
and decision was made to discontinue ongoing aggressive
resuscitation and focus on comfort. ACLS stooped at ~10:30AM,,
pt decased ~10:45AM. Pt declined autopsy, medical examiner made
aware.
*Hypotension/sepsis: Pt was hypotensive at admission. He was
known to have a UTI at the OSH, so it was thought that
hypotension was potentially [**1-28**] to urosepsis. His CXR also
showed a consolidation. He was pan cultured at that time and
started on vancomycin, flagyl and levaquin at that time. His
OSH records showed growth of enteroccocus in the urine,
sensitive to vancomycin. His cultures here later showed growth
of methicillan resitant coag negative staph in a bcx from [**6-8**]
and enterococcus in the urine on [**6-8**] as well. Initially it was
unclear whether pt's hypotension was [**1-28**] to sepsis or cardiac
source. As mentioned above he had nl EF and no evidence of
cardiac ischemia. SVO2 was high , also suggesting sepsis and
positive culture data was further c/w this. Pt also had a
cotrosyn stimulation test and the initial cortisol level was
low, so he completed a dose of stress dose steroids for 7 days.
He was weaned off pressors over several days. B/c he had
bacteremia and sepsis in the setting of a MVR, there was concern
for endocarditis. B/c of his h/o of esophagectomy he required
EGD to evaluate his esophagus and then esophageal dilatation
prior to TEE. Several attempts were made at a TEE, but were not
successful until [**6-16**]. TEE was negative for endocarditis and all
abx were stopped at that time. His ucx from [**6-13**] showed
continued growth of enterococcus so foley was changed on [**6-16**]
and ucx re-checked.
*Bradycardia: Patient was initially admitted to cardiology for
w/u of bradycardia and possible pacemaker replacement. EKGs
demonstrated several different rhythms from NSR and atrial
fibrillation to 2nd degree heart block. EKG here at one point
showed bradycardia with high degree heart block and junctional
escape rhythm. Pacemaker settings were changed by EP on [**6-8**].
His back-up rate was changed from 39 to 55.
* Hypernatremia: Na was slightly elevated at around 146 at
times. he had free water fluid boluses in his TFs to replace his
free H20 defecit.
*Renal insufficiency: Baseline Cr in [**2115**] was 0.6-0.9. During
his stay his UOP dropped and Cr slowly trended up. Renal u/s
was unchanged and urine lytes suggested pre-renal source. He did
not respond to fluid boluses and CVPs were high. He was then
diuresed with good results and only slight elevation in Cr.
*Anemia: Hct had been slowly trending down over his admission.
He received one unit PRBCs on [**6-14**] and remained hemodynamically
stable after. He had guiac + stools in the setting of being on
heparin but had been seen by GI and a decision was made that he
did not need to be scoped at this time. He also had some bloody
respiratory secretions which could also have contributed to slow
[**Month/Year (2) **] loss. His secretions continued to increase, and on [**6-19**]
frank [**Month/Year (2) **] was found in the trachea at time of emergent
bronchcopy described above.
* Abdominal distension: Pt was noted to have abd distension
during his stay. He had not had a BM in multiple days, so his
bowel regimen was increased. Pt had KUB that was negative for
obstruction and abd distension has decreased after having BMs.
He was being treated with lactulose, senna and colace.
*CAD: Pt has h/o CAD s/p CABG. He was continued on ASA and
started on a statin. BB was held in the setting of his
intermittent episodes of hypotension.
*MVR: Pt has MVR in place and took coumadin at home. He was
started on a heparin gtt at admission.
* Hematuria: suspect foley trauma in the setting of
anticoagulation. Appears to be lightening some. Good UOP so no
worry about clot at this time
*DM: Sugars well controlled with SSI and QID FS.
*Code Status: FULL CODE 9
*PPx: PPI, bowel regimen, heparin.
.
* Access:
- R subclavian placed [**6-8**]
- A-line placed [**6-8**]
.
*Contact: wife: [**Telephone/Fax (1) 54048**]
PCP: [**Name10 (NameIs) 54049**] [**Name11 (NameIs) **]
Medications on Admission:
MEDICATIONS ON TRANSFER:
1. Levoflox 250 daily (D#4)
2. Digoxin 0.0625 daily
3. Diamox 250 daily
4. Lopressor 25 TID
5. Levoxyl 88mcg daily
6. Protonix 40 daily
7. Colace 100 [**Hospital1 **]
.
MEDICATIONS AT HOME:
1. Lopressor 50 mg once daily
2. Digoxin 0.0625 mg daily
3. Levothyroxine 88 mcg daily
4. Lasix 40 mg b.i.d.,
5. Warfarin
6. Zantac b.i.d.
.
Allergies: Amoxicillin / Bactrim / Keflex
Discharge Disposition:
Expired
Discharge Diagnosis:
respiratory failure / pulseless electrical activity
Discharge Condition:
deceased.
Discharge Instructions:
none.
Followup Instructions:
none.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
|
[
"995.92",
"518.81",
"276.0",
"414.00",
"250.00",
"038.9",
"401.9",
"599.0",
"997.4",
"530.3",
"280.0",
"427.31",
"785.52",
"V45.81",
"V42.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.1",
"33.21",
"42.92",
"88.72",
"38.91",
"96.04",
"96.72",
"45.13",
"96.6",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
13473, 13482
|
6227, 13025
|
322, 366
|
13577, 13588
|
3814, 6204
|
13642, 13776
|
3326, 3405
|
13503, 13556
|
13051, 13051
|
13612, 13619
|
13266, 13450
|
3420, 3420
|
3442, 3795
|
251, 284
|
394, 1853
|
13076, 13245
|
1875, 3062
|
3094, 3294
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,850
| 169,283
|
33523
|
Discharge summary
|
report
|
Admission Date: [**2111-8-10**] Discharge Date: [**2111-8-13**]
Date of Birth: [**2058-3-29**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
mild DOE/decreased exer. tolerance
Major Surgical or Invasive Procedure:
[**2111-8-10**] bil. thoracoscopic mini-Maze/stapling LAA
History of Present Illness:
53 yo male with strong risk factors for CAD underwent stress
test in [**2109**], and was found to be in A fib. Started on digoxin
and sotalol, but stopped due to poor efficacy. Seen originally
by Dr. [**Last Name (STitle) 914**] in [**6-14**]. Completed pre-op workup and presents for
[**Doctor First Name **]. eval.
Past Medical History:
A Fib/flutter
HTN
elev. chol.
PSH: exp.lap /?SBO
right herniorrhaphies x2 in childhood, one with bowel resection
Social History:
lives with childreen
[**3-10**] glasses of wine /month
works as a manuf. mgr
denies tobacco
Family History:
father died of MI at 57, brother with VF arrest at 52
Physical Exam:
5'[**14**]" 235#
NAD
HR 80 irreg right 98/76, 108/76 left 122/82
skin unremarkable
PERRLA, EOMI, anicteric sclera, OP unremarkable
neck supple, no JVD or carotid bruits appreciated
CTAB
[**Last Name (un) **] S1 S2, no murmur noted
soft, NT, ND, + BS; no HSM/CVA tenderness; well-healed abd and
RLQ scars
no varicosities
MAE [**5-11**] strengths; nonfocal exam
2+ bil. fems/radials
1+ bil. DP/PTs
Pertinent Results:
Conclusions
1. The left atrium and right atrium are normal in cavity size.
No spontaneous echo contrast is seen in the body of the left
atrium. No spontaneous echo contrast or thrombus is seen in the
body of the left atrium or left atrial appendage. No
mass/thrombus is seen in the left atrium or left atrial
appendage. No thrombus is seen in the left atrial appendage.
2. No spontaneous echo contrast is seen in the body of the right
atrium. No atrial septal defect is seen by 2D or color Doppler.
3. Left ventricular wall thicknesses and cavity size are normal.
Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%).
4. Right ventricular chamber size and free wall motion are
normal.
5. There are simple atheroma in the descending thoracic aorta.
6. There are three aortic valve leaflets. The aortic valve
leaflets are mildly thickened. There is no aortic valve
stenosis. No aortic regurgitation is seen.
7. The mitral valve appears structurally normal with trivial
mitral regurgitation.
8. There is a trivial/physiologic pericardial effusion.
Dr. [**Last Name (STitle) 914**] was notified in person of the results.
POST MAZE procedure with LAA ligation. By 2-D and 3-D images,
Left atrial appendage is ligated with a horizontal suture line
present without intreruption. No flow detected across the suture
line. LUPV flow is normal at 60 cm/sec.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2111-8-10**] 13:02
Brief Hospital Course:
Mr. [**Name14 (STitle) 77728**] was admitted [**8-10**] and underwent a bilateral
thoracoscopic mini-MAZE and stapling of the left atrial
appendage with Dr. [**Last Name (STitle) 914**]. Transferred to the CVICU in stable
condition on a propofol drip. Bronchoscopy performed in CICU
immediately postop for mucus plugging. Extubated later that
afternoon and he was weaned from his vasoactive drips.
Amiodarone was started per protocol. He was transferred to the
surgical step down floor. His chest tubes were removed and he
was seen in consultation by the physical therapy service. He was
started on coumadin for his history of atrial fibrillation and
indocin, colchicine, and omeprazole per our mini-thoracotomy
protocol. By post-operative day three he was ready for
discharge to home.
Medications on Admission:
digoxin 0.125 mg daily
ASA 325 mg daily
simvastatin 80 mg daily
lisinopril 20 mg /HCTZ 25 mg daily
MVI daily
amiodarone 200 mg daily
amlodipine 5 mg/valsartan 160 mg daily (Exforge)
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*0*
3. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Indomethacin 25 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*0*
5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
7 days.
Disp:*7 Tablet(s)* Refills:*0*
6. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO once
a day for 7 days.
Disp:*7 Packet(s)* Refills:*0*
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): take for constipation while taking pain
medication.
Disp:*60 Capsule(s)* Refills:*0*
9. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 30 doses.
Disp:*30 Tablet(s)* Refills:*0*
10. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO BID (2 times a day) for 30
days.
Disp:*120 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
12. Outpatient Lab Work
INR draw on [**2111-8-16**] with results sent to the office of Dr.
[**Last Name (STitle) 14522**] Fax number ([**Telephone/Fax (1) 77729**].
13. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] Nursing Services
Discharge Diagnosis:
A Fib/flutter s/p bil thoracoscopic Mini-Maze procedure
HTN
elev. chol.
PSH: ex lap for ? SBO
right herniorrhaphies x2 in childhood, one with bowel resection
Discharge Condition:
good
Discharge Instructions:
no lotions, creams or powders on any incision
no lifting greater than 10 pounds for 2-3 weeks, then start
increasing slowly
no driving for 2 weeks minimum or until not taking any narcotics
call for fever greater than 100.5, redness, or drainage
Followup Instructions:
see Dr. [**Last Name (STitle) 14522**] in [**1-7**] weeks ([**Telephone/Fax (1) 77730**]
see Dr. [**Last Name (STitle) **] in [**2-8**] weeks
see Dr. [**Last Name (STitle) 914**] in 4 weeks [**Telephone/Fax (1) 170**]
An INR should be drawn on Monday [**2111-8-16**] and faxed to the office
of Dr. [**Last Name (STitle) 14522**] at ([**Telephone/Fax (1) 77729**]. Plan confirmed with Dr.
[**Last Name (STitle) 14522**] on [**8-13**]
Completed by:[**2111-8-13**]
|
[
"934.8",
"518.0",
"E915",
"401.9",
"272.0",
"427.32"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.33",
"96.05"
] |
icd9pcs
|
[
[
[]
]
] |
5955, 6023
|
3253, 4042
|
355, 415
|
6226, 6233
|
1514, 3230
|
6526, 6993
|
1022, 1077
|
4274, 5932
|
6044, 6205
|
4068, 4251
|
6257, 6503
|
1092, 1495
|
281, 317
|
443, 761
|
783, 897
|
913, 1006
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,862
| 113,307
|
49583
|
Discharge summary
|
report
|
Admission Date: [**2124-12-4**] Discharge Date: [**2124-12-26**]
Date of Birth: [**2062-12-13**] Sex: M
Service: MEDICINE
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
Intubation and Mechanical Ventilation
Arterial Line Placement
Bronchoscopy
History of Present Illness:
61 yo M with hypertension, COPD, alcoholism (unclear if active),
possible schizophrenia was admitted overnight through the ED.
His ability to relate a consistent hx is currently impaired, but
per prior notes, it seems that he was told by his neighbor to
come to the hospital as he appeared short of breath. The
initial assessment of ED staff was that the pt was massively
fluid overloaded in the setting of CHF and non-compliance with
lasix. He was treated with Lasix IV 40mg x 2, ASA 325 and nitro,
although no chest pain and EKG . Further review of OMR reveals
that the pt is no on lasix and has no clinical hx of CHF, last
echo in [**2119**] showed preserved LVEF of 55 with only mild Ao
dilation.
.
Initial labs were notable for Na of 116 with K of 6.6 (initial
7.8 was hemolyzed) and CR 2.7; no EKG changes. LFTs elevated AST
120, ALT 50, with bili 4.5, INR 1.6, albumin 2.6. With one dose
of kayexalate, potassium has trended down to 5.3. Serial
troponins 0.04. Initial CK 700 trending down with minimal MB
fraction.
.
In terms of his mental status, his PCP saw him one month ago at
which point he was at baseline A&OX3, independent for all ADLs.
MS not in ED not clearly documented. At 8AM this morning, he
trigerred for tachypnea with RR close to 30 and worsened MS
A&Ox1 only to self. [**Hospital **] transferred to the MICU. On
arrival, pt was on 2L and confused/somnolent. His audible
wheezing, tachypnea, and hypoxia improved rapidly with
albuterol. MS improved slightly when taken off supplemental O2.
ABG on room air: 7.4/35/73.
ROS: Denies any pain but unable to provide detailed ROS.
Past Medical History:
1. Multiple ED admissions for ETOH intoxication
2. HTN.
3. Emphysema.
4. Prostate hyperplasia
5. Nocturnal leg cramps
6. Finger reconstructive surgery
7. HIV? (per OMR note from [**2119**]) no ab tx in system
Social History:
-Tobacco history: 1ppd x 42 years
-ETOH: History of alcohol abuse but he claims he has not had a
drink in 2 years
-Illicit drugs: Patient denies, admission tox negative
Family History:
uanble to elicit
Physical Exam:
General Appearance: Overweight / Obese, total body anasarca
Eyes / Conjunctiva: PERRL, 3mm pupils reactive
Head, Ears, Nose, Throat: Normocephalic, Poor dentition
Lymphatic: Cervical WNL, Supraclavicular WNL, No(t) Cervical
adenopathy
Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,
No(t) Rub, (Murmur: No(t) Systolic, No(t) Diastolic)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Percussion: No(t)
Resonant : , No(t) Hyperresonant: , No(t) Dullness : ), (Breath
Sounds: Clear : , Wheezes : greatly improved with albuterol)
Abdominal: Soft, Distended, pitting edema over entire abdomen
Extremities: Right lower extremity edema: 4+, Left lower
extremity edema: 4+, Clubbing
Skin: Cool, Rash: LE venous stasis BL
Neurologic: No(t) Attentive, No(t) Follows simple commands,
Responds to: Not assessed, Oriented (to): ONLY SELF, Movement:
Purposeful, Tone: Normal
Pertinent Results:
[**2124-12-4**] 10:25AM BLOOD WBC-11.4*# RBC-3.27* Hgb-10.7* Hct-32.3*
MCV-99*# MCH-32.6* MCHC-33.1 RDW-15.2 Plt Ct-218#
[**2124-12-11**] 04:26AM BLOOD WBC-12.4* RBC-2.55* Hgb-9.0* Hct-25.6*
MCV-100* MCH-35.1* MCHC-35.0 RDW-16.8* Plt Ct-88*
[**2124-12-16**] 03:40PM BLOOD WBC-36.4* RBC-2.91* Hgb-9.8* Hct-29.0*
MCV-100* MCH-33.8* MCHC-33.9 RDW-17.7* Plt Ct-45*
[**2124-12-26**] 04:00AM BLOOD WBC-16.3* RBC-2.58* Hgb-8.9* Hct-28.0*
MCV-109* MCH-34.6* MCHC-31.9 RDW-21.0* Plt Ct-33*
[**2124-12-4**] 10:25AM BLOOD PT-18.0* PTT-35.4* INR(PT)-1.6*
[**2124-12-10**] 01:02PM BLOOD PT-26.0* PTT-54.5* INR(PT)-2.5*
[**2124-12-21**] 04:33AM BLOOD PT-39.5* PTT-56.8* INR(PT)-4.1*
[**2124-12-22**] 10:16AM BLOOD PT-64.8* PTT-81.0* INR(PT)-7.4*
[**2124-12-22**] 06:40PM BLOOD PT-111.4* PTT-105.1* INR(PT)-14.2*
[**2124-12-23**] 03:52PM BLOOD PT-105.0* PTT-96.5* INR(PT)-13.2*
[**2124-12-25**] 03:52AM BLOOD PT-150* PTT-114.7* INR(PT)->20.2
[**2124-12-25**] 10:45AM BLOOD PT-150* PTT-150* INR(PT)->20.2*
[**2124-12-25**] 04:22PM BLOOD PT-150* PTT-150* INR(PT)->20.2
[**2124-12-26**] 04:00AM BLOOD PT-150* PTT-127.5* INR(PT)-27.4*
[**2124-12-4**] 10:25AM BLOOD Glucose-72 UreaN-66* Creat-2.8*# Na-116*
K-7.8* Cl-87* HCO3-24 AnGap-13
[**2124-12-18**] 04:24AM BLOOD Glucose-112* UreaN-83* Creat-6.4*# Na-138
K-3.3 Cl-99 HCO3-23 AnGap-19
[**2124-12-26**] 04:00AM BLOOD Glucose-80 UreaN-8 Creat-0.9 Na-130*
K-3.7 Cl-97 HCO3-20* AnGap-17
[**2124-12-26**] 09:41AM BLOOD Glucose-48* Na-131* K-4.1 Cl-98 HCO3-17*
AnGap-20
[**2124-12-4**] 10:25AM BLOOD CK(CPK)-693*
[**2124-12-6**] 06:29AM BLOOD ALT-35 AST-71* LD(LDH)-246 CK(CPK)-225*
AlkPhos-86 TotBili-4.0*
[**2124-12-15**] 04:27AM BLOOD ALT-84* AST-230* AlkPhos-87 TotBili-8.4*
[**2124-12-17**] 04:21AM BLOOD ALT-589* AST-1196* LD(LDH)-506*
AlkPhos-151* TotBili-9.8*
[**2124-12-20**] 06:21PM BLOOD ALT-348* AST-387* CK(CPK)-14*
AlkPhos-171* TotBili-14.9*
[**2124-12-22**] 05:36AM BLOOD ALT-271* AST-344* AlkPhos-162*
TotBili-14.6*
[**2124-12-23**] 12:30AM BLOOD ALT-1307* AST-5023* LD(LDH)-2880*
AlkPhos-246* TotBili-13.3*
[**2124-12-23**] 03:52PM BLOOD ALT-2172* AST-7388* LD(LDH)-2712*
CK(CPK)-45 AlkPhos-412* TotBili-13.4*
[**2124-12-24**] 05:11AM BLOOD ALT-2203* AST-6404* AlkPhos-492*
TotBili-14.6*
[**2124-12-25**] 04:22PM BLOOD ALT-1549* AST-2710* LD(LDH)-878*
AlkPhos-564* TotBili-16.1*
[**2124-12-26**] 04:00AM BLOOD ALT-1325* AST-[**2071**]* LD(LDH)-824*
AlkPhos-589* TotBili-16.8*
[**2124-12-4**] 10:25AM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
[**2124-12-4**] 10:00PM BLOOD Ethanol-NEG
[**2124-12-8**] 05:22AM BLOOD C3-19* C4-6*
[**2124-12-20**] 05:26AM BLOOD IgG-2123*
[**2124-12-5**] 06:08PM BLOOD [**Doctor First Name **]-NEGATIVE
[**2124-12-5**] 06:08PM BLOOD AMA-NEGATIVE Smooth-POSITIVE *
[**2124-12-8**] 04:16PM BLOOD ANCA-NEGATIVE B
[**2124-12-23**] 03:52PM BLOOD Smooth-POSITIVE A
[**2124-12-5**] 06:08PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HAV
Ab-POSITIVE IgM HBc-NEGATIVE
[**2124-12-12**] 02:34PM BLOOD Cortsol-12.1
[**2124-12-12**] 03:15PM BLOOD Cortsol-17.8
[**2124-12-5**] 06:08PM BLOOD calTIBC-163* Hapto-<20* Ferritn-1368*
TRF-125*
[**2124-12-5**] 10:29AM BLOOD Lactate-1.7 K-5.0
[**2124-12-20**] 11:10AM BLOOD Lactate-2.3*
[**2124-12-21**] 04:58AM BLOOD Lactate-3.0*
[**2124-12-23**] 04:14PM BLOOD Lactate-5.9*
[**2124-12-23**] 11:27PM BLOOD Lactate-7.7*
[**2124-12-24**] 04:11PM BLOOD Lactate-6.1*
[**2124-12-25**] 04:01AM BLOOD Lactate-7.2*
[**2124-12-26**] 04:07AM BLOOD Lactate-7.6*
IMAGING:
[**2124-12-5**]:
PORTABLE SEMI-UPRIGHT CHEST RADIOGRAPH: Low lung volumes and
body habitus
limits the film. Heart size is probably top normal. There is
right hilar
fullness and a prominent azygous vein suggested volume overload.
Retrocardiac opacification may be dud to suboptimal film. No
pneumothorax. Recommend convention PA and lateral with
encouraged increased respiratory effort.
[**2124-12-5**]:
CT Head:
IMPRESSION: Limited study secondary to patient motion without
evidence of
gross acute intracranial abnormality. Global diffuse atrophy
[**2124-12-5**]:
CT Chest Abd/Pelvis:
IMPRESSION: Markedly limited examination secondary to patient
body habitus
and lack of intravenous contrast.
1. Nodular liver suggestive of cirrhosis. Splenomegaly, likely
indicative of portal hypertension.
2. Mild intra-abdominal ascites.
3. Mild centrilobular emphysema.
4. Cholelithiasis.
[**2124-12-11**]:
CT Chest/Abd/Pelvis:
IMPRESSION:
1. Interval development of bilateral lower lobe consolidations
with air
bronchograms concerning for aspiration pneumonia. Diffuse ground
glass
opacity throughout both lungs is also identified and may
represent
superimposed pulmonary edema.
2. Interval development of mediastinal and axillary lymph nodes
which may be reactive.
3. Cirrhotic-appearing liver with splenomegaly, unchanged.
4. Interval decrease in intra-abdominal ascites.
5. Cholelithiasis with gallbladder distention.
6. Emphysematous changes.
[**2124-12-20**]:
Liver U/S:
IMPRESSION: No evidence of acute gallbladder process. Gallstones
again
noted.
[**2124-12-21**]:
CT Chest/Abd/Pelvis:
IMPRESSION:
1. Interval improvement of bilateral lower lobe consolidations,
with
remaining basilar consolidation and small bilateral pleural
effusions.
2. Cirrhotic-appearing liver with splenomegaly, unchanged.
3. Interval increase in intra-abdominal ascites.
4. Cholelithiasis with gallbladder distention.
5. Mild fat stranding around the pancreas. Suboptimal evaluation
due to lack
of IV contrast.
6. Emphysema.
7. Low attenuation right renal lesion, most consistent with a
cyst.
Pathology:
Liver Biopsy [**2124-12-21**]:
Liver, transjugular needle core biopsy:
Markedly fragmented biopsy demonstrating:
1. Predominantly fragments of broad, fibrous septa with mild,
mixed inflammation and focal cholangiolar proliferation,
consistent with established cirrhosis (confirmed by trichrome
stain).
2. Scant, nodular foci of hepatic lobular parenchyma (totaling
only 20% of the total biopsy volume), with focal microvesicular
steatosis and moderate canalicular cholestasis.
3. No central veins or native portal tracts present for
evaluation in this limited sample.
4. Iron stain shows moderate iron deposition within
hepatocytes.
Note: The biopsy consists almost exclusively of fibrous tissue,
consistent with established cirrhosis. The scant lobular
parenchyma present shows only minimal, non-specific changes of
end stage liver disease. Dr. [**First Name (STitle) 4370**] [**Name (STitle) **] was notified of the
findings on [**2124-12-22**].
Brief Hospital Course:
This is a 61 yom with hx of HTN and COPD who initially presented
to the ED c/o SOB and noted to be massively fluid overloaded, in
ARF with hyponatremia/hyperkalemia, with transaminitis and
synthetic dysfunction who was then admitted to the MICU for
altered mental status and eventually intubated for respiratory
distress and fluid overload.
# Acute on Chronic Liver Failure: Mr. [**Known lastname **] presented with
total body fluid overload. He had a transaminitis which
improved and worsened several times throughout his hospital
stay. He had synthetic dysfunction of the liver manifested by
thrombocytopenia and coagulopathy. All of these findings were
consistent with cirrhosis. A CT scan on admission confirmed a
nodular liver. He slowly developed worsening liver failure
during his hospitalization. A liver biopsy was done on [**2124-12-21**]
which confirmed cirrhosis. Hepatitis serologies were sent and
were negative for Hep B and Hep C. Hep A antibody was positive.
Hepatology was consulted and cirrhosis was thought to be [**3-6**]
history of EtOH abuse. Tranaminitis in the hospital was unclear
but possibly [**3-6**] shock liver in the setting of hypotension. INR
continued to rise and peaked to a level of 27 today. Family was
involved and a family meeting was held today given his
worsensing liver failure and shock which was requiring 4
pressors. He was made CMO by his father, [**Name (NI) **] [**Name (NI) **], and the
patient passed away peacefully today at 225pm.
# Hypoxic respiratory failure/Pneumonia: Mr. [**Known lastname **] was
initially intubated for respiraroty distress in the setting of
hypoxemia [**3-6**] fluid overload. He was treated with diuretics
with minimal urine output. Renal was consulted and he was
diagnosed with Hepatorenal syndrome and required dialysis for
fluid removal. He was placed on HD with good removal of fluid
intitially. WBC then began to elevate and CXR was consistent
with Pneumonia so he was started on Vanco/Zosyn/Levo for
treament of hospital acquired pneumonia. He completed a 7 day
course for his PNA. He self extubated while in the MICU and was
then reintubated for respiratory distress. He then developed
VAP while intubated and was treated with Vanco/Zosyn/Cipro.
# Shock: Patient had acute decompensated liver failure along
with pneumonia which were likely contributing to his shock.
Broead infectious workup was done and workup remained negative
while in the hospital. He was treated with Vanco/Zosyn/Cipro
for treatment of HAP. Flagyl was started out of concern for
c.diff although c.diff cultures remained negative.
# Altered mental status: Thought to be secondary to hepatic
encephalopathy. Initially improved with lactulose. Patient was
treated with lactulose and rifaximin throughout his stay.
# Acute Renal Failure: Thought to be [**3-6**] hepatorenal syndrome.
He developed anuria while in the hospital. Given his fluid
overload and pulmonary edema requiring intubation, renal was
consulted and a dialysis line was placed. He was placed on HD
for removal of fluid. This was changed to CVVH when he became
hypotensive to allow for gentle fluid removal.
# Hyponatremia: Thought to be [**3-6**] fluid overload in the setting
of cirrhosis
# Coagulopathy: Likley [**3-6**] cirrhosis and liver failure
Medications on Admission:
1. COMBIVENT INHALER
2. CYCLOBENZAPRINE 10 MG TABLET
3. DOXAZOSIN MESYLATE 8 MG TAB
4. FINASTERIDE 5 MG TABLET
5. FLUCONAZOLE 200 MG TABLET
6. GABAPENTIN 100 MG CAPSULE
7. HYDROCHLOROTHIAZIDE 25 MG TAB
8. KETOCONAZOLE 2% CREAM
9. LACLOTION 12% LOTION
10. NYSTATIN 100,000 UNIT/GM POWD
11. UREA 40% CREAM
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
|
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icd9cm
|
[
[
[]
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[
"96.05",
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icd9pcs
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[
[
[]
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13751, 13760
|
10052, 12676
|
297, 373
|
13811, 13820
|
3514, 7396
|
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|
2449, 2467
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13391, 13696
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13844, 13853
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2482, 3495
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238, 259
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|
7405, 10029
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12691, 13364
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2029, 2241
|
2257, 2433
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,230
| 153,852
|
38370
|
Discharge summary
|
report
|
Admission Date: [**2104-9-16**] Discharge Date: [**2104-9-19**]
Date of Birth: [**2069-5-27**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins / Codeine / Ketorolac
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Interstitial lung disease.
Major Surgical or Invasive Procedure:
[**2104-9-17**]: Video-assisted thoracoscopy left wound wedges.
History of Present Illness:
35 year old former smoker (8 pack-year, quit 5 years prior)with
severe tracheobronchomalacia and reactive airway disease
transfered from [**Hospital6 7472**] on [**9-16**]. Patient was
intially admitted on [**9-4**] for shortness of breath and chest
pain. He was admitted to their ICU and received BiPAP
intermittently w/ albuterol and IV Solu-Medrol. His oxygenation
requirment gradually decreased over the course of his stay and
his steriods were tapered to his home dose of 20 mg Prednisone
daily. He is transfered for care and planned VATS lung biopsy
on [**9-17**].
Past Medical History:
-Asthma, steroid dependent, 2L home O2 requirement
-Tracheobronchomalacia s/p Dumon Y stent [**2104-7-19**], removed [**2104-8-1**]
-chronic back pain
-under narcotic contract, history of narcotic violations
-depression
Social History:
-previously worked in military, now disabled
-divorced, 4 children healthy
-remove tobacco use
-denies ETOH
Family History:
-Parents are both alive, no significant medical history
Physical Exam:
VS: T: 97.4 HR: 96-100's BP 120-146/70 RR 22 Sats: 96% 4L
General: walking in SICU with nasal cannula O2 in no apparent
distress
Card: RRR
Resp: decreased breath sounds with faint scattered wheezes
GI: obese, benign
Extr: warm no edema
Incison: L VAT site clean dry intact, no erythema
Neuro: AA & O MAE
Pertinent Results:
[**2104-9-19**] 03:07AM BLOOD WBC-22.4* RBC-4.19* Hgb-12.7* Hct-38.8*
MCV-93 MCH-30.2 MCHC-32.7 RDW-15.3 Plt Ct-278
[**2104-9-18**] 03:48PM BLOOD WBC-17.5* RBC-4.08* Hgb-12.5* Hct-37.9*
MCV-93 MCH-30.5 MCHC-32.8 RDW-15.2 Plt Ct-257
[**2104-9-16**] 07:55PM BLOOD WBC-13.4* RBC-3.98* Hgb-12.4* Hct-37.2*
MCV-93 MCH-31.1 MCHC-33.2 RDW-15.2 Plt Ct-220#
[**2104-9-19**] 03:07AM BLOOD Glucose-166* UreaN-12 Creat-0.8 Na-136
K-4.1 Cl-98 HCO3-26 AnGap-16
[**2104-9-18**] 03:48PM BLOOD Glucose-172* UreaN-12 Creat-0.7 Na-135
K-4.5 Cl-98 HCO3-29 AnGap-13
[**2104-9-16**] 07:55PM BLOOD Glucose-108* UreaN-17 Creat-0.8 Na-139
K-3.8 Cl-100 HCO3-30 AnGap-13
[**2104-9-19**] 03:07AM BLOOD Calcium-9.5 Phos-3.6 Mg-2.5
Culture: Tissue L pleural: no growth to date
CXR: [**2104-9-19**]: In comparison with the study of [**9-18**], there is
continued extensive atelectatic change bilaterally, more
prominent on the left. If there are any clinical symptoms
suggestive of pneumonia, the areas of opacification, especially
on the left, would be compatible with this diagnosis. No
evidence of pulmonary vascular congestion. There is mild
elevation of the left hemidiaphragm with blunting of the
costophrenic angle.
[**2104-9-18**]: No evidence of pneumothorax. There is substantially
better inspiration, though diffuse bilateral atelectatic changes
are seen,
more prominent on the left.
[**2104-9-17**]: Extremely low lung volumes. Increased opacifications
at the bases, especially on the right, is consistent with
post-surgical atelectasis. In the appropriate clinical setting,
the possibility of pneumonia would have to be considered.
Brief Hospital Course:
Mr. [**Known lastname **] [**Last Name (Titles) 1834**] Video-assisted thoracoscopy left wound wedges
on [**2104-9-17**]. He was extubated in the operating room, monitored
in the PACU. The patient received 100mg hydrocortisone in the OR
for stress dosing and [**Date Range 1834**] his L VATS lung biopsy without
complications yesterday evening. In the PACU, however, he
experienced respiratory distress and was placed on NRB with O2
sats only 83%. He was then placed on BIPAP with good effect. His
issue was thought to be mostly pain control. He was put on a
dilaudid PCA with decreased splinting and improved O2 sat to 92%
on 4L NC. He was then sent to the floor, where his pain
increased despite 10g dilaudid total. His respiratory status
began to worsen, and CXR showed decreased lung volumes
bilaterally without PTX or hemoTX. ABG was concerning:
7.27/75/80/36/4. Due to his tenuous respiratory status, he was
transferred to the SICU. In the SICU, he appeared to mostly
have trouble expiring, using his abdominal muscles. He denied
significant pain, and there were wheezes bilaterally. He
improved on BIPAP, and a steroid taper was started.
Events:
[**9-18**] - Admitted with acute respiratory distress. A-line Right
placed. NGT placed for emesis. ABG steadily improving. Requiring
BiPAP and now weaned to high flow O2 2L face tent, much
improved. NGT removed and Left chest pigtail/JP removed.
Shuffled pain meds. D/C Foley, Right A-line out.
Respiratory: Respiratory distress of unclear etiology, likely
reactive airways disease, TBM, pain. Trouble with
expiration>inspiration. On BIPAP initially, now FM 2-6L O2 high
flow. Receiving nebs Q4 and steroid taper. Received
Methylprednisolone 125 mg IV x 1 with Prednisone 80 mg PO Q6
after, weaned to baseline O2 requirement. Improved with
nebs/steroids.
Neurologic: Significant pain postoperatively and history of
significant home narcotic use. Restart home oxycontin 40 [**Hospital1 **],
prn Oxycodone and dilaudid. Restarted MS Contin home dose.
Cardiovascular: Sinus tachycardia and HTN in SICU, on Lopressor.
Gastrointestinal / Abdomen: s/p NGT which has been removed.
Clear liquid diet.
Nutrition: Tolerating clear liquids increased to regular
Renal: MIVF at 85cc/hr. Foley removed. UOP adequate.
Hematology: SQH, no issues.
Endocrine: RISS. Euglycemic.
Infectious disease: No issues at this time. Steroid-induced
leukocytosis noted.
Disposition: On discharge he was on his home dose oxygen 4 L
sats: 96%, Prednisone taper and previous home medications. He
will follow-up with his pulmonologist and Dr. [**Last Name (STitle) **] as an
outpatient.
Medications on Admission:
Prednisone 20 mg PO daily
Asmanex - two puffs [**Hospital1 **]
Oxycodone 30 mg PO Q6 PRN
Oxycodone Extend Release - 40 q12h
Nexium 20 mg PO daily
Singulair - 10 mg QHS
Nystatin swish and swallow 5 mL QID
Zyrtec-D - 1 tab daily
Celexa 40 QD
Omeprazole 40 mg QD
Formoterol 12 mcg q12h
Ativan 1 mg PO TID
Trazodone - 50mg QHS
Zyflo - 1200 mg [**Hospital1 **]
Ambien - 5mg QHS
Discharge Medications:
1. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: Two (2)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
2. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
4. Montelukast 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
5. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for Insomnia.
6. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Disp:*30 Tablet(s)* Refills:*1*
7. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours) as needed for pain.
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
10. Oxycodone 10 mg Tablet Sig: One (1) Tablet PO every four (4)
hours as needed for pain.
Disp:*70 Tablet(s)* Refills:*0*
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
12. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
13. Zyflo 600 mg Tablet Sig: Two (2) Tablet PO twice a day.
14. DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for
Nebulization Sig: Three (3) mL Inhalation every four (4) hours
as needed for shortness of breath or wheezing.
15. Foradil Aerolizer 12 mcg Capsule, w/Inhalation Device Sig:
One (1) Inhalation twice a day.
16. Mucinex 1,200 mg Tab, Multiphasic Release 12 hr Sig: One (1)
Tab, Multiphasic Release 12 hr PO twice a day.
17. Asmanex Twisthaler 220 mcg (120 doses) Aerosol Powdr Breath
Activated Sig: Two (2) Inhalation twice a day.
18. Flonase 50 mcg/Actuation Spray, Suspension Sig: One (1)
spray Nasal twice a day.
19. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation every four (4) hours as needed for
shortness of breath or wheezing.
20. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours).
Disp:*10 Tablet(s)* Refills:*2*
21. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO once a day:
taper as instructed.
Discharge Disposition:
Home
Discharge Diagnosis:
Interstitial lung disease.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 2348**] if you experience:
-If you develop drainage from your Left chest incision site.
-Chest tube site cover with a bandaid until healed
-You may shower. Wash incision with soap and water, rinse and
pat dry
-Steroid taper: 60 mg for 3 days, 50 mg s day, 40 x 3 days, 30 x
3 days then 20 mg daily. Please follow-up with your
pulmonologist for steriod taper.
-Antibiotics for 10 days.
-Continue nebs as previous
-Continue mucinex 1200 mg twice daily
Follow-up with the [**Hospital3 25750**] pulmonologist for
-Increased shortness of breath, cough or sputum production
-Increased pain medication
-Fevers > 101 or chills
Followup Instructions:
Provider: [**Name10 (NameIs) 1532**] [**Name11 (NameIs) 1533**], MD Phone:[**0-0-**]
Date/Time:[**2104-10-7**] 3:00 Tuesday on the [**Hospital Ward Name 516**] [**Hospital Ward Name 23**]
Clinical Center [**Location (un) 24**]
Chest X-Ray [**Location (un) 861**] Radiology 30 minutes before your
appointment
Completed by:[**2104-9-19**]
|
[
"519.19",
"V45.73",
"V15.82",
"V58.65",
"515",
"311",
"518.5",
"401.9",
"493.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"33.20"
] |
icd9pcs
|
[
[
[]
]
] |
8520, 8526
|
3427, 6040
|
328, 394
|
8597, 8597
|
1781, 3404
|
9452, 9791
|
1382, 1439
|
6463, 8497
|
8547, 8576
|
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|
8748, 9429
|
1454, 1762
|
261, 290
|
422, 997
|
8612, 8724
|
1019, 1240
|
1256, 1366
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,466
| 144,765
|
52829
|
Discharge summary
|
report
|
Admission Date: [**2132-12-24**] Discharge Date: [**2132-12-31**]
Service: MEDICINE
Allergies:
Codeine / Naprosyn / Atropine
Attending:[**First Name3 (LF) 8684**]
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
Angiography x 2
colonoscopy
History of Present Illness:
[**Age over 90 **] yo F w/hx of rectal prolapse (no comp in past) and BRBPR x 2
starting at 7 pm last night. No abd pain. No N/V, fevers.
Previous care has been at the [**Hospital1 112**].
Pt stated that she had a painless BM at 7pm and noted blood in
the toilet bowl. She then had another BM at around 2am and this
time had a looser stool with blood mixed in with stool.
On ROS, +dizziness. No nausea, no vomiting. +tenesmus.
No CP, no SOB. Pt has been becoming more DOE over the past 4
months. NO CP, no palpiations. No new foods. No sick contacts.
[**Name (NI) **] abd pain. No dysuria. Pt stated she had a c-scope about 10yrs
ago which was normal.
ED COURSE: In the ED, vss. T98.6; HR 16; BP 136/82, 100% ra. Pt
afebrile. Normal blood pressure. Examined, no prolapse on exam.
Protonix 40mg IV given.
Past Medical History:
Lumbar radiculopathy
balance difficulties
prolapsed rectum
HTN
cataract L eye
bilateral knee arthritis
Social History:
Lives in [**Hospital3 **]. No smoking, occasional glass of wine.
Family History:
NC
Physical Exam:
T: 96. BP 144/81; HR 941; R 18, 100% on 2L
Gen: NAD
HEENT:dry mucous membranes. NCAT, PERRL, EOMI
Neck: no masses. scar from prior thyroidectomy.
CV: RRR. 2/6 systolic murmur RUSB.
Resp: CTAB.
Abd: NABS, soft, NTND, no guarding/rigidity/rebound
Back: no CVA tenderness
Rectal: Guaiac: gross blood from rectum, not prolapsed currently
Ext: no CCE, 2+/4 symmetric pedal pulses
Pertinent Results:
[**2132-12-24**] CXR: The lungs are clear. The cardiomediastinal
structures are unremarkable. The bony structures show
mild-to-moderate right thoracic scoliosis and mild-to-moderate
left lumber scoliosis.
.
[**2132-12-25**]. EGD.
Erosions in the antrum
Otherwise normal EGD to second part of the duodenum
.
[**2132-12-25**]. Colonoscopy.
Grade 1 internal hemorrhoids
Diverticulosis of the whole colon
Polyp in the colon
There was mild rectal prolapse noted.There was no mucosal
ulcerations noted.
Otherwise normal colonoscopy to cecum
.
[**2132-12-26**]. Mesenteric angiography.
1. SMA arteriogram demonstrates no areas of active extravasation
of contrast.
2. Celiac arteriogram demonstrates an enlarged splenic artery
with multiple aneurysms up to 2 cm in diameter, with no areas of
active extravasation of contrast seen.
3. Aortogram at the level of L3 vertebra demonstrated no areas
of active extravasation of contrast as well as no opacification
of the inferior mesenteric artery.
.
[**2132-12-26**].
Bleeding scan.
IMPRESSION: Bleeding within the splenic flexure. The patient was
transported to angiography for further evaluation.
.
[**2132-12-28**]. Mesenteric angiography.
IMPRESSION: SMA arteriogram demonstrates no active areas of
extravasation. The inferior mesenteric artery is not identified
on lateral aortogram and is likely occluded.
.
[**2132-12-31**] WBC-4.9 RBC-2.95* Hgb-9.7* Hct-27.8* MCV-94 MCH-32.8*
MCHC-34.7 RDW-15.0 Plt Ct-215
[**2132-12-31**] Glucose-97 UreaN-9 Creat-0.5 Na-139 K-3.6 Cl-106
HCO3-30 AnGap-7*
Brief Hospital Course:
In summary, Ms. [**Known lastname **] is a [**Age over 90 **] yo female with no significant
PMH admitted for diverticular bleed s/p 2 failed attempts at
embolization.
.
Diverticular bleed. Patient was admitted for rectal bleeding.
Colonoscopy showed diverticuli but no active bleeding. Patient
was initially monitored in the ICU, but remained hemodynamially
stable so she returned to the floor. She had further rectal
bleeding on [**12-26**], so a tagged RBC scan was performed which
showed bleeding at the splenic flexure. She returned to the ICU
for further monitoring. Two attempts at embolization were
unsuccessful on [**12-26**] and [**12-28**]. She refused surgical
intervention. Patient required approximately 4 units PRBCs
during hospital stay. Patient had no further episodes of GI
bleeding following [**12-28**]. Her home cardia was held due to
hypotension. Aspirin and ibuprofen were also held. She was
started on a PPI for gastric erosions seen on EGD. She was
continued on a low residue diet. On day of discharge, Hct was
27.8 (down from 31.9) but patient denied any episode of GI
bleeding. She will need her Hct checked on [**1-1**] at the [**Last Name (un) 1188**]
house.
.
HTN. Patient has a history of hypertension and takes Cartia at
home. Cartia was held during hospital stay due to GI bleed.
Her blood pressure remained stable. She will follow up with her
PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], to determine if and when she should resume
antihypertensives.
.
DNR/DNI
.
HCP is [**Name (NI) **] [**Name (NI) **]: [**Telephone/Fax (1) 108955**].
Medications on Admission:
Cartia 120 qd
ASA 325
Senna
Omega 3 supp
MVI
PRN ibuprofen
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
3. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1186**] - [**Location (un) 538**]
Discharge Diagnosis:
Diverticular Bleed
.
Hypertension
Discharge Condition:
Good.
Discharge Instructions:
You were admitted for gastrointestinal bleeding. You had a
colonoscopy which showed diverticulosis. Two attempts to stop
the bleeding by angiography were unsuccessful.
.
Please resume taking all medications as you were previously
taking with the following exceptions:
* Please stop taking cardia until you follow up with Dr.
[**Last Name (STitle) **]
* Please stop taking aspirin
* Please take pantoprozale daily
.
.
Please call your physician or come to the emergency department
for blood in stool, abdominal pain, shortness of breath, chest
pain, or any other concerning symptoms.
Followup Instructions:
Please call Dr. [**Last Name (STitle) **] to schedule a follow up appointment in
one week. Ph [**Telephone/Fax (1) 608**].
|
[
"715.36",
"401.9",
"535.40",
"442.83",
"455.0",
"285.1",
"211.3",
"562.12"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.23",
"99.04",
"38.93",
"45.13",
"88.47"
] |
icd9pcs
|
[
[
[]
]
] |
5321, 5394
|
3320, 4927
|
245, 275
|
5472, 5480
|
1752, 3297
|
6113, 6240
|
1336, 1340
|
5037, 5298
|
5415, 5451
|
4953, 5014
|
5504, 6090
|
1355, 1733
|
200, 207
|
303, 1111
|
1133, 1238
|
1254, 1320
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,239
| 138,364
|
12779
|
Discharge summary
|
report
|
Admission Date: [**2133-6-22**] Discharge Date: [**2133-6-23**]
Date of Birth: [**2052-12-12**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5893**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
ERCP with sphincterotomy and common bile duct stent placement
History of Present Illness:
This is a 80 year old male with a history of CAD s/p MI s/p PCI
to LCA in [**2130**], s/p CCY, history of retained stones s/p ERCP c/b
post-op ERCP pancreatitis in [**2128**] transferred from [**Location 39400**]
with cholangitis here for ERCP. He had been in his usual state
of health until about 2:30 pm when he suddenly began to have
diffuse abdominal pain. This was accompanied by chills and cold
sweats. His temperature at home was 102.8. His wife brought him
to [**Hospital6 2561**] where he was noted to have an AST/ALT
of 503/507, TB 1.9 and noted to be tachycardic to 130s with SBP
90 with lactate of 3. He had a RUQ US that showed a 4 mm CBD
without stones, CT abd with 12.9 mm CBD with stones as well as
periportal edema. He was given levofloxacin, flagyl, 2 L IVF and
was sent here for ERCP.
.
In the ED, initial vs were: T 98.9 105/66 HR 75 RR 24 96% 2L. He
was given unasyn and morphine 4 mg. He is being sent to [**Hospital Unit Name 153**] for
evaluation for ERCP this morning.
.
On the floor, he has a [**5-6**] abdominal pain. Denies nausea,
vomitting, diarrhea.
.
Review of sytems:
(+) Per HPI
(-) Denies sinus tenderness, rhinorrhea or congestion. Denied
cough, shortness of breath. Denied chest pain or tightness,
palpitations. Denied nausea, vomiting, diarrhea, constipation or
abdominal pain. No recent change in bowel or bladder habits. No
dysuria. Denied arthralgias or myalgias.
Past Medical History:
Cholcystectomy in [**2128**]
Retained stones s/p ERCP c/b post-op ERCP pancreatitis in [**2128**]
CAD s/p MI s/p PCI to LCA in [**2130**]
Recent temporal artery bx for HA 1 week ago neg for temporal
arteritis
History of subdural hematoma with craniotomy in [**2093**]
Depression/anxiety
Diverticulosis and diverticulitis
Social History:
Lives at home with wife, remote tobacco use 30 years ago, denies
ETOH.
Family History:
Mother had coronary artery disease at the age of 47, father had
malignancy
Physical Exam:
Vitals: T: 97.7 BP: 118/69 P: 78 R: 17 O2: 95% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2
Abdomen: +BS, mild TTP diffusely, [**Doctor Last Name **] negative, no rebound or
guarding
Ext: warm, trace edema b/l, 2+ pulses, no clubbing
Pertinent Results:
[**2133-6-22**] 12:55PM BLOOD WBC-8.4 RBC-3.83* Hgb-12.8* Hct-38.6*
MCV-101* MCH-33.5* MCHC-33.2 RDW-14.1 Plt Ct-125*
[**2133-6-22**] 08:04AM BLOOD WBC-9.9 RBC-3.87* Hgb-13.1* Hct-39.5*
MCV-102* MCH-33.8* MCHC-33.1 RDW-14.1 Plt Ct-147*
[**2133-6-22**] 02:27AM BLOOD WBC-10.6 RBC-3.90* Hgb-13.1* Hct-39.9*
MCV-103* MCH-33.5* MCHC-32.7 RDW-13.6 Plt Ct-142*
[**2133-6-22**] 08:04AM BLOOD Neuts-80.7* Lymphs-11.1* Monos-6.1
Eos-2.0 Baso-0.2
[**2133-6-22**] 02:27AM BLOOD Neuts-83.3* Lymphs-10.0* Monos-5.6
Eos-0.9 Baso-0.2
[**2133-6-22**] 08:04AM BLOOD PT-13.1 PTT-26.9 INR(PT)-1.1
[**2133-6-22**] 02:27AM BLOOD PT-12.8 PTT-24.8 INR(PT)-1.1
[**2133-6-22**] 12:55PM BLOOD Glucose-92 UreaN-20 Creat-1.4* Na-141
K-4.0 Cl-110* HCO3-21* AnGap-14
[**2133-6-22**] 08:04AM BLOOD Glucose-97 UreaN-21* Creat-1.2 Na-143
K-4.2 Cl-113* HCO3-22 AnGap-12
[**2133-6-22**] 02:27AM BLOOD Glucose-116* UreaN-25* Creat-1.4* Na-142
K-4.8 Cl-109* HCO3-28 AnGap-10
[**2133-6-22**] 12:55PM BLOOD ALT-332* AST-179* CK(CPK)-355*
AlkPhos-111 Amylase-409* TotBili-6.2*
[**2133-6-22**] 08:04AM BLOOD ALT-350* AST-200* LD(LDH)-252*
AlkPhos-117 TotBili-5.7*
[**2133-6-22**] 02:27AM BLOOD ALT-395* AST-251* AlkPhos-123*
TotBili-3.9*
[**2133-6-22**] 12:55PM BLOOD Lipase-1692*
[**2133-6-22**] 02:27AM BLOOD Lipase-23
[**2133-6-22**] 12:55PM BLOOD CK-MB-5 cTropnT-0.07*
[**2133-6-22**] 12:55PM BLOOD Calcium-6.9* Phos-2.9 Mg-2.0
[**2133-6-22**] 08:04AM BLOOD Calcium-7.5* Phos-2.7 Mg-2.0
[**2133-6-22**] 02:26AM BLOOD Lactate-1.3
[**2133-6-22**] 02:29AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.024
[**2133-6-22**] 02:29AM URINE Blood-MOD Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-1 pH-6.5 Leuks-NEG
.
.
Micro (pending, no growth to date):
[**2133-6-22**] MRSA SCREEN MRSA SCREEN-PENDING INPATIENT
[**2133-6-22**] BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY [**Hospital1 **]
[**2133-6-22**] BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY [**Hospital1 **]
.
.
ERCP
Date: Monday, [**2133-6-22**] Endoscopist(s): [**Name6 (MD) **] [**Name8 (MD) **], MD
[**Last Name (Titles) 2530**] [**Last Name (NamePattern4) 39401**], MD (fellow)
Patient: [**Known firstname **] [**Known lastname 9201**]
Ref.Phys.: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 4223**], MD; [**First Name4 (NamePattern1) 1169**] [**Last Name (NamePattern1) 39402**], MD; [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 11367**], MD
Assisting Nurse(s)/
Other Personnel: [**Name6 (MD) 39403**] [**Name8 (MD) **], RN
Birth Date: [**2052-12-12**] (80 years) Instrument: TJF-160VF
[**Numeric Identifier 39404**] Indications: Cholangitis. 80 yo male with history of
choledocholithiasis diagnosed in [**3-5**]- with failed ERCP twice.
He re-presents with pain, jaundice, fever. Imaging reveals
choledocholithiasis.
A level 4 consult was performed
Medications: General Anaesthesia
Already on antibiotics
Procedure: The procedure, indications, preparation and potential
complications were explained to the patient, who indicated his
understanding and signed the corresponding consent forms. A
physical exam was performed. The patient was administered
General anesthesia. The patient was placed in the supine
position and an endoscope was introduced through the mouth and
advanced under direct visualization until the third part of the
duodenum was reached. Careful visualization was performed. The
procedure was not difficult. The quality of the preparation was
good. The patient tolerated the procedure well. There were no
complications.
Findings: Esophagus: Limited exam of the esophagus was normal
Stomach: Limited exam of the stomach was normal
Duodenum: Limited exam of the duodenum was normal
Major Papilla: There was pus discharge in the major papilla.
Cannulation: Cannulation of the biliary duct was successful and
deep with a Clever Cut sphincterotome using a free-hand
technique wire guided. Contrast medium was injected resulting in
complete opacification.
Biliary Tree: Multiple 6-8mm stones that were causing partial
obstruction were seen in the CBD. With the Clever Cut
sphincterotome approximately 5ml of pus was aspirated. A 10FR
by 9cm Cotton-[**Doctor Last Name **] biliary stent was placed successfully using
a Oasis system stent introducer kit.
Impression: Pus was noted at the major papilla.
Cannulation of the biliary duct was successful and deep with a
Clever Cut sphincterotome using a free-hand technique wire
guided. Contrast medium was injected resulting in complete
opacification.
Multiple 6-8mm stones that were causing partial obstruction were
seen in the CBD.
With the Clever Cut sphincterotome approximately 5ml of pus was
aspirated.
A 10FR by 9cm Cotton-[**Doctor Last Name **] biliary stent was placed successfully
using a Oasis system stent introducer kit.
Recommendations: Return patient to [**Hospital Unit Name 153**].
Repeat ERCP in 4 weeks. Will discuss with PCP, [**Name10 (NameIs) **] will need to
hold Plavix for 7 days prior and 3-5 days after next ERCP if
biliary sphincterotomy and stone extraction is to be performed.
Pt will discuss with PCP and his cardiologist (Dr. [**Last Name (STitle) 11367**].
Continue antibiotics.
If any problems- please call Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 2799**].
Additional notes: Mr. [**Known lastname 9201**] became hypoxic during the
procedure. The procedure was then halted. The patient was was
intubated and then procedure completed uneventfully.
Thank you Dr. [**Last Name (STitle) 11367**] for allowing me to participate in the care
of Mr. [**Known lastname 9201**].
_________________________________
[**Name6 (MD) **] [**Name8 (MD) **], MD
_________________________________
[**Name6 (MD) 2530**] [**Last Name (NamePattern4) 39401**], MD (fellow)
Case documentation started on [**2133-6-22**] 10:59:41 AM
Patient: [**Known firstname **] [**Known lastname 9201**] ([**Numeric Identifier 39404**])
Brief Hospital Course:
This is a 80 year old male with a history of CAD s/p MI s/p PCI
to LCA in [**2130**], s/p cholecystectomy, history of retained stones
s/p ERCP complicated by post-op ERCP pancreatitis associated
with cholangitis.
.
# Cholangitis: Likely secondary to choledocholithiasis given
fever, abdominal pain, marked transaminitis, and CT at outside
hospital showing 12.9 mm CBD with stones and
periportal edema. At, [**Hospital6 2561**] he was noted to have
an AST/ALT of 503/507, TB 1.9 and noted to be tachycardic to
130s with SBP 90 with lactate of 3, all concerning for sepsis.
Blood cultures negative to date. Upon arrival to [**Hospital1 18**], the
patient was given unasyn and morphine, and scheduled for ERCP,
which showed pus in the common bile duct, with multiple
partially obstructing stone. A stent was placed, sphincterotomy
performed, CBD drained of puss. Please see the attached report
for recommendations and outpatient followup (repeat ERCP in 4
wks with specific instructions to hold Plavix at that time).
Notably, during the procedure, the patient became hypoxic and
was intubated and then extubated post-procedurally without
complication. An EKG did not show any acute myocardial process.
Cardiac enzymes at 3pm were CK 355 MB 5 Trop-T 0.07 but there
was no clinical suspicion of ACS. We recommend following the 2nd
and 3rd set of cardiac enzymes q8 hrs. Finally, the patient was
continued on unasyn, gentle IV fluids at 75cc/hr, and monitored
in the ICU (was hemodynamically stable) before being sent to [**Hospital3 10959**] for completion of his care. We recommend close monitoring
of his vital signs and continuation of usasyn.
.
# ARF: With baseline Cr 1.2, now with Cr 1.4, GFR 50, mild ARF
in acute setting, likely secondary to hypovolemia. The pt was
given IV fluids with improvement. We held his home ACE
inhibitor.
.
# CAD: s/p PCI to left circ in [**2130**]. No other recent PCI. We
held his ASA and plavix given scheduled ERCP. We held his home
beta blocker and ACE inhibitor as well given his
hypotension/sepsis.
.
# FEN: IVF, replete electrolytes, regular diet
.
# Prophylaxis: Subutaneous heparin
.
Medications on Admission:
Plavix 75
Toprol XL 50
ASA 81
Lisinopril 2.5
? Remeron
Discharge Medications:
1. Ampicillin-Sulbactam 1.5 g IV Q6H
2. Morphine Sulfate 1 mg IV Q4H:PRN pain
hold for sedation
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary:
Cholangitis
Apnea
.
Secondary:
Cholcystectomy in [**2128**]
Retained stones s/p ERCP c/b post-op ERCP pancreatitis in [**2128**]
CAD s/p MI s/p PCI to LCA in [**2130**]
Recent temporal artery bx for HA 1 week ago neg for temporal
arteritis
History of subdural hematoma with craniotomy in [**2093**]
Depression/anxiety
Diverticulosis and diverticulitis
Discharge Condition:
afebrile, stable vitals, NPO, ambulatory
Discharge Instructions:
It was a pleasure taking care of you while you were in the
hospital. You were admitted to [**Hospital1 18**] because of an infection in
your bile ducts. You underwent a procedure called ERCP and
stones and infection were found. The infection was drained and
a stent was placed. You tolerated the procedure, but during the
procedure you had an episode of slow heart rate and not
breathing. You were placed on a breathing machine for the rest
of the procedure and tolerated it well. The tube was able to be
removed after the procedure. You will be transferred back to [**Hospital3 10959**] for further care.
Please follow the medications prescribed below.
Please follow up with the appointments below.
Please call your PCP or go to the ED if you experience chest
pain, palpitations, shortness of breath, nausea, vomiting,
fevers, chills, or other concerning symptoms.
Followup Instructions:
Please schedule a repeat ERCP in 4 weeks with your GI doctor.
.
Please follow all recommendations made by your doctors [**First Name (Titles) **] [**Hospital6 39405**].
|
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"995.91",
"574.51",
"E878.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"97.05",
"96.04",
"51.10"
] |
icd9pcs
|
[
[
[]
]
] |
11167, 11182
|
8815, 10940
|
331, 394
|
11587, 11630
|
2825, 8792
|
12554, 12726
|
2278, 2354
|
11046, 11144
|
11203, 11566
|
10966, 11023
|
11654, 12531
|
2369, 2806
|
277, 293
|
1523, 1829
|
422, 1505
|
1851, 2174
|
2190, 2262
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,802
| 102,324
|
31031
|
Discharge summary
|
report
|
Admission Date: [**2150-2-16**] Discharge Date: [**2150-2-19**]
Date of Birth: [**2067-8-4**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
Hyponatremia, hypothermia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 82 year-old Spanish speaking female with a history of
CAD s/p recent BMS to RCA, type II DM, hyperlipidemia,
hypertension, paroxysmal atrial fibrillation admitted following
a fall. Pt was recently hospitalized [**Date range (1) 34801**] from the
cardiology service with NSTEMI and had a BMS to RCA and new
atrial fibrillation. She was started on antiplatelet therapy
and started on anticoagulation. Pt notes that she has been
having fatigue and lethargy dating back to this hospitalization.
This AM she woke up to use the bathroom, when she felt her
"balance was off" and fell. Fall witnessed by her husband. She
hit her head on falling. She denies prodromes of
lightheadedness, palpitations, or chest pain. No LOC. Per her
daughter, she fell 2 days prior, attributed to poor balance,
resulting in trauma to her right foot. She notes poor PO intake
for 1 week due to poor appetite. Denies nausea, vomitting, or
loose stools. Notes constipation and is currently on
"laxatives." +Increasing cold intolerance. Also with dysuria
and chills dating back to prior admission.
In the field found to have FSG 30, given 1 amp D50. FSG 51 on
arrival to ED. Given another 1 amp D50, serum glucose
subsequently 256. In the ED, hypothermic to T 32, started on
beg hugger. Also with hyponatremia to 120, given 2 L warmed NS.
Also given ceftriaxone 1 gm for concern for sepsis without
clear source given hypothermia and hypoglycemia. Imaging
notable for CT abd/pelv without acute process, CT head and neck
notable for retrolisthesis of C5-C6 of unclear acuity. Seen by
spine c/s in ED and c-spine cleared. Decadron 10 mg given for
?adrenal insufficiency.
ROS: The patient denies any fevers, weight change, nausea,
vomiting, abdominal pain, diarrhea, melena, hematochezia, chest
pain, shortness of breath, orthopnea, PND, lower extremity
edema, cough, urinary frequency, urgency, lightheadedness, focal
weakness, vision changes, headache, rash or skin changes.
Past Medical History:
1. Coronary Artery Disease s/p BMS to RCA on [**2150-2-13**]
2. Diabetes Mellitus, type 2 - on insulin
3. Hypertension
4. Hyperlipidemia
5. Cataracts s/p surgical repair x2
6. Proliferative Retinopathy
7. Diabetic Neuropathy
Social History:
Social history is significant for the absence of current or
former tobacco use. There is no history of alcohol or drug
abuse. She lives with her husband and is able to perform ADLs.
Family History:
There is no family history of premature coronary artery disease
or sudden cardiac death. Mother died of MI at age 62. Father
died of kidney disease.
Physical Exam:
On Presentation:
Vitals: T:94.1 BP:131/46 HR:53 RR: 12 O2Sat: 100% RA
GEN: Elderly female, no acute distress
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, +MM dry, +mild bruising of tip of tongue, OP Clear
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: Bradycardia, RR, distant heart sounds, normal S1 S2, radial
pulses +2
PULM: Bibasilar crackles
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No C/C/E
NEURO: Alert, oriented to person, place, and time. CN II ?????? XII
grossly intact. Moves all 4 extremities. Strength 5/5 in upper
and lower extremities. Patellar DTR +1. Plantar reflex
downgoing. +Decreased sensation to light touch of lower
extremities up to ankles b/l
SKIN: No jaundice, cyanosis, or gross dermatitis. +Diffuse
echymoses of abdomen, and pelvic region. +Laceration of 4th
metatarsal.
.
.
Discharge:
VS T98 158/52 54 18 99RA
GEN: Elderly female, NAD. Non-toxic.
HEENT: EOMI, mmm.
RESP: CTA B. No WRR.
CV: Brady, regular
ABD: Soft, NT.
Ext: Small skin tear on toe R foot, no longer bleeding.
superficial.
Pertinent Results:
[**2150-2-16**] 06:40AM GLUCOSE-265* UREA N-35* CREAT-1.4*
SODIUM-120* POTASSIUM-4.0 CHLORIDE-87* TOTAL CO2-26 ANION GAP-11
[**2150-2-16**] 06:40AM CK(CPK)-423*
[**2150-2-16**] 06:40AM cTropnT-0.10*
[**2150-2-16**] 06:40AM CK-MB-9
[**2150-2-16**] 06:40AM OSMOLAL-271*
[**2150-2-16**] 06:40AM WBC-9.4 RBC-3.16* HGB-10.2* HCT-27.3* MCV-86
MCH-32.4* MCHC-37.5* RDW-13.9
[**2150-2-16**] 06:40AM NEUTS-87* BANDS-0 LYMPHS-8* MONOS-3 EOS-2
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2150-2-16**] 06:40AM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-OCCASIONAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL OVALOCYT-OCCASIONAL
[**2150-2-16**] 06:40AM PLT SMR-NORMAL PLT COUNT-274
[**2150-2-16**] 06:40AM PT-16.9* PTT-45.6* INR(PT)-1.5*
[**2150-2-16**] 06:40AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-100 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2150-2-16**] 06:40AM URINE RBC-0-2 WBC-[**3-26**] BACTERIA-NONE YEAST-NONE
EPI-0-2
[**2150-2-16**] 12:31PM TRIGLYCER-151* HDL CHOL-38 CHOL/HDL-3.1
LDL(CALC)-50
[**2150-2-16**] 12:31PM LIPASE-24
[**2150-2-16**] 12:31PM ALT(SGPT)-38 AST(SGOT)-44* LD(LDH)-256* ALK
PHOS-78 TOT BILI-0.5
[**2150-2-16**] 12:31PM GLUCOSE-188* UREA N-29* CREAT-1.3*
SODIUM-126* POTASSIUM-4.6 CHLORIDE-93* TOTAL CO2-23 ANION GAP-15
ECG: Sinus bradycardia to 55, LBBB, LAD, no acute ST/T changes
Imaging:
CXR ([**2-16**]): Mild volume overload, cardiomegaly, increased
pulmonary vascular prominence
CT Head ([**2-16**]):
1. Very small left parietovertex scalp subcutaneous hematoma.
2. No evidence of acute intracranial hemorrhage or mass effect.
3. No evidence of acute major territorial infarct. However, MRI
with diffusion-weighted imaging is more sensitive for evaluation
of acute ischemia.
CT C-spine ([**2-16**]):
1. No evidence of acute fracture.
2. Moderately severe degenerative changes within the cervical
spine with
grade 1 retrolisthesis of C5 on C6. Given the degenerative
findings, acuity this is likely chronic; however, there is
ventral canal narrowing at this and the C4-C5 level, and MRI of
the cervical spine is recommended if myelopathic symptoms
suggest acute cord injury.
3. Multilevel spinal stenosis secondary to disc bulges and
herniations and
spondylosis.
CT abd/pelvis ([**2-16**]):
1. No evidence of intra-abdominal infection. No acute abdominal
pathology.
2. 13 x 8 mm mural nodule along the right posterior bladder wall
which is
concerning for malignancy. Recommend further evaluation with
urine cytology and/or cystoscopy.
.
X-ray R foot:
IMPRESSION:
No fracture.
.
[**2150-2-19**] 08:00AM BLOOD WBC-11.5* RBC-3.44* Hgb-10.4* Hct-30.0*
MCV-87 MCH-30.2 MCHC-34.6 RDW-14.3 Plt Ct-427
[**2150-2-16**] 12:31PM BLOOD PT-18.5* PTT-35.4* INR(PT)-1.7*
[**2150-2-17**] 04:32AM BLOOD PT-17.6* PTT-29.9 INR(PT)-1.6*
[**2150-2-18**] 07:20AM BLOOD PT-20.1* PTT-60.0* INR(PT)-1.9*
[**2150-2-19**] 08:00AM BLOOD PT-20.4* INR(PT)-1.9*
[**2150-2-19**] 08:00AM BLOOD Glucose-93 UreaN-26* Creat-1.2* Na-132*
K-4.8 Cl-96 HCO3-26 AnGap-15
[**2150-2-19**] 08:00AM BLOOD Calcium-9.0 Phos-3.8 Mg-2.4
[**2150-2-16**] 06:40AM BLOOD CK-MB-9
[**2150-2-16**] 06:40AM BLOOD cTropnT-0.10*
[**2150-2-16**] 05:00PM BLOOD CK-MB-7 cTropnT-0.07*
[**2150-2-18**] 07:20AM BLOOD calTIBC-358 VitB12-762 Folate-16.4
Ferritn-131 TRF-275
[**2150-2-16**] 12:31PM BLOOD Triglyc-151* HDL-38 CHOL/HD-3.1
LDLcalc-50
[**2150-2-16**] 06:40AM BLOOD Osmolal-271*
[**2150-2-16**] 06:40AM BLOOD TSH-0.55
[**2150-2-16**] 06:40AM BLOOD Free T4-1.3
[**2150-2-19**] 01:32PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.012
[**2150-2-19**] 01:32PM URINE Blood-LG Nitrite-NEG Protein-TR
Glucose-70 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
[**2150-2-16**] 06:40AM URINE RBC-0-2 WBC-[**3-26**] Bacteri-NONE Yeast-NONE
Epi-0-2
Brief Hospital Course:
MICU COURSE:
82 year-old Spanish speaking female with a history of CAD s/p
recent BMS to RCA, type II DM, hyperlipidemia, hypertension,
paroxysmal atrial fibrillation admitted with hypothermia and
hyponatremia.
# Hypothermia:
# Hypoglycemia:
# Hyponatremia:
# CAD: Recent BMS to RCA, pt was continued on home ASA, plavix,
statin.
# Hypertension: Antihypertensives initially held. She was
restarted on her BB and [**Last Name (un) **] at lower doses. They should be
titrated up as needed.
# Atrial fibrillation: Currently in NSR, on coumadin for
anticoagulation. Lovenox held (had been on lovenox bridge to
coumadin from prior hospitalization) given extensive bruising on
her abdomen. Coumadin titrated up to 5 mg at time of transfer.
# Mass Along Bladder: On her CT scan from ED, she was noted to
have a mass on the posterior aspect of her bladder concerning
for malignancy. She had a urine cytology sent which is
currently pending and should have urology follow up for possible
cystoscopy.
# Left toe laceration: Secondary to fall, per preliminary
report, cannot rule out extension into bone. As her hypothermia
has resolved and there is little suscipicion of infection and
her exam benign, further imaging deferred.
.
.
82 spanish speaking F with afib, CAD s/p recent BMS to RCA, dm2,
admitted with fall, hyponatremia, hypothermia, hypoglycemia.
Pt initially presnted with hypothermia, bradycardia and
hyponatremia, concerning for hypothyroidism. TSH however was
wnl. Sepsis unlikely given pt hemodynamic stable and no clear
source for infection (symptom of dysuria in setting of foley
catheter, clean u/a), adrenal insufficiency also unlikely. Given
negative work up and occurence with hypoglycemia, hypothermic
episode most likely [**2-23**] her hypoglycemic episode. She received
external warming and her temperature normalized on the first day
of her hospital stay. Blood and urine cultures remained
negative throughout her ICU stay.
.
1. Fall/ C5-6 retrolisthesis:
Fall sounds mechanical in nature. CT showed C5-6 retrolisthesis.
c-spine was cleared by Neurosurgery in ED. Neuro exam remains
non-focal
- PT consult
- no events on tele except bradycardia - approx 50
.
# Hypothermia:
This resolved with simple warming measures, was likely [**2-23**]
hypoglycemia. There was initial concern for possible sepsis,
though bld cx and urine cx are NGTD. TSH wnl.
.
# Hypoglycemia/Type II Diabetes, controlled with complications:
Hypoglycemia was in setting of poor PO and continued long acting
insulin, now resolved. Also, it was found that pt's husband
administer's patient's insulin, but does not have a clear method
for calculating dose of insulin, and it appears that pt does not
even check her glucose daily or even weekly. Nursing spent
significant time educating patient, husband and daughter about
the need for frequent daily glucose monitoring, and the use of a
sliding scale. Patient was discharged on NPH and sliding scale,
as used during the hospitalization.
Recommend that patient have geriatrics consult with Dr. [**Last Name (STitle) 713**]
after discharge.
.
# Hyponatremia:
Pt noted to have hypovolemic hyponatremia on admission,
corrected with hydration. She was encouraged to increase her PO
intake.
Sodium runs baseline in 130s likely [**2-23**] diuretics.
.
# Chronic diastolic heart failure, EF 50%:
currently euvolemic
- patient returned to her home dosing of cardiac medications
prior to discharge.
.
# Mass Along Bladder: On her CT scan from ED, she was noted to
have a mass on the posterior aspect of her bladder concerning
for malignancy. She had a urine cytology sent which is
currently pending and should have urology follow up for possible
cystoscopy.
**Please follow up**
.
# CAD:
Recent BMS to RCA. No active CP symptoms, trop 0.07, though
baseline mildly elevated, ECG with LBBB
- Cont home ASA, plavix, statin, BB
.
# Chronic renal failure, Stage III:
cr 1.3 at baseline
- Cr currently at baseline
.
# Atrial fibrillation:
now in SR
- c/w coumadin, INR 1.9 at discharge
- c/w metoprolol
.
# Anemia:
hct 26.3, baseline around 30, has remained stable since
admission.
- request outpatient follow-up
.
# Left toe laceration:
Secondary to fall.
- Xray toe without fracture
.
# FEN: Cardiac, diabetic diet
.
# F/u: recommend outpatient Geriatrics consult with Dr. [**Last Name (STitle) 713**]
([**Telephone/Fax (1) 6846**]
# Comm: Pt and daughters, son in law [**Telephone/Fax (1) 73293**]
Medications on Admission:
-Atorvastatin 80 mg
-Citalopram 20 mg
-Ranitidine HCl 150 mg
-Hydrochlorothiazide 50 mg
-Losartan 100 mg
-Furosemide 20 mg QMOWEFR
-Isosorbide Mononitrate 60 mg
-NPH 40/20-->as of late has been taking NPH 30/15 due to poor PO
intake
-Lovenox 60 (day #4, bridge to coumadin fro afib per prior
discharge summary, had previously planned for 5 day bridge)
-Clopidogrel 75 mg
-Coumadin 4 mg
-Aspirin 81 mg
-Toprol 75 mg
Discharge Medications:
1. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Hydrochlorothiazide 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO 3X/WEEK
(MO,WE,FR).
6. Losartan 100 mg Tablet Sig: One (1) Tablet PO once a day.
7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: 1.5
Tablet Sustained Release 24 hrs PO once a day. Tablet Sustained
Release 24 hr(s)
10. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
Disp:*5 Tablet(s)* Refills:*0*
11. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
12. Insulin NPH Human Recomb 300 unit/3 mL Insulin Pen Sig: Ten
(10) units Subcutaneous twice a day.
Disp:*1 pen* Refills:*2*
13. Humalog Pen 100 unit/mL Insulin Pen Sig: per sliding scale
units Subcutaneous Breakfast, Lunch, Dinner.
Disp:*1 pen* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Uphams Corner Health Care
Discharge Diagnosis:
# Fall, with findings of C5-6 retrolistesis
# Type 2 diabetes, controlled with complications
# Hypoglycemia
# Hypothermia
# Chronic diastolic heart failure; EF 50%
# Coronary artery disease; s/p recent BMS to RCA
# Chronic renal failure, stage III
# Atrial fibrillation
# Anemia
Discharge Condition:
stable
Discharge Instructions:
Please check your blood sugars as instructed, and follow the
instructions provided for your sliding scale insulin. Please
take your medications as prescribed. Please seek medical
attention if you develop fevers, chills, difficulty controlling
your blood sugars, or any other concerns.
Followup Instructions:
recommend outpatient Geriatrics consult with Dr. [**Last Name (STitle) 713**] ([**Telephone/Fax (1) 15260**]
.
[**Name6 (MD) **] [**Last Name (NamePattern4) 6559**], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2150-3-13**]
1:00
|
[
"427.31",
"893.0",
"362.01",
"272.4",
"428.0",
"V58.67",
"250.80",
"414.01",
"403.90",
"780.65",
"357.2",
"428.32",
"285.21",
"410.92",
"E932.3",
"276.1",
"585.9",
"250.50",
"E888.9",
"722.4",
"250.60",
"V45.82"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
14034, 14090
|
7917, 12367
|
340, 347
|
14413, 14422
|
4106, 7894
|
14758, 14994
|
2817, 2969
|
12832, 14011
|
14111, 14392
|
12393, 12809
|
14446, 14734
|
2984, 4087
|
275, 302
|
375, 2353
|
2375, 2601
|
2617, 2801
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,203
| 188,439
|
22741
|
Discharge summary
|
report
|
Admission Date: [**2122-2-11**] Discharge Date: [**2122-2-19**]
Service: CARDIOTHORACIC
Allergies:
Celebrex / Vioxx
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Angina and DOE
Major Surgical or Invasive Procedure:
Coronary Artery Bypass Graft x 3
History of Present Illness:
This is an 87 y/o male with h/p CAD (+stress in 02') now c/o
angina and DOE. ETT in [**7-27**] shoed fixed anteroseptal
defect/small reversible post wall defect, EF65%. Pt. was then
referred for cardiac cath which showed 3 vessel disease.
Past Medical History:
CAD
OA
Spinal Stenosis
Sciatica
PVD
Mild AS
Past Surgical History:
Back Surgery [**19**]'
Appendectomy
Removal of benign breast lump
Hemmorhoidectomy
Social History:
Tob: None
ETOH: [**1-25**] glasses wine/day
Lives with wife in [**Name (NI) **]
Retired, Drives, Uses cane for balance
Family History:
- CAD Hx
Physical Exam:
Ht: 5'8" Wt: 175lbs VS: T97.8 BP112/50 P44 RR24 SaO295%
General: Sitting in bed in NAD
Neuro: A&O x 3, [**Last Name (LF) 58867**], [**First Name3 (LF) **]
Resp: Bilat Rales at bases
CV: [**Last Name (LF) 8450**], [**First Name3 (LF) **], +S1S2, 3/6 SEM
GI: Firm, Round, NT/ND +BS
Ext.: Warm, Well-perfused, -C/C/E, -varicosities
Pulses: Radial 2+ Bilat, DP 2+ Bilat, PT 1+ Bilat
Pertinent Results:
Cath [**2122-2-11**]: LMCA 70%, LAD 70%, LCx 70%, RCA 99%
Pre-op CXR [**2122-2-12**]: No acute cardiopulmonary changes.
[**2122-2-11**] 07:15PM BLOOD WBC-6.3 RBC-4.07* Hgb-13.2* Hct-39.1*
MCV-96 MCH-32.5* MCHC-33.9 RDW-13.4 Plt Ct-247
[**2122-2-19**] 05:50AM BLOOD WBC-8.2 RBC-3.20* Hgb-10.7* Hct-29.8*
MCV-93 MCH-33.5* MCHC-36.0* RDW-13.6 Plt Ct-262
[**2122-2-11**] 07:15PM BLOOD PT-13.2 PTT-26.4 INR(PT)-1.1
[**2122-2-11**] 07:15PM BLOOD Plt Ct-247
[**2122-2-19**] 05:50AM BLOOD Plt Ct-262
[**2122-2-11**] 07:15PM BLOOD Glucose-107* UreaN-28* Creat-1.2 Na-137
K-3.6 Cl-103 HCO3-24 AnGap-14
[**2122-2-19**] 05:50AM BLOOD Glucose-103 UreaN-29* Creat-0.9 Na-140
K-3.3 Cl-102 HCO3-31* AnGap-10
[**2122-2-11**] 07:15PM BLOOD ALT-15 AST-29 AlkPhos-89 Amylase-36
TotBili-1.1
[**2122-2-11**] 07:15PM BLOOD Albumin-4.1
[**2122-2-12**] 06:40AM BLOOD Calcium-8.9 Phos-4.1 Mg-2.0
[**2122-2-12**] 07:17PM BLOOD %HbA1c-6.0*
[**2122-2-13**] 12:12AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
[**2122-2-13**] 12:12AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.016
Brief Hospital Course:
As noted in HPI pt c/c was angina and DOE with previous +ETT.
Pt. Underwent Carciac Cath on [**2122-2-11**] which revealed 3VD.
Cardiac surgery service was consulted and pt consented for
bypass surgery. On [**2122-2-13**] pt was brought to the OR and after
general anesthesia pt underwent Coronary Artery Bypass Graft x 3
(LIMA to LAD, SVG to OM, SVG to RCA). Procedure performed by Dr.
[**Last Name (STitle) **]. Total bypass time was 57 minutes and total cross-clamp
time was 43 minutes. Following the procure pt. was transferred
to CSRU being titrated on propofol and neosynephrine gtt. His
MAP was 65, CVP 10, PAD 15, [**Doctor First Name 1052**] 21, and HR of 90 V-paced. Later
this day pt was extubated. On POD #1 pt was still receiving Neo
for pressure support. By POD #2 pt was weaned off of NEO and
lopressor and lasix was started. Pt. HR became bradycardic and
BB was changed to ACEI. His chest tubes were also removed. On
POD #3 pt. continued to improved, his foley was removed and he
was transferrd from CSRU to telemetry floor. On POD #4 pt. had
period of A. Fib. which was converted with lopressor and
Magnesium. EP recommened no further tx, except lopressor if
converts back into A. Fib. On POD #5 pt's epicardial pacing
wires were removed and his ACEI was changed to CCB (norvasc). On
POD#6 pt. appeared to be doing very well. He was d/c'd home
today in good condiditon with VNA services.
D/C PE:
Neuro: Alert, Oriented, Non-focal
Puml: Decreased at bases with bilat rales
Cardiac: [**Doctor First Name 8450**], +S1S2 and 2/6 SEM
Chest: Incision C/D/I without erythema or drainage
Abd: Soft, NT/ND, +BS
Ext: Warm -C/C/E, LLE incision C/D/I
Medications on Admission:
1. Isosorbide 120 mg po qd
2. Liptor 20 mg po qd
3. Bextra 20 mg po bid
4. ASA 325 mg po qd
5. Norvasc 5 mg po qd
6. NTG Patch 0.4 on AM/off HS
7. Quinine PRN
Discharge Medications:
1. Amlodipine Besylate 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
2. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
7. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours) for 7 days.
Disp:*14 Packet(s)* Refills:*0*
8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] Nursing Services
Discharge Diagnosis:
Coronary Artery Disease
s/p Coronary Artery Bypass Graft x 3
Arthritis
Spinal Stenosis
Sciatica
Mild Aortic Stenosis
PVD
Discharge Condition:
Good
Discharge Instructions:
Do not drive for 1 month
Do not lift more than 10 lbs for 8 weeks
Do not apply ointments, creams, lotions to incisions
Do not take bath for 1 month
Can take shower and wash incisions with gentle soap and warm
water, gently pat dry.
Followup Instructions:
Dr. [**Last Name (STitle) 11493**] in [**1-25**] weeks
Dr. [**Last Name (STitle) **] in 4 weeks
Completed by:[**2122-2-19**]
|
[
"411.1",
"401.9",
"440.20",
"414.01",
"724.3",
"427.31",
"276.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"88.53",
"37.22",
"36.15",
"36.12",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
5316, 5384
|
2449, 4107
|
245, 280
|
5549, 5555
|
1298, 2426
|
5835, 5962
|
874, 884
|
4317, 5293
|
5405, 5528
|
4133, 4294
|
5579, 5812
|
638, 722
|
899, 1279
|
191, 207
|
308, 548
|
570, 615
|
738, 858
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,252
| 101,291
|
25283
|
Discharge summary
|
report
|
Admission Date: [**2137-9-25**] Discharge Date: [**2137-10-9**]
Date of Birth: [**2073-6-5**] Sex: F
Service: MEDICINE
Allergies:
Ace Inhibitors
Attending:[**First Name3 (LF) 3326**]
Chief Complaint:
s/p cath for NSTEMI, Vfib arrest, GIB
Major Surgical or Invasive Procedure:
endotracheal intubation
central line placement
CVVH
cardiac catheterization
History of Present Illness:
HPI: 64yo woman with DM, HTN, ESRD on [**Hospital 58910**] transferred to the CCU
service from the MICU s/p cardiac catheterization. The patient
was in her home the day prior to admission cooking when she felt
like she was going to pass out and then lost consciousness. EMS
came and found her to have a v-fib arrest. They defibrillated 7
times in the field and brought her to [**Hospital 63273**] Hospital
[**Telephone/Fax (2) 63274**]). Here she was shocked three more times.
She was found to be hyperkalemic with an EKG showing widened QRS
and peaked T waves. At the OSH, she was treated with insulin,
glucose, and bicarb for hyperkalemia (6.5) and was started on an
amiodarone drip.
.
She was transferred to [**Hospital1 18**] hemodynamically stable and
intubated. Here, she was found to have a K of 7, and was treated
with bicarb, Ca, insulin and glucose. She was dialyzed yesterday
night with improvement in her K to 4.4 and resolution of her EKG
changes. She was started on levophed for hypotension and was
noted to have an elevated WBC with a left shift. She was also
noted to have an elevation in cardiac enzymes (CK 1440->1348, MB
27-23, MBI 1.9-1.7, Trop 0.39) and new [**Last Name (LF) **], [**First Name3 (LF) **] cardiology was
consulted.
.
Cardiology recommended that she go for an urgent cardiac
catheterization. At cath, she was noted to have 3+ MR< LVEF of
40%, and severe inferior hypokinesis. She had a 90% mid-LAD
lesion, a 70% LCx lesion at the ramus, and a 100% proximal RCA
lesion. She had two stents placed to the mid-LAD, but during the
procedure she vomited coffee-ground emesis and the
catheterization was terminated. She had an OGT placed but she
chewed it and it was removed. She was admitted to the CCU
service.
.
Notably, she has a history of GIB in the past per her husband.
[**Name (NI) **] does not know any details, but said that this occurred while
she was on heparin and prevented her from getting a renal tx at
the time. She apparently did not need hospitalization for this
and the etiology was never discovered, per the husband.
Past Medical History:
h/o GIB in the past, as above
DM not on insulin since [**5-19**] infection
ESRD secondary to PCKD, with HD qMWF
s/p renal transplant several years ago
HTN, not medically treated since [**5-19**] infection
h/o line infection [**5-19**]
Social History:
Married with children
Physical Exam:
On arrival in MICU:
Afebrile SBP 80s-100s on pressors RR10, 100% O2 on CMV at 40%
FiO2
Gen: Intubated, sedated, nonresponsive
HEENT: mmm, OP benign, PERRL
CV: RRR systolic murmur
Resp: coarse breath sounds bilaterally anteriorly
Abd: obese, NABS, soft, nondistended
Ext: edematous, warm. Left subclavian dialysis catheter, R
forearm fistula (maturing), left radial arterial line, left
femoral line
Skin: no rash
Nro: Intubated and sedated. Not following commands. See Neuro
note for complete exam when patient awake (prior to intubation)
Pertinent Results:
**SELECTED STUDIES**
SPINE MRI:
IMPRESSION: Endplate irregularity and enhancement at T7-8 level
is suggestive of discitis. However, in the absence of soft
tissue changes or abscess, the findings are not specific. Dual
energy gallium/bone scan would be helpful for further
evaluation. Other changes as above.
MRI HEAD ([**10-6**]):
IMPRESSION: 1. Limited study consisting only of DWI and FLAIR
sequences. The signal abnormality involving both medial temporal
lobes, insula bilaterally, and cingulate gyri appears to have
progressed, and demonstrates abnormal signal on
diffusion-weighted imaging.
2. New high signal intensity in the CSF overlying the right
parietal lobe, incompletely assessed. A focal area of
non-herpetic meningitis cannot be excluded.
CXR: ([**10-7**]):
A single portable chest radiograph again demonstrates an
endotracheal tube with its tip at the clavicular heads. A
left-sided central venous catheter is present with its tip in
the IVC. No right-sided central venous catheter is evident. No
pneumothorax. A nasogastric tube is present with its tip in the
stomach. Right hilar contour is unchanged from previous study of
[**2137-10-4**]. Retrocardiac opacity and mild pulmonary edema remain
unchanged.
CAROTID US ([**10-7**]):
IMPRESSION: Minimal plaque with bilateral less than 40% carotid
stenosis.
UE US ([**10-7**]): 1) No evidence of deep venous thrombosis or
collection.
Abd/pelvic CT ([**10-7**]):
IMPRESSION:
1. No evidence for abscess.
2. Right kidney complex hyperdense lesion likely consistent with
renal cell carcinoma and less likely a complex hemorrhagic cyst.
3. Mild intrahepatic ductal dilatation.
4. Right lung nodule.
5. Splenic infarct.
ECHO ([**10-8**]):
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 aortic valve leaflets are moderately thickened. There is
mild aortic valve stenosis.
4. The mitral valve leaflets are moderately thickened. There is
severe mitral annular calcification. There is moderate
thickening of the mitral valve chordae. Mild (1+) mitral
regurgitation is seen.
5. No obvious evidence of endocarditis seen.
6. Compared with the findings of the prior study of [**2137-9-25**],
there has been no significant change.
EEG ([**10-8**]):
IMPRESSION: Abnormal EEG due to overall slowing suggestive of a
diffuse
moderate encephalopathy with superimposed bursts and runs of
sharp and
slow, spike and slow discharges suggesting marked increase to
irritability overall.
Brief Hospital Course:
* Hypotension - The hypotension could have been from infection,
cardiogenic shock, or medications; there were no signs of
hemorrhage/volume depletion or neurogenic compromise. The
patient remained persistantly hypotensive on levophed during her
2 week stay in the MICU, with the addition of vasopressin and
continued hypotension. She received antibiotics and antivrials
to treat possible infections; her MRI was suggestive of HSV
encephalitis although CSF cultures were negative, and only one
set of sputum cultures ([**9-28**]) were positive, with no positive
blood cultures. An abdominal CT showed no source of infection,
there was no pneumonia seen on chest x-rays and no sign of
thrombophlebitis on US. Her LFTs showed no suggestion of hepatic
or biliary infection. ECHOs showed good cardiac function, making
cardiogenic shock unlikely. After two weeks of no improvement in
her overall status, family discussions about goals of care and
code status were initiated. From the first conversation, her
family (husband and children) were adamant that she would not
have wanted continued mechanical support and probably would not
have wanted admission in the first place. She was made DNR/DNI
and, after continued discussions, CMO with withdrawal of pressor
support and antibiotics. After a time of extreme hypotension
(SBPs 20s) and bradycardia, and after further discussion with
her family, the ventilator was turned off and she passed away.
Her family declined an autopsy and the ME declined the case.
.
* Mental Status changes: After her first extubation in the CCU
the patient was noted to have an asymmetric neuro exam, with
concern for CVA but head CT negative. An MRI was suggestive of
temporal lobe enhancement suggesting HSV encephalitis and the
patient was maintained on acyclovir. An LP yielded no organisms
in culture. EEG showed severe encephalopathy without seizure.
After her reintubation in the CCU prior to transfer to the MICU,
the patient never regained a normal mental status.
.
* NSTEMI - On arrival in the MICU, the patient was s/p cath,
able to get stents in LAD before termination. Pt only on Reopro,
which was stopped, ASA and plavix. No heparin. ASA and plavix
were continued. Repeat ECHOs showed good EF (>55%) and no
abnormalities to explain the patient's persistant hypotension.
.
* GI Bleed - The patient had a h/o GIB, and was on multiple
meds for cath that were anticoagulants, so the GIB not
surprising. NG lavage cleared. She received blood transfusion at
the time and had no reoccurrance of bleeding, with a stable
hematocrit.
.
* Vfib arrest- The etiology is most likely ischemic given h/o
chest pain prior to event. This acidosis probably caused
hyperkalemia as well, as pt's K was very high. There were no
more episodes of vfib or arrythmia during admission and the
patient received stents with ECHOs showing good function.
Electrolytes were monitored daily.
.
*Renal failure/hyperkalemia - She was followed by the renal team
and maintained on CVVH as her blood pressure permitted.
.
*DM - She was monitored closely and treated with an insulin
drip.
.
*Prophylaxis: - no sc heparin as initial GI bleeding; pneumatic
boots, PPI, bowel regimen
*Communication - with husband [**Name (NI) **] [**Name (NI) 42632**] ([**Telephone/Fax (1) 63275**]),
daughter [**Name (NI) **] [**Name (NI) 22807**] ([**Telephone/Fax (1) 63276**](H), [**Telephone/Fax (1) 63277**](C))
Medications on Admission:
ASA 81mg
protonix
lidoderm patch
SSI + NPH
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Respiratory failure
Persistant hypotension
status-post Ventricular fibrillation arrest
Encephalopathy with concern for herpes encephalitis
Polycystic kidney disease
Diabetes
GI bleeding
Hypertenion
End-stage renal disease on hemodialysis
Discharge Condition:
Expired
|
[
"038.9",
"518.81",
"414.01",
"276.2",
"570",
"276.7",
"578.0",
"428.0",
"348.31",
"285.9",
"424.0",
"250.00",
"753.12",
"458.8",
"V66.7",
"585.6",
"V42.0",
"403.91",
"995.92",
"410.71",
"790.4",
"V58.67"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"96.71",
"00.41",
"03.31",
"96.04",
"38.93",
"88.53",
"99.04",
"36.07",
"37.23",
"96.07",
"38.95",
"96.72",
"96.33",
"00.66",
"96.6",
"00.46"
] |
icd9pcs
|
[
[
[]
]
] |
9511, 9520
|
5988, 9389
|
312, 389
|
9801, 9811
|
3357, 5965
|
9482, 9488
|
9541, 9780
|
9415, 9459
|
2799, 3338
|
235, 274
|
417, 2486
|
2508, 2745
|
2761, 2784
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,267
| 139,025
|
20624+20625+20626
|
Discharge summary
|
report+report+report
|
Admission Date: [**2157-6-20**] Discharge Date: [**2157-6-26**]
Service: GU
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6157**]
Chief Complaint:
recurrence of bladder cancer in distal Left ureter
Major Surgical or Invasive Procedure:
ureterectomy with psoas hitch
History of Present Illness:
The patient is an 84 year old
male with a history of bladder carcinoma, who had presented
with the finding of left distal ureteral tumor. At this
point he was scheduled to undergo left distal ureterectomy
Past Medical History:
s/p ureterectomy with psoas hitch
coronary artery disease
congestive heart failure EF 40% mod MR
[**First Name (Titles) **]
[**Last Name (Titles) **]
Physical Exam:
Gen: alert and oriented
CV: RRR, loud MR
lungs: cta bilateraly
abd: soft, mildly distended, normal bowel sounds, nontender
ext: no calf tenderness, some pedal edema
Pertinent Results:
[**2157-6-20**] 10:30PM TYPE-ART PH-7.40
[**2157-6-20**] 10:30PM freeCa-1.13
[**2157-6-20**] 10:20PM POTASSIUM-4.3
[**2157-6-20**] 10:20PM CK-MB-4
[**2157-6-20**] 10:20PM CK(CPK)-104
[**2157-6-20**] 10:20PM MAGNESIUM-1.8
[**2157-6-20**] 02:38PM GLUCOSE-146* UREA N-24* CREAT-1.3* SODIUM-136
POTASSIUM-4.2 CHLORIDE-102 TOTAL CO2-25 ANION GAP-13
[**2157-6-20**] 02:38PM CK(CPK)-55
[**2157-6-20**] 02:38PM CK-MB-NotDone cTropnT-0.13*
[**2157-6-20**] 02:38PM CALCIUM-8.1* MAGNESIUM-1.9
[**2157-6-20**] 02:38PM WBC-11.9* RBC-3.65* HGB-9.9* HCT-29.7*
MCV-81* MCH-27.2 MCHC-33.5 RDW-14.4
[**2157-6-20**] 02:38PM PLT COUNT-203
[**2157-6-20**] 12:34PM TYPE-ART O2-50 PO2-205* PCO2-43 PH-7.42 TOTAL
CO2-29 BASE XS-3 INTUBATED-INTUBATED VENT-CONTROLLED
[**2157-6-20**] 12:34PM LACTATE-1.4
[**2157-6-20**] 12:34PM HGB-10.0* calcHCT-30
[**2157-6-20**] 11:22AM TYPE-ART PO2-165* PCO2-41 PH-7.44 TOTAL
CO2-29 BASE XS-4
[**2157-6-20**] 11:22AM GLUCOSE-169* LACTATE-1.2 NA+-133* K+-3.6
CL--102
[**2157-6-20**] 11:22AM HGB-9.8* calcHCT-29
[**2157-6-20**] 11:22AM freeCa-1.10*
[**2157-6-20**] 10:27AM TYPE-MIX
[**2157-6-20**] 10:27AM O2 SAT-85
[**2157-6-20**] 10:20AM TYPE-ART PO2-240* PCO2-40 PH-7.44 TOTAL
CO2-28 BASE XS-3
[**2157-6-20**] 10:20AM GLUCOSE-144* LACTATE-1.3 NA+-135 K+-3.6
CL--101
[**2157-6-20**] 10:20AM HGB-10.1* calcHCT-30
[**2157-6-20**] 10:20AM freeCa-1.11*
[**2157-6-20**] 08:12AM TYPE-ART PO2-375* PCO2-40 PH-7.47* TOTAL
CO2-30 BASE XS-5
[**2157-6-20**] 08:12AM GLUCOSE-102 LACTATE-1.5 NA+-133* K+-4.0
CL--101
[**2157-6-20**] 08:12AM HGB-9.9* calcHCT-30
[**2157-6-20**] 08:12AM freeCa-1.12
Brief Hospital Course:
Patient underwent left distal ureterectomy on [**2157-6-20**] and spent
night in ICU. Post op pt did well. On [**2157-6-23**] he got a
Nephrostogram which showed a small contained leak so the
percutanous nephrostomy tube was left in with intension of
reimaging in a week.
Discharge Medications:
. Senna 1 tab PO BID PRN constipation
2. Furosemide 40mg PO BID hold bp<100 or p<60
3. Hydralazine 25mg PO TID hold bp<110 or p <60
4. Metoprolol 25mg PO TID hold bp<100 or p<60
5. Finasteride 5mg po qd
6. terazosin 1mg po hs
7. alendronate 5mg po q
1. Senna 1 tab PO BID PRN constipation
2. Furosemide 40mg PO BID hold bp<100 or p<60
3. Hydralazine 25mg PO TID hold bp<110 or p <60
4. Metoprolol 25mg PO TID hold bp<100 or p<60
5. Finasteride 5mg po qd
6. terazosin 1mg po hs
7. alendronate 5mg po qd
8. isosorbide dinitrate 10mg po qd
9. Percocet 1-2tabs q4-6prn pain
10. Colace 100mg po bid prn constipation
11. Tylenol 325-650mg po q4-6p
Discharge Disposition:
Extended Care
Facility:
[**Last Name (un) 1687**] - [**Location (un) 745**]
Discharge Diagnosis:
s/p ureterectomy with psoas hitch
coronary artery disease
congestive heart failure (EF 40%, mod MR)
[**Location (un) **]
[**Location (un) **]
Discharge Condition:
Good: afebrile, tolerating regular diet, pain well controlled on
oral medications. Requires assitance ambulating.
Discharge Instructions:
1. Please monitor for the following: fever,chills, nausea,
vomiting, inability to tolerate food/drink. If any of these
occur, please contact your physician [**Name Initial (PRE) 2227**].
2. You make shower, but do not bathe/swim for four weeks.
Followup Instructions:
Please do a repeat Nephrostogram in 4 days.
Please call Dr. [**First Name (STitle) **] [**Name (STitle) **] office for a follow up visit in
7-10days.
Completed by:[**2157-6-26**] Admission Date: [**2157-6-20**] Discharge Date: [**2157-6-26**]
Service: GU
HISTORY OF PRESENT ILLNESS: The patient is an 84 year old
male with a history of bladder carcinoma who had presented
with findings of left distal ureteral tumor. At this point,
he is scheduled to undergo a left distal ureterectomy which
he received on [**2157-6-20**].
PAST MEDICAL HISTORY: Coronary artery disease.
Congestive heart failure with ejection fraction of 40
percent.
Moderate mitral regurgitation.
[**Date Range **].
Chronic renal insufficiency.
ALLERGIES: No known drug allergies.
MEDICATIONS:
1. Senna for constipation.
2. Furosemide 40 mg p.o. twice a day.
3. Hydralazine 25 mg p.o. three times a day.
4. Metoprolol 25 mg p.o. three times a day.
5. Finasteride 5 mg p.o. once daily.
6. Terazosin 1 mg p.o. q.h.s.
7. Alendronate 5 mg p.o. once daily.
8. Isosorbide Dinitrate 10 mg p.o. three times a day.
9. Promethazine 25 mg p.o. q6hours for nausea.
10. Percocet.
11. Colace.
HOSPITAL COURSE: Postoperatively, the patient did well but
was monitored in the Intensive Care Unit overnight.
Postoperative hematocrit was 30.0 and creatinine was 1.3.
The patient did well postoperatively and received a
nephrostogram on [**2157-6-23**]. Antegrade nephrostogram was
performed via the left percutaneous nephrostomy tube. The
end of the nephrostomy tube is present in the renal pelvis.
The surgically placed double J stent is in place. There is
no evidence of hydronephrosis. There is a small contained
leak at the uretero-ureteroanastomosis. Contrast does pass
into the bladder via the double J stent. These findings were
discussed with Dr. [**Last Name (STitle) 4229**] at the time of the procedure. A
percutaneous nephrostomy tube was left to external gravity
drains. A repeat antegrade nephrostogram will be performed
in approximately one week to evaluate for a leak at that
time. Postoperatively, the patient progressed, did well and
is being discharged to an extended care facility.
DISCHARGE INSTRUCTIONS: Monitor for fever, chills, nausea,
vomiting, inability to tolerate food or drink or to urinate.
If any of these occur, is to contact physician [**Name Initial (PRE) 2227**].
The patient should have a repeat nephrostogram on
approximately [**2157-6-29**], or [**2157-6-30**], and he should follow-up
with Dr.[**Name (NI) 13919**] office in seven to ten days.
CONDITION ON DISCHARGE: Good. He is afebrile, tolerating a
regular diet, ambulating with difficulty and requiring
assistance, pain well controlled on oral medications.
[**Name6 (MD) **] [**Last Name (NamePattern4) 8918**], [**MD Number(1) 19072**]
Dictated By:[**Last Name (NamePattern1) 15649**]
MEDQUIST36
D: [**2157-6-26**] 11:44:23
T: [**2157-6-26**] 12:36:11
Job#: [**Job Number 55124**]
Admission Date: [**2157-6-20**] Discharge Date: [**2157-6-26**]
Service: GU
HISTORY: The patient is an 84-year-old male with a history
of bladder carcinoma, who presented with findings of left
distal ureteral tumor, at this point, he was scheduled to
undergo left distal ureterectomy. On [**2157-6-20**], the patient
received a distal ureterectomy. Postoperatively, the patient
was taken to the ICU to recover. The patient did well.
LABORATORY DATA: Postoperative labs include hematocrit of
30, a creatinine of 1.3.
The patient's postoperative course was uncomplicated. The
patient received a nephrostogram on [**2157-6-23**], and the
impression, antegrade nephrostogram was performed via the
left percutaneous nephrostomy and the nephrostomy tube was
present in the renal pelvis. The surgically placed double J-
stent was then placed. There was no evidence of
hydronephrosis. There was a small contained leak at the
ureteroanastomosis. Contrast, both sections of the bladder
revealed a double J-stent. These findings were discussed
with Dr. [**Last Name (STitle) 4229**].
PROCEDURE: The percutaneous nephrostomy tube was left to the
external gravity drainage. A repeat antegrade nephrostomy
will be performed in approximately 1 week to evaluate for
leak at that time.
PAST MEDICAL HISTORY: Coronary artery disease.
Congestive heart failure with an EF of 40 percent, moderate
MR.
[**Last Name (STitle) **].
Chronic renal insufficiency.
ALLERGIES: No known drug allergies.
MEDICATIONS:
1. Senna for constipation.
2. Furosemide 40 mg p.o. b.i.d.
3. Hydralazine 25 mg p.o. t.i.d., hold for BP less than 110
or pulse less than 60.
4. Metoprolol 25 mg p.o. t.i.d., hold for BP less than 100 or
pulse less than 60.
5. Finasteride 5 mg p.o. q.d.
6. Terazosin 1 mg p.o. h.s.
7. Alendronate 5 mg p.o. q.d.
8. Isosorbide dinitrate 10 mg p.o. t.i.d.
9. Percocet p.r.n.
10. Colace p.r.n.
DISCHARGE STATUS: Discharged to extended care facility.
DISCHARGE INSTRUCTIONS: Monitor for the following: Fevers,
nausea, chills and inability to tolerate food. If any of
these occur, please contact a physician [**Name Initial (PRE) 2227**].
Discharge instructions include frequent ambulation and follow
up with Dr. [**Last Name (STitle) 4229**] in 1 week. He should get a repeat
nephrostogram in another 3-4 days approximately on [**6-29**] or
[**6-30**].
DISCHARGE CONDITION: Discharge condition is good, afebrile,
tolerated regular diet. Pain well controlled with oral
medications, but requiring assistance for ambulation.
[**Name6 (MD) **] [**Last Name (NamePattern4) 8918**], [**MD Number(1) 19072**]
Dictated By:[**Last Name (NamePattern1) 15649**]
MEDQUIST36
D: [**2157-6-26**] 11:36:45
T: [**2157-6-26**] 13:32:21
Job#: [**Job Number 55125**]
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61,005
| 145,554
|
47463
|
Discharge summary
|
report
|
Admission Date: [**2147-8-29**] Discharge Date: [**2147-9-4**]
Date of Birth: [**2079-11-18**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30062**]
Chief Complaint:
Hemoptysis.
Major Surgical or Invasive Procedure:
1. Embolization of left upper bronchial artery
2. Intubation
3. Right IJ central venous line placement
History of Present Illness:
67 yo M h/o CAD, CHF, presented to the ED with hemoptysis. He
was initially c/o sob and saw his PCP 10 days prior. He was
empirically started on levofloxacin after a CXR showed concern
for PNA. 5 days prior to presentation he began to cough dark
blood. He saw his PCP who set him up for a chest CT. This has
not been performed yet. His hemoptysis progressively worsened to
the point of coughing up blood continously. Since he wasn't
feeling well, he decided to go to the [**Location (un) 620**] ED. In [**Location (un) 620**],
intial vital signs were 98.7 92 18 80/53 91% which decreased to
88% on RA, ultimately placed on a non-rebreather with
improvement of his oxygenation. His Hct was 39.9.
In ED VS were 98.6 97/64 90 24 99% on Non-rebreather which was
ultimately weaned down to 3 liters. He became hypotensive with
sbp in the 90s and was started on levophed. Hct was 31.5. A
right IJ was placed. He was transfused 2 units of prbcs. He was
started on cefepime and azithromycin. non-con Ct showed
Extensive consolidation involving the left upper lobe. Left
hilar adenopathy. Small airway impaction with secretions. No
definite mass seen was seen. VS prior to transfer: 98.5 119/78
25 95% 3L
On the floor, patient is complaining of left sided chest pain
that is sharp and worse with inspiration. It developed after
coughing. Mildly relieved with IV morphine. 1 SL NTG did not
help. no EKG changes.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.
Past Medical History:
-CAD s/p Inferior MI [**2122**]
-Ischemic cardiomyopathy: Last TTE [**2142**] EF 35%, Moderate
regional LV systolic dysfunction with evidence of an extensive
inferior infarction
-Hypercholesterolemia
-Hypertension
-Gout
-Internal Hemorrhoids
Social History:
Married, quit smoking in [**2144**], >50 pack year smoking history.
Drinks two large drinks of scotch daily.
Physical Exam:
Admission Physical Exam:
VS:97 88 126/79 17 93% 3L
GA: AOx3, NAD
HEENT: PERRLA. MMM. no LAD. no JVD. neck supple.
Cards: PMI palpable at 5/6th IC space. No RVH. RRR S1/S2 heard.
no murmurs/gallops/rubs.
Pulm: CTAB no crackles or wheezes
Abd: soft, NT, +BS. no g/rt. neg HSM. neg [**Doctor Last Name 515**] sign.
Extremities: wwp, no edema. DPs, PTs 2+.
Skin:
Neuro/Psych: CNs II-XII intact. 5/5 strength in U/L extremities.
DTRs 2+ BL (biceps, achilles, patellar). sensation intact to LT,
pain, temperature, vibration, proprioception. cerebellar fxn
intact (FTN, HTS). gait WNL.
Pertinent Results:
ADMISSION LABS:
[**2147-8-29**] 05:30PM HCT-30.7*
[**2147-8-29**] 04:59PM HGB-11.1* calcHCT-33
[**2147-8-29**] 04:56PM GLUCOSE-114* UREA N-36* CREAT-1.6* SODIUM-138
POTASSIUM-4.5 CHLORIDE-111* TOTAL CO2-19* ANION GAP-13
[**2147-8-29**] 04:56PM ALT(SGPT)-10 AST(SGOT)-18 ALK PHOS-105 TOT
BILI-0.2
[**2147-8-29**] 04:56PM LIPASE-62*
[**2147-8-29**] 04:56PM ALBUMIN-3.2* CALCIUM-7.5* PHOSPHATE-2.9
MAGNESIUM-2.0
[**2147-8-29**] 04:56PM WBC-9.6 RBC-3.44* HGB-10.3* HCT-31.5* MCV-92
MCH-29.9 MCHC-32.7 RDW-15.1
[**2147-8-29**] 04:56PM NEUTS-89.9* LYMPHS-5.6* MONOS-3.5 EOS-0.6
BASOS-0.4
[**2147-8-29**] 04:56PM PLT COUNT-261
[**2147-8-29**] 04:56PM PT-13.1 PTT-24.0 INR(PT)-1.1
CYTOLOGY:
[**2147-8-30**] BRONCHIAL WASHINGS:
Bronchial Washings, Left Upper Lobe, Anterior Segment:
NEGATIVE FOR MALIGNANT CELLS.
Hemosiderin-laden alveolar macrophages.
No fungal organisms identified.
MICRO:
[**2147-8-30**] BRONCHIAL WASHINGS: LEFT UPPER LOBE SEGMENT.
GRAM STAIN (Final [**2147-8-30**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary):
ACID FAST SMEAR (Final [**2147-8-31**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
[**2147-8-29**] EKG: sinus rhythm at rate of 86. normal axis. q waves in
inferior leads c/w old inferior MI. Normal intervals.
[**2147-8-29**] CT CHEST w/o CONTRAST:
1. Extensive consolidation involving the left upper lobe with
reactive mediastinal and left hilar lymphadenopathy. These
findings have progressively worsened since the earlier chest
radiograph of [**2147-8-16**] and are highly concerning for pneumonia.
No definite masses are detected on this non-contrast study.
Recommended continued followup until resolution.
2. Small left pleural effusion.
3. Bilateral apical predominant centrilobular emphysema.
[**2147-8-29**] CXR:
1. The right internal jugular central venous catheter tip
terminates in the SVC.
2. Findings concerning for left upper lobe pneumonia.
3. Suboptimal study for assessing for pneumothorax as the lung
apices are excluded from the field of view.
[**2147-8-31**] CXR:
As compared to the previous radiograph, the patient has been
intubated. There is complete intubation of the right main
bronchus. Subsequent volume loss of the left lung, where the
pre-existing perihilar opacity has not changed. However, there
is now extensive retrocardiac opacity. Newly appeared
parenchymal opacity at the bases of the right upper lobe,
potentially related to volume loss.
[**2147-9-1**] Bilateral lower extremity ultrasound:
No evidence of DVT. Left [**Hospital Ward Name 4675**] cyst.
Brief Hospital Course:
67 year-old man who presented with hemoptysis and transient
hypotension with concern for lung mass.
# Hemoptysis: His hematocrit at [**Hospital1 **] [**Location (un) 620**], where he initially
presented, was 39.9 with a blood pressure of 80/53. He was
transferred to [**Hospital1 18**], ultimately received 2 units of prbcs,
central line was placed and transiently started on levophed
which was quickly weaned off after volume resuscitation. He
required no further blood products. He underwent rigid
bronchoscopy, biopsy performed and could not stop the bleeding.
He was sent to IR from IP suite and is s/p embolization of left
upper bronchial artery branches. He remained right mainstem
intubated after bronch overnight. A repeat flex bronch was
performed bedside the following morning and no signs of active
bleeding were present. The tube was pulled back to trachea and
he was quickly extubated the same day without incident. He
continued to have a profound cough with scant amounts of rusty
colored sputum. This was controlled with PO codeine and
lidocaine nebulizers. He also required supplemental oxygen with
a shovel mask initially, which was weaned down to 5 liters NC
prior to transfer to the floor. Over the course of the next
several days, he was weaned down to room air. With ambulation,
he was noted to have desaturations to ~88%, quickly resolving
after rest. Nevertheless, it was felt best to discharge him with
home oxygen as a temporizing measure - until he is able to clear
his airways fully of old blood and secretions.
He was empirically treated with ceftriaxone and azithromycin for
presumed CAP. He completed a five-day course of azithromycin in
house and will take two more days of cefpodoxime.
(As a note, pulmonary embolism was considered as an etiology for
his hemoptysis and hypoxia - during this admission, lower
extremity dopplers were done which were negative for DVT.
Furthermore, his oxygenation improved rapidly after transfer
from the intensive care unit - in tandem with resolution of
hemoptysis and clearing of secretions/old blood. CTA was
deferred even after his renal function improved because of his
improving clinical status. Furthermore, he would not be a
candidate for anticoagulation given the recent episode of
massive hemoptysis.)
We have asked that he schedule an appointment in pulmonary
clinic in two weeks. He will need repeat CT imaging to assess
for underlying cause for the bleeding.
# Acute Renal Failure: Felt to be secondary to pre-renal
azotemia in setting of blood loss. Initially Cr was 1.6, which
quickly resolved to 1.0 after receiving IVFs and prbcs.
# Chest Pain: Pleuritic in nature and tender to palpation
occuring after coughing. EKG not c/w ischemia. Felt to be
secondary to muscle strain. Treated with tylenol and lidocaine
patches with good relief.
# Hypertension: Hypotensive on presentation requiring brief use
of Levophed and phenylephrine (as above). Initial
anti-hypertensives held, and continue to be held at admission.
His blood pressures were well-controlled off of medications. We
have asked that he follow-up with his primary care physician,
[**Name10 (NameIs) 1023**] can restart the medicines later this week if necessary.
# Coronary artery disease: Patient continued on home
atorvastatin and zetia.
#Code: FULL CODE
Medications on Admission:
Zetia 10 mg daily
atorvastatin 80 mg daily
lisinopril 20 mg daily
atenolol 25 mg daily
Effexor 225 mg daily
Allopurinol
Flonase (new med)
claritin (new med)
cardizem daily (? new med)
Discharge Medications:
1. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Three (3)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
4. Allopurinol Oral
5. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every
12 hours) for 2 days.
Disp:*8 Tablet(s)* Refills:*0*
6. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal [**Hospital1 **] (2 times a day).
7. Claritin 10 mg Tablet Sig: One (1) Tablet PO once a day.
8. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for chest.
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*0*
9. Home oxygen
2L oxygen titrate to maintain oxygen saturation greater than
90%.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary Diagnoses:
1. Hemoptysis
2. Community-acquired pneumonia
Secondary Diagnoses:
1. Hypertension
2. Coronary artery disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 12166**],
You were admitted to the hospital with coughing up blood. You
were admitted to the ICU and given blood and intravenous fluids.
You had an embolization procedure to stop the bleeding in your
lungs. You had a CT scan of the lungs that showed you might have
a pneumonia. You were treated with antibiotics.
The following medications were changed during this admission:
--we ADDED cepodoxime; please take for two more days for
pneumonia
--we ADDED lidocaine patch for pain
--we ADDED oxygen, which you can use at home to make your
breathing comfortable as you recover from the pneumonia
--we STOPPED atenolol, lisinopril, and Cardizem (all medicines
that can affect your blood pressure) - these can be restarted by
your primary care physician after you [**Name9 (PRE) 702**] in clinic
Please continue all other medications you were on prior to this
admission.
Followup Instructions:
Please follow-up with the following appointments:
--please call your primary care physician to [**Name9 (PRE) 73001**] an
appointment later this week.
--please call the pulmonary clinic at [**Hospital1 827**] to arrange for an appointment in 2 weeks. The
number to schedule an appointment is [**Telephone/Fax (1) 612**]
Completed by:[**2147-9-4**]
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6,718
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44873+58764
|
Discharge summary
|
report+addendum
|
Admission Date: [**2200-12-7**] Discharge Date: [**2200-12-26**]
Date of Birth: [**2162-8-15**] Sex: M
Service: [**Location (un) **]
HISTORY OF PRESENT ILLNESS: Thirty-eight year old male with
history of multiple medical problems including quadriparesis,
decubitus ulcers, who presents with a low temperature.
Patient with recent admission to [**Hospital1 190**] from [**11-17**] through [**11-27**], where
he was treated for MRSA and pseudomonal bacteremia. Prior to
last admission, patient grew out MRSA and Pseudomonas from
his blood at the nursing home. He was given a two week
course of Vancomycin, ciprofloxacin. A PICC was placed for
IV antibiotics. He had mild acute renal failure with a
creatinine to 1.2.
Today patient was sent from his nursing home for agitation
and combativeness. He was recently treated on [**12-1**]
through [**12-5**] with levofloxacin for UTI. Vancomycin
discontinued [**12-6**]. In ED, patient had temperatures
from 90-92, bradycardia in the 40s, systolic blood pressures
of approximately 90 with fluid boluses, and received
ceftriaxone, Flagyl, and Cipro. Chest x-ray and head CT
done. Left femoral placed post right attempted. Also given
hydrocortisone 100 IV x1.
PAST MEDICAL HISTORY:
1. Quadriparesis.
2. Motor vehicle accident in [**2185**].
3. Diverting colostomy '[**98**].
4. Stage IV decubitus ulcer over the entire buttocks.
5. Renal transplant in [**2181**].
6. Splenectomy.
7. Recurrent UTIs.
8. Cocaine-induced MI in [**2188**].
9. Osteomyelitis in the coccyx and femur in [**May 2199**].
10. Right below the knee amputation.
11. MRSA/VRE.
12. Acute renal failure.
13. Hypomagnesemia.
14. Depression.
SOCIAL HISTORY: Lives at nursing home, history of tobacco
and cocaine use. Alcohol none currently.
ALLERGIES:
1. Zosyn.
2. Bactrim.
3. Cyclosporin.
4. Compazine.
5. Heparin leading to low platelets.
MEDICATIONS:
1. Prednisone 5 mg q.d.
2. Dulcolax.
3. Senna.
4. Nicotine gum.
5. Lorazepam 0.5 mg as needed.
6. Maalox as needed.
7. Valium 5 mg t.i.d. as needed.
8. Morphine sulfate 2 mg as needed.
9. Lactulose 30 mg q.8h.
10. Protonix 40 mg q.d.
11. Azathioprine 75 mg q.d.
12. Baclofen 20 mg t.i.d.
PHYSICAL EXAMINATION: Vital signs: Temperature 90-92.5.
Blood pressure 80-110/40-70, pulse 48-70, and 96% on 2 liters
nasal cannula. Ill appearing in no apparent distress.
HEENT: Anicteric. Oropharynx is clear. Cardiovascular:
regular rate and rhythm, S1, S2, no murmur. Pulmonary:
Slight crackles at the left base. Abdomen is soft, slightly
distended, positive bowel sounds, colostomy intact.
Extremities: Right below the knee amputation, right PICC
line with no erythema. Neurologic: Not alert, not oriented,
withdraws to pain. Sacrum: Large shallow sacral ulcer 12 x
12 cm, no erythema, no signs of infection.
LABORATORIES: White blood cell count of 6.3, hematocrit
29.6, platelets 272, neutrophils 81, lymphocytes 14,
monocytes 3. Electrolytes remarkable for a BUN of 38 and a
creatinine of 2.0, lactate 1.6.
Chest x-ray: Left retrocardiac opacity, atelectasis versus
infiltrate.
EKG: Sinus at 48, normal axis, increased QTc.
Head CT: No hemorrhage, infarction, or mass.
Urinalysis: Small leuks, [**2-13**] red blood cells, no bacteria,
0-2 epis.
Echocardiogram on [**11-22**] showed normal EF, no
vegetations on a transesophageal echocardiogram.
Micro on [**11-16**]: Blood cultures: Pseudomonas
aeruginosa sensitive to Cipro.
HOSPITAL COURSE:
1. The patient initially went to the MICU with concerns of
sepsis with his hypotension nonresponsive to fluid boluses.
He received steroids along with Cipro, Flagyl, and
Vancomycin. The patient was initially intubated due to
decreasing O2 saturations, but then was extubated the next
day. The patient never grew out anything from his blood
cultures at that time. The patient was then sent to the
floor.
2. UTI/pyelonephritis: The patient grew out Klebsiella
pneumonia which was panresistant and only sensitive to
meropenem. The patient was treated for a 14 day course.
Patient initially also grew out yeast in his urine.
Therefore, he was treated with a seven day course of
fluconazole. The suprapubic catheter was changed. A
regional ultrasound was performed, which showed no abscess
and no hydronephrosis.
3. Renal: We continued him on immunosuppression and
appreciated the renal input. His creatinine clearance was
calculated because of a low muscle mass. His baseline
creatinine is around 0.6. However, by collecting a 24-hour
urine, his creatinine clearance is estimated to be
approximately around 30. Therefore, his medications were
renally dosed.
4. Hyperkalemia: The patient was determined to be
hypoaldosterone by calculating a TTKG by checking urine
electrolytes. The patient had a TTKG less than 5 suggesting
hypoaldosteronism. The patient was started on
fludrocortisone 0.1 mg q.d. and his hyperkalemia resolved.
The patient did show peaked T waves and was initially treated
with calcium along with insulin and glucose, and received
Kayexalate and Lasix to try to further encourage the
potassium to be secreted. However, once starting the
fludrocortisone, the hyperkalemia resolved.
5. Seizure: Reportedly, the patient had what sounds like a
grand mal seizure, but then change in mental status following
it. Neurology requested an EEG which was shown to be within
normal limits. A MRI was requested, however, the patient
refused to get a MRI to assess for structural lesions because
he wants to be intubated and completely sedated. The patient
had no further seizures after that one episode. He was not
started on an antiseizure prophylaxis.
6. Sacral decubitus ulcers: Patient was cleaned with normal
saline twice a day and had wet-to-dry packings. It appeared
to be improving according to the nurses.
7. Right lower quadrant pain: The patient had vague right
lower quadrant pain, no guarding or rigidity of the abdomen,
but it is near his renal transplant. Ultrasound showed no
abscess or hydronephrosis earlier in admission. We
considered a CT scan, but we wanted to spare his transplanted
kidney from having a dye dose, so we requested a MRI.
However, the patient refused any MRI because of needing to be
completely sedated and intubated, and could not lay still for
it. The right lower quadrant pain resolved and really became
a nonactive issue.
DISCHARGE STATUS: Patient not able to perform any of his
activities of daily living and requires full nursing.
DISCHARGED TO: Rehab.
DISCHARGE MEDICATIONS:
1. Protonix 40 mg q.d.
2. Prednisone 5 mg q.d.
3. Azathioprine 75 mg q.d.
4. Miconazole powder t.i.d. as needed.
5. Acetaminophen 325-650 mg q.4-6h. as needed for pain.
6. Albuterol nebulizers as needed for shortness of breath or
wheezing q.6h.
7. Morphine sulfate 2 mg q.4h. as needed for breakthrough
pain.
8. Nicotine gum.
9. Baclofen 10 mg t.i.d.
10. Oxycodone 5/325 mg 1-2 tablets orally 4-6 hours as needed
for pain.
11. Diphenhydramine 50 mg q.6h. as needed for itching.
12. Lactulose 30 mL q.8h. as needed for constipation.
13. Fludrocortisone 0.1 mg orally q.d.
14. Magnesium oxide 400 mg b.i.d.
15. Meropenem 1,000 mg b.i.d. for four days.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-ADF
Dictated By:[**Name8 (MD) 26705**]
MEDQUIST36
D: [**2200-12-25**] 08:55
T: [**2200-12-25**] 08:54
JOB#: [**Job Number 95988**]
Name: [**Known lastname **], [**Known firstname 33**]/JR. Unit [**Name2 (NI) **]: [**Numeric Identifier 15068**]
Admission Date: [**2200-12-7**] Discharge Date: [**2201-1-7**]
Date of Birth: [**2162-8-15**] Sex: M
Service: Medicine, [**Location (un) **] Firm
ADDENDUM: This is an Addendum to the previous Discharge
Summary and will cover the period from [**2200-12-26**] to
[**2201-1-7**]
CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM
(CONTINUED):
1. URINARY TRACT INFECTION ISSUES: The patient completed a
14-day course of meropenem for his Klebsiella urinary tract
infection which was only sensitive to meropenem. The patient
then developed 10:100,000 yeast and is currently being
treated on a 7-day course of fluconazole 200 mg once per day.
This was thought to perhaps just be a colonization and not an
actual infection, but because of his immunocompromised state we
were treating for one week.
2. HYPOALDOSTERONISM ISSUES: The patient was switched to
fludrocortisone 0.1 mg once per day because he became
hypertensive on the twice per day dosing. His potassium
levels have remained in the 4 to 5 range on these doses. He
is now normotensive on the once per day dosing.
3. RIGHT LOWER QUADRANT PAIN ISSUES: The patient had waxing
and [**Doctor Last Name 2364**] right lower quadrant pain. He had multiple
computed tomography scans to evaluate this without
intravenous contrast due to worry of worsening his renal
function. They showed a hematoma which was also examined
under ultrasound. Because of the risks of infection, it was
not felt worth aspirating the hematoma to make a more
definitive diagnosis.
After discussions with the radiologists, they were convinced
that this was a hematoma. The hematoma has been stable for
over two years and had not changed in appearance. The
patient's pain was well controlled with his myriad of
narcotics and Percocet.
4. SACRAL DECUBITUS ULCERATION ISSUES: The patient
continued to refuse to use an air mattress or to have q.2h.
changing of positions. Therefore, wound care specialists
were consulted, and they are now cleansing the wound twice
per day and using damp-to-dry dressing changes. The Plastic
Service evaluated and felt there was no need for debridement
at this point.
5. BACTEREMIA ISSUES: The patient had [**12-14**] blood cultures
with coagulase-negative Staphylococcus. Repeat blood
cultures were all negative. He was treated for seven days
with vancomycin; however, this was felt to most likely be a
contaminant from the skin.
6. ACCESS ISSUES: The patient had a Port-A-Cath placement
so that he would have more permanent access and would not
need a peripherally inserted central catheter line which he
said would interfere with his movement.
MEDICATIONS ON DISCHARGE:
1. Protonix 40 mg by mouth once per day.
2. Prednisone 5 mg by mouth once per day.
3. 50 mg by mouth once per day.
4. Miconazole powder three times per day.
5. Acetaminophen 325 mg by mouth q.4-6h. as needed (for
pain).
6. Albuterol sulfate q.6h. as needed (for shortness of
breath or wheezing).
7. Morphine sulfate 2 mg q.4h. as needed (for breakthrough
pain).
8. Nicotine gum as needed (for desire to smoke).
9. Baclofen 10 mg by mouth three times per day.
10. Percocet 5/325-mg tablets one to two tablets by mouth
q.4-6h. as needed (for pain).
11. Diphenhydramine 25 mg by mouth q.6h. as needed (for
itching).
12. 25 mg to 50 mg by mouth q.6h. as
needed (for itching).
13. Lactulose 30 mL by mouth q.8h. as needed (for
constipation).
14. Magnesium oxide 400 mg by mouth twice per day.
15. Fludrocortisone 0.1 mg once per day.
16. Folic acid 1 mg by mouth once per day.
17. Bisacodyl 10 mg by mouth every day (hold for increased
colostomy output).
18. Senna one tablet by mouth twice per day.
19. Oxycodone 5 mg by mouth q.4-6h. as needed (for pain).
20. Multivitamin one tablet by mouth once per day.
21. Fluconazole 200 mg once per day (for five days).
22. Lorazepam q.4h. as needed (for anxiety and nausea).
DR.[**Last Name (STitle) **],[**First Name3 (LF) 77**] 12-ADF
Dictated By:[**Name8 (MD) 9631**]
MEDQUIST36
D: [**2201-1-7**] 08:21
T: [**2201-1-7**] 08:23
JOB#: [**Job Number 15237**]
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58,773
| 170,349
|
45303
|
Discharge summary
|
report
|
Admission Date: [**2133-4-1**] Discharge Date: [**2133-4-6**]
Date of Birth: [**2054-5-20**] Sex: F
Service: SURGERY
Allergies:
Penicillins / Vancomycin / Oxycodone
Attending:[**First Name3 (LF) 2836**]
Chief Complaint:
Chest pain - initial presenting complaint
Abdominal pain - developed during hospitalization
Major Surgical or Invasive Procedure:
Cardiac catheterization -- [**2133-4-1**]
Exploratory laparotomy with resection of ischemic transverse and
left colon and spleen -- [**2133-4-5**]
History of Present Illness:
Per Cardiology Service:
78 yo woman with a PMH of CAD, s/p CABG and PCI, CHF (systolic),
s/p BiV-ICD, AF, DM, HTN, HC, hypothyroidism, CKD, and breast
cancer s/p mastectomy in the 80's presents with chest pain.
This morning she noticed that her vision was slightly blurry
when she was [**Location (un) 1131**] directions on her cereal and her newspaper.
She was dyspnic walking to her bathroom at home, an activity
that does not typically cause dyspnea. Later in the morning she
was at [**Hospital **] clinic for a regular appointment when she noted
sudden onset [**8-7**] dull chest pain that radiated to her left arm
and back. This was associated with mild SOB and lightheadedness
when pain was at its worst, but no nausea, vomiting, change in
vision or diaphoresis. She affirms that this pain and
lightheadedness is very similar to her prior presentations,
including this [**Month (only) 956**].
.
Of note, per her Cardiologist, the patient has chronic chest
discomfort, which awakens her at night and is always present.
There is no exacerbation with her minimal physical activity and
it can last for up to hours at a time. She does not note any
exacerbation with food intake and differentiates this from her
typical "heartburn," which is more of a burning sensation in the
mid chest. She also notes that there is sometimes a sensation
of food getting stuck when she is trying to swallow.
.
She was hospitalized in late [**Month (only) 956**] with left-sided chest pain
and black stool. Troponins were negative, no EKG changes.
During that admission EGD revealed no bleeding but did show
candidal esophageal infection. She was seen in the ED on [**3-10**]
for chest pain, again cardiac enzymes negative. Pharmacologic
stress test showed no change and she was d/c without admission.
She last saw her cardiologist on [**3-19**] for a post-discharge visit
at which time she was noted to be volume overloaded. She also
complained of chronic chest pain at that time, and anti-fungal
treatment with fluconazole was recommended. The patient states
that she used "some antibiotic" that completed its course "a
while ago", but does not recall the name or timing. On [**3-20**] she
was switched from warfarin to dabigatran for anti-coagulation,
although the patient believes that dabigatran was later stopped.
Per clinic notes, she reported chest pain in late [**Month (only) 958**] ([**3-25**],
[**3-26**]) and requested additional NTG tablets. By her report she
uses these tablets perhaps once a week, 2-3 tablets per chest
pain episode. She does not believe that the pace of her chest
pain worsened over [**Month (only) 958**]. On [**3-26**] she complained of weakness
and her VNA noted she was pale; she also notes that about this
time she started to have increased dyspnea on exertion, such
that walking shorter distances caused her to be short of breath.
Prior to this time she could walk from her apartment to her car
without dyspnea, but in the last week she could no longer do
this. On [**3-31**] her VNA reported volume overload and her Lasix was
restarted at 40mg daily.
.
Today she was given ASA, NTG x2 at [**Last Name (un) **] prior to presentation.
In the ED, initial vitals were 97.8 81 135/55 16 100% RA. EKG
showed ST depressions in V1 and V2, troponin < 0.01. Started on
heparin gtt, nitro gtt, Plavix loaded with 600mg, ASA 325,
morphine 5mg IV.
.
Per report, her catheterization showed that 2 of her 3 CABG
grafts are occluded. The SVT to OM graft remains patent. No
intervention was performed.
.
On arrival to the floor, patient complains of a sensation of
urinary urgency, but denies chest pain or dyspnea.
.
REVIEW OF SYSTEMS
Positive for orthopnea (wedge and pillow, unchanged), feeling
cold, lightheadedness on standing.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis. 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
paroxysmal nocturnal dyspnea, palpitations, syncope or
presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
- CAD status post inferoposterior wall MI, CABG in [**2106**]
(LIMA-LAD, SVG-OM, SVG-PDA, known SVG to PDA stenosis)--> Taxus
stent to SVG - PDA in [**2125-2-26**]--> stenting of anterograde limb
of PDA in [**2127-9-28**]. Demonstration of SVGSVG-rPDA
demonstrated 40%ostial lesion consistent with in-stent
restenosis.
- small [**First Name9 (NamePattern2) 7792**] [**2132-8-28**]
- Ischemic CM, EF 25-30% s/p BiV upgrade on [**2131-5-2**], ([**Company 2275**] COGNIS). LV lead revision [**2132-5-16**]. NYHA Class III.
- Ventricular tachycardia status post ICD placement; generator
change [**6-2**]
3. OTHER PAST MEDICAL HISTORY:
- Hypertension/LVH
- Hyperlipidemia
- Type 2 diabetes (HbA1c 8.2% in [**2132-2-26**]), followed at the
[**Last Name (un) **] by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10083**].
- Mild AS/AR
- Atrial fibrillation
- Hypothyroidism
- Irritable bowel syndrome/diverticulosis
- Chronic kidney disease
- Anemia
- Arthritis
- Breast CA, s/p R mastectomy and XRT [**2108**]
- Gastritis on EGD, w/ hiatal hernia and candidal infection
- chronic low back pain
- obstructive sleep apnea
- osteoarthritis
Social History:
Widowed. Lives in apartment building across the hallway from
her daughter and son-in-law. [**Name (NI) **] a 30-year-old granddaughter.
Previously owned toy stores with husband. Lives independently at
home in [**Location (un) 55**]. Independent for all ADLs.
- Tobacco history: never
- ETOH: never
- Illicit drugs: never
Lifetime nonsmoker and nondrinker.
Retired from toy wholesale business.
Family History:
Mother died at 53 of an MI, also had a stroke. Brother died of
MI at 40; sister died of MI in her 60s, another brother died of
congenital heart defect at 32(valve). Father died at 86.
Children both have diabetes.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: 97.6 127/44 60 14 94% RA
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, MMM, OP clear. No thrush.
NECK: Supple with JVP of [**5-3**] cm.
Chest: s/p mastecomy on right
CARDIAC: RRR, normal S1 S2. 3/6 systolic crescendoing murmur
best heard at RSB. No S3 or S4.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no
rales, wheezes or rhonchi.
ABDOMEN: Soft, non-tender, non-distended. No HSM.
EXTREMITIES: No cyanosis, clubbing. trace pedal edema b/l. Cath
site CDI, no eccymosis or hematoma, no bruit.
NEURO: Tested [**Location (un) 1131**] with each eye, normal and not blurred.
CN II-XII tested and intact, strength 5/5 throughout, sensation
grossly normal. Gait not tested.
PULSES:
Right: Carotid 2+ DP 1+ PT dopp
Left: Carotid 2+ DP 1+ PT dopp
Pertinent Results:
Admission Labs:
[**2133-4-1**] 10:30AM BLOOD WBC-7.7 RBC-3.11* Hgb-8.9* Hct-28.1*
MCV-91 MCH-28.6 MCHC-31.6 RDW-13.8 Plt Ct-155
[**2133-4-1**] 10:30AM BLOOD PT-14.8* PTT-46.4* INR(PT)-1.4*
[**2133-4-1**] 10:30AM BLOOD Neuts-81.8* Lymphs-10.9* Monos-5.5
Eos-1.4 Baso-0.3
[**2133-4-1**] 10:30AM BLOOD Glucose-250* UreaN-45* Creat-1.7* Na-135
K-4.2 Cl-100 HCO3-23 AnGap-16
[**2133-4-1**] 10:30AM BLOOD Calcium-10.4* Phos-3.6 Mg-2.0
Cardiac Labs:
[**2133-4-1**] 10:30AM BLOOD cTropnT-0.01
[**2133-4-1**] 07:30PM BLOOD CK-MB-2 cTropnT-0.02* proBNP-[**Numeric Identifier 96779**]*
[**2133-4-1**] 07:30PM BLOOD CK(CPK)-40
[**2133-4-1**] 09:40PM BLOOD CK-MB-2 cTropnT-0.03*
[**2133-4-1**] 09:40PM BLOOD CK(CPK)-44
Discharge Labs:
Microbiology:
[**2133-4-1**] 1:20 pm URINE Site: NOT SPECIFIED
**FINAL REPORT [**2133-4-2**]**
URINE CULTURE (Final [**2133-4-2**]): NO GROWTH.
<br>
Imaging:
CXR [**2133-4-1**]
Mild fluid overload and probable trace pleural effusions, new
since prior exam
Cardiac Cath [**2133-4-1**]
1. Selective coronary angiography of this right dominant system
demonstrated severe three vessel coronary disease. The LMCA had
moderate disease. The LAD, LCX, and RCA were 100% occluded.
2. Selective arterial conduit angiography demonstrated patent
LIMA to LAD.
3. Venous conduit angiography demonstrated a patent SVG-OM and a
100% occluded SVG to D1 and SVG to PDA.
3. Limited resting hemodynamics demonstrated normotension.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Patent LIMA-LAD.
3. Two occluded SVGs.
<br>
Echo [**2133-4-2**]
The left atrium is markedly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity is
moderately dilated. There is severe regional left ventricular
systolic dysfunction with inferior and inferolateral akinesis,
as well as apical hypokinesis. There is mild hypokinesis of the
remaining segments (LVEF = 25-30%). No masses or thrombi are
seen in the left ventricle. Right ventricular chamber size is
normal. with mild global free wall hypokinesis. Tricuspid
annular plane systolic excursion is depressed (1.1 cm)
consistent with right ventricular systolic dysfunction. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. Trace aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Moderate
(2+) mitral regurgitation is seen. Moderate [2+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Dilated left ventricle with severe regional and
global left ventricular systolic dysfunction, most c/w
multivessel CAD. Mild right ventricular systolic dysfunction.
Moderate mitral regurgitation. Moderate tricuspid regurgitation.
Moderate pulmonary hypertension.
Compared with the prior study (images reviewed) of [**2132-1-29**],
left ventricular cavity size is larger. The other findings are
similar.
<br>
KUB [**2133-4-5**]
The ascending colon is markedly distended, particularly the
cecal region with maximal diameter of approximately 13 cm.
Additional loops of air-filled bowel are present beyond this
region in the transverse and distal colon, measuring up to about
6.6 cm in greatest diameter. On the left lateral decubitus view,
multiple air-fluid levels are present, but there is no evidence
of free intraperitoneal air. A small amount of gas is also noted
within the nondistended loops of small bowel.
IMPRESSION: Markedly distended cecum, without evidence of distal
colonic decompression. The possibility of intermittent cecal
volvulus should be considered, and a CT of the abdomen has
already been obtained for a more complete evaluation at the time
of this dictation.
<br>
CT abdomen and pelvis [**2133-4-5**]
IMPRESSION:
- No evidence to suggest cecal volvulus. Fluid-filled loops of
small bowel is suggestive of enteritis. Evaluation of mesenteric
ischemia is limited due to lack of IV contrast.
- Mild nonspecific thickening of the wall of the left colon
which could be secondary to infectious/ ischemic colitis.
- Extensive vascular disease involving the vessels of the
abdomen and pelvis.
- Trace perihepatic ascites.
- Small bilateral pleural effusions.
<br>
<br>
Post-op Labs [**2133-4-6**] 03:01a
pH 7.22 pCO2 35 pO2 56 HCO3 15 BaseXS -12
Type:Central Venous
freeCa:1.26
Lactate:10.1
O2Sat: 85
[**2133-4-6**] 02:40a
144 108 40 83 AGap=25
-------------<
4.3 15 2.6
Comments: Glucose: If Fasting, 70-100 Normal, >125 Provisional
Diabetes
Ca: 11.4 Mg: 2.2 P: 8.5 ∆
ALT: 218 AP: 34 Tbili: 0.5 Alb:
AST: 314 LDH: Dbili: TProt:
[**Doctor First Name **]: Lip:
9.1 \ 8.6 / 65
/ 27.7 \
N:43 Band:32 L:15 M:9 E:0 Bas:0 Metas: 1 Nrbc: 1
Comments: Plt-Ct: Verified
Hypochr: 3+ Anisocy: 1+ Poiklo: 1+ Macrocy: 1+ Burr: 2+ Pappenh:
1+
Plt-Est: Very Low
PT: 74.9 PTT: 126.0 INR: 7.6
Brief Hospital Course:
Cardiology Hospital Course:
78 yo woman with a PMH of CAD, s/p CABG and PCI, CHF (systolic),
s/p BiV-ICD, AF, DM, HTN, HC, hypothyroidism, CKD, and breast
cancer s/p mastectomy in the 80's presents with chest pain.
.
# CORONARIES: History of prior IMI, CABG in [**2106**], subsequent
stenting to SVG to PDA and anterograde limb of PDA. Per prior
cath records, the LIMA-LAD graft has been occluded since [**2130**].
Catheterization on [**4-1**] showed occlusion of the SVG-PDA lesion,
leaving only the SVG-OM patent. The chronicity of this occlusion
is uncertain, and she had no cardiac enzyme elevation. She has
a history of chronic chest pain, thought to be both of cardiac
and non-cardiac origin. Continued ASA, statin, metoprolol.
Nitrate was uptitrated. Lisinopril was held for two days due to
acute kidney injury (see below).
.
# PUMP: Chronic systolic heart failure, infarct mediated,
ejection fraction 30% status post biventricular ICD: NYHA III.
CXR showed mild pulmonary edema and trace effusions. BNP was
elevated, peripheral edema. TTE was not significantly changed
from prior. Home Lasix was initially continued, then held for
two days due to acute kidney injury (see below). Ranolazine was
started [**4-3**] in an attempt to reduce her chronic chest pain.
.
# RHYTHM: Chronic Afib, on anti-coagulation with dabigatran,
recently switched from warfarin due to compliance concerns. Per
patient, she was told to d/c dabigatran last week, but this is
not documented in the clinic notes. Dabigatran was restarted,
and it was emphasized to the patient to maintain this medication
unless specifically instructed to stop it by her cardiologist.
Metoprolol continued to rate control, digoxin started [**4-3**].
.
# Post-cath bleeding: When the sheath was pulled [**4-1**], the
patient had a small hematoma and 50 cc blood loss. Pressure was
held and the hematoma pressed out, groin was soft without
hematoma on [**4-2**]. No Hct loss, VSS. No need for ultrasound
given normal clinical appearance.
.
# Enteritis: On the evening of [**4-4**] at 2200 the patient was
given a dose of kayexelate for K 5.5. At 0430 she suddenly
developed explosive brown diarrhea with urgency, frequency, and
associated abdominal pain. Bowel sounds were hyperactive. At
0700 she began to have tachycardia to the low 100s (rate usually
controlled to 60-70s). BP at 0600 was 115/43, dropped to
90s/40s by noon. Diarrhea continued through the morning,
patient became clinically dehydrated with BP down to 80s/40s.
IVF boluses used to support fluid balance and pressure. Stool
guaiac positive, non-melanotic. KUB showed sign of either cecal
volvulus or ischemic colitis with distension, no sign of
perforation. Lactate elevated to 5.9, lactic acidosis with
venous pH 7.32. Surgery was consulted. Due to the patient's
hypotension, volume loss, and acidemia, she was transferred to
MICU for monitored resuscitation.
.
# Candidial esophagitis and GERD: EGD in [**2133-1-28**] showed no
bleeding, but did find candidal infection causing esophagitis.
Patient also complains of chronic GERD. Unclear if she
completed fluconazole for candidial esophagitis, although at
admission she had no thrush and no globus sensation. There is
concern that this esophagitis may be contributing to her chest
pain. Her PPI was continued.
.
# Blurred vision: The patient states that she noted slight
blurring of her vision the morning of [**4-1**], but this has now
resolved. No associated neuro signs. [**Month (only) 116**] be due to
hyperglycemia, but in case of embolic event her risk factors are
being mitigated, dabigatran restarted.
.
# UA: UA showed trace leuks, few bacteria. Patient complained
of some urinary frequency and burning. Urine culture negative.
Repeat UA [**4-3**] showed sign of infection, Cipro was started for
3-day course (4/6-8)
.
# AoCKD: baseline Cr 1.6-1.8 with Mild hypercalcemia due to
renally-derived secondary hyperparathyroidism. On [**4-3**] her Cr
increased to 2.0, then to 2.4 on [**4-4**]. Lisinopril and Lasix were
held. Her home dexedrcalciferol was continued and all
medications (including dabigatran and Cipro) renally dosed.
.
Inactive issues:
# Hyperlipidemia: continued statin as above, held fish oil (not
available on formulary)
# Anemia: Baseline Hb 10. No evidence of bleeding. Continued
iron supplementation, vit B12
# Hypothyroidism: last TSH 2.4 in [**2132-8-28**], continued
levothyroxine
# T2DM: on insulin, recently started sitagliptan. While
inpatient we used ISS and held sitagliptan.
# Health maintenance: continued MVI
.
CODE: FULL
EMERGENCY CONTACT: [**Name (NI) **] [**Name (NI) 3535**] [**Telephone/Fax (1) 96780**]
.
Transitional Issues:
- monitor digoxin levels, particularly in light of renal failure
- ongoing surveillance of renal function
- continue to emphasize appropriate and continued medication use
.
.
Surgery Hospital Course:
78F with multiple medical/surgical comorbidities as described
above. The ACS service was consulted on [**2133-4-5**] for acute
abdominal pain with distension and copious diarrhea that began
hours after patient had received kayexalate for treatment of
hyperkalemia on [**2133-4-4**]. Her symptoms persisted and she was
reportedly hypotensive and tachycardic briefly but responded to
IV fluid boluses on morning of [**2133-4-5**]. Her lactate was 5.9. A
KUB was done that demonstrated markedly distended cecum, without
evidence of distal colonic decompression and raised the
possibility of intermittent cecal volvulus. On physical exam at
this time, her abdomen was soft but moderately distended and
diffusely moderately tender, right abdomen greater than left but
there was no rebound. She was stable hemodynamically at the
time. She continued to have diarrhea that was heme positive but
non-melanotic or grossly bloody. Initial discussion of potential
surgical intervention with the patient was met with indecision
and the patient wanted to discuss this possibility with her
son/family. The patient understood that she was a high-risk
operative candidate for morbidity and mortality given her
numerous comorbidities and poor cardiac and renal functions. In
addition, she has been chronically anticoagulated with pradaxa.
Given the equivocal etiology of her abdominal symptoms, a
non-contrast CT scan was recommended for further evaluation (no
IV contrast given that her Cr was 3.0). The scan demonstrated no
evidence to suggest cecal volvulus but there were fluid-filled
loops of small bowel suggestive of enteritis along with mild
nonspecific thickening of the wall of the left colon which could
be secondary to infectious causes or ischemic colitis. At this
juncture, it was felt that this was possibly a pseudoobstructive
picture of the colon and GI was consulted for colonoscopy for
further evaluation of the colonic mucosa along with potential
endoscopic decompression. Chemical decompression was not
attempted given the patient's significant history of cardiac
dysrrhythmias. Her lactate had improved to 2.9 after IV fluid
boluses. However, she had some intermittent episodes of
hypotension to SBP 90's along with tachycardia and was
transferred to the MICU (no available SICU beds) with surgery
following closely. GI was unable to visualize colonic mucosa
secondary to copious amounts of stool and attempted to
decompression the colon with moderate effect. The patient
tolerated the procedure well without complications. Her exam
post-procedure demonstrated a softer, less distended abdomen and
mildly less tender. Her hemodynamics remained stable and she was
monitored closely.
She continued to have copious amounts of diarrhea, now collected
in a flexiseal system. A C. diff PCR was sent (eventually, this
returned as negative). Her stool started to appear more
blood-tinged and her coagulation panel returned with markedly
elevated INR 4.5 and PTT 150, which was not compatible with a
picture of possible supratherapeutic pradaxa levels. This was
confirmed with discussions with hematology. A concern for a
comsumptive coagulopathy was raised and a DIC panel was sent
(which eventually returned normal). Hematology reinforced the
point that there was no adequate methods of reversing pradaxa
effects.
Despite continued fluid resuscitation, she started to become
hemodynamically unstable around 10pm on [**2133-4-5**] and vasopressors
therapy was started along with arterial line placement. Her son
was [**Name (NI) 653**] earlier in the day to discuss his mother's
condition and the possibility of surgical intervention if she
did not improve or got worse. He had discussed this possibility
with his mother and sister and they were all in agreement
towards surgery if necessary. With the new hemodynamic
instability, her son was [**Name (NI) 653**] again, informed of the
situation and the need for surgery. Informed consent was
obtained from him given that the patient was somewhat somnolent
from recent pain medications. The great likelihood of death
associated with surgery was reinforced and her son understood
this risk.
The patient became increasingly unstable and was transferred to
the operating room emergently where she underwent an exploratory
laparotomy, resection of ischemic transverse and left colon and
spleen. She was coagulopathic despite pre-op/intra-op FFP and
required multiple units of blood and albumin. Please see
operative note for more details. At the conclusion of the case,
the patient had cardiovascular collapse despite maximal
vasopressor and IV fluid support. ACLS protocol was initiated
and eventually a perfusing cardiac rhythm was recovered. The
SICU intensivist was called to the OR for further critical care
support. At this time, Dr. [**First Name (STitle) **] had already been in contact with
the patient's son and she explained to him his mother's critical
condition and her son wished to continue resuscitation as
needed. The patient was briefly stabilized for transfer to the
SICU but shortly after arrival, she went into VTach with loss of
BP, ACLS protocol was initiated again and a blood pressure was
recovered. However, this was unable to be maintained and after
mutliple unsuccessful rounds of ACLS and further discussions
with her son who eventually agreed to stop active resuscitation,
she expired at 03:12am on [**2133-4-6**]. The medical examiner's office
was [**Date Range 653**] and the case was declined. Her son also declined
an autopsy due to personal/religious reasons. Her PCP's office
was notified as well.
Medications on Admission:
MEDICATIONS: from OMR, patient does not have list
DABIGATRAN 75 mg [**Hospital1 **] *** per patient, stopped last week ***
DOXERCALCIFEROL 1.0 mcg [**Hospital1 **]
FUROSEMIDE 40 mg daily
INSULIN GLARGINE [LANTUS] 5 units QAM
ISOSORBIDE MONONITRATE 30 mg daily
LEVOTHYROXINE 100 mcg daily
LISINOPRIL 5 mg daily
METOPROLOL SUCCINATE 100 mg daily
NITROGLYCERIN 0.3 mg SL q 5 min x 3 PRN chest pain
OMEPRAZOLE 20 mg [**Hospital1 **] 1/2 hr prior to breakfast and dinner
ROSUVASTATIN 20 mg QHS
SITAGLIPTIN 50 mg daily
ASPIRIN 81 mg daily
CYANOCOBALAMIN 100 mcg daily
FERROUS SULFATE 325 mg (65 mg Iron) daily
LOPERAMIDE 2 mg PRN loose stool
MULTIVITAMIN-MINERALS-LUTEIN 1 tablet daily
OMEGA-3 FATTY ACIDS-VITAMIN E 1,000 mg daily
PYRIDOXINE 100 mg daily
FLUCONAZOLE 400mg daily for 14 days Rx [**3-18**]
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Sepsis
Bowel ischemia
coronary artery disease s/p CABG and stent
chronic systolic heart failure
chronic atrial fibrillation on pradaxa
chronic kidney disease
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,127
| 138,212
|
41548
|
Discharge summary
|
report
|
Admission Date: [**2157-7-18**] Discharge Date: [**2157-7-23**]
Date of Birth: [**2099-9-15**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 28286**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
[**2157-7-19**] cardiac catheterization, no interventions
[**2157-7-21**] cardiac catheterization, drug eluding stent placed to
left circumflex artery and left main coronary artery at takeoff
of left circumflex
History of Present Illness:
57 YOM with history of 3VD s/p Quintuple CABG in [**2155-6-14**] and
redo CABG in [**4-/2157**] and PCI in [**Month (only) 404**] of this year, HTN, DM,
and CKD on Tu,[**Month (only) 5929**], Sunday [**Hospital **] transferred from OSH ED for
fever, SOB and EKG changes concerning for ischemia.
.
Brifely he was at his routine HD appointment yesterday and noted
to have fever to 102. He endorses URI type symptoms for the last
several days. HD center opted to forgoe dialysis and he was sent
to OSH ED for evaluation. En route he developed hypotension and
SSCP with radiation to his right arm. EKG on arrival to the OSH
ED showed.... STD in v2-v6 as well as elevations in aVR. There
was some question of elevation in II and III. He was started on
vancomycin, heparin, and nitro gtt and transferred to [**Hospital1 18**] out
of concern for ACS. He was hypotensive en route and started on
levophed.
.
On arrival to [**Hospital1 18**] ED. Pain free. Off levophed, nitro. He
reports his baseline SBP is in the 90's and falls as low as the
70's on HD. His levophed, and nitro gtt were DC'd. His CXR did
not appear to be overly congested and he was lying flat with no
hypoxemia. Bedside Echo did not show any wall motion
abnormality. ED felt him to be somewhat dry and began to give
him a 500 cc bolus.
.
Labs were notable for an OSH trop of 0.3, lactate of 1.2. [**Hospital1 18**]
enzymes ar pending.
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
- CABG:
-[**6-/2155**] VFib arrest with CABG at [**Hospital1 112**] for 3vd, 5vessel-CABG with
LIMA to LAD double touchdown with endarterectomy from D1 to
apex; SVG1 to OM1 and jump to OM2; and SVG2 to PDA
-[**4-/2157**] CABG Redo sternotomy and coronary artery bypass graft
x3, saphenous vein graft to obtuse marginal 1, 2 and 3.
- PERCUTANEOUS CORONARY INTERVENTIONS:
[**2-/2157**] PCI POBA to 70% L main occulsion, POBA 90% in LAD, DES
placed to L circ for 80% prox with 60% mid occlusion
Repeat cath [**5-2**] showed instent restenosis of L circ (extending
to L main)
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
- ESRD on hemodialysis (at Quality Care [**Location (un) **], Tu,[**Last Name (LF) 5929**],[**First Name3 (LF) **]
overnight dialysis)
- Diabetes mellitus with renal complications
- Neuropathy
- Retinopathy
-Obstructive Sleep Apnea (previously on CPAP, now resolved after
weight loss)
- Cataract
- Charcot foot due to diabetes mellitus
- Hypothyroidism
- Hyperlipidemia
- Obesity s/p Lap Band ([**2154**])
- Hyperparathyroidism [**3-17**] renal
- Renal osteodystrophy
- Pulmonary Nodule (Solitary)
- History of Colonic Adenoma
- Left arm fistula
- s/p Lap Band ([**2154**])
Social History:
Lives in [**Location **] with his wife and sister-in-law. [**Name (NI) **] 3
children who live in the area. Retired 3 years ago. Since
[**4-/2157**] CABG, has been back to his baseline after (except
lifting), but he is not very active at baseline.
Tobacco history: 30 pack year history, quit at time of CABG in
[**2155**].
ETOH: never
Illicit drugs: denies
Family History:
Father with kidney disease. No family history of early MI,
arrhythmia, cardiomyopathies, or sudden cardiac death. Uncle
with cancer, NOS.
Physical Exam:
PHYSICAL EXAM ON ADMISSION
VS: 104/65 P96 98% O2 on 2L NC
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with no JVP
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: Slightly decreased breathsounds at the bilateral bases.
No crackles or edema.
ABDOMEN: Soft, NTND +BS
NEURO: AAOx3
PULSES:
Right: DP 2+
Left: DP 2+
Physical Exam on Discharge:
afebrile, BP 90s-110s/60s
exam unchanged
Pertinent Results:
ADMISSION LABS:
[**2157-7-18**] 08:50AM BLOOD WBC-9.0# RBC-3.66* Hgb-11.8* Hct-35.6*
MCV-97 MCH-32.2* MCHC-33.1 RDW-16.3* Plt Ct-160
[**2157-7-18**] 08:50AM BLOOD Neuts-90.2* Lymphs-5.2* Monos-3.0 Eos-0.4
Baso-1.1
[**2157-7-18**] 08:50AM BLOOD PT-12.9* PTT-54.9* INR(PT)-1.2*
[**2157-7-18**] 08:50AM BLOOD Glucose-176* UreaN-66* Creat-12.7*#
Na-136 K-6.0* Cl-98 HCO3-21* AnGap-23*
[**2157-7-18**] 08:50AM BLOOD Calcium-7.7* Phos-5.1* Mg-2.6
CARDIAC ENZYMES:
[**2157-7-18**] 08:50AM BLOOD CK-MB-21* MB Indx-5.8
[**2157-7-18**] 08:50AM BLOOD cTropnT-1.60*
[**2157-7-18**] 03:00PM BLOOD CK-MB-23* MB Indx-5.1 cTropnT-3.71*
[**2157-7-18**] 11:12PM BLOOD CK-MB-11* cTropnT-5.66*
[**2157-7-20**] 04:23AM BLOOD CK-MB-4
[**2157-7-20**] 09:11AM BLOOD CK-MB-4 cTropnT-3.31*
DISCHARGE LABS:
[**2157-7-23**] 05:49AM BLOOD WBC-5.1 RBC-3.30* Hgb-10.3* Hct-32.5*
MCV-99* MCH-31.2 MCHC-31.6 RDW-16.0* Plt Ct-148*
[**2157-7-23**] 05:49AM BLOOD PT-11.2 PTT-31.7 INR(PT)-1.0
[**2157-7-23**] 05:49AM BLOOD Glucose-63* UreaN-36* Creat-8.5*# Na-140
K-4.4 Cl-100 HCO3-29 AnGap-15
[**2157-7-20**] 09:11AM BLOOD ALT-35 AST-55* CK(CPK)-134 AlkPhos-51
TotBili-0.4
[**2157-7-20**] 09:11AM BLOOD Lipase-43
[**2157-7-23**] 05:49AM BLOOD Calcium-7.6* Phos-4.4 Mg-2.4
[**2157-7-18**] 03:00PM BLOOD TSH-0.13*
MICROBIOLOGY:
[**2157-7-18**] BLOOD CULTURE X 4 NEGATIVE
[**2157-7-19**] CDIFF STOOL NEGATIVE
REPORTS:
[**2157-7-18**] Radiology CHEST (PORTABLE AP)
The lungs are clear. There is no focal consolidation to suggest
pneumonia. Heart size is enlarged, but unchanged. Bibasilar
opacities
represent atelectasis in the setting of low lung volumes.
Sternotomy wires and CABG clips are noted. There is no
pneumothorax. No definite pleural effusions are seen
[**2157-7-19**] ECHO:
This study was compared to the prior study of [**2157-7-5**].
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal
interatrial septum. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size.
Mild regional LV systolic dysfunction. No LV mass/thrombus. No
resting LVOT gradient. No VSD.
RIGHT VENTRICLE: Mildly dilated RV cavity. Mild global RV free
wall hypokinesis.
AORTA: Mildly dilated ascending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular calcification. Mild thickening of mitral valve
chordae. No MS. Mild to moderate ([**2-14**]+) MR.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. No
TS. Mild [1+] TR. Borderline PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: No PS.
PERICARDIUM: Very small pericardial effusion. No
echocardiographic signs of tamponade.
Conclusions
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 mild regional left ventricular
systolic dysfunction with inferior, infero-lateral, distal
LV/apical hypokinesis suggested. 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 ascending aorta is mildly dilated.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Mild to moderate
([**2-14**]+) mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. There is borderline pulmonary
artery systolic hypertension. There is a very small pericardial
effusiOn. There are no echocardiographic signs of tamponade.
Compared with the prior study (images reviewed) of [**2157-7-5**], no
change.
[**2157-7-19**] CARDIAC CATH;
1. Selective coronary angiography of this co dominant system
revealed
three vessel native coronary artery disease. The LMCA had a 90%
distal
instent restenosis. The LAD had 50% ostial disease and 95%
stenosis
after D1. D1 was 100% occluded. The Lcx had 99% proximal instent
restenosis. The mid Lcx had 80% stenosis and the OM1 was 100%
occluded.
The RCA was 100% totally occluded proximally.
2. Limited resting hemodynamics revealed borderline low systemic
blood
pressure of 80/50 mmHg that is close to patient's baseline.
Gentle IVF
were given since HD performed earlier that day.
3. Saphenous vein graft arteriography showed the SVG-RCA to be
widely
patent. The SVG-OM1 had mild irregularity only and the proximal
stent
was widely patent. There was 60% diffuse disease in the OM1
proximal and
distal to touchdown site. The jump segments of this graft to OM2
and OM3
(L. lpl) are flush occluded (similar to prior angiography
5/[**2157**]). There
is a jump segment (from first bypass surgery) from OM1 to Om2
which is
widely patent.
4. Arterial conduit angiography was deferred as LIMA-LAD known
patent
and competative flow seen in distal native LAD.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Patent SVG-RCA, patent SVG-OM1 with occluded jump segment.
3. PAtent proximal SVG-OM1 stent.
4. Borderline low blood pressure.
5. Demand ischemia likely due to limited flow through jump
segment from
om1-om2 with intervening disease between anastamosis sites.
6. Medical management, however if ongoing ischemia or chest
pain, would
consider PCI of native LMCA-Lcx to improve perfusion to distal
codominant Lcx system.
[**2157-7-21**] CARDIAC CATH
1. Selective coronary angiography in this right dominant system
demonstrated an 80% distal LMCA stenosis, a 99% ostial Cx
stenosis (both
in-stent restenosis) and a seperate 80% stenosis in the mid Cx.
2. Selective arterial conduit angiography revealed a widely
patent LIMA
to LAD/D1. There is an occlusion of the distal LAD beyonf the
touchdown
of the LIMA.
3. Limited resting hemodynamics revealed a central aortic
pressure of
89/54 mmHg.
4. Successful PTCA and stenting of the mid Cx with a 3.0x16mm
PROMUS
ELEMENT stent which was postdilated to 3.25mm. Final angiography
revealed no residual stenosis, no angiographically apparent
dissection
and TIMI III flow (see PTCA comments).
5. [**Name (NI) 9927**] PTCA and stenting of the LMCA and proximal Cx with
a
3.5x24mm PROMUS ELEMENT stent which was postdilated proximally
to 4.5mm
and distally to 4.0mm. Final angiography revealed no residual
stenosis,
no angiographically apparent dissection and TIMI III flow (see
PTCA
comments).
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Successful PTCA and stenting of the mid Cx with a DES.
3. Successful PTCA and stenting of the LMCa and proximal Cx with
a DES.
Brief Hospital Course:
Mr. [**Known lastname **] is a 57 year old male with history of diabetes,
hypertension, and coronary artery disease (CAD) status post CABG
x 2 with 8 total bypasses as well as recent PCI 2 weeks prior to
admission who was transferred from OSH with chest pain and
dynamic EKG changes in the setting of fever, hyperkalemia and
hypotension. He was admitted to the CCU for dialysis and
cardiac catheterization and recieved 2 drug eluding stents (DES)
to his left circumflex and left main coronary arteries.
# Coronary artery disease (CAD): Patient with extensive known
CAD. Patient was started on heparin drip at OSH and this was
continued on admission. He was also continued on atorvastatin 80
mg daily, ASA 325 mg daily, clopidogrel 75 mg daily and
metoprolol 12.5mg [**Hospital1 **]. Notably, he is not on an ACEI. He
underwent cardiac catheterization on [**2157-7-19**] which showed 3
vessel disease but he was not stented at this time because it
was felt that ST changes at OSH could represent acute coronary
syndrome vs demand ischemia from fever, hypotension and
tachycardia. He continued to have chest pain however, so he
returned to the cath lab on [**2157-7-21**] and had 2 DES placed. One in
his left circumflex and one in his left main, these jailed the
LAD--it is now only supplied by the LIMA graft. After the
stents were placed, he had resolution of his chest pain. His
medications were not changed except aspirin was decreased to 81
mg daily.
# Chronic systolic heart failure (sCHF): Patient was not grossly
volume overloaded on admission with no edema on CXR or exam.
Last known EF of 45% in [**Month (only) 116**] of this year.
Fluid status is managed with hemodialysis as patient does not
make urine. Recieved HD while he was an inpatient, continued on
metoprolol 12.5 mg [**Hospital1 **], no diuretics or ACEi given the renal
impairment.
# Fever: Patient presented with fever at dialysis and OSH after
developing sore throat and cough. His family had similar
symptoms raising concern for viral upper respiratory infection.
However, he was started on empiric vancomycin and zosyn at OSH
for presumed healthcare assoc pneumonia (HCAP). Zosyn was
transitioned to cefepime on transfer. CXR showed no evidence of
pneumonia and cultures grew nothing for 48 hours, Cdiff
negative. Thus, all antibiotics were discontinued and he did
not have any additional fevers.
CHRONIC PROBLEMS:
# [**Name2 (NI) **] stage renal disease (ESRD): Patient presented with mild
volume overload and hyperkalemia in setting of missed
hemodialysis (HD). He underwent urgent dialysis morning of
admission and was then continued on intermittent HD. He
continued his sevalamer with meals and nephrocaps daily.
# Diabetes mellitus, type 2 (DMT2): Continued home regimen of
long acting insulin 10 units qam and 20 units qpm with sliding
scale coverage.
# Hyperlipidemia (HLD): Continued Atorvastatin 80 mg daily.
# Hypothyroidism: Continued thyroxine 300 mcg 5x/week. TSH was
0.13.
TRANSITIONAL ISSUES:
- TSH was low, his levothyroxine dose should be discussed with
PCP
[**Name Initial (PRE) **] [**Name10 (NameIs) **] dialysis
- Consider adding ACEi for heart failure benefit even though he
has renal failure because this will not damage the kidneys
further
Medications on Admission:
1. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. insulin aspart 100 unit/mL Insulin Pen Sig: per sliding scale
Subcutaneous three times a day.
6. lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO Q8H
(every 8 hours) as needed for constipation.
7. levothyroxine 100 mcg Tablet Sig: Three (3) Tablet PO 5X/WEEK
(MO,TU,WE,TH,FR).
8. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
9. sevelamer carbonate 2.4 gram Powder in Packet Sig: Two (2)
packets PO TID (3 times a day).
10. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. NPH insulin human recomb 100 unit/mL Suspension Sig: as
directed units Subcutaneous as directed: 10 units qAM, 20-30
units qPM.
Discharge Medications:
1. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. insulin NPH & regular human 100 unit/mL (70-30) Suspension
Sig: as directed units Subcutaneous twice a day: 10 units at
breakfast, 20 units at bedtime.
6. insulin lispro 100 unit/mL Insulin Pen Sig: as directed units
Subcutaneous three times a day: per sliding scale.
7. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed for constipation.
8. levothyroxine 100 mcg Tablet Sig: Three (3) Tablet PO 5X/WEEK
(MO,TU,WE,TH,FR).
9. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
10. sevelamer carbonate 2.4 gram Powder in Packet Sig: Two (2)
packets PO three times a day: with meals.
11. aspirin 81 mg Tablet, Effervescent Sig: One (1) Tablet,
Effervescent PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
coronary artery disease
viral upper respiratory infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname **],
You were admitted to the hospital because you had some chest
pain while you had fevers. Your fevers were from a viral upper
respiratory infection and you were already getting better from
that. You underwent a cardiac cath which showed that your chest
pain likely came from some blockages to blood flow. You had
stents put in the arteries of your heart to open them up and we
expect your chest pain to be resolved.
Medication changes made:
We decreased your aspirin to a baby aspirin (81mg a day).
You should keep all of the follow-up appointments listed below.
Bring your medications to each appointment so your doctors [**Name5 (PTitle) **]
update their records and adjust doses as needed.
It was a pleasure taking care of you in the hospital!
Followup Instructions:
Name:[**Name6 (MD) 74722**] [**Name8 (MD) **],MD
Specialty: Priamry Care
Location: [**Location (un) 2274**]-[**Location (un) **]
Address: 111 [**Doctor Last Name **] DR, [**Location (un) **],[**Numeric Identifier 17464**]
Phone: [**Telephone/Fax (1) 17465**]
When: [**Last Name (LF) 766**],[**8-1**] at 10:00am
Name:[**Name6 (MD) 88768**] [**Last Name (NamePattern4) 90369**], MD
Specialty: Cardiology
Location: [**Hospital1 641**]
Address: 111 [**Doctor Last Name **] DR, [**Location (un) **],[**Numeric Identifier 34404**]
Phone: [**Telephone/Fax (1) 56771**]
When: [**Last Name (LF) 2974**], [**8-5**] a 11:00am
Department: HEMODIALYSIS
When: SATURDAY [**2157-7-23**] at 7:30 AM
|
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icd9cm
|
[
[
[]
]
] |
[
"36.07",
"37.22",
"00.66",
"88.49",
"39.95",
"00.46",
"00.42",
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] |
icd9pcs
|
[
[
[]
]
] |
16363, 16369
|
11059, 14037
|
316, 528
|
16488, 16488
|
4449, 4449
|
17445, 18131
|
3657, 3797
|
15331, 16340
|
16390, 16467
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14341, 15308
|
10864, 11036
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16638, 17422
|
5231, 9353
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3812, 4360
|
2059, 2656
|
4388, 4430
|
14058, 14315
|
4908, 5215
|
266, 278
|
556, 1954
|
4465, 4891
|
16503, 16614
|
2687, 3263
|
1976, 2039
|
3279, 3641
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,264
| 107,055
|
54848
|
Discharge summary
|
report
|
Admission Date: [**2162-7-25**] Discharge Date: [**2162-7-31**]
Date of Birth: [**2100-8-20**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern1) 4917**]
Chief Complaint:
abdominal pain
cecal carcinoma metastatic to liver
Major Surgical or Invasive Procedure:
diagnostic and therepeutic paracentesis
History of Present Illness:
Mr. [**Known lastname 112071**] is a 61M with cecal cancer metastatic to the liver
undergoing chemotherapy and radiation (last chemo 1.5wks ago)
who presented to an OSH with SOB, lethargy and abdominal pain.
Per EMS reports, pt was hypotensive with BP as low as 91/46,
breathing between 22-24 satting 97-99% on 4L.
In OSH [**Name (NI) **] pt. was tachycardic to the 150s, breathing 38 with a
BP of 86/30, satting 98% on nonrebreather. CT abdomen showed
ascites and free air. Pt. received Levaquin and Zosyn as well
as 1.6L NS prior to transfer to [**Hospital1 18**].
In the ED, initial VS were: T 98.8 BP 99/68, P 129, 99% 3LNC. Pt
was bolused 3L NS in the ED and BP improved to low 100s/60s.
On arrival to the MICU, patient's VS: T 98.2, BP 133/97, P 130,
RR 25 96% 2LNC.
Past Medical History:
Cecal cancer metastatic to liver, diagnosed in [**2162-5-25**]
Social History:
Pt. lives at home with wife, [**Name (NI) **] who is HCP [**Name (NI) **]:
[**Telephone/Fax (1) 112072**]).
Family History:
None
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: 97.7, 109/68, 120, 24, 96% on 4L
GENERAL: Ill-appearing but comfortable, NAD
HEENT: PERRL, sclera are icteric
NECK: Supple, no JVD
LUNGS: CTAB on anterior exam
HEART: Tachycardic but regular, no murmurs
ABDOMEN: Obese, distended but soft, NT, NABS
EXTREMITIES: WWP, no edema, pedal pulses intact
NEUROLOGIC: Sleepy but arousable, A&Ox3, CNs grossly intact,
strength and sensation grossly intact
Pertinent Results:
ADMISSION LABS
[**2162-7-25**] 06:00PM ASCITES TOT PROT-2.1 GLUCOSE-2 LD(LDH)-293
ALBUMIN-1.3
[**2162-7-25**] 06:00PM ASCITES WBC-1675* RBC-1300* POLYS-92*
LYMPHS-1* MONOS-7*
[**2162-7-25**] 02:15PM URINE HOURS-RANDOM CREAT-85 SODIUM-11
POTASSIUM-95 CHLORIDE-15 TOT PROT-128 PROT/CREA-1.5* albumin-3.5
alb/CREA-41.2*
[**2162-7-25**] 02:15PM URINE OSMOLAL-471
[**2162-7-25**] 02:15PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.031
[**2162-7-25**] 02:15PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-MOD UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2162-7-25**] 02:15PM URINE RBC-17* WBC-2 BACTERIA-NONE YEAST-NONE
EPI-5
[**2162-7-25**] 02:15PM URINE AMORPH-FEW
[**2162-7-25**] 02:02PM LD(LDH)-202
[**2162-7-25**] 04:53AM GLUCOSE-73 UREA N-47* CREAT-1.6* SODIUM-136
POTASSIUM-5.1 CHLORIDE-102 TOTAL CO2-21* ANION GAP-18
[**2162-7-25**] 04:53AM CALCIUM-7.8* PHOSPHATE-4.4 MAGNESIUM-2.1
[**2162-7-25**] 04:53AM WBC-0.7* RBC-3.36* HGB-9.8* HCT-30.1* MCV-90
MCH-29.1 MCHC-32.5 RDW-20.5*
[**2162-7-25**] 04:53AM PLT COUNT-106*
[**2162-7-25**] 12:03AM LACTATE-6.9*
[**2162-7-24**] 11:50PM GLUCOSE-79 UREA N-48* CREAT-1.5* SODIUM-135
POTASSIUM-5.0 CHLORIDE-98 TOTAL CO2-20* ANION GAP-22*
[**2162-7-24**] 11:50PM estGFR-Using this
[**2162-7-24**] 11:50PM ALT(SGPT)-43* AST(SGOT)-53* ALK PHOS-419* TOT
BILI-10.5*
[**2162-7-24**] 11:50PM LIPASE-8
[**2162-7-24**] 11:50PM proBNP-1103*
[**2162-7-24**] 11:50PM ALBUMIN-2.2*
[**2162-7-24**] 11:50PM WBC-.7* RBC-3.48* HGB-10.1* HCT-31.3* MCV-90
MCH-28.9 MCHC-32.1 RDW-20.6*
[**2162-7-24**] 11:50PM NEUTS-51 BANDS-7* LYMPHS-16* MONOS-20* EOS-0
BASOS-0 ATYPS-3* METAS-2* MYELOS-0 PROMYELO-1* NUC RBCS-1*
[**2162-7-24**] 11:50PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-1+
MACROCYT-1+ MICROCYT-1+ POLYCHROM-1+ OVALOCYT-1+ TEARDROP-1+
[**2162-7-24**] 11:50PM PLT SMR-LOW PLT COUNT-130*
[**2162-7-24**] 11:50PM PT-22.8* PTT-33.2 INR(PT)-2.2*
MICROBIOLOGY
[**2162-7-25**] 6:00 pm PERITONEAL FLUID
**FINAL REPORT [**2162-7-31**]**
GRAM STAIN (Final [**2162-7-25**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
FLUID CULTURE (Final [**2162-7-31**]):
GRAM NEGATIVE ROD(S). GROWING IN BROTH ONLY.
UNABLE TO ISOLATE ORGANISM TO IDENTIFY FURTHER.
ENTEROCOCCUS SP..
Isolated from broth media only, INDICATING VERY LOW
NUMBERS OF
ORGANISMS.
ANAEROBIC CULTURE (Final [**2162-7-31**]):
CLOSTRIDIUM SPECIES NOT C. PERFRINGENS OR C. SEPTICUM.
RARE GROWTH.
IMAGING
CT Abd and Pelvis w/o contrast [**7-25**]:
1. Limited study without IV contrast. Small intraperitoneal
air and large ascites. Hemoperitoneum cannot be excluded given
the slightly increased density of fluid in the cul de sac. The
etiology of the free air is not
identified on this study. Per discussion with Dr. [**Last Name (STitle) **], the
patient does not have a history of recent paracentesis.
2. Abnormal cecum consistent with known malignancy with liver
mestases,
peritoneal carcinomatosis and mesenteric and retroperitoneal
lymphadenopathy.
Correlate with prior imaging for interval change (not available
in our
system).
3. Bone metastases with impression on the thecal sac,
particularly at L5.
Consider MRI if there is no recent MRI already performed.
Consider radiation oncology consult.
Brief Hospital Course:
61M with cecal carcinoma metastatic to the liver, s/p 2 weeks of
radiation and chemotherapy who presented with increased
shortness of breath, fatigue and abdominal pain who was found to
have bowel perforation with bacterial peritonitis.
The patient was admitted to the [**Hospital Unit Name 153**] with abdominal pain and was
found to have ascites and free air w/ sepsis. Diagnostic and
therepeutic paracentesis was preformed, results showed high
polys and gram negative rods, it was felt that he had a small
perforation in his GI tract leading to bacterial peritonitis. He
was not a surgical candidate. Goals of care were discussed with
the patient, and he became DNR, DNI. Discussions were initiated
with palliative care. He was given broad vanc/zosyn and fluid
resuscitated, including albumin. Once his BP was stablized he
was transferred to the floors. Palliative care was consulted and
recommended increasing morphine for pain control. He has
worsening liver and kidney failure and his mental status
declined. After conversations with his family, outpatient
providers, and the palliative care service, he was made comfort
measures only and passed away.
# Bowel perforation: Pt was found to have had a perforated bowel
and was initially started on broad spectrum abx. He was seen by
surgery, and due to his condition he was deemed to not be a
surgical candidate given his neutropenia and coagulopathy. Pt
was found to have gram negative rods growing in his peritonial
fluid.
# Sepsis: He was initially hypotensive in the setting of
presumed infection but his BP stablilized after fluid
resuscitation.
# Metastatic colon ca/pancytopenia- The patient is s/p 2 weeks
of radiation and chemotherapy for metastatic colon cancer.
Recent chemotherapy is likely the cause of his pancytopenia as
it did improve somewhat after treatment for sepsis.
# Liver Failure/ [**Name (NI) 112073**] Pt had severe jaundice
secondary to hyperbilirubimemia which is likely related to his
liver mets and biliary cholestasis which was previously
diagnosed.
# Coagulopathy- Secondary to hepatic mets. INR was elevated. No
evidence of bleeding was present.
# [**Last Name (un) 13160**] Pt had poor renal function which was intially thought to
be seondary to his hypotension and pre-renal etiology. However
after adequate volume resuscitation, his kidney function
continued to progressively decline.
#Death: Pt died on [**2162-7-31**]. Cause of death
Primary Diagnosis: Bowel Perforation
Secondary Diagnosis: Metastatic Cecal Carcinoma
PCP and outpatient oncologist were notified of his death.
Medications on Admission:
1. Betoptios ophthalmic solution 0.25% 1 gtt [**Hospital1 **] in each eye
2. Ciprofloxacin 500 mg PO BID
3. Oxycodone 5 mg PO q4hrs prn pain
4. Oxycontin 20 mg PO BID
5. Denavir topical prn
6. Compazine 10 mg PO QID prn nausea/vomiting
Discharge Medications:
Deceased
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary Diagnosis: Bowel Perforation
Secondary Diagnosis: Metastatic Cecal Carcinoma
Discharge Condition:
Deceased
Discharge Instructions:
None
Followup Instructions:
None
|
[
"038.9",
"V15.3",
"995.91",
"789.59",
"790.92",
"569.83",
"782.4",
"285.1",
"153.4",
"584.5",
"V87.41",
"197.7",
"567.9",
"V49.86",
"V66.7",
"V15.82",
"288.00",
"568.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
8268, 8277
|
5367, 7804
|
363, 404
|
8406, 8416
|
1910, 5344
|
8469, 8476
|
1439, 1445
|
8235, 8245
|
8298, 8298
|
7974, 8212
|
8440, 8446
|
1486, 1891
|
273, 325
|
432, 1210
|
8356, 8385
|
8317, 8335
|
1232, 1297
|
1313, 1423
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,538
| 144,893
|
51020
|
Discharge summary
|
report
|
Admission Date: [**2145-1-7**] Discharge Date: [**2145-1-18**]
Date of Birth: [**2094-12-26**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 50-year-old
gentleman with history of HIV, CD4 count 211, and HIV viral
load greater than 100,000 most recently in [**11-26**], who was
recently started on HAART in [**11-26**], who presented with one
week of flu-like symptoms including fever, headache, and
generalized muscle aches. The patient took Advil and Aleve
as an outpatient. Five days prior to admission, the patient
self-discontinued Bactrim. On the day of admission, the
patient restarted Bactrim and 15 minutes later developed
diffuse erythematous rash, facial flushing, and fever to
101.5 degrees. The patient also complained of severe low
back pain, headache, and photophobia and called [**Hospital **] Clinic,
and was instructed to come to the emergency room. In the
emergency room, the patient rapidly became hypotensive
initially felt to be due to anaphylaxis, but did not change
with subcutaneous epinephrine. Because of question of
infection in an immunocompromised host as well as fever, the
patient was started on sepsis protocol. The patient was not
responsive to neo or Levophed, so epinephrine gtt was started
and the patient was admitted to the Medical Intensive Care
Unit.
PAST MEDICAL HISTORY: HIV, discontinued HAART in the past,
recently restarted HAART in [**11-26**]. Last CD4 211, last viral
load greater than 100,000, has had this for 15 years.
Hypertension.
Insomnia.
Depression and panic attacks.
Recent otitis media on the right side in [**11-26**].
MEDICATIONS: At home,
1. Lexapro 15 mg q.d.
2. Neurontin.
3. Zestril 10 mg q.d.
4. Oxandrin 5 mg b.i.d.
5. 3TC 150 mg b.i.d.
6. DUT 40 mg b.i.d.
7. Indinavir 800 mg t.i.d.
8. Bactrim x1 month.
FAMILY HISTORY: Hypertension in multiple family members.
Diabetes and cancer in his mother and brother.
SOCIAL HISTORY: Recently traveled to [**Country 149**] about six months
ago. No alcohol or tobacco use.
PHYSICAL EXAMINATION: Upon arrival to the Medical Intensive
Care Unit, temperature 100 degrees axillary, heart rate 104;
blood pressure 66/35, blood pressure had initially been
116/87 upon arrival to the emergency room; respiratory rate
22, saturating 90 percent on a nonrebreather. Generally,
diffusely erythematous, slightly lethargic gentleman. Pupils
are normal. Conjunctivae were injected bilaterally. Heart
exam: Normal. Lungs: Diffuse rhonchi anteriorly and
laterally. Abdomen: Obese, soft, and nontender. Normal
bowel sounds. No edema. Skin with diffuse maculopapular
rash that blanched sparing palms and soles, erythematous.
DIAGNOSTIC DATA: On admission, white count 6, hematocrit 47,
and platelets 180. Chemistries within normal limits. Chest
x-ray with mild congestive heart failure. No pneumothorax.
ECG, normal sinus rhythm at 90 beats per minute, but poor
quality.
CONCISE SUMMARY OF HOSPITAL COURSE: A 50-year-old gentleman
with HIV now with hypotension and diffuse rash. The patient
was emergently intubated for respiratory distress and drop in
saturations, and admitted to the Medical Intensive Care Unit.
Initially, it was found that the patient likely had a
staphylococcus or streptococcus toxic shock picture and the
patient was aggressively fluid resuscitated, also continued
on pressors and his epinephrine drip was changed to Levophed.
An ID consult was obtained as well. Infectious workup was
negative and the MICU team felt that the patient's
hypotension was more likely related to medication reaction to
the Bactrim. The patient was eventually extubated on
[**2145-1-13**] and transferred to the Medicine Floor in stable
condition.
PROBLEM LIST:
1. Previous hypoxic respiratory failure was likely secondary
to noncardiogenic pulmonary edema related to medication
side effect. The patient's chest x-ray was without
evidence of pneumonia or congestive heart failure. The
patient's respiratory status continued to improve on the
Medicine Floor, and he was stable on room air at the time
of discharge.
1. Hypotension: Likely related to distributive shock due to
drug reaction. The patient was started on systemic
steroids for this and this was tapered and planned
continued taper for a few days as an outpatient at the
time of discharge. The patient's blood pressure remained
stable off of pressors on the Medicine Floor in the
systolic 140 to 150 range. The patient's previous
hypotension resolved and he was restarted on his ACE
inhibitor, which he tolerated well.
1. Infectious Disease/HIV: The patient's HAART regimen was
not continued in-house. The patient was without any signs
or symptoms of active infection as mentioned above and was
not maintained on antibiotics. ID consult followed
through his hospital stay. The patient had been on
vancomycin and clindamycin in the Medical Intensive Care
Unit. Chest x-ray did find some atelectasis, but no
definite pneumonia. Given the patient's peculiar
situation previously, ID consult recommended levofloxacin
for a 14-day course, which was started on [**2145-1-7**].
1. Depression: Stable. The patient continued on Lexapro and
trazodone q.h.s. p.r.n.
Fluid, electrolytes, and nutrition: The patient tolerated
low-fat, low-residual diet well. The patient was initially
aggressively fluid resuscitated due to his hypotension,
however, self-diuresed after this and tolerated POs well.
The patient remained full code throughout his hospital stay.
DISCHARGE CONDITION: Stable.
DISCHARGE STATUS: To home.
DISCHARGE DIAGNOSES: Anaphylactic reaction to Bactrim.
History of pancreatitis.
Respiratory distress requiring intubation.
Hypotension due to drug reaction.
Human immunodeficiency virus and history of depression.
DISCHARGE MEDICATIONS:
1. Escitalopram 10 mg q.d.
2. Prednisone taper x3 days.
FOLLOWUP PLANS: The patient is to follow up with Infectious
Disease Clinic and has an appointment for [**1-27**].
[**Name6 (MD) **] [**Last Name (NamePattern4) **], MD [**MD Number(2) 105990**]
Dictated By:[**Last Name (NamePattern1) 4959**]
MEDQUIST36
D: [**2145-7-6**] 14:58:24
T: [**2145-7-7**] 03:53:53
Job#: [**Job Number **]
|
[
"518.81",
"995.90",
"573.3",
"042",
"038.9",
"577.0",
"584.9",
"511.9",
"785.52"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.91",
"96.04",
"96.72",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
5595, 5633
|
1842, 1931
|
5655, 5852
|
5875, 6296
|
2974, 3721
|
2061, 2945
|
160, 1335
|
3735, 5573
|
1358, 1825
|
1948, 2038
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,176
| 127,887
|
48267
|
Discharge summary
|
report
|
Admission Date: [**2185-4-20**] Discharge Date: [**2185-4-22**]
Date of Birth: [**2140-4-12**] Sex: F
Service: Neurosurgery
HISTORY OF PRESENT ILLNESS: The patient is a 44-year-old
woman with widely metastatic breast cancer originally
diagnosed in [**2179-4-10**]. She underwent lumpectomy with lymph
node dissection. Pathology showed poorly-differentiated
infiltrating ductal carcinoma with 1/17 lymph nodes positive
and estrogen receptor positive. She was treated with
chemotherapy and radiation. She developed a cough in [**2182**].
Chest x-ray showed pulmonary and bone metastases. She
continued on chemotherapy and was doing well.
In [**2184-8-9**] her tumor markers began to rise. Her neurologic
problems began about two weeks prior to admission when she
noted a bifrontal and sinus pressure headache. Usually her
headaches resolved with Tylenol, however this particular
headache was not resolved with Tylenol. She also experienced
some psychomotor slowing, short-term memory deficit, unsteady
gait and balance problems. There was no temporal pattern to
her headaches and they are not positional. She does not have
associated nausea, vomiting, seizure, fall or weakness in her
extremities.
PAST MEDICAL HISTORY: Significant only for breast cancer.
PAST SURGICAL HISTORY: Rhinoplasty in [**2177**].
MEDICATIONS ON ADMISSION: 1. Decadron 4 mg q.i.d. 2.
Methadone 10-20 mg p.o. q.h.s. 3. Vioxx two tablets p.o.
q.a.m. 4. Tylenol p.o. p.r.n. 5. Advil p.o. p.r.n.
ALLERGIES: The patient has no known drug allergies.
PHYSICAL EXAMINATION: Her blood pressure is 140/80, heart
rate 88, respiratory rate 18. HEENT: Unremarkable. Neck:
Supple. There was no cervical, axillary or subclavicular
lymphadenopathy. Cardiac: Examination reveals regular rate
and rhythm. Lungs: Clear. Abdomen: Soft. Extremities:
No cyanosis, clubbing or edema. Neurologic: She was awake,
alert and oriented x 3. There was no right-to-left confusion
or finger agnosia. Calculation was intact. Her language was
fluent with good comprehension, naming and repetition. Her
cranial nerve examination was intact. Her motor strength was
[**6-13**] in all muscle groups. Her sensations were intact
throughout to light touch. Her reflexes were 2+ throughout.
She did not have a positive Romberg. Her gait was normal.
Gadolinium-enhanced MRI scan of the brain on [**2185-3-25**] showed
a cystic solid enhancing mass in the left occipital brain
extending down to the deep occipital white matter.
HOSPITAL COURSE: The patient was admitted on [**2185-4-20**] and
had a occipital craniotomy for excision of metastatic
tumor. Postoperatively the patient's vital signs were
stable. She was afebrile awake,
alert, oriented x 3, smile was symmetric with no drift.Visual
field exam showed a right inferior quadrantanopia .
Her incision was clean, dry and intact. She remained
afebrile. She was tolerating a regular diet.
She will be discharged to home with follow up in the brain
tumor clinic on [**5-2**]. Staples will be removed at that
time and she will be weaned down to 2 mg p.o. b.i.d. of her
steroids.
CONDITION ON DISCHARGE: Stable.
[**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 342**], M.D. [**MD Number(1) 343**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2185-4-22**] 09:57
T: [**2185-4-22**] 10:18
JOB#: [**Job Number **]
|
[
"198.3",
"197.0",
"V10.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.59"
] |
icd9pcs
|
[
[
[]
]
] |
1369, 1563
|
2545, 3141
|
1314, 1342
|
1586, 2527
|
174, 1230
|
1253, 1290
|
3166, 3451
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,825
| 166,029
|
43255
|
Discharge summary
|
report
|
Admission Date: [**2131-11-27**] Discharge Date: [**2131-12-3**]
Date of Birth: [**2065-10-3**] Sex: M
Service: MEDICINE
Allergies:
Atenolol / Ms Contin
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 13621**] is a 66 year-old man with a history of COPD, AAA, and
HTN, recently discharged on [**2131-10-12**] after presenting with strep
pneumonia requiring intubation, who presents with worsening
dyspnea and is admitted to the MICU for respiratory distress.
.
He was in his USOH until three days ago when he developed a
cough productive of yellow/green sputum, dyspnea, and pleuritic
left chest pain. His symptoms progressively worsened and he
presented to the ED for evaluation.
.
In the ED, vital signs were initially: 98.0 122 174/85 16 92%ra.
Exam was notable for the absence of wheezes and a CXR was read
as interval improvement in previously present bibasilar
infiltrates. He was also complaining of pleuritic left chest
pain. He was given ceftriaxone/azithro, albuterol/atrovent nebs,
solumedrol 125 and placed on CPAP for tachypnea and concern that
he was tiring. BiPap settings prior to transfer were fio2 60%
and 15/5 with the most recent ABG 7.33/40/216.
.
REVIEW OF SYSTEMS:
No fevers, chills, weight loss, diaphoresis, headache, visual
changes, sore throat, chest pain, shortness of breath, nausea,
vomiting, abdominal pain, constipation, diarrhea, melena,
pruritis, easy bruising, dysuria, skin changes, pruritis.
Past Medical History:
COPD, admission to [**Hospital1 2177**] with COPD exacerbation last winter.
AAA
HTN
Hyperlipidemia
Gout
Osteoporosis, history of L1 burst fracture on chronic opioids
for pain relief, l3 compresion fracture
Social History:
History of EtOH abuse with beer, no history of illicit drug use.
Long history of smoking >40 years of 2 ppd, currently smoking
[**11-24**] pack per day. Lives by himself, is on disability.
Family History:
No history of CAD. Otherwise non-contributory.
Physical Exam:
VS: T P BP O2 %RA L NC admit weight: lbs/kg
Gen: Well/ill appearing, no acute distress, awake, alert,
appropriate, and oriented x 3, poor hygiene.
Skin: warm/cool to touch, no apparent rashes.
HEENT: No conjunctival pallor, no scleral jaundice, PERRLA,
EOMI, OP clear, no cervical LAD, no palpable thyroid nodules.
CV: JVP cmH20, carotid w/o bruits, diminished heart sounds, RRR
no audible m/r/g, PMI non-displaced, no RV heave, pulses R-DP
2+/1+/doppler, L-DP 2+/1+/Doppler, R-radial 2+/1+/Doppler,
L-radial 2+/1+/Doppler, No/1+/2+/3+ peripheral edema.
Lungs: clear to auscultation, wheezing, crackles, fremitus,
dullness to percussion.
Abd: soft, NT, normal BS, hemoccult neg. No hepatomegaly, No
splenomegaly. No abd bruits.
Ext: No C/C/E
Neuro: Gait, strength and sensation intact bilaterally.
Pertinent Results:
Admission:
[**2131-11-27**] 06:45PM GLUCOSE-99 UREA N-11 CREAT-0.8 SODIUM-130*
POTASSIUM-8.5* CHLORIDE-95* TOTAL CO2-18* ANION GAP-26*
[**2131-11-27**] 06:45PM estGFR-Using this
[**2131-11-27**] 06:45PM WBC-26.2*# RBC-4.78 HGB-14.6 HCT-44.9 MCV-94
MCH-30.6 MCHC-32.7 RDW-14.6
[**2131-11-27**] 06:45PM NEUTS-85* BANDS-6* LYMPHS-2* MONOS-7 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2131-11-27**] 06:45PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2131-11-27**] 06:45PM PLT COUNT-337#
[**2131-11-27**] 06:43PM COMMENTS-GREEN TOP
[**2131-11-27**] 06:43PM GLUCOSE-110* LACTATE-3.0* NA+-139 K+-4.4
CL--96* TCO2-24
Other:
[**2131-11-30**] 08:55AM BLOOD proBNP-2557*
Discharge:
[**2131-12-3**] 05:45AM BLOOD WBC-13.9* RBC-4.14* Hgb-12.9* Hct-39.0*
MCV-94 MCH-31.2 MCHC-33.1 RDW-14.7 Plt Ct-284
[**2131-12-3**] 05:45AM BLOOD Glucose-120* UreaN-23* Creat-0.7 Na-138
K-4.1 Cl-99 HCO3-30 AnGap-13
[**2131-12-3**] 05:45AM BLOOD Calcium-8.9 Phos-3.7 Mg-1.8
MICRO:
[**2131-11-28**] 1:05 am SPUTUM Site: EXPECTORATED
Source: Expectorated.
**FINAL REPORT [**2131-11-30**]**
GRAM STAIN (Final [**2131-11-28**]):
>25 PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS, CHAINS, AND
CLUSTERS.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2131-11-30**]):
MODERATE GROWTH Commensal Respiratory Flora.
GRAM NEGATIVE ROD #1. SPARSE GROWTH.
GRAM NEGATIVE ROD #2. RARE GROWTH.
CXR [**11-27**]
IMPRESSION: Marked interval improvement in previous pattern of
patchy
bibasilar opacities. Minimal residual linear opacities within
the left mid
lung field may represent the residual of prior infection. No new
areas of
focal consolidation seen. Severe emphysema.
CXR [**11-29**]:
HISTORY: Emphysema. Recent pneumonia. Readmitted with dyspnea.
IMPRESSION: PA and lateral chest compared to chest radiographs
since [**2129**],
most recently [**11-27**] and 6:
Coarse interstitial abnormality in the left lower lung has
worsened
accompanied by increase in small left pleural effusion and
hypervascularity of the left lung. The patient has severe
emphysema, which is likely to make an otherwise easily
recognizable process difficult to diagnose. Therefore, even
though heart is normal size and the right lower lung is
relatively clear; there is enough possibility that this is
asymmetric pulmonary edema. The patient should be treated with
that in mind in addition to receiving antibiotics dictated by
clinical circumstances. There is also coarsening of
bronchiectasis and scarring in the right lung apex, which has
progressed since [**11-27**]. Rather than ascribing this to a
second concurrent infection such as tuberculosis, it could be
another focus of asymmetric pulmonary edema.
CHEST X-RAY [**12-2**]
HISTORY: Short of breath, possible volume overload or pneumonia.
PA AND LATERAL VIEWS: Comparison with previous study done
[**2131-11-29**]. The lungs are hyperexpanded consistent with COPD as
before. There is scattered
parenchymal scarring as demonstrated previously most pronounced
in the upper lobes. Coarse interstitial markings are again noted
on the left. Compared with the previous study, these coarsened
interstitial markings appear slightly less prominent. There is
no new, focal infiltrate. The heart is normal in size. The aorta
is calcified. Mediastinal structures are unchanged. Orthopedic
hardware is again demonstrated in the thoracolumbar spine.
IMPRESSION:
Interval improvement in coarse interstitial markings in the
lower left lung. No other significant change.
ECHO:
The left atrium and right atrium are normal in cavity size. The
estimated right atrial pressure is 0-5 mmHg. Left ventricular
wall thickness, cavity size, and global systolic function are
normal (LVEF>55%). Due to suboptimal technical quality, a focal
wall motion abnormality cannot be fully excluded. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets are mildly thickened (?#). There is no
aortic valve stenosis. Trace aortic regurgitation is seen. The
mitral valve appears structurally normal with trivial mitral
regurgitation. The pulmonary artery systolic pressure could not
be determined. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Normal biventricular
cavity sizes with preserved global biventricular systolic
function. Aortic valve sclerosis.
Brief Hospital Course:
66 year-old man with emphysema, AAA, HTN, and recent PNA who
presented with dyspnea.
1. Acute hypoxic respiratory failure, with CHF exacerbation and
exacerbation of severe COPD: Dyspnea in the context of
leukocytosis and recent severe pneumonia requiring intubation
initially felt to be hospital acquired pneumonia and he was
treated for this. His sputum cultures were unrevealing and his
white count trended down. Antibiotics were narrowed to just
levofloxacin and he was also treated with prednisone and
nebulizers. Chest xray was read as possible asymmetric pulmonary
edema, and a BNP was sent and it was elevated at around 2550. He
was diuresed about 2 liters and a repeat chest xray demonstrated
improvement. An ECHO showed preserved systolic function. He was
discharged on a 2 wk prednisone taper, levofloxacin to complete
10 days and with close f/u with PCPs office in addition to VNA
care for cardiopulmonary assessment and home safety evaluation.
2. Congestive heart failure, with preserved systolic function
This diagnosis was discussed with the echocardiographer. There
is no indication for ace inhibitor or beta blocker. He should
continue a low sodium diet.
3. Hyperlipidemia: continued atorvostatin
4. Gout: continued allopurinol
5. Abdominal aortic aneurysm: would recommend PCP to arrange
[**Name9 (PRE) 702**] ultrasound
6. Chronic lower back pain: continued percocet prn
His code status was full
Medications on Admission:
1. Risedronate 35 mg Tablet Sig: One (1) Tablet PO once a week.
2. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for pain.
3. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO twice a day.
4. Vitamin D 400 unit Capsule Sig: Two (2) Capsule PO once a
day.
5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
6. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: One (1)
inhalation twice a day.
11. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Inhalation once a day.
12. Albuterol Sulfate 0.63 mg/3 mL Solution for Nebulization
Sig: [**11-24**] Inhalation every 4-6 hours as needed for shortness of
breath
13. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for Constipation.
3. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
4. Albuterol Sulfate 0.63 mg/3 mL Solution for Nebulization Sig:
[**11-24**] solution Inhalation every 4-6 hours as needed for shortness
of breath or wheezing.
5. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) puffs Inhalation four times a day as needed for
shortness of breath or wheezing.
6. Allopurinol 300 mg Tablet Sig: 0.5 Tablet PO once a day.
7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed for pain.
9. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day
for 4 days.
Disp:*4 Tablet(s)* Refills:*0*
11. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
12. Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO
Q6H (every 6 hours) as needed for cough.
Disp:*100 ML(s)* Refills:*0*
13. Prednisone 5 mg Tablet Sig: as directed Tablet PO once a day
for 2 weeks: Take 6 pills for 2 days, then 5 pills for 2 days,
then 4 pills for 2 days, then 3 pills for 2 days, then 2 pills
for 2 days, then 1 pill for 2 days, then one-half pill for 2
days
*reduce by one pill every two days.
Disp:*22 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary:
Emphysema
Congestive heart failure with preserved systolic function
Secondary:
AAA
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
Dear Mr. [**Known lastname 13621**],
You were admitted because you felt short of breath. You did not
have a pneumonia again, but you did have extra fluid in the
blood vessels in your lungs. We gave you a medicine called
furosemide which makes you urinate and reduces the fluid on your
lungs. The extra fluid usually means that your heart is having
trouble pumping it out. This could be because of your emphysema.
You may need to take furosemide at home to prevent fluid build
up. The echocardiogram will help us understand why this
happened.
The following changes were made to your medications:
START levofloxacin
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 2482**] [**Last Name (NamePattern4) 10466**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 250**]
Date/Time:[**2131-12-7**] 10:00
|
[
"272.4",
"275.2",
"275.3",
"V85.0",
"493.22",
"733.00",
"799.4",
"441.4",
"518.81",
"274.9",
"338.4",
"733.13",
"305.1",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11336, 11393
|
7509, 8932
|
286, 292
|
11530, 11530
|
2907, 7486
|
12315, 12490
|
2025, 2073
|
9712, 11313
|
11414, 11509
|
8958, 9689
|
11675, 12292
|
2088, 2888
|
1329, 1572
|
243, 248
|
320, 1310
|
11544, 11651
|
1594, 1802
|
1818, 2009
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,434
| 124,064
|
15071
|
Discharge summary
|
report
|
Admission Date: [**2189-2-23**] Discharge Date: [**2189-5-5**]
Date of Birth: [**2129-9-17**] Sex: F
Service: Liver Transplant Service
CHIEF COMPLAINT: End-stage liver disease secondary to
Hepatitis C.
HISTORY OF PRESENT ILLNESS: The patient is a 59-year-old
female admitted to the [**Hospital1 69**]
with hepatic encephalopathy, intractable ascites secondary to
hepatitis C with Child's class C cirrhosis for liver
transplantation.
PAST MEDICAL HISTORY: 1. Noninsulin dependent diabetes
mellitus. 2. History of intravenous drug use. 3. History of
ventral hernia. 4. Liver failure. 5. Child's class C
cirrhosis secondary to hepatitis C. 6. History of SVB with
E. coli. 7. Grade II esophageal varices. 8. Status post
cholecystectomy in [**2180**]. 9. Transthoracic echocardiogram in
[**2185**] with an ejection fraction of 60%.
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: The patient lives with her daughter and is
currently on disability. She is a former substance abuse
counselor.
MEDICATIONS ON ADMISSION: 1. Lasix 40 once a day. 2. Cipro
500 mg p.o. q.d. 3. Aldactone 100 mg p.o. q.d. 4. Protonix
40 mg p.o. q.d. 5. Lactose 30 cc titrated to three to four
bowel movements per day.
HOSPITAL COURSE: The patient was admitted to the
liver transplant service and underwent an orthotopic liver
transplantation on [**2189-4-24**]. The patient was transferred to
the intensive care unit postoperatively and by postoperative
day number four the patient was weaned down to a pressor
support of 5 and 5. She was doing fairly well off pressors
and with a bilirubin of 1.3. Despite weaning successfully
down to 5 and 5, she failed her initial extubation on
postoperative day five due to hypercarbia. The patient was
finally extubated on postoperative day eight.
On postoperative day 10 the patient underwent an ultrasound
which showed hepatic artery thrombosis. The patient was
taken back to the operating room where she underwent an aorta
to hepatic artery bypass with previous donor iliac artery.
The patient was again transferred to the intensive care unit
after the surgery.
Postoperatively the patient was acidotic with pressor
requirement and oliguria. These were all thought to be
secondary to hepatic ischemia. She required
retransplantation two days after being taken back to the
operating room for hepatic artery thrombosis. Her liver was
noted to be necrotic. She was transferred to the intensive
care unit after her second liver transplant on pressors and
oliguric.
By postoperative days number 20, number 10 and number 8, she
was off pressors tolerating tube feeds but still requiring
ventilatory support. She was on 10 of pressor support and 5
of PEEP.
On postoperative day 22 from her first liver transplant, she
was extubated but required reintubation that afternoon for
hypercarbia and respiratory distress. Despite aggressive
diuresis and multiple attempts at weaning the vent, the
patient failed these attempts and tracheostomy was finally
performed on [**2189-3-28**]. The rest of her hospital stay was
characterized by failure to wean from the ventilator.
Due to concerns for aspiration and vomiting when tube feeds
were placed into the stomach, the patient was fed with a
postpyloric tube and she tolerated tube feeds well. However
multiple times she pulled out her postpyloric tube. At
present the patient is on TPN and off antibiotics. She is
currently on 10 of pressor support with 5 or PEEP, 40% FIO2
and breathing comfortably.
DISCHARGE MEDICATIONS:
1. Bactrim 1 tablet p.o. q.d. This can also be given as an
elixir.
2. Lansoprazole oral suspension 30 mg per nasogastric tube
q.d.
3. Valganciclovir 450 mg p.o. q.d.
4. Heparin 5,000 units subcutaneous q. 8 hours.
5. Nystatin oral suspension 5 cc p.o. q.i.d.
6. Albuterol 1-2 puffs q. 6 hours.
7. Atrovent 2 puffs q.i.d.
8. Reglan 10 mg IV q. 8 hours.
9. Citalopram 20 mg p.o. q.d.
10. Lopressor 100 mg p.o. t.i.d.
11. Insulin sliding scale.
12. Lasix 20 mg IV b.i.d.
13. Methylprednisolone 50 mg IV q.d. This is part of her
immunosuppression regimen.
14. Cyclosporine (Neoral) 100 mg p.o. q. 12 hours.
15. CellCept 1,500 mg p.o. b.i.d.
Neoral level should be checked twice weekly.
DIET: For nutrition the patient has been on a stable TPN
regimen which is as follows: She gets two liters of TPN with
100 grams of amino acid per liter and 340 grams of dextrose
per liter.
The patient is on no antibiotics except for the prophylactic
Bactrim and valganciclovir.
DISPOSITION: She will be discharged to rehabilitation in
stable condition but with failure to wean from the
ventilator.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], M.D.,Ph.D. 02-366
Dictated By:[**Last Name (NamePattern1) 44026**]
MEDQUIST36
D: [**2189-5-5**] 09:34
T: [**2189-5-5**] 11:34
JOB#: [**Job Number **]
|
[
"570",
"571.5",
"070.54",
"997.5",
"518.81",
"444.89",
"V46.1",
"789.5",
"996.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"87.54",
"50.59",
"39.26",
"38.91",
"38.06",
"38.93",
"88.47",
"96.72",
"31.1",
"50.11",
"51.36",
"50.12"
] |
icd9pcs
|
[
[
[]
]
] |
3561, 4913
|
1073, 1254
|
1272, 3538
|
174, 225
|
254, 458
|
481, 916
|
933, 1046
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,439
| 120,530
|
13122
|
Discharge summary
|
report
|
Admission Date: [**2115-9-18**] Discharge Date: [**2115-9-28**]
Service: MEDICINE
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 5755**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
radiotherapy
History of Present Illness:
Pt is a 82 yo woman with a hx of meningioma who had resection in
[**6-27**] by Dr. [**Last Name (STitle) **]. She has been undergoing XRT Mon-Fri daily at
[**Hospital1 18**]. She presented to [**Hospital6 5016**] with altered mental
status. Found to be hypoxic in pulmonary edema and with rapid
afib. She was sent here for further evaluation and care.
Past Medical History:
ESRD stage, dialysis Mon-Wed-Friday
Hypertension
Renal vascular disease
CAD, CHF
Recurrent Meningioma
Colon CA s/p colectomy
Social History:
Lives at home with elderly husband.
Denies Etoh. Quit tobacco [**2078**].
Family History:
NC
Physical Exam:
97.4 104/80 110 20 97% RA
Pt is awake and responds but not completely oriented. She knows
she is at "[**Hospital **] HOspital" but unable to correctly answer
any other questions.
PERRL, EOMI
CV-IRRR
lungs - crackles at bases
abd - soft, NT
ext - no c/c/e
+ foley
RUE with surgical wound approx 15 cm clean with sutures still in
place
moves all extremities
does not cooperate with neuro exam otherwise
Pertinent Results:
[**2115-9-18**] 08:00PM GLUCOSE-89 UREA N-36* CREAT-7.6*# SODIUM-136
POTASSIUM-8.4* CHLORIDE-95* TOTAL CO2-25 ANION GAP-24*
[**2115-9-18**] 08:00PM ALT(SGPT)-21 AST(SGOT)-93* LD(LDH)-1122*
CK(CPK)-102 ALK PHOS-95 TOT BILI-0.7
[**2115-9-18**] 08:00PM CALCIUM-11.1* PHOSPHATE-6.7* MAGNESIUM-2.8*
[**2115-9-18**] 08:00PM TSH-0.83
[**2115-9-18**] 08:00PM WBC-4.9 RBC-4.76# HGB-13.9# HCT-42.5# MCV-89
MCH-29.2 MCHC-32.7 RDW-16.0*
[**2115-9-18**] 08:00PM NEUTS-68.4 LYMPHS-20.5 MONOS-9.1 EOS-1.7
BASOS-0.3
[**2115-9-18**] 08:00PM PT-15.2* PTT-25.1 INR(PT)-1.4*
.
BLOOD CX [**9-18**], [**9-21**]: PENDING
.
EKG: Atrial fibrillation with a rapid ventricular response. Left
bundle-branch block. Left axis deviation. ST-T wave changes
consistent with the left bundle-branch block. Compared to the
previous tracing no significant change.
.
PA/lateral CXR FINDINGS: The heart and mediastinal contours are
stable with cardiomegaly with left ventricular prominence. The
mediastinal contours are stable. The lungs are grossly clear.
There is blunting of the left costophrenic angle secondary to
small left pleural effusion. The pulmonary vasculature is
normal.
IMPRESSION: Stable cardiomegaly and small left pleural effusion.
No evidence for CHF.
.
NON-CONTRAST CT SCAN OF THE HEAD:
There has been no change from the previous examination of
[**2115-9-20**]. Malacic changes are noted in the right parietal
region attributable to the prior surgery for meningioma. There
are small low-density zones in the anterior aspect of the right
internal capsule attributable to chronic infarct.
CT angiogram of intravenous contrast material, multiplanar
reformatted images and additional 3-dimensional reconstructed
images.
FINDINGS: There is no evidence of aneurysm or flow abnormality.
Specifically, there is no evidence of flow abnormality in the
vertebrobasilar circuit or in the posterior cerebral arteries.
Note is made of an enhancing nodule subjacent to the operative
flap in the right parietal region, probably representing
recurrent meningioma. There is mild irregularity of the carotid
arteries in the post-cavernous and cavernous portions.
IMPRESSION: No evidence of posterior fossa circulation flow
abnormality. Enhancing nodule in operative bed consistent with
recurrent meningioma.
.
EEG IMPRESSION: Abnormal EEG due the presence of intermittent
slowing in
the right posterior quadrant, rasing the possiblity of a focal
subcortical dysfunction in that area. This was overshadowed by
the
background slowing and bursts of generalized delta frequency
slowing
suggestive of an encephalopathy; medications, infection and
metabolic
abnormalities are the most common causes. No epileptiform
discharges or
seizures were noted.
.
CT PULMONARY ANGIOGRAM WITHOUT AND WITH INTRAVENOUS CONTRAST: No
evidence of pulmonary embolus. The aorta contains
atherosclerotic calcifications with a small amount of mural
thrombus but is otherwise unremarkable. There are coronary
artery calcifications. The heart is enlarged. The airways are
patent to the segmental level bilaterally. There is a small
nodular opacity in the left upper lung lobe. There are minimal
dependent changes and subsegmental atelectasis at the lung bases
bilaterally. There is tiny left pleural effusion. There is a
3-mm nodule seen peripherally within the right upper lung lobe.
There are scattered bullae throughout the lung fields suggesting
emphysematous changes. There are small, non-pathologically
enlarged lymph nodes seen within the mediastinum, specifically
within the right paratracheal region measuring up to 8 mm. There
is no pathologically enlarged axillary, hilar, or mediastinal
lymphadenopathy. The visualized esophagus appears thickened
throughout its intrathoracic course. Within the visualized
abdomen, the visualized portion of the liver contains a 5-mm
hyperenhancing focus in the posterior aspect of the right lobe
of the liver, which is incompletely characterized on this
examination. The visualized portions of the spleen, stomach, and
adrenal glands are unremarkable.
BONE WINDOWS: There are no suspicious lytic or sclerotic osseous
lesions. Degenerative changes are seen throughout the visualized
thoracic spine.
CT REFORMATS: Coronal, sagittal, and oblique sagittal
reformatted images confirm the axial findings.
IMPRESSION:
1. No evidence for pulmonary embolus.
2. Small left upper lobe nodular opacity which may represent
scarring or early focus of airspace consolidation.
3. 3-mm right upper lung lobe nodule. This finding should be
followed with a CT of the chest in three months if the patient
has a primary malignancy; if there is no known primary
malignancy, the patient should receive a follow-up chest CT in
six months.
4. Small, 5-mm, enhancing focus in the posterior right lobe of
the liver, which is incompletely characterized on this
examination. When the patient's clinical condition improves, a
liver ultrasound may help for further characterization.
5. Possible thickening of the esophagus throughout its
intrathoracic course. Clinical correlation is recommended.
.
MRI EXAMINATION OF THE BRAIN WITH CONTRAST
Multiplanar T1- and T2-weighted images of the brain was obtained
without and with intravenous gadolinium administration.
Comparison is made to the prior brain MRI from [**2115-7-6**].
Patient has undergone previously known resection of a right
posterior frontoparietal convexity tumor presumably representing
a meningioma. There has been significant resolution of the
previously seen vasogenic edema. No midline shift or mass effect
is present.
The overall exam is degraded by repeated motion artifact.
Post-gadolinium enhancement images are significantly degraded by
motion artifact. There is a small area of residual enhancement
noted along the periphery of the posterior frontal convexity,
probably representing either residual meningioma or
postoperative meningeal scarring.
No acute territorial infarcts are seen within the brain on
diffusion images. Scattered foci of magnetic susceptibility are
noted within the left thalamus and right periventricular white
matter, unchanged in appearance since the previous exam
suggestive of possible small cavernous angiomas or changes
related to amyloid angiopathy. Scattered T2 hyperintense foci
are noted along the periventricular white matter suggestive of
chronic microvascular ischemic or gliotic changes.
IMPRESSION: Resolution of the previously noted vasogenic edema
since the prior exam of [**2115-7-6**], along the right posterior
frontal convexity. Patient has undergone resection of an
extraaxial lesion with postsurgical changes seen. There is no
underlying mass effect or edema on the current exam. The overall
exam is moderately degraded by repeated motion artifact. There
are several scattered foci of magnetic susceptibility
representing either small cavernomas or changes related to
amyloid angiopathy. Further followup is suggested based on
clinical grounds.
Brief Hospital Course:
# AMS:
Patient transferred from [**Hospital 189**] Hospital where she was brought
for altered mental status onset while undergoin brain xrt for
recurrent meningioma with accelerated changes on keppra for
seizure prophylaxis. Patient was found to have a urinary tract
infection, which was likely a contributing factor. She has
completed a 7 day course of cipro for this. Brain MRI was
without new findings. Patient was combative on admission but
soon after admission had an episode of unresponsiveness in the
setting of hypotension. EEG was without epileptic focus but did
show encephalopathy. Neurology was consulted and recommended
CTA brain to rule out filling defects. This was unremarkable.
Suspect episode was due to medication effect. Patient was taken
off her home ativan and keppra was switched to dilantin.
Patient has significantly improved. Patient is currently alert
and oriented to hospital and the month. She continues to be
inattentive and is still delirious, occasionally unable to give
the year. Likely this is the effect of ongoing brain xrt.
.
# Hypotension: This was transient soon after admission. Her
systolic blood pressure has been running in the 120's since ICU
callout [**2115-9-24**]. ECHO with suggestion of diastolic CHF but
normal EF. Cardiac enzymes negative x 2 and CTA chest negative
for PE. Cortisol 16. Patient has been monitored on tele which
has only shown SVT up to the 120s but generally in the low 100s.
.
# UTI: Patient completed 7 days of cipro (finished [**2115-9-28**]).
Recommend follow-up UA and urine culture to confirm resolution.
.
# ESRD: Patient has been continued on hemodialysis in house.
She takes renagel and nephrocaps. Her electrolytes and volume
status are stable. She receives epogen with hemodialysis.
.
# Meningioma: Brain xrt initially held but restarted [**2115-9-25**].
She has completed 20 of 33 total planned treatments. She will
continue on daily xrt here at [**Hospital1 18**]. Per neurooncology, she was
started on empiric steroids this admission. She is continued on
dilantin for seizure prophylaxis. She will need a dilantin
level rechecked on Tuesday. Please correct this for her renal
failure and low albumin (3.1).
.
# Thrombocytopenia: Platelets dropped from 259 to 111. Patient
was HIT antibody positive. Heparin products were stopped and
her platelets have since improved to 255. Heme fellow was
curbsided and staffed with attending. Suspect this was not true
HIT. Platelets may have been affected by concurrent
keppra-dilantin. No indication for anticoagulation. However,
avoiding all heparin products!
.
# Afib:
Patient admitted with afib with rapid ventricular response (hr
111). She continues to have occasional hr up to 120s also
consistent with afib with RVR. She is currently on metoprolol
50 mg po bid. This has been increased today to 62.5 mg po bid
for improved control given persistent hr in low 100s. Continue
ASA. Consider coumadin in the future. Discussed with
neurooncologist who states it would not be contraindicated given
low risk of bleeding with meningioma.
.
# Depression: Patient continued on her home lexapro.
.
# FEN. pureed, nectar thick, renal, cardiac diet with aspiration
precautions (needs assistance with feeding)
.
# PPx. PPI. Bowel regimen. Pneumoboots.
.
# Communication. Daughter [**Name (NI) 14880**] [**Last Name (NamePattern1) **] (HCP) ([**Telephone/Fax (1) 40061**]
.
# Code. Full per discussion with family but no prolonged
intubation.
.
# Dispo: discharged to [**Hospital **] Rehab
Medications on Admission:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed: please do not drive while
taking pain medications.
Disp:*45 Tablet(s)* Refills:*0*
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day). Tablet(s)
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
5. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
6. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
9. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
10. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
11. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
12. Levetiracetam 250 mg Tablet Sig: One (1) Tablet PO AM ().
13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Discharge Medications:
1. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
2. Metoprolol Tartrate 50 mg Tablet Sig: 62.5 mg PO twice a day:
hold for sbp < 100 or hr < 55.
3. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
9. Dexamethasone 2 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. Aspirin, Buffered 325 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Phenytoin 50 mg Tablet, Chewable Sig: Three (3) Tablet,
Chewable PO three times a day.
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
13. Aluminum Hydroxide Gel 600 mg/5 mL Suspension Sig: 5-10 MLs
PO Q8H (every 8 hours) as needed for GI upset.
14. Prochlorperazine 5 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for nausea.
15. insulin - regular
per sliding scale
16. Vitamin D 400 unit Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
delirium
urinary tract infection
recurrent meningioma
thrombocytopenia
end stage renal disease
atrial fibrillation with rapid ventricular response
Discharge Condition:
good: oriented x hospital, [**Location (un) 86**], [**Month (only) **] but not the year,
alert, afebrile
Discharge Instructions:
Please monitor for worsening mental status, temperature > 101,
or other concerning symptoms.
Followup Instructions:
Please follow-up with your primary care doctor, Dr. [**First Name4 (NamePattern1) 7019**] [**Last Name (NamePattern1) **],
in [**12-24**] weeks. Phone: [**Telephone/Fax (1) 40062**].
Please continue to follow-up for your daily radiation
treatments. Phone: ([**Telephone/Fax (1) 8082**]
Please continue your hemodialysis.
Please call to schedule follow-up with your neurooncologist upon
completion of radiation treatments. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**]. Phone:
([**Telephone/Fax (1) 6574**]
|
[
"E936.3",
"428.0",
"192.1",
"599.0",
"403.91",
"311",
"427.31",
"428.20",
"285.21",
"414.01",
"458.8",
"276.7",
"V10.05",
"585.6",
"287.5",
"E879.2",
"276.52",
"293.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"92.29",
"38.93",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
14453, 14532
|
8288, 11828
|
244, 258
|
14723, 14830
|
1335, 8265
|
14971, 15512
|
894, 898
|
13098, 14430
|
14553, 14702
|
11854, 13075
|
14854, 14948
|
913, 1316
|
183, 206
|
286, 639
|
661, 787
|
803, 878
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,073
| 192,491
|
4871
|
Discharge summary
|
report
|
Admission Date: [**2130-1-1**] Discharge Date: [**2130-1-4**]
Date of Birth: Sex: M
Service:
DISCHARGE DIAGNOSIS:
1. End-stage renal disease
2. Gangrenous appendicitis
3. Ischemic bowel
4. Multiple organ failure
DISCHARGE DISPOSITION: The patient expired on [**2130-1-4**].
HISTORY OF PRESENT ILLNESS: This is a 47-year-old gentleman
with end-stage renal disease who is five years status post
living-related donor kidney transplantation. He presented
with vomiting, diarrhea, and crampy abdominal pain.
He had presented to an outside hospital approximately one week
prior to admissioAfrican American male with a history of
prior to admission here with fevers and symptoms of a urinary
tract infection.
Of note, he has a history of significant multiple urinary
tract infections, cellulitis, hypertension, and morbid
obesity, and a ventral hernia that was repaired in [**2124**]. It
was felt that he was having another urinary tract infection
and subsequently grew enterococcus in his urine. He was
treated initially with intravenous antibiotics including
ciprofloxacin and then defervesced and had symtomatological
improvement within two days. His creatinine was slightly
elevated at this point but came back to his baseline prior to
discharge. He was discharged on oral Keflex.
Once he was home, he developed nausea, vomiting and diarrhea,
with crampy abdominal pain. He felt this was related to the
Keflex which he subsequently stopped. Since then, he was
feeling somewhat better.
PAST MEDICAL HISTORY:
1. Chronic renal failure secondary to membranous
glomerulonephropathy.
2. Hypertension.
3. Morbid obesity.
4. History of cellulitis.
5. History of urinary tract infections.
6. History of a large ventral hernia.
7. History of cytomegalovirus infection.
8. Left popliteal deep venous thrombosis.
PAST SURGICAL HISTORY:
1. Living-related kidney transplantation on [**2124-1-12**].
2. Ventral hernia repair in [**2124**].
3. Left arteriovenous fistula placement.
MEDICATIONS ON ADMISSION: Medications included sirolimus,
Neoral, prednisone, Bactrim, Prilosec, Lopressor, Librax,
Accupril, Lipitor, Coumadin, Catapres, Bumex, and colchicine.
PHYSICAL EXAMINATION ON PRESENTATION: On examination, he was
awake, alert, and morbidly obese. His temperature was 98.7,
heart rate was 112, and blood pressure was 118/70. Head and
neck examination was unremarkable. His neck was supple with
no lymphadenopathy. He had regular heart sounds. The lungs
were clear to auscultation. His abdomen was very obese and
difficult to examine but appeared to be soft and nondistended.
He had no gurading or rebound tenderness. No masses were
felt. Neurologic examination was grossly intact.
PERTINENT LABORATORY VALUES ON PRESENTATION: His white blood
cell count was 10.3 and hematocrit was 39.7. His creatinine
was up to 2.9. Liver function tests, amylase, and lipase were
normal.
HOSPITAL COURSE: He was admitted to undergo intravenous
hydration and further workup. He maintained good urine output
overnight and stayed afebrile.
Early in the morning he had respiratory deterioration and
acidosis quickly progressing to the stage that he required
intubation. Our initial concern was one of pulmonary
embolism, but we were unable to obtain a computed tomography
scan due to his size.
He was transferred to the Intensive Care Unit where he
continued to deteriorate hemodynamically, requiring pressor
support. At this point we felt that he was developing an
acute abdomen, and we decided to do surgical exploration.
Upon exploration, he was found to have an incarcerated ventral
hernia. Once this was reduced, we noted his appendix was
gangrenous but not perforated. This was excised. There were
several areas of patchy ischemia in the small bowel; two of
which were resected and left unanastomosed with a plan to
bring him back for a second-look laparotomy.
He was transferred back to the Intensive Care Unit, and his
abdomen was kept open and covered with an Ioban drape. He
continued to require pressor support and bicarbonate therapy
for correction of his acidosis. His urine output had petered
down to almost nothing, and he was started on continuous
venovenous hemofiltration.
The following day we brought him back for a second-look
laparotomy. At this stage, we noted sseveral other areas of
ischemic bowel. Also, his right colon was ischemic with some
areas in the cecum of frank gangrene. He underwent a right
colectomy and resection of a large segment of small bowel.
The plan was to bring him back for a third-look laparatomy in
the morning. We left his abdomen open and covered with a
sterile Ioban drape.
Overnight, his instability worsened in the Intensive Care
Unit. He required continuous pressor support and more and
more bicarbonate therapy with little response.
Throughout this process, we had close discussions with his
family; in particular his wife. The [**Name2 (NI) 20345**] prognosis was
explained to them. At this point, a collective decision was
made in cooperation with the family to withdraw support. This
was done, and the patient expired shortly thereafter. A
postmortem examination will be obtained.
[**Name6 (MD) 1344**] [**Name8 (MD) 1345**], M.D. [**MD Number(1) 1346**]
Dictated By:[**Name8 (MD) **]
MEDQUIST36
D: [**2130-4-28**] 11:06
T: [**2130-5-1**] 08:15
JOB#: [**Job Number 20346**]
|
[
"785.59",
"996.81",
"557.0",
"584.9",
"552.20",
"038.9",
"518.81",
"569.83",
"540.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"45.62",
"47.09",
"96.71",
"38.93",
"96.04",
"45.73",
"38.95",
"53.59"
] |
icd9pcs
|
[
[
[]
]
] |
268, 308
|
141, 244
|
2040, 2925
|
2943, 5430
|
1871, 2014
|
337, 1528
|
1550, 1848
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,391
| 134,160
|
38893
|
Discharge summary
|
report
|
Admission Date: [**2182-5-20**] Discharge Date: [**2182-5-31**]
Date of Birth: [**2100-8-23**] Sex: M
Service: MEDICINE
Allergies:
Lasix / metolazone / zeroxolyn
Attending:[**First Name3 (LF) 15397**]
Chief Complaint:
Melena, abdominal pain, decreased Hct
Major Surgical or Invasive Procedure:
EGD with clips/cauterization
EGD without intervention
Colonoscopy
History of Present Illness:
Mr. [**Known lastname 13004**] is an 81 year old man with a h/o thalamic hemorrhagic
stroke 1 year ago, recent GI bleed s/p EGD showing 3 duodenal
ulcers who presents from [**Hospital 100**] Rehab with melanotic stools, HCT
drop from 29->21.
The patient was recently admitted from [**Date range (3) 86309**] for
melena and HCT drop, and EGD revealed 3 duodenal ulcers. He was
given 1 unit of blood and discharged to [**Hospital 100**] Rehab with plans
for outpatient colonoscopy. Biopsies were negative for H pylori,
CMV, but did reveal [**Female First Name (un) **] infection, which has not yet been
treated.
Since then he has complained of [**3-5**] periumbilical pain,
nonradiating, dull and achy that does not change with eating
meals. He has not had nausea or vomitting. He denies recent
NSAID or alcohol use. He does report melena. He was seen by the
MD on call at [**Hospital **] Rehab who found his HCT to drop from 29 to
21.5, and therefore sent him to the ED.
In the ED, initial VS were: 98.3 84 138/74 16 100% RA. An NG
lavage revealed red flecks of blood in clear fluid. Two
peripheral IVs were placed and he was given pantoprazole 80mg IV
ONCE followed by a drip at 8mg/hr. GI was consulted who
recommended EGD in the AM. Although he was never hypotensive,
tachycardic or actively bleeding, he was admitted to the [**Hospital Unit Name 153**]
out of concern for impending GI bleed.
On arrival to the [**Hospital Unit Name 153**], the patient was comfortable but
complaining of mild periumbilical pain. The patient was
subsequently stabilized in the medical ICU with blood
transfusions and he underwent EGD with local therapy for the
bleeding ulcer site.
Once he was hemodynamically stable, the patient was transferred
to the hospital medicine service for ongoing management.
Past Medical History:
- HTN
- Diabetes
- CAD
- Systolic CHF, EF 40%, moderate MR
- Pulmonary HTN
- Dementia
- Atrial fibrillation
- Right thalamic hemorrhage with residual left hemiplegia
- CKD stage III (baseline ~2.4)
- Gout
- Hyposplenism with infarcted spleen
- GERD
- Hiatal hernia
- Antral ulcer s/p GI bleed
- hyposplenism
- herpes zoster
- Paresthesias of both hands
- Schrapnel wound on the abdomen and groin area
- Sclerotic bone lesions NOS - bone scan negative
Social History:
Lives in [**Hospital 100**] Rehab. Has 9 children. No tobacco history.
Worked as a mechanic for air planes in [**Country 3992**], shrapnel remains
in abdomen.
Family History:
No GI or other malignancy
Physical Exam:
ADMISSION PHYSICAL to the medical ICU:
Vitals: T 98.3 HR 86 BP 144/82 RR 17 O2 97%RA
General: [**Country **], oriented, elderly man, pleasant and in no acute
distress
HEENT: Sclera anicteric, MMM, oropharynx clear,
Neck: supple, JVP not elevated
CV: Irregularly irregular rhythm, normal rate, normal S1 + S2,
no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, very mild periumbilical tenderness to palpation,
no rebound or guarding
GU: no foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
DISCHARGE PHYSICAL:
[**Name (NI) **], friendly elderly male, no acute distress
irregular irrgular rhythem, slow rate, no murmurs, rubs or
gallops
lungs clear to auscultation bilaterally, no wheezes or crackles
abdomen soft, midepigastric tenderness, nondistended, no rebound
or guarding, +BS
No foley
Warm and well perfused, no edema
Pertinent Results:
Admission blood work:
[**2182-5-20**] 03:30PM BLOOD WBC-15.8* RBC-2.75* Hgb-8.1* Hct-25.1*
MCV-91 MCH-29.6 MCHC-32.4 RDW-16.7* Plt Ct-494*
[**2182-5-21**] 09:55AM BLOOD Hct-27.6*
[**2182-5-20**] 03:30PM BLOOD Glucose-125* UreaN-33* Creat-2.5* Na-138
K-4.2 Cl-106 HCO3-21* AnGap-15
[**2182-5-21**] 02:53AM BLOOD Glucose-110* UreaN-47* Creat-2.4* Na-141
K-3.8 Cl-110* HCO3-21* AnGap-14
[**5-21**] EGD:
The exam of esophagus was normal. The exam of stomach was
normal. A visible vessel with spurting blood was seen in the mid
of an ulcer on the lateral wall of duodenal sweep. Attempts to
place the hemoclips were made. A clip was misplaced at the side
of the visible vessel. Placement of two other clips was not
successful due to the scar tissue. Then a gold probe was applied
for hemostasis successfully with the visible vessel cauterized.
Otherwise normal EGD to third part of the duodenum
[**5-30**] EGD: Healing ulcer site at the distal bulb, no vissible
vessel or bleeding seen at this site. Edema of the mucosa with
stigmata of bleeding form an area of duodenitis at the apex of
the duodenal bulb. A gold probe was applied for hemostasis
successfully.
[**5-31**] Colonoscopy: Polyp in the ascending colon. Grade 2 internal
hemorrhoids. Otherwise normal colonoscopy to cecum.
Discharge blood work:
[**2182-5-31**] 05:40AM BLOOD WBC-9.4 RBC-3.58* Hgb-10.3* Hct-32.5*
MCV-91 MCH-28.8 MCHC-31.7 RDW-16.3* Plt Ct-349
[**2182-5-31**] 05:40AM BLOOD Glucose-104* UreaN-17 Creat-2.2* Na-145
K-3.9 Cl-115* HCO3-17* AnGap-17
[**2182-5-31**] 05:40AM BLOOD Calcium-8.6 Phos-3.4 Mg-1.8
Brief Hospital Course:
81-year-old male with history of thalamic hemorrhagic stroke 1
year ago, recent GI bleed s/p EGD showing 3 duodenal ulcers who
presents from [**Hospital 100**] Rehab with melanotic stools, HCT drop from
29->21, eventually underwent an EGD showing a bleeding vessel in
the duodenum with successful hemostasis. He had a number of
blood transfusions with a few more melanotic stools and hct
drops throughout the hospitalization. A repeat EGD showed
healing ulcers and no evidence of bleed.
# GI bleed: He had 3 duodenal ulcers on a previous
hospitalization. A repeat EGD ([**5-21**]) showed evidence of an
active bleeding vessel in the middle of an ulcer on the lateral
wall of the duodenum. Several unsuccessful attempts to place
hemostat clips were made. The vessel was eventually cauterized
and hemostasis was achieved. He was treated with high dose
pantoprazole. He remained hemodynamically stable. He received 2
packed RBCs and had a stable hematocrit for a few days. He was
transitioned to an oral PPI and transferred to the general
medical [**Hospital1 **]. He then had an episode of melena with a 4 point
hematocrit drop. His hemodynamics were again stable. His
hematocrit remain stable and uptrended for the next couple of
days. However, he again had melena and had a 4 point hematocrit
drop. Due to this he was transfused 1 unit of packed RBCs with
appropriate increase in hematocrit. He had a repeat EGD with
improvement of ulcers. Given that no source of bleeding was
found, he was prepped and underwent colonoscopy which did not
show any area of bleeding but did show a polyp. He should have a
repeat colonoscopy in 6 months for removal of this polyp. His
hematocrit was stable for >72 hours at the time of discharge
(and was increasing). He should get repeat hematocrit checks
twice weekly for the next couple of weeks to make sure his
hematocrit remains stable. This should be reported to the
medical staff at [**Hospital 100**] Rehab.
# Epigastric pain: He continued to have epigastric pain, which
was somewhat improved throughout the admission. He was to
continue PPI.
# Heart failure: The patient has a contraindication to ACEi. His
ethacrynic acid was held during the admission. He was euvolemic
and the medication was not re-started. He should be evaluated at
[**Hospital 100**] Rehab as this medication may need to be restarted in the
future.
# Urinary incontinence: The patient was noted to have urinary
incontinence without evidence of acute infection. We received
information in collateral that this is not a new condition. He
was checked for post-void residuals by bladder scanner on
several occasions, which did not exceed 500cc. This was
monitored throughout his admission.
# Urine cytology from prior admission: We were aware of his
urine cytology result concerning for atypical cells on a recent
admission. This would warrant further work-up including possible
urology evaluation and consideration for cystoscopy if that were
in keeping with the patient's wishes. Given the acuity of his
condition at this time, we did not specifically address this
finding while he was an inpatient, and suggest it be
re-addressed when his condition stabilizes.
# Bullous pemphigoid: Well controlled on prednisone at 20mg,
which was continued without change.
# HTN: Due to initial bleeding, and later decreased oral intake,
his amlodipine and hydralazine were held throughout much of his
admission. The hydralazine was restarted at the time of
discharge. His blood pressures will likely tolerate restarting
amlodipine as well, however, I will defer this to [**Hospital 100**] Rehab
medical staff.
# H/o stroke: His deficits were noted and confirmed from his
prior stroke. He was not noted to have recrudescence beyond his
baseline.
# A fib: Well rate controlled. Not felt to be a good
anticoagulation candidate likely due to major hemorrhagic stroke
and also major GI bleeding.
# Code: Confirmed Full
TRANSITIONAL ISSUES:
--Monitor Hct on oral twice daily PPI with pantoprazole, and
consider if repeat endoscopy will be needed based on course
--Atypical cells in urine cytology will require consideration
for follow-up once other conditions stabilized.
--Continue to address goals of care with patient, as able, and
family, given multiple recent admissions and overall
deconditioning.
--Repeat GI procedures, to be arranged by GI at [**Hospital1 18**]
Medications on Admission:
Medications:
1. Omeprazole 40 mg PO BID
2. PredniSONE 20 mg PO EVERY OTHER DAY
3. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
hold for sedation or rr < 10.
4. Ethacrynic Acid 50 mg PO EOD
5. Senna 2 TAB PO DAILY
hold for loose stools
6. Prochlorperazine 10 mg PO Q6H:PRN nausea
7. HydrALAzine 10 mg PO TID
hold for sbp < 100 or map < 60.
8. Nitroglycerin SL 0.4 mg SL Q5MIN;PRN chest pain
9. Amlodipine 10 mg PO DAILY
hold for sbp < 100 or map < 60.
10. Vitamin D 50,000 UNIT PO Q21DAYS
11. Acetaminophen 650 mg PO Q4H:PRN pain/fever
Do not exceed 4000mg in 24 hours.
12. Ciprofloxacin HCl 250 mg PO Q24H Duration: 4 Days
To be given through [**2182-5-20**].
Discharge Medications:
1. prednisone 20 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
2. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
3. fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
4. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO q3 weeks.
5. hydralazine 10 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day): hold for SBP < 120.
6. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for Pain.
7. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1)
Sublingual as needed as needed for chest pain: please take as
previously directed.
8. senna 8.6 mg Tablet Sig: Two (2) Tablet PO once a day as
needed for constipation.
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for Constipation.
10. Outpatient Lab Work
Diagnosis: GI bleed
Please check Hct twice weekly. Please have this value reported
to the staff at [**Hospital **] rehab.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 100**] Senior Life
Discharge Diagnosis:
Primary diagnoses:
Upper GI bleed
Urinary incontinence
Secondary diagnoses:
Thalamic stroke in past, with late effects
CAD, with systolic heart failure
Dementia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: [**Hospital1 **] and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
It was a pleasure to care for during this admission. As you and
your family are aware, you were admitted for bleeding from your
stomach despite taking pills against acid at your facility. You
had a procedure where the bleeding site was treated and clipped,
and you then stopped bleeding temporarily. You did require blood
transfusions, as you lost a significant amount of blood from
this ulcer. You required ICU care early in your admission. On
the floor, you had two episodes of bleeding, one of which
required another transfusion. You were treated with another
blood transfusion. You had a repeat procedure which showed
healing of the ulcers. You then had a colonoscopy which showed a
non-bleeding polyp but was otherwise normal. You will need
follow up with the gastroenterologist, Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] (the
gastroenterology office will contact you to set up this
appointment). You will have a repeat colonoscopy in 6 months.
The appointment is listed below and is with Dr. [**First Name (STitle) **] [**Name (STitle) **].
You were noted to have urinary incontinence, which your family
tells us is usual for you. We also know that from a prior
admission, you had tests in your urine that revealed atypical
cells that could represent a malignancy. You should speak with
Dr. [**Last Name (STitle) **] or Dr. [**Last Name (STitle) **] the doctors at the facility about seeing a
urologist to further evaluate this condition, once you recover
from this illness.
We treated you with intravenous acid blocking medication, in
addition to your procedure. These medications were changed to
higher doses of pill medications after several days, at higher
doses than you were taking when you came to the hospital. You
should continue on this medication (pantoprazole) for at least
4-8 weeks, and until you speak with your doctors to [**Name5 (PTitle) 788**] if you
need any further tests.
You were started on fluconazole, because you had some fungus in
your small bowel which may have been contributing to your
ulcers. This medication should be continued for 5 more days.
For the next two weeks, please have your hematocrit checked
twice a week to make sure it remains stable.
We made the following changes to your medications:
-START PANTOPRAZOLE at 40mg twice daily
-STOP Amlodipine (this can be restarted once you do not show any
more bleeding)
-STOP ethacrynic acid (you did not need this medication while
you were inpatient, you may need to resume this medication in
the future)
-HOLD ibuprofen and other NSAIDs
-START fluconazole for 5 more days
Followup Instructions:
You should see your primary care physician when you leave rehab,
within one week. In the interim, you will be seen by the
physician at the [**Hospital3 102**] facility.
You should proceed with the following previously-scheduled
appointment for your kidneys:
Department: WEST [**Hospital 2002**] CLINIC
When: WEDNESDAY [**2182-6-5**] at 4:00 PM
With: [**Doctor Last Name **] [**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 721**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: ENDO SUITES
When: FRIDAY [**2182-11-29**] at 9:00 AM
Department: DIGESTIVE DISEASE CENTER
When: FRIDAY [**2182-11-29**] at 9:00 AM
With: [**Name6 (MD) 1948**] [**Last Name (NamePattern4) 1949**], MD [**Telephone/Fax (1) 463**]
Building: [**First Name8 (NamePattern2) **] [**Hospital Ward Name 1950**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 3202**]
Campus: EAST Best Parking: Main Garage
|
[
"112.85",
"416.8",
"427.31",
"403.90",
"424.0",
"428.22",
"285.1",
"694.5",
"585.4",
"532.40",
"428.0",
"788.30",
"530.81",
"274.9",
"438.20",
"250.00",
"V58.65"
] |
icd9cm
|
[
[
[]
]
] |
[
"44.43",
"45.23"
] |
icd9pcs
|
[
[
[]
]
] |
11663, 11722
|
5517, 9439
|
330, 397
|
11928, 11928
|
3912, 5494
|
14728, 15820
|
2886, 2913
|
10611, 11640
|
11743, 11799
|
9917, 10588
|
12117, 14351
|
2928, 3893
|
11820, 11907
|
9460, 9891
|
14380, 14705
|
253, 292
|
425, 2219
|
11943, 12093
|
2241, 2693
|
2709, 2870
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,361
| 165,651
|
1419
|
Discharge summary
|
report
|
Admission Date: [**2163-12-25**] Discharge Date: [**2163-12-31**]
Date of Birth: [**2082-12-1**] Sex: M
Service: MEDICINE
Allergies:
Aspirin
Attending:[**First Name3 (LF) 1646**]
Chief Complaint:
respiratory distress
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 8498**] is an 81 year-old former smoker with [**Last Name (un) 309**] body
dementia and dysphagia who presents with respiratory distress.
He is bedbound at baseline, cared for by his family, and has
been having likely aspiration for at least one year, with
worsening over the past week, as demonstrated by increased
coughing after eating. He was doing well until last night when
he began coughing more frequently, though his cough was
non-productive. This morning, he developed gradually worsening
dyspnea and was brought to the E.D. by his daughter and
son-in-law, Dr. [**Last Name (STitle) 1911**], one of the attending cardiolgoists
at the [**Hospital1 18**]. He was also described as having difficultly
clearing his secretions en route. ROS was negative for fevers,
chills, sick contacts, pets, n/v/diarrhea.
.
In the ED, vital signs were initially: 98.2 120 106/61 27 89%ra.
He appeared in marked respiratory distress and was placed on
cpap (peep 5), with improvement in his respiratory status. An
ABG demonstrated 7.32/39/71 and a CXR was concerning for a
likely LLL pneumonia. He was given ceftriaxone, azithro, and
clinda for aspiration and transferred to the [**Hospital Unit Name 153**].
.
REVIEW OF SYSTEMS (per family):
No fevers, chills, weight loss, chest pain, nausea, vomiting,
abdominal pain, constipation, diarrhea.
.
Past Medical History:
- [**Last Name (un) 309**]-body Dementia
- REM Behaviour Disorder (followed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **])
- BPH
- Status post partial gastrectomy
- Hypertension
- Left Radical Nephrectomy, [**3-5**] (for pT1b papillary RCC)
.
Social History:
He lives at home with his wife, daughter and son-in-law. [**Name (NI) **] has
been having cognitive/functional decline for many months now,
more so in the last month. Prior heavy smoker, quit 18 yrs ago.
Family History:
NC
Physical Exam:
VS: 98.8 80 102/49 18 96%4L
GEN: agitated, breathing with accessory muscles but appears
comfortable, not cooperative with exam
SKIN: Open decubitus on right heel and heeling pressure ulcer on
left elbow
HEENT: No JVD, neck supple, No lymphadenopathy in cervical,
posterior, or supraclavicular chains noted.
CHEST: Lungs with bilateral rhonchi
CARDIAC: Regular rhythm; no murmurs, rubs, or gallops.
ABDOMEN: Non-distended, and soft without tenderness
EXTREMITIES:no peripheral edema
NEUROLOGIC: not cooperative with exam, only able to say name. CN
II-XII grossly intact. BUE [**5-31**], and BLE [**5-31**] both proximally and
distally. +Cogwheel rigidity.
Brief Hospital Course:
Mr. [**Known lastname 8498**] is an 81 year-old former smoker with [**Last Name (un) 309**] body
dementia and dysphagia who presented with respiratory distress.
.
Primary Diagnosis: 486 PNEUMONIA, ORGANISM UNSPECIFIED
Likely secondary to aspiration pneumonitis versus pneumonia.
Now has a persistent infiltrate on CXR likely an aspiration
pneumonia vs community-acquired pneumonia. After receiving bipap
he was sent to the ICU. His respiratory status improved enough
to be transferred to the floor soon afterwards. He was treated
with levofloxacin to complete a 10 day course. At the time of
discharge he was on room air breathing comfortably.
.
Secondary Diagnosis: 584.9 ACUTE RENAL FAILURE
Secondary Diagnosis: 585.3 CHRONIC KIDNEY DISEASE, STAGE III
(30-59)
Cr elevated to 3.2 from baseline of 1.2. Improved with IVF and
intake from TF. To be checked the week following discharge.
.
Secondary Diagnosis: 276.0 HYPERNATREMIA
The patient was dehydrated on admission. Free water repleted
with combination of IV and NG free water. Nutrition recommended
daily intake of 450cc a day to maintain sodium, which did not
appear to work as his sodium was increasing on this regimen, so
he was discharged on 750cc/day of free water to be checked in
the week following discharge.
.
Secondary Diagnosis: 287.5 THROMBOCYTOPENIA, UNSPECIFIED
Has baseline Plts in mid 100's. fell lower with fluids, but
returned to baseline.
.
Secondary Diagnosis: 787.20 DYSPHAGIA, UNSPECIFIED
S/S evals revealed aspiration. Plan for 2 weeks of TF to regain
strength and to clear infection along with heavy secretions. At
2-3 weeks, repeat bedside swallowing eval to be performed to
return to prior PO intake.
.
Secondary Diagnosis: 331.82 DEMENTIA, [**Last Name (un) **] BODIES (PICK'S)
Patient with baseline severe dementia, but is able to walk with
assistance and can be alert and vocal(although oriented x 0).
Plan is to continue conservative management. Geriatrics was
consulted and recommended continuing Aricept as this has some
effects even in advance [**Last Name (un) 309**] body dementia.
Medications on Admission:
MEDICATIONS AT HOME (per OMR):
CLONAZEPAM - 0.5 mg Tablet - [**1-30**] Tablet(s) by mouth at bedtime
DONEPEZIL [ARICEPT] - 10 mg Tablet - 1 Tablet(s) by mouth once a
day
Discharge Medications:
1. Docusate Sodium 50 mg/5 mL Liquid Sig: Two (2) doses PO BID
(2 times a day) as needed for constipation.
2. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Senna 8.8 mg/5 mL Syrup Sig: Ten (10) ML PO HS (at bedtime)
as needed for constipation.
4. Levofloxacin 500 mg Tablet Sig: 0.5 Tablet PO once a day for
4 days.
Disp:*2 Tablet(s)* Refills:*0*
CLONAZEPAM - 0.5 mg Tablet - [**1-30**] Tablet(s) by mouth at bedtime
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
Primary Diagnosis: 486 PNEUMONIA, ORGANISM UNSPECIFIED
Secondary Diagnosis: 331.82 DEMENTIA, [**Last Name (un) **] BODIES (PICK'S)
Secondary Diagnosis: 584.9 ACUTE RENAL FAILURE
Secondary Diagnosis: 585.3 CHRONIC KIDNEY DISEASE, STAGE III
(30-59)
Secondary Diagnosis: 276.0 HYPERNATREMIA
Secondary Diagnosis: 287.5 THROMBOCYTOPENIA, UNSPECIFIED
Secondary Diagnosis: 787.20 DYSPHAGIA, UNSPECIFIED
Secondary Diagnosis: 293.0 DELIRIUM, NOS
Discharge Condition:
Mental Status:Confused - always
Activity Status:Out of Bed with assistance to chair or
wheelchair
Level of Consciousness:Lethargic but arousable
Discharge Instructions:
-Tube Feeding:The tube feeds will operate on a continuous pump
at 50ml/hr. The dobhoff tube has been marked at it's current
site and please ensure that it is secured at all times. When the
patient is getting out of bed or laying flat in bed, the tube
feeds should be put on hold for [**11-10**] minute prior if possible.
While the tube feeds are running the head of the bed should be
at >45 degrees. The free water flushes should start at 125 ml
six times a day and can be administered by shutting off the tube
feeds for 5-10 minutes, then slowly infused with a syringe. Our
nutritionist recommend 125 ml flushes 3 times a day to meet his
free water goals, but he appeared to require approximately 6 to
maintain his blood tests in normal range. The free water will
likely need to be adjusted based on his laboratory findings
which will be drawn by VNA 2 times in the next week.
-Swallowing function:We recommend re-evaluating his swalling
with a bedside swallowing evaluation in [**3-1**] weeks when his
strength has returned to pre-hospitalization levels. While his
swallowing function is improving, we recommend oral care every 6
hours to prevent aspiration pneumonia.
-Antibiotics:He received 7 doses of antibiotics during the
hospitalization and he will only need 3 more days of treatment.
This can be done by crushing and soaking the pills in water and
flushing them in the tube once a day.
Followup Instructions:
Dr. [**Last Name (STitle) 665**] has been contact[**Name (NI) **] about his discharge and we
recommend calling his office for follow up plans on monday. If
you would like to arrange a new patient follow up with a
geriatrician in your area that is recommended as well.
|
[
"294.10",
"486",
"584.9",
"787.20",
"707.01",
"276.0",
"507.0",
"585.3",
"287.5",
"600.00",
"403.90",
"327.42",
"707.20",
"331.82",
"V45.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
5669, 5752
|
2915, 3078
|
291, 297
|
6233, 6233
|
7824, 8096
|
2216, 2220
|
5211, 5646
|
5773, 5773
|
5016, 5188
|
6404, 7801
|
2235, 2892
|
231, 253
|
325, 1685
|
6190, 6212
|
5792, 5828
|
6247, 6380
|
1707, 1979
|
1995, 2200
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,556
| 179,659
|
41076
|
Discharge summary
|
report
|
Admission Date: [**2122-1-22**] Discharge Date: [**2122-2-4**]
Date of Birth: [**2076-10-28**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Vicodin
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Endocarditis
Major Surgical or Invasive Procedure:
[**2122-1-30**]
1. Aortic valve replacement with a size 23-mm St. [**Male First Name (un) 923**]
Regent mechanical valve.
2. Mitral valve replacement with a size 29 St. [**Male First Name (un) 923**]
mechanical valve.
[**2122-1-29**] Cardiac catheterization
History of Present Illness:
45 year old male with a history of
IVDA, Hepatitis B&C, found to have aortic and mitral valve
vegetations on echocardiogram. Endocarditis initially treated
with Vancomycin, Ciprofloxacin and Daptomycin at [**Hospital 17436**] Hospital.
Antibiotic coverage changed to Vancomycin/Gentamycin at [**Hospital1 89177**]
Past Medical History:
Hepatitis B, Hepatitis C, Depression,
IVDA(patient states he uses Herion/Cocaine 2x/wk x5 mo)-last use
2weeks ago (urine tox screen at [**Hospital 17436**] Hosp positive for
opiates),
left arm abcess, C4-5 fx-diving accident
Past Surgical History: Shoulder repair,
Nissen Fundoplication-[**2120**]
vasectomy
Social History:
Lives with: alone
Occupation: works at [**Company 22957**]-computers
Tobacco: quit 1 mo ago (2ppd x20ys)
ETOH: quit 10yrs ago (1 quart QOD)
Herion/Cocaine 2x/wk x5 mo
Family History:
adopted-no known cardiovascular disease
Physical Exam:
Temp 97.2 Pulse: 96 Resp: 16 O2 sat: 97%-RA
B/P Right: 110/41 Left:
Height: 5'[**20**]" Weight: 83.9 kg
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x] MMM, anicteric
Neck: Supple [x] Full ROM [x] no JVD or LA
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur 3/6 systolic murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] +BS [x]
Extremities: Warm [x], well-perfused [x] Edema: none
Left forearm with incised abcess site-draining seropurulent
fluid
Track marks visible on both arms
Varicosities: None [x]
Neuro: Grossly intact, nonfocal exam
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit radiated murmur bilat
Pertinent Results:
[**2122-2-4**] 05:05AM BLOOD WBC-12.0* RBC-3.25* Hgb-8.8* Hct-28.0*
MCV-86 MCH-27.2 MCHC-31.6 RDW-17.4* Plt Ct-510*
[**2122-2-2**] 05:19AM BLOOD WBC-11.5* RBC-3.07* Hgb-8.3* Hct-25.7*
MCV-84 MCH-27.2 MCHC-32.5 RDW-17.4* Plt Ct-340
[**2122-2-4**] 05:05AM BLOOD PT-32.2* PTT-76.0* INR(PT)-3.2*
[**2122-2-3**] 10:20AM BLOOD PT-24.7* PTT-56.0* INR(PT)-2.4*
[**2122-2-2**] 05:19AM BLOOD PT-16.0* PTT-26.4 INR(PT)-1.4*
[**2122-2-1**] 04:59AM BLOOD PT-13.4 INR(PT)-1.1
[**2122-1-30**] 01:01PM BLOOD PT-13.8* PTT-34.7 INR(PT)-1.2*
[**2122-1-30**] 11:57AM BLOOD PT-15.3* PTT-36.5* INR(PT)-1.3*
[**2122-1-30**] 05:03AM BLOOD PT-12.2 PTT-24.6 INR(PT)-1.0
[**2122-2-4**] 05:05AM BLOOD Glucose-97 UreaN-12 Creat-0.7 Na-133
K-4.8 Cl-101 HCO3-28 AnGap-9
[**2122-2-2**] 05:19AM BLOOD Glucose-85 UreaN-21* Creat-0.7 Na-132*
K-4.9 Cl-99 HCO3-28 AnGap-10
Intra-op TEE [**2122-1-30**]
Conclusions
Prebypass
The left atrium is dilated. No spontaneous echo contrast is seen
in the body of the left atrium or left atrial appendage. No
spontaneous echo contrast is seen in the body of the right
atrium. A patent foramen ovale is present.
Left ventricular wall thicknesses are normal. The left
ventricular cavity is moderately dilated. Overall left
ventricular systolic function is normal (LVEF>55%). [Intrinsic
left ventricular systolic function is likely more depressed
given the severity of valvular regurgitation.]
Right ventricular chamber size and free wall motion are normal.
The number of aortic valve leaflets cannot be determined. The
aortic valve is abnormal. There are two moderate-sized
vegetations on the aortic valve. Severe (4+) aortic
regurgitation is seen. There is no evidence of aortic root
abscess or any aortic to RA/RV fistula.
The mitral valve leaflets are structurally normal. There is a
large vegetation on the mitral valve anterior leaflet and
appears perforated. Severe (4+) mitral regurgitation is seen.
There is a small pericardial effusion.
Dr. [**First Name (STitle) **] was notified in person of the results on [**Known firstname **]
before bypass.
Postbypass:
Patient is on epinehrine 0.04mcg/kg/min, norepinephrine 0.1
mcg/kg/min and vasopressin 4units/hour.
His RV systolic function appears normal at the time of chest
closure.
LVEF 50% .
The mechanical prostheses at the mitral and aortic position are
in situ, stable and functioning well with acceptable resting
gradients (means at 10mm of Hg) and classic washing jets. Intact
thoracic aorta.
Brief Hospital Course:
This 45-year-old patient with a known history of drug abuse
presented with bacterial
endocarditis involving both the aortic and mitral valves. He
was transferred from an outside hospital, and a transesophageal
echo confirmed severe regurgitation with a
destroyed aortic valve leaflet with multiple vegetations and
vegetation on the mitral valve anterior leaflet with further
destruction and mitral regurgitation. There was no clear-cut
abscess or any fistula seen from the aortic root to other
cardiac [**Doctor Last Name 1754**]. He was initially managed with IV antibiotics,
but given his severe destruction of both the aortic and mitral
valve leaflets, he was taken to the
operating room on an urgent basis for aortic and mitral valve
replacements and possible homograft placement if there was any
abscess in the aortic root. Peoperatively, multiple discussions
were had with the patient and the family,
emphasizing the need for complete abstinence from drugs after
surgery, and the patient and the family were very focused on him
staying away from drugs. Preoperatively, he also had a coronary
angiogram with injection of only the left coronary artery which
was disease-free. The right coronary artery was not injected
given the presence of a large vegetation at the right coronary
leaflet, close to the right coronary ostium. The bacteria
involved was Strep viridans. He also had a left arm abscess
which grew MRSA. After about 10 days of antibiotic
treatment, he was taken to the operating room on [**2122-1-30**] where
the patient underwent aortic valve replacement with a size 23-mm
St. [**Male First Name (un) 923**] Regent mechanical valve and Mitral valve replacement
with a size 29 St. [**Male First Name (un) 923**] mechanical valve. Overall the patient
tolerated the procedure well and post-operatively was
transferred to the CVICU in stable condition for recovery and
invasive monitoring. POD 1 found the patient extubated, alert
and oriented and breathing comfortably. The patient was
neurologically intact and hemodynamically stable on no inotropic
or vasopressor support. Beta blocker was initiated and the
patient was gently diuresed toward the preoperative weight. He
was started on Coumadin for double mechanical valves and Heparin
drip was also started on post operative day 3 unitl INR was
greater than 2.5. The patient was transferred to the telemetry
floor for further recovery. Chest tubes and pacing wires were
discontinued without complication. The infectious disease team
was following closely. He was continued on Gentamycin and
Ceftriaxone with end dates as noted. Right upper quandrant US
was performed [**2-4**] to rule out choleystasis while on Ceftriaxone
and this was unchanged from previous US with no acute process
seen. All other liver function tests were improving at the time
of discharge. The patient was evaluated by the physical therapy
service for assistance with strength and mobility. His PICC
line was pulled [**2-2**] due to being in preoperatively while he was
infected and was replaced by IR on [**2-4**] for long term
antibiotics. By the time of discharge on POD 6 the patient was
ambulating freely, the wound was healing well and pain was
controlled with oral analgesics. The patient was discharged to
[**Hospital1 **] Hopsital in good condition with appropriate
follow up instructions including appointments and lab draws.
Medications on Admission:
Medications at home: Zoloft 100 Daily
Meds on transfer:
Heparin 5000''' SC
Vancomycin 1gm Q8hr
Gentamycin 80mg Q8hrs
Zoloft 100 QD
Lorazepam 2mg IV Q4hrs/prn
MSO4 2mg IV Q4hrs/PRN
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet 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. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
5. metoprolol tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
6. sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. white petrolatum-mineral oil Cream Sig: One (1) Appl
Topical [**Hospital1 **] (2 times a day).
8. 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.
9. ceftriaxone in dextrose,iso-os 2 gram/50 mL Piggyback Sig:
One (1) Intravenous Q24H (every 24 hours) for 1 months: End
date [**2122-3-5**].
10. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 7 days.
11. gentamicin in NaCl (iso-osm) 80 mg/50 mL Piggyback Sig: One
(1) Intravenous Q8H (every 8 hours) for 2 weeks: End date
[**2122-2-19**].
12. Coumadin 5 mg Tablet Sig: 1-2 Tablets PO once a day: Give as
directed for INR goal 3.0-3.5 for mech AVR/Mech MVR. Tablet(s)
13. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2222**] - [**Location (un) 538**]
Discharge Diagnosis:
Endocarditis
s/p mechanical AVR and MVR this admission
PMH:
Hepatitis B, Hepatitis C, Depression,
IVDA(patient states he uses Herion/Cocaine 2x/wk x5 mo),
left arm abcess, C4-5 fx-diving accident
Past Surgical History: Shoulder repair,
Nissen Fundoplication-[**2120**]
vasectomy
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Edema 1+
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**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:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2122-2-23**]
10:30
Provider: [**First Name4 (NamePattern1) 2482**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2122-3-16**] 11:00
Surgeon: Dr [**First Name (STitle) **] [**Telephone/Fax (1) 170**] Date/Time:[**2122-2-23**] 2:00
Infectious disease: Dr [**Last Name (STitle) 977**] [**Telephone/Fax (1) 457**] Date: [**2122-2-4**] 12:00
PM
Please call to schedule appointments with your
Primary Care Dr [**Last Name (STitle) 4467**] after discharge from rehab [**Telephone/Fax (1) 89563**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication Mechanical AVR and MVR
Goal INR 3.0-3.5
First draw
Please check INR monday, wednesday and friday for two weeks and
then decrease to twice a week for two weeks then weekly and prn
as needed based on results - to be dosed by rehab physician [**Name Initial (PRE) **]
[**Name10 (NameIs) **] arrange management with PCP at discharge
Please check BUN/Creatinine 2X per week while on Gent then
weekly after Gent course completed
Check weekly Gent peak and trough (goal trough <1, goal peak
[**2-20**]), CBC, ESR, LFT's and CRP
***Please check gent peak and trough in 3 days***
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**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2122-2-4**]
|
[
"428.0",
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"285.29",
"041.12",
"790.7",
"V11.3",
"070.32",
"421.0",
"041.09",
"682.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"37.22",
"35.24",
"39.61",
"35.22",
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
9786, 9859
|
4784, 8176
|
286, 554
|
10182, 10396
|
2300, 4761
|
11237, 12999
|
1430, 1472
|
8408, 9763
|
9880, 10076
|
8202, 8202
|
10420, 11214
|
8223, 8241
|
10099, 10161
|
1487, 2281
|
234, 248
|
582, 898
|
920, 1145
|
1246, 1414
|
8259, 8385
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,738
| 114,629
|
37669
|
Discharge summary
|
report
|
Admission Date: [**2170-6-26**] Discharge Date: [**2170-8-1**]
Date of Birth: [**2117-5-28**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Oxycontin
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
Ascites and malnutrition.
Major Surgical or Invasive Procedure:
Intubation.
EGD x2 with variceal banding.
Diagnostic and therapeutic paracenteses x2.
History of Present Illness:
Mrs. [**Known lastname 84458**] is a very nice 53-year-old woman with HCV cirrhosis
and end-stage liver failure who presented after a recent
admission with weakness, abdominal pain, and malnutrition.
Patient was recently admitted [**6-16**] to [**6-20**] with fever of unclear
etiology, abdominal pain, all infectious work-up was negative
and patient was stable off broad spectrum antibiotics for >48
hours before D/C. Upon returning home, patient had continuous
bilateral epigastric pain, waxing and [**Doctor Last Name 688**] in severity,
associated with nausea and one episode of vomiting on the day
prior to admission. She took once baby dose of ibuprofen, which
helped. Patient had been unable to eat due to nausea, early
satiety and poor appetite. She has felt weak, using walker to
ambulate, and barely able to get out of bed for 4 days. This AM,
she felt lightheaded. She had "whooshing" sounds in her ears.
She presented to appt with Dr. [**Last Name (STitle) **], who was concerned about
her malnutrition and deconditioning.
.
Since admission she was noted to have one positive blood culture
[**6-26**] with coagulase negative staph. With no further positive
cultures, this was presumed to be a a contaminant. She was
treated Vancomycin / Metronidazole / Ceftriaxone on and off from
[**6-26**] - [**6-30**]. Over the next several days care focused on diuresis
with Lasix, nutritional support and pain control. On the day of
transfer to the MICU, patient became nauseated and vomited
approximately 800cc of BRB. Upon arrival the MICU she complains
of nausea and pain.
.
No fevers, +chills. No localized weakness/numbness/tingling. No
headaches/visual changes. No blood in stool or urine. No
dysuria. No cough, SOB.
Past Medical History:
- Chronic hepatitis C infection (genotype 1) with cirrhosis,
Child-[**Doctor Last Name 14477**] B
- Possible HCC with hypodense lesion on CT in [**4-/2170**] and
elevated AFP and CEA
- Portal hypertension, s/p banding of varices
- Chronic epigastric pain
- Chronic nausea
- Asthma
- Seasonal allergies
.
Past Surgical History:
- BSO
- tummy tuck
Social History:
Originally from [**First Name9 (NamePattern2) 8880**] [**Country **] and lives with husband and children.
Has been unemployed since [**2-11**] because of general weakness.
States, "I have no daily life," due to weakness and fatigue.
- Tobacco: Smoked age 19 to 35, 1 PPD, total of 15 pack years
- etOH: Denies, used to drink socially only
- Illicits: Denies, denies IVDU
Family History:
No family history of liver disease
Physical Exam:
VS - 98.3, 93, 108/61, 13, 97/RA
GENERAL - chronically ill-appearing in NAD, uncomfortable
HEENT - NC/AT, PERRLA, EOMI, sclerae icteric, MM dry, OP clear
NECK - supple, no thyromegaly, JVD at 11cm
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - RRR, 2/6 SEM murmur at LUSB
ABDOMEN - distended, TTP at RUQ, unablet to appreciate
organmegaly given distension
EXTREMITIES - 2+ bilateral LE edema
SKIN - no rashes or lesions
NEURO - Awake, A&O x 3, CNs II-XII grossly intact, no asterixis
Brief Hospital Course:
Ms. [**Known lastname 84458**] is a 53 year-old transplant candidate with a history
of hepatitis C cirrhosis, possible HCC, portal hypertension s/p
variceal banding who presents with deconditioning/malnutrition
and abdominal pain.
# ESOPHAGEAL VARICES: Ms. [**Known lastname 84458**] had an episode of massive
hematemesis on [**7-7**] in the setting of bleeding esophageal
varices. She went immediately to the ICU were she was scoped
and banded. She had a repeat EGD the following AM with more
banding. Ms. [**Known lastname 84458**] was intubated for airway protection and
eventually stopped bleeding. She went for surveillence EGD on
[**7-20**] and an additional band was placed. Ms. [**Known lastname 84458**] was
maintained on nadolol, PPI, and sucralfate. When she was
received in the ICU on [**2170-7-27**], the patient was noted to have
bleeding from the oropharynx. Liver service scoped the patient
and was unable to stop bleeding. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] was placed. The
following morning, on [**2170-7-28**], the patient underwent a TIPS
procedure, with a drop in gradient pressure from 13 to 5.
However, blood flow to the varices was not noted to decrease
post procedure. A paracentesis was also perfored by IR, with 4L
of bloody ascites removed. Albumin was provided to protect
against hepatorenal syndrome. Multiple units of pRBCs,
platelets, and FFP were given during procedure. LFTs, ammonia,
CBC, fibrinogen were followed closely. The esophageal balloon
was deflated before 24 hours, with a small amount of blood
expressed into the aspiration port upon deflation. Patient was
transfused in the ensuing days to keep Hct, INR, fibrinogen, and
platelets at acceptable levels. The gastric balloon was also
deflated eventually, while the [**Last Name (un) **] was left in place. The
[**Last Name (un) **] was removed by hepatology on [**2170-7-30**], after the
patient showed minimal bleeding from oropharnyx and ports.
# ALTERED MENTAL STATUS- Patient arrived to the ICU with
significant altered mental status. Wide differential including
hepatic encephalopathy, primary CNS, morphine, fluid shits from
pericentesis and transfusions, worsening uremia, infection,
among other causes. Most likely from worsening hepatic
encephalopathy perhaps coupled with primary CNS etiology given
CT findings, perhaps complicated by fluid shifts after
paracentesis and transfusions. Patient was unable to receive
treatment for possible hepatic encephalopathy during treatment
for esophageal bleed. Once off propofol, altered mental status
remained. Patient remained unresponsive, with increased
sluggishness of pupils. A CT of the head was performed on
[**2170-7-30**] initially was read as no acute process but showed
evidence of cerebral edema on final read. With progressive
brain edema and poor mental status, a family meeting was held
and decision was made to withdraw care once all family was
present. Patient was then terminally extubated.
# HEPATITIS C CIRRHOSIS: Ms. [**Known lastname 84458**] has HCV cirrhosis and
possible HCC. She was continued on rifaximin and lactulose.
Lasix and spironolactone were initially held for hyponatremia
and restarted when the sodium levels came up. The patient
arrived to the ICU with significant altered mental status,
presumably from hepatic encephalopathy. Esophageal varices
treated as above. Ascites removed after TAPs procedure and
again on [**2170-7-30**] with the help of IR. Both showed hemmorhagic
ascites. Lactulose and rifaximin were help while the [**Last Name (un) **]
was in place and the patient was being treated for esophageal
bleeding. The patient was on propofol while on mechanical
ventilation, which was decreased on [**2170-7-29**] to asses changes
in encephalopathy. Even off sedation, the patient was
significantly altered and unresponsive. Patient was given
albumin daily to protect from hepatorenal syndrome. Once the
[**Last Name (un) **] was removed, an OG was placed on [**2170-7-30**]. Patient
was seen and followed by transplant surgery and was awaiting
possible transplant throughout course.
.
# RESPIRATORY DISTRESS: Patient was intubated on [**2170-7-27**] and
most likely aspirated blood during that procedure. CXRs showed
bilateral pleural effusions and worsening physical exam.
Patient also had increasing WBCs. Patient was on antibiotic
converage for UTI that covered organisms for presumed aspiration
pneumonia. Patient remained intubated until she expired.
Medications on Admission:
(At time of transfer)
- Meropenem 500 mg IV Q8H Duration: 7 Days
day 1 = [**7-23**] (day 1 of 7 days)
- Midodrine 10 mg PO TID
- Multivitamins 1 TAB PO/NG DAILY
- Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
- Nadolol 10 mg PO DAILY
- Claritin *NF* 10 mg ORAL DAILY
- Octreotide Acetate 200 mcg SC Q8H
- Dextrose 50% 25 gm IV PRN hypoglycemia
- Ondansetron 4-8 mg IV Q8H:PRN nausea
- Fluticasone-Salmeterol Diskus (500/50) 1 INH IH [**Hospital1 **]
- Pantoprazole 40 mg IV Q12H
- Ipratropium Bromide MDI 2 PUFF IH QID
- Rifaximin 400 mg PO/NG TID
- Lactulose 45 mL PO/NG TID titrate to 4 bowel movements/day.
- Simethicone 40-80 mg PO/NG TID
- Lactulose 30 mL PO/NG TID
- Lidocaine 5% Patch 1 PTCH TD DAILY
- Linezolid 600 mg PO/NG Q12H Day #1 is [**7-22**].
- Sucralfate 1 gm PO/NG QID
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Cardiopulmonary Arrest
Discharge Condition:
Expired
Discharge Instructions:
None
Followup Instructions:
None
|
[
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"572.4",
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"276.7",
"564.00",
"531.40",
"537.89",
"276.1",
"348.5",
"571.5",
"V49.83",
"584.9",
"260",
"782.4",
"311",
"599.0",
"456.20",
"070.71"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.07",
"39.1",
"44.43",
"39.95",
"38.95",
"00.14",
"38.93",
"96.04",
"99.07",
"99.04",
"54.91",
"38.91",
"42.33",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
8919, 8928
|
3531, 8052
|
303, 390
|
8994, 9003
|
9056, 9063
|
2920, 2956
|
8890, 8896
|
8949, 8973
|
8078, 8867
|
9027, 9033
|
2494, 2515
|
2971, 3508
|
238, 265
|
418, 2145
|
2167, 2471
|
2531, 2904
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,765
| 184,762
|
30324
|
Discharge summary
|
report
|
Admission Date: [**2192-3-14**] Discharge Date: [**2192-3-22**]
Service: MEDICINE
Allergies:
Codeine / Shellfish / Phenergan
Attending:[**First Name3 (LF) 1974**]
Chief Complaint:
N/V/D
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
87yoW with h/o . She presented to [**Hospital6 33**] [**2192-2-27**]
with complaint of abdominal pain, vomiting, and blood-streaked
diarrhea. She denied fevers at that time. Initial CT scan
diagnosed ileitis of the distal ileum, and she was treated with
iv levofloxacin/metronidazole, and kept NPO. Repeat CT showed
improvement in inflammation, but she failed po trial, and
continues to have nausea, diarrhea, and abdominal pain. She
underwent upper and lower endoscopies and small bowel follow
through studies that were nondiagnostic, showing only a small
patch of cecal inflammation and left diverticulosis. She has
been evaluated by GI and surgical services at [**Hospital1 34**]. Stools
studies for c.difficile were negative. She developed a non-anion
gap metabolic acidosis, thought to be due to ongoing diarrhea.
TTG was 3, ANCA negative, stool cultures negative. She was to be
transferred to [**Hospital1 112**] for capsule endoscopy, but as bed was not
available, she was transferred to [**Hospital1 18**] for further evaluatin
and treatment.
.
On presentation now she complains of continued bilateral lower
quadrant abdominal pain, L>R, nausea, diarrhea, and also of LLE
pain. The LLE pain developed while hospitalized at [**Hospital1 34**]. Doppler
U/S was negative for DVT there.
Past Medical History:
Asthma
COPD
Diverticulosis
Atrial fibrillation
Diastolic dysfunction
s/p pacemaker
Type II diabetes mellitus
Hypertension
chronic neck and back pain s/p neck surgery
s/p cholecystectomy
s/p hysterectomy
Social History:
Lives with her son, widow. walks with cane at baseline.
Denies Tob, EtOH use
Family History:
Non-contributory
Physical Exam:
T 98.8 HR 124 BP 98/56 RR 18 98%RA Wt 128lb
Gen: fatigued, alert, speaking full sentences
HEENT: PERRL, anicteric, MM dry, OP clear
Neck: supple, no LAD, JVP nondistended
CV: PMI nondisplaced, pacemaker right chest. tachycardic,
regular, II/VI SEM, no gallops
Resp: trace left basilar crackles, o/w CTA
Abd: +BS, soft, ttp diffusely, greatest LLQ>RLQ, no
rebounding, +guarding but delayed, no masses
Ext: trace BLE edema, 1+ bilateral DPs, 2+ radials
Neuro: A&Ox3, CN II-XII intact, strength 4/5 BUE, 3/5BLE hip
flexor, dorsi- and plantar flexion, no pronator drift,
coordination intact FTN
Pertinent Results:
[**2192-3-14**] 09:12PM WBC-6.8 RBC-3.61* HGB-11.2* HCT-33.6* MCV-93
MCH-30.9 MCHC-33.3 RDW-14.0
[**2192-3-14**] 09:12PM NEUTS-79* BANDS-0 LYMPHS-10* MONOS-6 EOS-0
BASOS-0 ATYPS-5* METAS-0 MYELOS-0
[**2192-3-14**] 09:12PM PLT COUNT-435
[**2192-3-14**] 09:12PM PT-13.1 PTT-29.4 INR(PT)-1.1
[**2192-3-14**] 09:12PM ALBUMIN-2.9* CALCIUM-8.6 PHOSPHATE-3.8
MAGNESIUM-1.9
[**2192-3-14**] 09:12PM GLUCOSE-123* UREA N-17 CREAT-1.1 SODIUM-141
POTASSIUM-4.0 CHLORIDE-108 TOTAL CO2-24 ANION GAP-13
[**2192-3-14**] 09:12PM ALT(SGPT)-11 AST(SGOT)-26 LD(LDH)-267*
CK(CPK)-61 ALK PHOS-64 AMYLASE-72 TOT BILI-0.2
[**2192-3-14**] 09:12PM LIPASE-32
[**2192-3-14**] 09:12PM CK-MB-3 cTropnT-0.07*
.
CT ABD/PELVIS:
1. Presacral soft tissue stranding of unclear etiology, but
indicates inflammatory process at this site. This is of unclear
clinical significance.
Has the patient had prior radiation?
2. Inflammatory fat stranding within the subcutaneous tissues of
the back.
3. Bilateral pleural effusions (right greater than left) with
associated atelectasis.
4. Intrahepatic and extrahepatic biliary ductal dilation that is
likely secondary to cholecystectomy and likely chronic.Mo
retained stones are seen.Correlation with LFTs is recommended.
.
TTE:
The left atrium is mildly dilated. There is moderate symmetric
left
ventricular hypertrophy. 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. The aortic
valve leaflets
(3) are mildly thickened but aortic stenosis is not present.
There is no
aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve
leaflets are mildly thickened. Trivial mitral regurgitation is
seen. The
tricuspid valve leaflets are mildly thickened. There is moderate
pulmonary
artery systolic hypertension. There is a small to moderate sized
pericardial
effusion. There are no echocardiographic signs of tamponade.
.
HEAD CT:
There is no evidence of hemorrhage, mass effect, shift of
normally midline structures or hydrocephalus. There are again
noted mild periventricular changes of small vessel disease.
There is prominence of ventricles and sulci, consistent with
age-related mild involutional change. Noted again are vascular
calcifications. Imaged paranasal sinuses and mastoid air cells
are well aerated. Osseous structures are unremarkable.
Brief Hospital Course:
1) NAUSEA/VOMITING:
At OSH, pt had evidence of ileitis on CT scan. Repeat CT here
showed resolution of this. It was likely an infectious
enteritis. This may have provoked N/V that is persisting due to
IBS or another cause. Medications effect was considered and
pt's pain regimen was altered and digoxin dose was reduced. In
addition, a head CT was done to r/o intracranial mass lesion.
Before discharge, she was tolerated simple small meals. She was
also started on TPN for supplementation.
.
2) SVT:
Pt went into an SVT, likely afib or aflutter with RVR and
required admission to ICU. There her nodal blocking agents were
titrated up. Dig was increased to 0.375. With this her rate
was controlled and her rhthym was subsequently mostly sinus.
However, due to high dig level, dig dose was reduced back down
to 0.125. Last dig level was 1.4. She was maintained on
lopressor for HR and BP control. Ideally, digoxin can be
tapered off completely given narrow therapeutic range.
.
3) CHF:
Pt had total body fluid overload with b/l pleural effusions,
pericardial effusions. She was gently diuresed with lasix. An
echo was done which showed mild LVH with preserved EF. There
was mild LVOT gradient. Cozaar (which she took at home) was
restarted and can be titrate up as tolerated by BP.
.
4) CHRONIC LEG PAIN:
Continued on fentanyl patch. Neurontin re-added to her regimen.
This will need to be titrated up every few days as tolerated
until effect. RTC tylenol added. Avoid morphine or other IV
opioids which were likely contributing to nausea.
.
5) DM2:
Glipizide was held due to limited PO intake. Pt was placed on
sliding scale insulin and insulin was added to TPN. This should
continue. Glipizide can be restarted when pt taking better POs.
.
6) CHRONIC DIARRHEA:
No clear etiology for this was found. At [**Hospital6 **],
pt had abd Ct, colonoscopy, CTA which did not reveal etiology.
Infectious workup was negative. Diarrhea was fairly minimal ie
once a day though at baseline occured 2-3 times a day. Pt will
continue to have workup with outpt GI follow up but can use
lomotil for now.
.
7) ASTHMA:
At home, pt on chronic prednisone, singulair. It was not clear
why pt was on chronic prednisone as this is not the ideal
management of asthma. In the hospital, she was moving air well
and had no evidence of asthma exacerbation. Therefore,
predisone was stopped, singulair continued, and given prn
bronchodilators. If required, an inhaled steroid can be started
but at this point, not necessary.
.
8) ANEMIA:
Iron studies consistent with ACD though level of anemia and lack
of chronic inflammation made this unusual. Her hct was variable
between 24-30 but did not require any transfusions. Stools were
guiac negative and hemolysis labs were negative.
Medications on Admission:
Home Meds:
Glipizide 2.5mg daily
KCl 10mEq [**Hospital1 **]
Cozaar 50mg [**Hospital1 **]
Atenolol 25mg daily
Lipitor 10mg daily
Digoxin 250mcg daily
Prednisone 10mg daily
Singulair 10mg daily
Duragesic 25mg daily
Lasix 20mg daily
Neurontin 600mg TID (was not taking prior to admit)
.
Meds On Transfer:
Tylenol prn
Combivent nebs Q4hr, prn
Phenergen 12.5mg Q6hr prn
Zofran 4mg Q6hr prn
Dilaudid 1mg Q3hr prn
Insulin regular
Flagyl 600mg iv Q6hr
Theophylline 200mg po TID
KCl 10mEq [**Hospital1 **]
Lasix 20mg daily
Lipitor 20mg daily
Glipizide 2.5mg daily
Verapamil 80mg TID
Atenolol 25mg QPM, 50mg QAM
Levofloxaxin 250mg iv daily
Fentanyl 50mcg TP Q72hrs
Lovenox 40mg SC daily
Discharge Medications:
1. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
4. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
5. Bismuth Subsalicylate 262 mg/15 mL Suspension Sig: Fifteen
(15) ML PO QID (4 times a day).
6. Gabapentin 100 mg Tablet Sig: One (1) Capsule PO three times
a day.
7. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
8. Cozaar 25 mg Tablet Sig: One (1) Tablet PO once a day.
9. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
10. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for SOB.
11. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for SOB.
12. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day): until pt is ambulatory.
13. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
15. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
16. Zofran 4 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for nausea.
17. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: sliding
scale with meals units Subcutaneous qACHS.
18. TPN for [**3-22**]
Volume: 1250 mL: 150g/d dextrose, 75 g/d amino acids, 25 g/d
lipid.
Electrolytes: 30mEq NaCl, 40mEq NaPhos, 25mEq KCl, 5mEq
MagnesiumSulfate, 10mEq CaCluc, 13units insulin
Discharge Disposition:
Extended Care
Facility:
NE [**Hospital1 **]
Discharge Diagnosis:
PRIMARY:
1) Chronic diarrhea
2) Ileitis
3) Afib with RVR
4) Congestive heart failure.
SECONDARY:
1) Asthma, chronic stable
2) Chronic leg pain
3) DM2
4) HTN
Discharge Condition:
Good-afebrile, vital signs stable.
Discharge Instructions:
1. Take medications as prescribed.
2. Follow up as below.
Followup Instructions:
1. You have an appointment with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 54392**], on [**2192-4-12**]
at 2:00.
.
2. Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD (GI) Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2192-4-10**] 2:00. [**Location (un) 453**] [**Hospital Unit Name 1825**], [**Hospital Ward Name **]
[**Hospital1 18**]
|
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"V58.65",
"558.9",
"707.05",
"428.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
10180, 10226
|
5006, 7787
|
245, 253
|
10427, 10464
|
2570, 4550
|
10571, 10941
|
1912, 1930
|
8515, 10157
|
10247, 10406
|
7813, 8097
|
10488, 10548
|
1945, 2551
|
200, 207
|
281, 1574
|
4559, 4983
|
1596, 1801
|
1817, 1896
|
8115, 8492
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,363
| 117,258
|
141
|
Discharge summary
|
report
|
Admission Date: [**2179-3-18**] Discharge Date: [**2179-3-24**]
Date of Birth: [**2105-12-17**] Sex: F
Service: MEDICINE
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 949**]
Chief Complaint:
hypothermia, sepsis
Major Surgical or Invasive Procedure:
EGD
flex sig
History of Present Illness:
73yo F with PBC, decompensated cirrhosis c/b encephalopathy,
ascites, and esoph varices, who was discharged 2 days prior to
admission with AMS thought to be related to hepatic
encephalopathy. At that time she was also found to have
hypoglycemia, PNA (tx w/ Azithro), and a UTI (tx w/ Bactrim).
She was referred from clinic at [**Hospital Unit Name **] with chief
complaint of BRBPR. She noted 2 painless BM's with BRBPR, and
blood was noted on rectal exam without melena. She denied any CP
or SOB, but does note feeling weak. She does note some decreased
urine output lately, as well as increased LE edema and abdominal
distention. She notes abdominal 'fullness' for the last few
weeks, but denies nausea/vomiting. She notes some
lightheadedness and thirst while in the ED.
.
In the ED she was initially normotensive, but was later found to
have SBP's in the 70's (baseline SBP in 90's). She was also
noted to be hypothermic with core temp of 93.4. Because of
concern for sepsis an IJ was placed and she was placed on sepsis
protocol. She was given Vanc/CTX/Flagyl and hydrocort, and was
also noted to have worsening renal function with a Cr of 2.1
from NL baseline. Because of an initial potassium of 6.9, she
was given D50/insulin/kayexylate. She was admitted to the MICU
for further monitoring.
Past Medical History:
1. PBC cirrhosis x 13 yrs, known varices, followed by Dr.[**Last Name (STitle) 497**]
2. Liver cirrhosis
3. Hypothyroidism
4. Osteopenia
5. Status post cholecystectomy
6. History of ankle fractures
7. Hypertension
Social History:
Tobacco stopped 15 yrs ago, 30 pack-yrs, no alcohol or drug use,
married with three children. Lives at home with husband
Family History:
No family history of strokes, seizures. Mother and father died
in 90s.
Physical Exam:
vitals (ED)- T=93.4(now ax95), HR=77, BP=114/33-70/48, RR=16,
O2sat 95%RA
General - alert, interactive, in NAD
HEENT- PERRL, sclerae mildly icteric(?), mucosa slightly dry
Neck- supple, no JVD noted
Lungs- mild end-exp wheezes bil, otherwise CTA
Heart- RRR, 2/6 SEM heard best at LUSB
Abd- +BS's, distended, tympanitic, mild/mod diffuse tenderness,
no
rebound/guarding; rectal exam in ED w/ BRBPR guaiac+
Ext- 3+ pitting LE edema b/l
Neuro- AAO x 3, follows commands, +asterixis
Pertinent Results:
CT abdomen:
1. Diffuse anasarca with soft tissue edema as well as ascites
and nonspecific mesenteric stranding. Ascites is increased
compared to the previous study.
2. Limited evaluation of the bowel with no definite wall
thickening. There is no pneumatosis or free air. Patency within
mesenteric vessels cannot be assessed without IV contrast.
3. Acute right posterior rib fracture that does not appear to be
present on the study of [**2179-1-20**]. No evidence of pneumothorax in
the imaged portions of the lungs.
CXR: The lungs are hyperinflated and the diaphragms are
flattened, consistent with COPD. Heart size is at the upper
limits of normal with left ventricular configuration. The aorta
is calcified and unfolded. There is no CHF, frank consolidation
or effusion. Again seen is eventration of the left hemidiaphragm
posteriorly. There is probably some associated atelectasis, but
no definite pneumonic infiltrate.
RUQ: Targeted examination was performed. There is small ascites.
Hepatic veins appear patent. The portal vein appears patent with
hepatopetal flow. Hepatic arteries appear patent. No spot marked
for tap.
Brief Hospital Course:
73 y/o F with PBC, decompensated cirrhosis with now presents
with weakness, ARF, hypothermia, and hypotension.
.
HYPOTENSION/HYPOTHERMIA: On admission there was some concern
that the patient was septic given her hypotermia and
hypotension. She is known to have a low baseline SBP in the
~90's and may have low temp at baseline. Given her tenuous
state, she was covered empirically with CTX and Flagyl. Naldol
and diuretics were held. An abdominal U/S was obtained and
showed ascites fluid, but of insufficicent quantity to tap. Her
CXR and UA were negative for evidence of infection. In light of
the patient's persistent hypotension and hypothermia, patient
was transferred to the ICU where she was started on levophed and
vasopressin. An abdominal CT was ordered to assess for possible
obstruction and a surgery consult was obtained. The CT scan
showed diffuse anasarca, ascites, and no convincing evidence of
obstruction although the study was limited [**2-11**] lack of IV
contrast. There was also an incidental finding of a new right
posterior rib fracture. Her clinical condition gradually
improved and she was weaned off pressors on ICU day 4 with a
baseline SBP of 90/50. CTX and flagyl were d/c'd and patient
was called out to the floor on [**3-22**].
.
ARF: Patient was found to have a creatinine of 2.1 in the
setting of decreased UO and increased abdominal distention. Her
urine lytes were consistent with a sodium-avid state, either a
pre-renal etiology or hepatorenal syndrome. Later labs were
consistent with a ATN vs HRS. Nephrology was consulted and
agreed with treating with ocreaotide. Patient was found to have
a Klebsiella UTI, which was treated with a seven day course of
bactrim, and candiduria. She did receive 2 units of PRBC and
albumin in order to improve her UOP without worsening her
anasarca. Her creatinine gradually improved and was still
trending down on day of discharge.
.
ABDOMINAL DISTENTION: Initially thought to be [**2-11**] ascites but
abd U/S showed only a small amount of fluid. There was no
evidence of obstruction/ileus on CT and patient continued to
pass stool asd flatus. Transplant surgery was consulted and
patient was made NPO. Eventually the distention was attributed
to bowel wall edema in the setting of total body anasarca.
Patient was started on lasix and aldactone.
.
BRBPR: Her initial presentation was for painless BRBPR, but her
Hct has remained stable. In the MICU she had a maroon stool.
NGT was placed and lavage was negative, with stable f/u Hct.
This seemed to be consistent with a lower source such as an AVM,
diverticular bleed, or hemorroids. Patient underwent an EGD
which showed 1 non-bleeding cord of grade III varices, which was
banded, and no evidence of active bleed. Patient also had a
sigmoidoscopy which showed medium grade 1 hemorroids.
.
PULMONARY: Patient has some very mild hypoxia likely related to
abdominal distention vs cardiac asthma vs reactive airways. She
maintained her oxygen saturations and did not require
intubation.
.
PPx: Patient maintained of PPI, Lactulose, and pneumoboots for
DVT prophylaxis.
.
DISPO: Patient was discharged home with services in stable
condition with close follow up with her PCP, [**Name10 (NameIs) **] hepatologist,
and Dr. [**Last Name (STitle) 118**] of nephrology.
Medications on Admission:
Synthroid 75mcg QD
Protonix 40mg
Ursodiol 500AM/750PM
Nadolol 20mg QD
Colace 100mg [**Hospital1 **]
Folate
CaCO3
Rifaximin 400mg TID
Lactulose 30mg [**Hospital1 **]
Lasix 40mg QD
Aldactobe 100mg HS
Bactrim 1 tab [**Hospital1 **] until [**3-22**] for UTI
Discharge Medications:
1. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
4. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
Disp:*180 Tablet(s)* Refills:*2*
5. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q6H (every
6 hours) as needed.
Disp:*100 ML(s)* Refills:*0*
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Ursodiol 250 mg Tablet Sig: Two (2) Tablet PO QAM (once a day
(in the morning)).
Disp:*60 Tablet(s)* Refills:*2*
8. Ursodiol 250 mg Tablet Sig: Three (3) Tablet PO QPM (once a
day (in the evening)).
Disp:*90 Tablet(s)* Refills:*2*
9. Nadolol 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Prednisone 20 mg Tablet Sig: One (1) Tablet PO QD () for 1
days.
Disp:*1 Tablet(s)* Refills:*0*
11. Prednisone 10 mg Tablet Sig: One (1) Tablet PO QD () for 2
doses: start after done with 20mg dose.
Disp:*2 Tablet(s)* Refills:*0*
12. Prednisone 5 mg Tablet Sig: One (1) Tablet PO QD () for 2
days: start after done with 10mg dose.
Disp:*2 Tablet(s)* Refills:*0*
13. Outpatient Lab Work
CBC, CHEM 10, LFTS, and PT, PTT, INR
Please have this bloodwork performed on [**2179-3-26**] and have the
results faxed to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] office at the [**Hospital1 771**] Department of Hepatology
Discharge Disposition:
Home with Service
Facility:
[**First Name8 (NamePattern2) 1495**] [**Doctor Last Name 122**]
Discharge Diagnosis:
Variceal Bleed s/p banding
Sepsis
Acute Renal Failure
Anasarca
Primary Billary Cirrhosis
Discharge Condition:
stable
Discharge Instructions:
Please take all medications as perscribed. Please report to the
[**Hospital1 18**] emergency room with any fevers, chills, nausea, vomiting,
abdominal pain, bright red blood per rectum, hemetamesis.
Please keep all follow up appointments.
Followup Instructions:
[**First Name5 (NamePattern1) 1494**] [**Last Name (NamePattern1) 1496**]- Primary Care Physician- [**0-0-**]/28/06
at 12:15PM- please have your CBC, Chem 10 and Liver Function
Tests, and coagulation studies checked at that visit and have
results faxed to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] office.
Please also have the blood work checked on [**2179-3-26**] faxed to Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] office.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**]-Hepatology-[**Hospital 1497**] clinic will call you
within 24H to schedule your follow up appointment, but if you do
not hear from them within 24H, please call the clinic yourself.
[**First Name4 (NamePattern1) 429**] [**Last Name (NamePattern1) 118**]-Nephrology-[**Telephone/Fax (1) 60**]-[**2179-04-05**] at 12:30 PM
|
[
"584.9",
"599.0",
"456.20",
"560.1",
"038.9",
"995.92",
"280.0",
"455.2",
"287.5",
"285.29",
"276.7",
"571.6",
"276.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"42.33",
"45.13",
"45.23",
"38.93",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
9069, 9164
|
3769, 7078
|
295, 309
|
9297, 9306
|
2615, 3746
|
9594, 10469
|
2028, 2101
|
7382, 9046
|
9185, 9276
|
7104, 7359
|
9330, 9571
|
2116, 2596
|
236, 257
|
337, 1636
|
1658, 1873
|
1889, 2012
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,355
| 128,015
|
9169
|
Discharge summary
|
report
|
Admission Date: [**2186-10-31**] Discharge Date: [**2186-11-2**]
Date of Birth: [**2130-12-6**] Sex: F
Service: [**Year (4 digits) 662**]
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 7333**]
Chief Complaint:
pericardial effusion and hypotension
Major Surgical or Invasive Procedure:
[**2186-10-31**] - Pulmonary vein isolation procedure with ablation
History of Present Illness:
This is a 55 year-old woman was diagnosed with paroxysmal atrial
fibrillation 2 years ago after developing palpitations,
insufficiently controlled with Flecainide 100mg [**Hospital1 **] and
Metoprolol. She continue to have increasing episodes of atrial
fibrillation, lasting from minutes to hours, occurring 3-4 times
per week. She is symptomatic with exertional dyspnea and
decreased energy level. Due to her increasing symptoms on
Flecainide, she was referred for PVI. On the morning of
admission, she underwent PVI with difficult transeptal access to
pulmonary veins. She had transient atypical flutter with low
blood pressure, got cardioverted intraoperatively. Post-PVI, it
was noted that she had small pericardial effusion. Plan is to
have echo this pm then start pradexa tonight.
.
When patient arrived to the unit, she was in no acute distress.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: Hypertension
2. CARDIAC HISTORY:
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: None
.
3. OTHER PAST MEDICAL HISTORY:
- paroxysmal atrial fibrillation
- hypertension
- thyroid nodules s/p biopsy (negative)
- w/u for pheocromocytoma d/t admission to [**Hospital3 **] for
hypertension
- Partial hysterectomy with bladder suspension 10 years ago
- Hand tingling in setting of hypertension ? TIA
- Presumptive UTI Saturday [**2186-10-28**]-started CIPRO 500mg [**Hospital1 **]
- tonsillectomy as a child
Social History:
The patient is married with 2 children, ages 24 and 20. She
works as a dietician and diabetes educator in private practice.
She previously smoked for many years and quit 35 years prior.
She denies alcohol or recreational substance use.
Family History:
Father died of CAD at age 65. Mother died in her 50s from colon
cancer.
Physical Exam:
ADMISSION EXAM:
VS: T=99 BP=108/72 HR=78 RR=18 O2 sat=100% on mask
Height 5 feet 8 inches
Weight: 203 lbs
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: with soft neck collar on.
CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits, + catheters on exam
SKIN: burn noted on her back.
PULSES:
Right: DP 2+ PT 2+
Left: DP 2+ PT 2+
Pertinent Results:
[**2186-10-31**] 02:34PM BLOOD WBC-7.2 RBC-4.21 Hgb-13.6 Hct-38.7 MCV-92
MCH-32.2* MCHC-35.0 RDW-11.8 Plt Ct-207
.
[**2186-11-2**] 03:13AM BLOOD WBC-7.1 RBC-3.44* Hgb-11.2* Hct-32.0*
MCV-93 MCH-32.6* MCHC-35.1* RDW-11.6 Plt Ct-145*
.
[**2186-10-31**] 02:34PM BLOOD PT-12.0 PTT-47.3* INR(PT)-1.1
.
[**2186-11-2**] 03:13AM BLOOD PT-15.3* PTT-48.4* INR(PT)-1.4*
.
[**2186-10-31**] 07:00AM BLOOD Glucose-106* UreaN-24* Creat-0.9 Na-138
K-4.9 Cl-106 HCO3-23 AnGap-14
.
[**2186-11-2**] 03:13AM BLOOD Glucose-117* UreaN-13 Creat-0.8 Na-134
K-4.1 Cl-104 HCO3-23 AnGap-11
.
[**2186-10-31**] 02:34PM BLOOD ALT-32 AST-52* AlkPhos-52 TotBili-0.6
.
[**2186-11-1**] 05:29AM BLOOD ALT-28 AST-47* LD(LDH)-214 AlkPhos-42
TotBili-0.7
.
[**2186-10-31**] 02:34PM BLOOD Calcium-8.7 Phos-3.3 Mg-1.7
.
MICROBIOLOGIC DATA:
[**2186-10-31**] MRSA screen - pending at discharge
.
IMAGING STUDIES:
[**2186-10-31**] 2D-ECHO - There is a small-sized pericardial effusion.
There are no echocardiographic signs of tamponade.
.
[**2186-11-1**] 2D-ECHO - Overall left ventricular systolic function is
normal (LVEF>55%). Right ventricular chamber size and free wall
motion are normal. There is a small pericardial effusion. There
are no echocardiographic signs of tamponade. Compared with the
prior study (images reviewed) of [**2186-10-31**], no change.
.
[**2186-11-1**] CXR - As compared to the previous radiograph, there is a
newly appeared small retrocardiac atelectasis. Small bilateral
pleural effusions might also have newly occurred. No overt
pulmonary edema. Unchanged appearance of the cardiac silhouette
and the mediastinum.
Brief Hospital Course:
55F with a PMH significant for paroxysmal atrial fibrillation
insufficiently controlled with Flecainide and Metoprolol, but
without previous anticoagulation, who presented as an outpatient
with continued worsening of symptoms, who underwent pulmonary
vein isolation and ablation on [**2186-10-31**] which was notable for a
circumferential pericardial effusion seen on echocardiogram with
some evidence of hypotension which warranted CCU admission for
monitoring.
.
# PERICARDIAL EFFUSION, HYPOTENSION ?????? The patient presented with
transient intra-op hypotension and some 2D-Echo evidence of
pericardial effusion following PVI procedure for atrial
fibrillation. Etiologies considered included: myocardial
infarction, severe hypothyroidism, or end-stage renal disease
and malignancy can all be precipitating etiologies, but these
were deemed unlikely ?????? post-intervention effusion is most
likely. She has remained hypotensive in the CCU in the 75-80
mmHg systolic range, which has responded subtly to 3L of
resuscitation fluid. Her pulsus paradoxus remains < 10 mmHg ([**3-1**]
mmHg on serial monitoring) and repeat 2D-Echo this admission
showed a stable, small pericardial effusion without tamponade
physiology. She will have a repeat echocardiogram as an
outpatient. She remained hemodynamically stable prior to
discharge.
.
# ATRIAL FIBRILLATION ?????? The patient has a history of paroxysmal
atrial fibrillation which has been rate controlled with
Metoprolol and she has had intermittent rhythm control with
Flecainide. Per her outpatient Cardiologist, she has been having
increasing episodes of atrial fibrillation lasting anywhere from
minutes to hours and she knows when she is in atrial
fibrillation immediately, not because of heart racing, but
because she feels short of breath and does not have much energy.
She is s/p pulmonary vein isolation from [**2186-10-31**] as an
outpatient with ablation which was complicated by a small
pericardial effusion (see above). This remained stable without
tamponade physiology on serial echocardiography. She remained in
normal sinus rhythm on discharge. Her rate was controlled with
Metoprolol 50 mg XL PO daily. Her rhythm control ?????? was
previously on Flecainide and will continue on this medication;
PVI procedure went well and she remains in normal sinus rhythm.
For her anticoagulation, we started and will continue Pradaxa
150 mg PO BID ?????? she did have some nausea with this medication.
We optimized her electrolytes and monitored her via telemetry.
.
# ARTHRITIS ?????? We continued her home medication of
Oxycodone-Acetaminophen 1-2 tabs PO Q4H PRN pain and Toradol
dosing. She had no acute issues or new symptoms.
.
# HYPERTENSION - We held her home Lisinopril and Spironlactone
medications given her tenuous blood pressures, but we continued
her Metoprolol dosing with good effect.
.
# URINARY TRACT INFECTION - She was completing her final day of
a Ciprofloxacin course on [**2186-11-1**] given an outpatient positive
urine dipstick. No dysruria or hematuria complaints this
admission. No urine culture data in our system. Afebrile without
leukocytosis this admission.
.
TRANSITION OF CARE ISSUES:
1. The patient will have outpatient laboratory studies checked
(including her LFTs, INR and CBC with electrolytes) which will
be followed-up by her primary care physician.
2. She will have repeat 2D-Echocardiogram imaging, that will be
followed-up by Dr. [**Last Name (STitle) **], to evaluate her small and stable
pericardial effusion.
3. At the time of discharge, she had no pending laboratory
evaluations. Her MRSA swab from admission to the ICU was pending
on discharge. She had no pending radiologic imaging studies at
discharge.
4. Your primary care physician will determine (in addition to
your Cardiologist) the need for resuming your Spironolactone and
Lisinopril medication once your blood pressure stabilizes.
5. She had a small burn from a grounding pad placed during her
procedure that was treated with silvadene dressings and was
healing well at discharge.
6. She will have follow-up with Dr. [**Last Name (STitle) **] and her primary
care physician, [**Name10 (NameIs) 3**] an outpatient.
Medications on Admission:
1. Conjugated estrogens (premarin) 0.625 mg/gram cream (1 gram)
intravaginally twice daily
2. Flecainide 150 mg PO in the AM, 75 mg PO in the PM
3. Lisinopril 40 mg PO daily
4. Metoprolol succinate 50 mg PO daily
5. Spironolactone 25 mg PO daily
6. Aspirin 325 mg PO daily
7. Calcium carbonate 500 (1250 mg) PO daily
8. Docusate sodium 100 mg PO BID
9. Omega-3 fatty acid-Vitamin E
Discharge Medications:
1. Outpatient Lab Work
Please check INR, ALT, AST, total bilirubin, electrolytes, CBC.
Please send results to [**Last Name (LF) **],[**First Name3 (LF) 1238**] E. Phone: [**Telephone/Fax (1) 31529**].
FAX NUMBER: [**Telephone/Fax (1) 31530**]
2. Premarin 0.625 mg/gram Cream Sig: One (1) gram Vaginal twice
weekly.
3. flecainide 50 mg Tablet Sig: Three (3) Tablet PO BREAKFAST
(Breakfast).
4. flecainide 50 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime).
5. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*0*
7. calcium carbonate 500 mg calcium (1,250 mg) Tablet Sig: One
(1) Tablet PO once a day.
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. omega-3 fatty acids-vitamin E Oral
10. silver sulfadiazine 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
Disp:*2 tubes* Refills:*0*
11. dabigatran etexilate 150 mg Capsule Sig: One (1) Capsule PO
BID (2 times a day).
Disp:*60 Capsule(s)* Refills:*0*
12. indomethacin 50 mg Capsule Sig: One (1) Capsule PO three
times a day for 1 weeks.
Disp:*21 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
1. Paroxysmal atrial fibrillation
2. Hypotension
.
Secondary Diagnoses:
1. Essential hypertension
2. Chronic low back pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Patient Discharge Instructions:
.
You were admitted to the Coronary Care Unit at [**Hospital1 771**] on [**Hospital Ward Name 121**] 6 regarding management of your
atrial fibrillation. You underwent a successful pulmonary vein
isolation procedure with ablation and restoration of your normal
heart rhyhm. You had some low blood pressure and evidence of a
small collection of fluid around the heart (pericardial
effusion) which was serially imaged and appeared stable. You
will follow-up with Dr. [**Last Name (STitle) **] as an outpatient in 6-weeks and
have repeat 2D-Echo imaging to assess the fluid, as an
outpatient. You will also see your primary care physician next
week. Overall you were feeling well prior to discharge.
.
Please call your doctor or go to the emergency department if:
* You experience new chest pain, pressure, squeezing or
tightness.
* You develop new or worsening cough, shortness of breath, or
wheezing.
* You are vomiting and cannot keep down fluids, or your
medications.
* If you are getting dehydrated due to continued vomiting,
diarrhea, or other reasons. Signs of dehydration include: dry
mouth, rapid heartbeat, or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit, or have a
bowel movement.
* You experience burning when you urinate, have blood in your
urine, or experience an unusual discharge.
* Your pain is not improving within 12 hours or is not under
control within 24 hours.
* Your pain worsens or changes location.
* You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
* You develop any other concerning symptoms.
.
CHANGES IN YOUR MEDICATION RECONCILIATION:
.
* Upon admission, we ADDED:
START: Indomethacin by mouth for 5-days total (end date
[**2186-11-6**])
START: Dabigatran 150 mg by mouth twice daily
START: Silver Sulfadiazine (1% cream) 1 application applied
twice daily to burn on back, as needed
.
We CHANGED: decreased your Aspirin from 325 to 81 mg by mouth
daily
.
* The following medications were DISCONTINUED on admission and
you should NOT resume:
HOLD: Lisinopril (until discussing this with your Cardiologist
or PCP)
HOLD: Spironolactone (until discussing this with your
Cardiologist or PCP)
DISCONTINUE: Ciprofloxacin
.
* You should continue all of your other home medications as
prescribed, unless otherwise directed above.
Followup Instructions:
Department: Primary Care
Name: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
When: Monday [**2186-11-6**] at 11:00 AM
Location: [**Hospital1 **] [**First Name (Titles) 3860**] [**Last Name (Titles) 662**] OF [**Location (un) **]
Address: [**Street Address(2) 31531**], [**Location (un) **],[**Numeric Identifier 31532**]
Phone: [**Telephone/Fax (1) 31529**]
.
Department: Cardiology
Name: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
When: Dr. [**Last Name (STitle) 31533**] office is working on a hospital follow up
appointment for you in 6-weeks after your hospital discharge. If
you have not heard from the office in 2 business days please
call the number listed below.
Location: [**Hospital1 **]
Address: [**Location (un) **], [**Hospital Ward Name **] 7, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 62**]
.
You have an outpatient repeat 2D-Echocardiogram (heart
ultrasound) scheduled in 1-week on Thursday, [**2186-11-9**]
at 2:00 PM.
.
Department: CARDIAC SERVICES
When: THURSDAY [**2186-11-9**] at 2:00 PM
With: ECHOCARDIOGRAM [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"458.29",
"427.32",
"948.00",
"E876.8",
"599.0",
"997.1",
"716.90",
"E879.0",
"420.90",
"724.2",
"401.9",
"427.31",
"942.14"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.34",
"99.62"
] |
icd9pcs
|
[
[
[]
]
] |
10673, 10679
|
4774, 8950
|
359, 429
|
10865, 10865
|
3148, 4001
|
13412, 14700
|
2331, 2404
|
9382, 10650
|
10700, 10770
|
8976, 9359
|
11048, 13389
|
2419, 3129
|
10791, 10844
|
1570, 1648
|
283, 321
|
457, 1490
|
10880, 10992
|
1679, 2062
|
1512, 1550
|
2078, 2315
|
4018, 4751
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,623
| 139,796
|
54084
|
Discharge summary
|
report
|
Admission Date: [**2128-5-8**] Discharge Date: [**2128-5-12**]
Date of Birth: [**2110-5-1**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Doctor First Name 2080**]
Chief Complaint:
fever, nausea/vomiting, hypotension
Major Surgical or Invasive Procedure:
Central venous catherization
History of Present Illness:
18 year old healthy woman with who presented after developing
acute onset of vomitting, rigors and confusion. She vomitted 15
episodes of emesis in total. She had two episode of intense
diarrhea. She was found by her mother on the floor,
confused/agitated and dizzy. She initially went to an OSH ED
where temp was 101.8F and pelvic exam revealed tender cervix, no
vaginal discharge. No tampons were found within the vagina.
She was given oxacillin 2 gm, 5L ns, zofran, toradol, motrin and
tylenol. Blood cultures were taken at OSH and are pending. She
was then transferred to [**Hospital1 18**] for concern for toxic shock
syndrome.
Upon arrival to [**Hospital1 18**] ED, vitals were 98.4F 128 89/42 16 100%
RA. SBP was persistently low ~75 despite 3L NS given. RIJ
placed and levophed was started with improvement in SBP to 110s.
Exam notable for diffuse morbilliform, erythematous, blanching
rash present on face, arms, legs, while sparing palms, soles,
and oral mucosa. A second, distinct rash was noted around anal
area and vaginal area; described as pink plaque around vaginal
introitus that is tender to palpation. She has a tender left
knee with small effusion and insect bite on the lateral aspect
of the left knee. She received vancoymcin, ceftriaxone,
clindamycin and acetaminophen. Vitals prior to transfer: pulse
of 114, RR 26, 109/56 on levophed, not febrile in our ED, O2 sat
of 99% on room air.
.
On arrival to the ICU, HR 123 sinus, BP 107/74 on levophed, 100%
RA. She states she has had a non-pruritic painful rash around
her anus for approximately 1.5 months. No change in vaginal
discharge. She is currently on day 4 of menses. Used tampons
on days [**2-4**] (super tampons, kept in for 4 hours at a time). She
is sexually active with one partner, uses condoms consistently.
No dysmenorrhea. No history of STDs, but has not had pelvic
exams prior to admission. Has never been tested for HIV. She
complains of new bilateral hand paresthesias.
.
Review of systems:
(+) Fever, chills, headache, mild neck stiffness since CVL
placed, weakness, hand paresthesias, anal rash, mild shortness
of breath. She has burning of her anal rash when she urinates.
(-) Denies night sweats, recent weight loss or gain, sinus
tenderness, rhinorrhea or congestion. Denies cough, or wheezing.
Denies chest pain, chest pressure, palpitations. Denies
abdominal pain, changes in bowel habits, melena/hematochezia.
Denies urinary frequency, or urgency. Denies arthralgias or
myalgias.
Past Medical History:
Acne
Possible Raynauds disease
Social History:
Lives with parents, in high school, planning on becoming a
physical therapist. Denies smoking. Has had 4 alcoholic drinks
in total in the past year, none prior to admission. No illicit
drug use. Sexual history per HPI.
Family History:
Father hypothyroidism, vitiligo, maternal grandmother
sarcoidosis/psoriasis/hypothyroidism, maternal grandfather with
[**Name2 (NI) 499**] CA.
Physical Exam:
ADMISSION EXAM
Vitals: 99.3 HR 123 sinus, BP 107/74 on levophed, RR 23, 100%
RA
General: Alert, oriented, no acute distress, interactive, weak
appearing
HEENT: Sclera anicteric, MMM, oropharynx without erythema or
petechiae
Neck: supple, no neck stiffness aside from mild guarding due to
CVL, no cervical LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: Foley present. Punctate erythematous macules around anus,
non-blanching, tender to palpation, non-vesicular or exudative.
Pelvic exam revealed pink vaginal mucosa with menses. No
abnormal vaginal discharge. Cervix not tender to palpation
during internal exam.
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis,
diffuse mild non-pitting edema in extremities bilaterally, no
knee effusions or increased warmth, recent blue/red papule
lateral to left knee at site of recent insect bite
Skin: minimal flushing on face around nasal bridge. No other
rash visible. No desquamation.
Neurologic: CN2-12 intact, 5/5 strength, no sensory deficits
.
DISCHARGE EXAM
Vitals: 98.3 HR 83, BP 108/68, RR 18, 100% RA
General: Alert, oriented, no acute distress
HEENT: MMM
Lungs: Clear to auscultation bilaterally
CV: Regular rate and rhythm,no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, no rebound or guarding
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis,
previous site of erythema on right leg now resolved
Pertinent Results:
Admission Labs
Labs:
Color Straw
Appear clear
SpecGr 1.010
pH 5.0
Urobil Neg
Bili Neg
Leuk Neg
Bld Neg
Nitr Neg
Prot Neg
Glu Neg
Ket Neg
.
Lactate:1.7
.
143 116 11 105 AGap=12
3.7 19 0.7
.
ALT: 11 AP: 39 Tbili: 0.4 Alb: 2.6
AST: 17
.
WBC 5.6 Hb 10.8 Hct 33.4 Plt 160 MCV 90
N:84 Band:6 L:2 M:8 E:0 Bas:0
PT: 12.3 PTT: 26.2 INR: 1.1
.
DISCHARGE LABS
[**2128-5-11**] 06:00AM BLOOD WBC-5.6 RBC-4.23 Hgb-13.2 Hct-38.9 MCV-92
MCH-31.3 MCHC-34.0 RDW-13.2 Plt Ct-207
[**2128-5-11**] 06:00AM BLOOD PT-10.2 PTT-27.9 INR(PT)-0.9
[**2128-5-11**] 06:00AM BLOOD Glucose-101* UreaN-10 Creat-0.7 Na-141
K-3.8 Cl-108 HCO3-26 AnGap-11
[**2128-5-10**] 02:59AM BLOOD ALT-25 AST-21 AlkPhos-51
[**2128-5-11**] 06:00AM BLOOD Calcium-8.4 Phos-4.9* Mg-2.0
[**2128-5-8**] 06:25PM BLOOD HIV Ab-NEGATIVE
[**2128-5-8**] 08:21AM BLOOD Lactate-1.7
.
Micro: blood cultures pending x 2
**FINAL REPORT [**2128-5-10**]**
C. difficile DNA amplification assay (Final [**2128-5-9**]):
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
FECAL CULTURE (Final [**2128-5-10**]): NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final [**2128-5-10**]): NO CAMPYLOBACTER
FOUND.
[**2128-5-8**] 2:31 pm SWAB Source: Vaginal.
GENITAL CULTURE FOR TOXIC SHOCK (Preliminary):
STAPH AUREUS COAG +. SPARSE GROWTH.
YEAST VAGINITIS CULTURE (Final [**2128-5-10**]):
YEAST. SPARSE GROWTH.
**FINAL REPORT [**2128-5-10**]**
MRSA SCREEN (Final [**2128-5-10**]): No MRSA isolated.
.
Images:
CXR [**2128-5-8**]: No effusions, PTX, consolidations, Line in good
position
.
RUQ US: [**2128-5-8**]: The gallbladder is moderately distended and
there is gallbladder wall edema with the wall measuring up to
9mm. There is also evidence of a small amount of fluid in
[**Location (un) 6813**] pouch. There are however no cholelithiasis or ductal
dilatations. These findings are non-specific and may be seen in
the setting of cholecystitis, hepatitis, or with third spacing
of fluid. Clinical correlation is recommended.
.
EKG [**2128-5-8**]: sinus tach 125bpm, normal intervals, normal axis, no
ST/changes, low voltage throughout
Brief Hospital Course:
18 year old woman who presented with vomiting, rigors and
confusion, found to be hypotensive requiring pressors.
.
Distributive Shock/MSSA Toxic Shock Syndrome: Presentation was
consistent with toxic shock syndrome. Data supporting TSS
include rapid onset of symptoms, presence of diffuse macular
rash, diarrhea/vomiting, hypoalbuminemia and mild
encephalopathy. Risk factors for her include using tampons
(last used morning of admission). Symptoms of TSS develop within
2-3 days of onset of menses, therefore the timing is quite
consistent with this diagnosis. Initially septic shock from
another source was also considered however blood cultures were
negative x several days. GC/Chlamydia and PID were also
considered and a culture were sent and were negative. She did
not display signs of meningismus and meningitis was much lower
on the differential. Micro from outside hospital was positive
for a urine culture that grew MSSA as well as a vaginal swab
that also was positive for MSSA. She was started on Vancomycin
and Clindamycin for coverage of toxic shock syndrome. We also
added Ceftriaxone to cover for GC and Chlamydia while cultures
were pending this was discontinued when cultures returned
negative. When cultures returned with MSSA vancomycin was
discontinued and she was started on nafcillin to complete total
14 day course. She was continued on oral clindamycin for a total
of 7 days. A central line was placed in the ED and she was
aggressively fluid resuscitated and initially required blood
pressure support with Levophed on admission. This was weaned off
the following day. We continued to follow her I/Os and matched
her urine output with LR boluses. At the time of transfer from
the ICU her blood pressure was stable with SBPs in the low 100s.
Because the pt is sexually active the decision was made to send
an HIV which was negative. On the floor pressures remained
stable and the patient remained afebrile. She was discharged
with instructions to avoid tampon use for the next several
menstrual cycles and intercourse for the next several weeks. She
will have close follow-up with her primary care physician.
.
# Non-anion gap acidosis: Likely secondary to fluid
resuscitation with normal saline. Fluid resuscitation was
switched to lactated ringers and the anion gap resolved.
.
# Transitional:
- Blood cultures were pending at the time of discharge
- Full code
- Patient will follow-up with her PCP
[**Name Initial (PRE) **] [**Name10 (NameIs) **] will continue IV nafcillin for 10 more days and oral
clindamycin for 3 days
Medications on Admission:
OCP - Aviane
Acne cream
Discharge Medications:
1. Apri 0.15-30 mg-mcg Tablet Sig: One (1) Tablet PO daily ().
2. nafcillin in D2.4W 2 gram/100 mL Piggyback Sig: Two (2) gram
Intravenous Q4H (every 4 hours) for 10 days: last dose [**2128-5-21**],
58 doses .
Disp:*114 grams * Refills:*0*
3. clindamycin HCl 150 mg Capsule Sig: Four (4) Capsule PO Q8H
(every 8 hours) for 3 days: last dose on [**2128-5-14**].
Disp:*32 Capsule(s)* Refills:*0*
4. Outpatient Lab Work
Please check CBC with diff, Chem-7 and LFTs on [**2128-5-19**] and fax
results to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 110861**]
Discharge Disposition:
Home With Service
Facility:
Home Solutions
Discharge Diagnosis:
Staphlococcal toxic shock syndrome
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms [**Name13 (STitle) **],
It was a pleasure participating in your care while you were
admitted to [**Hospital1 69**]. As you know
you were admitted because you were having nausea, vomiting, and
diarrhea. You were found to have an infection caused by an
organism called staph. This bacteria forms a toxin which caused
your symptoms. You were started on antibiotics. You may notice
flaking of you skin over the next few weeks which can be a late
effect of this toxin. You should also avoid using tampons for
the next several menstrual cycles.
We made the following changes to your medications
1. START nafcillin 2 g IV every 4 hours for 10 more days last
day [**2128-5-21**]
2. START clindamycin 600 mg every 8 hours for 3 more days last
dayon [**2128-5-14**]
Please take all other medications as instructed. Please feel
free to call with any questions or concerns.
Followup Instructions:
Name:[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP
Specialty: Primary Care
Location: FAMILY MEDICINE ASSOCIATES
Address: [**Location (un) 29112**], [**Location (un) 29113**],[**Numeric Identifier 29114**]
Phone: [**Telephone/Fax (1) 29115**]
When: [**Last Name (LF) 766**], [**5-17**] at 11:15am
|
[
"704.8",
"276.2",
"995.92",
"038.11",
"785.52",
"040.82",
"348.30"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.97",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
10502, 10547
|
7240, 9797
|
339, 370
|
10626, 10626
|
5000, 7217
|
11670, 11993
|
3211, 3355
|
9872, 10479
|
10568, 10605
|
9823, 9849
|
10777, 11647
|
3370, 4981
|
2402, 2900
|
264, 301
|
398, 2383
|
10641, 10753
|
2922, 2955
|
2971, 3195
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,462
| 176,131
|
603
|
Discharge summary
|
report
|
Admission Date: [**2130-11-14**] Discharge Date: [**2130-11-27**]
Date of Birth: [**2058-9-27**] Sex: F
Service: SURGERY
Allergies:
Latex / Penicillins / Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
Abdominal pain; BRBPR
Major Surgical or Invasive Procedure:
Hartmann's resection of the sigmoid colon, end colostomy with
Hartmann's pouch
History of Present Illness:
72F with history of rheumatoid arthritis on steroids presents
with severe abdominal pain of one day duration. Patient reports
long standing trouble with gastric ulcers due to her
immunosuppressive therapy, however her medication was stopped
due to intolerance. She had not had episodes of abdominal pain
in the past. Her current pain is not accompanied by nausea,
vomiting, or diarrhea. She has not been passing flatus since her
pain started. She has normal bowel movements and reports a
normal recent colonoscopy. She denies fevers, chills, and
malaise. Her main health problems at this time are related to
her RA which is severe and has recently required citoxan therapy
for which a tunneled L SCV line was placed about 6 weeks ago.
Her last dose of citoxan was 5 weeks ago. She was recently
admitted at [**Hospital3 **] for management of MRSA cellulitis
from her chronic vasculitic LE leg wounds. At outside hospital,
received meropenem and flagyl. Of note, her plavix has been held
for the last 4 days.
Past Medical History:
PMH: LE vasculitis, MRSA from leg wound, htn, R stroke with
minor
weakness of LUE, diabetes, rhematoid arthritis, vasculitis, CAD,
bronchiectasis with pigeon chest, diastolic CHF, corpus calosum,
osteoperosis, anemia, anxiety
PSH: Cervical fusion, R shoulder, b/l wrist, b/l THR, b/l knee
replacement, b/l ankle
Social History:
SH: Accompanied by her sons, came from rehab facility. Denies
tobacco use, occasional alcohol use.
Family History:
FH: No known GI cancers
Physical Exam:
On exam:
VS:97.6 100 140/85 18 98%
Gen: Appears comfortable, NAD
CV: RRR
Resp: CTAB, anterior protrusion of chest wall
Abd: Distended, tympanitic, very tender to percussion and
palption, + guarding, no rebound
Ext: 2 deep wounds (1.5 cm area) over lateral surface of RLE and
posterior calf of her LLE, chronic from vasculitis. Multiple
healing ulcers. Palpable pulses b/l. Warm, no edema.
Pertinent Results:
[**2130-11-14**] 10:30PM BLOOD WBC-25.4* RBC-3.88* Hgb-11.1* Hct-34.0*
MCV-88 MCH-28.7 MCHC-32.8 RDW-18.3* Plt Ct-249 [**2130-11-14**]
Neuts-96.0* Lymphs-2.2* Monos-1.4* Eos-0.2 Baso-0.1 PT-12.8
PTT-23.5 INR(PT)-1.1 Glucose-98 UreaN-20 Creat-0.7 Na-138 K-4.1
Cl-106 HCO3-20* AnGap-16
[**2130-11-14**] 11:17PM BLOOD Lactate-1.7
[**2130-11-16**] 02:47AM BLOOD freeCa-1.23
[**2130-11-18**] 04:56AM BLOOD WBC-10.0 RBC-3.73* Hgb-10.0* Hct-33.1*
MCV-89 MCH-26.7* MCHC-30.1* RDW-18.2* Plt Ct-282 Calcium-8.3*
Phos-3.0 Mg-2.0
Glucose-108* UreaN-20 Creat-0.4 Na-142 K-4.2 Cl-114* HCO3-19*
AnGap-13
[**2130-11-14**]:
Rapid irregularly irregular narrow complex rhythm is present
consistent
with atrial fibrillation. A single monomorphic ventricular
premature beat is present. Non-specific ST-T wave changes are
present. The development of
atrial fibrillation is new compared with the previous tracing of
[**2113**]
Echo [**9-7**] at [**Hospital3 **]: LVEF 65%, 3+ MR, 1+ TR, mild
pHTN,
mild [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 1915**], LVID 5.2 diastolic, 3.5 systolic
Brief Hospital Course:
The patient was transferred from an OSH after an Abd CT scan
revealed free air and fluid within her pelvis without a clear
source of perforation. She was initially admitted to the trauma
ICU, but was taken emergently to the operating room on [**11-14**], [**2130**] where she underwent a Hartmann's resection of the
sigmoid colon and end colostomy with Hartmann's pouch; please
see operative report for further details.
Postoperatively, the patient was transferred to the ICU. She
was extubated and transitionted to IV dilaudid for pain control
with continued intravenous metronidazole and meropenem. Her NGT
was discontinued and po medications were initiated. Given
hemodynamic stability, she was transferred to the general
surgical [**Hospital1 **] on [**Month (only) 359**] POD2 for further management.
Neuro: The patient was alert and oriented throughout her
hospitalization; post-extubation, pain was initially managed
with intravenous hydromorphone. This was transitioned to oral
oxycodone and acetaminophen on POD5 with well controlled pain.
Of note, the patient did occasionally require intravenous
morphine for breakthrough pain control.
CV: Upon transfer from the OSH, the patient was noted to be in a
fib with intermittent RVR. Oral metoprolol was resumed on POD1
and a cardiology consult was obtained on POD4 with
recommendations for anticoagulation with either heparin gtt or
lovenox bridged to oral warfarin or to begin anticoagulation
with dabigatran. [**Month (only) 4692**], possible cardioversion either as
an in/outpatient was suggested; anticoagulation not resumed at
this time as per surgeon due to very high risk for falls. The
patient remained asymptomatic and hemodynamically stable,
therefore, inpatient cardioversion was not attempted. She will
follow-up with her primary care provider upon discharge for
ongoing management of these issues. She was not started on
anticoagulation, outside of subcutaneous heparin, because of
fall risk and the thought that her irregular heart rate was a
post-surgical response. This will be reassessed when she follows
up in [**Hospital 2536**] clinic and with her PCP. [**Name10 (NameIs) 4692**], the patient
presented with a tunneled line in place for outpatient citoxan,
which was noted to be out of position on POD2, requiring IR
removal and replacement. Pulmonary: The patient remained
intubated post-operatively due to difficulty with initial
intubation for surgery. Given respiratory stability she was
extubated on POD1. She remained stable until POD6 when she
developed acute SOB. A CXR was obtained and suggested
'unchanged left lower lung collapse and improved bilateral
pleural effusions'. The event did not recur and the patient
remained stable throughout the remainder of her hospitalization;
vital signs were routinely monitored. Good pulmonary toilet,
early ambulation and incentive spirometry were encouraged
throughout hospitalization. Patient has history of diastolic
heart failure, chronic, that was monitored throughout this
hospitalization and she ahd no acute issues realted to her heart
failure.
GI/GU/FEN: Bowel function returned by POD3 as noted by gas/
stool within the ostomy appliance. The patient received
teaching regarding ostomy care including emptying pouch and
changing the appliance from the Ostomy RN. However, her ability
to perform these tasks was limited by her hand deformities.
Occupational therapy was consulted for further assistance and
will continue at the rehab facility. She was initially NPO, but
was advanced sequentially following return of bowel function to
diabetic diet, which was well tolerated. Nutrition was consulted
due to multiple bilateral chronic lower extremity ulcerations;
recommendations included high protein supplements and food
choices. Patient's intake and output were closely monitored
with electrolyte repletion prn. She was taking adequate food and
had gppd output through her ostomy.
ID: Intravenous metronidazole and meropenem were initiated and
continued through POD2 & POD7, respectively. On POD 7, the
patient's WBC began trending upward, therefore, blood cultures
were sent and an CT Torso was obtained and her antibiotics were
switched to vancomycin, zosyn, and fluconazole; results from CT
scan showed small amount of free fluid in the pelvis but no
signs of abscess and otherwise normal CT. On POD 8, the WBC
began trending downward and on POD 9 patient was kept on only
diflucan with a planned 5 day course for what appeared per derm
and rheum to be a yeast infection on her back. She was
discharged on no antibioics as she had finished her course of
diflucan and her back rash was much improved. At time of
discharge her blood cultures had no growth to date. She has a JP
drain on her left side that has been draining minimal amout of
serous fluid but will be left in until follow-up appointment.
She also has staples in her abdominal wound that will be left in
until her follow-up appointment with [**Hospital 2536**] clinic.
Rheum: No acute change in managment of RA while inpatient,
patient will follow up with her outpatient rheumatologist Dr
[**Last Name (STitle) 1492**]. Daily predinsone, at home dosage, was continued while
in-house. [**Last Name (STitle) 4692**], on POD8, a large rash was noted on the
patients back. Rheumatology felt this was fungal in nature and
recommended topical antifungal treatment with derm consultation
who also agreed with antifungal treatment.
Prophylaxis: The patient received subcutaneous heparin during
this stay; she was encouraged to get out of bed as ealry as
possible.
Rehab: The patient was seen by physical therapy for in-patient
evaluation and treatment. PT recommended transfer to rehab upon
discharge due to the level of assistance required in addition to
pt living at home alone; see evaluation for details. At the time
of discharge to rehab, the patient was doing well, afebrile with
stable vital signs. The patient was tolerating a diabetic diet,
ambulating with assistance and use of a rolling walker. She was
voiding without assistance, and pain was well controlled. The
patient received discharge teaching and follow-up instructions
with understanding verbalized and agreement with the discharge
plan.
Medications on Admission:
Folic acid 1g daily
Plavix 75 mg daily
Vitamin B12 1000 mcg daily
Lasix 20 mg daily
Metoprolol 50 mg daily
Spironolactone 125 mg daily
Neurontin 100 mg [**Hospital1 **]
Prednisone 10 mg daily
Iron 325 mg daily
MVI 1 tablet daily
Maalox 30 mg prn
Discharge Medications:
1. gabapentin 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for pain.
2. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
3. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every four (4)
hours as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
6. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. spironolactone 25 mg Tablet Sig: Five (5) Tablet PO once a
day.
9. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 2 days.
10. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
11. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
12. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] of [**Location (un) 4693**]
Discharge Diagnosis:
Sigmoid diverticulitis with ruptured pelvic abscess and
peritonitis
Atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were transferred to [**Hospital1 18**] from an outside hospital after
experiencing abdominal pain associated with bright red blood per
rectum. An abdominal CT scan revealed free air within the
abdominal cavity due to perforation. Therefore, you underwent
an emergent operation to repair a ruptured pelvic abscess. You
have recovered from surgery in the hospital and have also worked
with occupational therapy, physical therapy and the ostomy care
RN and are now preparing for discharge to a rehab facility for
ongoing recovery.
Followup Instructions:
Please call for an Acute Care Service appointment at
[**Telephone/Fax (1) 600**]. You should schedule this appointment for [**8-6**]
days from discharge with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. At this appointment
you will possibly have your drain removed and your staples taken
out.
Please follow-up with Dr. [**First Name11 (Name Pattern1) 1494**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 1492**], your PCP, [**Last Name (NamePattern4) **]
[**0-0-**] in the next 2 weeks. This would be regarding this
hospitalization if cardiology referral is needed for further
follow-up of the mitral regurgitation found on your Echo. You
should also discusss the possibility of a repeat Echo.
Completed by:[**2130-11-27**]
|
[
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"401.9",
"V58.69",
"733.00",
"112.3",
"567.21",
"300.00",
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"427.31",
"789.59",
"714.2",
"V58.65",
"562.10",
"250.00",
"447.6",
"707.13",
"428.0",
"V43.64",
"707.12",
"V45.4",
"511.9",
"428.32"
] |
icd9cm
|
[
[
[]
]
] |
[
"46.11",
"86.28",
"45.76"
] |
icd9pcs
|
[
[
[]
]
] |
10993, 11068
|
3479, 9710
|
337, 417
|
11200, 11200
|
2374, 3456
|
11910, 12677
|
1924, 1949
|
10006, 10970
|
11089, 11179
|
9736, 9983
|
11351, 11887
|
1964, 2355
|
276, 299
|
445, 1454
|
11215, 11327
|
1476, 1791
|
1807, 1908
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,275
| 121,843
|
53892
|
Discharge summary
|
report
|
Admission Date: [**2113-12-9**] Discharge Date: [**2114-1-15**]
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Morphine / Ultram / Lidocaine
Attending:[**Doctor First Name 3298**]
Chief Complaint:
altered mental status, weakness
Major Surgical or Invasive Procedure:
Endotracheal intubation
History of Present Illness:
[**Age over 90 **] year-old woman with lymphoma, colon cancer, atrial
fibrillation, presenting with 2 days of weakness, cough, altered
mental status and poor PO intake. One week ago, patient had
URI-like illness, but improved and was feeling back to her
baseline. Patient started feeling weak and noted a cough 2 days
ago. She called her PCP who recommended she take a previously
prescribed antibiotic (family thinks antibiotic may have been
levaquin, no record in OMR). Today the patient had one loose
bowel movement. Patient did not improve, so she was brought
into ED today by family.
In the ED, initial vitals: 97.9, 86, 95/54, 14, 98 3L NC.
Patient had and EKG showing sinus rhythm with multiple PVCs. A
chest x-ray showed bilateral fluffy infiltrates that appear
worse than her prior CXR. Labs were notable for WBC of 15.5 with
75% polys and 6% bands. She received ceftriaxone and
azithromycin for CAP. Blood pressure ranged 80s -90s in ED for
which patient received 2L IVF. While in the ED, patient was
noted to have multiple 20 - 30 beat runs of v-tach. Cardiology
was consulted and recommended IV amiodarone load, which was
started in ED. Cardiology reviewed tele strips and felt tracing
consistent with monomorphic v tach, not a.fib with aberrancy.
Transfer vitals were 87, 100/49, 20, 97% on 2L.
On arrival to the MICU, patient felt tired, but responds to
family's questions. She complains of cough, but otherwise has
no complaints.
Past Medical History:
1. Brain meningioma.
2. CLL in [**2094**], transformed to NHL, status post CHOP and [**Hospital1 **].
3. Hypogammaglobulinemia with recurrent sinopulmonary
infections, improved with IVIG replacement therapy. Last IVIG
infusion [**2103-9-18**]. ([**2107-12-27**]: IgG 1245, IgA 183, IgM 55)
4. Colon cancer status post hemicolectomy (Stage 3, T3N1M0).
5. Motor vehicle accident, status post splenectomy.
6. SVC clot in [**2104**] in setting of indwelling central line.
7. Pneumonia complicated by adult respiratory distress
syndrome in [**1-30**]. Pneumonia with prolonged intubation [**4-30**]
8. Ejection fraction greater than 60%, mild mitral
regurgitation and mild pulmonary hypertension on an
echocardiogram from [**2105-1-28**].
9. Chronic low back pain
10. Interstitial Lung Disease; PFTs [**8-31**]: FEV1 1.17 (108%pred),
FVC 1.63 (94%pred), FEV1/FVC 72 (116% pred)
Social History:
The patient is a nonsmoker, nondrinker. She lives alone but
near daughter. Farsi speaking, originally from [**Country **].
Family History:
Non-contributory
Physical Exam:
On Admission:
General: Alert, oriented to self and "hospital" in Farsi
HEENT: Sclera anicteric, PERRL, slightly dry mucus membranes
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, no murmurs/rubs/gallops
Lungs: b/l velcro-like crackles
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: foley in place
Ext: warm, well perfused, 1+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII grossly intact
Pertinent Results:
[**2114-1-10**] 03:56AM BLOOD WBC-10.3 RBC-3.02* Hgb-8.6* Hct-32.1*
MCV-106* MCH-28.6 MCHC-26.9* RDW-19.1* Plt Ct-336
[**2114-1-9**] 04:01AM BLOOD WBC-8.7 RBC-3.46* Hgb-9.7* Hct-36.7#
MCV-106* MCH-28.1 MCHC-26.5* RDW-19.7* Plt Ct-354
[**2114-1-8**] 03:41AM BLOOD WBC-9.7 RBC-2.85* Hgb-8.2* Hct-29.1*
MCV-102* MCH-29.0 MCHC-28.3* RDW-19.8* Plt Ct-344
[**2114-1-7**] 03:56AM BLOOD WBC-12.9* RBC-2.48* Hgb-7.3* Hct-26.0*
MCV-105* MCH-29.5 MCHC-28.3* RDW-19.9* Plt Ct-300
[**2114-1-6**] 04:51AM BLOOD WBC-11.0 RBC-2.51* Hgb-7.3* Hct-26.1*
MCV-104* MCH-29.1 MCHC-28.0* RDW-20.6* Plt Ct-300
[**2114-1-5**] 04:11AM BLOOD WBC-8.5 RBC-2.88* Hgb-8.1* Hct-30.0*
MCV-104* MCH-28.2 MCHC-27.1* RDW-20.5* Plt Ct-278
[**2114-1-4**] 03:24AM BLOOD WBC-9.6 RBC-3.03* Hgb-8.7* Hct-31.5*
MCV-104* MCH-28.8 MCHC-27.7* RDW-21.0* Plt Ct-233
[**2114-1-3**] 01:33AM BLOOD WBC-10.7 RBC-2.99* Hgb-8.6* Hct-31.5*
MCV-106* MCH-28.7 MCHC-27.2* RDW-20.9* Plt Ct-180
[**2114-1-2**] 02:03AM BLOOD WBC-11.9* RBC-2.66* Hgb-7.7* Hct-27.6*
MCV-104* MCH-28.9 MCHC-27.9* RDW-21.0* Plt Ct-170
[**2114-1-1**] 07:42AM BLOOD WBC-10.2 RBC-2.82* Hgb-8.3* Hct-29.2*
MCV-104* MCH-29.5 MCHC-28.4* RDW-21.8* Plt Ct-175
[**2114-1-1**] 02:09AM BLOOD WBC-9.8 RBC-2.74* Hgb-8.0* Hct-29.1*
MCV-106* MCH-29.1 MCHC-27.4* RDW-20.9* Plt Ct-205
[**2113-12-31**] 02:38AM BLOOD WBC-12.3* RBC-2.48* Hgb-7.3* Hct-26.6*
MCV-107* MCH-29.5 MCHC-27.5* RDW-21.7* Plt Ct-174
[**2114-1-10**] 03:56AM BLOOD Plt Ct-336
[**2114-1-9**] 04:01AM BLOOD Plt Ct-354
[**2114-1-8**] 03:41AM BLOOD Plt Ct-344
[**2114-1-7**] 03:56AM BLOOD Plt Ct-300
[**2114-1-6**] 04:51AM BLOOD Plt Ct-300
[**2114-1-5**] 04:11AM BLOOD Plt Ct-278
[**2114-1-4**] 03:24AM BLOOD Plt Ct-233
[**2114-1-3**] 01:33AM BLOOD Plt Ct-180
[**2114-1-2**] 02:03AM BLOOD Plt Ct-170
[**2114-1-1**] 07:42AM BLOOD Plt Ct-175
[**2113-12-31**] 02:38AM BLOOD PT-14.5* PTT-62.1* INR(PT)-1.4*
[**2113-12-30**] 05:25AM BLOOD PT-17.6* PTT-49.4* INR(PT)-1.7*
[**2114-1-10**] 03:56AM BLOOD Glucose-94 UreaN-24* Creat-0.4 Na-146*
K-3.7 Cl-113* HCO3-31 AnGap-6*
[**2114-1-9**] 04:01AM BLOOD Glucose-78 UreaN-31* Creat-0.5 Na-154*
K-4.5 Cl-121* HCO3-31 AnGap-7*
[**2114-1-8**] 03:41AM BLOOD Glucose-121* UreaN-35* Creat-0.4 Na-150*
K-4.0 Cl-120* HCO3-28 AnGap-6*
[**2114-1-7**] 04:30PM BLOOD Glucose-85 UreaN-37* Creat-0.4 Na-152*
K-3.9 Cl-122* HCO3-28 AnGap-6*
[**2114-1-7**] 03:56AM BLOOD Glucose-140* UreaN-40* Creat-0.5 Na-150*
K-4.4 Cl-122* HCO3-25 AnGap-7*
[**2114-1-6**] 04:51AM BLOOD Glucose-198* UreaN-45* Creat-0.5 Na-146*
K-3.7 Cl-116* HCO3-26 AnGap-8
[**2113-12-30**] 05:25AM BLOOD ALT-16 AST-46* LD(LDH)-224 AlkPhos-87
TotBili-1.7*
[**2113-12-19**] 10:40AM BLOOD ALT-13 AST-34 AlkPhos-88 TotBili-0.7
[**2113-12-13**] 04:28AM BLOOD ALT-13 AST-31 AlkPhos-103 TotBili-0.4
[**2114-1-10**] 03:56AM BLOOD Calcium-8.1* Phos-3.2 Mg-1.4*
[**2114-1-9**] 04:01AM BLOOD Calcium-8.8 Phos-4.1 Mg-1.8
[**2114-1-8**] 03:41AM BLOOD Calcium-8.4 Phos-3.1 Mg-1.7
[**2114-1-7**] 04:30PM BLOOD Calcium-8.4 Phos-2.5* Mg-1.8
[**2114-1-2**] 10:10AM BLOOD TSH-2.9
[**2113-12-18**] 03:47AM BLOOD Hapto-88
[**2114-1-2**] 10:10AM BLOOD Triglyc-49
[**2113-12-11**] 05:13PM BLOOD Vanco-15.4
[**2114-1-10**] 03:56AM BLOOD Digoxin-2.1*
[**2114-1-9**] 04:01AM BLOOD Digoxin-3.0*
[**2114-1-8**] 03:41AM BLOOD Digoxin-1.6
[**2114-1-9**] 04:56PM BLOOD Lactate-1.0
[**2114-1-9**] 04:56PM BLOOD freeCa-1.21
[**2114-1-9**] 11:27AM BLOOD freeCa-1.26
[**2114-1-8**] 12:01PM BLOOD freeCa-1.24
Brief Hospital Course:
Ms. [**Known lastname **] is a [**Age over 90 **] year-old woman with history of lymphoma,
colon cancer, atrial fibrillation presenting with weakness and
cough, found to have hypotension.
# Sepsis: Found to have acinetobacter pneumonia and Clostridium
difficile diarrhea. She was treated with cefepime for
acinetobacter and completed a 2 week course of this. She was
also treated with flagyl for C.diff until 14 days after she
completed other antibiotics. She required 20 liters of IV
fluids and a prolonged period of vasopressors (~ 25 days) for
hypotension, but eventually was weaned in the setting of care
being deescalated and transferred from the MICU to the medical
floor. r.
# Hypoxemic respiratory failure: Her respiratory failure was
multifactorial including pneumonia as discussed above on a
baseline of severe interstitial lung disease (ILD--with dead
space 78%) and then pulmonary edema from the extensive fluid
resuscitation needed for sepsis. She was intubated with
endotracheal tube for ~ 30 days in the MICU. The family
repeatedly refused tacheostomy and ultimately decided that she
would be terminally extubated. She was treated with IV lasix
drip and transitioned to daily IV lasix to maintain her
respiratory ease. After extubation, she was able to maintain
her oxygen saturations on relatively low levels of supplementary
oxygen, however, her blood gases continued to show elevated PCO2
concentrations. This was likely due to her underlying ILD.
Ultimately, the family elected to make her "comfort measures
only" with the exception of fluids PRN and no more aggressive
measures were pursued for her respiratory failure.
# Altered mental status: Patient with worsening fatigue and
confusion as per family. This was a multifactorial problem
including electrolyte derangements, infection, and also concern
for hypercarbia. Ultimately, it was also thought that she
possibly had a hypomanic delirium from such a long period of
critical illness and ICU care. Even after electrolytes were
fixed, she did not follow commands or show repeatedly
appropriate responses to her family members. She was transferred
to the floor with this altered mental status with inability to
maintain alertness even loud voice commands or painful stimuli.
She remained very minimally responsive until she passed away.
# Ventricular tachycardia: Unclear precipitant. Patient also
with evolving j-point elevation on EKG, reviewed with cardiology
who felt that ST elevation in the setting of LBBB, does not meet
Sgarbossa's criteria. She was treated with aspirin and a statin
for most of her ICU stay until she was extubated and lost OG
tube access for oral medications. Her code status was made CMO
at this time as well.
# Atrial fibrillation (afib): She continued to have episodes of
afib with rapid ventricular response (RVR) and during this time
she would have hypotension. She was tried on an amiodarone drip
but this did not control the afib. Later, she was started on
digoxin which did control her rate very well and she did not
have episodes of hypotension. However, her digoxin level rose
to 3.0 with frequent electrical pauses noted on telemetry and so
digoxin was discontinued. At this time she had been
transitioned to CMO care.
# Hypernatremia: After the OG tube was removed at the time of
intubation, Ms. [**Name13 (STitle) 40643**] developed hypernatremia to the mid 150s
due to absence of oral intake and inability to drink to thirst.
She was corrected with IV D5W. Her family continued to refuse a
feeding tube as they felt it inconsistent with her goals of
care.
# Goals of care: Repeated discussions with the family and health
care proxy of Ms. [**Known lastname **] during her ICU stay. It was stated
clearly to the family that she would not be a candidate for
re-intubation and that leaving her intubated without a
tracheostomy for so long was injurious to her. Also, they
understood that she was not safe to eat on her own but they
asserted that a feeding tube would not be something that the
patient would have wanted. When the pressors were finally
weaned, the family agreed that it would not make sense for her
to have further resuscitation efforts in the future including
CPR, pressors, and cardioversion. The patient was made CMO care
with the exception that fluids would be given for hydration
purposes. The patient received fluids except when she appeared
fluid overloaded, at which point the fluids would be held. This
was discussed with the family, who agreed with this plan. The
patient was then transferred to the floor and ultimately passed
away there without significant awakening or responsiveness.
Medications on Admission:
1. Ergocalciferol 50,000 units every other week
2. ipratropium bromide 2 puffs INH every 6 hours as needed for
shortness of breath
3. meloxicam 7.5 mg daily PRN pain
4. aspirin 325 mg daily
Discharge Disposition:
Expired
Discharge Diagnosis:
none
Discharge Condition:
none
Discharge Instructions:
none
Followup Instructions:
none
Completed by:[**2114-1-18**]
|
[
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"038.3",
"008.45",
"276.2",
"518.81",
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"518.4",
"202.80",
"427.32",
"V10.05",
"427.31",
"789.59",
"286.9",
"427.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"33.24",
"96.72",
"96.6",
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] |
icd9pcs
|
[
[
[]
]
] |
11731, 11740
|
6835, 8498
|
304, 329
|
11788, 11794
|
3379, 6812
|
11847, 11882
|
2871, 2889
|
11761, 11767
|
11516, 11708
|
11818, 11824
|
2904, 2904
|
233, 266
|
357, 1815
|
2918, 3360
|
8513, 11490
|
1837, 2713
|
2729, 2855
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,920
| 167,854
|
52867
|
Discharge summary
|
report
|
Admission Date: [**2183-4-16**] Discharge Date: [**2183-4-24**]
Date of Birth: [**2121-3-14**] Sex: M
Service: MEDICINE
Allergies:
Vancomycin Analogues / Histamine / Ciprofloxacin / Penicillins /
Cephalosporins / Atorvastatin / Rosuvastatin / morphine / Sulfa
(Sulfonamide Antibiotics) / mushrooms, all types
Attending:[**First Name3 (LF) 4327**]
Chief Complaint:
Peri-procedure [**First Name3 (LF) **]
Major Surgical or Invasive Procedure:
Atrial tachycardia ablation
Left knee tap and injection
Pulmonary intubation
History of Present Illness:
Mr. [**Known lastname 26818**] is a 62 year old man with ischemic cardiomyopathy,
pulmonary hypertension, CABG/MVR [**8-/2182**], LAA clot on warfarin
who is admitted after EP ablation for symptomatic atrial
tachycardia.
.
Mr. [**Known lastname 28510**] primary problem has been chronic atrial tachycardia
since [**2182-9-5**], resulting in fatigue, lightheadedness,
palpitations, DOE, and chest pain with exertion. Today, [**4-16**], a
catheter ablation procedure was performed. This revealed two
discreet macroreentrant atrial tachycardias: One was mapped to
the left atrial septum, and the second was typical flutter
around the tricuspid annulus. With ablation of the second focus,
the patient converted to sinus rhythm. The procedure was
tolerated well under general anesthesia until the period after
restoration of sinus rhythm, when he became hypotensive. It was
suspected that his hypotension was secondary to blood loss after
his hematocrit dropped from 43 to 38 to 32 to 29 during the
procedure. Intracardiac echo and transthoracic echo revealed no
pericardial effusion. All vascular access was via the femoral
veins; there was no arterial puncture for the procedure. The
patient was sent to CT scan from the EP lab before arriving in
the CCU.
.
On arrival to the CCU, the patient was intubated and sedated on
dopamine gtt, phenylephrine gtt, epinephrine gtt.
.
ROS: unable to perform secondary to inutbation/sedation
Past Medical History:
PAST MEDICAL HISTORY (per OMR)
- Ischemic Cardiomyopathy with chronic systolic congestive heart
failure
- s/p MVR and CABG [**8-/2182**] (LIMA-LAD, SVG-AM and dRCA)
- Type 2 Diabetes Mellitus
- Hyperlipidemia
- Hypertension
- Atrial tachycardia causing cardiogenic [**Year (4 digits) **] in [**2182-9-5**]
- Severe pulmonary hypertension
- PFO
- CVA in [**2175**] with residual L sided facial droop
- CKD with baseline Cr 1.6-1.8
- Osteoarthritis
- Depression
- H/O Hodgkin's disease s/p surgical excision and CTX at age 18
.
NON-CARDIAC PAST SURGICAL HISTORY:
1. Appendectomy.
2. Hernia repair.
3. Back surgery after falling from 36 feet.
4. Multiple operations on his left knee and his right knee.
5. Multiple abdominal surgeries, first to remove small bowel
polyps and then followed by surgeries to fix complications of
previous surgeries.
6. Lymph node removal from the groin that was infected
Social History:
-He lives with his sister and her family. He has 3 children.
-Tobacco history: Neversmoker
-ETOH: remote use
-Illicit drugs: denies
Family History:
- Father had his first heart attack at 35 then died of MI at 45.
- Mom had diabetes and died of AAA rupture.
Physical Exam:
ADMISSION:
GEN: Intubated, sedated
Heart: Tachycardic, regular rhythm
PULM: Clear anteriorly
ABD: Multiple abdominal scars. Not tense, not distended
EXT: Warm, well perfused
Pulses: 2+ Left; not present on right (manual pressure being
applied to femoral artery)
DISCHARGE:
VS- Tmax/Tcurrent; 97.9/97.6 HR 74-86 RR: 18 BP: 106-132/69-73
O2 sat 100% RA
GEN: appears comfortable lying flat in bed.
Heart: irregularly irregular, S3 gone, JVP flat
PULM: CTAB post.
ABD: Multiple abdominal/thoracal scars. not distended, no
tenderness. Pos BS.
EXT: no c/c, 1+ edema b/l, warm, slightly pallor, no changes in
pulses. Left knee is swollen on ant and medial aspect, no
redness, no tenderness.
Right groin: Mild bruising, no palpable hematoma.
SKIN: No stasis dermatitis, ulcers.
Pertinent Results:
Admission-
[**2183-4-16**] 07:10AM BLOOD WBC-11.1*# RBC-5.00 Hgb-13.9*# Hct-43.4#
MCV-87 MCH-27.8 MCHC-32.0 RDW-15.9* Plt Ct-167
[**2183-4-16**] 07:10AM BLOOD Neuts-78.0* Lymphs-14.5* Monos-4.3
Eos-2.4 Baso-0.8
[**2183-4-16**] 07:10AM BLOOD Glucose-153* UreaN-47* Creat-1.8* Na-138
K-3.7 Cl-100 HCO3-29 AnGap-13
[**2183-4-16**] 07:11PM BLOOD Calcium-8.5 Phos-3.6 Mg-1.8
[**2183-4-16**] 07:10AM BLOOD PT-30.1* INR(PT)-2.9*
Discharge-
[**2183-4-24**] 07:00AM BLOOD WBC-14.3* RBC-4.05* Hgb-11.5* Hct-36.8*
MCV-91 MCH-28.3 MCHC-31.2 RDW-15.9* Plt Ct-262
[**2183-4-24**] 07:00AM BLOOD PT-22.5* INR(PT)-2.1*
[**2183-4-24**] 07:00AM BLOOD Glucose-290* UreaN-53* Creat-1.3* Na-137
K-4.8 Cl-101 HCO3-25 AnGap-16
CT ABD & PELVIS W/O CONTRAST ([**2183-4-16**])
1. Large retroperitoneal hematoma extending from the right
anterior pararenal space down into the extraperitoneal space of
Retzius as well as into the subperitoneal pelvis bilaterally,
greater on the right than the left. There is no evidence of
intraperitoneal hemorrhage.
2. Right lower lobe opacities likely representative of
developing pneumonia, possibly due to aspiration. Otherwise,
there is no evidence of hemorrhage in the thorax.
3. Stable right renal hemorrhagic cyst.
Brief Hospital Course:
62 year old man with ischemic cardiomyopathy, pulmonary
hypertension, CABG/MVR [**8-/2182**], LAA clot on warfarin who was
admitted to the CCU for hypovolemic [**Year (4 digits) **] after EP ablation for
symptomatic atrial tachycardia, found to have a retroperitoneal
bleed.
ACUTE
# Hypovolemic [**Year (4 digits) 21020**]:
He was found to be hypotensive toward the end of his EP ablation
procedure. He was sent directly to the CT scanner, where he was
found to have a large retroperitoneal hematoma. On arrival to
the CCU, the patient was already intubated and sedated on
dopamine gtt, phenylephrine gtt, epinephrine gtt. He was
transfused 6 units of PRBCs over the course of his first 2 days
in the CCU. Given his coagulopathy from warfarin, this was
reversed with a total of 6 units FFP. Dopamine and epi were
quickly discontinued, and phenylephrine was weaned over the
first couple days. He remained hemodynamically stable without
further evidence of bleeding.
# Ischemic cardiomyopathy / chronic systolic CHF / CAD:
His most recent EF is 25%. He was monitored very closely for
heart failure given the large amount of blood products and
fluids that were given. Intubation was continued given his high
risk for pulmonary edema. Diuretics and anti-hypertensives were
held, as well as aspirin given his bleed. When stable his
sildenafil, spironolactone, torsemide and digoxin were
restarted. As renal function improves, consider starting low
dose ACE inhibitor.
# Intubation:
This was performed electively pre-procedure. He remained
intubated for the first day in the CCU, then was quickly
extubated.
# Gout
He was found to have swelling and tenderness in his left knee on
[**4-20**]. This was tapped, which showed 17k WBCs and
monosodium urate crystals, consistent with gout. He has no
history of gout. He was started on colchicine and rheumatology
was consulted to perform a steroid injection in his knee. This
improved his pain significantly.
CHRONIC
# Chronic Kidney Disease:
Baseline creatinine of 1.8 which was stable.
# Atrial tachycardia:
Ablation was performed by EP, with subsequent resultant sinus
rhythm. INR initially reversed, then warfarin was restarted when
stable. He rermained in NSR for the duration of the
hospitalization.
# Pulmonary hypertension: Holding home sildenafil in setting of
[**Month (only) **]. Restarted when stable.
# DM, type II, insulin dependent:
Sliding scale humalong. Restarted home lantus when tolerating PO
# Hyperlipidemia:
Continued statin when tolerating PO
TRANSITIONAL
-- Consider starting allopurinol for maintenance prevention of
gout flares.
-- Monitor warfarin and INR given left atrial appendage clot.
-- Consider starting ACEi as renal function improves.
Medications on Admission:
ALBUTEROL SULFATE 90 mcg HFA Aerosol Inhaler 2 HFA(s) inhaled
every 4-6 hours
DIGOXIN -125 mcg Tablet 1 Tablet(s) by mouth every other day
FOLIC ACID - 1 mg Tablet by mouth daily
INSULIN GLARGINE [LANTUS] - 100 unit/mL Solution - 20u at
bedtime
INSULIN LISPRO [HUMALOG] - slilng scale as needed TID
METOPROLOL SUCCINATE - 25 mg 1 Tablet(s) by mouth DAILY
OXYCODONE-ACETAMINOPHEN - 5 mg-325 mg Tablet; 1 Tablet(s) by
mouth every six (6) hours as needed for pain- has narcotics
contract
POTASSIUM CHLORIDE - 20 mEq Tablet, ER Particles/Crystals - 1
Tablet(s) by mouth once a day
SILDENAFIL [REVATIO] - 20 mg Tablet - 2 Tablet(s) by mouth TID
SIMVASTATIN - 20 mg Tablet - 1 Tablet(s) by mouth once a day
SPIRONOLACTONE - 25 mg Tablet - 1 Tablet(s) by mouth daily
TORSEMIDE - 20 mg Tablet - 4 Tablet(s) by mouth DAILY (Daily)
WARFARIN - 5 mg Tablet - one Tablet(s) by mouth daily
ZOLPIDEM - 5 mg Tablet - 1 Tablet(s) by mouth at bedtime
ASPIRIN - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet daily
Discharge Medications:
1. sildenafil 20 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
2. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
3. digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
4. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day: hold
HR <60, SBP< 100.
5. insulin glargine 100 unit/mL Solution Sig: Fourteen (14)
units Subcutaneous at bedtime: Pt was on 20 units at bedtime at
home.
6. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO four times a day as needed for pain.
7. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation every four (4) hours as needed for
shortness of breath or wheezing.
8. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO once a day.
10. spironolactone 25 mg Tablet Sig: One (1) Tablet PO once a
day.
11. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
12. torsemide 20 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
13. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
14. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily).
15. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Discharge Disposition:
Extended Care
Facility:
Newbridge on the [**Doctor Last Name **] - [**Location (un) 1411**]
Discharge Diagnosis:
Atrial tachycardia
Acute Blood loss Anemia
Hypovolemic [**Location (un) 21020**]
Left Knee Gout
Chronic systolic congestive heart failure
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted for an atrial tachycardia ablation. Two areas
in your heart were ablated and the procedure seems to have
worked well. You developed some bleeding after the procedure in
your groin and back area requiring blood infusions and medicine
to keep your blood pressure up. You were on a ventilator for a
few days because you were so sick. You are now back on your
previous home medicines and your labs are stable.
You developed an acute gout flare in your left knee and needed a
cortisone injection to treat the pain.
Weigh yourself every morning, call [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] NP if weight
goes up more than 3 lbs in 1 day or 5 pounds in 3 days. You
weight at discharge is 198 pounds.
.
We made the following changes to your medicines:
1.Increase the metoprolol to 100 mg daily
2. Start Miralax and senna to prevent constipation
Followup Instructions:
Department: CARDIAC SERVICES
When: THURSDAY [**2183-5-8**] at 3:40 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 11899**], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: TUESDAY [**2183-5-20**] at 3:00 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
|
[
"428.0",
"998.09",
"V58.67",
"425.4",
"416.8",
"V49.87",
"428.22",
"998.11",
"V45.81",
"272.4",
"V17.41",
"403.90",
"250.00",
"E879.8",
"V12.54",
"274.01",
"427.32",
"285.1",
"V10.72",
"585.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.27",
"37.34",
"37.28",
"81.91",
"96.71",
"99.23",
"81.92"
] |
icd9pcs
|
[
[
[]
]
] |
10450, 10544
|
5273, 7996
|
477, 556
|
10726, 10726
|
4017, 5250
|
11813, 12460
|
3100, 3211
|
9044, 10427
|
10565, 10705
|
8022, 9021
|
10908, 11790
|
2596, 2934
|
3226, 3998
|
399, 439
|
584, 2013
|
10741, 10884
|
2035, 2573
|
2950, 3084
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,948
| 178,084
|
13430
|
Discharge summary
|
report
|
Admission Date: [**2122-1-16**] Discharge Date: [**2122-1-19**]
Date of Birth: [**2093-2-24**] Sex: M
Service: MEDICINE
Allergies:
Morphine / Darvocet-N 100 / Ketorolac / Cephalexin /
Metronidazole
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
DKA, ICU admission as on insulin drip
Major Surgical or Invasive Procedure:
right IJ placement
History of Present Illness:
He is a 28 yo male with polyglandular autoimmune syndrome type 2
with DM1 and Addison??????s syndrome. He presented to our ED after
recent hospitalization at [**Location (un) 8973**] Hospital where he underwent
a cardiac cath on [**1-13**] for a report of a positive stress test.
The catheterization report (that we obtained on [**1-19**]) was
without any blockage(s) or valvular abnormalities. He was
discharged
to home from [**Location (un) 8973**].
He was then admitted to the [**Hospital1 18**] on [**3-31**] and per the
discharge
summary at that time had significant gastroparesis and
abdominal discomfort. Per the discharge summary he became
upset when he was not allowed off the floor to smoke and signed
out AMA; there was no mention of LE weakness or numbness, no
report of trauma. The patient gave a very different account of
these events. He returned less than 24 hours later with a
complaint of bilateral lower extremity numbness and weakness.
In the ED patient was given IVF and insulin gtt. for glucose of
332 and A-gap of 13. Central line was placed. His CK was 2429
with flat Trop. He had CT spine done w/o signs of acute fracture
or cord compression. He was seen by neurology.
His vital signs remained stable with T 97.1 BP 136/90 HR 100
O2Sat100%RA
.
.
Review of systems:
Reports recent low grade temp and chills, 100.2. No cough, n/v/d
or abdominal pain, no SOB. Recent weight loss or gain. Denies
headache, sinus tenderness, rhinorrhea or congestion. Denied
cough, shortness of breath. Denied chest pain or tightness,
palpitations. Denied nausea, vomiting, diarrhea, constipation or
abdominal pain. No recent change in bowel or bladder habits. No
dysuria. Denied arthralgias or myalgias.
Past Medical History:
1. Polyglandular Autoimmune Disease - type 2 with Addison's
disease, DM type I, and Hypothyroidism
2. CAD
3. Asthma
4. PUD
5. Mild mental retardation
6. hx of pancreatitis
7. s/p ccy/appy
Social History:
smokes, does not drink or take illicit drugs, married has 4
children, can't read or write
Family History:
+ early CAD and Ca
Physical Exam:
Vitals: T: 97.6 BP: 125/77 P: 94 R: 10 18 O2:100%
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: upper extremities strength 5/5 in all muscle groups with
preserved sensation. Lower extremities [**12-1**] in all major muscle
groups, no babinskie, no sensation to prick and reflexes 1+ in
upper and lower extremities, and symmetrical
Pertinent Results:
[**2122-1-19**] 05:22AM BLOOD WBC-9.5 RBC-3.34* Hgb-10.6* Hct-28.5*
MCV-85 MCH-31.9 MCHC-37.4* RDW-13.3 Plt Ct-294
[**2122-1-16**] 03:30AM BLOOD WBC-11.5* RBC-3.64* Hgb-11.8* Hct-31.6*
MCV-87 MCH-32.4* MCHC-37.3* RDW-12.9 Plt Ct-253
[**2122-1-16**] 03:30AM BLOOD Neuts-86.9* Lymphs-10.9* Monos-1.9*
Eos-0.2 Baso-0.2
[**2122-1-17**] 03:00AM BLOOD PT-12.5 PTT-28.7 INR(PT)-1.1
[**2122-1-16**] 03:30AM BLOOD Glucose-332* UreaN-18 Creat-1.0 Na-133
K-5.0 Cl-98 HCO3-22 AnGap-18
[**2122-1-19**] 05:22AM BLOOD Glucose-107* UreaN-14 Creat-0.8 Na-144
K-3.3 Cl-109* HCO3-29 AnGap-9
[**2122-1-16**] 03:30AM BLOOD CK(CPK)-2429*
[**2122-1-18**] 05:58AM BLOOD ALT-36 AST-30 LD(LDH)-129 CK(CPK)-353*
AlkPhos-72 TotBili-0.1
[**2122-1-19**] 05:22AM BLOOD CK(CPK)-267*
[**2122-1-16**] 03:30AM BLOOD cTropnT-0.02*
[**2122-1-16**] 10:16AM BLOOD CK-MB-10 MB Indx-0.5 cTropnT-0.02*
[**2122-1-16**] 04:43PM BLOOD CK-MB-8 cTropnT-0.03*
[**2122-1-18**] 10:51PM BLOOD CK-MB-3 cTropnT-<0.01
[**2122-1-18**] 05:58AM BLOOD Albumin-2.3* Calcium-6.8* Phos-3.0 Mg-1.6
[**2122-1-16**] 10:16AM BLOOD TSH-1.1
[**2122-1-16**] 10:16AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2122-1-16**] 03:39AM BLOOD Lactate-1.0
[**2122-1-16**] 02:17PM BLOOD [**Doctor First Name **]-PND
.
CT ABDOMEN W&W/O C & RECONS: Unremarkable abdominal CT.
.
CT CHEST: 1. No evidence of aortic dissection. 2. Prominent
thymus may be related to known polyglandular autoimmune
syndrome; however, neoplastic etiologies such as thymoma are
possible. MRI can be obtained for further evaluation if
clinically indicated.
.
MR C, T, L-SPINE W& W/O CONTRAST: No findings to account for the
patient's symptoms. Specifically, there is no imaging evidence
for cord infarct, cord contusion or epidural hematoma.
.
CT T, L-SPINE: 1. No evidence of acute fracture or malalignment.
2. No change in appearance of mild anterior wedge-shaped
abnormality at T12 vertebral body.
Brief Hospital Course:
28 yo male with polyglandular autoimmune syndrome type 2 with
DM1 and addison??????s syndrome s/p cath p/w called out from MICU
after DKA and lower extremity pain/numbness.
.
# MICU COURSE: Patient was started on insulin drip and given IV
hydration. He was given volume resuscitation until gap closed
then insulin ggt and D5W. Blood sugar was difficult to control
initially taken off insulin drip on [**1-16**] once gap closed and
resumed for high sugars. Patient was started on glargine with
good control of blood sugars. He was seen neurology and
neurosurgery. Surgery was consultd for possible removal of
broken insulin needle in abdominal wall. On further evaluation,
there was no needle. He had an MRI with no evidence of cord
compression.
.
# Diabetes/ketoacidosis. Patient with DM1 [**12-29**] PGA type 2. His
DNA has resolved. Patient takes home regimen of NPH 35 QAM and
15u at lunch and 10 QHS. He was hyperglycemic on glargine 15U.
He was seen and evaluated by [**Last Name (un) **] consult. He had been seen
there as an outpatient sveral years ago, but is no longer
followed since he is no longer a pediatric patient. He was
started on glarging 26 U nightly. He should follow up with his
PCP or [**Name9 (PRE) **] for further management.
.
# Lower extremity pain/numbness/urinary retention: His symptoms
resolved without intervention. Patient ambulated with PT with
minimal pain. No evidence of cord compression on MRI. History
of symptoms following cath is concerning for embolic phenomenon,
however no evidence of infarction on MRI. Urinary retention
resolved following restarting home anti bladder spasm
medication. As his symptoms improved markedly during his
hospitalization, neurology did not feel further imaging was
necessary. He was able to ambulate without dificulty and was
cleared by PT. He was given a cane for comfort.
- He will follow up with neurology reagarding his symptoms and
given high protein in CSF
.
# Chest pain: Patient had atypical chest pain on [**1-19**] that came
on at rest and resolved spontaneously. An EKG was unchanged and
cardiac enzymes were normal. He has had a cardiac
catheterization in the past week with normal coronary arteries.
Most likely cause is atelectasis or esophagitis. He was given
reassurance and continued on his PPI.
.
# CK Elevation: Patient had a CK elevation on admission with
normal CK-MB. This elevation improved with hydration and was
likley related to recent trauma. Also could be related to
autoimmune or viral myositis. If this problem returned and he
was symptomatic, could consider muscle biopsy.
.
# PGA type 2- Addisons: continue outpatient hydrocortisone and
florinef. Hemodynamically stable and no signs of crisis. He was
given additional dose of hydrocort in stress setting. He was
discharged on his home dose.
.
# Thymus abnormality on CT scan: Per report, "Prominent thymus
may be related to known polyglandular autoimmune syndrome;
however, neoplastic etiologies such as thymoma are possible. MRI
can be obtained for further evaluation..." Findings were
discussed with patient.
- He should follow up with his PCP to consider an outpatient
MRI.
.
# Communication: Patient wife hope [**Telephone/Fax (1) 40748**], and mother
[**Name (NI) **] [**Telephone/Fax (1) 40749**]
Medications on Admission:
1. Hydrocortisone
2. Florinef
3. Reglan
4. Protonix
5. Thyroid replacement
6. Seroquel
7. Insulin (30/18/18) plus sliding scale of Humalog
Discharge Medications:
1. Lantus 100 unit/mL Solution Sig: Twenty Six (26) Units
Subcutaneous at bedtime.
Disp:*QS one month * Refills:*2*
2. Insulin Lispro 100 unit/mL Solution Sig: 1-12 units
Subcutaneous four times a day: Per sliding scale.
3. Hydrocortisone 20 mg Tablet Sig: One (1) Tablet PO at
bedtime.
4. Hydrocortisone 20 mg Tablet Sig: Two (2) Tablet PO QAM (once
a day (in the morning)).
5. Bethanechol Chloride 25 mg Tablet Sig: One (1) Tablet PO Q 8H
(Every 8 Hours).
6. Seroquel 200 mg Tablet Sig: Three (3) Tablet PO at bedtime.
7. Carafate 100 mg/mL Suspension Sig: Two (2) PO twice a day.
8. Levoxyl 25 mcg Tablet Sig: One (1) Tablet PO once a day.
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO three
times a day.
12. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Cane Device Sig: One (1) Miscellaneous once.
Disp:*1 * Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Diabetes
Ketoacidosis
Lower extremity pain and weakness
Urinary retention
Chest pain
Addison's
Secondary: Polyglandular autoimmune syndrome type 2
Discharge Condition:
Ambulating, stable
Discharge Instructions:
You were admitted with diabetic ketoacidosis and pain in your
legs and back. The ketoacidosis results from not taking your
insulin. You were changed to a more simple insulin regimen,
that you may be more able to take. You should continue to
follow up with the [**Last Name (un) **] diabetes center. You were seen by
Neurology and had imaging to evaluate your spine. There were no
immediately concerning findings, but you may need to follow up
with them if your symptoms persist.
You had a small abnormality on your thymus that was seen on CT
scan. You should discuss with your PCP about getting [**Name Initial (PRE) **] MRI to
evaluate this.
If you have new or worsening symptoms, or any other concerning
findings, please seek medical attention.
Followup Instructions:
Please follow up with your PCP. [**Name10 (NameIs) **] have an appointment
scheduled for [**2125-2-2**]:45 PM.
Please arrange a follow up appointment with a diabetes
specialist. You can call [**Telephone/Fax (1) 2384**] to arrange an appointment
with Dr. [**Last Name (STitle) 40750**] at [**Hospital **] clinic. If your insurance does not
cover this clinic, please contact you PCP.
You have a follow up appointment scheduled with Neurology.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6855**], M.D. Phone:[**Telephone/Fax (1) 6856**]
Date/Time:[**2122-2-3**] 11:00
Completed by:[**2122-1-20**]
|
[
"250.13",
"317",
"533.90",
"244.9",
"255.41",
"276.8",
"412",
"788.20",
"782.0",
"414.01",
"493.90",
"275.2",
"V58.67"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
9757, 9763
|
5223, 8487
|
364, 384
|
9954, 9975
|
3265, 5200
|
10778, 11410
|
2465, 2485
|
8677, 9734
|
9784, 9933
|
8513, 8654
|
9999, 10755
|
2500, 3246
|
1710, 2130
|
287, 326
|
412, 1691
|
2152, 2342
|
2358, 2449
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,968
| 174,392
|
27500
|
Discharge summary
|
report
|
Admission Date: [**2135-8-28**] Discharge Date: [**2135-9-5**]
Service: MEDICINE
Allergies:
Penicillins / Fosamax
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
cardioversion
History of Present Illness:
83 yo M with history of DM2, HTN, hyperlipidemia, AAA s/p
repair, recent IMI [**7-10**], s/p DES to LCx with severely depressed
EF admitted to CCU now returns with recurrent chest pain.
Patient reports developing chest "tightness" localized to LUQ,
lower left chest, focal, non radiating, no N/V/diaphoresis, no
SOB. Anginal equivalent is sob, never has had CP before. He was
at rest, wife gave him 3 sl ntg without relief, here nitro
without relief, relieved by morphine. Of note, patient w/ SVT
atrial flutter s/p DCCV on last admission. Patient went to
[**Hospital1 **], transferred to [**Hospital1 **] for further management.
.
In the ED VS 110/72 77 18 99% 2L. Given ASA 162, sl ntg x 3,
nitro past, plavix, heparin gtt, integrilin gtt, morphine 2 mg
IV x 2, nitro gtt. Continued to have CP [**2139-4-5**] at 12:25, nitro
increased with relief of pain to 0/10, no EKG changes. Again CP
[**4-13**] at 17:20, nitro increased, came up to floor with 1/10 CP
not able to be relieved.
.
Upon arrival to the floor, VSS, denies any CP, says morphine
helping, denies any change in stool, no melena/brbpr, last BM
yesterday, normal diet cooked by wife last night, no PND, stable
2 pillow orthopnea. No N/V/diarrhea as mentioned above, no
cough, URI symptoms. Ambulates around house, does not do stairs,
limited by arthritis. Reports compliance with meds since
discharge in [**7-10**].
Past Medical History:
- CAD s/p IMI [**7-7**] stent to LCx
- CHF with EF <25% global hypokinesis
- AAA status post repair about 15 years ago
- DM2
- Hypertriglyceridemia
- Hypertension
- Basal cell carcinoma of the ear
- Squamous cell carcinoma, sublingual
- BPH
- COPD
- Gastritis s/p GI bleed EGD [**2135-7-11**] showing mild esophagitis and
gastritis with erosions, Brunner's gland hypertrophy, H.pylori
negative.
Social History:
Smokes Heavy smoker for 60 years. Currently smokes 0.5-1 pack
per day. Denies alcohol use or IVDU. Lives with his wife. [**Name (NI) **]
one daughter, 4 grandchildren, retired electric inspector.
Family History:
NC
Physical Exam:
VS: 97.5 122/63 75 20 100% 4L
Gen: elderly man, lying flat, NAD, pleasant
Heent: red face, OP clear, moist, anicteric, no pallor
Neck: supple, no JVD appreciable
Chest: very poor air entry, decreased BS at bases, ?crackles
right base
CVS: nl S1 S2, irreg, very distant heart sounds, no m/r/g
appreciated
Abd: obese, soft NT/ND in all 4 quadrants, NABS
Ext: warm, trace edema, 1+ dp pulses b/l
Pertinent Results:
[**2135-8-28**] 10:10AM BLOOD WBC-4.3# RBC-3.51* Hgb-10.0* Hct-29.6*
MCV-84 MCH-28.4 MCHC-33.7 RDW-16.5* Plt Ct-226
[**2135-9-5**] 07:35AM BLOOD WBC-4.9 RBC-3.26* Hgb-9.3* Hct-27.6*
MCV-85 MCH-28.6 MCHC-33.7 RDW-16.0* Plt Ct-235
[**2135-8-28**] 10:10AM BLOOD PT-25.7* PTT-37.8* INR(PT)-2.6*
[**2135-8-28**] 05:00PM BLOOD PT-26.1* PTT-80.1* INR(PT)-2.7*
[**2135-8-29**] 06:10AM BLOOD PT-27.0* PTT-86.9* INR(PT)-2.8*
[**2135-8-30**] 06:40AM BLOOD PT-23.1* PTT-25.0 INR(PT)-2.3*
[**2135-9-1**] 05:15AM BLOOD PT-39.6* PTT-33.9 INR(PT)-4.4*
[**2135-9-2**] 05:13AM BLOOD PT-69.7* INR(PT)-8.9*
[**2135-9-2**] 03:05PM BLOOD PT-41.2* PTT-35.8* INR(PT)-4.7*
[**2135-9-3**] 05:15AM BLOOD PT-17.3* INR(PT)-1.6*
[**2135-9-5**] 07:35AM BLOOD PT-14.2* PTT-28.3 INR(PT)-1.3*
[**2135-9-5**] 07:35AM BLOOD Glucose-148* UreaN-15 Creat-1.1 Na-138
K-3.9 Cl-97 HCO3-32 AnGap-13
[**2135-9-1**] 05:15AM BLOOD Glucose-118* UreaN-27* Creat-1.5* Na-139
K-4.0 Cl-101 HCO3-27 AnGap-15
[**2135-9-1**] 06:45PM BLOOD Glucose-102 UreaN-27* Creat-1.6* Na-137
K-4.0 Cl-99 HCO3-28 AnGap-14
[**2135-9-2**] 05:13AM BLOOD Glucose-107* UreaN-25* Creat-1.4* Na-138
K-3.7 Cl-101 HCO3-28 AnGap-13
[**2135-8-28**] 10:10AM BLOOD CK(CPK)-41
[**2135-8-28**] 05:00PM BLOOD ALT-23 AST-34 LD(LDH)-237 CK(CPK)-35*
AlkPhos-71 Amylase-79 TotBili-0.5
[**2135-8-29**] 06:10AM BLOOD CK(CPK)-32*
[**2135-8-29**] 07:16PM BLOOD CK(CPK)-59
[**2135-8-30**] 06:40AM BLOOD CK(CPK)-57
[**2135-9-3**] 05:33PM BLOOD CK(CPK)-17*
[**2135-9-4**] 05:23AM BLOOD CK(CPK)-14*
[**2135-8-28**] 05:00PM BLOOD Lipase-59
[**2135-8-28**] 10:10AM BLOOD CK-MB-NotDone
[**2135-8-28**] 10:10AM BLOOD cTropnT-0.01
[**2135-8-28**] 05:00PM BLOOD CK-MB-NotDone cTropnT-0.01
[**2135-8-29**] 06:10AM BLOOD CK-MB-NotDone cTropnT-0.02* proBNP-1322*
[**2135-8-29**] 07:16PM BLOOD CK-MB-2 cTropnT-<0.01
[**2135-8-30**] 06:40AM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2135-9-3**] 05:33PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2135-9-4**] 05:23AM BLOOD CK-MB-NotDone cTropnT-0.01
[**2135-8-29**] 06:10AM BLOOD TSH-0.45
[**2135-9-1**] 06:45PM BLOOD TSH-0.24*
[**2135-8-29**] 06:10AM BLOOD Free T4-1.5
[**2135-9-2**] 03:05PM BLOOD Free T4-1.1
[**2135-9-2**] 05:13AM BLOOD Cortsol-29.1*
[**2135-8-28**] 05:00PM BLOOD Digoxin-1.0
[**2135-9-1**] 05:15AM BLOOD Digoxin-1.0
CXR [**8-28**]: FINDINGS: Again noted is apical bullous disease. There
is no focal consolidation or superimposed edema-like process.
There is mild tortuosity of an atherosclerotic aorta. Cardiac
silhouette remains borderline enlarged. No pleural effusion or
pneumothorax is seen.
IMPRESSION: Emphysema with no radiographic evidence for volume
overload.
CTA CHEST WITH IV CONTRAST [**8-29**]: Pulmonary arteries enhance
normally without filling defect. There is an enlarged nodular
goiter. Moderate emphysematous changes in the lungs. Biapical
scarring. Again identified is a concerning spiculated nodule
just adjacent to the minor fissure, which is difficult to
accurately measure but is approximately 1.4 x 0.8 cm. However,
it appears more pronounced and denser than on the prior CT.
There is a second 3-mm pulmonary nodule in the right lower lobe,
which is unchanged. Small nonspecific nodular opacity in the
right lower lobe appears new. Scarring in the left lower lobe.
There is extensive calcified atherosclerotic plaque throughout
the ascending aorta with multiple areas of large penetrating
ulcers. There been no interval development of extension into
aortic dissection. Ectasia but no definite aneurysmal
dilatation. No pathologically enlarged lymph nodes are seen
throughout the axilla, mediastinum, and hilum. Heart,
pericardium, and great vessels are unremarkable with the
exception of coronary artery calcification and heart size upper
limits of normal. Limited axial imaging through the upper
abdomen demonstrates no abnormalities. No focal osseous
abnormalities.
IMPRESSION:
1) No pulmonary embolism.
2) Severely atherosclerotic thoracic aorta with multiple
prominent penetrating ulcers.
3) Multiple pulmonary nodules; the spiculated nodule along the
minor fissure appears worrisome, and perhaps slightly more dense
than the prior CT scan. PET/CT may be helpful for further
assessment.
4) Emphysema with biapical scarring.
Persantine MIBI [**8-30**]: The image quality is adequate. The arms
are suboptimally positioned. Motion correction was performed on
the stress perfusion images.
Left ventricular cavity size is normal.
Resting and stress perfusion images reveal uniform tracer uptake
throughout the myocardium.
Gated images reveal septal hypokinesis. The loss of photon
counts in the last frame of the gated images is consistent with
arrhythmia (atrial fibrillation). The calculated left
ventricular ejection fraction is 58%.
There is no prior myocardial perfusion imaging study available
for comparison.
IMPRESSION: Normal myocardial perfusion. Normal left ventricular
cavity size. Septal hypokinesis. Calculated LVEF 58%.
Stress [**8-30**]:
INTERPRETATION: This 83 year old type 2 IDDM man with a history
of
CAD and AF was referred to the lab for evaluation of chest pain.
The
patient was infused with 0.142 mg/kg/min of dipyridamole over 4
minutes.
Prior to the test, he noted a "severe" chest discomfort that was
localized to under his left breast. This discomfort did not
change
throughout the procedure. There were no additional ST segment
changes
during the infusion or in recovery. The rhythm was atrial
fibrillation
throughout. Appropriate hemodynamic response to the infusion.
The
dipyridamole was reversed with 125 mg of aminophylline IV.
IMPRESSION: Atypical symptoms in the absence of ST segment
changes.
Nuclear report sent separately.
TTE [**9-2**]: Conclusions:
1. The left ventricular cavity size is normal. Overall left
ventricular
systolic function is mildly depressed.
2. The aortic root is mildly dilated.
3. The aortic valve leaflets (3) are mildly thickened.
4. The mitral valve leaflets are mildly thickened.
5. Mild pulmonary hypertension is present.
6. Compared with the prior study (images reviewed) of [**2135-7-9**],
LV function has improved.
Admission ECG: Atrial flutter with variable block. Right axis
deviation. Compared to the previous tracing of [**2135-7-12**] atrial
flutter is new.
Brief Hospital Course:
1. Chest pain: There was no clear etiology of his pain. His
symptoms were somewhat atypical, in that his chest pain was
generally relieved with burping. His ECGs did not show any
ischemic changes, and numerous sets of cardiac enzymes were
negative. A persantime-MIBI was negative for ischemic changes
in the setting of having chest pain immediately prior to the
test (please see report above). A CTA demonstrated penetrating
aortic ulcers, which per review with radiology was unchanged
from [**3-10**]. CT Surgery was consulted and saw him in-house, and
they did not feel his pain was related to these ulcers. He has
f/u with them already arranged. He was continued on his
aspirin, plavix, and statin. He was given amlodipine in case
his chest pain was from esophageal spasm, but this was
discontinued as it did not seem to help.
On [**9-2**], he became acutely hypotensive and bradycardic
(30s-40s). He had received one dose of beta-blocker that AM.
He was given glucagon and atropine without response, and was
transferred to the CCU. While there, his bp/pulse were
maintained with dopamine. He was found to be in atrial flutter
with variable block, and was cardioverted. He was transferred
back to the floor a couple of days later after being weaned off
of the dopamine and remaining hemodynamically stable. His
digoxin was discontinued (although dig level was not elevated,
at 1.0).
2. PUMP. Severely depressed EF after IMI, although calculated EF
on MIBI was 58%. He did not appear overtly volume overloaded on
exam. He was continued on his statin. An ace inhibitor was
started without complication. A beta-blocker resulted in
bradycardia and hypotension as above. He was continued on his
home dose of Lasix (20 mg daily).
3. Rhythm: He was found to be in atrial flutter with variable
block. While in the CCU, he was cardioverted. He was continued
on his amiodarone 200 mg daily. His coumadin was held for a
supratherapeutic INR (as high as 8) but was restarted upon
discharge. His INR was low on discharge (1.3) and so he was
bridged with lovenox. This was discussed with his wife and his
outpt cardiologist. Thyroid studies were normal.
4. Spiculated lung nodule: Seen on prior CTA [**3-10**] as well as CTA
done [**2135-8-29**]. Per pt's wife, he is having an extensive workup as
an outpt, including a PET which was nondiagnostic. They are
currently seeing a thoracic surgeon regarding this.
5. Fever: Had fever overnight on [**8-30**], with UTI (pan-[**Last Name (un) 36**] e
coli) and pneumonia on CXR. These were both treated with a ten
day course of levofloxacin.
6. DM: on humalog 75/25 at home as well as metformin and actos.
These were held as he was hypoglycemic in the CCU. He was
restarted on half-dose 75/25, and continued on his metformin.
His actos was held and he was given instructions to hold it
until follow-up with his PCP.
7. COPD: Not on rx at home, exam c/w COPD. He was given
atrovent as needed.
8. H/o GIB/gastritis: continued on PPI.
9. HTN: continued on home regimen, started on lisinopril as
above.
Medications on Admission:
- Coumadin 1.5-3.0 mg daily
- Ecorin 325 mg daily
- gemfibrozil 600 mg [**Hospital1 **]
- metformin 500 mg [**Hospital1 **]
- Insulin Humalog 75/25 36 U AM/25 U pm
- Nexium 40 mg daily
- Amiodarone 200 mg daily
- Actos 45 mg daily
- Lipitor 20 mg daily
- Plavix 75 mg daily
- Lasix 20 mg daily
- Digoxin 0.125 mg daily
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Hospital1 **]:*30 Tablet(s)* Refills:*2*
2. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
[**Hospital1 **]:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Hospital1 **]:*30 Tablet(s)* Refills:*2*
4. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q6H (every 6 hours) as needed for shortness of
breath or wheezing.
[**Hospital1 **]:*1 inhaler* Refills:*6*
5. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed for pain.
[**Hospital1 **]:*200 ML(s)* Refills:*2*
6. Aspirin 81 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable
PO DAILY (Daily).
[**Hospital1 **]:*60 Tablet, Chewable(s)* Refills:*2*
7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
[**Hospital1 **]:*30 Tablet(s)* Refills:*2*
8. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
[**Hospital1 **]:*30 Tablet(s)* Refills:*2*
9. Enoxaparin 80 mg/0.8 mL Syringe Sig: Eighty (80) mg
Subcutaneous Q12H (every 12 hours): take until instructed to
stop by your doctor.
[**Last Name (Titles) **]:*28 syringes* Refills:*0*
10. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Last Name (Titles) **]:*30 Tablet(s)* Refills:*2*
11. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
[**Hospital1 **]:*1 Disk with Device(s)* Refills:*2*
12. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
[**Hospital1 **]:*60 Tablet(s)* Refills:*2*
13. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Hospital1 **]:*30 Tablet(s)* Refills:*2*
14. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
[**Hospital1 **]:*90 Tablet(s)* Refills:*2*
15. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO once a day
for 4 days.
[**Hospital1 **]:*4 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Home Health Care
Discharge Diagnosis:
Atrial flutter with variable block
Discharge Condition:
stable, ambulating, tolerating po, chest pain-free
Discharge Instructions:
You were admitted to the hospital for chest pain. You had a
stress test that indicated you were not having a heart attack,
and your labs were negative for any evidence of damage to your
heart.
You were also seen by the Cardiac Surgeons because you have an
ulcer in your aorta. The ulcer was unchanged from your CAT scan
in [**Month (only) 547**] of this year. You have an appointment scheduled with
them later this month to further discuss this.
You have a mass in your lung, which we discussed with you. You
are currently have a workup of this done as an outpatient.
You were started on lovenox here, which you should take until
your coumadin is therapeutic.
We made several [**Month (only) 4085**] changes while you were here. Your
digoxin was discontinued. Your actos and Humalog 75/25 were
also discontinued because your sugar level was low the morning
that you were transferred to the CCU. You can restart your
Humalog 75/25 at HALF the dose you were taking before. Check
your fingersticks 4 times per day. Do not restart your Actos
until we have discussed this with your primary care doctor. You
are still taking your Metformin. We started you on a new blood
pressure [**Month (only) 4085**] called Lisinopril. We also started you on 2
inhalers to help your breathing: Atrovent and Flovent.
You had a fever while you were here, and your chest x-ray showed
a pneumonia. We started you on levofloxacin, which is an
antibiotic. You should take this to complete a 10 day course (4
more days).
Please call your doctor or come to the ER for fevers, chills,
chest pain, shortness of breath, or any other concerns.
Followup Instructions:
Follow up with your Cardiologist, Dr. [**Last Name (STitle) **], this week to
discuss your Lovenox and Coumadin, as well as discussing your
diabetes medications.
You also have an appointment with your Cardiac Surgeon:
Provider: [**Name10 (NameIs) **],[**Last Name (Prefixes) 413**] CARDIAC SURGERY LMOB 2A
Date/Time:[**2135-9-22**] 2:00
We made you an appointment with Dr. [**Last Name (STitle) **] to discuss
possible ablation of your atrial flutter, which you discussed
with him in the hospital:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 285**]
Date/Time:[**2135-10-19**] 1:20
|
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"E942.1",
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"272.4",
"428.0",
"600.00",
"518.89",
"414.01",
"424.0",
"V45.82",
"427.89",
"496"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.17",
"99.62"
] |
icd9pcs
|
[
[
[]
]
] |
14507, 14570
|
8986, 12054
|
238, 254
|
14649, 14702
|
2746, 8963
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|
14726, 16360
|
2332, 2727
|
188, 200
|
282, 1664
|
1686, 2083
|
2099, 2297
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,204
| 159,455
|
1188
|
Discharge summary
|
report
|
Admission Date: [**2168-1-12**] Discharge Date: [**2168-1-16**]
Date of Birth: [**2087-5-5**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 7539**]
Chief Complaint:
Shortness of breath
CHF
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is an 80 yo male with no known significant CAD but
history of HTN, CKD, COPD, restrictive lung disease by PFTs,
severe emphysema radiographically, hx of active TB (treated in
[**2154**]), and diastolic dysfunction documented on previous
echocardiogram who presents with 4 day history of increasing
dyspnea on exertion, lower extremity edema, and PND. Patient was
recently an inpatient at [**Hospital1 18**] for left iliac artery aneurysm
coiling. This hospital course was complicated by respiratory
arrest and hypotension of unclear etiology, although per [**Name (NI) **]
thought to be likely secondary to hypercarbic resp failure
(although no ABGs demonstrate this). In the setting of this
event the patient developed a RBBB which resolved over a short
interval. Cardiology was consulted with reported recs of ASA,
statin, Beta blocker and heparin drip. Per the patient's report,
after discharge from the hospital his respiratory symptoms were
relatively improved from his baseline, although he had developed
bilateral lower extremity edema which was new. This past friday,
the patient was seen by a VNA nurse who heard crackles on lung
exam and doubled his home lasix from 20mg PO qd to 40mg PO.
Despite this intervention, the following day the patient
developed symptoms of PND. Over the course of a few days the
patient has been having worsening respiratory symptoms,
ultimately necessitating a visit to the E.D. today. He denies
any recent URI symptoms, chest pain, diaphoresis, N/V,
increasing sputum production, or F/C. The patient reports he has
been compliant with his medications and denies any significant
change in his diet.
.
In the ED the patient was assessed and thought to be in
decompensated CHF. The patient was given 80mg Lasix x1, 40mg x 1
and nitro gtt for BP control. The patient was placed on BIPAP
([**9-15**]), 50% Fi02. The patient diuresed 1800cc in 12 hours in the
ED. The patient was temporarily weaned from BIPAP but had
subsequent desat to low 80's, requiring replacement of mask. CCU
transfer was requested by ED attending at this point.
.
Allergies: NKDA
Past Medical History:
- S/p Coil embolization of 2 outflow vessels from left internal
iliac artery aneurysm + Endovascular repair of left hypogastric
artery aneurysm with coverage stent graft. Hospital course
complicated by respiratory arrest. ([**2167-12-27**])
- COPD(Emphysema)/Interstitial Lung Disease, on home O2 ([**1-15**]
liter/min)
- CAP in [**2160**], [**2165**]
- Hypertension
- TB in [**2154**], treated for active DZ
- thrombocytopenia
- BPH
- CKD, Baseline Cr (1.4-2.4)
Social History:
Patient previously was employed as a taxi cab driver and
additionally worked on the rairoad, reportedly in a grain
elevator. The patient with 50 pack-year history of tobacco, but
quit 40 years prior. The patient denies any significant ETOH or
illicit drug use
Family History:
Patient's daughter with DM, denies history of CAD, cardiac
problems
Physical Exam:
Physical Exam:
Vitals: BP: 123/82 HR: 72 RR: 12 O2 99% on BIPAP
.
Gen: Patient is sitting at 30 degrees with BIPAP mask in place,
appears to be in mild respiratory ditress, no accessory muscle
use.
HEENT: NCAT, EOMI. BIPAP mask in place
Neck: JVD difficult to assess [**1-14**] mask, JVP appears 7-8cm
Chest: Anterior: Relatively CTA. Post: crackles bilaterally to
mid lung fields, R > L
Cor: RRR, no M/R/G
Abd: Soft, NT, ND
Ext: No cyanosis. + Mild clubbing. 3+ pedal edema
Pulses: 2+ DP, 2+ femoral, 1+ PT bilaterally
Pertinent Results:
Admission Labs:
.
[**2168-1-12**] 12:00PM PT-13.2* PTT-25.1 INR(PT)-1.2*
[**2168-1-12**] 12:00PM PLT COUNT-201
[**2168-1-12**] 12:00PM HYPOCHROM-1+ ANISOCYT-1+ MACROCYT-2+
[**2168-1-12**] 12:00PM NEUTS-62.6 LYMPHS-25.0 MONOS-8.0 EOS-2.7
BASOS-1.7
[**2168-1-12**] 12:00PM WBC-4.3 RBC-3.62* HGB-11.5* HCT-34.9*# MCV-97
MCH-31.8 MCHC-33.0 RDW-16.6*
[**2168-1-12**] 12:00PM CK-MB-NotDone cTropnT-0.02* proBNP-[**Numeric Identifier 7540**]*
[**2168-1-12**] 12:00PM CK(CPK)-74
[**2168-1-12**] 12:00PM GLUCOSE-89 UREA N-14 CREAT-1.4* SODIUM-141
POTASSIUM-4.0 CHLORIDE-103 TOTAL CO2-28 ANION GAP-14
[**2168-1-12**] 06:30PM CK-MB-NotDone cTropnT-<0.01
[**2168-1-12**] 06:30PM CK(CPK)-63
[**2168-1-12**] 07:43PM O2 SAT-85
[**2168-1-12**] 07:43PM TYPE-ART PO2-51* PCO2-45 PH-7.45 TOTAL
CO2-32* BASE XS-6 INTUBATED-NOT INTUBA
[**2168-1-12**] 07:43PM CALCIUM-8.2* PHOSPHATE-3.6
[**2168-1-12**] 07:43PM GLUCOSE-98 UREA N-14 CREAT-1.5* SODIUM-139
POTASSIUM-4.5 CHLORIDE-102 TOTAL CO2-30 ANION GAP-12
Additional Labs/Studies:
BNP: 10,207 ([**2168-1-12**])
Troponon: .02 -> .01 -> .02
ABG:
7.45/45/51/32/ O2 Sat 85%
Cr: 1.4 ([**2168-1-12**]) -> 1.8 ([**2168-1-16**]) ; baseline 1.4 - 2.0
HgA1C: 5.9%
Lipid Panel (1-31-0): TC-136 Tri-67 HDL-42 LDL-81
.
ECG: Rate 65, NSR, Nml Axis. Normal intervals. TWI V1 + III
.
[**2168-1-12**]: Portable Chest: Advanced CHF with pulmonary edema
pattern. These findings existed already on the previous
examinations, [**12-18**] and [**2167-12-15**].
.
[**2168-1-13**]: Echocardiogram:
1.The left atrium is mildly dilated.
2.There is mild symmetric left ventricular hypertrophy. There is
mild
(non-obstructive) focal hypertrophy of the basal septum. The
left ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%). Left ventricular
dysnchrony is present.
3.Right ventricular chamber size is normal. Right ventricular
systolic
function is normal.
4.The ascending aorta is mildly dilated. The descending thoracic
aorta is
mildly dilated.
5. The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion. Mild (1+) aortic regurgitation is seen.
6.The mitral valve leaflets are structurally normal. No mitral
regurgitation is seen.
7.The estimated pulmonary artery systolic pressure is normal.
8.The main pulmonary artery is dilated.
9.There is a trivial/physiologic pericardial effusion.
.
[**2168-1-14**]: Portable Chest - Chest CT and radiographs in [**Month (only) **]
[**2166**] showed severe emphysema, and probable mild interstitial
lung disease with surprisingly low lung volumes. Interstitial
abnormality was more pronounced on [**12-18**] and had progressed
by [**1-12**], may indicate pulmonary edema or progression of
interstitial lung disease. Slight improvement since [**1-12**] suggests at least a component of pulmonary edema. Heart is
normal size. No appreciable pleural effusion.
Discharge Labs:
.
[**2168-1-16**] 05:20AM BLOOD WBC-4.2 RBC-3.32* Hgb-9.9* Hct-30.7*
MCV-93 MCH-29.9 MCHC-32.3 RDW-15.9* Plt Ct-199
[**2168-1-16**] 05:20AM BLOOD Glucose-90 UreaN-21* Creat-1.8* Na-141
K-3.7 Cl-98 HCO3-35* AnGap-12
[**2168-1-16**] 05:20AM BLOOD Calcium-8.5 Phos-3.6 Mg-1.7
Brief Hospital Course:
Patient is an 80 year old male with PMHx significant for HTN,
CKD, COPD, interstitial lung disease, TB infection s/p
treatment, and diastolic dysfunction who presents to ED with 3
to 4 days of worsening respiratory symptoms and CHF
exacerbation.
.
Cardiology
#. PUMP: The patient presented to the ED with evidence of
decompensated CHF given pulmonary exam with crackles and
significant peripheral edema. However, the patient additionally
has a history of significant pulmonary disease including severe
emphysema as well as interstitial restrictive disease, making
the patient's hypoxia and respiratory symptoms likely
multifactorial. The patient had a prior echo in [**2167-10-13**]
which demonstrated preserved systolic function, EF > 55%, but
evidence of impaired ventricular relaxation. There was no clear
precipitant for the patient's decompensation on admission,
although he has had prior admissions for uncontrolled
hypertension. He ruled out for an acute ischemic event x 3 and
denied any medical non-compliance or change in his diet. On
admission he was placed on a nitro drip for BP control, treated
with captopril and metoprolol 50mg po bid and diuresed with
lasix. Over the course of his first two days the patient
diuresed over 5 liters (120mg lasix IV day 1, 80mg IV + 80mg PO
day 2). A repeat echo was performed which again demonstrated
preserved systolic function and an E/A ratio of 0.5, consistent
again with impaired relaxation. A dobutamine-MIBI was
contemplated, but given no evidence for new systolic
dysfunction, was decided to be not necessary. The patient was
transferred to the step down and medical regimen was changed to
long acting agents including Toprol XL and lisinopril. The
patient was diuresed in total approximately 8 Liters over the
course of his admission. On discharge, the patient was
instructed to continue taking Lasix 40mg po qd. Prior to
admission the patient was taking 20mg po qd and had just
recently been increased to 40mg po qd, which he likely failed as
he was already so fluid overloaded. As the patient is euvolemic
on discharge it is anticipated that 40mg will be an adequate
dose to maintain his current volume status. Prior to discharge
the patient was given nutritional counseling about a low sodium
cardiac healthy diet and was further instructed about the
warning signs of volume overload and instructed to weigh himself
daily. The patient was additionally discharged on a less
aggressive antihypertensive regimen including Toprol XL 50mg qd
and Lisinopril 2.5mg po qd (previously on Atenolol 75mg and
Lisinopril 5mg). This was done because in the setting of
effective diuresis the patient was not requiring such large
anti-hypertensive dosing and was actually mildly hypotensive
with SBP in the 90-100 range. The patient has follow up with his
PCP who will continue to follow the patient and adjust his
diuretics and anti-hypertensives as appropriate.
.
CAD: The patient presented with no known history of previous MI
or existing CAD, although has known history of HTN and
peripheral vascular disease. He had previously had an
exercise-MIBI that was negative in [**2160**]. On admission, the
patient was continued on ASA 81mg po qd and metoprolol 50mg po
bid (home dose atenolol 75mg po qd) with discharge med of Toprol
XL 50mg qd for reasons above. The patient on last admission had
discharge medications including atorvastatin 80 mg po qd
although the patient reports he never received this prescription
and dose not take this medication. A cholesterol panel performed
in house revealed an LDL of 81. The patient was ruled out for
acute ischemic event with enzymes x 3. The patient was not
started on a statin on this admission.
.
Rhythm: The patient remained in NSR throughout his admission
with some ventricular ectopic beats on telemetry but no
concerning Arrythmias.
.
#. Pulmonary: As above the patient presented with shortness of
breath and O2 sats in the 80s on room air. The patient was
admitted to the CCU for treatment of CHF. However, the patient
additionally has a history of COPD and interstitial lung
disease, which are likely additionally contributing greatly to
his symptoms of dyspnea. The patient was maintained on
ipratropium nebulizers and albuterol PRN but did not receive any
steroids or antibiotics as his symptoms were not consistent with
a COPD exacerbation. [**Year (4 digits) **] review revealed the patient had
previously been evaluated for his pulmonary symptoms by the
consult service in house during a previous admission. Impression
at that time were that the patient's lung findings likely
represented chronic interstitial lung disease as well as COPD.
Because of his age, he was not felt to be a candidate for either
transplant or immunomodulatory therapy, and thus biopsy was
deferred at that time, but recommendation for repeat PFTs was
made. This patient would likely benefit from a pulmonary consult
upon discharge for repeat PFTs as well as ongoing management of
his pulmonary disease. The patient's PCP was made aware of these
recommendations prior to discharge. The patient received oxygen
as needed throughout the admission to maintain goal O2 of 92-93%
and was titrated as tolerated with diuresis. On discharge the
patient was requiring 1L NC at rest to maintain O2 sat > 90%.
.
#. CKD: Patient had known chronic kidney disease on admission.
His Creatinine was 1.4, close to the patient's baseline and was
monitored with ongoing diuresis. After diuresis the patient's
creatinine was 1.8, still within his previous range of baseline
creatinines over the past 2 years. His electrolytes were
monitored and repleted as needed.
.
#. Anemia: Patient with known chronic anemia. Prior iron binding
studies consistent with anemia of chronic disease. The patient's
Hct remained stable throughout hospital course.
.
#. FEN: Patient was maintained on a cardiac Healthy, Low Na diet
with fluid restriction < 1500cc.
.
#. Contact info: HCP: Daughter [**Name (NI) **] [**Known lastname **]
PCP: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 7537**] [**Telephone/Fax (1) 7538**]
Medications on Admission:
Confirmed with patient's daughter on [**2168-1-12**]:
.
Protonix 40mg po qd
Albuterol MDI PRN
Lisinopril 5 mg po qd
Atenolol 75mg po qd
Lasix 20mg po qd, recently increased to 40mg po qd
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
4. Albuterol Inhalation
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
6. Toprol XL 50 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
7. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary Diagnosis:
1. Congestive Heart Failure (Diastolic Heart Failure)
.
Secondary Diagnosis:
COPD (2-3L/min home O2)
Interstitial Lung Disease
Hypertension
TB in [**2154**], treated for active DZ
BPH
Chronic Kidney Disease, baseline Cr (1.4-2.4)
Discharge Condition:
Good. Patient is breathing with O2 sat > 90% with baseline O2
requirement of 2-3L min. Patient is afebrile, hemodynamically
stable without chest pain.
Discharge Instructions:
1. Please take all medications as prescribed
2. Please keep all outpatient appointments
3. Please return to hospital for symptoms of worsening shortness
of breath, chest pain, fever/chills, swelling that is not
responding to lasix or any other concerning symptoms. If you
feel lightheaded after taking your blood pressure medications,
call you primary care doctor.
4. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid restriction: 1.5L per day
Followup Instructions:
Please follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 7537**] at
[**University/College 7541**], [**Location (un) 686**] MA. You have an appointment on
[**1-27**] (Wednesay), 9:15 a.m. Please call his office at
[**Telephone/Fax (1) 7538**] with any questions or scheduling needs.
.
You have significant pulmonary disease as well as cardiac
disease which is likely contributing to your shortness of
breath. You should be seen by a pulmonologist for these
symptoms. Please ask your primary care doctor about making this
referral.
|
[
"403.91",
"515",
"428.0",
"496",
"428.30"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
14199, 14256
|
7111, 13187
|
346, 352
|
14549, 14702
|
3884, 3884
|
15261, 15843
|
3257, 3326
|
13424, 14176
|
14277, 14277
|
13213, 13401
|
14726, 15238
|
6814, 7088
|
3356, 3865
|
283, 308
|
380, 2478
|
14373, 14528
|
3900, 6798
|
14296, 14352
|
2500, 2964
|
2980, 3241
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,860
| 158,547
|
22991
|
Discharge summary
|
report
|
Admission Date: [**2203-6-4**] Discharge Date: [**2203-6-7**]
Date of Birth: [**2134-9-28**] Sex: F
Service: MEDICINE
Allergies:
Dapsone / Cyclosporine / Cefepime / Aztreonam / Azithromycin /
Vancomycin
Attending:[**First Name3 (LF) 3913**]
Chief Complaint:
fever, bleeding, and hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
68yo woman with h/o NHL s/p SCT in [**2199**] who presented to the ED
with bleeding HD fistula and developed fever and hypotension.
Pt started on HD 3 weeks ago using Shiley catheter. Pt was
waiting for LUE fistula to mature, however, due to clot
formation superior to the fistula it was unable to be used for
HD. On [**6-3**], she had a graft placed in her Right UE and had the
fistula in her left UE "disconnected" and stitched over. On
[**6-4**], day of presentation to ED, she had HD in the morning where
she states they took approx 1L of fluid off. After the post-HD
blood pressure cuff was inflated on her left arm, the patient
started bleeding from the closed fistula site. The bleeding
stopped with application of pressure but then the new surgical
graft on her RUE started to bleed. At this point she was
prompted to go to the ED.
On presentation to the ED, her vitals were T 98 HR 105 BP
163/79. Surgery checked the fistula and said that it was
erythematous and indurated but not infected. During her
evaluation in the ED, she was noted to clinically deteriorate.
Repeat vitals showed T 101.4, HR 110s and SBP 110s. She was
empirically started on Vancomycin and Zosyn and infectious
work-up begun. CXR was clear and blood cultures drawn. There
was no urine for Cx. During the workup the patient became
hypotensive with SBP's in the 80's and was adequately
resuscitated with a 1 L fluid bolus. The patient was
transferred to the ICU in stable condition, without any further
episodes of hypotension.
Past Medical History:
- Large Cell Lymphoma: Diagnosed [**2197**], s/p allogeneic SCT in
[**6-13**]. Has had multiple regimens of chemotherapy c/b GVHD
- Chronic Graft vs Host Disease, mild (cutaneous, liver)
- CKD Stage V: Unclear if secondary to chemotherapy,
cyclosporin, or GVHD. Had LUE AV fistula placed but found to
have occluded left brachiocephalic vessel on fistalugram. Now
with RUE fistula.
- Hyponatremia felt to be due to increased fluid intake
- s/p Thyroidectomy for thyroid mass, pathology was benign
- Herpes zoster c/b post-herpetic neuralgia s/p nerve block
Social History:
Married with 2 children. Lives with her husband. Quit smoking 36
years ago. No alcohol.
Quit smoking 36 yrs ago. Very occ EtOH use. Married with two
daughters. Formerly worked in human resources at a department
store.
Family History:
No fam history of blood clots
Her mom deceased age 87 of cerebral hemorrhage.
Father deceased age 48 of malignant hypertension.
Aunt deceased from breast cancer.
Brother [**Name (NI) 59335**] massive MI at the age of 66.
Additional brother with hypertension and emphysema
Physical Exam:
97.6 120/61 14 96% on RA
Dry weight 52.4 kg
General: lying in bed, alert, NAD
HEENT: PERRL, MMM, oropharynx clear, left eye ptosis, CN II-XII
grossly intact, Neck supple, no adenopathy.
CV: RRR, S1, S2, no murmurs or gallops.
Lungs: Clear to auscultation bilaterally
Abd: soft, non-tender, non-distended, +BS
Extremities: no cyanosis or edema. R UE with bandaged graft,
dressing c/d/i. Left UE with stitches over old fistula.
Strength 5/5 in UE and LE b/l.
Skin: Dark discoloration of skin over arms and back. scales
over bilateral shins.
Pertinent Results:
[**2203-6-4**] 04:45PM PT-12.9 PTT-96.2* INR(PT)-1.1
[**2203-6-4**] 10:12PM LACTATE-3.8*
[**2203-6-4**] 04:45PM GLUCOSE-76 UREA N-15 CREAT-2.7*# SODIUM-139
POTASSIUM-3.9 CHLORIDE-98 TOTAL CO2-28 ANION GAP-17
[**2203-6-4**] 04:45PM WBC-10.3 RBC-3.66* HGB-11.6* HCT-36.5
MCV-100* MCH-31.6 MCHC-31.6 RDW-18.4*
[**2203-6-4**] 04:45PM NEUTS-73* BANDS-8* LYMPHS-4* MONOS-11 EOS-3
BASOS-0 ATYPS-0 METAS-1* MYELOS-0
Brief Hospital Course:
This is a 68 year old woman with h/o non-Hodgkin's lymphoma s/p
SCT in [**2199**] and ESRD newly started on hemodialysis who presents
with bleeding from both her old left fistula and her newly
placed right upper extremity fistula after a dialysis session
which was complicated with fever and hypotension responsive to
IV fluids.
# ESRD: The patient is s/p fistula placement on [**6-3**] and had HD
via a right sided HD catheter on [**6-4**]. Upon presentation, the
patient's new fistula in the RUE was erythematous, indurated,
and bleeding. However, the more extensive bleeding was from her
old left extremity fistula which was recently reversed and
prompted to bleed by the squeezing of the blood pressure cuff
during hemodialysis. An ultrasound of the new fistula did not
show evidence of infection, although there was a surrounding
hematoma. The renal and surgery services continued to see the
patient throughout her hospital stay. The patient's
electrolytes were serially monitored and she did not require
unscheduled hemodialysis.
# Fever: The patient was found to be febrile to 100.9 in the ED.
She was treated with tylenol, vancomycin, and zosyn. Although
the patient had no localizing symptoms, she had a high index of
suspicion for infection given her chronic immunosuppression with
steriods for GVHD and elevated lactate. CXR was unremarkable,
blood cultures peripherally and from her HD catheter were
negative at time of discharge, and urine culture was also
negative. The patient was afebrile for 48 hours prior to
discharge and was discharged on a 14 day course of vancomycin IV
for possible line infection.
# Right upper extremity fistula: The patient was instructed in
how to bandage and care for her new fistula by both the surgical
team and nursing.
# Hypotension: She had one episode of hypotension in the ED with
a SBP=80. This was most likely secondary to the extensive
bleeding at dialysis and was responsive to a 1L fluid bolus.
She remained normotensive the remainder of her hospital course.
# Anemia: The patient's anemia is likely secondary to her ESRD
and her hematocrit returned to her baseline prior to discharge.
# GVHD: Patient was maintained on her outpatient dose of
prednisone.
# Hypothyroidism: Patient was maintained on outpatient dose of
levothyroxine.
Medications on Admission:
Prednisone 2.5 mg Tablet Daily
Levothyroxine 125 mcg Daily
Nortriptyline 10 mg qHS
Pregabalin 25 mg [**Hospital1 **]
Aspirin 81 mg Daily
B Complex-Vitamin C-Folic Acid 1 mg Daily
Simvastatin 20 mg q day (pt unclear on if she takes this)
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. B-Complex with Vitamin C Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO BID (2 times a day).
4. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-10**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
5. Senna 8.6 mg Capsule Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
6. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Prednisone 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Pregabalin 25 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
9. Nortriptyline 10 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
10. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day) as needed for constipation.
12. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
Intravenous HD PROTOCOL (HD Protochol).
Discharge Disposition:
Home
Discharge Diagnosis:
Final diagnosis: Hypotension secondary to hemorrhage, fever.
Secondary diagnoses:
1. Chronic kidney disease on dialysis Tuesday, Thursday,
Saturday
2. Chronic graft versus host disease
3. Hypothyroidism
4. Dyslipidemia
5. Peripheral neuropathy
Discharge Condition:
stable, afebrile, ambulatory
Discharge Instructions:
You were admitted to [**Hospital1 **] Hospital with fevers
and decreased blood pressure as a result of extensive bleeding
from your fistula during dialysis. Your fevers could be as a
consequence of your recent surgical procedure or could also be
related to an infection of your dialysis catheter. You will be
maintained on vancomycin for 14 days which you will receive at
your dialysis sessions. Please change your surgical bandage as
directed by the surgical team.
The following changes have been made in your medication regimen:
You will be receiving vancomycin on dialysis days to complete a
14 day course.
Please follow-up with your out-patient providers at the
appointments detailed below.
If you experience fevers, chills, dizziness, lightheadedness, or
any other concerning symptoms, please seek medical care
immediately.
Followup Instructions:
Please follow-up with your out-patient appointments as detailed
below:
1. Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) **], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2203-6-8**] 3:20
2. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2203-6-17**] 2:30
3. Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3919**], [**Name12 (NameIs) 280**] Phone:[**Telephone/Fax (1) 3241**]
Date/Time:[**2203-7-4**] 11:00
|
[
"996.85",
"285.21",
"279.52",
"E878.2",
"996.73",
"790.92",
"272.0",
"V45.11",
"599.0",
"272.4",
"585.5",
"E878.0",
"053.19",
"V10.79",
"244.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.42",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
7687, 7693
|
4059, 6364
|
365, 372
|
7982, 8013
|
3617, 4036
|
8897, 9442
|
2758, 3031
|
6652, 7664
|
7714, 7714
|
6390, 6629
|
7731, 7776
|
8037, 8874
|
3046, 3598
|
7797, 7961
|
293, 327
|
400, 1926
|
1948, 2506
|
2522, 2742
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,405
| 120,923
|
26707
|
Discharge summary
|
report
|
Admission Date: [**2180-3-27**] Discharge Date: [**2180-4-21**]
Date of Birth: [**2123-8-4**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1493**]
Chief Complaint:
Hematuria, shortness of breath
Major Surgical or Invasive Procedure:
Intubation/extubation, mechanical ventilation
Multiple paracenteses
Thoracentesis X2 (bilateral)
Nasogastric tube placements
ORIF of hip fracture
History of Present Illness:
56 yo M c h/o Hep C cirrhosis on transplant list intially
admitted 2 days prior with hematuria, SOB. Patient unable to
confirm history now as he is intubated.
.
Per floor admission note:
Patient states that he noticed his urine was dark red this AM.
Denies F/C, chest pain, N/V, abd pain, change in bowel habits,
flank pain, dysuria, increased frequency, hematemesis, melena,
or hematochezia. Patient has no h/o hematuria or
nephrolithiasis. The patient states that his urine has been
gradually clearing since this morning. He can urinate without a
catheter and has had no evidence of clots or obstruction.
.
The patient also notes gradually worsening SOB over the past
several weeks. He had been stable on diuretics and has not
required a paracentesis in two years. However, he states that he
had recently broken his ankle and had been in rehabilitation in
[**1-18**]. During his time in rehabilitation, he felt that
his fluid status was worsening and he began to notice weight
gain, worsened abdominal distention, BLE swelling, and slowly
progressive worsening SOB. He was seen in Liver clinic twice
over the past month, at which time his diuretics were
uptitrated. He had followup scheduled this Wednesday, at which
time he expected that he would need to be tapped again.
.
Of note, the patient had been admitted [**9-14**] to [**2179-9-22**] with
pleuritic CP and SOB and was found to have BL small PTX and a
left pleural effusion which was borderline
exudative/transudative and of unclear etiology. He was followed
in pulm clinic, they felt his PTX was likely [**3-14**] severe
coughing. They thought that the elevated LDH was [**3-14**] the large
amount of RBC and that the TPr was more consistent with a
transudative process.
.
In the ED, VS 97.0 66 106/58 16 98% RA. Patient was found to
have plt count of 39 and INR of 1.9, which represents his
baseline. UA showed evidence of hematuria without evidence of
red cell casts. CXR showed L-sided pleural effusion. Patient was
admitted to ET for further workup of his hematuria and SOB. On
transfer, VS 64, 110/54, 28, 97% RA.
.
Since admission he underwent thoracentesis on [**3-28**] given
continued SOB and large L pleural effusion. Per report had
thoracentesis in [**9-18**], Appeared more exudative than prior with
some concern for tuberculosis per primary team. ID was
contact[**Name (NI) **] and noted prior negative sputum x 1 with negative PPD.
Procedure consulted for repeat thoracentesis this admission.
Thought needed belly tapped to see if that helped. Got 3.5 L off
[**3-28**] night, but respiratory status did not improve.
Subsequently, fell overnight [**3-28**] and broke left hip with
femoral neck fracture. Prior to OR continued to some
oxygenation problems but was not hypoxic on RA but could not lie
flat. Went to the OR, got 4 bags platelets and 2 bags FFP. Was
intubated but had difficulty continuously desatting on his
lateral side so they had to abort the procedure. RIJ and R
arterial line in place. CXR with R side white-out. R
paracentesis done in PACU. 2.5 L serosanguinous fluid. Getting
0.8 mcg neo. Oxygenation better.
.
Upon admission to the MICU, patient is still in the PACU,
sedated on propofol/fentanyl and needed phenylephrine. Unable
to confirm history further.
.
ROS: See above. All other systems negative.
Past Medical History:
(PER OMR, cannot confirm)
1. Cirrhosis:
- Secondary to hepatitis C (from blood txn)
- Listed for liver transplant, MELD 19
- AFP 2.3 ([**1-18**])
- 3 cords of grade II and 1 cord of grade 1 non-bleeding varices
([**1-17**])
- ascites requiring paracenteses q2-4 weeks previously but well
controlled now
- h/o hepatic encephalopathy
- h/o SBP on cipro prophylaxis
2. Hepatitis C:
- Genotype 1, Viral load 412,000 IU/mL ([**10-17**])
- failed interferon tx (thrombocytopenia)
3. History of CVA, [**2175**] w/ mild residual R sided weakness
4. Heterozygous for H63D for hemochromatosis
5. Hypertension
6. Osteoporosis
7. h/o PTX [**9-18**] with pleural effusion thought to be transudative
by Pulm in clinic
8. progressive LE weakness thought to be [**3-14**] parkinsonism or
manganism [**3-14**] chronic liver disease by Neuro in [**11-18**]
9. s/p R ankle fx in [**12-19**]
Social History:
(PER OMR, cannot confirm)
Married and lives with his wife. Formerly worked as a custodian.
History of smoking but quit 10 years ago. Smoked 1ppd x [**8-17**]
years. Denies alcohol or drug use.
Family History:
(PER OMR, cannot confirm)
Significant for Alzheimer disease in mother and an unspecified
cancer in father and brother.
Physical Exam:
Vitals - T: 98.7 BP 123/60 HR 65 RR 18 100/CMV 40%
GENERAL: sedated, intubated, jaundiced
HEENT: NCAT, PERRL, anicteric
CARDIAC: RRR s mrg, distant heart sounds.
LUNG: CTA anteriorly and in axilla, difficult to assess
posteriorly
ABDOMEN: +BS, soft, distended, no grimace to deep palpation,
mild eccymoses
EXT: WWP, 2+ pulses, 2+ pitting edema to shins bilaterally
NEURO: Sedated
Pertinent Results:
134 100 12 105 AGap=12
3.7 26 1.0
.
ALT: 20 AP: 164 Tbili: 4.3 Alb:
AST: 39 Lip: 44
.
CBC
101
3.8 > 11.3 < 39
33.3
N:75.7 L:10.4 M:6.9 E:4.9 Bas:2.0
.
PT: 20.5 PTT: 42.3 INR: 1.9
.
Abdominal ultrasound with dopplers:
1. Cirrhotic liver with sequela of portal hypertension including
worsening
ascites and unchanged splenomegaly. No focal hepatic lesion.
2. Normal Doppler interrogation of the liver.
3. Site for paracentesis marked in the left lower quadrant.
.
Pleural fluid: Transudative X2, negative for malignant cells
.
CT head non-con: No fracture or recent hemorrhage.
.
Bilateral hip films: Displaced left femoral neck fracture.
.
Ankle films: ....
Brief Hospital Course:
This is a 56 year old male on the liver transplant list for
hepatitis C cirrhosis complcated by esophageal varices, hepatic
encephalopathy, worsening ascites, and h/o SBP on Cipro
prophylaxis also with PMH of CVA with R-sided weakness who
originally presented for hematuria and shortness of breath but
had a prolonged hospital course complicated by altered mental
status secondary to hepatic/metabolic encephalopathy, an
in-hospital fall resulting in a left femoral neck fracture
requiring ORIF followed by an ICU stay after the procedure for
hypotension requiring pressors and prolonged intubation, as well
as multiple paracenteses and thoracenteses.
.
# L femoral head fracture: Unfortunately, the patient fell in
the hospital resulting in a traumatic fracture of his left
femoral head which required an ORIF. He has Childs-[**Doctor Last Name 14477**] class C
cirrhosis and was a high operative risk for a high risk
procedure. However, it was deemed that the benefits of the
procedure outweighed the risks. The patient was intubated for
surgery, but then acutely decompensated when placed in the
lateral decubitus position. He briefly required Neosynephrine
in the ICU to maintain blood pressures. His respiratory
condition improved after a large volume thoracentesis
bilaterally. Of note, the patient's post-operative chest X-ray
was concerning for white-out of right lung fields but he did
respond well to mechanical ventilation. On post-operative day
#1, the patient was found to be in mild hypovolemic shock in the
setting of significant peri-operative blood loss. He was
transfused 4 units pRBC, 2 units platelets, 1 unit FFP and
hence, extubation was deferred until post-operative day #2 given
his significant volume overload with transfusion products. On
post-operative day #3, patient was started on active diuresis
for concerns of pleural effusions/volume overload on chest xray
and physical exam. Patient diuresed well to Lasix 60mg IV,
cardiac status remained stable by EKG and troponins, and RUQ
ultrasound was negative for ascites that could push on diaphragm
and compromise respiratory status. He was then transferred back
to the floor off of pressors and on nasal cannula. Currently he
is satting well on room air with occasional PRN nebulizer
treatments. He was continued on calcium and vitamin D, but can
only start on alendronate bisphosphonate therapy starting [**5-11**] per ortho protocol s/p fracture due to bisphosphonate effect
on bone remodeling. He will also need to continue on Lovenox
30mg [**Hospital1 **] until [**2180-5-1**] to complete 4 weeks of treatment to
prevent DVT. His left hip wound is currently edematous, but
intact without purulence.
.
# Hepatitis C cirrhosis - His MELD score was tracked throughout
his admission and remained around 19. He is on the transplant
list. He was continued on Cipro for SBP prophylaxis, nadolol,
as well as his lactulose/rifaximin regimen. The patient's
nutritional status was a major issue during this
hospitalization. Several NG feeding tubes were placed because
the patient would pull them out. Finally an NG tube was placed
and bridled and the patient will continue on Nutren 2.0 tube
feeds at 50cc/hr in addition to a soft dysphagia diet. Several
diagnostic and therapeutic paracenteses were performed during
her stay. He did not develop SBP and his most recent
paracentesis was performed [**4-21**] with a total of 8 Liters
removed. He was administered albumin IV per protocol after each
paracentesis.
.
# AMS - Following transfer to the floor from the unit, the
patient had altered mental status with slurred speech and
waxing/[**Doctor Last Name 688**] orientation and alertness, although he had no
significant asterixis on exam. No focal neurologic deficits
were appreciated. He was given lactulose. Given concern for
ongoing slurred speech even with improved alertness and
orientation with the patient's history of CVA, an MRI of the
head was ordered which did not show any acute pathology. It is
likely that his AMS was related to a hepatic, a metabolic
(related to his fluctuating sodium levels, see below) as well as
a postoperative encephalopathy/syndrome. He was also found to
have a UTI and will be completing a 14 day course of Bactrim DS
[**Hospital1 **].
.
# Fluctuating sodium levels - The patient developed worsening
hypernatremia following transfer to the floor from the unit,
peaking at 154. It was felt that this was likely [**3-14**] excessive
GI losses from aggressive lactulose regimen intended to clear
his possible hepatic encephalopathy. His lactulose was
temporarily held and he received aggressive free water flushes
and IV D5W. His sodium continued to be difficult to bring down
in this setting and lasix diuresis was re-initiated
concomitantly with increased free water flushes. Eventually the
patient became hyponatremic on this regimen thought to be
secondary to aggressive diuresis. His diuretics were held
starting [**2180-4-18**] and the patient was started on a 1.2 Liter PO
fluid restriction and his free water flushes were discontinued.
His sodium was 130 on discharge and he will be discharged off of
diuretics. His labs will be checked next week and his diuretic
regimen may be restarted based on these lab values.
.
# Hematuria - This manifestation resolved spontaneously with no
evidence of obstruction or clots. Hct was 33.3 on admission
which was stable from Hct checked 3-4 weeks prior. It is
suspected that this was due to a spontaneous bleed in setting of
thrombocytopenia/coagulopathy [**3-14**] cirrhosis.
.
# Thrombocytopenia/Anemia - Former felt likely due to hepatic
dysfunction and splenomegaly/splenic sequestration. Responded to
8 units platelets and remained stable in the 40s on discharge.
Patient's anemia was felt in part due to recent surgical
intervention, recent hematuria, chronic disease, low-grade
hemolysis and DIC by labs. Patient was transfused aggressively
with 12 units pRBC in the setting of his recent surgery and
concern for hypovolemic shock.
.
# CODE: The patient's code status was confirmed as full code
thoughout his hospital stay.
.
# CONTACT: The patient's wife and HCP [**Name (NI) **] [**Name (NI) 13144**] can be
reached at [**Telephone/Fax (1) 65807**]. She is very involved in her husband's
care and was contact[**Name (NI) **] with frequent updates throughout his
hospital stay.
Medications on Admission:
cipro 250mg PO daily
citalopram 10mg PO daily
folic acid 1mg PO daily
furosemide 40mg PO bid
lactulose 30-60 grm PO 3-4x daily prn
nadolol 20mg PO daily
compazine 10mg PO BID prn nausea
rifaximin 600mg PO BID
spironolactone 200mg PO daily
calcium Carb - Vit D3 1 tab [**Hospital1 **]
multivit
omeprazole 20mg PO BID
.
ALLERGIES: NKDA (PER OMR, cannot confirm)
Discharge Medications:
1. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day): Please titrate to [**4-13**] BMs per day.
2. Rifaximin 200 mg Tablet Sig: Three (3) Tablet PO BID (2 times
a day).
3. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours).
4. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Lactulose 10 gram/15 mL Syrup Sig: Sixty (60) ML PO Q4H
(every 4 hours) as needed for constipation.
8. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for Pain.
9. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
10. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
12. Vitamin D 400 unit Tablet Sig: One (1) Tablet PO twice a
day.
13. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) ampule Inhalation Q4H (every 4 hours)
as needed for Shortness of breath or wheeze.
14. Ipratropium Bromide 0.02 % Solution Sig: One (1) ampule
Inhalation Q6H (every 6 hours) as needed for SOB.
15. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
16. Enoxaparin 30 mg/0.3 mL Syringe Sig: Thirty (30) mg
Subcutaneous Q12H (every 12 hours): please stop this medication
on [**2180-5-1**].
17. Sulfamethoxazole-Trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day): Please stop [**2180-4-23**].
18. Compazine 10 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for nausea.
19. Fosamax 70 mg Tablet Sig: One (1) Tablet PO once a week:
Please start this medication on [**2180-5-11**]. Please give to the
patient on an empty stomach and have him sit up for 30 minutes
after administration.
20. Outpatient Lab Work
Please check CBC, chem-7, PT, PTT, LFTs (AST, ALT, alkaline
phosphatase, total bili, albumin) on Monday [**4-24**] and fax to
liver transplant clinic, Attention: Dr. [**Last Name (STitle) 696**] [**Telephone/Fax (1) 697**]
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Hepatitis C cirrhosis, osteoporosis, left femoral neck fracture
s/p ORIF, hypernatremia, hyponatremia, hepatic encephalopathy,
malnutrition, urinary tract infection
Discharge Condition:
Mental Status: Confused - sometimes
Activity Status: Out of Bed with assistance to chair or
wheelchair
Level of Consciousness: Lethargic but arousable
Discharge Instructions:
You were admitted to [**Hospital1 **] Hospital for
evaluation of blood in your urine and shortness of breath. The
blood in your urine spontaneously resolved and your shortness of
breath was found to be due to fluid accumulation in your lung
which needed to be tapped. During your admission you also
developed hepatic encephalopathy and fluctuating sodium levels
in your blood which was thought to be the major causes for your
change in mental status. Unfortunately, you fell during your
hospital stay and fractured your left hip which required
surgical repair. Your nutritional status was also a concern
during your hospital stay and a nasogastric tube was placed with
a bridle to ensure that your nutritional status will be able to
be maintained on constant tube feeds.
.
The following changes have been made to your home medication
regimen:
-You will increase your vitamin D to 400IU twice daily
-You will be started on albuterol/ipratropium nebulizer
treatments as needed for your wheezing and shortness of breath
-You can start taking Dulcolax as needed for constipation
-You will be on Lovenox 30mg injections twice daily until [**5-1**]
-You will be started on Fosamax 70mg weekly starting [**5-11**]
to improve you bone strength
-You will continue on Bactrim DS twice daily for 2 more days to
complete a 14 day course for a urinary tract infection
.
Please follow-up with all of your outpatient medical
appointments listed below.
Followup Instructions:
Please follow-up with all of your outpatient medical
appointments listed below:
.
1. Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 3688**] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2180-4-28**] 2:20
|
[
"456.8",
"997.39",
"511.9",
"572.3",
"518.5",
"584.9",
"V64.1",
"287.5",
"263.9",
"733.00",
"286.7",
"E878.8",
"E888.9",
"571.5",
"998.0",
"780.79",
"456.21",
"438.89",
"288.50",
"V85.31",
"070.44",
"401.9",
"285.1",
"599.70",
"820.09"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.71",
"54.91",
"34.91",
"96.6",
"38.91",
"81.52",
"33.24",
"96.04",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
15232, 15329
|
6193, 12573
|
345, 492
|
15538, 15538
|
5495, 6170
|
17180, 17437
|
4957, 5077
|
12984, 15209
|
15350, 15517
|
12599, 12961
|
15715, 17157
|
5092, 5476
|
275, 307
|
520, 3832
|
15553, 15691
|
3854, 4729
|
4745, 4941
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,060
| 103,497
|
8283
|
Discharge summary
|
report
|
Admission Date: [**2180-1-20**] Discharge Date: [**2180-1-25**]
Date of Birth: [**2113-4-30**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
OPCABx3(LIMA->LAD, SVG->Diag, PDA) [**1-21**]
History of Present Illness:
66 yo with recent symptoms while shoveling, EKG at well visit
with changes, cath with 3VD referred for surgery.
Past Medical History:
CAD s/p RCA stent [**2171**], HTN, lipids, DM, cataracts, T&A
Social History:
wine buyer
denies tobacco, etoh
Family History:
sister with heart problems in 70s
mother deceased from MI at 72
Physical Exam:
Admission exam unremarkable with the exception of bilateral
groin cath sites C/D/I.
Pertinent Results:
[**2180-1-24**] 08:00AM BLOOD WBC-7.7 RBC-2.60* Hgb-8.4* Hct-25.0*
MCV-96 MCH-32.5* MCHC-33.7 RDW-13.1 Plt Ct-212
[**2180-1-23**] 02:28AM BLOOD WBC-8.8 RBC-2.67* Hgb-8.7* Hct-25.1*
MCV-94 MCH-32.5* MCHC-34.7 RDW-13.0 Plt Ct-162
[**2180-1-24**] 08:00AM BLOOD Plt Ct-212
[**2180-1-21**] 11:49AM BLOOD PT-13.8* PTT-26.3 INR(PT)-1.2*
[**2180-1-24**] 08:00AM BLOOD Glucose-273* UreaN-20 Creat-1.1 Na-137
K-3.8 Cl-99 HCO3-30 AnGap-12
CHEST (PA & LAT) [**2180-1-25**] 10:05 AM
CHEST (PA & LAT)
Reason: evaluate effusion
[**Hospital 93**] MEDICAL CONDITION:
66 year old man with s/p cabg
REASON FOR THIS EXAMINATION:
evaluate effusion
HISTORY: Status post CABG.
FINDINGS: In comparison with the study of [**1-22**], the patient has
taken a better inspiration. Residual atelectatic changes persist
at the left base with blunting of the costophrenic angle.
No evidence of acute pneumonia.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 29375**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 29376**] (Complete)
Done [**2180-1-21**] at 8:57:54 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **]
Division of Cardiothoracic [**Doctor First Name **]
[**First Name (Titles) **] [**Last Name (Titles) **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2113-4-30**]
Age (years): 66 M Hgt (in): 69
BP (mm Hg): 134/78 Wgt (lb): 169
HR (bpm): 72 BSA (m2): 1.92 m2
Indication: Intraoperative TEE for CABG procedure
ICD-9 Codes: 786.51, 440.0, 424.1, 424.0
Test Information
Date/Time: [**2180-1-21**] at 08:57 Interpret MD: [**Name6 (MD) 1509**] [**Name8 (MD) 1510**],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1510**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2008AW2-: Machine: [**Pager number 29377**]
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Ejection Fraction: 45% >= 55%
Aorta - Ascending: 2.8 cm <= 3.4 cm
Aortic Valve - Peak Velocity: 1.1 m/sec <= 2.0 m/sec
Findings
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. Small secundum ASD.
LEFT VENTRICLE: Normal regional LV systolic function. Mild
global LV hypokinesis. Mildly depressed LVEF.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. Normal descending aorta diameter.
Simple atheroma in descending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+)
MR.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient.
Conclusions
Off pump CABG
1. A small secundum atrial septal defect is present.
2.Regional left ventricular wall motion is normal. There is mild
global left ventricular hypokinesis (LVEF = 45 %). Overall left
ventricular systolic function is mildly depressed (LVEF= 45 %).
3.Right ventricular chamber size and free wall motion are
normal.
4.There are simple atheroma in the descending thoracic aorta.
5.The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Trace aortic regurgitation is seen.
6.The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen.
7. Post revascularization inferior wall is moderately
hypokinetic. EF 40%
Brief Hospital Course:
He was transferred to cardiac surgery. On [**1-21**] he was taken to
the operating room on where he underwent an off pump CABG x 3.
He was transferred to the ICU in stable condition. He was
extubated later that same day. He was transferred to the floor
on POD#2. He did well postoperatively and was ready for
discharge home on POD #4.
Medications on Admission:
atenolol 100', norvac 2.5', benicar-hct 40-25, glipizide er 10',
lantus 25/25, byetta [**5-8**], metformin 1500/500, crestor 20, asa,
MVI, fish oil
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
6. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0*
7. Ferrous Gluconate 300 mg (35 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
9. Metformin 500 mg Tablet Sig: Two (2) Tablet PO QAM (once a
day (in the morning)).
Disp:*60 Tablet(s)* Refills:*0*
10. Metformin 500 mg Tablet Sig: Three (3) Tablet PO QPM (once a
day (in the evening)).
Disp:*90 Tablet(s)* Refills:*0*
11. Crestor 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
12. Glipizide 10 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1)
Tab,Sust Rel Osmotic Push 24hr PO once a day.
Disp:*30 Tab,Sust Rel Osmotic Push 24hr(s)* Refills:*0*
13. Lantus 100 unit/mL Solution Sig: Twenty Five (25) units
Subcutaneous twice a day.
Disp:*qs 1 month* Refills:*0*
14. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 5 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 BID (2 times a
day) for 5 days.
Disp:*10 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
CAD now s/p CABG
Chronic systolic heart failure
CAD s/p RCA stent [**2171**], HTN, lipids, DM, cataracts, T&A
Discharge Condition:
Good.
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions, creams or powders to incisions.
No lifting more than 10 pounds or driving until follow up with
surgeon.
Followup Instructions:
Dr. [**Last Name (STitle) 29378**] 2 weeks
Dr. [**First Name (STitle) **] 4 weeks
Dr. [**Last Name (STitle) 5874**] 2 weeks
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2180-1-25**]
|
[
"414.01",
"401.9",
"V45.82",
"272.4",
"250.00",
"428.22",
"428.0",
"413.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"89.60",
"36.12"
] |
icd9pcs
|
[
[
[]
]
] |
7246, 7295
|
4741, 5077
|
324, 372
|
7449, 7457
|
847, 1365
|
7756, 8002
|
663, 728
|
5275, 7223
|
1402, 1432
|
7316, 7428
|
5103, 5252
|
7481, 7733
|
743, 828
|
281, 286
|
1461, 4718
|
400, 513
|
535, 598
|
614, 647
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,143
| 177,152
|
49851
|
Discharge summary
|
report
|
Admission Date: [**2189-5-6**] Discharge Date: [**2189-5-21**]
Date of Birth: [**2138-6-13**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
MICU-->Acetaminophen overdose/respiratory distress
floor--> fulminant hepatic failure [**1-28**] acetominophen OD
Major Surgical or Invasive Procedure:
None
History of Present Illness:
50F Hepatitis C, IVDU found down by sister and brought to OSH.
Apparently suicide note left at scene. Pt was last seen over 24
hours ago. Pt was intubated in the field. Narcan 4mg IM given en
route to OSH by EMS. Upon arrival to OSH ED, VS T 85 BP 66/28 P
88 Pox 97% on ventilator. Initial ABG 7.23/22/652 on 100% FiO2
with vent settings PS 10, PEEP 0. Other labs were significant
for tylenol level of 511, INR 2.1 and AST/ALT in the 300-400
range; K 2.6. Hct stable at 51.6. Of note, when NG tube placed,
500cc coffee ground material was retrieved. Patient treated with
charcoal per report, but not per records, given dose of NAC
140mg/kg (total 8.4 grams based on guesstimated weight of 60kg),
vitamin K 10 mg SC x 1, 2.5L NS with 40mEq K, Ativan 1 mg IV x
2, 1 amp HCO3and transferred to [**Hospital1 18**] for further management.
.
In the MICU, pt's HD and respiratory issues stablized. She was
extubated [**5-7**], has been hemodynamically stable since then but
her coagulopathy worsened, LFTs peaked at..., and she was noted
to be intermittently confused and disoriented, progressing to
frank encephalopathy. Her renal function deteriorated as well
[**1-28**] ATN from tylenol, hypotension/UGIB. She was followed by
toxicology,
hepatology, renal and psych services. Not considered transplant
candidate as pt has long hx of chronic, intractable depression
with multiple suicide attempts, and has clearly and consistently
stated plan to die with significantly downward course over last
three years. She received NAC until her INR was <2 and her LFTs
gradually improved. Her creat has been climbing and on day of
transfer is 6.3 (was 0.9 on admission), though her Uop had been
increasing. Given she had no further ICU needs, she was
transferred to the floor for management by the medicine team.
Past Medical History:
: (no records here, usually followed at [**Hospital1 2025**])
1. Hepatitis C (genotype, VL, past Rx); Patient had liver bx at
[**Hospital1 2025**] in [**2186**] which showed mildly active hep C hepatitis, no
cirrhosis.
2. IVDU
3. Psych history-Multiple personality disorder; chronic suicidal
ideation in the past
Last suicide attempt 6 months ago
4. "Very bad lungs" ?emphysema
.
Social History:
: Tobacco 2ppd x 35(+)years; No ETOH abuse; drug addict; ?extra
methadone two days ago; lives at home alone; worked at a drug
treatment program for pregnant women until she relapsed 2 months
ago
.
Family History:
"Alot of psych" per sister
Schizophrenia, bipolar
Father [**Name (NI) 3495**] disease; MI at age 50; had a pacemaker
Mother emphysema
Physical Exam:
On presentation to the MICU:
T 93.6 (oral) BP 92/59 HR 109 RR 30(+)
Vent settings AC 500 x 30 PEEP 4 FiO2 40%
General intubated, sedated, arousal; coffee ground material
suctioned from NGT
HEENT pupils dilated, minimally reactive. right slightly greater
than left.
Heart tachycardic s1 s2 no m/g/r
Lungs CTA B
Abd soft NT, ND, BS(+); transverse scar across abdomen
Ext warm, no edema; 2(+) DP pulses
Neuro arousable, but not oriented, moving all extremities and
responds to pain
.
On transfer:
Gen: Sleeping, NAD, NGT in place
HEENT: icteric sclerae, pupils
CVS: RRR, 2/VI SEM
Chest: CTA B
Abd: soft, NT/ND, NABS
Ext:
Neuro: A&Ox , +asterixis; MAE
Pertinent Results:
On admission:
[**2189-5-6**] 11:51PM GLUCOSE-216* UREA N-16 CREAT-1.1 SODIUM-143
POTASSIUM-3.0* CHLORIDE-107 TOTAL CO2-14* ANION GAP-25
[**2189-5-6**] 11:51PM ALT(SGPT)-435* AST(SGOT)-402* LD(LDH)-469*
ALK PHOS-58 AMYLASE-1171* TOT BILI-0.9
[**2189-5-6**] 11:51PM LIPASE-50
[**2189-5-6**] 11:51PM ALBUMIN-3.7 CALCIUM-7.8* PHOSPHATE-4.0
[**2189-5-6**] 11:51PM OSMOLAL-302
[**2189-5-6**] 11:51PM ASA-NEG ETHANOL-NEG ACETMNPHN-473.4*
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2189-5-6**] 11:51PM WBC-12.5* RBC-5.13 HGB-13.9 HCT-41.2 MCV-80*
MCH-27.0 MCHC-33.7 RDW-16.2*
[**2189-5-6**] 11:51PM NEUTS-87.9* BANDS-0 LYMPHS-8.4* MONOS-3.5
EOS-0.1 BASOS-0.2
[**2189-5-6**] 11:51PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL TARGET-1+ BURR-2+
[**2189-5-6**] 11:51PM PLT SMR-LOW PLT COUNT-135*
[**2189-5-6**] 11:51PM PT-20.4* PTT-38.0* INR(PT)-2.7
.
On d/c:
[**2189-5-13**] 05:55AM BLOOD WBC-12.8* RBC-3.17* Hgb-8.1* Hct-24.0*
MCV-76* MCH-25.6* MCHC-33.9 RDW-16.1* Plt Ct-103*
[**2189-5-12**] 04:03AM BLOOD Neuts-82.7* Bands-0 Lymphs-12.4*
Monos-4.3 Eos-0.3 Baso-0.3
[**2189-5-8**] 02:36AM BLOOD PT-42.8* PTT-49.5* INR(PT)-12.1
[**2189-5-13**] 05:55AM BLOOD PT-14.2* PTT-29.2 INR(PT)-1.3
[**2189-5-13**] 05:55AM BLOOD Glucose-128* UreaN-70* Creat-6.3* Na-148*
K-3.5 Cl-102 HCO3-20* AnGap-30*
[**2189-5-13**] 05:55AM BLOOD ALT-1128* AST-95* AlkPhos-216*
TotBili-3.8*
[**2189-5-8**] 06:28AM BLOOD ALT-9220* AST-[**Numeric Identifier 104156**]* CK(CPK)-4041*
AlkPhos-70 TotBili-3.5*
[**2189-5-13**] 05:55AM BLOOD Calcium-9.9 Phos-4.8* Mg-2.3 Iron-13*
[**2189-5-13**] 05:55AM BLOOD calTIBC-192* Ferritn-225* TRF-148*
[**2189-5-12**] 04:03AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-PND
HAV Ab-POSITIVE
[**2189-5-12**] 04:03AM BLOOD Acetmnp-NEG
[**2189-5-6**] 11:51PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-473.4*
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2189-5-19**] 05:05AM BLOOD WBC-8.2 RBC-3.73*# Hgb-10.6*# Hct-30.5*#
MCV-82 MCH-28.4 MCHC-34.7 RDW-16.4* Plt Ct-90*
[**2189-5-19**] 05:05AM BLOOD Plt Ct-90*
[**2189-5-19**] 05:05AM BLOOD Glucose-73 UreaN-49* Creat-3.7* Na-141
K-3.7 Cl-105 HCO3-23 AnGap-17
[**2189-5-18**] 04:56AM BLOOD ALT-221* AST-36 LD(LDH)-287* AlkPhos-151*
TotBili-1.2
[**2189-5-19**] 05:05AM BLOOD Calcium-8.6 Phos-4.3 Mg-1.6
[**2189-5-12**] 04:03AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-POSITIVE HAV Ab-POSITIVE
CT head: No intracranial hemorrhage is seen.
Repeat: No intracranial hemorrhage is identified. The previously
noted focal hypodensity adjacent to the left frontal gyrus is no
longer apparent, and likely represented an artifact.
.
Abd U/S: ) Patent intrahepatic vasculature. Widely patent main
portal vein, with flow in the appropriate direction.
2) Cholelithiasis, without son[**Name (NI) 493**] evidence of acute
cholecystitis. The dilated common duct is of unknown
significance. Clinical correlation is recommended.
3) Trace perihepatic ascites
.
CXR ([**5-13**]): Increasing alveolar air space opacities most likely
representing aspiration. Small right apical pneumothorax.
Interval extubation.
Echo: 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%). 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 pericardial effusion.
.
Video swallow eval: IMPRESSION: Premature spillover leading to
significant aspiration. Moderate residual within the
vallecula/piriform sinuses, requiring multiple swallows to
clear. Please see speech pathologist's report for more detail
and recommendations.
.
CXR:Bilateral upper lobe air space consolidation. No significant
change radiographically compared to [**2189-5-14**].
.
Brief Hospital Course:
A/P: 50F Hepatitis C, IVDU presents from OSH with tylenol OD
level > 500, respiratory failure, ?sepsis.
.
# Respiratory failure-The patient was initially intubated for
airway protection in the field due to diphenhydramine OD
(Tylenol PM). CRX did not show PNA. She was weaned from the vent
and extubated witin 24 hours. She has had not resp issues since.
.
# Tylenol PM overdose/fulminant hepatic failure: Her initial
level was >500 which was very very concerning for potential
fulminant liver failure. She was given NAC infusion uneil her
INR was below 2. Her LFTs, HCT, and coagulation studies were
checked q 4 hours. LFTs and coags both peaked her 4th hospital
day. She was given FFP for an INR of 12. She was maintained on
D10 fluids while her LFTS were climbing and an no episodes of
hypoglycemia. As these trended [**Last Name (un) 8636**], her total bilirubin
begain to rise and she developed asterixs. During her stay,
toxicology and hepatology services were consulting. Since the
patient had recently used IVD, she was not a canditate for
transplant. Her NAC was continued until her Tylenol dose was
undectebale on [**5-12**]. Of note, the patient underwent a liver bx
at [**Hospital1 2025**] (records in chart) in [**2185**] which showed chronic hep C
without cirrhosis. Full Hep panel revealed that she has Ab to
HepBc and HepBs as well as HAV Ab. It is unclear whether the Hep
A Ab represents prior infection vs. immunization; however, her
HepBcAb positivity indicates that she was exposed to the virus
in the past. Hep B VL was pending at discharge and may be
followed-up on an outpatient basis. Pt's LFTs were decreasing
and should be followed for resolution.
.
# Renal failure: [**1-28**] ATN from APAP toxicity/HoTN. The patient's
renal failure was worsening at time of transfer to the floor.
However, it peaked at..and then started to trend down. Dialysis
was not necessary. Her creat was 3.7 on day of discharge. The
renal service followed the pt through her time on the floor.
.
# Acidosis- The patient was admitted with an ABG 7.23/22/300s
c/w and anion gap metabolic acidosis with respiratory
compensation. There was high suspicion for ketoacidosis given
she has been down for an unknown period of time, but urine
ketones negative. Her lactate, however, was 12.5, so likely all
[**1-28**] lactic acidosis from hypotension, low tissue perfusion, and
less likely sepsis. As her renal failure progressed, she
developed a gap metabolic acidosis from uremia and a comcominant
metabolic alkalosis of unknown cause. Her gap closed as her
renal function improved.
.
# GI bleed-At the OSH, the patient reportdely had 500cc of
coffee ground emesis from her NGT once it was placed. Her HCT
decreased here from 41 to 26, but this was likely from the
massive fluid recusatiaion she recieved. No evidence of bleeding
here. She was cotinuted on PPI [**Hospital1 **] and received 4U PRBCs for
HCT<25 with appropriate response. Stools were OB-. She should
have an outpatient EGD in [**4-1**] weeks for further evaluation.
.
# Anemia: The paitent likley has a baseline anemia, exacerbated
by her renal and liver failure and her recent bleed. She was Fe
deficient with a component of ACD. FeSO4 was started and epogen
was initiated. Pt's stools were OB negative and there was no
evidence of hemolysis on lab studies. She should continue to
receive epogen 3000units weekly until her renal function
normalizes. She should be work-up for Fe deficiency as an
outpatient. Her HCT on discharge was 35.
.
# Elevated CK-Likely from being found down. Resolved with IVF.
.
# Psych/IVDU-Multiple sucide attempts. The Psychiatry service
followed the pt while in-house and recommended starting seroquel
for her anxiety. Ativan was held, as pt was noted to be
disoriented on initial transfer to the floor. She may receive
haldol prn for agitation. Her Geodon and ativan may be restarted
once her LFTs return to baseline and psychiatry approves.
.
#AMS: As noted, pt had periods of agitation and confusion during
her hospitalization. Head CT showed no bleed. EEG revealed
diffuse encephalopathy. This was likely multifactorial, related
to her liver failure, renal failure, baseline medical issues,
and medications she was receiving. Her mental status continued
to improve and she was at her baseline level of functioning on
discharge.
.
#Aspiration PNA: Pt had a low-grade temp to 100.1 and CXR showed
upper airway consolidation. Levaquin was started for a 10 day
course, which will be completed on an outpatient basis. She
should have a follow-up CXR in [**4-1**] weeks to document clearance.
.
12. Code-FULL
.
13. [**Doctor First Name 104157**] [**Name (NI) 104158**], sister ([**Telephone/Fax (1) 104159**] cell ([**Telephone/Fax (1) 104160**]
[**Name (NI) **], sister ([**Telephone/Fax (1) 104161**]
.
14. [**Name (NI) 11053**] Pt was dischrged to Deaconness 4 for psychiatric
rehab once she was medically stable and above issues had been
fully addressed.
Medications on Admission:
1. Geodon (dose unknown)
2. Seroquel (dose unknown)
3. Methadone 90 mg daily
4. Ativan 1 mg PO BID-TID
on transfer:
RISS
Protonix 40"
lactulose 30""
e-mycin 250"'
methadone 15"'
Epo 1000QM/W/F
Discharge Medications:
1. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily).
2. Cepacol 2 mg Lozenge Sig: One (1) Lozenge Mucous membrane
PRN (as needed).
3. Methadone HCl 5 mg Tablet Sig: Three (3) Tablet PO TID (3
times a day).
4. Quetiapine Fumarate 25 mg Tablet Sig: Two (2) Tablet PO HS
(at bedtime).
5. Epoetin Alfa 2,000 unit/mL Solution Sig: 1000 (1000) units
Injection QMOWEFR (Monday -Wednesday-Friday).
6. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily): please give 4 hours after protonix.
7. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q48H (every
48 hours) for 8 days: first dose given [**2189-5-18**].
9. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
10. Methadone HCl 10 mg Tablet Sig: Three (3) Tablet PO QHS
(once a day (at bedtime)).
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Tylenol overdose
Acute Renal Failure
Fulminant hepatic failure
aspiration pneumonia
Anemia
Upper GI bleed
Discharge Condition:
Good
Discharge Instructions:
Please call your doctor and return to the hospital for any
fever/chills, shortness of breath, confusion, abdominal
pain/swelling, or any other concerning symptoms you may have.
.
Please take all medications, as prescribed and keep your
follow-up appointments.
Followup Instructions:
Please follow-up with Dr.[**Last Name (STitle) **] in one week after discharge.
Please call for appointment.
.
Please follow-up with your Hepatologist in [**7-5**] days after
discharge. Please call for appointment.
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,943
| 189,103
|
11999+56315+56316
|
Discharge summary
|
report+addendum+addendum
|
Admission Date: [**2197-11-29**] Discharge Date:
Date of Birth: [**2123-5-9**] Sex: M
Service:
DIAGNOSIS:
1. Left thalamic bleed
2. Pleural thickening consistent with advanced stage
mesothelioma
3. Multiple nodules in the adrenal gland and liver
consistent with possible metastatic spread of previous renal
cell carcinoma
HISTORY OF PRESENT ILLNESS: This is a 74 year old man with
past medical history of asthma, metastases of renal cell
carcinoma, status post nephrectomy in [**2191**] and history of
deep vein thrombosis on Coumadin and was in his usual state
of health until approximately 2 PM on the day of admission,
[**11-29**]. He suddenly complained of weakness and being
unable to stand up from sitting. He was apparently
conversant at the time and denied any headache, nausea, or
vomiting. He was taken to an outside hospital at that time.
Day #5 at outside hospital, computerized axial tomography
scan showed 2 by 2 by 2 left thalamic bleed. His INR was 2.3
and he was reversed with 2 units of fresh frozen plasma and
given 1 gm of Dilantin intravenously. At this time he began
to become agitated and developed difficulty speaking which
was apparently noted to be aphasia. He was transferred to
[**Hospital6 256**] for further care.
In the Emergency Room the patient is unable to give any
additional history due to confusion and aphasia. He had a
computerized axial tomography scan repeated here which showed
a 2.7 by 2 by 2 cm extension of bleed with minimal right
shift. He still denies headache, nausea, vomiting and chest
pain. He has shortness of breath which is found to be
baseline due to his asbestosis.
PAST MEDICAL HISTORY:
1. Asbestosis with chronic obstructive pulmonary disease.
2. Renal cell carcinoma resected in [**2191**].
3. Deep vein thrombosis 18 years ago.
ALLERGIES: Codeine
FAMILY HISTORY: Non-contributory.
SOCIAL HISTORY: Ex-smoker for six years; formerly one pack a
day social drinker, former asbestos worker.
REVIEW OF SYSTEMS: Not able to be reliably obtained, but
denies chest pain, shortness of breath, nausea or vomiting,
headache, fever or chills.
ADMISSION PHYSICAL EXAMINATION: Vital signs reveal heartrate
100, systolic blood pressure in 170 to 180 range. General,
alert, disoriented and agitated. Head, eyes, ears, nose and
throat, neck is supple with no masses, no carotid bruits,
regular rate and rhythm. S1 and S2 is present without any
murmurs. Pulmonary, decreased breathsounds throughout with
fine crackles at the bases. Abdomen was soft, nontender.
Bowel sounds present. Extremities, no edema or calf
tenderness. Neurological examination showed the patient to
be alert, oriented to name, speech fluent with frequent
paraphrasic errors. Repetition is intact, comprehension is
intact to one-step tasks but not to two-step tasks. Mental
status, attention is poor. Cranial nerves showed pupils
2 mm and reactive on the left and right pupil post surgical,
left gaze preference. Extraocular movements full without
nystagmus. Fundi difficult to visualize, probable right
field cut. Not blinking to confrontation. Face symmetric,
facial sensation intact. Questionable decrease on right.
Motor, right extremities flaccid with extensive posturing to
noxious stimuli. Right lower extremity with some tone and
spontaneous movement but triple flexion to pain. Difficult
to assess for left sensory, normal withdraw to pain
on left, reflexes poor to pain on the right as described
above, he does not say that he is feeling the pain or that he
is being touch on the right leg. He can not do DSS due to
comprehension. Gait was not assessed. Coordination,
finger-nose-finger was intact on left, left upper extremity
reflexes brisker on the right 2+, lower extremities, 3 on the
left, 3+ on the right. Toes upgoing on the left, downgoing
on the left.
LABORATORY DATA: Labs on admission outside hospital day #5
computerized tomography scan of head as above.
HOSPITAL COURSE: This is an unfortunate 74 year old man who
had a left thalamic intracranial hemorrhage for which he was
transferred to [**Hospital6 256**] from an
outside hospital. He was initially managed in the Intensive
Care Unit and since then he had to be intubated on [**11-30**] for respiratory distress. Otherwise the patient's blood
pressure was kept in 120 to 140 and electrolytes and coags
were monitored. His INR steadily decreased and he was
transferred to the floor on [**12-6**] in stable but guarded
condition with problem[**Name (NI) 115**] pulmonary status. On the floor he
had fevers and he had been started on Levaquin. However,
fevers continued and on [**12-10**], an infectious disease
consult was obtained who suggested changing the patient to
Vancomycin and Ceftazidime intravenously with further
recommendation to discontinue the Levofloxacin and send the
central for culture. At the time of dictation none of these
cultures have grown positive. However, after starting the
Vancomycin and Ceftazidime the patient has not had any
further episodes of fever. His pulmonary status has remained
guarded with episodes of tachypnea and decreased oxygen
saturation. Several chest x-rays have been done that were
suggestive of consolidative process. However, on one of the
last x-rays the comment was made that findings were
concerning for pleural thickening and on radiology's
suggestion computerized axial tomography scan of the chest
was obtained. This study showed - 1. Left pleural
thickening consistent with mesothelioma; 2. Lymphangitic
progression on the right base, also with bronchovascular
thickening and there was extensive mucous plug noted. Given
the results, we contact[**Name (NI) **] pulmonary medicine who left a note
today. They feel that this is metastatic cancer from either
kidney or there is end stage mesothelioma. They had
extensive discussions with the son and wife and they feel
that the prognosis for this patient is extremely poor and
they have discussed end-of-life issues with the patient's
family further, medical point of view, and who will institute
talks on the patient's code status and who will initiate
percutaneous endoscopic gastrostomy tube placement shortly
with view of placement in hospice care versus nursing home.
From the neurological point of view, the patient has not
improved dramatically since his initial examination and he
still remains aphasic and unable to communicate with fluency
to our examinations.
DISCHARGE PHYSICAL EXAMINATION: Physical examination on
[**12-13**] showed temperature of 97.0, respirations 20,
blood pressure 110/60, sating 91% on 4 liters. He was in no
acute distress, sitting up in a chair, regular rate and
rhythm, difficult to assess lung sounds, because of coarse
breathsounds. The patient from the neurology point of view,
the patient continues to have right hemiparesis, unable to
communicate intelligibly.
His sodium is 146, potassium 3.8, BUN 127, creatinine 1.2.
White blood count 7.6, hematocrit 30.5, platelets 255.
Vancomycin peak was 17.4 and trough was 10.5. We are
awaiting further instructions from Infectious Disease to
determine the new level of Vancomycin. Of note, the patient
also had an episode of hypernatremia which was corrected by
increasing free water boluses from 250 q. 8 to 300 q. 6.
MEDICATIONS:
1. Ceftazidime 1 gm q. 12
2. Vancomycin 750 mg q. 18
3. Norvasc 2.5 mg per tube q.d.
4. Sliding scale insulin
5. Hydralazine 14 mg q. 6
6. ATTB 25 mg q. day
7. Colace 100 mg b.i.d.
8. Prevacid 30 mg q. day
9. Albuterol and Atrovent nebulizers q. 4 prn
10. Tylenol 650 mg p.r. q. 6 prn
11. Nystatin Swish and Swallow prn
Of note, when the patient is discharged a new updated list
for follow up. Undetermined at this time, the patient is
likely to go to a nursing home versus hospice care.
[**Doctor Last Name **] [**Name8 (MD) 8346**], M.D. [**MD Number(1) **]
Dictated By:[**Name8 (MD) 11440**]
MEDQUIST36
D: [**2197-12-13**] 17:32
T: [**2197-12-13**] 20:26
JOB#: [**Job Number **]
Name: [**Known lastname 6809**],[**Known firstname 6810**] Unit No: [**Numeric Identifier 6811**]
Admission Date: Discharge Date:
Date of Birth: Sex:
Service:
ADDENDUM: The patient completed a course of Ceftazidime and
Vancomycin as per the Infectious Disease Department.
CONSULTATION: The patient did not have any further episode
of fevers. General condition improved as previously noted.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 6812**]
Dictated By:[**Name8 (MD) 6368**]
MEDQUIST36
D: [**2197-12-21**] 10:56
T: [**2197-12-21**] 11:53
JOB#: [**Job Number **]
Name: [**Known lastname 6809**],[**Known firstname 6810**] Unit No: [**Numeric Identifier 6811**]
Admission Date: [**2197-11-29**] Discharge Date:
Date of Birth: [**2123-5-9**] Sex: M
Service:
ADDENDUM:
1. Patient has been admitted to a rehab facility where he is
going to be transferred today.
2. PEG tube was successfully placed and currently he is at
tube feed goal of 80 cc per hour of ProMod with fiber. We
performed another bedside swallow evaluation two days ago and
he failed that test.
3. Please note that in the medication list previously
dictated the #6 it not ATTB 25 mg q day, it should read HCTZ
25 mg q day.
4. Exit physical and neurological examination: Patient has
slightly improved. Now there is a hello and good-bye and is
able to follow very simple commands. He is still not fluent
but has increased strength on the right with the ability to
flex his arm. This is a slight improvement from previous.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 2172**]
Dictated By:[**Name8 (MD) 6368**]
MEDQUIST36
D: [**2197-12-21**] 08:56
T: [**2197-12-21**] 09:05
JOB#: [**Job Number 6813**]
|
[
"276.0",
"569.62",
"197.2",
"518.81",
"507.0",
"431",
"784.3",
"501",
"342.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.15",
"46.32",
"96.04",
"96.6",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
1865, 1884
|
3994, 6480
|
6503, 9907
|
2011, 2147
|
374, 1657
|
1679, 1848
|
1901, 1991
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,911
| 158,833
|
33310
|
Discharge summary
|
report
|
Admission Date: [**2117-5-14**] Discharge Date: [**2117-5-18**]
Date of Birth: [**2055-1-28**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 943**]
Chief Complaint:
variceal bleed
Major Surgical or Invasive Procedure:
endoscopic banding
History of Present Illness:
62M w/ EtOH cirrhosis decompensated with varices, HTN, who
presented to the [**Hospital3 **] ED with hematemesis on [**5-10**].
The patient is unable to answer questions. History is from OSH
d/c summary. Exam was notable for hypotension and tachycardia,
and labs were notable for a Hct 12.4 and INR 2.6 on
presentation. He received 4U PRBC in the ED and was admitted to
the ICU. He was seen by GI and had an EGD which showed multiple
cords of grade 2 esophageal varices with stigmata of recent
bleeding. They did not band the varices. His Hct after
transfusion was 27. He was started on IV Protonix and
octreotide gtt. On the evening of [**5-11**], he had large volume
hematemesis, hypotension to SBP 60s. He was intubated for
airway protection and started on neosyncephrine and levophed.
GI repeated EGD and found an actively bleeding varix which they
sclerosed. He received a total of 9U PRBC and 4U FFP. Levophed
and neosynephrine were weaned on [**5-12**]. He was subsequently
hypertensive 160s-180s. On [**5-12**]/3 bottles of his admission
blood cultures grew gram positive cocci, later speciated to
Viridans Strep, suspected enteric source with variceal bleed.
No prior history of indwelling lines, endocarditis, or IV drug
use. He was started on vancomycin and Zosyn before culture
speciation returned. Surveillance blood cultures on [**5-12**] from
femoral line grew [**2-3**] coag negative Staph. Admission urine
culture grew 10-50K E. coli, but UA was not suspicious for UTI.
The patient developed loose stools and distended abdomen on [**5-13**]
in the setting of rising WBC, so stool was sent for C. diff
(results not available) and patient was started on empiric
metronidazole. Octreotide gtt was d/c'd [**5-14**]. He was extubated
the morning of [**5-14**]. Post-extubation, he was noted to be
confused and lethargic. His altered mental status was felt to
be secondary to poorly metabolized Versed. His ammonia level
was 43, so hepatic encephalopathy was felt to be lower on the
differential. He was transferred to [**Hospital1 18**] for consideration of
non-emergent TIPS.
.
On arrival to the [**Hospital1 18**] MICU, he was afebrile with HR 80s, BP
151/97, afebrile, 100% on RA. He was moving all extremities but
not responding to name or following commands. He rarely
spontaneously opened his eyes.
Past Medical History:
1. EtOH cirrhosis: decompensated with varices, h/o variceal
bleed [**3-12**] s/p banding
2. Hypertension
Social History:
Lives with wife, [**Name (NI) **]. [**Name2 (NI) **] drink sometime between [**Date range (1) 66379**]
per wife. She is not aware of how much he drinks daily.
Occasional tobacco use. Wife reports no history of drug use.
Family History:
Unable to obtain.
Physical Exam:
Vitals- 98.0, 88, 151/97, 20, 98% RA
Gen- mildly agitated, not responsive to name, not following
commands, rarely spontaneously opens eyes
HEENT- icteric sclerae, pupils 1-2mm, NGT in place
Neck- supple, no JVD appreciated
Pulm- CTAB but patient not cooperative with exam
CV- RR, no murmurs auscultated
Abd- distended but fairly soft, tympanitic, no bulging flanks or
appreciable dullness to percussion, no fluid wave, patient did
not grimace to deep palpation
Extrem- L femoral TLC, trace ankle edema b/l, pneumoboots in
place, DP/PT pulses full b/l
Neuro- occasionally spontaneously opened eyes during exam,
moving all 4 extremities, did not cooperate with/resisted neuro
exam
Pertinent Results:
WBC-18.2* RBC-3.74* HGB-11.1* HCT-31.5* MCV-84 MCH-29.8
MCHC-35.3* RDW-15.7* PLT COUNT-103*
- NEUTS-82.3* LYMPHS-11.3* MONOS-5.0 EOS-1.2 BASOS-0.3
PT-16.5* PTT-34.7 INR(PT)-1.5*
GLUCOSE-91 UREA N-11 CREAT-1.1 SODIUM-141 POTASSIUM-3.9
CHLORIDE-114* TOTAL CO2-20*
CALCIUM-7.7* PHOSPHATE-2.4* MAGNESIUM-1.8
ALT(SGPT)-401* AST(SGOT)-390* ALK PHOS-74 TOT BILI-2.7*
Hep B and C studies pending
[**5-15**] urine cx, blood cx, catheter tip cx NGTD as of [**5-16**]
[**5-15**] C diff toxin negative
[**5-15**] abdominal ultrasound: 1. Small amount of right upper
quadrant ascites. 2. Patent portal vein. 3. Decompressed
gallbladder with stones and sludge within its lumen. Gallbladder
wall edema. This could represent third spacing due to low
albumin. No albumin results are available on OMR for this
patient, and therefore correlation with laboratory values is
recommended. If clinical concern exists for acute cholecystitis,
consider a HIDA scan.
[**5-15**] single view CXR: An NG tube is present, tip beneath
diaphragm. There are low inspiratory volumes. Heart is probably
not enlarged. There is no CHF. There is bibasilar atelectasis.
No gross effusion. Slight prominence of the cardiomediastinal
silhouette is likely accentuated by low lung volumes and
lordotic positioning, probably also with unfolded aorta.
[**5-15**] TTE: The left atrium is mildly dilated. Left ventricular
wall thickness, cavity size and regional/global systolic
function are normal (LVEF >55%) The estimated cardiac index is
normal (>=2.5L/min/m2). Transmitral Doppler and tissue velocity
imaging are consistent with normal LV diastolic function. Right
ventricular chamber size and free wall motion are normal. The
aortic root is mildly dilated at the sinus level. The ascending
aorta is mildly dilated. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. No masses or vegetations are seen on the aortic
valve. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. No mass or vegetation is seen on
the mitral valve. Mild (1+) mitral regurgitation is seen. There
is a trivial/physiologic pericardial effusion.
[**5-18**] EGD: 3 cords of grade II esophageal varices. Evidence of
sclerotherapy of one varix in the lower third of the esophagus.
3 bands were placed successfully on the varices.
Friability, erythema, congestion, nodularity and mosaic
appearance in the fundus compatible with portal gastropathy
Varices at the lower third of the esophagus and gastroesophageal
junction (ligation)
Otherwise normal EGD to second part of the duodenum
Brief Hospital Course:
1. Variceal bleed: Patient transferred 15U variceal bleed, s/p
sclerosis of actively bleeding varix. Patient's hematocrit
subsequently stabilized and he remained hemodynamically stable.
The liver service performed an EGD that demonstrated 3 cords of
grade II esophageal varices with evidence of sclerotherapy of
one varix in the lower third of the esophagus. 3 bands were
placed successfully on the varices. The patient will need
repeat EGD in [**3-7**] weeks for repeat evaluation and possible
further banding. He will continue on pantoprazole 40mg QD and
nadolol.
2. Bacteremia: Viridans Strep from [**5-12**] blood cultures at [**Hospital1 **], presumed enteric source in setting of variceal bleed,
initially on Vancomycin at OSH, but changed to ceftriaxone.
Pip-Tazo was stopped given absence of gram negative aetiology
for sepsis. Was initially on metronidazole for empiric C.
difficile treatment given diarrhea and marked leukocytosis, but
C. difficile toxin was negative so this was discontinued.
Written for 2 week course of ceftriaxone from [**2117-5-12**] to
[**2117-5-26**]. He was initially on vancomycin for coagulase
negative Staph but per OSH culture data appears to be
contaminant, so Vancomycin discontinued. Echocardiogram was
done to assess for endocarditis and transthoracic Echo was
negative. Per ID the patient will need a transesophageal
echocardiogram as an outpatient prior to completion of two week
courses of ceftriaxone to determine whether he had endocarditis
and will need a longer course of therapy. Dr. [**Last Name (STitle) 44890**], his
primary care physician has been [**Name (NI) 653**] and will coordinate
the TEE. He should have CBC, electrolytes, and LFTs remeasured
as an outpatient while he is on the ceftriaxone to monitor renal
and liver function.
3. Alcoholic cirrhosis: Decompensated with variceal bleed.
Wife denies history of encephalopathy, ascites, and SBP. Liver
enzymes elevated here, only mildly elevated AST on admission.
Management of variceal bleed as above. He was restarted on
nadolol prophylaxis as above.
4. FULL CODE
Medications on Admission:
OUTPATIENT MEDS:
Protonix 40mg daily
Nadolol 20mg daily (?noncompliant)
MVI
Folic acid 1mg daily
Thiamine 100mg daily
.
MEDS ON TRANSFER:
Protonix 40mg IV BID
Vancomycin 1g Q12H
Piperacillin-Tazobactam 3.375g IV Q6H
Metronidazole 500mg IV Q8H
Albuterol nebs Q6H
Discharge Medications:
1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day.
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Ceftriaxone-Dextrose (Iso-osm) 1 gram/50 mL Piggyback Sig:
One (1) gram Intravenous Q24H (every 24 hours) for 8 days.
Disp:*7 gram* Refills:*0*
4. PICC Line Care
PICC line care per NEHT protocol.
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
6. Nadolol 20 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 511**] Home Therapy
Discharge Diagnosis:
variceal bleed
ETOH Cirrhosis
Hypertension
Discharge Condition:
hemodynamically stable
Discharge Instructions:
You were admitted to the hospital with bleeding from veins in
your esophagus. You required many blood transfusions to replace
blood you lost from bleeding. Endoscopic procedures at [**Hospital1 **]
and here treated the varices with application of bands and with
injection of solutions to prevent bleeding. You will need a
repeat endoscopy in three weeks to reassess your bleed.
In addition you were found to have an infection in your blood.
You will need antibiotics for a total of two weeks through your
IV. There is a chance that this infection may be affecting your
heart. Dr. [**Last Name (STitle) 44890**] will help you set up an appointment for a scan
of your heart to determine whether you have this infection; if
you do you will need to be treated for a longer period of time
with antibiotics.
Please continue to take your medications as prescribed. Please
follow appropriate care for your PICC line. If you develop
bleeding, fevers, chills, confusion, or any other concerning
symptoms please contact a physician [**Name Initial (PRE) 2227**].
Followup Instructions:
Please follow up with your primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 44890**] on
Thursday [**5-20**]. You can call him at ([**Telephone/Fax (1) 68965**].
Provider: [**Name10 (NameIs) **] [**Apartment Address(1) **] (ST-3) GI ROOMS Date/Time:[**2117-6-3**] 1:30
Provider: [**Name10 (NameIs) 1382**] [**Name11 (NameIs) 1383**], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2117-6-3**] 1:30
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 2424**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2117-7-27**] 11:45
Completed by:[**2117-5-21**]
|
[
"041.09",
"401.9",
"790.7",
"571.2",
"456.20",
"789.59"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"42.33"
] |
icd9pcs
|
[
[
[]
]
] |
9407, 9474
|
6475, 8569
|
329, 350
|
9561, 9586
|
3839, 6452
|
10695, 11296
|
3105, 3124
|
8881, 9384
|
9495, 9540
|
8595, 8715
|
9610, 10672
|
3139, 3820
|
275, 291
|
378, 2720
|
2742, 2848
|
2864, 3089
|
8733, 8858
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,790
| 189,460
|
52277
|
Discharge summary
|
report
|
Admission Date: [**2172-12-21**] Discharge Date: [**2173-1-6**]
Service: CARDIOTHORACIC
Allergies:
Amoxicillin / Biaxin
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Worsening chest pain and dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2172-12-25**] Redo Sternotomy. Off Pump Single Vessel Coronary Artery
Bypass Grafting utilzing Saphenous Vein Graft to Left Anterior
Descending Artery
[**2172-12-22**] Cardiac Catheterization
[**2172-12-28**] Cardiac Catheterization with Percutaneous Intervention
History of Present Illness:
81 y/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 4746**] with a PMHx of CAD s/p MI in [**2153**], s/p CABG in [**3-/2171**]
(3 SVGs as below), HTN, CRI, PAF admitted to [**Hospital1 18**] for precath
hydration in AM tomorrow. Pt has a [**4-10**] month h/o worsening CP
and dyspnea on exertion, even occuring with slight exertion over
the past week. Pt had a CABG in [**3-/2171**] and was doing well
without any CP or SOB on exertion until 4 months ago when he
began to develop worsening CP/SOB on exertion. Pt now having
CP/exertion with slight exertion including several steps, or 1
flight of stairs. Pt had a P-Mibi today which a showed
reversible, moderate to severe apical defect involving the LAD
territory along with septal akinesis and an EF of 62%. Pt was
admitted to [**Hospital1 18**] today for precath hydration due to his h/o
CRI. Denies any palpitations, LH/dizziness, orthopnea, PND. No
other c/o today. Eating/drinking/urinating well.
Past Medical History:
1. CAD s/p MI in [**2153**] s/p CABG in [**3-/2171**] (SVG -> distal RCA,
SVG -> LAD, SVG -> OM1). ETT today with reversible apical defect
in LAD territory (see full report below).
2. HTN
3. PAF 50yrs ago, not on coumadin
4. Spinal stenosis, not able to ambulate s cane
5. CRI Baseline Cr 1.6-1.8
6. Bilat kidney stones
7. Diverticulitis
8. Bladder CA s/p excision
9. Prostate CA s/p prostatectomy
10. intermittant gout
11. GB stones
Social History:
Pt is a retired neurologist, lives at home with wife. [**Name (NI) **] [**Name2 (NI) **]
h/o. EtOH: 1 drink/night. Denies IVDU.
Family History:
M/F healthy, B CABG [**51**], S healthy, B died of prostate CA
Physical Exam:
GEN: NAD, sitting/talking comfortably
HEENT: PERRL. EOMI. MMM.
NECK: Supple. No elevated JVP.
CV: Regular, nml s1,s2. No s3 or murmur.
RESP: CTAB. No c/w/r.
ABD: Soft, NTND. +BS. No HSM.
EXT: No edema bilat. DP/PT/Femoral pulses 2+ bilat.
NEURO: AAOx3. Moves all extremities spontaneously.
Pertinent Results:
[**2172-12-22**] 05:20AM BLOOD WBC-5.8 RBC-3.34* Hgb-10.6* Hct-30.0*
MCV-90 MCH-31.7 MCHC-35.3* RDW-13.8 Plt Ct-219
[**2172-12-22**] 12:15PM BLOOD PT-12.6 PTT-26.9 INR(PT)-1.1
[**2172-12-22**] 05:20AM BLOOD Glucose-121* UreaN-29* Creat-1.5* Na-142
K-3.9 Cl-105 HCO3-28 AnGap-13
[**2172-12-22**] 03:36PM BLOOD %HbA1c-5.3 [Hgb]-DONE [A1c]-DONE
Brief Hospital Course:
Following a Persantine MIBI that showed a reversible, moderate
to severe apical defect, he was admitted to the [**Hospital1 18**] for
hydration prior to cardiac catheterization. Selective coronary
angiography on [**12-22**] revealed a right dominant system
with severe three vessel including left main disease and
occluded vein grafts. The LMCA was diffusely diseased with a a
90% distal stenosis. The LAD had severe diffuse disease with a
90% ostial stenosis and a 80% stenosis in the mid
LAD after a large D1. The D1 was diffusely diseased. The LCx
had a 70% ostial stenosis with diffuse disease in the proximal
and mid portions. It gave off a large OM with a mid-vessel 90%
focal stenosis. The RCA had 70% ostial stenosis with a 40%
stenosis in the mid vessel and diffuse 0% stenoses in the PDA.
Supravalvular aortography did not demonstrate any patent vein
grafts and given his chronic renal insufficiency, left
ventriculography was not performed. Based on the above results,
cardiac surgery was consulted and further evaluation was
performed. An echocardiogram showed normal left ventricular
function(greater than 55%) with mild to moderate mitral
regurgitation. The aortic valves were mildly thickened with only
mild aortic insufficiency. The aortic root was normal diameter
and the ascending aorta was mildly dilated, measuring 3.7
centimeters. A carotid ultrasound showed mild to moderate
stenoses of both internal carotid arteries, measuring between
40-59%. Vein mapping also revealed suitable greater saphenous
vein in his left leg. His preoperative course was otherwise
uneventful. He remained stable on medical therapy and was
eventually cleared for surgery.
On [**12-25**], Dr. [**Last Name (STitle) **] performed a redo sternotomy and
off pump coronary artery bypass grafting. Due to severe
adhesions from prior operation, incomplete revascularization was
performed. This was decided prior to the operation with near
future plans for percutaneous intervention. For surgical
details, please see seperate operative report. After the
operation, he was brought to the CSRU for invasive monitoring.
Within 24 hours, he awoke neurologically intact and was
extubated. He experienced episodes of paroxysmal atrial
fibrillation but otherwise maintained stable hemodynamics. On
postoperative day three, he returned to the cardiac cath lab for
percutaneous intervention. Successful stenting of the left main,
circumflex, first diagonal and right coronary artery was
performed without complication. He was subsequently started on
Plavix which he will need to continue for at least 12 months.
He remained in hospital awaiting a therapeutic INR. He converted
to a NSR. He was transfused one unit PRBCs on [**2173-1-3**] for a HCT
of 26 with a post transfusion HCT of 29.
Echo today revealed a slightly depressed LV, [**2-9**]+ MR, 2+TR.
INR today is 2.2
He was ready for discharge to rehab on [**2173-1-6**]. He will need
follow up and dosing of his coumadin.
Medications on Admission:
Niacin 500"
Plavix 75'
Lisinopril 20'
Toprol XL 100'
Lipitor 10'
ASA 325'
Nitro patch 0.1mg/hr q72
Ranitidine 300'
Prilosec 20'
Halcion 0.125mcg'
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. Triazolam 0.25 mg Tablet Sig: One (1) Tablet PO hs prn ().
6. Coumadin 1 mg Tablet Sig: 0.5 Tablet PO once a day: please
check INR qd and dose coumadin for goal INR 2.0-2.5.
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO every 4-6 hours as needed for pain.
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 10 days: [**Hospital1 **] x 10 days then QD.
9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
10. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
12. Disopyramide 100 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO Q12H (every 12 hours).
13. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Coronary artery disease - s/p redo CABG, s/p percutaneous
intervention; postoperative atrial fibrillation; hypertension;
history of paroxsymal atrial fibrillation; spinal stenosis;
chronic renal insufficiency; diverticular disease; bladder
cancer - s/p excision; prostate cancer - s/p prostatectomy;
gout; cholelithiasis; history of nephrolithiasis
Discharge Condition:
Good
Discharge Instructions:
Patient may shower, no baths. No creams, lotions or ointments to
incisions. No driving for at least one month. No lifting more
than 10 lbs for at least 10 weeks from the date of surgery.
Monitor wounds for signs of infection. Please call with any
concerns or questions.
Followup Instructions:
Cardiac surgeon, Dr. [**Last Name (STitle) **] in [**5-12**] weeks.
Local PCP [**Last Name (NamePattern4) **] [**3-12**] weeks.
Local cardiologist in [**3-12**] weeks.
Completed by:[**2173-1-6**]
|
[
"V13.01",
"413.9",
"514",
"V10.51",
"285.9",
"997.1",
"424.2",
"401.9",
"585.9",
"427.31",
"V10.46",
"412",
"414.02",
"724.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"88.72",
"00.48",
"00.66",
"36.07",
"99.07",
"00.43",
"99.04",
"36.11",
"89.68",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
7325, 7395
|
2919, 5886
|
279, 548
|
7788, 7795
|
2553, 2896
|
8114, 8312
|
2163, 2227
|
6083, 7302
|
7416, 7767
|
5912, 6060
|
7819, 8091
|
2242, 2534
|
195, 241
|
576, 1544
|
1566, 2002
|
2018, 2147
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,010
| 145,447
|
2157
|
Discharge summary
|
report
|
Admission Date: [**2172-4-3**] Discharge Date: [**2172-4-24**]
Date of Birth: [**2093-9-5**] Sex: F
Service: MEDICINE
Allergies:
Levofloxacin
Attending:[**First Name3 (LF) 8684**]
Chief Complaint:
right hip pain and erythema
Major Surgical or Invasive Procedure:
PICC placement
Bronchoscopy
Relocation of hip prosthesis with hip washout
History of Present Illness:
78 yo female who was recently admitted on [**3-18**] for Hemi
arthroplasty, right femoral neck fracture and pen reduction and
internal fixation, greater trochanter. She had sustained a
mechanical fall after a slip on the ice. This resulting in a
right femoral neck fracture and trochanteric fracture, no other
injuries indentified.
Patient represents from rehab where she had low grade
temperatures, noted to have increased erythema, induration, and
drainage from her incision. She was also started on [**3-23**] on
levoquin for a pna and also was switched from Lovenox to
coumadin. Patient presented with incision pain, but denies any
CP, or SOB. Denies any dysuria or change in bowel movements.
Patient was febrile to 101.4.
Pt was brought to medicine floor and with a plan to treat with
vanco/zosyn. As her Hct had fallen and her INR was at 3.1, FFP
was given to reverse her coagualopapthy. Pt became tachycardic
to 140's and then hypotense on the floor. The patient was
transferred to the ICU where a central line was placed and
aggressive fluid and PRBC resuscitation occurred. Pt's code
status was confirmed as DNR/DNI.
An MRI of right leg was done to assess wound and no definite
collection observed.
Pt currently has oozing from site where hematoma was opened on
[**4-4**]. The ortho team is considering I&D today or tomorrow
Past Medical History:
Past Medical History:
1. Small cell lung cancer status post Cisplatin in [**2163**] and
BT16 that was complicated by peripheral neuropathy.
2. Chronic obstructive pulmonary disease.
3. Paroxysmal atrial fibrillation.
4. Hypertension.
5. Hypothyroidism.
6. Anemia.
7. Non-melanoma skin cancer.
8. Neuropathy
Social History:
Social History:
The patient lives at home with her husband.She has a remote, but
extensive tobacco history. She hasoccasional alcohol use.
Family History:
Family History:
Noncontributory.
Physical Exam:
PE: T 99.3 BP:130/60 HR: 120 RR 18 93% on 3 liters
HEENT: dry mmm, no LAD, no JVD, PERRLA
Cardiac: tachy, RRR, no m/r/g
Lungs: CTA bilat
Abdomen: soft, NT, ND, nabs
Musculoskeletal: right incision site- indurated, +warmth,
evidence of serous drainage from upper area of incision
Pulses: 2+ DP pulses, no EDEMA
Neurologic exam: AEO x 3, CNII -XII intact
Skin: diffuse 3-5 mm macular lesions on abdomen and lower
extremities
Pertinent Results:
EKG: tachy 118, lateral EKG changes with T wave inversion in
V5-v6 and ST segment depression in V4
chest x-ray: New left upper lobe atelectasis, which could be due
to mucous plugging,
infection or endobronchial tumor. Interval resolution of the
left
retrocardiac opacity. Otherwise, stable radiographic appearance
of the chest
compared to the prior exam.
RADIOLOGY Preliminary Report
MR HIP W/O CONRAST [**2172-4-5**] 12:42 AM
MR HIP W/O CONRAST
Reason: infection
[**Hospital 93**] MEDICAL CONDITION:
78 year old woman with s/p ORIF
REASON FOR THIS EXAMINATION:
infection
INDICATION: Hip pain status post open reduction internal
fixation.
TECHNIQUE: Multiplanar MRI of the hips including T1W and
inversion recovery imaging sequences.
FINDINGS: The right femoral and acetabular prosthesis are
dislocated from the right acetabulum and displaced superiorly.
The patient is also status post left hip replacement with
associated susceptibility artifact. Within the right acetabulum,
there is fluid and possibly a heme-fluid level. There is a
hematoma within the right lateral thigh which measures 15 x 3 x
4 cm. There is a right hamstring avulsion fracture, partially
imaged in this study. There is extensive subcutaneous edema,
with relative sparing of the left buttock. There is edema within
the right adductor muscles. There is also a moderate amount of
ascites within the pelvis.
A 2 cm right renal cyst is partially imaged on this study.
IMPRESSIONS:
1) Dislocation of the right hip prosthesis, with a possible heme
arthrosis and hematoma within the right lateral thigh.
2) Avulsion fracture of the right hamstrings, partially imaged
in this study.
DR. [**First Name11 (Name Pattern1) 640**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 11515**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 6892**]
PATIENT/TEST INFORMATION:
Indication: Atrial fibrillation/flutter. Chronic lung disease.
Left ventricular function. Aortic valve disease.
Height: (in) 65
Weight (lb): 126
BSA (m2): 1.63 m2
BP (mm Hg): 140/74
HR (bpm): 101
Status: Inpatient
Date/Time: [**2172-4-6**] at 11:01
Test: Portable TTE (Complete)
Doppler: Full doppler and color doppler
Contrast: None
Tape Number: 2005W104-0:00
Test Location: West MICU
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name8 (NamePattern2) **] [**Name (STitle) **]
DR. [**First Name8 (NamePattern2) **] [**Name (STitle) **]
MEASUREMENTS:
Left Atrium - Long Axis Dimension: *4.3 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: *5.8 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: *5.4 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: 1.1 cm (nl 0.6 - 1.1 cm)
Left Ventricle - Inferolateral Thickness: 0.9 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 4.3 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 2.0 cm
Left Ventricle - Fractional Shortening: 0.53 (nl >= 0.29)
Left Ventricle - Ejection Fraction: >= 55% (nl >=55%)
Aorta - Valve Level: 3.2 cm (nl <= 3.6 cm)
Aorta - Ascending: *3.9 cm (nl <= 3.4 cm)
Aortic Valve - Peak Velocity: 1.7 m/sec (nl <= 2.0 m/sec)
Aortic Valve - Pressure Half Time: 330 ms
Mitral Valve - E Wave: 1.4 m/sec
Mitral Valve - A Wave: 1.3 m/sec
Mitral Valve - E/A Ratio: 1.08
Mitral Valve - E Wave Deceleration Time: 190 msec
TR Gradient (+ RA = PASP): *47 mm Hg (nl <= 25 mm Hg)
INTERPRETATION:
Findings:
This study was compared to the report of the prior study (tape
not available)
of [**2169-6-9**].
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D
images. Normal LV wall thickness, cavity size, and systolic
function
(LVEF>55%). Normal regional LV systolic function.
RIGHT VENTRICLE: Normal RV chamber size. Focal apical
hypokinesis of RV free
wall.
AORTA: Normal aortic root diameter. Mildly dilated ascending
aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Mild to
moderate ([**2-2**]+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular
calcification. Mild to moderate ([**2-2**]+) MR.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild
to moderate
[[**2-2**]+] TR. Moderate PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR.
PERICARDIUM: Small pericardial effusion. Effusion
circumferential. No
echocardiographic signs of tamponade.
GENERAL COMMENTS: Based on [**2164**] AHA endocarditis prophylaxis
recommendations,
the echo findings indicate a moderate risk (prophylaxis
recommended). Clinical
decisions regarding the need for prophylaxis should be based on
clinical and
echocardiographic data. Left pleural effusion.
Conclusions:
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity
size, and systolic function are normal (LVEF>55%). Regional left
ventricular
wall motion is normal. Right ventricular chamber size is normal
with focal
hypokinesis of the apical free wall. The ascending aorta is
mildly dilated.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not
present. Mild to moderate ([**2-2**]+) aortic regurgitation is seen.
The mitral
valve leaflets are mildly thickened. Mild to moderate ([**2-2**]+)
mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened.
There is moderate pulmonary artery systolic hypertension. There
is a very
small circumferential pericardial effusion with no
echocardiographic signs of
tamponade.
Compared with the prior study (report only) of [**2169-6-9**], the
estimated
pulmonary artery systolic pressure is slightly higher and focal
right
ventricular apical hypokinesis is evident.
Based on [**2164**] AHA endocarditis prophylaxis recommendations, the
echo findings
indicate a moderate risk (prophylaxis recommended). Clinical
decisions
regarding the need for prophylaxis should be based on clinical
and
echocardiographic data.
Electronically signed by [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4083**], MD on [**2172-4-6**]
14:52.
[**Location (un) **] PHYSICIAN:
RADIOLOGY Final Report
CT CHEST W/O CONTRAST [**2172-4-18**] 6:57 PM
CT CHEST W/O CONTRAST
Reason: r/o obstruction/infiltrate
Field of view: 28.8
[**Hospital 93**] MEDICAL CONDITION:
78 year old woman with h/o small cell lung ca, COPD, who p/w
increaasing SOB and L sided consolidation/atelectasis
REASON FOR THIS EXAMINATION:
r/o obstruction/infiltrate
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 78-year-old female with history of small-cell lung
cancer and COPD with increasing shortness of breath and
left-sided consolidation seen on chest radiographs.
TECHNIQUE: CT imaging of the chest without intravenous contrast.
Comparison is made to a CT of the torso performed during a PET
CT from [**2171-10-23**].
CT OF THE CHEST WITHOUT CONTRAST: There is significantly
increased pulmonary parenchymal consolidation involving the left
lower lobe and left upper lobe. It has progressed when compared
to [**2171-10-23**]. Post-surgical change is seen within the left lung
apex. A speculated nodule within the left upper lobe (series 2,
image 12) measuring 1.4 x 1.1 cm is unchanged in size and
configuration when compared to the prior examination. Scarring
is present related to the patient's left upper lobe wedge
resection. High-attenuation foci are present within the right
lung, which could represent the effects of prior pleurodesis or
alternatively, it could represent aspirated barium by prior
imaging study. A precarinal lymph node that measured 1.1 x 0.8
cm, has increased in size, now measuring 1.2 x 1.1 cm.
Evaluation for additional hilar lymphadenopathy is limited due
to lack of intravenous contrast.
In the limited views of the upper abdomen, the liver has a
nodular appearance that is stable when compared to the prior
examination. A calcified aneurysm is seen likely related to the
splenic artery.
Bone windows show no suspicious lytic or sclerotic lesions.
There is again seen extensive degenerative change within the
right glenohumeral joint.
IMPRESSION: Significantly increased consolidation within the
medial aspects of the left upper lobe and left lower lobe when
compared to [**2171-10-23**]. _____ areas of high attenuation are seen
within the left lung, which could represent the effects of prior
pleurodesis or aspirated barium. These findings are concerning
for recurrent disease with lymphangitic carcinomatosis, given
the presence of increased intralobular septal thickening on the
left. These findings could also represent an infectious
etiology.
[**2172-4-3**] 10:00AM PT-22.1* PTT-45.4* INR(PT)-3.1
[**2172-4-3**] 10:00AM PLT COUNT-427#
[**2172-4-3**] 10:00AM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2172-4-3**] 10:00AM NEUTS-95.6* BANDS-0 LYMPHS-2.3* MONOS-1.5*
EOS-0.6 BASOS-0.1
[**2172-4-3**] 10:00AM DIGOXIN-0.6*
[**2172-4-3**] 10:00AM ALBUMIN-3.3* CALCIUM-8.9 PHOSPHATE-4.0
MAGNESIUM-1.7
[**2172-4-3**] 10:00AM ALT(SGPT)-11 AST(SGOT)-18 LD(LDH)-286* ALK
PHOS-77 TOT BILI-0.5
[**2172-4-3**] 10:00AM GLUCOSE-97 UREA N-25* CREAT-1.0 [**Year/Month/Day 11516**]-129*
POTASSIUM-4.6 CHLORIDE-92* TOTAL CO2-31* ANION GAP-11
[**2172-4-3**] 10:09AM LACTATE-0.9
[**2172-4-3**] 01:00PM URINE RBC-0 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-0
[**2172-4-3**] 01:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2172-4-3**] 01:00PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.014
[**2172-4-3**] 05:30PM PLT SMR-NORMAL PLT COUNT-420
[**2172-4-3**] 05:30PM HYPOCHROM-1+ ANISOCYT-NORMAL
POIKILOCY-OCCASIONAL MACROCYT-1+ MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2172-4-3**] 05:30PM WBC-9.9 RBC-2.68* HGB-8.2* HCT-25.6* MCV-95
MCH-30.7 MCHC-32.2 RDW-14.3
[**2172-4-3**] 05:30PM CALCIUM-8.2* PHOSPHATE-3.7 MAGNESIUM-1.6
[**2172-4-3**] 05:30PM CK-MB-NotDone cTropnT-0.02*
[**2172-4-3**] 05:30PM CK(CPK)-69
[**2172-4-3**] 05:30PM GLUCOSE-81 UREA N-23* CREAT-0.9 [**Year/Month/Day 11516**]-131*
POTASSIUM-4.0 CHLORIDE-94* TOTAL CO2-27 ANION GAP-14
[**2172-4-3**] 07:19PM HCT-24.8*
[**2172-4-3**] 09:28PM PT-19.0* PTT-47.5* INR(PT)-2.3
[**2172-4-3**] 09:42PM RET AUT-1.8
[**2172-4-3**] 09:42PM PLT SMR-NORMAL PLT COUNT-380
[**2172-4-3**] 09:42PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2172-4-3**] 09:42PM NEUTS-94.1* BANDS-0 LYMPHS-2.7* MONOS-1.6*
EOS-1.6 BASOS-0
[**2172-4-3**] 09:42PM WBC-7.7 RBC-2.58* HGB-8.0* HCT-24.2* MCV-94
MCH-31.2 MCHC-33.2 RDW-14.5
[**2172-4-3**] 09:42PM CORTISOL-24.9*
[**2172-4-3**] 09:42PM TSH-10*
[**2172-4-3**] 09:42PM calTIBC-181* VIT B12-1233* FOLATE-13.4
HAPTOGLOB-107 FERRITIN-656* TRF-139*
[**2172-4-3**] 09:42PM GLUCOSE-96 UREA N-22* CREAT-0.9 [**Year/Month/Day 11516**]-132*
POTASSIUM-3.7 CHLORIDE-95* TOTAL CO2-29 ANION GAP-12
[**2172-4-3**] 11:48PM LACTATE-1.0
on dc: na- 129
hct: 27.3
Brief Hospital Course:
1) Sepsis- Etiology of sepsis was initially not entirely clear.
1/4 bottles + MRSA on admission, and patient was started on
vanco. When patient was transferred to ICU, patient was also
briefly treated with zosyn and clinda. Given the oozing from
previous operative wound infection seemed most likely. MRI was
done of right hip that showed a dislocation of right hip
prosthesis, with a possible hemarthrosis and hematoma within the
right lateral thigh. Ortho service was the consulted for a wash
out of right hip and relocation of hip prosthesis. MRSA
infection of right hip fluid was discovered. Surveillance
cultures were negative.
2) MRSA infection of right hip fluid- ID was consulted, who
stated that patient will need six weeks of vanc and given the
high likelihood that the hip hardware is infected, gent was
added for synergy for a brief time. Ultimatley it was decided
that the patient will need a total of six weeks of vancomycin
and rifampin (end [**5-20**]). TEE was done and was negative.
Ortho felt that there is no need for repeat washout unless
patient fails therapy. After this time, patient will likely be
started on oral suppressive therapy. Patient will follow up in
[**Hospital **] clinic on [**2172-5-15**] at 10 AM. A detailed list of labs that need
to be monitored are listed in dc plan
Patient will follow up with ortho in 3 weeks.
3) Anticoagulation: Attending was patients PC, who had never
placed the patient on anticougulation for PAF in the past
because she felt that the patient was a high likelihood to
bleed. Patient had been previously discharged post-op on a
lovenox. But at rehab facility, she was switch to coumadin.
Given her initial drop in hct on admission, PCP felt that she
had likely bled into the right hip, creating a nidus for
infection and precipitating this entire hospitalization.
Therefore post op patient on this admission, patientwas not
initially anticoagulated. It was eventually decided to start
patient on low dose of lovenox with close monitoring. However
after a few days on 40 mg SQ lovenox, patients hct began to drop
with increasing right hip pain, so the lovenox was held given
concern for rebleed. Ortho service was very concerned for
potential PE and has recommended an IVC filter be placed,
however attending does not feel this is indicated given no
current or previous clots. NO ANTICOAGULATION AT ALL!
3) CV: Patient had episodes of afib in the PACU post op,
responded to dilt. Patient went back into sinus. She was
continued on dignoxin.
CAD: Pt had lateral ischemic changes with tachycardia on
admission. Ck's flat and Trop noted to be 0.02.
PUMP: Echo done during this hospitalization showed EF>55%,
2+MR, 2+AI, 2+ TR, mod pulm art HTN. Low dose captopril added
back to regimen.
5) Resp: COPD: Patient was continued on albuterol/atrovent nebs
prn, and montelukast.
After suregry, patient developed an increased oxygen
requirement. Chest x-ray showed increased pleural effusion with
a left lower lobe consolidation or collapse. Concern was for
either atelectasis of the lobe vs a recurrence of lung
malignancy (patient has a history of small cell lung cancer).
Procedure team was consulted for a diagnostic and therapeutic
tap. However, it was determined that there was not enough fluid
to be tapped. A CT of chest showed an increased consolidation
of LUL and LLL with a spiculated nodule and a pericardial LN.
Pulm felt that the ddx: recurrence of lung ca vs aspiration vs
pna. It was decided that a bronch should be done. Bronch
showed evidence of scar tissue in the area. A biopsy was done
and BAL also grew pseudomonas so patient should be treated with
a 14 day course of ceftaz. Ultimately, pulm felt that LLL
collapse may occur intermittently (seen on cxr a few months ago)
given distorted anatomy (h/o radiation). Pulm did not feel
patient needs pulm follow up. Dr. [**Last Name (STitle) **] will follow up
biopsy results.
6) Endo- cont levothyroxine. Free T4 was normal with a elevated
TSH 8.2, however given that she is already on 200 mcg of
synthroid, concern regarding whether or not it is being taken
properly. Spoke with attending, who decided to hold off on
increasing dose.
7) Drug Rash- on inital presentation, patient had some itching
with a diffuse macular rash, thought to be related to levoquin
she was given prior to admission. Rash resolved with benadryl.
8) Hyponatremia: patient has a history of SIADH, but the
hyponatremia was concerning for a recurrence of lung malignancy.
A bronch was done to further evaluate for recurrence of lung
malignancy- biopsy to be followed up by PCP. [**Name10 (NameIs) **] is stable on
dc and should be monitored as outpatient.
Medications on Admission:
Meds: Digoxin, Singulair, Captopril, Amitryptyline , Furosemide,
thyroxine
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 533**] [**Last Name (NamePattern1) **] for Extended Care - [**Location 1268**]
Discharge Diagnosis:
MRSA bacteremia
Pseudomonal lung infection
1. Small cell lung cancer status post Cisplatin in [**2163**] and
BT16 that was complicated by peripheral neuropathy.
2. Chronic obstructive pulmonary disease.
3. Paroxysmal atrial fibrillation.
4. Hypertension.
5. Hypothyroidism.
6. Anemia.
7. Non-melanoma skin cancer.
8. Neuropathy
Discharge Condition:
stable
Discharge Instructions:
Please call your doctor or come to ED if you develop shortness
of breath, chest pain, weakness, nausea/ vomiting, or high
fevers
NO ANTICOAGULATION PLEASE
Followup Instructions:
Provider: [**First Name8 (NamePattern2) 7805**] [**Name11 (NameIs) **], MD Where: LM [**Hospital Unit Name 4337**]
DISEASE Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2172-5-15**] 10:00
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 252**], M.D. Where: [**Hospital6 29**]
[**Hospital3 1935**] CENTER Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2172-7-7**] 11:00
Please call Dr. [**Last Name (STitle) **] and make an appointment within one
week of dc- [**Telephone/Fax (1) 608**]
Please follow up in three weeks with orthopedics with Dr.
[**Last Name (STitle) 1005**], please call [**Telephone/Fax (1) 11517**] to make an appointment
Completed by:[**2172-4-24**]
|
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icd9cm
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[
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icd9pcs
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232, 261
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2628, 2727
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1788, 2076
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2108, 2235
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