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43,038
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Discharge summary
|
report
|
Admission Date: [**2179-2-5**] Discharge Date: [**2179-2-13**]
Date of Birth: [**2100-4-8**] Sex: F
Service: MEDICINE
Allergies:
ciprofloxacin / Sulfa(Sulfonamide Antibiotics) / Penicillins /
Macrobid / Cleocin
Attending:[**Doctor First Name 3290**]
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
1. EGD [**2179-2-5**]
History of Present Illness:
Ms. [**Known lastname 19122**] is a 78F with PMH of cardiomyopathy (EF 45% per OSH
records), atrial fibrillation on coumadin, questionable liver
cirrhosis, recent ERCP [**2179-1-29**] with sphincterotomy given CBD,
discharged on [**2179-1-31**]. She said that after she was discharged to
home, she continued to feel poorly, weak, just not herself. She
wasn't eating much. Then, beginning yesterday, she felt very
short of breath in the morning. Her caretaker took her to her
[**Hospital 197**] clinic appt, where she was SOB and pale. From there she
was taken to the [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], where she was given lasix 40mg IV
x1, with 900cc urine output, with improvement in respiratory
status. She was tachycardic initially (not documented if sinus
or Afib with RVR), and given lopressor 5mg IV x1, with
improvement in rate to sinus 60s. She was then admitted for
further management with concern for acute on chronic systolic
heart failure exacerbation. where she was found to have Hct drop
from 28 to 21. She says that she had only taken one dose of the
Coumadin, and was taking Lovenox daily as a bridge. Then, at
[**Hospital3 **], she had [**2-19**] dark black stools. She denies any
chest pain, pressure, lightheadedness with this. Per [**Hospital1 **], these were guaiac positive and thought to be
melanotic.
.
After discharge on [**1-31**], she said her PCP had also discontinued
her Lasix. Therefore, in the last week, all of her
anti-hypertensives had been discontinued for low blood pressure.
She denies any recent NSAID use. She says that she had bright
blood in her underwear back in [**Month (only) 1096**]. At that time she
reports being evaluated at [**Hospital3 **]. She never had a
c-scope at that time.
.
She presented during the last admission from [**1-29**] to [**1-31**] for
elective ERCP based on obstructive picture with elevated Tbili
and mild transaminitis during admission at [**Hospital3 **] with
CT scan showing CBD at that time. She had an ERCP on [**1-29**] with
sphincterotomy.
.
On arrival to the ICU, VS T 96.5 HR 63 BP 102/49 RR 18 O2 sat
99%RA. She says that she feels tired from the long day. She
denies any abdominal pain, nausea or vomiting. She denies any
SOB, chest pain, chest pressure or lightheadedness.
.
Review of systems:
(+) Per HPI. Also positive for anorexia
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
Past Medical History:
1. Cardiomyopathy: EF ~45% per pt and OSH record, "severely
dilated left atrium, mild global hypokinesis, mild septal
hypokinesis"
2. Paroxysmal atrial fibrillation
3. Anemia
4. Asthma
5. Hypertension, benign
6. GERD
7. Hypothyroidism
8. Hyperlipidemia
PSgHx:
1. vulva excision
2. dual chamber pacemaker
3. CCY
4. tonsillectomy
5. kyphoplasty
Social History:
She denies tobacco. She drinks 1 glass wine every few months.
She denies drugs. She lives at home alone, and has a 24 hour
caretaker since her broken elbow in [**2178-7-17**].
Family History:
Mother died at 59 of emphasema.
Father died at 76 of sudden cardiac death.
Physical Exam:
Admission Physical:
VS T 96.5 HR 63 BP 102/49 RR 18 O2 sat 99%RA.
General: Alert, oriented, no acute distress, appears mildly
fatigued
HEENT: EOMI, pale subjunctiva, sclera anicteric, dry MM,
oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: no use of accessory muscles, clear to auscultation
bilaterally, no wheezes, rales, rhonchi
CV: RRR, normal S1 + S2, [**3-23**] holosystolic murmur, heard
throughout the precordium, no rubs, gallops
Abdomen: ecchymoses on abdomen (site of Lovenox), soft,
non-tender, non-distended, bowel sounds present, no rebound
tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: A&Ox3, appropriate, moving all extremities
Pertinent Results:
[**2179-2-6**] 03:14AM BLOOD WBC-7.2# RBC-2.24* Hgb-8.4* Hct-25.3*
MCV-113* MCH-37.5* MCHC-33.3 RDW-22.6* Plt Ct-101*
[**2179-2-12**] 07:30AM BLOOD WBC-8.9# RBC-3.23* Hgb-11.0* Hct-33.8*
MCV-105* MCH-34.0* MCHC-32.5 RDW-22.8* Plt Ct-109*
[**2179-2-9**] 07:18AM BLOOD PT-14.3* PTT-35.1 INR(PT)-1.3*
[**2179-2-12**] 07:30AM BLOOD Glucose-93 UreaN-19 Creat-0.9 Na-135
K-4.7 Cl-104 HCO3-27 AnGap-9
[**2179-2-5**] 07:44PM BLOOD calTIBC-257* Hapto-<5* Ferritn-201*
TRF-198*
[**2179-2-6**] 03:14AM BLOOD tTG-IgA-6
[**2179-2-5**] 07:44PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
[**2179-2-5**] 07:44PM BLOOD HCV Ab-NEGATIVE
TEE REPORT: The left atrium is dilated. No atrial septal defect
is seen by 2D or color Doppler. Overall left ventricular
systolic function is mildly depressed (LVEF= 40-45 %). Right
ventricular chamber size and free wall motion are normal. The
ascending, transverse and descending thoracic aorta are normal
in diameter and free of atherosclerotic plaque to 30 cm from the
incisors. The aortic valve leaflets are moderately thickened. No
masses or vegetations are seen on the aortic valve. No aortic
valve abscess is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. No mass or
vegetation is seen on the mitral valve. Mild to moderate ([**1-18**]+)
mitral regurgitation is seen. No vegetation/mass is seen on the
pulmonic valve. There is no pericardial effusion.
IMPRESSION: No valvular vegetation, or pacemaker associated mass
or vegetation visualized. Mild to moderate mitral regurgitation.
Mildly depressed left ventricular systolic function.
Liver u/s
1. Limited evaluation demonstrating nodular hepatic contour with
increased
heterogeneous hepatic echogenicity, suggestive of cirrhosis.
2. Ascites.
3. Patent hepatic vasculature without evaluation of the right
posterior
portal vein due to patient body habitus and overlying gas.
Evaluation of the
hepatic arteries was also suboptimal due to patient difficulty
breath-holding.
Colonoscopy report:
Two 3mm sessile polyps of benign appearance were found in the
sigmoid colon. Single-piece polypectomies were performed using a
cold forceps in the sigmoid colon. The polyps were completely
removed.
Impression: Polyps in the sigmoid colon (polypectomy)
Otherwise normal colonoscopy to cecum
EGD report:
The ampulla was s/p previous sphincterotomy. There was oozing of
blood at 3 o'clock. The apexes and 3 o'clock were injected with
3 ml of epinephrine 1/[**Numeric Identifier 961**] with good hemostasis. Cauterization
with a gold probe was applied at 3 o'clock successfully.
Impression: The exam of the esophagus was normal.
There was minimal erythema at the distal antrum.
The ampulla was s/p previous sphincterotomy. There was oozing of
blood at 3 o'clock. The apexes and 3 o'clock were injected with
3 ml of epinephrine 1/[**Numeric Identifier 961**] with good hemostasis. Cauterization
with a gold probe was applied at 3 o'clock successfully.
Otherwise normal EGD to third part of the duodenum.
Capsule study pending
If clinical concern persists, repeat examination could be
attempted.
Brief Hospital Course:
Brief Course:
Ms. [**Known lastname 19122**] is a 78F with PMH of cardiomyopathy (EF 45% per OSH
records), atrial fibrillation on coumadin, questionable liver
cirrhosis, recent ERCP [**2179-1-29**] with sphincterotomy given CBD,
discharged on [**2179-1-31**], who was transferred for Hct drop and dark
stools. She was admitted to the ICU for EGD and monitoring. EGD
showed post-sphincterotomy bleed, which was injected with epi.
She had no recurrent bleeding.
.
# Anemia/GIB: She had acute GI bleeding on account of a post
sphincterotomy bleed. She had no further bleeding after
injection of the sphincterotomy site with epinephrine.
In discussion with her outpatient providers, we learned that she
had been admitted to [**Hospital3 3765**] in [**2178**] with a hematocrit
of 20 with guaiaic positive stool. To evaluate this previous
anemia she had an colonoscopy and capsule study. Two benign
appearing polyps were found during the colonoscopy, and these
were sent for evaluation by pathology. SHe had a capsule study,
and the preliminary report is negative, but final report not yet
available. Given that she had no recurrent bleeding, and that
no additional potential bleeding site was identified, she was
advised to resume coumadin with lovenox bridge at home on the
night of discharge. Hematocrit was 33. She will follow up with
her gastroenterologist. Evaluation with hematology would be a
next step.
.
# ? Cirrhosis: u/s showed nodular liver suggestive of
cirrhosis, but no mention of portal hypertension on that exam.
W/u for infectious hepatitis was negative. She will have follow
up with [**Hospital1 18**] liver specialists.
#. Atrial fibrillation: Pt was in sinus on admission and through
much of the hospitalization. On discharged, she is being paced
at 60 beats per minute.
# Chronic congestive heart failure EF at OSH 45% per report.
Patient did require a few doses of lasix during this
hospitalization. On discharge, patient has no rales on exam.
# LE edema: Patient with marked hyperpigmentation, suggestive
of venous stasis. She does have 1+ pitting edema on discharge
with a pressure blister over her left shin. LE edema likely
from venous stasis and prednisone use as her lungs are clear.
She has low dose lasix at home which she will take.
# Hypothyroidism: most recent TSH elevated at 15.66, free T4
1.11. Continued
Levothyroxine 150 mcg daily, and will need repeat TFT's with
outpatient PCP
# Hypertension: Bp meds held during admission b/c of initial
hypotension and GI bleed. Patient advised to restart diovan at
home, and to wait until PCP visit until resuming metoprolol.
# Asthma exacerbation: Patient had acute development of
wheezing while hospitalized. She required a five day course of
prednisone and bronchodilators.
# Bacteremia: Patinet had 2/2 bottles of coagulase negative
bacteremia. It likely developed after she had a picc line
placed in the right UE. PICC line was removed on discovering
bacteremia and she received seven days of IV vancomycin per the
ID team. She had a TTE and TEE that did not demonstrate
vegetation on heart valve or on pacemaker lead.
Medications on Admission:
- amiodarone 200mg daily
- Lovenox 70mcg q12hr
- Levothyroxine 125mcg daily
- Omeprazole 20mg [**Hospital1 **]
- Pravastatin 20mg qhs
- Warfarin 2mg daily
- ASA 81mg daily
- Ativan 1mg po qhs prn insomnia
Discharge Medications:
1. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. levothyroxine 150 mcg Tablet Sig: One (1) Tablet PO once a
day.
4. Diovan 40 mg Tablet Sig: One (1) Tablet PO once a day.
5. Lovenox 80 mg/0.8 mL Syringe Sig: 70 mg Subcutaneous twice a
day: take 70mg every twelve hours until instructed to stop by
your coumadin clinic.
6. Coumadin 2 mg Tablet Sig: One (1) Tablet PO at bedtime.
7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
9. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day:
take as needed for leg swelling, or as otherwise specified by
your primary care doctor.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] home care
Discharge Diagnosis:
Post sphincterotomy bleed
Asthma exacerbation
Chronic systolic heart failure
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - walks with cane.
Discharge Instructions:
You were transferred to [**Hospital3 **] Hospital from [**Hospital1 4494**] for evaluation of bleeding. You had a procedure called
an ERCP and were found to have blood loss at the site of the
sphincterotomy which you had recently had. The
gastroenterologists injected the site so that it would not bleed
again, and you have not had any more bleeding. You received
blood, and your hematocrit is now 33.8, and you have not had any
additional blood loss.
You also had bacteria in your blood. You were evaluated by the
infectious disease team who advised that you have an ECHO, or
ultrasound of your heart. There were no infectious growths on
your heart valve as a consequence of having bacteria in your
blood. You received one week of IV antibiotics for this.
Subsequent blood cultures showed that the bacteria had been
cleared from your blood with this treatment.
You had a worsening of your asthma when you were here and
required a few days of prednisone and breathing treatments.
Your breathing is now much improved.
You were also seen by our gastroenterology team in evaluation of
anemia (low blood count) that your doctors [**First Name8 (NamePattern2) **] [**Last Name (Titles) **] were
evaluating. You had an endoscopy and colonoscopy that were not
revealing, and a capsule study to look at your small intestine.
We are awaiting final results on the capsule study, but it
appears not to show any source of blood loss.
You developed some swelling in your legs and a blister in your
legs. You likely held on to some fluid because of the
prednisone that you needed to receive. You may take the lasix
that you have at home.
Please keep the area of blistered skin clean and apply
bacitracin so that it does not become infected.
Since your blood count has been stable for several days, please
resume your lovenox and coumadin at home tonight. Call the
[**Hospital1 **] coumadin clinic on Monday to set up your next blood
check (INR).
In addition, there was some evidence that you may have
cirrhosis, or scarring of the liver. We have set up an
appointment for you to see one of our liver specialists after
you have been discharged.
Followup Instructions:
Please see Drs [**Last Name (STitle) **] and [**Name5 (PTitle) **] next week. Call them to make
an appointment. I will fax each of them a copy of your
discharge summary.
Department: LIVER CENTER
When: THURSDAY [**2179-3-25**] at 1 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
[
"285.1",
"V45.01",
"244.9",
"790.7",
"427.31",
"530.81",
"428.0",
"493.92",
"287.5",
"707.15",
"578.1",
"425.4",
"998.11",
"999.31",
"571.5",
"E879.8",
"E878.8",
"428.23",
"211.3",
"272.4",
"401.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.42",
"44.43",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
12005, 12062
|
7781, 10911
|
350, 373
|
12196, 12196
|
4640, 7758
|
14521, 15002
|
3788, 3864
|
11167, 11982
|
12083, 12175
|
10937, 11144
|
12350, 14498
|
3879, 4621
|
2712, 3188
|
302, 312
|
401, 2693
|
12211, 12326
|
3232, 3578
|
3594, 3772
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,580
| 116,353
|
26296
|
Discharge summary
|
report
|
Admission Date: [**2130-7-3**] Discharge Date: [**2130-7-5**]
Date of Birth: [**2083-8-25**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 3012**] is a 46 y/oM who presents to the [**Hospital1 18**] ED for
shortness of breath. He has had previous admissions for EtOH in
the past. He reports 2-3 days of feeling ill with a diarrheal
illness (nonbloody, awakens him from sleep) accompanied by some
left sided abdominal pain and some vomiting, also non-bloody.
This morning, he developed shortness of breath and was
tachypneic. He has reported some cough with phlegm which is
above baseline and some runny nose in the recent past. No chest
pain. He made his way from the [**Hospital1 **] Shelter to the neareast
"T" station where he called 911, and was brought by EMS to the
[**Hospital1 18**].
He reports his last alcoholic drink approximately on Saturday.
Of note, he had blunt violent trauma to his head in [**Month (only) 958**], and
had fracture of C6-C7. He has been mainly in a [**Location (un) 2848**] J since
then, and states that Dr. [**Last Name (STitle) 363**] is planning on operating once
he has been away from cigarettes for one month. He has had
repeat head imaging for concern of intracranial bleed as he has
had interval ED visits for EtOH and head abraisons, but no ICH
seen.
In the ED, his triage vitals were 97.7 141/101 HR 103 RR 24 Sat
100% on NRB. He was later weaned to 97% on room air. His
shortness of breath improved over time. He had a chest xray that
was unremarkable. For his nausea/vomiting, he had a normal
lipase. He had an abdominal/pelvis CT scan that was unremarkable
without evidence of pancreatitis. He was given 3mg of ativan,
zofran, and 2L of normal saline.
Past Medical History:
- Hepatitis C per patient history, immunized A and B. Past HIV
neg
- Alcohol Abuse - previous withdrawal seizures, DT's
- Depression
- C6/7 spinal cord contusion [**4-17**] admission
- Thrombocytopenia, since [**4-17**]
- Anemia
- Leukopenia
- [**2129-4-7**] Fracture of the lamina papyracea/medial wall of the
left
orbit.
Social History:
Lives in shelters or at his families home in [**Location (un) **]. on SSDI.
Smokes 1/2ppd. No other drug use.
Family History:
NC
Physical Exam:
Vitals: T: 98.1, BP: 117/88, P: 55, RR: 18, O2: 98% RA.
PE:
Gen: A & O x3, nervous affect, in C-collar
CV: RRR, no MGR
RESP: CTAB
ABD: ND, +BS, vol guarding, marked LLQ tenderness, no reboud
tenderness, liver edge 3-4cm below rib.
Extr: No edema
Neuro: Reports decreased sensation to no sensation in both arms
across multiple dermatomal distributions, [**5-14**] motor strength
throughout both arms, nl motor strength in all other major
muscle groups, nl EOM, nl cerebellar tests, mild tremor on had
extension.
Pertinent Results:
Admission labs:
[**2130-7-3**] 02:40AM WBC-6.1 RBC-4.21* HGB-13.4* HCT-37.5* MCV-89
MCH-31.8 MCHC-35.7* RDW-15.8*
[**2130-7-3**] 02:40AM NEUTS-68.2 LYMPHS-22.4 MONOS-8.6 EOS-0.6
BASOS-0.4
[**2130-7-3**] 02:40AM GLUCOSE-120* UREA N-13 CREAT-0.9 SODIUM-131*
POTASSIUM-4.0 CHLORIDE-93* TOTAL CO2-19* ANION GAP-23*
[**2130-7-3**] 02:40AM ALT(SGPT)-157* AST(SGOT)-236* ALK PHOS-61 TOT
BILI-1.0
[**2130-7-3**] 02:40AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG\
Imaging:
Portable CXR:
COMPARISON: [**2130-7-3**].
SINGLE PORTABLE SUPINE CHEST RADIOGRAPH: The right middle lobe
opacification
seen only on the lateral view on the prior study cannot be
evaluated by this
study. Cardiomediastinal silhouette is unchanged. There is no
focal
consolidation, large effusion, or pneumothorax. Pulmonary
vasculature is
within normal limits. Osseous structures are grossly normal.
IMPRESSION: In order to compare with the initial exam, a lateral
radiograph
is needed.
PA and lateral upright chest radiograph was compared to [**2130-7-4**] obtained
at 05:35 a.m.
The heart size is normal. Mediastinal position, contour and
width are
unremarkable. Lungs are clear. There is no abnormality seen on
the lateral
view that might correspond to previously suspected abnormality
in the right
middle lobe. There is no pleural effusion or pneumothorax. There
is
diminishing of the neutral lordosis of the thoracic spine a
finding that in
combination with relatively straight orientation of the ribs
might be
consistent with straight back syndrome.
The AP diameter of the trachea is relatively [**Name2 (NI) 15015**], about 10 mm
compared to
20 mm of the AP diameter better appreciated on the lateral view.
There is
also questionable narrowing of the upper trachea at the level of
the
clavicular heads compared to the areas below with some upper
mediastinal
thickening, findings that might be consistent with thyroid
enlargement.
Findings better partially imaged on the CT of the spine obtained
on [**2130-4-27**]. Correlation with thyroid ultrasound is recommended.
Discharge labs:
[**2130-7-5**] 06:15AM BLOOD WBC-3.8* RBC-4.13* Hgb-13.0* Hct-36.4*
MCV-88 MCH-31.5 MCHC-35.8* RDW-15.3 Plt Ct-41*
[**2130-7-5**] 06:15AM BLOOD Plt Ct-41*
[**2130-7-5**] 06:15AM BLOOD Glucose-122* UreaN-12 Creat-0.8 Na-134
K-3.7 Cl-98 HCO3-26 AnGap-14
[**2130-7-5**] 06:15AM BLOOD ALT-168*
[**2130-7-5**] 06:15AM BLOOD Phos-3.2
[**2130-7-3**] 10:10AM BLOOD HBsAb-NEGATIVE HBcAb-NEGATIVE HAV
Ab-POSITIVE
[**2130-7-3**] 10:10AM BLOOD HCV Ab-POSITIVE*
[**2130-7-3**] 10:10AM BLOOD calTIBC-408 Ferritn-247 TRF-314
Brief Hospital Course:
46 y/o man with EtOH abuse p/w acute shortness of breath after a
few days of nausea, vomiting, and diarrhea.
#) SOB: He required NRB at arrival but he was weaned to RA over
minutes implying no seriously ongoing pulmonary pathology.
Differential diagnosis is unclear given the rapid resolution of
symptoms on arrival. Initial CXR findings were more c/w
atelectasis. He had no oxygen requirement during his stay and
no further episodes. Repeat PA/LATERAL CXR showed no
consolidation. SOB was likely due to anxiety or panic attack.
#) Nausea/Vomiting: No intraabdominal pathology was seen on CT
such as diverticulitis. LLQ tenderness appears to be chronic.
He was found to be C. diff negative.
#) Anion Gap: Present on admission along with a venous lactate
of 2.7. Both of which resolved with hydration. C/w volume
depletion from GI losses vs ETOH abuse.
#) EtOH Withdrawal: CIWA, diazepam 10mg PO q2h as needed. Has
only required 40mg Valium total dose over 24 hours. S/p banana
bag administration. He only needed 50mg diazepam total.
# Thrombocytopenia/Anemia. Likely related to Alcohol. Retic
count low given anemia which is c/w marrow suppression from
ETOH. Iron studies showed no iron deficiency. Could also be
marrow suppression secondary to GI infection.
#) C6-C7 spinal canal stenosis: to be managed by spine surgery
electively. His current exam suggests no changes. Dr.
[**Last Name (STitle) 739**] was contact[**Name (NI) **] during the stay. Sensory exam and
motor exam were not convincing for any sensory deficit or motor
deficit related to C6-7 contusion. A follow up appointment was
scheduled with his neurosurgeon, Dr. [**Last Name (STitle) 65103**] on [**7-19**] at 9AM at [**Hospital Unit Name **].
#) Hepatitis C: likely not an active problem, but checked
hepatitis serologies (Hehp B surface and [**Last Name (un) **] antibody
negative, HAV antibody positive, HCV antibody positive). CT
showed steatosis, no focal lesions. Advise outpatient followup.
#) CXR finding of tracheal stenosis: Pt not SOB, no stridor, no
thyromegaly, no history of intubation. This will need PCP
follow up.
Medications on Admission:
Fluoxetine 20 mg Capsule Two (2) Capsule by mouth DAILY
Lamotrigine 100 mg Tablet Two (2) Tablet by mouth DAILY
Discharge Medications:
1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Paroxetine HCl 10 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
5. Lamotrigine 100 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
gastroenteritis
Hepatitis C
Alcohol abuse
C6-7 spinal canal stenosis
Discharge Condition:
Stable, afebrile.
Discharge Instructions:
You were admitted to the hospital with complaints of shortness
of breath. Your shortness of breath resolved quickly and you
were achieving high oxygen saturations on room air. You also
had ongoing diarrhea. You were found not to have a bacterial
illness called Clostridium Difficile. There was also concern
about you going into alcohol withdrawal, so you were given a
medicine called diazepam to stop you from going into serious
withdrawal. You were discharged in stable condition.
Please follow up with your primary care doctor within two weeks
to discuss your general health, alcohol abuse issues, and
hepatitis C.
Please follow up with your neurosurgeon, Dr. [**Last Name (STitle) 65103**] on
[**7-19**] at 9AM at [**Hospital Unit Name **] about your
C6-7 contusion. You can call ([**Telephone/Fax (1) 88**]) if you have any
problems with this appointment.
Please seek medical attention if you have a fever over 102
degrees F, if you feel dizzy or faint, if you vomit profusely or
vomit blood, or if you have any blood in your diarrhea.
Followup Instructions:
Please follow up with your primary care doctor within two weeks
to discuss your general health, alcohol abuse issues, and
hepatitis C.
Please follow up with your neurosurgeon, Dr. [**Last Name (STitle) 65103**] on
[**7-19**] at 9AM at [**Hospital Unit Name **] about your
C6-7 contusion. You can call ([**Telephone/Fax (1) 88**]) if you have any
problems with this appointment.
Completed by:[**2130-7-5**]
|
[
"558.9",
"291.81",
"300.00",
"519.19",
"284.1",
"518.0",
"276.50",
"070.54",
"723.0",
"571.3"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8232, 8238
|
5585, 7708
|
290, 296
|
8351, 8371
|
2947, 2947
|
9469, 9880
|
2396, 2400
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|
8259, 8330
|
7734, 7848
|
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2415, 2928
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231, 252
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324, 1906
|
2964, 5034
|
1928, 2253
|
2269, 2380
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,768
| 144,932
|
38111
|
Discharge summary
|
report
|
Admission Date: [**2134-7-11**] Discharge Date: [**2134-7-15**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known firstname **] [**Last Name (NamePattern1) 85045**] is a very nice [**Age over 90 **] year-old man with Atrial
Fibrillation, chronic kidney disease coming with chest pain. He
was in his prior state of health until earlier today when he
developed chest pain and weakness at his [**Hospital3 **]
facility. He was sent to the hospital from there.
.
In [**Hospital1 **]-[**Location (un) 620**] ER he was found to have a HR in the 30 with
otherwise normal VS. His ECG showed third degree heart block
with junctional rhythm in the 30s. He received atropine x2
without impromvent in his HR. His digoxin level was 1.2,
troponin T 0.095. He received 325 mg of ASA, morphine and was
trasnfered to [**Hospital1 18**] for further work up.
.
In the ER his VS were: HR 30 BPM, BP 130/50 mmHg, RR 20 X', SpO2
100%. He looked comfortable, had normal JVP, no canon waves,
clear lungs and guaiac negative. His ECG showed third degree
heart block with junctional escape rhythm at a rate of 30 BPM.
He received atropine without improvement on his symptoms.
Cardiology was consulted and recommended starting heparin and
admitting to CCU for further monitoring. No temporal wire or
pressors were needed. He has pacer pads on. While in the ED he
was desating to 92% on 5 L NC while sleeping and sats improved
while awake.
<br>
On review of systems, he denies any cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
<br>
Cardiac review of systems is notable for absence of paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope
or presyncope.
<br>
In the CCU, the patient was lying comfortably in bed. He did
complain of nausea after he was started on dopamine, however
this soon passed. Patient did have a potassium of 8.7, however
this specimen was hemolyzed and a repeat returned 4.4.
Past Medical History:
TIA age 62 attributed to afib(unclear what documented) on dig
and Coumadin ever since with no recurrence - Coumadin recently
discontinued due to supratherapeutic INR
Neuropsych testing/w/u around age [**Age over 90 **] negative, cleared to
continue driving
Hearing impairment, has hearing aides and complains they don't
work well
Melanoma of left ear, excised
Multiple basal cell skin cancers
Nocturia x 5, denies issues during day, not improved with Flomax
s/p tonsillectomy as a child
Social History:
Widowed [**2132**], married for almost 59 yrs, wife was a former
nurse. Lived in [**Location 85046**], [**State 1727**] in own home until [**3-/2134**] -now
in [**Hospital3 **] in [**Location (un) 1411**] sice [**4-/2134**] at [**Last Name (NamePattern1) 85047**]Emeritus. Retired age 62 after lifetime work as engineeer in
paper [**Doctor Last Name **]. No cigarettes for over 50 yrs. Walks with no
assistive device.
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
GENERAL - elderly male in NAD, Oriented x2, comfortable, Mood,
affect appropriate.
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear,
NECK - supple, no JVD, no carotid bruits, 5cm JVP
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI located in 5th intercostal space, midclavicular
line. irregular rhythm, bradycardic, normal S1, S2. No m/r/g. No
thrills, lifts. No S3 or S4.
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding. +abdominal bruit
EXTREMITIES - WWP, no c/c/e, 1+ peripheral pulses (radials,
DPs), No c/c/e. No femoral bruits.
SKIN - Large scar on right anterior shin, present for years
according to patient.
NEURO - awake, CNs II-XII grossly intact, muscle strength 5/5
throughout, sensation grossly intact throughout
Pertinent Results:
[**2134-7-11**] 10:15PM BLOOD WBC-9.5# RBC-4.18* Hgb-13.9* Hct-39.0*
MCV-93 MCH-33.3* MCHC-35.6* RDW-13.7 Plt Ct-251
[**2134-7-13**] 04:14AM BLOOD WBC-7.5 RBC-3.64* Hgb-11.4* Hct-34.1*
MCV-94 MCH-31.4 MCHC-33.5 RDW-13.9 Plt Ct-180
[**2134-7-13**] 04:14AM BLOOD PT-14.2* PTT-58.2* INR(PT)-1.2*
[**2134-7-12**] 05:52PM BLOOD PTT-57.1*
[**2134-7-13**] 04:14AM BLOOD Glucose-104* UreaN-36* Creat-1.6* Na-136
K-4.2 Cl-105 HCO3-22 AnGap-13
[**2134-7-13**] 11:23AM BLOOD CK(CPK)-660*
[**2134-7-13**] 04:14AM BLOOD CK(CPK)-857*
[**2134-7-12**] 05:56PM BLOOD CK(CPK)-768*
[**2134-7-12**] 12:15PM BLOOD CK(CPK)-699*
[**2134-7-12**] 05:42AM BLOOD ALT-24 AST-93* LD(LDH)-327* CK(CPK)-644*
AlkPhos-70 TotBili-0.6
[**2134-7-11**] 10:15PM BLOOD CK(CPK)-398*
[**2134-7-13**] 04:14AM BLOOD CK-MB-35* MB Indx-4.1 cTropnT-2.59*
[**2134-7-12**] 05:56PM BLOOD CK-MB-58* MB Indx-7.6* cTropnT-3.11*
[**2134-7-12**] 12:15PM BLOOD CK-MB-74* MB Indx-10.6* cTropnT-3.63*
[**2134-7-12**] 05:42AM BLOOD CK-MB-78* MB Indx-12.1* cTropnT-3.41*
[**2134-7-11**] 10:15PM BLOOD cTropnT-0.36*
[**2134-7-12**] 05:42AM BLOOD Triglyc-38 HDL-50 CHOL/HD-2.5 LDLcalc-65
[**2134-7-12**] 05:42AM BLOOD %HbA1c-5.5 eAG-111
TTE: The left atrium is normal in size. The right atrium is
moderately dilated. There is mild symmetric left ventricular
hypertrophy with normal cavity size. There is mild regional left
ventricular systolic dysfunction with severe hypokinesis of the
infererior and inferolateral wall. The remaining segments
contract normally (LVEF = 55%). 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 no aortic valve stenosis. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild to moderate ([**11-28**]+) mitral regurgitation is seen.
The tricuspid valve leaflets are mildly thickened. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
mild regional systolic dysfunction c/w CAD. Pulmonary artery
systolic hypertension. Mild-moderate mitral regurgitation. Mild
aortic regurgitgation.
Compared with the prior study (images reviewed) of [**2134-6-11**],
the regional left ventricular systolic dysfunction is new and
c/w interim ischemia/infarction. The estimated PA systolic
pressure is also now higher.
CLINICAL IMPLICATIONS:
Based on [**2130**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
Brief Hospital Course:
[**Age over 90 **] y/o male with no sig PMHx who presents from OSH with chest
pain and bradycardia. Found to be in complete heart block with
atrial fibrillation. Elevated cardiac enzymes as well.
# Complete Heart block - Patient presented from OSH with
bradycardia in the 30s. Diff dx includes ischemia of AV node,
likely from RCA infarct as most people are right dominant. Dig
toxicity, lyme disease are also potential causes. He had a dig
level of 1.2 at OSH and in the setting of renal insufficiency
could be toxic. He does not have any outdoor exposures that
would predispose him to lyme disease. EKG from OSH showed
ventricular bigeminy and 3rd degree AV block with junctional
rhythm, both of which can be seen with digoxin toxicity. Patient
showed no response to atropine and had ST depressions in V3-V5
when given dopamine. Option of temporary pacing wire was
discussed with daughter, and she agreed to it if needed.
However, patient remained hemodynamically stable. Digoxin was
stopped and patients heart rate improved over hospitalization,
to levels in the 60s at rest and up to 90s with minimal
activity. Patient was asymptomatic at discharge with no
lightheadedness, shortness of breath or chest pain. No beta
blocker was started due to patients bradycardia; however, a low
dose ACEi was given.
.
# ACS - Patient had developed chest pain at home. ECG showed ST
depression in V3-V5 when given dopamine. Patient was found to
have elevated cardiac enzymes in setting of chest pain. After
discussion with the family and considering comorbidities and the
patientis stability, cardiac catheterization was not pursued.
Patient was started on a heparin drip, Plavix, aspirin and
atorvasatin were started. No beta blocker was given because of
the patient's bradycardia. Low dose ACEi was started prior to
discharge. Echocardiogram showed regional LV systolic
dysfunction that was new in comparison to [**2134-6-11**], likely
representative of ischemia/infarction. LV EF was 55%. Troponin
peaked at 3.63, CPK at 857, and CK-MB at 78. Patient was
asymptomatic at discharge.
.
# Atrial fibrillation - Patient recently stopped on coumadin by
his PCP as he was supratherapeutic and risk of fall was
considered higher than benefit of coumadin by PCP. [**Name10 (NameIs) **] was
in slow a fib on telemetry later in hospitalizaion. Digoxin was
held due to bradycardia and AV block. Patient will continue on
ASA and Plavix with no anticoagulation therapy.
.
# Renal insufficiency - Chronic per OSH records and daughter,
with baseline creatinine between 1.5-1.7. Creatinine between 1.6
and 1.8 during hospitalization. Urine electrolytes indicated
likely prerenal azotemia. Patient was given gentle hydration
with IVF and responded with slight decrease to patients
baseline.
.
# Normocytic anemia ?????? Hct stable during his hospitalization with
mild decrease likely secondary to hydration. Patient did have
positive guiac x1. Further work up was not pursued as an
inpatient because patient was stable. Recommend outpatient work
up as deemed necessary by family and PCP.
.
# Delirium- Patient had periods of delirium, particularly at
night, but controllable without medication. Daughter had some
concern about his confusion and evaluation by by PT suggested
rehab. No obvious cause of delirium ?????? no signs of infection,
moving bowels, good urine output. Patient did become more alert
and oriented as the hospitalization progressed.
Medications on Admission:
DIGOXIN 0.25 MG TABS (DIGOXIN) one po alternating with one and
a half po daily
METAMUCIL 30.9 % POWD (PSYLLIUM) one tbsp noon and evening
Coumadin - recently discontinued in [**Month (only) 205**]
Discharge Medications:
1. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for Chest pain.
Disp:*20 Tablet, Sublingual(s)* Refills:*0*
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
Primary: Complete heart block, NSTEMI
Secondary: atrial fibrillation
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 6359**],
It was a pleasure to take care of you during your
hospitalization.
You came to the hospital after experiencing chest pain. It was
found that your heart rate was very slow and you also had a
heart attack. You were brought to the Cardiac Care Unit for
treatment and monitoring. We treated your heart attack with
blood thinners and took a picture of your heart that showed a
small area of injury, but still good overall function. We also
stopped your digoxin because it was the likely cause of your
slow heart rate.
New Medications:
Aspirin 325 mg by mouth daily: important blood thinner to
decrease risk of another heart attack
Plavix 75mg by mouth daily: important blood thinner to decrease
risk of another heart attack
Lisinopril 5mg by mouth daily: Blood pressure medication that
also helps your heart heal
Atorvastatin 80mg by mouth daily: This medication lowers
cholesterol to decrease risk of another heart attack
STOP: Digoxin
.
Please follow up with your doctors as listed below.
Followup Instructions:
Dr.[**Name (NI) 5103**] Cardiology office will call you at home with
details regarding your follow up appointment. If you do not hear
from them in the next few days please call phone: [**Telephone/Fax (1) 62**]
Dr. [**Last Name (STitle) **] [**2134-8-4**] @ 3:20PM.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
|
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59,943
| 199,699
|
36693
|
Discharge summary
|
report
|
Admission Date: [**2177-7-11**] Discharge Date: [**2177-7-17**]
Date of Birth: [**2108-12-9**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Tetanus / Meropenem
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Fever, diarrhea, lethargy
Major Surgical or Invasive Procedure:
None
History of Present Illness:
68 year-old female, ventilator dependent secondary to
[**Last Name (un) 4584**]-[**Location (un) **], insulin-dependent diabetes mellitus, systolic
heart failure, recurrent urinary tract infections with chronic
indwelling Foley catheter, recent C difficile infection on
vancomycin PO admitted from [**Hospital 100**] Rehab for fever x1 week. Per
report, low-grade fevers began approximately one week ago. Blood
cultures were negative at that time. Patient was empirically
treated with vancomycin, Zosyn, and PO vancomycin. As fevers
worsened and associated with leukocytosis, Zosyn changed to
Imipenem.
Night prior to admission she was noted to have temperature 102.
She appeared lethargic and diaphoretic. She is usually very
interactive, but was not interested in verbal communication. She
was also noted to have WBC count 21.2, hematocrit 27.4. She was
also noted ot have diarrhea of unknown duration and thick,
yellow secretions from trach.
.
Of note, in [**6-5**] when patient was treated for VAP (LLL
infiltrate) and UTI at [**Hospital1 2177**].
.
In the ED, initial vs were T101.2 107 145/79 16 99 on CMV 500x12
Fio2 0.35, PEEP 5. She complained of abdominal distention. On
exam, she was rhonchorous with a nontender abdomen. A CT
abdomen/pelvis was order which showed no evidence of colitis but
concerning for pneumonia (?LLL vs. multilobar). Patient was
given given linzeolid for VRE coverage given persistent
fever/leukocytosis on vancomycin/imipenem, levofloxacin for
atypical coverage, Tylenolol PR, and IVF (1 liter). On transfer
to the ICU, HR 89, BP 92/41, RR 20, O2 saturation 92% on CMV
500x12 Fio2 0.35, PEEP 5.
.
On the floor, history is difficult because no volume with
patient's speech. Reports feeling tired. Complains of
intermittent headaches, sinus congestion, thick secretions from
trach (unable to quantify duration). Reports 'so so' abdominal
pain with considerable diarrhea recently (again, duration not
known). Denies nausea, vomiting.
Past Medical History:
- [**Last Name (un) 4584**]-[**Location (un) **], ventilator dependent: Diagnosed [**2153**].
Recurrence of [**Last Name (un) 4584**]-[**Location (un) **] at [**Hospital1 2177**] [**6-5**]. Per records, has no
sensation/movement of upper or lower extremities. Previously
treated with IVIG.
- Obesity
- Chronic respiratory failure, vent setting AC 12x500, PEEP 5,
Fi02 35%. Treated with Rocephin for VAP ([**Date range (1) 82985**]).
- Diabetes mellitus, insulin-dependent
- Systolic heart failure, EF 40% at baseline. TTE 66%, 1+ MR,
trace PR, trace AR in [**6-5**].
- Chronic indwelling Foley catheter with recurrent UTIs. Treated
for Pseudomonas, enterococcus UTI x10 days in [**6-5**].
- History of C. difficile infection
- Dysphagia
- Chronic pain, including chronic neuropathic pain
- Anemia with recent baseline ~29. Concern for GI bleed during
[**6-5**] admission, no evidence of bleeding found.
- OSA
- Hypertension
.
Per [**Hospital1 2177**] Records (Hospitalized [**2177-5-28**]) - obtained [**2177-7-14**]:
-Hct dropped from 38 --> 29. GI consulted -felt EGD not
warranted. Hct remained stable in high 20s.
-EMG results: severe, axonal, sensory-motor polyneuropathy
-Echo([**2177-5-29**]): EF 66%. No LVH. Normal [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 1934**]. 1+ MR. PASP
is 30 (slightly elevated).
-MRSA negative [**2177-6-9**]
Social History:
Currently lives at [**Hospital 100**] Rehab. Denies alcohol, tobacco,
illicit drug use. Initially lived with brother, also a
paraplegic. Former airline attendant.
Family History:
Brother with hereditary spastic paraplegia.
Physical Exam:
On [**Hospital Unit Name 153**] admission:
100.4, 93, 120/60, 15, 93% [CMV 500x12 FiO2 0.35, PEEP 5]
General: Mildly diaphoretic, appears slightly uncomfortable;
thick secretions at trach site
HEENT: Sclera anicteric, dry mucous membranes, scant white
plaqueing roof of mouth
Neck: Supple, JVP difficult to assess given habitus although no
obvious distention, no appreciable LAD
Lungs: Limited secondary to anterior exam and body habitus;
decreased breath sounds at left base. No wheezes, rales, ronchi
appreciated.
CV: Regular rate and rhythm, normal S1/S2, I/VI early systolic
murmur best heard at LLSB
Abdomen: Obese, umbilical hernia (reducible), tympanic bowel
sounds, PEG tube in place with nondraining slightly red
surrounding tissue, mild RUQ TTP, [**Doctor Last Name 515**] sign negative
GU: Foley
Ext: Warm, well perfused, 2+ pulses; upper extremity edema, 1+
Skin: Mild erythema surrounding PEG insertion site; erythematous
patch on both thighs, medially, near groin
Neuro: PERRL; EOMI; upper extremity movement limited to moving
fingers; no lower extremity movement
Pertinent Results:
CBC
[**2177-7-16**] 03:08AM BLOOD WBC-9.2 RBC-2.76* Hgb-8.6* Hct-25.8*
MCV-94 MCH-31.0 MCHC-33.1 RDW-16.8* Plt Ct-501*
[**2177-7-15**] 04:01AM BLOOD WBC-7.8 RBC-2.72* Hgb-8.2* Hct-25.9*
MCV-95 MCH-30.2 MCHC-31.8 RDW-16.8* Plt Ct-460*
[**2177-7-14**] 03:41PM BLOOD WBC-7.4 RBC-2.72* Hgb-8.2* Hct-25.9*
MCV-95 MCH-30.1 MCHC-31.6 RDW-16.8* Plt Ct-448*
[**2177-7-14**] 03:29AM BLOOD WBC-7.5 RBC-2.78* Hgb-8.6* Hct-26.3*
MCV-95 MCH-30.8 MCHC-32.5 RDW-16.6* Plt Ct-474*
[**2177-7-13**] 04:47PM BLOOD WBC-6.6 RBC-2.30* Hgb-7.2* Hct-22.7*
MCV-99* MCH-31.2 MCHC-31.6 RDW-15.8* Plt Ct-406
[**2177-7-13**] 03:40AM BLOOD WBC-10.2 RBC-2.62* Hgb-8.1* Hct-25.3*
MCV-97 MCH-31.2 MCHC-32.2 RDW-15.6* Plt Ct-520*
[**2177-7-12**] 04:52AM BLOOD WBC-15.8* RBC-2.47* Hgb-8.0* Hct-23.4*
MCV-95 MCH-32.2* MCHC-34.0 RDW-15.4 Plt Ct-489*
[**2177-7-11**] 12:15PM BLOOD WBC-18.3* RBC-2.83* Hgb-8.6* Hct-27.1*
MCV-96 MCH-30.2 MCHC-31.7 RDW-15.3 Plt Ct-519*
.
Chemistry
[**2177-7-16**] 03:08AM BLOOD Glucose-148* UreaN-7 Creat-0.2* Na-139
K-3.8 Cl-103 HCO3-30 AnGap-10
[**2177-7-15**] 04:01AM BLOOD Glucose-147* UreaN-6 Creat-0.3* Na-138
K-3.9 Cl-104 HCO3-26 AnGap-12
[**2177-7-14**] 03:29AM BLOOD Glucose-136* UreaN-8 Creat-0.3* Na-139
K-4.5 Cl-107 HCO3-25 AnGap-12
[**2177-7-13**] 04:47PM BLOOD Glucose-138* UreaN-8 Creat-0.3* Na-138
K-3.7 Cl-106 HCO3-26 AnGap-10
[**2177-7-13**] 03:40AM BLOOD Glucose-148* UreaN-10 Creat-0.3* Na-136
K-3.7 Cl-97 HCO3-31 AnGap-12
[**2177-7-12**] 04:52AM BLOOD Glucose-173* UreaN-11 Creat-0.3* Na-136
K-3.9 Cl-97 HCO3-29 AnGap-14
[**2177-7-11**] 12:15PM BLOOD Glucose-263* UreaN-13 Creat-0.4 Na-135
K-4.1 Cl-94* HCO3-32 AnGap-13
[**2177-7-16**] 03:08AM BLOOD Calcium-8.6 Phos-2.4* Mg-2.1 Iron-40
[**2177-7-15**] 04:01AM BLOOD Calcium-8.4 Phos-2.2* Mg-1.9
[**2177-7-13**] 03:40AM BLOOD Calcium-8.8 Phos-3.5 Mg-2.2
[**2177-7-14**] 03:29AM BLOOD Albumin-2.2* Calcium-8.1* Phos-3.1 Mg-1.9
[**2177-7-11**] 12:15PM BLOOD Albumin-2.8* Calcium-9.0 Phos-2.9 Mg-2.2
.
LFT
[**2177-7-13**] 03:40AM BLOOD ALT-14 AST-13 AlkPhos-124* TotBili-0.3
[**2177-7-11**] 12:15PM BLOOD ALT-19 AST-12 AlkPhos-176* TotBili-0.4
.
Iron Studies
[**2177-7-16**] 03:08AM BLOOD calTIBC-146* Ferritn-699* TRF-112*
.
Haptoglobin
[**2177-7-13**] 04:47PM BLOOD Hapto-493*
.
Vitamin B12/Folate
[**2177-7-12**] 04:52AM BLOOD VitB12-255 Folate-19.2
.
SPUTUM CULTURE Site: ENDOTRACHEAL
GRAM STAIN (Final [**2177-7-11**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Preliminary):
OROPHARYNGEAL FLORA ABSENT.
PSEUDOMONAS AERUGINOSA. MODERATE GROWTH.
AZTREONAM SENSITIVITY REQUESTED BY DR [**Last Name (STitle) **] [**Last Name (NamePattern4) 19840**] ([**Numeric Identifier 77608**])
[**2177-7-15**].
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. SECOND
MORPHOLOGY.
AZTREONAM SENSITIVITY REQUESTED BY DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 19840**] ([**Numeric Identifier 77608**])
[**2177-7-15**].
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. THIRD
MORPHOLOGY.
AZTREONAM SENSITIVITY REQUESTED BY DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 19840**] ([**Numeric Identifier 77608**])
[**2177-7-15**].
.
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
| PSEUDOMONAS AERUGINOSA
| | PSEUDOMONAS
AERUGINOSA
| | |
CEFEPIME-------------- 8 S 8 S 8 S
CEFTAZIDIME----------- 4 S 4 S 4 S
CIPROFLOXACIN--------- 1 S =>4 R =>4 R
GENTAMICIN------------ 8 I 4 S 4 S
MEROPENEM-------------<=0.25 S <=0.25 S <=0.25 S
PIPERACILLIN---------- 8 S <=4 S <=4 S
PIPERACILLIN/TAZO----- 8 S <=4 S <=4 S
TOBRAMYCIN------------ <=1 S <=1 S <=1 S
.
URINE CULTURE (Final [**2177-7-12**]):
YEAST. >100,000 ORGANISMS/ML.
.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2177-7-13**]):
Feces negative for C.difficile toxin A & B by EIA.
.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2177-7-15**]):
Feces negative for C.difficile toxin A & B by EIA.
.
Respiratory Viral Antigen Screen (Final [**2177-7-14**]):
Negative for Respiratory Viral Antigen.
Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
and RSV by immunofluorescence.
.
[**7-11**] CT Chest:
1. Widespread patchy opacities throughout both lungs with more
confluent
opacification in the left lower lobe. These findings are
concerning for
multifocal pneumonia. ARDS and acute interstitial pneumonia
cannot be
excluded.
2. Extensive mediastinal lymphadenopathy (prevascular,
paratracheal, pretracheal).
3. NG tube balloon malpositioned, likely within tract in the
anterior
abdominal wall.
4. Tracheostomy cuff overinflated.
5. Mild splenomegaly.
.
CHEST (PORTABLE AP) Study Date of [**2177-7-15**] 5:15 AM
IMPRESSION:
Increased cavitation in the dense consolidation of the left mid
lung with
worsening of the multifocal opacities in the right lung and
improvement in the consolidation in the left lower lung.
.
CT CHEST W/O CONTRAST Study Date of [**2177-7-15**] 4:04 PM
1. Multifocal peribronchial consolidation and peribronchial
ground-glass
densities and complete opacification of the left lower lobe is
suggestive of bronchopneumonia. No cavitation. No abscess.
2. Small bilateral pleural effusion, left greater than right.
3. Multiple pathologically enlarged central nodes, most likely
reactive to
bronchopneumonia.
.
LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Study Date of
[**2177-7-13**] 11:14 AM : No evidence of acute cholecystitis. No
evidence of cholelithiasis or choledocholithiasis.
Brief Hospital Course:
68F ventilator-dependent secondary to [**Last Name (un) 4584**]-[**Location (un) **],
insulin-dependent diabetes mellitus, recurrent urinary tract
infections with chronic indwelling Foley catheter, recent C
difficile infection on vancomycin PO admitted from [**Hospital 100**] Rehab
for fever x1 week, diarrhea, and lethargy x1 days.
#. Multifocal Pneumonia: Admission CT showed consolidation in
LLL in addition to bilateral fluffy infiltrates. Prior to
admission, patient had been covered with vancomycin and zosyn,
then subsequently vancomycin and meropenem with no improvement.
Meropenem was stopped given pt developed a drug [**Hospital **]. Given the
bilateral ground glass opacities the concern was for atypical
bacterial or viral infections. CT chest performed on [**7-15**]
showed no abscess, no cavitation, only evidence of multifocal
pneumonia. Legionella was negative. Sputum culture returned
positive for pseudomonas sensitive to cefepime. Pt was started
on cefepime on [**7-15**], plan for 2 week course of cefepime.
.
#. RUQ pain: LFTs normal were normal on admission. The concern
was for colitis given prior C. difficile infections. C.diff was
negative x 2 on admission. There was no evidence of colitis or
other intrabdominal pathology to explain abdominal pain. RUQ
ultrasound was obtained which showed no evidence of
cholelithiasis, cholelithiasis, or choledocholithiasis.
.
#. Chronic respiratory failure: Secondary to [**Last Name (un) 4584**]-[**Location (un) **]. Pt
is vent dependent. Currently on home settings, but with FiO2 at
0.4, with good O2 saturation.
.
#. Abnormal UA: Pt has history of recurrent UTIs. Abnormal UA
expected given chronic indwelling Foley catheter. Small
leukocyte esterase, negative nitrite. UTI is unlikely in light
of the antibiotics she was covered with. Urine cultures showed
yeast. Pt's foley was changed.
.
# [**Name (NI) **] - pt developed [**Name (NI) **] on meropenem. Improved after
meropenem stopped. Meropenem added to pt's allergy list.
.
#. History of C difficile colitis: Pt was C diff negative x 2
during course of admission, but in light of anticipated
prolonged antibiotic treatment for multifocal pneumonia,
continued patient on PO vancomycin. Plan to keep patient on PO
vancomycin for a week past last dose of antibiotics for
pneumonia.
.
#. Lethargy: Mental status improved over course of stay. Is
now alert and interactive. Multiple potential sources, most
likely due to toxic-metabolic encephalopathy in setting of
pneumonia. Infection high on list but also concern for
contribution from [**Last Name (un) 4584**] [**Location (un) **] given patient had recent
exacerbation which required IVIG.
.
#. Anemia: Unknown baseline. Patient was guiaic negative and
has no signs of active bleeds at this time. Given low albumin,
may be secondary to poor nutrition status. Continued home dose
of folic acid
.
#. Diabetes mellitus, type II: Tight blood glucose control
particularly important in setting of infection. Continued on
Lantus and sliding scale as per home regimen with good control
of blood glucose
.
#. Anxiety: Continued patient on home dose of klonopin and
trazodone.
.
#. Heart failure: Does not appear to be in overt heart failure
at this time. Most recent TTE at [**Hospital1 2177**] ([**6-5**]) was without
indication of systolic dysfunction (LVEF 66%).
Medications on Admission:
Acetylcysteine inhalation [**Hospital1 **]
Albuterol
Vitamin C 500mg PEG [**Hospital1 **]
Chlorhexidine 15ml QID
Clonazepam 1mg PEG [**Hospital1 **]
Fentanyl patch
Folic acid 1mg PO daily
Gabapentin 700mg PO QID
Imipenem, started [**2177-7-9**]
Lantus 44 units QHS
Humalog sliding scale insulin
Ipratropium Q 4hours
Lidocaine patch
Nystatin swish and swallow 5ml TID
Omeprazole 20mg PO BID
NaCl 1 gram PO daily
Trazodone 50mg PO QHS
Vancomycin IV, started [**2177-7-7**]
PRN: Acetaminophen, Maalox, Albuterol, Lidocaine, Lorazepam,
Morphine SL, Zofran
Discharge Medications:
1. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical once a day: please
place over area of greatest pain. 12 hours on, 12 hours off.
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
3. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO TID
(3 times a day): After meals, swish and spit.
4. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Ten (10)
Puff Inhalation QID (4 times a day): inhalation.
5. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Four (4) mg
Injection every six (6) hours as needed for nausea.
7. Cefepime 2 gram Recon Soln Sig: Two (2) grams Injection Q8H
(every 8 hours) for 14 days: Please continue for 2 week
treatment. First dose given [**7-15**]. Last day of treatment [**7-29**].
8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomina.
10. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours): Please continue for 3 weeks. End date: [**8-4**].
11. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Ten (10) Puff Inhalation Q4H (every 4 hours) as needed for
wheezing.
12. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day): Apply between legs for [**Hospital1 **].
13. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15)
ML Mucous membrane [**Hospital1 **] (2 times a day).
14. Gabapentin 250 mg/5 mL Solution Sig: Seven Hundred (700) mg
PO four times a day: PLease give by mouth or G-tube.
15. Lantus 100 unit/mL Cartridge Sig: Forty Four (44) units
Subcutaneous at bedtime.
16. Insulin Sliding Scale
Administer within 15 min before or every 6h subcutaneously
BS less than 150: no insulin;
151-175: 2 Units SQ;
176-200: 3 Units SQ;
201-225: 4 units SQ;
225-260: 5 units SQ;
>260: 6 units SQ;
17. Fentanyl 12 mcg/hr Patch 72 hr Sig: One (1) patch
Transdermal Q72H (every 72 hours): Apply together with 25 mcg
patch for total of 37mcg.
18. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) patch
Transdermal every seventy-two (72) hours: Apply together with 12
mcg patch for total dose of 37 mcg.
19. Sodium Chloride 1 gram Tablet Sig: One (1) Tablet PO DAILY
(Daily).
20. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day: G- tube.
21. Vitamin C 500 mg/5 mL Syrup Sig: Five Hundred (500) mg PO
twice a day: via G-tube or mouth.
22. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush: PICC,
heparin dependent: Flush with 10mL Normal Saline followed by
Heparin as above daily and PRN per lumen.
23. Acetaminophen 160 mg/5 mL Liquid Sig: 650 mg PO every four
(4) hours as needed for fever or pain: Do not exceed 4 gram per
day.
24. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours as needed: For anxiety. Tablet(s)
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary Diagnosis:
Multifocal Pneumonia caused by Psuedomonas Aeruginosa
Secondary Diagnosis:
[**Last Name (un) 4584**]-[**Location (un) **], ventilator dependent
Obesity
Chronic respiratory failure secondary to [**Last Name (un) 4584**] [**Location (un) **]
Diabetes mellitus, insulin-dependent
Systolic heart failure (EF 40%)
Recurrent UTIs with chronic indwelling Foley catheter
History of C. difficile colitis
Dysphagia
Chronic pain, including chronic neuropathic pain
Anemia
Obstructive Sleep Apnea
Hypertension
Discharge Condition:
Good, Afebrile, Stable.
Discharge Instructions:
You were admitted to the [**Hospital1 69**]
intensive care unit for fevers and change in your mental status.
Chest CTs and chest X-rays obtained over the course of your
admission showed multifocal pneumonia for which you are being
treated with antibiotics.
Some changes were made to your medications:
- new medication: cefepime 2 grams IV every 8 hours for 2 weeks
- new medication: vancomycin 250 mg PO every 6 hours for 3 weeks
- new medication: heparin 5000 units subcutaneous TID
The rest of your outpatient medications were not changed, please
continue to take them as originally prescribed.
If you experience chest pain, shortness of breath, or any other
worrisome symptoms, please return to the emergency room.
Followup Instructions:
Please follow up with your Primary Care Physician [**Last Name (NamePattern4) **] 2 weeks.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
|
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|
5055, 7555
|
19383, 19603
|
3895, 3940
|
14920, 17936
|
18046, 18046
|
14343, 14897
|
18637, 19360
|
3955, 5036
|
7596, 10929
|
251, 278
|
350, 2319
|
18141, 18566
|
18065, 18120
|
2341, 3699
|
3715, 3879
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,759
| 107,939
|
45728
|
Discharge summary
|
report
|
Admission Date: [**2188-9-17**] Discharge Date: [**2188-12-10**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4365**]
Chief Complaint:
Ankle Fracture (Left)
Major Surgical or Invasive Procedure:
- Open reduction and internal fixation of right ankle fracture
on [**2188-9-18**]
- G tube placement and removal
- PICC line placement
History of Present Illness:
80 yo M transferred from the ortho service, etoh abuse presents
with a ankle fracture s/p fall in bathroom while intoxicated.
Pt. drinks 1 pint of tequila a day and his last drink was on the
day of admission. He lives in an elderly hosing unit and he
pulled the bathroom emergency cord. Maintenance man found him
lying on floor in toilet water with a half empty bottle of
Tequila. He is s/p an ORIF on [**9-18**]. After the surgery, he was
noted to be hypertensive in the pacu to 190/110. He was also
confused and agitated. The primary team had a high suspicion for
etoh withdrawal given the timing and hx of etoh use. His BP was
controlled with lopressor and IV hydral. He was started on an
ativan CIWA (q2hrs). Psychiatry liason feels the symptoms are
more c/w post-op delirium and recommend haldol and not using
benzos in this elderly man. Medicine consulted for help in
management of withdrawal symptoms and agitation and felt that
presentation was consistent with acute alcohol withdrawal. No
more surgical issues per ortho therefore recommended transfer to
medicine.
Past Medical History:
1. alcohol abuse
2. history of prostate cancer [**2178**], [**Doctor Last Name **] grade [**6-12**], s/p
TURP [**4-/2179**]
3. GERD
4. history of central retinal vein occlusion
5. hypertension
6. history of anemia, thought to be due to alcoholic bone
marrow suppression
7. glaucoma
Social History:
Drinks about 1.5 quarts of Tequila, per previous report. Former
smoker.
Family History:
noncontributory
Physical Exam:
General Appearance: Well nourished
Tmax: 36.8 ??????C (98.2 ??????F)
Tcurrent: 36.8 ??????C (98.2 ??????F)
HR: 112 (82 - 112) bpm
BP: 156/69(90) {106/59(68) - 156/73(92)} mmHg
RR: 30 (15 - 30) insp/min
SpO2: 90%
Eyes / Conjunctiva: No(t) PERRL
Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,
(Murmur: No(t) Systolic, No(t) Diastolic)
Peripheral Vascular: (Right radial pulse: Not assessed), (Left
radial pulse: Not assessed), (Right DP pulse: Not assessed),
(Left DP pulse: Not assessed)
Respiratory / Chest: (Breath Sounds: Clear : anteriorly)
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right: Absent, Left: Absent
Skin: Not assessed
Neurologic: No(t) Attentive, No(t) Follows simple commands,
Responds to: Verbal stimuli, No(t) Oriented (to): , Movement:
Non -purposeful, Tone: Not assessed
Pertinent Results:
[**2188-9-17**] 11:05AM BLOOD:
WBC-7.9 RBC-3.76* HGB-12.0* HCT-34.9* MCV-93 MCH-32.0 MCHC-34.5
RDW-13.9 NEUTS-69.7 LYMPHS-23.8 MONOS-4.1 EOS-2.1 BASOS-0.3 PLT
COUNT-238
PT-13.8* PTT-25.5 INR(PT)-1.2*
GLUCOSE-93 UREA N-11 CREAT-0.8 SODIUM-145 POTASSIUM-4.0
CHLORIDE-108 TOTAL CO2-22 ANION GAP-19
.
[**2188-11-7**] RPR: negative
[**Date range (3) 97446**]: C. diff negative x5
.
RIGHT HIP, KNEE, ANKLE X-RAY [**2188-9-17**]
FINDINGS:
There are degenerative changes present at the hip joints as well
as the lowerlumbar spine. There is no right hip fracture.
There are degenerative changes present at the right knee joint.
There is
vascular calcification noted. There is no acute fracture.
There is a comminuted fracture present through the lateral
malleolus, with
subluxation of the ankle mortice.
.
CT HEAD [**2188-9-17**]
FINDINGS: There is no evidence for edema, mass effect,
hemorrhage, or
infarction. There is no shift of normally midline structures.
There is
preservation of normal [**Doctor Last Name 352**]-white matter differentiation. There
is mild-to-moderate prominence of the ventricles and the sulci
consistent with age-related parenchymal loss. There is a
moderate periventricular hypodensities suggestive of small
vessel microvascular ischemia, unchanged compared to prior
examination. There are calcifications in the basal ganglia and
left dentate nuclei which are age related and unchanged. Soft
tissue density material in the right external auditory canal
most likely representative of cerumen and would recommend
clinical correlation. The visualized sinus airspaces are clear,
and the mastoid air cells are unremarkable. There are no
fractures identified.
IMPRESSION: No acute intracranial pathology.
.
CT CSPINE [**2188-9-17**]
CONCLUSION:
1. Widening of the right odontoid-lateral mass interval of
approximately 6 mm as compared to the left, which is 3 mm may
represent rotatory subluxation. If clinical suspicion is high,
further imaging may be warranted.
2. Multilevel degenerative changes in the cervical spine with
congenital
fusion at multiple levels as described above.
3. Anterolisthesis of the bodies of C5 on C6 and C7 on T1.
.
EEG [**2188-9-26**]
MPRESSION: This is an abnormal portable EEG in the awake and
sleeping
states due to the bursts of generalized slowing and background
suppression and the slow and disorganized background. These
abnormalities suggest a moderate encephalopathy involving both
cortical
and subcortical structures. Medications, metabolic disturbances
and
infection are among the most common causes. The excessive beta
activity
suggests a medication effect. There were no lateralized or
epileptiform
features seen.
.
CT HEAD [**2188-10-10**]
FINDINGS: There is a small right frontal subgaleal hematoma
without
intraluminal air to suggest laceration. There is no underlying
fracture
detected. The visualized paranasal sinuses and mastoid air cells
are clear.
There are bilateral lens replacements in the orbits. The orbital
regions are otherwise unremarkable.
There is no acute intracranial hemorrhage, mass lesion, shift of
normally
midline structures or evidence of major territorial infarct.
Bilateral basal ganglia calcifications noted. Moderate confluent
periventricular
hypoattenuation is consistent with chronic small vessel
ischemia.
IMPRESSION:
1. No acute intracranial hemorrhage or mass effect.
2. Small right frontal subgaleal hematoma without underlying
fracture.
3. Moderate chronic small vessel microvascular ischemia within
the
periventricular white matter.
.
CT CSPINE [**2188-10-10**]
FINDINGS: There is an acute fracture of the dens type 2 in which
the anterior arch of C1 is subluxed posteriorly through the
fracture line. There is extensive surrounding hematoma within
the anterior and posterior vertebral space. The cranial most
aspect of the dens is tipped posteriorly.
Multilevel degenerative changes present within the cervical
spine are again noted with fusion of C2 through C4.
Anterolisthesis of C5 on C6 and C7 on T1 are again noted. There
is stable minimal widening of the right odontoid lateral mass
interval in which rotatory subluxation cannot be excluded.
Vascular calcifications of the internal carotid arteries are
again noted.
Interstitial changes within the lung apices are grossly stable.
IMPRESSION:
1. Acute fracture of the dens (type 2) with posterior
translation of the
anterior arch of C1 into the fracture line. There is significant
post-
fracture hematoma. Posterior subluxation is present of C1 on C2.
This is an unstable fracture and cervical stabilization is
necessary as discussed with Dr. [**First Name (STitle) **] at 10:40 p.m. on the date
of exam. MRI without gadolinium is
recommended as well as neurosurgical consultation.
2. Degenerative changes as previously described.
3. Vascular calcifications.
.
TIB/FIB RIGHT (AP & LAT) [**2188-10-17**]
FINDINGS: In comparison with study of [**10-16**], the cast has been
removed. No
change in the appearance of the metallic fixation device about a
previous
fracture of the distal fibula. The fracture line is still
faintly seen.
Views of the knee and upper leg show no abnormality.
.
XRAY ENTIRE SPINE [**2188-10-30**]:
IMPRESSION:
1. Cervical spine -- known base of dens fracture seen, but not
well visualized. See comment.
2. Thoracic spine -- moderately severe to severe multilevel
degenerative changes. No obvious fracture. See comment.
3. Lumbar spine: Moderately severe to severe multilevel
degenerative changes. No obvious fracture. See comment
Brief Hospital Course:
The [**Hospital 228**] hospital course by problem is as follows:
.
Ankle Fracture:
The patient was admitted after being found down, intoxicated,
with new right ankle fracture. He underwent ORIF on [**2188-9-18**] by
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5322**]. He was initally put in a hard boot/air cast and was
non-weight bearing on that extremity. He was seen again by
ortho in [**Month (only) **] and felt that he could begin walking again. He
is now ambulating with a cam walker until further advised by
ortho. PT was re-initiated and has been tolerating it well. He
is also on lovenox for DVT prophylaxis until ortho feels safe it
can be stopped. He will follow up with orthopedics ideally 2
weeks after discharge.
.
EtOH Withdrawal / Encephalopathy
Following surgery, the patient was found to be agitated and
mildly hypertensive within the window for EtOH withdrawal. Given
his history of known withdrawal, he was started on aggressive
benzodiazepene treatment for withdrawal, and moved into the
intensive care unit for further monitoring. His admission head
CT and a follow-up head CT in the ICU showed no development of
intracranial bleed. He received valium per the CIWA scale for 7
days. He also received oxycodone for pain control, and was
administered oxycodone whenever he developed tachycardia or
hypertension. His HR and BP stabilized after oxycodone
administration, leading to the belief that a large component of
his agitation was secondary to pain. His vitamin b12 was also
found to be low and he was repleted with IM cyanocobalmin. After
7 days, he still remained quite sedated with episodes of
agitation manifested by tachycardia and hypertension. He was
therefore treated with haldol for six days without change in his
mental status. He remained for 10 days post BZD use in a coma
without purposeful movement but with intact reflexes and
respiration. Neurologic exam remained non-focal. EEG showed no
epileptiform activity. A trial of flumazenil on [**10-1**] produced
improvement in ability to follow commands such as opening eyes
or moving toes, but this remained short lived. He remained
sedated and unresponsive on [**10-2**], and eventually becomae
responsive to verbal stimuli, capable of performing purposeful
movements on [**10-3**]. He was therefore transitioned to the the
medical floor. On the floor, his mental status improved
somewhat,and he was intermittently A&Ox2 (person and place) and
able to ask and answer questions appropriately in spanish.
Spanish is his primary language, but he does speak some english.
Unfortunately, he continued to have episodes of agitation.
Toxic/metabolic/infectious work-up of delirium was unrevealing.
The psychiatry team reevaluated the patient and felt that this
may be a new baseline secondary to extensive alcohol history and
nutritional deficiencies. He received increased doses of
thiamine, folic acid. Given his prolonged period of altered
mental status, he was evaluated by the speech and swallow team
and was felt unsafe to take anything po. A G-tube was placed by
interventional radiology on [**10-16**]. Tubefeeds were started on
[**10-18**]. On [**10-23**] he was reevaluated by speech and able to take a
modified diet (pureed and nectar thickened liquids). He was
continued on tube feeds to supplement his diet. on [**11-16**] speech
and swallow allowed him to advance his diet and his G-tube was
removed in IR on [**11-20**]. The patient was eating and drinking
well without evidence of aspiration. On [**10-23**], the patient was
given B12 treatment with dosing/administration appropriate for
pernicious anemia (please see below under anemia). His agitation
improved very slowly. The patient was given Seroquel QHS,
depakote and haldol prn for agitiation. Starting in [**Month (only) 1096**],
his mental status appeared to settle down. He was maintained on
standing low dose Haldol 0.5mg [**Hospital1 **], Quetiapine 50mg at night, as
well as Valproate, and low dose haldol for breakthrough. BZD
were avoided. There was concern for persistent short term
memory loss for which he had neuropsych testing that confirmed
this. By the middle of [**Month (only) 1096**] the patient was completely
lucent, agreeable and alert and oriented x3.
.
Dens fracture: The patient suffered a fall out of a chair at the
nurses station where he was placed to be more carefully
monitored on [**10-10**]. The patient was found to have a dens
fracture (type 2). He was transferred to the ICU and evaluated
by the spine team. He was neurologically intact. They
recommended a hard collar to be worn continuously for 3 months.
Patient repeatedly removed collar and required a 1:1 sitter for
prevention. As patient's mental status improved to baseline he
began to understand the importance of keeping the collar on to
prevent the risk of paralysis. We was able to be weaned off 1:1
sitter without removing his collar. Must wear hard c-collar at
all times until [**2188-1-10**] unless further advised by orhto.
.
Urinary Tract Infection: The patient was found to have a proteus
UTI in his course in the ICU. He was treated with a 10 day
course of ceftriaxone. On [**10-23**] he was again found to have
another UTI. Urine cultures were contaminated initally and then
negative. He was treated with a 7 day course of ceftriaxone.
Currently he has no urologic issues.
.
Concern for PICC Infection: For low grade temperatures, patient
was cultured and had GPC that speciated to coag-neg staph from
his initial PICC line placed in [**Month (only) 359**]. He received vancomycin
for 3 days while awaiting culture data and the PICC line was
pulled. Antibiotics were discontinued when culture returned
with coag neg staph. Subsequent cultures remained negative.
His most recent PICC was placed on [**2188-10-11**] and has had no
evidence of cellulitis or infection. His PICC was D/C'd in early
[**Month (only) 1096**] as the patient no longer required IV ABX or
medications.
.
Anemia: The patient's anemia is likely related to repeated
phlebotomy draws as it had slowly trended down from the mid 30s
on admission as well as to his B12 deficiency and alcohol abuse.
There was no evidence of bleeding. The patient was initially
given IM and then oral B12 repletion doses for treatment of B12
deficiency. However with his continued delirium there was
concern for pernicious anemia. On [**10-23**], he was given a second
course of B12 treatment with B12 1 gm IV x 7 days. He should
continue B12 1gm IV/IM once a month indefinately. His Hct has
remained stable in the high 20s.
.
Asbestosis: CXR shows right pleural plaque consistent with
asbestosis. Will need outpatient pulm follow up.
.
Alcohol abuse: We recommend sobriety. A social work consult was
obtained to assist counseling the patient and give the patient
resources for support. MVI, folate and thiamine were continued
in house.
.
Hypertension: Metoprolol was continued with good effect until
the end of [**Month (only) 1096**] when it was noted that his SBP was mostly in
the 90s and HR in the 50s. Metoprolol was discontinued and his
BP remained stable
.
Code: FULL code for this admission
Medications on Admission:
" eye drops and sleeping pills"
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) injection
Subcutaneous DAILY (Daily).
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
6. Quetiapine 25 mg Tablet Sig: Two (2) Tablet PO QPM (once a
day (in the evening)).
7. Polyethylene Glycol 3350 100 % Powder Sig: One (1) PO DAILY
(Daily) as needed for constipation.
8. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times 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. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
11. Valproic Acid 250 mg Capsule Sig: Two (2) Capsule PO Q12H
(every 12 hours).
12. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed for abdominal pain.
13. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
14. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
15. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
16. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-5**] Sprays Nasal
QID (4 times a day) as needed for nasal congestion.
17. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
18. Haloperidol 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
19. Calcium Carbonate 500 mg Capsule Sig: One (1) Capsule PO
twice a day.
20. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-5**]
Ophthalmic twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1186**] - [**Location (un) 538**]
Discharge Diagnosis:
Right ankle fracture
Acute alcohol withdrawal
C1-spine fracture (Dens type 2)
Hypertension
Discharge Condition:
Stable
Discharge Instructions:
You were admitted after a fall while intoxicated. You were
found to have a right ankle fracture. On [**2188-9-18**] you had an
operation to repair your ankle fracture.
Your hospital course was complicated by acute alcohol withdrawal
requiring monitoring and treatment in the intensive care unit.
You suffered a fall and fractured your cervical spine. To
prevent paralysis you must WEAR YOUR COLLAR AT ALL TIMES FOR at
least 3 MONTHS (until [**2188-1-10**]). Orthopedics will help to
determine when it is ok to remove the collar.
We recommend that you do not drink alcohol in the future.
Please follow your medication list closely.
Attend all follow up appointments.
Please contact your doctor or go to the emergency room if you
experience any of the following symptoms: body weakness,
difficulty moving, increased pain, fevers >100.4, chills, chest
pain, shortness of breath, leg pain or other concerning
symptoms.
Followup Instructions:
Orhtopedics Provider: [**First Name4 (NamePattern1) 6100**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2189-1-2**] 11:30. The orthopedics office is attempting
to make an earlier appointment that that they will contact you
with the final appiontment time.
.
PCP: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Hospital1 2177**] [**Telephone/Fax (1) 11463**]. [**2188-1-1**] at 2pm
Completed by:[**2188-12-10**]
|
[
"E849.0",
"999.31",
"790.7",
"E879.8",
"281.0",
"V10.46",
"780.01",
"041.6",
"530.81",
"348.30",
"707.09",
"291.81",
"E849.7",
"501",
"E888.9",
"293.0",
"805.01",
"V15.88",
"707.22",
"722.4",
"365.9",
"E884.2",
"824.2",
"303.01",
"401.1",
"599.0",
"263.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"43.19",
"96.6",
"79.36",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
17468, 17541
|
8353, 15512
|
285, 422
|
17676, 17685
|
2826, 8330
|
18655, 19133
|
1943, 1960
|
15594, 17445
|
17562, 17655
|
15538, 15571
|
17709, 18632
|
1975, 2807
|
224, 247
|
450, 1524
|
1546, 1836
|
1852, 1927
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,556
| 146,739
|
52130
|
Discharge summary
|
report
|
Admission Date: [**2105-5-28**] Discharge Date: [**2105-6-10**]
Date of Birth: [**2038-12-16**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Pollen/Hayfever
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
Dyspnea, nausea/vomiting/decreased G tube intake.
Major Surgical or Invasive Procedure:
[**2105-5-29**]: Thoracentesis with pigtail catheter placement.
[**2105-6-1**]: R lung decortication.
History of Present Illness:
Mr. [**Known lastname **] is a 66 year-old male with a past medical history of
squamous cell carcinoma of the head and neck of unknown primary
site s/p radiation in [**2100**], emphysema, s/p PEG tube placement
who presented to the ED with worsening nausea/vomiting and
decreased ability to feed himself through the G tube for the
past several days. Per clinic notes, patient has been
experiencing increasing SOB and fatigue over the last several
weeks. On questioning, he states that his SOB has actually not
acutely worsened, but he feels that his trachael "fibrosis" has
become worse.
.
In the ED, initial vitals were 99.6 103 126/65 18 95% RA. CXR
showed large loculated effusion on the right vs. consolidation.
He recived levofloxacin, ceftriaxone, 2 L of fluid for SBPs
90-95. On transfer, he was 96% 2.5 L.
.
On the floor, patient is comfortable, sating in the high 90s on
2.5 L, answering questions appropriately.
Past Medical History:
ONCOLOGIC HISTORY:
- [**3-/2101**]: Noticed right-sided neck swelling, right submandibular
mass on ultrasound; CT neck with contrast demonstrated
pathologically enlarged lymph node
- [**4-/2101**] FNA of lymph node suspicious for squamous cell
carcinoma
- [**5-/2101**] biopsy of right lateral base of the tongue demonstrated
squamous mucosa with dysplasia and focally associated with
high-grade dysplasia; direct laryngoscopy demonstrated a small
nodule in the lateral inferior aspect of the right base of the
tongue
- FDG PET demonstrated mild FDG uptake in region of large
necrotic right lymph node; also prominent FDG uptake R>L
(?physiologic)
- Diagnosed with TxN1 disease
- [**6-/2101**] initiated cisplatin and XRT, with PEG placement;
completed two cycles cisplatin, held afterwards because of
toxicity (mucusitis)
- [**10/2101**] CT neck demonstrated residual disease; underwent right
modified radical neck dissection and left lymph node biopsy on
[**2101-10-24**], with pathology demonstrating no persistence of disease
- [**1-/2102**] admitted with post-surgical abscess (group B strep) and
right IJ thrombosis, Lovenox initiated (discontinued in [**8-/2102**])
- [**4-/2102**] Underwent dilation of cervical esophageal stricture
- [**6-/2102**] Underwent endoscopy for further dilation of cervical
esophageal stricture; c/b loss of prosthetic tooth, s/p foreign
body extraction in tracheobronchial tree
- PEG removed [**2102-12-13**]; PEG replaced (because of decreased PO
intake and weight loss) [**2103-3-12**].
PAST MEDICAL HISTORY:
- Prostatitis
- Anxiety
- Thrush
- Squamous cell carcinoma of the neck (unknown primary)
- s/p Right modified radical neck dissection w/deep left level
2A
jugular lymph node biopsy ([**10-26**])
- s/p G-tube placement ([**6-25**]), removed [**11/2102**]; replaced [**2103-3-12**]
- s/p chemo/radiation therapy for neck SCC
Social History:
Live with wife. Retired stage carpenter. 1.5 packs per day x 45
years (quit [**2100**]). Occasional EtOH prior to illness. No
illicits.
Family History:
- Mother had ovarian CA
- Sister has HTN
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T 97 79 114/63 21 96% 2L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: + Egophony on left, decreased tactile fremitus on left,
decreased breath sounds on left side
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: G tube site intact, 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
Discharge Vital signs:
T 98.1, HR 76Reg, BP 124/70, RR 20, O2 sats 94% RA
Discharge Exam:
Gen: pleasant in NAD. A & O x 4 without deficits
Lungs: slight crackles BLL, clear otherwise. R VATS
incisions.C/D/I
2 chest tubes to pneumostats with airleaks, double sutured
CV: RRR S1, S2, no MRG
Abd: soft, NT, ND, PEG intact
Ext: warm, trace gen. edema
Pertinent Results:
ADMISSION LABS:
.
[**2105-5-28**] 06:18PM BLOOD WBC-16.6*# RBC-3.33* Hgb-10.3* Hct-31.6*
MCV-95 MCH-31.0 MCHC-32.6 RDW-14.2 Plt Ct-332#
[**2105-5-28**] 06:18PM BLOOD Neuts-92.7* Lymphs-4.5* Monos-2.5 Eos-0.1
Baso-0.1
[**2105-5-28**] 06:18PM BLOOD PT-14.5* PTT-25.0 INR(PT)-1.3*
[**2105-5-28**] 06:18PM BLOOD ALT-42* AST-47* LD(LDH)-157 AlkPhos-299*
Amylase-21 TotBili-0.6
[**2105-5-28**] 06:18PM BLOOD Albumin-2.8* Calcium-8.0* Phos-2.7 Mg-2.3
[**2105-5-28**] 06:30PM BLOOD Lactate-1.2
.
DISCHARGE LABS:
[**2105-6-9**] 06:00PM BLOOD WBC-7.3 RBC-2.51* Hgb-8.0* Hct-24.2*
MCV-97 MCH-31.7 MCHC-32.8 RDW-17.2* Plt Ct-392
[**2105-5-28**] 06:18PM BLOOD WBC-16.6*# RBC-3.33* Hgb-10.3* Hct-31.6*
MCV-95 MCH-31.0 MCHC-32.6 RDW-14.2 Plt Ct-332#
[**2105-6-1**] 06:44PM BLOOD PT-16.7* PTT-27.5 INR(PT)-1.5*
[**2105-6-9**] 02:50PM BLOOD Glucose-99 UreaN-22* Creat-1.1 Na-140
K-4.4 Cl-102 HCO3-28 AnGap-14
[**2105-5-28**] 06:18PM BLOOD Glucose-122* UreaN-25* Creat-0.9 Na-132*
K-4.5 Cl-96 HCO3-25 AnGap-16
[**2105-6-6**] 04:06AM BLOOD ALT-25 AST-28 AlkPhos-142* TotBili-0.3
[**2105-5-28**] 06:18PM BLOOD ALT-42* AST-47* LD(LDH)-157 AlkPhos-299*
Amylase-21 TotBili-0.6
[**2105-5-30**] 05:40AM BLOOD calTIBC-118* VitB12-1706* Folate-15.9
Ferritn-1092* TRF-91*
.
[**2105-5-28**] CXR:
Large right hemithorax opacity which is presumably large at
least
partially loculated effusion with associated atelectasis.
Underlying
pneumonia or mass lesion is difficult to entirely exclude.
Consider CT scan for further evaluation.
[**2105-5-29**] (Pre-Thoracentesis) Chest CT:
1. Large loculated right pleural fluid collection, most likely
empyema, but incompleteley imaged, nodular right pleural
thickening and possible basal lung or pleural mass suggest
alternative diagnosis of malignant pleural effusion.
Thoracentesis should be diagnostic
2. Mediastinal lymphadenopathy.
3. Right upper lobe posterior segment pulmonary nodule, stable
from
[**2104-12-1**] exam.
[**2105-5-29**] Abdominal XR:
A PEG tube projects over the right mid abdomen. Contrast is seen
in the renal calices without dilation. The bowel gas pattern is
nonspecific without evidence of obstruction or ileus. There is
no free air. Opacity at the right lung base is better assessed
on CXR [**2105-5-28**] and CT [**2105-5-29**]. Osseous structures are intact.
No evidence of obstruction or free air.
[**2105-5-29**] (Post-Thoracentesis) Chest Ct:
Large right pleural effusion is decreased in size from [**2105-5-28**] exam.
Pigtail catheter projects over right lower lobe hemithorax.
Right lung base opacity likely represents atelectasis. Left lung
is clear. There is no left pleural effusion or pneumothorax. The
hilar and mediastinal silhouettes are unchanged. Heart size is
normal. Pulmonary vasculature is unremarkable. Moderate-to-large
right pleural effusion, slightly decreased in size from [**2105-5-28**]
exam.
[**2105-6-5**] Videoswallow:
IMPRESSION: Gross aspiration of both thin and nectar thick
barium
[**2105-6-9**] CXR: IMPRESSION:
Stable mild-to-moderate right hydropneumothorax without
significant change
compared to most recent prior.
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the ED on [**2105-5-28**] with nausea and
vomiting, and cough, found to have a large right sided pleural
effusion. He was admitted to the MICU team and started on
levaquin, flagyl and ceftriaxone. He was covered with
ceftriaxone/levofloxacin for CAP, flagyl for anaerobic coverage
for poor dentition. CT chest was performed on [**2105-5-29**] revealing
a Right locualted effusion and RUL stable lung nodule (from
[**11-28**]). The loculated effusion was tapped by IP for 160 cc on
[**5-29**] and then put out 90cc from pigtail drain before transfer to
floor and grew GPC in pairs and clusters on stain. Ceftriaxone
was subsequently discontinued given clinical stability. He was
taken to the OR by Dr. [**First Name (STitle) **] for Right video-assisted
thoracoscopic surgery decortication of lung and flexible
bronchoscopy on [**2105-6-1**].
He was brought out intubated on neosynephrine to the ICU under
the care of Thoracic surgery. He was diuresed and antibiotics
were changed to vancomycin and zosyn postop. He was diuresed and
eventually weaned of pressors and extubated on [**2105-6-4**]. He
transfered to the floor on [**2105-6-5**]. Below is a systems review of
his hospital course.
Pulmonary: Aggressive pulmonary toilet was continued with
nebulizers and incentive spirometry. He had three right sided
chest tubes to suction with ongoing airleak in the anterior and
posterior apical chest tubes. The basilar chest tube remained
without leak and was dc'd on [**2105-6-8**], with Stable
mild-to-moderate right hydropneumothorax without significant
change on chest xray. The two remaining chest tubes were placed
to pneumostats with ongoing airleaks.
CV: He remained in NSR with stable blood pressures out of the
unit.
GI/Nutrition:
Initial KUB was done for admission N/V, which revealed no
evidence of obstruction or free air. He was kept NPO with fluids
for hydration. Nutrition was consulted early on and he was
started on tube feedings via his G-tube for nutrition. On
[**2105-6-5**] he underwent videoswallow which he failed. He was kept
strict NPO with good oral care [**Hospital1 **], and tolerated isosource
advanced to goal cycled. He was continued on stool softeners and
had bowel movements. He was continued on PPI for his GERD. He
was changed to nutren 2.0 by dietary on [**6-9**] at a lower rate as
he had on and off nausea. Zofran was given and effective.
GU: A foley was placed for surgery and removed on [**2105-6-5**]. He
voided well thereafter. Electrolytes were watched and repleted.
ID: The patient was pancultured upon admission. Blood and urine
cultures were negative. The pleural fluid from initial tap and
OR cultures came back positive for strep anginois (milleri)
group. ID was consulted on [**2105-6-5**] and recommended changing
antibiotics to flagyl 500mg po TID and ceftriaxone 2 gram IV
daily. Abdominal CT was performed to assess for abdominal absess
on [**2105-6-6**] which was negative. PICC line was placed [**2105-6-3**]. ID
recommended 4-6 weeks of antibiotics depending on imaging.
Hyponatremia: Urine lytes show likely SIADH, in setting of
malignancy. This resolved. Postoperatively he received free
water boluses and his sodiums were Endo: Continued
levothyroxine throughout stay.
Pain: His pain has been controlled with short acting oral
morphine and tylenol.
He has been off wellbutrin x 9 days and wishes to stay off.
Attempts were made to contact wife with [**Name2 (NI) 107877**] # (Dr.
[**Last Name (STitle) **], but did not connect with psych. Pt was transferred off
wellbutrin and should followup with psychiatry regarding this,
especially if depressive symptoms return.
Lines: PICC placed on [**2105-6-3**] at 42 cm.
Dispo: Patient was accepted at [**Hospital3 **] for ongoing
support with tube feedings, chest tube management and IV
antibiotics. He should see Dr. [**First Name (STitle) **] with CT chest in two weeks.
He will followup with outpatient infectious disease as well.
Medications on Admission:
ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler - 2
puffs inhaled every 6 hours as needed for shortness of
breath/wheeze
BUPROPION HCL - (Prescribed by Other Provider) - 75 mg Tablet -
150 mg Tablet(s) by mouth twice daily
LANSOPRAZOLE - (Prescribed by Other Provider) - 30 mg
Tablet,Rapid Dissolve, DR - 1 Tablet(s) by mouth twice a day
LEVOTHYROXINE - (Prescribed by Other Provider) - 75 mcg Tablet
-
1 Tablet(s) by mouth daily
SILDENAFIL [VIAGRA] - (Prescribed by Other Provider) - Dosage
uncertain
TESTOSTERONE [TESTIM] - (Prescribed by Other Provider) - 50
mg/5
gram (1 %) Gel - once daily
Discharge Medications:
1. levothyroxine 75 mcg Tablet [**First Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
2. docusate sodium 50 mg/5 mL Liquid [**First Name (STitle) **]: Ten (10) ml PO BID (2
times a day).
3. senna 8.6 mg Tablet [**First Name (STitle) **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
4. morphine 15 mg Tablet [**First Name (STitle) **]: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
5. acetaminophen 650 mg/20.3 mL Solution [**First Name (STitle) **]: Twenty (20) ml PO
Q6H (every 6 hours) as needed for ha, pain.
6. metronidazole 500 mg Tablet [**First Name (STitle) **]: One (1) Tablet PO Q8H (every
8 hours): give via PEG.
7. 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.
8. 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.
9. CeftriaXONE 2 gm IV Q24H
10. ZOFRAN ODT 8 mg Tablet, Rapid Dissolve [**First Name (STitle) **]: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for nausea.
11. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] twice a day.
12. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Last Name (STitle) **]:
Two (2) puffs inh Inhalation every four (4) hours as needed for
shortness of breath or wheezing.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital - [**Hospital1 8**]
Discharge Diagnosis:
Right step milleri empyema with two remaining chest tubes for
air leak
Hyponatremia resolved
Nausea
Hypothyroid on synthroid with normal TSH [**4-29**]
Squamous cell carcinoma of R head and neck, s/p radiation
Central-lobular emphysema
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 treated in the medical intensive care unit and regular
medicine floor after you were found to have fluid in the area
around your lungs. You were taken to the operating room where
cultures revealed strep milleri. You are on antibiotics and have
chest tubes for drainage and until air leaks resolve.
Call Dr.[**Name (NI) 5067**] office at [**Telephone/Fax (1) 2348**] if you have have fevers
greater than 101.5, chills, worsening cough, shortness of
breath.
Call if your right incisions develop redness, swelling or
drainage.
Chest tubes:
Two chest tubes remain (anterior and posterior apical) to
pneumostats with airleaks. Drain twice a day and keep recordings
of outputs.
If these fall out notify us immediately as pt may develop
worsening pneumothoraces.
Change dressing around chest tube site daily and as needed.
PEG tube: Change dressing daily.
PICC line care per protocol.
Antibiotics continue until ID stops.
Weekly labs: CBC, BUN/Creatinine, LFT's. Fax to [**Telephone/Fax (1) 1419**]
Followup Instructions:
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2105-6-23**] 10:00
[**Hospital Ward Name 23**] [**Location (un) **] [**Hospital Ward Name **]
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD Phone:[**0-0-**]
Date/Time:[**2105-6-23**] 11:30 [**Hospital1 18**] [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] [**Location (un) **]
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2105-7-6**]
9:50 LMOB [**Last Name (NamePattern1) **]. (Infectious disease)
Completed by:[**2105-6-10**]
|
[
"262",
"276.51",
"244.9",
"311",
"V10.01",
"510.9",
"530.81",
"492.8",
"507.0",
"253.6",
"787.01",
"041.09",
"285.9",
"V44.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.91",
"34.52",
"33.23",
"38.97",
"96.71",
"96.6",
"96.05",
"34.04"
] |
icd9pcs
|
[
[
[]
]
] |
13721, 13792
|
7577, 11568
|
334, 439
|
14072, 14072
|
4452, 4452
|
15278, 15900
|
3462, 3505
|
12232, 13698
|
13813, 14051
|
11594, 12209
|
14248, 15255
|
4956, 7554
|
3545, 4158
|
4174, 4433
|
244, 296
|
467, 1393
|
4468, 4940
|
14087, 14224
|
2967, 3292
|
3308, 3446
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,222
| 101,136
|
375+384
|
Discharge summary
|
report+report
|
Admission Date: [**2163-2-22**] Discharge Date: [**2163-2-27**]
Date of Birth: [**2086-12-13**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Percocet / Lipitor / Zocor
Attending:[**First Name3 (LF) 2291**]
Chief Complaint:
fatigue, anorexia, worsening lung lesions from imaging
Major Surgical or Invasive Procedure:
Bronchoscopy with biopsy and BAL
Pigtail catheter placement to treat iatrogenic pneumothorax
History of Present Illness:
76 year old female with h/o hypothyoidism, HTN/HLP, AAA repair
in past with notable known lung adenoCA and new RLL lung mass
which has enlarged in size over the last 4 months, being
followed by Dr. [**Last Name (STitle) **] in oncology, who presented to Dr.[**Name (NI) 3371**]
clinic today for follow-up of recent multiple ground glass
opacities and recent biopsy of RL lung with c/o progressive
night sweats, anorexia, weakness. Pt is being admitted directly
from oncology clinic for further evaluation and inability to
care for herself at home secondary to weakness. Notable results
from recent biopsy revealed new squamous cell CA (different than
prior adenoCA).
.
Regarding the patient's symptoms - noted last seen by Dr. [**Last Name (STitle) **]
3wks prior - with progressive symptoms of fatigue, wt loss (10
lb past 6 mo), NS, decreasing BP with PCP down titrating BP meds
recently. Overall symptoms had started [**4-10**] mo ago with
rhinorrea, dry cough, ear pain all without fevers - tx with
several courses of azithromycin/levofloxacin. In addition with
progressive fatigue - pt with further difficulty ambulating 50m
more due to gen decreased strength, no focal symptoms, does have
mild DOE without SOB at rest, productive cough/hemopytosis. Pt
with general mild mid-lower back pain without any current CP
complaints presently. Pt denies any current ear pain, HA, or
sinus complaints. Note patient has not taken any of her home
medication yet today at time of evaluation.
.
ROS: Denies skin changes, changes in urination or bowels,
otherwise 10-point ROS is negative except as detailed above.
Past Medical History:
Onc PHMx:
.
1. Stage I adenocarcinoma of the lung, 1.5 cm in [**2154**] (stage
IA).
Did not receive adjuvant therapy. Tumor harbors had a KRAS
mutation and was EGFR wild-type.
2. Multiple pulmonary ground glass opacities with indolent
growth
pattern (unclear etiology, thought to be possible
adenocarcinomas) since [**2154**].
3. Stage I (T1c, N0, M0), ER/PR positive, HER-2/neu positive
breast cancer of the left breast in [**2148**].
4. Possible early stage squamous cell carcinoma of the lung
diagnosed on [**2163-2-11**] (growing right lower lobe lesion).
.
TREATMENTS:
1. Status post adjuvant hormone therapy (tamoxifen) from [**2148**] to
[**2150**] for her stage I breast cancer.
2. Status post right lower lobe wedge resection in [**2155-1-27**].
3. Status post erlotinib 150 mg/day from [**4-2**] to [**2156-4-22**]
(intolerant to medication due to grade [**2-6**] rash).
.
PMHx:
.
- hypothyroidism
- osteoporosis
- HTN
- HLD
- hiatal hernia and GERD
- AAA s/p repair [**2132**], then [**2134**] with concurrent b/l fem-[**Doctor Last Name **]
bypasses with complicated post-op course
- h/o peritonitis [**2134**]
- h/o SBO [**1-6**] abdominal adhesions in [**2132**]
- s/p cholecystectomy [**2138**]
- depression [**2153**]
- Lung adenocarcinoma stage 1, s/p RLL wedge resection [**2154**], no
adjuvant tx, multiple pulm ground glass opacities with very
indolent growth pattern ? bronchioloalveolar carcinoma since
[**2154**], s/p erlotinib
- Stage 1 ER/PR+, HER2/neu + breast ca of left breast in [**2148**],
s/p tamoxifen
- cervical myelopathy
Social History:
Prior smoker. Approximately 50 pack-years. Quit in [**2140**]. Lives
with husband. Married. [**Name2 (NI) **] 2 children. She is currently retired
but previously worked in payroll.
Family History:
She has a daughter who was diagnosed with breast cancer at the
age of 38. The daughter is a thoracic nurse [**First Name (Titles) **] [**Name (NI) 3372**]. Daughter has undergone genetic testing and is
BRCA1 and 2 negative. There is no family history of ovarian
cancer. Her father died at the age of 53 of pancreatic cancer.
There is a strong family history of coronary artery disease and
cerebrovascular disease.
Physical Exam:
VITAL SIGNS:
.
98.1 150/60 69 16 100% RA
Wt: 112.2 lb
.
GENERAL: NAD, Lying in bed. AA0 x 3.
SKIN: No new rashes.
HEENT: No lesions. Anicteric sclerae. Oropharynx is clear. No
palor or jaundice.
NECK: Supple, No LAD.
CHEST: no crackles, mild end exp wheezing in R fields,
otherwise clear.
CARDIAC: Regular rate and rhythm. [**12-10**] hsm, no r/g
ABDOMEN: Soft, nontender, and nondistended, noted old scars,
BS+.
EXTREMITIES: No edema. Pulses symmetric.
PHYSCH: Normal affect.
NEURO: Non-focal motor exam, motor strength 5+ in upper and
lower
extremities, sensory exam symmetric.
Pertinent Results:
MR HEAD W & W/O CONTRAST Study Date of [**2163-2-23**] IMPRESSION:
Stable MRI examination of the brain with no evidence of
leptomeningeal
disease.
[**2163-2-25**] - bronchoscopy report
Impression: 76 year old woman with history of squamous cell
carcinoma of the lung now with new lung mass, underwent flexible
bronchoscopy with transbronchial biopsies under fluoroscopy, and
bronchoalveolar lavage, also endobronchial ultrasound with
transbronchial needle aspiration. Transbronchial biopsies taken
from the right middle lobe lateral segment, and right upper lobe
anterior segment. BAL taken from right upper lobe anterior
segment. TBNA taken from station 7. Patient tolerated the
procedure well, with no complications.
Recommendations: Follow up with Dr [**Last Name (STitle) 3373**] on [**3-3**]
Follow up cytology and pathology
[**2163-2-22**] 02:25PM BLOOD WBC-13.0* RBC-3.12* Hgb-9.2* Hct-28.0*
MCV-90 MCH-29.4 MCHC-32.8 RDW-12.5 Plt Ct-402
[**2163-2-23**] 06:00AM BLOOD WBC-13.7* RBC-3.14* Hgb-9.2* Hct-28.4*
MCV-90 MCH-29.2 MCHC-32.3 RDW-12.6 Plt Ct-430
[**2163-2-23**] 06:00AM BLOOD Neuts-69.3 Lymphs-12.6* Monos-6.6
Eos-10.9* Baso-0.6
[**2163-2-24**] 11:15AM BLOOD PT-12.9* PTT-26.6 INR(PT)-1.2*
[**2163-2-22**] 02:25PM BLOOD ESR-107* Gran Ct-[**Numeric Identifier 3374**]*
[**2163-2-22**] 02:25PM BLOOD UreaN-16 Creat-0.8 Na-126* K-5.0 Cl-94*
HCO3-20* AnGap-17
[**2163-2-23**] 06:00AM BLOOD Glucose-106* UreaN-11 Creat-0.9 Na-132*
K-4.3 Cl-101 HCO3-20* AnGap-15
[**2163-2-24**] 06:06AM BLOOD Glucose-105* UreaN-11 Creat-0.9 Na-133
K-4.5 Cl-102 HCO3-21* AnGap-15
[**2163-2-22**] 02:25PM BLOOD ALT-12 AST-17 AlkPhos-82 TotBili-0.3
[**2163-2-22**] 02:25PM BLOOD Albumin-3.5 Calcium-8.7 Phos-3.3 Mg-2.0
[**2163-2-22**] 02:25PM BLOOD RheuFac-10
[**2163-2-23**] 11:00AM BLOOD B-GLUCAN-negative
[**2163-2-23**] 11:00AM BLOOD ASPERGILLUS GALACTOMANNAN
ANTIGEN-Negative
URINE CULTURE (Final [**2163-2-23**]): <10,000 organisms/ml.
____________________________________
PENDING:
Pathology Tissue: RIGHT MIDDLE LOBE MASS
Cytology TBNA EBUS 7
Cytology BRONCHIAL WASHINGS
[**2163-2-22**] BLOOD CULTURE, Routine-PENDING [**Last Name (LF) 831**],[**First Name3 (LF) **]
[**2163-2-22**] BLOOD CULTURE ( MYCO/F LYTIC BOTTLE)
BLOOD/FUNGAL CULTURE-PRELIMINARY; BLOOD/AFB CULTURE-PRELIMINARY
[**2163-2-25**] 2:30 pm BRONCHOALVEOLAR LAVAGE RIGHT UPPER LOBE
BAL.
GRAM STAIN (Preliminary): 1+ PMN's, no organisms.
RESPIRATORY CULTURE (Preliminary): 10,000-100,000
ORGANISMS/ML. Commensal Respiratory Flora
ACID FAST SMEAR (Preliminary): negative direct AFB smear,
concentrated smear pending
ACID FAST CULTURE (Preliminary): pending
FUNGAL CULTURE (Preliminary): pending
.
Urine studies:
[**2163-2-22**] 03:10PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.005
[**2163-2-22**] 03:10PM URINE RBC-<1 WBC-0 Bacteri-NONE Yeast-NONE
Epi-0
[**2163-2-22**] 10:54PM URINE Hours-RANDOM Creat-47 Na-80 K-17 Cl-75
[**2163-2-22**] 10:54PM URINE Osmolal-350
Brief Hospital Course:
76 year old female with h/o hypothyoidism, HTN/HLP, AAA repair
in past, known prior stage I lung adenoCA (pt of Dr. [**Last Name (STitle) **] s/p
limited resection 04' with now new RLL lung mass along with
multiple ground glass opacities with new RLL lesion biopsied
showing new squamous cell CA, was admitted for evaluation of
recent progressive sx of night sweats, anorexia, weakness with
decreased ability to care for self.
.
.
# Anorexia, Fatigue, nightsweats, mild DOE
# Eosinophilia
Given the subacute nature of her presentation and climbing
eosinophilia, there was concern for the possibility of fungal
lung infection. Interventional Pulmonary was consulted, and pt
underwent flexible bronchoscopy with biopsies and BAL for micro.
She tolerated the procedure well, but had a pneumothorax
following the procedure. A follow up repeat CXR was obtained,
which showed an increase in the size of the pneumothorax, and
therefore Interventional Pulmonary placed a pigtail catheter to
treat. Her pneumothorax remained stable with the chest tube in
place, and the chest tube was removed on the day of discharge.
She will follow up with Dr. [**Last Name (STitle) **] as an outpatient for the
results from the bronchoscopy.
Her serum galactomannan and beta-glucan are negative. All her
culture data is negative to date, but final results are still
pending.
.
# Lung CA - prior slow progressive adenoCA with now noted new,
more aggressive squammous cell CA.
After d/w Dr. [**Last Name (STitle) **], he was concerned about possible
leptomeningeal spread of malignancy given her constellation of
symptoms, and he requested MRI head. MRI head was performed,
which did not show any e/o malignancy, and specifically did not
show any leptomeningeal disease. She will follow up as an
outpatient for further evaluation and management of her
malignancy, and follow up of pending bronch biopsies.
.
# Hyponatremia/SIADH
Pt was noted to have hyponatremia on presentation, with sodium
126. Urine studies were obtained, and confirmed the hyponatremia
was consistent with SIADH. She was placed on 1200 cc fluid
restriction, and her sodium subsequently improved. She was
discharged with recommendations for ongoing fluid restriction of
1500cc. She should have her sodium rechecked at her next
clinical appointment.
.
# Hypothyroidism - continued home dose synthroid in-house.
.
# HLP - continued home dose lovastatin
.
# HTN
- continued home BP regimen (metoprolol, enalpril, amlodipine).
.
FEN: regular diet, nutrition consult
Proph: heparin
Disp: discharged to home
Medications on Admission:
ALPRAZOLAM - 0.5 mg Tablet - [**12-6**] Tablet(s) by mouth qhs prn
AMLODIPINE - (Prescribed by Other Provider) - 5 mg Tablet - 1
Tablet(s) by mouth qam (NO LONGER TAKING PER PT)
AMLODIPINE - (Prescribed by Other Provider) - 2.5 mg Tablet - 1
Tablet(s) by mouth at bedtime
BENZONATATE - 200 mg Capsule - 1 Capsule(s) by mouth q 8hr as
needed for cough (NOT NEEDING AS OFTEN)
ENALAPRIL MALEATE - 10 mg Tablet - 1 Tablet(s) by mouth twice a
day
FLUTICASONE - 50 mcg Spray, Suspension - 1 spray(s) nasally once
a day each nostril (NOT NEEDING PER PT)
LEVOTHYROXINE - (Prescribed by Other Provider; Dose adjustment
-
no new Rx) - 88 mcg Tablet - 1 Tablet(s) by mouth once a day
LOVASTATIN - 40 mg Tablet - 2 Tablet(s) by mouth once a day
METOPROLOL TARTRATE - (Prescribed by Other Provider) - 25 mg
Tablet - 1 Tablet(s) by mouth once a day, [**12-6**] tab in evening
SERTRALINE [ZOLOFT] - 100 mg Tablet - 1 Tablet(s) by mouth once
a
day
Medications - OTC
ASPIRIN - (OTC) - 81 mg Tablet, Chewable - 1 Tablet(s) by mouth
once a day
COENZYME Q10 [CO Q-10] - (OTC) - Dosage uncertain
DOCUSATE SODIUM [COLACE] - (Prescribed by Other Provider) - 100
mg Capsule - 2 Capsule(s) by mouth once daily
SALMON OIL-OMEGA-3 FATTY ACIDS [FISH OIL] - (OTC) - 500 mg-100
mg Capsule - 1 Capsule(s) by mouth daily
--------------- --------------- ---------------
Discharge Medications:
1. alprazolam 0.5 mg Tablet Sig: 1-2 Tablets PO at bedtime as
needed for insomnia.
2. amlodipine 5 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
3. benzonatate 100 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day) as needed for cough.
4. enalapril maleate 10 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. lovastatin 40 mg Tablet Sig: Two (2) Tablet PO once a day.
7. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO QHS (once
a day (at bedtime)).
9. sertraline 100 mg Tablet Sig: One (1) Tablet PO once a day.
10. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily): restart on [**3-2**].
11. coenzyme Q10 Oral
12. docusate sodium 100 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
13. salmon oil-omega-3 fatty acids 500-100 mg Capsule Sig: One
(1) Capsule PO once a day.
14. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO at bedtime.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*1*
15. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
# Anorexia, Fatigue, nightsweats, mild DOE
# Eosinophilia
# Concern for possible pulmonary fungal disease
# Lung cancer
# Hyponatremia/SIADH
# Pneumothorax s/p bronchoscopy with BAL/Biopsy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were hospitalized for evaluation of your progressive
symptoms of night sweats, poor appetite, fatigue, and weakness.
There is concern for possible fungal infection in your lungs,
and you underwent bronchoscopy for biopsies and labs to further
evaluate. The results from these tests are still pending, and
you will need to follow up with Dr. [**Last Name (STitle) **] for these results and
next steps.
.
You also had an MRI of your head, which did not show any
evidence of cancer.
.
You were found to have a pneumothorax following your
bronchoscopy procedure, and a catheter was placed to treat this.
The pneumothorax was stable, and the catheter was removed.
.
You were also found to have low sodium levels, likely due to a
syndrome known as SIADH. Your sodium levels have corrected with
fluid restriction. We recommend you continue with fluid
restriction of 1500ml/day.
.
You had your AM amlodipine STOPPED on this admission, as you
reported that you had been having low BP's as an outpt, and that
you had stopped taking your AM amlopdipine. Your blood pressure
has been in good range during this hospitalization. We recommend
you continue to HOLD your AM amlodipine.
.
Please follow-up with your physicians as instructed below.
.
Please take your medications as prescribed below.
.
Followup Instructions:
Department: [**Hospital **] MEDICAL GROUP
Specialty: Primary Care
When: FRIDAY [**2163-3-4**] at 1 PM
With: DR. [**First Name8 (NamePattern2) 132**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 133**]
Building: [**Street Address(2) 3375**] ([**Location (un) **], MA) [**Location (un) 858**]
Campus: OFF CAMPUS Best Parking: On Street Parking
Name: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD, PHD
Specialty: Hematology/Oncology
Location: [**Hospital1 18**]-DIVISION OF HEMATOLOGY/ONCOLOGY
Address: [**Location (un) **], [**Hospital Ward Name **] 9, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**0-0-**]
We are working on a follow up appointment with Dr. [**Last Name (STitle) **] in the
next 9-15 days. You will be called at home with the appointment.
If you have not heard within 2 business days or have questions,
please call [**0-0-**].
Admission Date: [**2163-2-28**] Discharge Date: [**2163-3-7**]
Date of Birth: [**2086-12-13**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Percocet / Lipitor / Zocor /
Levaquin
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
arterial line
History of Present Illness:
76 year old female with h/o hypothyoidism, HTN/HLP, AAA repair
in past with notable known lung adenoCA and new RLL lung mass
which has enlarged in size over the last 4 months, being
followed by Dr. [**Last Name (STitle) **] in oncology, was discharged yesterday
after admission for bronchoscopy, c/b pneumothorax for which a
pigtail was placed (removed at time of discharge). Tonight was
home, noted to have increased cough with rusty colored sputum
and fever to 102. Also seemed to be more lethargic to family
members. FSG 97 for EMS. Sats low 90's on 3L nc.
.
ED Course: Initial Vitals/Trigger: 102, 97/37, 17, 94% 6L nc.
Chest xray notable for possible increased patchy opacity R lung.
Labs notable for WBC 16.7 (N 82.2), Na 128, Creat 2.1, lactate
0.9, Hct 29.2. UA wnl. Sputum, blood, and urine cultures sent.
She was given 3L IVF NS, and started on empiric IV abx coverage
with cefepime 1g, vancomycin 1g, and levofloxacin 750mg IV. She
received benadryl for extremity erythema and itching during
peri-administration with vancomycin - slowed rate of infusion as
well. She received tylenol for fever 102 in the ED. IP fellow
was notified about re-presentation.
Admission Vitals: 90, 91/25, 12, 93% 5L nc. Access: 18G x2.
Received 3L NS IVF.
.
On arrival to the ICU, pt is sedated secondary to benadryl (per
daughter) but easily arousable. Daughter says that mental status
improved after IVF and abx administration in the ED with
increased somnolence after IV benadryl administration. Daughter
and pt confirm the above story.
.
Review of systems:
(+) Per HPI
(-) Denies night sweats, recent weight loss or gain. Denies
headache, sinus tenderness, rhinorrhea or congestion. Denies
chest pain, chest pressure, palpitations, or weakness. Denies
nausea, vomiting, diarrhea, constipation, abdominal pain, or
changes in bowel habits. Denies dysuria, frequency, or urgency.
Denies arthralgias or myalgias. Denies rashes or skin changes.
Past Medical History:
Onc PHMx:
.
1. Stage I adenocarcinoma of the lung, 1.5 cm in [**2154**] (stage
IA).
Did not receive adjuvant therapy. Tumor harbors had a KRAS
mutation and was EGFR wild-type.
2. Multiple pulmonary ground glass opacities with indolent
growth
pattern (unclear etiology, thought to be possible
adenocarcinomas) since [**2154**].
3. Stage I (T1c, N0, M0), ER/PR positive, HER-2/neu positive
breast cancer of the left breast in [**2148**].
4. Possible early stage squamous cell carcinoma of the lung
diagnosed on [**2163-2-11**] (growing right lower lobe lesion).
.
TREATMENTS:
1. Status post adjuvant hormone therapy (tamoxifen) from [**2148**] to
[**2150**] for her stage I breast cancer.
2. Status post right lower lobe wedge resection in [**2155-1-27**].
3. Status post erlotinib 150 mg/day from [**4-2**] to [**2156-4-22**]
(intolerant to medication due to grade [**2-6**] rash).
.
PMHx:
.
- hypothyroidism
- osteoporosis
- HTN
- HLD
- hiatal hernia and GERD
- AAA s/p repair [**2132**], then [**2134**] with concurrent b/l fem-[**Doctor Last Name **]
bypasses with complicated post-op course
- h/o peritonitis [**2134**]
- h/o SBO [**1-6**] abdominal adhesions in [**2132**]
- s/p cholecystectomy [**2138**]
- depression [**2153**]
- Lung adenocarcinoma stage 1, s/p RLL wedge resection [**2154**], no
adjuvant tx, multiple pulm ground glass opacities with very
indolent growth pattern ? bronchioloalveolar carcinoma since
[**2154**], s/p erlotinib
- Stage 1 ER/PR+, HER2/neu + breast ca of left breast in [**2148**],
s/p tamoxifen
- cervical myelopathy
Social History:
Prior smoker. Approximately 50 pack-years. Quit in [**2140**]. Lives
with husband. Married. [**Name2 (NI) **] 2 children. She is currently retired
but previously worked in payroll.
Family History:
She has a daughter who was diagnosed with breast cancer at the
age of 38. The daughter is a thoracic nurse [**First Name (Titles) **] [**Name (NI) 3372**]. Daughter has undergone genetic testing and is
BRCA1 and 2 negative. There is no family history of ovarian
cancer. Her father died at the age of 53 of pancreatic cancer.
There is a strong family history of coronary artery disease and
cerebrovascular disease.
Physical Exam:
ADMISSION PHYSICAL EXAM:
General: Alert, oriented, thin elderly female no acute distress,
drowsy but easily arousable
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: right sided bandage over former pigtail site, diffuse
rhonchi with occasional expiratory wheezes, rales b/l extending
to R mid lung field and L base
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
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Pertinent Labs:
[**2163-2-27**] 06:43AM BLOOD WBC-14.7* RBC-3.19* Hgb-9.5* Hct-29.2*
MCV-91 MCH-29.8 MCHC-32.6 RDW-12.7 Plt Ct-483*
[**2163-2-27**] 06:43AM BLOOD Neuts-73.6* Lymphs-14.2* Monos-4.0
Eos-7.6* Baso-0.5
[**2163-3-1**] 02:56AM BLOOD PT-13.5* PTT-29.1 INR(PT)-1.3*
[**2163-2-27**] 06:43AM BLOOD Glucose-110* UreaN-10 Creat-0.8 Na-133
K-4.3 Cl-97 HCO3-28 AnGap-12
[**2163-2-27**] 06:43AM BLOOD Calcium-9.2 Phos-3.2 Mg-2.0
[**2163-2-28**] 10:42AM BLOOD Hapto-293*
[**2163-2-28**] 04:00PM BLOOD Cortsol-35.0*
[**2163-2-28**] 03:00PM BLOOD Cortsol-11.5
[**2163-2-28**] 10:42AM BLOOD Cortsol-14.9
[**2163-2-28**] 05:51AM BLOOD Lactate-0.9
[**2163-2-28**] 05:55AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.012
[**2163-2-28**] 05:55AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
[**2163-2-28**] 05:55AM URINE RBC-0 WBC-<1 Bacteri-NONE Yeast-NONE
Epi-<1
Micro:
URINE CULTURE (Final [**2163-3-1**]): NO GROWTH
Imaging:
CHEST (PORTABLE AP) Study Date of [**2163-2-27**] 10:02 AM
FINDINGS: In comparison with the study of [**2-26**], there is little
change in the
minimal right apical pneumothorax. Pigtail catheter remains in
place. Some
areas of increased opacification was seen in the right mid and
lower zones,
consistent most likely with atelectasis.
CHEST (PORTABLE AP) Study Date of [**2163-2-27**] 1:55 PM
FINDINGS: In comparison with the earlier study of this date,
there is no
change in the small apical pneumothorax on the right following
clamping of the chest tube.
Portable TTE (Complete) Done [**2163-2-28**] at 2:38:43 PM FINAL
Conclusions
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). Right ventricular chamber size and free wall
motion are normal. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic stenosis or aortic regurgitation. The mitral valve
leaflets are structurally normal. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. There is mild
to moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Normal biventricular cavity sizes with preserved
global and regional biventricular systolic function.
Mild-moderate pulmonary artery systolic hypertension. Mild
mitral regurgitation.
Compared with the prior study (images reviewed) of [**2162-11-4**],
the severity of tricuspid regurgitation has increased.
CHEST (PORTABLE AP) Study Date of [**2163-2-28**] 5:32 AM
FINDINGS: There has been interval removal of right-sided pigtail
catheter.
Tiny right apical pneumothorax likely still persists. Bilateral
areas of
atelectasis are again noted to be increased bilaterally and
there maty be
increasing vascular congestion. Otherwise, little change in
comparison to
prior study from yesterday.
Brief Hospital Course:
76 year old female with h/o hypothyoidism, HTN/HL, AAA s/p
repair, known prior stage I lung adenoCA s/p limited resection
with new RLL lung mass along with multiple ground glass
opacities with new RLL lesion showing new squamous cell CA,
admitted with hypotensiona and fever concerning for pna.
The patient was admitted with hypotension, fever, and
leukocytosis. Her admission labs and chest xray were concerning
for the development of a healthcare-associated pneumonia (she
underwent bronchoscopy a couple of days prior to admission) and
she was treated with broad spectrum antibiotics.
Ms. [**Known lastname 3441**] [**Last Name (NamePattern1) 3442**] septic physiology which was initially
responsive to IV fluid resuscitation in the ICU. Despite
treatment with antibitoics, however, she developed worsening
hypoxia and respiratory distress which required intubation. She
became intermittently hypotensive while intubated and required
vasopressors.
Her ICU course was complicated by bilateral infiltrates on chest
xray which were ultimately thought to represent ARDS vs.
pulmonary edema. She also suffered a demand myocardial
infarction in the ICU with resultant apical hypokinesis on
echocardiography. Cardiology was consulted and the patient was
treated along the ACS pathway.
Given her underlying cancer, which was known to be progressing,
and the severity of her acute illness with refractory
respiratory failure, possible ARDS, and ongoing hypotension,
many family meetings took place with members of the ICU team.
In keeping with the patient's wishes, the [**Known lastname 3441**] family decided to
focus on comfort and withdraw life-supporting. She was
terminally extubated on [**2163-3-7**].
Medications on Admission:
N/A
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
N/A
Discharge Condition:
N/A
Discharge Instructions:
N/A
Followup Instructions:
N/A
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"288.3",
"E930.8",
"512.1",
"244.9",
"584.9",
"272.0",
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"253.6",
"995.92",
"428.0",
"518.81",
"162.8",
"410.71",
"401.9",
"416.8",
"038.9",
"E878.8",
"482.9",
"693.0",
"428.21"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
25806, 25815
|
24010, 25724
|
16087, 16102
|
25862, 25867
|
20941, 20941
|
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19860, 20280
|
25778, 25783
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25836, 25841
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25750, 25755
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20320, 20922
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7601, 7612
|
7642, 7939
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7418, 7568
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17681, 18066
|
16042, 16049
|
16130, 17662
|
13391, 13503
|
20957, 23987
|
18088, 19645
|
19661, 19844
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,871
| 154,638
|
38561
|
Discharge summary
|
report
|
Admission Date: [**2128-5-25**] Discharge Date: [**2128-6-3**]
Date of Birth: [**2072-2-28**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
shortness of breath with exertion
Major Surgical or Invasive Procedure:
Patch clousre of right sinus of Valsalva aneurysm [**2128-5-25**]
History of Present Illness:
56 year old male with known right sinus of Valsalva aneurysm and
mildly dilated Aortic root and minimally dilated ascending
aorta. Followed with serial
echocardiograms and CT scans. The echocardiograms for several
years leading up to visit in [**2125**] showed pretty stable aneurysm
measuring approximately 5.2cm. Recommendation was no surgery and
follow-up in 1 year with repeat CT and Echo. Recently underwent
CT scan in [**2128-1-22**] but given lack of contrast, it was
difficult to assess the sinuses of Valsalva. Aorta measured
4.0cm
at level of main pulmonary artery. He underwent an echo
which revealed the aorta at the level of the sinus measured
6.1cm. He was underwent cardiac catheterization in
preperation for surgical repair and found to have clean
coronaries.
He is admitted for surgical repair.
Past Medical History:
Right sinus of Valsalva aneurysm Aortic root dilatation COPD
Hypertension Rheumatoid arthritis Seizures (last one over 10
years ago)Possible Gout
Social History:
Lives with:Divorced with four children. One of his sons lives
with him
Occupation:Works as a custodian
Cigarettes: Smoked no [] yes [x] Hx:smoked up to 2ppd for about
25 years. He quit 12 years ago
Other Tobacco use:denies
ETOH: < 1 drink/week [x] [**12-30**] drinks/week [] >8 drinks/week []
Illicit drug use:denies
Family History:
Premature coronary artery disease- Uncle with "heart disease".
Mother with hypertension
Physical Exam:
Pulse:74 Resp:18 O2 sat:96/RA
B/P Right: 119/83 Left: 117/81
Height:5'8" Weight:181 lbs
General:
Skin: Dry [x] intact [x] Macular rash on chest, patchy rash left
forearm, left shoulder x several years (eczema)
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema-none
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right:2+ Left:2+
DP Right:2+ Left:2+
PT [**Name (NI) 167**]:2+ Left:2+
Radial Right:2+ Left:2+
Carotid Bruit Right: Left:
no bruits
Pertinent Results:
ECHO:
PRE-BYPASS:
The left atrium is normal in size. No spontaneous echo contrast
or thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler.
Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Due to suboptimal
transgastric technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function is low normal (LVEF 50-55%).
Right ventricular chamber size and free wall motion are normal.
The aortic root is severely 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 stenosis or aortic regurgitation. The mitral valve
leaflets are mildly thickened. Trivial mitral regurgitation is
seen.
There is no pericardial effusion.
There was a 2cm x 2cm [**Location (un) 49109**] aneurysm of the right coronary
sinus with a broad neck. No associated VSDs seen.
Dr. [**Last Name (STitle) **] was notified in person of the results before
surgical incsion.
Post Bypass:
Preserved biventricular systolic function.
LVEF 55%.
No valvular findings.
Intact thoracic aorta.
The sinus patch appears intact and no flow across. The old
aneurysm appears to be excluded from the main
flow.
[**2128-6-3**] 05:10AM BLOOD WBC-7.7 RBC-3.23* Hgb-10.4* Hct-30.8*
MCV-95 MCH-32.2* MCHC-33.8 RDW-13.2 Plt Ct-315
[**2128-5-25**] 10:44AM BLOOD WBC-16.0*# RBC-2.81*# Hgb-9.1*#
Hct-26.8*# MCV-95 MCH-32.5* MCHC-34.1 RDW-13.2 Plt Ct-138*
[**2128-5-26**] 04:47AM BLOOD PT-12.1 PTT-27.1 INR(PT)-1.1
[**2128-6-3**] 05:10AM BLOOD Glucose-90 UreaN-16 Creat-0.8 Na-137
K-4.0 Cl-101 HCO3-29 AnGap-11
[**2128-5-25**] 11:53AM BLOOD UreaN-17 Creat-0.9 Na-141 K-4.8 Cl-108
HCO3-29 AnGap-9
Brief Hospital Course:
As mentioned in the HPI, Mr. [**Known lastname **] is 56 year old male with
known right sinus of Valsalva aneurysm and mildly dilated Aortic
root and minimally dilated ascending aorta. Followed with serial
echocardiograms and CT scans. The echocardiograms showed
increased aneurysm size and surgerical repair was advised.
During the pre-op work up a diagnostic cardiac cath was done on
[**4-8**] showed non- significant coronary disease.
On [**5-25**] he was brought to the operating room where he underwent a
patch closure of his right sinus of valsalva. Please see
operative report for surgical details. Following surgery he was
transferred to the CVICU for invasive monitoring in stable
condition. Later that day he was weaned from sedation, awoke
neurologically intact and extubated. He was started on lopressor
and lasix. Chest tubes and temporary pacing wires were removed
per protocol. He did develop an ileus. General surgery was
consulted. The patient was kept NPO on IVF with an NGT. Ileus
resolved and the patient's diet was advanced as tolerated.
Additionally, he developed pain in the left foot. XRay showed
no fracture or bony abnormality detected.
He was evaluated by physical therapy for strength and
conditioning and cleared for discharge to home on POD#9. All
instructions and appointments were advised.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Lisinopril 10 mg PO DAILY
2. Hydroxychloroquine Sulfate 200 mg PO BID
3. Metoprolol Tartrate 100 mg PO BID
4. Phenytoin Sodium Extended 400 mg PO DAILY
5. Budesonide (Nasal) *NF* 2 puff NU [**Hospital1 **]
Discharge Medications:
1. Aspirin EC 81 mg PO DAILY
RX *Enteric Coated Aspirin 81 mg 1 tablet(s) by mouth DAILY Disp
#*60 Tablet Refills:*2
2. Metoprolol Tartrate 37.5 mg PO TID
RX *metoprolol tartrate 25 mg 1.5 tablet(s) by mouth three times
a day Disp #*90 Tablet Refills:*2
3. Hydroxychloroquine Sulfate 200 mg PO BID
RX *hydroxychloroquine 200 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*2
4. Docusate Sodium 100 mg PO BID
RX *Colace 100 mg 1 capsule(s) by mouth twice a day Disp #*60
Tablet Refills:*2
5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH [**Hospital1 **]
RX *Advair Diskus 250 mcg-50 mcg/Dose 1 PUFF INH twice a day
Disp #*1 Inhaler Refills:*1
6. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth DAILY Disp #*60 Tube
Refills:*2
7. Budesonide (Nasal) *NF* 2 puff NU [**Hospital1 **]
RX *budesonide 2 PUFFS twice a day Disp #*1 Inhaler Refills:*0
8. Metoclopramide 10 mg PO QIDACHS Duration: 5 Days
RX *metoclopramide HCl 10 mg 1 tablet(s) by mouth qidachs Disp
#*20 Tablet Refills:*2
9. Phenytoin Sodium Extended 400 mg PO DAILY
RX *phenytoin sodium extended 200 mg 2 capsule(s) by mouth DAILY
Disp #*60 Tablet Refills:*2
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 2203**] VNA
Discharge Diagnosis:
Patch clousre of right sinus of Valsalva aneurysm [**2128-5-25**]
Right sinus of Valsalva aneurysm Aortic root dilatation COPD
Hypertension Rheumatoid arthritis Seizures (last one over 10
years ago)Possible Gout
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Edema: trace
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] on [**2128-6-23**] at 1:30p in the [**Hospital **] medical
office building, [**Doctor First Name **]. [**Hospital Unit Name **]
Wound check [**2128-6-3**] at 10:30am in the [**Hospital **] medical office
building, [**Last Name (NamePattern1) **], [**Hospital Unit Name **]
Please call to schedule appointments with your
Cardiologist: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
Primary Care Dr. [**First Name8 (NamePattern2) 3613**] [**Last Name (NamePattern1) 5263**] [**Telephone/Fax (1) 7401**] in [**2-26**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2128-6-3**]
|
[
"345.90",
"997.49",
"274.9",
"560.1",
"747.29",
"V15.82",
"714.0",
"E878.8",
"401.9",
"492.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.39",
"39.61"
] |
icd9pcs
|
[
[
[]
]
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7401, 7460
|
4530, 5860
|
344, 412
|
7716, 7894
|
2636, 4507
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8735, 9561
|
1775, 1865
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6216, 7378
|
7481, 7695
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5886, 6193
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7918, 8712
|
1880, 2617
|
270, 306
|
440, 1254
|
1276, 1423
|
1439, 1759
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,522
| 111,369
|
27822
|
Discharge summary
|
report
|
Admission Date: [**2151-1-3**] Discharge Date: [**2151-1-12**]
Date of Birth: [**2107-7-23**] Sex: F
Service: MEDICINE
Allergies:
Erythromycin Base / Penicillins / Gentamicin / Latex /
Iodine-Iodine Containing / Hydromorphone / Phenylbutazone /
Efavirenz / Quinolones / Macrolide Antibiotics
Attending:[**First Name3 (LF) 2279**]
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
Central Venous Line
Bone Marrow Biopsy
History of Present Illness:
42F with past medical history of HIV not on HAART who presented
initally to [**Hospital3 **] for evaluation of right ankle pain after
a fall 1 week ago. States that while in the OSH ED began to have
fevers and headaches. Cough became worse as the day progresed.
With with fever, SOB, and cough. She was found to be febrile to
103.2, tachycardic, hypotensive, short of breath, and have a
right lower lobe infiltrate. Also had a CT head for headache and
diszziness that was negative. She was reported to be satting low
90s on RA. She was given doses of vanc and levo and transferred
to [**Hospital1 18**] for further management. In the [**Hospital1 18**] ED, initial VS
101.0 130 104/69 16 96% 2L. She recieved a dose of IV Bactrim.
Total, she recieved 2L on IVF before admission to the ICU. She
also recieved a dose of Zofran, Ativan, and morphine as well as
30mg Toradol for for pleuritic CP and headache. Ca, Mag were
repleted. VS prior to transfer were BP 105/62 HR 132 RR 30s O2
Sat 100%3-4L NC. Became hypotensive to low 80s just prior to
transfer, bolused another liter, R IJ placed, and started on
norepi. Increased diffuse infiltrate on line placement CXR.
ROS: No HA currently. Denies URI Sx. C/o right-sided mouth pain
from infected tooth. Sore throat [**3-3**] coughing. Cough productive
of blood-tinged sputum. R-sided pleuritic CP. SOB when talking.
Denies abd pain, nausea currently. RLE swelling and numbness.
Past Medical History:
1. HIV from blood transfusions in [**2120**], not currently receiving
HAART (CD4 17 [**1-8**])
2. Diabetes Mellitus
3. Uterine CA s/p hysterectomy
4. Chronic gastrointestinal problems including chronic diarrhea
5. h/o Nephrolithiasis
6. Asthma
Social History:
She is single. Lives alone, currently not working. She has never
smoked, no drug use. She rarely drinks wine.
Family History:
Father has a [**Last Name 4241**] problem, but is otherwise alive and well.
Mother has hepatitis C from a needle stick on her
job. She has two sisters and two brothers alive and well. She
has
two adult children who are alive and well.
Physical Exam:
Admission Exam:
.
VS: T:101, BP:112/65, HR:127, RR:32, SO2:100%
Gen: anxious female, speaks only [**1-31**] words before stopping to
take a breath, no accessory muscle use
HEENT: Pupils round and equil, dry MM
CV: S1, S2 tachycardic but regular
Pulm: Decreased inspiratory effort. Bibasilar crackles, R > L
Abd: soft, ND, mild epigastric tenderness
Ext: warm, no edema
.
Discharge Exam:
AVSS
General: well-appearing in NAD, AO x 3
HEENT: NC/AT, PERRL, EOMI. MMM
Neck: supple
Chest: CTA-B, no w/r/r
CV: RR slightly tachycardic, no m/g/r
Abd: soft, NT/ND, NABS
Ext: no c/c/e
Pertinent Results:
Admission Results:
.
[**2151-1-3**] 08:45PM BLOOD WBC-2.5* RBC-2.50*# Hgb-7.8*# Hct-24.1*#
MCV-96# MCH-31.2 MCHC-32.4 RDW-17.4* Plt Ct-82*#
[**2151-1-3**] 08:45PM BLOOD Neuts-41* Bands-40* Lymphs-12* Monos-5
Eos-0 Baso-0 Atyps-1* Metas-1* Myelos-0
[**2151-1-4**] 02:58AM BLOOD PT-17.2* PTT-44.3* INR(PT)-1.5*
[**2151-1-4**] 02:58AM BLOOD WBC-2.6* Lymph-19 Abs [**Last Name (un) **]-494 CD3%-74
Abs CD3-366* CD4%-3 Abs CD4-17* CD8%-61 Abs CD8-300 CD4/CD8-0.1*
[**2151-1-3**] 08:45PM BLOOD Glucose-123* UreaN-9 Creat-0.5 Na-143
K-3.7 Cl-116* HCO3-17* AnGap-14
[**2151-1-3**] 08:45PM BLOOD ALT-58* AST-94* LD(LDH)-273* AlkPhos-342*
TotBili-0.5
[**2151-1-3**] 08:45PM BLOOD Calcium-6.9* Phos-2.1*# Mg-1.0*
.
CXR ([**2151-1-3**]):
1. Bibasilar airspace opacities, right worse than left,
concerning for
multifocal pneumonia.
2. Probable mild pulmonary edema.
.
CXR ([**2151-1-3**], s/p line placement):
In comparison with the earlier study of this date, there has
been
placement of a right IJ catheter that extends to the lower
portion of the SVC. Again, there is evidence of elevated
pulmonary venous pressure with more focal area of opacification
in the right mid and lower lung zones, concerning for pneumonia.
.
Interval Results:
.
CT Chest, Abdomen and Pelvis ([**2151-1-4**]):
1. Multifocal consolidation, worse in the right middle and lower
lobes,
concerning for multifocal pneumonia. No evidence of interstitial
or alveolar edema.
2. Bilateral pleural effusions, moderate on the right and small
on the left.
3. Lymphadenopathy, particularly in the left retroperitoneum and
mediastinum, which may relate to the patient's HIV disease.
.
Right Ankle XR ([**2151-1-4**]):
No evidence of acute fracture.
.
TTE ([**2151-1-5**]):
The left atrium is elongated. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%). The right ventricular cavity is mildly dilated with
normal free wall contractility. There is abnormal Doppler signal
at the right and left ventricular apices, throughout the cardiac
cycle (cine loops 36, 37, 54, 55). Although a Doppler artifact
is possible, this may also represent a congenital coronary
artery-to-ventricular fistula. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic regurgitation. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. There is borderline pulmonary artery systolic
hypertension. There is no pericardial effusion. Mildly dilated
right ventricle with normal global and regional biventricular
systolic function. Possible coronary artery-to-ventricular
fistula.
.
Microbiology Data:
1. Blood cultures ([**2151-1-3**]): negative
2. Urine culutres ([**2151-1-3**]): negative
3. Urinary Legionella antigen ([**2151-1-3**]): negative
4. Influenza A/B DFA ([**2151-1-3**]): negative
5. Sputum PCP [**Name Initial (PRE) **] ([**2151-1-4**]): negative
6. Sputum Cultures ([**2151-1-3**]): negative
7. Sputum Cultures ([**2151-1-4**]): negative
8. CMV Viral Load ([**2151-1-4**]): negative
9. Toxoplasma IgM, IgG ([**2151-1-4**]): negative
10. Cryptococcal Antigen ([**2151-1-4**]): negative
11. Sputum AFB Smear ([**2151-1-4**]): negative
12. Sputum AFB Culture ([**2151-1-4**]): negative
13. Blood Fungal Cultures ([**2151-1-4**]): negative
14. Stool O&P, microsporidia/cyclospora ([**1-7**], [**1-9**]): negative
15. Stool AFB ([**2151-1-7**]): negative
16. Stool AFB ([**2151-1-9**]): PENDING
.
HIV VL 78,663
HIV Genotype pending
CMV IgG Ab positive
CMV IgM AB negative
.
PENDING DATA:
[**1-9**] Stool AFB cultures x 1 pending
[**1-8**] Bone Marrow Bx pathology, cytogenetics, cultures - pending
.
CXR [**2151-1-12**]: There is marked interval improvement in the degree
of opacity in the right lung and bilateral upper lobe venous
diversion, which likely represented right lower lobe pneumonia
with associated
pulmonary edema. The cardiac and mediastinal contours appear
normal.
.
Discharge labs:
[**2151-1-12**] 07:00AM BLOOD WBC-1.5* RBC-2.75* Hgb-8.5* Hct-26.0*
MCV-95 MCH-30.8 MCHC-32.6 RDW-17.3* Plt Ct-98*
[**2151-1-12**] 07:00AM BLOOD Neuts-51 Bands-0 Lymphs-37 Monos-8 Eos-4
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2151-1-11**] 06:10AM BLOOD WBC-1.3* RBC-2.64* Hgb-8.0* Hct-24.9*
MCV-94 MCH-30.2 MCHC-32.1 RDW-17.0* Plt Ct-102*
[**2151-1-11**] 06:10AM BLOOD Neuts-45* Bands-4 Lymphs-35 Monos-12*
Eos-2 Baso-0 Atyps-2* Metas-0 Myelos-0
[**2151-1-10**] 07:15AM BLOOD WBC-1.7* RBC-2.80* Hgb-8.5* Hct-26.7*
MCV-95 MCH-30.5 MCHC-32.0 RDW-17.1* Plt Ct-110*
[**2151-1-8**] 10:15AM BLOOD Neuts-46* Bands-0 Lymphs-39 Monos-15*
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2151-1-12**] 07:00AM BLOOD ALT-56* AST-66* LD(LDH)-278* AlkPhos-569*
TotBili-0.3
Brief Hospital Course:
43 y/o HIV+ female who was transferred from an OSH with a
community-acquired pneumonia with sepsis.
.
#. Pneumonia with Sepsis: Patient presented with productive
cough and CXR evidence of RLL pneumonia. Fevers, bandemia of 40%
and tachycardia were consistent with sepsis without evidence of
end-organ ischemia. Patient with no recent concerning
health-care contacts so was started on Levofloxacin for CAP
coverage, as well as Vancomycin and Cefepime for broader
coverage given septic physiology and history of HIV with unknown
CD4 count. Blood and urine cultures, and urinary legionella
antigen were sent prior to giving antibiotics. Urine cultures
came back negative. Patient was on Bactrim for PCP prophylaxis
as an outpatient and increasing to treatment dosing was
considered but not pursued given CXR appearance and high oxygen
saturation on room air. Influenza DFA was checked and was
negative. Sputum for PCP was negative by immunofluorescence and
a CT of the chest was inconsistent with PCP [**Name Initial (PRE) 1064**].
Cryptococcal antigen was sent and was negative. Toxoplasma IgM
and IgG were negative. Legionella culture was also negative.
Sputum AFB stain was negative. With regards to the patient's
sepsis, the patient initially responded to normal saline boluses
alone but eventually required the addition of pressors, first
with Norepinephrine but then was switched to Phenylephrine as
the patient was persistent tachycardic. The patient was able to
be weaned from her pressors several days into her hospital
course and eventually required no further fluid boluses. After
blood cultures were negative for 48 hours and the patient
continued to improve clinically, the Cefepime was discontinued
and the patient was transferred to the medicine service,
whereupon Vanco was discontinued. Sputum cultures were negative.
She completed a full course of Levofloxacin through [**2151-1-10**].
.
#. Pancytopenia: On admission patient had WBC of 2.5, hematocrit
of 24.1, and platelet count of 82. The only records in the [**Hospital1 18**]
system on admission were from [**2146**] with the admission results
demonstrating a significant change. There was concern for an
HIV-associated pancytopenia but also for DIC, specifically with
regard to the anemia and thrombocytopenia, so DIC labs were
checked but showed no signs of DIC with fibrinogen always > 200,
and coags were slightly elevated on admission but remained
stable with no significant elevations. Haptoglobin and bilirubin
were within normal limits. The PCP was [**Name (NI) 653**] for further
information who stated that the pancytopenia has been a problem
for years. The patient's leukopenia was attributed to her
HIV/AIDS with a possible septic component. Her anemia was likely
anemia of chronic inflammation from her HIV/AIDS.
Thrombocytopenia was attributed to HIV/AIDS. Her counts were
followed closely throughout her ICU stay. The patient did
require on transfusion for a hematocrit of 19 with an
appropriate bump to 24. Stool guaiacs were negative and the
change was attributed to vigorous IV hydration with a reported
significant blood loss during central line placement. BMBx was
performed on [**2151-1-8**] to rule out pathology or BMInfection.
Pathology was still pending at the time of discharge but prelim
results showed no abnormal cells. Bone marrow AFB,
cytogenetics, and culture were PENDING at the time of discharge,
will be followed up by our hematology team here. Bactrim was
discontinued as noted below in the event this was contributing
to her pancytopenia. At the time of discharge, her WBC was
stable but low at 1.5 with functional neutropenia (50%
neutrophils). The patient was advised of neutropenic
precautions and to watch for fevers > 100.5.
.
# Orthostatic Hypotension: When out of ICU. AM fasting cortisol
was normal, TSH normal, was fluid responsive. With increased
ambulation, this improved. She may typically run lowish blood
pressure. Prior to discharge this remained stable and she was
no longer orthostatic
.
#. Chronic Diarrhea: Long standing for >1yr with exhaustive
work-up by Dr. [**Last Name (STitle) 67812**] at [**Hospital1 2177**]. Here, C. diff, microsporidia,
O&P, Cryptosporidia all negative. AFB culture (for MAC)
negative x 1 (2nd culture pending). DDx largely is MAC vs HIV
enteropathy. As above, stool studies were negative though AFB
culture for MAC are pending for the last stool culture.
Loperamide given prn.
.
#. HIV / AIDS: Not currently on HAART. Last CD4 count in our
system was 37 in [**2146**] with CD4 of 17 this admission, and mildly
recent 20 (as outpatient). This indicates advanced HIV WHO Stage
IV. ID conuslt [**Year (4 digits) 653**] here to arrange followup. HIV VL and
gentoype was sent and results are noted in the results section.
Prefer to rule out MAC infection prior to HAART if possible to
determine need to treat or to prophylax. BMBx for AFB Cx also
pending. Will follow up with [**Hospital **] Clinic on [**2-1**]. Importance of
HAART therapy underscored to patient, who understood. She was
continued on Bactrim for PCP [**Name9 (PRE) 31424**] but this was changed to
Atovaquone given her pancytopenia, in case Bactrim was
contributing to this. She will require prior authorization for
the Atovaquone, so both her pharmacy and insurance company were
[**Name9 (PRE) 653**] to expedite this and we will be notified in the next
24 hours of their decision. She was provided with 2 extra doses
to take at home on [**1-13**] and [**1-14**], and will follow-up with her
PCP [**Last Name (NamePattern4) **] [**1-14**], who will follow-up in regards to the Atovaquone in
the event the prior authorization is not settled in the next
24-48 hours.
.
# Elevated LDH / Transaminitis: Could be sign of underlying
MAC. No abnormal imaging and clinically asymtpomatic from
hepatobiliary standpoint. LFTs remained stable but elevated,
this should be trended to ensure no worsening.
.
#. Candidal Esophagitis (presumed): Patient was complaining of
mild odynophagia several days into her hospitalization. She was
initially treated with Nystatin swish and swallow with minimal
improvement. She was then started on Clotrimazole troches with
improvement in her symptoms.
.
#. Right Ankle Pain: Patient has been walking with crutches
prior to admission. Presented to an outside hospital for this
reason. Ankle x-ray was negative for fracture at [**Hospital1 18**]. She
worked with PT and will need home PT services.
.
#. Diabetes Mellitus: Patient takes Novolog at home for her
diabetes when needed. Stated that blood sugars have been
well-controlled recently in the 100-120s without insulin.
Patient was maintained on a Humalog insulin sliding scale while
in the ICU but never required any sliding scale coverage during
her ICU stay and on the medical floor, so this was discontinued.
She was encouraged to check her sugars regularly at home and to
use her Novolog sliding scale as needed.
Medications on Admission:
Lutein
Albuterol
Bactrim 1 tab daily
Prochlorperazine
[**Name (NI) **] (Pt says hasn't been taking her insulin lately as sugars
have been good)
Novolog sliding scale
Iron 325 daily
Multivitamin
Opium 10% eye drops
KCl 40mEq daily
omeprazole 20mg daily
loratidine 10mg daily
Vitamin D 1000 units daily
Vitamin E 400 units daily
Flax Seed Oil 1000 daily
Fish Oil 1000 daily
Budesonide nasal spray 2 sprays [**Hospital1 **]
Vicodin 1-2 tabs q6 hrs PRN
Discharge Medications:
1. atovaquone 750 mg/5 mL Suspension Sig: Ten (10) milliliters
PO DAILY (Daily).
Disp:*qS (for one month) mL* Refills:*2*
2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain, fever.
3. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
4. prochlorperazine maleate 5 mg Tablet Sig: One (1) Tablet PO
every six (6) hours as needed for nausea.
5. loperamide 2 mg Capsule Sig: Two (2) Capsule PO QID (4 times
a day) as needed for diarrhea.
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Comm Aquire Pneumonia w/ sepsis
Chronic diarrhea - final evalation pending
Pancytopenia
HIV / AIDS
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with sepsis from pneumonia and hospitalized in
ICU. This has been fully treated. You have low blood counts
concerning for side effect of sepsis, or due to bone marrow
process. A Bone marrow bx was done and pathology showed
preliminarily did not show any abnormal cells. However,
cultures are still pending. You were evaluated for causes of
chronic diarrhea which may be due to infection or HIV
enteropathy. Studies are pending. You met with an infectious
disease clinician and will need to be on anti-HIV meds for
advanced AIDS. You were evaluated by physical therapy who felt
you were safe to go home with a walker and home services.
If you develop any fevers > 100.5, please call your doctor or
return to the hospital immediately. Please avoid contact with
people who any upper respiratory illnesses, given your low white
count.
MEDICATION RECONCILIATION:
1. START Atovaquone 1500 mg daily for PCP [**Name Initial (PRE) 1102**]
(AIDS-related infection).
2. STOP Bactrim
3. Continue loperamide and compazine as needed for diarrhea and
nausea, respectively.
4. Continue insulin sliding scale as needed for your blood
sugars based on your home dose of sliding scale.
5. STOP potassium supplements
6. Continue omeprazole twice daily
Followup Instructions:
PCP [**Name Initial (PRE) **]: Tuesday, [**1-14**] at 11:15am
With: [**First Name8 (NamePattern2) 539**] [**Last Name (NamePattern1) 67813**],[**First Name3 (LF) **]
Location: PRIMACARE
Address: [**Street Address(2) 17177**], [**Location (un) **],[**Numeric Identifier 33806**]
Phone: [**Telephone/Fax (1) 67814**]
Department: INFECTIOUS DISEASE
When: MONDAY [**2151-2-1**] at 10:00 AM
With: [**First Name4 (NamePattern1) 2482**] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2285**]
Completed by:[**2151-1-12**]
|
[
"V58.67",
"V88.01",
"042",
"276.2",
"482.9",
"V15.88",
"112.84",
"719.47",
"284.1",
"285.21",
"038.9",
"785.52",
"V10.42",
"287.49",
"611.72",
"625.8",
"V13.01",
"787.91",
"250.00",
"428.0",
"428.31",
"799.4",
"536.9",
"518.81",
"V85.1",
"995.92"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"38.93",
"41.31"
] |
icd9pcs
|
[
[
[]
]
] |
16100, 16149
|
7950, 14887
|
427, 468
|
16292, 16292
|
3178, 7163
|
17734, 18544
|
2334, 2570
|
15386, 16077
|
16170, 16271
|
14913, 15363
|
16443, 17711
|
7180, 7927
|
2585, 2956
|
2972, 3159
|
382, 389
|
496, 1923
|
16307, 16419
|
1945, 2191
|
2207, 2318
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,330
| 193,396
|
1880+1881
|
Discharge summary
|
report+report
|
Admission Date: [**2109-8-20**] Discharge Date: [**2109-8-23**]
Date of Birth: [**2048-10-2**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Bacitracin / Abilify / Tetrabenazine / Gluten
Attending:[**First Name3 (LF) 64**]
Chief Complaint:
right knee pain
Major Surgical or Invasive Procedure:
[**2109-8-20**]: s/p right total knee replacement
History of Present Illness:
R knee OA
Past Medical History:
OSA requiring bipap, CHF (diastolic), HLD, HTN, CAD s/p LAD BMS
and s/p LCx and RCA DES [**7-10**], atrial septal defect, mitral
regurg, Tracheobronchomalacia s/p tracheobronchoplasty,
hypothyroid, GERD/gastroparesis s/p Nissen '[**07**], anemia, diabetes
on insulin pump, pulmonary edema, pleural effusion s/p talc
pleurodesis, R knee pain
1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY: Has had 3 PCI last [**7-/2108**] as per below. CAD,
status post LAD BMS x2 (01/[**2097**]).
Chronic diastolic heart failure. Small secundum ASD with normal
RV size/function. Dyspnea.30% ramus, 40% mid LCx.
Echo [**10/2106**]: Normal biventricular function, trivial MR/TR/PR,
TR gradient 26 mmHg. ETT-MIBI [**1-/2108**]: 9.5 minutes mod [**Doctor First Name **],
5/10 chest pain, no ST changes, normal perfusion, LVEF 70%.
.
-PERCUTANEOUS CORONARY INTERVENTIONS:per below
3. OTHER PAST MEDICAL HISTORY:
Severe tracheobronchomalacia s/p tracheobronchoplasty in [**2103**]
Gastroparesis
Mild pulmonary hypertension
Severe GERD s/p fundoplication
Juvenile diabetes mellitus (type 1)- on insulin pump
Coronary artery disease, s/p stenting LAD BMS x 2 ([**2094**] and
[**2097**],
[**2107**])
Chronic diastolic dysfunction
Small ASD with normal RV size/function
Obstructive sleep apnea compliant with BiPap (17/14 cm H20 with
supplemental oxygen)
Depression/anxiety
Hypothyroidism
Impotence
Low back pain
Hyperlipidemia
Tardive Dyskinesia (from abilify)
Celiac Sprue
Tracheomalacia (status post tracheobronchoplasty)
Urinary retention
Gastric Polyp
Constipation
Bilateral carpal tunnel release
Polyneuropathy
Right Meniscus surgery
Social History:
Lives with wife in [**Name2 (NI) **] with 4 floors; does have difficulty
walking up stairs in setting of arthritis pain. Has children,
grown up.
-Tobacco history:none
-ETOH: none
-Illicit drugs:none
Family History:
Mother with CAD and DM. Father with HTN. Brother healthy.
Physical Exam:
Well appearing in no acute distress
Afebrile with stable vital signs
Pain well-controlled
Respiratory: CTAB
Cardiovascular: RRR
Gastrointestinal: NT/ND
Genitourinary: Voiding independently
Neurologic: Intact with no focal deficits
Psychiatric: Pleasant, A&O x3
Musculoskeletal Lower Extremity:
* Incision healing well with staples
* Scant serosanguinous drainage
* Thigh full but soft
* No calf tenderness
* 5/5 strength
* SILT, NVI distally
* Toes warm
Pertinent Results:
[**2109-8-23**] 07:55AM BLOOD WBC-5.9 RBC-3.41* Hgb-10.9* Hct-29.7*
MCV-87 MCH-32.0 MCHC-36.7* RDW-13.5 Plt Ct-184
[**2109-8-22**] 06:35AM BLOOD WBC-6.0 RBC-3.41* Hgb-10.9* Hct-30.5*
MCV-89 MCH-32.0 MCHC-35.8* RDW-13.9 Plt Ct-137*
[**2109-8-21**] 06:10AM BLOOD WBC-5.5 RBC-3.53* Hgb-11.3*# Hct-31.4*#
MCV-89 MCH-32.1* MCHC-36.2* RDW-14.2 Plt Ct-122*
[**2109-8-21**] 06:10AM BLOOD Neuts-73.8* Lymphs-12.8* Monos-8.2
Eos-4.7* Baso-0.5
[**2109-8-23**] 07:55AM BLOOD Glucose-259* UreaN-25* Creat-1.3* Na-133
K-3.9 Cl-94* HCO3-29 AnGap-14
[**2109-8-22**] 06:35AM BLOOD Glucose-189* UreaN-16 Creat-1.3* Na-135
K-4.2 Cl-95* HCO3-31 AnGap-13
[**2109-8-21**] 06:10AM BLOOD Glucose-206* UreaN-15 Creat-1.4* Na-135
K-3.1* Cl-94* HCO3-33* AnGap-11
[**2109-8-21**] 06:10AM BLOOD Calcium-8.5 Phos-3.4 Mg-1.7
[**2109-8-22**] 06:35AM BLOOD Free T4-1.9*
Brief Hospital Course:
The patient was admitted to the orthopaedic surgery service and
was taken to the operating room for above described procedure.
Please see separately dictated operative report for details. The
surgery was uncomplicated and the patient tolerated the
procedure well. Patient received perioperative IV antibiotics.
Postoperative course was remarkable for the following:
1. [**Last Name (un) **] Diabetes Consult - Per protocol, [**Last Name (un) **] co-management
for self-administered insulin pump. On POD 2, patient was found
to be confused and unable to demionstrate appropriate use of
insulin pump. Pump was discontinued and patient was started on
standing lantus with a RISS for blood sugar management. Patient
should follow-up with [**Last Name (un) **] after discharge from rehab.
Otherwise, pain was initially controlled with a PCA followed by
a transition to oral pain medications on POD#1. The patient
received lovenox for DVT prophylaxis starting on the morning of
POD#1. The foley was removed on POD#2 and the patient was
voiding independently thereafter. The surgical dressing was
changed on POD#2 and the surgical incision was found to be clean
and intact without erythema or abnormal drainage. The patient
was seen daily by physical therapy. Labs were checked throughout
the hospital course and repleted accordingly. At the time of
discharge the patient was tolerating a regular diet and feeling
well. The patient was afebrile with stable vital signs. The
patient's hematocrit was acceptable and pain was adequately
controlled on an oral regimen. Te operative extremity was
neurovascularly intact and the wound was benign.
The patient's weight-bearing status is weight bearing as
tolerated on the operative extremity.
Mr. [**Known lastname 10087**] is discharged to rehab in stable condition.
Medications on Admission:
Advair 250/50mcg 1 puff [**Hospital1 **]
[**Hospital1 **] 81mg daily
Buspirone 22.5mg qAM, and 15mg qhs
Clindamycin phospahte injection
clonazepan 1g [**Hospital1 **]
rosuvastatin 40mg daily
doxazosin 8mg daily
fluticasone 50mcg spray daily
Insulin pump with humalog
Atrovent 21mcg spray
furosemide 160mg [**Hospital1 **]
levothyrxine 125mcg daily
gabapentin
NTG sl prn chest pain
Plavix 75ng daily
Potassium 20meq daily
Protonix
Seroquel 100mg qhs
ranitidine 150mg [**Hospital1 **]
ezetimibe 10mg daily
amiloride 20mg daily
finasteride 5mg daily
amitizia 24mcg [**Hospital1 **]
provigil 200mg daily
metazolone 5mg prn weight gain
Discharge Medications:
1. Lovenox 40 mg/0.4 mL Syringe Sig: One (1) syringe
Subcutaneous once a day for 4 weeks.
Disp:*28 syringe* Refills:*0*
2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
5. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
6. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO BID (2 times a day) as needed for Constipation.
7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
8. multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
9. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q6H (every 6 hours).
10. doxazosin 4 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
11. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal DAILY (Daily).
14. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) inhalation Inhalation DAILY (Daily).
15. furosemide 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
16. gabapentin 300 mg Capsule Sig: Three (3) Capsule PO Q12H
(every 12 hours): Home med.
17. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler
Sig: One (1) Puff Inhalation [**Hospital1 **] (2 times a day).
18. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
19. lamotrigine 100 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
20. Amitiza 24 mcg Capsule Sig: One (1) Capsule PO twice a day.
21. modafinil 100 mg Tablet Sig: Two (2) Tablet PO once a day.
22. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
23. quetiapine 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
24. rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
25. alpha lipoic acid 300 mg Capsule Sig: One (1) Capsule PO
twice a day.
26. amiloride 5 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).
27. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
28. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
29. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
6AM ().
30. clonazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for anxiety: Hold for confusion/sedation.
31. oxycodone 5 mg Tablet Sig: 0.5-1 Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
32. insulin glargine Subcutaneous
33. buspirone 15 mg Tablet Sig: 1.5 Tablets PO QAM (once a day
(in the morning)).
34. buspirone 15 mg Tablet Sig: One (1) Tablet PO at bedtime.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] Of [**Location (un) 5176**]
Discharge Diagnosis:
Right knee osteoarthritis
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:
1. Please return to the emergency department or notify your
physician if you experience any of the following: severe pain
not relieved by medication, increased swelling, decreased
sensation, difficulty with movement, fevers greater than 101.5,
shaking chills, increasing redness or drainage from the incision
site, chest pain, shortness of breath or any other concerns.
2. Please follow up with your primary physician regarding this
admission and any new medications and refills.
3. Resume your home medications unless otherwise instructed.
4. You have been given medications for pain control. Please do
not drive, operate heavy machinery, or drink alcohol while
taking these medications. As your pain decreases, take fewer
tablets and increase the time between doses. This medication can
cause constipation, so you should drink plenty of water daily
and take a stool softener (such as colace) as needed to prevent
this side effect. Call your surgeons office 3 days before you
are out of medication so that it can be refilled. These
medications cannot be called into your pharmacy and must be
picked up in the clinic or mailed to your house. Please allow
an extra 2 days if you would like your medication mailed to your
home.
5. You may not drive a car until cleared to do so by your
surgeon.
6. Please keep your wounds clean. You may shower starting five
(5) days after surgery, but no tub baths or swimming for at
least four (4) weeks. No dressing is needed if wound continues
to be non-draining. Any stitches or staples that need to be
removed will be taken out by the visiting nurse (VNA) or rehab
facility two
weeks after your surgery.
7. Please call your surgeon's office to schedule or confirm your
follow-up appointment in four (4) weeks.
8. Please DO NOT take any non-steroidal anti-inflammatory
medications (NSAIDs such as celebrex, ibuprofen, advil, aleve,
motrin, etc).
9. ANTICOAGULATION: Please continue your lovenox for four (4)
weeks to help prevent deep vein thrombosis (blood clots). [**Male First Name (un) **]
STOCKINGS x 6 WEEKS.
10. WOUND CARE: Please keep your incision clean and dry. It is
okay to shower five days after surgery but no tub baths,
swimming, or submerging your incision until after your four (4)
week checkup. Please place a dry sterile dressing on the wound
each day if there is drainage, otherwise leave it open to air.
Check wound regularly for signs of infection such as redness or
thick yellow drainage. Staples will be removed by the visiting
nurse or rehab facility in two (2) weeks.
11. VNA (once at home): Home PT/OT, dressing changes as
instructed, wound checks, and staple removal at two weeks after
surgery.
12. ACTIVITY: Weight bearing as tolerated on the operative
extremity. Mobilize. CPM/ROM as tolerated. No strenuous exercise
or heavy lifting until follow up appointment.
Physical Therapy:
RLE WBAT
ROM unrestricted
CPM 2-3x/day for 2-3hr sessions
Mobilize frequently
Treatments Frequency:
Dry sterile dressing daily as needed for drainage
Wound checks
Ice and elevation
Staple removal POD 14 - replace with steristrips
TEDs
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2109-8-26**]
1:40
Provider: [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3260**], [**MD Number(3) 3261**]:[**Telephone/Fax (1) 1228**]
Date/Time:[**2109-9-20**] 12:40
Call the [**Last Name (un) **] Diabetes Center for follow-up after discharge
from rehab.
Completed by:[**2109-8-23**] Admission Date: [**2109-8-24**] Discharge Date: [**2109-8-30**]
Date of Birth: [**2048-10-2**] Sex: M
Service: MEDICINE
Allergies:
Bacitracin / Abilify / Tetrabenazine / Gluten
Attending:[**First Name3 (LF) 10488**]
Chief Complaint:
AMS, right knee erythema post TRK repair on [**2109-8-20**]
Major Surgical or Invasive Procedure:
none
History of Present Illness:
60 yo male with extensive pmh including OSA requiring bipap, CHF
(diastolic), HLD, HTN, CAD s/p LAD BMS and s/p LCx and RCA DES
[**7-10**], atrial septal defect, mitral regurg,
Tracheobronchomalacia s/p tracheobronchoplasty, hypothyroid,
GERD/gastroparesis s/p Nissen '[**07**], anemia, DM 1 on insulin pump
(which was stopped 2 days ago due to confusion), pulmonary
edema, pleural effusion s/p talc pleurodesis, osteorthritis s/p
R TKR on [**2109-8-20**], bipolar disorder and discharged on [**8-23**] to
rehab who presents with AMS. He was discharge yesterday from
ortho service to a rehab facility and was brought to the ED this
AM for AMS, concern of right knee infection and hyperglycemia.
.
As per the discharge note, pt hospital course was complicated by
AMS on post-op day #2 on [**8-22**]. His insulin pump was then
stopped due to his inability to give bolus and he was placed on
Lantus and slinding scale. His surgical wound on the right knee
was noted to be clean and intact without erythema or abnormal
drainage on [**8-22**].
.
In the ED inital vitals were 98.4 92 114/84 18 100% 4L NC. His
initial glucose was 538 w/ anion gap of 15 with a bicarb of 23
and K of 4.3. Urine had trace of ketone, he was given 10 u of R
insulin and was given IV fluids (total of 4L). His physical exam
was notable for confusion and agitation, and R knee tenderness
erythema and edema. His Head CT showed no acute IC process and
prominent ventricles. He had right knee xray which showed
post-op changes, but no significant effusion. As per nursing
report, pt developed a temperature of 102F. He had blood and
urine culture done and he was started on IV vanco. His glucose
decreased to 300s and his anion gap closed. He was also very
agitated requiring 2mg of Ativan and 5mg of Haldol IV.
.
On the floor, pt is calm and cooperative. He is A+O x place and
person responding appropriately to question, but he has word
finding difficulty. He c/o having increase cough and mild-mod
pain on his right knee.
.
Review of systems:
(+) Per HPI, + headaches (however he could not tell me for
howlong of if this was a recent change), he denies having HA at
this time.
(-) Denies chills, night sweats, recent weight loss or gain.
Denies headache, sinus tenderness, rhinorrhea or congestion.
Denies cough, shortness of breath, or wheezing. Denies chest
pain, chest pressure, palpitations, or weakness. Denies nausea,
vomiting, diarrhea, constipation, abdominal pain, or changes in
bowel habits. Denies dysuria, frequency, or urgency. Denies
arthralgias or myalgias. Denies rashes or skin changes
Past Medical History:
OSA requiring bipap, CHF (diastolic), HLD, HTN, CAD s/p LAD BMS
and s/p LCx and RCA DES [**7-10**], atrial septal defect, mitral
regurg, Tracheobronchomalacia s/p tracheobronchoplasty,
hypothyroid, GERD/gastroparesis s/p Nissen '[**07**], anemia, diabetes
on insulin pump, pulmonary edema, pleural effusion s/p talc
pleurodesis, R knee pain
1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY: Has had 3 PCI last [**7-/2108**] as per below. CAD,
status post LAD BMS x2 (01/[**2097**]). Chronic diastolic heart
failure. Small secundum ASD with normal RV size/function.
Dyspnea.30% ramus, 40% mid LCx. Echo [**10/2106**]: Normal
biventricular function, trivial MR/TR/PR, TR gradient 26 mmHg.
ETT-MIBI [**1-/2108**]: 9.5 minutes mod [**Doctor First Name **], 5/10 chest pain, no ST
changes, normal perfusion, LVEF 70%.
.
3. OTHER PAST MEDICAL HISTORY:
Severe tracheobronchomalacia s/p tracheobronchoplasty in [**2103**]
Gastroparesis
Mild pulmonary hypertension
Severe GERD s/p fundoplication
Juvenile diabetes mellitus (type 1)- on insulin pump
Coronary artery disease, s/p stenting LAD BMS x 2 ([**2094**] and
[**2097**],
[**2107**])
Chronic diastolic dysfunction
Small ASD with normal RV size/function
Obstructive sleep apnea compliant with BiPap (17/14 cm H20 with
supplemental oxygen)
Depression/anxiety
Hypothyroidism
Impotence
Low back pain
Hyperlipidemia
Tardive Dyskinesia (from abilify)
Celiac Sprue
Tracheomalacia (status post tracheobronchoplasty)
Urinary retention
Gastric Polyp
Constipation
Bilateral carpal tunnel release
Polyneuropathy
Right Meniscus surgery
Social History:
Lives with wife in [**Name2 (NI) **] with 4 floors; does have difficulty
walking up stairs in setting of arthritis pain. Has children,
grown up.
-Tobacco history:none
-ETOH: none
-Illicit drugs:none
Family History:
Mother with CAD and DM. Father with HTN. Brother healthy.
Physical Exam:
Vitals: 99.9, 88, 123/69, 16, 99% on RA
General: Alert, oriented x person and place, having difficulty
with word finding and very tangentional, calm in no acute
distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple (however complains of mild discomfort when touching
chin to chest), JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, except bil Lower lobe
scat crackles, no wheezes, rales
CV: Regular rate and rhythm, normal S1 + S2, + 2/6 SEM on bil
upper sternal borders, non-radiating, no rubs, gallops
Abdomen: soft, + tenderness of right LQ to palpation, area
mildly bulging (site of Insulin pump site), but soft, bowel
sounds present, no rebound tenderness or guarding, no
organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis
R Knee: with incision with Staples- edematous, erythematous,
warm to touch and limitation to flexion. No fluid collection
noted, no wound drainage. +2 pulses bil LE, good cap refill
Neuro: A+ ox 3, CN II-CN XII intact, + mild intentional tremor,
intact sensation.
Pertinent Results:
[**2109-8-23**] 07:55AM BLOOD WBC-5.9 RBC-3.41* Hgb-10.9* Hct-29.7*
MCV-87 MCH-32.0 MCHC-36.7* RDW-13.5 Plt Ct-184
[**2109-8-25**] 03:48AM BLOOD WBC-4.5 RBC-2.74* Hgb-8.7* Hct-24.4*
MCV-89 MCH-31.9 MCHC-35.8* RDW-13.9 Plt Ct-193
[**2109-8-24**] 01:55AM BLOOD Neuts-75.9* Lymphs-13.5* Monos-9.4
Eos-0.9 Baso-0.3
[**2109-8-24**] 11:56AM BLOOD Neuts-68.9 Lymphs-13.5* Monos-11.2*
Eos-5.5* Baso-0.9
[**2109-8-23**] 07:55AM BLOOD Plt Ct-184
[**2109-8-24**] 02:40AM BLOOD PT-12.5 PTT-33.1 INR(PT)-1.1
[**2109-8-24**] 11:56AM BLOOD Plt Ct-195
[**2109-8-24**] 01:55AM BLOOD ESR-110*
[**2109-8-23**] 07:55AM BLOOD Glucose-259* UreaN-25* Creat-1.3* Na-133
K-3.9 Cl-94* HCO3-29 AnGap-14
[**2109-8-24**] 01:55AM BLOOD Glucose-538* UreaN-35* Creat-1.6* Na-127*
K-4.3 Cl-89* HCO3-23 AnGap-19
[**2109-8-24**] 03:28AM BLOOD Glucose-339* UreaN-32* Creat-1.4* Na-132*
K-3.6 Cl-100 HCO3-24 AnGap-12
[**2109-8-24**] 11:56AM BLOOD Glucose-98 UreaN-20 Creat-1.1 Na-142
K-3.6 Cl-107 HCO3-26 AnGap-13
[**2109-8-25**] 03:48AM BLOOD Glucose-437* UreaN-15 Creat-1.1 Na-132*
K-3.7 Cl-98 HCO3-21* AnGap-17
[**2109-8-24**] 11:56AM BLOOD ALT-10 AST-20 AlkPhos-52 TotBili-0.4
[**2109-8-24**] 03:28AM BLOOD cTropnT-<0.01
[**2109-8-24**] 11:56AM BLOOD Albumin-3.3* Calcium-7.9* Phos-2.2*
Mg-2.2
[**2109-8-25**] 03:48AM BLOOD Calcium-8.1* Phos-2.4* Mg-2.0
[**2109-8-25**] 03:48AM BLOOD VitB12-799
[**2109-8-24**] 03:28AM BLOOD Acetone-NEGATIVE
[**2109-8-24**] 11:56AM BLOOD TSH-<0.02*
[**2109-8-24**] 03:28AM BLOOD CRP-244.6*
[**2109-8-25**] 03:48AM BLOOD HoldBLu-HOLD
[**2109-8-24**] 01:58AM BLOOD Glucose-497* Lactate-1.7
[**2109-8-24**] XRay knee AP, lateral and oblique
The patient is status post total knee arthroplasty
with a skin staple line still projecting over the knee. The
femoral and
tibial components are well seated and show no evidence of
loosening or
periprosthetic fracture. No joint effusion or subcutaneous gas.
The study and the report were reviewed by the staff radiologist.
[**2109-8-24**] CXR
No acute cardiopulmonary process.
The study and the report were reviewed by the staff radiologist.
[**2109-8-24**] CT head without contrast
1. No evidence of an acute intracranial process.
2. Unchanged mild prominence of the ventricles and sulci most
likely
indicates mild cerebral atrophy.
The study and the report were reviewed by the staff radiologist.
[**2109-8-24**] CXR
Cardiomediastinal contours are within normal limits. Pleural and
parenchymal scarring in the right lung appear unchanged. No new
areas of
consolidation are evident to suggest a site of active pulmonary
infection.
[**2109-8-24**] Abdomen supine
A non-obstructed, nonspecific bowel gas pattern is visualized
with
a large amount of stool throughout the colon. Free
intraperitoneal air cannot
be assessed on this supine radiograph. Incidentally noted is
calcification of
the vas deferens.
[**2109-8-24**] EKG
EKG: RRR, normal axis, rate in 80s, PR interval ~ 200
(borderline 1st degree block), Jpoint elevations on inf-lat
leads unchanged from prior.
Brief Hospital Course:
60 yo male with multiple medical problems including DM 1
(>50yrs), CAD s/p LAD BMS and s/p LCx and RCA DES [**7-10**], CHF
(diastolic), OSA requiring bipap, HLD, HTN, atrial septal
defect, mitral regurg, Tracheobronchomalacia s/p
tracheobronchoplasty, hypothyroid, GERD/gastroparesis s/p Nissen
'[**07**], recent penile implant and RTK replacement who comes in for
AMS, hyperglycemia and right knee erythema concerning for
infection
.
# Hyperglycemia/DKA: on admission, pt's gluc was >500 and he had
an anion gap of 15, however his bicarb was WNL and he had trace
ketones and neg acetone in blood. This quickly corrected with
fluids and 10 units of insulin. He had a insulin pump for years
and as of 2 days ago this was changed to SS and glargine given
confusion. Not in DKA. [**Last Name (un) **] was consulted (he is normally
followed there by Dr. [**Last Name (STitle) 10088**] and sliding scale and insulin
glargine were initiated per their recs. His glucose was
initialyl well controlled, but following downtitration of the
sliding scale, trended up once again on the morning of [**2109-8-25**].
[**First Name8 (NamePattern2) **] [**Last Name (un) **] recs, the insulin sliding scale was uptitrated once
again. As his mental status improved, he was put back on his
insulin pump.
.
# Acute encephalopathy, metabolic, post-operative delirium: Per
his wife he has had baseline short term memory loss, for which
he has recently undergone neurocognitive testing at
[**Hospital1 **]-[**Location (un) **]. In addition, he has had prior episodes of waxing
and [**Doctor Last Name 688**] confusion during prior hospitalization. He was noted
to be confused on POD #2. So, possible due to post-op delerium.
Other etiologies contributing to his delirium including
medications (opiates were used periprocedurally, witholding of
his home psychotropic medications, hyperglycemia, fever, pain
related to his knee surgery, and low TSH of 0.02. B12 was
normal. CT head was negative for any acute intracranial
process. However, enlarged ventricles which were seen on prior
study. This is possible due to chronic micro-infarcts given hx.
This is turn could be leading to progressive dementia since wife
states that pt was having hard time adjusting when changing
enviroment and seems more forgetful. The patient also initially
reported neck stiffness, but this was not evident by [**2109-5-25**]
despite persistent waxing/ [**Doctor Last Name 688**] delirium, worse at night; LP
was not obtained given very low clinical suspicion for
meningitis. On the night of [**2109-8-24**], he experienced
sundowning, became very agitated and disorientated. He was
treated first with seroquel, and following minimal response,
with haldol, to which he responded well, but became somnolent.
He was also treated with broad spectrum antibiotics (initally
vancomycin and zosyn, then narrowed to vancomycin alone). His
defervesced, and his mental status later improved.
.
#Fever: pt on POD #4 from TKR, he has fever up to 102 overnight
and he is high risk for infection given long term DM and poorly
glycemic control. His right knee was very tender to palpation,
warm to touch, and erythematous. These findings were concerning
for surgical site infection, although this is quite early in the
post-op course. He was seen by orthopedic surgery, who felt that
his knee did not appear septic and that his symptoms were
normal post-op. Other infectious sources could possibly include
pneumonia since he [**Last Name (un) **] coughing and had recent intubation; and
gastroenteritis, since he was complaining of pain on palpation
on R quadrants and his abdomen was slightly distended, although
soft. His lactate was normal and he did not have leukocytosis.
He was treated with vancomycin (and initially zosyn) and he
defervesced. CXR and KUB were negative for any intrathoracic or
intraabdominal pathology. Blood and urine cultures were
obtained and were negative. Although there was no evidence of a
clear source, the most likely candidate is soft tissue infection
associated with his knee operation. He was therefore planned to
be treated with vancomycin for 14 days and was discharged with a
PICC.
.
# S/p R TKR: He was followed by orthopedic surgery, who thought
that his knee looked good. His opiates were restarted as his
mental status improved. He will follow up with orthopedic
surgery as outlined in the discharge plan.
.
# Chronic diastolic heart failure: pt with hx of diastolic HF
with EF >60% on last Echo done in [**2105**]. JVD not elevated, sl
crackles at base of lungs which clear with cough. Patient was
continued on lasix 80mg once daily and amiloride.
.
# Chronic kidney disease: Creatine at admission at 1.6, his
baseline has been around 1.3-1.7 prior to the surgery. He denied
having any urinary complains and UA was negative except for
glucose and trace ketones. Pt received a total of 5L of fluid in
the ED. In the ICU, his creatinine continued to trend down to
1.5 and IV fluids were subsequently held.
.
# Hyponatremia: Likely due to hyperglycemia. Corrected sodium
was normal. Improved with IV fluids.
.
# Hypothyroidism - Patient has a history of hypothyroidism with
recent low TSH at <0.22. His last Free T4 was actually elevated.
His dose of levothyroxine was increased to 200mcg, however
uncertain about the time. He was seen by [**Last Name (un) **], and continued
on levothyroxine 200mcg po daily.
.
# Bipolar Disease: Patient has a history of bipolar disease and
as per wife has been well controlled except for "tardive
dyskinesia". He is on seroquel, Lamictal and clonazepam.
Lamotrigine was continued, but seroquel and clonazepam were held
in the setting of altered mental status.
Medications on Admission:
1. Lovenox 40 mg/0.4 mL Syringe Sig: One (1) syringe
Subcutaneous once a day for 4 weeks.
2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
6. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO BID (2 times a day) as needed for Constipation.
7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. multivitamin Tablet Sig: One (1) Cap PO DAILY
9. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q6H (every 6 hours).
10. doxazosin 4 mg Tablet Sig: Two (2) Tablet PO DAILY
11. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY
12. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY
13. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal DAILY (Daily).
14. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) inhalation Inhalation DAILY
15. furosemide 40 mg Tablet Sig: Two (2) Tablet PO DAILY
16. gabapentin 300 mg Capsule Sig: Three (3) Capsule PO Q12H
(every 12 hours): Home med.
17. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler
Sig: One (1) Puff Inhalation [**Hospital1 **] (2 times a day).
18. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY
19. lamotrigine 100 mg Tablet Sig: Two (2) Tablet PO DAILY
20. Amitiza 24 mcg Capsule Sig: One (1) Capsule PO twice a day.
21. modafinil 100 mg Tablet Sig: Two (2) Tablet PO once a day.
22. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
23. quetiapine 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
24. rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
25. alpha lipoic acid 300 mg Capsule Sig: One (1) Capsule PO
twice a day
26. amiloride 5 mg Tablet Sig: Four (4) Tablet PO DAILY
27. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY
28. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
29. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
6AM
30. clonazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for anxiety: Hold for confusion/sedation.
31. oxycodone 5 mg Tablet Sig: 0.5-1 Tablet PO Q4H (every 4
hours) as needed for pain.
32. insulin glargine Subcutaneous (Glargine 20 Units Glargine
10 Units) and aggressive Humalog SS
Insulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
Humalog Humalog Humalog Humalog
Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose
0-70 mg/dL Proceed with hypoglycemia protocol Proceed with
hypoglycemia protocol Proceed with hypoglycemia protocol Proceed
with hypoglycemia protocol
71-99 mg/dL 0 Units 0 Units 0 Units 0 Units
100-139 mg/dL 5 Units 5 Units 5 Units 0 Units
140-179 mg/dL 7 Units 7 Units 7 Units 0 Units
180-219 mg/dL 9 Units 9 Units 9 Units 2 Units
220-259 mg/dL 11 Units 11 Units 11 Units 3 Units
260-400 mg/dL 13 Units 13 Units 13 Units 4 Units
33. buspirone 15 mg Tablet Sig: 1.5 Tablets PO QAM
34. buspirone 15 mg Tablet Sig: One (1) Tablet PO at bedtime.
Discharge Medications:
1. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) syringe
Subcutaneous once a day for 4 weeks: Last dose: [**2109-9-17**].
Disp:*18 syringe* Refills:*0*
2. vancomycin 500 mg Recon Soln Sig: 1250 (1250) mg Intravenous
Q 12H (Every 12 Hours) for 7 days: last day [**2109-9-6**].
Disp:*[**Numeric Identifier 10489**] mg* Refills:*0*
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*qs Tablet(s)* Refills:*0*
5. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q4H (every 4 hours) as needed for
SOB/Wheezing.
6. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal DAILY (Daily).
8. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
9. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
10. rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
11. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. levothyroxine 100 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
13. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler
Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day).
14. amiloride 5 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).
15. furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. lamotrigine 100 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
17. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
18. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
19. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
20. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain .
Disp:*30 Tablet(s)* Refills:*0*
21. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea.
Disp:*30 Tablet, Rapid Dissolve(s)* Refills:*0*
22. Insulin Pump IR1250 Miscellaneous
23. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed for constipation.
Disp:*1500 ML(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Hospice and VNA
Discharge Diagnosis:
Delirium
Soft tissue infection
Discharge Condition:
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Discharge Instructions:
You have been admitted with delirium and fever due to an
infection, likely a soft tissue infection related to your knee
operation. Your knee has been evaluated and looks good. However,
given the severity of your presentation, you are recommended a
14-day course of iv antibiotics.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
1. Please return to the emergency department or notify your
physician if you experience any of the following: severe pain
not relieved by medication, increased swelling, decreased
sensation, difficulty with movement, fevers greater than 101.5,
shaking chills, increasing redness or drainage from the incision
site, chest pain, shortness of breath or any other concerns.
2. Please follow up with your primary physician regarding this
admission and any new medications and refills.
3. Resume your home medications unless otherwise instructed.
4. You have been given medications for pain control. Please do
not drive, operate heavy machinery, or drink alcohol while
taking these medications. As your pain decreases, take fewer
tablets and increase the time between doses. This medication can
cause constipation, so you should drink plenty of water daily
and take a stool softener (such as colace) as needed to prevent
this side effect. Call your surgeons office 3 days before you
are out of medication so that it can be refilled. These
medications cannot be called into your pharmacy and must be
picked up in the clinic or mailed to your house. Please allow
an extra 2 days if you would like your medication mailed to your
home.
5. You may not drive a car until cleared to do so by your
surgeon.
6. Please keep your wounds clean. You may shower starting five
(5) days after surgery, but no tub baths or swimming for at
least four (4) weeks. No dressing is needed if wound continues
to be non-draining. Any stitches or staples that need to be
removed will be taken out by the visiting nurse (VNA) or rehab
facility two
weeks after your surgery.
7. Please call your surgeon's office to schedule or confirm your
follow-up appointment in four (4) weeks.
8. Please DO NOT take any non-steroidal anti-inflammatory
medications (NSAIDs such as celebrex, ibuprofen, advil, aleve,
motrin, etc).
9. ANTICOAGULATION: Please continue your lovenox for four (4)
weeks after surgery to help prevent deep vein thrombosis (blood
clots). [**Male First Name (un) **] STOCKINGS x 6 WEEKS.
10. WOUND CARE: Please keep your incision clean and dry. It is
okay to shower five days after surgery but no tub baths,
swimming, or submerging your incision until after your four (4)
week checkup. Please place a dry sterile dressing on the wound
each day if there is drainage, otherwise leave it open to air.
Check wound regularly for signs of infection such as redness or
thick yellow drainage. Staples will be removed by the visiting
nurse or rehab facility in two (2) weeks.
11. VNA (once at home): Home PT/OT, dressing changes as
instructed, wound checks, and staple removal at two weeks after
surgery.
12. ACTIVITY: Weight bearing as tolerated on the operative
extremity. Mobilize. CPM/ROM as tolerated. No strenuous exercise
or heavy lifting until follow up appointment.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3260**], [**MD Number(3) 3261**]:[**Telephone/Fax (1) 1228**]
Date/Time:[**2109-9-20**] 12:40
Department: ORTHOPEDICS
When: FRIDAY [**2109-9-20**] at 12:40 PM
With: [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3260**], PA [**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: ADULT SPECIALTIES
When: FRIDAY [**2109-10-11**] at 10:00 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 10490**],PHD [**Telephone/Fax (1) 8645**]
Building: [**Location (un) 2790**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Department: ADULT SPECIALTIES
When: MONDAY [**2109-10-21**] at 2:00 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD, PHD [**Telephone/Fax (1) 8645**]
Building: [**Location (un) 2790**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Department: INTERNAL MEDICINE
When: THURSDAY [**2109-9-5**] at 3:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 10491**], MD [**Telephone/Fax (1) 10492**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 24**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
[
"276.1",
"244.9",
"414.01",
"V45.82",
"401.9",
"428.0",
"348.31",
"327.23",
"998.59",
"250.13",
"V43.65",
"428.32",
"V58.67"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
33827, 33889
|
22212, 27905
|
13540, 13546
|
33964, 34086
|
19170, 22189
|
37400, 38931
|
18014, 18073
|
31390, 33804
|
33910, 33943
|
27931, 31367
|
34147, 36600
|
18088, 19151
|
12445, 12523
|
12545, 12681
|
16598, 17025
|
15590, 16152
|
13440, 13502
|
36612, 37377
|
13574, 15571
|
34101, 34123
|
17056, 17781
|
16174, 16578
|
17797, 17998
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,022
| 152,125
|
51769
|
Discharge summary
|
report
|
Admission Date: [**2105-5-30**] Discharge Date: [**2105-6-22**]
Date of Birth: [**2041-6-2**] Sex: M
Service: SURGERY
Allergies:
Procainamide / Ivp Dye, Iodine Containing
Attending:[**First Name3 (LF) 1**]
Chief Complaint:
Nauswa/vomiting
Major Surgical or Invasive Procedure:
Exploratory laparotomy, small bowel resection
Exploratory laparotomy revision
Exploratory laparotomy revision
Exploratory laparotomy revision
Placement of tracheostomy and gastrostomy tube
History of Present Illness:
MR [**Known lastname 107214**] is a 63M who presented to the ED with
nausea/vomiting and diarrhea. CT was consistent with ischemia
and perforation. With his past history of artificial heart valve
requiring anti-coagulation, and extensive cardiac disease, he
was a high operative risk. However, as bowel ischemia would
proved fatal in this patient, it was decided to operate.
Past Medical History:
EXTENSIVE CARDIAC HISTORY AS LISTED BELOW:
bioprosthetic AVR in '[**80**] -> repeat in '[**83**] -> stenosed AVR ->
mechanical AVR '[**96**]
CABG [**2088**]
SVG --pDA, SVG-LAD, SVG-LCX
-CABG '[**96**] (redo bypass)
SVG-D1, SVG-OM, SVG-RCA,SVG to PDA to PLB
-97-removal of sternal wire due to protrusion into heart
..
MIBI ( modified [**Doctor First Name **]; ETT-MIBI); stopped for fatigue; [**6-9**] CP
and received 1 SL nitro; EF 27%, global HK, esp septal with
fixed apical defect, transient ischemic dilitation of LV, and
mod part reversible distal anterior, inferior and septal
defects.
..
-cath (1/03)90% SVG-RCA -> Ultra 4.5x28. SVG-D down, but native
diag collateralized. SVG-OM down, but LCX disease moderate at
that point. Unclear why no LIMA.
..
Carotid u/s: ([**6-3**]): R minimal plaque. w <40% stenosis. L mod
plaque w/ 59% carotid stenosis
GERD
hyperlipidemia
severe COPD
depression
CVA'[**95**]
h/o heamturia-neg cystocscopy
diet controlled diabetes
Social History:
+ significant tobacco history, lives at rest home
Physical Exam:
Physical exam on discharge:
VS: 98.0 68 115/70 18 97%RA
Gen: No apparent distress, breathing comfortable with trach
CV: Audible murmur, consistent with history of heart valve
replacement.
Ch: Coarse BS at bases, no distinct crackles
Abd: Soft, non-tender, non-distended
Ext: WWP
Pertinent Results:
[**2105-6-22**] 05:47AM BLOOD WBC-8.5 RBC-3.78* Hgb-11.3* Hct-34.0*
MCV-90 MCH-29.9 MCHC-33.2 RDW-14.9 Plt Ct-300
[**2105-6-22**] 05:47AM BLOOD PT-20.5* PTT-32.2 INR(PT)-2.8
Brief Hospital Course:
In the ED, his CT was consistent with ischemia and perforation.
He was emergently taken to the operating room for an ex lap with
small bowel resection. Due to his prosthetic aortic valve, it
was deemed essential to resume his anti-coagulation. He re-bled
and was taken back to the OR, after which his anticoagulation
was restarted. Although he at first stabilized, he eventually
needed 2 further emergent revisions for bleeding from the
anastomosis.
He was transferred to the SICU after his emergent surgical
issues had resolved. He was maintained on vancomycin,
levofloxacin, and fluconazole as empiric coverage for his
perforated viscus. He made slow gradual improvement. A Dobhoff
tube was palced and he started tubefeeds on [**2105-6-3**]. On [**2105-6-5**] he
passed copious old dark blood per rectum. His hematocrit
remained stable, and this blood was deemed to be old
intraluminal blood and not an indicator of new bleeding. He
continued to have sporadic respiratory difficulties while
intubated, with bilateral infiltrates seen on CXR that were slow
to resolve. However, it is unlikely that there is an infectious
process in the lungs.
Neurologically, he remained fairly heavily sedated while
intubated, although he remained responsive and was able to move
all extremities. After his trach placement, respiratory
stabilization, and weaning from sedation, he was doing quite
well neurologically and answered questions appropriately,
alhtough at times he seemed somewhat confused about the events
of the past few weeks.
He continued to tolerate his tubefeeds well, and gradually
improved. Although his anticoagulation continued throughout, he
did not re-bleed. He had some intermittent problems with
agitation, although this was managed with haldol, and pt's
sensorium gradually improved. By [**6-17**], he was tolerating
tubefeeds at 80cc/hr, and was respiring well on trach mask only,
without added ventilatory support. It is our opinion that he
will not need continued antibiotics. On [**6-22**] he underwent both
bedisde and video swallow eval. Per their evaluation, he can
tolerate thin liquids alternating with pureed solids,
alternating bite and sip, and needs to be supervised. Solid
foods are NOT advisable at present.
Medications on Admission:
1. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**2-1**]
Puffs Inhalation Q4H (every 4 hours).
2. Acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal Q6H (every 6 hours) as needed for fever.
3. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
5. Lansoprazole 15 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO once a
day.
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 2 days.
9. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
Discharge Medications:
1. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**2-1**]
Puffs Inhalation Q4H (every 4 hours).
2. Acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal Q6H (every 6 hours) as needed for fever.
3. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
5. Lansoprazole 15 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO once a
day.
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 2 days.
9. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
GERD
hyperlipidemia
COPD
depression
diet controlled diabetes
Discharge Condition:
Stable
Discharge Instructions:
Pt will require tracheostomy care, physical therapy, nutritional
optimization, and monitoring of anti-coagulation due to
artificial heart valve.
Followup Instructions:
Please call Dr[**Name (NI) 10946**] office to schedule your follow up
appointment, approx 2 weeks.
|
[
"496",
"V43.3",
"272.4",
"530.81",
"997.4",
"557.0",
"V58.67",
"998.11",
"311",
"518.5",
"286.9",
"250.00",
"428.0",
"V45.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.64",
"45.62",
"96.6",
"99.77",
"99.15",
"31.1",
"33.22",
"54.12",
"43.11",
"00.17",
"45.91",
"46.73"
] |
icd9pcs
|
[
[
[]
]
] |
6398, 6468
|
2481, 4720
|
313, 503
|
6573, 6581
|
2283, 2458
|
6774, 6875
|
5572, 6375
|
6489, 6552
|
4746, 5549
|
6605, 6751
|
1983, 1983
|
2012, 2264
|
258, 275
|
531, 907
|
929, 1900
|
1916, 1968
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,664
| 155,936
|
33649
|
Discharge summary
|
report
|
Admission Date: [**2201-4-14**] Discharge Date: [**2201-5-5**]
Date of Birth: [**2178-10-24**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 473**]
Chief Complaint:
abdominal pain, nasuea and constipation
Major Surgical or Invasive Procedure:
Sigmoidectomy, end colostomy (hartmans pouch), R
salpingoophrectomy, TAH, removal of pelvic mass
History of Present Illness:
22 y/o LMP [**2201-4-11**] with Trisomy 13 mosaic, cardiomyopathy
transferred from [**Hospital **] Hospital overnight with a new pelvic
mass. She originally presented to OSH with signs of distress
abdominal pain, nasuea and constipation. CT scan there revealed
a right pelvic mass measuring 10.6 cm. The was also evidence of
partial large bowel obstruction. She was subsequently
transferred to [**Hospital1 18**] for further management.
.
In the ED, the patient was without nausea/vomiting. She has
passed liquid stool. She is now voiding without difficulty. She
has not required any pain medications. Ultrasound was an
inadequate study. General surgery and OB/GYN were consulted.
Past Medical History:
Trisomy 13 Mosaicism
Mentral Retardation - nonverbal at BL
Cardiomyopathy - Unknown status. Had ECHO last at [**Hospital1 336**]
(pending).
PDA (congenital, closed per mother without OR)
"Slow heartbeat"
Aspiration PNA
Neck anatomic deformity with inverted crichoid/hypoid. Pt
assists herself with her fingers on the outside of her throat to
pass food.
.
GYN HISTORY: LMP: [**2201-4-11**], regular menses with cramping
OB HISTORY:G:0
.
PAST SURGICAL HISTORY: Fundoplication
Social History:
SOCIAL HISTORY: No T/ETOH/IV drugs
Family History:
Breast cancer
Physical Exam:
BP: 113/53 HR 89 RR 17 Ox sat 96% on RA
GEN: Female in bed, eyes open, tracks to voice in NAD
HEENT: Perrl, EOMI (not to commands), MMM
CV: Tachy with no m/r/g
Lung: CTA no w/r/r; upper airway noises
Abd: soft distended, tender, guarding
Ext: No edema, clubbing or cyanosis
Neuro: Alert, nonverbal, CN II-XII intact
Pelvic (per OB): Normal external genitalia with an anteverted
uterus
Pertinent Results:
[**2201-4-14**] 03:30AM BLOOD WBC-9.2 RBC-3.94* Hgb-10.3* Hct-32.1*
MCV-82 MCH-26.2* MCHC-32.1 RDW-14.0 Plt Ct-172
[**2201-4-27**] 08:33AM BLOOD WBC-13.7* RBC-3.48* Hgb-9.8* Hct-30.1*
MCV-87 MCH-28.1 MCHC-32.4 RDW-16.7* Plt Ct-618*
[**2201-4-27**] 03:56AM BLOOD Glucose-98 UreaN-26* Creat-0.4 Na-135
K-4.6 Cl-104 HCO3-27 AnGap-9
[**2201-4-27**] 03:56AM BLOOD Amylase-340*
[**2201-4-27**] 03:56AM BLOOD Lipase-716*
[**2201-4-27**] 03:56AM BLOOD Calcium-9.0 Phos-4.6* Mg-1.9
[**2201-4-23**] 05:25PM BLOOD calTIBC-273 Ferritn-137 TRF-210
[**2201-4-17**] 02:23AM BLOOD Triglyc-194*
[**2201-4-14**] 03:30AM BLOOD CA125-43*
[**2201-4-20**] 02:04PM BLOOD Digoxin-1.2
.
PELVIS, NON-OBSTETRIC [**2201-4-14**] 3:33 AM
IMPRESSION: Non-diagnostic examination as described above. Large
deep pelvic cystic complex cystic mass partially visualized with
a second possibly cystic structure in right pelvis
.
SPECIMEN SUBMITTED: FS RIGHT TUBE AND OVARY, UTERUS & CERVIX,
LEFT COLON, SIGMOID COLON, PELVIC CYST WALL, APPENDIX.
Procedure date Tissue received Report Date Diagnosed
by
[**2201-4-14**] [**2201-4-14**] [**2201-4-18**] DR. [**Last Name (STitle) **]. [**Doctor Last Name **]/hw
DIAGNOSIS:
I. Right fallopian tube and ovary (A-I):
Marked acute and chronic salpingitis with abscess formation,
necrosis, and marked dilation of the tube.
Paratubal cyst.
No ovarian tissue seen.
II. Sigmoid colon (J-Q):
unremarkable colonic mucosa.
Serosa with congestion and mild acute serositis.
III. Left colon (R-V):
Unremarkable colonic mucosa.
Mild acute serositis.
IV. Uterus and cervix (W-AC):
unactive-type endometrium with focal breakdown.
Unremarkable cervix.
V. Pelvic cyst wall (AD): Benign squamous-lined cyst.
VI. Appendix (AE):
Acute serositis with inflammatory infiltrate into muscularis
propria.
Focal acute cryptitis, otherwise unremarkable mucosa.
.
CTA CHEST W&W/O C&RECONS, NON-CORONARY [**2201-4-18**] 11:40 AM
IMPRESSION:
1. No pulmonary embolism.
2. Multifocal airspace opacities predominantly in the right
upper lobe, but also seen in the right middle lobe, lingula, and
left lower lobe. Primary consideration is a multifocal
pneumonia, but asymmetric pulmonary edema could have this
appearance as well.
3. Right lower lobe collapse, secondary to mucus plug in the
proximal right lower lobe bronchus.
4. Small bilateral pleural effusions.
5. Moderate distention of the azygous and hemiazygous veins with
contrast, raises suspicion for thrombus in the superior vena
cava, especially with catheter in place in the SVC, though no
definite sign of this is seen.
.
CHEST (PORTABLE AP) [**2201-4-23**] 4:47 AM
FINDINGS: As compared to the previous examination, the
pre-existing multifocal opacities show further regression and
are barely visible on today's examination. Today's examination
shows no evidence of pleural effusion. Otherwise no relevant
changes, the size of the cardiac silhouette is also unchanged.
.
CT ABDOMEN W/CONTRAST [**2201-4-28**] 3:47 PM
[**Hospital 93**] MEDICAL CONDITION:
22 year old woman s/p sigmoidectomy, end colostomy, R
salpingoophorectomy, TAH, now with tachycardia, desaturation,
and rising WBC count
REASON FOR THIS EXAMINATION:
eval for PE, pneumonia, intra-abdominal fluid collection, PO and
IV contrast
1. Limited evaluation of the pulmonary arteries as above due to
patient motion. No evidence of central pulmonary embolism.
2. Interval improvement in bilateral pneumonia with residual
patchy opacities in the posterior lobes.
3. Three fluid collection in the right abdomen and pelvis as
above.
4. Abnormal enhancement pattern of the liver. Thrombus in the
splenic vein and possibly SMV/splenic vein confluence.
Nonvisualization of the portal vein and SMV. Nonopacification of
the hepatic veins. Further evaluation with Doppler ultrasound is
recommended to better assess patency of the portal and hepatic
veins.
5. Diffuse dilatation of small and large bowel, likely related
to postoperative ileus.
.
VIDEO OROPHARYNGEAL SWALLOW [**2201-4-30**] 9:09 AM
IMPRESSION: Aspiration with thin consistency barium.
Brief Hospital Course:
This is a 22 year old nonverbal Female with h/o mosaic Trisomy
13 and cardiomyopathy (EF=35%) who was xfer'd from OSH with R
pelvic mass and dilated large bowel.
She is s/p TAH/RSO, drainage of pelvic cyst, sidmoid colon
resection with end colostomy and [**Doctor Last Name **] pouch, and
appendectomy on [**2201-4-14**]
*)Neuro - nonverbal at baseline, but able to understand some.
Her pain seemed well controlled
*)Pulm - She was difficult to wean- continued Lasix, dig. Shw
was hypoxemic post-op requiring 60-80% high flow. Initial
thought that she might have an intracardiac shunt causing
hyupoxemia given relatively normal CXR. But CTA showed RLL
collapse as well as RUL > LUL ground glass (no PE) and Small b/l
pleural effusions. She then required hi flow face mask,
suctioning q4h. She was eventually weaned to RA. A CXR on [**4-28**]
showed RLL atelectasis. She had a rising WBC and a repeat CTA on
[**4-28**] was doen to look for any abscess or infectious process.
This showed no PE, interval improved B/L PNA and no worisome
infectious fluid collections. She was treated for PNA and her
WBC quickly improved.
*)CV
She was tachycardia/hypotensive in PACU. She received IVF
resuscitation and the hypotension resolved. The tachycardia
persisted - volume vs. cardiomyopathy vs pain. Her Hct was
stable at 29.5. Her home meds were restarted for cardiomyopathy
- digoxin, enalapril and lasix.
She had an intra-op Echo - EF 35%, [**4-14**] Echo L atrium mildly
dilated. No ASD. The estimated RA pres is 0-10mmHg. LVEF=
30-35%. Nl RV. Nl A valve. Nl MR w/ trivial regurg.
She had post-op tachycardia, likely due to hypovolemia. She was
gently repleated with IVF and had resolution of her tachycardia.
*)ID
She had a temp to 102.4 in PACU. She was started on Zosyn
empirically.
[**4-15**] Bld: Corynebacterium
[**4-14**] Fluid: E.coli (pan sensitive)
She was started on Vanc/Cefepime on [**4-28**] for Aspiration
Pneumonia
*)GI/FEN: She was NPO with IVF and a NGT. A PICC was placed and
TPN started. The NGT was then clamped. Her ostomy began putting
out gas and then some stool. On [**4-21**] she had a swallow strudy
and she was allowed - pureed solids and thin liquids.
Due to the pneumonia, a repeat video swallow was performed and
showed that she was aspirating thin liquids and occasional
thickened liquids. She was allowed honey thickened liquids. The
family declined a PEG tube and felt that once she was home, they
would be able to help feed her more effectively.
Medications on Admission:
enalapril 10', digoxin 0.25', lasix 10', sertraline 50', miralax
Discharge Medications:
1. Cefepime 2 gram Recon Soln Sig: Two (2) g Injection Q12H
(every 12 hours) for 4 days: Last dose [**2201-5-8**].
Disp:*7 g* Refills:*0*
2. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 4 days: Last dose [**5-8**].
Disp:*11 Tablet(s)* Refills:*0*
3. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) g
Intravenous Q 12H (Every 12 Hours) for 4 days: Last dose [**5-8**].
Disp:*7 g* Refills:*0*
4. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Furosemide 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
6. Enalapril Maleate 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
10. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS
(4 times a day (before meals and at bedtime)).
Disp:*120 Tablet(s)* Refills:*2*
11. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed.
Disp:*45 Tablet(s)* Refills:*0*
12. PICC
PICC care per protocol.
Please remove PICC after last dose of antibiotics.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 511**] Home Therapies
Discharge Diagnosis:
Pelvic Mass
Post-op Aspiration Pneumonia
Post-op RLL collapse and pleural effusion
Discharge Condition:
Good
Discharge Instructions:
Discharge Instructions:
-It is OK wash your abdominal incision. No baths or swimming.
-Keep incision clean and dry.
-Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
.
Please call your doctor or return to the ER for any of the
following:
* 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.
* 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.
* Continue on IV antibiotics thru [**5-8**].
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 468**] in 3 weeks. Call [**Telephone/Fax (1) 2835**]
to schedule an appointment.
Completed by:[**2201-5-5**]
|
[
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"319",
"556.9",
"997.3",
"425.4",
"789.39",
"758.1",
"560.9",
"751.4",
"567.29"
] |
icd9cm
|
[
[
[]
]
] |
[
"46.03",
"38.93",
"45.76",
"54.23",
"46.82",
"68.49",
"70.12",
"47.19",
"99.15",
"65.49"
] |
icd9pcs
|
[
[
[]
]
] |
10118, 10187
|
6252, 8733
|
353, 452
|
10314, 10321
|
2166, 5141
|
11397, 11556
|
1730, 1745
|
8849, 10095
|
5178, 5315
|
10208, 10293
|
8759, 8826
|
10369, 11374
|
1644, 1661
|
1760, 2147
|
274, 315
|
5344, 6229
|
480, 1163
|
1185, 1621
|
1693, 1714
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
608
| 171,266
|
20688+20693
|
Discharge summary
|
report+report
|
Admission Date: [**2167-2-22**] Discharge Date: [**2167-3-6**]
Date of Birth: [**2098-12-20**] Sex: M
Service: Thoracic Surgery
HISTORY OF PRESENT ILLNESS: The patient is a 68 year old
male, retired fighter pilot, with a medical history
significant for advanced chronic obstructive pulmonary
disease, anxiety and depression who has deteriorated
significantly over the past two months requiring
hospitalization. He was separated from his wife in [**2163**] and
has been living alone on [**Location (un) **] in an isolated situation,
diagnosed with depression several years ago by his primary
care physician and has undergone a slow decline over the past
several years. He has had several episodes of pneumonia but
was doing reasonably well until [**Holiday **] of last year when
he developed bronchitis which progressed to pneumonia and he
was admitted to [**Hospital 1562**] Hospital. Since that point his
decline has resulted in traumatic weight loss and the
development of skin necrosis and ulceration in the bilateral
lower extremities and tips of his fingers during his last
hospital stay. Despite an aggressive workup during the
involvement of many specialists, they were unable to pinpoint
the exact etiology of the problem. The patient denied any
fevers, chills or sweats, hemoptysis, new neurological,
musculoskeletal or gastrointestinal complaints. He denies
issues with his kidneys, pancreas, liver, gallbladder and
heart.
PAST MEDICAL HISTORY: 1. History of atrial fibrillation; 2.
Anxiety/depression; 3. Chronic obstructive pulmonary
disease.
PAST SURGICAL HISTORY: Unremarkable.
MEDICATIONS ON ADMISSION:
1. Protonix 40 mg p.o. q. day
2. Thiamine 50 mg p.o. q. day
3. Lovenox 40 mg p.o. q. day
4. Toradol 15 mg intravenously q. 6 hours prn for pain.
5. Vancomycin 500 mg intravenously q. day
6. Ciprofloxacin 500 mg p.o. b.i.d.
7. Doxycycline 100 mg p.o. q.i.d.
8. Solu-Medrol 30 mg intravenously q. 8 hours
9. Albuterol inhaler
ALLERGIES: The patient has an allergy to Procaine,
Novocaine, [**Female First Name (un) **] anesthetics and Penicillin.
SOCIAL HISTORY: Significant for a 45 year pack year history
of smoking.
FAMILY HISTORY: Unremarkable.
PHYSICAL EXAMINATION: On physical examination the patient
was afebrile with vital signs stable, sating 93% on room air.
The patient was a thin cachectic male who appeared in minimal
to moderate distress. Head was atraumatic, normocephalic.
Sclera were anicteric. Neck was soft, supple with no masses
noted and no carotid bruits. Lungs were clear to
auscultation bilaterally, however, breath sounds were
slightly decreased, no wheezes noted. Heart was regular rate
and rhythm with no murmur. Thorax was symmetrical without
any lesions. Abdomen was scaphoid, soft, nontender,
nondistended. Extremities showed no cyanosis, clubbing or
edema, however, they did show larger areas of ulceration and
necrosis, right greater than left in the lower extremities,
upon which the skin appeared to be sloughing off of his body.
The patient also had some areas of punctate ulceration
necrosis on his hands as well. Neurologically, the patient
had no deficits. Further detailed lower extremity
ulcerations, the patient had two large necrotic ulcerations
directly inferior to the right kneecap and then from
approximately mid calf down the patient had large reddish
ulcerations with minimal bleeding in a patchy distribution.
On the left lower extremity the patient had minimally
bleeding ulceration on the left forefoot that did not extend
superiorly to the ankle.
HOSPITAL COURSE: The patient is a 68 year old male with
severe chronic obstructive pulmonary disease, malnutrition,
lower extremity ulcerations of unknown etiology who presented
to the Thoracic Surgery Service for further evaluation and
treatment of multiple problems. On hospital day #2, the
patient went for chest x-ray which demonstrated no definite
pneumonia or cardiac failure, prominence of the right aortic
contour concerning for ascending aortic aneurysm. The
patient then went for a computerized tomography scan on
hospital day #3 which revealed head computerized tomography
scan which showed no intracranial pathological process,
computerized tomography scan of the torso which demonstrated
no evidence of malignancy, diffuse extensive emphysema with
small peripheral patchy opacities, extensive vasculopathy
with suggestion of infrarenal aortic stenosis and post
traumatic dilatation, an ascending aortic aneurysm measuring
4.2 cm and a prominent left adrenal gland.
At this time multiple consultations were obtained. Pulmonary
consultation evaluating the patient's pulmonary function
tests were performed which demonstrated severe emphysematous
pattern consistent with the patient's disease process.
Pulmonary then recommended various nebulizer treatments which
were enacted. On [**2167-2-24**], the patient was seen by
Psychiatry for increasing anxiety, depression and possible
delirium change in mental status. Psychiatry recommended
Haldol prn for agitation and also recommended checking TSH,
B12 and Folate levels which were all normal. There were no
further recommendations made at this time, and the patient's
mental status had improved over the course of the hospital
stay. On [**2167-2-24**], the patient was also seen by
nutrition consultation which recommended Boost supplements
t.i.d. and calorie counts and q. day weights to monitor
nutritional status. Also on [**2167-2-24**], the patient was
seen by the Dermatology Service who made an assessment of
vasculitis of unknown origin or an embolic phenomenon. Two
punch biopsies were taken at this time, one from the right
lower extremity and one from the left index finger and these
were sent to Pathology for further analysis. Also on [**2167-2-24**], Neurology saw the patient. They reviewed the
computerized tomography scan which was normal and had no
recommendations at this time. On [**2167-2-25**], Vascular
Surgery saw Mr. [**Known lastname 25699**], recommendations included noninvasive
arterial studies of the lower extremities which demonstrated
significant arterial disease on the right lower extremity
with flexions of 9 and 6 at the ankle and metatarsal areas
respectively on the right lower extremity. In addition,
computerized tomography scan was evaluated and infrarenal
narrowing of the aorta was noted but thought to be
subclinical. Dr. [**Last Name (STitle) **], the vascular surgeon at this time,
recommended bilateral lower extremity angiogram with possible
intervention. In addition Vascular Surgery recommended
Silvadene and adaptic dressings to the lower extremity
ulcerations b.i.d.
On [**2167-2-26**], the patient was seen by Nutrition again.
The patient was taking in approximately 44 gm of protein and
1400 cal/day which was sufficient for the patient's
nutritional needs. The patient was demonstrating a steady
weight gain. On [**2167-2-27**], the patient went for
bilateral lower extremity angiogram by Dr. [**First Name (STitle) **] in the
Cardiac Catheterization Laboratory. The patient was found to
have near total occlusion of the right common iliac artery
and two stents were placed after angioplasty of this area as
well as two stents placed in the left common iliac artery.
The patient did well post procedure with no groin hematoma,
no bruit in the groin. Immediately post procedure the
patient reported feeling much better in the lower extremities
than prior. Up until this point the patient had a white
count that was hovering between 20 and 24. Skin cultures at
this point came back only positive for Corynebacteria. Blood
cultures have been negative to date. On [**2167-2-28**],
Infectious Disease saw the patient. Recommendations included
discontinuing the Vancomycin which the patient was on and
changing it to Linezolid 600 mg p.o. q. 12 hours and
continuing the Ciprofloxacin. The patient was also
recommended to have Clostridium difficile sent off which all
were negative.
On [**2167-2-28**], the patient's punch biopsy by Dermatology
returned negative for vasculitis in the lower extremity
biopsy sample, but the left index finger was positive for
vasculitis with definite changes in the small/medium sized
arteries. At this time, differential diagnosis included
systemic vasculitis or drug vasculitis. Multiple systemic
laboratory data were sent off including Cryoglobulin, C3, C4
which all returned negative.
The patient was seen by Plastic Surgery on [**2167-3-2**] for
possible skin graft treatment for her lower extremity
ulcerations which were somewhat improving. Plastic Surgery
evaluated the patient and made no recommendations at this
time, hoping for the patient's ulcerations to heal slightly
prior to repeat evaluation assessment as an outpatient.
Secondary to the patient's persistent high white count the
patient was sent for bone scan to rule out osteomyelitis and
on [**2167-3-2**] the patient was sent and test was negative.
Post intervention PVRs demonstrated increased flow of
arterial supply in the right lower extremity. On [**2167-3-3**], the patient was seen by Rheumatology for assessment of
vasculitis. Additional laboratory data were sent off
including ESR, CRPNA which were all negative. Tentative
diagnosis at this time of the etiology of lower extremity
ulceration was drug vasculitis due to Vancomycin. On
hospital day #13, the patient was seen as fit to be
transferred to a rehabilitation center.
Unfortunately, he was then was found down and hypotensive
and required intubation and resusitation and transfer to the
ICU. The details of which are in a followup addendum.
DISCHARGE STATUS: To rehabilitation.
DISCHARGE CONDITION: Stable.
DISCHARGE DIAGNOSIS:
1. Drug vasculitis.
2. Severe pulmonary emphysema.
3. Anxiety, depression.
4. Peripheral vascular disease.
FOLLOW UP: The patient is to follow up with multiple
services, Plastic Surgery, Dr. [**First Name (STitle) **], Infectious Disease, Dr.
[**Last Name (STitle) 977**], Rheumatology, Dr. [**Last Name (STitle) **], [**First Name3 (LF) 1092**] Surgery, Dr.
[**Last Name (STitle) 952**] in one to two weeks, please call for an appointment,
Vascular Surgery, Dr. [**Last Name (STitle) **].
MEDICATIONS ON DISCHARGE:
1. Protonix 40 mg p.o. q. day
2. Thiamine 100 mg p.o. q. day
3. Heparin 5000 units subcutaneously b.i.d. while in bed.
4. Combivent inhaler 1 nebulizer q. 6 hours.
5. Serevent inhaler 1 disc q. 12 hours.
6. Silver sulfadiazine cream apply topically b.i.d.
7. Folic acid 1 mg p.o. q. day
8. Multivitamin one tablet p.o. q. day
9. Aspirin 325 mg p.o. q. day
10. Plavix 75 mg p.o. q. day
11. Albuterol inhaler one nebulizer q. 6 hours prn
12. Ultram 50 to 100 mg p.o. q. 6 hours prn for pain
13. Ibuprofen 600 mg p.o. q. 6 hours
14. Neurontin 300 mg p.o. q.h.s.
15. Solu-Medrol 30 mg, 20 mg and 30 mg q. day until [**2093-3-7**] mg, 10 mg and 30 mg until [**2093-3-12**] mg, 30 mg until
[**2093-3-17**] mg 20 mg until [**2093-3-22**] mg then 10 mg until
[**2093-3-27**] mg until [**2083-4-2**] mg until [**4-8**] and 10 mg
until [**4-13**], intravenously as directed.
16. Linezolid 600 mg p.o. q.12 hrs to be adjusted at follow
up.
17. Ciprofloxacin 500 mg p.o. q. 12 hours to be adjusted at
further follow up.
DISCHARGE INSTRUCTIONS: The patient is to have wound care as
directed, Silvadene adaptic dressings to lower extremities
b.i.d.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3351**], M.D. [**MD Number(1) 3352**]
Dictated By:[**Name8 (MD) 7190**]
MEDQUIST36
D: [**2167-3-6**] 09:00
T: [**2167-3-6**] 09:34
JOB#: [**Job Number 55246**]
Admission Date: [**2167-2-22**] Discharge Date: [**2167-3-24**]
Date of Birth: [**2098-12-20**] Sex: M
Service: MICU ROM
HISTORY OF PRESENT ILLNESS: Patient is a 68-year-old
gentleman with a past medical history significant for severe
COPD, AFib, anxiety and depression, who was transferred from
[**Hospital 1562**] Hospital on [**2167-2-22**] to [**Hospital1 190**] for further evaluation of his COPD.
Specifically, the patient was admitted to the CT Surgery
service for evaluation for potential lung volume reduction
surgery.
The patient's primary pulmonologist at [**Hospital 1562**] Hospital is
Dr. [**Last Name (STitle) 55254**] and he referred the patient specifically to Dr.
[**Last Name (STitle) 952**], a CT Surgery attending at [**Hospital3 **]. The [**Hospital 228**]
hospital course from [**2167-2-22**] up until [**2167-3-6**] has been
dictated previously by a CT surgeon on Dr.[**Name (NI) 1816**] team. To
briefly summarize their report, the patient was transferred
on [**2167-2-22**] with issues including failure to thrive, COPD,
cachexia with severe malnutrition, and a small/medium vessel
vasculitis resulting in multiple skin erosions on all four of
the patient's extremities.
While on the CT Surgery service, the patient was evaluated by
multiple services, including Dermatology, Plastic Surgery,
Vascular Surgery, Infectious Disease, Rheumatology,
Pulmonary, Nutrition, and Physical Therapy. The Pulmonary
service recommended inhaled steroids as well as
around-the-clock MDIs including Atrovent and albuterol for
his pulmonary disease. He had pulmonary function testing on
[**2-25**] that revealed a SVC of 2.98, which is 70% of
predicted, a FEV1 of 0.96, which is 33% predicted, and a
FEV1:FVC ratio of 32, which is 47% predicted. This is
consistent with very severe COPD.
The patient had a CT of the chest with and without contrast
on [**2167-2-24**] that showed no lymphadenopathy, extensive
emphysematous changes bilaterally, and multiple small
bilateral vague patchy areas of nodularity of uncertain
significance. There were no pleural or pericardial
effusions, no infiltrates. An incidental finding was made of
an infrarenal aortic stenosis and extensive vascular
calcifications. Because of this incidental finding, the
patient had bilateral PVR testing that revealed significantly
decreased flow to the right leg and a normal PVR of the left
leg. The patient subsequently had bilateral lower extremity
angiograms on [**2167-2-27**], which revealed near total occlusion
of the right common iliac artery and therefore, the patient
underwent two stents by Dr. [**First Name (STitle) **] being placed in that
artery.
As far as further significant events during his CT Surgery
hospital course, the patient was evaluated by Dermatology and
had multiple biopsies of the skin ulcerations. He was
diagnosed with a medium vessel vasculitis thought to be
secondary to medications. The most likely culprit is
amoxicillin, which the patient had been taking for a COPD
flare prior to his hospitalization at [**Hospital 1562**] Hospital.
There was no evidence of a systemic vasculitis or
rheumatologic issue based on multiple testing including
negative [**Doctor First Name **], negative rheumatoid factor, negative ANCA, and
negative RPR.
Of note, Infectious Disease was also consulted as mentioned
above at the outside hospital. These ulcers secondary to
vasculitis on the patient's extremities grew out both MRSA
and Enterococcus, therefore the patient was placed on
linezolid and ciprofloxacin to cover these organisms. The
reason antibiotics were started was that the patient had a
leukocytosis with a peak white blood cell count of 28,000
while on the CT Surgery service team. Also from an ID
perspective, the patient was treated empirically for
Clostridium difficile infection because of profuse diarrhea,
which improved with Flagyl.
This describes the [**Hospital 228**] hospital course on the CT
Surgery service as noted in a previous dictation. It was
felt that because of the patient's multiple comorbidities
including malnutrition and this vasculitis, he was not
currently a candidate for lung volume reduction surgery.
The patient was transferred to the MICU Green Team Resident
Only Service on [**2167-3-9**] for hypercapnic respiratory failure.
For 24 hours prior to transfer, the patient had been having
difficulty breathing and was somnolent on the floor. Serial
ABGs showed a worsening hypercapnia. His ABG on the evening
of [**2167-3-8**] was 7.3, 60, and 80.
The next morning the patient was still having difficulty.
Was noted to be somnolent, and his ABG was 7.21 pH, 80 pCO2,
and 80 O2. Therefore, the MICU team was called. The patient
on examination was noted to have diffuse expiratory wheezes
and was found to be in hypercapnic respiratory failure. He
was transferred immediately to the MICU. A trial of BiPAP
was initiated as the patient had responded to this in the
past. An A-line was placed in the patient's right arm
immediately. After 15 minutes on BiPAP, repeat ABG was pH
7.19, pCO2 87, and pO2 had dropped to 52. Therefore,
Anesthesia was called for an elective intubation. The
patient was sedated with Fentanyl, Versed, was intubated and
placed on assist control 550/16 100 FIO2. Repeat blood gas
immediately after intubation was 7.23, pCO2 of 70, and pO2 of
367. The vent was therefore changed to AC at 50% FIO2, 550
tidal volume by 20% respiratory rate with a repeat ABG of pH
7.32, pCO2 of 55, and pO2 of 101.
Of note, immediately after intubation, the patient was noted
to become hypotensive with mean arterial pressures between 40
and 50 and required the use of Levophed as a pressor. A
chest x-ray was obtained post intubation that showed no
evidence of infiltrate, no new pneumothoraces, and no obvious
explanation for why the patient had a hypercapnic respiratory
failure.
PAST MEDICAL HISTORY:
1. COPD: Patient has had heavy tobacco use for 30 plus
years. Of note the patient had recently been hospitalized in
[**Month (only) 404**] for a pneumonia and a COPD flare requiring BiPAP use.
Prior to this hospitalization at [**Hospital1 18**], however, the patient
had never required intubation. A month prior to admission,
the patient had been on p.o. prednisone for COPD flare.
Baseline sats were 93% per outside hospital records. Patient
was not on home O2.
2. Paroxysmal atrial fibrillation, not anticoagulated.
3. MRSA wound infections in the lower extremities, also
Enterococcus, and gram-negative rods in the wound
infection/vasculitis.
SOCIAL HISTORY: The patient lives on [**Hospital3 **]. He lives by
himself. He is a retired Air Force pilot. He was a prior
competitive swimmer. He is separated from his wife since
[**2163**]. [**Name2 (NI) **] has two children, who are very involved in his
care, a son who lives on [**Location (un) **], and a daughter, who lives
in [**Name (NI) 51454**].
MEDICATIONS ON TRANSFER FROM THE CT SURGERY SERVICE:
1. Protonix 40 IV q.d.
2. Thiamine 50 p.o. q.d.
3. Lovenox 40 subq q.d.
4. Toradol 15 IV q.6h. prn.
5. Vancomycin 500 mg IV q.d.
6. Ciprofloxacin 500 mg p.o. b.i.d.
7. Doxycycline 100 mg IV q.d.
8. Solu-Medrol 30 mg q.8h.
9. Albuterol prn.
ALLERGIES: Procaine, novocaine, [**Female First Name (un) **] anesthetics, and
penicillin.
PHYSICAL EXAM ON ADMISSION TO THE MICU: The patient was
afebrile. Blood pressure was quite labile ranging from
systolic blood pressure of 60-190/diagnostic of 40-100, pulse
was 70-120 and was regular. In general, the patient prior to
intubation appeared very labored from a breathing
perspective. He was quite somnolent and only responded to
questions with a lot of prompting and shaking. Patient is
very cachectic. HEENT: Pupils are equal, round, and
reactive to light and accommodation. Extraocular muscles are
intact. Oropharynx is clear. Heart: S1, S2, regular, no
murmurs, rubs, or gallops. Lungs: Diffuse expiratory
wheezes bilaterally, no crackles. Abdomen was soft,
nontender, and nondistended, positive bowel sounds.
Extremities: Multiple ulcers in the legs and arms and some
areas of modeling in the legs. Neurologically: The patient
was responsive to commands, but otherwise quite somnolent and
was subsequently intubated.
DATA ON ADMISSION: Hematocrit was 31.6, white count was 17.5
with 96% neutrophils and 0 bands. INR is 0.8. PTT 28, PT
11. Platelet count was 413. Chemistries: Sodium 140,
potassium 5, chloride 103, bicarb 28, BUN 43, creatinine 0.5,
glucose 127, calcium 8.9, magnesium 1.7, phosphorus 4.9.
Urine electrolytes were significant for a FENa of 0.1%.
Clostridium difficile was negative x2. Blood cultures from
admission and [**2167-2-28**] showed no growth to date.
EKG was normal sinus rhythm, rate 100, normal axis, prominent
P waves. Old Q waves in the inferior leads and slightly
early R-wave progression. These EKG changes were old.
ASSESSMENT AND PLAN: Patient is a 68-year-old gentleman with
severe COPD initially admitted to the CT Surgery service on
[**2167-2-22**] for evaluation for potential lung volume reduction
surgery. As the patient had multiple other comorbidities as
noted including a medium vessel vasculitis thought to be
secondary to medication, extreme cachexia from his COPD and
malnutrition, and likely Clostridium difficile colitis, the
surgery was deferred. The patient had an episode of
hypercapnic respiratory failure and therefore was transferred
to the MICU for further care and was intubated.
HOSPITAL COURSE:
1. Respiratory failure: On initial admission, it was unclear
as to the etiology of the patient's hypercapnic respiratory
failure. Initial chest x-ray on admission showed no evidence
of pulmonary infiltrates, and no evidence of pneumothoraces.
Status post intubation, the patient became more and more
hypotensive and pressor dependent. While a central line was
being placed in the right internal jugular vein, the patient
became severely bradycardic and eventually asystolic. A
cardiac arrest code was called, and the patient went from
asystole to a PEA arrest requiring Epinephrine and atropine
dosing. The patient then entered a ventricular fibrillation
and was shocked multiple times. The patient then returned to
[**Location 213**] sinus rhythm in the 80s with a blood pressure that
rose using multiple pressors.
In this setting, a repeat chest x-ray was obtained. This
showed a very large right-sided tension pneumothorax. A
needle decompression was performed and a chest tube was
immediately placed by the Surgery service.
Based on the above description, it was felt that the
patient's hypotension post BiPAP and intubation likely
reflected the beginnings of a pneumothorax and that with
subsequent PEEP as well as auto PEEP, this developed into a
tension pneumothorax leading to a PEA arrest. Although this
occurred in the setting of a right IJ placement, it was not
felt that the pneumothorax was due to the right IJ being
placed, although this is a possibility. As the patient
became hypotensive immediately after intubation, however, it
is most likely that the patient had an apical bleb then
ruptured with intubation.
The patient's pneumothorax resolved with needle decompression
and placement of a chest tube. He was intubated and weaned
until [**2167-3-12**] at which time the patient was extubated.
However, over the next 24 hours, the patient began more and
more hypercapnic and required reintubation on [**2167-3-13**]. The
right apical pneumothorax was stable and this decompensation
was felt to be due to extremely severe COPD.
As the patient was becoming difficult to wean, it was decided
that it would be in the patient's best interest to have a
tracheostomy placed for further weaning and for patient's
safety. Therefore, a tracheostomy was placed on Tuesday,
[**2167-3-17**]. At the same time, a PEG was also placed. These
are both done by Dr. [**Last Name (STitle) **] with the patient's consent and
the family were also very involved in the decision and agreed
with these procedures.
The patient tolerated the tracheostomy without complications.
He was able to be weaned to CPAP with pressure support and on
the day of discharge to the pulmonary rehab facility, he was
requiring 0 PEEP and a pressure support of 8 with excellent
oxygenation and no signs of hypercapnia.
The patient was continued on intravenous Solu-Medrol that was
eventually tapered. The day of discharge he was to be
discharged to prednisone 12.5 mg p.o. q.d. as this correlated
to his Solu-Medrol dose of 10 IV q.d. It was decided to
change to p.o. as the patient no longer had any IV access as
these were all removed to prevent line-related infection, and
as the patient was clinically was much more stable. The
patient was continued on albuterol and Atrovent MDIs as well.
Chest x-ray prior to admission showed no pneumothorax, no
infiltrates.
Furthermore, the patient was fitted with a Passy-Muir valve
on two days prior to discharge and was able to use this
without any respiratory difficulty.
2. Cardiovascular: As noted above, the patient was
hypotensive immediately post BiPAP and post intubation likely
secondary to the tension pneumothorax on the right side.
Levophed pressor was required to maintain adequate blood
pressure during the patient's first 24 hours within the MICU,
but then this was quickly weaned with decompression at the
right pneumothorax. After the patient's cardiac arrest,
which as stated above included asystole, then PEA, then
ventricular tachycardia and ventricular fibrillation, he was
placed on an amiodarone drip for 24 hours. This was then
discontinued. The patient does have a history of paroxysmal
atrial fibrillation, however, the patient remained in normal
sinus rhythm during his hospital course.
The patient had no other cardiac issues during his hospital
stay. He was noted at times to have some hypertension once
he was weaned off the pressors. The highest blood pressure
was 150 systolic with a heart rate in the high 90s.
Therefore, he was placed on Lopressor for a short period of
time. However, he did not tolerate this longterm and became
somewhat hypotensive with the use of Lopressor. The patient
has no history of essential hypertension, and therefore he
was not rechallanged with Lopressor.
3. Thrombocytopenia: When the patient was admitted, he had a
reactive thrombocytosis most likely with platelets up to
600,000. This came down throughout his hospital course and
on [**2167-3-16**], the patient's platelet count had dropped to
34,000. The patient had been receiving subq Heparin since
admission to [**Hospital1 69**]. At the
outside hospital, he had been on Lovenox for prophylaxis.
The degree of drop in platelets as well as the time course
was highly consistent with heparin-induced thrombocytopenia.
Therefore, the [**Doctor First Name **] test for HIT was sent, and this returned
negative. However, with the high clinical suspicion, the
patient was kept off all Heparin products. As the patient's
platelet count continued to drop off of Heparin, Hematology
consult was obtained. They agreed with the high clinical
suspicion for HIT and recommended sending a second HIT test.
The second test also returned negative as this is a highly
sensitive test for Heparin dependent antibodies and the HIT
syndrome, it was felt that he does not have heparin-induced
thrombocytopenia. Rather, it was felt that the patient's
thrombocytopenia was medication induced, most likely
secondary to linezolid.
The patient had an extensive workup for this thrombocytopenia
before this conclusion was made, however, including he was
ruled out for DIC, ruled out for TTP, and ruled out for ITP
with a negative platelet antibody test. While entertaining
the diagnosis of HIT, it was decided to ultrasound all four
of the patient's extremities as HIT can also cause clinically
significant clots. The patient was noted to have old clots
within his left femoral artery as well as in his left upper
extremity. Therefore, once the patient's platelet count
returned to within normal limits and showed upward trend,
based on recommendations from the Hematology service, the
patient was started on prophylaxis for further clots of
Lovenox 30 subq b.i.d. He tolerated this medication well and
his platelets remained quite stable with a platelet count in
he 300's upon discharge.
The patient was placed on Plavix while in the CT Surgery
service after the two stents had been placed in the right
ileac artery. Even with the patient's thrombocytopenia, the
Plavix was continued as the risk for instent thromboses quite
high within the first month of stent placement. His aspirin
was held while he was severely thrombocytopenic, but then
reinitiated when his platelet count returned to [**Location 213**].
4. FEN: As stated above, the patient had a PEG tube placed
on [**2167-3-17**] at the same time of tracheostomy placement. He
tolerated this well, and his tube feeds were at goal 24 hours
post placement of the PEG. The patient had a speech and
swallow evaluation on two separate occasions, once
immediately pre-PEG placement and one on the day prior to
discharge to rehab. On both occasions, the patient failed
the speech and swallow evaluation and was noted to aspirate
thin liquids. A decision was made that the patient could
have ice chips, but nothing else p.o. at the time of
discharge.
The patient had fairly normal electrolytes and only required
repletion of potassium and magnesium on an infrequent basis.
Even with his profound nutritional deficiency, his coags
including INR were within normal limits.
5. Infectious disease: The patient did have a leukocytosis
as mentioned above with a peak white blood cell count of
28,000. This was felt to be due to both steroid use as well
as the infection in the vasculitic ulcers in the patient's
extremities. The patient was placed on linezolid and
ciprofloxacin for these ulcers. These medications were
discontinued on the MICU service as the patient no longer had
a white count, was afebrile, and his skin lesions were much
improved. Of note, the linezolid was discontinued prior to
the development of thrombocytopenia. As this patient not
infrequently causes thrombocytopenia, the drop in platelets
was attributed to this medication.
The patient was empirically treated for Clostridium difficile
for a 14-day course. Three Clostridium difficile toxins were
negative, however, with cessation of Flagyl on the CT Surgery
service, the patient developed severe diarrhea and with
reinitiation of Flagyl, this stopped. Once he finished his
Flagyl course, he had no recurrence of diarrhea. There were
no other infectious issues throughout the rest of the
[**Hospital 228**] hospital course. He remained afebrile with no
evidence of pneumonia, no line infections, and his skin
lesions did not become reinfected.
6. Vasculitis: As above, this was diagnosed as a small to
medium vessel vasculitis that was medication related. It is
recommended that the patient not receive amoxicillin or other
penicillin products for this reason in the future.
7. Code: The patient remained full code throughout his
hospital course as this was his wish as communicated by the
patient on numerous occasions and as affirmed by his family.
His daughter is his healthcare proxy.
8. Communication: The patient's family is very involved and
were present every hospital day of the patient's stay. His
daughter is his healthcare proxy. The family should be
contact[**Name (NI) **] before any changes are made in the patient's care.
The daughter's name is [**Name (NI) **]. The patient's wife's name is
[**Name (NI) 2147**] [**Name (NI) 25699**], her work phone is [**Telephone/Fax (1) 55255**]. Her home
phone is [**Telephone/Fax (1) 55256**]. The patient's son is [**Name (NI) **] [**Name (NI) 25699**],
who also lives on [**Location (un) **], his work phone is [**Telephone/Fax (1) 55257**]. His home phone is [**Telephone/Fax (1) 55258**].
9. The Psychiatry service did see the patient for his history
of depression and anxiety, and followed him throughout his
hospital course. They recommended avoiding benzodiazepines
and narcotics as much as possible as they resulted in
paradoxical reactions with the patient's mood. Specifically,
benzodiazepines resulted in hallucinations and altered
sensorium. Therefore, the psychiatrist recommended the use
of Haldol or other antipsychotics on a prn basis.
10. Pneumothorax. The chest tube was kept on suction until
[**2167-3-20**]. When the air leak subsided, chest tube was place to
waterseal. Chest tube was then pulled out on [**2167-3-23**].
DISCHARGE MEDICATIONS:
1. Prednisone 12.5 mg p.o. q.d. to be tapered as per
Pulmonary Rehab.
2. Aspirin 325 p.o. q.d.
3. Lovenox 30 subq b.i.d. for clot prophylaxis.
4. Multivitamin q.d.
5. Albuterol MDI q.4h. standing.
6. Atrovent MDI q.6h. standing.
7. Albuterol inhaled MDI q.2h. prn wheezing.
8. Regular insulin-sliding scale while on prednisone.
9. Haldol 1-2 mg q.4h. prn agitation. This is recommended by
a Psychiatry service consult.
10. Neurontin 300 mg p.o. b.i.d.
11. Plavix 75 p.o. q.d.
12. Folic acid 1 mg p.o. q.d.
13. Silver sulfadiazine 1% cream one application TP b.i.d. to
the legs and arms specifically to the ulcers.
14. Thiamine 100 mg p.o. q.d.
[**Name6 (MD) 2467**] [**Last Name (NamePattern4) 10404**], M.D. [**MD Number(1) 10405**]
Dictated By:[**Last Name (NamePattern1) 5851**]
MEDQUIST36
D: [**2167-3-24**] 12:40
T: [**2167-3-24**] 12:40
JOB#: [**Job Number 55259**]
|
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icd9cm
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,200
| 120,009
|
48633
|
Discharge summary
|
report
|
Admission Date: [**2114-2-2**] Discharge Date: [**2114-2-17**]
Service: MEDICINE
Allergies:
Lasix
Attending:[**First Name3 (LF) 317**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 32729**] is a [**Age over 90 **] y/o F w/ h/o diastolic CHF, COPD w/ CO2
retention (baseline bicarb approx 35, CO2 approx 60), OSA
(non-compliant with bipap, only on O2 at night) who presented
with dyspnea. She developed DOE approx 4 days pta. She had
increasing somnolence during the day for the prior 2 weeks. She
also reports orthopnea, some peripheral edema, no PND. In the
ED, her vitals were notable for RR 16 and satting 57% on RA,
which increased to 92% on Venturi mask. Subsequent resp rates
noted to be 22, and 30. She received combivent x3, prednisone
60mg, ceftriaxone, and azithromycin.
.
Patient was admitted to the floor where she was continued on
treatment for PNA/COPD exacerbation and continued on her home
dose of diuresis for a presumed CHF exacerbation. However, she
became increasingly hypoxic, desatting to 82% no 8L, which
improved to 93% following nebs. Her ABG at that time was
7.47/58/41. She then received Lasix and nebs and was transferred
to the ICU for further monitoring.
.
In the MICU, she was treated with steroids and antibiotics for
COPD exacerbation and diuretics (Bumex up to 4). She had BiPAP
but was not intubated. She improved, with O2 sats now at 88% on
1L. She is now transferred back to the floor.
.
ROS: She denies cough, fever/chills, n/v/d, dysuria.
Past Medical History:
1. Restrictive lung dz [**3-2**] kyphoscoliosis (FEV1/FVC 113%pred)
2. COPD w/ CO2 retention (FEV1 0.86, bicarb approx 35, CO2 55)
3. Diastolic dysfunction EF>55%
4. PAF
5. OSA: intolerant of BiPAP in past, uses nocturnal O2 0.5 L NC
6. HTN
7. spinal stenosis
8. Grave's disease: s/p ablation, now on Synthroid
9. TAH [**3-2**] fibroids
10. ASD, secundum type noted in [**2108**]
11. Hx of lacunar infarct
12. L eye CVA: residual visual field defect, [**2101**], on coumadin
13. L cataract surgery
[**21**]. Right breast CA s/p radiation on [**2084**]
Social History:
Widow, 2 kids, lives w/ daughter, +tob 100 pk yr
Family History:
+ca, cva, 3 siblings.
Physical Exam:
Admission Exam:
.
Physical Exam:
Vitals: 99.4 79 26 91 % on face mask
HEENT: face mask in place.
Neck: Supple, no lymphadenopathy
CV: RRR no murmurs, rubs, normal S1 S2
Lungs: crackles bilaterally, midway up lungs
Abd: NT/ND BS normoactive
Ext: trace ankle edema 1+ bilat
Neuro: grossly intact
.
ICU Admission Exam:
t99.4, bp 133/76, hr 79, rr 25, 85% on 40% face tent.
Well appearing female in moderate respiratory distress.
PERRL
OP clr
9cm JVP. Thyroid benign. No cervical/sm/sc LAD.
Regular s1,s2. No m/r/g
b/l basilar fine rales, extending to [**1-30**] lung height on R, [**1-31**]
on L. No egophony.
+bs. soft. nt. nd.
1+ LE edema.
No clubbing/cyanosis.
Pertinent Results:
Notable Labs (Also see below):
BNP on admission: 4121
CK: 33 -> 36 -> 38; MB not done; Trop <0.01 x3
TSH: 1.2
Chem 7:
145 99 60. 155
4.5 40 1.1
Ca: 8.8 Mg: 2.3 P: 3.4
WBC: 7.6; Hct: 31.1; Plt: 67 (from 165)
PT: 28.0 PTT: 32.7 INR: 2.9
.
Studies:
- EKG: Sinus rhythm at 75 bpm with atrial premature beats.
Since the previous tracing of [**2114-2-2**] there is a more dominant P
wave, probably sinus with left atrial abnormality. Since tracing
#1, the rhythm is more regular. Otherwise, features are as
previously noted.
- CXR [**2114-2-2**]: New small bilateral pleural effusions with
associated bibasilar atelectasis. Mild pulmonary congestion.
- CXR [**2114-2-9**]: Portable AP chest radiograph compared to [**2-7**], [**2114**]. The heart size is moderately enlarged but stable.
The aorta is calcified. The mediastinal contours are unchanged.
The small bilateral pleural effusions, right more than left,
grossly unchanged on the left and slightly increased on the
right being partially loculated. Atelectasis of right middle
opacified lower lobe is
demonstrated, new.
Brief Hospital Course:
Ms. [**Known lastname 32729**] is a very pleasant [**Age over 90 **]-year-old woman with a
history of paroxysmal atrial fibrillation, COPD, and Congestive
Heart Failure who presented with dyspnea on exertion. Her brief
hospital course by problem is as follows:
.
1. COPD. Although she was admitted to the floor, she was quickly
transferred to the MICU as she became increasingly hypoxic on
nasal cannula, and even non-invasive respiratory support did not
normalize her blood gases. She refused BiPAP, but fortunately
improved on nasal cannula. This acute decompensation was thought
secondary to a combination of CHF and COPD (see below for CHF
treatment). Her COPD was treated with methylprednisolone and
then a prednisone taper over two weeks and given standing
albuterol/ipratropium nebulizer treatments. Because she is a
chronic CO2 retained, her O2 sats were maintained carefully
between 88 and 91%; above this, she began to become somnolent.
She was also given a course of azithromycin, ceftriaxone, and
vancomycin.
.
2. CHF, diastolic. She was fluid overloaded on her admission
exam and her chest film showed pulmonary edema. This
exacerbation was thought to be triggered by a tracheobronchitis.
She was diuresed with Lasix and Bumex initially; just Bumex
after the first 6 days; and then with ethacrynic acid when Bumex
was implicated in her thrombocytopenia. Her volume status
improved and she was continued on Na and fluid restrictions. She
was continued on diltiazem for HR control given her diastolic
dysfunction; lisinopril was deferred. Cardiac enzymes ruled out
an MI.
.
3. Pneumonia, possibly hospital-acquired. Her CXR showed a
questionable opacity at the right base. Given her poor
oxygenation, she was treated for pneumonia on this basis.
Ceftriaxone and vancomycin were used given her frequent
hospitalizations. She improved.
.
4. Thrombocytopenia. Hematology was consulted for this problem
and felt it was likely induced by either her Lasix or her Bumex.
Initially, the decline coincided with Lasix, but when she failed
to improve after several days without Lasix, Bumex was thought
to be the problem. She was therefore diuresed with ethacrynic
acid.
.
5. Atrial fibrillation. She was effectively rate controlled with
diltiazem. Her anticoagulation was held given her dramatic
thrombocytopenia.
.
6. Hypertension. Her BP was well controlled with diltiazem and
nifedipine. Her Isordil was discontinued to maximize her
pulmonary perfusion.
.
7. Acute Renal Failure. This was thought secondary to her poor
effective circulating volume. Her elevated creatinine resolved
with diuresis.
.
8. [**Doctor Last Name 933**] s/p thyroid ablation. She was continued on Synthroid.
.
9. Communication: Daughter [**Name (NI) **] [**Telephone/Fax (1) 102300**]
.
10. CODE: FULL
.
11. Dispo: She was discharged to home with PT services once her
platelet count began to improve.
Medications on Admission:
1. Levothyroxine 1 mg po qday
2. Diltiazem HCl 30 mg po bid
3. Nifedipine SR 30 mg po qday
4. Isosorbide Dinitrate 20 mg po tid
5. Folic Acid 1 mg PO DAILY
6. Multivitamin 1 tab qday
7. Naphazoline-Pheniramine 0.025-0.3 % Drops 1 drop [**Hospital1 **] prn
8. Sodium Chloride 0.65 % Aerosol, Spray 1 Spray [**Hospital1 **] prn nasal
9. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
10. Bumetanide 2 mg Tablet 1 Tab PO qday
11. Warfarin 5 mg Tablet 1 Tab PO HS
12. Albuterol 90 mcg/Actuation Aerosol 1-2 Puffs Q6H
13. NTG sl prn chest pain
14. Colace 1 tab qevening
15. Spiriva 1 capsule puff qday
16. 02 at bedtime 1-1.5 liter for sleep apnea
.
MEDICATIONS ON TRANSFER:
MethylPREDNISolone 40 mg IV Q8H
Multivitamins 1 CAP PO DAILY
Albuterol 0.083% Neb Soln 1 NEB IH Q6H
Albuterol 0.083% Neb Soln 1 NEB IH Q3-4H:PRN
NIFEdipine CR 30 mg PO DAILY
Naphazoline-Pheniramine Ophth. Solution 1 DROP OU [**Hospital1 **]
Bisacodyl 10 mg PO/PR [**Hospital1 **]:PRN constipation
PredniSONE 60 mg PO Daily (tapering)
Bumetanide 4 mg PO DAILY
Diltiazem 45 mg PO TID
Docusate Sodium 100 mg PO BID
FoLIC Acid 1 mg PO DAILY
Hypotears *NF* 1 % OU qday
Insulin Sliding Scale
Sodium Chloride Nasal [**1-30**] SPRY NU QID:PRN
Ipratropium Bromide Neb 1 NEB IH Q6H
Levothyroxine Sodium 100 mcg PO DAILY
Tiotropium Bromide 1 CAP IH DAILY
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
3. Naphazoline-Pheniramine 0.025-0.3 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
4. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: One (1)
Dropperette Ophthalmic qday ().
5. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-30**] Sprays Nasal
QID (4 times a day) as needed.
6. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Nifedipine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
8. Diltiazem HCl 90 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day).
Disp:*45 Tablet(s)* Refills:*2*
9. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1) cap Inhalation once a day.
10. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q6H (every 6 hours).
11. Home Oxygen
1 to 1.5L NC at night
12. Ethacrynic Acid 25 mg Tablet Sig: Four (4) Tablet PO once a
day.
Discharge Disposition:
Home With Service
Facility:
Care Network
Discharge Diagnosis:
COPD exacerbation
CHF exacerbation
Medication-related thrombocytopenia
Discharge Condition:
Stable. Platelet counts improving, respiratory and volume status
stable.
Discharge Instructions:
You were admitted with an exacerbation of your COPD and heart
failure. You also had a reaction to one of your medications,
most likely bumex, which resulted in your platelets dropping.
They are now recovering, and your COPD and heart failure have
stabilized.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 2L
You should contact your physician if you have any bleeding,
shortness of breath, weight gain more than 3 pounds, worsening
ankle swelling, or for any other problems that concern you.
Dr. [**Last Name (STitle) **] will contact you regarding follow-up appointments and
for further blood work. Your coumadin is being held. Your bumex
was changed to ethacrynic acid. Your diltiazem dose was
increased.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 10012**] Appointment should be
in [**8-7**] days
Completed by:[**2114-2-21**]
|
[
"428.33",
"V10.3",
"287.4",
"E944.4",
"327.23",
"584.9",
"491.21",
"428.0",
"401.9",
"737.30",
"427.31",
"486",
"518.81",
"745.5"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9391, 9434
|
4064, 6946
|
220, 227
|
9549, 9624
|
2955, 2990
|
10454, 10643
|
2234, 2257
|
8362, 9368
|
9455, 9528
|
6972, 7668
|
9648, 10431
|
2305, 2936
|
172, 182
|
255, 1575
|
3004, 4041
|
7693, 8339
|
1597, 2151
|
2167, 2218
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,314
| 170,599
|
51115
|
Discharge summary
|
report
|
Admission Date: [**2159-1-31**] Discharge Date: [**2159-2-3**]
Date of Birth: [**2077-8-10**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr [**Known lastname 33681**] is an 81 year old man with history of hypertension,
COPD BPH s/p photovaporization of the prostate, presenting
with worsening dyspnea for the last week.
.
Patient reports that he has had COPD for many years and has
dyspnea on exertion. Starting one week ago however, patient
began feeling more short of breath with less activity. Patient
also started having difficulty laying flat at night and for the
past two nights had to sleep sitting up in a chair. He reports a
cough with some yellowish sputum, but denies any fevers, chills,
nausea, vomiting or diarrhea. Mr [**Known lastname 33681**] is not on supplemental
oxygen at home. He denies any recent travel or known sick
exposures. Patient started prednisone at home per his PCP
instructions, however his symptoms did not improve. PCP office
instructed patient to present to ED for further evaluation.
.
In the ED, Temp 97.7, HR 122, BP 151/80 and RR 32 at 2L NC with
96% saturation. Patient however remained tachypneic with
increasing supplemental oxygen doses, and eventually was placed
on Bipap at 30% FIO2 at 12/8 with good respose in symptoms.
Patient was given IV solumedrol, Ceftriaxone and azithromycin,
aspirin, and admitted to ICU for further management.
Review of systems is otherwise unremarkable.
Past Medical History:
COPD(last PFT's with FEV1 54% predicted on [**2154-8-20**])
HTN
BPH- Impression:of UDS- [**2158-10-11**]
1. Bladder outlet obstruction with fairly weak detrusor. (grade
[**11-21**] obstruction)./Confirmed with cystoscopy in [**9-23**]
2. Normal bladder compactly and compliance.
3. Some detrusor over activity.
Colonoscopy in [**4-/2158**] + adenomas
Social History:
H/O heavy ETOH use- now abstinent, > 60 pk year history. He quit
in [**2152**]. He lives with his wife of 58 years in [**Hospital1 3494**]. They
have two children and 6 grandchildren and 1 great grand child.
Orginally from [**Country 6257**]. Emigrated here in [**2103**]. Used to work in
the foundry. He is independent of ADLs. His wife does most of
his [**Name (NI) 4461**] including bills, shopping, laundry and housework. He
does not do these [**12-18**] dyspnea. He mostly watches TV.
Family History:
Noncontributory
Physical Exam:
GENERAL: Pleasant, well appearing in moderated NAD
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No
LAD, No thyromegaly.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**]. JVP= >20 cm (at mandible)
LUNGS: Diffuse expiratory wheezes bilaterally,
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: 3+ edema of lower extremities, Left > Right. 2+
dorsalis pedis/ posterior tibial pulses.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout. [**11-17**]+ reflexes,
equal BL. Normal coordination. Gait assessment deferred
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
[**2159-1-31**] 04:00PM BLOOD WBC-13.7*# RBC-3.82* Hgb-10.8* Hct-32.5*
MCV-85 MCH-28.1 MCHC-33.1 RDW-14.0 Plt Ct-218
[**2159-2-1**] 09:30AM BLOOD WBC-12.1* RBC-3.16* Hgb-9.1* Hct-26.7*
MCV-85 MCH-28.9 MCHC-34.2 RDW-14.8 Plt Ct-168
[**2159-1-31**] 04:00PM BLOOD Neuts-91.4* Lymphs-5.6* Monos-2.8 Eos-0.2
Baso-0
[**2159-2-1**] 09:30AM BLOOD Glucose-106* UreaN-55* Creat-2.5* Na-141
K-4.5 Cl-103 HCO3-27 AnGap-16
[**2159-1-31**] 04:00PM BLOOD CK(CPK)-560*
[**2159-2-1**] 09:30AM BLOOD CK(CPK)-375*
[**2159-2-1**] 12:57AM BLOOD CK-MB-18* MB Indx-4.5 cTropnT-0.23*
[**2159-2-1**] 09:30AM BLOOD CK-MB-13* MB Indx-3.5 cTropnT-0.19*
[**2159-1-31**] 04:00PM BLOOD CK-MB-33* MB Indx-5.9 proBNP-6188*
[**2159-2-1**] 09:30AM BLOOD Calcium-8.4 Phos-4.3 Mg-1.5*
[**2159-1-31**] 08:42PM BLOOD Type-ART pO2-50* pCO2-50* pH-7.37
calTCO2-30 Base XS-1
[**2159-1-31**] 09:21PM BLOOD Type-ART pO2-218* pCO2-38 pH-7.43
calTCO2-26 Base XS-1
[**2159-1-31**] 04:38PM BLOOD Lactate-2.7*
Urine and blood cultures neg/pending
[**2159-2-1**] ECHO:
The left atrium is moderately dilated. There is mild symmetric
left ventricular hypertrophy. The left ventricular cavity is
mildly dilated. There is mild regional left ventricular systolic
dysfunction with mild inferior wall hypokinesis. Overall left
ventricular systolic function is low normal (LVEF 50-55%). Right
ventricular chamber size and free wall motion are normal. The
aortic root is moderately dilated at the sinus level. The aortic
valve leaflets are moderately thickened. There is moderate to
severe aortic valve stenosis (area 0.8-1.0cm2). Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Moderate to severe (3+) mitral regurgitation is seen.
The tricuspid valve leaflets are mildly thickened. Moderate [2+]
tricuspid regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. Significant pulmonic regurgitation
is seen. There is a trivial/physiologic pericardial effusion.
Compared with the prior study (images reviewed) of [**2158-10-30**],
the left ventricular function is low normal with worsened mitral
regurgitation and aortic stenosis.
Brief Hospital Course:
81 year old man with history of COPD, presenting with acute
respiratory distress
.
#. RESPIRATORY DISTRESS: Pt was initially treated for COPD
exacerbation with IV steroids, nebs and antibiotics. By the next
day, pt was able to be weaned from bipap to 3L NC and was
satting comfortably in the mid 90s. Given elevation in troponin
however and evidence of mild pulmonary edema on CXR and
peripheral edema, there was concern for CHF. A TTE confirmed
worsening valvular disease compared to ECHO preformed several
months prior. Pt. was seen by cardiology who recommended BB if
tol. by COPD, no other interventions. They felt he was
euvolemic at the time of examination and recommended against
further diuresis.
.
#. NSTEMI: Pt's troponin peaked at .23 on admission. He had had
no prior known cardiac disease, and was never seen by a
cardiologist. EKGs were repeatedly at baseline. He was treated
with full dose aspirin, statin and was started on low dose beta
blocker with holding parameters at HR <70 to avoid poor filling.
Pt was seen by cardiology who felt he was medically optimized.
.
#. CHRONIC RENAL INSUFFICIENCY: Pt remained at his recently new
baseline of 2.5.
#. Hypertension: Home BP meds were intially held as his regimen
was adjusted for new worsening valvular disease and NSTEMI.
Medications on Admission:
- Lipitor
- Flomax
- Combivent
- HCTZ
- Finasteride
- Omeprazole
- Prednisone taper (started 2 days ago)
- Norvasc
- Flovent
Discharge Medications:
1. Docusate Sodium 50 mg/5 mL Liquid Sig: Five (5) mL PO BID (2
times a day) as needed for constipation.
Disp:*60 mL* Refills:*0*
2. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation every six (6) hours.
Disp:*2 inhalers* Refills:*2*
3. Atrovent HFA 17 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation every six (6) hours.
Disp:*2 inhalers* Refills:*0*
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 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:*0*
6. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*0*
9. Prednisone 20 mg Tablet Sig: as per taper, below Tablet PO
DAILY (Daily) for 4 days: [**2-4**]: two tablets
[**2-5**]: one tablet
[**2-6**]: one tablet
[**2-7**]: one tablet
then stop.
Disp:*5 Tablet(s)* Refills:*0*
10. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 2 days: [**2-4**] and [**2-5**] then stop.
Disp:*2 Tablet(s)* Refills:*0*
11. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0*
12. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
Disp:*30 Tablet(s)* Refills:*0*
13. Fluticasone 220 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation twice a day.
Disp:*1 inhaler* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
COPD exacerbation
NSTEMI
Discharge Condition:
Stable
Discharge Instructions:
Return to the [**Hospital1 18**] Emergency Room for acute chest pain or
worsening shortness of breath.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8941**], MD Phone:[**Telephone/Fax (1) 4537**]
Date/Time:[**2159-2-13**] 10:00
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 252**], M.D. Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2159-3-1**] 2:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8941**], MD Phone:[**Telephone/Fax (1) 4537**]
Date/Time:[**2159-2-27**] 11:00
|
[
"410.71",
"416.8",
"428.0",
"491.21",
"428.43",
"403.90",
"396.2",
"585.4"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8830, 8888
|
5556, 6851
|
322, 328
|
8956, 8964
|
3397, 5533
|
9115, 9565
|
2550, 2567
|
7027, 8807
|
8909, 8935
|
6877, 7004
|
8988, 9092
|
2582, 3378
|
275, 284
|
356, 1650
|
1672, 2025
|
2041, 2534
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,707
| 101,809
|
10154
|
Discharge summary
|
report
|
Admission Date: [**2169-6-22**] Discharge Date: [**2169-6-28**]
Date of Birth: [**2096-7-13**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
Chest pain and shortness of breath
Major Surgical or Invasive Procedure:
PICC line placed on [**6-22**]. S/p intubation and extubation.
History of Present Illness:
72 M with CAD s/p CABG, ESRD on HD, HTN, DM. Pt awoke on the
morning of admission with CP, SOB, called EMS who found pt to be
in VT. Pt subsequently lost pulse, was given lidocaine 100mg
bolus, and was transferred to [**Location (un) 620**] ED. There he persisted in
VT, received amiodarone 300mg bolus, was started on amio drip,
intubated for airway protection, had 2 cardioversions, had
subsequent PEA, received epi, atropine, also received CaCl,
bicarb, D50, insulin, kayexalate for empiric tx of hyperkalemia.
Started on levophed for hypotension, and was transferred to CCU
for further care.
Notably pt recently hospitalized at [**Location (un) 620**] from [**5-16**] to [**5-19**]
with CP/SOB, ruled out for MI and discharged home. Notably no
dialysis during that hospitalization, planned for outpt
dialysis.
EKG showed baseline LBBB, s/p arrest EKG showing deep ST
depressions in V2-3 post code.
.
Access: Hickman right chest. [**Location (un) 620**] ED attempted a subclavian
on left but couldn't threat wire, L femoral line placed instead
(has hx right fem-[**Doctor Last Name **] graft).
Past Medical History:
- CAD, MI [**11-28**], (S/P cath with PTCA to OM in [**4-30**], s/p CABG
[**2163-1-6**] [**Location 1268**], LIMA to LAD, SVG to PDA & OM) CATH
performed on [**2169-3-4**] : Severe native three vessel coronary
artery disease, Patent LIMA and vein grafts, widely patent OM
stent.
- CHF, EF 55%
- DM
- Hypertension
- Hyperlipidemia
- End stage renal disease, dialysis dependent, AV fistula in L
arm.
- Peripheral vascular disease s/p fem-[**Doctor Last Name **] on right
- s/p toe amputations
.
Cardiac Risk Factors: Diabetes, Dyslipidemia, Hypertension, PVD,
ESRD
.
Cardiac History: CABG LIMA-LAD, SVG-OM, SVG-PDA
Pacemaker/ICD: n/a
Old EKG from [**2169-3-29**] similar with same T wave inversions,
slightly less pronounced ST depressions V4-V5.
TELEMETRY demonstrated: VT on rhythm strips from outside
hospital, here in AFib with episodes of sinus tach.
.
2D-ECHOCARDIOGRAM [**4-30**]: EF 55%. mildly dilated LA, moderate
symmetric LVH, mod. dilated LV. mild LV systolic dysfunction
with basal infero-lateral thinning and akinesis. mildly
thickened AV. no AS. 1+AR. MV mildly thickened. 1+MR. [**First Name (Titles) **] [**Last Name (Titles) 33904**]l effusion. Compared with the prior study (images
reviewed) of [**2167-2-24**], no definite change (prior study was of
poor quality to exclude above findings).
.
CARDIAC CATH [**3-1**]:
1. patent LIMA to LAD with no significant disease distal to the
[**Female First Name (un) 899**]. The SVG to PDA and SVG to OM were also widely patent. The
stent in the OM was widely patent and the 80% lesion in the
lower pole was unchanged.
2. The native coronary arteries were not injected due to known
severe
disease.
3. Limited resting hemodynamics revealed an opening aortic
pressure of 114/61mmHg.
FINAL DIAGNOSIS:
1. Severe native three vessel coronary artery disease.
2. Patent LIMA and vein grafts, widely patent OM stent.
.
Social History:
>100 pack year smoking hx, worked as a security guard. No etoh
or drugs.
Lives at home in [**Location (un) 620**]. Daughter in law is the only family
member.
Family History:
father died of MI in 70's. Mother died in 80's of cerebral
aneurysm. Divorced & estranged from remainder of family.
Physical Exam:
VS: T 96.9 BP 97/58 HR 104 (AFib) RR 16 O2 100% on CMV
600x20/8/100%
Gen: elderly appearing male, intubated, sedated, nonresponsive.
HEENT: NCAT. Sclera anicteric. Pupils small, equal, minimally
responsive. Conjunctiva were pink, no pallor or cyanosis of the
oral mucosa.
Neck: Supple, unable to visualize JVP.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Equal
breath sounds bilaterally with coarse crackles bilaterally.
Abd: Soft, NTND. + BS. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
Ext: L groin with triple lumen in place, R groin with old scar.
Extremities with chronic hemostatis, changes, multiple toe
amputations. Minimal pitting edema.
Pulses:
Right: Carotid 2+ DP 1+ PT 1+
Left: Carotid 2+ DP 1+ PT 1+
Pertinent Results:
LABORATORY DATA at OSH:
WBC 13.5, HCT 32.6, Plt 137
Na 142, K 5.3, Cl 104, Co2 27, Bun 44, Cr 7.0, Gluc 192
Ca 11.8, Mg 2.0, Alt 35, AST 33,
CK 98, MB 1.6, Trop T 0.240 (baseline)
LAB DATA [**Hospital1 18**]:
[**2169-6-22**] PT-14.1* PTT-53.3* INR(PT)-1.3*
[**2169-6-22**] WBC-12.3* RBC-3.63* HGB-11.7* HCT-35.7* MCV-99*
MCH-32.3* MCHC-32.8 RDW-17.8*NEUTS-88.9* LYMPHS-4.2* MONOS-6.6
EOS-0.1 BASOS-0.1
GLUCOSE-188* UREA N-49* CREAT-7.8* SODIUM-141 POTASSIUM-4.5
CHLORIDE-98 TOTAL CO2-29 ALBUMIN-3.6 CALCIUM-10.2 PHOSPHATE-6.7*
MAGNESIUM-2.2
ALT(SGPT)-105* AST(SGOT)-127* LD(LDH)-274* CK(CPK)-165 ALK
PHOS-82 AMYLASE-69 TOT BILI-0.6
[**2169-6-22**] 09:27AM CK-MB-13* MB INDX-7.9* cTropnT-0.49*
[**2169-6-22**] 06:21PM CK(CPK)-126 CK-MB-15* MB INDX-11.9*
cTropnT-0.91*
[**2169-6-22**] TYPE-ART PO2-147* PCO2-38 PH-7.49* TOTAL CO2-30 BASE
XS-6
IMAGING:
CXR [**2169-6-22**]: Increased right lower lobe opacity, probably due to
pulmonary edema or infection. (Initially read as wedge-shaped
opacity).
TTE [**6-22**]: Severe regional left ventricular systolic dysfunction
- EF = 20-25%. Mild AR. Moderate-to-severe MR. Compared with the
prior study (images reviewed) of [**2168-5-2**], LV systolic function
has markedly deteriorated and severity of MR has increased.
inferior and inferolateral hypokinesis was present on the prior
study.
CXR [**2169-6-23**]: More extensive left lower lobe opacity, probably
due to atelectasis, although pneumonia cannot be excluded.
Bilateral effusions and persistent right lower lobe process,
suggesting edema versus infection.
Brief Hospital Course:
Mr. [**Known lastname 33905**] is a 72 yo M with history of CAD s/p CABG, ESRD on
HD who presented with VT/ PEA/ cardiac arrest with prolonged
resuscitation (CPR > 45min), intubated for airway protection,
whose course was complicated by anoxic brain injury. Hospital
course by problem:
1)Arrhythmia: The original rhythm (VT/ PEA/ cardiac arrest) was
unclear as EMS found pt down and shocked him right away. The
patient was treated with cardioversion, initially started on
lidocaine, then started on amiodarone to prevent further
episodes of VT. The patient briefly went into atrial
fibrillation (although he had no documented history of this in
the past), but remained in NSR throughout the remainder of his
hospital course, with only occasional APBs and PVCs on
telemetry. The etiology of original arrhythmia was most likely
scar-induced. Electrolyte abnormality was unlikely given stable
electrolytes at OSH. Ischemic etiology was unlikely given
cardiac enzymes not commensurate with that of MI.
2)Hemodynamics: Upon admission the pt was initially hypotensive.
BP was maintained with a levophed drip, which was slowly weaned
as tolerated. Follow-up echo on [**2169-6-22**] showed EF of 20-25% with
severe regional left ventricular systolic dysfunction, which had
markedly deteriorated. Volume management was maintained via
hemodialysis.
3) CAD w/3 vessel disease:The patient was maintained on ASA and
statin given his history of CAD.
4)Poor oxygenation: CXR findings on [**6-22**] (above) were initally
read as concerning for PE. But because PE could not be ruled out
(as contrast could not be administered through the pt's IV site
and the patient??????s family did not want to place a central line
with a larger lumen for this purpose), patient was started on a
heparin drip. The patient remained intubated for airway
protection throughout his hospital stay. Ventilator settings
were weaned as tolerated to FiO2 of 50%. Subsequent CXR
findings (Above) showed evidence of a LLL infiltrate and +
sputum stain of GPC on [**6-22**], and the patient was empirically
treated for a PNA with vancomycin/levofloxacin/flagyl. On
hospital day 2 neurology recommended that levo/flagyl be
discontinued as these meds could decrease the seizure threshold
(see below), and ceftriaxone was started instead.
4) Anoxic brain injury: On hospital day 2, the patient was
observed to have twitching of his eyelids and chin. He was
placed on 24 hour EEG monitoring, and neurology determined him
to be in status epilepticus secondary to anoxic brain injury.
The patient was started on dilantin and phenobarbitol and was
placed on continuous EEG monitoring. After hospital day 3 there
were no observed recurrences of this seizure-like activity.
However, after performing serial neuro exams, the neurology team
felt that the patient??????s overall prognosis was grim for a
meaningful neurological recovery.
5) DM was controlled with an ISS.
6) FEN: On hospital day 2 tube feeds were started without
complication.
7) Prophylaxis: The patient received heparin gtt initially for
suspected PE, and was maintained on heparin drip for atrial
fibrillation. Pt also received a PPI, and bowel meds prn for
prophylaxis.
8)After much discussion with the primary team with input from
neurology, on [**2169-6-27**] the patient??????s daughter and health care
proxy decided to remove the ventilator and proceed with comfort
level of care. Patient was extubated on [**2169-6-27**]. He passed away
at 12:27 pm.
Medications on Admission:
Aspirin 81mg daily
Lipitor 40mg daily
Lisinopril 5mg daily
Toprol 50mg daily
Phoslo 1334 mg TID with meals
ISS (regular)
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
Ventricular tacchycardia arrest
Atrial fibrillation
Status epilepticus
Anoxic brain injury
Pneumonia
End stage renal disease on hemodialysis
Coronary artery disease
Congestive heart failure
Diabetes
Hypertension
Discharge Condition:
deceased
Discharge Instructions:
n/a
Followup Instructions:
n/a
Completed by:[**2169-6-28**]
|
[
"424.0",
"790.7",
"250.00",
"427.31",
"428.0",
"585.6",
"V45.81",
"348.1",
"403.91",
"345.3",
"427.1",
"486",
"414.01",
"415.19"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"38.93",
"39.95",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
9948, 9957
|
6263, 9748
|
349, 413
|
10213, 10223
|
4671, 6240
|
10275, 10309
|
3628, 3746
|
9920, 9925
|
9978, 10192
|
9774, 9897
|
3320, 3435
|
10247, 10252
|
3761, 4652
|
275, 311
|
441, 1540
|
1562, 3303
|
3451, 3612
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,089
| 155,263
|
26087
|
Discharge summary
|
report
|
Admission Date: [**2152-12-1**] Discharge Date: [**2152-12-5**]
Date of Birth: [**2099-10-15**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Aspirin
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Extertional Angina
Major Surgical or Invasive Procedure:
[**2152-12-1**] Coronary Artery Bypass Graft x 2(LIMA to LAD, Vein
Graft to Obtuse Marginal)
History of Present Illness:
53 y/o female with was experiencing exertional angina as well as
neck pain and palpitations over the past few months. She had a
positive ETT and then referred for cardiac cath. Cath revealed
60-70% osital left main disease. She was then referred for
cardiac surgery.
Past Medical History:
Hypertnesion
Hypercholesterolemia
Borderline Diabetes Mellitus (diet controlled)
Factor 5 Leiden Deficiency gene
Obesity
Migraine Headache's
s/p Tonsillectomy
s/p C-section
s/p tubal ligation
s/p D & C
s/p Right breast scar removal
Social History:
Lives alone. Never smoked and rarely drinks.
Family History:
Mother had 2 MI's in her 70's. Sister had CVA at young age. w/u
revealed factor 5 Leiden deficiency.
Physical Exam:
VS: 62 18 120/80 5'3" 170#
General: Well-appearing female in NAD
Skin: Unremarkable with no lesions
HEENT: NC/AT, EOMI, PERRL
Neck: Suppple, FROM, -JVD, -carotid bruit
Chest: CTAB -w/r/r
Heart: RRR, +S1S2, -c/r/m/g
Abd: Soft, NT/ND, +BS
Ext: Warm, well-perfused, -c/c/e, -varicosities, 2+ pulses
throughout
Neuro: A&O x 3, MAE, non-focal
Pertinent Results:
[**2152-12-1**] 09:56AM BLOOD WBC-8.9 RBC-2.39*# Hgb-7.2*# Hct-21.1*#
MCV-88 MCH-30.2 MCHC-34.2 RDW-12.6 Plt Ct-157
[**2152-12-4**] 08:10AM BLOOD WBC-6.3 RBC-3.39* Hgb-10.3* Hct-29.3*
MCV-86 MCH-30.2 MCHC-35.0 RDW-13.3 Plt Ct-227
[**2152-12-1**] 09:56AM BLOOD PT-16.3* PTT-32.4 INR(PT)-1.8
[**2152-12-5**] 07:50AM BLOOD UreaN-14 Creat-0.7 K-4.0
CXR [**12-4**]: Small left apical pneumothorax. Left lower lobe
effusion and atelectasis. Small right pleural effusion.
[**2152-12-4**] 08:10AM BLOOD Glucose-114* UreaN-12 Creat-0.8 Na-135
K-3.8 Cl-98 HCO3-29 AnGap-12
[**2152-12-5**] 07:50AM BLOOD UreaN-14 Creat-0.7 K-4.0
[**2152-12-4**] 08:10AM BLOOD Calcium-8.1* Phos-2.1*# Mg-1.5*
Brief Hospital Course:
Patient was a same day admit and on [**2152-12-1**] she was brought
directly to the operating room where she underwent a coronary
artery bypass graft x 2. Please see op note for surgical
details. Pt tolerated the procedure well without complications
and was transferred to the CSRU in stable condition. Later on op
day pt was weaned from mechanical ventilation and sedation and
was extubated. She was neurologically intact. She was weaned off
of any Inotropes or drips by post operative day 1 and was
transferred to the telemetry floor. She was started on diuretics
and beta blockers. On post op day two her chest tubes were
removed. On post op day three her epicardial pacing wires were
removed. She continued to make a steadily recovery without
complications and cleared level 5 on post op day four. She
maintained stable hemodynamics and remained in a normal sinus
rhythm. Her electrolytes were repleted as needed and labs were
stable at time of discharge. She will be discharged with two
weeks of Lasix since she is still approximately 5 kg above her
pre-op wt. She will be discharged home with VNA services and the
appropriate follow up appointments. At time of discharge, her BP
ranged from 98-110/58 with a heart rate of 90-100. She was
tolerating room air with 99% oxygen saturations with chest x-ray
notable for only a small right pleural effusion. All surgical
wounds were clean, dry and intact.
Medications on Admission:
1. Atenolol 25 mg qd
2. Lipitor 10mg qd
3. Plavix 75mg qd
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
3. Atorvastatin 10 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.
Disp:*40 Tablet(s)* Refills:*0*
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
7. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours) for 2
weeks.
Disp:*56 Capsule, Sustained Release(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Home Health Care
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 3
Hypertnesion
Hypercholesterolemia
Borderline Diabetes Mellitus (diet controlled)
Factor 5 Leiden Deficiency gene
Obesity
Discharge Condition:
good
Discharge Instructions:
Can take shower. Wash incisions with water and gentle soap. Do
not apply lotions, creams, ointments or powders to incisions. Do
not swim or take bath.
Do not drive for 1 month.
Do not lift greater than 10 pounds for 2 months.
If you notice any drainage from incisions or redness or have
fever greater than 101, please contact office immediately.
Followup Instructions:
Dr. [**Last Name (STitle) 28946**] in 4 weeks
Dr. [**Last Name (STitle) 32255**] in [**1-20**] weeks
Dr. [**Last Name (STitle) **] in [**12-19**] weeks
Completed by:[**2152-12-20**]
|
[
"411.1",
"289.81",
"E849.8",
"414.01",
"070.30",
"512.1",
"E878.8",
"346.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"39.61",
"36.11"
] |
icd9pcs
|
[
[
[]
]
] |
4607, 4670
|
2210, 3617
|
308, 402
|
4895, 4901
|
1506, 2187
|
5295, 5478
|
1031, 1133
|
3725, 4584
|
4691, 4874
|
3643, 3702
|
4925, 5272
|
1148, 1487
|
250, 270
|
430, 698
|
720, 953
|
969, 1015
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,034
| 170,998
|
35037
|
Discharge summary
|
report
|
Admission Date: [**2128-12-27**] Discharge Date: [**2129-1-1**]
Date of Birth: [**2100-8-14**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Tachycardia, Hyperpyrexia
Major Surgical or Invasive Procedure:
[**11-26**] a.m. Ventriculostomy placemtent
[**11-26**] A-Comm Aneurysm coiling
[**11-26**] Ventriculostomy placement
[**12-2**] Cerebral angiogram
[**12-8**] IVC filter
[**12-8**] Tracheostomy
[**12-8**] Peg
[**12-29**] Bronchoscopy for washings
History of Present Illness:
28 yo otherwise healthy male who was admitted [**2128-11-26**] for ACA
aneurysm rupture, who was discharged on [**2128-12-27**], found with
fever to T 101 at rehab facility and mild tachycardia to 110's,
sent back to [**Hospital1 18**] ER, and readmitted for workup of fever.
Please refer to d/c summary for full details.
Past Medical History:
as noted in previous summary
Social History:
Per mother: no Tobacco
[**Name (NI) 80077**] use
Family History:
Non contributory
Physical Exam:
On Discharge:
Vital signs stable, afebrile. Eyes open spontaneoulsy, and
tracks examiner. PERRL 4mm to 2mm bilaterally.Following commands
RUE>LUE, AOx1, w/draws LE to noxious. Wound C/D/I.
Pertinent Results:
[**2128-12-30**] 03:09AM BLOOD WBC-8.5 RBC-3.80* Hgb-12.0* Hct-34.2*
MCV-90 MCH-31.5 MCHC-34.9 RDW-15.2 Plt Ct-413
[**2128-12-30**] 03:09AM BLOOD PT-17.4* PTT-27.8 INR(PT)-1.6*
[**2128-12-30**] 03:09AM BLOOD Glucose-111* UreaN-14 Creat-0.7 Na-142
K-3.7 Cl-103 HCO3-31 AnGap-12
[**2128-12-30**] 03:09AM BLOOD Calcium-9.5 Phos-3.7 Mg-2.3
***************
[**2128-12-31**] 03:12AM BLOOD WBC-9.1 RBC-3.75* Hgb-11.6* Hct-33.2*
MCV-89 MCH-30.9 MCHC-34.8 RDW-15.0 Plt Ct-361
[**2128-12-31**] 03:12AM BLOOD Glucose-162* UreaN-15 Creat-0.6 Na-139
K-3.7 Cl-103 HCO3-28 AnGap-12
[**2128-12-31**] 03:12AM BLOOD Calcium-9.2 Phos-3.7 Mg-2.1
Imaging:
CXR [**12-27**]:
FINDINGS:
The tracheostomy is seen in situ. There is an ill-defined
opacity in the
right upper lobe, likely unchanged since the prior examination.
Cardiomediastinal silhouette is unremarkable. Left lung is
clear.
Chest CT w/Contrast [**12-28**]:
COMPARISON: Chest radiographs [**12-23**] and [**2128-12-27**].
TECHNIQUE: MDCT axial images of the chest were obtained without
intravenous contrast and displayed at 5- and 1.25-mm
collimation. A series of sagittal and coronal images were
reformatted for review.
FINDINGS: A tracheostomy tube is appropriately placed and the
central airways are patent. Mass- like consolidation likely
within the posterior segment of the right upper lobe measures
3.1 cm without evidence of cavitation. Streaky atelectasis is
seen within both lower lobes. An ill- defined subpleural area of
consolidation in the left lower lobe may represent atelectasis,
aspiration, or a second focus of consolidation (3:35). Scattered
mediastinal lymph nodes including a 9-mm right paratracheal node
and 10-mm subcarinal lymph node are likely reactive. The heart
and great vessels are unremarkable. No pleural or pericardial
effusions.
The examination is not designed for subdiaphragmatic evaluation
except to note a PEG tube within the stomach and normal adrenal
glands. There is evidence of bilateral gynecomastia.
CXR [**12-30**]:
No interval change in right upper and left lower lobe
consolidations. No PTX.
Brief Hospital Course:
Patient was readmitted to the neurosurgery service from
rehabilitation facility on Decemeber 8th for concerns of one
febrile episode to 101 and low grade tachycardia.
In brief summary,
28M otherwise healthy male who was admitted [**2128-11-26**] for ACA
aneurysm rupture, who was discharged on [**2128-12-27**], found with
fever to T 101 at rehab facility, sent back to [**Hospital1 18**] ER, and
readmitted for workup of fever. Please refer to d/c summary for
full details from previous admission. Briefly, during hospital
course, patient had coiling, craniectomy and EVD placement on
[**2128-11-26**], trach/PEG/IVC filter on [**12-9**], VPS placed [**12-15**].
Infectious issues during post-op course included A) single coag
neg staph from CSF on [**12-6**] (likely contaminant), B) MSSA VAP
(BAL [**12-11**]), Rx with total 14 days Cipro, C) GNR VAP ([**12-21**]
sputum w/2+GNR), s/p 7-day Rx with Zosyn &
Vanco.
Temp curve past 5 days prior to discharge:
Tmax
[**12-27**] 99.6
[**12-26**] 99.8
[**12-25**] 100.2
[**12-24**] 99.7
[**12-23**] 99.9
[**12-22**] 99.8
Per family, no change in mental status or respiratory status. In
ER, with Temp 101.1. RR 24, O2Sat 100% on Trach mask. Patient
cont'd on Zosyn & vanco, and ciprofloxacin added on admit.
Present abx course(Zosyn, Cipro, Vanco) to continue pending
finalization of sensitivities of above cultures until [**1-5**], [**2128**]. Once cultures are finalized, antibiotic therapy can
be adjusted to more specific treatment.
Medications on Admission:
Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every
6 hours) as needed for pain, fever.
Ibuprofen 100 mg/5 mL Suspension Sig: One (1) PO Q8H (every
8 hours) as needed for T>101.5.
Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML
Mucous membrane [**Hospital1 **] (2 times a day).
Warfarin 5 mg Tablet Sig: Two (2) Tablet PO QPM (once a day
(in the evening)).
Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours).
Piperacillin-Tazobactam Na 4.5 g IV Q8H
Vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous
twice a day for 4 days.
Regular insulin Sliding Scale
Regular insulin sliding scale per Nursing print-out
Discharge Medications:
1. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain, fever.
5. Ibuprofen 100 mg/5 mL Suspension Sig: One (1) PO Q8H (every
8 hours) as needed for T>101.5.
6. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
8. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML
Mucous membrane [**Hospital1 **] (2 times a day).
9. Warfarin 5 mg Tablet Sig: Two (2) Tablet PO QPM (once a day
(in the evening)).
10. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours).
12. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
13. Piperacillin-Tazobactam Na 4.5 g IV Q8H
14. Ciprofloxacin 400 mg IV Q12H
15. Vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous
twice a day for 4 days.
16. Zosyn 4.5 gram Recon Soln Sig: One (1) Intravenous three
times a day for 4 days.
17. Cipro I.V. 400 mg/40 mL Solution Sig: One (1) Intravenous
twice a day for 4 days.
18. Regular insulin Sliding Scale
Regular insulin sliding scale per Nursing print-out.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Aneursymal Subarachnoid Hemorrhage
Anterior communicating artery aneurysm
Atrial fibrillation
L common fem DVT
Respiratory failure/Pneumonia
Cerebral Vasospasm
dysphagia / peg placed
Pneumonia
Discharge Condition:
Neurologically Stable
Discharge Instructions:
General Instructions
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? 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.
?????? You have been prescribed Keppra as an anti-seizure medication,
please continue to take this until follow up w/Dr. [**First Name (STitle) **]. you
will not require blood work to monitor levels.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Please call [**Telephone/Fax (1) 1669**] for an appointment to be seen by Dr.
[**First Name (STitle) **] in 2 weeks. You will need a CT scan of your head prior to
that appointment(without contrast)
Completed by:[**2128-12-31**]
|
[
"780.09",
"V44.0",
"V45.2",
"997.31",
"780.79",
"785.0",
"438.89",
"V44.1",
"507.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
7703, 7773
|
3428, 4922
|
343, 592
|
8010, 8034
|
1320, 3405
|
9315, 9546
|
1078, 1096
|
6194, 7680
|
7794, 7989
|
4949, 6171
|
8058, 9292
|
1111, 1111
|
1125, 1301
|
278, 305
|
620, 943
|
965, 995
|
1011, 1062
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,275
| 184,381
|
53890
|
Discharge summary
|
report
|
Admission Date: [**2108-1-31**] Discharge Date: [**2108-2-10**]
Service: MEDICINE
Allergies:
Sulfonamides / Morphine / Ultram
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
cough and weakness
Major Surgical or Invasive Procedure:
R internal jugular central line
History of Present Illness:
85F with complicated medical history significant for NHL s/p
chemo, colon cancer s/p hemicolectomy, and asplenia who presents
with 3 day history of wet but non-productive cough, progressive
shortness of breath, and fevers and chills at home. Patient
denied abdominal pain, chest pain, rash. + Nausea and vomiting x
1day. + [**First Name3 (LF) **] contact- daughter with pneumonia. Chronic low back
pain is stable. Patient received flu shot [**1-1**] and pneumovax in
[**2104**].
ED course: Patient spiked a fever to 101.6 rectally, treated
with tylenol, Ceftriaxone 1g x 1 and Azithromycin 500mg x 1.
Also treated with combivent and robitussin. Patient became
hypotensive to 77/42 which improved to SBP in 90s after 4L IVF,
but then with increased O2 requirement. Patient then placed on
NRB, started on levophed for BP support and admitted to ICU for
further management.
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 [**1-31**]. 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 with her
daughter
Family History:
Non-contributory
Physical Exam:
T99.8--> 101.6 rectal BP96/63 HR91 RR20 O2sat94% 3L-->100% NRB
(ED)
T100.6 BP99/43(Levophed 0.1mcg/kg/min) HR74 RR28 O2sat 97% 2L
([**Hospital Unit Name 153**])
Gen: frail, elderly woman, ill appearing but non-toxic. alert,
oriented
HEENT: PERRL, EOMI, OP-clear, MMM.
neck supple, no LAD. R IJ in place.
Chest: tachypneic, using accessory muscles; crackles [**3-2**] the way
up bilaterally, no wheezes.
CV: regular rate, normal S1, S2. no murmurs.
Abd: soft, nontender, nondistended. + BS
Ext: no edema, good pulses.
Pertinent Results:
Labs on admission:
WBC 8.43, Hct 38.3, MCV 83, Plt 387
(DIFF: 58N, 4B, 29L, 8M, 1Baso)
PT 14.2*, PTT 32.8, INR(PT) 1.4
Na 135, K 4.2, Cl 98, HCO3 24, BUN 14, Cr 0.6, Glu 95
ALT 17, AST 47*, LDH 299*, AlkP 82, [**Doctor First Name **] 66, TBili 0.2, Lip 24
CK(CPK) 34, CK-MB 2, cTropnT <0.01
Ca 8.4, Phos 2.7, Mg 1.5*
Cortsol 33.4*
CRP 39.7*
ABG: pO2-87 pCO2-38 pH-7.43 calHCO3-26 Base XS-0
freeCa 1.14
Lactate 1.2
.
Labs on discharge:
WBC 11.7*, Hct 28.7*, MCV 84, Plt 432
Ret 2.3
Na 137, K 4.2, Cl 98, HCO3 32, BUN 10, Cr 0.4, Glu 87
Ca 8.7, Phos 3.1, Mg 1.7, Fe 31, TIBC 164, B12 1329, Folate
12.5, Ferritin 332*, TRF 126*
.
Micro:
[**2108-2-9**]: URINE CULTURE (Final [**2108-2-12**]):
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
GRAM POSITIVE BACTERIA. >100,000 ORGANISMS/ML..
Alpha hemolytic colonies consistent with alpha
streptococcus or
Lactobacillus sp.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ =>32 R
CHLORAMPHENICOL------- 8 S
LEVOFLOXACIN---------- =>8 R
LINEZOLID------------- 2 S
NITROFURANTOIN-------- 32 S
VANCOMYCIN------------ =>32 R
.
[**2108-2-2**] urine cx NGTD
[**2108-2-1**] Influenza A/B NEGATIVE
[**2108-2-1**] Legionella Urinary Ag: NEG FOR LEGIONELLA SEROGROUP 1 AG
[**2108-1-31**] urine cx NGTD
[**2108-1-31**] blood cx x2 NGTD
.
Imaging:
CXR [**2108-1-31**]: 1. Patchy opacity in the left retrocardiac region,
which could represent an early focus of pneumonia. 2. Diffuse
interstitial fibrosis.
.
CXR [**2108-2-1**]: Right jugular CV line is in distal SVC. No
pneumothorax. There are low lung volumes. Allowing for this,
heart size is normal. There is a diffuse bilateral reticulo-
nodular pattern consistent with a known chronic interstitial
fibrosis. Discoid atelectases are present at the left base but
no definite new confluent pulmonary consolidation and no
pneumothorax.
.
CXR [**2108-2-2**]: Developing multifocal opacities possibly
representing pneumonia. Edema is also considered.
.
CXR [**2108-2-3**]: Stable appearing multifocal opacities bilaterally,
concerning for pneumonia.
.
CXR [**2108-2-5**]: A single AP upright view at 12:00 hours is compared
to previous examination of [**2108-2-3**]. The lung volumes are
low. There are bilateral diffuse parenchymal opacities with
small pleural effusions without significant change since the
previous exam. The findings are suggestive of pneumonia
superimposed on patient's known interstitial lung disease. There
is enlargement of both pulmonary arteries, indicating pulmonary
hypertension. Although the heart size is within normal limits
there may be an element of interstitial pulmonary edema.
.
Brief Hospital Course:
# PNA: Ms. [**Known lastname **] likely had community acquired pneumonia. She
was ruled out for legionella and influenza, but was unable to
provide an adequate sputum sample to determine causative
organism. She was treated with ceftriaxone/cefpodoxime and
azithromycin, which covered her for encapsulated organisms
(patient is asplenic). She also likely had a component of
pulmonary edema, as she had received 4L of IVF on admission due
to her hypotension/sepsis. She began autodiuresing on her own,
and became I/O negative during her last several days of
hospitalization. She was able to be weaned off oxygen and her
sats remained stable on RA. She was given albuterol/atrovent
nebs for her breathing and robitussin prn for her cough.
.
# SEPSIS: On admission, she appeared to be in septic shock,
likely from her pneumonia. Despite receiving 4L of IVF in the
ED, she remained hypotensive and was transferred to the [**Hospital Unit Name 153**] on
levophed for BP support. Random cortisol level was normal, as
was a cortisol stim test, so she was not felt to be adrenally
insufficient. She was started on antibiotics (ceftriaxone and
azithromycin) with improvement in her hemodynamics. Blood and
urine cultures from admission showed no growth. The levophed was
eventually weaned and her BP remained stable. She was
transferred out of the [**Hospital Unit Name 153**] to the regular floor for continued
monitoring and weaning of her O2 requirement.
.
# ILD: Ms. [**Known lastname **] has known interstitial lung disease, with her
last pulmonary evaluation being in [**8-31**]. At that time, no
further w/u was pursued as she was asymptomatic. Per her primary
outpt pulmonologist, she has been admitted multiple times in the
past essentially for respiratory failure and has received
steroids with improvement in her symptoms. Pulmonary was
consulted once the patient was stablized on the floor but they
did not feel steroids were indicated at this time. Her O2 sats
were much improved, to 94-95% on [**Last Name (LF) **], [**First Name3 (LF) **] she was continued on her
albuterol/atrovent nebulizers. She was switched to inhalers upon
discharge.
.
# CONJUNCTIVITIS: She developed conjuncitivitis and was treated
with erythromycin ointment starting on [**2108-2-6**].
.
# PAIN MANAGEMENT: Ms. [**Known lastname **] had been on narcotics for chronic
back pain as an outpatient but they were held after the patient
was transferred to 11R as she began to develop an elevated
bicarb and it was felt that the narcotics may be contributing to
this. Her pain was adequately controlled with tylenol and she
was discharged without any narcotics.
.
# ? UTI: Ms. [**Known lastname **] had a urine cx sent prior to discharge, from
foley catheter, which grew enterococcus and gram positive
bacteria, but she was asymptomatic at that time and still
receiving cefpodoxime. The decision was made to not give any
further antibiotics at this time, but her family was told that
if the patient developed symptoms of a UTI, to call her PCP for
antibiotics for possible UTI.
.
# FEN: While in the [**Hospital Unit Name 153**], she was kept NPO. IVF boluses were
used PRN based on CVP, BP and UOP. Once transferred to the
floor, she kept to a regular, kosher diet. Her electrolytes were
checked daily and were repleted as needed.
.
# ACCESS: R IJ
.
# PPX: She was on heparin SC and pneumoboots for DVT ppx. She
had no history of GERD thus PPI was not indicated. She was given
a bowel regimen to prevent constipation while on narcotics.
.
# COMM: grandson [**Name (NI) **] [**Telephone/Fax (1) 110552**]
.
# CODE: FULL, confirmed with family.
.
# DISPO: To home with services. She is to receive PT at home as
well as oxygen, to keep her O2 sats >92%.
Medications on Admission:
Fosamax qwk, Propoxy N/APAP 50/325 [**1-30**] QID PRN, Fentanyl patch
12mcg/hr, Flonase
Discharge Medications:
1. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed.
Disp:*1 bottle* Refills:*0*
2. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day) for 7 days.
Disp:*1 diskus* Refills:*0*
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for fever or pain.
4. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours).
Disp:*qs 30 days inhaler* Refills:*2*
5. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
Disp:*qs 30 days inhaler* Refills:*2*
6. Oxygen
Please provide ONE oxygen tank with nasal cannula for patient to
use as needed for shortness of breath or oxygen saturation <90%
on RA.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] Family & [**Hospital1 1926**] Services
Discharge Diagnosis:
Community-acquired pneumonia
Interstitial lung disease
Discharge Condition:
Good. Afebrile. BP 104/68, HR 80, RR 20, sats 97% on RA.
Discharge Instructions:
1. Please call your PCP or go to the nearest ER if you develop
any of the following symptoms: fever >101, chills, chest pain,
shortness of breath, difficulty breathing, decreased energy
level, nausea, vomiting, or any other worrisome symptoms.
2. Please take all your medications as prescribed. You can
resume taking fosamax as per your regular schedule.
Followup Instructions:
1. Please follow-up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], in [**3-3**] weeks.
His office number is [**Telephone/Fax (1) 250**].
2. Please keep your appointment for a mammogram on [**2108-3-27**] at
3pm. If you have any questions or need to reschedule, please
call:
MAMMOGRAPHY at [**Telephone/Fax (1) 327**].
3. Please call to make a follow up appointment with your
pulmonologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], in [**5-5**] weeks. Her number is
[**Telephone/Fax (1) 612**].
|
[
"276.52",
"785.52",
"515",
"724.2",
"V10.05",
"995.92",
"428.30",
"486",
"276.2",
"202.80",
"038.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"00.17"
] |
icd9pcs
|
[
[
[]
]
] |
10262, 10348
|
5608, 9335
|
257, 290
|
10447, 10506
|
2761, 2766
|
10909, 11464
|
2190, 2208
|
9473, 10239
|
10369, 10426
|
9361, 9450
|
10530, 10886
|
2223, 2742
|
199, 219
|
3196, 5585
|
318, 1191
|
2780, 3177
|
1213, 2089
|
2105, 2174
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,764
| 161,039
|
21342
|
Discharge summary
|
report
|
Admission Date: [**2144-12-22**] Discharge Date: [**2144-12-24**]
Service: [**Month/Day/Year 662**]
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
Syncope
Complete heart block
Major Surgical or Invasive Procedure:
St. [**Male First Name (un) 923**] Pacemaker implantation
History of Present Illness:
89 y/o M with a past medical history of CAD s/p POBA to 80%
ostial lesion D2 [**2137**], aortic stenosis, hypertension,
hyperlipidemia presented to [**Hospital1 **] [**Location (un) 620**] after being found
unresponsive at home by son and wife. [**Name (NI) **] son's report, patient
was in usual state of health earlier in the afternoon when
patient's wife found him unresponsive. On EMS arrival, patient
was lethargic with HR 40, .5 mg atropine x 2 was given. On
arrival to ED, patient was still lethargic with rhythm strip
showing high grade AV block, HR 40 BP 120/70. He was given
versed with attempted transcutaneous pacing at 110 mA, which was
successful. He recived aspirin 325 and was sent to [**Hospital1 18**] for
further evaluation and treatment.
.
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 denies exertional buttock or calf pain. All of the other
review of systems were negative.
.
Cardiac review of systems is notable mild ankle edema, which
patient states is baseline. There is absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
- PERCUTANEOUS CORONARY INTERVENTIONS: [**4-14**] Cardiac cath with
D2 ostial 80% stenosis s/p POBA
3. OTHER PAST MEDICAL HISTORY:
1. HTN
2. s/p prostatectomy for prostate CA in [**2127**]
3. h/o hydrocele
4. Hypercholesterolemia
5. Baseline urinary incontinence
6. T11 fx after fall s/p kyphoplasty [**2141**]
7. Osteopenia
8. Aortic stenosis
9. Depression
10. age-related senility per neurology
11. Recurrent falls and shuffling gait- on treatment for
Parkinson's disease, possible vascular dementia
Social History:
Completed the sixth grade. He is a business owner, been retired
for 20 years. Married and lives with his wife. [**Name (NI) **] does not
smoke, does not drink and denies any illicit drug use.
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory. Family history
notable for Alzheimer's. The mother and father have since passed
away.
Physical Exam:
VS: T= 97.6 BP= 139/69 HR= 39 RR= 10 O2 sat= 100%
GENERAL: NAD. Oriented x 1.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 7 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. Brady, III/VI SEM at USB, indicative of AS. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Sparse bibasilar
crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominial bruits.
EXTREMITIES: 1+ pitting edema to mid-shin. No femoral bruits.
Weak pedal pulses b/l.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
1. Labs on admission:
[**2144-12-22**] 08:30PM BLOOD WBC-6.5 RBC-4.05* Hgb-12.5* Hct-37.3*
MCV-92 MCH-30.9 MCHC-33.6 RDW-12.7 Plt Ct-192
[**2144-12-22**] 08:30PM BLOOD PT-13.3 PTT-24.5 INR(PT)-1.1
[**2144-12-22**] 08:30PM BLOOD Glucose-92 UreaN-35* Creat-0.9 Na-140
K-5.0 Cl-111* HCO3-24 AnGap-10
[**2144-12-22**] 08:30PM BLOOD cTropnT-0.02*
[**2144-12-23**] 03:10AM BLOOD cTropnT-0.03*
[**2144-12-22**] 08:30PM BLOOD Calcium-8.4 Phos-3.3 Mg-2.0
.
2. Labs on discharge:
[**2144-12-24**] 06:45AM BLOOD WBC-7.9 RBC-3.73* Hgb-11.7* Hct-33.9*
MCV-91 MCH-31.5 MCHC-34.7 RDW-12.9 Plt Ct-198
[**2144-12-24**] 06:45AM BLOOD Plt Ct-198
[**2144-12-24**] 06:45AM BLOOD Glucose-97 UreaN-33* Creat-0.9 Na-137
K-3.9 Cl-107 HCO3-24 AnGap-10
.
3. Imaging/diagnostics:
- CXR ([**2144-12-24**]): Successful uncomplicated placement of permanent
pacer. No
pneumothorax. Patient has moderate marked cardiomegaly and a
mild degree of pulmonary congestion.
Brief Hospital Course:
89 y/o M with a past medical history of CAD s/p POBA to 80%
ostial lesion D2 [**2137**], aortic stenosis, hypertension,
hyperlipidemia presents with a syncopal episode, now in 3rd
degree heart block, asymptomatic.
.
# RHYTHM: On admission, patient had asymptomatic 3rd degree AV
block. Mental status similar to baseline, with stable BP and
urine output. He was supported with dopamine gtt overnight and
then [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] pacemaker was placed. Patient tolerated procedure
with no complications afterwards. He will be discharged on
Keflex for 2 days.
.
# CAD: Cath from [**2137**] showing 80% ostial lesion D2 s/p POBA,
with medical therapy since. Patient currently asymptomatic. He
was continued aspirin, statin.
.
# HTN: Continued on amlodipine.
.
# HLD: Continued on statin.
.
# Dementia: Patient has cognitive impairment at baseline
according top son and has a waxing and [**Doctor Last Name 688**] memory. Likely
secondary to vascular dementia per recent neuro notes. Continual
neuro exam was stable.
.
#. Parkinsonian features/Gait disturbances: Continued Sinemet.
.
#. Depression: Continued sertraline.
.
#. Urinary tract obstruction: Baseline problem and is followed
by urology for chronic bladder neck stricture and radiation for
prostate cancer. Post-void residual was monitered. Patient was
asymptomatic throughout and will follow-up with outpatient
urologist.
Medications on Admission:
Sinamet 25/100 [**Hospital1 **]
Sertraline 25 daily
Amlodipine 2.5 daily
Simvastatin 20 daily
Aspirin 81 mg
Discharge Medications:
1. cephalexin 250 mg Tablet Sig: One (1) Tablet PO three times a
day.
Disp:*6 Tablet(s)* Refills:*0*
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. sertraline 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
6. carbidopa-levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
7. Tylenol Extra Strength 500 mg Tablet Sig: 1-2 Tablets PO four
times a day as needed for pain.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Complete heart block
Dementia
Discharge Condition:
Level of Consciousness: Alert and interactive.
Mental Status: Confused - always.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You had a slow rhythm called complete heart block that caused
you to be unresponsive. We implanted a pacemaker to prevent the
rhythm from being slow again. You can take tylenol for any pain
or discomfort at the site. Keep dressing over left chest site
for 72 hours, then pt/wife can remove and pt may shower. No
baths or pools for one week. No lifing more than 5 pounds with
the left hand for 6 weeks. No lifting left arm over head for 6
weeks.
.
We made the following changes to your medicines:
1. Take Cephalexin to prevent and infection at the pacer site
2. Take tylenol for any pain at the pacer site.
Followup Instructions:
Device Clinic:
Department: CARDIAC SERVICES
When: THURSDAY [**2144-12-31**] at 10:00 AM
With: [**First Name11 (Name Pattern1) 539**] [**Last Name (NamePattern4) 13861**], NP [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Name: [**Last Name (LF) **],[**First Name3 (LF) 275**] L.
Location: [**Hospital1 **] [**First Name (Titles) 3860**] [**Last Name (Titles) 662**] CENTER
Address: [**Street Address(2) 3861**], [**Location (un) **],[**Numeric Identifier 3862**]
Phone: [**Telephone/Fax (1) 3858**]
Appt: [**12-29**] at 12:30pm
Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) 122**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital1 **] [**Location (un) 620**]-Cardiology
Address: [**Street Address(2) 3001**], [**Location (un) 620**], MA
Phone: ([**Telephone/Fax (1) 8937**]
Appt: [**1-11**] at 2:30pm
Completed by:[**2144-12-26**]
|
[
"V49.86",
"414.01",
"V45.82",
"332.0",
"733.90",
"424.1",
"426.0",
"401.9",
"V10.46",
"272.4",
"311",
"294.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.83",
"37.72"
] |
icd9pcs
|
[
[
[]
]
] |
6624, 6682
|
4458, 5883
|
297, 357
|
6756, 6803
|
3499, 3507
|
7568, 8572
|
2546, 2747
|
6041, 6601
|
6703, 6735
|
5909, 6018
|
6938, 7545
|
2762, 3480
|
1816, 1917
|
229, 259
|
3969, 4435
|
385, 1722
|
3521, 3950
|
6818, 6914
|
1948, 2320
|
1744, 1796
|
2336, 2530
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,436
| 186,346
|
20685
|
Discharge summary
|
report
|
Admission Date: [**2111-3-14**] Discharge Date: [**2111-3-23**]
Date of Birth: [**2047-11-20**] Sex: M
Service: NEUROSURGERY
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 63-year-old
gentleman who developed weakness, diaphoresis, slurred
speech, and nausea, as well as headache and came to the
Emergency Room and was found to have a large cerebellar bleed
and dilatation of ventricles.
PAST MEDICAL HISTORY:
1. Reveals an MI.
2. Status post a CABG 2 years ago.
ALLERGIES: He has no known drug allergies.
MEDS AT ADMISSION:
1. Lopressor.
2. Aspirin.
3. Lipitor.
PHYSICAL EXAM: Temperature 96.1, heart rate 76, respirations
18, O2 sat 97% on face mask. He was awake but not oriented.
He was moving all four extremities. Pupils were equal, round
and reactive to light. He did have some nystagmus with left
lateral gaze. His face was symmetric. Shoulder shrugs were
equal. Grips were [**5-20**] in the upper extremities and lower
extremities. Exam showed alternating hands appropriately.
No pronator drift. Some difficulty with slurred speech. He
had some left arm difficulty with finger-to-nose. Right arm
was normal.
LABS AT ADMISSION: White count 9.1, hematocrit 45, platelets
246, sodium 145, chloride 107, bicarb 21, BUN 19, creatinine
1, glucose 152. PT, PTT and INR were 12.4, 20.3 and 1.0.
HOSPITAL COURSE: He was admitted and brought to the
operating room where he underwent a suboccipital craniotomy
with evacuation of hematoma and placement of a
ventriculostomy. He tolerated this procedure well and was
transferred to the Intensive Care Unit. He did have some
agitation postoperatively, but this was felt secondary to
anesthesia, and it did clear. Postoperatively, his vital
signs were stable. His IC pressures were [**3-21**]. He was
attentive, alert and oriented. Pupils were [**4-18**] bilaterally.
He did have some horizontal nystagmus. His face was
symmetric. He did have some mild left pronator drift and
some left dyskinesia.
His diet was increased, and he was allowed to get out of bed,
though the drain to the ventriculostomy remained. His Foley
was DC'd. He remained on antibiotics while the drain was in
place. There was some leaking of fluid around the drain site
and this was resutured on [**3-19**], after which it was dry.
The drain was clamped and then removed on [**Month (only) 958**]. The patient
tolerated this well.
He continued on a decadron taper. He continued to do well
neurologically. He was seen by physical therapy, and his
activity was increased. He was transferred to the floor.
Physical therapy did feel he would do well with some home
physical therapy. He was advised not to take aspirin for at
least 1 month, and he was advised to discuss this with his
cardiologist. He will follow-up in one month's time with Dr.
[**First Name (STitle) **] and have an MRI at that time. His staples were removed.
[**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 342**], M.D. [**MD Number(1) 343**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2111-3-23**] 09:31
T: [**2111-3-23**] 09:55
JOB#: [**Job Number 55241**]
|
[
"412",
"331.4",
"V45.81",
"431"
] |
icd9cm
|
[
[
[]
]
] |
[
"02.2",
"01.31"
] |
icd9pcs
|
[
[
[]
]
] |
1367, 3191
|
617, 1349
|
175, 422
|
444, 601
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,960
| 192,744
|
9997
|
Discharge summary
|
report
|
Admission Date: [**2106-10-1**] Discharge Date: [**2106-10-9**]
Date of Birth: [**2063-12-2**] Sex: F
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1055**]
Chief Complaint:
Change in mental status, increased somnolence
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
42 year old woman with HEP B&C, childhood seizures and Devics
syndrome (recurrent myelitis) with chronic back pain who
presents with somnolence and mental status change times one day
now resolved. Pt difficult to arouse and not following even
simple commands (per neuro not very far from baseline). At OSH
pt received tox screen (pos only for opiods for her baseline
back pain), head ct and mri which were negative. transfered to
[**Hospital1 **] since her neurologist, Dr. [**Last Name (STitle) **] is here. here had
unimpressive LP with only high protien with traumatic tap. given
history of back pain (acute on chornic), some urinary incontince
and history of IVDU in distant past pt underwent mri here which
revealed ? soft tissue density at t9-sacrum without contrast. Pt
subsequently intubated for repeat mri of better quality w/
contrast. repeat mri revealed no epidural abcess, soft tissue
mass outside her spinal canal. In Er pt recieved CTX, vanco and
acylovir for herpes encephalitis, LP sent for culture and HSV
pcr which are pending. Of note, LDH 1,400 (was 190 or so [**3-17**]!)
no signs of hemolysis, pcp/pna so likley some kind of lymphoma
(possibly the soft tissue mass seen on mri). ER course c/b right
mainstem intubation and infiltration of right arm with propofol
(preserved arterial pulses-no compartment syndrome). Transferred
from MICU (for ventilation, intubated for MRI) on [**2106-10-3**] to the
floor service.
Past Medical History:
1. Hepatitis B.
2. Hepatitis C, genotype 1
3. Hypercholesterolemia.
4. History of seizure disorder as a child due to head trauma.
Seizures from age 19-31, had been on dilantin. Seizure free with
d/c of dilantin since age 32.
5. History of depression.
6. Demyelinating syndrome involving recurrent optic neuritis and
myelitis as described above.
7. s/p misplaced pheresis catheter into left subclavian artery
s/p repair and graft stent [**12-15**]
Social History:
Divorced. Has two sons, ages 19 and 23. Worked as a substance
abuse therapist in the past. Has h/o cocaine, LSD, and marijuana
use. Smokes ?????? ppd x many yrs. Has had difficulty arranging
housing for self outside of [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 731**], her nursing home. At
baseline is wheelchair-bound. Wants to return to [**Last Name (un) 17679**] to
be at home with family.
Family History:
No family history of neurological disorder but significant for
alcohol and substance abuse. Father: episode(s) of V-tach. GF: 9
MI's.
Pertinent Results:
[**2106-10-1**] 08:00AM CEREBROSPINAL FLUID (CSF) PROTEIN-94*
GLUCOSE-59
[**2106-10-1**] 08:00AM CEREBROSPINAL FLUID (CSF) WBC-2 RBC-1100*
POLYS-47 LYMPHS-22 MONOS-0 MACROPHAG-31
[**2106-10-1**] 08:00AM CEREBROSPINAL FLUID (CSF) WBC-36 RBC-8833*
POLYS-88 LYMPHS-9 MONOS-0 EOS-2 MACROPHAG-1
[**2106-10-1**] 02:04AM TYPE-ART PO2-303* PCO2-53* PH-7.35 TOTAL
CO2-30 BASE XS-2
[**2106-10-1**] 02:04AM LACTATE-0.8
[**2106-10-1**] 01:10AM URINE HOURS-RANDOM
[**2106-10-1**] 01:10AM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2106-10-1**] 01:10AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.006
[**2106-10-1**] 01:10AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2106-10-1**] 01:00AM GLUCOSE-88 UREA N-18 CREAT-0.7 SODIUM-148*
POTASSIUM-4.3 CHLORIDE-109* TOTAL CO2-28 ANION GAP-15
[**2106-10-1**] 01:00AM ALT(SGPT)-113* AST(SGOT)-78* LD(LDH)-1421*
CK(CPK)-1609* ALK PHOS-96 AMYLASE-70 TOT BILI-0.4
[**2106-10-1**] 01:00AM LIPASE-22
[**2106-10-1**] 01:00AM OSMOLAL-314*
[**2106-10-1**] 01:00AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2106-10-1**] 01:00AM WBC-11.1* RBC-4.97 HGB-12.8 HCT-40.4 MCV-81*
MCH-25.8* MCHC-31.8 RDW-16.3*
[**2106-10-1**] 01:00AM NEUTS-82.3* LYMPHS-12.0* MONOS-3.5 EOS-1.7
BASOS-0.4
[**2106-10-1**] 01:00AM HYPOCHROM-3+ ANISOCYT-1+ MICROCYT-1+
[**2106-10-1**] 01:00AM PLT COUNT-289
Brief Hospital Course:
1. MS CHANGE
- Quickly resolved. Was on ceftriaxone 2 gm IV 12 then 1 gm IV
12 and then discontinued on [**2106-10-6**] secondary to no clear source
of infection and mental status now at baseline. It was felt
that her AMS was probably secondary to doxepin and its
associated cholingeric effects.
2. HIGH LDH, HIGH CK, T9 MASS:
- With no evidence of hemolysis, liver enzymes elevated, but
trended down quickly.
- Concern that LDH may be related to mass at T9, representing a
lymphoma - CT torso on [**2106-10-7**] showed no evidence of lymphoma or
[**Doctor First Name **]
- Neurosurgery was consulted, requested gallium scan to better
assess mass before considering biopsy - will get injection on
Friday, [**10-8**] and scan (3 days total) beginning Monday as an
outpatient.
- Other concern for myositis with elevated CKs, rheum was
consulted, felt not an inflammatory myositis was less likely but
possibly a steroid myopathy, will f/u with rheumatology as an
outpatient.
3. PERSISTENT FEVERS
- h/o spiking temps but has been afebrile since antibiotics
d/c'd, concerned mass at T9 is infectious, check blood cultures.
CXR shows no consolidation/pneumonia. Antibiotics d/c'd on
[**2106-10-6**]. Interestingly, no fevers after antibiotics were d/c'd.
CSF negative. Cryptococal serum levels normal. Blood cultures
negative, urine cultures negative. Pt had been afebrile for 48'
at time of discharge, no final source identified, but WBC
trended down to normal levels.
4. BACK PAIN- chronic, not new
- Contiued morphine prn, added back neurontin 300 [**Hospital1 **] then
increased to 600 TID then 600 four times daily as per neuro
attending who knows her well, added Baclofen now 20 mg TID with
goal to increase every day by 10 mg to 25 mg QID, added MsContin
XR 15 TID, Morphine IV prn. Pain was well controlled on this
regimen.
5. Anemia - Her anemia remained stable throughout the course and
was felt to be due to chronic disease/inflammation and thus not
amenable to Fe-therapy.
Medications on Admission:
Doxepin 150 HS
Lorazepam 2mg HS
Morphine 15mg Q8 PRN
Lasix 20 Daily
Effexor XR 150 Daily
Buspirone 10 TID
Calcium Carbonate 1000 [**Hospital1 **]
Detrol 2 [**Hospital1 **]
Senna
Famotidine 20 Q12
Valium 5 QPM
Prednisone 80/60 QOD
Baclofen 5 QID
Neurontin 800 QID
MS Contin 15 Q8
Klor-Con 10mEq Daily
Discharge Medications:
1. Tolterodine Tartrate 2 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Buspirone HCl 10 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
5. Venlafaxine HCl 75 mg Capsule, Sust. Release 24HR Sig: Two
(2) Capsule, Sust. Release 24HR PO QD (once a day).
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed.
8. Baclofen 10 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
9. Zinc Oxide-Cod Liver Oil 40 % Ointment Sig: One (1) Appl
Topical PRN (as needed).
10. Morphine Sulfate 15 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO Q8H (every 8 hours).
11. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
12. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
13. Diazepam 5 mg Tablet Sig: One (1) Tablet PO QPM (once a day
(in the evening)).
14. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO QD (once a
day).
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 731**] N.H.
Discharge Diagnosis:
Change in mental status, probable T9 paraspinal myositis
Discharge Condition:
Stable.
Discharge Instructions:
Please return to the ER or call your primary physician if you
experience any fevers/chills/rigors or night sweats, increased
or new weakness, or increased/new pain.
Please do not restart doxepin as there is concern that this
medication has deleterious anticholinergic effects.
Please increase dose of neurontin to 800 PO TID over one week.
Followup Instructions:
You will need to be seen by Dr. [**Last Name (STitle) 16932**] in rheumatology, please
call ([**Telephone/Fax (1) 1668**] to make an appointment to be seen in
approximately two weeks.
Please call your PCP to arrange an appointment to be seen in one
to two weeks.
Provider: [**First Name11 (Name Pattern1) 20**] [**Last Name (NamePattern4) 33453**], M.D. Where: [**Hospital6 29**] EYE
UNIT Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2107-3-21**] 2:00
Please return to [**Hospital1 18**] on Monday for your gallium scan. You will
need to call [**Telephone/Fax (1) 327**] to schedule a time.
Patient will need a sleep study as an outpatient for suspected
obstructive sleep apnea.
|
[
"070.32",
"285.29",
"428.0",
"272.0",
"599.0",
"070.54",
"341.9",
"724.5",
"729.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"83.21",
"96.04",
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
8006, 8106
|
4415, 6403
|
356, 363
|
8207, 8216
|
2904, 4392
|
8606, 9294
|
2749, 2885
|
6754, 7983
|
8127, 8186
|
6429, 6731
|
8240, 8583
|
271, 318
|
391, 1832
|
1854, 2303
|
2319, 2733
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,284
| 137,036
|
952
|
Discharge summary
|
report
|
Admission Date: [**2128-9-29**] Discharge Date: [**2128-10-9**]
Date of Birth: [**2069-6-26**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: Patient is a 59-year-old
gentleman diagnosed with metastatic renal cell cancer in [**2127-7-5**]. He underwent a debulking left nephrectomy with Dr.
[**Last Name (STitle) **] on [**2127-8-25**], and was diagnosed with metastatic
kidney cancer by thyroidectomy in [**2127-7-5**]. This
revealed high grade renal cell carcinoma that was metastatic
to the adrenal gland. Following debulking nephrectomy, he
was found to be presented with severe bone pain. Location of
his pain was in the right shoulder. Given that the pain did
not resolve, he underwent a MRI which showed ultimately a
lytic lesion in the right shoulder and was treated with
radiation therapy to the shoulder as well as ultimately
undergoing treatment with chemotherapy. He did not respond
to chemotherapy and developed a large lytic lesion in the
left femur requiring an operative embolization and rod
placement in 02/[**2128**]. Following that, he had multiple
radiation therapies to the spine as well as right scapula as
well as left femur.
He was seen on multiple occasions over the last several weeks
complaining of increasing pain in the right shoulder. CT
scan revealed a large lytic lesion. Given that this area had
been radiated twice, tentatively booked to see Dr. [**First Name (STitle) **]
in Radiology for radiofrequency ablation for pain relief. He
has been on OxyContin 40 mg p.o. b.i.d. and Morphine elixir
for breakthrough pain, and he has been a little better over
the last few days. He has not moved his bowels in three
days, and also had difficulty urinating. This initially felt
to be related to the increase in narcotic, but now he
describes difficulty feeling a full bladder, and had been
voiding very little over the last day. He was admitted to
the Oncology service for workup of this urinary retention.
He is also complaining of leg weakness.
PHYSICAL EXAMINATION: He was a gentleman in no acute
distress. HEENT: Pupils are equal, round, and reactive to
light. EOMs full. Cardiovascular: Regular, rate, and
rhythm, no murmurs, rubs, or gallops. Abdomen is soft,
nondistended, positive bowel sounds. Neurologically, cranial
nerves II through XII intact. His motor strength is [**5-8**] in
the right upper extremity, [**6-7**] in the left upper extremity,
and [**6-7**] on bilateral lower extremities. His reflexes in the
upper extremities and lower extremities is symmetric, and
sensation to cold and pin prick and light touch bilaterally,
gait are normal. There is no saddle anesthesia.
He was admitted now with urinary retention and bowel
retention likely due to increased pain medication, but will
rule out cord compression. He had a MRI of his cervical
spine, which showed evidence of tumor at the T1-T3 level with
moderate-to-severe cord compression. Also disease at the T1
level causing some deformity of the spinal cord. Therefore
Neurosurgery was consulted.
The patient was taken to the Neurosurgery service and brought
to the operating room for decompression laminectomy of the
thoracic and cervical spine. First on [**2128-10-3**], underwent
a thoracic embolization of the tumor, and then was taken to
the operating room on [**2128-10-4**], and underwent T2-T3
resection of metastatic lesions, spinal cord decompression
with segmental C7-T4 stabilization.
Postoperative, his vital signs were stable. He was afebrile.
His motor strength was [**6-7**] in all muscle groups. He had no
pronator drift. His laboratories were within normal limits.
He was neurologically stable and transferred to the regular
floor. He has had two drains in place, which stayed in until
postoperative day #5. He had minimal output of both drains
on day five, and they were pulled. Continued on IV
antibiotic treatment while drains were in place. His
incisions were clean, dry, and intact. He was seen by
Physical Therapy and Occupational Therapy, and was thought to
possibly acquire rehab, although made significant improvement
over his hospital stay, and opted for discharge to home with
followup with Dr. [**Last Name (STitle) 1132**] in two weeks for staple removal.
DISCHARGE MEDICATIONS:
1. Diazepam 5 mg p.o. q.6h.
2. Gentamicin ophthalmic solution one drop OU q.4h.
3. Protonix 40 mg p.o. q.d.
4. Lactulose 30 cc p.o. q.4h. prn.
5. OxyContin 40 mg p.o. b.i.d.
6. Morphine 5-10 mg p.o. q.4-6h. for breakthrough pain.
7. Senna one tablet p.o. b.i.d.
8. Colace 100 mg p.o. b.i.d.
9. Levothyroxine 125 mcg p.o. q.d.
CONDITION ON DISCHARGE: Stable. He has a figure-of-eight
brace, which he should wear at all times until his followup
with Dr. [**Last Name (STitle) 1327**] in two weeks for staple removal. His
incisions was clean, dry, and intact. He ambulation was
improved. His sensation and strength in his lower
extremities is intact. He will follow up also with his
oncologist in [**Month (only) **]. His vital signs are stable at the
time of discharge.
[**Name6 (MD) 1339**] [**Last Name (NamePattern4) 1340**], M.D. [**MD Number(1) 1341**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2128-10-8**] 11:37
T: [**2128-10-8**] 11:36
JOB#: [**Job Number 6345**]
|
[
"198.5",
"244.9",
"788.20",
"197.8",
"336.3",
"197.0",
"V10.52",
"198.7",
"564.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.05",
"03.4",
"99.29",
"81.03"
] |
icd9pcs
|
[
[
[]
]
] |
4269, 4596
|
2030, 4246
|
160, 2007
|
4621, 5308
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,940
| 182,678
|
20890
|
Discharge summary
|
report
|
Admission Date: [**2121-11-28**] Discharge Date: [**2121-12-5**]
Date of Birth: [**2061-6-15**] Sex: F
Service: MEDICINE
Allergies:
Bactrim Ds / Hurricaine / Zosyn / Glipizide
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
Fever, rash.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
60 yo W w/ hx DMII, R mastectomy, Charcot foot, s/p several
recent ICU admissions transferred from rehab [**11-28**] for fever and
rash, on the floor w/ agitation, [**Month/Year (2) **] responsive to
fluids, now sedated post-haldol, clonazepam, seroquel.
.
Pt was initially admitted for elective foot repair in [**2121-10-28**].
She developed respiratory distress, wound infection, demand
ischemia, and ARF. She had a 2 day ICU stay. Her foot was
debrided and she was found to have pseudomonas & MRSA in her
foot. She was started on vanco and zosyn. Additionally,
pulmonary fibrosis was noted on CT of the chest. Pt was then
transferred to rehab.
.
She returned to [**Hospital1 18**] 12 hrs later [**2-3**] rash, fever, and
[**Month/Day (2) **]. She received 4L fliud and was quickly weaned off a
levophed gtt. She was in the ICU 4 days again and received a
short course of steroids [**2-3**] low cortisol level in critical
illness setting. She also had demand ischemia, and also
underwent a TEE to r/o endocarditis, which was negative for
vegetations. She developed acute methemoglobunemia [**2-3**]
hurricaine spray w/ her TEE and received methylene blue. She
was continued on vanco and zosyn and had a central line placed
[**2121-11-20**]. Additionally, her screws were removed from her foot
and she was on a Vac dressing. She was discharged to rehab once
again.
.
She remained at rehab x 4 days, then on [**2121-11-28**] developed rash
and fever (T to 101.8) and was transferred back to [**Hospital1 18**]. She
remained hemodynamically stable on the floor. Overnight she
became agitated and received haldol, clonazepam, and seroquel.
She was also hypotensive to SBP 70's and responded to 1L NS.
.
On morning of transfer to the MICU, she had SBP's 70-80's got
IVF and her BP responded. She continues to be seen by ID who
recommended continuing the vanco for a 42 day course for
osteomyelitis, d/cing the Zosyn (?drug reaction), and starting
levo for ?pseudomonas in foot/wound culture (started [**11-30**]).
Rash is thought to be [**2-3**] to a drug (glipizide, lasix, zosyn).
She is now on Vanco for the osteo, eucerin for rash, PICC placed
[**12-2**] (central line removed, ?infection). Foot wound is being
followed by [**Month/Year (2) **], was recently debrided, XR from [**12-1**] still
question of osteo at medial remnant of tarsal bones
.
On transfer back to the floor, she was stable hemodynamically,
afebrile, at baseline mental status (?uncommunicative, sleepy).
Past Medical History:
PMHx:
HTN,
hyperlipidemia,
DMII w/ peripheral neuropathy,
diastolic CHF
CRI baseline creat ~ 1.5,
COPD,
pulmonary fibrosis,
OSA on BiPAP
psoriasis
+PPD
LBP
hypothyroidism
s/p mastectomy
hyponatremia (Na ~ 130's)
Charcot foot
osteomyelitis (see above)
Depression s/p ECT yrs ago
Meds on admission:
Vanco 1mg daily (d25/42)
Levo 250 d3
Clonazepam
Metoprolol 12.5 [**Hospital1 **]
Sarna
Eucerin
Seroquel 100 mg [**Hospital1 **]
Baclofen 20 mg TID
Oxycodone PRN
FE 325
Famotidine prior to Vanco
ASA 325
Atrovent
Albuterol
SQ Hep
SSI
Fluticasone
Zocor 20 mg daily
Senna
Levothyroxine
Colace
ALL: Bactrim-rash, Hurricaine spray-methemoglobinemia
Social History:
The pt. is divorced and lives in an apartment in [**Location (un) 1110**]. 35
year history of cigarette smoking, 1-2 packs per day. Denied
use of EtOH or illicit drugs.Her sister, [**Name (NI) 335**] [**Name (NI) 55586**], is
her health care proxy.
Family History:
Non-contributory.
Physical Exam:
T: 98.7 76 98/43 16 92% 2L NC
General: pt. was awake, in NAD, very sleepy on exam, not very
communicative, could not give name/location/date
HEENT: PERRL, EOMI, anicteric sclerae, MM dry, no lesions in OP
Neck: supple, FROM, no nuchal rigidity, no LAD, JVD not apparent
Chest: Left subclavian in place without erythema or drainage
Pulmonary: lungs CTA bilaterally but rhonchorous bs, no w/r
Cardiac: RRR, nl S1S2, II/VI SEM
Abdomen: soft, NT/ND, NABS, obese, no ascites, no HSM
Extremities: some peripheral edema bilaterally, 1+; with
boots/heel supports on bilaterally
Skin: confluent, blanching, erythematous macular rash over back
and upper chest. Also erythematous papular rash over bilateral
lower extremities extending from lower knees to ankles
bilaterally.
Neurologic: pt very sleepy, difficult to assess neuro exam,
seems grossly intact
Pertinent Results:
Labs on admission:
[**2121-11-28**] 06:42PM LACTATE-1.8
[**2121-11-28**] 06:28PM GLUCOSE-96 UREA N-15 CREAT-1.2* SODIUM-132*
POTASSIUM-4.4 CHLORIDE-99 TOTAL CO2-23 ANION GAP-14
[**2121-11-28**] 06:28PM WBC-9.5 RBC-3.50* HGB-9.7* HCT-30.2* MCV-86
MCH-27.7 MCHC-32.1 RDW-19.3*
[**2121-11-28**] 06:28PM NEUTS-86.6* LYMPHS-6.2* MONOS-3.5 EOS-3.5
BASOS-0.1
[**2121-11-28**] 06:28PM PLT COUNT-494*
[**2121-11-28**] 06:28PM PT-13.2 PTT-28.3 INR(PT)-1.1
Micro:
[**11-30**]: Urine, legionella, blood-ngtd
[**11-29**]: bld, urine, fungal blood-ngtd
[**11-28**] Ucx-neg
[**11-28**] wound Cx: Pseudomonas
[**11-17**] swab: pseudomonas/MRSA
[**11-10**] swab: pseudomonas/MRSA
[**11-3**] swab: pseudomonas/MRSA/diphtheroids
[**2121-9-3**] foot Cx: pseudomonas
[**2121-8-11**] foot Cx: pseudomonas
.
TEE: [**2121-11-17**] EF 60-65%, no vegetations, no focal wall motion
abnormalities; aortic atheroma present;
.
EKG: lat TWI on admission c/w baseline, repeat w/ ST depressions
in I, avL, ST elevation in III
.
[**12-2**]:
[**12-1**]: foot XR: stable, cannot exclude osteo at medial remnant
of tarsal bones
Brief Hospital Course:
A/P
60 yo W w/ hx DMII, osteomyelitis, CRI, CAD, COPD, OSA s/p
repeated hospitalizations now admitted to the ICU w/ rash,
fever, decreased MS [**First Name (Titles) **] [**Last Name (Titles) **], now stable hemodynamically,
still with rash but afebrile. (Initially admitted to floor,
transferred to MICU overnight, MICU [**Date range (1) 55587**], on floor
[**Date range (1) 55588**])
1. Fever - ddx includes drug fever (given mild eosinophilia)
(?zosyn, lasix, glipizide), line infection, sepsis,
osteomyelitis. All cultures are NGTD (pseudomoas in foot swab).
She is currently afebrile and doing better clinically.
?whether residual osteomyelitis on foot XR. All surveillance
cultures remained negative. She will continue her course of
Levofloxacin/Vanco (42 days total) until [**2121-12-19**]. Zosyn was
changed to levofloxacin as it was thought that the zosyn may be
causeing her drug fever/rash. Her SC line was removed, and she
was discharged with a PICC. [**Month/Day/Year **] debrided the foot wound at
bedside on [**12-1**]. She was continued with her vacuum dressing
(125 mmHG) on discharge, and she will follow up with [**Month/Year (2) **] in
1 week. The cause of this most recent fever was most likely
drug fever and she remained afebrile throughout her hospital
course.
2. Rash - Her diffuse, erythematous body rahs was thought to be
a drug reaction. Her Zosyn, lasix, and glipizide were held, and
her rash did improve throughout hospitalization. She was less
erythematous, and the rash was desquamating at time of
discharge. Dermatology saw her in-house, agreed with diagnosis
of drug reaction, and recommended Eucerin cream.
3. [**Month/Year (2) **] - She was initially hypotensive on presentation
which in part prompted her initial transfer to the MICU. Her
blood pressure responded to fluids, she was only transiently on
pressors, and her urine lytes were consistent with a prerenal
etiology. In addition, CVP was low supporting this diagnosis.
Upon transfer back to the floor, her bp was stable, her dose of
lopressor had been decreased, and she remained hemodynamically
stable.
4. Hyponatremia - resolved with NS hydration. Her Na resolved
to within normal limits after NS hydration. She was maintained
on a fluid restriction of 1 L; cause of baseline hyponatremia is
unclear, but her baseline seems to be in the low 130's.
5. Delirium - She was agitated at times and combative with
symptoms of delirium. She was seen by psychiatry who
recommended tapering her Klonopin as tolerated and posssibly
d/cing it at some point. She was discharged on Klonopin 0.25
[**Hospital1 **] with plans to taper. Her seroquel dose was also decreased
to 50 qhs, and her percocet was minimized in an attempt to
decrease any symptoms of delirium. She was relatively stable
from a psych point of view on discharge.
6. COPD - She was continued on nebulizers, inhalers, and
fluticasone. She continued on her BIPAP/CPAP overnight for OSA
(settings [**12-10**]). At times she was reluctant to wear the mask at
night [**2-3**] discomfort.
7. Anemia - hct 26, pt w/ Fe Def anemia, anemia of chronic
disease. Her Hct remained stable throughout hospitalization,
and she was discharged on daily iron supplementation.
8. EKG changes - pt likely has some demand ischemia [**2-3**]
[**Month/Day (2) **]. She had a negative P-MIBI in [**10-16**] with neg CK's
and a mild rise in tnt's. She had equivocal EKG changes and no
further symptoms. MEdical managment was continued with her
ASA/BB/zocor.
9. DM: continue SSI, goal FSBG<140. Glipizide was held as it
was thought it may have been causing her drug rash. Her BS were
under good control with the SSI.
10. Pain control: baclofen, tylenol, oxycodone PRN
11. Hypothyroidism: continue levothyroxine
12. Code: FULL
13. PPX: has heel protectors, taking PO's with aspiration
precautions, bowel regimen, sq heparin, famotidine
14. Dispo: she was discharged back to [**Hospital3 102**]
facility to follow up with [**Hospital3 **] in 1 week (appointment
scheduled). She will complete her 42 day course of antibiotics
and follow up with her PCP 1 week after discharge from rehab.
She was stable and doing well at time of discharge.
Medications on Admission:
1. Albuterol 90 mcg/Actuation Aerosol Sig: 2-4 Puffs Inhalation
Q4H (every 4 hours) as needed.
2. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Levothyroxine Sodium 75 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
6. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Six (6)
Puff Inhalation [**Hospital1 **] (2 times a day).
7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Quetiapine Fumarate 100 mg Tablet Sig: One (1) Tablet PO HS
(at bedtime).
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
11. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
12. Baclofen 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
13. Oxycodone HCl 5 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for pain.
14. Vancomycin HCl 10 g Recon Soln Sig: one-tenth Recon Soln
Intravenous Q12H (every 12 hours).
15. Piperacillin-Tazobactam 2-0.25 g Recon Soln Sig: One (1)
Recon Soln Intravenous Q6H (every 6 hours).
16. Lisinopril 5 mg 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).
18. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
19. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
20. Glipizide 5 mg Tablet Sig: one-half Tablet PO twice a day.
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Levothyroxine Sodium 75 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation [**Hospital1 **] (2 times a day).
6. Insulin Regular Human 100 unit/mL Solution Sig: sliding scale
Injection ASDIR (AS DIRECTED): For BS 150-200, give 2 U, BS
201-250 give 4 U, BS 251-300, give 6U, BS 301-350, give 8U, BS
351-400, give 10 U.
7. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
8. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H PRN as needed.
9. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H PRN as needed.
10. Albuterol 90 mcg/Actuation Aerosol Sig: 2-4 Puffs Inhalation
Q4H (every 4 hours) as needed.
11. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
12. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
14. Hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal PRN (as
needed).
15. Baclofen 10 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
16. White Petrolatum-Mineral Oil Cream Sig: One (1) Appl
Topical [**Hospital1 **] (2 times a day).
17. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
18. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day).
19. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
20. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
21. Quetiapine Fumarate 25 mg Tablet Sig: Two (2) Tablet PO HS
(at bedtime).
22. Clonazepam 0.5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day): Please taper to off as allowed by patient.
23. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed: Please use as little as
possible to prevent possible symptoms of delirium.
24. Famotidine 20 mg IV BEFORE VANCOMYCIN
please give 30 minutes before vancomycin
25. Haloperidol 1-2 mg IV TID:PRN anxiety, agitation
26. Levofloxacin in D5W 500 mg/100 mL Piggyback Sig: One (1)
Intravenous Q24H (every 24 hours) for 14 days: Continue until
[**12-19**].
27. Vancomycin HCl 1,000 mg Recon Soln Sig: One (1) Intravenous
once a day for 14 days: Continue until [**12-19**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - Acute Rehab
Discharge Diagnosis:
Drug Rash and Fever
Osteomyelitis
Discharge Condition:
Stable
Discharge Instructions:
1. Please take all your medications as described in the
discharge instructions. You will need to complete a 42 day
course of Vancomycin and Levofloxacin for your osteomyelitis
(until [**2121-12-19**]). We are trying to taper your klonopin
(currently on 0.25 mg [**Hospital1 **]) until you are no longer on this
medication. Please minimize the amount of percocet taken as this
can contribute to symptoms of delirium. Please continue to hold
glipizide, lasix, and zosyn. It was felt that these medications
may have been contributing to your rash.
2. You will need to follow up with [**Hospital1 **] within 1 week of
discharge for a wound check
3. Please follow up with your PCP [**Name Initial (PRE) 176**] 1 week of discharge
from [**Hospital3 **] facility.
4. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1L
5. Please call your PCP if you are experiencing chest pain,
shortness of breath, fever/chills, or with any other concerns
Followup Instructions:
1. Please follow up with Dr. [**Last Name (STitle) **] in [**Last Name (STitle) **] on [**12-15**]
(1:30 pm, in [**Hospital Ward Name 121**] 3), 1-888-SAV-FEET
2. Please follow up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 931**] ([**Telephone/Fax (1) 55589**])
within one week of discharge from rehabilitation facility
3. Provider: [**Name10 (NameIs) **] SCAN Where: [**Hospital6 29**] RADIOLOGY
Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2122-1-9**] 11:00
4. Provider: [**Name10 (NameIs) 1571**] BREATHING TESTS Where: [**Hospital6 29**]
PULMONARY FUNCTION LAB Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2122-1-9**]
12:00
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
|
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45,829
| 169,810
|
16504
|
Discharge summary
|
report
|
Admission Date: [**2190-9-19**] Discharge Date: [**2190-10-1**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Bloody diarrhea
Major Surgical or Invasive Procedure:
BiPAP
EGD and colonoscopy [**2190-9-21**]
History of Present Illness:
88 yoF with a history of CKD [**2-16**] HTN and on coumadin for prior
PE. She presents with diarrhea and abdominal cramps since
midnight last night. She has had 5-7 episodes of non-bloody
diarrhea before she noted blood in her stools. She has no
history of GIB in the past. She denies fever, nausea, vomiting.
She thought her symptoms were due to food poisoning initially.
.
VS in the ED were 96.2, 60, 138/30, 17, 100% on RA. NG lavage
negative. She had gross BRBPR. CXR negative for free air. She
was given Vitamin K 10 mg IV, protonix 80 mg IV then ggt, 2
units FFP, lasix 20 mg IV, and one unit PRBC.
Past Medical History:
1) HTN, stage 3
-- since more than 20 yrs ago
-- prior admissions for hypertensive urgency
2) CHF
-- since more than 10 yrs ago
-- sleeps on at least 2 pillows a night
-- last proBNP [**1-23**]: 3688
-- last [**Month/Year (2) 113**] on OMR is from [**2-17**]: "Preserved left ventricular
systolic function. Severe pulmonary artery systolic
hypertension. Right ventricular hypertrophy with cavity
enlargement and free wall hypokinesis. Moderate mitral
regurgitation. The severity of pulmonary artery hypertension
appears to be in excess of that expected from the mitral
regurgitation and suggests a chronic (or acute on chronic)
pulmonary process (COPD, recurrent pulmonary embolism, etc.)"
3) Pulm HTN - see above
4) CKD, thought to be due to hypertensive nephrosclerosis
-- stage 4
-- low Na, Low K diet
-- follows w/ Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
5) Renal osteodystrophy
-- on Calcitriol
-- last Vit D level > 30
6) Chronic anemia [**2-16**] CKD
-- no evidence of iron or Vit B12 deficiency
-- discussing Aranesp therapy if Hgb < 9.5
7) Osteoporosis
8) Glaucoma, open angle, b/l
-- vision on [**3-24**]: 20/70 OD, pressures 16/16
-- on Combigan [**Hospital1 **] and Travatan-Z
-- follows w/ Dr. [**Last Name (STitle) **]
9) hx of DVT in [**9-15**]
10) Dementia
11) Recent UTI, [**8-24**]
-- treated with ciprofloxacin then switched to Bactrim d/t
nausea and vomiting on cipro (unclear if sxs d/t cipro)
12) Constipation
13) Osteoarthritis, knees
14) s/p hysterectomy, for abnormal vaginal bleeding in [**2177**]
15) s/p cataract sx, both eyes per pt report
Social History:
Lives with daughter, who is her only child, in [**Name (NI) 86**]. Was
widowed 6 yrs ago. Has 2 grandchildren who live in NY. Used to
own and serve as director of 2 schools, but currently
unemployed.
- Tobaccos: None
- EtOH: Occasional
- Illicit drugs: None
Family History:
Father with stroke in his 70's, diabetes and question of "heart
trouble" and high BP.
Mother passed away while patient was 9 yr old d/t pellagra.
Uncle with diabetes.
No h/o cancer in the family.
Physical Exam:
VS in the ED: T 96.2, HR 60, BP 138/30, RR 17, O2Sat 100% on RA
VS on arrival to the MICU: T 96.5, HR 76, BP 128/56, O2sat 100%
on RA
VS on arrival to the medical floor: T 98.4, HR 65, BP 126/41, RR
20, O2sat 100% on RA
.
GENERAL: Comfortable, NAD, thin elderly woman
HEENT: b/l arcus senilis, both eyes surgical, EOMI, OP clear,
slightly dry MM, dentures
NECK: Supple. No LAD.
LUNGS: Fine crackles at bases, otherwise no rhonchi or wheezes.
Thorax expands symmetrically on inspiration. Good breath sounds.
CARDIO: RRR, good S1 and S2, III/VI harsh systolic ejection
murmur best heard at RUSB, radiates to carotids. No rubs or
gallops. Collapsing pulse present.
ABD: +BS, soft, non-distended. Mildly tender in the LLQ, but no
rebound, no guarding. No hepatomegaly. No CVA tenderness.
EXT: Warm. 3+ [**Location (un) **], symmetric, to knee. b/l posterior calf
tenderness, mild, which patient says is chronic. 2+ radial and
DP pulses, symmetric. Hyperpigmentation c/w venous stasis
changes b/l.
NEURO: A+Ox3, CN II-XII intact, muscle bulk and tone good
throughout, strength 5/5 distally in UE and LE, no pronator
drift, sensation to light touch grossly intact, DTRs 2+ and
symmetric in brachioradialis, biceps, triceps, 1+ in patellar,
babinski negative, no asterixis.
Pertinent Results:
[**2190-9-19**] 04:20PM BLOOD WBC-4.6 RBC-1.85*# Hgb-5.1*# Hct-17.2*#
MCV-93 MCH-27.4 MCHC-29.3* RDW-17.8* Plt Ct-253
[**2190-9-20**] 04:57AM BLOOD WBC-5.6 RBC-3.06*# Hgb-9.1*# Hct-27.2*#
MCV-89 MCH-29.6 MCHC-33.3# RDW-15.6* Plt Ct-149*
[**2190-9-20**] 06:00PM BLOOD WBC-7.1 RBC-3.56* Hgb-10.9* Hct-32.0*
MCV-90 MCH-30.7 MCHC-34.2 RDW-16.0* Plt Ct-148*
[**2190-9-21**] 12:01AM BLOOD Hct-28.8*
[**2190-9-21**] 06:20AM BLOOD WBC-7.0 RBC-2.87* Hgb-8.7* Hct-25.1*
MCV-87 MCH-30.2 MCHC-34.6 RDW-15.9* Plt Ct-138*
[**2190-9-21**] 03:40PM BLOOD WBC-8.4 RBC-3.56* Hgb-10.6* Hct-32.6*#
MCV-91 MCH-29.8 MCHC-32.6 RDW-16.0* Plt Ct-179
[**2190-9-22**] 06:45AM BLOOD WBC-6.4 RBC-3.02* Hgb-9.0* Hct-27.5*
MCV-91 MCH-29.6 MCHC-32.6 RDW-16.1* Plt Ct-171
[**2190-9-22**] 03:30PM BLOOD WBC-6.7 RBC-3.17* Hgb-9.6* Hct-28.4*
MCV-90 MCH-30.2 MCHC-33.7 RDW-16.4* Plt Ct-145*
[**2190-9-23**] 01:45AM BLOOD Hct-24.4*
[**2190-9-23**] 06:25AM BLOOD WBC-6.6 RBC-2.61* Hgb-7.9* Hct-23.7*
MCV-91 MCH-30.1 MCHC-33.3 RDW-16.8* Plt Ct-145*
[**2190-9-23**] 08:03PM BLOOD Hct-38.9#
[**2190-9-24**] 07:00AM BLOOD WBC-8.3 RBC-3.74*# Hgb-11.2*# Hct-33.8*
MCV-90 MCH-30.0 MCHC-33.3 RDW-16.8* Plt Ct-162
[**2190-9-25**] 05:33AM BLOOD WBC-9.8 RBC-4.07* Hgb-12.6 Hct-36.1
MCV-89 MCH-30.9 MCHC-34.9 RDW-16.4* Plt Ct-158
[**2190-9-25**] 01:26PM BLOOD Hct-34.1*
[**2190-9-25**] 08:15PM BLOOD WBC-9.1 RBC-3.62* Hgb-11.0* Hct-32.8*
MCV-91 MCH-30.5 MCHC-33.6 RDW-16.3* Plt Ct-155
[**2190-9-26**] 05:10AM BLOOD WBC-9.4 RBC-3.68* Hgb-11.0* Hct-33.6*
MCV-91 MCH-29.8 MCHC-32.7 RDW-16.3* Plt Ct-165
[**2190-9-27**] 06:20AM BLOOD WBC-8.4 RBC-3.76* Hgb-11.0* Hct-34.5*
MCV-92 MCH-29.3 MCHC-32.0 RDW-15.9* Plt Ct-178
[**2190-9-28**] 04:50AM BLOOD WBC-7.4 RBC-3.60* Hgb-10.9* Hct-32.3*
MCV-90 MCH-30.2 MCHC-33.6 RDW-15.6* Plt Ct-149*
[**2190-9-29**] 09:50AM BLOOD WBC-7.9 RBC-3.80* Hgb-11.4* Hct-34.3*
MCV-90 MCH-30.1 MCHC-33.3 RDW-15.3 Plt Ct-174
[**2190-9-30**] 05:20AM BLOOD WBC-8.2 RBC-3.60* Hgb-11.0* Hct-33.2*
MCV-92 MCH-30.5 MCHC-33.1 RDW-15.6* Plt Ct-199
[**2190-10-1**] 06:10AM BLOOD WBC-8.3 RBC-3.37* Hgb-10.5* Hct-31.4*
MCV-93 MCH-31.2 MCHC-33.6 RDW-15.3 Plt Ct-210
[**2190-9-19**] 04:20PM BLOOD Neuts-69.8 Lymphs-25.0 Monos-3.5 Eos-1.0
Baso-0.6
[**2190-9-24**] 09:09PM BLOOD Neuts-89.6* Lymphs-6.6* Monos-3.3 Eos-0.2
Baso-0.4
.
.
[**2190-9-19**] 04:20PM BLOOD PT-26.4* PTT-28.0 INR(PT)-2.6*
[**2190-9-20**] 04:57AM BLOOD PT-15.3* PTT-26.6 INR(PT)-1.3*
[**2190-9-21**] 06:20AM BLOOD PT-12.6 PTT-24.6 INR(PT)-1.1
[**2190-9-22**] 03:30PM BLOOD PT-12.4 PTT-24.5 INR(PT)-1.0
[**2190-9-24**] 03:41PM BLOOD PT-12.6 PTT-23.4 INR(PT)-1.1
[**2190-9-24**] 09:09PM BLOOD PT-12.4 PTT-21.7* INR(PT)-1.0
.
[**2190-9-19**] 04:20PM BLOOD Glucose-148* UreaN-84* Creat-3.1* Na-141
K-4.8 Cl-112* HCO3-15* AnGap-19
[**2190-9-20**] 04:57AM BLOOD Glucose-74 UreaN-79* Creat-2.8* Na-142
K-4.1 Cl-109* HCO3-17* AnGap-20
[**2190-9-21**] 06:20AM BLOOD Glucose-85 UreaN-71* Creat-2.5* Na-140
K-4.2 Cl-107 HCO3-23 AnGap-14
[**2190-9-22**] 06:45AM BLOOD Glucose-86 UreaN-57* Creat-2.1* Na-139
K-3.8 Cl-108 HCO3-21* AnGap-14
[**2190-9-23**] 06:25AM BLOOD Glucose-92 UreaN-48* Creat-1.9* Na-141
K-4.4 Cl-112* HCO3-20* AnGap-13
[**2190-9-24**] 07:00AM BLOOD Glucose-97 UreaN-43* Creat-1.9* Na-143
K-4.5 Cl-111* HCO3-22 AnGap-15
[**2190-9-24**] 03:41PM BLOOD Glucose-178* UreaN-37* Creat-1.8* Na-139
K-4.4 Cl-107 HCO3-17* AnGap-19
[**2190-9-24**] 09:09PM BLOOD Glucose-170* UreaN-40* Creat-2.0* Na-139
K-4.7 Cl-105 HCO3-17* AnGap-22*
[**2190-9-25**] 05:33AM BLOOD Glucose-102* UreaN-41* Creat-1.8* Na-141
K-4.7 Cl-107 HCO3-22 AnGap-17
[**2190-9-25**] 01:26PM BLOOD Glucose-85 UreaN-41* Creat-2.0* Na-141
K-4.4 Cl-105 HCO3-22 AnGap-18
[**2190-9-25**] 08:15PM BLOOD Glucose-99 UreaN-41* Creat-2.0* Na-140
K-5.1 Cl-107 HCO3-22 AnGap-16
[**2190-9-26**] 05:10AM BLOOD Glucose-82 UreaN-42* Creat-2.0* Na-139
K-4.5 Cl-105 HCO3-24 AnGap-15
[**2190-9-27**] 06:20AM BLOOD Glucose-89 UreaN-46* Creat-2.2* Na-142
K-4.1 Cl-102 HCO3-28 AnGap-16
[**2190-9-27**] 12:50PM BLOOD Glucose-99 UreaN-44* Creat-2.2* Na-141
K-3.7 Cl-101 HCO3-30 AnGap-14
[**2190-9-28**] 04:50AM BLOOD Glucose-83 UreaN-49* Creat-2.2* Na-140
K-3.6 Cl-101 HCO3-25 AnGap-18
[**2190-10-1**] 06:10AM BLOOD Glucose-81 UreaN-56* Creat-2.0* Na-138
K-3.8 Cl-101 HCO3-25 AnGap-16
[**2190-9-19**] 04:20PM BLOOD ALT-31 AST-40 AlkPhos-83 Amylase-115*
TotBili-0.3
[**2190-9-23**] 08:50AM BLOOD CK(CPK)-52
[**2190-9-23**] 08:03PM BLOOD CK(CPK)-75
[**2190-9-24**] 08:55AM BLOOD CK(CPK)-50
[**2190-9-24**] 09:09PM BLOOD CK(CPK)-93
[**2190-9-25**] 05:33AM BLOOD CK(CPK)-114
[**2190-9-25**] 01:26PM BLOOD CK(CPK)-133
[**2190-9-26**] 05:10AM BLOOD ALT-16 AST-35 AlkPhos-69 TotBili-0.8
[**2190-9-29**] 09:50AM BLOOD ALT-13 AST-29 AlkPhos-66 TotBili-0.3
.
[**2190-9-19**] 04:20PM BLOOD cTropnT-0.06*
[**2190-9-23**] 08:50AM BLOOD CK-MB-2 cTropnT-0.04*
[**2190-9-23**] 08:03PM BLOOD CK-MB-2 cTropnT-0.07*
[**2190-9-24**] 08:55AM BLOOD CK-MB-2 cTropnT-0.07*
[**2190-9-24**] 03:41PM BLOOD proBNP-[**Numeric Identifier **]*
[**2190-9-24**] 09:09PM BLOOD CK-MB-4 cTropnT-0.11*
[**2190-9-25**] 05:33AM BLOOD CK-MB-7 cTropnT-0.14*
[**2190-9-25**] 01:26PM BLOOD CK-MB-7 cTropnT-0.13*
[**2190-9-28**] 04:30PM BLOOD CK-MB-2 cTropnT-0.11*
.
[**2190-9-20**] 04:57AM BLOOD Calcium-8.1* Phos-6.0*# Mg-2.1
[**2190-9-21**] 06:20AM BLOOD Calcium-7.8* Phos-3.9# Mg-2.0
[**2190-9-22**] 06:45AM BLOOD Calcium-8.1* Phos-3.6 Mg-1.9 Iron-35
[**2190-9-23**] 06:25AM BLOOD Calcium-7.9* Phos-2.9 Mg-2.0
[**2190-9-24**] 07:00AM BLOOD Calcium-8.4 Phos-2.6* Mg-1.8
[**2190-9-24**] 03:41PM BLOOD Calcium-8.7 Phos-3.4 Mg-1.9
[**2190-9-24**] 09:09PM BLOOD Calcium-8.7 Phos-4.0 Mg-1.8
[**2190-9-25**] 05:33AM BLOOD Calcium-8.4 Phos-3.6 Mg-1.7
[**2190-9-25**] 01:26PM BLOOD Calcium-8.7 Phos-3.7
[**2190-9-26**] 05:10AM BLOOD Albumin-3.1* Calcium-8.6 Phos-3.3 Mg-2.0
[**2190-9-27**] 06:20AM BLOOD Calcium-8.5 Phos-3.2 Mg-1.9
[**2190-9-27**] 12:50PM BLOOD Calcium-8.8 Phos-3.0 Mg-2.0
[**2190-9-28**] 04:50AM BLOOD Calcium-7.8* Phos-3.6 Mg-1.8
[**2190-9-29**] 09:50AM BLOOD Albumin-3.3* Calcium-8.4 Phos-3.3 Mg-1.8
[**2190-9-30**] 05:20AM BLOOD Calcium-7.8* Phos-3.5 Mg-1.8
[**2190-10-1**] 06:10AM BLOOD Calcium-8.1* Phos-3.4 Mg-1.8
.
[**2190-9-22**] 06:45AM BLOOD calTIBC-225* Ferritn-97 TRF-173*
[**2190-9-24**] 03:45PM BLOOD TSH-6.2*
[**2190-9-24**] 03:45PM BLOOD T4-6.4
[**2190-9-23**] 06:25AM BLOOD tTG-IgA-4
.
[**2190-9-24**] 07:48PM BLOOD Type-ART pO2-182* pCO2-34* pH-7.32*
calTCO2-18* Base XS--7
[**2190-9-24**] 07:48PM BLOOD Lactate-3.8*
[**2190-9-20**] 05:30AM BLOOD Lactate-0.8
.
[**2190-9-26**] 12:51PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.005
[**2190-9-19**] 08:06PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.007
[**2190-9-26**] 12:51PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
[**2190-9-19**] 08:06PM URINE Blood-LG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-TR
[**2190-9-19**] 08:06PM URINE RBC-0-2 WBC-0-2 Bacteri-RARE Yeast-NONE
Epi-0-2
.
MRSA screen negative [**9-20**]
[**2190-9-23**]
FECAL CULTURE - R/O E.COLI 0157:H7 (Final [**2190-9-26**]):
NO E.COLI 0157:H7 FOUND.
BC [**2190-9-24**] and [**2190-9-25**] no growth
Urine [**2190-9-26**]
Nil significant on UA and pt asymptomatic
URINE CULTURE (Final [**2190-9-28**]):
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ 1 S
.
Cardiology
.
Cardiology Report ECG Study Date of [**2190-9-19**] 5:42:46 PM
Sinus rhythm with atrial premature beats. Left atrial
abnormality. Left
ventricular hypertrophy. ST-T wave changes with borderline
prolonged
QTc interval are non-specific. Since the previous tracing of
[**2182-12-30**] further
ST-T wave changes are present and the QTc interval appears
longer.
.
Echocardiogram [**2190-9-25**]
The left atrium is moderately dilated. There is mild symmetric
left ventricular hypertrophy with normal cavity size. There is
mild regional left ventricular systolic dysfunction with mid to
distal anterior and anterolateral hypokinesis. Overall left
ventricular systolic function is low normal (LVEF 50-55%). The
right ventricular cavity is mildly dilated with borderline
normal free wall contractility. The aortic valve leaflets are
moderately thickened. There is moderate aortic valve stenosis
(valve area 1.0-1.2cm2). Moderate (2+) aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. There is
no mitral valve prolapse. There is moderate thickening of the
mitral valve chordae. Moderate to severe (3+) mitral
regurgitation is seen. The left ventricular inflow pattern
suggests a restrictive filling abnormality, with elevated left
atrial pressure. There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Mild regional left ventricular systolic dysfunction
consistent with coronary artery disease. Moderate aortic
stenosis. Moderate aortic regurgitation. Moderate to severe
mitral regurgitation.
Compared with the report of the prior study (images unavailable
for review) of [**2183-2-17**], left ventricular systolic dysfunction,
moderate aortic stenosis, and moderate aortic regurgitation are
new.
.
ECG [**2190-9-25**]
Cardiology Report ECG Study Date of [**2190-9-25**] 12:25:18 PM
Sinus rhythm with atrial premature beats. Probable left
ventricular
hypertrophy. ST segment elevation in leads V2-V3 with diffuse T
wave inversion
most pronounced in the precordial leads. Consider myocardial
ischemia.
Borderline prolonged Q-T interval. Compared to the previous
tracing of [**2190-9-19**]
the ST-T wave changes and prolonged Q-T interval are new. There
is loss R wave
in lead V3 but that could be due to lead placement.
.
ECG [**2190-9-25**]
Cardiology Report ECG Study Date of [**2190-9-25**] 3:38:54 PM
Sinus tachycardia. Consider left ventricular hypertrophy.
Diffuse T wave
abnormalities. Cannot exclude myocardial ischemia. Clinical
correlation is
suggested. Since the previous tracing of same date no
significant change.
.
Cardiology Report ECG Study Date of [**2190-9-28**] 2:34:52 PM
Sinus rhythm with slowing of the rate as compared with previous
tracing
of [**2190-9-25**]. There is Q-T interval prolongation and deep T wave
inversion which
is global and consistent with extensive anterolateral and apical
ischemia
and/or myocardial infarction and likely further evolution as
compared with
previous tracing of [**2190-9-25**]. Followup and clinical correlation
are suggested.
.
[**Date Range **] [**9-30**]
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 mild
hypokinesis of the apical segments and apical cap. Diastolic
function could not be assessed. The right ventricular free wall
is hypertrophied. The right ventricular cavity is mildly dilated
with mild global free wall hypokinesis. There are three aortic
valve leaflets. The aortic valve leaflets are moderately
thickened. Moderate (2+) aortic regurgitation is seen. The
mitral valve leaflets are moderately thickened. There is no
mitral valve prolapse. Moderate (2+) mitral regurgitation is
seen. [Due to acoustic shadowing, the severity of mitral
regurgitation may be significantly UNDERestimated.] The
tricuspid valve leaflets are mildly thickened. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Regional LV systolic dysfunction consistent with
mild or resolving stress cardiomyopathy. The RV is mildly
dilated/hypokinetic. At least moderate mitral regurgitation.
Moderate aortic regurgitation. Moderate to severe pulmonary
artery systolic hypertension.
Compared with the prior study (images reviewed) of [**2190-9-25**],
the function of the distal segments has improved slightly. On
the prior [**Year (4 digits) 113**] the anteroseptal and inferior apical segments
were hypokinetic (although not reported as so). Both echoes are
consistent with stress cardiomyopathy, resolving to normal on
the current study. Pulmonary pressures are similar on both
studies (under-reported on prior). Degree of mitral
regurgitation is probably similar.
.
ECG [**2190-9-30**]
Cardiology Report ECG Study Date of [**2190-9-30**] 1:04:52 AM
Sinus rhythm. Diffuse T wave abnormalities with borderline
prolonged
QTc interval suggests myocardial ischemia. Clinical correlation
is suggested.
Since the previous tracing of [**2190-9-28**] T wave abnormalities are
less prominent.
.
Radiology
.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2190-9-19**] 6:48
FINDINGS: Single AP upright portable view of the chest was
obtained. Right
base atelectasis is noted. There is patchy left base
retrocardiac opacity,
atelectasis versus consolidation. Enlarged cardiac silhouette
persists. The
aorta is calcified and tortuous. No large pleural effusion or
pneumothorax is
seen. No overt pulmonary edema is present. There is diffuse
osteopenia and
degenerative changes seen at both shoulder joints. Additionally,
leftward
deviation of the lower cervical trachea is again seen, which is
without
significant change since [**2183**], but could relate to large right
thyroid gland.
IMPRESSION: Right base atelectasis, early consolidation not
excluded.
Persistent enlargement of the cardiac silhouette. No overt
pulmonary edema.
.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2190-9-23**]
12:03
FINDINGS: Mild cardiomegaly. Perihilar opacities are increased,
interstitial
lung markings consistent with volume overload, has increased
when compared to
prior exam. There are small bilateral pleural effusions and
bibasilar
atelectasis. Mild deviation of the trachea to the right is
unchanged. No
evidence of pneumothorax. Bilateral degenerative changes of the
glenohumeral
joints is noted.
IMPRESSION: Mild pulmonary edema with small bilateral pleural
effusions and
bibasilar atelectasis. Mild cardiomegaly.
The study and the report were reviewed by the staff radiologist.
.
Radiology Report PORTABLE ABDOMEN Study Date of [**2190-9-23**] 3:42 PM
FINDINGS: Gas is seen throughout the small bowel and the colon.
There are no
focal dilated loops of bowel. There is no free air. There is
severe lumbar
degenerative joint disease. There is a lucent area projecting
over the region
of left hip and pelvis consistent with bowel gas. Calcification
of the
chondrocostal junction can be seen bilaterally. There are
cardiac leads on
the left side of the patient's chest. There are no radiopaque
retained
foreign bodies consistent with retained capsule.
IMPRESSION:
1. No acute intra-abdominal process. No retained capsule could
be
visualized.
2. These results were conveyed to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
The study and the report were reviewed by the staff radiologist.
.
Radiology Report MR ENTEROGRAPHY ([**Numeric Identifier 46893**]&[**Numeric Identifier 46894**]) SBFT Study Date
of [**2190-9-24**] 8:34 AM
FINDINGS: On the limited views which were acquired, the liver
did not show
any abnormality. There is no intrahepatic biliary dilatation.
The
gallbladder is unremarkable. The right kidney demonstrates a
cortical cyst in
the upper pole.
The limited views of the bowel do not demonstrate a gross
abnormality. Due to
the limited views of this current study, further evaluation is
recommended by
CT.
MRI OF THE PELVIS: The urinary bladder is unremarkable.
Evaluation of the
bowel loops in the pelvis is hindered by the limited views.
IMPRESSION: No gross abnormalities on the limited views
acquired. Further
evaluation is recommended by CTE due to the patient's
claustrophobia.
The study and the report were reviewed by the staff radiologist.
.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2190-9-24**] 5:02
FINDINGS: Comparison is made to previous study from [**2190-9-23**].
Study is limited by motion as patient was unable to hold her
breath. There is
again seen bibasilar atelectasis and likely small pleural
effusions. There is
a baseline bronchovascular prominence and there may be an
element of fluid
overload; however, this is a limited study. Calcification of the
trachea are
seen. Severe degenerative changes of bilateral glenohumeral
joints are seen.
The study and the report were reviewed by the staff radiologist.
.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2190-9-25**] 5:54
FINDINGS: Comparison is made to previous study from [**9-24**], [**2190**].
There remains cardiomegaly. There are again seen likely small
pleural
effusions bilaterally with blunting of bilateral costophrenic
angles. There
is a baseline prominence of bronchovascular markings. Overall,
there is no
appreciable change since the previous study. There is again seen
a left
retrocardiac opacity which is stable. No pneumothoraces are
identified.
Degenerative changes of bilateral glenohumeral joints are again
visualized.
.
GI Ix
.
Colonoscopy [**2190-9-21**]
Findings:
Protruding Lesions Non-bleeding grade 1 internal hemorrhoids
were noted.
Excavated Lesions Multiple non-bleeding diverticula were seen
in the whole colon.
Impression: Diverticulosis of the whole colon
Grade 1 internal hemorrhoids
Otherwise normal colonoscopy to cecum
Recommendations: Potential bright red blood per rectum from
internal hemorrhoids or diverticula. No active bleeding or mass
lesion identified.
Additional notes: The procedure was performed by the fellow and
the attending. The attending was present for the entire
procedure.
.
UGI Endoscopy [**2190-9-21**]
Findings: Esophagus: Normal esophagus.
Stomach: Normal stomach.
Duodenum: Normal duodenum.
Other
findings: Small hiatal hernia noted.
Impression: Small hiatal hernia noted.
Otherwise normal EGD to third part of the duodenum
Recommendations: No source of bleeding noted on upper endoscopy.
Small hiatal hernia noted.
Additional notes: The attending was present for the entire
procedure.
Brief Hospital Course:
88F with dCHF, pulmonary hypertension, CKD admitted [**2190-9-19**] with
GIB of unclear etiology, transfused 5 units and no focus of
bleeding seen. Flash pulmonary edema after significant fluid and
blood resuscitation following lying flat for MR-scan requiring
furosemide infusion with decreasing IV requirements to her dry
weight. Raised TnT with associated tachycardia suggested
possible cardiac event although may have been rate related with
diffuse new T-wave inversions. Echocardiogrphy revealed stress
cardiomyopathy. Had an episode of expressive apahsia (subjective
and noted by daughter) which resolved after 2 hours and may have
represented a small stroke - no imaging was performed. Increased
metoprolol and started high dose statin for this and led to much
improved rate control. GI do not want to do further
investigation as long as remains stable but would consider if
further bleeding. Now very deep TwI on ECG - likely progression
of changes as TnT continued to fall. Cardiology felt "cerebral"
TwI. [**Month/Day/Year **] - improving stress cardiomyopathy with stable valve
disease on repeat [**Month/Day/Year 113**]. Restarted home amlodipine on discharge
to rehab.
.
#. BLOODY DIARRHEA: In the ED, she was hemodynamically stable,
but her Hct was low at 17. NG lavage was unremarkable, and CXR
was negative for free air. She had gross BRBPR on DRE. She was
given Vitamin K 10 mg IV (for INR 2.4), Pantoprazole 80 mg IV
then ggt, 2 units FFP and 1 unit PRBC. In the MICU, she received
2 more units of PRBC. All of her anti-hypertensive medications
and Coumadin were held in the setting of GIB, though she
received IV Lasix. On the second day, she was transferred to the
medical floor. Her Hct had elevated to 27, appropriate given the
transfusion, and she was complaining of only mild abdominal
cramping that had significantly improved. GI was consulted, and
she was prepared for colonoscopy and EGD to take place. While
prepping with GoLytely, she had one BM with bright red blood and
two BM with maroon blood, which then became clear. Her Hct was
closely monitored. Colonoscopy revealed multiple non-bleeding
diverticula in the whole colon and grade 1 internal hemorrhoids;
EGD was unremarkable. Capsule endoscopy was performed per GI
recommendations, and revealed an intraluminal mass with a smooth
pink surface in the small bowel, without bleeding at the site.
She passed additional clots and BRBPR on day 4 and 5 of her
admission, resulting in Hct drop to 23.7, and received 2 more
units of PRBCs with appropriate response in Hct. For further
work-up and follow-up on capsule study, she underwent MR
enterography which was not completed due to an episode of flash
pulmonary edema. She had no further episodes of GIB and did not
need additional transfusions, and remained hemodynamically
stable throughout the hospital stay. Differential dx includes
lesion small bowel (AVM, malignancy) or proximal colon that was
not visualized. Ischemic colitis less likely given lack of abd
pain but considerable cardiac history. Gi were unkeen to do
other investigations of her bleeding unless this recurred at
which point a tagged RBC scan and/or CT-enterography could be
done. No further bleeding and Hb/HCt stable on discharge. PCP to
consider further investigation in collusion with GI. GI will see
as an out-patient.
.
#. ANEMIA: Her Hct in the ED was 17.2 (baseline 31-33.5), likely
secondary to the acute bleed superimposed on her known, chronic
anemia due to CKD. It responded appropriately to the transfusion
as noted above, increasing to 27 by the next morning. After 3
bloody bowel movements during preparation for colonoscopy, it
decreased back to 25. However, it then stabilized at 28-32, but
after several episodes of passing clots and BRBPR, Hct dropped
again to 23.7. She received 2 additional units of PRBCs, and Hct
bumped up to 33.8. It remained stable in the range 31-34 for the
remaining hospital course.
.
#. HTN: Her BP on presentation was 138/30 (baseline unknown). In
the setting of acute GIB, all of her home anti-hypertensive
medications (amlodipine, metoprolol, minoxidil, furosemide) were
held in the ED and MICU. On her third day of hospitalization,
her BP elevated to the range 160-170. As there was no active
bleeding and Hct was stable, we placed her back on amlodipine 5
mg daily, but continued holding the rest of the regimen. On day
4 of her hospital stay, she had an episode of sinus tachycardia,
so we also started her on metoprolol 50 mg [**Hospital1 **] with good effect,
HR stabilizing back to 80s-90s. She was up titrated on her
metoprolol to home dose with good rate control. Cardiology
recommended a trial of ACE-I 2.5mg lisinopril in the comminity.
Target <140/80 if urinary pr <220g/day or for <130/80 if
>220mg/day. we restarted home dose of amlodipine.
.
Decompensated dCHF: Post lying flat for MR [**First Name (Titles) 9140**] [**Last Name (Titles) **] and
pulmonary edema on CXR. This was likely triggered by recent
transfusions, tachycardia with diastolic dysfunction, and laying
flat for MRI. Could also have been triggered by ACS given ECG
changes. Pt transferred to MICU on [**9-24**] for respiratory
distress, RR 30s-40s, hypoxia to 80s on 4-5L requiring NRB,
tachycardia to 130s, bilateral crackles, minimal response to
lasix (40mg Iv x 2, 80mg IV, 120mg IV) on the floor. Upon
trasnfer, pt started on bipap 8/5 and lasix drip with rapid
improvement in symptoms and was weaned to 2L NC with RR 18-20.
She was on BiPap for approximately 6-8 hours. She was diuresed a
total of 1.5L and was transitioned to 80mg IV bolus lasix dosing
with good response. ESM was noted on exam and AS/AR/MR [**First Name (Titles) **] [**Last Name (Titles) 113**].
Stress cardiomyopathy improved on repeat [**Last Name (Titles) 113**]. She continued IV
furosemide diuresis on transfer to the floor and she was
eventually euvolemic and started on her home furosemide dose.
During her whole time post ICU d/c she was saturating well on
room air and her shortness of breath greatly improved.
Cardiology recommended a repeat [**Last Name (Titles) 113**] in 1 year to monitor MR.
.
# ? left TIA/stroke. Episode of apparent expressive aphasia w
hypertension and tachycardia. Completely resolved after 2 hours.
Statin increased to atorvastatin 80mg qd and up-titrated
metoprolol to her home dose with good bP control. We restarted
amlodipine. No imaging per attending. No further episodes.
.
# ECG changes and tachycardia: Pt with TWI relatively diffusely
inferolaterally, new compared with prior ECGs while on MICU,
likely secondary to rate related demand and strain in setting of
LVH and stress cardiomyopthy. Too high risk for heparin or ASA
in setting of GIB so continued to monitor, minimize stress on
the floor. TnT was max 0.14 which could represent small NSTEMI
but baseline is also high given CRF. TnT fell despite worse ECG
changes with deep TwI especially anteriorly but present
throughout ECG and felt by cardiology to possibly represent
"cerebral" T-waves. CEs Continued to fall. On repeat [**Last Name (Titles) 113**] after
these new changes, it was felt that the function of the distal
segments had improved slightly. On the prior [**Last Name (Titles) 113**] the
anteroseptal and inferior apical segments were hypokinetic
(although not reported as so). Both echoes were consistent with
stress cardiomyopathy, resolving to normal on the repeat study.
Pulmonary pressures were similar on both studies (under-reported
on prior) and degree of mitral regurgitation was probably
similar.
.
# Acute on Chronic Kidney Injury: Likely related to CHF and
decreased renal perfusion and should improve with diuresis.
Wasgenerally stable Cr 1.8-2.2 with normal K. We trended this
and there was slight improvement on reducing diuresis.
.
# Possible UTI: Enterococcus on culture but UA negative. Removed
Foley catheter. 1 day treatment with co-amoxyclav then d/c'ss as
felt little evidence of UTI. No symptoms.
.
# h/o DVT: Holding anticoagulation in setting of GIB as above.
This was solely for DVT in [**2183**] and has contraindication so no
indication for anticoagulation currently. Pneumoboots to
continue in rehab until ambulatory
.
# Hypertension: [**Last Name (un) **] home antihypertensives minoxidil,
amlodipine. Continuing metoprolol for rate control at 200mg XL
daily. Cardiology felt trial of lisinopril would be appropriate
if her renal function coped with this. Restarted home amlodipine
dose. BP goals as above.
.
# Renal osteodystrophy and Osteoporosis: We restarted calcitriol
and alendronate
.
# Low mood. Sarted citalopram 20mg qd on [**10-1**] - this can be
reviewed on discharge by PCP
.
# Glaucoma: Continue combigan and travanost eye drops
Medications on Admission:
Alendronate (Fosamax) 35 mg PO qSunday early AM
Amlodipine (Norvasc) 5 mg PO daily
Atorvastatin (Lipitor) 20 mg PO qPM
Brimonidine-Timolol (Combigan) 0.2 %-0.5 % Drop both eyes [**Hospital1 **]
Calcitriol (Rocaltrol) 0.25 mcg PO daily
Furosemide (Lasix) 60 mg PO daily
Metoprolol succinate (Toprol XL) 200 mg PO daily
Minoxidil (Rogaine) 2.5 mg PO daily
Tramadol (Ultram) 50 mg tab 1-2 tabs by PO q4-6h:prn for pain
Travoprost (Travatan Z) 0.004 % drop both eyes qHS
Trazodone (Desyrel) 25 mg PO qHS:prn for insomnia
Warfarin (Coumadin) 3 mg tab 1-3 tabs PO daily as directed by
the coumadin clinic to maintain INR
Docusate sodium (Colace) 100 mg PO BID
Senna 17.2 mg PO daily
Discharge Medications:
1. Alendronate 70 mg Tablet Sig: 0.5 Tablet PO QFRI (every
Friday).
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
4. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
5. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
6. Furosemide 40 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
7. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily):
hold for sbp < 100, HR < 55.
8. Travoprost 0.004 % Drops Sig: One (1) drop Ophthalmic qhs ().
9. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
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. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] Senior Healthcare of [**Location (un) 55**]
Discharge Diagnosis:
Primary:
- Gastrointestinal bleed
- Blood loss anemia
- Small bowel mass NOS
- Acute on chronic diastolic heart failure
- Regional LVSD, takasubo variant
- Moderate aortic stenosis ([**Location (un) 109**] 1.0-1.2cm2)
- Aortic and mitral regurgitation
- Asymptomatic bacteruria
Secondary:
- Hypertension
- CKD stage IV
- Dementia
- Postoperative DVT [**2176**]
- Glaucoma
- s/p hysterectomy
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
It was a pleasure looking after you during your stay at the
[**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **]. You were admitted to the
hospital for bleeding in your GI tract. You were given blood
products. Given the poor condition of your heart, your body was
not able to process the extra fluid in the blood products and
therefore backed up into your heart and lungs. You were treated
for this extra fluid ("pulmonary edema" and "congestive heart
failure") in the ICU with a mask to help you breathe and extra
lasix. Given the improvement in your breathing, you were
transferred to a regular medical floor. Your fluid balance and
breathing improved and you were seen by physical therapy who
felt you needed further ongoing rehab in a facility. You had no
recurrence of teh fluid on your lungs.
While in the hospital, you underwent a colonoscopy and upper GI
endoscopy (too look for possible bleeding points within the
upper bowel and stomach) to look at your bowel. These did not
reveal a cause of your initial blood loss. You also had a
capsule endoscopy (a capsule with a camera to record as it goes
through your bowel and produce pictures of the bowel wall) which
showed an abnormality in your small bowel that was not clearly
bleeding. Given your recent acute illness and fragile state and
the fact that your blood counts remained stable for several days
without any further blood products, further work up for this
abnormality was not done while you were in the hospital. You
should have follow up for this as an outpatient. In addition, it
is possible that you may have bleeding again in the future. This
will be monitored for at your rehab facility.
.
You had an episode of problems with your speech which your
daughter and yourself noticed. It is unclear whether this was a
small stroke but given previous problems with scanning and the
fact that blood thinning treatment (one of the main therapies in
stroke) coudl not be given due to your previous significant
bleeding meant taht we did not investigate further. Your speech
improved and had no problems with weakness or other features of
stroke following this episode.
.
Given your heart failure and some EKG changes noted during your
hospitalization, you were seen by a cardiologist. You had a
echocardiogram (heart ultrasound) which revealed changes to your
heart related to stress. These changes were minor and were felt
to be improving rather than progressing. In order to continue
this improvement it is most important that you maintain a normal
blood pressure.
.
You were also felt to be significantly low in mood and an
anti-depressant medication wa started - the need for this should
be reviewed by your PCP.
CHANGES TO YOUR MEDICATIONS:
1. INCREASE Atorvastatin to 80mg daily.
2. STOP Minoxidil.
3. STOP Ultram.
4. STOP Coumadin.
5. START Citalopram
Followup Instructions:
Department: WEST [**Hospital 2002**] CLINIC
When: WEDNESDAY [**2190-10-20**] at 9:30 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2540**], RN [**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: ORTHOPEDICS
When: FRIDAY [**2190-12-24**] at 2:40 PM
With: [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3260**], PA [**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: [**Hospital3 249**]
When: THURSDAY [**2190-10-14**] at 10:10 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3404**], MD [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: DIVISION OF GI
When: FRIDAY [**2190-11-12**] at 9:20 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
|
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"365.9",
"733.00",
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"410.71",
"584.9",
"588.0",
"585.4",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"45.23",
"93.90"
] |
icd9pcs
|
[
[
[]
]
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33146, 33236
|
22636, 31335
|
276, 320
|
33672, 33672
|
4369, 22613
|
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|
2868, 3065
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|
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|
31361, 32039
|
33857, 36611
|
3080, 4350
|
36640, 36754
|
221, 238
|
348, 955
|
33687, 33833
|
977, 2577
|
2593, 2852
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,602
| 104,262
|
40591
|
Discharge summary
|
report
|
Admission Date: [**2149-7-7**] Discharge Date: [**2149-7-14**]
Service: MEDICINE
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 1515**]
Chief Complaint:
worsening shortness of breath, severe aortic stenosis, here to
get corevalve
Major Surgical or Invasive Procedure:
corevalve [**2149-7-8**]
History of Present Illness:
Cardiac Surgeon: Dr. [**First Name (STitle) **] [**Name (STitle) **], MD
Cardiologist: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD
Referring Physician: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**], MD
PCP:[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD
Reason for Consult: severe aortic stenosis
Chief Complaint: worsening shortness of breath
HPI: 89 year old gentleman with history of severe aortic
stenosis
followed by serial echocardiograms. In [**Month (only) 205**] he had a lower
gastrointestinal bleed on coumadin and work-up revealed an
adenocarcinoma. Given his critical aortic stenosis, he underwent
an aortic valvuloplasty so that he could undergo a
hemicolectomy.
His valve area improved from 0.68cm2 to 0.82cm2. Postoperative
course was complicated by heparin induced thrombocytopenia. In
regards to his aortic stenosis, he continues to be symptomatic
with increasing fatigue over the last few months, shortness of
breath after going up 5 stairs, shortness of breath with walking
on an incline. He denies chest pain or lightheadedness. Family
reports a decline in his functional status. He was evaluated by
cardiac surgery and deemed to be of prohibitive extreme surgical
risk for conventional surgical AVR. After informed consent, he
was screened for Corevalve TAVR. He met all inclusion criteria
and did not meet exclusion criteria. He is admitted for
transfemoral TAVR procedure.
NYHA Class: III
Past Medical History:
Aortic stensosis
Atrial fibrillation (low dose warfarin due to hematuria)
Arthritis
RLE DVT
Peptic ulcer disease
Congestive Heart Failure
Rheumatoid arthritis (hands)
GERD
Adenocarcinoma of colon s/p resection
***Heparin Induced Thrombocytopenia***
Past Surgical History:
[**2148-6-22**] Left hemicolectomy with primary anastomosis
[**2148-6-21**] Aortic valvuloplasty
Active Medication list as of [**2149-7-7**]:
Medications - Prescription
FINASTERIDE - (Prescribed by Other Provider) - 5 mg tablet - 1
tablet(s) by mouth daily
FUROSEMIDE - (Prescribed by Other Provider) - 40 mg tablet - 3
tablet(s) by mouth daily 120mg daily
HERBAL LAXATIVE - (Prescribed by Other Provider) - - 2 tabs
daily
LISINOPRIL - (Prescribed by Other Provider) - 40 mg tablet - 1
tablet(s) by mouth daily
METOPROLOL SUCCINATE - (Prescribed by Other Provider) - 50 mg
tablet extended release 24 hr - 1 tablet(s) by mouth DAILY
(Daily)
OMEPRAZOLE - (Prescribed by Other Provider) - 20 mg
capsule,delayed release(DR/EC) - 1 Capsule(s) by mouth DAILY
(Daily)
POTASSIUM CHLORIDE [KLOR-CON 10] - (Prescribed by Other
Provider) - 10 mEq tablet extended release - 1 tablet(s) by
mouth daily
TAMSULOSIN - (Prescribed by Other Provider) - 0.4 mg
capsule,extended release 24hr - 1 Capsule(s) by mouth DAILY
(Daily)
WARFARIN [COUMADIN] - (Prescribed by Other Provider) - 4 mg
tablet - 1 tablet(s) by mouth Once Daily at 4 PM dose daily
based on INR goal of [**1-17**]
Medications - OTC
CALCIUM CARBONATE [ANTACID] - (Prescribed by Other Provider) -
200 mg calcium (500 mg) tablet, chewable - 1 Tablet(s) by mouth
three times a day
COENZYME Q10 [CO Q-10] - (Prescribed by Other Provider) - 300
mg capsule - 1 capsule(s) by mouth daily
--------------- --------------- --------------- ---------------
Allergies: HEPARIN AGENTS
Social History:
SOCIAL HISTORY: Lives with wife in one level home. Works at his
bowling alley 7 days/week x 53 years. Independent ADL's, drives.
Family History:
FAMILY HISTORY: Father deceased age 80's, CAD. Mother deceased
age [**Age over 90 **], sepsis. Brother deceased age 87, cirrhosis, CAD, DM.
Sons
x 4, alive and well.
Physical Exam:
Pulse: 68 (irreg)
B/P: 145/64
Resp: 22
O2 Sat: 100% (RA)
Temp: 97.5
Height: Weight: 62.9 kg
General: Alert pleasant elderly male in NAD at rest, vague at
times.
Skin: Color tan, skin warm and dry. Turgor fair.
HEENT: Normocephalic, thinning hair. Anicteric. EOMI's. Good
dentition, oropharynx moist.
Neck: supple, trachea midline, carotid bruit vs. referred murmer
Chest: Decreased bases, no whz, otherwise clear.
Heart: murmer RSB radiating throughout
Abdomen: soft, nontender, nondistended. (+)BS. New left soft
mass left groin c/w inguinal hernia. Prior well healed surgical
scar. No discoloration, nontender. 2+palp femoral pulses bilat.
No bruits. 1x2cm palpable ridge rt groin prior cath site area.
Extremities: 1+ lower extremity edemaleft, trace edema RLE. 2+
edema, tight fingers with decreased ROM c/w rheum arth.
Neuro: alert, pleasant, vague at times, denies pain, gait fairly
steady. Limited STM.
Pulses: palpable peripheral pulses.
Pertinent Results:
[**2149-7-7**] 12:00PM GLUCOSE-90 UREA N-22* CREAT-1.0 SODIUM-141
POTASSIUM-3.8 CHLORIDE-99 TOTAL CO2-33* ANION GAP-13
[**2149-7-7**] 12:00PM estGFR-Using this
[**2149-7-7**] 12:00PM ALT(SGPT)-13 AST(SGOT)-23 CK(CPK)-102 ALK
PHOS-67 TOT BILI-0.8
[**2149-7-7**] 12:00PM proBNP-2620*
[**2149-7-7**] 12:00PM ALBUMIN-4.3
[**2149-7-7**] 12:00PM WBC-5.4 RBC-4.03* HGB-12.3* HCT-36.7* MCV-91
MCH-30.4 MCHC-33.4 RDW-15.4
[**2149-7-7**] 12:00PM PLT COUNT-132*
[**2149-7-7**] 12:00PM PT-15.7* PTT-35.5 INR(PT)-1.5*
Cardiac Catheterization: Study Date [**2148-6-21**]
Interventional details
Crossed the aortic valve with a straight wire through a 5 French
[**Doctor Last Name **]-1 catheter. Advanced a 20 mm x 6 cm Tyshak balloon and
inflated while rapid ventricular pacing at 200 bpm to arrest the
heart. A single manual inflation was performed without
incident.
Peak to peak gradient decreased from 60 mm hg to 25 mm Hg
approximately with an increase in systemic blood pressure.
Assessment & Recommendations
1. No significant coronary disease
2. Sheath out when ACT <180 seconds
3. 8 Hours bed rest.
Echocardiogram: [**2149-6-12**] Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *4.9 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *7.4 cm <= 5.2 cm
Right Atrium - Four Chamber Length: *7.6 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: *1.4 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.4 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.7 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 50% >= 55%
Left Ventricle - Stroke Volume: 57 ml/beat
Left Ventricle - Cardiac Output: 3.17 L/min
Left Ventricle - Cardiac Index: *1.80 >= 2.0 L/min/M2
Left Ventricle - Lateral Peak E': 0.12 m/s > 0.08 m/s
Left Ventricle - Septal Peak E': *0.06 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': 11 < 15
Aorta - Sinus Level: 3.3 cm <= 3.6 cm
Aorta - Ascending: 2.8 cm <= 3.4 cm
Aorta - Arch: 2.9 cm <= 3.0 cm
Aortic Valve - Peak Velocity: *5.0 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *100 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 60 mm Hg
Aortic Valve - LVOT VTI: 18
Aortic Valve - LVOT diam: 2.0 cm
Aortic Valve - Valve Area: *0.4 cm2 >= 3.0 cm2
Aortic Valve - Pressure Half Time: 588 ms
Mitral Valve - E Wave: 1.0 m/sec
Mitral Valve - A Wave: 0.3 m/sec
Mitral Valve - E/A ratio: 3.33
Mitral Valve - E Wave deceleration time: 165 ms 140-250 ms
TR Gradient (+ RA = PASP): *38 mm Hg <= 25 mm Hg
Findings
LEFT ATRIUM: Marked LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Markedly dilated RA.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Mild symmetric LVH. Normal LV cavity
size. Low normal LVEF. No resting LVOT gradient.
RIGHT VENTRICLE: RV hypertrophy. Dilated RV cavity. RV function
depressed. [Intrinsic RV systolic function likely more depressed
given the severity of TR].
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in aortic root. Normal ascending aorta diameter.
Focal calcifications in ascending aorta. Normal aortic arch
diameter. Focal calcifications in aortic arch.
AORTIC VALVE: Severely thickened/deformed aortic valve leaflets.
Critical AS (area <0.8cm2). Moderate (2+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP.
Moderate mitral annular calcification. Mild thickening of mitral
valve chordae. Calcified tips of papillary muscles. No MS.
Moderate (2+) MR. [Due to acoustic shadowing, the severity of MR
may be significantly UNDERestimated.]
TRICUSPID VALVE: Normal tricuspid valve leaflets. Normal
tricuspid valve supporting structures. No TS. Moderate to severe
[3+] TR. Eccentric TR jet. Moderate PA systolic hypertension.
Given severity of TR, PASP may be underestimated due to elevated
RA pressure.
PERICARDIUM: No pericardial effusion.
Conclusions
The left atrium is markedly dilated. The right atrium is
markedly dilated. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. Overall
left ventricular systolic function is low normal (LVEF 50%). The
right ventricular free wall is hypertrophied. The right
ventricular cavity is dilated with depressed free wall
contractility. [Intrinsic right ventricular systolic function is
likely more depressed given the severity of tricuspid
regurgitation.] There are focal calcifications in the aortic
arch. The aortic valve leaflets are severely thickened/deformed.
There is critical aortic valve stenosis (valve area 0.4 cm2). At
least moderate (2+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Moderate (2+) mitral regurgitation is seen. [Due to
acoustic shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] Moderate to severe [3+] tricuspid
regurgitation is seen. The tricuspid regurgitation jet is
eccentric and may be underestimated. There is at least moderate
pulmonary artery systolic hypertension. [In the setting of at
least moderate to severe tricuspid regurgitation, the estimated
pulmonary artery systolic pressure may be underestimated due to
a very high right atrial pressure.] There is no pericardial
effusion.
EKG:
CT Scan : ([**2149-6-12**])
FINDINGS:
CT CHEST: Airways are patent to the subsegmental level
bilaterally. Bilateral subpleural interstitial opacities are
noted, most likely representing nonspecific interstitial lung
disease. No masses or consolidations to suggest infectious
process or neoplasm is demonstrated. Small amount of left
pleural effusion is present.
Degenerative changes are present in the thoracic spine but no
lytic or sclerotic lesions worrisome for infection or neoplasm
is demonstrated.
No mediastinal, hilar or axillary pathologically enlarged
lymph nodes are present.
Pulmonary artery is substantially enlarged up to 4.2 cm with
also enlargement of the right, 3 cm, and left, 2.7 cm arteries,
highly suspicious for pulmonary hypertension.
No pericardial effusion is present.
CT ABDOMEN: Liver, gallbladder, spleen, adrenals and kidneys are
unremarkable. There is no evidence of bowel wall dilatation or
bowel wall thickening. The patient is after transverse colon
surgery.
CT PELVIS: Inguinal hernia containing a most likely small bowel
loop is noted without strangulation. Substantially enlarged
prostate is demonstrated, approaching 7 x 8 cm in diameter.
Minimal amount of free pelvic fluid is noted, origin unclear.
Irregularity in the wall of the bladder are demonstrated,
potentially might be related to hypertrophy, but dedicated
imaging with ultrasound is required.
No lytic or sclerotic lesions are noted in the imaged portion
of the skeleton in abdomen and pelvis. Extensive degenerative
changes are seen.
Small pericardial effusion is present.
Coronary arteries have conventional origin.
Assessment of aortic valve demonstrate the following parameters:
diameter 22.7 x 29.8mm, perimeter 110mm.
Aorta is calcified with focal aneurysmatic dilatation at the
level of the aortic arch. No aneurysmatic dilatation of the
aorta throughout is demonstrated.
Substantial dilatation of celiac trunk is demonstrated up to
12 cm,
aneurysmatic.
Abdominal aorta is tortuous. There is also tortuosity of both
iliac arteries noted. Iliac vessels are patent.
Diameter of the peripheral axis are as following: right common
iliac artery 12.1*14.6mm, right external iliac artery
9.1*11.1mm, right superficial femoral artery 6.3*8.9mm; left
common iliac artery 10.8*13.7mm, left external iliac artery
10.6*8.8mm, left superficial femoral artery 9.3*7.9mm.
IMPRESSION:
1. CT criteria worrisome for pulmonary hypertension.
2. Extensive coronary and aortic valve calcifications
consistent with known aortic stenosis. Mild cardiomegaly.
3. Dilated celiac artery up to 12 cm.
4. Inguinal hernia containing small bowel loop with no current
evidence of obstruction.
5. Substantial enlargement of the prostate. Questionable
irregularity of the bladder wall, correlation with ultrasound is
required.
PFT's: ([**2149-6-12**])
FEV1 2.10L/102%, DLCO 78%
Carotid dopplers: ([**2149-6-12**])
Impression: Right ICA <40% stenosis.
Left ICA <40% stenosis.
LV diastolic dysfunction
Grade: [ ] None [ ] I [ ] II [ ] III [ ] IV
Chest wall deformity Yes [ ] No [x]
History of IE Yes [ ] No [x]
Peripheral vascular disease Yes [ ] No [x]
Cirrhosis of Liver Yes [ ] No [x]
If yes, Child [**Doctor Last Name 14477**] Score A [ ] B [ ] C [ ]
History of anemia req transfusion Yes [x] No [ ]
Ulcer disease Yes [ ] No [x]
Connective tissue disease Yes [ ] No [x]
Hostile mediastinum Yes [ ] No [x]
Immunosuppressive therapy Yes [ ] No [x]
Previous Cardiac Surgery?: NO
Previous Balloon Valvuloplasty?: BAV ([**2148-6-21**])
Permanent Pacemaker/ICD in-situ?: none
Brief Hospital Course:
89 year old gentleman with history of severe aortic stenosis,
atrial fibrillation on low dose coumadin, systolic CHF (EF
45-50%), h/o DVT, HIT, GI bleed on coumadin and colon CA s/p
resection came to [**Hospital1 18**] for a corevalvae for severe aortic
stenosis.
# Severe aortic stenosis: [**Location (un) 109**] 0.4cm2, peak gradient 60mmHg prior
to corevalve. Currently doing well following surgery, no
evidence of perivalvular leak or other complications. The
corevalve procedure was uncomplicated (please see the results
section for detail on the procedure) He was extubated the
evening after the procedure. He was monitored very closely and
was placed on the corevalve protocol. He was on neosynephrine
the day after the procedure but that was discontinued the next
day. Patient had a relatively benign post-op course and was
transferred down to the cardiology floor for further monitoring
until discharge. He was discharged on an increased dose of
Metoprolol succinate 100 mg daily and a decreased dose of
Lisinopril 10 mg daily (from 40 mg). His lasix 120 mg daily was
also held as patient was euvolemic during hospital course after
the procedure. [**7-10**] echo showed trace paravalvular aortic
valve leak is present. This will be followed up in the
outpatient setting with Dr [**Last Name (STitle) **].
# Bradycardia: Noted to have bradycardia in the 30s prior to
corevalve placement, so opted to have permanent pacemaker placed
during corevalve procedure.We gave him cefazolin 2g IV q8H for 3
days as per protocol for placing a pacemaker. Post op xray
confirmed correct placement of the pacemaker leads. No further
issues of bradycardia during post-op course
# Chronic diastolic and systolic heart failure: most recent EF
40% on TEE . Pt's CHF was well controlled and he did not
require lasix. Lisinopril management as above. As above, lasix
is being held.
# Atrial fibrillation: At home he is rate controlled with
metoprolol and anticoagulated with coumadin at home. His
metoprolol was held at first and then we started him back on it.
We gave him PO 50 metoprolol TID. We also gave him
IV metoprolol 2.5mg boluses PRN for HR >100 though when his PO
metoprolol dose was increased heh no longer needed those doses.
He was successfully bridged back to coumadin and is being
discharged on 5 mg daily. INR upon discharge was 1.7.
# Hematuria: Patient had hematuria after Foley placement.
Urology consulted and felt this was from the foley. Hematuria
resolved in on [**2149-7-10**].
#Anemia: Ht dropped from 31 to 26 on the second day of hospital
stay after the procedure. We felt this was most likely from some
blood loss from the procesure as well as from his hematuria.
Differential included: blood loss from hematuria vs hemolytic
anemia from corevalve causing shearing of RBCs vs GIB (though he
has adenocarcinoma s/p colectomy GIB unlikely bc he did not have
bowelmovements) vs TTP (he did have low platlets as well however
his kidney function, mental status were fine he has no fever
either). There may also be a hemodiltuion effect bc he is net
positive 3L since he has been and his platelets are also lowWe
did not transfuse as he was not symptomatic and his Ht was
stable. No recurrent signs of acute anemia.
#Thrombocytopenia: Platelets were 83 dropped from 101. Most
likely from blood loss from the procedure. Also considered was
shearing pletlets and RBCs from new corevalve. He has h/o HIT
however he was not been given any heparin, not even heparin
flushes while in house. He was not been given thiazides or sulfa
medications which are also known to cause HIT. Pt has no known
liver disease, normal LFTs. We continued to monitor his platlets
and there was no further acute drop
# H/o HIT: Bivalrudin used in the peri-op period rather than
heparin, however it was stopped. Patient was given no heparin
products while here. He was given plavix and ASA as dual
antiplatelets
CHRONIC ISSUES:
#BPH: patients tamsulosin was restarted soon after the procedure
#GERD: continued omeprazole
TRANSITIONAL ISSUES:
# patient will follow up with Dr [**Last Name (STitle) **] regarding how he is doing
post-corevalve.
# Discharged on lower dose of lisinopril than admitted with.
(40-->10mg). Needs cardiology f/u for uptitration
# Also needs f/u for his lasix 120 mg daily that was being held
in the hospital. He was discharged without a current dose
#[**7-10**] echo (post corevalave) showed trace paravalvular aortic
valve leak is present. This will be followed up in the
outpatient settingwith Dr [**Last Name (STitle) **]
Medications on Admission:
FINASTERIDE - (Prescribed by Other Provider) - 5 mg tablet - 1
tablet(s) by mouth daily
FUROSEMIDE - (Prescribed by Other Provider) - 40 mg tablet - 3
tablet(s) by mouth daily 120mg daily
HERBAL LAXATIVE - (Prescribed by Other Provider) - - 2 tabs
daily
LISINOPRIL - (Prescribed by Other Provider) - 40 mg tablet - 1
tablet(s) by mouth daily
METOPROLOL SUCCINATE - (Prescribed by Other Provider) - 50 mg
tablet extended release 24 hr - 1 tablet(s) by mouth DAILY
(Daily)
OMEPRAZOLE - (Prescribed by Other Provider) - 20 mg
capsule,delayed release(DR/EC) - 1 Capsule(s) by mouth DAILY
(Daily)
POTASSIUM CHLORIDE [KLOR-CON 10] - (Prescribed by Other
Provider) - 10 mEq tablet extended release - 1 tablet(s) by
mouth daily
TAMSULOSIN - (Prescribed by Other Provider) - 0.4 mg
capsule,extended release 24hr - 1 Capsule(s) by mouth DAILY
(Daily)
WARFARIN [COUMADIN] - (Prescribed by Other Provider) - 4 mg
tablet - 1 tablet(s) by mouth Once Daily at 4 PM dose daily
based on INR goal of [**1-17**]
Medications - OTC
CALCIUM CARBONATE [ANTACID] - (Prescribed by Other Provider) -
200 mg calcium (500 mg) tablet, chewable - 1 Tablet(s) by mouth
three times a day
COENZYME Q10 [CO Q-10] - (Prescribed by Other Provider) - 300
mg capsule - 1 capsule(s) by mouth daily
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Docusate Sodium 100 mg PO BID
do not give if he has diarrhea
3. Finasteride 5 mg PO DAILY
4. Lisinopril 10 mg PO DAILY
5. Metoprolol Succinate XL 100 mg PO DAILY
please hold for SBP<100 and HR<60
6. Omeprazole 20 mg PO DAILY
7. Tamsulosin 0.4 mg PO HS
8. Warfarin 5 mg PO DAILY16
INR goal 2-2.5
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 701**] VNA
Discharge Diagnosis:
Severe aortic stenosis s/p corevalve and permanent pacemaker
placement
Chronic systolic and diastolic heart failure
Atrial Fibrillation
Hyperlipidemia
Hematuria on high dose anticoagulation therapy
HIT- heparin induced thrombocytopenia [**2147**]
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Last Name (Titles) 88841**],
You were admitted to the hospital for a "core valve" procedure.
This procedure allowed your cardiologist to place a new aortic
valve in your heart by a transcatheter percutaneous approach.
You also received a permanent pacemaker which ensures your heart
rate does not go too slow. You had a smooth post-operative
course and we moved you down to the main cardiology floor from
the CCU. The following changes to your medications have been
made
1. Metoprolol Succinate has been INCREASED to 100 mg daily, from
50 mg daily
2. Lisinopril has been DECREASED from 40 mg daily to 10 mg daily
3. Furosemide has been STOPPED for now. You will follow up with
your cardiologist regarding resuming this medication
It has been a pleasure taking care of you while at [**Hospital1 18**] Mr.
[**Known lastname 70820**]
Followup Instructions:
Department: CARDIAC SERVICES
When: FRIDAY [**2149-7-18**] at 2:00 PM
With: DEVICE CLINIC [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: ECHO LAB
When: WEDNESDAY [**2149-8-13**] at 10:00 AM
With: ECHOCARDIOGRAM [**Telephone/Fax (1) 62**]
Building: GZ [**Hospital Ward Name **] BUILDING (FELBEERG/[**Hospital Ward Name **] COMPLEX) [**Location (un) 1951**]
Campus: EAST Best Parking: Main Garage
Department: CARDIAC SERVICES
When: WEDNESDAY [**2149-8-13**] at 11:00 AM
With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Your Primary Care Physicians office will be calling you at home
with an appointment, if you have not heard in two days please
call their office.
Name: [**First Name11 (Name Pattern1) 488**] [**Last Name (NamePattern4) 10541**], MD
Specialty: Primary Care
Location: [**Hospital **] MEDICAL GROUP-[**Location (un) 8720**] CARDIOLOGY
Address: 15 [**Doctor Last Name 8721**] BROTHERS WAY, [**Location 8723**],[**Numeric Identifier 8724**]
Phone: [**Telephone/Fax (1) 8725**]
Your Primary Care Physicians office will be calling you at home
with an appointment, if you have not heard in two days please
call their office.
|
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18,659
| 165,752
|
8151+55916
|
Discharge summary
|
report+addendum
|
Admission Date: [**2113-1-14**] Discharge Date: [**2113-1-24**]
Service: MEDICINE
Allergies:
Zestril / Lipitor
Attending:[**First Name3 (LF) 6114**]
Chief Complaint:
Fever, hypotension. Transfer from [**Hospital3 7571**]Hospital.
Major Surgical or Invasive Procedure:
Central venous line placement (femoral)
PICC line insertion
Transesophageal echocardiogram
History of Present Illness:
89 year-old male with CAD s/p CABG, a fib on Coumadin,
cryptogenic cirrhosis, DM type 2, and myelodysplastic syndrome
with pancytopenia, with recent history of enterococcus UTI and
bacteremia ([**2112-12-18**]) at OSH complicated by presumed subacute
endocarditis ([**2113-1-4**], TEE negative at OSH), recently
discharged on [**1-12**] from OSH to rehabilitation center with PICC
in right arm with plan to complete a total of 4 weeks of Amp and
Gent.
On [**1-13**] at NH, patient developed recurrent fever to 100.6, +SOB
with saturation 92% RA. He was given Vancomycin 1 gm IV X1 and
transferred to [**Location (un) **] ED where BP 88/57. A dopamine infusion
was initiated. A CXR was consistent with CHF, with BNP 1090 and
patient was given Lasix 80 mg IV X1. He was subsequently
transferred to the [**Hospital1 18**] ED for further care, where BP initially
70/40 on 5 mcg/kg/min of dopamine.
In the ED, blood cultures were sent. A bedside echo was
performed and showed no pericardial effusion. On ROS, +SOB, +
cough productive of white sputum. + chills at OSH. The patient
was admitted to the MICU.
Past Medical History:
1. CAD s/p CABG in [**2098**]
2. DM type 2 on Prandin
3. Chronic atrial fibrillation on Coumadin
4. Myelodysplastic syndrome with pancytopenia (not transfusion
dependent)
5. Cryptogenic cirrhosis diagnosed by biopsy
6. Chronic renal insufficiency with [**Year (4 digits) 5348**] creatinine 2.0
7. Hyperlipidemia
8. H/O CHF, query diastolic dysfunction (normal EF)
9. Enteroccus UTI and bacteremia ([**2112-12-18**]), complicated by
presumed enterococcus endocarditis ([**2113-1-4**]).
Social History:
He lives in [**Location **] (MA) with his wife. Remote ex-smoker, with
10 pack-year smoking history. He quit in [**2070**], No EtOH
consumption.
Family History:
Non-contributory.
Physical Exam:
Per admission note on [**2112-1-14**].
VS: 98.7, 117/85, HR 87, R 18, 96% 2L
Gen: NAD, very pleasant
HEENT: EOMI, O/P clear
Neck: Supple, JVP at 8cm
Chest: Scattered rhonchi, wheezes, crackles at bases bilaterally
CV: RRR, 3/6 SEM that radiates to clavicle and carotid
Abd: Soft, distended, NT, + BS
Ext: No edema, 2 PIV
Neuro: A and O X 3, moves all 4 extremities
Pertinent Results:
Relevant laboratory data on admission:
CBC:
[**2113-1-14**] WBC-2.8* RBC-2.61* HGB-9.7* HCT-28.7* MCV-110*
RDW-15.5 PLT -102 (NEUTS-83* BANDS-2 LYMPHS-5* MONOS-9 EOS-0
BASOS-1 ATYPS-0 METAS-0)
Coagulation profile:
PT-17.4* PTT-37.8* INR(PT)-1.9
Chemistry:
GLUCOSE-119* UREA N-37* CREAT-1.8* SODIUM-138 POTASSIUM-3.4
CHLORIDE-100 TOTAL CO2-33* ANION GAP-8 CALCIUM-8.3*
PHOSPHATE-3.4 MAGNESIUM-2.1
ALT-34 AST-61* CK(CPK)-303* AlkPhos-148* Amylase-128*
TotBili-2.1*
LACTATE-2.2*
RANDOM CORTISOL 17.5
Cardiac enzymes:
[**2113-1-14**] 02:10AM CK-MB-4 c TropnT-0.09*
[**2113-1-14**] 03:28PM CK-MB-6 cTropnT-0.08*
[**2113-1-15**] 04:23AM CK-MB-5 cTropnT-0.07*
[**2113-1-16**] 06:11AM cTropnT-0.06*
Urinalysis:
[**2113-1-14**] 02:10AM BLOOD-MOD NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG
KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG
URINE RBC-0-2 WBC-0 BACTERIA-RARE YEAST-NONE EPI-1
EKG: Atrial fibrillation. Probable old septal infarct.
Inferior/lateral T changes are nonspecific. Repolarization
changes may be partly due to rhythm. Since previous tracing, no
significant change.
CXR: The cardiac contour is somewhat rounded, but normal in
size. Mediastinal contours are normal. There is slight blunting
of both costophrenic angles with minor atelectatic changes seen
at the lung bases. There is no focal consolidation. Pulmonary
vasculature appears slightly prominent, but there is no CHF. The
patient is post CABG with median sternotomy wires and clips seen
in the mediastinum. The osseous structures are unremarkable.
IMPRESSION:
Slight blunting of the costophrenic angles. No definite CHF. No
pneumonia.
Relevant data in hospital:
TEE [**2113-1-16**]:
1. 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.
2. Left ventricular wall thicknesses and cavity size are normal.
Left
ventricular function is normal (LVEF 60-65%).
3. Right ventricular chamber size and free wall motion are
normal.
4.There are simple atheroma in the ascending aorta, in the
aortic arch, and in the descending thoracic aorta.
5.The aortic valve leaflets are severely thickened/deformed. No
masses or
mobile vegetations are seen on the aortic valve, however cannot
exclude a
sessile vegetation (the valve leaflets are severely calcified).
No aortic
valve abscess is seen. There is probably moderate aortic valve
stenosis
(recommend transthoracic echo for complete evaluation of the
aortic stenosis if clinically indicated). Trace aortic
regurgitation is seen.
6. The mitral valve leaflets are moderately thickened. No mass
or vegetation is seen on the mitral valve. Moderate to severe
(3+) mitral regurgitation is seen.
7.The tricuspid valve leaflets are mildly thickened. Moderate
[2+] tricuspid regurgitation is seen.
8.There is no pericardial effusion. No prior strudy available
for comparison.
[**2113-1-17**]: LIMITED ABDOMEN ULTRASOUND: There is a tiny amount of
fluid adjacent to the liver. There are no loculated fluid
collections.
Brief Hospital Course:
89 year-old male with MMP including CAD, atrial fibrillation on
Coumadin, and recent admission to OSH with enterococcus fecalis
UTI and bacteremia, complicated by presumed enteroccus
endocarditis (negative TEE but recurrent positive blood cultures
and ongoing fever), treated with Ampicillin IV (1 gm IV q 6
hours) and Gentamicin IV (started on [**2113-1-5**]), now admitted
with fever, hypotension and respiratory symptoms. His hospital
course will be reviewed by problems.
1) Hypotension/fever: Given the hypotension in the setting of
recurrent fever and recent enterococcal bacteremia, the most
likely etiology was felt to be septic shock +/- cardiogenic
component. A bedside echo on admission showed relatively
preserved EF, no pleural effusion. It was unclear whether his
fever/hypotension were related to persistent enterococcal
infection or a new nosocomial infection. CXR was without PNA and
U/A clear. Cultures sent. Given concern over potential line
infection, PICC line was D/C'd on admission. The antibiotic
regimen was changed to Vancomycin IV and Gentamycin IV for Rx of
enterococcus +/ line infection. The patient was quickly weaned
off Dopamine in the ICU, and was transferred to the floor on
[**2113-1-15**].
All cultures at [**Hospital1 18**] were unremarkable. However, Mr. [**Known lastname **]
continued to spike fever up to 102.3 on Vancomycin and
Gentamicin. A repeat TEE was performed on [**2113-1-16**], which
revealed normal LVEF 60-65%, and no vegetation although a
sessile vegetation could not be ruled out given severe
calcification of aortic valve. Probable moderate AS, trace AR,
moderate to severe MR (mild MR in [**2111**]), moderate TR. An
abdominal U/S was also performed, which revealed a small amount
of ascites and no fluid collection. ID was consulted. Given his
respiratory symptoms, Levofloxacin 500 mg PO QD was added to
cover for pulmonary organisms. A nasal wash was also sent to
rule out Influenza, which came back positive for Influenza A. In
retrospect, his acute presentation was felt likely secondary to
Influenza. Given the duration of his symptoms and clinical
improvement, decision was taken not to treat. He was kept on
droplet precautions in hospital (D/C'd on [**2113-1-24**]).
Levofloxacin D/C'd on [**2113-1-20**]. Respiratory symptoms resolved at
the time of discharge. Intermittent wheezing in hospital, kept
on Albuterol and Ipratropium nebs prn.
Of note, sensitivities were repeated on the OSH isolate and
Ampicillin sensitivity was confirmed, MIC <=2. Antibiotics were
changed back to Ampicillin 1 gm IV q 6 hours, and Gentamicin 80
mg IV q 48 hours (dose adjusted according to levels and
creatinine) on [**2113-1-20**]. Ampicillin increased to 2 gm IV q 8
hours on [**2113-1-23**] after discussion with ID team. Plan is to
complete 6 weeks of therapy with Ampicillin and Gentamicin (last
doses on [**2113-2-16**]). PICC line in place. Will need Gentamicin
levels every 4th day (goal peak=3, trough=1). Hold Gentamicin if
creatinine >2.5.
2) CHF: Lasix and spironolactone were held on admission given
hypotension, restarted on [**2113-1-15**]. CXRs in hospital revealed
progressive fluid overload, and Lasix dose was titrated up to
maintain negative fluid balance. Per patient's wife, out-patient
Lasix dose is 160 mg PO QAM and 120 mg PO QPM. On Lasix 80 mg PO
BID at discharge, with goal to titrate to even to negative fluid
balance as an out-patient. [**Date Range **] weight 140lbs. Low threshold
to increase Lasix if increasing edema on exam, or >=3lbs weight
gain as creatinine tolerates.
3) CAD: Troponin 0.09 (peak) on admission, felt likely troponin
leak in the setting of infection and renal failure. EKG without
acute ischemic changes. In hospital, he was continued on
Metoprolol and ASA. History of adverse reaction to ACE. Also
continued on Zetia for hyperlipidemia.
4) Atrial fibrillation: Metoprolol initially held in the setting
of hypotension, restarted as BP tolerated. Good rate control on
25 mg PO BID. Patient also continued on Coumadin, with goal INR
[**2-16**]. Coumadin dose decreased to 1 mg PO QHS given elevated INR
in hospital (out-patient dose 2mg PO QHS). INR 2.0 Will need
close monitoring at rehab.
5) Diabetes mellitus type 2: Poor glycemic control in hospital.
Prandin was held, and he was started on Glargine at night,
titrated up to 9 units QHS, along with RISS, with plan to manage
on Glargine as an out-patient. Patient will need teaching at
rehab center. Would not restart Prandin.
6) MDS with pancytopenia: Per patient's PCP, [**Name10 (NameIs) 5348**] Hct around
32-33. While in hospital, patient transfused a total of 3 units
of PRBCs to maintain Hct >30 given known CAD. Platelets stable
in low 100K, and WBC around [**Name10 (NameIs) 5348**] of 3.
7) Chronic renal insufficiency: Creatinine around [**Name10 (NameIs) 5348**] of 2
in hospital, slightly higher on [**2113-1-23**] at 2.2. Gentamicin
levels monitored carefully in hospital given risk of
nephrotoxicity and ototoxicity. Patient will need Gentamicin
levels q 4 days, with goal peak=3 and trough=1. Plan to D/C
Gentamicin if creatinine >=2.5.
8) Cryptogenic cirrhosis: Patient continued on spironolactone
and Lactulose in hospital. Of note, patient noted to have mild
elevation of alkaline phosphatase, total bilirubin and GGT in
hospital, also elevated at OSH. Abdominal U/S at OSH negative
for CBD dilatation, no GB wall thickening, no pericholecystic
fluid. No acute issues in hospital.
9) Prophylaxis: On Coumadin, protonix (history of PUD) and bowel
regimen in hospital.
Code: DNR/DNI per discussion with patient and family.
Medications on Admission:
Meds on transfer from MICU:
Coumadin 2 mg PO qD
Lasix 80 mg IV qD
Spironolactone 25 mg PO qD
Gentamicin 120 mg IV qD (D2)
Lacutlose 30 mg PO TID
Vancomycin 1 g IV qD (D2)
Dulcolax 10 mg PO/PR prn
Senna prn
Atrovent neb q 6h
Albuterol neb q 6h prn
ASA 325 mg PO qD
Zetia 10 mg PO qD
Colace 100 mg PO BID
Folate 1 mg PO qD
MVI 1 PO qD
Protonix 40 mg PO qD
Celexa 10 mg PO qD
RISS
Tylenol prn
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Citalopram Hydrobromide 20 mg Tablet Sig: 0.5 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. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q6HRS: PRN as needed for shortness of breath or
wheezing.
10. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6HRS: PRN as needed for shortness of breath or
wheezing.
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
13. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
15. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day): Titrate to 2 BM per day.
16. Warfarin Sodium 1 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime): Please monitor daily INR until stable.
17. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): Please monitor daily weight. .
18. Gentamicin in Normal Saline 80 mg/50 mL Piggyback Sig:
Eighty (80) mg Intravenous Q48H (every 48 hours): Please hold
dose on [**2113-1-24**].Check daily creatinine; if stable or
decreasing, then resume dose q48 hours on [**2113-1-26**]. Please check
Gentamicin levels every 4th day (every 2 doses). Last doses on
[**2113-2-16**].
19. Ampicillin Sodium 2 g Recon Soln Sig: One (1) Recon Soln
Injection Q8H (every 8 hours): Please give 2 gm IV q8 hours.
Last doses on [**2113-2-16**].
20. Insulin Glargine 100 unit/mL Solution Sig: Nine (9) units
Subcutaneous at bedtime.
21. Regular insulin sliding scale
[**Hospital1 **]
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 25759**] & Rehab Center - [**Location (un) **]
Discharge Diagnosis:
Primary diagnoses:
Influenza A
Probable enterococcus endocarditis
Coronary artery disease
Atrial fibrillation
Congestive heart failure
Diabetes mellitus type 2
Myelodysplastic syndrome
Chronic renal insufficiency
Secondary diagnoses:
Cryptogenic cirrhosis
Hyperlipidemia
Discharge Condition:
Patient discharged to rehab facility in stable condition.
Discharge Instructions:
Patient will need follow-up with PCP (Dr. [**Last Name (STitle) 29032**] after D/C from
rehab facility. Please arrange follow-up appointment prior to
D/C.
Followup Instructions:
Please arrange follow-up with Dr. [**Last Name (STitle) 29032**] (PCP) prior to D/C from
rehab.
Completed by:[**2113-1-24**] Name: [**Known lastname 5077**],[**Known firstname 5078**] Unit No: [**Numeric Identifier 5079**]
Admission Date: [**2113-1-14**] Discharge Date: [**2113-1-24**]
Date of Birth: [**2023-10-9**] Sex: M
Service: MEDICINE
Allergies:
Zestril / Lipitor
Attending:[**First Name3 (LF) 1513**]
Addendum:
Principal diagnoses:
Sepsis due to Influenza A
Septic shock
Pneumonia
Probable enterococcus endocarditis
Additional diagnoses:
Coronary artery disease
Atrial fibrillation
Congestive heart failure
Diabetes mellitus type 2
Myelodysplastic syndrome
Chronic renal insufficiency
Cryptogenic cirrhosis
Hyperlipidemia
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 5025**] & Rehab Center - [**Location (un) **]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1514**] MD [**MD Number(2) 1515**]
Completed by:[**2113-3-29**]
|
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"250.00"
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icd9cm
|
[
[
[]
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[
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icd9pcs
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,483
| 122,617
|
33764
|
Discharge summary
|
report
|
Admission Date: [**2124-6-22**] Discharge Date: [**2124-7-6**]
Date of Birth: [**2048-2-29**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2836**]
Chief Complaint:
Major GI Bleed
Major Surgical or Invasive Procedure:
splenic artery pseudoaneurysm embolization [**6-23**].
unclogging of J tube in IR [**7-4**]
IVC filter placement [**7-4**]
PICC line placement [**7-4**]
History of Present Illness:
The patient is a 76 year-old man well known to the surgical
service following a prolonged admission from [**Month (only) 956**] until
[**2124-3-14**] with necrotizing pancreatitis.
He was then readmitted 4 times since discharge in early [**Month (only) 547**] --
once for a biliary leak, once for hypotension presumably related
to pneumonia and once with fever also related to pneumonia. He
was most recently admitted [**Date range (1) 78093**] for melena. He had an
EGD on [**5-19**] which demonstrated a nonbleeding erosion in the
second
portion of the duodenum, otherwise normal. Repeat EGD on [**2124-5-20**]
for hypotension and hematochezia found a clot adherent to GJ
tube
in stomach, but no other source of bleeding. Angiogram was
performed and was negative. His PTC was exchanged. He then
developed hematemesis, hematochezia, hypotension, and
desaturation requiring intubation and pressors. Repeat
angiogram
demonstrated a thrombosed GDA, but no source of bleed. He then
developed ARDS requiring bilateral pigtail catheters and broad
spectrum antibiotics. His PTC was again changed, as well as his
GJ tube. He could not be weaned from the vent and a
tracheostomy
was done and he was transferred to a vent rehab on [**2124-6-19**].
On [**2124-6-21**] at 8pm he developed hematochezia and was tranferred to
[**Hospital3 7362**]. He had a second episode of hematochezia as well
as hemetemesis, and GI performed an EGD overnight that
demonastrated a large clot in his fundus and stomach but they
were unable to locate a bleeding site. He then underwent
angiography which was unrevealing. On the morning on [**6-22**] he
become hypotensive to SBP's 30s and had a near code transiently
requiring pressors. He was rescoped and again they found oozing
with clot in stomach as well as a healing stomach ulcer, normal
esophagus and duodenum. He continued to have gross blood from G
tube port (per nursing transfer report, J tube mainly draining
yellow bilious fluid) and had received 7 units PRBCs and was
transferred to [**Hospital1 18**] for further stabalization and potential
surgical intervention.
Upon arrival to [**Hospital1 18**] the patient was intubated, sedated, with
gross blood coming out of his GJ tube.
Past Medical History:
PMH: gallstone pancreatitis, necrotizing pancreatitis, CAD s/p
MI (15 years ago), HTN, hyperlipidemia, obesity, OA, BPH,
duodenal ulcer, DM, atrial fibrillation, pneumonia, GI Bleed
PSH: open trach ([**2124-2-4**]), open G/J tube placement ([**2124-2-11**],
percutaneous cholecystostomy tube ([**2124-2-17**]), open subtotal
cholecystectomy ([**2124-4-2**]), internal-external biliary drain
placement ([**2124-4-7**]), drain upsizing ([**2124-4-13**]), replacement of
PTBD with biliary stent/pigtail ([**2124-4-27**]),
b/l TKR (most recently R [**2124-1-5**])
Social History:
Being admitted from rehab. Previously lived with 2nd wife. [**Name (NI) **]
a daughter and 4 sons. Quit smoking 15 yrs ago. No history of
alcohol or IVDU. Retired contractor.
Family History:
Parents - HTN
Mother - CVA
Physical Exam:
VS: 110/80, 80, 100% on AC 500/12/5/0.7
GEN: intubated, sedated
HEENT: anicteric
CVS: RRR, nl s1s2, no m/r/g
LUNGS: CTAB anteriorly
ABD: Distended, + BS, GJ tube in place draining blood, right
flank PTC clean/dry/intact.
EXT: edema
Pertinent Results:
[**2124-7-3**] 01:44AM BLOOD WBC-13.7* RBC-3.27* Hgb-9.9* Hct-29.5*
MCV-90 MCH-30.2 MCHC-33.4 RDW-15.7* Plt Ct-198
[**2124-6-22**] 03:24PM BLOOD WBC-26.8*# RBC-4.29*# Hgb-12.8*#
Hct-35.9*# MCV-84# MCH-29.7 MCHC-35.5* RDW-15.0 Plt Ct-218
[**2124-7-3**] 01:44AM BLOOD Glucose-143* UreaN-10 Creat-0.4* Na-142
K-3.8 Cl-108 HCO3-28 AnGap-10
[**2124-6-22**] 03:24PM BLOOD Glucose-210* UreaN-27* Creat-0.7 Na-138
K-4.4 Cl-108 HCO3-21* AnGap-13
[**2124-6-22**] 03:24PM BLOOD ALT-19 AST-18 CK(CPK)-16* AlkPhos-79
Amylase-39 TotBili-1.1
[**2124-6-22**] 03:24PM BLOOD Lipase-27
[**2124-6-28**] 01:58AM BLOOD CK-MB-NotDone cTropnT-0.03*
[**2124-7-3**] 01:44AM BLOOD Albumin-2.3* Calcium-7.9* Phos-2.7 Mg-1.9
Iron-37*
[**2124-6-22**] 03:24PM BLOOD Albumin-2.5* Calcium-7.9* Phos-5.2*
Mg-2.0
[**2124-7-3**] 01:44AM BLOOD calTIBC-113* Ferritn-1129* TRF-87*
[**2124-7-3**] 01:44AM BLOOD Triglyc-130
[**2124-6-29**] 04:13AM BLOOD Digoxin-0.7*
.
EGD [**2124-6-22**]
Impression: Blood in the esophagus
Blood in the stomach
Blood in the first part of the duodenum and second part of the
duodenum
Otherwise normal EGD to second part of the duodenum
Recommendations: Please continue to follow serial HCTs.
If aggressively bleeds, pursue angiography for embolization.
Please administer IV erythromycin to help with gastric motility.
Will consider rescope tomorrow to see if clot displaced and
further visualization of the stomach is possible.
.
GI BLEEDING STUDY Clip # [**Clip Number (Radiology) 78094**]
Reason: 76 YR OLD MAN WITH GI BLEED/ LOCATION OF GI BLEED
IMPRESSION:
Abnormal collection of tagged RBCs in the left upper quadrant,
likely stomach, first appearing at 100 minutes.
.
Radiology Report [**Numeric Identifier 78095**] MOD SEDATION, EACH ADDL 15 MIN. Study
Date of [**2124-6-23**] 12:45 PM
MESSENERTIC IMPRESSION: Arteriogram demonstrating the presence
of a pseudoaneurysm at the proximal portion of the splenic
artery with extravasation of contrast material likely into a
pseudocyst.
Uncomplicated embolization of the splenic pseudoaneurysm with
coils and
thrombin until no flow was observed.
Uncomplicated prophylactic embolization of the left gastric
artery with
Gelfoam slurry.
.
Radiology Report RENAL U.S. PORT Study Date of [**2124-6-24**] 11:44 AM
RENAL ULTRASOUND: The right kidney measures 11.3 cm and the left
kidney
measures 11.3 cm, with no hydronephrosis, masses, or stones. The
Foley
catheter is presumably within the decompressed bladder, though
definitive
location cannot be given without filling the bladder. The
prostate is not
visualized due to lack of filling of the bladder.
IMPRESSION:
1. No hydronephrosis.
2. Foley catheter likely within the bladder, however this cannot
be confirmed without filling the bladder.
.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
Findings
Due to machine software glitch, images are dated [**2119-12-14**]. A
small study of two clips was generated from same machine to
update vault, but we are unable to change date in vault for the
study done at 14:45 on [**2124-6-26**].
This study was compared to the prior study of [**2124-5-25**].
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.
LEFT VENTRICLE: Normal LV wall thickness and cavity size. Normal
regional LV systolic function. Low normal LVEF.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Mildly dilated aortic sinus. Mildly dilated ascending
aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Mild (1+) AR.
MITRAL VALVE: Normal mitral valve leaflets. No MVP. Mild
thickening of mitral valve chordae. Mild to moderate ([**12-15**]+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
Moderate PA systolic hypertension.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Echocardiographic results were reviewed by
telephone with the houseofficer caring for the patient. Left
pleural effusion.
Conclusions
The left atrium is mildly dilated. Left ventricular wall
thicknesses and cavity size are normal. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is low normal (LVEF 50-55%). Right ventricular
chamber size and free wall motion are normal. The aortic root is
mildly dilated at the sinus level. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. Mild (1+) aortic regurgitation
is seen. The mitral valve leaflets are structurally normal.
There is no mitral valve prolapse. Mild to moderate ([**12-15**]+)
mitral regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2124-5-25**],
left ventricular systolic function is less dynamic. Mild
moderate mitral regurgitation and pulmonary artery systolic
hypertension are now present.
If the clinical suspicion for endocarditis is moderate or high,
a TEE is suggested to better define the mitral valve morphology
.
Radiology Report VIDEO OROPHARYNGEAL SWALLOW Study Date of
[**2124-6-29**] 2:12 PM
IMPRESSION: Aspiration of thin liquids.
.
***** [**7-3**] B/L LOWER EXTREMITY ULTRASOUNDS:
IMPRESSION:
1. No evidence of DVT in the right lower extremity.
2. Non-occlusive thrombus in the left common femoral vein which
extends into
the left greater saphenous vein.
.
***** [**7-3**] R UPPER EXTREMITY ULTRASOUND:
IMPRESSION:
Nonocclusive right internal jugular vein thrombus with a
completely occluded
right cephalic vein. Remainder of the upper extremity deep veins
are patent.
The study and the report were reviewed by the staff radiologist.
.
Brief Hospital Course:
This is a 76 year-old male with a recent prolonged
hospitalization for necrotizing pancreatitis and more recent
admission for melena c/b ARDS, renal failure, and need for
tracheostomy who represents with GIB. Recent EGD last night and
this morning showed large clot in body and fundus of the stomach
with no identifiable bleeding site.
# Acute Major GI Bleed/Blood Loss Anemia:
EGD performed on [**2124-6-22**] and showed blood refluxed into the
esophagus, blood and large clot in stomach and fundus, and blood
in the duodenum, although this blood looked older and than that
found in the stomach. There was no erosion noted around the
bumper where the GJ tube exited, and no active vessel
visualized.
He received multiple units of red blood cell (17 units), plasma
(9 units), platelets (2 units) and was on aggressive fluid
resuscitation. He was hypotensive, hypovolemic, anuric.
Called for repeat EGD due to increasing bleeding. Repeat EGD
performed with even poorer visualization of the stomach due to
increased fresh blood and clot. The stomach was difficult to
distent and we were unable to get into the antrum or
beyond due to the extend of blood/clot. Unable to localize an
active bleeding source.
He then went for life saving IR Arteriogram demonstrating the
presence of a pseudoaneurysm at the proximal portion of the
splenic artery with extravasation of contrast material likely
into a pseudocyst. Uncomplicated embolization of the splenic
pseudoaneurysm with coils and thrombin until no flow was
observed.
# Atrial Fibrillation: He developed rapid A-fib and was started
on amiodarone and 75 Lopressor TID. Cardiology was consulted and
we added digoxin. At the time of discharge he was in normal
sinus rhythm. Continue to monitor Dig level.
# Respiratory: Trach'd, no issues
# DVT: US of LLE revealed DVT in the common femoral vein. IVC
filter was placed in the operating room on [**2124-7-4**].
# Septicemia: [**6-22**] blood: E. faecium (S to amp, PCN, vanc). His
antibiotic regimen was tailored down to PO ampicillin which he
will continue until [**2124-7-10**].
# UTI: [**6-22**] urine: E.coli (S to ceph, gent, [**Last Name (un) 2830**], Zosyn, tobra,
Bactrim). He continued on antibiotics and had his Foley chagned
over a wire.
# Clogged J tube: IR successfully unclogged the Jtube with a
wire on [**2124-7-4**].
# FEN: He was started on tubefeedings. He was evaluated by
speech and swallow and aspirated thin liquids and intermittent
coughing with all other po trials. As patient presents with
baseline cough, difficult to determine if intermittent coughing
is directly related to pos. After Video Swallow, he was started
on Regular; Nectar prethickened liquids for solids.
# Depression: Related to prolonged and complicated medical
issues. Psych was consulted and he would not benefit from
pharmacologic intervention at this time. Increased contact time
with treatment team, including explanations of the day's plan
and any procedures for the day will help patient feel more
involved in his care and protect his remaining dignity and
autonomy.
Medications on Admission:
amiodarone 200'', lopressor 25'',lansoprazole 40', simvastatin
40, paroxetine 20, olanzapine 5', hep SC, colace, viocase,
albuterol, ipratropium
Discharge Medications:
1. Insulin Regular Human 100 unit/mL Solution [**Date Range **]: Sliding scale
units Injection ASDIR (AS DIRECTED): Glucose Insulin Dose
0-60 mg/dL [**12-15**] amp D50
61-160 mg/dL 0 Units
161-200 mg/dL 2 Units
201-240 mg/dL 4 Units
241-280 mg/dL 6 Units
281-320 mg/dL 8 Units
> 320 mg/dL Notify M.D.
.
2. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Month/Day (2) **]: Six (6)
Puff Inhalation Q4H (every 4 hours).
3. Amiodarone 200 mg Tablet [**Month/Day (2) **]: Two (2) Tablet PO DAILY
(Daily).
4. Lorazepam 0.5 mg Tablet [**Month/Day (2) **]: 1-2 Tablets PO Q6H (every 6
hours) as needed for agitation.
5. Metoprolol Tartrate 50 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO TID
(3 times a day).
6. Heparin (Porcine) 5,000 unit/mL Solution [**Month/Day (2) **]: 5000 (5000)
UNITS Injection TID (3 times a day).
7. Digoxin 250 mcg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY (Daily).
8. Pantoprazole 40 mg Recon Soln [**Month/Day (2) **]: One (1) Recon Soln
Intravenous Q12H (every 12 hours).
9. Ampicillin Sodium 2 gram Recon Soln [**Month/Day (2) **]: One (1) Recon Soln
Injection Q6H (every 6 hours) for 4 days.
10. Hydralazine 20 mg/mL Solution [**Month/Day (2) **]: Twenty (20) mg Injection
Q4H (every 4 hours) as needed for for SBP>160.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Medical Center - [**Hospital1 3597**]
Discharge Diagnosis:
Acute GI Bleed
Splenic Artery Pseudoaneurysm
Acute Blood Loss Anemia
UTI
Septicemia
Atrial Fibrillation
DVT
Discharge Condition:
Good
Discharge Instructions:
Please call or return to ED with fevers >101.5, chills,
vomiting, hematemesis, melena or hematochezia, obstipation,
severe abdominal pain unresponsive to medication, incisional
erythema or purulent drainage,
.
Clamp G tube. All tube feeds via J tube. Physical therapy as
tolerated. Biliary drain capped. Medications as listed. 15L
trach mask, 50% FiO2, suction as needed.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 468**] in 1 month. Call [**Telephone/Fax (1) 2835**]
to schedule an appointment
Completed by:[**2124-7-6**]
|
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icd9cm
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[
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[]
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,970
| 188,939
|
40883
|
Discharge summary
|
report
|
Admission Date: [**2149-4-1**] Discharge Date: [**2149-4-4**]
Date of Birth: [**2067-2-28**] Sex: F
Service: MEDICINE
Allergies:
Terbutaline / Dicloxacillin / Advair Diskus / Codeine /
Penicillins / Zantac / Fosamax / Heparin Agents / Ativan /
Percocet / Vancomycin / Glucocorticoids (Corticosteroids) / Ace
Inhibitors / Amoxicillin / alendronate sodium / NSAIDS
Attending:[**First Name3 (LF) 28286**]
Chief Complaint:
worsening anginal symptoms
Major Surgical or Invasive Procedure:
c. cath
History of Present Illness:
82-year-old female with history of CAD s/p MI in [**2117**], angina,
history of stent to LAD in [**2140**], HTN, HL, PVD, AAA s/p repair,
CEA, CKD (Cr 2.5), severe pulmonary hypertension, HIT, history
of PE, oxygen-dependent COPD presents in setting of increasing
dyspnea and chest discomfort to CCU for aspirin desensitization
in setting of history of aspirin sensitive asthma and pre-cath
hydration.
Patient was seen in clinic on [**2149-2-27**] with worsening dyspnea on
exertion and chest discomfort for approximately 6 months now. Of
note, she was hospitalized a year ago at [**Hospital3 3765**] for
COPD exacerbation, possible pneumonia, and possible heart
failure episode. CXR on [**10-23**] noted new left pleural effusion
that has persisted. She also noticed over the past 3-4 months in
addition to shortness of breath, anginal-type symptoms. Dr.
[**Last Name (STitle) 2257**] had evaluated her in [**Month (only) 956**] and felt that she could
be having ischemic symptoms and recommended cardiac
catheterization; however, there was concern about chronic kidney
disease and risk of dye load causing permanent renal damage.
PFTs at the time were stable. She also has a small left pleural
effusion that was unchanged. It was felt that her lung disease
would not explain the degree of symptoms that she is currently
having. Dr. [**Last Name (STitle) 2257**] (cardiology) was also concerned about her
symptoms. It was discussed whether or not she would want to
proceed with a cardiac catheterization and risk of additional to
her kidneys from contrast
For her symptoms, her shortness of breath occurs with almost any
type of activity and rapidly followed by severe discomfort in
the chest relieved by nitroglycerin especially with walking long
distances. With continued rest, her pain completely resolves.
She is however able to ambulate around her living quarters
without symptoms most of the time. She describes her symptoms as
central non-radiating chest discomfort that is "frightening"
with associated shortness of breath lasting minutes. Dr.
[**Last Name (STitle) 2257**] had increased her metoprolol to 240 mg PO qD but the
patient is only taking metoprolol SR 150 mg PO qD. Her
isosorbide had also been increased. Her last episode of
discomfort was the day prior to admission.
After discussion with Dr. [**Last Name (STitle) 33746**], it was planned to admit her to
the CCU for aspirin desensitization in setting of history of
aspirin-sensitive asthma and hydration prior to cath.
She has been on warfarin for possible prior history of PE with
last dose on [**2149-3-28**].
On the floor, patient is resting comfortably in bed with no
complaints.
.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, bleeding at the time of surgery,
myalgias, joint pains, cough, hemoptysis, black stools or red
stools. She denies recent fevers, chills or rigors. She denies
exertional buttock or calf pain. All of the other review of
systems were negative.
.
Cardiac review of systems is notable for absence of paroxysmal
nocturnal dyspnea, ankle edema, palpitations, syncope or
presyncope. She sleep on two pillows on an incline and is unable
to lay flat. This has been a chronic issue that she attributes
to COPD.
Past Medical History:
1. CARDIAC HISTORY:
-PERIPHERAL VASCULAR DISEASE
-HYPERCHOLESTEROLEMIA
-HISTORY TOBACCO USE
-MYOCARDIAL INFARCTION [**2117**]
-History of Stents RCA/LAD [**2140**]- Dr. [**Last Name (STitle) 2257**], [**Location 17065**]
-CORONARY ARTERY DISEASE, UNSPEC VESSEL TYPE
-ANGINA PECTORIS (persistant/daily/chronic)
- Possible Congestive Heart Failure (last EF 50-55 %)
Last lipid panel: Chol 161 HDL 44 LDL 88 TG 145 ([**2148-7-8**])
HYPERTENSION
2. OTHER PAST MEDICAL HISTORY:
- ? History of HIT
-CANCER - RECTUM
-Oxygen-dependent COPD
2 L/min at night and increase to 3 l/min with activity
-Chronic kidney disease (Baseline Cr 2.5-2.9) secondary to renal
hypoplasia
- History of pulmonary embolism
On coumadin indefinitely, followed by [**Location (un) 1514**] Anticoagulation
Program
-Thyroid disease
-Iron deficiency anemia
-PULMONARY HYPERTENSION (PA systolic pressure estimated by ECHO
[**9-22**] calculated from peak TR velocity is 45 to 75)
-METHICILLIN RESISTANT STAPH AUREUS CULTURE POSITIVE
-ANEURYSM - ABDOMINAL AORTIC
-HISTORY CAROTID ENDARTERECTOMY
-ADRENAL DISORDER
-DEPRESSIVE DISORDER
Social History:
Lives at [**Hospital3 **] facility
-Tobacco history: quit smoking in [**2128**], 30 pack-years
-ETOH: Denies usage
-Illicit drugs: none
Family History:
Strong family history of CAD and cardiac death before age 50.
Father died from MI at age 45.
Physical Exam:
VS: HR 64 BP 168/71 RR 14 SaO2 95 on 3 L
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
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, lung sounds
distant
ABDOMEN: Soft, central hernia present that is reducible. No HSM
or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
I. Labs
A. Admission
[**2149-4-1**] 04:00PM BLOOD WBC-6.6 RBC-4.41 Hgb-13.9 Hct-40.3 MCV-91
MCH-31.4 MCHC-34.4 RDW-15.6* Plt Ct-134*
[**2149-4-1**] 04:00PM BLOOD PT-16.8* PTT-34.8 INR(PT)-1.5*
[**2149-4-1**] 04:00PM BLOOD Glucose-87 UreaN-45* Creat-2.5* Na-142
K-3.9 Cl-104 HCO3-29 AnGap-13
[**2149-4-1**] 04:00PM BLOOD Calcium-9.4 Phos-3.2 Mg-2.2
[**2149-4-2**] 04:41AM BLOOD %HbA1c-5.9 eAG-123
[**2149-4-2**] 04:41AM BLOOD Triglyc-114 HDL-44 CHOL/HD-3.2 LDLcalc-75
B. Discharge
[**2149-4-4**] 07:55AM BLOOD WBC-5.1 RBC-4.17* Hgb-12.8 Hct-38.1
MCV-91 MCH-30.8 MCHC-33.7 RDW-15.8* Plt Ct-124*
[**2149-4-4**] 07:55AM BLOOD Plt Ct-124*
[**2149-4-4**] 07:55AM BLOOD PT-15.6* PTT-35.5* INR(PT)-1.4*
[**2149-4-4**] 07:55AM BLOOD Glucose-75 UreaN-30* Creat-2.2* Na-145
K-3.7 Cl-112* HCO3-24 AnGap-13
[**2149-4-3**] 04:55AM BLOOD Calcium-8.8 Phos-3.9 Mg-2.1
II. Cardiology
A. ECG
Cardiology Report ECG Study Date of [**2149-4-1**] 1:51:02 PM
Sinus rhythm. Right bundle-branch block. Other ST-T wave
abnormalities. No
previous tracing available for comparison. Clinical correlation
is suggested.
Read by: [**Last Name (LF) **],[**First Name3 (LF) 900**] A.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
63 172 126 468/473 49 50 -26
B. C. Cath ([**2149-4-3**])
BRIEF HISTORY: This 82 year old with a history of coronary
artery
disease, with stenting of LAD in [**2141**] now presents with
disabling stable
angina (CCS III-IV).
INDICATIONS FOR CATHETERIZATION:
Angina
PROCEDURE:
Conscious Sedation: was provided with appropriate monitoring
performed by
a member of the nursing staff.
HEMODYNAMICS RESULTS BODY SURFACE AREA: m2
HEMOGLOBIN: gms %
FICK
**PRESSURES
AORTA {s/d/m} 186/81/122
TECHNICAL FACTORS:
Total time (Lidocaine to test complete) = 0 hour53 minutes.
Arterial time = 0 hour39 minutes.
Fluoro time = 5 minutes.
IRP dose = 392 mGy.
Contrast injected:
Non-ionic low osmolar (isovue, optiray...), vol 20 ml
Premedications:
Midazolam 0.5 mg IV
Fentanyl 25 mcg IV
ASA 325 mg P.O.
Anesthesia:
1% Lidocaine subq.
Anticoagulation:
Heparin - units IV
Cardiac Cath Supplies Used:
75MM ALLEGIANCE, CUSTOM STERILE PACK
75MM MERIT, LEFT HEART KIT
5FR COOK, MICROPUNCTURE INTRODUCER SET
COMMENTS:
1. Selective coronary angigraphy in this right dominant system
demonstrates three vessel coronary artery disase. The left main
contains
a 70-80% lesion in the distal portion of the vessel. The right
coronary
is proximally occluded and the distal vessel fills via
collaterals from
the circumflex. The left anterior descending has an 80% in stent
restenosis and a 60% lesion at the bifurction of the first
diagonal. The
circumflex has a 60% lesion in the mid vessel.
2. Limited hemodynamics demonstrate systemic hypertension.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Elevated systemic blood pressure.
Brief Hospital Course:
82-year-old female with history of CAD s/p MI in [**2117**], angina,
history of stents to LAD in [**2140**], HTN, HL, PVD, AAA s/p repair,
CEA, CKD (Cr 2.5), severe pulmonary hypertension, HIT, history
of PE, oxygen-dependent COPD presents in setting of increasing
dyspnea and chest discomfort to CCU for successful aspirin
desensitization in setting of history of aspirin sensitive
asthma and pre-cath hydration. C. cath showed three vessel
disease, with critical Left main disease with evaluation for
CABG deferred.
# Aspirin-sensitive asthma
Patient reporting asthma attack 30 years ago from taking
aspirin. She was admitted to CCU for aspirin desensitization in
setting of aspirin-sensitive asthma per [**Hospital1 18**] AERD protocol. Her
baseline FEV1 was 61 % predicted. Her baseline peak flow was 250
mL on admission. She tolerated the protocol with peak flow not
dropping below 200 and symptoms such as wheezing, hives,
dyspnea, rhinitis. She was subsequently continued on aspirin 325
mg PO qD and should take this medication indefinitely. If she
should stop aspirin for greater than 48 hours, the protocol must
be repeated.
# Coronary artery disease
Patient admitted for c. cath in setting of 6 month history of
increasing dyspnea associated with central chest discomfort
relieved by rest and nitroglycerin. Patient has multiple cardiac
risk factors and CAD equivalent given PVD. She presents with
several month history of increased frequency of anginal symptoms
that appears consistent with angina despite increased medical
therapy. No episodes of chest discomfort in hospital. No active
signs/symptoms to indicate acute ischemia including admission
ECG similiar to prior. She underwent cardiac cath with
pre-hydration/mucomyst showing three vessel coronary artery
disease (see c. cath report for full details). Cardiac surgery
evaluated patient and discussed high risk candidacy for
revascularization. The patient and her family discussed the
option and deferred surgery at this time.
She was discharged on atorvastatin instead of home simvastatin
in addition to plavix/aspirin. Her metoprolol succinate was
uptitrated from 150 to 200 mg PO qD.
She will follow-up with Dr. [**Last Name (STitle) 2257**] (atrius cardiology).
# PUMP:
Patient has history of coronary artery disease. Last ECHO in
[**2147**] showing LVEF 50-55 %. No active signs or symptoms to
suggest heart failure
# RHYTHM: Patient was in NSR with ectopy
# COPD
Patient has no active signs/symptoms of COPD exacerbation.
Patient is not on [**Last Name (un) **] or steroids as "seem to bother her voice
and mouth too much." She was continued on spiriva and home
oxygen (2 L/min at night, 3 L/min with activity) with goal pOx
of 88-95 %.
.
# History of PE
Patient has history of PE (unknown if
segmental/subsegmental/other) and unknown setting. She is
anti-coagulated for life with target INR [**1-16**]. Warfarin was held
during the peri-procedure period and re-started upon discharge
at warfarin 1 mg PO qD. INR at discharge was 1.4. There was a
plan for follow up in her [**Hospital 263**] clinic on [**2149-4-7**].
.
# Hypercholesterolemia
Her lipid panel was checked during hospitalization with
Cholesterol 142, TG 114, HDL 44, and LDL 75. She was discharged
on atorvastatin instead of home simvastatin
.
# Hypertension
She was continued on metoprolol and furosemide. Her lasix was
held on the day of and after her cath to avoid exacerbating
possible contrast induced nephropathy.
.
# Questionable history of HIT:
It is uncertain if the patient has true heparin-induced
thrombocytopenia as records are not available and the
circumstances surrounding this allergy are unclear. She was
assumed to have a history of heparin-induced thrombocytopenia,
and all heparin products were avoided.
# Chronic kidney disease: Patient has a baseline Cr of 2.5 -
2.9. Her creatinine at discharge was 2.2. Her CIN risk scored
indicated that she had approximately a 20 % chance of developing
CIN with minimal risk of requiring dialysis.
# Iron deficiency anemia: Labs did not indicate anemia. She was
continued on iron and will follow-up with her PCP for further
discussion.
# Thrombocytopenia: Patient had thrombocytopenia on admission
that was stable at 150s throughout hospitalization. The etiology
is of unclear origin, and outpatient work-up is advised.
# Pulmonary hypertension: The patient had an ECHO performed on
[**10-23**] which showed peak TR velocity of 45-75. Uncertain WHO
classification given prior PE, COPD. No severe valvular disease
per last ECHO except mild MR. [**Name13 (STitle) 6**] outpatient work-up was advised
to further evaluate her pulmonary hypertension.
# MRSA screen: Patient had a prior history of MRSA, and she was
placed on MRSA precautions.
# Transitions of care
anticoag, Cr,
Medications on Admission:
Fexofenadine 60 mg PO BID
Dipyridamole 75 mg PO BID (to replace aspirin)
Simvastatin 80 mg PO qD
Omeprazole 20 mg PO qD
Folic acid 1 mg PO qD
metoprolol succinate 150 mg PO qD
Furosemide 20 mg PO qD
Oxygen 2 L/min at night, 3 L/min with activity
Warfarin 1 mg PO qD
Isosorbide mononitrate ER 120 mg PO qD (prescribed 240 mg PO qD)
Nitroglycerin Sub 0.4 mg 1 tablet SL prn chest pain
Spiriva 18 mcg 1 puff daily qD
Xalatan 0.005 % eye drops 1 drop in right eye qHS
Slow Fe 142 mg 1 tab PO qD
Centrum Silver 1 tab PO qD
Discharge Medications:
1. fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
2. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest
discomfort: Please take every five minutes for chest pain. If
your chest pain does not resolve after two doses please call
your cardiologist. If your chest pain does not resolve after
three doses please call 911.
6. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
7. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
8. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Slow Fe 142 mg (45 mg iron) Tablet Extended Release Sig: One
(1) Tablet Extended Release PO once a day.
10. isosorbide mononitrate 120 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO twice a day.
Disp:*60 Tablet Extended Release 24 hr(s)* Refills:*2*
11. Coumadin 1 mg Tablet Sig: One (1) Tablet PO once a day.
12. Medication
Oxygen: 2L/min at night, 3L/min activity
13. Outpatient Lab Work
Please have INR check on Monday [**2149-4-7**]
14. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day: Please
restart on [**2149-4-5**].
15. metoprolol succinate 200 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
16. aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
17. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Crescendo Angina
Secondary Diagnosis
Pulmonary hypertension
Chronic obstructive pulmonary disease
Coronary artery disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 43113**]-
You were admitted to the hospital for increasing shortness of
breath with exertion and chest discomfort. You underwent
aspirin desensitiziation and you also underwent a cardiac
catheterization which demonstrated worsening coronary artery
disease. The cardiac surgeons evaluated you for surgery, but
felt you were high risk. At a later day you may be able to
undergo another cardiac cathaterization and have a stent placed
to help with your symptoms. You should discuss the options to
treat your shortness of breath and chest pain with your
cardiologist.
The following medication changes were made:
ADDED: Plavix, Aspirin, Atorvastatin
STOPPED: Dipyridamole, Simvastatin
CHANGED: Metoprolol
Followup Instructions:
Name: [**Last Name (LF) 5448**], [**Name8 (MD) 6339**] MD
Location: [**Location (un) 2274**]-[**Location (un) **]
Address: [**Hospital Ward Name **] EXTENSION, [**Location (un) **],[**Numeric Identifier 15215**]
Phone: [**Telephone/Fax (1) 28262**]
Appointment: Tuesday [**4-15**] at 10:15AM
Name: [**Last Name (LF) 2257**], [**First Name3 (LF) **] B. MD
Location: [**Hospital1 641**]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2258**]
We are working on a follow up appointment with Dr. [**Last Name (STitle) 2257**]
within 1-2 weeks. You will be called at home with the
appointment. If you have not heard from the office within 2 days
or have any questions, please call the number above.
Completed by:[**2149-4-6**]
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53,871
| 102,565
|
41948
|
Discharge summary
|
report
|
Admission Date: [**2154-10-21**] Discharge Date: [**2154-10-27**]
Date of Birth: [**2104-8-29**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 2736**]
Chief Complaint:
SOB, Pleural Effusions, PNA, pericardial effusion, concern for
tamponade
Major Surgical or Invasive Procedure:
pericardial window, thoracentesis with chest tube
History of Present Illness:
Ms [**Known lastname 35028**] is a 50yoF with PMH significant for depression,
though negative for cardiac risk factors including CHF or CAD.
She was transferred to CCU on [**2154-10-21**] with concern for
pericardial tamponade.
She originally presented to [**Hospital3 **] with 2 weeks of
progressive productive cough, fever, SOB, and DOE despite 2
courses of PO abx (z-pack started [**10-3**]; levaquin started
[**10-16**])for outpatient treatment of PNA, and was found to have a
leukocytosis to 13.7, and a large pericardial effusion, B/L
pleural effusions and LLL opacity on CT scan.
Vitals in ED showed T101.8F, RR 20's-low 30's; winded with any
activity or with talking. Sats high 90's on 4l NC. Of note, she
has had a 50lb intentional weight loss over the last year with
strict diet modification. Prior to this episode, no F/C/NS. She
does also complain of some epigastric discomfort ([**2-21**], dull,
worse with cough). She mentions that she had a few short
episodes of palpitations on exertion in the last weeks prior to
her admission. She denies chest pain, lightheadedness or
dizziness. No sick contacts. Of note she took a cruise to the
Bahamas in late [**Month (only) **] for 1 week. Goes to Caribbean for 1
week every year, otherwise no TB exposure history.
.
ED course: WBC 13.7, chem7 normal. Cardiology was consulted and
bedside echo suggestive of pericardial effusion. Blood cultures
taken. Given PO Azithromycin and IV Ceftriaxone. Given Tylenol
1gm
.
When getting to the CCU, the patient is in NAD, though quite
anxious. Afebrile, hemodynamically stable, mildly tachypnic.
Pulsus paradoxus is 12mmHg.
.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies exertional buttock or calf
pain. All of the other review of systems were negative except
per above.
.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, orthopnea, ankle edema, syncope or
presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: negative for DM, HTN, HLD
2. CARDIAC HISTORY: none
3. OTHER PAST MEDICAL HISTORY:
- Depression / paranoia
- cellulitis in lower extremity x2 2-3 years ago
- breast biopsy several years ago (2 sisters with breast cancer
diagnosed at 35 and 40)
Social History:
owner of a uniform supply store. Lives with husband, who is a
paramedic. No recent sick contacts. Travels to Caribbean for 1
week of vacation every year.
- Tobacco history: none
- ETOH: rare, social
- Illicit drugs: none
Family History:
- No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death; otherwise non-contributory.
Two sisters have breast cancer, one diagnosed at about age 35,
the other around age 40. Pt has had a breast biopsy several
years ago and states that the results were not concerning. She
says she gets yearly mammograms.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: T99.4; P98; BP115/73; RR25; O2 sat 96% 4L NC; Pulsus
paradoxus 12mmHg
GENERAL: Middle-aged woman in NAD, obese, comfortable and
appropriate though quite anxious
HEENT: NC/AT, PERRL, EOMI OP Clear, MMM
Chest: decreased breath sounds LLL up to mid-lung, otherwise
CTAB
Cardiovascular: borderline tachycardia, NL S1 and S2 with normal
splitting of S2, no JVP appreciated although exam inhibited [**2-13**]
body habitus
ABDOMEN: Soft, mildly tender in epigastric region, non-distended
GU/Flank: No costovertebral angle tenderness
Musc/Extr/Back: No joint pain, no cyanosis, clubbing or edema
Skin: No rashs, Warm and dry
Neuro: Speech fluent, A+Ox3
Psych: Normal mentation, Normal mood.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
.
DISCHARGE PHYSICAL EXAMINATION:
VS: T98.5; P98.1; BP108/71; RR21; O2 sat 96% ra, pulsus
paradoxus 8mmHg
GENERAL: Middle-aged woman in NAD, obese, comfortable and
appropriate
HEENT: NC/AT, PERRL, EOMI OP Clear, MMM
Chest: decreased breath sounds in left base
Cardiovascular: borderline tachycardia, NL S1 and S2 with normal
splitting of S2, JVP 8cm
ABDOMEN: Soft,non-tender, non-distended, no HSM, BS+
GU/Flank: No costovertebral angle tenderness
Musc/Extr/Back: No joint pain, no cyanosis, clubbing or edema
Skin: No rashs, Warm and dry
Neuro: Speech fluent, A+Ox3
Psych: Normal mentation, Normal mood.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
ADMISSION LABS:
[**2154-10-21**] 12:31AM BLOOD WBC-13.7* RBC-4.37 Hgb-12.1 Hct-36.4
MCV-83 MCH-27.6 MCHC-33.1 RDW-12.9 Plt Ct-443*
[**2154-10-21**] 12:31AM BLOOD Neuts-82.5* Lymphs-11.8* Monos-4.5
Eos-0.8 Baso-0.4
[**2154-10-21**] 08:07AM BLOOD PT-14.8* PTT-27.4 INR(PT)-1.3*
[**2154-10-21**] 12:31AM BLOOD Glucose-136* UreaN-14 Creat-0.6 Na-136
K-4.1 Cl-99 HCO3-24 AnGap-17
[**2154-10-21**] 12:54AM BLOOD Lactate-1.2
.
RELEVANT LABS:
[**2154-10-21**] 02:10PM PLEURAL WBC-7250* RBC-[**Numeric Identifier 36798**]* Polys-75*
Lymphs-15* Monos-4* Meso-3* Macro-3*
[**2154-10-21**] 02:10PM PLEURAL TotProt-3.5 Glucose-127 LD(LDH)-470
Albumin-2.0
[**2154-10-21**] 02:16PM OTHER BODY FLUID WBC-[**Numeric Identifier **]* RBC-[**Numeric Identifier 91055**]*
Polys-84* Lymphs-6* Monos-4* Macro-6*
[**2154-10-21**] 02:16PM OTHER BODY FLUID TotProt-4.9 Glucose-91
LD(LDH)-[**2100**] Albumin-2.4
.
DISCHARGE LABS:
[**2154-10-27**] 04:39
White Blood Cells 8.2 Hemoglobin 11.0* Hematocrit 33.3 MCV 83
MCH 27.4 MCHC 33.0 31 - 35 %
RDW 13.9
Platelet Count 391 150 - 440 K/uL
Glucose 142 Urea Nitrogen 9 Creatinine 0.5 Sodium 139 Potassium
4.1 Chloride 102 Bicarbonate 31 Calcium, Total 9.0 Phosphate 3.2
Magnesium 1.8
IMAGING:
TTE [**2154-10-21**]:
LEFT VENTRICLE: Normal LV wall thickness, cavity size, and
global systolic function (LVEF>55%).
PERICARDIUM: Moderate to large pericardial effusion. RV
diastolic collapse, c/w impaired fillling/tamponade physiology.
CONCLUSIONS: Left ventricular wall thickness, cavity size, and
global systolic function are normal (LVEF>55%). There is a
moderate to large sized pericardial effusion. There is right
ventricular diastolic collapse, consistent with impaired
fillling/tamponade physiology.
.
TTE [**2154-10-25**]:
LEFT VENTRICLE: Normal LV thickness, cavity size and global
systolic function (LVEF>55%)
RIGHT VENTRICLE: chamber size and free wall motion are normal.
No AR, AS. Trivial MR.
PERICARDIUM: stable small echodense pericardial effusion,
consistent with blood, inflammation or other cellular elements.
.
Chest x-ray PA/lat [**2154-10-21**]:
1. Enlarged heart consistent with history of pericardial
effusion.
2. Extensive opacification of the left lung suspicious for
pneumonia. The
amount of left pleural fluid may be better assessed with either
decubitus
views or CT.
MICROBIOLOGY:
Blood cultures [**2154-10-21**]: negative
.
Pleural fluid (pleural effusion left): [**2154-10-21**]
GRAM STAIN: 4+ (>10 per 1000X FIELD): PMN LEUKOCYTES
no microorganisms seen. negative cultures (aerob, anaerob).
negative acid fast smear and culture. negative fungal culture
and potassium hydroxide preparation
WBC 7250/RBC [**Numeric Identifier 36798**]/Prot 3.5/Gluc 127/LDH 470/Alb 2.0
.
Pericardial fluid (pericardial effusion):[**2154-10-21**]
GRAM STAIN: 3+ (5-10 per 1000X FIELD): PMN LEUKOCYTES
no microroganisms seen.negative cultures (aerob, anaerob).
negative acid fast smear and culture. negative fungal culture.
WBC [**Numeric Identifier **]/RBC [**Numeric Identifier 91055**]/4.9/Gluc 91/LDH [**2100**]/Alb 2.4
.
Sputum: [**2154-10-21**]
GRAM STAIN: <10 PMNs and <10 epithelial cells/100X field. no
microorganisms
negative culture.
.
Urine culture [**2154-10-21**]: <10,000 organisms/ml
.
MRSA screen [**2154-10-21**]: negative for Staph aureus (Skin, Axillae,
Breast) and neg nasal swab for MRSA
.
PATHOLOGY:
Pericardial biopsy: [**2154-10-21**]
GRAM STAIN: 2+ (1-5 per 1000X FIELD): PMN LEUKOCYTES.
no microorganisms seen.negative cultures (aerob, anaerob).
negative acid fast smear and culture. negative fungal culture
and potassium hydroxide preparation
.
CYTOLOGY:
Pericardial fluid [**2154-10-22**]: NEGATIVE FOR MALIGNANT CELLS.
Predominantly neutrophils and histiocytes.
.
Pleural fluid [**2154-10-22**]: NEGATIVE FOR MALIGNANT CELLS. Reactive
mesothelial cells, histiocytes, lymphocytes, and neutrophils.
Brief Hospital Course:
Ms [**Known lastname 35028**] is a 50yoF with PMH significant for depression, who
was transferred from [**Hospital3 **] with a large pericardial
effusion, bilateral pleural effusions and a LLL opacity, with a
hospital course complicated by atrial fibrillation with rapid
ventricular response.
.
# Pericardial effusion with cardiac tamponade physiology:
On admission to CCU, an ECHO confirmed a moderate-to-large
pericardial effusion, without echocardiographic signs of
tamponade at that time. Initial EKG on admission showed NSR with
low voltages across all leads without signs for pericarditis.
Repeated measurements of pulsus paradoxus were approximately
12mmHg. She was referred to CT Surgery, and underwent
pericardial window on [**2154-10-21**], during which 1 chest tube on
the left and 1 pericardial drain were placed. She was
transferred still intubated, [**2-13**] bronchospasm/coughing in the
OR, in addition to SVT (10 seconds) and desaturation to SatO2
75%. She was extubated several hours after intervention
uneventfully. Analysis of the pericardial fluid revealed
exudative character, narrowing differential to infectious vs.
malignant vs. rheumatic etiology (despite no prior personal h/o
malignancy or rheumatologic symptoms, although does have a
strong family history of breast ca and a breast biopsy in the
past). Tissue analysis of the pericardium showed fibrinous and
organizing pericarditis. There was no evidence of malignancy in
this sample. Further no significant acute inflammation was
identified. Pericardial fluid cytology was negative for
malignant cells. Sputum, pericardial fluid, blood cultures and
PPD were negative. F/u TTE on [**10-22**] revealed decreased RV
function with septal bowing, likely secondary to constrictive
physioogy from organizing effusion. She was continued on empiric
broad-spectrum antibiotics (Vanc/Cefepime) for total treatment
of 10 days. The pericardial drain was discontinued on [**2154-10-24**]
after 214ml total output and minimal (<20ml) output over
previous 24hours. F/u TTE on [**10-25**] showed normal LV function
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. There is a stable small echodense pericardial
effusion, consistent with blood, inflammation or other cellular
elements. At time of discharge, measurement of pulsus paradoxus
was within normal limits, and pt denied any chest
pain/discomfort, difficulty breathing or any positional
dyspnea/orthopnea related to presenting chief complaint.
.
# LLL PNA complicated by parapneumonic effusion:
CT chest at [**Hospital3 **] identified a LLL opacity thought to
be c/w consolidation vs. mass. Of note, pt had previously
completed outpatient course of levofloxacin and azithromycin
without improvment in symptoms (fevers, SOB) before this
presentation. On transfer, she was considered to have PNA with
resistant organisms vs. post-obstructive PNA vs. malignancy, and
was treated with 10-day course of vanc/cefepime with adequate
improvement of symptoms, resolving leukocytosis and no fever. As
mentioned, a chest tube was placed on the left, which drained a
total output of 1420mL of exudative fluid, negative for
organisms or malignant cells. Sputum, blood and pleural fluid
culture were negative for organisms. PPD was negative. Chest
tube was discontinued on [**2154-10-25**]. At time of discharge, pt
denied fevers/chills, night sweats, cough, and difficulty
breathing. She will need repeat chest CT 4-6 weeks after
discharge to evaluate for resolution of effusion and
consolidation. Furthermore, in outpatient setting PCP should be
sure she is up to date on all recommended malignacy screening
tests, with particular attention to breast cancer given strong
family history.
.
# Afib with RVR:
On hospital day 3 ([**2154-10-23**]), pt was noted to have several
short (<5 minutes) episodes of Afib with RVR (up to
180-200bpm)with spontaneous resolution. These episodes recorded
on telemetry were accompanied by subjective palpitations that
the pt related to previous chest sensations during exertion
during the preceding weeks at home. Etiology of this dysrhythmia
was thought multifactorial, [**2-13**]: irritation of the atrium by
effusion, pericardial drain and PICC line. The PICC line was
subsequently pulled back 2cm, and this coincided with decreased
frequency of these episodes. Pt was started on metoprolol
tartrate 12.5mg [**Hospital1 **], and experienced no additional rhythm
disturbance thereafter. She continued to be in NSR with a rate
in the 70's-80's. She was started on aspirin 325mg daily, given
CHADS2-score of 0. On discharge, the plan included monitoring
for outpatient events with Kings of Hearts monitor.
.
CHRONIC ISSUES:
# Depression: Documented history of this problem. The patient's
home abilify 2mg PO qPM was continued during this admission.
.
TRANSITIONAL ISSUES:
# Pt will need to schedule follow-up visits with PCP [**Last Name (NamePattern4) **] 2 weeks
and cardiology in 1 month.
# Recommend age-appropriate malignancy screening to rule out
other malignant etiologies.
# Pt will require [**Doctor Last Name **] of Hearts monitoring upon discharge to
evaluate for more episodes of paroxysmal atrial fibrillation,
with twice daily rhythm checks (with teaching).
# Pt will need repeat CT scan in [**4-17**] weeks to evaluate for
resolution of LLL consolidation.
# Pt will need repeat Echocardiogram in 4 weeks to evaluate for
progression/resolution of pericardial effusion
# Pt was started on Aspirin 325mg daily, metoprolol 12.5mg PO
daily, and was sent home with a PICC in place for 2.5 more days
of vancomycin and cefepime with VNA.
Medications on Admission:
- Abilify 2mg PO qHS
- Levofloxacin,
- Promethazine-codeine
- Multivitamin
- Calcium-magnesium
- Potassium
Discharge Medications:
1. vancomycin 500 mg Recon Soln Sig: Three (3) Recon Soln
Intravenous Q 8H (Every 8 Hours) for 4 days.
Disp:*11 Recon Soln(s)* Refills:*0*
2. aripiprazole 2 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
3. cefepime 2 gram Recon Soln Sig: One (1) Recon Soln Injection
Q8H (every 8 hours) for 4 days.
Disp:*11 Recon Soln(s)* Refills:*0*
4. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
6. multivitamin Tablet Sig: One (1) Tablet PO once a day.
7. benzonatate 100 mg Capsule Sig: [**1-13**] Capsules PO three times a
day as needed for cough.
Disp:*90 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Community VNA of [**Location (un) 6981**]
Discharge Diagnosis:
Pericardial effusion
Pleural effusion
Hospital Acquired Pneumonia
Atrial Fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Activity Status: Ambulatory - Independent.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
Dear Ms. [**Known lastname 35028**],
It was a pleasure taking care of you during your hospital stay
at [**Hospital1 69**]. You were admitted
because you had fluid accumulating around your heart. You were
also found to have pneumonia and fluid accumulating around your
lungs.
You were taken to surgery to remove the fluid around your heart
and lungs and a drain was placed around your heart. This drain
was then removed. The fluid accumulation is most likely
secondary to your pneumonia. You will remain on 4 more days of
IV antibiotics after discharge.
While in the hospital, you also developed several episodes of a
fast irregular rhythm called atrial fibrillation. We are
prescribing you metoprolol to help control the heart rate and a
full-dose aspirin to help prevent any blood clots from the
rhythm.
We made the following changes to your medications:
- ADDED Metoprolol
- ADDED Aspirin
- ADDED Vancomycin
- ADDED Cefepime
- ADDED Benzonatate
- STOPPED Levofloxacin
Followup Instructions:
Please call your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] at [**Telephone/Fax (1) 91056**] to make a
follow-up appointment within the next week.
We would also like you to see one of our cardiologists for
follow-up. Please call ([**Telephone/Fax (1) 2037**] to make an appointment for
4-6 weeks from your discharge. You can make the appointment
with Dr. [**Last Name (STitle) **] if you would like.
|
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"297.1",
"745.5",
"486",
"511.9",
"423.3",
"311",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.04",
"37.24",
"88.72",
"37.12"
] |
icd9pcs
|
[
[
[]
]
] |
15476, 15548
|
8921, 13599
|
367, 418
|
15678, 15678
|
5025, 5025
|
16831, 17256
|
3088, 3424
|
14695, 15453
|
15569, 15657
|
14564, 14672
|
15829, 16664
|
5928, 8898
|
3439, 3449
|
2634, 2639
|
4313, 5006
|
13764, 14538
|
16693, 16808
|
255, 329
|
446, 2540
|
5041, 5912
|
15693, 15805
|
2670, 2832
|
13615, 13743
|
2562, 2613
|
2848, 3072
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,920
| 148,445
|
29015
|
Discharge summary
|
report
|
Admission Date: [**2101-12-24**] Discharge Date: [**2102-2-7**]
Date of Birth: [**2078-12-23**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
worsening CHF
Major Surgical or Invasive Procedure:
[**2102-1-5**] AVR (25 mm [**Company **] mosaic porcine valve), Abscess
closure (Mitral repair), placement of pacemaker and
biventricular leads
History of Present Illness:
23 yo M with h/o IVDU and endocarditis. Known to have large
aortic vegetation and root abscess. Was treated with IV
antibiotics at [**Hospital6 16029**] and subsequently
developed renal and hepatic failure and was intubated.
Transferred to [**Hospital1 18**] for AVR/root evaluation.
Past Medical History:
Endocarditis
Hep C positive
IVDU (cocaine & heroin)
3PPD smoker (since age 10)
ARF
s/p cholecystostomy tube ([**12-18**])
Social History:
incarcerated at the time of admission to [**Hospital6 16029**]
smokes 3ppd
IVDU (heroin & cocaine)
Family History:
non-contributory
Physical Exam:
On admission:
99.2 84 NSR 105/76 15/100% AC/30%/650x15
Sedated intubated
MMM, anasarca
RRR
CTAB, dim breath sounds at bilat bases.
Abdomen soft/NT/ND, anterior PTC drain with clear bile draining.
extrem warm, 2+ pp, trace LE edema
Discharge:
VS T97 HR70 AsensedVpaced BP 113/70 RR 18 O2sat 100% on 35%
trach mask
Neuro: Alert responsive, nonfocal exam
Pulm: CTA bilat, trach in place site CDI
CV: RRR, s1-s2, sternum stable, incision healing well
Abdm: soft non distended, slightly tender at J tube site, Chole
tube site CDI
Ext: no edema, Rt SVG site/CDI
TLD; Foley-gravity, Chole tube-gravity, PICC- rt antecub, Trach,
J tube
Pertinent Results:
[**2101-12-24**] 11:59AM UREA N-26* CREAT-0.9 SODIUM-140 CHLORIDE-107
TOTAL CO2-26
[**2101-12-24**] 12:13PM GLUCOSE-88 K+-4.0
[**2101-12-24**] 11:59AM ALT(SGPT)-166* AST(SGOT)-90* LD(LDH)-386*
CK(CPK)-572* ALK PHOS-67 AMYLASE-76 TOT BILI-1.4
[**2101-12-24**] 11:59AM LIPASE-127*
[**2101-12-24**] 11:59AM ALBUMIN-2.7* CALCIUM-8.4 PHOSPHATE-4.8*
MAGNESIUM-2.3
[**2101-12-24**] 11:59AM WBC-12.5* RBC-3.77* HGB-10.6* HCT-32.7*
MCV-87 MCH-28.2 MCHC-32.6 RDW-17.7*
[**2101-12-24**] 11:59AM PLT COUNT-223
[**2101-12-24**] 11:59AM PT-13.4* PTT-31.1 INR(PT)-1.2*
[**2102-2-6**] 04:09AM BLOOD WBC-15.4* RBC-2.72* Hgb-8.2* Hct-26.2*
MCV-97 MCH-30.3 MCHC-31.5 RDW-21.8* Plt Ct-542*
[**2102-2-5**] 04:45AM BLOOD PT-13.2* PTT-30.2 INR(PT)-1.2*
[**2102-2-6**] 04:09AM BLOOD Plt Ct-542*
[**2102-2-6**] 04:09AM BLOOD Glucose-97 UreaN-13 Creat-0.7 Na-140
K-4.4 Cl-104 HCO3-30 AnGap-10
[**2102-2-6**] 04:09AM BLOOD ALT-108* AST-105* LD(LDH)-320*
AlkPhos-346* Amylase-36 TotBili-6.4*
[**2102-2-6**] 04:09AM BLOOD Lipase-43
[**2102-2-6**] 04:09AM BLOOD Albumin-3.2*
CHEST (PA & LAT) [**2102-2-6**] 10:26 AM
CHEST (PA & LAT)
Reason: evaluate effusion right
[**Hospital 93**] MEDICAL CONDITION:
23 year old man s/p AVR
REASON FOR THIS EXAMINATION:
evaluate effusion right
INDICATION: Status post 23 year status post AVR, evaluate for
right effusion.
COMPARISON: [**2102-2-2**].
FRONTAL & LATERAL CHEST RADIOGRAPHS:
Tracheostomy tube again seen with tip approximately 3.5 cm from
the carina. Median sternotomy wires again noted. Pacing leads
again seen in unchanged position. Cardiac and mediastinal
contours appear stable. No focal consolidations are seen within
the lungs. Loculated right pleural effusion appears relatively
unchanged. New small amount of free air is seen under the right
hemidiaphragm, improving left basilar atelectasis and effusion
also again noted.
IMPRESSION: Persistent loculated right pleural effusion. A small
amount of free air noted under the right hemidiaphragm,
consistent with patient's recent history of PEG placement.
Cardiology Report ECHO Study Date of [**2102-1-16**]
PATIENT/TEST INFORMATION:
Indication: Aortic valve disease. Endocarditis. Evaluation for
abscess. Left ventricular function. Right ventricular function.
Height: (in) 72
Weight (lb): 190
BSA (m2): 2.09 m2
BP (mm Hg): 101/56
HR (bpm): 74
Status: Inpatient
Date/Time: [**2102-1-16**] at 14:14
Test: Portable TEE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2007W000-0:00
Test Location: West SICU/CTIC/VICU
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **]
MEASUREMENTS:
Aortic Valve - Peak Velocity: *3.0 m/sec (nl <= 2.0 m/sec)
Aortic Valve - Peak Gradient: 36 mm Hg
INTERPRETATION:
Findings:
The patient was intubated and sedated with infusions of
midazolam and fentanyl during the procedure.
This study was compared to the prior study of [**2102-1-5**].
LEFT ATRIUM: Normal LA size.
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. No ASD by 2D or color
Doppler.
LEFT VENTRICLE: Severely dilated LV cavity. Depressed LVEF.
RIGHT VENTRICLE: Normal RV chamber size. Severe global RV free
wall
hypokinesis.
AORTA: Normal ascending, transverse and descending thoracic
aorta with no
atherosclerotic plaque.
AORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR). AVR
well seated, normal leaflet/disc motion and transvalvular
gradients. No masses or vegetations on aortic valve. Trace AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR. [**Name13 (STitle) **]
mass or
vegetation on mitral valve.
TRICUSPID VALVE: Normal tricuspid valve leaflets. No mass or
vegetation on
tricuspid valve. Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Thickened pulmonic valve
leaflets. No
vegetation/mass on pulmonic valve. Significant PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Local anesthesia was provided by benzocaine
topical spray. The patient was sedated for the TEE. Medications
and dosages are listed above (see Test Information section). No
TEE related complications. 0.2 mg of IV glycopyrrolate was given
as an antisialogogue prior to TEE probe insertion.
The patient appears to be in sinus rhythm.
Conclusions:
The left atrium is normal in cavity size. No atrial septal
defect is seen by 2D or color Doppler. The left ventricular
cavity is severely dilated with severe global hypokinesis.
There is severe global right ventricular free wall hypokinesis.
The ascending, transverse and descending thoracic aorta are
normal in diameter and free of atherosclerotic plaque. A
bioprosthetic aortic valve prosthesis is present. The aortic
prosthesis appears well seated, with normal leaflet motion. No
masses or vegetations are seen on the aortic valve. Trace aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. No mass or vegetation
is seen on the mitral valve. The pulmonic valve leaflets are
thickened. No vegetation/mass is seen on the pulmonic valve.
Significant pulmonic regurgitation is seen. There is no
pericardial effusion.
IMPRESSION: Well seated aortic valve prosthesis with no echo
evidence of
abscess or vegetation. Severely dilated left ventricular cavity
with severe global hypokinesis. Severe right ventricular free
wall hypokinesis.
Compared with the post-operative images from the prior study
(images reviewed)
of [**2102-1-5**], the findings are similar.
Brief Hospital Course:
He was admitted to the cardiac surgery ICU [**2101-12-24**]. He failed a
spontaneous breathing trial and remained intubated with tube
feeds. He was seen by infectious disease and placed on
vancomycin, unasyn, gentamicin and doxycycline. TEE on [**12-25**]
showed abscess at confluence of anterior mitral leaflet and
posterior aspect of aortic root, markedly thickened and
edematous anterior aortic root, a bicuspid AV, wide open AI,
large vegetation on AV.EF 30%. On [**12-26**] he was extubated and
reintubated for respiratory distress. A thoracentesis was
performed for 1600 cc. He was seen by general surgery for his
chole tube, with recommendations to complete cardiac surgery
first and then perform chole in [**1-28**] months. He was seen by
cardiology for his PPM. Bronchoscopy on [**12-29**] showed no lesions,
bleeding or secretions. BAL was done. He had a temp of 102.5 and
was found to have 4+GNR in his sputum for which he continued on
Zosyn. He again failed a CPAP trial, a pigtail was placed for a
pleural effusion. Extubation was again attempted, however he
became progressively hypoxic and asystolic. He was reintubated
and received ACLS with return to SR and improved sats. His BAL
grew stanotrophomonous for which he was treated with Bactrim.
He was seen by ENT for right ear drainage from a ruptured TM for
which he was treated with ciprodex gtt. His creatinine worsened
and he was seen by renal who recommended volume. He was started
on CVVH. He remained in the ICU on antibiotics until He was
taken to the operating room where he underwent an AVR (25 mm
[**Company **] mosaic porcine valve, abscess closure (mitral repair)
and placement of intraabdominal [**Company **] pacemaker and
biventricular leads. He remained paralyzed on multiple pressors
with poor oxygenation, high PEEP and CVVH. HIs vasoactive drips
were gradually weaned to just pitressin, and his antibiotics
were broadened to meropenum, cipro, doxycycline, vanc and gent.
He was started on tube feeds. He was seen by hematology for
thrombocytopenia, a HIT antibody was negative. He developed a
right ptx for which a chest tube was placed. He was started on
fluconazole for candiduria. stopped [**1-15**]. His paralytics were
dc'd and he was weaned from his pitressin. His respiratory staus
continued to improve. His CVVH was stopped with hopes to
transition to HD, however he began to make urine had no needs
for HD. He began to spike fevers with a high white count off of
CVVH, for which he was cultured. He was seen by general surgery
and hepatology for jaundice and a high total bilirubin, he was
started on ursodiol, a chole tube study was negative, and he was
changed from fluc to caspo. On [**2102-1-25**] he underwent a
tracheostomy and he began to be screened for rehab. Infectious
diseases signed off on [**1-25**] with plans to continue caspofungin
x 1 week, d/c cipro and cefepime after tracheostomy. He was able
to tolerate increasing amounts of trach collar and was off of
the ventilator entirely by [**2102-1-30**]. His methadone (started for
pain management/agitation) wean continued. A passy-muir valve
was placed, but he remained NPO due to a weak swallow, and
remained on tube feeds. His cholestatis jaundice improved and
Hepatology signed off with plans for outpatient follow up. On
[**2102-2-3**] he went to the operating room with thoracic surgery for
an open J-tube. He was transferred to the floor. His tube feeds
were switched from his dobhoff to his J tube which he tolerated
well. He was ready for discharge to rehab on POD #30.
Medications on Admission:
colace 100"
Pepcid 20"
Nystatin powder
lasix 20"
Heparin 5000 TID
Levaquin 500'
unasyn
Doxacycline
Fentanyl
Robitussin
Ativan/prn
Discharge Medications:
1. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
Disp:*30 Tablet,Rapid Dissolve, DR(s)* Refills:*0*
2. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: One (1) PO BID (2
times a day).
Disp:*QS 1 month* Refills:*0*
3. Ursodiol 300 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO BID (2 times
a day).
Disp:*60 Capsule(s)* Refills:*0*
4. Aspirin 81 mg Tablet, Chewable [**Last Name (STitle) **]: One (1) Tablet, Chewable
PO DAILY (Daily): NG. Tablet, Chewable(s)
5. Fluticasone 110 mcg/Actuation Aerosol [**Last Name (STitle) **]: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
6. Carvedilol 12.5 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times
a day). Tablet(s)
7. Lisinopril 5 mg Tablet [**Hospital1 **]: 0.5 Tablet PO DAILY (Daily).
8. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1)
Injection TID (3 times a day).
9. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol [**Hospital1 **]: Four
(4) Puff Inhalation Q4H (every 4 hours).
10. Methadone 5 mg/5 mL Solution [**Hospital1 **]: Twenty (20) mg PO twice a
day: wean as tolerated.
Discharge Disposition:
Extended Care
Facility:
[**First Name9 (NamePattern2) 44027**] [**Location (un) 5583**]
Discharge Diagnosis:
Endocarditis s/p AVR/MV patch and PPM. s/p Trach and Jtube
PMH:
Hepatitis C
IVDU
CHF
Aortic endocarditis
Discharge Condition:
Good.
Discharge Instructions:
Call with fever, redness or drainage from incisions.
Followup Instructions:
Hepatology - Follow up after discharge from rehab.
General Surgery at [**Hospital6 16029**] for chole tube
removal.
Cardiologist at [**Hospital6 16029**] 2-3 weeks
PCP after discharge from rehab
Dr [**Last Name (STitle) 914**] in 4 weeks
Completed by:[**2102-2-7**]
|
[
"746.4",
"518.81",
"305.1",
"576.8",
"263.9",
"398.91",
"427.5",
"493.90",
"287.5",
"421.0",
"570",
"995.92",
"396.2",
"070.70",
"112.2",
"482.83",
"305.50",
"512.1",
"584.5",
"038.49",
"382.01",
"511.9",
"426.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.50",
"99.07",
"34.91",
"37.89",
"99.60",
"37.77",
"96.6",
"99.05",
"33.24",
"99.15",
"46.39",
"38.95",
"39.95",
"96.05",
"35.21",
"31.1",
"35.12",
"99.04",
"88.72",
"34.09",
"00.12",
"38.93",
"96.72",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
12248, 12338
|
7302, 10845
|
335, 480
|
12487, 12495
|
1755, 2909
|
12596, 12863
|
1072, 1090
|
11025, 12225
|
2946, 2970
|
12359, 12466
|
10871, 11002
|
12519, 12573
|
3882, 7279
|
1105, 1105
|
282, 297
|
2999, 3856
|
508, 793
|
1119, 1736
|
815, 939
|
955, 1056
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,737
| 183,580
|
8964
|
Discharge summary
|
report
|
Admission Date: [**2138-6-7**] Discharge Date: [**2138-6-12**]
Date of Birth: [**2053-12-3**] Sex: F
Service: MEDICINE
Allergies:
Verapamil / Iodine-Iodine Containing / Zoloft / Atenolol /
Toprol XL / Norvasc / Pindolol / Zestril / Clonidine / Keflex /
Meclizine / Wellbutrin / Penicillins / Erythromycin Base
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
Lightheadedness
Fast heart rate
Major Surgical or Invasive Procedure:
Cardioversion
History of Present Illness:
Ms [**Known lastname 31125**] is a 84F with paroxysmal atrial fibrillation s/p
cardioversion x3 (last in [**2134**]), diastolic heart failure (EF
>55% via echo in [**2134**]) admitted to the CCU for management of
atrial fibrillation with rapid ventricular rate.
.
The patient noted a gradual onset of elevation in HR over the
last 1-2 weeks when checking her daily BP and HR. Her typical
HRs were in the 60s. In the last week, her HRs increased to the
80s and her rhythm was also noted to be irregular from the
monitor read. The morning of [**2138-6-7**] her HR was found to be in
the 110s-120s which prompted presentation to the ED. During
episodes of elevated rates, she reported feelings of dizziness,
lightheadedness as well chest tightness localized to under the
left arm.
.
Her lasix dose was increased from 20mg to 40mg daily for the
last 3 days after reporting elevated BPs to cardiologists
office.
.
She denied any associated nausea, vomiting and shortness of
breath, localising symptoms or infection, subjective fevers,
chills, abdominal pain, cough and diarrhoea.
.
On presentation to the ED, the patient was found to be in atrial
fibrillation and triggered for HRs in the 140s. She received
10mg IV dilt. She complained of dizziness and was found to be
hypotensive with SBPs in the 80s. She received 1L of IVF and
started on dilt ggt at a rate of 5mg/hr. EKG was consistent with
rapid atrial fibrillation with mild ST depressions in the
lateral leads. The first set of biomarkers were negative. She
received ASA 325mg. Prior to transfer, her vital signs were as
follows - HR: 129 in atrial fibrillation BP: 103/54 RR: 16
O2sat: 99% on 2L.
.
On arrival to the CCU, the patient was without complaint. The
lightheadness, dizziness and chest discomfort had largely
resolved.
.
On review of systems, she denied any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denied recent fevers, chills or
rigors. She denied exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems was notable for chest discomfort; but
she denied paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: -Diabetes, -Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
- Diastolic congestive heart failure
- Atrial fibrillation s/p cardioversion
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
- COPD
- Obstructive sleep-disordered breathing, mild - not on CPAP
- Diverticulosis
- Benign paroxysmal positional vertigo
- Anxiety
- Anemia
- Hyponatremia
- MSSA sepsis in [**2134-7-18**]
- Pneumonia (~[**2132**])
Social History:
Occupation: Retired.
Drugs: Denies.
Tobacco: Quit smoking 16 years ago with 80 pack-year history.
Alcohol: Social.
Other: Lives alone; completes all ADLs, walks with a cane on
left at baseline.
Family History:
- Father died of myocardial infarction in his 40s.
- Mother died of congestive heart failure at 88.
- Otherwise, no family history of arrhythmia, cardiomyopathies,
or sudden cardiac death; otherwise non-contributory.
Physical Exam:
On Admission:
VS: HR 105 in Atrial Fibrillation BP 90/52mmHg RR 16 SpO2 98% on
2LNC T 98.2
GENERAL: Alert, oriented, NAD. Oriented x3. Mood, affect
appropriate; speaking in full sentences without problem
[**Name (NI) 4459**]: [**Name (NI) 12476**]. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. OP clear without
exudates, lesions.
NECK: Supple with JVP of 9cm cm, no LAD.
CARDIAC: irreg, irreg, tachycardiac, normal S1, S2. No m/r/g. No
thrills, lifts. No S3 or S4. JVD with + HJR
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Mild bibasilar
crackles, R>L; no wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ DP dopp PT dopp
Left: Carotid 2+ Femoral 2+ DP dopp PT dopp
.
On Discharge:
VS: BP 110/80 mmHg 50-60s in NSR RR 16 SpO2 98% T 98.2
GENERAL: Alert, oriented, NAD. Oriented x3. Mood, affect
appropriate; speaking in full sentences without problem
[**Name (NI) 4459**]: [**Name (NI) 12476**]. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. OP clear without
exudates, lesions.
NECK: Supple without JVD, no LAD.
CARDIAC: RRR normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Mild bibasilar
crackles, no wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ DP dopp PT dopp
Left: Carotid 2+ Femoral 2+ DP dopp PT dopp
Pertinent Results:
Labs:
On Discharge: [**2138-6-12**] 06:05
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
7.4 3.73* 11.4* 33.4* 90 30.6 34.2 14.0 198
.
Glucose UreaN Creat Na K Cl HCO3 AnGap
103 18 1.0 133 4.5 97 30 11
.
ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili
13 27 158 67 52 0.4
.
Ddimer: <150
.
TSH: 8.6
Free T4: 6.0
.
Biomarkers:
CK-MB cTropnT proBNP
[**2138-6-9**] 05:32 5 0.14
ADDED CHEM 8:26AM
[**2138-6-8**] 04:34 10 0.12
[**2138-6-7**] 20:42 9 0.10
[**2138-6-7**] 14:05 <0.013
LIGHT GREEN TOP
[**2138-3-22**] 19:45 2686
[**2138-3-22**] 18:30 2742
micro:
[**2138-6-7**] 3:05 pm URINE Site: CLEAN CATCH
**FINAL REPORT [**2138-6-9**]**
URINE CULTURE (Final [**2138-6-9**]):
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Imaging:
CHEST (PORTABLE AP) ([**2138-6-7**] 2:16 PM)
The lungs are low in volume but clear. The cardiomediastinal
silhouette, hilar contours, and pleural surfaces are normal. The
aorta is unfolded with atherosclerotic calcification. No pleural
effusion or pneumothorax is present. A circular opacity over the
left upper lobe is likely external.
.
IMPRESSION:
No acute intrathoracic process.
.
ECHO Portable TTE (Focused views) ([**2134-7-27**] 2:56:24 PM)
The left atrium is moderately dilated. The estimated right
atrial pressure is 5-10 mmHg. Left ventricular wall thickness,
cavity size, and systolic function are normal (LVEF>55%). Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. 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 valve leaflets are mildly thickened. No
masses or vegetations are seen on the aortic valve. There is no
aortic valve stenosis. Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are structurally normal. No mass or
vegetation is seen on the mitral valve. Trivial mitral
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is an anterior space which most
likely represents a fat pad.
.
Compared with the prior study (images reviewed) of [**2134-7-14**],
estimated pulmonary artery systolic pressures are now higher.
There are no obvious vegetations are visualized. The severity of
mitral regurgitation is slightly reduced. The other findings are
similar.
.
ECG ([**2138-6-7**] 1:49:30 PM)
Atrial fibrillation with a rapid ventricular response.
Non-specific
ST-T wave changes but may be rate-related. Compared to the
previous tracing of [**2138-3-22**] the atrial fibrillation and the rapid
ventricular response are new.
TRACING #1
.
ECG ([**2138-6-7**] 9:49:56 PM)
Atrial fibrillation with a rapid ventricular response. Single
beats of aberrant conduction after long and short intervals
consistent with [**Last Name (un) 31129**] phenomenon. Compared to the previous
tracing the aberrancy is new and the rate has decreased.
TRACING #2
.
ECG ([**2138-6-8**] 4:34:46 AM)
Atrial fibrillation with rapid ventricular response.
Non-specific ST segment changes. Compared to tracing #2 no
significant difference.
TRACING #3
.
Portable TEE (Complete) ([**2138-6-9**] 9:40:00 AM)
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 right atrial appendage
ejection velocity is depressed (<0.2m/s). No atrial septal
defect is seen by 2D or color Doppler. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. There are complex
(>4mm), non-mobile atheroma in the aortic arch and descending
thoracic aorta. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Trivial mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. There is no pericardial
effusion.
.
IMPRESSION: No spontaneous echo contrast or thrombus in the
atria or atrial appendages. Mild aortic regurgitation. Complex
atheroma of the aortic arch and descending aorta.
Brief Hospital Course:
Ms [**Known lastname 31125**] is a 84y/o female with history of PAF s/p
cardioversion x3, diastolic heart failure (last LVEF>55% in
[**2134**]) presenting with chest discomfort admitted to the CCU for
evaluation and mgmt of Atrial Fibrillation with rapid
ventricular rate.
.
# Atrial Fibrillation with Rapid ventricular Rate. CHADS2 = 3.
Unclear precipitator to reversion to irregular rate. Patient
denies any history of insensible loss (decreased PO intake,
n/v/d/fever). Endorses that home lasix dose was recently
increased from 20mg->40mg daily x last 3-4 days however symptoms
onset preceded increased diuresis. Patient denies infectious
trigger - no fever, chills, or localizing complaints of
infection (cough, n/v/d, dysuria). Patient remained afebrile,
WBC wnl, UA clean, and CXR without infiltrate. Though patient
with h/o CHF did not appear in florid HF as precipitant to AF on
this admission. Regarding potential ischemic trigger, patient
did endorse intermittent upper chest discomfort as well as left
side chest tightness, 1st set of biomarkers negative, 2nd set
trop elevation to 0.10 likely secondary to demand. Lateral ST
depressions noted on admission EKG with rates in 140s resolved
with rate control. PE was thought to be clinically unlikely and
in this setting ruled out per d-dimer < 150.
Regarding rate control planned to increase nadolol but this was
kept at home dose given low BP??????s. Patient underwent successful
TEE/DC cardioversion with reversion to normal sinus rhythm.
Post-procedure patient was maintained on nadalol 10mg daily with
rates predominantly in the 50s-60s.
Regarding anticoagulation patient continued on home ASA 325mg.
Of note, during hospitalization team had extensive discussion
with patient regarding risks and benefits of anticoagulation
with coumadin, pradexa, or lovenox. After lengthy discussion
patient expressed reluctance to start any new medications and
refused Coumadin due to bleed in the past and apprehension
regarding monitoring of Coumadin.
OUTPATIENT ISSUES:
-- Continue nadolol; consider uptitration or BB if SBP and HRs
allow
-- Patient will plan to continue anticoagulation discussion
with outpatient cardiologist.
.
# CHF. Patient with history of diastolic heart failure. Last TTE
in [**2134**]. LVEF~55%, no WMA. Received ~1L of IVF in ED. Admission
exam consistent with mild volume overload: elevated JVP, +HJR,
mild bibasilar crackles. Patient without respiratory complaints
and saturating >95% on minimal O2 supplementation. In house
daily weights
and I/Os strictly monitoring. Diuresised with Lasix PO and IV
intermittently to meet fluid goals. TEE performed prior to
cardioversion demonstrated preserved EF. On day prior to
discharge patient noted to have bilateral crackles with
complaints of subjective SOB. Decision made to increase Lasix to
30mg PO QD x3 days for additional diuresis with plan to return
to 20mg QD thereafter.
OUTPATIENT ISSUEs:
-- Monitor daily weight
-- Continue diuresis with Lasix PO daily' 30mg x3days following
discharge with plan to decrease to 20mg QD thereafter
.
# HTN. Per patient history of labile blood pressures. Patient
initially relatively hypotensive in setting of Afib. After
cardioversion patient normotensive and continued on home
nadolol, [**Last Name (un) **] and lasix.
.
# COPD. No home oxygen requirement. Last PFTs with mild
obstructive defect. Patient continued on ipratroprium nebs prn.
Patient weaned off supplemental oxygen prior to discharge.
.
# Anxiety. On admission held home xanax in setting of relative
hypotensive. After resolution of Afib with RVR and hypotension
restarted home xanax.
Medications on Admission:
# Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain or fever.
# Valsartan 40 mg Tablet Sig: One (1) Tablet PO once a day.
# Nadolol 20 mg Tablet Sig: 0.5 Tablet PO QAM
# Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
# Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
# Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO BID (
# Alprazolam 0.25 mg Tablet Sig: 0.5 Tablet PO QHS (once a day
(at bedtime)) as needed for insomnia.
# Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID
Discharge Medications:
1. furosemide 20 mg Tablet Sig: 1-2 Tablets PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
2. nadolol 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
3. alprazolam 0.25 mg Tablet Sig: 0.5 Tablet PO at bedtime as
needed for insomnia.
4. alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO twice a day
as needed for anxiety.
5. benzonatate 100 mg Capsule Sig: One (1) Capsule PO twice a
day as needed for cough.
6. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO four times a
day as needed for pain.
7. ipratropium bromide 0.02 % Solution Sig: One (1) vial
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
8. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. valsartan 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Atrial fibrillation with rapid ventricular response
Acute on chronic diastolic congestive heart failure
Hypertension
Anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms [**Known lastname 31125**], it was pleasure taking care of you.
You were admitted to the CCU for management of your atrial
fibrillation with a fast heart rate. We cardioverted you back
into a normal sinus rhythm and adjusted your medicines to help
you stay in that rhythm.
You had developed congestive heart failure because of the high
heart rate and you were given some intravenous lasix to get rid
of the extra fluid. You need to weigh yourself every morning as
you have been doing. Call Dr. [**Last Name (STitle) **] if weight goes up more
than 3 lbs in 1 day or 5 pounds in 3 days. You should also
continue to check your pulse at home and call Dr. [**Last Name (STitle) **] if
you notice it is rapid or irregular. We discussed
anticoagulation of the blood with you and decided that you would
talk to Dr. [**Last Name (STitle) **] at your next visit.
You should take 1 1/2 tablets of lasix (30mg) for the next 2
days and then go back to 1 tablet (20mg). Dr. [**Last Name (STitle) **] may
further adjust this when you see him next week.
Followup Instructions:
Department: MEDICAL SPECIALTIES
When: MONDAY [**2138-6-23**] at 2:30 PM
With: DR. [**First Name8 (NamePattern2) 3688**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: MONDAY [**2138-6-23**] at 2:40 PM
With: [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern4) 2761**], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2138-6-13**]
|
[
"401.9",
"414.01",
"780.59",
"458.9",
"428.0",
"496",
"285.9",
"428.33",
"300.00",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"99.62"
] |
icd9pcs
|
[
[
[]
]
] |
15187, 15244
|
10132, 13758
|
479, 494
|
15413, 15413
|
5715, 5721
|
16672, 17323
|
3564, 3782
|
14402, 15164
|
15265, 15392
|
13784, 14379
|
15596, 16649
|
3797, 3797
|
2935, 3088
|
5735, 10109
|
408, 441
|
522, 2828
|
3811, 4784
|
15428, 15572
|
3119, 3337
|
2850, 2915
|
3353, 3548
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,880
| 182,925
|
38940
|
Discharge summary
|
report
|
Admission Date: [**2199-1-24**] Discharge Date: [**2199-1-26**]
Date of Birth: [**2119-3-22**] Sex: F
Service: MEDICINE
Allergies:
Nifedipine / Singulair
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
shortness of breath, fatigue
Major Surgical or Invasive Procedure:
none
History of Present Illness:
79 yo F with COPD, DMII, HTN who lives at [**Location **] presented to an OSH
early today with fever, increasing sputum production, and
shortness of breath. Per report, she has been having increased
shortness of breath and productive cough over the proceeding
week and was completing a course of Levofloxacin (started [**1-18**]).
The patient is unable to report why she was brought to the
hospital today and denies productive cough. She denies chest
pain, palpitations, fevers, chills, sweats, nausea, vomiting,
diarrha, dysuria. She has had no recent hospitalizations.
.
At [**Hospital1 **], she received albuterol/ipratropium nebs,
levofloxacin IV, methylprednisolone 250mg IV, morphine IV,
budesonide nebs. Due to persistent hypercarbia, she was
transferred to [**Hospital1 18**] for non-invasive ventilation when her ABG
was 7.36/61/98 on 2-4L NC. Most recent ABG at the time of
transfer to the [**Hospital1 18**]-[**Location (un) 86**]: 7.38/54/107/31.9.
.
On arrival to the [**Hospital Unit Name 153**], patient reports that she is uncertain
how she got to the hospital, but acknowledges 1 week of
shortness of breath and fatigue and a new scratchy sore throat.
Past Medical History:
Diabetes Mellitus Type II
Iron deficiency Anemia
Hypertension
COPD/Emphysema
Asthma
Anxiety
Arthropathy
CHF (EF unknown)
Social History:
Patient was a homemaker, raised 14 children. She now lives by
herself at [**Location (un) 1036**].
Tobacco: 45 pack years, quit 5-6 months ago
EtOH: None
Illicits: None
Family History:
NC
Physical Exam:
Vitals: T: BP:153/81 P:123 R:19 O2: 95% 2L
General: Alert, oriented (hospital, [**2199-1-21**]), in mild
respiratory distress sitting upright in bed (sleeps this way at
baseline)
HEENT: Sclera anicteric, MMD, oropharynx mildly erythematous
Neck: supple, JVP not elevated, no LAD
Lungs: Purse lipped breathing, deminished through out, prolonged
expiratory phase with diffuse expiratory wheezing, no rhonchi or
crackles
CV: Tachy, reg, heart sounds very distant
Abdomen: obese, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, 1+ edema to mid calf b/l,
no cynanosis or clubbing
Pertinent Results:
Labs: OSH
WBC 9.5 RBC 4.39 HGB 13.2 HCT 39.7 MCV 90.3 MCH 30.1 MCHC 33.4
PLT 190 RDWCV 14.0 SEG 74.8 [**Last Name (un) **] 11.2 MON 11.7 EO 2.1 BAS 0.3
.
INR 1.1 PTT 28
.
139 97 12
------------< 133
4.1 34.3 0.7
.
ABG 7.36/61/97
.
Lactate 1.0 Trop <0.01
Theophylline 8.5L
Brief Hospital Course:
Mrs. [**Known lastname **] is a 79 yo F with DMII, HTN, COPD who presented to the
[**Hospital Unit Name 153**] as an OSH transfer for 2 weeks of shortness of breath,
fever, and cough productive of yellow sputum.
.
At 03:15 on [**2199-1-26**], the patient was noted by her RN who was in
her room to begin seizing (no seizure history). She was given
Ativan 2 mg IV x 2, and found to be non-responsive. She was
noted to be desaturating, and given her DNI status, was placed
on a non-rebreather. An ABG done with the patient on the
non-rebreather showed a marked acidosis: 7.11/132/397/45. An EKG
done at that time showed NSR. The family was called. The
seizure was felt to be secondary to acidemia and hypercarbia vs.
PFO with embolus vs. mass lesion or other CNS event. Given the
goals of care decided by the patient's family, the patient was
made CMO later on [**2199-1-26**], and a morphine drip was initiated.
The patient expired at 3:05 PM on [**2199-1-26**] with her family
present.
.
Below is her detailed hospital course by problem.
.
She was found to be in respiratory distress with fever. She had
a h/o COPD/Asthma requiring oral steroids at home. Per
documentation, patient had a fever to 102, cough productive of
yellow sputum, and shortness of breath x 1 week for which she
completed a 5 day course of Levaquin without improvement in
symptoms. An ABG at OSH suggested chronic CO2 retention and a
CXR did not demonstrate a consolidation or infiltrate. Concern
for a pulmonary infection with resulting COPD exacerbation was
high at the time of admission. She was treated with steroids,
ipratropium and albuterol nebs, and antibiotics. Initially she
was placed on vancomycin and ceftrixone for HAP, but as culture
data was unrevealing, and our suspicion for CAP became higher,
these were switched to Azithromycin. The patient was doing well
on ICU day #2, with resolution of her fever and improvement in
her respiratory status.
.
On presentatation to the OSH, the patient was noted to be
tachycardic-and remained tachycardic here to the 120's. ECG
demonstrates sinus tachycardia. She did not receive any IVF's or
nodal agents at the OSH given concern for her uncertain h/o
heart failure. Her tachycardia seemed c/w COPD exacerbation with
possible concomitant infection, a repeat EKG showed no acute
changes. Her heart rate was noted to improve with resolution of
her fever and improvement of her respiratory status.
.
She was also hypertensive on presentation to 170's per report
from [**Hospital1 18**]-[**Location (un) 620**]. She did not receive any medication for her
hypertension and this was also noted to resolve with treatment
of her COPD exacerbation.
.
The patient was a type II diabetic: unknown HgbA1c.
Diet-controlled at home, but received high dose steroids at
[**Hospital1 18**]-[**Location (un) 620**] for COPD exacerbation, so was maintained on QACHS
fingersticks and Humalog SS.
.
CHF (EF unknown): Patient with unknown/uncertain history of
congestive heart failure. No recent echocardiograms, not on any
cardiac medications at home aside from a statin. ECG
demonstrates RBBB. She was continued on her home Zocor 10mg PO
qHS.
.
Communication: Patient & patient's daughters ([**Name (NI) **] [**Doctor Last Name 4048**] or [**First Name4 (NamePattern1) **]
[**Name (NI) **] [**Telephone/Fax (1) 86385**])
Medications on Admission:
Advair 250/50 [**Hospital1 **]
Spiriva 18mcg daily
Fortical 200u NAS daily
Senna 2 tabs qHS
Requip 0.5mg qHS
Zocor 10mg qHS
Colace 200mg PO qHS
Omeprazole 20mg PO daily
Multivitamin PO daily
Prednisone 5mg PO daily
Aspirin 81mg PO daily
Calcium 500 + D 1 tab [**Hospital1 **]
Vitamin B-12 1000mcg daily
Theophylline 100mg PO QID
Xopenex 1.25ml/3ml Neb PRN
Tylenol 650mg PO PRN
Milk of Magnesia PRN
Bisacodyl 10mg PR PRN
Fleet Enema PRN
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
hypercarbic respiratory failure
COPD
seizure
Discharge Condition:
expired
Discharge Instructions:
n/a
Followup Instructions:
n/a
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2199-1-26**]
|
[
"250.00",
"276.2",
"780.39",
"493.22",
"486",
"401.9",
"300.00",
"518.81",
"428.0",
"785.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6742, 6751
|
2893, 6227
|
319, 325
|
6839, 6848
|
2596, 2870
|
6900, 7070
|
1873, 1877
|
6714, 6719
|
6772, 6818
|
6253, 6691
|
6872, 6877
|
1892, 2577
|
251, 281
|
353, 1525
|
1547, 1670
|
1686, 1857
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,352
| 188,046
|
41264
|
Discharge summary
|
report
|
Admission Date: [**2172-4-25**] Discharge Date: [**2172-5-19**]
Date of Birth: [**2099-5-27**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Meropenem
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Hypoxemic respiratory failure
Major Surgical or Invasive Procedure:
[**2172-5-14**]
1. Aortic valve replacement with a 19-mm [**Doctor Last Name **] Magna Ease
aortic valve bioprosthesis.
2. Coronary artery bypass grafting x2 with left internal
mammary artery to left anterior descending coronary;
reverse saphenous vein single graft from the aorta to
the distal right coronary artery.
3. Duplex scan of the ascending aorta.
4. Endoscopic right greater saphenous vein harvesting
[**2172-5-9**] Full mouth dental extraction x10
[**2172-5-5**] Cardiac catheterization
History of Present Illness:
72 year old female with a history of aortic stenosis,
hypertension, hyperlipidemia who was in her usual state of good
health until today, when she developed the sudden onset of
shortness of breath and presumed neck and arm pain. Per her
husband, the patient awoke feeling well and ate breakfast of
cereal. They had planned to travel to [**State 108**] this evening on
9:30 PM flight and patient was discussing options for where to
go to dinner prior to flight. Mid-afternoon she was watching TV
on the couch when her husband heard her call from the other room
that she was having trouble breathing. He reports that she
repeated "I can't breathe" over and over, but had trouble
getting her words out. She also reported pain; he tried to ask
whether she had chest pain and she indicated that it was neck
and arm pain. He is not sure of further details because she was
too SOB to elaborate. He called 911, and an ambulance brought
her to [**Hospital3 **].
During the ambulance ride to [**Hospital3 4107**], she received a
duoneb and was then noted to go into respiratory arrest. Per
report, she lost her pulse and received 1 mg atropine, 1 mg
epinephrine, and approximately 1 minute of CPR. She then
recovered her pulse. She was placed on BiPAP and then intubated
on arrival to [**Hospital3 4107**]. She was able to respond to verbal
commands but attempted to remove tube and desatted twice. She
was given 8 mg Pavulon and placed in wrist restraints. She was
stabilized and transferred to [**Hospital1 18**]. On arrival to our ED, her
vitals were T 35.3, HR 91, BP 105/58, RR 18, O2 sat 100%
intubated on 100% FiO2. CTA was done to rule out PE, and was
negative. Her EKGs were evaluated by cardiology fellow [**First Name5 (NamePattern1) **]
[**Last Name (NamePattern1) 72656**] and did not show evidence of acute infarct. She remained
hemodynamically stable during her ED course. Vitals on transfer
to the floor were HR 85, BP 112/64, on assist control VT 450 x
rate 14, PEEP 5, FiO22 100%.
On arrival to the floor, the patient was sedated but responding
to commands. Review of systems was not possible at this time.
Remainder of medical history was per husband and discharge
summary from [**Name (NI) **] [**2168**].
Past Medical History:
Aortic stenosis
Hyperlipidemia
Hypertension (
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] syndrome
C-sections x 4
Social History:
Married 53 years, lives with husband [**Name (NI) 4559**]. Four children, two
sons have passed away. 2 daughters who are local, 7
grandchildren, 3 great-grandchildren. Ex-smoker, quit [**2146**] when
husband had CABG. Drinks alcohol socially, scotch and soda, [**3-19**]
drinks per occasion probably [**4-17**] nights a week.
Family History:
noncontributory
Physical Exam:
ADMISSION EXAM
GEN: Sedated and does not open eyes, but is following some
commands and shaking head; appears comfortable
HEENT: ET tube in place. Pupils unequal and not round, minimally
reactive to light. Very poor oral hygiene with marked
gingivitis and multiple missing teeth. Significant soft tissue
around jowls makes estimation of JVP extremely difficult.
RESP: Referred upper airway noise from ventillator heard
throughout; some dry rales bilaterally
CV: RRR, harsh 3/6 systolic ejection murmur radiating to
carotids
ABD: Soft, non-distended, no apparent TTP, +NABS
EXT: No significant peripheral edema, 2+ DP pulses bilaterally,
feet warm/well-perfused
SKIN: No rash
NEURO: Swueezing hands, wiggling toes though movements are very
weak (did receive paralytics earlier). Shakes/nods head in
response to some Qs.
Pertinent Results:
[**2172-5-19**] 04:25AM BLOOD WBC-16.6* RBC-2.80* Hgb-9.0* Hct-26.3*
MCV-94 MCH-32.2* MCHC-34.2 RDW-15.1 Plt Ct-305
[**2172-4-25**] 05:10PM BLOOD WBC-18.6* RBC-3.80* Hgb-12.2 Hct-35.8*
MCV-94 MCH-32.0 MCHC-34.1 RDW-13.6 Plt Ct-254
[**2172-5-13**] 05:25AM BLOOD Neuts-52.6 Lymphs-18.6 Monos-4.8
Eos-23.2* Baso-0.8
[**2172-4-26**] 03:24AM BLOOD Neuts-90.1* Lymphs-6.3* Monos-2.2 Eos-1.0
Baso-0.5
[**2172-5-19**] 04:25AM BLOOD Plt Ct-305
[**2172-4-25**] 05:10PM BLOOD PT-12.2 PTT-20.3* INR(PT)-1.0
[**2172-4-25**] 05:10PM BLOOD Plt Ct-254
[**2172-5-14**] 12:07PM BLOOD Fibrino-143*#
[**2172-5-19**] 04:25AM BLOOD Glucose-108* UreaN-20 Creat-1.2* Na-138
K-4.3 Cl-98 HCO3-32 AnGap-12
[**2172-5-18**] 05:40AM BLOOD Glucose-98 UreaN-21* Creat-1.2* Na-137
K-5.0 Cl-101 HCO3-31 AnGap-10
[**2172-4-26**] 03:24AM BLOOD Glucose-100 UreaN-19 Creat-0.9 Na-137
K-4.6 Cl-107 HCO3-22 AnGap-13
[**2172-4-25**] 05:10PM BLOOD UreaN-22* Creat-1.2*
[**2172-5-13**] 07:48PM BLOOD CK(CPK)-31
[**2172-5-5**] 11:30AM BLOOD ALT-12 AST-21 AlkPhos-60 TotBili-0.7
[**2172-4-26**] 03:24AM BLOOD CK(CPK)-66
[**2172-4-29**] 02:52PM BLOOD Lipase-58
[**2172-5-13**] 07:48PM BLOOD CK-MB-2 cTropnT-0.12*
[**2172-4-26**] 11:51PM BLOOD CK-MB-60* MB Indx-9.2* cTropnT-2.62*
[**2172-4-27**] 05:47AM BLOOD CK-MB-47* MB Indx-8.8* cTropnT-2.14*
[**2172-5-19**] 04:25AM BLOOD Mg-1.9
[**2172-5-5**] 11:30AM BLOOD %HbA1c-5.5 eAG-111
[**2172-5-1**] 05:16AM BLOOD Vanco-19.8
[**2172-4-25**] 05:10PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
URINE CULTURE (Final [**2172-5-15**]):
ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML..
YEAST. ~1000/ML.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ =>32 R
LINEZOLID------------- 1 S
NITROFURANTOIN-------- 128 R
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ =>32 R
INDICATION: 70-year-old woman status post CABG/AVR. Evaluate for
effusion.
COMPARISON: Multiple priors, most recent of [**2172-5-17**].
FRONTAL AND LATERAL VIEWS OF THE CHEST: Midline sternotomy wires
remain
intact. Aortic valve replacement is noted. There is a
moderate-sized
right-sided pleural effusion which appears stable in size with
adjacent
atelectasis. There is also linear atelectasis at the left lung
base with a
small pleural effusion. The lungs are otherwise clear. There is
no
pneumothorax. Cardiomegaly is stable. Heavily calcified aortic
knob is again
noted.
IMPRESSION: Moderate-sized right pleural effusion, unchanged in
size. Small
left sided pleural effusion.
Findings
Epiaortic ultrasound performed - some simple atheroma was seen
distal to intended cannulation site.
Multiplanar reconstructions were generated and confirmed on an
independent workstation.
LEFT ATRIUM: No spontaneous echo contrast in the body of the [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) **] LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Lipomatous hypertrophy of the
interatrial septum. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size.
Normal regional LV systolic function. Overall normal LVEF
(>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending aorta diameter. Simple atheroma in
ascending aorta. Normal aortic arch diameter. Simple atheroma in
aortic arch. Normal descending aorta diameter. Complex (>4mm)
atheroma in the descending thoracic aorta.
AORTIC VALVE: ?# aortic valve leaflets. Severely
thickened/deformed aortic valve leaflets. Critical AS (area
<0.8cm2). Mild (1+) AR.
MITRAL VALVE: Moderately thickened mitral valve leaflets.
Moderate mitral annular calcification. Mild thickening of mitral
valve chordae. Minimally increased gradient consistent with
trivial MS. Trivial MR.
PERICARDIUM: Small pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient.
Conclusions
Prebypass
No spontaneous echo contrast is seen in the body of the left
atrium or left atrial appendage. No atrial septal defect is seen
by 2D or color Doppler. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal.
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. There
are simple atheroma in the ascending aorta. There are simple
atheroma in the aortic arch. There are complex (>4mm) atheroma
in the descending thoracic aorta. The number of aortic valve
leaflets cannot be determined. The aortic valve leaflets are
severely thickened/deformed. There is critical aortic valve
stenosis (valve area <0.8cm2). Mild (1+) aortic regurgitation is
seen. The mitral valve leaflets are moderately thickened. There
is a minimally increased gradient consistent with trivial mitral
stenosis. Trivial mitral regurgitation is seen. There is a small
pericardial effusion.
Postbypass
The patient is on an infusion of phenylephrine. There is a
bioprosthetic valve in the aortic position which is well seated
with perivalvular leak or significant intravalvular
regurgitation. Gradients are peak/mean of 21/10 mmHg at a CO of
3.5 L/min. Biventricular systolic function is preserved. Mitral
regurgitation continues to be trace. The thoracic aorta is
intact post decannulation.
Brief Hospital Course:
72 F with critical AS and hypertension who presents with the
sudden onset of shortness of breath followed by out of hospital
cardiac arrest with hospital course complicated by NSTEMI and
hypoxemic respiratory failure.
# Hypoxemic respiratory failure: Patient presented in
respiratory distress likely in setting of flash pulmonary edema
from critical AS. In addition, patient was persistently febrile
for several days on admission, with sputum culture speciating
with MSSA for which she was treated with 7 days of vancomycin.
In addition, she received 7 days of meropenem empirically. The
patient while intubated was diuresed aggressively with a lasix
gtt.
# NSTEMI: Troponin peak 2.62 on [**4-26**] and subsequently
downtrended. Given MB elevation, this was felt by Cardiology to
represent ACS with plaque rupture, and the patient was treated
with ASA and heparin gtt. Clopidogrel was not started given
high likelihood for procedure.
# Hypotension: Patient hypotensive in setting of respiratory
failure requiring intubation and critical AS. Levophed weaned
off after intubation.
# Aortic stenosis: Critical as seen on cardiac cath.
# Fever/leukocytosis: Patient persistently febrile during
initial admission with leukocytosis. As above, treated with
vancomycin for 7 days for MSSA pneuomonia, and meroponem
empirically for 7 days. In addition, poor dentition was felt to
be a potential source, thus dental and OMS consulted. All teeth
were extracted. Patient developed drug rash, likely to either
meropenem/vancomycin. Eosinophilia and leukocytosis improved
after stopping antibiotics.
# Possible clavicle fracture: Noted on admission CXR. Will need
dedicated films after stabilization.
On [**2172-5-14**] was brought to the operating room for Aortic valve
replacement and coronary artery bypass graft surgery. See
operative report for further details. She was transferred to the
intensive care unit for hemodynamic management. In the first
twenty four hours she was weaned from sedation, awoke
neurologically intact and was extubated without complications.
She remained in the intensive care unit for respiratory and
renal management. She continued to progress and was ready for
transfer to the floor on post operative day three. Physical
therapy worked with her on strength and mobility. She continued
to progress and was ready for discharge home with services on
post operative day five.
Medications on Admission:
- Labetalol 200 mg once daily (note: [**Hospital1 **] on discharge from
[**Hospital1 **] [**2168**])
- Simvastatin 40 mg once daily
- Amlodipine 10 mg PO once daily
- Lisinopril 5 mg PO once daily
- Aspirin 325 mg PO daily
- Acetaminophen PRN (none recently)
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. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every four (4) hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
6. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*0*
8. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 7
days.
Disp:*7 Tablet(s)* Refills:*0*
9. Combivent 18-103 mcg/Actuation Aerosol Sig: Two (2)
Inhalation every 4-6 hours as needed for shortness of breath or
wheezing.
Disp:*1 inhaler* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Aortic stenosis s/p AVR
Coronary artery disease s/p CABG
Hypoxemic respiratory failure
Preop Pneumonia
Preop urinary tract infection VRE
Non-ST elevation myocardial infarction
Preop drug rash due to meropenum with eosinophila
Hypertension
Hyperlipidemia
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with percocet
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right - healing well, no erythema or drainage.
Edema +1 bilteral lower extremities
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr [**Last Name (STitle) 914**] [**Telephone/Fax (1) 170**] [**2172-6-16**] 1:15
Cardiologist: Dr [**Last Name (STitle) 10543**] [**6-24**] at 11:30
Wound check Appt: cardiac surgery office - [**Telephone/Fax (1) 170**] [**5-26**] at
11am
Please call to schedule appointments with your
Primary Care Dr [**Last Name (STitle) 6707**] [**Telephone/Fax (1) 14214**] in [**5-19**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2172-5-19**]
|
[
"478.19",
"E930.8",
"V12.54",
"401.9",
"458.8",
"584.9",
"E928.8",
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"424.1",
"288.3",
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"V12.53",
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"272.4",
"599.0",
"041.11",
"410.71",
"693.0",
"810.00",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"88.56",
"39.61",
"23.09",
"36.11",
"35.21",
"96.04",
"36.15",
"38.93",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
14006, 14061
|
10192, 12591
|
305, 824
|
14359, 14604
|
4462, 10169
|
15527, 16163
|
3591, 3608
|
12901, 13983
|
14082, 14338
|
12617, 12878
|
14628, 15504
|
3623, 4443
|
236, 267
|
852, 3072
|
3094, 3232
|
3248, 3575
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,321
| 122,388
|
9629
|
Discharge summary
|
report
|
Admission Date: [**2176-11-15**] Discharge Date: [**2176-11-17**]
Date of Birth: [**2092-9-8**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Demerol
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
left lower lobe nodule
Major Surgical or Invasive Procedure:
None
History of Present Illness:
84 year-old male with T2N0 squamous cell carcinoma s/p Right
upper sleeve lobectomy 07/[**2170**]. His Chest CT on [**2176-10-22**] showed
a new 9-mm nodule in the left lower lobe concerning for a
metachronous primary lung cancer.
Past Medical History:
Hypertension, Left bundle branch block, sleep apnea (not on
CPAP), CFI, hypothyroid, Non insulin diabetes mellitus, s/p
appendectomy, s/p Cholycystectomy. Left Ventricular ejection
fraction 59%, right upper lobe nodule for squamous cell cancer
Social History:
divorced, lives alone, 3 children, used to work as telephone
installer, + smoking history, social EtOH
Family History:
HTN, DM, CAD, no cancer
Physical Exam:
Vitals: Tm 98.6, Tc 98.6, HR 87, 132/53, RR 16, SO2 99% 3L, FSG
145
Gen: NAD
Cards: RRR
Pulm: RLL crackles, otherwise CTAB
Abd: Soft, nontender
Pertinent Results:
Labs:
[**2176-11-14**] 11:00AM BLOOD WBC-5.5 RBC-3.99* Hgb-13.0* Hct-36.8*
MCV-92 MCH-32.7* MCHC-35.4* RDW-13.1 Plt Ct-205
[**2176-11-17**] 07:15AM BLOOD WBC-11.9* RBC-3.49* Hgb-10.5* Hct-31.7*
MCV-91 MCH-30.0 MCHC-33.0 RDW-13.2 Plt Ct-182
[**2176-11-14**] 11:00AM BLOOD UreaN-18 Creat-1.8* Na-144 K-4.2 Cl-108
HCO3-29 AnGap-11
[**2176-11-17**] 07:15AM BLOOD Glucose-122* UreaN-24* Creat-1.5* Na-141
K-4.2 Cl-105 HCO3-27 AnGap-13
[**2176-11-15**] 03:48PM BLOOD Calcium-9.7 Phos-4.0 Mg-2.0
Imaging:
[**2176-11-15**] CXR: In comparison with study of [**2175-8-3**], there is
little change.
Specifically, there is no convincing evidence of aspiration at
this time.
[**2176-11-17**] CXR: 1. Status post surgery with volume loss on the
right. Bibasilar atelectasis and background COPD. Possible
background pulmonary hypertension. 2. No new patchy opacities to
confirm the presence of aspiration pneumonitis.
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the thoracic surgery service on
[**2176-11-15**] following his scheduled LLL wedge resection, which was
not performed due to an aspiration event in the OR upon
induction. Instead, he had a broncheoalveolar lavage and
bronchoscopy for his aspiration. He was initially admitted to
the SICU for close monitoring of his pulmonary status with
concern for aspiration pneumonitis. He was NPO and on IVFs. His
O2 sats remained stable throughout his ICU course and he was
transferred to the floor the next day. CXR on [**2176-11-16**] did not
show radiologic evidence of pneumonitis, but his O2 saturation
decreased to the 80s upon ambulation. Thus, it was decided not
to take him to the OR on Sunday to perform the previously
scheduled wedge resection. He was stable on 2L NC overnight on
the floor and had no symptomatic complaints and no shortness of
breath. He was started on a full liquid diet and advanced
quickly to a diabetic diet. His home medications were restarted
and his IVF stopped when he started PO. He ambulated without
difficulty and his pain was well controlled on minimal pain
medication. He was ready for discharge from the hospital on
[**2176-11-17**] to home with the plan to return in a couple weeks for
completion of his wedge resection at a future date.
Medications on Admission:
ATENOLOL 25 mg daily, CILOSTAZOL 100 mg [**Hospital1 **], GLIPIZIDE 5 mg
daily, LEVOTHYROXINE 137 mg daily, LISINOPRIL 10 mg daily,
SIMVASTATIN 40 mg daily
Discharge Medications:
1. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. cilostazol 100 mg Tablet Sig: One (1) Tablet PO twice a day.
3. glipizide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. levothyroxine 137 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
6. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Left lower lobe nodule, aspiration event
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 thoracic surgery service to have
surgery on your left lung. When you were going to sleep for
this surgery there was some question as to whether you may have
aspirated some fluid from your stomach. Because we want you to
be in the best shape possible before surgery, we decided to
postpone your surgery until a later date. Please follow up with
Dr. [**Last Name (STitle) **] at the below appointment regarding future
surgery.
No changes were made to your medications during this admission.
Please resume your home medications when you leave.
Thank you for letting us participate in your care. We wish you
a speedy recovery.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 3020**] Date/Time:[**2176-12-10**]
11:00
in the [**Hospital Ward Name 121**] Building [**Hospital1 **] [**First Name (Titles) **] [**Last Name (Titles) 479**] [**Hospital 7755**] CLinic
Report to the [**Location (un) **] Radiology Dept in the [**Hospital Ward Name 517**]
Clinical Center for a Chest X-Ray 30 minutes before your
appointment
Completed by:[**2176-11-18**]
|
[
"426.3",
"281.1",
"V10.11",
"250.00",
"493.00",
"518.89",
"585.9",
"327.23",
"403.90",
"244.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
4040, 4046
|
2106, 3420
|
298, 305
|
4131, 4131
|
1174, 2083
|
4993, 5433
|
970, 995
|
3626, 4017
|
4067, 4110
|
3446, 3603
|
4282, 4970
|
1010, 1155
|
236, 260
|
333, 566
|
4146, 4258
|
588, 834
|
850, 954
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,909
| 140,454
|
23400
|
Discharge summary
|
report
|
Admission Date: [**2189-11-12**] Discharge Date: [**2189-11-24**]
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
81 year old white femaole with chest pain, shortness of breath,
and known arotic stenosis.
Major Surgical or Invasive Procedure:
Cardiac catheterization
AVR w/ 19mm [**Doctor Last Name **] Lifescience pericardial valve [**2189-11-16**]
History of Present Illness:
81 y/o female with PMH sig for HTN and AS transferred from OSH
for cath. Pt was admitted to OSH [**11-9**] with CP, dyspnea and
presyncope. She had an echo at OSH showing severe AS. In light
of risks associated with stress in severe AS, she was
transferred to [**Hospital1 18**] for cath.
Pt recalls that on Monday [**2189-11-9**], she was walking up a ramp
with her son-in-law to get a flu shot. After this exertion, she
had sudden, excruciating CP, diaphoresis (no nausea) and SOB.
She believes that she may have syncopized (but no record of
this) as the next thing she knew, EMS had arrived. She has had
twinges of CP in the past, but never any severe pain such as
this, nor known hx of CAD.
Past Medical History:
PMH:
1) UGIB [**1-12**] PUD [**2183**]
2) ? Crohn's Dz, but has never had diarrhea or tx thereof.
3) AS
4) Steroid-induced DM
5) AFR [**1-12**] rhamdomyolysis
6) CRI
7) HTN
8) LE edema
9) OA
10) HOH
11) Hx of ascites with ? cirrhosis on CT [**2186**] per d/c summary,
pt unaware.
Social History:
SH: Widowed, lives with daughter, used to smoke 1ppd but quit 41
years ago (20ish pack years). Used to drink 1-2 drinks after
work, but ceased after dx of Crohn's "years ago." No IVDA.
Family History:
3 children, all healthy. [**Last Name (un) **] with CAD , deceased at 46. Mother
lived to 91. Father died in his 70's of "disease from
travelling"
Physical Exam:
PE: HR 80, BP 144/81/HR 22/ Sat 98% RA
Gen: Pleasant, elderly female, NAD, HOH
HEENT: Right proptosis, EOMI, PERRL, anicteric sclerae, b/l
arcus senilus. O/p clear, MMM, missing a tooth
Neck: No bruits, no LAD, supple
Heart: [**2-14**] HSM loudest over LSB but heard throughout the
precordium. RR, no rubs appreciated.
Lungs: CTAB
Abd: Obese, soft, NT/ND, NABS, no masses, no organomegaly
Ext: No LE edema, 2+ dps b/l. No groin bruit. No cyanosis or
clubbing.
Pertinent Results:
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2189-11-23**] 04:45AM 5.5 3.84* 12.0 33.8* 88 31.2 35.4* 14.4
116*
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2189-11-23**] 04:45AM 116*
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2189-11-23**] 04:45AM 96 38* 1.5* 137 3.5 96 35* 10
Brief Hospital Course:
The patient was admitted to [**Hospital Unit Name 196**] for cardiac catheterization
which revealed a right dominant system with mildly elevated
LVEDP, severe AS, trace MR, nl L ventricular systolic function
and by angiography:
LMCA: ostial 40-50%; distal 30%
LAD: D1 prox 70%
LCx: diffuse plaquing in AV groove to 30%; OM1 30-40%
RCA: mildly calcified; diffuse plaquing to 40% proximally
Dr. [**Last Name (STitle) **] was consulted and on [**2189-11-16**] she underwent AVR with
a 19mm [**Doctor Last Name **] Lifescience pericardial valve. Cross clamp time
was 69 minutes and total pump time was 96 mins. The patient was
transferred to the CSRU on Milrinone, Propofol, and Neo. She
required large amounts of volume on her post op night and a
bedside TEE revealed a very thickened, hyperdynamic ventricle
that was underfilled. Her pressors were discontinued and she
improved with volume. Her chest tubes were discontinued on
POD#1 and she was extubated on POD#2. She had a few episodes of
Afib, but remained in sinus rhythm on Amiodorone. She had her
pacing wires discontinued on POD#4 and continued to slowly
progress. POD#7 she was transferred to the floor and she was
discharge to rehab in stable condition on POD#8.
Of note, she had a low platelet count pre and postop, and had 2
negative HIT screens.
Medications on Admission:
Meds on transfer:
ECASA 325
SLNTG
Meds PTA:
Ecotrin 325 mg PO daily
Detrol
Toprol XL
Spironolactone
Celebrex
Doses unknown
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. Furosemide 40 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 7 days.
Disp:*14 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:*2*
4. Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day) for 5 days: Then decrease to 400 mg PO for 1 week,
then decrease to 200 mg PO qd after 400mg ad dose completed.
5. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO BID (2 times a day) for 7
days.
6. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
7. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 38**] Manor - [**Location (un) 38**]
Discharge Diagnosis:
Aortic stenosis
Coronary artery disease
s/p gastric ulcer with bleed
Crohn's disease
Chronic renal insufficiency
Discharge Condition:
Good.
Discharge Instructions:
Follow medications on discharge instructions.
You may not drive for 4 weeks.
You may not lift more than 10 lbs. for 3 months.
You should shower, let water flow over wounds, pat dry with a
towel.
Followup Instructions:
Make an appointment with Dr. [**Last Name (STitle) 42310**] for 1-2 weeks.
Make an appointment with Dr. [**Last Name (STitle) 13175**] for 2-3 weeks.
Make an appointment with Dr. [**Last Name (STitle) **] for 4 weeks.
Completed by:[**2189-11-24**]
|
[
"V12.79",
"593.9",
"414.01",
"997.1",
"401.9",
"V17.3",
"427.31",
"287.5",
"424.1",
"458.9",
"V15.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.13",
"37.23",
"35.21",
"99.05",
"99.61",
"88.53",
"88.56",
"39.61",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
5131, 5211
|
2769, 4085
|
361, 470
|
5367, 5374
|
2372, 2746
|
5618, 5868
|
1723, 1875
|
4259, 5108
|
5232, 5346
|
4111, 4111
|
5398, 5595
|
1890, 2353
|
231, 323
|
498, 1201
|
1223, 1504
|
1520, 1707
|
4129, 4236
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,928
| 190,130
|
45539
|
Discharge summary
|
report
|
Admission Date: [**2205-8-24**] Discharge Date: [**2205-8-27**]
Date of Birth: [**2128-9-19**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
Acute STEMI
Major Surgical or Invasive Procedure:
Cardiac catetherization
History of Present Illness:
76M with CAD s/p LAD cypher [**3-10**] p/w chest pain. He was in his
USOH free of anginal symptoms until today at roughly 10am when
he developed the acute onset of substernal chest pain radiating
to the L shoulder after vacuuming in his house. He states that
he became diaphoretic noting perspiration on his forehead and
mildly dyspneic and lightheaded, no palpitations. He took a NTG
SL without any change in his sx (he has never before needed a
NTG). His wife called for an ambulance and he arrived to the ED
within 1 hour of the onset of symptoms. Initial vitals in the
ED: t 96.6 p58 111/86 18 98RA. He was found to have ST
elevations V1-4 on the ECG, was started on heparin, integrilin,
given asa, plavix 600mg PO x1. He was sent to the cath lab where
he was found to have a TO LAD within the stent and unable to be
crossed, LCx was TO mid-vessel and RCA had no signifant disease.
POBA was used to treat diag and first septal. The pt tolerated
the cath without complications and was admitted to the CCU
service for monitoring overnight in the setting of STEMI.
.
On review of symptoms, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
.
Cardiac review of systems is notable for CP, dyspnea, and SOB as
per HPI. No orthopnea, ankle edema, palpitations, syncope or
presyncope.
Past Medical History:
CAD s/p LAD cypher [**3-10**]
hypertension,
hypotriglyceridemia,
back surgery [**09**] years ago,
arthroscopic surgery on the right knee in [**2197**],
sigmoid polyps and
UGIB [**2-8**] nsaids in [**2198**]
b/l hip replacement
Social History:
The patient is married, lives with his wife and works in sales
and marketing. He quit smoking 30 years ago and smoked one half
pack per day times 25 years. Occasional Etoh, no illicits. Walks
without need of cane or walker.
Family History:
Mother died at 83 of CHF and diabetes
Father died at 67 of MI
Brother died of MI in 50s
Physical Exam:
VS: T 97.8, BP 135/38, HR 61, RR 15, 98O2 % on 2L
Gen: WDWN middle aged male in NAD, resp or otherwise. Oriented
x3. Mood, affect appropriate. Pleasant.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP of 8 cm.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No S4, no S3.
Chest: Basilar crackles. No chest wall deformities, scoliosis or
kyphosis. Resp were unlabored, no accessory muscle use.
Abd: soft, NTND, No HSM or tenderness. No abdominial bruits.
Ext: No c/c/e. R groin small hematoma, No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Pertinent Results:
[**2205-8-24**] 05:56PM GLUCOSE-120* UREA N-12 CREAT-0.7 SODIUM-136
POTASSIUM-3.1* CHLORIDE-96 TOTAL CO2-30 ANION GAP-13
[**2205-8-24**] 05:56PM CK(CPK)-327*
[**2205-8-24**] 05:56PM CK-MB-54* MB INDX-16.5* cTropnT-0.24*
[**2205-8-24**] 05:56PM CALCIUM-8.7 PHOSPHATE-3.0 MAGNESIUM-2.3
CHOLEST-109
[**2205-8-24**] 05:56PM TRIGLYCER-164* HDL CHOL-35 CHOL/HDL-3.1
LDL(CALC)-41
[**2205-8-24**] 05:56PM WBC-9.8# RBC-4.11* HGB-13.6* HCT-36.7* MCV-89
MCH-33.1* MCHC-37.0* RDW-14.0
[**2205-8-24**] 05:56PM PLT COUNT-215
[**2205-8-24**] 05:56PM PT-11.8 PTT-29.1 INR(PT)-1.0
[**2205-8-24**] 11:45AM GLUCOSE-109* UREA N-17 CREAT-0.8 SODIUM-140
POTASSIUM-3.6 CHLORIDE-102 TOTAL CO2-32 ANION GAP-10
[**2205-8-24**] 11:45AM estGFR-Using this
[**2205-8-24**] 11:45AM cTropnT-<0.01
[**2205-8-24**] 11:45AM CK-MB-3
[**2205-8-24**] 11:45AM WBC-5.1 RBC-4.14* HGB-13.0* HCT-37.0* MCV-90
MCH-31.5 MCHC-35.2* RDW-14.0
[**2205-8-24**] 11:45AM NEUTS-65.1 LYMPHS-25.5 MONOS-6.7 EOS-2.2
BASOS-0.5
[**2205-8-24**] 11:45AM PLT COUNT-210
[**2205-8-24**] 11:45AM PT-11.8 PTT-29.0 INR(PT)-1.0
[**8-24**] CARDIAC CATH
Brief Hospital Course:
76 yo male with CAD (s/p cypher stent LAD [**2202**]), HTN,
hypercholesterolemia presents with substernal chest pain while
vacuuming.
.
Hospital course presented by problem.
.
#NSTEMI:
Patient initially presented to the ED w/ STEMI. He was given
ASA, plavix, heparin gtts, integrillin, and morphine. Patient
urgently underwent cardiac catheterization. An in-stent
thrombosis in the LAD was found but unable to be crossed. The
diagonal and first septal arteries were opened with angioplasty
but not stented. Afterwards, the patient remained chest pain
free and hemodynamically stable. Toprol Xl was titrated up and
he was put on his home dose [**Last Name (un) **] (valsartan) since he gets a
cough to ACE-I. An echocardiogram showed anterior LV
dysfunction and he was started on anticoagulation for this,
initially w/ heparin and coumadin and then bridged to a
therapeutic INR w/ lovenox 80 mg [**Hospital1 **]. His peak CK was 860. He
will see his Cardiologist Dr. [**Last Name (STitle) **] tomorrow in [**Location (un) 620**]. He
will take Toprol, valsartan, atorvastatin, aspirin, and plavix.
He was also evaluated by cardiothoracic surgery given his three
vessel disease; he will call to schedule an appointment with
them for a planned CABG in early [**Month (only) **].
.
#PUMP
Systolic dysfunction, EF ~45% as above. He remained
compensated.
.
#Rhythm
Post MI < 48 hrs patient had several episodes of NSVT however
these resolved over time and with beta blockade titration as
well as electrolyte repletion.
.
#Hyperlipidemia
Atorvastatin 80 mg was provided and should be continued as an
outpatient.
.
Patient remained hemodynamically stable and afebrile during
admission. He should follow up with Dr. [**Last Name (STitle) **] (cardiology),
his PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1699**], and CT surgery. He should continue to take
coumadin and have his INR followed by either his PCP or
cardiologist. He should no longer take norvasc or
hydrochlorothiazide. Aspirin was increased to 325 mg daily.
Beta blockade was increased to toprol xl 100 mg daily.
Atorvastatin was increased to 80 mg from 10 mg daily.
Medications on Admission:
Diovan/HCTZ 160/12.5'
Atenolol 50'
Lipitor 10'
Norvasc 5'
Aspirin 81
Discharge Medications:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Warfarin 5 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)).
Disp:*30 Tablet(s)* Refills:*2*
6. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
7. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous
[**Hospital1 **] (2 times a day) for 5 days.
Disp:*5 5* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary:
myocardial infarction
CAD - three vessel disease
HTN
hypercholesterolemia
Discharge Condition:
good
Discharge Instructions:
You were admitted to the hospital with a heart attack (ST
elevation myocardial infarction). You had a heart
catheterization which showed blockage of the LAD (left anterior
descending artery) as well as the other arteries of the left
coronary artery.
.
You should continue to take your medications as prescribed. You
will need to follow up the cardiothoracic surgeon as well as
your PCP and cardiologist.
.
If you have recurrent chest pain, shortness of breath, excessive
bleeding, you feel light-headed or dizzy with standing, or
bloody / dark black foul smelling stolls please return to the
emergency room or call your PCP.
Followup Instructions:
Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2205-9-12**]
10:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2205-9-12**] 11:00
.
Cardiothoracic Surgery - you must call to make an appointment
.
Primary care doctor
.
Cardiology - [**Doctor Last Name **], in [**Location (un) 620**]: ([**Telephone/Fax (1) 8937**], 3PM, [**2205-8-28**]
.
Cardiology
|
[
"V45.82",
"414.01",
"285.9",
"410.71",
"272.0",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.53",
"88.56",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
7580, 7638
|
4539, 6690
|
326, 351
|
7765, 7772
|
3396, 4516
|
8447, 8926
|
2447, 2537
|
6810, 7557
|
7659, 7744
|
6716, 6787
|
7796, 8424
|
2552, 3377
|
275, 288
|
379, 1939
|
1961, 2190
|
2206, 2431
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,684
| 148,216
|
35200
|
Discharge summary
|
report
|
Admission Date: [**2150-11-8**] Discharge Date: [**2150-11-20**]
Date of Birth: [**2086-7-10**] Sex: F
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Left hemiparesis, transfer from OSH as Code Stroke
Major Surgical or Invasive Procedure:
Cerebral angiography
Intubation/Extubation
History of Present Illness:
64 y LH Persian woman. According to her sister [**Name (NI) 17**], she was in
a car at 15:15 h, and then she had a sudden onset of a left
hemiparesis and left facial droop. She was taken to [**Hospital1 34585**]. She had an MRI imaging and was found to have a M1 R MCA
stroke. She was given IVtPA by Dr [**First Name (STitle) **] (Neurologist) around
17:56 h, and the time the IVtPA ended was 18:06 h. She was given
a 7 mg bolus followed by 63 mg over one hour. Ms [**Known lastname 80321**] is deaf,
and only understands sign language and her sister's Farsi. She
was confused and agitated when she was taken to the CT scanner
at 19:15 h at [**Hospital1 18**], and was intubated. She was transferred to
[**Hospital1 18**] for IAtPA ([**Hospital1 17436**] device), depending on the repeat CT head
scan.
Past Medical History:
1. Hyperthyroidism
2. Pruritic skin condition
3. Hyperlipidemia
Social History:
Lives with her sister [**Name (NI) 17**], who is also her health care
proxy (cell: [**Telephone/Fax (1) 80322**]).
Her PCP is Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11907**] ([**Hospital3 **])
Patient is deaf and she does not speak English
Family History:
Father died of an MI in his 50s
Physical Exam:
**NIHSS
1a LOC =0
1b Orientation =0
1c Commands =0
2 Gaze =1
3 Visual Fields =0
4 Facial Paresis =2
5a Motor Function R UE =0
5b Motor Function L UE=4
6a Motor Function R LE=0
6b Motor Function L LE=3
7 Limb Ataxia =0
8 Sensory perception =1
9 Language = 0
10 Dysarthria = 0
11 Extinction/Inattention = 1
TOTAL = 12
Vitals: T-98 BP-206/45 HR-97 RR-18 O2Sat 98% on room air
Gen: Lying in bed, obese, agitated, with multiple excoriations
on the arms, trunk and legs.
HEENT: NC/AT, moist oral mucosa
Neck: No tenderness to palpation, normal ROM, supple, no carotid
or vertebral bruit
Back: No point tenderness or erythema
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
aBd: +BS soft, nontender
ext: no edema
Neurologic examination:
Mental status: Awake and alert, difficult exam and her sister
was having to help with the translation and Ms [**Known lastname 80321**] was
agitated. She was able to relay her age, her birth day month
(which is [**Month (only) 956**] and not [**Month (only) **], but legally [**Month (only) **]), and was able
to identify a pen. There appeared to be a slight neglect on the
left side.
Cranial Nerves:
Pupils equally round and reactive to light, 4 to 2 mm
bilaterally. Visual field cut on the left, difficult to examine
fully due to the communication barrier. Extraocular movements
intact bilaterally, no nystagmus. Appears to have sensation
V1-V3. Extensive left sided facial droop. Deaf. Palate
elevation symmetrical. Sternocleidomastoid and trapezius normal
bilaterally. Tongue midline, movements intact.
Motor:
Normal bulk bilaterally. Tone normal. No observed myoclonus or
tremor
No pronator drift
[**Doctor First Name **] Tri [**Hospital1 **] WF WE FE FF IP H Q DF PF TE TF
R 5 5 5 5 5 5 5 5 5 5 5 5 5 5
L 2 2 2 2 2 2 2 1 1 1 1 1 1 1
Sensation: Difficult to assess: light touch, pinprick,
vibration, proprioception, or extinction to DSS
Reflexes: +2 on the left and 2 on the right, Babinski on the
left.
Coordination: did not cooperate
Gait: Could not assess due to her left hemiparesis.
Pertinent Results:
LABS:
[**2150-11-8**] 07:10PM BLOOD WBC-14.7* RBC-4.62 Hgb-12.9 Hct-37.9
MCV-82 MCH-27.9 MCHC-34.1 RDW-13.8 Plt Ct-360
[**2150-11-20**] 04:52AM BLOOD WBC-16.2* RBC-3.92* Hgb-11.0* Hct-31.7*
MCV-81* MCH-28.2 MCHC-34.8 RDW-14.3 Plt Ct-671*
[**2150-11-8**] 07:10PM BLOOD Neuts-80.6* Lymphs-15.5* Monos-2.1
Eos-1.4 Baso-0.4
[**2150-11-8**] 07:10PM BLOOD PT-13.1 PTT-24.8 INR(PT)-1.1
[**2150-11-20**] 04:52AM BLOOD PT-15.8* PTT-26.1 INR(PT)-1.4*
[**2150-11-8**] 07:10PM BLOOD Glucose-137* UreaN-24* Creat-1.0 Na-135
K-5.8* Cl-105 HCO3-21* AnGap-15
[**2150-11-20**] 04:52AM BLOOD Glucose-114* UreaN-16 Creat-0.7 Na-131*
K-4.4 Cl-97 HCO3-25 AnGap-13
[**2150-11-9**] 10:13AM BLOOD CK(CPK)-529*
[**2150-11-20**] 04:52AM BLOOD CK(CPK)-27
[**2150-11-9**] 10:13AM BLOOD cTropnT-<0.01
[**2150-11-20**] 04:52AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2150-11-8**] 07:10PM BLOOD Calcium-9.1 Phos-4.1 Mg-2.0
[**2150-11-9**] 10:13AM BLOOD Albumin-3.5 Calcium-7.9* Phos-3.2 Mg-1.9
Cholest-127
[**2150-11-9**] 10:13AM BLOOD Triglyc-606* HDL-39 CHOL/HD-3.3
LDLmeas-55
[**2150-11-9**] 10:13AM BLOOD %HbA1c-5.9
[**2150-11-9**] 10:13AM BLOOD TSH-1.9
[**2150-11-16**] 06:39PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.001
[**2150-11-16**] 06:39PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
[**2150-11-16**] 06:39PM URINE RBC-1 WBC-0 Bacteri-NONE Yeast-NONE Epi-0
[**2150-11-16**] 06:39PM URINE Hours-RANDOM Creat-6 Na-LESS THAN
MICRO:
Blood Cx ([**11-11**]): No growth
Urine Cx ([**11-11**]): STAPH AUREUS COAG +. >100,000 ORGANISMS/ML
Sputum Cx ([**11-11**]):
GRAM STAIN (Final [**2150-11-11**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>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 [**2150-11-13**]):
MODERATE GROWTH OROPHARYNGEAL FLORA.
STAPH AUREUS COAG +. MODERATE GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- 0.5 S
PENICILLIN G---------- =>0.5 R
TRIMETHOPRIM/SULFA---- <=0.5 S
Urine Cx ([**11-16**]): No growth
Stool Cx ([**11-18**]):
FECAL CULTURE (Pending):
CAMPYLOBACTER CULTURE (Pending):
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2150-11-19**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
IMAGING:
CTA head/neck (OSH) ([**11-8**]):
1. Dimminished perfusion in the right MCA territory with cutoff
of the right MCA M1 segment.
2. Abnormal right pharyngeal tonsil with masslike appearance.
ENT consultation suggested.
3. Abnormal multinodular thyroid gland.
MRI brain (OSH) ([**11-8**]): subtle restricted diffusion in the
right basal ganglia and insula. Impression: Right MCA territory
stroke.
CXR (OSH) ([**11-8**]): Impression: Findings consistent with
congestive heart failure.
CT Head/CTP ([**11-8**]): IMPRESSION: Increase in mean transit time
throughout the entire territory of the right MCA. Decrease in
blood volume and blood flow within the right putamen and globus
pallidus consistent with infarct in this area.
TTE ([**11-9**]): The left atrium is mildly dilated. No atrial septal
defect or patent foramen ovale is seen by 2D, color Doppler or
saline contrast at rest. The interatrial septum is bowed toward
the right atrium (c/w increased LA pressure). Left ventricular
wall thickness, cavity size and regional/global systolic
function are normal (LVEF >60%). Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic stenosis. Trace aortic regurgitation is seen. The mitral
valve appears structurally normal with trivial mitral
regurgitation. Moderate [2+] tricuspid regurgitation is seen.
There is moderate pulmonary artery systolic hypertension. There
is no pericardial effusion.
IMPRESSION: Moderate pulmonary artery systolic hypertension.
Moderate tricuspid regurgitation. These findings are c/w a
primary pulmonary process (e.g., pulmonary embolism,
bronchospasm, pneumonia, etc.).
MRI/MRA Head ([**11-9**]): IMPRESSION: Area of infarct of the right
putamen and globus pallidus and subsequent hemorrhagic
transformation. Small amount of surrounding edema with mass
effect on the right lateral ventricle without significant shift
of midline structures. Diffusion-weighted images are difficult
to interpret due to large amount of hemorrhage.
ECG ([**11-14**]): Atrial flutter with 2:1 block at a rate of 154.
There is ST segment depression in leads I, II, III, aVF and
V2-V6. This is consistent with diffuse ischemia.
Abdominal X-ray ([**11-16**]): IMPRESSION: No evidence of ileus or
bowel obstruction.
CXR AP ([**11-16**]): As compared to the prior radiograph, there has
been improved aeration in the lung bases with near resolution of
atelectasis. Left PICC line has apparently been repositioned,
with distal tip now at or just below the cavoatrial junction
(difficult to assess due to marked patient rotation). Heart size
is normal, and there is no evidence of congestive heart failure.
CT Head ([**11-19**]): IMPRESSION: Hemorrhagic conversion of known
right basal ganglia infarct is stable in size and appearance
from previous examination from [**2150-11-11**]. There is no progression
of hemorrhage. Followup as clinically indicated.
Brief Hospital Course:
1. Cardioembolic stroke-Right MCA territory with infarct of the
right putamen and globus pallidus and subsequent hemorrhagic
transformation, s/p hemorrhagic transformation. The patient
initially presented to [**Hospital6 1597**] with sudden onset
left hemiparesis and left facial droop. CTA head/neck (OSH)
showed diminished perfusion in the right MCA territory with
cutoff of the right MCA M1 segment. MRI brain showed subtle
restricted diffusion in the right basal ganglia and insula. She
was bolused IV tPA and transferred to [**Hospital1 18**]. At [**Hospital1 18**], CTP
showed increase in mean transit time throughout the entire
territory of the right MCA, decrease in blood volume and blood
flow within the right putamen and globus pallidus consistent
with infarct in this area. She was intubated and sent for
cerebral angiography, where she recived IA tpa (6mg) and MERCI
retrival with partial recanlization of MCA noticed except
inferior branch. She received nitroglycerine for vasospasm,
however again during the procedure M1 reocculded and another
trial of MERCI retrievial done, then penumbra was succesful in
in opening up MCA. She was transferred to the NeuroICU.
TTE showed LVEF >60%, no ASD or PFO, moderate [2+] tricuspid
regurgitation. Repeat MRI/A brain showed area of infarct of the
right putamen and globus pallidus and subsequent hemorrhagic
transformation, small amount of surrounding edema with mass
effect on the right lateral ventricle without significant shift
of midline structures. Repeat Head CTs showed stable size and
appearance of the hemorrhagic transformation.
While in the NeuroICU, she was found to be in atrial
fibrillation/atrial flutter (see below). Given that her stroke
was likely cardioembolic, she was started on Coumadin. She will
follow up with Dr. [**First Name8 (NamePattern2) 2530**] [**Name (STitle) **] in Neurology as an outpatient.
2. Atrial fibrillation/flutter: While in the NeuroICU, she was
found to be in atrial fibrillation/flutter with rapid
ventricular response. This is the most likely cause of her
stroke. She initially required Esmolol IV, Diltiazem gtt, and
Amiodarone gtt. Cardiology was consulted, and they recommended
to continue rate conrol with Diltiazem and discontinue
amiodarone gtt. Elecrophysiology was also consulted, and
determined that presumably the stroke was due to conversion of
atrial fibrillation to sinus rhythm. They also recommended
discontinuation of amiodarone gtt, and to rate control with
Diltiazem. They did not want to convert her to sinus ryhthm for
now as that would be greater risk for embolic phenomenom. If she
converts to normal sinus rhythm by herself, can consider
antiarrythmic at that time to keep her in sinus rhythm. She was
started on Metoprolol 75 mg PO q8, Diltiazem 90 mg qid, and
Coumadin. She should have INRs checked frequently until INR is
at the goal of 2.0-3.0. She will follow up with Dr. [**Last Name (STitle) **] in
Cardiology as an outpatient.
3. Hyperlipidemia/Hypertriglyceridemia: FLP: Chol 127, TG 606,
HDL 39, LDL 55. She was started on Tricor 48 mg daily, increased
Simvastatin to 40 mg qhs. She should have a repeat fasting lipid
panel 6 weeks after discharge.
4. MSSA Pneumonia and Urinary Tract Infection: Her WBC was 14.7
on admission with 81% neut/16% lymphs, and should continue to be
trended after discharge. Blood culture showed no growth. Urine
culture showed Staph aureus coag +, and sputum cx showed 4+
MSSA, 2+ GNRs. She was intially on Ciprofloxacin, but this was
changed to Ceftriaxone 1 gm IV daily to complete a 7 day course.
Repeat urine culture showed no growth. Stool culture was
negative for C. diff, but fecal and campylobacter cultures were
pending at the time of discharge. WBC was 16.2 at the time of
discharge.
5. Hyperthyroidism: TSH 1.9. She was continued on Methimazole 10
mg daily.
6. Abnormal right pharyngeal tonsil with masslike appearance.
She was scheduled an appointment with ENT for follow up as an
outpatient.
Medications on Admission:
1. Methimazole 10 mg Qday
2. Hydroxyzine 20 mg [**Hospital1 **]
3. Simvastatin 20 mg Qday
4. Naproxen 500 mg [**Hospital1 **]
([**Location (un) 535**] contact[**Name (NI) **] for current medication list).
Discharge Medications:
1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
2. Methimazole 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Hydroxyzine HCl 10 mg Tablet Sig: Two (2) Tablet PO twice a
day.
4. Fenofibrate Micronized 48 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. Diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
6. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO Q
8H (Every 8 Hours).
7. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4
PM.
8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
9. Outpatient Lab Work
Check INR daily until is therapeutic (goal [**2-15**])
10. Outpatient Lab Work
You should have a repeat fasting lipid panel (cholesterol,
triglycerides, HDL, LDL) checked in 6 weeks on [**2150-12-28**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
PRIMARY:
Cardioembolic stroke-Right MCA territory with infarct of the
right putamen and globus pallidus and subsequent hemorrhagic
transformation, s/p hemorrhagic transformation
Atrial fibrillation/flutter
Hyperlipidemia
Hypertriglyceridemia
MSSA Pneumonia and Urinary Tract Infection
SECONDARY:
Hyperthyroidism
Abnormal right pharyngeal tonsil with masslike appearance.
Discharge Condition:
Does not speak, flattening of left NLF, lifts right UE and LE
against gravity, does not withdraw LUE to noxious, triple flexes
her LLE to noxious, regaining some tone in her LUE and LLE
Discharge Instructions:
You were admitted to the hospital with left sided weakness, and
were found to have a stroke. You received IV tPA, and when
transferred to [**Hospital1 18**] underwent a cerebral angiography for IA tPA
and clot retrieval. You were initially admitted to the NeuroICU
for close monitoring, and you were found to have some bleeding
around the area of the stroke. You were also found to have
atrial fibrillation and atrial flutter, and this heart rhythm
was likely the cause of your stroke. You were started on
medications to slow your heart rate. You were found to have
elevated triglycerides, and were also started on a medication
for that. You also developed a urinary tract infection and
pneumonia, and were treated with 7 days of antibiotics.
The following changes were made to your medications: Your
Simvastatin was increased to 40 mg daily. You were started on
Tricor 48 mg daily. You were started on Diltiazem 90 mg four
times a day and Metoprolol 75 mg three times a day. You were
started on Coumadin 3 mg daily, and should have your INR checked
daily until you reach your goal INR [**2-15**].
If you develop weakness or numbness, decreased vision or double
vision, difficulty speaking or swallowing, fevers/chills,
diarrhea, cough, or pain/burning on urination, call your PCP or
return to the ED.
Followup Instructions:
You have a follow up appointment with Dr. [**First Name (STitle) **] [**Name (STitle) **] in ENT
([**Telephone/Fax (1) 2349**]) on [**2150-12-16**] at 10:00 am for the masslike
appearance of your right pharyngeal tonsil on CTA. The address
is [**Location (un) **]. in [**Location (un) 55**]. You will need to get a
referral from your primary care physician for this appointment.
You have a follow up appointment with Dr. [**First Name8 (NamePattern2) 2530**] [**Name (STitle) **] in
Neurology ([**Telephone/Fax (1) 44**]) on [**2150-12-21**] at 2:30 in the [**Hospital Ward Name 23**]
Center, [**Location (un) 858**].
You have a follow up appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in
Cardiology ([**Telephone/Fax (1) 3342**]) on [**2151-1-1**] at 3:20 in the [**Hospital Ward Name 23**]
Center, [**Location (un) **].
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
|
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"041.11",
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"342.90",
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icd9cm
|
[
[
[]
]
] |
[
"88.41",
"38.93",
"96.71",
"99.10"
] |
icd9pcs
|
[
[
[]
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] |
14968, 15038
|
9874, 13852
|
367, 412
|
15454, 15642
|
3816, 9851
|
16994, 17953
|
1631, 1665
|
14107, 14945
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15059, 15433
|
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15666, 16971
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277, 329
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440, 1243
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2854, 3797
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2466, 2838
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2451, 2451
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1265, 1331
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1347, 1615
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,035
| 133,130
|
8515
|
Discharge summary
|
report
|
Admission Date: [**2123-8-1**] Discharge Date: [**2123-8-3**]
Date of Birth: [**2065-9-23**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
ARF, hypoglycemia, SBO
Major Surgical or Invasive Procedure:
None
History of Present Illness:
57 yo male with h/o EtOH cirrhosis s/p Liver Tx in [**2118**] c/b 2
cardiac arrests and biliary leak. On routine MRI screening in
[**5-20**], pt was noted to have mult liver lesions and dx'd with HCC.
Now s/p 2 chemo rx (cisplatin and gemcitabine) most recently 9
days ago. Pt c/o 2 days of n/v, "26 episodes in 30 hrs." Unable
to tolerate any POs x 2 days. Decrease stool output, most
recent BM 1 day ago. + flatus. Continued to take medications as
prescribed, went to OSH and found to have FS 12 and briefly
unresponsive. Pt describes several episodes of hot flashes over
past 24hrs. Per pt [**Name (NI) 13866**] x 2 days 80-90s.
.
-- Had KUB with dilated loops at OSH today. episode of
unresponsiveness with FSG of 12 in ER at OSH. Started on D10
gtt, octreotide gtt, and given 1g ceftriaxone in [**Hospital1 18**] EW.
.
Admitted to the [**Hospital Unit Name 153**], evaluated by Transplant Sx. and Hemo Onc.
and toxicology. All agreed that he had SBO and that his
hypoglycemia was likely due to sulfonylurea toxicity in the
setting of diminshed clearence from renal insufficiency. He was
maintanined NPO, with NG tube to suction, and placed on a D20
gtt. He underwent paracentesis to evaluate for SBP and result
is negative, but cultures pending. Tox. recommended
alkylinization of the urine, and he was gently hydrated. His BG
normalized, and the SBO resolved. At the time of transfer to
the OMED service, he in normo to hyperglycemic, being covered on
a sliding scale. His diet has been advanced to low sodium
solids, and he is ambulating and moving his bowels. Finally, he
has experienced a drop in hct from baseline with Guaiac positive
stools, without evidence of [**Known firstname **], active bleeding.
Past Medical History:
PAST MEDICAL HISTORY:
1. OLT in [**2118**] [**2-17**] EtOH cirrhosis
2. Diabetes Mellitus II.
3. Chronic renal failure. In [**2118**], his creatinine by the
patient's report was up to 5 or 6 he was considered for a joint
kindey/liver transplant. As the kidney was not available at the
time of transplant, he only recieved a liver. His creatinine
more recently has been 1.3-1.7 range.
4. Hypercholesterolemia
5. A fib/a flutter status post ablation.
6. EF=70%.
7. EGD [**8-19**] showed a three- to four-millimeter nodule at 35 cm
in the esophagus. Biopsy showed squamous papilloma.
Social History:
He has a 46-pack a year smoking history. He was
a prior heavy drinker. He quit in [**2115**]. He is married, with
three children. He was in [**Hospital1 1474**]. He is on disability. He
was
a former [**Hospital1 **] carpenter.
Family History:
Mother had coronary artery disease. Sister has
diabetes. Father had diabetes and esophageal cancer (smoker).
Physical Exam:
97 88 163/70 13 96 RA
NAD
Obese
Alert, oriented, pleasant - sitting on edge of bed
EOMI, non-icteric
Habitus makes evaluation of JVP difficult
RRR 3/6 HSM no rubs or gallop
Poor air movement throughout, diffuse expiratory wheezes
Abdomen obese, distended, but non-tender.
Trace LE edema
Ambulatory independently.
Pertinent Results:
RADIOLOGY:
CT abd/pelvis ([**8-1**]):
1. A few prominent loops of small bowel consistent with partial
small-bowel obstruction. G-tube is in place.
2. Heterogeneous appearance of the liver, consistent with the
given history of liver cancer. Assessment of disease
progression cannot be made due to the lack of IV contrast.
3. Interval increase in the ascites
[**2123-8-3**] 06:15AM BLOOD WBC-4.6 RBC-3.24* Hgb-9.0* Hct-27.5*
MCV-85 MCH-27.7 MCHC-32.6 RDW-15.7* Plt Ct-141*
[**2123-8-2**] 10:33PM BLOOD Hct-26.2*
[**2123-8-2**] 04:17AM BLOOD WBC-4.2 RBC-3.25* Hgb-9.0* Hct-26.9*
MCV-83 MCH-27.8 MCHC-33.6 RDW-15.4 Plt Ct-95*
[**2123-8-1**] 08:14AM BLOOD WBC-3.2* RBC-3.56* Hgb-9.8* Hct-29.8*
MCV-84 MCH-27.4 MCHC-32.8 RDW-15.1 Plt Ct-71*
[**2123-8-1**] 06:40AM BLOOD WBC-3.1* RBC-3.53* Hgb-9.7* Hct-29.4*
MCV-83 MCH-27.4 MCHC-32.9 RDW-15.3 Plt Ct-65*
[**2123-7-31**] 10:32PM BLOOD WBC-3.1* RBC-3.44* Hgb-9.7* Hct-28.7*
MCV-83 MCH-28.2 MCHC-33.8 RDW-15.3 Plt Ct-60*#
[**2123-8-1**] 08:14AM BLOOD Neuts-55 Bands-3 Lymphs-34 Monos-6 Eos-1
Baso-0 Atyps-1* Metas-0 Myelos-0 NRBC-5*
[**2123-8-1**] 06:40AM BLOOD Neuts-61.8 Bands-0 Lymphs-34.7 Monos-2.9
Eos-0.4 Baso-0.3
[**2123-7-31**] 10:32PM BLOOD Neuts-67 Bands-1 Lymphs-25 Monos-4 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-1* Hyperse-2* NRBC-1*
[**2123-8-1**] 08:14AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-NORMAL
Macrocy-2+ Microcy-NORMAL Polychr-1+
[**2123-8-1**] 06:40AM BLOOD Hypochr-NORMAL Anisocy-3+ Poiklo-NORMAL
Macrocy-2+ Microcy-2+ Polychr-1+ Target-1+
[**2123-7-31**] 10:32PM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-NORMAL
Macrocy-NORMAL Microcy-1+ Polychr-NORMAL Ovalocy-OCCASIONAL
Target-OCCASIONAL
[**2123-8-3**] 06:15AM BLOOD Plt Ct-141* LPlt-1+
[**2123-8-2**] 04:17AM BLOOD Plt Smr-LOW Plt Ct-95*
[**2123-8-2**] 04:17AM BLOOD PT-13.3 PTT-23.6 INR(PT)-1.2
[**2123-8-1**] 08:14AM BLOOD Plt Smr-LOW Plt Ct-71*
[**2123-8-1**] 08:14AM BLOOD PT-12.9 PTT-20.9* INR(PT)-1.1
[**2123-8-1**] 06:40AM BLOOD Plt Smr-LOW Plt Ct-65*
[**2123-8-1**] 06:40AM BLOOD PT-13.9* PTT-21.2* INR(PT)-1.3
[**2123-7-31**] 10:32PM BLOOD Plt Smr-VERY LOW Plt Ct-60*#
[**2123-7-31**] 10:32PM BLOOD PT-12.3 PTT-20.2* INR(PT)-1.0
[**2123-8-1**] 08:14AM BLOOD FDP-10-40
[**2123-8-1**] 08:14AM BLOOD Fibrino-576* D-Dimer-5958*
[**2123-8-3**] 06:15AM BLOOD Glucose-110* UreaN-53* Creat-1.8* Na-134
K-4.6 Cl-99 HCO3-23 AnGap-17
[**2123-8-2**] 04:17AM BLOOD Glucose-130* UreaN-59* Creat-2.1* Na-133
K-4.3 Cl-98 HCO3-23 AnGap-16
[**2123-8-1**] 03:37PM BLOOD Glucose-202* UreaN-61* Creat-2.2* Na-128*
K-5.3* Cl-93* HCO3-22 AnGap-18
[**2123-8-1**] 12:35PM BLOOD Glucose-227* UreaN-62* Creat-2.1* Na-129*
K-5.2* Cl-94* HCO3-20* AnGap-20
[**2123-8-1**] 08:14AM BLOOD Glucose-143* UreaN-63* Creat-2.0* Na-130*
K-3.8 Cl-95* HCO3-21* AnGap-18
[**2123-8-1**] 06:40AM BLOOD Glucose-32* UreaN-64* Creat-1.9* Na-131*
K-3.5 Cl-95* HCO3-21* AnGap-19
[**2123-7-31**] 10:32PM BLOOD Glucose-43* UreaN-69* Creat-2.0* Na-133
K-3.8 Cl-96 HCO3-21* AnGap-20
[**2123-8-2**] 04:17AM BLOOD ALT-108* AST-156* LD(LDH)-307*
AlkPhos-341* Amylase-33 TotBili-1.0
[**2123-8-1**] 08:14AM BLOOD ALT-101* AST-185* LD(LDH)-300*
AlkPhos-348* TotBili-1.1
[**2123-8-1**] 06:40AM BLOOD ALT-106* AST-191* AlkPhos-368* Amylase-40
TotBili-1.1
[**2123-7-31**] 10:32PM BLOOD ALT-97* AST-178* AlkPhos-354* Amylase-41
TotBili-1.0
[**2123-8-3**] 06:15AM BLOOD Calcium-8.2* Phos-2.9 Mg-1.5*
[**2123-8-2**] 04:17AM BLOOD Albumin-3.0* Calcium-8.2* Phos-4.0
Mg-1.3*
[**2123-8-1**] 03:37PM BLOOD Calcium-7.9* Phos-4.4 Mg-1.3*
[**2123-8-3**] 06:15AM BLOOD FK506-2.8*
[**2123-8-1**] 08:14AM BLOOD FK506-3.1*
[**2123-8-1**] 08:06AM BLOOD FK506-3.9*
[**2123-8-1**] 06:40AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG
[**2123-8-1**] 07:06AM BLOOD Lactate-1.9
[**2123-7-31**] 10:56PM BLOOD Lactate-3.1*
[**2123-8-1**] 07:59AM BLOOD C-PEPTIDE-PND
Brief Hospital Course:
57 y/o M with HCC s/p liver transplant in [**2118**], transferred from
[**Hospital Unit Name 153**]. Pt admitted w/ hypoglycemia from sulfonylurea toxicity
[**2-17**] [**Doctor First Name 48**], SBO (resolved), HCC (on chemo), and OLT (on immune
suppression).
.
1) Hypoglycemia ?????? BS down to a min of 12 at OSH, received
multiple amps D50, octreotide. Best theory is that w/decreased
PO, N/V patient became pre-renal and had increased increased
serum sulfonylurea [**2-17**] decreased renal clearance. Pt was DCed
from [**Hospital Unit Name 153**] to OMED normo- to hyper-glycemic, and covered on SSI
to which he again became hypogylcemic to 26 on the day of
admission. The OMED team discussed at length with the patient
the importance of remaining inpatient for further titration of
his DM regimen, but he insisted on departure. He is not open to
insulin. We suggested instead DCing all anti-hyperglycemics
until his appointment on Fri; he was not open to this as he
feels that other providers will use his ensuing hyperlycemia as
justification for parenteral insulin. He did agree to decrease
his glyburide to 2.5 QD and to call Dr. [**First Name (STitle) **] immediately for
any BG <50. He complained that he sometimes cannot reach a
doctor [**First Name (Titles) **] [**Last Name (Titles) **] clinic; his PCP will serve as a backup-call
for hypoglycemia and I have given him my phone number as another
backup.
.
2) Anemia ?????? baseline Hct 34, drop from 29.8 to 26.9 since
admission, but then stable. Did have guaiac (+) stools. [**Month (only) 116**]
also have component of anemia [**2-17**] past chemo. Hemolysis labs and
tbili normal. Remained stable until DC; to be rechecked in
clinic on Fri
.
3) HCC ?????? S/P liver transplant, s/p chemo for HCC, now with
recurring ascites. Diagnostic / therapeutic paracentesis on [**8-1**]
no SBP by cell counts & chemistries, cultures ngtd on DC.
-- RUQ U/S scheduled as outpt on [**8-12**]
-- ascites fluid cultures to be followed at clinic on Fri
-- continue immunosuppresant meds
.
4) CRI ?????? baseline Cr 1.2-1.7, to peak 2.2 then decreased to 1.8
on DC. Likely combo of nephropathy, chemo and pre-renal. Will
recheck chemistries in clnic on Fri.
.
5) Asthma - Managed inpatient on nebs of atrovent standing and
PRN albuterol. Pt was anxious for DC and did not wait for
scripts for OP bronchidaltors. Recommend standing inhaled
steroid or ipratropium puffers at OP appt Fri.
.
6) N/V ?????? likely [**2-17**] past chemo, though did have dilated loops of
bowel by abd film. Now tol PO intake, moving bowels, and flatus.
.
7) FEN ?????? low Na diet ad lib given; lytes repleted PRN
.
8) Proph ?????? PPI, pneumoboots were used while inpatient
.
9) Access ?????? 1 PIV, removed on DC
.
10) Dispo ?????? Home on [**8-3**] per compromise between patient and
attending. Pt and family voiced agreement to call for any
hypoglycemia. Pt and family verbalized understanding of the
risks of DC at this time given hypoglycemia and renal failure.
.
11) Code: Full throughout hospital stay
.
12) Comm ?????? pt and wife
Medications on Admission:
1. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO BID (2 times
a day).
2. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Mycophenolate Mofetil 500 mg Tablet Sig: Four (4) Tablet PO
BID (2 times a day).
4. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Lansoprazole Oral
6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
9. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
10. Lisinopril 10 QD
11. Amitryptiline 50 QD
Prograf 2 [**Hospital1 **]
cellcept [**2118**] [**Hospital1 **]
lasix 120 qd
Discharge Medications:
1. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO BID (2 times
a day).
2. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Mycophenolate Mofetil 500 mg Tablet Sig: Four (4) Tablet PO
BID (2 times a day).
4. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Lansoprazole Oral
6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
9. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Acute renal failure, hypoglycemia
Discharge Condition:
Fair
Discharge Instructions:
Please take all medications as directed. Please take your blood
sugars at each meal and at hour of sleep and record in a log
which you should take to appointments with doctors. At length,
we have advised you to stay one more day to monitor your blood
glucose and kidneys; you have agreed to call Dr. [**First Name (STitle) **] with any
blood glucose less than 50 and to decrease your glyburide to
once per day. You have agreed to discuss your blood glucose
further with your PCP.
Followup Instructions:
Provider [**First Name11 (Name Pattern1) 396**] [**Last Name (NamePattern4) 397**], MD Where: [**Hospital6 29**]
HEMATOLOGY/[**Hospital6 **] Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2123-8-6**] 12:15
Provider [**Name9 (PRE) **],HEM/ONC HEMATOLOGY/[**Name9 (PRE) **]-CC9 Where: [**Hospital 4054**] HEMATOLOGY/[**Hospital **] Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2123-8-6**] 12:15
Provider [**Name Initial (PRE) 4426**] 17 Date/Time:[**2123-8-6**] 1:00
Please call your PCP: [**Name10 (NameIs) 29982**],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 29983**] immediately
for a followup appointment within three days to evaluate your
glycemic control regimen.
|
[
"996.82",
"287.4",
"250.80",
"584.9",
"E933.1",
"427.31",
"493.90",
"285.9",
"E878.0",
"155.0",
"560.9",
"789.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
11775, 11781
|
7285, 10367
|
336, 342
|
11858, 11864
|
3442, 7262
|
12395, 13098
|
2982, 3093
|
11144, 11752
|
11802, 11837
|
10393, 11121
|
11888, 12372
|
3108, 3423
|
274, 298
|
370, 2101
|
2145, 2717
|
2733, 2966
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,375
| 154,218
|
10504
|
Discharge summary
|
report
|
Admission Date: [**2171-8-21**] Discharge Date: [**2171-9-13**]
Date of Birth: [**2109-9-5**] Sex: M
Service: Cardiothoracic
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 410**] is a 61-year-old man
admitted from the emergency room to the cardiology service
with five hours of stuttering chest pain and transient
anterolateral ST changes. Chest pain woke him from sleep on
the day of admission. It was associated with shortness of
breath, no nausea, vomiting, or radiation.
PAST MEDICAL HISTORY: 1. Asthma. 2. Hypercholesterolemia.
3. Benign prostatic hypertrophy.
MEDICATIONS PRIOR TO ADMISSION: 1. Flovent. 2. Singulair.
3. Serevent. 4. Pravachol. 5. Terazosin. 6. Albuterol. No
doses were provided.
ALLERGIES: The patient has no known drug allergies.
PHYSICAL EXAMINATION: In the Emergency Department his
temperature was 98, heart rate 70, blood pressure 161/81,
respiratory rate 16, oxygen saturation 94% on room air.
Neck: Supple. HEENT: Pupils were equal, round, and
reactive to light. Extraocular movements intact. Lungs:
clear to auscultation bilaterally. Heart: Regular rate and
rhythm, S1 and S2 with no murmur. Abdomen: Soft, nontender,
nondistended.
EKG showed changes in the anterior ST depressions.
HOSPITAL COURSE: The patient was treated in the emergency
room with aspirin, sublingual nitroglycerin, IV Lopressor,
and heparin. He was seen by the cardiology service and was
transferred from the emergency room directly to the Cardiac
Catheterization Laboratory. The patient's catheterization
showed a preserved ejection fraction of 50%, trace MR, a left
main with an eccentric mid and distal lesion involving a
pinching of the left anterior descending coronary artery and
circumflex coronary artery at the origin, and left anterior
descending coronary artery with an 80% lesion in addition to
the lesion at the origin. The left circumflex coronary
artery had a 70% lesion at the origin, and a large
nondominant right coronary artery.
Cardiothoracic surgery was consulted while the patient was in
the catheterization laboratory. He was seen and taken
directly from the catheterization laboratory to the operating
room for coronary artery bypass grafting. Once in the
operating room the anesthesia team was unable to intubate the
patient. He underwent an emergency cricothyroidectomy with a
tracheostomy tube placement. At that time he also had an
intra-aortic balloon pump placed. Coronary artery bypass
grafting was delayed and he was transferred from the
operating room to the cardiothoracic intensive care unit.
Please see the operating room and the anesthesia notes for
full details.
Over the next several days the patient was followed closely.
He underwent flexible bronchoscopy at the bedside to evaluate
his airway and his pulmonary status. On [**2171-8-26**] he returned
to the operating room at which time he underwent coronary
artery bypass grafting x 4. Please see the operating room
report for full details. In summary, he had a CABG x 4 with
left internal mammary artery to the left anterior descending
coronary artery, saphenous vein graft to diagonal, saphenous
vein graft to obtuse marginal #1, and saphenous vein graft to
obtuse marginal #2. He tolerated the surgery well and was
transferred from the operating room to the cardiothoracic
intensive care unit. Please see the operating room report
for full details.
On arrival to the cardiac surgery recovery unit the patient
was noted to be in atrial fibrillation. He was treated with
IV amiodarone. He remained hemodynamically stable however he
did require a Neo-Synephrine infusion to maintain an adequate
blood pressure. On the morning of postoperative day one the
patient remained hemodynamically stable. At that time his
intra-aortic balloon pump was discontinued. He was weaned
from his Neo-Synephrine drip. Sedation was discontinued and
he was weaned from mechanical ventilation to pressure support
ventilation.
On postoperative day two the patient's tracheostomy was
downsized to a #4 Shiley. During this time he was also seen
by the cardiology service for his persistent atrial
fibrillation, and by the speech and swallow service for
swallow evaluation and fitting for a Passy-Muir valve.
Over the next couple of days the patient continued to
progress well. He was weaned from all cardioactive IV
medications and placed on oral medications. Additionally, he
was started on levofloxacin for increasing pulmonary
secretions.
Over the next several days the patient continued to stay in
the cardiothoracic intensive care unit to monitor his
respiratory status as well as his cardiac status. He
continued to remain hemodynamically stable although he did
have periods of rapid atrial fibrillation with a ventricular
response rate up to 120. From a respiratory standpoint he
weaned from his pressure support and was tolerating trach
mask with intermittent period of Passy-Muir valve in place.
He had started on an oral diet and tolerated that well. His
activity level was increased on a daily basis with the
assistance of the nursing staff and physical therapy.
On postoperative day seven the patient was transferred from
the cardiothoracic intensive care unit to [**Hospital Ward Name 121**] 2 for
continuing postoperative care and cardiac rehabilitation.
On postoperative day nine the patient was noted to have
sternal drainage. He was transferred from the floor back to
the cardiothoracic intensive care unit for closer monitoring
and then ultimately brought to the operating room where his
sternum was reexplored and he underwent debridement and
rewiring with a Robachek weave. Prior to his reexploration
and rewiring, the patient's trach was replaced with a #8
Shiley. The patient tolerated this operation well. Please
see the operating room report for full details.
Following the surgery he was transferred from the operating
room to the cardiothoracic intensive care unit. On
postoperative day one the patient continued to have
additional episodes of rapid atrial fibrillation with a heart
rate in the 120s. He remained hemodynamically stable during
that period. He was again treated with IV Lopressor and
amiodarone, after which we achieved rate control. Following
surgery the patient was again weaned from his anesthesia and
sedation and from the ventilator. On postoperative day one
he was back to a trach collar, was reassessed for a
Passy-Muir valve, and tolerated that well. On postoperative
day two following his reexploration, the patient was again
transferred from the cardiothoracic intensive care unit to
[**Hospital Ward Name 121**] 2 for continuing postoperative care and cardiac
rehabilitation. The patient remained hemodynamically stable
over the next several days. His sternal incision remained
dry until [**2171-9-10**] when he was noted to have a small amount
of serosanguinous drainage from his mid incision line. A
chest x-ray done at that time showed a small left pleural
effusion with some right and left lower lobe atelectasis with
all sternal wires intact. The patient continued to drain
from his mid sternal incision. On [**2171-9-11**] he was brought
for a chest CT that showed multiple intact sternal wires with
no fluid collection, no sternal dehiscence, and mild heart
failure.
Over the next several days the patient's sternal drainage
continued to be closely followed. His incision remained free
of erythema, and his vital signs remained stable.
On postoperative day 18 it was decided that the patient was
stable and ready to be transferred to rehabilitation for
continuing postoperative care.
PHYSICAL EXAMINATION ON TRANSFER: Vital signs were
temperature 99, heart rate 82 and sinus rhythm, blood
pressure 100/49, respiratory rate 18, oxygen saturation 97%
on trach collar with mist. Weight preoperatively was 88.5
kg; at discharge is 82.4 kg. Neurologic examination showed
him to be alert and oriented x 3, moving all extremities,
following commands. Lungs: #6 Shiley trach in place.
Breath sounds clear to auscultation bilaterally. Cardiac:
Regular rate and rhythm, S1 and S2, sternum with staples, no
erythema, small mid incision area with serous drainage.
Abdomen: Soft, nontender, nondistended, normal active bowel
sounds. Extremities: Warm and well perfused with no edema.
Left lower extremity incision open to air, clean and dry.
LABORATORY DATA: White count 11, hematocrit 28.4, platelet
count 703, INR 2.5, sodium 137, potassium 4.0, chloride 100,
CO2 28, BUN 12, creatinine 0.8, glucose 105.
DISCHARGE MEDICATIONS:
1. Ranitidine 150 mg b.i.d.
2. Aspirin 81 mg q.d.
3. Levofloxacin 500 mg q.d. x 2 weeks.
4. Vancomycin 1,000 mg IV b.i.d. x 2 weeks.
5. Flovent 2 puffs b.i.d.
6. Salmeterol 1 puff b.i.d.
7. Albuterol 2 puffs q. 4 hours p.r.n.
8. Singulair 10 mg q.d.
9. Amiodarone 400 mg q.d. x 1 weeks, then 200 mg q.d.
10. Pravastatin 20 mg q.d.
11. Metoprolol 75 mg t.i.d.
12. Warfarin 3 mg for the past three days, [**9-10**], [**9-11**], and
[**9-12**]. He is to receive 2 mg on [**9-13**], goal INR is 2 to 2.5.
13. Terazosin 5 mg q.h.s.
14. Lasix 20 mg q.d. x 10 days.
15. Potassium chloride 20 mEq q.d. x 10 days.
16. Percocet 5/325, 1-2 tablets q. 4 hours p.r.n.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DIAGNOSES:
1. Coronary artery disease status post coronary artery bypass
grafting x 4 with left internal mammary artery to the left
anterior descending coronary artery, saphenous vein graft to
diagonal, saphenous vein graft to obtuse marginal #1 and
saphenous vein graft to obtuse marginal #2.
2. Hypertension.
3. Hypercholesterolemia.
4. Benign prostatic hypertrophy.
5. Atrial fibrillation.
6. Status post tracheostomy.
7. Asthma.
DISPOSITION: The patient is to be discharged to
rehabilitation at [**Hospital 38**] [**Hospital **] Hospital. He is
to have follow up with Dr. [**Last Name (STitle) 70**] in three to four weeks
and follow up with his primary care physician also in three
to four weeks.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Name8 (MD) 415**]
MEDQUIST36
D: [**2171-9-13**] 12:17
T: [**2171-9-13**] 12:58
JOB#: [**Job Number 34637**]
|
[
"600.0",
"427.31",
"493.90",
"996.03",
"411.1",
"507.0",
"272.0",
"997.3",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"34.79",
"97.44",
"34.04",
"96.72",
"37.22",
"31.1",
"88.56",
"37.61",
"36.13",
"39.61",
"97.23",
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] |
icd9pcs
|
[
[
[]
]
] |
9277, 10262
|
8565, 9222
|
1284, 8542
|
630, 795
|
818, 1266
|
175, 503
|
526, 597
|
9247, 9256
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,835
| 102,994
|
12472
|
Discharge summary
|
report
|
Admission Date: [**2136-4-15**] Discharge Date: [**2136-5-3**]
Date of Birth: [**2072-6-12**] Sex: F
Service: SURGERY
Allergies:
Percocet / Latex / Ciprofloxacin
Attending:[**Last Name (NamePattern1) 4659**]
Chief Complaint:
ABDOMINAL PAIN
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This 63 yo female with a history of prior trauma presented
with acute, sudden onset, intense pain in her epigastrium
associated with nausea and vomiting. The pain was very severe.
She had no diarrhea. She had no fever or chills.
The pain was ongoing and continues at the time of this
evaluation. It can be controlled with narcotic pain
medications.
.
The patient has history of severe trauma in [**2129**] after being hit
by a truck. She had multiple fractures that required surgical
repair. She also required a hip and knee replacement. At the
time of her initial trauma an IVC filter was placed
prophylactic.
She had a significant pelvic fracture putting her at high risk
for DVT. However, she did well with no clots at that time. She
has no previous history of clots. Recently she has been very
physically active working out at a gym 3 times a week and
swimming on weekends. She says she has been more fatigued
recently.
Past Medical History:
Obesity
Atrial Fibrilation
Hypertension
Social History:
social drinker, and denies tobacco
Family History:
non contributory to this admission
Physical Exam:
At discharge:
Vitals- T 98.4, HR 74, BP 100/56, RR 18, O2sat 98% RA
Gen- NAD, alert
Head and neck- AT, NC, soft, supple, no masses
Heart- RRR, no murmurs
Lungs- CTAB, no rhonchi, no crackles
Abd- soft, ND, NT, + BS
Ext- warm, well-perfused, no edema
Pertinent Results:
CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST [**4-15**]
1. Several loops of abnormally appearing bowel within the pelvis
and right
lower quadrant with surrounding interloop fluid and small amount
of free
pelvic fluid. Possible clot detected within the SMV including
ileocolic
branch suggesting venous ischemic etiology.
2. Degenerative changes within the spine.
.
CXR [**4-15**]
No CHF or pneumonia. Boot-shaped cardiac configuration
suggests LV enlargement though clinical correlation is advised.
.
FLOW CYTOMETRY REPORT/FLOW CYTOMETRY IMMUNOPHENOTYPING
INTERPRETATION
Red blood cells, granulocytes, and monocytes were examined for
phosphatidylinositol linked antigens. RBCs and granulocytes
express expected levels of DAF (CD55) and MIRL (CD59). These
findings do not support a diagnosis of paroxysmal nocturnal
hemoglobinuria (PNH).
.
CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS [**4-18**]
1. Interval increase in amount of free fluid in the abdomen and
pelvis.
2. Diffuse, more extensive dilated bowel loops are noted
compared to prior
study. No wall thickening or pneumatosis.
3. New left small pleural effusion.
4. Collapse of IVC inferior to the filter and decreased
opacification of
iliac veins compared to [**2136-4-15**].
5. Previously suggested thrombosis within the superior
mesenteric vein is
again identified, approximately unchanged compared to prior
study on [**2136-4-15**].
6. Significant interval improvement of thrombosis in portal
vein.
.
CT PELVIS W/CONTRAST [**2136-4-21**]
Findings suggestive of a mechanical small-bowel obstruction
(likely adhesion) with transition point likely within the mid
pelvis. Little change to degree of pelvic fluid when compared to
most recent comparison. No evidence of bowel perforation or
necrosis at this time.
.
KUB [**4-23**]
Persistent small-bowel obstruction.
[**2136-4-25**] 03:40AM BLOOD WBC-8.0 RBC-3.96* Hgb-12.0 Hct-35.5*
MCV-90 MCH-30.2 MCHC-33.7 RDW-13.2 Plt Ct-379
[**2136-4-15**] 08:30AM BLOOD Neuts-86.6* Lymphs-9.4* Monos-3.4 Eos-0.1
Baso-0.4
[**2136-5-3**] 06:00AM BLOOD PT-15.7* PTT-76.7* INR(PT)-1.4*
[**2136-4-16**] 11:05AM BLOOD Thrombn-55.4*
[**2136-5-1**] 09:40AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.006
[**2136-5-1**] 09:40AM URINE Blood-NEG Nitrite-POS Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM
[**2136-5-1**] 09:40AM URINE RBC-1 WBC-14* Bacteri-FEW Yeast-NONE
Epi-<1
[**2136-5-1**] 09:40AM URINE Mucous-RARE
Brief Hospital Course:
In the ED she was found to have a mild elevation in lactic acid.
On CT scan she was found to have a clot in the SMV with evidence
of intestinal ischemia. The patient was admitted to the ICU and
was made NPO, with IVF/PCA/med, foley, antibiotics and was
placed on bed rest. The patient was started on a heparin drip
and titrated to a theraputic range. A PICC line was placed and
the patient was started on TPN. Patient's abd exams improved and
she c/o of less pain.
.
The patient was transfered to stonman 5 on HD 2. She was NPO,
with IVF/meds/TPN, PCA, foley and telemetry. The patient
appeared more distended on HD 3 a CTA/CTV was done indicating
([**4-18**]): Increased ascites and more distended bowel loops (no
thickening or pneumatosis); clot in SMV unchanged in size or
location; IVC below IVC filter collapsed (acute change); new L
pleural effusion.
.
Serial abd exams improved, however the patient c/o nausea and an
NGT was placed with bilious output. The patient stated that
nausea resolved. With decreased NGT output the NGT was removed.
With the return of bowel function the patient's diet was
advanced and her TPN was d/c'd. Foley was removed without any
issues. The patient later c/o of burning with urination a UC was
done and was positive, the patient was started on ABX.
.
The patient was started on coumading and all other PO meds when
diet was advanced.
Her heparin drip was d/c'd and she was started on lovenox (120)
/coumadin (10) bridge. The patient refused VNA stating she has
done this in the past. The [**Name8 (MD) **] RN went over lovenox teaching
with pt and the patient did well.
.
The patient will follow up with her PCP [**Last Name (NamePattern4) **] [**5-4**] and the D/C
summary was faxed to the office. Dr. [**Last Name (STitle) **] spoke directly with
Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] by phone and reviewed the [**Hospital 228**] hospital
course and outpatient discharge plan with him. He will set up
Coumadin monitoring with the patient and will follow up on her
hematologic workup. She will also follow up in the Hem/coag on
[**5-25**].
Medications on Admission:
tegretol 100', lisinopril 40'
Discharge Medications:
1. Carbamazepine 200 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
2. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Warfarin 5 mg Tablet Sig: Take as directed Tablet PO ONCE
(Once): Take as directed.
Disp:*60 Tablet(s)* Refills:*2*
4. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 2 days.
Disp:*4 Tablet(s)* Refills:*0*
5. Enoxaparin 120 mg/0.8 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours).
Disp:*60 * Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Small bowel ischemia secondary to Superior mesentaric branch
thrombosis
Small bowel obstruction
Urinary tract infection.
.
Secondary:
seizure disorder, multiple ortho injuries s/p trauma, OA, h/o
MRSA, HTN, Afib
Discharge Condition:
Stable.
Tolerating regular diet.
Pain well controlled.
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
*Avoid lifting objects > 5lbs until your follow-up appointment
with the surgeon.
*Avoid driving or operating heavy machinery while taking pain
medications.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to ambulate several times per day.
.
Medications:
1. Coumadin:
-You were started on this medication secondary to a SMV clot.
-You should take as directed and follow up with your PCP to have
lab work done.
-Your coumadin level will be adjusted according to your lab
work.
.
2. Lovenox injections:
-You were started on this medication to secondary to your DVT.
-You should take this every 12 hrs.
-You have done this in the past and education was provided.
-Please follow up with your PCP regarding this medication and to
have lab work down.
Followup Instructions:
1. Please follow up with Dr. [**Last Name (STitle) **] as needed. [**Telephone/Fax (1) 8792**].
2. An appointment has been made for you to follow up with Dr.
[**First Name (STitle) **],[**First Name3 (LF) 20**], [**Telephone/Fax (1) 14751**], on [**2136-5-4**] at 2:15 to have lab work
draw.
.
You will see both the Hem/coag Attending and Fellow:
Provider: [**First Name4 (NamePattern1) 569**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2136-5-25**]
11:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2503**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2136-5-25**] 11:00. [**Hospital Ward Name 23**] building [**Location (un) **].
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **] MD, [**MD Number(3) 4661**]
Completed by:[**2136-5-4**]
|
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"715.90",
"276.2",
"906.4",
"599.0",
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icd9cm
|
[
[
[]
]
] |
[
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
6936, 6942
|
4215, 6329
|
314, 320
|
7207, 7264
|
1735, 4192
|
8959, 9836
|
1413, 1449
|
6409, 6913
|
6963, 7186
|
6355, 6386
|
7288, 8936
|
1464, 1464
|
1478, 1716
|
260, 276
|
348, 1281
|
1303, 1344
|
1360, 1397
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,507
| 121,709
|
51636
|
Discharge summary
|
report
|
Admission Date: [**2165-1-19**] Discharge Date: [**2165-1-31**]
Date of Birth: [**2082-8-30**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 896**]
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
Endotrachial intubation
PICC line placement
History of Present Illness:
This is an 82 year old man who presented to [**Hospital **] Hospital
on [**1-18**] for fever and chills for 2 days. He initially called
EMS because he fell to the floor while pending over to pull his
pants up. He told the EMS about his fever and weakness. His
fever was as high as 102.7 at home. At [**Hospital **] Hospital , he
received 4 L of normal saline and imipenem, flagyl, Zosyn, and
CT of the abdomen and plevis. The latter showed multiple liver
abscess. He was transferred to [**Hospital1 18**] ED where he was
hypotnesive. He received IV fluids, Zosyn, Surgery and ERCP
consultations. The patient has history of hemorrhagic
pancreatitis status post distal pancreatectomy, splenectomy and
multiple debridements, with a history of stents to the
pancreatic duct and biliary stent occlusion with multiple
replacements. He also had multiple hepatic abscesses positive
for Streptococcus milleri treated for 4 weeks with IV
antibiotics i [**2156**]. He also has a history of recent pseudomonas
sepsis in [**8-/2164**] which was treated with Zosyn and Levaquin. Of
note, he also underwent upper and lower endoscopy by his GI
which showed "varices". He denied any GI symptoms excpet
abdominal pain (RUQ) with deep inspiration and mild diarrhea
today and yesterday. ROS: all remaining systems were reviewed
and symptoms were negative.
Past Medical History:
1. Pancreatitis status post distal pancreatectomy ([**2151**]) and
strictures requiring serial dilations and stent placements
2. Diabetes secondary to the pancreatectomy
3. Multiple hepatic abscesses positive for Streptococcus milleri
treated for 4 weeks with IV antibiotics ([**2156**])
4. Pancreatic cutaneous fistula.
5. Status post splenectomy in [**2152-8-31**].
6. Status post open cholecystectomy in [**2150**].
7. Status post right and left total hip arthroplasty.
8. Duodenal ulcer in [**2154**] secondary to NSAID use.
9. Status post left rotator cuff surgery.
Social History:
The patient is divorced. He denies intravenous drug use. He has
a distant smoking history more than 50 years ago, and rare
alcohol use. He lives in [**Location 106997**] living housing for elderly.
Sons and Daughters are in MA and TX.
Family History:
No pancreatitis
Physical Exam:
Temperature of 99.8, blood pressure of 98/60, pulse of 68,
respiratory rate
of 18. In general, Mr. [**Known lastname 21288**] was an elderly male, appeared
younger than his stated age, in no apparent distress. HEENT
examination revealed no jaundice or scleral icterus. Oropharynx
was clear. Neck was supple without meningismus.
Heart examination revealed a regular rate and rhythm with a
grade 1/6 systolic murmur at the right upper sternal border.
Respiratory examination revealed lungs fields that were clear to
auscultation bilaterally. Abdomen had normal
active bowel sounds, with mild distention. There was mild
discomfort in the RUQ to deep palpation, otherwise, nontender.
Extremities were without edema.
Pertinent Results:
Admission Labs
WBC-25.2*# RBC-3.66* Hgb-12.3* Hct-35.9* MCV-98 MCH-33.6*
MCHC-34.2 RDW-13.6 Plt Ct-247
BLOOD Glucose-89 UreaN-36* Creat-1.2 Na-137 K-4.1 Cl-104
HCO3-19* AnGap-18
ALT-79* AST-120* AlkPhos-92 TotBili-1.2
Discharge Labs
WBC-17.0* RBC-3.28* Hgb-10.8* Hct-33.0* MCV-101* MCH-32.9*
MCHC-32.7 RDW-14.6 Plt Ct-698*
Glucose-35* UreaN-19 Creat-1.0 Na-138 K-3.7 Cl-101 HCO3-29
AnGap-12
ALT-36 AST-53* AlkPhos-141* TotBili-0.8
Other labs:
calTIBC-217* VitB12-GREATER TH Folate-19.8 Ferritn-675* TRF-167*
ABSCESS CULTURE: WOUND CULTURE (Final [**2165-1-24**]): STREPTOCOCCUS
ANGINOSUS (MILLERI) GROUP. MODERATE GROWTH.
CT-GUIDED drainage: Technically successful ultrasound-guided
aspiration of a 7-mm hepatic lesion concerning for an abscess,
yielding 2 cc of purulent fluid which was sent for microbiologic
analysis.
ECHO: The left atrium is dilated. The right atrium is moderately
dilated. The estimated right atrial pressure is 0-5 mmHg. Left
ventricular wall thicknesses are normal. The left ventricular
cavity size is normal. Due to suboptimal technical quality, a
focal wall motion abnormality cannot be fully excluded. 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. Mild (1+) mitral regurgitation is seen. The
pulmonary artery systolic pressure could not be determined.
Significant pulmonic regurgitation is seen. The end-diastolic
pulmonic regurgitation velocity is increased suggesting
pulmonary artery diastolic hypertension. There is no pericardial
effusion.
Brief Hospital Course:
1. Liver abscess. Noted to have recurrent pyogenic liver abscess
and underwent IR drainage of the abscess. The pus grew same
bacteria from [**2157**] {STREPTOCOCCUS ANGINOSUS (MILLERI). He was
treated with ceftriaxone and metronidazole and infectious
diseases will follow-up with him on [**2165-2-11**].
2. ARDS. Soon after admission was transferred to the ICU with
severe ARDS (acute respiratory distress syndrome). His CXR
showed diffuse bilateral airspace infiltrates. His
echocardiography was notable for significant pulmonary
regurgitation and diastolic pulmonary hypertension.
3. Diabetes with hypoglycemia. Noted to have episodes of morning
hypoglycemia with down-titration of insulin in response.
4. Hypertension. During hospitalization lisinopril was held with
stable blood pressures. This may be restarted if blood pressure
increases.
5. Diarrhea. Noted to have occasional loose stools. Multiple
c.diff tests were sent and negative. Tihs may be related to
antibiotics or to his chronic pancreatitis.
Medications on Admission:
Triameterene-HCTZ stopped recently
Lisinopril 10 mg or 5 Mg
Lantus 40 units at night
Novolog
Ursodiol 300 mg daily
pancreatic enzymes
Discharge Medications:
1. ceftriaxone in dextrose,iso-os 2 gram/50 mL Piggyback Sig:
Two (2) gm Intravenous Q24H (every 24 hours).
Disp:*30 gm* Refills:*0*
2. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours).
Disp:*90 Tablet(s)* Refills:*0*
3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever.
5. ursodiol 300 mg Capsule Sig: One (1) Capsule PO once a day.
6. Lantus 100 unit/mL Solution Sig: Twenty (20) units
Subcutaneous once a day.
7. Humalog 100 unit/mL Solution Sig: as directed Subcutaneous
four times a day: See attached sliding scale.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 15644**] Long Term Care - [**Location (un) 47**]
Discharge Diagnosis:
1. Liver abscesses from STREPTOCOCCUS ANGINOSUS (MILLERI)
2. Acute respiratory distress syndrome
3. Cholangitis
4. Chronic pancreatitis
5. Diabetes, uncontrolled with episodic hypoglycemia
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 multiple, small liver abscesses. You underwent drainage
and the pus from one of the liver abscess grew bacteria called
STREPTOCOCCUS ANGINOSUS (MILLERI). It is the same bacteria that
caused you liver abscesses in [**2157**]. You will receive IV
antibiotics for several weeks and see infectious disease doctors
in [**Name5 (PTitle) **] for regular follow up. You were admitted to the MICU
for respiratory failure from ARDS (Acute respiratory distress
syndrome). You underwent MRCP which did not show any areas of
discrete blockage in your bile ducts.
Followup Instructions:
Department: INFECTIOUS DISEASE
When: MONDAY [**2165-2-11**] at 2:30 PM
With: [**Known firstname **] [**Last Name (NamePattern4) 288**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: INFECTIOUS DISEASE
When: TUESDAY [**2165-3-5**] at 3:00 PM
With: [**Known firstname **] [**Last Name (NamePattern4) 288**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
[
"V88.12",
"572.0",
"518.5",
"V58.67",
"251.3",
"401.9",
"424.3",
"281.9",
"577.1",
"787.91",
"576.1",
"416.8",
"041.09"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"38.93",
"96.04",
"96.71",
"88.74",
"50.91"
] |
icd9pcs
|
[
[
[]
]
] |
7086, 7174
|
5155, 6170
|
309, 355
|
7407, 7407
|
3354, 3788
|
8172, 8834
|
2584, 2601
|
6355, 7063
|
7195, 7386
|
6196, 6332
|
7590, 8149
|
2616, 3335
|
264, 271
|
383, 1720
|
7422, 7566
|
1742, 2315
|
2331, 2568
|
3801, 5132
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,661
| 116,460
|
25850
|
Discharge summary
|
report
|
Admission Date: [**2128-4-27**] Discharge Date: [**2128-5-5**]
Date of Birth: [**2049-12-10**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (un) 7835**]
Chief Complaint:
Fever and altered mental status
Major Surgical or Invasive Procedure:
ERCP with placement of biliary stent
History of Present Illness:
78 year old man with h/o Afib on Coumadin, CHF, with recent
admission to [**Hospital1 18**] need/[**Location (un) **] for ascending cholangitis (d/c
[**4-23**]) had ERCP with stent replacement, who presents today from
rehab with elevated white blood count (26 at rehab) and shaking.
Patient was recently admitted to [**Hospital1 18**] from 5/55/12-6/1/12 for
ascending cholangitis and UTI after presenting with AMS, fevers
with abdominal US demonstrating obstruction. He underwent ERCP
which demonstrated gross pus. A previously placed mental stent
was removed. A previously placed plastic stent had migrated into
the right hepatic duct/bilary tree - removal was not attempted
given concurrent cholangitis. He further underwent placement of
a 5cm by 10FR double pig tail biliary stent was placed
successfully for decompression with the proximal end terminating
in the left hepatic duct with good biliary flow. He was
initially treated with zosyn which was subsequently narrowed to
Augmentin for a planned 14 day course (last day [**2128-4-29**]). As
above the patient has a previous history of obstruction with
placement of 2 stents. Plan was originally for removal in summer
of [**2126**] however he was lost to follow-up.
The day of presentation patient was noted to have shaking chills
at rehab, labs were done and demonstrated a white count of 26.
He presented [**Hospital1 **] Needeham from rehab where labs were notable for
elevated WBC,lipase of 42 and bili of 9. CXR demonstrated
pulmonary edema but no PNA. Head CT was negative for an acute
process. He was given IVF, zosyn/ vanc and transfered to [**Hospital1 18**]
for further management.
In the ED, initial VS were: 96.5 86 86/49 92% ra. He was given
2 L of NS with improvement in BP to the 130s. Labs were notable
once again for bili 7.5, ALT/AST in the 100s, alk phos of 949,
WBC 22, CR of 1.4 and Na of 148. RUQ US showed intrahepatic
biliary dilation, penumobilia, bilary sludge, and stable
pancreatic duct dilitation. He was given 10 mg IV vitamin K for
an INR of 3.2. The ERCP fellow was contact[**Name (NI) **] with plan for ERCP
tomorrow. He was admitted to the ICU for further management.
On arrival to the MICU, patient's VS were afebrile 89 141/74 99%
2L NC.He denies any complaint including chest pain, shortness of
breath, abdominal pain, headache, nausea, vomiting.
Review of systems:
on able to obtain
Past Medical History:
CAD, s/p MI [**2095**]
Cardiomyopathy, EF 45%
Afib on Coumadin
HTN
HLD
Mild cognitive impairment
TIA - in the setting of low INR
Biliary obstruction - s/p biliary stent in the past with
migration, replaced by metal stent in [**1-3**], supposed to be
re-evaluated/possibly removed [**5-3**] but was not done
PVD s/p L fem-[**Doctor Last Name **] bypass [**2126**]
s/p bladder repair for tear [**3-4**]
s/p AAA repair [**8-2**]
Prostate ca - s/p radiation
Gout
UTIs
Social History:
Lives with his wife, also has a home in [**Name (NI) 108**]. History of
tobacco use, but quit in [**2114**]. Does not drink alcohol.
Family History:
Father with prostate problems. Mother died at age 89 after hip
fracture, ?clot.
Physical Exam:
96.5 86 86/49 92% ra
General: Alert, oriented to person only, no acute distress
HEENT: Sclera icteric, dry mucous membranes, oropharynx clear,
EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: irreg irreg, normal S1 + S2, no murmurs, rubs, gallops
Lungs: crackles at bilateral bases
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding
GU: foley in place
Ext: Warm, well perfused, 1+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, decreased strength throughout, grossly
normal sensation,gait deferred.
Pertinent Results:
ADMISSION LABS ([**2128-4-27**]):
WBC-22.5*# RBC-3.58* Hgb-9.2* Hct-30.5* MCV-85 MCH-25.7*
MCHC-30.2* RDW-16.2* Plt Ct-172 Neuts-96.2* Lymphs-1.8*
Monos-1.1* Eos-0.1 Baso-0.9
PT-32.7* PTT-37.8* INR(PT)-3.2*
Glucose-104* UreaN-33* Creat-1.4* Na-148* K-3.3 Cl-115* HCO3-22
AnGap-14
ALT-123* AST-171* CK(CPK)-168 AlkPhos-949* TotBili-7.5*
Albumin-2.4* Calcium-7.8* Phos-3.3 Mg-1.9
RUQ ULTRASOUND ([**2128-4-28**]):
1. Intrahepatic biliary dilatation and pneumobilia. Stent in
common bile duct with stable dilatation of pancreatic duct.
2. Distended gallbladder with sludge and thickened wall, most
likely due to third spacing.
3. Right pleural effusion and ascites.
ECHO ([**2128-4-29**]):
Suboptimal image quality. There is a small mobile mass which may
represents a small vegetation on the tricuspid valve. If
clinically indicated, a transesophageal echocardiographic
examination is recommended. Decreased biventricular systolic
function with abnormal septal wall motion. Mild aortic
regurgitation. Mild to moderate mitral regurgitation. Moderate
tricuspid regurgitation. Mild pulmonary artery systolic
hypertension. Large left pleural effusion.
RUE ULTRASOUND ([**2128-4-30**]): Clot in the right basilic vein. No DVT
in the right upper extremity.
BIOPSY ([**2128-4-28**]): Periampullary mass, mucosal biopsies:
Adenomatous mucosal fragments, predominantly with low grade
dysplasia; see note. Note: Occasional areas demonstrate nuclei
with disordered polarity and cytologic features worrisome for
high grade dysplasia. No definite carcinoma in these biopsy
samples.
BRUSHINGS ([**2128-4-28**]): POSITIVE FOR MALIGNANT CELLS, consistent
with adenocarcinoma.
CXR [**2128-5-4**]:
Moderately-severe pulmonary edema is unchanged, but moderate
right and small left pleural effusion have both increased
substantially since [**4-28**]. Cardiac silhouette is partially
obscured, but probably still mildly enlarged. Heavy
calcification of the cardiac silhouette along the diaphragmatic
surface is probably left ventricular aneurysm or pseudoaneurysm.
Brief Hospital Course:
78 yo male with recent cholangitis s/p ERCP with stent placement
who presents from rehab with chills, AMS, elevated WBC, elevated
bilirubin, LFTs and concern for recurrent cholangitis.
1. Severe sepsis with septic shock; secondary to:
2. VRE, pseudomonas, and enterobacter septicemia
3. Cholangitis
4. Possible endocarditis
Presented with fever, leukocytosis, confusion, and acute renal
failure. Imaging demonstrated biliary dilitation, pneumobilia,
biliary sludge and stable pancreatic duct dilitation. ERCP
demonstrated frank pus draining from behind an obstructed
proximal stent. The stent was removed, however a more distal
stent in the right hepatic duct was not removed. Initial
treatment for enterococcus was vancomycin, then switched to
daptomycin when noted to be VRE. Initial treatment for GNR was
pip-tazo.
Regarding possible bacterial endocarditis, an echo showed a
small mobile mass which may represents a small vegetation on the
tricuspid valve. While a TEE would provide a more definitive
diagnosis, this was deferred in favor of empiric treatment with
6 weeks of antibiotics. Yet, due to goals of care, antibiotics
were stopped prior to discharge home on hospice.
5. Adenocarcinoma: CT abdomen showed enhancing lesion around
pacreatic head. ERCP showed a 4mm fungating mass at the major
papilla. Brushings were positive for adenocarcinoma. After
discussion with the family, oncology consultation was pursued
but pt's poor performance status as well as significant
comorbidities precludes surgery or aggressive therapy.
6. Acute renal failure: Initially elevated with improvement
after IVF then another increase later in course.
7. Encephalopathy: Family reports waxing and [**Doctor Last Name 688**] mental
status over the past several weeks (especially in hospital
setting). Likely multifactorial.
8. Acute on chronic diastolic CHF: Noted to have pulmonary edema
on CXR in the setting of IVF for hypotension. Lisinorpil was
held due to hypotension and ARF. Metoprolol was restarted prior
to ICU callout. He had persistent HTN so this was titrated up
with response. day prior to discharge he was noted to require
oxygen and repeat CXR showed increased bilateral pleural
effusions. IVFs had been stopped due to no IV access.
9. Atrial fibrillation: On admission he was supratherapeutic and
was given vitamin K for ERCP. After procedure he was restarted
on home dose of warfarin. Given a CHADS2 score of 5 with prior
TIA bridging anticoagulation was used (initially with IV
heparin, then enoxaparin given difficulty obtaining PTT levels
routinely). Enoxaparin (as well as warfarin) based on poor
prognosis and due to goals of care.
10. Peripheral vascular disease: Has difficult to
palpate/doppler DP pulse on the left. Feet are often noted to be
blue (often seen at home from wife's report).
11. Goals of care: Discussion with HCP/family on [**2128-5-1**]
documented in OMR. DNR/DNI. Based on poor overall prognosis
with new diagnosis of pancreatic or biliary adenocarcinoma,
family wanted to avoid further invasive measures or aggressive
treatment as it had been the pt's wish to spend his time at
home. He was discharged home on home hospice.
Medications on Admission:
1. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. amoxicillin-pot clavulanate 875-125 mg Tablet Sig: One (1)
Tablet PO Q12H (every 12 hours) for 13 doses: last day of
antibiotics is [**2128-4-29**].
3. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
4. warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
8. docusate sodium 50 mg/5 mL Liquid Sig: One (1) tab PO BID (2
times a day).
9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Discharge Medications:
1. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*0*
2. morphine concentrate 100 mg/5 mL (20 mg/mL) Solution Sig:
2-20 mg PO q1hr as needed for pain.
Disp:*30 ml* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Hospice of the Good [**Doctor Last Name 9995**]
Discharge Diagnosis:
1. Severe sepsis and setic shock due to:
* Cholangitis with biliary obstruction, likely secondary to
adenocarcinoma
* Septicemia (VRE; pseudomonas; enterobacter)
* Possible endocarditis
2. Encephalopathy
3. Acute renal failure
4. Hypernatremia
5. Atrial fibrillaton with history of TIA
6. Acute on chronic diastolic congestive heart failure
7. Coronary artery disease
8. Peripheral vascular disease
9. Prostate cancer
10. Right basilic vein thrombus
11. NSVT
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
You were admitted with a severe infection (cholangitis) and well
as bacteria in the bloodstream. These were treated with ERPC
with new stent placement and antibiotics.
Unfortunately, a biopsy performed during ERCP showed evidence of
adenocarcinoma. Due to multiple comorbidities and your overall
status at this time you are not a candidate for surgery or
aggressive treatment. After a discussion with your wife and
sons, the decision was made to get you home so you can spend
time with your family with home hospice services.
Followup Instructions:
None scheduled
|
[
"038.0",
"276.0",
"427.31",
"V58.61",
"584.9",
"576.1",
"428.0",
"E878.1",
"443.9",
"274.9",
"428.33",
"348.30",
"421.0",
"785.52",
"414.01",
"995.92",
"038.49",
"453.81",
"425.4",
"576.2",
"272.4",
"038.43",
"574.51",
"275.41",
"996.59",
"156.1",
"V15.82",
"412",
"401.9",
"427.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"97.05",
"51.14",
"51.88"
] |
icd9pcs
|
[
[
[]
]
] |
10567, 10645
|
6234, 9410
|
334, 372
|
11156, 11156
|
4157, 6211
|
11844, 11861
|
3448, 3529
|
10308, 10544
|
10666, 11135
|
9436, 10285
|
11291, 11821
|
3544, 4138
|
2773, 2793
|
263, 296
|
400, 2754
|
11171, 11267
|
2815, 3281
|
3297, 3432
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,564
| 179,641
|
17569
|
Discharge summary
|
report
|
Admission Date: [**2169-6-9**] Discharge Date: [**2169-6-13**]
Date of Birth: [**2103-1-1**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**Doctor First Name 1402**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
66M with no known PMH, but suspected HTN and DM, who presents
with shortness of breath and increased LE edema. The patient has
not followed up with doctors, and is a somewhat difficult
historian, but essentially reports 2-3 weeks of increased
difficulty breathing, with LE edema and difficulty ambulating at
home with a fall this AM. He reports having to sleep sitting in
a chair for the past year and a half. Denies any chest pain at
rest or with exertion; no LH, palpitations, URI sx, F/C. Reports
an occasional cough, non-productive. Was seen in ED about a year
ago for a fall on the job, where he was noted to have elevated
sugars and hypertension, and was seen in follow up not at [**Hospital1 18**]
(uncertain where), and was told to start metformin although he
did not take it. Reports today that he woke from sleep and
"couldn't get a deep breath." Tried to walk around, but felt
unsteady and apparently fell, although he did not hit his head.
No LOC or presyncope
Past Medical History:
?Hyperglycemia, HTN. s/p injury from fall about 1 year ago--seen
in [**Hospital1 18**] ED.
Social History:
Retired appliance technician and mechanic, retired since injury
last year. Lives in [**Location 86**] with wife, son here as well. Smoked
1-2ppd over 30+ years, quit about 20 years ago. ETOH: about 3
pints of whisky a week, with heavier use in younger years (about
1.5 gallons a week). Denies cocaine or IVDU.
Family History:
No significant CAD, HTN, DM
Physical Exam:
per Dr. [**Last Name (STitle) **]:
VS: T 97.5 BP 146/88 HR 107 RR 28 O2 95% 2LNC
Gen: Obese male, NAD. Slightly dyspneic.
HEENT: NCAT. Sclera anicteric. Dry MM.
Neck: Supple with JVD to ear. Thick neck.
CV: Irregularly irregular, normal S1, S2. P2 tap on palpation.
No m/r/g appreciated. No S3 or S4.
Chest: BS BL, diminished at bases. No appreciable crackles,
wheezes.
Abd: Distended. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits.
Ext: Skin changes c/w venous stasis. 3+ pitting edema.
Skin: Acanthosis nigricans on neck. Venous stasis changes as
above.
Pertinent Results:
Admit EKG: Atypical flutter vs Afib at 122. Low voltage. NL
axis/intervals. QS in V1V2 concerning for prior anterior MI.
Nonspecific TW flattening in inferior-lateral leads. No prior
available for comparison.
.
Admit CXR: Cardiac size cannot be evaluated. Large bilateral
pleural effusions are present. Some upper zone redistribution is
seen. Appearances are most suggestive of cardiac failure.
Infiltrates in both lower lobes cannot be excluded.
IMPRESSION: Evidence of failure with bilateral effusions.
.
Admit labs:
Trop-T: 0.01 to 0.02
CK: 214 to 146
MB: 5 to 4
136 97 8
--------------< 331
4.2 34 1.0
ALT: 38 AP: 79 Tbili: 0.4 Alb: 3.6
AST: 29 LDH: Dbili: TProt:
TSH:2.8
Cholesterol:149
Triglyc: 79
HDL: 65
LDLcalc: 68
proBNP: 1730
.
14.2
6.5 >----< 230
43.6
N:63.7 L:26.7 M:7.8 E:1.7 Bas:0.1
.
Discharge labs:
WBC-5.1 RBC-4.78 Hgb-13.3* Hct-41.4 Plt Ct-222
PT-13.8* PTT-53.1* INR(PT)-1.2*
Glucose-150* UreaN-11 Creat-0.9 Na-141 K-4.2 Cl-100 HCO3-36*
AnGap-9
.
Radiology
[**6-11**]: Echo: The left atrium is mildly dilated. The right atrium
is moderately dilated. The estimated right atrial pressure is
16-20 mmHg. There is moderate 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 low
normal (LVEF 50%). The right ventricular cavity is moderately
dilated with 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 (1+) mitral regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. The main
pulmonary artery is dilated. There is no pericardial effusion.
IMPRESSION: Right ventricular cavity enlargement with free wall
hypokinesis, pulmonary artery dilation and moderate pulmonary
artery systolic hypertension. This constellation of findings is
suggestive of a primary pulmonary process. Prominent left
ventricular hypertrophy with low normal systolic function. In
the absence of a history of systemic hypertension, an
infiltrative process (e.g., amyloid) should be considered.
.
[**6-12**]: DVT scan: negative
Brief Hospital Course:
66M with likely PMH DM, HTN, and COPD, who p/w progressive LE
edema and shortness of breath in the setting of taking no
medications. He was also found to be in atrial fibrillation.
Hospital course by problem:
.
#) CHF: diastolic dysfunction and predominantly right sided
heart failure. The patient likely had untreated CHF and a
progressive decline. The etiology was likely [**2-10**] 1) untreated
HTN leading to diastolic dysfunction, 2) OSA leading to right
heart failure, and 3) atrial fib leading to mild systolic
dysfunction. We aggressively diuresed initially to IV lasix (pt
responds to 40 IV) with goal 2-3 L negative per day. We
diuresed 11L with improvement in his O2 requirement to RA and
improvement in his leg edema. He also initially was treated
with a nitro gtt but this was weaned off in the setting of
starting the ACEi, aldactone, lasix PO, and BB. The patient had
an echo as above which supported these conclusions. Upon
discharge, he was on RA and ambulating. We also counseled him
on the importance of low Na diet and monitoring weight closely.
** discharge weight is 136 kilograms **
.
# Cards Ischemic: There was no evidence of ischemia which
prompted the above exacerbation. EKG and echo as above. We
started ASA, checked lipids, treated with BB. He will need
close followup with PCP and NP as outpt for management.
.
# Cards Rhythm: patient presented in AFib with unknown
chronicity. We treated with increasing doses of metoprolol for
rate control. We also treated with heparin gtt and bridged with
coumadin for three days. His INR remained subtherapeutic at
d/c. He received coumadin 5mg qhs x3 doses. Per [**Company 191**] anticoag
nurses, we discharged him on 7.5mg qhs x1 then back to 5mg qhs
thereafter. He has an INR check scheduled for [**6-15**] at [**Company 191**].
-We recommend he followup with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**] for echo and
potential DCCV in [**1-10**] months if he is documented properly
anticoagulated for >1 month time. We are concerned he will not
be a good candidate for longterm anticoagulation given poor med
compliance in the past. TSH normal.
.
# DM: A1c was checked and pending. We treated with ISS and
temporarily with glargine. We held metformin on dispo given his
heart failure. We started glyburide 5 daily with followup in
[**Last Name (un) **]. If he becomes hypoglycemic, please d/c glyburide.
.
# OSA: patient with witnessed desats and apneic episodes at
night. Has thick neck. We were unable to get BiPap trial in
house [**2-10**] patient refusal. He will benefit from outpt sleep
study. This was strongly conveyed to patient and wife.
.
# HTN: ACEI, aldactone, and BB as above, titrated up to current
doses
.
# Dysuria: U/A neg, resolved. received one dose of cipro but
this was stopped.
.
# FEN: DM/Low Na/Cardiac diet. Lytes need to be checked later
this week then again several weeks later to ensure that K and
Creatinine are stable.
.
# Code: Full
.
# Contact/social: family very involved. patient had not
received medical care in the past. He will need frequent
followup and encouragement. Without his wife present, he can
get somewhat agitated but redirected easily.
.
# Dispo: we strongly recommended rehab but the patient refused.
Medications on Admission:
none
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. GlyBURIDE 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
5. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
6. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Outpatient Lab Work
please have your INR and electrolytes checked on [**6-15**]. Your
goal INR is [**2-11**] and your coumadin may need to be adjusted. Your
potassium needs to be monitored and your cardiac meds adjusted
as needed.
8. Warfarin 2.5 mg Tablet Sig: variable Tablet PO at bedtime: **
take 3 tabs (7.5mg) the night of [**6-13**], then 2 tabs (5mg) the
following night. then have your INR checked on [**6-15**] and the [**Company 191**]
nurses will make further adjustments.
Disp:*100 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary:
- CHF exacerbation: right sided failure, mild systolic
dysfunction, diastolic dysfunction.
- DMII
- HTN
- Atrial fibrillation (unknown duration)
- likely obstructive sleep apnea
Secondary:
- hyperlipidemia
Discharge Condition:
fair
Discharge Instructions:
You were admitted with shortness of breath. You had atrial
fibrillation and congestive heart failure. You also have
diabetes, high blood pressure, high cholesterol, and obstructive
sleep apnea. We treated you for all of these conditions.
.
You came in with no medications. We started multiple
medications and it is very important for you to take them all as
instructed.
.
You need to keep your followup appointments as scheduled. It is
important for you to have your coumadin level checked regularly.
You should also have your electrolytes and INR checked within
three days
.
Please weigh yourself daily. Please adhere to a low sodium
diet. Your weight on discharge was 136 kilograms. If you gain
more than 2 pounds in a day, please contact your PCP.
.
Please contact your PCP or return to the emergency department if
you experience shortness of breath, chest pain, worsening leg
swelling, abdominal pain, dizziness, severe headache.
.
We recommended that you go to rehab for a short stay to improve
your physical and medical health. You refused despite our
request.
Followup Instructions:
*** Please contact [**Name (NI) 191**] at [**Telephone/Fax (1) **] TONIGHT or TOMORROW to
confirm your registration info. *****
Please followup with Dr. [**Last Name (STitle) **] at [**Company 191**] on [**6-15**] at 4:10 pm.
His number is [**Telephone/Fax (1) **]. His office is located on [**Hospital Ward Name 23**]
[**Location (un) **] in the central suite. Please have lab work performed
at this time.
.
Please followup with Dr. [**First Name8 (NamePattern2) 48991**] [**Name (STitle) 19868**] on [**7-19**] at 2pm. His
office is located in the [**Hospital 191**] clinic on [**Hospital Ward Name 23**] 6, at [**Hospital1 18**] [**Hospital Ward Name **]. Phone number [**Telephone/Fax (1) **].
.
Please followup in the [**Hospital **] Clinic. They are located at 1
[**Last Name (un) **] Way. Phone number: ([**Telephone/Fax (1) 4847**]. Thursday [**6-22**]
at 2pm.
.
Please followup with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**] in one month. His number
is ([**Telephone/Fax (1) 1987**]. Please contact his office for an
appointment.
.
Please have a sleep study performed. The phone number is ([**Telephone/Fax (1) 48992**]. Please contact them for an appointment
.
The coumadin clinic at the [**Company 191**] center will monitor your coumadin
level for you.
|
[
"250.00",
"428.0",
"402.91",
"327.23",
"428.32",
"272.0",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9276, 9333
|
4733, 4915
|
291, 298
|
9592, 9599
|
2412, 3229
|
10724, 12034
|
1757, 1786
|
8075, 9253
|
9354, 9571
|
8046, 8052
|
9623, 10701
|
3245, 4710
|
1801, 2393
|
232, 253
|
4943, 8020
|
326, 1300
|
1322, 1414
|
1430, 1741
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,281
| 151,991
|
29101
|
Discharge summary
|
report
|
Admission Date: [**2156-12-11**] Discharge Date: [**2156-12-27**]
Date of Birth: [**2099-6-9**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
epistaxis
Major Surgical or Invasive Procedure:
Splenectomy
History of Present Illness:
57M with a history of ITP and autoimmune hemolytic anemia who
p/w epistaxis. His initial presentation was in [**12-31**] when he
developed dark urine and DOE. He presented to ED in [**2-1**] with a
hct of 18.7. He was treated for a warm autoimmune hemolytic
anemia with prednisone. He did well until [**2154-9-27**] he
presented with epistaxis and had a plt of 1000 and was treated
with prednisone and IVIG. He has been followed by his
hematologist [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1557**] since [**2155**].
He was in his USOH until Friday when he started to have
epistaxis when he was at work at [**Company 2676**] and he went to see the
nurse's office. The bleeding would not stop and he sought
further care in the ED at [**Hospital6 5016**]. The epistaxis
stopped shortly after arriving in the ED. His CBC was WBC 8.3,
hct 44.1, plt 2. He was evaluated by hematologists there and was
given solumedrol 100 IV q8 and IVIG 25g x2.
Past Medical History:
DM
HTN
Social History:
Works at [**Company 2676**]. Lives alone. No smoking or etoh use,
Family History:
sister with ITP
Physical Exam:
VS: Temp: 98.6 BP: 138/91 HR: 97 RR: 16 O2sat: 98RA
.
Gen: In NAD.
HEENT: PERRL, EOMI. No scleral icterus.
Neck: Supple, no JVP elevation.
Lungs: CTA bilaterally, no wheezes, rales, rhonchi. Normal
respiratory effort.
CV: RRR, no murmurs, rubs, gallops.
Abdomen: obese, soft, NT, ND, NABS, no HSM.
Extremities: warm and well perfused, no edema. petechia
diffusely across legs
Neurological: alert and oriented X 3
Skin: Petechia most prominently on LE
Psychiatric: Appropriate.
Pertinent Results:
[**2156-12-25**] 05:12AM BLOOD WBC-31.1* RBC-2.35* Hgb-7.4* Hct-22.0*
MCV-94 MCH-31.6 MCHC-33.7 RDW-20.7* Plt Ct-243
[**2156-12-25**] 05:12AM BLOOD Plt Ct-243
[**2156-12-22**] 01:57AM BLOOD Glucose-97 UreaN-49* Creat-1.1 Na-138
K-3.6 Cl-106 HCO3-22 AnGap-14
HBV DNA not detected.
BONE MARROW ALSO R/O HSV.
GRAM STAIN (Final [**2156-12-17**]): NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2156-12-20**]): NO GROWTH.
ACID FAST SMEAR (Final [**2156-12-20**]):
TEST CANCELLED, PATIENT CREDITED.
TEST NOT PERFORMED ROUTINELY. REQUESTS FOR TESTING CAN BE
MADE BY
CALLING THE MICROBIOLOGY LAB DIRECTOR ON-CALL..
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
SPECIMEN SUBMITTED: immunophenotyping - spleen
Procedure date Tissue received Report Date Diagnosed
by
[**2156-12-14**] [**2156-12-16**] [**2156-12-24**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 3157**]/vf
Previous biopsies: [**-8/4521**] spleen.
[**Numeric Identifier 70061**] Bone marrow for immunophenotyping.
[**Numeric Identifier 70062**] BONE MARROW (1).
[**Numeric Identifier 70063**] Immunophenotyping, peripheral blood.
DIAGNOSIS:
FLOW CYTOMETRY REPORT
FLOW CYTOMETRY IMMUNOPHENOTYPING
The following tests (antibodies) were performed: HLA-DR, FMC-7,
Kappa, Lambda, and CD antigens 3, 5, 7, 10, 19, 20, 23.
RESULTS
Three color gating is performed (light scatter vs. CD45) to
optimize lymphocyte yield.
B cells comprise 42% of lymphoid-gated events, are polyclonal,
and do not express aberrant antigens.
T cells comprise 42% of lymphoid gated events, express mature
lineage antigens.
INTERPRETATION
Diagnostic immunophenotypic features of involvement by lymphoma
are not seen in specimen. Correlation with clinical findings and
morphology (see S08-[**Numeric Identifier 70064**]) is recommended. Flow cytometry
immunophenotyping may not detect all lymphomas as due to
topography, sampling or artifacts of sample preparation.
Brief Hospital Course:
This is a 57 yo M with a history of ITP and autoimmune hemolytic
anemia who presented to OSH with epistaxis and plt of [**2148**],
transferred here for further management.
.
# Thrombocytopenia/epistaxis/mucosal bleeding/petechiae: Felt to
be due to ITP +/-degree of splenic sequestration given h/o
enlarged spleen on prior CT scan. Bone marrow biopsy a year ago
c/w reactive process. Pts plt have not responded to plt given at
OSH and unit of plt given last night. Plt also did not respond
to solumedrol or IVIG given at OSH. Per heme/onc, other options
may include decadron, rhogam. No evidence of DIC or TTP on
review of peripheral smear by heme/onc. Direct Coomb's test and
ab screen are negative. Pt may ultimately need splenectomy. Plt
still less than 5. Pt had some recurrent epistaxis now resolved
earlier this morning, and some dried blood on his oral mucosa.
No GI bleeding.
-heme/onc following, appreciate input; pending recs tomorrow
will likely need repeat CT scan abdomen to eval degree of
splenomegaly
-give prednisone 120 mg today (1 mg/kg); per heme onc we may
consider decadron
-give dose of 120 mg IVIG ; Benadryl/Tylenol prior to and during
IVIG infusions
-recheck plt after IVIG; will discuss with heme whether to start
decadron if plt count does not bump
-Patient underwent a splenectomy on [**12-14**] and remained in the
ICU monitoring his platelet count. He was transferred to the
floor for continued monitoring. He continued on dexamethasone.
He will be discharged on dexamethasone 8mg [**Hospital1 **] until follow up
with heme/onc.
.
# Anemia/history of hemolytic anemia: Plt at OSH 44, 36 here. No
evidence of DIC. Hemolytic labs are negative, so no evidence of
hemolysis currently. Per heme/onc, IVIG and rhogam could
potentially worsen his hemolytic anemia and cause hemolysis.
-maintain active T&S
-trend hct/hemolysis labs
.
# Diabetes Mellitus Type II, uncontrolled, without
complications: Hyperglycemic here, but pt was not on his home
regimen (was on NPH 70 U [**Hospital1 **] at home, but at OSH was on less
dosing). Also hyperglycemia likely [**2-28**] steroids.
-NPH 70 U [**Hospital1 **] (can titrate up as needed with on steroids)/SSI
-metformin
.
# HTN/LE swelling: BP well controlled. LE swelling noted.
-Continue lasix (for LE edema)but increased from 60 mg daily to
100 mg daily given numerous infusions patient is receiving (will
need to trend renal function and adjust based on it). Pt had
been increased to 60 mg twice daily at OSH, but pt does not like
receiving lasix at night
-continue valsartan
.
# FEN: regular diet
.
# PPx: ambulation, stool softeners to prevent straining with
bowel movements
Medications on Admission:
metformin 500 TID
valsartan 40'
lasix 60'
prilosec
NPH 70U [**Hospital1 **]
Discharge Medications:
1. Metformin 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
2. Furosemide 40 mg Tablet Sig: 1.5 Tablets PO every twelve (12)
hours.
Disp:*90 Tablet(s)* Refills:*2*
3. Famotidine 20 mg Tablet Sig: Three (3) Tablet PO Q12H (every
12 hours).
Disp:*90 Tablet(s)* Refills:*2*
4. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Disp:*30 Tablet(s)* Refills:*2*
5. Dexamethasone 4 mg Tablet Sig: Two (2) Tablet PO Q12H (every
12 hours).
Disp:*120 Tablet(s)* Refills:*2*
6. Furosemide 40 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Primary:
Idiopathic thrombocytopenic purpura s/p splenectomy
Secondary:
Diabetes Mellitus II
Hypertension
Discharge Condition:
Good
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:
*You may shower. Pat incision dry.
*Avoid swimming and baths until further instruction at your
followup appointment.
*Leave the steri-strips on. They will fall off on their own, or
be removed during your followup.
*Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
Followup Instructions:
Please call the office of Dr. [**Last Name (STitle) **] to arrange a follow up
appointment in [**2-29**] weeks at [**Telephone/Fax (1) 600**]
Please call the office of Dr. [**Last Name (STitle) **] to arrange a follow up
appointment in [**2-29**] weeks at [**0-0-**]
|
[
"789.2",
"285.1",
"287.31",
"346.80",
"784.7",
"276.52",
"V58.67",
"401.9",
"528.9",
"289.51",
"278.00",
"578.1",
"571.5",
"V58.65",
"287.32",
"459.0",
"250.92",
"458.9",
"593.9",
"782.7",
"289.52"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.05",
"38.93",
"99.07",
"96.6",
"41.31",
"99.14",
"41.5",
"88.47",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
7441, 7490
|
4053, 6704
|
325, 339
|
7641, 7648
|
2003, 2653
|
8864, 9135
|
1460, 1477
|
6830, 7418
|
7511, 7620
|
6730, 6807
|
7672, 8502
|
8517, 8841
|
1492, 1984
|
2689, 2689
|
2722, 4030
|
276, 287
|
367, 1331
|
1353, 1361
|
1377, 1444
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,123
| 185,530
|
17904
|
Discharge summary
|
report
|
Admission Date: [**2159-5-6**] Discharge Date: [**2159-5-18**]
Service: HEPATOBILIARY GOLD SURGERY
HISTORY OF THE PRESENT ILLNESS: The patient is a 78-year-old
male with a history of hypertension presenting for recurrent
GI bleed, status post ERCP with sphincterotomy. The patient
presented to [**Hospital6 1597**] six days prior to admission
with three to four day symptoms of epigastric pain. No
associated nausea, vomiting, or bowel symptoms. The patient
was diagnosed with biliary obstruction and cholangitis and
was transferred to [**Hospital1 **] [**First Name (Titles) **] [**2159-5-1**]
for ERCP revealing a small stone in the distal common bile
duct.
The patient underwent sphincterotomy with stone extraction
with pus noted after extraction. The patient returned to [**Hospital3 **] where he had melena times two days with a hematocrit
drop of 31 to 25. He was sent back to [**Hospital1 **]
on [**2159-5-4**], two days prior to admission, for repeat ERCP
notable for active oozing vessel adjacent to the
sphincterotomy site. He was injected with epinephrine and
hemoclipped. The patient returned to [**Hospital6 1597**]
with reports of persistent melenic stools times with one
episode of bright red blood per rectum.
On the day of admission, the patient also had associated
nausea and dry heaving. No actual emesis. No chest pain or
shortness of breath noted. The patient's hematocrit dropped
from 31.5 to 28.6 and in the a.m. of admission the patient
was noted to be tachycardiac with persistent melenic stools
times three to four episodes. The patient had a hypotensive
episode which responded to intravenous fluids. The patient
was transfused 2 units of packed red blood cells and a
central line was placed prior to transfer to the hospital.
PAST MEDICAL HISTORY:
1. Hypertension.
2. History of CVA.
3. Arthritis.
4. High cholesterol.
5. Hemorrhoidal surgery.
MEDICATIONS AT HOME:
1. Aspirin 81 mg.
2. Captopril 50 mg b.i.d.
3. Atenolol 50 mg q.d.
4. Vioxx 25 mg q.d.
5. Tylenol.
6. Colace.
7. Serax.
8. Lipitor 20 mg q.d.
9. Hydrochlorothiazide 25 mg q.d.
10. Protonix.
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: The patient has a distant smoking history
and only occasional alcohol usage.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: The patient
was afebrile with vital signs stable. General: The patient
was in no acute distress. Heart: Regular rate and rhythm.
Lungs: Clear to auscultation bilaterally. Abdomen: Soft,
mildly obese, nondistended with mild epigastric tenderness to
palpation.
LABORATORY DATA/STUDIES: On admission, the laboratories were
notable for a white count increasing from 8 to 16.5 and
hematocrit drop from 34.6 down to 28 with a 2 unit
transfusion bringing it up to 30.5. The electrolytes were
within normal limits as were the coagulations. The LFTs were
elevated; ALT to 79, AST 193, alkaline phosphatase 394, total
bilirubin 1.2.
The patient's ERCP on [**2159-5-1**] showed large periampullary
diverticulum, small stone in the distal common bile duct,
biliary sphincterotomy stretching with common bile stone. No
cannulation of pancreatic duct.
ERCP on [**2159-5-4**] showed active oozing of visible vessel at
the apex of sphincterotomy site consistent with bleed with
epi injected and hemoclipped.
HOSPITAL COURSE: Surgery was consulted after the GI Fellow
had informed the medical team that ERCP or EGD would not be
helpful at the time as the patient continued to require
transfusions. Interventional Radiology felt that angiogram
would not be helpful. The patient was continued to be
transfused and the hematocrit continued to decrease.
On hospital day number three, the patient was taken to the
Operating Room for an exploratory laparotomy,
cholecystectomy, common bile duct exploration, and repair os
sphincter of Oddi bleeder, placement of duodenostomy,
gastrostomy, and jejunostomy tubes. The patient tolerated
the procedure without complications, but did require 7 units
of packed red blood cells and 4 units of FFP with 4 liters of
crystalloid perioperatively. The patient's hematocrit
eventually stabilized on postoperative day number three.
The patient was placed on tube feeds and eventually was
transferred to the floor on postoperative day number three
and started on sips. The patient's tube feeds continued to
be advanced and the patient was advanced to clears on
postoperative day number six to full liquids to soft solids
on postoperative day number seven. The patient continued to
do well.
He was felt to be ready for discharge on postoperative day
number ten as he was tolerating a regular diet, ambulating
relatively well with good p.o. pain control and passing
flatus and having bowel movements. The patient was felt to
be ready for home with home PT and VNA just for J tube
flushing. The patient is to follow-up with Dr. [**Last Name (STitle) 468**].
DISCHARGE MEDICATIONS:
1. Iron supplements.
2. Tylenol.
3. Atenolol 50 mg q.d.
4. Aspirin 81 mg q.d.
5. Captopril 50 mg b.i.d.
6. Lipitor 20 mg q.d.
7. Hydrochlorothiazide 25 mg q.d.
8. Percocet one to two tablets q. four to six hours p.r.n.
9. Protonix 40 mg q.d.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: To home.
DISCHARGE DIAGNOSIS:
1. Status post exploratory laparotomy, cholecystectomy, and
common bile duct exploration with repair of sphincter of Oddi
bleeder with placement of duodenostomy, gastrostomy, and
jejunostomy tubes.
[**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 4984**]
Dictated By:[**Name8 (MD) 5915**]
MEDQUIST36
D: [**2159-5-18**] 06:04
T: [**2159-5-18**] 19:08
JOB#: [**Job Number 49619**]
cc:[**Last Name (NamePattern1) 49620**]
|
[
"E878.8",
"458.2",
"785.0",
"272.0",
"401.9",
"998.11",
"577.0",
"715.90",
"574.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.51",
"99.29",
"96.6",
"39.30",
"51.83",
"43.19",
"38.93",
"46.39",
"44.43",
"51.22",
"38.80",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
4944, 5196
|
5278, 5765
|
3351, 4921
|
1928, 2182
|
2313, 3333
|
1805, 1907
|
2199, 2298
|
5221, 5257
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,666
| 157,362
|
19925
|
Discharge summary
|
report
|
Admission Date: [**2147-1-13**] Discharge Date: [**2147-1-16**]
Date of Birth: [**2090-7-16**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Doctor First Name 1402**]
Chief Complaint:
transfer for pericardiocentesis
Major Surgical or Invasive Procedure:
Pericardiocentesis with drain placement, s/p drain removal
History of Present Illness:
This is a 56 yo female with a history of hypertension,
hyperlipidemia, new onset afib (~1wk ago) who presented to
[**Location (un) 620**] with a 1.5 week history of epigastric pain diagnosed
with viral pericarditis and transferred here for
pericardiocentesis.
The pt had viral illness that started about two weeks PTA with
HA, nausea and epigastric discomfort x 3 days. The HA and nausea
resolved but the epigastric pain continued and worsened. She
went to [**Hospital **] Hospital about five days after her symptoms
started and was dx with afib and subsequently started on a BB
and coumadin. She then presented to her PCP for [**Name Initial (PRE) **] check of her
INR after discharge from [**Hospital3 4107**] with increasing
epigastric/rib pain in addition to DOE, orthopnea and PND. She
was sent to [**Hospital1 18**] [**Location (un) 620**]. A CT was ordered for the workup of
her epigastric discomfort and found a pericardial effusion. An
echo obtained on [**1-12**] showed a large pericardial effusion
(1.5-2cm anteriorly; No posterior accumulation). A subsequent
echo obtained [**1-13**] showed an expanding pericardial effusion
(3.0 - 3.2cm anteriorly and 2.4 - 2.6cm posteriorly)with no
echocardiographic evidence of tamponade. The patient was
transferred to [**Hospital1 18**] for placement of pericardial drain and RHC.
The patient had no h/o rheumatologic diseases, cancer, or TB. No
h/o arthritis, myalgias, or joint pains. She is up to date on
pap screening and has had a colonoscopy within the last year.
Her last [**Last Name (un) 3907**] was a few yrs ago.
.
The patient was taken to cath lab and had RHC, PCWP 30-->25, RA
25-->17, PP25-->6 fem artery pr: 152/75/105, PA: 45/25/35, RV:
44/13. Pericardiocentesis performed with difficulty [**2-17**] fibrotic
pericardium. hemodynamics consistent with tamponade. SBP prior
to drainage 70. 470 cc bloody fluid removed.
.
Note: pt had neg stress test 2 mo ago at OSH for LUQ pain.
Past Medical History:
htn
hypercholesterolemia
possible TIA in past
new onset Afib (1wk PTA)
Social History:
No tobacco, occ ETOH, no drugs. Pt lives at home with husband
and is a decorative painter.
Family History:
grandmother RA, aunt with breast ca, CAD father with first MI
late 40s, died at 83.
Physical Exam:
T 97.5 HR 90 BP 136/71 RR 18 PO2 99%
Gen: NAD
HEENT: Clear OP, MMM,
NECK: Supple; no cervical LAD, JVP ~10cm
CV: RRR. NL S1, S2. + pericardial friction rub. No m/g
LUNGS: CTAB no c/w/r
ABD: Soft, NT, ND. NL BS. No HSM
EXT: No LE edema. 1+ DP/PT pulses BL
SKIN: No lesions
NEURO: A&Ox3, CN II-XII, 5/5 strength b/l, sensation intact b/l.
Pertinent Results:
[**2147-1-13**] 03:00PM HGB-13.0 calcHCT-39 O2 SAT-98
[**2147-1-13**] 03:00PM TYPE-ART PO2-106* PCO2-42 PH-7.42 TOTAL
CO2-28 BASE XS-2 INTUBATED-NOT INTUBA
[**2147-1-13**] 03:30PM OTHER BODY FLUID WBC-3339* HCT-22* POLYS-15*
LYMPHS-84* MONOS-0 MESOTHELI-1*
[**2147-1-13**] 03:30PM OTHER BODY FLUID TOT PROT-5.9 GLUCOSE-142
LD(LDH)-209 AMYLASE-27 ALBUMIN-3.5
[**2147-1-13**] 09:15PM PT-14.8* PTT-25.4 INR(PT)-1.3*
[**2147-1-13**] 09:15PM PLT SMR-UNABLE TO
[**2147-1-13**] 09:15PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2147-1-13**] 09:15PM NEUTS-90* BANDS-0 LYMPHS-5* MONOS-5 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2147-1-13**] 09:15PM WBC-10.2 RBC-3.66* HGB-11.4* HCT-33.5* MCV-92
MCH-31.2 MCHC-34.1 RDW-12.8
[**2147-1-13**] 09:15PM CALCIUM-8.8 PHOSPHATE-3.8 MAGNESIUM-2.1
[**2147-1-13**] 09:15PM estGFR-Using this
[**2147-1-13**] 09:15PM GLUCOSE-149* UREA N-13 CREAT-0.9 SODIUM-141
POTASSIUM-3.9 CHLORIDE-107 TOTAL CO2-25 ANION GAP-13
.
CCath:
COMMENTS: 1. Right heart catheterization revealed
hemodynamics
consistent with cardiac tamponade with RA mean equal to mean
PCPW of
25mmHg. Initial pericardial pressure was also 25mmHG an tracked
with the
RA presure recording. Cardiac index was normal at 3.5l/min/m2.
2. Pericardiocentesis was performed via the subxyphoid approach.
There
was difficulty advancing the catheter due to markedly fibrotic
pericardium. 475cc of bloody fluid was removed. At end of
procedure,
PCPW reamined elevated at 25mmHg. Mean RA fell to 17mmHg and
pericardial
pressure fell to 5mmHg.
3. The patient transiently became hypotensive to SBP 70s during
the
procedure. She was briefly administered dopamine and atropine.
He BP
normalized with removal of pericardial fluid.
FINAL DIAGNOSIS:
1. Pericardial tamponade.
2. Successul pericardiocentesis of 475cc of fluid.
.
[**2147-1-13**] TTE:
Conclusions:
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. There
is a small pericardial effusion (layering mainly posteriorly).
There are no echocardiographic signs of tamponade. There at
least mild mitral regurgitation.
[**1-14**] TTE:
Conclusions:
Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is low normal (LVEF 50-55%). Right ventricular
chamber size is normal. Right ventricular systolic function is
borderline normal. There is a trivial/physiologic pericardial
effusion. There are no echocardiographic signs of tamponade.
Compared with the findings of the prior study (images reviewed)
of [**2147-1-13**], no major change.
.
[**1-15**] TTE:
Conclusions:
Left ventricular wall thickness, cavity size, and systolic
function are normal (LVEF>55%). The right ventricular cavity is
mildly dilated. There is mild global right ventricular free
wall hypokinesis. There is no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2147-1-14**], no major change is evident.
Brief Hospital Course:
This is a 56 yo female with a history of HTN, hyperlipidemia,
new onset afib (~1wk ago)who was supratherapuetic on coumadin dx
with viral pericarditis now s/p pericardiocentesis and
pericardial drain placement and removal. The following issues
were addressed during her hospitalization:
.
1. Cardiovascular:
A. Pericarditis: This patient was transferred to [**Hospital1 18**] with a
pericardial effusion and tamponade physiology seen on right
heart cath. Her effusion was likely secondary to a viral
pericarditis given her recent GI illness. Myocarditis also
cannot be ruled out. Other etiologies of her effusion were
considered such as rheumatologic causes and specific viral
etiologies. Labs drawn in [**Location (un) 620**] were negative for Hep B, Hep
C, CMV, HIV, [**Doctor First Name **], RF. The patient's EBV labs showed infection at
some point in the past.
Upon arrival at [**Hospital1 18**], the patient was taken to the cath lab and
a pericardiocentesis, drain placement, and RHC were performed.
470 cc of bloody fluid was drained initially. A pericardial
drain was left in place for 24hrs and then was pulled once the
drainage had slowed. Repeat echos confirmed that there was no
reaccumulation of the fluid after the drain was pulled. It is
likely that pericarditis induced the atrial fibrillation. The
bloody effusion is thought to be due to bleeding into the
pericardium induced by her supratherapuetic INR 3.1 from her
coumadin. The patient's pleuritic chest pain was treated with
ibuprofen and then indomethacin in addition to oxycodone prn. It
was recommended that the patient have a cardiac MR [**First Name (Titles) 3**] [**Last Name (Titles) 3782**] to
assess for myocarditis/scar and resolution of pericardial
fibrosis in the future. She will also need a repeat echo in [**1-17**]
weeks along with f/u with a cardiologist in [**Location (un) 620**]. The patient
was advised to get a referral to one of the [**Hospital1 18**] cardiologists
in [**Location (un) 620**] and to make an appoinment for the week after
discharge.
After discharge the Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] called to report atypical
lymphocytes in the pericardial fluid. Although these could be
reactive lymphoctyes, this warrents follow up. The PCP [**Last Name (NamePattern4) **].
[**Last Name (STitle) 32848**] was informed.
.
B. Coronaries: This patient has no h/o of CAD. During this
admission she has no signs of ischemia on EKG. Cardiac enzymes
were neg at [**Location (un) 620**]. She was continued on metoprolol but this
was held for two days due to hypotension. She was also kept on
lipitor 40 QD.
.
C. Pump: The patient had evidence of tamponade on RHC. Her EF
was estimated a 55%, which may be consistent with some degree of
mycoarditis. She did become hypotensive to SBP high 80s-90s. She
was given a fluid bolus and encouraged to take po liquids.
Her SBP subsequently improved.
.
D. Rhythm: The patient was admitted in NSR with a recent h/o of
new onset afib, likely secondary to pericarditis. She remained
in NSR until the day of discharge. Therefore, she was started on
lopressor 25 [**Hospital1 **] for rate control. Anticoagulation was not
continued due to her recent bloody effusion. She was advised to
make an appointment with a cardiologist in [**Location (un) 620**] next week for
follow up for her effusion and atrial fibrillation.
.
2. hypotension: The patient had an episode of hypotension with
SBP in the high 80s-90s. She is known to be hypertensive at
baseline. Her hypotension is most likely secondary to
hypovolemia. A repeat echo was negative for reaccumulation of
fluid, thereby ruling out tamponade physiology. She was given a
fluid bolus and her metoprolol was discontinued for 24 hrs. She
was encouraged to increase her PO intake of fluids. She was
restarted on metoprolol 25 [**Hospital1 **] on the day of discharge given her
afib returned with RVR to 120s. She was advised to discontinue
her antihypertensive medications and to follow up with her PCP
upon discharge.
.
3. ARF: The patient's Cr increased transiently to 1.3 at the
same time that she became hypotensive. This was thought to be
secondary to [**Month (only) **] PO intake. Her ARF resolved s/p a fluid bolus.
Upon discharge her cr was 0.9.
.
4. HTN: The patient's HCTZ/triamcinolone was held during this
admission for hypotension. She was continued on lopressor 25
[**Hospital1 **].
.
5. Hyperlipidemia: She was continued on lipitor 40 QD.
.
Medications on Admission:
MEDS on admission from [**Hospital 620**] hosp:
Prednisone 60 mgQD
Morphine Sulfate (last dose 12/28 at 6pm)
Protonix
lopressor
lipitor
coumadin
.
meds at home:
Lopressor 75 [**Hospital1 **]
Lipitor 40 QD
Traimpterene/HCTZ 37.5/25 QD
coumadin 5mg QD
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed for pain for 6 doses.
Disp:*6 Tablet(s)* Refills:*0*
2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
3. Indomethacin 25 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day) as needed for pain for 7 days.
Disp:*21 Capsule(s)* Refills:*0*
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
5. Discontinued medications
We are holding your Triamterene/HCTZ since your blood pressures
have been on the low side. Please discuss restarting these
medications with your primary doctor.
6. Lopressor 50 mg Tablet Sig: 0.5 Tablet PO twice a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Viral pericarditis complicated by pericardial effusion and
tamponade.
Secondary:
Hypertension
Transient A.fib likely secondary to pericardial irritation
Discharge Condition:
Good - mild pleuritic chest pain, ambulating, stable heart rate
and blood pressure.
Discharge Instructions:
Please take all of your medications as directed. We are holding
Diuretic since your blood pressure has been on the low side.
Please discuss restarting these with your primary care physician
when you seen her next week.
Please ensure that you follow up with your primary care doctor
within one week following discharge. You will also need to be
seen by a Cardiologist. Please call Dr. [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) **] office
to schedule an appointment with him or another physician. [**Name10 (NameIs) **] is
very important that you have a repeat ECHOCARDIOGRAM performed
in one weeks time to ensure that no other fluid is
reaccumulating around your heart.
Please contact your [**Name2 (NI) 53756**] or proceed to the nearest emergency
room with any shortness of breath, worsening chest pain or any
other complaints whatsoever.
Followup Instructions:
PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 31529**].
Cardiology: [**Last Name (LF) **],[**First Name3 (LF) **] P. [**Telephone/Fax (1) 127**]
Completed by:[**2147-1-18**]
|
[
"401.9",
"584.9",
"276.52",
"420.91",
"458.29",
"427.31",
"787.91",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.0",
"37.21"
] |
icd9pcs
|
[
[
[]
]
] |
11786, 11792
|
6226, 10699
|
348, 409
|
11990, 12076
|
3065, 4854
|
12989, 13221
|
2605, 2690
|
11000, 11763
|
11813, 11969
|
10725, 10977
|
4871, 6203
|
12100, 12966
|
2706, 3046
|
277, 310
|
438, 2386
|
2408, 2481
|
2497, 2589
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,681
| 167,848
|
31747
|
Discharge summary
|
report
|
Admission Date: [**2174-8-11**] Discharge Date: [**2174-8-25**]
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Coronary Artery Bypass Graft x2 (Saphenous vein graft > left
anterior descending, saphenous vein graft > right coronary
artery) and mitral valve replacement (31 mm [**Company **] mosaic
porcine valve) Intra aortic balloon pump [**2174-8-16**]
History of Present Illness:
85 year old male with 1 month history of increasing shortness of
breath resulting in heart failure and admission to outside
hospital. He had known mitral regurgitation and referrred for
surgical evaluation
Past Medical History:
Coronary artery disease
Mitral regurgitation
Aortic insufficiency
Tricuspid regurgitation
Chronic Renal insufficiency
Large Cell Lymphoma (remission)
Social History:
Lives alone
denies ETOH
denies Tobacco
Family History:
NC
Physical Exam:
NAD
Neuro grossly intact
Pulm CTA bilat
Cor RRR Systolic murmur
Abd Benign
Ext warm no edema + pulses
Pertinent Results:
[**2174-8-25**] 06:20AM BLOOD WBC-9.9 RBC-4.02* Hgb-12.3* Hct-36.0*
MCV-89 MCH-30.6 MCHC-34.2 RDW-15.2 Plt Ct-169#
[**2174-8-11**] 07:25PM BLOOD WBC-8.5 RBC-4.12* Hgb-12.5* Hct-36.0*
MCV-87 MCH-30.4 MCHC-34.7 RDW-15.1 Plt Ct-175
[**2174-8-25**] 06:20AM BLOOD Plt Ct-169#
[**2174-8-11**] 07:25PM BLOOD PT-12.8 PTT-29.0 INR(PT)-1.1
[**2174-8-11**] 07:25PM BLOOD Plt Ct-175
[**2174-8-25**] 06:20AM BLOOD Glucose-104 UreaN-25* Creat-1.1 Na-135
K-4.7 Cl-97 HCO3-30 AnGap-13
[**2174-8-11**] 07:25PM BLOOD Glucose-126* UreaN-42* Creat-1.7* Na-138
K-4.1 Cl-98 HCO3-30 AnGap-14
[**2174-8-17**] 02:12AM BLOOD ALT-36 AST-67* LD(LDH)-397* AlkPhos-56
Amylase-56 TotBili-0.9
[**2174-8-11**] 07:25PM BLOOD ALT-186* AST-72* LD(LDH)-190 AlkPhos-124*
TotBili-0.5
[**2174-8-17**] 02:12AM BLOOD Lipase-16
[**2174-8-11**] 07:25PM BLOOD %HbA1c-6.4*
RADIOLOGY Final Report
CHEST (PA & LAT) [**2174-8-24**] 3:47 PM
CHEST (PA & LAT)
Reason: r/o inf, eff
[**Hospital 93**] MEDICAL CONDITION:
85 year old man with mr
REASON FOR THIS EXAMINATION:
r/o inf, eff
HISTORY: Mitral valve repair. Assess for interval change.
PA AND LATERAL CHEST RADIOGRAPHS
Comparison is made to [**8-20**] examination. In the interval,
epicardial leads and Swan-Ganz catheter have been removed with
slightly decreased widening in the superior mediastinum
identified. Moderate bilateral pleural effusions with fluid in
fissures and adjacent atelectases, not significantly changed.
There is no evidence of pneumothorax or pulmonary edema.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
DR. [**First Name8 (NamePattern2) 4075**] [**Last Name (NamePattern1) 5999**]
Approved: WED [**2174-8-24**] 8:04 PM
Cardiology Report ECG Study Date of [**2174-8-16**] 3:28:42 PM
Sinus rhythm
Nondiagnostic inferior Q wave
T wave changes
Low QRS voltages
Since previous tracing of [**2174-8-11**], the heart rate is slower, and
T wave
abnormalities more marked
Clinical correlation is suggested
Read by: [**Last Name (LF) **],[**First Name3 (LF) 900**] A.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
88 196 98 362/411 73 85 3
Cardiology Report ECHO Study Date of [**2174-8-16**]
PATIENT/TEST INFORMATION:
Indication: Intraoperative TEE for CABG/MVR
Status: Inpatient
Date/Time: [**2174-8-16**] at 13:53
Test: TEE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2007AW1-:
Test Location: Anesthesia West OR cardiac
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name (STitle) 412**] [**Last Name (Prefixes) 413**]
MEASUREMENTS:
Left Atrium - Long Axis Dimension: *5.7 cm (nl <= 4.0 cm)
Left Ventricle - Inferolateral Thickness: 0.6 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: *6.6 cm (nl <= 5.6 cm)
Left Ventricle - Ejection Fraction: 15% to 20% (nl >=55%)
Aorta - Valve Level: 2.6 cm (nl <= 3.6 cm)
Aorta - Ascending: 2.8 cm (nl <= 3.4 cm)
Aorta - Descending Thoracic: 2.3 cm (nl <= 2.5 cm)
Aortic Valve - LVOT Diam: 2.2 cm
INTERPRETATION:
Findings:
LEFT ATRIUM: Dilated LA. No spontaneous echo contrast or
thrombus in the
LA/LAA or the RA/RAA. Good (>20 cm/s) LAA ejection velocity.
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA
and extending into the RV. Normal interatrial septum. No ASD by
2D or color
Doppler.
LEFT VENTRICLE: Moderately dilated LV cavity. Severely depressed
LVEF.
RIGHT VENTRICLE: Moderate global RV free wall hypokinesis.
AORTA: Normal aortic diameter at the sinus level. Simple
atheroma in aortic
root. Normal ascending aorta diameter. Simple atheroma in
ascending aorta.
Normal descending aorta diameter. Simple atheroma in descending
aorta.
AORTIC VALVE: Three aortic valve leaflets. Moderately thickened
aortic valve
leaflets. Mild (1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP.
Mild mitral
annular calcification. Moderate to severe (3+) MR.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild
[1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify
I was present in compliance with HCFA regulations. No TEE
related
complications. The patient appears to be in sinus rhythm.
Results were
Conclusions:
PRE-BYPASS:
1. No atrial septal defect is seen by 2D or color Doppler.
2. The left ventricular cavity is moderately dilated.
3. Overall left ventricular systolic function is severely
depressed (LVEF= 20
%). The lateral wall and the basal inferior wall regional wall
function is
relatively preserved.
4. There is moderate global right ventricular free wall
hypokinesis.
5. There are simple atheroma in the aortic root. There are
simple atheroma in
the ascending aorta. There are simple atheroma in the descending
thoracic
aorta.
6. There are three aortic valve leaflets. The aortic valve
leaflets are mildly
thickened. The noncoronary cusp is calcified. Mild (1+) aortic
regurgitation
is seen.
7. The mitral valve leaflets are mildly thickened. Moderate to
severe (3+)
central mitral regurgitation is seen. There is no mitral valve
prolapse or
flail segments.
8. The tricuspid valve leaflets are mildly thickened.
9. Post-induction patient required intra-aortic balloon pump;
epinephrine,
neosynephrine, and nitro gtt with improvement of biventricular
function.
POST-BYPASS:
Patient off cardiopulmonary bypass with intra-aortic balloon
pump,
epinephrine.
There is mild improvement of global LV and RV systolic function.
LVEF 20 to
25%. Thoracic aortic contour is preserved.
There is a bioprosthetic valve in the native mitral position
well seated and
functioning well with no residual mitral regurgitation and a
transmitral mean
gradient of less than 5mmof Hg.
Electronically signed by [**Name6 (MD) 3892**] [**Name8 (MD) 3893**], MD on [**2174-8-16**]
23:09.
[**Location (un) **] PHYSICIAN:
Pathology Examination
Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 74553**],[**Known firstname **] [**2089-7-13**] 85 Male [**-6/3376**]
[**Numeric Identifier 74554**]
Report to: DR. [**Last Name (STitle) **] [**Last Name (Prefixes) 413**]
Gross Description by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 35324**]/cofc
SPECIMEN SUBMITTED: MEDIASTINAL LYMPH NODE AND MITRAL VALVE
LEAFLETS.
Procedure date Tissue received Report Date Diagnosed
by
[**2174-8-16**] [**2174-8-16**] [**2174-8-19**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 7001**]/mrr??????
DIAGNOSIS:
1. Mediastinal lymph node (A):
Lymph node fragments with sinus histiocytosis; no malignancy is
identified.
2. Mitral valve leaflets (B-C):
Cardiac valve with extensive myxoid degeneration.
Note: Dr. [**Last Name (STitle) **]. Mariappan reviewed slide A and concurs with the
diagnosis.
Clinical: Cardiogenic shock.
Gross: The specimen is received fresh, in two parts, each
labeled with the patient's name "[**Known firstname 1313**], [**Known lastname **]", the medical
record number and also labeled "mediastinal lymph node", and
consists of fragments of fatty tissue measuring 1.5 x 1.0 x 0.3
cm. The specimen is entirely submitted in A.
Part 2 is additionally labeled "mitral valve leaflets", and
consists of a fragment of a valve which measures approximately
2.8 x 1.5 x 0.3 cm. Two definite valvular leaflets are
identified. There are areas of possible atherosclerosis. The
specimen is serially sectioned to reveal focal mucinous
degeneration. It is entirely submitted in B-C.
Brief Hospital Course:
Transferred from outside hospital for cardiac surgery
evaluation. He underwent preoperative workup and on [**2174-8-16**]
went to the operating room. He had coronary artery bypass
graft, mitral valve replacement, and intra aortic balloon
placement, please see operative report for further details. He
was transferred to the cardiac surgery recovery unit on
levophed, milirone, epinephrine, and vasopressin with IABP. He
remained intubated and requiring hemodynamic support. On POD 2
IABP was removed and extubated without complications. He
continued to progress with pressors and inotropes being weaned
off. He continued to improve and milirone was slowly weaned off
POD 7. He was started on amiodarone for atrial flutter and
converted to NSR, he has remained in NSR for 48 hours. He was
transferred to the floor on POD 8 and continued to do well. He
was ready for discharge to rehab on POD 9.
Medications on Admission:
Digoxin 0.125 every other day
flonase
ASA
Protonix 40 daily
colace
lipitor 20 daily
lisinopril 2.5 daily
lopressor 12.5 twice a day
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. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
5. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): decrease to 200mg daily on [**8-31**] .
6. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
9. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO once a day.
10. medications
Will need to start ACE inhibitor when blood pressure will
tolerate
Discharge Disposition:
Extended Care
Facility:
[**Doctor Last Name **] [**Doctor Last Name **] hospital
Discharge Diagnosis:
Coronary artery disease s/p CABG
Mitral regurgitation s/p MVR
Cardiogenic Shock
Systolic heart failure
Aortic insufficiency
Tricuspid regurgitation
Chronic Renal insufficiency
Large Cell Lymphoma (remission)
Discharge Condition:
Good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
[**Last Name (NamePattern4) 2138**]p Instructions:
Dr [**Last Name (Prefixes) **] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for
appointment
Dr [**Last Name (STitle) **] in 1 week ([**Telephone/Fax (1) 14358**]) please call for appointment
Dr [**Last Name (STitle) **] in [**1-22**] weeks ([**Telephone/Fax (1) 74555**]) please call for
appointment
Completed by:[**2174-8-25**]
|
[
"397.0",
"428.20",
"V10.79",
"427.32",
"599.0",
"414.01",
"428.0",
"585.9",
"396.3",
"785.51"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"37.64",
"36.15",
"37.61",
"36.11",
"35.23"
] |
icd9pcs
|
[
[
[]
]
] |
10872, 10955
|
8793, 9698
|
288, 533
|
11207, 11214
|
1157, 2093
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7097, 8770
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959, 999
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,798
| 159,053
|
49688
|
Discharge summary
|
report
|
Admission Date: [**2105-2-24**] Discharge Date: [**2105-3-2**]
Date of Birth: [**2021-12-18**] Sex: M
Service: MEDICINE
Allergies:
Blue Dye / Aspirin / Dyazide / Lisinopril / Ace Inhibitors
Attending:[**First Name3 (LF) 7651**]
Chief Complaint:
SOB, fevers
Major Surgical or Invasive Procedure:
None
History of Present Illness:
83 yo man with cerebral palsy, h/o AVR with bioprosthetic valve
([**2085**]), paroxysmal AFib (previously on coumadin, stopped in
[**11/2104**] in the setting of GI bleed), h/o DVT ([**11/2104**]), who
presented to his PCP with three days of worsening SOB associated
with fevers. No chest pain, palpitations, dizziness, syncope,
PND, orthopnea, leg pain or swelling, nausea, vomiting, or
diarrhea. He was referred to the ED for further evaluation.
.
In the ED, inital vitals were: HR 109, BP 128/50, RR 16, 100% 3L
(90% on RA). WBC 9.0 with 85.8% PMNs. CXR with possible
pneumonia. U/A negative. EKG showed NSR, LAD, bifasicular block
c/w prior. He received ceftriaxone and azithromycin for presumed
CAP and was admitted to the floor.
.
At 5AM on the morning of hospital day 2, the patient was noted
to have low O2 sats on 3L NC (had been satting 92% on 3L NC
earlier in the night). He was placed on a shovel mask and was
given albuterol nebs. Suctioning revealed copious whitish
sputum. Repeat ABG went from 7.4/43/81 --> 7.30/50/68. CXR
appeared unchanged from previous. He was noted to be able to
follow simple commands, answering 'yes' and 'no' to questions
appropriately. Of note, the patient was not eating prior to the
event, has no known history of COPD or emphysema, and did not
receive any narcotics or sedating medication on the floor.
Past Medical History:
- Cerebral palsy
- Paroxysmal atrial fibrillation
- AVR with bioprosthetic valve ([**2085**])
- Diabetes
- Dyslipidemia
- Hypertension
- CRI (baseline Cr ~1.5-1.8)
- Bladder Cancer s/p TURBT [**2098**]; cystoscopy [**3-/2099**] wnl
- H/o several GI bleeds; most recent in [**12/2104**] secondary to
polyps in setting of supratherapeutic INR (3.4)
- Left ankle fracture s/p ORIF complicated by LLE DVT in
[**2104-11-25**] (partially treated on coumadin - LENI on [**2105-2-20**] neg for
DVT)
- GERD
- BPH
- Pancreatic tail lesion (outpatient MRI scheduled)
- Appendectomy
- Hernia repair
Social History:
Lives independently but has multiple friends who come by the
house to help. Has a sister and [**Name2 (NI) 802**] on the West [**Name (NI) **], has a
cousin who lives nearby. No smoking or EtOH.
Family History:
Mother with melanoma. No family history of CAD or early MI,
arrhythmia, or sudden death.
Physical Exam:
ADMISSION EXAM:
VS: T 97.8, BP 136/74, HR 106, RR 24, 92% on 3L
GEN: Uncomfortable appearing male.
HEENT: PEERL. Anicteric sclera. MMM.
Neck: Supple. JVP not elevated. No LAD.
CV: Tachycardic. Normal S1/S2. No murumurs rubs or gallops
appreciated.
LUNGS: Rhonchorous. Coarse BS B/L. Apnic phases for 5 seconds.
Wheezes b/l at bases.
ABD: NTND. NABS. Cannot appreciated organomegaly.
[**Name (NI) **]: Flexed extremities. 2+ PTP B/L.
NEURO: Patient AOx3. Dysarthric at baseline. EOMI intact. Equal
facial sensation throughout. Symmetric smile. Can open both
eyes. Uvula midline. Hypertonic extremities at baseline. [**6-18**]
grip strength BL. MAE.
.
DISCHARGE EXAM:
VS: T 97.7, BP 112/60, P 50s-70s, R 18, 97% on 2L
GEN: A&Ox3. Slow speech, but able to converse easily w/o SOB.
HEENT: NCAT. No conjunctival pallor or scleral icterus. MMM.
Filling missing in upper left tooth.
NECK: Supple. No LAD. JVP not elevated.
PULM: Rhonchorous upper airway sounds transmitted diffusely.
Decreased BS at bases with scant crackles. No accessory muscle
use.
CV: Regular, nml S1/S2. [**4-19**] diastolic murmur at LUSB. [**3-22**]
systolic murmur at apex. No gallops or rubs.
ABD: Soft. NTND. NABS.
[**Month/Day (4) **]: WWP. No LE edema.
SKIN: No ulcers or rashes.
NEURO: A&Ox3. CNs II-XII intact, motor and sensory function
grossly intact.
Pertinent Results:
ADMISSION LABS:
[**2105-2-24**] 05:00PM BLOOD WBC-9.0 RBC-4.02* Hgb-10.4* Hct-32.6*
MCV-81* MCH-25.8* MCHC-31.8 RDW-15.9* Plt Ct-293
[**2105-2-24**] 05:00PM BLOOD Neuts-85.8* Lymphs-7.9* Monos-4.8 Eos-0.9
Baso-0.6
[**2105-2-24**] 05:00PM BLOOD PT-13.4 PTT-24.7 INR(PT)-1.1
[**2105-2-24**] 05:00PM BLOOD Glucose-113* UreaN-30* Creat-1.7* Na-142
K-5.0 Cl-106 HCO3-26 AnGap-15
[**2105-2-24**] 10:15PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.013
[**2105-2-24**] 10:15PM URINE Blood-TR Nitrite-NEG Protein-25
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
.
PERTINENT LABS:
[**2105-2-24**] 09:06PM BLOOD Lactate-0.6
[**2105-2-24**] 09:12PM BLOOD Lactate-0.8
[**2105-2-25**] 05:01AM BLOOD Lactate-0.8
[**2105-2-25**] 06:29AM BLOOD Lactate-0.9
[**2105-2-25**] 10:03PM BLOOD Lactate-1.0
[**2105-2-25**] 06:21AM BLOOD CK-MB-4 cTropnT-0.05*
[**2105-2-25**] 11:49AM BLOOD CK-MB-4 cTropnT-0.05*
[**2105-2-25**] 06:25PM BLOOD CK-MB-3 cTropnT-0.05*
[**2105-2-25**] 06:21AM BLOOD CK(CPK)-343*
[**2105-2-25**] 11:49AM BLOOD CK(CPK)-386*
[**2105-2-25**] 06:25PM BLOOD CK(CPK)-339*
[**2105-2-27**] 07:30AM BLOOD Chol-131 TG-126 HDL-42 LDL-64
.
DISCHARGE LABS:
[**2105-3-2**] 07:40AM BLOOD WBC-4.0 RBC-3.73* Hgb-9.4* Hct-30.5*
MCV-82 MCH-25.2* MCHC-30.8* RDW-15.7* Plt Ct-204
[**2105-3-2**] 07:40AM BLOOD Glucose-98 UreaN-40* Creat-1.6* Na-143
K-4.7 Cl-105 HCO3-34* AnGap-9
[**2105-3-2**] 07:40AM BLOOD Calcium-8.6 Phos-3.2 Mg-2.1
.
MICRO:
[**2105-2-24**] Urine Cx: negative
[**2105-2-24**] Blood Cx: negative
[**2105-2-25**] MRSA screen: negative
[**2105-2-25**] Urine Legionella Ag: negative
[**2105-2-25**] Blood Cx: negative
.
IMAGING:
[**2105-2-20**] LENI: No evidence of DVT in either leg.
.
[**2105-2-24**] CXR: Left basilar opacity may represent atelectasis
adjacent to a large hiatal hernia, although underlying infection
cannot be excluded. Mild patchy opacity in the right lung base
may also represent atelectasis or infection. Small bilateral
pleural effusions.
.
[**2105-2-25**] ECHO: LA is elongated. LV wall thicknesses and cavity
size are normal. Mild regional LV systolic dysfunction with
focal hypokinesis of the inferior wall. The remaining segments
contract normally (LVEF =45-50%). The estimated CI is normal
(>=2.5L/min/m2). RV chamber size is normal with moderate global
free wall hypokinesis. The ascending aorta is mildly dilated. A
bioprosthetic aortic valve prosthesis is present. The prosthetic
aortic valve leaflets are thickened. The transaortic gradient is
higher than expected for this type of prosthesis. Moderate to
severe (3+) AR. The aortic regurgitation jet is eccentric. The
mitral valve leaflets are mildly thickened. No MVP. Mild (1+)
MR. [**First Name (Titles) **] [**Last Name (Titles) **] valve leaflets are mildly thickened. There is
moderate pulmonary artery systolic hypertension. No pericardial
effusion.
IMPRESSION: Bioprosthetic aortic valve with moderate to severe
regurgitation and high transvalvular gradients c/w prosthetic
valve stenosis. Mild regional LV dysfunction c/w CAD. Moderate
pulmonary hypertension. Moderate RV systolic dysfunction. Mild
MR.
.
[**2104-2-27**] CXR: Unchanged from prior. Moderate cardiomegaly.
Bilateral areas of atelectasis and likely small bilateral
pleural effusions.
.
[**2105-3-1**] CXR: Comparison with the previous study of [**2105-2-26**]. The
lung apices and thoracic inlet are partially obscured by the
patient's chin. There is streaky density at the lung bases
likely representing subsegmental atelectasis. In addition, there
is hazy density in the left costophrenic sulcus that may
represent pleural fluid. The retrocardiac area is not well
penetrated. The patient is status post median sternotomy as
before. Mediastinal structures are unchanged.
IMPRESSION: No significant change.
Brief Hospital Course:
83 yo man with cerebral palsy, paroxysmal Afib, h/o DVT, and h/o
aortic valve replacement, admitted with fevers/SOB secondary to
[**Hospital **] hospital course complicated by an episode of hypoxic
respiratory distress.
.
# CAP/Hypoxic respiratory distress: Patient noted early on the
morning of hospital day 2 to have low O2 sats on 3L NC (90-93%)
with increased work of breathing and increased secretions. There
was concern for worsening pneumonia vs aspiration in the setting
of his cerebral palsy. No known history of COPD or restrictive
lung disease. He did not appear volume overloaded on exam. EKG
without any new ischemic changes concerning for ACS and
troponins were flat at 0.05 (pt with CKD). Although he had a DVT
in [**11/2104**], LENI on [**2105-2-20**] was negative for DVT in either leg.
He was switched to shovel mask with albuterol/ipratroprim nebs
PRN, aggressive suctioning, pulmonary toilet, and chest PT. By
MICU day 2, the patient's breathing had improved and his
facemask settings remained stable. Repeat CXR was concerning for
fluid overload so he was diuresed with IV lasix. ECHO showed
worsened aortic regurgitation and prosthetic valve stenosis, so
he was transfered to the [**Hospital1 1516**] cardiology service for further
management. Upon reviewing the ECHO, there is no LV enlargement
so the aortic regurgitation is unlikely to be as severe as
suggested, and the patient was euvolemic on exam. He was gently
diuresed with 20mg PO lasix daily and he completed a 7-day
course of the ceftriaxone and azithromycin. His respiratory
symptoms were likely due to the pneumonia and possibly a silent
aspiration. Speech and swallow evaluated the patient and
recommend a diet of thin liquids with soft solids. Oxygen
saturation is currently 95% on 2L nasal cannula, to be weaned as
tolerated.
- He was noted to have brief apneic episodes during sleep, so we
recommend an outpatient sleep study
.
# H/o aortic valve replacement: ECHO shows moderate to severe
aortic regurgitation and high transvalvular gradients c/w
prosthetic valve stenosis. There is no left ventricular
enlargement, so the aortic regurgitation may not be as severe as
suggested, and the patient is euvolemic on exam.
- Started 20mg PO lasix daily
.
# H/o Paroxysmal AFib: Patient remained in NSR during this
admission. He is not currently on any nodal agents, possibly due
to his prolonged PR interval. He is also not anticoagulated
considering his h/o GI bleeds. Recommend outpatient follow up.
.
# Coronaries: Cardiac cath in [**2085**] was negative for CAD, however
recent ECHO revealed mild regional LV systolic dysfunction with
focal hypokinesis of the inferior wall consistent with CAD.
Patient w/o angina, EKG w/o ischemic changes, and troponins flat
at 0.05 (patient has CKD). The patient is not currently taking
aspirin considering his history of GI bleeds. Lipid management
as discussed below.
.
# Hypercholesterolemia: Chol 131, TG 126, HDL 42, LDL 64. LDL is
at goal, so we continued atorvastatin 10mg daily.
.
# Diabetes Mellitus: Patient was monitored via FSBS with regular
insulin sliding scale. Upon discharge he was restarted on
glipizide 5mg daily.
.
# Hypertension: Well controlled. Continued lisinopril 10mg
daily, and tamsulosin 0.4mg daily. Decreased amodipine to 5mg
daily. Started lasix 20mg daily.
.
# CKD: Baseline Cr~1.5-1.8. Currently at baseline.
.
# Anemia: Normocytic. Hct stable ~29-33. No evidence of active
bleeding and stool is guiac negative. Iron studies, B12, folate
all wnl. Possibly in the setting of CKD. Recommend outpatient
follow up.
.
# GERD: Asymptomatic. Continued omeprazole.
.
# BPH: Continued tamsulosin.
.
# Cerebral Palsy: Patient lives independently but was discharged
to an LTAC for physical therapy.
.
# Dental: Patient reports a missing filling on his left upper
jaw. Recommend outpatient dentistry consult.
Medications on Admission:
1. glipizide 5 mg Tablet 1 Tablet PO once a day.
2. tamsulosin 0.4 mg Capsule, Sust. Release 24 hr 1
Capsule, Sust. Release 24 hr PO HS (at bedtime).
3. atorvastatin 10 mg Tablet po daily
4. oxybutynin chloride 5 mg Tablet 1 po daily
5. lisinopril 10 mg Tablet 1 Tablet PO DAILY
6. amlodipine 10 mg Tablet 1 Tablet PO once a day.
7. FerrouSul 325 mg (65 mg Iron) Tablet 1 Tablet PO daily
8. omeprazole 40 mg Capsule, Delayed Release(E.C.) 1
Capsule, Delayed Release(E.C.) PO twice a day for 14 days.
9. docusate sodium 100 mg Capsule 1 Capsule PO BID
10. polyethylene glycol 3350 17 gram/dose Powder 1
packet PO DAILY as needed for constipation.
11. sucralfate 1 gram Tablet PO QID (4 times a day) for 3 days:
mix tab w/ hot water to make a slurry and drink 4 times daily.
This medicine protects your stomach after your procedure.
Discharge Medications:
1. glipizide 5 mg Tablet Sig: One (1) Tablet PO once a day.
2. tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
3. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. oxybutynin chloride 5 mg Tablet Sig: One (1) Tablet PO once a
day.
5. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. ferrous sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet Daily.
8. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) packet PO once a day as needed for constipation.
11. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital - [**Hospital1 8**]
Discharge Diagnosis:
pneumonia
aortic regurgitation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Mr. [**Known lastname 57141**],
You were admitted to the hospital with fevers and shortness of
breath due to pneumonia, which we have treated with antibiotics.
We have also been giving you diuretics to remove extra fluid and
make it easier for your heart to pump.
.
We have made the following changes to your medications:
- STARTED furosemide 20mg daily
- DECREASED amlodipine from 10mg to 5mg daily
Followup Instructions:
You should call your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 131**] to schedule an appointment
within 1-2 weeks after you leave rehab. ([**Telephone/Fax (1) 17909**].
Completed by:[**2105-3-2**]
|
[
"250.00",
"530.81",
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"585.9",
"V58.61",
"428.0",
"V42.2",
"272.4",
"426.53",
"600.00",
"427.31",
"285.9",
"V10.51",
"428.23"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
13499, 13570
|
7821, 11677
|
331, 337
|
13645, 13645
|
4006, 4006
|
14252, 14468
|
2552, 2642
|
12558, 13476
|
13591, 13624
|
11703, 12535
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|
5183, 7798
|
2657, 3307
|
3323, 3987
|
14150, 14229
|
280, 293
|
365, 1713
|
4022, 4594
|
13660, 13804
|
4610, 5167
|
1735, 2323
|
2339, 2536
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
83,124
| 135,467
|
2734
|
Discharge summary
|
report
|
Admission Date: [**2104-10-3**] Discharge Date: [**2104-10-5**]
Date of Birth: [**2063-12-8**] Sex: M
Service: MEDICINE
Allergies:
Azulfidine / Penicillins
Attending:[**First Name3 (LF) 1185**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
40M with history of CAD s/p cath [**9-25**], DM2, hypertension,
multinodular goiter with microcalcifications, ulcerative colitis
status post colectomy with permanent ileostomy, presents with
atypical chest pain. He was discharged on [**9-26**] for admission
for positive stress test, found to have 50% LAD stenosis which
was not intervened on given poor medical compliance, started on
high dose statin and discharged. He presents again today with
chest pain, however he declines to give a history. Per PCP call
in, pt stated "I want to blow myself up" "Put myself in front
of a car to be run over" and "My mind is just too full, too
chaotic, just want it to stop." States the "it" he wants to
stop is his medical difficulties. Patient also states
that he wants to "blow us all up" pointing to the doctor, myself
and his mother in the room with him, and using his hand in what
looks like pressing detonator of an explosive. [**Name (NI) 1094**]
mother states he talks like this when he is at medical
appointment, but at home is calm and notin danger. He was sent
to ED for psych evaluation and for evaluation of chest pain. No
abd pain, vomiting, diarrhea.
.
In the ED, initial VS were: 98.1 99 160/90 20 99%. EKG with
sinus tach to 103, LVH, nl axis, and TWI in I, aVL, V4, V6. ABG
was done for question of altered mental status which showed pH
7.29, pCO2 38, pO2 36, HCO3 19, non-gap. Stox and Utox
negative. Given kayexalate 60 gm x 1 for K of 5.7. Als
received ceftriaxone and dexamethasone. CXR with changse c/w
CHF. Cardiology fellow called, felt that he is not a candidate
for stenting given his likely noncompliance with medication. He
was given a dose of dexamethasone for possible adrenal
insufficiency in this presentation. Pt was diuresed with 40 mg
IV lasix and admitted to the MICU for acidosis. VS on transfer
100, 191/84, 16, 99% RA.
.
On arrival to the MICU, pt interviewed with mother and
Portuguese interpreter. He denies any complaints but is upset
that he is here. Since discharge on [**9-26**], he has felt well, no
medication changes other than the lipitor started at his last
discharge. No diarrhea, no vomiting, no ingestions, denies any
drug use. He presented to clinic for a scheduled discharge
followup visit and says that his comments above were said under
stress of meeting a new doctor who was "asking too many
questions." Denies any SI/HI and requesting to be left alone to
rest. He feels better in that his lower extremity edema has
improved, but was not short of breath at home. Ate out at Panera
and Subway multiple times this week.
.
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY: CHF with EF 40%
3. OTHER PAST MEDICAL HISTORY:
1. Poorly controlled type 2 diabetes with an
albumin-to-creatinine ratio of 2812.5, complicated also by right
eye vision loss secondary to subhyaloid hemorrhage that has been
refractory to panretinal photocoagulation treatment, now
requiring a vitrectomy.
2. Hypertension.
3. Goiter.
4. Ulcerative colitis status post colectomy and permanent
ileostomy.
5. Osteoporosis secondary to prolonged steroid courses for his
ulcerative colitis.
6. Compression fractures.
7. Elevated LFTs, suspected to be secondary to fatty liver.
8. Erectile dysfunction.
9. CKD with uptrending baseline, last Cr~1.6
10. CHF with EF 40%
Social History:
Denies tobacco, ethanol or drugs. Lives at home with his mother
and father. [**Name (NI) **] is an only child. Continues to be unemployed
and was enrolled in special needs classes growing up.
Family History:
There is a strong family history of type 2 diabetes in both his
father, mother, and several extended family members.
Physical Exam:
On Admission:
Vitals: 97.2 102 186/87 28 100% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly, ostomy bag in place
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities
On discharge patient's blood pressure had improved to SBP in
160's.
Lower extremity edema was present.
All crackles in lungs had resolved.
Pertinent Results:
Admission labs:
[**2104-10-3**] 02:00PM BLOOD WBC-10.3 RBC-3.40* Hgb-10.1* Hct-29.2*
MCV-86 MCH-29.7 MCHC-34.6 RDW-14.0 Plt Ct-254
[**2104-10-3**] 02:00PM BLOOD Neuts-84.0* Lymphs-9.1* Monos-4.1 Eos-2.6
Baso-0.2
[**2104-10-3**] 02:00PM BLOOD PT-14.5* PTT-28.9 INR(PT)-1.3*
[**2104-10-3**] 02:00PM BLOOD Glucose-193* UreaN-59* Creat-1.6* Na-133
K-5.7* Cl-106 HCO3-15* AnGap-18
[**2104-10-3**] 02:00PM BLOOD ALT-32 AST-23 LD(LDH)-260* CK(CPK)-69
AlkPhos-85 TotBili-0.3
[**2104-10-3**] 02:00PM BLOOD Calcium-9.2 Phos-4.5 Mg-2.3
[**2104-10-3**] 10:50PM BLOOD Osmolal-308
[**2104-10-3**] 02:00PM BLOOD TSH-0.95
[**2104-10-3**] 02:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2104-10-3**] 04:11PM BLOOD Type-[**Last Name (un) **] pO2-36* pCO2-38 pH-7.29*
calTCO2-19* Base XS--8
[**2104-10-3**] 04:50PM BLOOD Lactate-1.0
CXR:
PA AND LATERAL VIEWS OF THE CHEST: There is central pulmonary
vascular
congestion with moderate pulmonary edema. The chronicity of
these findings is unknown due to the lack of comparison studies.
There is no focal
consolidation, pneumothorax, or pleural effusion.
IMPRESSION: Congestive heart failure, likely acute. Acute
myocardial
infarction should be ruled out as the cause of failure given
patient's young age and acuity of presentation.
.
EKG: No evidence of ischemic changes. NSR unchanged from prior
baseline.
Brief Hospital Course:
Mr. [**Known lastname 13531**] is a 40 man with history of CAD s/p cath [**2104-9-25**], DM2,
hypertension, multinodular goiter with microcalcifications,
ulcerative colitis status post colectomy with permanent
ileostomy, presents with non-anion gap metabolic acidosis,
possible SI/HI, lower extremity edema. Patient initially
admitted to MICU for non-anion gap acidosis.
1. Non-anion gap metabolic acidosis: Previously noted on prior
recent blood chemistry, although bicarb slightly lower. pCO2 of
38 not c/w respiratory compensation. Anion gap is 12 (wnl). On
differential diagnosis was GI loss, RTA, ingestions,
post-hypocapnia (renal wasting of HCO3 after respiratory
alkalosis with transient acidosis). No h/o diarrhea, ingestions
or medication changes. Patient currently appears
hemodynamically stable and mental status is at baseline per
mother and interpreter.
Prior to transfer from ICU, bicarb improved to 19. On discussion
with renal overall picture most consistent with type IV RTA.
Patient [**Name (NI) **] was stopped and switched to amlodipine.
2. CHF: On exam appears to be fluid overloaded given bilateral
crackles at bases, lower extremity edema, and evidence on CXR.
Already received 40 mg IV lasix with some improvement in edema.
Patient received an additional dose of IV lasix in the MICU and
was transitioned to his PO dose of lasix on day 2 of admission.
He has had recent cardiac problems and the decision was made
not to treat a stenosis on the basis of his noncompliance. He
had also been written for home lasix which he had not been
taking. Given lack of EKG changes and negative enzymes x 1 in
context of recent cardiac workup no further cardiac evaluation
was performed.
3. Suicial/Homicidal Ideation: Patient expressed SI/HI during
clinic visit for which he was sent to emergency department.
Throughout admission patient denied any HI/SI. He was initially
under section 12 based on his behavior and psych eval in clinic.
He was seen by the inpatient psychiatric team who felt the
patient was safe from psychiatric point of view, discontinue 1:1
sitter, discontinue section 12, okay to discharge from
psychiatric point of view.
4. HTN: BP elevated today in 180s, however baseline BP per pt
and in clinic notes 170s systolic. Pt has been resistant to
increases in BP medications as an outpatinet. Patient's losartan
was discontinued as he was hypokalemic. Home dose of HCTZ and
metoprolol were continued. Started on amlodipine 5mg.
5. Hyperkalemia: Pt received kayexalate and lasix in ED, no EKG
changes. Pt has CKD, but renal function is at baseline today,
also is on losartan and has had elevated K in the past.
Patient's losartan was stoppped.
6. DM: Held glipizide as inpatient, patient was kept on insulin
sliding scale.
7. CAD: Continuted home dose of aspirin, lipitor.
8. GERD: Continuted omeprazole.
9. Code: DNR/DNI
Medications on Admission:
1. losartan-hydrochlorothiazide 100-25 mg Tablet Sig: One (1)
Tablet PO once a day.
2. Toprol XL 100 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO once a day.
3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. glipizide 10 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet
Extended Rel 24 hr PO once a day.
7. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Medications:
1. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
2. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
6. aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
7. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
Disp:*30 Tablet(s)* Refills:*2*
8. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
suicidal/homicidal ideation
metabolic acidosis
hyperkalemia
pulmonary edema
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You came to the hospital with agitation and high potassium. We
adjusted your medications and fixed your potassium levels. Our
psychiatrists cleared you to go home.
We have adjusted your medictations.
Please stop your combination losartan/hydrochlorothiazide pill.
START: Amlodipine 5mg daily
START: Hydrochlorothiazide 25mg daily
Please follow up with your primary care providers as below
Followup Instructions:
Please call [**Telephone/Fax (1) 250**] to make a follow up appointment with
Dr. [**Last Name (STitle) 303**].
Department: OPTHALMOLOGY
When: MONDAY [**2104-10-6**] at 9:30 AM [**Telephone/Fax (1) 253**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital3 1935**] CENTER
When: TUESDAY [**2104-10-7**] at 9:10 AM
With: [**First Name11 (Name Pattern1) 354**] [**Last Name (NamePattern4) 3013**], M.D. [**Telephone/Fax (1) 253**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: WEST [**Hospital 2002**] CLINIC
When: THURSDAY [**2104-10-30**] at 1 PM
With: [**First Name11 (Name Pattern1) 1877**] [**Last Name (NamePattern1) 1878**], M.D. [**Telephone/Fax (1) 721**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
[**Name6 (MD) **] [**Name8 (MD) **] MD [**Doctor Last Name 1189**]
Completed by:[**2104-10-5**]
|
[
"530.81",
"250.42",
"583.81",
"V62.84",
"585.9",
"428.23",
"733.00",
"362.01",
"276.7",
"414.01",
"250.52",
"241.1",
"403.90",
"V49.86",
"V44.2",
"428.0",
"276.2"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10511, 10517
|
6214, 9090
|
297, 303
|
10637, 10637
|
4812, 4812
|
11206, 12309
|
3938, 4057
|
9770, 10488
|
10538, 10616
|
9117, 9747
|
10788, 11183
|
4072, 4072
|
3040, 3056
|
246, 259
|
331, 2935
|
4829, 6191
|
4086, 4793
|
10652, 10764
|
3087, 3710
|
2957, 3019
|
3726, 3922
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,607
| 163,290
|
2128
|
Discharge summary
|
report
|
Admission Date: [**2115-8-12**] Discharge Date: [**2115-8-16**]
Date of Birth: [**2049-7-11**] Sex: F
Service: NMED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5378**]
Chief Complaint:
status epilepticus
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 66 year old woman with a history of seizures who now
presents to the ED reportedly after having four seizures since
4pm today according to her husband. She was found by EMS in bed
lying on her side, eyes deviated to the right with both upper
extremities flexed in a tonic upward position. They were not
certain as to what her lower extremities were doing. They were
informed by her husband (whom I cannot reach because the phone
number in the computer is out of service) that she has
approximately one a month and only takes dilantin for her
seizures. She was incontinent. They took her on her stretcher
and
she gripped the handrail and was thought to be shaking on her
left arm. When she arrived to the ED the nurse [**First Name (Titles) 8706**] [**Last Name (Titles) **]
arm shaking with the eyes fixed right, beating quickly to the
left, all of which broke with benzodiazepines, first 5mg valium
given by EMS and then 2mg ativan when it recurred. She has also
since received 2g ceftriaxone and 1g dilantin.
I was finally able to reach the husband at [**Telephone/Fax (1) 11437**]. [**Name2 (NI) **]
tells
me that she has had seizures, approximately once a month and
they
occur more frequently when she is under a great deal of stress.
She was recently diagnosed with a urinary tract infection and
placed on ciprofloxacin because she was unable to go to the
bathroom. She apparently was well until today at 3:30pm when she
had the first of several seizures. In between each seizure she
went to sleep. She denied headache, abdominal pain to him but
she
apparently did vomit a couple of times. Her primary care
physician is [**Last Name (NamePattern4) **]. [**Last Name (STitle) 11438**] in [**Location (un) **], MA at [**Telephone/Fax (1) 11439**].
Past Medical History:
Seizure disorder, hypertension, hypercholesterolemia, diabetes,
mild anemia, history of hyponatremia with flurry of seizures,
coronary artery bypass graft surgery [**2110**], old left PCA infarct
seen on old MRI scan in [**2107**], left below- the-knee amputation
[**2110**], recent coronary? stents put in 6 months ago at [**Hospital1 756**] and
Women's Hospital
Social History:
She and her husband living in a nursing facility
Habits: not known, reportedly no smoking, alcohol, or drugs
Family History:
unknown
Physical Exam:
T 103 BP 220/111 HR 112 RR 18 O2 sat 99% NRB
General appearance: ill appearing older woman
Heart: regular rate and rhythm without murmurs, rubs or gallops
Lungs: clear to auscultation bilaterally.
Abdomen: soft, nontender
Extremities: no clubbing, cyanosis or edema
Skull & Spine: Neck is supple.
Mental Status: The patient is sleepy, intermittently opening her
eyes to voice. She does not follow commands.
Cranial Nerves: She does not blink to threat bilaterally. There
is no nystagmus in primary gaze. She is able to make horizontal
eye movements. The optic discs could not be visualized because
she was moving her eyes around to avoid the light. Eye movements
are normal, the pupils react normally to light, both directly
and
consensually. There appears to be a right facial droop. There is
no nystagmus.
Sensory/Motor System: There is left below the knee amputation.
She withdraws all 4 extremities to pain. There is decreased tone
in the right arm.
Reflexes: The tendon reflexes are present, symmetric and normal
in the upper extremities, absent in the lower extremities. The
plantar reflexes are extensor on the right.
Pertinent Results:
[**2115-8-12**] 10:27PM CK(CPK)-189*
[**2115-8-12**] 10:27PM CK-MB-13* MB INDX-6.9* cTropnT-1.07*
[**2115-8-12**] 02:30PM GLUCOSE-149* UREA N-34* CREAT-1.8* SODIUM-139
POTASSIUM-4.1 CHLORIDE-105 TOTAL CO2-22 ANION GAP-16
[**2115-8-12**] 02:30PM CK(CPK)-224*
[**2115-8-12**] 02:30PM CK-MB-19* MB INDX-8.5* cTropnT-0.93*
[**2115-8-12**] 02:30PM CALCIUM-8.5 PHOSPHATE-3.2 MAGNESIUM-1.7
[**2115-8-12**] 02:30PM PLT COUNT-185
[**2115-8-12**] 02:30PM PLT COUNT-185
[**2115-8-12**] 04:35AM LACTATE-3.2*
[**2115-8-12**] 02:30PM PT-12.8 PTT-18.4* INR(PT)-1.0
[**2115-8-12**] 04:25AM GLUCOSE-228* UREA N-35* CREAT-1.9* SODIUM-138
POTASSIUM-3.1* CHLORIDE-98 TOTAL CO2-19* ANION GAP-24*
[**2115-8-12**] 04:25AM ALT(SGPT)-15 AST(SGOT)-24 CK(CPK)-90 ALK
PHOS-134* TOT BILI-0.3
[**2115-8-12**] 04:25AM CK-MB-NotDone cTropnT-0.38*
[**2115-8-12**] 04:25AM CALCIUM-8.8 PHOSPHATE-3.6 MAGNESIUM-1.8
[**2115-8-12**] 04:25AM PHENOBARB-<1.2* PHENYTOIN-15.6
[**2115-8-12**] 04:25AM CARBAMZPN-<1.0*
[**2115-8-12**] 04:25AM URINE HOURS-RANDOM
[**2115-8-12**] 04:25AM URINE UHOLD-HOLD
[**2115-8-12**] 04:25AM WBC-9.6# RBC-4.07* HGB-12.9 HCT-35.8* MCV-88
MCH-31.8 MCHC-36.2* RDW-13.2
[**2115-8-12**] 04:25AM NEUTS-97* BANDS-1 LYMPHS-1* MONOS-0 EOS-0
BASOS-0 ATYPS-0 METAS-1* MYELOS-0
[**2115-8-12**] 04:25AM PLT COUNT-242
[**2115-8-12**] 04:25AM PT-12.8 PTT-18.0* INR(PT)-1.0
[**2115-8-12**] 04:25AM URINE COLOR-Straw APPEAR-Hazy SP [**Last Name (un) 155**]-1.016
[**2115-8-12**] 04:25AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-500
GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2115-8-12**] 04:25AM URINE RBC-0-2 WBC->50 BACTERIA-MANY YEAST-NONE
EPI-0-2
Brief Hospital Course:
Pt was initially admitted to the ICU for status epilepticus.
She was found to have a UTI with proteus, resistant to multiple
antibiotics, was treated on ceftriaxome IV for three days and
did not have any adverse reactions. She has a h/o Left PCA/MCA
watershed encephalomalacia and cerebellar hypodensities on CT
but has no new strokes on MRI. We treated her initially on
Dilantin 200/100/200 and Keppra 500 [**Hospital1 **]. She had a stable
neurologic exam with baseline disorientation to time/date. She
had no further siezures and we feel that her sz were from UTI
giving her a metabolic derangement. We also found that the
patient has a poor compliance with medications and is almost
paranoid about letting people help her with her medications.
Initially pt had an elevation in her troponin to 1.07 and a
downtrend (see lab section). Cardiology has been involved. Pt
has had several episodes of chest pain on the floor, and has had
several more EKG's showing no evidence of acute infarct.
Cardiology was reconsulted and recommended persantine studies,
but as pt would not want to proceed with catheterization, there
is no utility to pursuing this study at this time. Chest pain
was not felt to be cardiac in origin.
Medications on Admission:
Dilantin 200/100/200, sodium bicarbonate, ativan,
folate, plavix, quinine sulfate, protonix, keppra one tab twice
a
day (unsure what dose is), lipitor, norvasc, lasix, cipro
Discharge Medications:
1. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
2. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
3. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO QD (once a day).
5. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2) Capsule
PO BID (2 times a day).
Disp:*120 Capsule(s)* Refills:*0*
6. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Norvasc 10 mg Tablet Sig: One (1) Tablet PO once a day.
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
9. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO four times a
day.
10. Quinine Sulfate 260 mg Tablet Sig: One (1) Tablet PO at
bedtime.
11. Sodium Bicarbonate 650 mg Tablet Sig: One (1) Tablet PO
three times a day.
12. Lorazepam 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Toprol XL 100 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*
14. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
15. Imdur 30 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
1. Seizure disorder
2. Urinary tract infection
3. Troponin leak
4. Peripheral vascular disease
5. Diabetes
6. Hypercholesterolemia
7. Anemia
8. Hypertension
Discharge Condition:
Stable, tolerating an oral diet, afebrile.
Discharge Instructions:
Please take your medications as prescribed. Please get your
dilantin level checked in one week at your doctor's office (no
appointment needed). Please keep your follow up appointments.
Call your doctor or return to the emergency department if you
have recurrent seizures, persistent headaches, changes in your
vision, fevers, chills, nausea, vomiting, chest pain or
pressure, shortness of breath, incontinence of bowel or bladder,
or any other symptoms concerning to you.
Followup Instructions:
Please keep the following appointments:
1. [**Hospital 875**] clinic with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2442**]. Please call
[**Telephone/Fax (1) 2928**] and update your insurance information with the
receptionist. If you have [**Hospital **] [**Hospital **] Health Care you will
need to get your doctor to give you a referral for this
appointment (you may want to reschedule it for later if that is
the case).
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], MD Where: [**Hospital6 29**] NEUROLOGY
Phone:[**Telephone/Fax (1) 3506**] Date/Time:[**2115-8-28**] 2:30
2. Vascular Surgery Appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]:
Wednesday [**2115-9-4**] at 11:00am. [**Last Name (NamePattern1) **]. [**Location (un) 6332**] Suite B. [**Telephone/Fax (1) 1784**]. Provider: [**Name10 (NameIs) **],[**First Name3 (LF) **] D.
VASCULAR SURGERY Where: VASCULAR SURGERY Date/Time:[**2115-9-4**]
11:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5379**] MD, [**MD Number(3) 5380**]
|
[
"250.00",
"440.20",
"285.9",
"345.40",
"V45.81",
"599.0",
"041.4",
"414.01",
"427.31",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8441, 8516
|
5554, 6782
|
330, 336
|
8717, 8761
|
3840, 5531
|
9283, 10401
|
2662, 2671
|
7007, 8418
|
8537, 8696
|
6808, 6984
|
8785, 9260
|
2686, 2984
|
272, 292
|
364, 2129
|
3112, 3821
|
2999, 3096
|
2151, 2518
|
2534, 2646
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,850
| 103,518
|
45777
|
Discharge summary
|
report
|
Admission Date: [**2196-11-14**] Discharge Date: [**2196-11-19**]
Service: NEUROSURGERY
Allergies:
Sulfonamides / Epinephrine / Diltiazem / Pletal
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Depressed Mental status
Major Surgical or Invasive Procedure:
Left Craniotomy for SDH evacuation
History of Present Illness:
86 y/o female with history of afib on Coumadin. Ms [**Known lastname 97533**]
was with her son yesterday and fell getting bundles out of her
car. She hit her head on the pavement and did not have a loss of
consciousness. She was able to do her normal activities she went
to bed last night and her son attempted to arrouse her at 2am
for
which he stated "she did not fully awake" this morning when his
mother did not wake up he found her in her room and was able to
minimally arrouse her. She was brought by ambulance here.
Past Medical History:
Atrial fibrillation, Diabetes, HTN, Menieres Disease, S/P
multiple falls recent radius/humeral fractures.
Social History:
Retired nurse, lives with son, non [**Name2 (NI) 1818**], no alcohol
Family History:
NC
Physical Exam:
O: T: BP:169/78 HR:80 R17 O2Sats 100%
Gen: Seen prior to intubation, [**Name (NI) 91248**] respirations, no
commands
HEENT: Pupils: surgical bilateral 2mm
Neck: In collar
Neuro:
Does not follow commands
Does not open eyes
Extensor postures in upper extremities will slightly withdraw
legs left greater than right
Face symmetric
Toes mute
Normal tone
Difficult to obtain any reflexes most likely hyporeflexic and
symmetric
Pertinent Results:
[**Hospital1 69**]
[**Location (un) 86**], [**Telephone/Fax (1) 15701**]
Pathology Examination
Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 97534**],[**Known firstname **] [**2109-12-5**] 86 Female [**-8/4553**]
[**Numeric Identifier 97535**]
Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]
[**Last Name (NamePattern1) 2093**] Description by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/mtd
SPECIMEN SUBMITTED: left subdural hematoma, left subdural
hematoma.
Procedure date Tissue received Report Date Diagnosed
by
[**2196-11-14**] [**2196-11-14**] [**2196-11-17**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/ttl
Previous biopsies: [**Numeric Identifier 97536**] EGD (3).
[**Numeric Identifier 97537**] (Not on file)
DIAGNOSIS:
Left subdural hematoma:
Blood clot.
Clinical: Left subdural hematoma.
Gross:
The specimen is received fresh in a container labeled with the
patient's name, "[**Known lastname 97533**], [**Known firstname **]", and the medical record number
and additionally labeled "left subdural hematoma". It consists
of a blood clot measuring 6 x 2 x 0.2 cm. Representative
sections are submitted in cassette A.
[**Known lastname **],[**Known firstname **] [**Medical Record Number 97538**] F 86 [**2109-12-5**]
Cardiology Report ECG Study Date of [**2196-11-14**] 9:15:36 AM
Sinus rhythm. Left atrial abnormality. Left ventricular
hypertrophy with
ST-T wave abnormalities. Since the previous tracing of [**2196-5-4**]
further
ST-T wave changes are present.
Read by: [**Last Name (LF) **],[**First Name3 (LF) 177**] W.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
76 180 78 [**Telephone/Fax (2) 97539**]0
[**Known lastname **],[**Known firstname **] [**Medical Record Number 97538**] F 86 [**2109-12-5**]
Radiology Report CT C-SPINE W/O CONTRAST Study Date of [**2196-11-14**]
9:22 AM
[**Last Name (LF) **],[**First Name3 (LF) **] EU [**2196-11-14**] 9:22 AM
CT C-SPINE W/O CONTRAST Clip # [**Clip Number (Radiology) 97540**]
Reason: fx, dislocation
[**Hospital 93**] MEDICAL CONDITION:
86 year old woman with s/p fall and ams
REASON FOR THIS EXAMINATION:
fx, dislocation
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Wet Read: LLTc MON [**2196-11-14**] 10:47 AM
NO acute fx or malalignment.
Final Report
INDICATION: 86-year-old female status post fall with acute
mental status
changes.
TECHNIQUE: CT of the C-spine without IV contrast.
COMPARISON: MR of the C-spine available from [**2191-6-5**].
FINDINGS: There are no acute fractures or traumatic
malalignment. There is
mild straightening of lordosis, consistent with the presence of
cervical
collar. There are moderate to severe degenerative changes
throughout the
cervical spine, including severe facet arthropathy, and loss of
intervertebral disc space, most severely at C5 through T1. There
is grade 1 anterolisthesis of C4 over C5. Diffuse disc bulging
is present at C5-C6 and C6-C7, resulting in moderate spinal
canal stenosis, most severely at C5-C6.
There is no prevertebral hematoma or adjacent soft tissue
abnormalities.
Included views of the lungs demonstrate mild dependent
atelectasis
bilaterally. There are multiple nodules within the slightly
enlarged right
thyroid lobe.
IMPRESSION:
1. No acute fractures or traumatic malalignment.
2. Moderate-to-severe degenerative changes throughout the
cervical spine,
most severely at C5-C6, with associated moderate spinal canal
stenosis.
3. Multiple right thyroid nodules.
The study and the report were reviewed by the staff radiologist.
[**Known lastname **],[**Known firstname **] [**Medical Record Number 97538**] F 86 [**2109-12-5**]
Radiology Report CT HEAD W/O CONTRAST Study Date of [**2196-11-14**]
9:22 AM
[**Last Name (LF) **],[**First Name3 (LF) **] EU [**2196-11-14**] 9:22 AM
CT HEAD W/O CONTRAST Clip # [**Clip Number (Radiology) 97541**]
Reason: ICH
[**Hospital 93**] MEDICAL CONDITION:
86 year old woman with s/p fall and AMS
REASON FOR THIS EXAMINATION:
ICH
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Wet Read: LLTc MON [**2196-11-14**] 10:44 AM
Left subdural hematoma with mixed hyperdensity, concerning for
active bleed, tracking along the left convexivity and left
tentorium.
Rightward shift of midline structures up to 17 mm, with
significant
effacement of the left lateral ventricle. Dilated temporal [**Doctor Last Name 534**]
of right
lateral ventricle concerning for early hydrocephalus.
Rightward subfaclcine herniation. Early righward uncal
herniation.
Final Report
INDICATION: 86-year-old female status post fall and acute mental
status
changes.
TECHNIQUE: CT of the head without IV contrast.
COMPARISON: CT of the head available from [**2193-12-12**].
FINDINGS:
There is a large left cerebral subdural hematoma, measuring up
to 17 mm in
thickness, with blood tracking along the left tentorium. There
is significant neighboring mass effect on left cerebral sulci
and the left lateral ventricle with subfalcine herniation and
17-mm rightward shift of normally midline structures. The
hematoma has mixed hyper and hypoattenuating components,
consistent with an acute on chronic bleeding. There is slight
effacement of the suprasellar cistern, concerning for an early
rightward uncal herniation. Slight hyperattenuation along the
suprasellar cistern borders may represent trace subarachnoid
blood. The quadrigeminal cistern is preserved but slightly
asymmetric. The right lateral ventricle is slightly effaced, and
the temporal [**Doctor Last Name 534**] is slightly dilated in comparison to the prior
CT exam from [**2193-12-12**], concerning for possible early
hydrocephalus.
Again, there is significant hypoattenuation of the
periventricular white
matter, consistent with chronic microvascular ischemic disease.
There are no acute fractures. There is a large subgaleal
hematoma overlying the left parietal and occipital regions, with
a more focal hyperattenuating region representing a more focal
hematoma. The middle ear cavities and included portions of the
mastoid air cells and paranasal sinuses are clear. The orbits
are symmetrical and intact.
IMPRESSION: Large acute left subdural hematoma with associated
mass effect, subfalcine herniation and left uncal herniation.
Findings were communicated with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at 10:45 a.m.
on [**2196-11-14**].
The study and the report were reviewed by the staff radiologist.
[**Known lastname **],[**Known firstname **] [**Medical Record Number 97538**] F 86 [**2109-12-5**]
Radiology Report MR HEAD W/O CONTRAST Study Date of [**2196-11-15**]
2:09 PM
[**Last Name (LF) **],[**First Name3 (LF) **] J. NSURG SICU-A [**2196-11-15**] 2:09 PM
MR HEAD W/O CONTRAST Clip # [**Clip Number (Radiology) **]
Reason: 86 year old woman with SDH, on coumadin. Eval for
interval c
[**Hospital 93**] MEDICAL CONDITION:
86 year old woman with SDH, on coumadin. Eval for interval
change. ***PLEASE
INCLUDE DWI***
REASON FOR THIS EXAMINATION:
86 year old woman with SDH, on coumadin. Eval for interval
change. ***PLEASE
INCLUDE DWI***
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Final Addendum
Dedicated imaging of the intracranial arteries can be considered
with MRA.
DR. [**First Name (STitle) 10627**] PERI
Approved: [**Doctor First Name **] [**2196-11-17**] 11:04 AM
[**Last Name (LF) **],[**First Name3 (LF) **] J. NSURG SICU-A [**2196-11-15**] 2:09 PM
MR HEAD W/O CONTRAST Clip # [**Clip Number (Radiology) **]
Reason: 86 year old woman with SDH, on coumadin. Eval for
interval c
[**Hospital 93**] MEDICAL CONDITION:
86 year old woman with SDH, on coumadin. Eval for interval
change. ***PLEASE
INCLUDE DWI***
REASON FOR THIS EXAMINATION:
86 year old woman with SDH, on coumadin. Eval for interval
change. ***PLEASE
INCLUDE DWI***
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Final Report
INDICATION: 86-year-old woman with subdural hematoma on
Coumadin, status post
evacuation. Evaluate for interval change.
COMPARISON: Multiple head CTs most recent of [**2196-11-14**].
TECHNIQUE: Sagittal T1 and axial fat-saturated T2, FLAIR,
gradient echo, and diffusion-weighted images were obtained of
the head.
FINDINGS: Multiple areas of restricted diffusion are noted,
consistent with acute infarcts in the left anterior, middle, and
posterior cerebral artery vascular territories. In addition,
areas of acute infarct are noted in the right anterior and
posterior cerebral artery vascular territories, involving the
right thalamus. There is no evidence of hemorrhagic
transformation of these infarcts. There is persistent rightward
shift of midline structures which has improved since the
previous study, now measuring approximately 6 mm down from 10
mm. Previously noted pneumocephalus is resolving. Residual left
subdural hemorrhage and intraparenchymal hemorrhage are again
seen, unchanged. The ventricles remain unchanged in size. The
major vascular flow voids appear
patent.
IMPRESSION:
Acute multi vascular territorial infarcts most pronounced in the
left
hemisphere, as described above. While these can relate to
compression of the arteries from the extensive SDH and mass
effect, embolic etiology is also in the differential diagnosis.
Findings were discussed with Dr. [**Last Name (STitle) **] [**Name (STitle) **] shortly after
review on [**2196-11-15**].
The study and the report were reviewed by the staff radiologist.
Brief Hospital Course:
Ms. [**Known lastname 97533**] arrived to the ED intubated for airway protection.
She recieved Profiline 9 and several units of FFp to reverse her
coagulopathy and went emergently for a left sided craniotomy for
SDH evacuation. Post operatively she was left intubated and
transferred to the Surgical intensive care unit.
Her exam never improved. She was followed clinically for the
next few days. An MRI was performed for prognostics. She was
made CMO after a family meeting. She later expired.
Medications on Admission:
Medications prior to admission: Amiodarone 200 QD, Carvedilol
25mg [**Hospital1 **], Metformin 500mg tid, pravastatin 10 at HS, Januvia 100
QD, and Coumadin
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Left sided Acute on Chronic SDH
Hyperglycemia
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
Completed by:[**2196-11-28**]
|
[
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"386.00",
"790.92",
"401.9",
"348.4",
"E885.9",
"V58.61",
"250.00",
"V66.7",
"427.31",
"852.21",
"E934.2",
"780.97",
"V15.51",
"781.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"01.39"
] |
icd9pcs
|
[
[
[]
]
] |
11886, 11895
|
11148, 11649
|
283, 320
|
11985, 11994
|
1577, 3713
|
12047, 12083
|
1106, 1110
|
11857, 11863
|
9298, 9393
|
11916, 11964
|
11675, 11675
|
12018, 12024
|
1125, 1558
|
11707, 11834
|
220, 245
|
9425, 11125
|
348, 873
|
895, 1003
|
1019, 1090
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,104
| 163,671
|
16291
|
Discharge summary
|
report
|
Admission Date: [**2123-6-18**] Discharge Date: [**2123-6-22**]
Date of Birth: [**2063-10-16**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
Unresponsive
Major Surgical or Invasive Procedure:
Intubation, extubation
Central venous line placement, removal
History of Present Illness:
Mr. [**Known lastname 4186**] is a 59 year old alcoholic man with bipolar disorder.
His wife was in bed and noticed he came home around 2pm and
layed down next to her smelling of alcohol. She awoke at 5pm and
found him laying face down in the kitchen snoring surrounded by
pillows and a bottle of wellbutrin pills and unchewed welbutrin
pills scattered around him and a bottle of unopened lamictal.
His mouth was bloody; his wife turned him on his side; she says
he was not dusky or blue. She noted he was not moving his right
side. EMS took him to [**Location (un) 620**] where he was unresponsive; NG
lavage did not retreive any pill fragments,VS were P 91, BP
141/98, RR 17, 100% on RA. He was given Narcan and intubated. He
was immediately intubated. EtOH level was 275; head CT negative
at [**Location (un) 620**]. Tox only positive for alcohol. Transferred here
where initial Vs were HR 70 BP 92/61 SaO2 100% on vent. Pupils
noted to be 3mm and minimally reactive on a versed drip at 2mg.
Reflex squeezes L hand; no withdrawal to pain; upgoing does
Bilaterally per ED team.
Past Medical History:
elevated LFTs
bipolar disorder
alcoholism
Hypertension
Obesity s/p gastric bypass in [**2118**]
Glucose intolerance
Prior pancreatitis
Sleep apnea (does not use CPAP)
Social History:
alcoholism since [**30**] years old, then quit for many years,
restarted drinking [**3-6**] to life stressors. per wife, smokes 1ppd
and does not use illicit drugs. Pt. works as a computer
technician and has a business with his son. However, due to his
alcoholism and financial issues, they are losing the business.
He has a son who suffers from depression and drug abuse. Wife is
a nurse.
Family History:
father and grandfather-alcoholism
Physical Exam:
(on admission)
T AF 97.4 BP 152/92 HR66 SaO2 98% RR 22
General: intubated/sedated. thrashing around when off sedation
HEENT: NCAT PERRL (sluggish),mouth with some dried blood
Respiratory: lungs clear anteriorly
Cardiovascular: RRR no m/r/g
Abdomen: soft, non-distended, non-tender
Extremity: L-foot with abrasion/deformity over 1st MTP
Neuro: Moves all extremities. Will squeeze hands to command. B
pupils 4mm and reactive. REsponds to voice
.
(on discharge)
96.0 162/86 (126-162) 76 20 97RA
HEENT: healing scrapes and bruises on face, MMM
Respiratory:
Cardiovascular: RRR no m/r/g
Abdomen:
Extremity: no c/c/e
Neuro: CN II-XII intact, grossly intact
Pertinent Results:
Admission labs:
[**2123-6-18**] 09:58PM WBC-5.6 RBC-4.20* HGB-13.9* HCT-40.7 MCV-97
MCH-33.0* MCHC-34.1 RDW-14.7
[**2123-6-18**] 09:58PM NEUTS-82.6* LYMPHS-13.4* MONOS-3.4 EOS-0.4
BASOS-0.3
[**2123-6-18**] 09:58PM PLT COUNT-237
[**2123-6-18**] 09:58PM GLUCOSE-110* UREA N-21* CREAT-1.2 SODIUM-138
POTASSIUM-5.1 CHLORIDE-106 TOTAL CO2-23 ANION GAP-14
[**2123-6-18**] 09:58PM ALBUMIN-3.8 CALCIUM-7.7* PHOSPHATE-4.6*
MAGNESIUM-2.5
[**2123-6-18**] 09:58PM ALT(SGPT)-27 AST(SGOT)-55* ALK PHOS-85 TOT
BILI-0.3
[**2123-6-18**] 09:58PM ASA-NEG ETHANOL-222* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2123-6-18**] 09:58PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2123-6-18**] 09:58PM OSMOLAL-344*
.
CT head at OSH negative
Brief Hospital Course:
A/P: 59 yo alcoholic man presenting with obtundation and
depressed mental status concerning for anoxic brain injury.
.
The following medical problems were [**Name2 (NI) 13744**] in hospital:
.
# Acute alcohol intoxication +/- Wellbutrin OD
Initially there was concern of hypoxic brain injury due to
depressed mental status (although exam was on versed) and
abnormal neurologic exam. Head CT was reportedly normal at OSH.
Neuro was consulted, EEG was not grossly abnormal. Pt woke up
and was oriented, exam nml, expressing desire to sign out AMA.
He was also ruled out for MI. He was given given a section 12
after psych eval. A 1:1 sitter placed on valium q1hrs per CIWA
scale and had hallucination and agitation consistent with severe
alcohol withdrawal. Initially he was [**Doctor Last Name **] steadily on CIWA
scale but on [**6-22**] pt had not scored on CIWA for >24 hrs and was
THEREFORE MEDICALLY CLEARED FOR DISCHARGE to psych inpatient
facility. Neuro did not feel antiepileptic indicated as do not
feel have seizure disorder (rather alcohol induced). Psych felt
that based on events prior to presentation (pt found down,
intoxicated, pills surrounding him) as well as wife's report of
pt's concerning behavior at home over past several weeks
(seeming increasingly paranoid, acting in a belittling/cruel
manner) and pt's inability/unwillingness to fully engage in
psychiatric evaluation, they felt he was at risk of harm to self
either intentionally or unintentionally and in need of an
inpatient psychiatric admission for safety, stabilization,
psychopharm evaluation, and connection with outpatient treaters
which he does not current have in place. Therefore pt was
discharged to [**Hospital1 **] 4 at [**Hospital1 18**]. For his alcohol abuse,
multivitamins, folate and thiamine were added and social work
consult was placed.
.
# Respiratory failure: Pt was intubated due to depressed MS [**First Name (Titles) **] [**Last Name (Titles) 46443**]y protection. He was extubated on hospital day #2 without
event and without need for supplemental oxygen.
.
# Bipolar Depression: It is unclear if this represents a suicide
attempt, which pt denied. Psychiatry was consulted and advised
that pt is not allowed to leave hospital by section 12 as likely
suicide attempt, likely needs inpatient psych placement.
.
# Hypertension: Home BB increased slightly to 37.5mg of
metoprolol to achieve better control.
.
# Code: Full. Patient would not want prolonged life support per
wife.
Medications on Admission:
bupropion 100mg po bid
citalopram 40mg po dailiy
lamictal 25mg po daily
ranitidien 300mg po QHS
omeprazole 20mg po daily
metoprolol 25mg po bid
acamprosate 666mg po tid
B12, folate, B1
vicodin prn
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO TID (3 times a day) as needed for agitation.
3. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
4. Haloperidol Lactate 5 mg/mL Solution Sig: 2.5 mg Injection
TID (3 times a day) as needed for agitation: to be used only if
pt refuses PO zyprexa first for agitation.
5. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
7. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Discharge Disposition:
Extended Care
Discharge Diagnosis:
bipolar disorder
toxic overdose with Wellbutrin
alcohol abuse
hypertension
Discharge Condition:
Not requiring benzodiazepines
Blood pressure reasonably controlled (SBP 120-160)
Discharge Instructions:
Please take all medications as directed.
You are beign discharged to the [**Hospital1 18**] psychiatric inpatient unit
([**Hospital1 **] 4). Please work with the psychiatrists there to
continue to avoid alcohol and also to be treated for your
psychiatric illness.
You are currently "detoxed" from alcohol and have not required
medications to prevent withdrawal.
Please continue taking your new blood pressrue medication,
metoprolol. Please stop taking lamictal.
Followup Instructions:
Please continue to work with inpatient psychiatry.
Please call your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] within 1
week of discharge for a follow up appointment and to check your
blood pressure.
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
|
[
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"296.80",
"780.39",
"303.01",
"327.23",
"518.81",
"E849.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"94.62",
"96.71",
"89.19"
] |
icd9pcs
|
[
[
[]
]
] |
7221, 7236
|
3612, 6103
|
285, 348
|
7355, 7438
|
2800, 2800
|
7951, 8325
|
2071, 2106
|
6351, 7198
|
7257, 7334
|
6129, 6328
|
7462, 7928
|
2121, 2781
|
233, 247
|
376, 1457
|
2816, 3589
|
1479, 1648
|
1664, 2055
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,375
| 110,559
|
47098
|
Discharge summary
|
report
|
Admission Date: [**2178-10-14**] Discharge Date: [**2178-11-3**]
Date of Birth: [**2120-5-31**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Lamictal /
Shellfish Derived
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
For full H&P please refer to Nightfloat admission note briefly
this is a 58 y.o. Female with a history of gastric bypass 4
years ago w/ multiple recent complications including spinal
abscess, osteomyelitis, intraabdominal leak, spinal
osteomyelitis with abscess, sepsis who was initially admitted
for weakness.
.
On review of her initial note it appears she was discharged
following the aforementioned complicated course on a course of
first Clindamycin x [**1-28**] wks which was changed to Levaquin and
Vancomycin. On the day of her admission she was found by her [**Month/Day (3) 269**]
to be extremely weak specifically with lower extremity weakness
but no bladder/bowel incontinence or anaesthesia. She initially
was seen at [**Hospital3 4107**] and then transferred to [**Hospital1 18**] as pt
did not want further care at [**Hospital1 112**].
.
She was then admitted to the [**Hospital1 1516**] service where she was noted to
have hypokalemia due to increased K+ wasting though it is
unclear as to why this was occuring. She was also noted to be in
[**Last Name (un) **] thought to be secondary to Vancomycin toxicity (her reported
Vancomycin was noted to be 80?). An MRI was obtained given her
lower extremity weakness and was notable for worsening L4-5
disco-osteomyelitis. Orthopaedics were consulted and pt
underwent a diskectomy, debridement and anterior fusion on
[**10-20**]. Following induction of her anaesthesia she was noted to
be tachycardic ranging from 80s-110s. She underwent a 1.5 hour
surgery which was uneventful. In the PACU though her BP was
noted to drop from 110s to 70s, though she was mentating well.
BP was not fluid responsive and pt was started on Neo ar 0.3 and
titrated up to a max of 0.8. Following IVF resuscitation 2.8L as
well as 1u PRBC post-op (she received 2u PRBC prior to surgery)
she was able to wean off pressors and have an increase in her
urine output. For work-up of her hypotension she underwent [**Last Name (un) **]
stim testing which was negative for adrenal insufficiency.
.
Her ICU course has also been notable for a diffuse morbilliform
rash with palm and sole sparing. Dermatology were consulted for
possible SJS. Given lack of mucosal involvement SJS was ruled
out however Dermatology is still following the patient. The
rash, which has steadily been improving, was thought to be due
to Lamotrigine toxicity given her progressively poor Creatinine
Clearance. Though interestingly enough unclear if Lamotrigine
has dose adjustments based on renal clearance.
.
With regards to her diskitis, her blood cultures have thus far
been negative and she is currently on Aztreonam and Vancomycin
per ID recs. She is still being followed by Ortho who will take
her to the OR tomorrow for posterior fusion, after which she
will be able to participate in PT.
.
She is also being followed by Renal for her [**Last Name (un) **] which is thought
to be AIN [**12-29**] Vancomycin toxicity. Renal are currently
considering possible biopsy to confirm AIN.
.
On review of her vitals in the unit over the past few hours her
Tmax has been 100.2, Tc 98.6, HRs 109-118, SBP 114-149/59-70, RR
24, 100% on RA.
.
ROS per HPI.
Past Medical History:
Gastric Bypass 4 years ago with multiple complications
Spinal Abscess and Osteo
Bipolar disorder requiring hospitalization in the [**2158**]
Congestive heart failure - apparently this resolved after her
bariatric surgery and subsequent weight loss (EF unknown).
Social History:
Living Situation: She lives with daughter and granddaughter. [**Name (NI) **]
[**Name2 (NI) 269**] at her house
Tobacco: denied
EtOH: denied
IVDU: denied
Family History:
FAMILY HISTORY:
Father: HTN
Mother: CHF
Brother: [**Name (NI) **] CA
Physical Exam:
PE: T:99.4 BP:142/67 HR:93 RR:18 O2 96% RA
Gen: NAD/ ill appearing/ Comfortable/ appears stated age/
pleasant
HEENT: AT/NC, PERRLA, EOMI, anicteric, no conjuctival pallor,
dryMM, clear oropharynx, no erythema, no exudates no rhinorrhea/
discharge,
NECK: supple, trachea midline, no LAD, no thyromegaly
LUNG: CTA-B/L, no R/R/W
CV: S1&S2, RRR, II/VI SEM no/G/M
ABD: well healed surgical scar, Soft/+BS/ mild tenderness in the
RLQ/ ND/no rebound/ no guarding/
EXT: No C/C/E
+2 pulses radial, DP, PT b/l & symetrical
SKIN: No lesions, rashes, bruises
BACK: tenderness in the L4-L5 region
RECTAL: normal tone
NEURO: AAOx3
CN II-XII grossly intact and non-focal b/l
5/5 strength in upper ext
[**3-1**] hip flexors, [**3-31**] in the rest of the lower ext b/l
Sensation to pain, temp, position intact b/l
Reflexes [**12-31**] brachioradialis, biceps, triceps,
Unable to elicit in the lower ext patellar, Achilles
Toes down going
Unremarkable finger/nose, unremarkable rapid/alternating
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
ADMISSION LABS:
[**2178-10-14**] 08:21PM BLOOD WBC-7.0 RBC-3.57* Hgb-8.1* Hct-25.7*
MCV-72* MCH-22.7* MCHC-31.6 RDW-17.5* Plt Ct-250
[**2178-10-14**] 08:21PM BLOOD Neuts-84.2* Lymphs-9.6* Monos-3.6 Eos-2.1
Baso-0.5
[**2178-10-14**] 08:21PM BLOOD Glucose-86 UreaN-16 Creat-2.8* Na-138
K-2.2* Cl-94* HCO3-25 AnGap-21*
[**2178-10-14**] 08:31PM BLOOD Lactate-0.7 K-2.2*
Vancomycin 82.4* ug/mL (10 - 20)
[**2178-10-15**] 07:20AM BLOOD Vanco-78*
---------------
DISCHARGE LABS:
[**2178-11-3**] 05:04AM BLOOD WBC-10.2 RBC-3.16* Hgb-8.4* Hct-25.7*
MCV-81* MCH-26.5* MCHC-32.6 RDW-18.2* Plt Ct-253
[**2178-11-3**] 05:04AM BLOOD Glucose-102 UreaN-10 Creat-0.9 Na-141
K-3.4 Cl-105 HCO3-29 AnGap-10
[**2178-11-3**] 05:04AM BLOOD Calcium-8.0* Phos-4.1 Mg-2.4
---------------
EKG ([**2178-10-14**] 20:35): NSR, rate 90, Left axis deviation, poor
R-wave progression, LVH
---------------
IMAGING STUDIES:
CXR ([**2178-10-14**]): No acute cardiopulmonary process.
.
Renal US ([**2178-10-15**]): Unremarkable renal son[**Name (NI) **]. [**Name2 (NI) **]
hydronephrosis.
.
CXR ([**2178-10-15**]):
1. Right PICC catheter terminates at the junction of right
subclavian and right internal jugular vein, without evidence of
pneumothorax.
2. New-onset small right pleural effusion.
.
MR spine ([**2178-10-15**]):
1. Signal changes at L4-5 which has progressed since [**2178-9-17**]
and is concerning for disco-osteomyelitis. No definite epidural
extension is identified, although the lack of intravenous
contrast does decrease sensitivity. Endplate degenerative
changes are also a differential consideration (type 1), but
considered less likely given the progression.
2. Transitional anatomy with sacralization of the L5 vertebral
body.
3. Mild degenerative disc disease at other levels as detailed
above, most significant at the T7-8 level, where there is mild
spinal canal narrowing and indentation of the ventral aspect of
the spinal cord.
.
CT Abd/Pelvis ([**2178-10-16**]):
1. Limited examination secondary to lack of intravenous and oral
contrast.
2. Free intra-abdominal air within the upper abdomen is somewhat
less in amount compared to the outside hospital CT exam from
[**2178-9-18**]. Evidence of extensive inflammatory changes in the
upper abdomen, not well assessed on this non-contrast
examination. No definte intra-abdominal collection..
3. Mesenteric adenopathy.
4. Left adrenal myelolipoma, stable.
5. Erosive changes involving the endplates of the L5 vertebral
body and S1 portion of the sacrum concerning for osteomyelitis,
better delineated on the recent MRI of the lumbar spine. No
other erosive changes evident throughout the visualized
skeleton.
6. Right lower lobe consolidation versus atelectasis.
.
Lumbar Spine Xray ([**2178-10-20**]):
Single intraoperative cross-table lateral image of the LS spine
shows placement of a metallic interbody fusion device at L4-5.
Normal vertebral body alignment and discs. We have no
preoperative comparison radiographs.
.
CXR ([**2178-10-21**]):
Lungs are fully expanded and clear. Previous mild vascular
engorgement has resolved and may reflect hypovolemia. Heart size
top normal, unchanged. No pleural effusion or pneumothorax.
Right-sided central venous line tip projects over the mid SVC.
[**2178-10-30**]: EGD
Impression: The stomach remnant appeared normal
Erythema in the lower third of the esophagus
Large small bowel ulcer which could represent the site of
bleeding (biopsy)
Otherwise normal EGD to third part of the duodenum
Recommendations:
Return patient to floor.
Continue high dose ppi.
Await biopsy report
Post discharge, patient needs outpatient GI follow up in fellow
clinic
[**2178-10-30**] Colonoscopy:
Impression:
Stool in the [**Month/Day/Year 499**] noted.
Otherwise normal colonoscopy to hepatic flexure of [**Month/Day/Year 499**]. No
obvious bleeding source was noted.
Recommendations:
Return patient to floor
Since the colonoscopy was aborted at the level of hepatic
flexure, patient will need a colonoscopy as an outpatient.
Brief Hospital Course:
ASSESSMENT: 58 y.o. Female s/p distant gastric bypass
complicated by recent hospitalization for leak s/p repair,
sepsis initially admitted for LE weakness, hospitalization c/b
diskitis s/p anterior fusion/debridement, ICU stay for
hypotension on pressors now transferred to floor awaiting
posterior fusion.
PLAN:
## Diskitis: Pt was initially admitted for lower extremity
weakness with mild weakness with the hip flexors, normal rectal
tone. MRI work up was notable for L4-L5 disco-osteomyelitis.
Unclear as to the source of her disco-osteomyelitis though given
her recent discharge for sepsis it is possible that she seeded
when she was bacteremic. Pt underwent debridement under OR and
anterior fusion and later posterior fusion. Anterior fusion
post-op course complicated by sepsis (discussed below). OR Swabs
and multiple subsequent bld cultures have been negative.
- Continued on Aztreonam and Vancoymcin per ID recs, switched
from aztreonam to levofloxacin. Now on Levofloxacin PO Q24H, and
vancomycin 1gm IV Q24H
- post-op pain control: PCA switched to morphine contin 15mg PO
Q12H, plus morphine 5-15mg PO Q6H PRN breakthrough pain (has had
little pain med requirements, pain well controlled)
- Ortho recommended PT
- [**Name (NI) **] need a vanc trough drawn on [**2178-11-4**] and dose adjustement
accordingly
##. Rash: Pt noted to have diffuse rash over entire body with
sparing of mucousal membranes, feet soles and palm. Dermatology
followed and concluded this was due to lamictal, secondary to
increased levels during ARF. Pt now noted to have lamictal
allergy.
-Held lamictal and rash resolved without signs of mucositis
-Pt to continue triamcinolone cream for a total of 2 weeks
(start date [**2178-10-23**])
## Sepsis: Pt admitted to the unit for sepsis. Although resolved
it is unclear as to the exact cause. Pt's hypotensive episode
occured several hours after anterior fusion surgery so unlikely
to be anaesthesia induced. Given requirement of pressors
following surgery in an area complicated by infection
hypotensive episode may be [**12-29**] transient bacteremia. Vanc and
levo broadened to vanc and aztreonam. After several days,
aztreonam switched back to levofloxacin. Bld cultures and swabs
have thus far been negative. Sepsis resolved after less than 24
hours and pt has been off pressors since.
- was continued on Aztreonam and Vancomycin per ID recs and
later switched back to levofloxacin
- To rehab facility: Pt has a f/u appointment at the [**Hospital **] clinic
of [**Hospital6 1708**] with [**First Name8 (NamePattern2) 402**] [**Last Name (NamePattern1) **], MD on
[**2178-11-5**] 1000am. #: [**Telephone/Fax (1) 39041**]. They will decide the stop date
of patient's antibiotics.
.
## ARF: Unclear etiology. Creatinine peaked to 2.8 but
eventually resolved now at 0.9. Per renal, ARF may have been due
to vancomycin toxicity from too high dosing. (vanc level 80 at
one point). No signs of uremia and no dialysis was employed.
- To rehab facility: Please make sure to f/u vanc troughs every
three days, as pt has unstable vancomycin pharmacokinetics
## Guiac positive stool: Pt with guiac positive melena. Hct and
hemodynamics remained stable. Pt underwent EGD which showed a
large jejunal ulcer with stigmata of bleeding but no active
bleeding. This may have been due to the stress from all the
acute illnesses of osteo/discitis, sepsis, etc. No intervention
done. Colonoscopy non-diagnostic due to poor prep. Hct stable.
Pt continued on pantoprazole IV Q12H until GI follow determines
when to discontinue.
## Malnutrition: Pt malnourished with an albumin of 1.9 and INR
of 1.4 secondary to vitamin K deficiency thought to be related
to her severe illnesses during the last 2 months. Pt refusing
TPN initially, calorie count initiated, only 200-300 calories
per day, therefore, TPN initiated inhouse started [**2178-11-2**].
Patient also with K and Mg abnormalities.
- To rehab facility: Please see Page 2 for nutrition recs.
- To rehab facility: Please check daily K and Mg and replete
lytes as necessary.
Medications on Admission:
MEDICATIONS:
Vancomycin 1.5g Q12
Levaquin 500mg daily
Flexeril 10mg TID
Carvidilol 25mg [**Hospital1 **]
Paxil 40mg daily
Lamictal 100mg daily
Seroquel 50mg daily
Klonopin 1mg TID
Dilaudid 2mg prn
Discharge Medications:
1. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q48H (every
48 hours).
2. Carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day.
3. Paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Lamotrigine 100 mg Tablet Sig: One (1) Tablet PO once a day.
5. Quetiapine 50 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) SC
injection Injection TID (3 times a day).
7. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day): Please hold for sedation and RR <12.
8. Cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) as needed for pain: hold for sedation
.
9. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain: Please hold for sedation and RR <12.
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day): hold for diarrhea .
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation: hold for diarrhea.
12. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain/fever.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Primary:
Hypokalemia
Weakness
Osteomyelitis/Diskitis
S/p gastric bypass revision with leakage, intra-abdominal
abscess and Spinal abscess
Jejunal ulcer
Acute on chronic diastolic congestive heart failure
Malnutrition
Secondary:
HTN
Depression
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Vital signs stable
Activity Status:Ambulatory - requires assistance or aid (walker
or cane)
Discharge Instructions:
You were admitted to the [**Hospital1 18**] for weakness. You had gastric
bypass 4 years ago and a recent revision in [**2178-5-27**] that was
complicated by intra-abdominal leakage and spinal abscess with
osteomyelitis. During your hospital stay your surgery to debride
the osteomyelitis was complicated by sepsis, which promptly
resolved after IV fluids and IV antibiotics. You also developed
kidney failure, possibly due to vancomycin toxicity (high serum
levels at presentation) which also resolved over time. You
developed a rash thought to be related to a lamictal allergy in
the setting of increased reduced lamictal clearance given kidney
failure. This too resolved with time. Also, you developed an
ulcer which bled, and a scope showed that this ulcer remained
stable. You will follow up with GI regarding the ulcer here at
[**Hospital1 18**] and you will return to the [**Hospital **] clinic at [**Hospital1 112**], where they
know you quite well. You also developed malnutrition secondary
to all of these illnesses, which is requiring total parenteral
nutrition.
Please make sure to follow up with all your follow up
appointments.
Followup Instructions:
You have an appointment at the [**Hospital **] clinic of [**Hospital6 13185**] with [**First Name8 (NamePattern2) 402**] [**Last Name (NamePattern1) **], MD already an appointment on
[**2178-11-5**] 1000am. #: [**Telephone/Fax (1) 39041**].
Date/Time:[**2178-12-2**] 2:00
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 10314**], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2178-11-17**] 1:30
Completed by:[**2178-11-5**]
|
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"567.22",
"722.93",
"V45.86",
"428.33",
"693.0",
"534.40",
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"276.8",
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"269.0",
"403.90",
"285.1",
"300.4",
"730.08",
"293.0",
"041.04",
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"327.23",
"E878.2",
"038.9",
"428.0",
"998.59",
"262",
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] |
icd9cm
|
[
[
[]
]
] |
[
"80.51",
"77.89",
"45.23",
"03.09",
"84.51",
"99.15",
"38.93",
"81.62",
"81.08",
"45.16",
"84.52",
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] |
icd9pcs
|
[
[
[]
]
] |
14637, 14709
|
9191, 13243
|
347, 353
|
14997, 14997
|
5165, 5165
|
16360, 16806
|
4031, 4085
|
13490, 14614
|
14730, 14976
|
13269, 13467
|
15193, 16337
|
5643, 6046
|
4100, 5146
|
299, 309
|
381, 3541
|
5181, 5626
|
15011, 15169
|
3563, 3827
|
3843, 3999
|
6063, 9168
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,553
| 184,905
|
29954
|
Discharge summary
|
report
|
Admission Date: [**2113-2-13**] Discharge Date: [**2113-3-5**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Abdominal Pain
Ascities
Major Surgical or Invasive Procedure:
Nephrostomy tube
Paracentesis
History of Present Illness:
Pt is a 83 y.o. male who is s/p gastro-jejunostomy more than 20
years ago who presented with abdominal pain and ascites and had
a
CT of his abdomen that is concerning for a mass in the common
bile duct extending to the head of the pancreas. He initially
saw his PCP back in early [**Month (only) 404**] who noted that his LFTs were
elevatd and sent him to [**Hospital1 18**] for ERCP. On ERCP it was
difficult
to visualize the papilla and the patient was referred for the
above CT scan. This mass seen on CT scan is thought to be a
cholangiocarcinoma.
He reports gas-like pain, bloating and constipation.
Past Medical History:
AAA
gallstone
kidney stones
Gout
PUD
MI ([**2084**])
Social History:
Quit smoking years ago, ETOH in the past as well, Lives in
[**Location 2624**] and has two daughters in the area.
Family History:
No history of colon cancer
Physical Exam:
Gen: Resting comfortably
HEENT: + jaundice, PERRL, EOMI
CVS: RRR with holosystolic murmur
Lungs: CTA
Abdomen: well heeling scar (from AAA surgery), soft, slightly
tender RUQ.
Pertinent Results:
[**2113-2-17**] 09:10AM BLOOD WBC-22.5* RBC-2.70* Hgb-9.3* Hct-29.0*
MCV-108* MCH-34.6* MCHC-32.2 RDW-14.4 Plt Ct-320
[**2113-2-16**] 10:35AM BLOOD Neuts-93* Bands-5 Lymphs-0 Monos-2 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2113-2-16**] 04:11AM BLOOD Glucose-153* UreaN-21* Creat-1.3* Na-135
K-4.5 Cl-106 HCO3-18* AnGap-16
[**2113-2-16**] 04:11AM BLOOD ALT-199* AST-153* AlkPhos-1157*
TotBili-3.6*
[**2113-2-14**] 06:50AM BLOOD Lipase-151*
[**2113-2-16**] 04:11AM BLOOD Calcium-7.8* Phos-4.3 Mg-1.9
[**2113-2-15**] 06:30AM BLOOD calTIBC-186* TRF-143*
[**2113-2-15**] 06:30AM BLOOD Albumin-2.6* Iron-38*
CT ABDOMEN W/CONTRAST [**2113-2-14**] 12:09 AM
IMPRESSION:
1. Prominent intrahepatic biliary ductal dilatation. A soft
tissue density mass is seen within the common bile duct
extending to the head of the pancreas is concerning for tumor.
Prominent gallbladder wall thickening may be related to
patient's underlying ascites, as the gallbladder is not tensely
distended.
2. Significant peripancreatic stranding and decreased
enhancement of the pancreatic body are concerning for
pancreatitis in the right clinical setting.
Ill defined soft tissue around the celiac axis raises the
possibility of an infiltrating tumor
3. Large intra-abdominal ascites.
4. Status post repair of abdominal aortic aneurysm without
evidence of leak.
5. Left lower quadrant spigelian hernia containing normal
appearing sigmoid colon and fluid.
6. Prostatic enlargement.
.
MULTI-PROCEDURE SAME DAY [**2113-2-15**] 7:37 AM
IMPRESSION:
1. Percutaneous cholangiogram demonstrates a markedly dilated
intrahepatic ducts as well as distal CBD and presence of stones
within the common bile duct.
2. Successful placement of an external modified 8-French
nephrostomy tube via a right biliary with pigtail coiled with it
and CBD.
3. Paracentesis was performed with drainage of 300 cc of
serosanguineous ascitic fluid. That was sent for cytology.
4. We will reattempt procedure within two days to pass the
obstruction site and internalize the biliary tube.
.
Cytology Report PERITONEAL FLUID Procedure Date of [**2113-2-15**]
DIAGNOSIS: Ascites from paracentesis:
NEGATIVE FOR MALIGNANT CELLS
.
BILIARY STENT [**2113-2-17**] 9:03 AM
[**Hospital 93**] MEDICAL CONDITION:
83 year old man with likely cholangiocarcinoma with obstructive
disease
REASON FOR THIS EXAMINATION:
Internalize stent
INDICATION FOR EXAM: This is an 83-year-old man with CBD
obstruction status post right PTBD with external biliary
drainage placed, needs procedure to pass the level of the
obstruction. Also needs internalization of the stent.
IMPRESSION:
1. Pullback cholangiogram demonstrates distal CBD obstruction
and duodenal obstruction at the level of the ligament of Treitz.
2. Successful placement of 2 stents within the ligament of
Treitz and the CBD.
3. Successful placement of an 8-French modified external drain
with pigtail coiled within the ligament of Treitz and the CBD.
.
BILIARY CATH CHECK [**2113-2-20**] 7:22 AM
CHOLANGIOGRAM AND STONE REMOVAL AND TUBE CHANGE
INDICATION: 83-year-old man with biliary obstruction, status
post biliary and duodenal stenting, now with increasing LFT.
IMPRESSION:
1. Status post biliary and duodenal stenting.
2. Multiple stones in the common duct.
3. Percutaneous stone removal with improved appearance of the
common duct on the followup cholangiogram.
4. Replacement of the internal-external drainage catheter.
Brief Hospital Course:
He was admitted 0n [**2113-2-13**] with epigastric pain and elevated
LFT's. He likely had metastatic cholangiocarcinoma based on the
CT and due to the large amount of ascites and PTC drain was
thought to be a better option.
On [**2113-2-15**] he went for a PTC and had successful placement of an
external modified 8-French nephrostomy tube via a right biliary
with pigtail coiled with it and CBD, and Paracentesis was
performed with drainage of 300 cc of serosanguineous ascitic
fluid.
On [**2113-2-17**], he went back to IR for internalization of the drain.
While in the PACU on [**2-15**], after the first procedure, he had
post-procedure hypovolemia, hypotension and tachycardia. He
required IV fluid and Albumin and he responded appropriately
within a couple hours.
He was tolerating a regular diet.
On [**2-20**], he went to IR again for status post biliary and
duodenal stenting, Multiple stones in the common duct,
Percutaneous stone removal with improved appearance of the
common duct on the follow up cholangiogram, Replacement of the
internal-external drainage catheter. The Bile grew out
Vancomycin sensitive ENTEROCOCCUS. He was placed on Vanc/Zosyn.
Palliative Care: He was seen by [**First Name8 (NamePattern2) 2270**] [**Last Name (NamePattern1) 1764**] and she discussed
with him and the family some options for home.
Respiratory Distress: On [**2-21**], he was noted to be tachypneic
with a RR to 40, and an O2 sat in the 80's%. An ABG showed 68*
31* 7.48* 24. He also complained to right sided flank pain and
right shoulder pain. He was placed on a non-rebreather and his
O2 sats rose to the 90's%. He received Morphine for pain
control. He was stabilized. Later that evening, he was
transferred to the ICU for a repeat episode of low O2 sats. His
WBC rose to 25.2. A CT was done on [**2-22**] and showed increased
IP: HD 10, he went to IP for a thoracentesis. 1.8 liter of fluid
was pulled off and was + for bile. This was + for [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **]
/ [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] - RARE GROWTH, and he was started on
Fluconzole
VATS: He went to the OR on [**2-23**] for a washout and new drain
placement.
[**2113-2-23**] Cholangiogram -
1. Successful placement of a third stent extending towards the
confluence of the right and left hepatic ducts.
2. Good flow inside of the stent into the duodenum.
3. Successful removal of the internal and external drain.
4. Successful placement of 8 French drain placed into the
perihepatic space for drainage.
He remained in the ICU for several days while he recovered from
the procedure.
He was transferred back to the floor and was stable, but
continued to have an elevated WBC, elevated transaminase and a
Tbili in the 6-8 range. His biliary drain was flushed to keep
patent and the PICC line was pulled.
On [**2113-3-1**], IP placed a pig-tail drain in the right pleural space
and withdrew 500cc of yellowish fluid. Cultures revealed no
growth.
A CT on [**2113-3-1**] revealed:
1. Improved appearance of right pleural effusion, with residual
left pleural effusion. Peribronchial thickening in both lower
lobes may represent atelectasis vs infection.
2. Similar appearance of intra-abdominal ascites. A small amount
of air adjacent to perihepatic drain may be related to frequent
flushing.
3. Similar appearance of left spigelian hernia without
obstruction.
4. Similar appearance of aortic abdominal aneurysm.
On [**2113-3-3**] he went for PTBD. Cholangiogram demonstrated dilated
ducts with contrast passing through the stent into the duodenum.
There was successful placement of a left biliary drainage tube
placed for internal/external drainage.
He was in the PACU and dropped his blood pressure and unable to
get an O2 sat. CXR revealed no pneumothorax. He was then
intubated and required pressors. He received several fluid
boluses for blood pressure support. He then went to the ICU. His
WBC continued to climb from 7 to a high of 66 on [**3-4**]. He
required increased pressor support.
A family meeting was held on [**2113-3-4**]. He was made DNR. The
patient expired [**2113-3-5**].
Medications on Admission:
metoprolol 25", allopurinol, lipitor, prilosec, Fe
Discharge Disposition:
Home
Discharge Diagnosis:
Biliary Obstruction
Discharge Condition:
Expired
Completed by:[**2113-3-6**]
|
[
"576.4",
"995.92",
"537.0",
"197.6",
"511.8",
"155.1",
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"486",
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"518.81",
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icd9cm
|
[
[
[]
]
] |
[
"87.51",
"51.12",
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"38.93",
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] |
icd9pcs
|
[
[
[]
]
] |
9111, 9117
|
4859, 9009
|
283, 315
|
9181, 9218
|
1417, 3629
|
1178, 1206
|
3666, 3738
|
9138, 9160
|
9036, 9088
|
1221, 1398
|
220, 245
|
3767, 4836
|
343, 952
|
974, 1029
|
1045, 1162
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,079
| 155,906
|
36389
|
Discharge summary
|
report
|
Admission Date: [**2116-5-16**] Discharge Date: [**2116-5-21**]
Date of Birth: [**2091-12-9**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
found down in car
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: 23 yo male who was reportedly found by friends in the back
of a car disoriented. Unclear what took place, but pt allegedly
assaulted. Taken to OSH by two friends where notes describe him
as unresponsive but seen to move all extremities. Serum EtOH
level at OSH 272. CT scan of the head demonstrated SDH, IPH
(described below). He was given a number of sedating medications
for intubation and transferred to [**Hospital1 18**] ED for further
evaluation. RN notes that he has moved all extremities slightly
here but has been on a propofol gtt.
Past Medical History:
PSH Traumatic section of multiple tendons and nerves of the R
hand [**1-13**] glass cut at age 18 years old, s/p plastic surgery. The
hand has numbness in dig [**2-13**] inclduing palm > dorsum, and has a
little decreased strength. But he is R handed and still uses it
for everything, including fine finger motions.
Social History:
[**Country **] Rican background.
Self-employed contractor/renovations, single, has 3 year old
son, lives in
[**Name (NI) 47**].
Brother and sister very involved, sister [**Name (NI) 82439**] acts
as spokesperson - very good English.
Family History:
Unknown
Physical Exam:
PHYSICAL EXAM:
O: 98.5 80 16 112/74 100% FiO2 of 1
Gen: WD/WN, comfortable, NAD.
HEENT: Ecchymoses under right eye.
Neck: In cervical collar.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Lying on stretcher with eyes closed. Does not
open
eyes to voice or noxious stimulation (note made that he was on a
low dose of propofol gtt at the time of the initial encounter in
preparation for repeat imaging studies).
Cranial Nerves:
Pupils equally round and reactive to light, 3 to 2
mm bilaterally. Unable to perform oculocephalics due to C collar
but gaze appeared conjugate. Face appears grossly symmetric.
Motor: No response to noxious stim throughout. No spontaneous
movement noted.
Sensation: No grimace to noxious stimulation throughout.
Reflexes: B T Br Pa Ac
Right 1 1 1 1 1
Left 1 1 1 1 1
Toes mute bilaterally
Discharge Exam:
General- patient is A&O X3 and NAD.
PERRL 4-3mm bilaterally
EOMs intact
Tongue midline
Face is symmetrical
Sensation intact to light touch
Negative pronator drift
Motor- B T D IP HAM QUAD [**Last Name (un) **] AT [**Last Name (un) 938**]
R 5 5 5 5 5 5 5 5 5
L 5 5 5 4 3 3 2 0 0
Pertinent Results:
CT head from OSH: Roughly 6mm holohemispheric SDH on the right
with slight mass effect on adjacent sulci. 6mm of midline
shift.Roughly 1.4 cm right frontal hemorrhagic contusion. Repeat
CT of head here stable.
[**2116-5-16**] 06:20AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.018
[**2116-5-16**] 06:20AM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-1000 KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2116-5-16**] 06:20AM URINE RBC-[**10-30**]* WBC-0-2 BACTERIA-FEW
YEAST-NONE EPI-0-2
[**2116-5-16**] 06:20AM PT-12.7 PTT-22.2 INR(PT)-1.1
[**2116-5-16**] 06:20AM WBC-16.1* RBC-4.61 HGB-15.2 HCT-43.1 MCV-94
MCH-32.9* MCHC-35.2* RDW-13.6
[**2116-5-16**] 06:20AM PLT COUNT-266
[**2116-5-16**] 06:20AM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2116-5-16**] 06:20AM ASA-NEG ETHANOL-173* ACETMNPHN-NEG
bnzodzpn-POS barbitrt-NEG tricyclic-NEG
Radiology Report CTA HEAD/ NECK W&W/O C & RECONS Study Date of
[**2116-5-18**] 10:49 AM COMPARISON: MRI brain, [**2116-5-17**] and CT
head, [**2116-5-16**].
CT HEAD: There is stable hyperdense right convexity subdural
hematoma causing effacement of the sulci and gyri along the
right convexity. There is persistent leftward bowing of the
cavum septum pellucidum of approximately 8 mm, but no evidence
for shift of normally midline structures. In the inferior right
frontal lobe (2:12) is a region of hyperdense blood surrounded
by hypodensity likely edema which is stable in size compared to
most recent MRI. The possible right opercular region contusion
described on the MRI is less well appreciated on CT. No new
areas of hemorrhage are identified. The ventricles are unchanged
in their size or configuration. [**Doctor Last Name **]-white matter
differentiation is overall well preserved. There is mild mucosal
thickening of the sphenoid sinuses and mild opacification of the
ethmoid air cells. Mastoid air cells, frontal and maxillary
sinuses are clear. Osseous structures appear intact.
CTA HEAD: The vasculature of the circle of [**Location (un) 431**] appears normal
in
configuration without aneurysm, stenosis, occlusion, or
dilation. No evidence for arterial vascular malformation is
present.
CTA NECK: The neck vasculature including bilateral vertebral and
bilateral
common and internal carotid arteries are normal in their
appearance. There is no stenosis at their origin. No
flow-limiting stenosis is present in either the right or left
internal carotid arteries. The distal right ICA measures 5.1 mm
and the distal left ICA measures 4.8 mm. No dissection,
stenosis, occlusion, or aneurysm is present.
There are persistent opacifications in the right upper lung lobe
seen on CT torso from [**2116-5-16**], which may represent foci of
aspiration pneumonia. No pneumothorax. Osseous structures appear
intact. There are bilateral impacted mandibular wisdom teeth.
There are bilateral non-descended posterior molars off the
maxilla.
IMPRESSION:
1. Stable right subdural hematoma causing mild sulcal effacement
but no
midline shift.
2. Stable right frontal intraparenchymal hemorrhagic contusion
with
surrounding edema, stable.
3. No anomalies of the circle of [**Location (un) 431**] vasculature or neck
vessels. No
aneurysm, dissection, occlusion, or AVM. No CT evidence for
ischemia.
4. Persistent opacifications in the right upper lobe may
represent foci of
aspiration pneumonia.
5. Unchanged leftward deviation of the septum pellucidum without
shift of
normally midline structures.
6. Impacted upper and lower molars bilaterally.
7. Unchanged sinus opacification.
Radiology Report MR HEAD W/O CONTRAST Study Date of [**2116-5-17**]
7:17 PM
MRI/MRA BRAIN: Sagittal T1, axial FLAIR, axial T2, axial
gradient echo and
diffusion-weighted imaging was performed. 3D time-of-flight was
performed
through the circle of [**Location (un) 431**] with multiplanar reformats.
COMPARISON: CT head [**2116-5-16**].
MRI BRAIN: There is a stable right convexity subdural hematoma
causing
minimal sulcal and gyral effacement. In the right frontal lobe
(8:12) is a
1.9 x 1.7 cm area of susceptibility artifact with surrounding
high FLAIR
signal consistent with previously seen hemorrhagic contusion in
the right
frontal lobe. An additional area of high FLAIR signal is seen in
the right
operculum (6:10). Additional susceptibility artifact is present
in the right operculum, likely consistent with an area of
hemorrhagic contusion with surrounding edema. There is unchanged
leftward deviation of the septum pellucidum without obvious
significant mass effect, and this may represent a congenital
finding.
On diffusion-weighted imaging, there is restricted diffusion
seen in the
cortical and subcortical regions of the right parietal and
frontal vertices (402:25, 27) with corresponding low signal on
ADC. These areas are concerning for post-traumatic ischemia or
areas of traumatic contusions. No other areas concerning for
acute infarction are present. There is no hydrocephalus. Minimal
mucosal thickening is present in the ethmoid air cells. Other
paranasal sinuses and mastoid air cells are clear.
MRA BRAIN: Visualized circle of [**Location (un) 431**] vasculature appears
normal without
aneurysm, stenosis or occlusion. Vessels extending to the vertex
at the site of previously mentioned traumatic ischemia or
contusions were not evaluated.
IMPRESSION:
1. Regions in the right parietal and frontal lobes demonstrate
restricted
diffusion and are concerning for traumatic ischemia or
contusion.
2. Hemorrhagic contusions with surrounding edema in the right
frontal lobe
and right opercular region.
3. Stable right subdural hematoma.
4. Unchanged leftward deviation of the septum pellucidum without
significant
mass effect, and this may represent a congenital finding. No
hydrocephalus.
5. Unremarkable appearance to the circle of [**Location (un) 431**] without
aneurysm,
dissection or vascular occlusion.
6. Mild sulcal effacement along the right convexity at site of
subdural
hematoma.
Radiology Report MR THORACIC SPINE W/O CONTRAST Study Date of
[**2116-5-16**] 8:04 PM
The study is normal. Alignment of the thoracic and lumbar spine
appears normal. There is no evidence of fracture or subluxation.
There is no encroachment on the spinal cord
Radiology Report CT C-SPINE W/O CONTRAST Study Date of [**2116-5-16**]
6:37 AM
There is no fracture or acute alignment abnormality. There is
loss
of the normal cervical lordosis. The atlantoaxial and
atlanto-occipital
articulations are maintained. Vertebral body heights are
maintained and there is no prevertebral soft tissue swelling.
MR/MRA HEAD W/O CONTRAST Study Date of [**2116-5-17**] 7:17 PM
MRI/MRA BRAIN: Sagittal T1, axial FLAIR, axial T2, axial
gradient echo and
diffusion-weighted imaging was performed. 3D time-of-flight was
performed
through the circle of [**Location (un) 431**] with multiplanar reformats.
COMPARISON: CT head [**2116-5-16**].
MRI BRAIN: There is a stable right convexity subdural hematoma
causing
minimal sulcal and gyral effacement. In the right frontal lobe
(8:12) is a
1.9 x 1.7 cm area of susceptibility artifact with surrounding
high FLAIR
signal consistent with previously seen hemorrhagic contusion in
the right
frontal lobe. An additional area of high FLAIR signal is seen in
the right
operculum (6:10). Additional susceptibility artifact is present
in the right operculum, likely consistent with an area of
hemorrhagic contusion with surrounding edema. There is unchanged
leftward deviation of the septum pellucidum without obvious
significant mass effect, and this may represent a congenital
finding.
On diffusion-weighted imaging, there is restricted diffusion
seen in the
cortical and subcortical regions of the right parietal and
frontal vertices (402:25, 27) with corresponding low signal on
ADC. These areas are concerning for post-traumatic ischemia or
areas of traumatic contusions. No other areas concerning for
acute infarction are present. There is no hydrocephalus. Minimal
mucosal thickening is present in the ethmoid air cells. Other
paranasal sinuses and mastoid air cells are clear.
MRA BRAIN: Visualized circle of [**Location (un) 431**] vasculature appears
normal without
aneurysm, stenosis or occlusion. Vessels extending to the vertex
at the site of previously mentioned traumatic ischemia or
contusions were not evaluated.
IMPRESSION:
1. Regions in the right parietal and frontal lobes demonstrate
restricted
diffusion and are concerning for traumatic ischemia or
contusion.
2. Hemorrhagic contusions with surrounding edema in the right
frontal lobe
and right opercular region.
3. Stable right subdural hematoma.
4. Unchanged leftward deviation of the septum pellucidum without
significant mass effect, and this may represent a congenital
finding. No hydrocephalus.
5. Unremarkable appearance to the circle of [**Location (un) 431**] without
aneurysm,
dissection or vascular occlusion.
6. Mild sulcal effacement along the right convexity at site of
subdural
hematoma.
CTA NECK W&W/OC & RECONS Study Date of [**2116-5-18**] 10:49 AM
CTA HEAD AND NECK: Contiguous axial imaging was performed
through the brain without IV contrast administration.
Subsequently, after uneventful
administration of 80 cc of Optiray, contiguous helical imaging
was performed from the aortic arch through the vertex. Sagittal,
coronal, and axial MIPs were performed. Multiplanar curved
reformats and volume-rendered images were generated on a
separate workstation.
COMPARISON: MRI brain, [**2116-5-17**] and CT head, [**2116-5-16**].
CT HEAD: There is stable hyperdense right convexity subdural
hematoma causing effacement of the sulci and gyri along the
right convexity. There is persistent leftward bowing of the
cavum septum pellucidum of approximately 8 mm, but no evidence
for shift of normally midline structures. In the inferior right
frontal lobe (2:12) is a region of hyperdense blood surrounded
by hypodensity likely edema which is stable in size compared to
most recent MRI.
The possible right opercular region contusion described on the
MRI is less
well appreciated on CT. No new areas of hemorrhage are
identified. The
ventricles are unchanged in their size or configuration.
[**Doctor Last Name **]-white matter
differentiation is overall well preserved. There is mild mucosal
thickening of the sphenoid sinuses and mild opacification of the
ethmoid air cells. Mastoid air cells, frontal and maxillary
sinuses are clear. Osseous structures appear intact.
CTA HEAD: The vasculature of the circle of [**Location (un) 431**] appears normal
in
configuration without aneurysm, stenosis, occlusion, or
dilation. No evidence
for arterial vascular malformation is present.
CTA NECK: The neck vasculature including bilateral vertebral and
bilateral
common and internal carotid arteries are normal in their
appearance. There is no stenosis at their origin. No
flow-limiting stenosis is present in either the right or left
internal carotid arteries. The distal right ICA measures 5.1 mm
and the distal left ICA measures 4.8 mm. No dissection,
stenosis, occlusion, or aneurysm is present.
There are persistent opacifications in the right upper lung lobe
seen on CT torso from [**2116-5-16**], which may represent foci of
aspiration pneumonia. No pneumothorax. Osseous structures appear
intact. There are bilateral impacted mandibular wisdom teeth.
There are bilateral non-descended posterior molars off the
maxilla.
IMPRESSION:
1. Stable right subdural hematoma causing mild sulcal effacement
but no
midline shift.
2. Stable right frontal intraparenchymal hemorrhagic contusion
with
surrounding edema, stable.
3. No anomalies of the circle of [**Location (un) 431**] vasculature or neck
vessels. No
aneurysm, dissection, occlusion, or AVM. No CT evidence for
ischemia.
4. Persistent opacifications in the right upper lobe may
represent foci of
aspiration pneumonia.
5. Unchanged leftward deviation of the septum pellucidum without
shift of
normally midline structures.
6. Impacted upper and lower molars bilaterally.
7. Unchanged sinus opacification.
CT HEAD W/O CONTRAST Study Date of [**2116-5-20**] 5:03 PM
NON-CONTRAST HEAD CT: In comparison to [**2116-5-18**], there is no
significant
interval change. Again demonstrated is a right sided subdural
hematoma,
measuring up to 5 mm from the inner table. Also redemonstrated
is a region of hyperdense hemorrhagic contusion with surrounding
edema in the inferior right frontal lobe, measuring 24 mm,
unchanged. There is effacement of the right cortical sulci
adjacent to the subdural hematoma, with persistent leftward
bowing of the cavum septum pellucidum, currently 8 mm as on
prior study. However, there is again no evidence for subfalcine
herniation.
There is no new hemorrhage. The [**Doctor Last Name 352**]-white matter
differentiation is
preserved, with no evidence for acute large vascular territory
infarction. The basilar cisterns are preserved. Ventricles are
symmetric in caliber. Mild ethmoid and sphenoid sinus mucosal
thickening is unchanged. The mastoid air cells remain normally
pneumatized and clear.
IMPRESSION:
1. Unchanged small right subdural hematoma with associated
sulcal effacement.
There is leftward bowing of the septum pellucidum, but no shift
of normally midline structures.
2. Unchanged right inferior frontal intraparenchymal hemorrhage
with adjacent edema.
3. No new acute intracranial hemorrhage.
Brief Hospital Course:
Pt was admittted to neurosurgery service and monitored closely
in ICU. He was extubated HD#2 and transferred to the floor. He
was found to have weak left leg and underwent work up including
MRI THORACIC AND LUMBAR SPINE [**2116-5-16**] which was normal;MRI/MRA
brain which showed small region of cortical and subcortical
infarcts involving high vertex medial right parietal and frontal
lobes (likely both motor and sensory strip). Midline shift,
right SDH and Rt IPH are stable. Circle of [**Location (un) 431**] appears
patent. CTA head and neck also within normal limits.6/7/09this
patient was transferred to the floor. [**2116-5-19**] exam is stable,
urine analysis is negative. [**2116-5-20**] physical therapy evauation
recommending dispo to rehab for continued physical therapy.
Medications on Admission:
Tylenol
Discharge Medications:
1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
7. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 10 days: Stop after last dose on [**2116-5-28**].
8. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: [**12-13**]
Tablets PO Q4H (every 4 hours) as needed for HA.
9. Lorazepam 0.5-1 mg IV Q4H:PRN ciwa > 10
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
right subdural hematoma
Discharge Condition:
stable
Discharge Instructions:
General Instructions
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
?????? If you have been prescribed Dilantin (Phenytoin) for
anti-seizure medicine, take it as prescribed and follow up with
laboratory blood drawing in one week. This can be drawn at your
PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**].
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion, lethargy or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? New onset of the loss of function, or decrease of function on
one whole side of your body.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**First Name (STitle) **], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast prior to
your appointment. This can be scheduled when you call to make
your office visit appointment.
Completed by:[**2116-5-21**]
|
[
"E968.9",
"348.5",
"851.01",
"729.89",
"782.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
17880, 17950
|
16250, 17040
|
335, 342
|
18018, 18027
|
2804, 3884
|
19292, 19654
|
1525, 1534
|
17098, 17857
|
17971, 17997
|
17066, 17075
|
18051, 19269
|
1564, 1795
|
2473, 2785
|
278, 297
|
370, 918
|
2049, 2457
|
12373, 14960
|
14969, 16227
|
1810, 2033
|
940, 1258
|
1274, 1509
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
620
| 190,776
|
6540
|
Discharge summary
|
report
|
Admission Date: [**2155-1-28**] Discharge Date: [**2155-2-5**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4980**]
Chief Complaint:
word finding difficulties
Major Surgical or Invasive Procedure:
G-tube placed
History of Present Illness:
A [**Age over 90 **]yoM with multiple stroke risk factors admitted for after a
[**11-28**] minute period of word-finding difficulty, ruled out for
stroke and now transferred from neurology service to medicine
for management of uncontrolled hypertension. Pt. was on BB and
nitrate for bp control prior to admission, and currently remains
with SBP>190 on IV ACE-i and BB with IV hydralazine PRN.
Past Medical History:
h/o strokes in [**2145**], [**2137**]
CAD/MI, s/p CABG in [**2144**]
hypercholesterolemia
s/p R CEA in [**2147**]
HTN
Social History:
lives alone in ECF, ambulates with walker, frequent falls
recently, no EtOH.
Family History:
NC
Physical Exam:
VS: 96.8 | 195/87 | 77 | 22 | 97% on RA
gen: NAD, breathing sounds and looks distressed (Pt. appears to
be gasping and has a lot of secretions) but says he is breathing
fine.
HEENT: OP clear, dry MMM, no LAD, PERRL and EOM intact.
CV: RRR, nl S1S2, no murmurs.
chest: CTA b/l, no crackles or wheezes.
abd: soft, NT/ND, +bs, no organomegaly.
extr: no edema, no cyanosis, [**2-10**]+ distal pulses.
neuro: right-handed, awake, alert, garbled speech, when
comprehensible Pt. answers appropriately, but usually difficult
to understand. nl. muscle tone.
Pertinent Results:
[**2155-1-28**] HEAD CT:
IMPRESSION: No acute intracranial hemorrhage, mass effect, or
change since [**2154-7-8**]. For the diagnosis of acute
infarction, MR [**First Name (Titles) 151**] [**Last Name (Titles) 3631**]- weighting is the test of choice.
.
[**2155-1-28**] MRA BRAIN:
IMPRESSION: No evidence of acute infarction. No change in the
appearance of the brain since [**2149-12-10**].
.
[**2155-1-28**] CXR:
IMPRESSION: No evidence of CHF or pneumonia.
.
[**2155-1-29**] CAROTID SERIES:
IMPRESSION: Mild plaque is present in the carotid arteries
bilaterally with stenosis evaluated as less than 40% on each
side.
.
[**2155-1-29**] ECHO:
Conclusions:
1.The left atrium is normal in size.
2. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is hard to assess given the limited views but
is probably mildly decreased (LVEF 45-50%). There is hypokinesis
of the basal and mid portion of the inferolateral wall.
3.Right ventricular chamber size is normal. Right ventricular
systolic
function is normal.
4.The ascending aorta is mildly dilated.
5.The aortic valve leaflets are mildly thickened. No aortic
regurgitation is seen.
6.The mitral valve leaflets are mildly thickened. Moderate (2+)
mitral
regurgitation is seen. The mitral regurgitation jet is
eccentric.
7.Moderate [2+] tricuspid regurgitation is seen.
8.There is no pericardial effusion.
Compared with the findings of the prior report (images
unavailable for review)of [**2149-12-12**], there is no significant
change in the overall EF. However, the inferior hypokinesis is
not well seen given the limited views.
IMPRESSION:
No cardiac source of embolus seen.
.
[**2155-1-30**] CXR PORTABLE:
IMPRESSION: No acute cardiopulmonary disease.
.
[**1-28**] ECG:
Sinus rhythm. Right bundle-branch block. Borderline left axis
deviation.
Possible left anterior fascicular block - cannot exclude prior
infero-posterior myocardial infarction. Compared to the previous
tracing of [**2154-7-8**] multiple abnormalities as noted persist
without major change.
TRACING #1
.
[**2155-1-30**] ECG:
Sinus rhythm. Right bundle-branch block. Borderline left axis
deviation.
Possible left anterior fascicular block. Cannot exclude prior
inferior wall myocardial infarction. Borderline prolonged Q-T
interval. Compared to the previous tracing of [**2155-1-28**] multiple
abnormalities persist without major change. The Q-T interval is
now prolonged.
.
LABS:
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2155-2-5**] 12:18PM 10.8 3.96* 12.5* 35.9* 91 31.6 34.8 14.2
210
[**2155-2-4**] 05:10AM 12.0* 4.54* 14.2 41.1 90 31.4 34.7 14.2
260
[**2155-2-3**] 05:20AM 12.5* 4.15* 13.0* 37.7* 91 31.3 34.4 14.3
239
[**2155-2-2**] 06:35AM 13.7* 3.98* 12.4* 36.9* 93 31.1 33.6 14.0
226
[**2155-2-1**] 05:07AM 10.9 4.34* 13.2* 39.5* 91 30.4 33.4 14.2
257
[**2155-1-31**] 05:40AM 13.7* 4.99 15.3 44.3 89 30.7 34.6 13.8
249
[**2155-1-30**] 05:10AM 15.5*# 4.85 14.9 43.0 89 30.6 34.6 13.8
259
[**2155-1-29**] 03:27AM 8.0 4.33* 13.6* 38.2* 88 31.5 35.7* 13.5
226
[**2155-1-28**] 02:45PM 8.7 3.84* 12.5* 35.6* 93 32.5* 35.1* 13.6
228
.
Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2155-2-5**] 12:18PM 141* 30* 0.9 145 3.1* 109* 241 15
[**2155-2-4**] 09:10PM 122* 24* 0.9 145 3.3 108 231 17
[**2155-2-4**] 05:10AM 112* 27* 0.9 147* 3.4 112* 241 14
[**2155-2-3**] 05:20AM 108* 35* 1.0 150* 3.81 115* 21*2 18
[**2155-2-2**] 06:35AM 137* 37* 1.0 147* 4.41 115* 17*2 19
[**2155-2-1**] 05:07AM 88 37* 1.1 144 4.01 110* 16*2 22*
[**2155-1-31**] 05:40AM 95 26* 1.0 140 3.5 106 19*1 19
[**2155-1-30**] 08:05PM 111* 23* 1.0 138 3.9 106 20*1 16
[**2155-1-30**] 05:10AM 126* 23* 1.1 140 3.8 103 21*1 20
[**2155-1-29**] 03:27AM 91 24* 1.0 140 4.0 105 271 12
[**2155-1-28**] 11:00PM 102 28* 1.0 137 3.9 102 251 14
[**2155-1-28**] 02:45PM 124* 31* 1.2 138 4.71 103 302 10
.
CK-MB MB Indx cTropnT
[**2155-1-30**] 08:05PM 12* 4.1 0.04*
[**2155-1-29**] 03:27AM NotDone1 <0.01
[**2155-1-28**] 11:00PM NotDone1 <0.01
[**2155-1-28**] 02:45PM NotDone1 <0.01
.
Cholest Triglyc HDL CHOL/HD LDLcalc
[**2155-1-29**] 03:27AM 157 581 55 2.9 90
Brief Hospital Course:
A/P: [**Age over 90 **]yoM with h/o strokes and multiple stroke risk factors now
with uncontrolled HTN.
.
A [**Age over 90 **]yoM with multiple stroke risk factors, admitted s/p [**11-28**]
min. period of word finding difficulty, with some feeling of
unsteadiness, and complete recovery prior to EMS arrival, c/w
TIA. Physical exam most notable for brisk reflexes and
increased tone on L along with L facial droop, likely related to
prior strokes. Symptoms were resolved upon arrival to ED. MRI
was negative for stroke. ASA was changed to Aggrenox (started
1cap QD w/baby ASA, then incr to 1cap [**Hospital1 **] and ASA d/c'd).
Statin was increased for elev LDL (goal <70). Pt. received
haldol for agitation in the ICU, and zyprexa x1 on [**1-30**]. Pt was
transferred to the medicine after he was r/o'd for a stroke. His
aggrenox was continued. Pt's mental status was very labile, it
waxed & waned but he never completely recovered his speech. He
was confused throughout his admission, oriented to self at
times. He had to be restrained on a few occassions for agitation
and to prevent pulling PIV, which he did several times.
.
HTN: Pt. had c/o chest pain which resolved; ruled out for MI on
admission (CEs negative x3); he remained CP free s/p labetalol
gtt on [**11-16**]. However again became hypertensive to 200s on
[**1-30**]. On alternating Metoprolol, Enalaprilat. Had short
asymptomatic run of V-tach [**1-30**], rpt ECG showed no changes,
lytes, cardiac enzymes negative for ischemic chanes. [**1-29**] echo
showed EF 45-50%, hypokinesis of inferolateral wall, mod MR, mod
TR, no significant change in EF comp to [**2149**]. [**1-29**] carotid u/s
<40% stenosis bilaterally. HTN remained difficult to
control(SBP 190s). Initially holding parameters to keep SBP 140
in setting of potential stroke made it difficult to up titrate
BB and Hydral IV without decreasing his BP too much. In setting
of holding his meds his BP would increase to SBP 180s-190s. He
received a nitropatch x2 with minimal control. His BB was
increased to metoprolol 25mg IV q4 hours and hydral increased to
30mg IV Q6 hours. In this setting he also required nitropaste 1
inch thick for SBP 180. Throughout his admission he did not
regain the ability to swallow, which therefore all his meds were
given IV. Several attempts were made to pass an NGT for access
to meds and nutrition unsuccessfully. Nifedipine crushed under
the tongue was also used on 2 occassions with moderate response.
On his last day of admission, his BP was better controlled
w/25mgIVBB, 30mgIV hydral, Nitropatch. IV ACE-i d/c'd on [**1-31**];
continue BB, start nitro patch; eventually transition back to PO
meds and restart ACE-i for d/c (Pt. should be on ACE-i due to
h/o CABG).
.
FEN/GI: Did not pass swallow eval [**1-30**]. Unable to pass NGT
after multiple attempts. Currently receiving meds IV. His
medications were continued IV for no bp control in the absence
of the pt's inability to swallow and no other means to provide
meds. Because pt had pulled several PIV, the team was relunctant
to place a central line for IV access for fluids, meds and TPN.
The medicine team tried again unsuccessfully to place an NGT as
well as a doboff tube. On [**2-4**] pt again self d/c'd PIV. He
received a double lumen PICC on [**2-5**] with the intention of
starting TPN if GI could not place the G-tube. Per GI pt
received a G-tube on [**2-5**] without complications. Pt was sent
back to the floor. TF order was placed in anticipation of pt
receiving TF the following day post 12 hours after procedure.
.
ID: On Cipro for UTI (positive u/a, cx contaminated). WBC incr.
to 15 on [**1-30**], currently 15.5, afebrile. No evidence of
infiltrate on CXR. ?pharyngitis (c/o sore throat, +erythema),
rapid strep/Cx pending. Changed Abx to Levofloxacin. Rpt urine
Cx with no growth after Levo was started. He had completed 6
days of levo, no WBC and remained afebrile.
.
Endo: QID D-sticks, Insulin sliding scale prn. HbA1C=6.2.
.
Ppx: pneumoboots, heparin, H2 blocker, olanzapine PRN agitation.
.
Code: DNR/DNI
.
Dispo: Case Manager aware of pt's need for rehab. Pt was to be
screened by [**Hospital3 **] when G-tube placed to establish
nutrition and better access for meds.
.
**Pt expired [**2-5**] at 1550 post PEA. He was DNR/DNI. Dr. [**Last Name (STitle) **]
and the son, [**Name (NI) 1158**] [**Name (NI) 25068**] were notified.
.
Medications on Admission:
Meds (home): pravachol 40QD, toprol XL 100QD, ISMO 60QD, ASA EC
81QD.
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Deceased
Completed by:[**2155-2-5**]
|
[
"V45.81",
"397.0",
"435.9",
"599.0",
"276.0",
"272.0",
"443.9",
"276.51",
"412",
"424.0",
"462",
"401.9",
"427.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"45.13",
"43.11"
] |
icd9pcs
|
[
[
[]
]
] |
10322, 10331
|
5811, 10202
|
287, 302
|
10382, 10420
|
1569, 1585
|
980, 984
|
10352, 10361
|
10228, 10299
|
999, 1550
|
222, 249
|
330, 727
|
1594, 5788
|
749, 869
|
885, 964
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,834
| 153,420
|
48007
|
Discharge summary
|
report
|
Admission Date: [**2174-11-29**] Discharge Date: [**2174-12-14**]
Date of Birth: [**2109-8-1**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Keflex / Latex / Lipitor / Zosyn
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Sternal dehisence
Major Surgical or Invasive Procedure:
[**2174-11-30**] sternal debridement
[**2174-12-5**] Repair of sternal dehiscence, bilateral pectoralis
flaps and platig x4.
History of Present Illness:
65 year old female status post CABGx3 on [**2174-11-14**] (both mammary
arteries were used) now with a poorly healing sternal wound. She
is a diabetic and also has a history of right breast surgery
with radiation for breast cancer. Plastic surgery is consulted
for skin/soft tissue coverage after debridement.
Past Medical History:
Coronary Artery Disease s/p Coronary artery bypass grafting x 3
[**2174-11-14**]
Hypertension
Diabetes
Mild PVD
Hypercholesterolemia
Right Breast CA in [**2166**] s/p lumpectomy and radiation therapy
with recurrence in [**2170**] s/p right breast mastectomy and
reconstruction
Left great toe to left shin cellulitis s/p Cephalexin and
Bactrim course completed 1-2 weeks ago with resolution. This is
an intermittent problem.
Depression
Restless leg syndrome
Hypothyroidism
DVTs in the past
s/p appendectomy
Social History:
Lives with:daughter
Occupation:retired meat manager at grocery store
Cigarettes: Smoked no [] yes [x] Hx:1ppd for 15 years and quit
25
to 30 years ago
Other Tobacco use:denies
ETOH: < 1 drink/week [x] [**1-17**] drinks/week [] >8 drinks/week []
Illicit drug use:denies
Family History:
non-contributory
Physical Exam:
Admission: [**2174-11-29**]
Pulse: 72 Resp:14 O2 sat:92/RA
B/P Right:no BP in right arm d/t mastectomy Left:112/68
Height:5'3" Weight:191 lbs (Preop)
General: Mild resp distress. Pale appearing.
Skin: Warm, Dry and intact
STERNUM: Bone is unstable. There is an area of erythema at
distal
[**12-13**] of sternotomy with scab and drainage. Drianage is yellow/tan
colored.
HEENT: NCAT, PERRLA, EOMI, slcera anicteric, OP benign
Neck: Supple [x] Full ROM [x]
Chest: Insp/Exp wheeze noted throughout bilateral lung fields
with diminished breath sounds at bases.
Heart: RRR, No M/R/G
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] 2+ (B) LE Edema.
Thrombosis of GSV and LSV noted. R>L
Neuro: Mild weakness of left hand. A+Ox3. No other focal
deficits.
Pulses:
Femoral Right: +1 Left:+1
DP Right: +1 Left:+1
PT [**Name (NI) 167**]: +1 Left:+1
Radial Right: +2 Left:+2
Pertinent Results:
CT chest [**11-30**]
Sternal dehiscence at the inferior aspect of the sternotomy with
displacement of the wire and a probably hemorrhagic fluid
collection at the level of the left and right sternal
components.
Extensive stranding of the retrosternal fat. No evidence of
circumscribed fluid collection. No pericardial effusion. No
abnormality in the postoperative appearance of the heart and of
the large mediastinal vessels. Small gas inclusion in the soft
tissues and 2 cm paramedian structure with calcified margin.
Bilateral right more than left pleural effusion with subsequent
areas of atelectasis.
CXR [**2174-12-5**]
No spontaneous echo contrast is seen in the body of the left
atrium or left atrial appendage. No atrial septal defect is seen
by 2D or color Doppler. Left ventricular wall thicknesses are
normal. The left ventricular cavity size is normal. Regional
left ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%). Doppler parameters are
most consistent with normal left ventricular diastolic function.
Right ventricular chamber size and free wall motion are normal.
There are simple atheroma in the descending thoracic aorta. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve appears structurally
normal with mild (1+) mitral regurgitation. There is no
pericardial effusion. Dr. [**First Name (STitle) **] was notified in person of the
results at time of surgery.
Post chest closure: Right ventricular function is mildly
depressed. Left ventricular function is unchanged. No
pericardial effusion is seen.
CXR [**2174-12-13**]
IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided
5 French
Preliminary Reportdouble-lumen PICC line placement via the left
basilic venous approach. Internal length is 41 cm, with the tip
positioned in the distal SVC. The line is ready to use.
[**2174-12-14**] 04:58AM BLOOD WBC-10.9 RBC-3.47* Hgb-9.7* Hct-29.9*
MCV-86 MCH-27.9 MCHC-32.4 RDW-15.2 Plt Ct-364
[**2174-12-13**] 06:02AM BLOOD WBC-11.1* RBC-3.64* Hgb-10.1* Hct-31.0*
MCV-85 MCH-27.8 MCHC-32.6 RDW-15.0 Plt Ct-375
[**2174-12-12**] 04:31AM BLOOD WBC-10.0 RBC-3.54* Hgb-9.8* Hct-30.6*
MCV-87 MCH-27.7 MCHC-32.0 RDW-15.1 Plt Ct-320
[**2174-12-14**] 04:58AM BLOOD Glucose-194* UreaN-41* Creat-1.7* Na-136
K-4.3 Cl-103 HCO3-22 AnGap-15
[**2174-12-13**] 06:02AM BLOOD Glucose-68* UreaN-39* Creat-1.5* Na-136
K-3.8 Cl-101 HCO3-25 AnGap-14
[**2174-12-12**] 04:31AM BLOOD Glucose-105* UreaN-39* Creat-1.4* Na-136
K-3.7 Cl-98 HCO3-29 AnGap-13
[**2174-12-11**] 04:31AM BLOOD Glucose-79 UreaN-46* Creat-1.4* Na-142
K-3.7 Cl-99 HCO3-34* AnGap-13
[**2174-12-10**] 05:30AM BLOOD Glucose-69* UreaN-44* Creat-1.3* Na-141
K-3.8 Cl-96 HCO3-37* AnGap-12
Brief Hospital Course:
Mrs. [**Known lastname **] was admitted on [**2174-11-29**] for a sternal dehisence.
Zosyn and Vancomycin were initiated. A chest CT was done which
showed Sternal dehiscence at the inferior aspect of the
sternotomy with displacement of the wire and a probably
hemorrhagic fluid collection. She was taken to the operating
[**2174-11-30**] for Sternal debridement, intraoperative cultures
and placement of wound vac. She transfer to the ICU inubated,
sedated and paralyed. She was successfully extubated [**2174-12-7**]
following Repair of sternal dehiscence, bilateral pectoralis
flaps and plating x4 with Plastic Surgery on [**2174-12-5**].
Infectious disease was consulted and recommended continuing
Zosyn and Vancomycin. Final cultures [**2174-12-8**] with no growth.
The only positive culture was PSEUDOMONAS AERUGINOSA SPARSE
GROWTH from a [**12-7**] sputum culture. The antibiotics were
changed to Cipro 500mg twice daily and Vancomycin 750 mg every
24 hours until [**2175-1-16**] for presumed osteomylitis. Vancomycin
dose was changed on [**2173-12-13**] to 750 mg daily and trough is to be
checked on [**2174-12-16**] at 1900 before the 4th dose. [**2174-12-11**] she
began to have multiple loose stools. Flagyl was started until
C. diff cultures returned - Cdiff was negative x 3 and Flagyl
and po Vanco were stopped and patient was given Lomotil for
diarrhea. PICC line was placed [**2174-12-13**] and is in good position
for 6 week course of antibiotics which is to be completed
[**2175-1-16**]. Plastic continue to follow her. JP drains x 2 remained
until outpatient follow up with Plastics. She remained
hemodynamically stable sinus rhythm with blood pressures
140-150's. Lisinopril and Lasix were stopped on [**2174-12-13**] with a
rising creatinine to 1.7 and Norvasc was added for blood
pressure control. This is to be titrated as needed. She was
tolerating regular diet with blood sugars 110-220 range. Lantus
was increased on [**12-13**] to 80 units daily and this is to be
titrated up (home dose of 110 units) based on blood sugars. She
was followed by physical therapy and was ambulating with
assistance at the time of discharge. She did have a stage II
pressure ulcer on her sacrum which was being treated with
Criticide. She continued to progress well and was felt safe for
tranfer to [**Hospital 100**] Rehab in [**Location (un) 2312**].
Medications on Admission:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. pravastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
5. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain/fever.
7. metformin 500 mg Tablets Sig: Two (2) Tablet PO BID
8. bacitracin zinc 500 unit/g Ointment Sig: One (1) Appl Topical
QID
9. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: Three (3) ml Inhalation q2h as needed for
shortness of breath or wheezing.
10. Lantus 100 unit/mL Solution Sig: Eighty (80) units
Subcutaneous QBreakfast : home dose 110 units please continue to
titrate up to home dose based on BG .
11. Ultram 50 mg Tablet Sig: One (1) Tablet PO every four (4)
hours as needed for pain.
12. Imdur 60 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO once a day for 3 months.
13. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO
qsaturday.
14. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: one (1)PO
once a day.
15. Insulin scale insulin Humalog 10 units premeal plus sliding
scale
100-140 - 4 units 141-180 - 8 units 181-210 - 12 units
211-240 - 14 units
241-280 - 16 units 281-320 - 18 units
16. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
17. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Medications:
1. Outpatient Lab Work
[**Last Name (un) 15058**] CBC w/diff, BUN/CRE, LFTs
VANCO TROUGH AT 1900 on [**2174-12-16**]
Please fax results to infectious disease RN [**Telephone/Fax (1) 1419**]
2. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours): through [**2175-1-16**].
3. vancomycin in D5W 1 gram/200 mL Piggyback Sig: Seven Hundred
Fifty (750) milligram Intravenous Q 24H (Every 24 Hours):
through [**2175-1-16**].
4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
6. pravastatin 20 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
7. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO 1X/WEEK (SA).
9. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
11. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: Three (3) mL Inhalation Q4H (every 4 hours) as
needed for wheezes.
12. ipratropium bromide 0.02 % Solution Sig: Three (3) mL
Inhalation Q6H (every 6 hours) as needed for wheezes.
13. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day).
16. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
17. isosorbide mononitrate 60 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
18. hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
19. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Hold for SBP<100.
20. diphenoxylate-atropine 2.5-0.025 mg Tablet Sig: One (1)
Tablet PO Q6H (every 6 hours) as needed for diarrhea.
21. insulin glargine 100 unit/mL Solution Sig: Eighty (80) units
Subcutaneous once a day: Q AM - patient's home dose is 110
units daily - please titrate based on Blood sugars.
22. heparin, porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
sternal wound infection and dehiscence s/p CABG
Hypertension
-Diabetes
-Mild PVD
-Hypercholesterolemia
-Right Breast CA in [**2166**] s/p lumpectomy and radiation therapy
with recurrence in [**2170**] s/p right breast mastectomy and
reconstruction
-Left great toe to left shin cellulitis s/p Cephalexin and
Bactrim course completed with resolution. This is an
intermittent
problem.
-Depression
-Restless leg syndrome
-Hypothyroidism
-DVTs in the past with pulmonary embolism (? hypercoaguable
state)
-s/p appendectomy
-Obesity
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Edema - trace
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] Wednesday [**2174-12-21**] @ 1:30 in the [**Last Name (un) 2577**]
Building [**Last Name (NamePattern1) **]
Cardiologist: Dr. [**Last Name (STitle) **] ([**Location (un) 2274**] [**Location (un) **]) Tuesday [**1-3**] @ 2:30
PM
[**Hospital **] Clinic: Attending visit: [**2174-12-23**] at 10AM
ID Fellow visit: [**2175-1-16**] at 10:30AM
Plastics: Dr. [**First Name (STitle) **] [**Telephone/Fax (1) 1416**] on [**2174-12-22**] at 3:45 PM
JP drains to remain in place until follow up with Dr [**First Name (STitle) **]
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) **] in [**1-13**] weeks [**Telephone/Fax (1) 6803**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
[**Last Name (un) 15058**] CBC w/diff, BUN/CRE, LFTs.
VANCO TROUGH at [**2174-12-16**] at 1900 Please fax results to infectious
disease RN [**Telephone/Fax (1) 1419**]
Completed by:[**2174-12-14**]
|
[
"707.03",
"998.59",
"244.9",
"787.91",
"730.08",
"278.00",
"250.00",
"E879.8",
"276.1",
"438.0",
"729.89",
"V58.67",
"V10.3",
"998.31",
"707.22",
"V45.71",
"V45.81",
"V15.3",
"401.9",
"V12.51",
"V12.55",
"438.89",
"731.3",
"285.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.74",
"96.6",
"84.94",
"77.61",
"77.81",
"96.72",
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
11838, 11904
|
5493, 7863
|
318, 445
|
12475, 12653
|
2643, 5470
|
13577, 14690
|
1618, 1636
|
9487, 11815
|
11925, 12454
|
7889, 9464
|
12677, 13554
|
1651, 2624
|
261, 280
|
473, 785
|
807, 1314
|
1330, 1602
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,856
| 197,996
|
6918
|
Discharge summary
|
report
|
Admission Date: [**2190-8-24**] Discharge Date: [**2190-8-31**]
Date of Birth: [**2116-2-10**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 74-year-old man
who was admitted status post a fall two days prior to
admission with urinary retention, history of TURP in [**2180**],
hypertension. Since the fall, the patient has decreased
urine output and constipation, left leg weakness, dribbling,
urgency with no hematuria. Last bowel movement was Sunday.
Polyneuropathy manifested lack of balance. No urinary
symptoms since TURP in [**2180**]. No chronic urinary retention or
chronic constipation. No lower back pain. The patient is
also status post volvulus, depression, bilateral hernia
repair.
ALLERGIES: The patient has no known allergies.
ADMISSION MEDICATIONS;
1. Prilosec
2. Zoloft
3. Wellbutrin
PHYSICAL EXAM:
VITAL SIGNS: Temperature 98.1??????, heart rate 67, blood
pressure 210/92, respiratory rate 18, saturations 99%.
GENERAL: In no acute distress.
LUNGS: Clear to auscultation.
CARDIAC: Regular rate and rhythm, no murmurs, rubs or
gallops.
ABDOMEN: Soft, positive bowel sounds, positive suprapubic
tenderness. Genitourinary service was consulted to place
Foley catheter.
RECTAL: The patient, on rectal exam, had diminished tone
with no numbness.
EXTREMITIES: 2+ radial pulses, no edema. Motor strength,
the patient was 5 out of 5 in all muscle groups. Sensation
was intact to light touch throughout. The patient had no
clonus. Toes were downgoing bilaterally and he had absent
reflexes in the lower extremity.
The patient had a Foley catheter placed by the genitourinary
service, had 700 cc of clear yellow urine in his bladder.
The patient will have Foley catheter in place x2 weeks. The
patient had MRI scan on admission which showed an intradural
epidural mass at the L5-S1 level, question of a hematoma.
The patient also has a past medical history of Charcot [**Doctor Last Name **]
Tooth disease x2 years.
HOSPITAL COURSE: On [**2190-8-24**], the patient underwent an
L4-L5 laminectomy and decompression of epidural hematoma and
primary repair of dural. Postoperative vital signs were
stable. The patient was monitored in the Neurosurgical
Intensive Care Unit for 24 hours where his neurologic status
remained stable. He had no complaints. His IP strength was
5 out of 5 in all muscle groups. Sensation was grossly
intact to lower extremities bilaterally. His dressing was
clean, dry and intact.
On [**2190-8-26**], the patient spiked a temperature to 102.3??????.
His other vital signs remained stable. He was fully
cultured. To date, there are no positive cultures. The
patient's temperature did come down and he did not spike
further temperatures. He was seen by physical therapy and
occupational therapy and found to require rehabilitation stay
prior to discharge to home. His Foley catheter is still in
place and the patient will need to follow up with urology in
a week's time for a voiding trial after hospital stay. The
patient will be discharged to rehabilitation with follow up
with Dr. [**Last Name (STitle) 1132**] in two to three weeks' time. His vital signs
have remained stable and he is currently afebrile.
DISCHARGE MEDICATIONS;
1. Zoloft 100 mg po q day
2. Zantac 150 mg po bid
3. Colace 150 mg po bid
4. Lopressor 25 mg po bid
5. Percocet 1 to 2 tablets po q4h prn for pain
6. Tylenol 650 po q4h prn
The patient's vital signs are stable and the patient was
afebrile and transferred to rehabilitation in stable
condition with follow up with Dr. [**Last Name (STitle) 1132**] in two to three
weeks' time and follow up with urology in one week's time for
a voiding trial. The patient was stable at the time of
discharge.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7762**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2190-8-31**] 10:10
T: [**2190-8-31**] 10:43
JOB#: [**Job Number 26052**]
|
[
"041.10",
"722.10",
"E885.9",
"356.1",
"599.0",
"356.9",
"530.81",
"952.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.09"
] |
icd9pcs
|
[
[
[]
]
] |
2005, 4001
|
864, 1987
|
160, 849
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,753
| 196,171
|
37987
|
Discharge summary
|
report
|
Admission Date: [**2159-2-16**] Discharge Date: [**2159-2-23**]
Date of Birth: [**2116-7-9**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Penicillins / Zyban / Wellbutrin / Codeine
Attending:[**First Name3 (LF) 16613**]
Chief Complaint:
Left foot pain and discomfort with discharge
Major Surgical or Invasive Procedure:
Irrigation and debridement with bone biopsy of left foot
History of Present Illness:
42 year old women with multiple foot surgery and history of
osteomyolitis. She continues to have pain and draining form her
left foot.
Past Medical History:
none
Social History:
n/c
Family History:
n/c
Physical Exam:
Gen; AOx3, NAD
Heart: RRR, No M/R/G
Lungs: CTA-B
Left LE: positive capillary refill, positive [**Last Name (un) 938**] and FHL, NVI
Pertinent Results:
[**2159-2-23**] 06:29AM BLOOD WBC-6.5 RBC-4.09* Hgb-12.5 Hct-38.4
MCV-94 MCH-30.6 MCHC-32.7 RDW-13.1 Plt Ct-219
[**2159-2-22**] 01:00PM BLOOD WBC-8.1 RBC-4.16* Hgb-12.5 Hct-38.2
MCV-92 MCH-30.1 MCHC-32.8 RDW-12.9 Plt Ct-246
[**2159-2-21**] 04:15AM BLOOD WBC-6.5 RBC-4.36 Hgb-13.7 Hct-39.2 MCV-90
MCH-31.3 MCHC-34.9 RDW-13.1 Plt Ct-233
[**2159-2-20**] 05:05PM BLOOD WBC-5.4 RBC-4.17* Hgb-13.1 Hct-38.9
MCV-93 MCH-31.4 MCHC-33.6 RDW-12.8 Plt Ct-223
[**2159-2-19**] 06:05AM BLOOD WBC-4.6 RBC-4.15* Hgb-12.9 Hct-38.3
MCV-92 MCH-31.1 MCHC-33.7 RDW-13.1 Plt Ct-224
[**2159-2-18**] 05:38AM BLOOD WBC-4.5 RBC-3.71* Hgb-11.5* Hct-34.8*
MCV-94 MCH-31.0 MCHC-33.1 RDW-12.9 Plt Ct-221
[**2159-2-17**] 05:59AM BLOOD WBC-7.4 RBC-3.76* Hgb-11.7* Hct-35.4*
MCV-94 MCH-31.1 MCHC-33.0 RDW-13.0 Plt Ct-226
[**2159-2-16**] 07:17PM BLOOD WBC-10.0 RBC-3.93* Hgb-12.7 Hct-36.9
MCV-94 MCH-32.3* MCHC-34.4 RDW-13.3 Plt Ct-220
[**2159-2-21**] 04:15AM BLOOD Neuts-60.7 Bands-0 Lymphs-27.8 Monos-0.8*
Eos-3.6 Baso-1.0
[**2159-2-17**] 05:59AM BLOOD Neuts-61.8 Lymphs-28.6 Monos-6.5 Eos-2.2
Baso-0.8
[**2159-2-16**] 07:17PM BLOOD Neuts-70.1* Lymphs-23.8 Monos-3.6 Eos-1.9
Baso-0.6
[**2159-2-23**] 06:29AM BLOOD Plt Ct-219
[**2159-2-23**] 06:29AM BLOOD Glucose-95 UreaN-11 Creat-1.1 Na-137
K-3.6 Cl-101 HCO3-29 AnGap-11
[**2159-2-22**] 01:00PM BLOOD Glucose-128* UreaN-10 Creat-1.0 Na-138
K-3.4 Cl-99 HCO3-30 AnGap-12
[**2159-2-21**] 04:15AM BLOOD Glucose-118* UreaN-9 Creat-0.9 Na-136
K-3.7 Cl-101 HCO3-25 AnGap-14
[**2159-2-20**] 05:05PM BLOOD Glucose-134* UreaN-9 Creat-0.9 Na-137
K-4.7 Cl-103 HCO3-27 AnGap-12
[**2159-2-23**] 06:29AM BLOOD ALT-31 AST-24 LD(LDH)-165 AlkPhos-73
TotBili-0.3
[**2159-2-22**] 01:00PM BLOOD ALT-43* AST-35 LD(LDH)-178 AlkPhos-77
TotBili-0.4
[**2159-2-21**] 04:15AM BLOOD ALT-47* AST-49* LD(LDH)-172 AlkPhos-78
TotBili-0.4
[**2159-2-16**] 07:17PM BLOOD ALT-20 AST-22 AlkPhos-69 TotBili-0.3
[**2159-2-23**] 06:29AM BLOOD Albumin-3.5
[**2159-2-21**] 04:15AM BLOOD Calcium-8.6 Phos-3.6 Mg-2.2
[**2159-2-16**] 07:17PM BLOOD CRP-1.7
[**2159-2-19**] 07:45PM BLOOD Vanco-9.6*
Brief Hospital Course:
Brief MICU course:
Ms. [**Known lastname 84867**] was transferred to the ICU for nafcillin
desensitization due to her penicllin allergy. Tissue cultures
revealed an MSSA osteomyelitis, for which the patient will
require long-term antibiotics. It was felt that nafcillin was
the ideal [**Doctor Last Name 360**] for this, so Allergy felt it was warranted for
the patient to undergo a desensitization protcol. She was given
7 escalating titrations of nafcillin, with H1 and H2 blockers
(Benadryl, famotidine), methylprednisolone, ibuprofen, and
epinephrine on hand in case of allergic reaction. She tolerated
the desensitization well and did not require any of these
medications. A PICC line was placed while in the unit for
long-term antibiotic administration. On routine blood testing,
a transaminitis was noted and should be monitored while on
nafcillin.
The patient was admitted to the orthopaedic surgery service and
was taken to the operating room for above described procedure.
Please see separately dictated operative report for details. The
surgery was uncomplicated and the patient tolerated the
procedure well. Patient received perioperative IV antibiotics.
Otherwise, pain was initially controlled with a PCA followed by
a transition to oral pain medications on POD#1. The patient
received lovenox for DVT prophylaxis starting on the morning of
POD#1. The patient was seen daily by physical therapy.
At the time of discharge the patient was tolerating a regular
diet and feeling well. The patient was afebrile with stable
vital signs. The patient's pain was adequately controlled on
an oral regimen. The operative extremity was neurovascularly
intact. The patient is non-weight-bearing on the left lower
extremity.
Ms. [**Known lastname 84867**] is discharged to home with services in stable
condition with prescriptions for nafcillin, PICC line flushes,
Lovenox, pain medication.
Medications on Admission:
none
Discharge Medications:
1. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours.
Disp:*60 Tablet(s)* Refills:*0*
2. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) 40mg/0.4mL
syringe Subcutaneous DAILY (Daily) for 3 weeks: End date:
[**2159-3-16**].
Disp:*21 syringe* Refills:*0*
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. aspirin, buffered 325 mg Tablet Sig: One (1) Tablet PO twice
a day: Begin after the completion of lovenox.
Disp:*60 Tablet(s)* Refills:*2*
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
6. sodium chloride 0.9 % 0.9 % Syringe Sig: One (1) syringe
Injection Q8H (every 8 hours) as needed for line flush.
Disp:*60 syringe* Refills:*2*
7. heparin, porcine (PF) 10 unit/mL Syringe Sig: Two (2) mLs
Intravenous PRN (as needed) as needed for line flush.
Disp:*30 syringe* Refills:*2*
8. nafcillin in D2.4W 2 gram/100 mL Piggyback Sig: Two (2) grams
Intravenous Q4H (every 4 hours) for 6 weeks: Est end date:
[**2159-4-6**].
Disp:*504 grams* Refills:*1*
9. Outpatient Lab Work
Check CBC, BUN, Cr, ESR, CRP, and LFTs via PICC every Thurday.
Fax labs results to ID RNs at [**Telephone/Fax (1) 1419**]
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] home therapies
Discharge Diagnosis:
Left foot osteomyolitis
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:
1. Please return to the emergency department or notify your
physician if you experience any of the following: severe pain
not relieved by medication, increased swelling, decreased
sensation, difficulty with movement, fevers greater than 101.5,
shaking chills, increasing redness or drainage from the incision
site, chest pain, shortness of breath or any other concerns.
2. Please follow up with your primary physician regarding this
admission and any new medications and refills.??????
3. Resume your home medications unless otherwise instructed.
4. You have been given medications for pain control. Please do
not drive, operate heavy machinery, or drink alcohol while
taking these medications. As your pain decreases, take fewer
tablets and increase the time between doses. This medication can
cause constipation, so you should drink plenty of water daily
and take a stool softener (such as colace) as needed to prevent
this side effect.?????? Call your surgeons office 3 days before you
are out of medication so that it can be refilled.?????? These
medications cannot be called into your pharmacy and must be
picked up in the clinic or mailed to your house.?????? Please allow
an extra 2 days if you would like your medication mailed to your
home.
5. You may not drive a car until cleared to do so by your
surgeon or your primary physician.
6. Please call your surgeon's office to schedule or confirm your
follow-up appointment in two (2) weeks.
7. Please DO NOT take any non-steroidal anti-inflammatory
medications (NSAIDs such as celebrex, ibuprofen, advil, aleve,
motrin, etc).
8. ANTICOAGULATION: Please continue your lovenox for three weeks
to help prevent deep vein thrombosis (blood clots).?????? After
completing the lovenox, please take Aspirin 325mg?????? TWICE?????? daily
for an additional three weeks.
9. ACTIVITY: Non-weight bearing as tolerated on the operative
extremity. No strenuous exercise or heavy lifting until follow
up appointment.
10. Antibiotics/PICC/labs: Please keep your PICC line clean dry.
All antibiotic infusions and lab draws to be done off the PICC
line.
Physical Therapy:
LLE NWB at all times
2 crutches
Treatments Frequency:
PICC line changes and line flushes per facility protocol
Lab Draws
- Check CBC, BUN, Cr, ESR, CRP, LFTs
- Check every week (Thursdays)
- Fax results to Infectious Disease RNs at [**Telephone/Fax (1) 1419**]
Followup Instructions:
Please call [**Telephone/Fax (1) 1228**] to confirm your appointment.
Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 27264**], [**MD Number(3) 3261**]:[**Telephone/Fax (1) 1228**]
Date/Time:[**2159-3-8**]
[**Name6 (MD) 13978**] [**Name8 (MD) **] MD [**MD Number(2) 16614**]
Completed by:[**2159-2-23**]
|
[
"V07.1",
"E929.0",
"998.59",
"041.11",
"730.17",
"905.4",
"707.15",
"E878.1",
"V14.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"77.68",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
6144, 6210
|
2906, 4817
|
352, 411
|
6278, 6278
|
813, 2883
|
8869, 9260
|
641, 646
|
4872, 6121
|
6231, 6257
|
4843, 4849
|
6461, 8563
|
661, 794
|
8581, 8613
|
8635, 8846
|
268, 314
|
439, 576
|
6293, 6437
|
598, 604
|
620, 625
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,785
| 166,654
|
33000
|
Discharge summary
|
report
|
Admission Date: [**2170-3-3**] Discharge Date: [**2170-3-16**]
Date of Birth: [**2110-1-2**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 358**]
Chief Complaint:
Intraventricular bleed.
Major Surgical or Invasive Procedure:
1. External ventricular drainage
2. Closed reduction and percutaneous pinning of left fourth and
fifth proximal phalanx fractures.
History of Present Illness:
60 year old male presents after reportedly falling at a carwash.
When EMS arrived, he was able to tell them that he had fallen
and had been able to break his fall with his left hand. He also
admitted to drinking alcohol during the day. He was brought to
[**Hospital **] Hospital where his systolic blood pressure was in the
200s. He was given labetalol 20 mg IV x 2. The patient also had
fractures of the left 5th metacarpal and dislocation of the 4th
proximal phalanx. He was splinted at the OSH. The patient
reportedly became "more obtunded" and his head CT showed a large
IVH. He was intubated, loaded with dilantin and transferred to
[**Hospital1 18**].
Past Medical History:
1. Alcohol abuse.
Social History:
Works at [**Company 18650**] college. Drinks 7-9 beers per day, denies
liquor. Smokes, will not say how much. No history of
drugs--specifically no IVDU or cocaine use.
Family History:
N/C
Physical Exam:
On admission:
PHYSICAL EXAM:
T:98.1 BP:142/85 HR:86 RR:12 O2Sats: 100% vented
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: PERRL EOMs-unable to test
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Opens eyes slightly, intubated.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 2 to 1 mm
bilaterally.
III-[**Doctor First Name 81**]: unable to test
XII: Tongue midline without fasciculations.
Motor: Moves all extremities spontaneously and to command.
Sensation: Appears to be intact to light touch throughout.
Toes mute bilaterally
Pertinent Results:
[**2170-3-2**] 11:05PM WBC-5.6 RBC-4.10* HGB-14.7 HCT-40.0 MCV-98
MCH-35.8* MCHC-36.7* RDW-13.0
[**2170-3-2**] 11:05PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2170-3-2**] 11:05PM GLUCOSE-198* UREA N-12 CREAT-0.9 SODIUM-135
POTASSIUM-3.5 CHLORIDE-95* TOTAL CO2-27 ANION GAP-17
[**2170-3-2**] Head CT - Intraventricular hemorrhage involving both
lateral ventricles, right greater than left, as well as third
and fourth ventricles. Symmetric large size of the ventricular
system without prior study to assess chronicity of this finding.
Probable small foci of subarachnoid hemorrhage of the bilateral
parietal lobes. Fluid levels in the left maxillary and sphenoid
sinuses.
[**2170-3-6**] L hand - comminuted fracture of the proximal aspect of
the fifth proximal phalanx is again seen, again with dorsal
angulation. Alignment does not appear significantly changed
compared to the previous exam
[**2170-3-8**] Head CT - Status post removal of intraventricular drain
with decreased amount of hemorrhage in the bilateral lateral
ventricles and posterior horns, right greater than left. Small
amount of intraventricular air is noted in the anterior horns of
the lateral ventricles. Unchanged size of ventricles since the
prior exam. Sphenoid sinus mucosal thickening is marked, but
stable.
[**2170-3-11**] Head CT - Continued evidence of blood layering within
the occipital horns, slightly less prominent than on the prior
study, with improvement in the intraventricular air
[**2170-3-12**] Head CTA - No intracranial aneurysms, stenoses,
occlusions, or vascular malformations are seen
Brief Hospital Course:
Neurosurgery course: Admission for traumatic
intraventricular/intracerebral hemmorhage.
Patient initially admitted to the trauma ICU. Transfused 6 packs
of platelets for level of 79. An EVD was placed and was started
on ceftriaxone/flagyl for aspiration pneumonia. Patient
remained in the ICU and neuro exam slowly improved. Placed on
CIWA protocol for ETOH withdrawal. EVD slowly raised as his
ICPs tolerated it and was eventually clamped and d/c'ed on HD6.
Repeat CT was not worrisome for hydrocephalus. He was taken to
the OR by plastics for pinning of L 5th proximal phalanx. Neuro
exam continued to improve although he did have many episodes of
sundowning which was treated with haldol and ativan. Had
persistently labile blood pressure that was as high as 180
systolic. Was transferred to medical team for hypertension and
hypotension.
Medicine course:
1. Hyponatremia: Thought to be secondary to SIADH given urine
sodium >100. Treated with fluid rescriction and salt tabs with
serum sodium in the 128-132 range for >1 week.
2. Hypertension:
Not on any medications as any outpatient. Started three drug
regimen inhouse with improvement. Currently regimen includes:
metoprolol, lisinopril and amlodipine.
3. Alcohol abuse:
CIWA scale was used initially with no clear withdrawal.
4. Mental status change:
Intermittant confusion thought to be multifactorial (recent head
trauma, surgery, medications). He improved over the final days
of his hospitalization and discharged to short term
rehabilitation for further physical therapy and medication
management.
Medications on Admission:
None.
Discharge Medications:
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 1294**]
Discharge Diagnosis:
Intraventricular hemorrhage, L 5th proximal phalanx fracture,
Hypertension
Discharge Condition:
stable
|
[
"E888.9",
"293.0",
"816.01",
"287.5",
"853.01",
"253.6",
"507.0",
"291.81",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.05",
"96.71",
"02.2",
"79.14"
] |
icd9pcs
|
[
[
[]
]
] |
5427, 5501
|
3766, 5346
|
336, 469
|
5619, 5628
|
2114, 3743
|
1401, 1406
|
5404, 5404
|
5522, 5598
|
5372, 5379
|
1451, 1710
|
273, 298
|
497, 1158
|
1774, 2095
|
1436, 1436
|
1725, 1758
|
1180, 1199
|
1215, 1385
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,223
| 151,333
|
24374
|
Discharge summary
|
report
|
Admission Date: [**2188-7-16**] Discharge Date: [**2188-7-20**]
Date of Birth: [**2125-8-5**] Sex: F
Service: PLASTIC
Allergies:
Percocet
Attending:[**First Name3 (LF) 5883**]
Chief Complaint:
Breast cancer s/p bilateral mastectomy
Major Surgical or Invasive Procedure:
Bilateral delayed [**Last Name (un) 5884**] flap reconstruction.
History of Present Illness:
This is a 62 year-old woman with history of breast cancer, s/p
bilateral mastectomy in [**2182**] and [**2183**]. She was seen in the
plastic surgery clinic in [**2188-4-30**], for evaluation for breast
reconstruction. After discussion of various options, she elected
for [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5884**] flap reconstruction.
Past Medical History:
HTN
skin cancer
thyroid disease
breast cancer
blood transfusion ([**2140**])
s/p hysterectomy
s/p tubal ligation
s/p bilat reast reduction [**2179**]
s/p bilateral mastectomy [**2183**]
Social History:
h/o tobacco, none now
Family History:
HTN
CAD
Physical Exam:
T97.4 BP 143/69 P88-104 R18 95%RA
Well-appearing, out of bed in chair
Incisions clean, dry and intact.
JP drains in place with serosanguinous fluid.
Flaps well-perfused and warm, with good doppler signal
bilaterally
Pertinent Results:
[**2188-7-16**] 10:41PM GLUCOSE-168* UREA N-24* CREAT-0.7 SODIUM-145
POTASSIUM-4.4 CHLORIDE-108 TOTAL CO2-25 ANION GAP-16
[**2188-7-16**] 10:41PM CALCIUM-9.1 PHOSPHATE-4.7* MAGNESIUM-1.5*
[**2188-7-16**] 10:41PM WBC-16.8*# RBC-3.95* HGB-12.0 HCT-35.8*
MCV-91 MCH-30.4 MCHC-33.6 RDW-13.0
[**2188-7-16**] 10:41PM PLT COUNT-274
[**2188-7-16**] 10:41PM PT-12.2 PTT-21.7* INR(PT)-1.0
[**2188-7-16**] 10:33PM TYPE-ART PO2-140* PCO2-58* PH-7.25* TOTAL
CO2-27 BASE XS--2
[**2188-7-16**] 10:33PM GLUCOSE-172* LACTATE-3.1*
[**2188-7-16**] 10:33PM freeCa-1.21
[**2188-7-16**] 06:03PM TYPE-ART RATES-10/ TIDAL VOL-618 PO2-144*
PCO2-43 PH-7.38 TOTAL CO2-26 BASE XS-0 INTUBATED-INTUBATED
VENT-CONTROLLED
[**2188-7-16**] 06:03PM GLUCOSE-182* LACTATE-4.1* NA+-142 K+-4.2
CL--109
[**2188-7-16**] 06:03PM HGB-12.4 calcHCT-37
[**2188-7-16**] 06:03PM freeCa-1.20
[**2188-7-16**] 04:11PM TYPE-ART RATES-20/ TIDAL VOL-617 O2-47
PO2-170* PCO2-37 PH-7.43 TOTAL CO2-25 BASE XS-1
INTUBATED-INTUBATED VENT-CONTROLLED
[**2188-7-16**] 04:11PM GLUCOSE-171* LACTATE-5.0* NA+-140 K+-4.6
CL--104
[**2188-7-16**] 04:11PM HGB-12.1 calcHCT-36
[**2188-7-16**] 04:11PM freeCa-1.22
[**2188-7-16**] 01:40PM TYPE-ART PO2-184* PCO2-40 PH-7.39 TOTAL
CO2-25 BASE XS-0 INTUBATED-INTUBATED
[**2188-7-16**] 01:40PM GLUCOSE-167* LACTATE-4.0* NA+-141 K+-4.7
CL--106
[**2188-7-16**] 01:40PM HGB-12.4 calcHCT-37
[**2188-7-16**] 01:40PM freeCa-1.22
[**2188-7-16**] 10:44AM GLUCOSE-157* LACTATE-2.0 NA+-141 K+-4.2
CL--104
[**2188-7-16**] 10:44AM HGB-12.0 calcHCT-36 O2 SAT-98
[**2188-7-16**] 10:44AM HGB-12.0 calcHCT-36 O2 SAT-98
Brief Hospital Course:
The patient was admitted [**2188-7-16**], and underwent an
uncomplicated [**Last Name (un) 5884**] flap reconstruction (bilateral) by Drs. [**First Name (STitle) **]
and [**Name5 (PTitle) 3228**]. Please see the operative note for full details.
Post-operatively the patient did well, with no major
complications. Throughout her stay both flaps remained
well-perfused with good doppler signals. None of her incisions
showed signs of infection and she remained on IV antibiotics.
Her pain was well-controlled on dilaudid and her diet and
activity levels were advanced slowly with no problems. She was
discharged home with the JP drains in place on POD#4 in good
condition.
Medications on Admission:
atenolol
syntrhoid
restasis
all: percocet (unclear--h/o nausea and sweating but no problems
with narcotics here)
Discharge Medications:
Pre-admission medications as well as:
1. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*45 Tablet(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*50 Capsule(s)* Refills:*0*
3. Cephalexin 500 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:
Breast cancer, s/p bilateral mastectomies
Discharge Condition:
Good
Discharge Instructions:
Patient to be discharged to home and to call physician or come
to ER if having worsening pains, fevers, chills, nausea,
vomiting, shortness of breath, chest pain, redness or drainage
about the wounds, or if there are any questions or concerns.
Patient should also come to the ER or call a physician if there
the breast flaps become cool or change in color, or if there is
an increase in pain.
Patient to take antibiotics and other medications as directed.
Patient not to drive or operate heavy machinery while on any
narcotic pain medication such as percocet as it can be sedating.
Patient to take colace to soften the stool as needed for
constipation as narcotic pain medication can cause this issue.
JP drains should remain in place until seen at follow-up visit.
Patient should strip drains and record output daily.
Patient may continue pre-admission medications but should not
take motrin or aspirin.
Followup Instructions:
Call Dr. [**First Name (STitle) **] for a follow-up appoitment. ([**Telephone/Fax (1) 6331**])
|
[
"V10.3",
"244.9",
"553.1",
"V45.71",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"85.7",
"53.49"
] |
icd9pcs
|
[
[
[]
]
] |
4183, 4189
|
2934, 3607
|
306, 373
|
4275, 4282
|
1287, 2911
|
5238, 5336
|
1027, 1036
|
3771, 4160
|
4210, 4254
|
3633, 3748
|
4306, 5215
|
1051, 1268
|
228, 268
|
401, 763
|
785, 972
|
988, 1011
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,521
| 123,546
|
15364
|
Discharge summary
|
report
|
Unit No: [**Numeric Identifier 44622**]
Admission Date: [**2113-4-17**]
Discharge Date: [**2113-4-24**]
Date of Birth: [**2091-7-11**]
Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 21-year-old
male with a history of end-stage renal disease (on
hemodialysis) secondary to reflux nephropathy, and focal
segmental glomerulosclerosis who presented with fevers to 102
and a facial rash.
Initially, he had a temperature of 100.6 at [**Location (un) 4265**]
Hemodialysis Unit on [**2113-3-27**]. There, he received
vancomycin which was complicated by red man syndrome. This
consisted of a fever and rash from the forehead down to his
waistline. He was given Benadryl and Tylenol and sent home.
He received hemodialysis on [**2113-4-12**] uneventfully. At
hemodialysis on [**2113-4-14**] he had a temperature to 102.7.
Blood cultures were taken from his hemodialysis line. He was
given 1 gram of Kefzol and referred to the Emergency
Department.
In the Emergency Department, a chest x-ray showed no
pneumonia. Laboratories with a white blood cell count of
5.4. Urinalysis had small leukocyte esterase, but no
nitrites. Therefore, he was started empirically on
ciprofloxacin 500 mg twice per day times seven days for a
possible urinary tract infection. Urine culture ultimately
returned negative. He began taking ciprofloxacin in the
morning of [**2113-4-15**]. He woke up on [**2113-4-16**] with
"dots" all over and pruritus. He took his last dose of
ciprofloxacin on [**2113-4-16**] in the evening. His rash was
not relieved with Benadryl or Tylenol, so he came to the
Emergency Department for further evaluation.
In the Emergency Department - on [**2113-4-17**] - he was
noted to have a temperature of 98.8, his blood pressure was
128/64, his pulse was 98, his respiratory rate was 16, and
his oxygen saturation was 100 percent on room air. In the
Emergency Department, he was pan-cultured and given one dose
of vancomycin intravenously and ceftriaxone intravenously.
Laboratories at that time showed a potassium of 6.3 with
questionable peaked T waves on his electrocardiogram.
Therefore, he also received calcium gluconate 1 gram, 10
units of regular insulin, 1 ampule of dextrose, 1 ampule of
bicarbonate, and Kayexalate 60 grams. Before leaving to the
Emergency Department, he spiked a temperature to 103.6.
Therefore, Tylenol was given.
Of note, he had a recent admission in [**Month (only) 956**] after two
generalized tonic-clonic seizures. At that time he was
started on Dilantin. Also during that admission, he
completed a 3-day course of ciprofloxacin for a urine culture
that grew out Acinetobacter.
During this admission, review of systems was significant for
fevers, sore throat, and generalized malaise. He denied any
rigors, night sweats, or weight loss. He denied chest pain,
shortness of breath, palpitations, orthopnea, or paroxysmal
nocturnal dyspnea. There was no cough, wheezing, or
hemoptysis. There was no dysuria, abdominal pain, or
suprapubic tenderness. No nausea, vomiting, diarrhea, or
constipation. No recent travel. No recent medication
changes. No outdoor activities or camping. No recent
vaccinations. No pets or tic exposures. No recent sexual
contacts other than his longtime girlfriend with whom he is
in a monogamous relationship.
PAST MEDICAL HISTORY: End-stage renal disease (on
hemodialysis) secondary reflux, nephropathy, and focal
segmental glomerulosclerosis. He is dialyzed on Monday,
Wednesday, and Friday. He started hemodialysis on [**2113-3-1**]. Reflux nephropathy resulted in recurrent ascending
Escherichia coli infections. He is status post placement of
a right subclavian Perm-A-Cath on [**2113-3-15**] and an
arteriovenous fistula was placed on [**2113-3-17**].
Spina bifida; status post repair as an infant - complicated
by bowel and bladder incontinence, with a history of straight
catheterization three times daily - complicated by numbness
in the soles of the feet and backs of both thighs as well as
left foot weakness and hyperreflexive bilateral lower
extremities.
Newly diagnosed seizure disorder on [**2113-3-14**] for two
generalized tonic-clonic seizures - started on Dilantin on
[**2113-3-26**]. Seizures characterized by initial head
deviation toward to the right followed by generalized tonic-
clonic movements. His first seizure on [**2113-3-14**] was
felt to be secondary to hypercalcemia in the setting of a
calcium level of 6. His second seizure took place on
[**2113-3-26**] and was felt to be idiopathic. At that
time, he was loaded on dilatation 300 mg three times per day.
He erroneously continued on Dilantin 300 mg three times per
day until a follow-up appointment on [**2113-4-6**]. At that
time, he was switched to a regimen of 300 mg in the morning
and 200 mg in the evening.
Hypoparathyroidism.
History of multiple urinary tract infections; last diagnosed
in [**2113-2-26**] and treated with ciprofloxacin.
Anemia of chronic disease.
ALLERGIES: The patient reports no known drug allergies.
MEDICATIONS PRIOR TO ADMISSION:
1. Dilantin 300 mg by mouth in the morning alternating with
200 mg by mouth in the evening.
2. Lisinopril 10 mg by mouth once per day.
3. Epogen subcutaneously every week.
4. Sodium bicarbonate tablets four tablets by mouth twice per
day.
5. Oxybutynin 5 mg by mouth twice per day.
6. Tums 500 mg by mouth three times per day.
7. Calcitriol at each hemodialysis session.
8. Nephrocaps once per day.
SOCIAL HISTORY: The patient is a sophomore at [**University/College 5130**]
[**Location (un) **]. He lives in a dormitory. He is originally from
[**Location (un) 17004**], [**State 531**]. He denies any tobacco or illicit drug use,
but he reports occasional social alcohol intake. He is in a
monogamous sexual relationship with a longstanding
girlfriend.
FAMILY HISTORY: The patient reports no family history of
seizures or kidney disease.
PHYSICAL EXAMINATION ON PRESENTATION: Generally, this was
well-developed, well-nourished, thin, young male. He was
uncomfortable and ill-appearing, but nontoxic. Vital signs
revealed his temperature was 99.8, his blood pressure was
128/64, his heart rate was 98, his respiratory rate was 16,
and his oxygen saturation was 100 percent on room air. Head
and neck examination was remarkable for normocephalic and
atraumatic. The pupils were equal, round, and reactive to
light. The mucous membranes were moist. The posterior
oropharynx was erythematous, but there were no lesions
exudates. The neck was supple with no masses or
lymphadenopathy. The chest wall had hemodialysis catheter
site bandaged with no evidence of edema, fluctuance or
purulent discharge. The lungs were clear to auscultation
bilaterally. There were no rhonchi, rales, or wheezes.
Cardiovascular examination revealed a regular rate and rhythm
with normal first and second heart sounds auscultated. There
were no murmurs, rubs, or gallops. The abdomen was soft,
nontender, and nondistended. There were positive normal
active bowel sounds. There was no hepatosplenomegaly.
Examination of the back revealed no spinal or costovertebral
angle tenderness. The extremities were warm and well
perfused. There was no clubbing, cyanosis, or edema. The
left forearm arteriovenous fistula had some serous drainage;
but no erythema, edema, or fluctuance. A bruit was
auscultated over the arteriovenous fistula. His skin
demonstrated erythematous, raised, maculopapular rash
diffusely, but concentrated mostly on the face, abdomen,
extremities, palms, and soles. The lesions were
approximately 1 cm in diameter. On the face, the eyelids
were spared. Otherwise, the rash was confluent, pruritic,
blanching, nonconfluent on the body with a questionable
appearance of wheels. There were no bullae formation. No
target lesions. The skin examination was also remarkable for
a tuft of hair on his back and a scar overlying his previous
spina bifida surgery site. Neurologically, he was alert and
oriented times three with no tremor or asterixis.
PERTINENT LABORATORY VALUES ON PRESENTATION: A complete
blood count on admission revealed his white blood cell count
was 5.1 (with 61 percent neutrophils, 26 percent lymphocytes,
5 percent monocytes, 7.2 percent eosinophils - 2.9 percent on
[**2113-3-26**] - and 0.5 percent basophils), his
hematocrit was 41.6, and his platelets were 194. Chemistries
showed his sodium was 138, potassium was 6.3, chloride was
95, bicarbonate was 27, blood urea nitrogen was 58,
creatinine was 13.5, and his blood glucose was 87. His
calcium was 10.6, his phosphorous was 4.4, and his magnesium
was 2.5. Coagulation profile revealed his prothrombin time
was 12.7, his partial thromboplastin time was 26.4, and his
INR was 1.1. Hemolysis studies on [**2113-4-18**] showed a
haptoglobin of 87, his fibrinogen was 253, and his D-dimer
was elevated at 2274. An additional workup for his rash and
fever revealed a throat swab with culture negative for beta
streptococcal infection. Stool culture was negative. Mono
spot was negative. ASO titer from [**4-19**] demonstrated a
positive ASO screen with a titer positive to 200 to 400.
Rapid plasma reagin nonreactive. [**Doctor Last Name 3271**]-[**Doctor Last Name **] virus titer
showed the patient to be IgG positive and IgM negative.
Urine culture from [**2113-4-14**] was also negative for
growth.
BRIEF SUMMARY OF HOSPITAL COURSE: FEVER ISSUES: A concern
over line source of fevers in the Emergency Department, the
patient received a vancomycin. He was started on ceftriaxone
for gram-negative coverage given his history of multiple
urinary tract infections and a history of straight
catheterization use. Prior to antibiotic initiation, he was
pan-cultured. On the night of admission, he spiked a
temperature to 103.7 which decreased to 101.5 with Tylenol.
On the morning of [**2113-4-18**] he went to hemodialysis and
there spiked a temperature to 105. He was cultured from his
hemodialysis line and sent back to the General Medicine
floor. As the fever started after hemodialysis sessions and
appeared to worsen with accessing his hemodialysis line, the
Interventional Radiology Service was contact[**Name (NI) **] for removal of
the patient's tunnel catheter. Initially, the Interventional
Radiology Service did not feel the catheter needed to be
removed. Thereafter, the patient himself refused removal.
Later on the day of [**2113-4-18**] he was dialyzed via his
arteriovenous fistula with no adverse events.
He was seen in consultation by the Infectious Disease Service
who recommended holding vancomycin, ciprofloxacin, and
Dilantin. An exhaustive workup; including pan cultures,
liver function tests, Mono spot, cytomegalovirus, [**Doctor Last Name 3271**]-
[**Doctor Last Name **] virus, mycoplasma, and titers, rapid plasma reagin, ASO,
throat swab, antineutrophil cytoplasmic antibody, rheumatoid
factor, and sedimentation rate was initiated out of concern
for drug fevers, viral infection, line infection, vasculitis,
toxic shock syndrome, primary human immunodeficiency virus
infection.
The patient was covered initially with aztreonam after he
spiked a fever to 107.3 in the setting of a normal blood
pressure of 140/90 and a heart rate of 120. In addition to
aztreonam during this temperature spike he also received 1
gram of Tylenol and Benadryl. He was moved from the floor to
the Medical Intensive Care Unit for further monitoring.
Out of continued concern for a line infection in spite of
negative culture data, the patient's tunneled Port-A-Cath was
removed on [**2113-4-19**]. He continued to have dialysis and
was dialyzed on [**2113-4-20**] through his arteriovenous
fistula. About one hour into that hemodialysis session, he
had rigors. There was some question of whether his fevers
and rigors could be secondary to a membrane issue.
As all of the patient's culture data was negative, and his
fevers subsided status post discontinuation of vancomycin and
Dilantin, it was felt that his fevers were most likely
secondary to an acute drug reaction. It is therefore
recommended that he avoid exposure to vancomycin and Dilantin
in the future.
RASH ISSUES: It was unclear whether the patient's rash was
drug related versus infectious in etiology. The onset
occurred after therapy with ciprofloxacin and had an
urticaria appearance and peripheral eosinophilia which was
suggestive of a drug related process. However, in light of
the high fevers ________ was maintained for infectious
sources as well.
An exhaustive workup (as outlined above) was undertaken in
order to help delineate the source of the patient's fevers.
An infectious workup was negative. For symptoms, he was
continued on Benadryl and an H2 blocker to decrease histamine
release. He was not initially treated with steroids out of
concern for infection.
On [**2113-4-18**] he was noted to have cracking and peeling
as well as a edema of his lips and a question ulcerative
lesion in his oropharynx and conjunctivae. This was
concerning for [**Doctor Last Name **]-[**Location (un) **] syndrome. He was seen in
consultation by the Dermatology, Infectious Disease, and
Ophthalmology services. Ophthalmology saw only mild
conjunctivitis on their examination and recommended
Artificial Tears and Lacri-Lube. Per Dermatology, the likely
culprits for the patient's rash included vancomycin and
Dilantin. However, there was really no way to delineate
which of these two agents were the cause of this. With
conservative and symptomatic therapy, the patient's rash
improved.
END-STAGE RENAL DISEASE ISSUES: On the day of his admission,
the patient had discontinuation of his tunneled Port-A-Cath.
He started hemodialysis via an arteriovenous fistula. He
tolerated this well with the exception of intermittent fever
spikes. He was continued on Nephrocaps, calcium acetate,
Epogen, and Calcitriol per the Renal team.
SEIZURE DISORDER ISSUES: In light of the suspicion of
Dilantin as an etiologic [**Doctor Last Name 360**] for the patient's fevers and
rash, Dilantin was discontinued. He was monitored closely in
the setting of fevers due to the fact that fevers can
decrease seizure threshold. He was started on gabapentin
after consultation with the Neurology Service. Outpatient
Neurology followup was arranged as well.
CODE STATUS ISSUES: The patient was a full code.
CONDITION ON DISCHARGE: Good - afebrile times 36 hours and
hemodynamically stable. Dilantin and vancomycin levels were
trending down. Skin rash was improving. All culture data
was negative for acute infection.
DISCHARGE STATUS: The patient was discharged to home.
DISCHARGE DIAGNOSES: Drug fever and reaction secondary to
vancomycin or Dilantin.
End-stage renal disease (on hemodialysis).
History of recurrent urinary tract infections.
History of a seizure disorder.
History of spina bifida; status post surgical repair.
Bowel and bladder incontinence.
Anemia of chronic disease.
MEDICATIONS ON DISCHARGE:
1. Gabapentin 300 mg by mouth at hour of sleep.
2. Lisinopril 20 mg by mouth once per day.
3. Epogen injections subcutaneously at hemodialysis.
4. Oxybutynin 5 mg by mouth twice per day.
5. Calcium acetate 670 mg two tablets by mouth three times
per day (with meals).
6. Nephrocaps one capsule by mouth every day.
7. Artificial Tears 1 drop each eye q.2h.
8. Lacri-Lube one application each eye at hour of sleep.
9. Benadryl 25 mg one capsule by mouth q.4-6h. as needed (for
itching).
10. Calcitriol.
FOLLOW-UP PLANS: The patient was instructed to call his
primary care physician or visit [**Name Initial (PRE) **] local Emergency Room if he
experienced recurrent fevers, shaking chills, headaches,
chest pain, confusion, recurrent skin rash, or any other
worrisome symptoms. He was instructed if he feels fevers and
rash, the most likely reaction was medications; however, we
could not ascertain whether the reaction was due to Dilantin
or vancomycin. We strongly suggested that he absolutely
avoid both of these agents in the future. He was instructed
to discontinue his Dilantin and sodium bicarbonate.
Additionally, he had follow-up appointments with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] in the Neurology Department on [**2113-6-6**]. He was
instructed to call both Dr. [**Last Name (STitle) 44623**] and Dr. [**Last Name (STitle) **] from the
Renal Division for follow-up appointments after discharge.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 20314**]
Dictated By:[**Last Name (NamePattern1) 14378**]
MEDQUIST36
D: [**2113-7-6**] 16:30:22
T: [**2113-7-6**] 22:13:09
Job#: [**Job Number 44624**]
cc:[**Last Name (NamePattern1) 44625**]
|
[
"E936.1",
"693.0",
"780.6",
"276.7",
"741.90",
"E930.8",
"780.39",
"996.73",
"403.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"86.09"
] |
icd9pcs
|
[
[
[]
]
] |
5856, 9395
|
14677, 14979
|
15005, 15519
|
9424, 14384
|
5071, 5478
|
15537, 16775
|
185, 3317
|
3340, 5039
|
5495, 5839
|
14409, 14655
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,156
| 178,453
|
43732
|
Discharge summary
|
report
|
Admission Date: [**2149-3-25**] Discharge Date: [**2149-4-1**]
Date of Birth: [**2074-4-26**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 5569**]
Chief Complaint:
Clotted AV Graft
Hyperkalemia
Major Surgical or Invasive Procedure:
[**2149-3-25**]: Right femoral temporary dialysis line placement
[**2149-3-26**]: IR LUE AVF thrombectomy c/b Radial
art occlusion s/p extraction of thrombus.
History of Present Illness:
74M well known to the transplant surgery service presents
with clotted AVG of the left upper extremity and hyperkalemia to
6.8. According to patient he is unaware when graft lost it's
pulse and thrill, but today at HD it was noted to be
nonfunctioning. He was unable to be dialyzed and referred to
[**Hospital1 18**] for thrombectomy. However, in the preop holding area
patient preoperative labs were notable for K of 6.8. HE was
given insulin 10 units iv and d50. Attempts at placing an HD
line were unsuccessful he is currently awaiting IR placement of
temporary HD line.
Past Medical History:
1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension
.
2. CARDIAC HISTORY:
-PERCUTANEOUS CORONARY INTERVENTIONS
(1) CAD s/p NSTEMI and stenting of the distal RCA, OM2 in [**2-/2147**]
complicated by GIB and paroxysmal atrial fibrillation
(2) s/p NSTEMI and unstable angina in [**2148-10-2**], cath showed
compelte occlusion of all three stents placed in [**2-/2147**], stent
placed in LCx
(3) s/p unstable angina, [**Year (4 digits) **] to LCx since LCx placed in [**9-/2148**]
had instent stenosis
.
3. OTHER PAST MEDICAL HISTORY:
-Three vessel CAD: see above for details
-Perioperative (bowel resection) vasospasm requiring cardiac
cath with NTG
-Mild-moderate MR
[**Name13 (STitle) 37625**] EF: 45% with focal inferior-posterior wall motion
abnormalities
-ESRD on HD, Cr [**2-18**] at baseline
-Ischemic Colitis: s/p SMA thrombectomy, with [**Doctor Last Name 3379**] pouch
and end ileostomy. Also complicated by recent diversion colitis
in 2/[**2146**].
-Peripheral [**Year (4 digits) 1106**] disease s/p aortobifemoral bypass [**2131**]
-Raynauds
-Dementia
-Atrial fibrillation
-H/o perioperative CVA: no deficits
-Hyperlipidemia
-HTN
-H/o Achalasia s/p esophageal dilation
-H/o VRE infection
-Anemia
-[**2149-3-26**] IR LUE AVF thrombectomy c/b Radial
art occlusion with thrombus extraction .
Social History:
Patient lives with his wife. [**Name (NI) **] outside help needed. Active at
baseline.
-Tobacco history: 40 pack years, quit 11 years ago
-ETOH: None
-Illicit drugs: None
Family History:
Comes from a family of 20 kids. Only 2 are still alive.
Significant history of cardiac disease in the family.
Physical Exam:
VS: 56 139/58 18 O2 sat=98% RA
NAD, Answers all questions, easily arousable but sleepy
bradycardic
crackles L> R
Soft abdomen with ileostomy with gas and + Output, Nontender
Ext: WWP, no edema. LUE with radial avf scar well healed with
LUE AVG without pulse or thrill. 1+ radial bilaterally
Pertinent Results:
[**2149-3-30**] 04:19AM BLOOD WBC-6.2 RBC-3.33* Hgb-10.3* Hct-30.4*
MCV-91 MCH-30.9 MCHC-33.9 RDW-16.8* Plt Ct-140*
[**2149-3-31**] 05:15AM BLOOD PT-17.2* PTT-74.6* INR(PT)-1.5*
[**2149-3-30**] 04:19AM BLOOD PT-14.8* PTT-57.3* INR(PT)-1.3*
[**2149-3-29**] 04:16AM BLOOD PT-13.8* PTT-49.0* INR(PT)-1.2*
[**2149-3-30**] 04:19AM BLOOD Glucose-95 UreaN-24* Creat-5.5*# Na-139
K-3.6 Cl-96 HCO3-33* AnGap-14
[**2149-3-30**] 04:19AM BLOOD Calcium-9.0 Phos-4.7* Mg-2.0
Brief Hospital Course:
74 y/o male admitted with non-functioning AV graft, found at HD.
On admission labs the potassium was 6.8. At this time an attempt
was made to place a temporary IJ line for emergent HD. Right IJ
was very small in caliber and left IJ was unable to be wired.
Procedure was stopped and the patient sent to IR to have femoral
line placed given past history of bilateral aorto-[**Hospital1 **] fems.
Hemodialysis was performed via that line with post HD potassium
of 4.3.
On [**2149-3-26**], he underwent IR LUE AVF thrombectomy c/b radial art
occlusion that requried consulting Dr. [**Last Name (STitle) **] who
performed extraction of thrombus with export device. He was
treated w/ heparin, integrelin and TPA. Completion angiogram
demonstrated patent radial and ulnar arteries. However, the left
radial pulse was not palpable, but the ulnar was palpable.
On [**3-29**], hemodialysis was successfully performed via the left
arm AVG. On [**3-30**], the temporary right groin dialysis line was
removed. He did experience bleeding at this site requiring a
pressure dressing that was removed on [**3-31**]. No futher bleeding
occurred at groin site. He was dialyzed again on [**4-1**] without
incident via the left AVG.
He remained on a heparin drip until [**3-31**]. Coumadin (5mg) was
given on [**3-30**] and [**3-31**]. INR increased to 2.2 on [**4-1**]. After
furhter review, long term coumadin was stopped given h/o of GI
bleed 6months prior. He was to continue on aspirin and plavix
given h/o cardiac stents.
The left arm AVG had a thrill and was working well for dialysis
on [**4-1**]. Vital signs were notable for sbp in 160-190 range.
Amlodipine 5mg qd was started. He was tolerating food and ostomy
was functioning well. PT assessed him and declared him safe for
discharge to home. He will resume dialysis in [**Location (un) **].
Of note, PT recommended a rolling walker and home PT. This was
arranged prior to discharge.
.
Medications on Admission:
aspirin 325 mg Tablet, Plavix 75 mg, amiodarone 200 mg',
carvedilol 12.5 mg", lisinopril 7.5 mg', loperamide 2 mg ",
pantoprazole 40 mg', lovastatin 10 mg', sevelamer HCl 800 mg"',
1337 mg "', isosorbide mononitrate 30 mg', Nephrocaps 1 mg'.
Discharge Medications:
1. carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
2. loperamide 2 mg Capsule Sig: One (1) Capsule PO Q 12H (Every
12 Hours).
3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
5. calcium acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
6. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
7. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO BID (2 times a
day).
8. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain or fever: no more than 4000mg per
day.
9. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. lovastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home with Service
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
ESRD
thrombosed AVG
left radial artery occlusion
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:
Please call Dr.[**Name (NI) 8584**] office [**Telephone/Fax (1) 673**] if you have any of
the following:
fever, chills, Left arm swelling, discoloration, numbness,
increased pain or bleeding or you experience any bleeding from
right groin old catheter site
You can resume dialysis at [**Location (un) **]. Dr. [**Last Name (STitle) **] will manage your
Coumadin dosing
Followup Instructions:
[**Name6 (MD) 5536**] [**Name8 (MD) **], MD ([**Hospital **] Care Center) Phone:[**Telephone/Fax (1) 5537**]
Date/Time:[**2149-4-21**] 1:00
Completed by:[**2149-4-1**]
|
[
"996.73",
"276.7",
"585.6",
"444.89",
"440.20",
"V45.11",
"427.31",
"443.0",
"V15.82",
"403.91",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"38.95",
"99.10",
"39.49"
] |
icd9pcs
|
[
[
[]
]
] |
6969, 7039
|
3552, 5488
|
332, 493
|
7132, 7132
|
3067, 3529
|
7710, 7880
|
2629, 2740
|
5781, 6946
|
7060, 7111
|
5514, 5758
|
7316, 7687
|
2755, 3048
|
1198, 1624
|
263, 294
|
521, 1102
|
7147, 7292
|
1655, 2424
|
1124, 1178
|
2440, 2613
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,711
| 157,883
|
40573
|
Discharge summary
|
report
|
Admission Date: [**2126-5-26**] Discharge Date: [**2126-5-29**]
Date of Birth: [**2046-7-1**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization s/p BMS placed to SVG to PDA graft
([**2126-5-27**])
History of Present Illness:
79M with h/o CAD s/p CABG in [**2106**] c/b longstanding sternal wound
infection transferred from [**Hospital6 **] for inferior
STEMI. He reports that he was in his USOH until last night ~ 11
PM. He was lying down to go to sleep and had the acute onset of
SSCP - described as pressure, [**2125-7-23**], no diaphoresis/nausea,
radiated to L shoulder and up L neck. He denies having pain like
this since his last MI in [**2106**]. He called 911 and went to [**Hospital **]. At [**Hospital3 15402**], EKG showed 2mm STE in II, III,
and aVF and subtle ST depressions in V1. He was Plavix loaded
with 600 mg, received ASA 325 mg, was started on heparin bolus
and gtt and nitro gtt. Of note, he was hypertensive to 200/116
at OSH. He also received morphine IV x 2, which relieved the
pain. CP resolved at [**Hospital3 **].
.
At [**Hospital1 18**] ED, initial VS 98.2 77 181/118 18 97% on 2L. EKG showed
NSR 82, LAD, Q-waves in II, III, aVF and subtle depressions in
V2. Labs showed Cr 0.8, Hct 35.7, PTT 76.3, Trop 0.05. CXR was
performed and showed mild pulmonary vascular congestion, prior
sternotomy and CABG clips (my read), no infiltrate. BP trended
down to 110s-120s/70s-80s - nitro gtt on at 1.5 mcg/kg/min.
Heparin gtt was continued.
.
Currently, the patient denies CP though does endorse pain in his
L shoulder and L neck. He had mild SOB on presentation to [**Hospital **] but denies this at present. He denies any history of HTN.
He also mentions increased swelling in his bilateral feet for
the past 2-3 days - has never had this in the past. He is active
at baseline and has not noticed any chest discomfort until last
night. Finally, the patient has a 1-cm open wound on his chest
with some superficial purulence - he states that his CABG
incision has remained open since his surgery in [**2106**]. He was
initially treated for a sternal wound infection but never
followed-up when the infection recurred a few months later.
.
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 denies exertional buttock or calf pain. All of the other
review of systems were negative.
.
Cardiac review of systems is notable for absence dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, palpitations,
syncope or presyncope.
Past Medical History:
. CARDIAC RISK FACTORS: -Diabetes, ? Dyslipidemia, -
Hypertension per patient
2. CARDIAC HISTORY:
- CABG: [**2106**] - [**Hospital6 **], c/b sternal wound infection
that was initially treated post-op, but recurred several months
later - has not followed up for this
3. OTHER PAST MEDICAL HISTORY:
None per patient
Social History:
Lives in [**Location 21487**], MA with his wife. Had 7 children (1
passed away from rheumatic fever as child) - several live near
him. Worked as a fisherman and then dockside repairman - now
retired. Still active painting houses. Walks without a cane.
- Tobacco history: 40 pack-year smoking history - quit in [**2106**]
- ETOH: no history of heavy drinking, no current EtOh
- Illicit drugs: none
Family History:
- No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death; otherwise non-contributory.
Physical Exam:
Admission Exam
VS: 98.2 83 117/74 22 97% on 2L
GENERAL: NAD. Oriented x3. Pleasant.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP not elevated
CARDIAC: Prior sternotomy - 1 cm open wound at top of healed
incision with small amt of purulence on bandaid. Frequent
premature beats, normal S1, S2. No m/r/g.
LUNGS: Resp were unlabored, no accessory muscle use. Crackles at
L base > R, otherwise clear.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No edema appreciated in patient's ankles.
PULSES: 2+ dps and pts bil, 2+ radials bil
.
On discharge:
clear lungs, heart with RR, no murmurs, JVP not elevated, clear
lungs, R groin without hematoma, good distal pulses
Pertinent Results:
[**2126-5-26**] 02:15AM BLOOD WBC-6.7 RBC-4.24* Hgb-12.1* Hct-35.7*
MCV-84 MCH-28.4 MCHC-33.7 RDW-14.3 Plt Ct-218
[**2126-5-26**] 02:15AM BLOOD Neuts-85.5* Lymphs-11.6* Monos-1.7*
Eos-0.6 Baso-0.6
[**2126-5-26**] 02:15AM BLOOD Glucose-143* UreaN-23* Creat-0.8 Na-142
K-3.8 Cl-108 HCO3-23 AnGap-15
[**2126-5-26**] 03:09PM BLOOD Glucose-95 UreaN-25* Creat-0.8 Na-142
K-4.0 Cl-108 HCO3-22 AnGap-16
[**2126-5-26**] 02:15AM BLOOD CK(CPK)-271
[**2126-5-26**] 03:09PM BLOOD CK(CPK)-698*
[**2126-5-26**] 02:15AM BLOOD cTropnT-0.05*
[**2126-5-26**] 08:40AM BLOOD CK-MB-46* cTropnT-0.36*
[**2126-5-26**] 03:09PM BLOOD CK-MB-78* MB Indx-11.2* cTropnT-0.67*
[**2126-5-26**] 03:09PM BLOOD Calcium-8.5 Phos-2.6* Mg-1.9
.
CXR ([**2126-5-26**])
Sternotomy wires are midline and intact. Surgical clips are
noted along the left mediastinum. There is mild-to-moderate
cardiomegaly. Mild pulmonary vascular congestion is noted. The
bilateral lung volumes are low with crowding of bronchovascular
markings; however, no focal consolidation, pleural effusion or
pneumothorax is noted. A
large hiatal hernia is noted.
.
COMMENTS:
1. Selective coronary angiography of this right dominant system
revealed
native 3 vessel coronary artery disease. The LM had 30% ostial
stenosis.
The LAD had 60% proximal stenosis; mid 70% from D2 to subtotally
occluded S1; modest high D1 with moderate origin stenosis; large
branching D2 with moderarte origin stenosis; mild diffuse
disease in
mid-distal LAD without competitive flow seen. The LCx had
proximal 30%;
mid 50%; high OM1; OM2 proximal 50% followed by tubular 50%;
small AV
groove LCx; large OM3 with 70% stenosis at first bifurcation
into LPL.
The RCA had proximal 60%, mid subtotal occlusion followed by
total
occlusion at AM2.
2. Selective conduit angiography revealed LIMA-LAD with atretic,
functionally occluded at mid-chest. The SVG-RPDA had slow TIMI1
flow in
a slightly ectatic graft (with some contrast hang-up) with
mid-distal
35%; the distal anastomosis had a hazy filling defect (?avulsed
plaque
vs thrombus) to about 60% stenosed into the moderate caliber
RPDA with
mild plaquing in the proximal RPDA; there was retrograde filling
of
small RPL.
3. Limited resting hemodynamics revealed mildly elevated left
sided
filling pressures with an LVEDP of 20mmHg. There was normal
systemic
arterial pressure of 132/61mmHg.
FINAL DIAGNOSIS:
1. Native 3 vessel coronary artery disease.
2. Occluded LIMA to LAD.
3. Moderate stenosis at the distal anastomosis of the SVG-RPDA
with hazy
filling defect suggesting thrombus or avulsed plaque.
4. Tortous right iliac artery.
.
[**2126-5-26**] 03:09PM BLOOD CK-MB-78* MB Indx-11.2* cTropnT-0.67*
[**2126-5-26**] 07:53PM BLOOD CK-MB-77* cTropnT-0.94*
[**2126-5-28**] 05:42AM BLOOD CK-MB-13* MB Indx-3.8
.
The left atrium is elongated. The right atrium is moderately
dilated. No atrial septal defect is seen by 2D or color Doppler.
There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. There is mild regional left
ventricular systolic dysfunction with inferior and
infero-lateral hypokinesis. No masses or thrombi are seen in the
left ventricle. There is no ventricular septal defect. The
aortic root is mildly dilated at the sinus level. The ascending
aorta is mildly dilated. The aortic arch is mildly dilated. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No masses or vegetations are seen on
the aortic valve. Trace aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. No mass or vegetation is seen on the mitral valve.
Mild (1+) mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. There is borderline pulmonary
artery systolic hypertension. No vegetation/mass is seen on the
pulmonic valve.
Brief Hospital Course:
79M with h/o CAD s/p CABG in [**2106**] c/b longstanding sternal wound
infection transferred from [**Hospital6 **] for inferior
STEMI.
# CAD s/p CABG: Inferior STEMI though STE and CP resolved since
transfer. He had Q-waves present inferiorly and thus decision
was made to initially treat him medically. He was continued on
aspirin, plavix, atorvastatin, metoprolol, heparin and nitro
gtt. His troponins continued to rise with peak at 1.77, MB
peaked at 78. He was taken to cardiac catheterization on [**5-27**],
which showed occluded LIMA to LAD, native 3-vessel CAD, and a
thrombus in the distal SVG. A bare metal stent was placed to the
distal SVG. He was scheduled with cardiology f/u. Discharge
regimen was ASA 325, Toprol 25 mg, atorvastatin 80 mg, Plavix 75
mg qday x at least 1 month, and lisinopril 2.5 mg qday.
# PUMP: TTE showed mild LV hypertrophy and systolic dysfunction.
Study also showed inferior and inferolateral hypokinesis. EF was
estimated at 50%. He was discharged on Toprol 25 mg qday and
lisinopril 2.5 mg qday to be uptitrated as tolerated as an
outpatient.
# RHYTHM: NSR w/ occasional PVCs and rare 3-4 beat runs of NSVT.
# HTN: 200/116 on arrival to OSH. Patient reported no history of
hypertension. His blood pressure remained elevated the day after
admission. Discharge regimen was lisinopril 2.5 mg qday and
metoprolol 25 mg [**Hospital1 **].
# Sternal wound: Patient reports that wound has been open since
[**2106**]. It intermittently drains small amounts of purulence. No
fevers/chills, no leukocytosis. Wound swab and blood cultures
were obtained - wound culture grew staph species. Blood cultures
were negative. He was scheduled with an outpatient plastic
surgery follow-up. The patient may need further imaging to rule
out sternal involvement and osteomyelitis.
CODE: Full code, confirmed
COMM: wife [**Name (NI) 88816**] [**Name (NI) 931**] [**Telephone/Fax (1) 88817**]
Medications on Admission:
ASA 81 mg qday
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*11*
2. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*11*
3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*11*
4. Nitrostat 0.3 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual ASDIR as needed for chest pain: take 1 tablet at
onset of chest pain, can take 2nd tablet after 5 minutes if no
relief, take 3rd tablet 5 min after 2nd if continued pain . Call
911 if chest pain persists. .
Disp:*1 bottle* Refills:*3*
5. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*11*
6. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
0.5 Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*11*
Discharge Disposition:
Home With Service
Facility:
VNA of Southeastern Mass.
Discharge Diagnosis:
Primary:
STEMI s/p bare metal stent placed to SVG graft to PDA
Sternal Wound infection
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure caring for you at the [**Hospital1 827**]. You had a heart attack and subsequently went to
the catheterization lab and had a stent placed. You also have
diffuse remaining coronary artery disease. You were started on
medications called PLAVIX, ATORVASTATIN, LISINOPRIL, AND
METOPROLOL. Your aspirin was increased to 325 mg daily. A bare
metal stent was placed in your vein graft supplying your
posterior descending artery of the heart.
IT IS EXTREMELY IMPORTANT YOU CONTINUE TO TAKE YOUR MEDICATIONS
AS PRESCRIBED. YOU SHOULD NEVER STOP YOUR ASPIRIN UNLESS
DIRECTED BY YOUR CARDIOLOGIST. YOU SHOULD ALSO TAKE PLAVIX FOR
AT LEAST NEXT 30 DAYS AND DISCUSS WITH YOUR CARDIOLOGIST HOW
LONG YOU SHOULD TAKE YOUR PLAVIX.
FOLLOWING MEDICATION CHANGES WERE MADE TO YOUR MEDICAL REGIMEN
INCREASE ASPIRIN TO 325 mg by mouth daily
START METOPROLOL SUCCINATE 12.5 mg by mouth daily
START ATORVASTATIN 80 mg by mouth daily
START PLAVIX 75 mg by mouth daily
START Lisinopril 2.5 mg per day
.
Your follow-up information is listed below.
Followup Instructions:
Please call [**Telephone/Fax (1) 4105**] to schedule Nuclear (MIBI/Thallium)
stress test which should be performed prior to seeing your
cardiologist on [**6-5**]
Plastic Surgery
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
4pm, Thursday [**5-30**]
[**Apartment Address(1) **], [**Street Address(2) **]., [**Location (un) **] MA
Department: [**Hospital **] HEALTHCARE OF [**Location (un) **]
When: WEDNESDAY [**2126-6-5**] at 2:30 PM
With: [**First Name11 (Name Pattern1) 20**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 3070**]
Building: [**Street Address(2) 8172**] ([**Location (un) 620**], MA) Ground
Campus: OFF CAMPUS Best Parking: Parking on Site
Name: [**Last Name (LF) **],[**First Name3 (LF) **]
Location: [**Hospital1 **]-[**Location (un) **]
Address: [**Street Address(2) **], [**Location (un) **],[**Numeric Identifier 3002**]
Phone: [**Telephone/Fax (1) 4105**]
Appointment: Thursday [**2126-6-20**] 11:00am
|
[
"998.59",
"414.02",
"414.01",
"041.11",
"401.9",
"410.41",
"E878.8",
"414.04"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"00.40",
"00.45",
"36.06",
"88.56",
"00.66"
] |
icd9pcs
|
[
[
[]
]
] |
11305, 11361
|
8432, 10349
|
313, 392
|
11505, 11505
|
4565, 6921
|
12723, 13742
|
3624, 3741
|
10414, 11282
|
11382, 11484
|
10375, 10391
|
6938, 8409
|
11656, 12700
|
3756, 4414
|
2975, 3143
|
4428, 4546
|
263, 275
|
420, 2855
|
11520, 11632
|
3174, 3193
|
2877, 2955
|
3209, 3608
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,572
| 192,622
|
39422
|
Discharge summary
|
report
|
Admission Date: [**2111-9-12**] Discharge Date: [**2111-9-18**]
Date of Birth: [**2090-3-29**] Sex: F
Service: NEUROSURGERY
Allergies:
Ibuprofen
Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
No sensation on lower extremities
Major Surgical or Invasive Procedure:
T4-T10 posterior fusion with iliac crest graft
History of Present Illness:
Pt is a 21f who arrives to the ER after she fall off a
second story porch and landed on her legs and back. At this time
she says she twisted in an awkward position and she had no
feeling in her lower extremities and was unable to move both her
legs. She remains unable to move her lower limbs and has no
sensation in them either. She denies bowel or bladder
incontinence at time of injury. She currently denies cervical
spine tenderness and she arrived with a c collar in place.
Social History:
Senior at [**University/College **]
Family History:
NC
Physical Exam:
BP:115 / 74 HR: 77 R 16 O2Sats
Gen: Awake, teary.
HEENT: Pupils: PERRLA EOMs FULL
Neck: Supple. C collar in place. No pain to palpation
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:
D B T WE WF IP Q H AT [**Last Name (un) 938**] G
R 5 5 5 5 5 0 0 0 0 0 0
L 5 5 5 5 5 0 0 0 0 0 0
No sensation in lower extremities to light touch or noxious
stimuli
Toes mute bilaterally
No rectal tone
On Discharge:
BUE [**5-13**]
BLE 0/5
Incision C/D/I
Pertinent Results:
CT Chest/Abdomen/Pelvis
1. Comminuted fracture/dislocation at T7 and T8 with multiple
osseous
fragments in the spinal canal at T7, causing near complete
obliteration of the central canal, highly concerning for spinal
cord injury and possible spinal cord transsection. High density
in the central canal at this level raises concern for
intraspinal hematoma. Consider further evaluation of the spinal
cord with MRI. Adjacent paraspinal hematoma, extends from T6 to
T10-T11.
2. Fracture of the posterior right sixth through eighth ribs
with a few small foci of underlying subcutaneous/intramuscular
emphysema. Fracture of the bilateral T7 transverse processes and
displaced fractures of the right T8 and T9 transverse processes.
3. Small right pneumothorax. Areas of mild peripheral right
pulmonary
opacity, most likely representing contusion.
4. No findings to suggest acute visceral injury in the abdomen
or pelvis.
Bil Lower Ext Ultrasound:
Negative for DVTs
Tspine AP/Lat Xrays:
Proper alignment of hardware and fusion.
Brief Hospital Course:
Patient was admitted to the Trauma ICU and taken to the
Operating room on [**9-13**] for posterior insturmented fusion of T4-
T10. Operative course was uncomplicated. Post operatively the
patient remained intubated as she had recieved 5 liters of fluid
during the procedure. She required a small amount of Neo and IVF
post opertively for SBP support.
She was extubated on [**9-14**] and stable from a pulmonary status. He
exam remained unchanged with full strength in her upper
extremities, a T8 sensory level and no lower extremity movement
or sensation. She was weaned off Neo on [**9-14**]. She was febrile x2
on [**9-14**] and [**9-15**]- screening LENIS was negative.
She was transferred from the ICU to the floor on [**9-16**]. JP drain
was removed on [**9-16**].
She was discharged to [**Hospital3 **] [**Location (un) 86**] on [**2111-9-18**]
Medications on Admission:
Singulair, Advair, OCP,
Discharge Medications:
1. Methocarbamol 500 mg Tablet Sig: 1.5 Tablets PO QID (4 times
a day).
2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
6. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
7. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
8. Hydromorphone 2 mg Tablet Sig: 1-3 Tablets PO Q3H (every 3
hours) as needed for Pain.
9. Ondansetron 4 mg IV Q8H:PRN nausea
10. HYDROmorphone (Dilaudid) 0.5-2 mg IV Q3H:PRN breakthrough
pain
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Spinal Fracture T7 and T8
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
?????? Do not smoke.
?????? Keep your wound(s) clean and dry / No tub baths or pool
swimming for two weeks from your date of surgery.
?????? You will need suture/staple removal 10 days post-operatively.
You may shower 72 hours post-op, but refrain from submerging the
incision.
?????? No pulling up, lifting more than 50 lbs
?????? Have a friend or family member check your incision daily for
signs of infection.
?????? You are required to wear a back brace. This should be worn
when out of bed to ambulate. You may sit up without your brace.
?????? You may shower briefly without the back brace
?????? Take your pain medication as instructed; you may find it best
if taken in the morning when you wake-up for morning stiffness,
and before bed for sleeping discomfort.
?????? Do not take any anti-inflammatory medications such as Motrin,
Advil, Aspirin, and Ibuprofen etc. unless directed by your
doctor.
?????? Increase your intake of fluids and fiber, as pain medicine
(narcotics) can cause constipation. We recommend taking an over
the counter stool softener, such as Docusate (Colace) while
taking narcotic pain medication.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 548**] in 6 weeks. You will need Xrays
prior to your visit. Please call [**Doctor First Name **] [**Telephone/Fax (1) 2992**] to make
this appointment.
Staple removal on [**2111-9-23**].
Completed by:[**2111-9-18**]
|
[
"806.26",
"E884.9",
"807.03",
"958.4",
"860.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.53",
"81.05",
"77.79",
"81.63"
] |
icd9pcs
|
[
[
[]
]
] |
4480, 4550
|
2720, 3576
|
308, 356
|
4620, 4620
|
1671, 2697
|
5909, 6175
|
934, 938
|
3650, 4457
|
4571, 4599
|
3602, 3627
|
4755, 5886
|
955, 1153
|
1612, 1652
|
235, 270
|
384, 865
|
4635, 4731
|
881, 918
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,292
| 123,808
|
30615+57711
|
Discharge summary
|
report+addendum
|
Admission Date: [**2102-5-21**] Discharge Date: [**2102-5-23**]
Date of Birth: [**2037-8-24**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
Bradycardia.
Major Surgical or Invasive Procedure:
1. Temporary pacemaker wire placement ([**2102-5-21**]).
2. Permanent pacemaker placement ([**2102-5-22**]).
History of Present Illness:
Mr. [**Known lastname **] is a 64 year-old male with a history of CAD with
prior MI and stent placement in [**2100**] who presents with
bradycardia, chest pressure and a 10 second pause on telemetry.
Was in his USOH until 10pm today when ~1-2 minutes after getting
up to grab a glass of milk felt lightheaded, mild nausea, and a
sensation of emesis and pre-syncope. He does not remember
collapsing, but his wife witnessed the fall and stated that he
slumped slowly down to his legs and over onto his left side. He
was unresponsive for ~1 minute and then was mildly groggy. No
bowel/bladder incontinence or tongue biting. He denies any
presyncopal palpitations, chest pain, shortness of breath. EMS
was called and per family, when they attempted to have him sit
up, he again felt presyncopal and lost consciousness for a brief
period. EMS found him to have a HR in the 20s and he was brought
to [**Hospital 16843**] Hospital. He notes that on the way he noted some
mild lower chest discomfort, worse with deep inspiration. He was
given ASA 325mg, started on a nitro gtt. While sitting up for a
CXR at around 11:31pm, had a 10 second pause on telemetry with
an additional LOC. Again he denied any CP, palpitations, SOB. He
returned to NSR spontaneously and was transferred to [**Hospital1 18**] for
further care.
In our ED, his HR was 78 in NSR, BP 129/54, 100%RA. His nitro
gtt was continued, and he was started on a heparin gtt. He is
currently CP free, with no SOB, palpitations, LH, dizziness, or
presyncope sensations. He was admitted to the CCU for further
monitoring.
Past Medical History:
1. Coronary artery disease:
- s/p IMI with stent placement (unclear [**Name2 (NI) 12425**])
- s/p abnormal stress test and cath with stend placement
(unclear [**Name2 (NI) 12425**])
Cardiac Risk Factors: (+) Dyslipidemia, (+) Hypertension, (-)
Diabetes
Cardiac History: CABG: none
Percutaneous coronary intervention
- [**12/2099**] in setting of AMI and [**8-/2100**] in setting of abnormal
stress test: unknown vessels (done at [**Hospital 1559**] Medical)
Pacemaker/ICD: none
2. Hypertension
3. Hypercholesterolemia
4. BPH
5. Chronic LBP
6. s/p intestinal bypass surgery during appy
7. Left kidney mass, stable over 3+ years
Social History:
Married, lives at home with wife and daughter. Employed as a
custodian. Significant for the absence of current tobacco use.
There is no history of alcohol abuse.
Family History:
No family history of sudden death. Brother with CAD.
Physical Exam:
VS: T98.0 BP 103/66 (RA) 119/72 (LA) HR77 RR22 O2 99%RA
Gen: WDWN obese 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.
Neck: Supple with JVP of 7 cm. No carotid bruits bilaterally.
CV: PMI located in 5th intercostal space, midclavicular line.
Heart sounds distant, but RR, normal S1, S2. No m/r/g. No
thrills, lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits. Mild TTP over left flank to
palpation; no CVA tenderness bilaterally.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
ADMIT LABS ([**2102-5-21**]):
CBC:
WBC-16.3* RBC-4.99 Hgb-15.2 Hct-43.0 MCV-86 MCH-30.5 MCHC-35.3*
RDW-13.6 Plt Ct-241
Neuts-87.2* Bands-0 Lymphs-7.2* Monos-3.6 Eos-1.3 Baso-0.7
COAGS:
PT-12.0 PTT-22.7 INR(PT)-1.0
CHEMISTRIES:
Glucose-152* UreaN-19 Creat-1.1 Na-135 K-4.7 Cl-104 HCO3-18*
AnGap-18
Calcium-9.6 Phos-3.1 Mg-2.4
LFTS:
ALT-20 AST-31 CK(CPK)-84 AlkPhos-63 Amylase-30 TotBili-1.9*
DirBili-0.4* IndBili-1.5
CARDIAC ENZYMES:
[**2102-5-21**] 01:45AM cTropnT-<0.01
[**2102-5-21**] 11:03AM CK-MB-NotDone cTropnT-<0.01
MISC:
Triglyc-350* HDL-30 CHOL/HD-4.5 LDLcalc-34
CXR ([**2102-5-21**]):
There is a temporary pacer wire seen entering from a right IJ
approach with distal tip in the right ventricle. Cardiac
silhouette and mediastinum are within normal limits. There are
no pneumothoraces identified. Lungs are grossly clear.
ECHO ([**2102-5-22**]):
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is mild
to moderate regional left ventricular systolic dysfunction with
focal hypokinesis of the basal half of the inferior and
inferolateral walls. The remaining left ventricular segments
contract normally. Overall EF 40-45% Right ventricular chamber
size and free wall motion are normal. The ascending aorta and
aortic arch are 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 (1+) mitral regurgitation is seen.
Moderate [2+] tricuspic regurgitation is seen. The estimated
pulmonary artery systolic pressure is top normal. There is an
anterior space which most likely represents a fat pad.
Brief Hospital Course:
1. Rhythm (complete heart block):
Presented after having had syncopal events, with HR in 20s noted
on occasion and complete heart block (~7 seconds with no
ventricular activity) on another. Prior history of an inferior
MI, but no prior arrythmia/syncope. Clinical history, EKG
findings and normal biomarkers made ACS unlikely as the
etiology. Review of telemetry appears to be complete heart block
with atrial activity and no conducted ventricular beats. Likely
from degeneration of conduction system in setting of his prior
IMI.
Was admitted to the CCU and a temporary wire was placed via the
right IJ. The morning after admission, an echo was obtained
that showed an EF of 40-45%. A permanent pacemaker was placed
on [**2102-5-22**]. Metoprolol was initially held, but restarted after
pacemaker placement.
2. Coronary artery disease:
Presented with a history of prior MI (inferior), on aspirin,
ACEI and beta-blocker. Recently had stopped statin
(atorvastatin 40mg). Cardiac enzymes were checked and he ruled
out for new MI. The aspirin was continued, the ACEI was
titrated and the beta-blocker was held (and later restarted). A
lipid panel was checked and showed a low LDL and HDL in addition
to high triglycerides. He was dischared on Gemfibrozil.
3. Pump:
Echo obtained showed an EF of 40-45% and focal hypokinesis of
the basal half of
the inferior and inferolateral wall. Mild symmetric left
ventricular hypertrophy with normal cavity size. mild (1+)
mitral regurgitation and moderate [2+] tricuspid regurgitation
were seen. Given his EF, an ICD was not placed.
4. Non-gap acidosis:
Felt to be secondary to diarrhea (a chronic issue); resolved on
HD #2.
5. Hyperbilirubinemia:
Unclear etiology. Other LFTs were within normal limits.
Rechecked and remained mildly elevated. The patient was
asymptomatic; outpatient follow-up was recommended.
6. Hyperlipidemia:
Previously treated with statin, weaned off in last several
months due to improving lipid panel. As above, Gemfibrozil was
started.
7. HTN:
Lisinopril dose was increased. Beta-blocker was held (as above)
and restarted before discharge.
Medications on Admission:
Aspirin 325mg daily
Lopressor 25mg [**Hospital1 **]
Lisinopril 5mg daily
Lipitor 40mg (d/c'ed several months ago)
Discharge Medications:
1. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO twice
a day.
3. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1. Syncope secondary to complete heart block
Secondary:
1. Coronary artery disease
2. Hyperlipidemia
3. Hypertension
Discharge Condition:
Hemodynamically stable and in normal sinus rhythm.
Discharge Instructions:
You were admitted after having a syncopal episode (fainting).
This is thought to be from having a complete heart block. Given
this, a permanent pacemaker (PPM) was placed.
Please be sure to call your PCP if you experience pain or
swelling at the incision site, experience fever >100.4, have
chest pains, problems breathing or feel lightheaded or dizzy.
Do not drive until you check in with your primary care
physician. [**Name10 (NameIs) **] should avoid sudden or forceful movements of the
arm on the side where the pacemaker is for about one month. Do
not lift anything greater than 5 pounds, or push or pull
anything with your left arm, for one month. You should also be
sure to NOT raise your left arm above your head for one month.
The following medication changes were made:
1. Lisinopril: Dose was increased to 10mg daily
2. Aspirin: You do not need to take 325mg daily; 81mg (a baby
aspirin) is fine.
3. Gemfibrozil: Please start taking 600mg twice daily
Followup Instructions:
Please be sure to schedule a follow-up appointment with your PCP
[**Name Initial (PRE) 176**] 2-3 weeks.
Dr.[**Name (NI) 72610**] office was contact[**Name (NI) **]. Please call his office at
([**Telephone/Fax (1) 72611**] if you need to change this appointment or have
questions. Your appointment is [**6-1**] at 2:45.
You are scheduled to follow up with Dr. [**First Name (STitle) **] [**Name (STitle) 1911**]
for evaluation of your pacemaker. Your appointment is on
Wednesday, [**2102-5-31**] at 1pm. He is located at the [**Hospital3 18201**]. Please call [**Telephone/Fax (1) 62845**] if you need to
reschedule or you need directions.
Name: [**Known lastname 12105**],[**Known firstname 12106**] Unit No: [**Numeric Identifier 12107**]
Admission Date: [**2102-5-21**] Discharge Date: [**2102-5-23**]
Date of Birth: [**2037-8-24**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 296**]
Addendum:
Pacemaker: [**First Name8 (NamePattern2) **] [**Male First Name (un) 744**] dual-chamber PM
Discharge Disposition:
Home
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 297**] MD [**MD Number(1) 298**]
Completed by:[**2102-5-23**]
|
[
"V45.82",
"272.0",
"276.2",
"412",
"427.89",
"401.9",
"426.6",
"600.00",
"272.4",
"782.4",
"427.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.78",
"37.72",
"37.83"
] |
icd9pcs
|
[
[
[]
]
] |
10657, 10818
|
5653, 7777
|
284, 395
|
8476, 8529
|
3912, 4333
|
9549, 10634
|
2849, 2904
|
7941, 8276
|
8326, 8455
|
7803, 7918
|
8553, 9526
|
2919, 3893
|
4350, 5630
|
232, 246
|
423, 2001
|
2023, 2654
|
2670, 2833
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,090
| 184,896
|
725
|
Discharge summary
|
report
|
Admission Date: [**2110-9-15**] Discharge Date: [**2110-10-23**]
Date of Birth: [**2060-1-1**] Sex: M
Service: MEDICINE
Allergies:
Ibuprofen
Attending:[**First Name3 (LF) 465**]
Chief Complaint:
lethargy
Major Surgical or Invasive Procedure:
intubation x2
colonoscopy
EGD
right femoral line
left sunclavian line
left cordis with Swan
arterial line
History of Present Illness:
The pt is a 50yo M with PMHx significant for alcohol abuse and
CAD with multiple MI's, prior MI [**2105**] with OM stent, and PCI at
[**Hospital1 18**] [**2109-4-20**] of the proximal RCA and mid-RCA (both Taxus),
LAD stent at [**Hospital1 112**] in [**2105**]. The patient initially was in the
[**Hospital 5353**] Hospital ED on [**9-8**] with chest pain. EKG showed NSR,
nonspecific ST-T changes per report. The paitent left AMA before
further w/u was done. He then presented to [**Hospital3 **] via
EMS on [**9-15**] with increase lethergy and jaundice for the last
three days. He was transfeed to [**Hospital1 18**] ED for a GIB and a HCT of
21. He was transfused before transfer with 1 unit.
.
From the medicine admission note:
Pt states he has never had liver problems or h/o jaundice, but
has taken about 14 tylenol over past week for chronic back pain.
Pt reports he was on an alcohol binge while in [**Location (un) 5354**] one
week ago. Around the time he came back he developed chest pain
and was seen in the [**Hospital3 **] ED where chest pain resolved
with NG and he was discharged. Pt is very unclear about this -
states that he had an MI but was only given SL NG and was
discharged without admission. [**Hospital3 **] was contact[**Name (NI) **] and
they currently have no record of EKGs or other records
indicating that pt was seen one week ago - at last communication
with RN in ED of [**Hospital1 **], it was felt that perphaps visit had not
yet been logged in to computer and will need to contact again
tomorrow. Since that time he developed melena and jaundice. He
denies dizziness or chest pain but in the [**Hospital3 **] ED he
was found to have elevated LFTs, Hct of 22, received 1u PRBC and
transferred to [**Hospital1 18**]. Here pt refused EGD and NG lavage. In
[**Hospital1 18**] ED received 2u PRBC, octreotide and PPIs as well as KCL
for hypokalemia, N-acetylcysteine for elevated tylenol levels,
and antibiotics for bandemia. RUQ showed gall baldder sludge but
no bilary dilation. He was felt to have no ascites and so was
not tapped. After receiving the two units of PRBC he desaturated
to from 96% to 88% on RA. Received Lasix for volume overload
.
The paitent was then admitted to a medicine team via NF. He
recieved a total of 3 transfusions here and his and his HCT has
only gone up from 22.6 to 25.2. Also, he has having multiple
episodes of melana. He went for an EGD today ([**9-16**]) but was not
coorperative despite midazloam 3mg and meperidene 75mg. He also
started to have hallucinations on the floor. Therefore, he was
tx to the MICU for closer monitoring and intubation for EGD.
.
.
ROS: denies CP, SOP, abd pain. Per wife, he always hs wheezing,
not dx with a lung condition. He has been having increasing
swelling in his left lower leg for the past 6 months.
Past Medical History:
-alcohol abuse - pt reports that he drinks 2-3 beers per day,
denies DTs. no prior history of liver disease
-CAD s/p MI [**2105**], stent LAD [**2107**], stent mid and prox RCA in [**2108**]
- Per wife, in [**2082**], the patient had a motorcycle accident and
broke his femur and had compartment syndrome leading to a
fasicotomy in the right lower leg. He has had multiple DVT's
since in that leg.
- herniated lumbar disc with sciatica, on chronic pain
medications
Social History:
90 tobacco pack yr history, lives alone, drinks beer and liquor
[**1-24**] drinks per day, on diasbilty for the last 10 years
Per the patient's wife: The patient has a h/o a sucide attempt
by cutting his wrists 5 years ago. She dose not know of any
inpatient ETOH detox stays, DT,s or seizures. The patient has
been living alone for the last 6 months becaue she could not
tolerate his drinking. recently, he has switched to vodka.
Family History:
multiple MI's
Physical Exam:
T 99.7 P 90 BP: 112/72, RR 20; O2sat 92% RA 95.8 KG
Gen: Jaundiced, hallucinating
HEENT: poor dentition, Sclera interic
Neck: No LAD, No JVD
Lungs: Lungs b/l wheezes
CV: RRR nl s1s2 no mrg
Abd: distended, diffusly tender to deep palpation, no rebound or
gaurding, no ecchymosis, no spider angiomata, no caput medusae,
no hepatomegaly, no [**Doctor Last Name 515**] sign Liver edge not felt.
Ext: cheonic LE edema, ?h/o fasicotomy. 2+ pitting edema to the
knee on the left.
Neuro: AAOX3, minor asterixis. hallucinating
Pertinent Results:
[**9-8**] from [**Hospital1 392**]: Total bili: [**7-30**], CKMB: 1.16, Trop I: <0.15,
CK: 38, AST: 242, ALT: 59, HCT 28Plts: 90,
.
[**9-15**] from [**Hospital1 **]: HCT 21.8, K 2.5, Trop I 0.05, CK and MB not
reported, ETOH: 327, BNP 418
Admission labs:
[**2110-9-15**] 05:50PM BLOOD WBC-6.9 RBC-1.96*# Hgb-8.0*# Hct-22.9*#
MCV-117*# MCH-40.8*# MCHC-34.8 RDW-20.9* Plt Ct-77*
[**2110-9-15**] 05:50PM BLOOD PT-14.0* PTT-35.4* INR(PT)-1.3
[**2110-9-15**] 05:50PM BLOOD Glucose-74 UreaN-9 Creat-0.7 Na-132*
K-2.9* Cl-88* HCO3-27 AnGap-20
[**2110-9-15**] 05:50PM BLOOD ALT-33 AST-134* CK(CPK)-35* AlkPhos-327*
Amylase-81 TotBili-18.5*
[**2110-9-15**] 05:50PM BLOOD Albumin-2.4* Calcium-7.7* Phos-3.7 Mg-1.6
[**2110-9-16**] 10:39AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE IgM HAV-NEGATIVE
[**2110-9-15**] 05:50PM BLOOD ASA-NEG Ethanol-254* Acetmnp-5.6
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Micro:
Radiology:
[**9-15**] RUQ US: Echogenic liver consistent with fatty
infiltration. Other forms of liver disease including hepatitis
and severe hepatic fibrosis/cirrhosis cannot be excluded on this
examination. Nondistended gallbladder containing sludge.
Associated mild gallbladder wall edema is a non-specific finding
which can be seen in low albumin states. No definite evidence
for cholecystitis.
[**9-17**] echo: EF 40%, 1. The left atrium is normal in size. The
left atrium is elongated. The right atrium is markedly dilated.
2. Left ventricular wall thicknesses are normal. The left
ventricular cavity is mildly dilated. Overall left ventricular
systolic function is mildly depressed. Resting regional wall
motion abnormalities include basal and mid inferior and
inferolateral akinesis.. 3.The aortic valve leaflets (3) are
mildly thickened. No aortic regurgitation is seen.
4.The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen. 5.Moderate [2+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. 6.There is no pericardial effusion.
[**9-17**] CT abd: 1. Markedly fatty liver containing a
subcentimeter hypodense lesion that is too small to accurately
characterize. An additional focus of hyperdensity anteriorly
within segment IV is incompletely characterized, and could
represent a focus of fatty sparing. 6 month follow up CT is
recommended. 2. No evidence of mesenteric vascular occlusion or
secondary signs of mesenteric ischemia.
3. Bibasilar atelectasis.
[**9-21**] renal US: The right and left kidneys measure 12.8 and 13.2
cm
respectively without evidence of stones, masses or
hydronephrosis.
[**9-25**] CT torso: 1. Patchy bilateral pulmonary opacities and
dense bilateral lower lobe atelectasis and consolidation,
findings that suggest infectious process superimposed upon
atelectasis. Bilateral pleural effusions. 2. Fatty
infiltration of the liver. Interval increase in intraabdominal
ascites. 3. No definite evidence of free intraperitoneal air.
Two foci of gas within the right lower quadrant are likely
located within decompressed and non-opacified loops of small
bowel.
Brief Hospital Course:
A/P: Pt is a 50yo man with anemia, GI bleed, liver
insufficiency, hyperbilirubinemia, bandemia, elevated troponin
with new EKG changes, desaturation consistent with volume
overload, alcohol abuse. Could not tolerate EGD therefore
transferred to the MICU for intubation and EGD.
1. Blood loss Anemia and GI bleed- Likley [**12-25**] to GIB, acute on
chronic since he was also anemic on [**9-8**] at [**Hospital1 392**]. GI
preformed EGD which showed gastropathy and grade I varices, no
active or h/o bleeding. He was transferred to MICU for
intubation prior to this study. ABdominal CT scan revealed
hyperdensity in the liver and fatty infiltration. A colonoscopy
showed a non-bleeding small polyp. He was transfused to keep
his hct>25. Hematocrit was monitored daily, and hct was kept
>25.
2. ESLD: On admission, differential for this was tylenol
toxicity vs. alcoholic hepatitis. On presentation, he was
jaundiced, had evidence of GI bleeding. He had reportedly been
on a recent EtOH binge in [**Location (un) 5354**]. His liver failure was
likely a result of alcoholic hepatitis. He was initially
treated with N-acetyl cysteine and lipitor was held. Liver was
consulted and felt that the prognosis was poor. He was started
on pentoxyfylline without much improvement. This was ultimately
discontinued for ineffectiveness. RUQ US showed GB wall edema
with sludge, no biliary obstruction, no ascites, some fatty
infiltration of the liver. CT scan (no contrast) of the abdomen
showed ascites with an enlarged liver, with evidence of fatty
infiltration. Hepatitis serologies were negative for infection
(Hep A, B, C). Bilirubin improved slightly with these
supportive measures, but this still remained very elevated. INR
was [**11-24**], with some improvement to vitamin K. Albumin was in the
2's as well. After 5-6 weeks of supportive care, liver team
felt that possibility of improvement was remote. After
discussion with family, patient was made CMO and transferred
home for hospice care.
3. Hypercarbic Respiratory failure: Pt was initially intubated
semi-electively for EGD, performed in MICU. This was difficult
to wean post-procedure. The reasons for this were thought to be
neuromuscular weakness, PNA. He was ultimately trached (after
failing extubation). He was weaned from pressure support to
trach mask, with adequate saturation on this. This was
continued upon transfer home to hospice.
4. Encephalopathy: Patient had altered MS that was likely
multifactorial. Neurology was consulted and felt that this was
likely secondary to a toxic-metabolic cause. EEG was done;
results were non-specific. LP was deferred given low likelihood
for infectious etiology. MRI of the brain was performed and was
negative for any focal lesion, enhancement, or other
abnormality. Mental status cleared; confusion was likely a
result of hepatic and uremic encephalopathy.
5. ID: Although initially afebrile on admission, he developed
a WBC count and fever, bandemia. Ascites was tapped and was
negative for signs of infection/SBP. CXR was suspicious for
blossoming pneumonia. After intubation, he was treated for VAP
with 7 days of imipenem with subsequent Vancomycin therapy for
MRSA in his sputum. All blood/urine cultures remained negative.
The only significant culture data was +MRSA in his sputum. He
remained febrile with a leukocytosis, however; he did remain
hemodynamically stable. He completed 13 days of vancomycin
therapy before he was made CMO.
6. CAD: On [**9-8**], he went to an outside hospital with chest
pain, had an EKG with "nonspecific ST-T changes", and once his
pain resolved he left the ED AMA. Cardiology evaluated him and
thought his current changes in the inferior lead was demand
ischemia (in the setting of blood loss anemia). He has ruled out
for an MI. An echocardiogram revealed a markedly dilated right
atrium, 2+tr, moderate pulmonary hypertension, mildly dilated LV
with basal, mid-inferior and inferolateral akinesis with 1+mr
and EF 40%. His atenolol and aspirin were held while he had a
GI bleed. Once hemodynamically stable, metoprolol was
restarted. Patient also developed an atrial tachycardia; rate
was controlled with beta-blocker as above. ASA was held given
GI bleed.
7. Hepatorenal syndrome: Creatinine/renal function was normal
on admission but then dramatically rose to 3-4 as liver function
worsened. This was most likely due to hepatorenal syndrome.
Renal was consulted and recommended starting Octreotide and
midodrine. In addition, CVVHD was initiated to manage volume
and electrolyte status. This was discontinued upon transition
to CMO care.
8. Alcohol detox: He was initially actively withdrawing from
alcohol on admission, with visual hallucinations. He was
managed with benzodiazepines as necessary and transitioned to a
versed drip in the MICU.
9. Disposition: After a prolonged course in the MICU without
apparent improvment in liver or kidney function, patient was
made CMO. This decision was discussed with the patient, his
family, and various subspecialists involved in his care. He was
discharged home with hospice level care, as per patient and
family's wishes.
Medications on Admission:
Lisinopril 10 mg po qd
Lipitor 10 mg po qd
Atenolol 100 mg po qd
Does not take ASA or plavix
Oxycontin 30 [**Hospital1 **]
oxycodone 120/month
the patient had been taking many percoct in the week before
admission
Discharge Medications:
1. Ativan 0.5 mg Tablet Sig: [**11-24**] Tablet(s) PO q1-2 hrs as
needed: sublingual tablets.
Disp:*60 tabs* Refills:*2*
2. Morphine Concentrate 20 mg/mL Solution Sig: 15-30 mg PO q1 hr
as needed for pain: sublingual.
Disp:*qs 1* Refills:*0*
3. Hydroxyzine HCl 10 mg/5 mL Syrup Sig: [**11-24**] PO every 4-6 hours
as needed for itching.
Disp:*qs 1* Refills:*2*
4. Morphine 20 mg/5 mL Solution Sig: 5-20 mg PO q2 hrs as needed
for pain: immediate release.
Disp:*qs 1* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
GI bleed
Grade 1 esophageal varices
Colonic polyp
Alcohol withdrawal
Alcoholic hepatitis
internal hemorrhoids
Acetaminophen toxicity
Fatty liver
Discharge Condition:
Poor
Discharge Instructions:
Please give medications as per prescribed
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 472**]
Completed by:[**2110-10-23**]
|
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icd9cm
|
[
[
[]
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] |
[
"96.72",
"96.6",
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icd9pcs
|
[
[
[]
]
] |
13829, 13878
|
7876, 13060
|
278, 386
|
14067, 14074
|
4750, 4990
|
4178, 4193
|
13323, 13806
|
13899, 14046
|
13086, 13300
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14098, 14292
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4208, 4731
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230, 240
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414, 3224
|
5007, 7853
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3246, 3714
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3730, 4162
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,352
| 192,369
|
39639
|
Discharge summary
|
report
|
Admission Date: [**2187-8-25**] Discharge Date: [**2187-9-18**]
Date of Birth: [**2150-8-27**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
s/p fall down stairs
Major Surgical or Invasive Procedure:
Placement of ICP Bolt Monitor
Bitemporal Crani for EDH, SDH evacuation
History of Present Illness:
This patient is a 36 year old male who presented after fall
down 12 stairs. Family heard a thump at the bottom of the
stairs and found him unresponsive. When EMS arrived his GCS
was 3and intubation was attempted in the field without success.
Patient was transfered here from [**Hospital **] hospital.
Past Medical History:
None
Social History:
Works as a cook
Family History:
N/C
Physical Exam:
PHYSICAL EXAM:
Gen: Intubated
HEENT: Pupils: 2mm, Non-reactive, No eye movement
Neck: C- Collar in Place
Extrem: Cool and well-perfused.
Neuro:
Mental status:
GCS of 3. Unable to assess neuro exam. We will remove propofol
to attempt an exam. +Gag.
PHYSICAL EXAM UPON DISCHARGE:
asleep
arouses to stimulation, eyes open intermittently
PERRL, does not attend
trach mask
MAE's spontaneously Right > left. purposeful with R upper
extremity.
intermittent simple commands
incisions- well healing, dissolvable sutures.
Pertinent Results:
ADMISSION LABS:
[**2187-8-25**] 01:31AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-250 KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2187-8-25**] 01:31AM PT-11.1 PTT-20.7* INR(PT)-0.9
[**2187-8-25**] 01:31AM WBC-20.3* RBC-5.11 HGB-16.3 HCT-48.8 MCV-95
MCH-31.8 MCHC-33.3 RDW-13.3
[**2187-8-25**] 01:31AM ASA-NEG ETHANOL-179* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2187-8-25**] 01:34AM HGB-17.4 calcHCT-52 O2 SAT-84 CARBOXYHB-2 MET
HGB-0
DISCHARGE LABS:
IMAGING:
CT Head [**8-25**]:
1. Extensive fractures through the left temporal, sphenoid, and
parietal
bones as described above.
2. Left-sided epidural hematoma, right-sided subdural hematoma,
and diffuse subarachnoid hemorrhage as described above.
As fracture may extend to the left carotid canal, further
evaluation with CTA of the head is recommended to exclude
vascular injury.
CTA Head [**8-25**]:
IMPRESSION: Stable appearance of left-sided epidural hematoma,
right-sided
subdural hematoma, diffuse subarachnoid hemorrhage and multiple
fractures,
previously described on a dedicated CT of the head. There is no
evidence of major vascular occlusion or vascular dissection.
Ct Head [**8-25**]:
Stable appearance of left-sided epidural hematoma, right-sided
subdural hematoma, and diffuse subarachnoid hemorrhage. Findings
were
discussed with Dr. [**Last Name (STitle) **] at the time of review on [**2187-8-25**].
CT Head [**8-25**]:
Post-surgical changes as delineated above. Pneumocephalus in the
right middle cranial fossa displaces the right temporal lobe
posteriorly. An apparent hypodensity in the inferior right
temporal lobe could indicate a contusion. No new hemorrhage
CT Head [**8-26**]:
Evolving right temporal infarction/contusion. No new hemorrhage
MRI Head [**8-27**]:
IMPRESSION:
1. Acute infarction/contusion in the right temporal lobe.
2. Supratentorial subarachnoid hemorrhage is again visualized.
Foci of
hemorrhage in the posterior inferior left cerebellar hemisphere
could be
subarachnoid or parenchymal.
3. A punctate hemorrhage in the genu of the right corpus
callosum is
suggestive of diffuse axonal injury
CT Head [**8-27**]:
Stable right temporal lobe hypodensity, bilateral subarachnoid
hemorrhages, ventricular and basilar cistern effacement.
Decreased soft tissue swelling, pneumocephalus, subcutaneous
emphysema. Ethmoid air cell and sphenoid sinus opacification.
CT Head [**8-28**]: No significant change
Stable
CTA Chest, Abd, Pelvis [**8-31**]:
Small filling defect in a subsegmental branch supplying the left
lower
lobe consistent with a small subsegmental pulmonary embolus.
2. Bilateral consolidation at the lung bases, likely aspiration;
however,
cannot exclude pneumonia.
3. Interval resolution of opacity at the right upper lobe
suggesting
resolution of prior atelectasis.
4. Soft tissue structure in anterior mediastinum similar in
size; however,
now decreased density suggesting likely aging/evolving hematoma.
5. Slightly prominent single mediastinal lymph node
CT Head [**9-6**]:
On the postcontrast images, there is mild enhancement of the
temporal lobe
cortex posterior to the surgical resection cavity, in the right
internal
capsule and right frontal lobe which may relate to post-surgical
changes,
inflammation or less likely infection. COnsider MR [**Name13 (STitle) 430**] without
and with
contrast, if not contra-indicated for better assessment if there
is continued concern for intracranial process. No prior
postcontrast iamges are available since the surgery for
comparison.
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2187-9-17**] 05:41 11.1* 3.40* 10.8* 31.9* 94 31.8 33.9 13.5
324
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2187-9-17**] 05:41 1001 25* 0.5 142 3.8 99 35* 12
BASIC COAGULATION (PT, PTT, INR)
Source: Line-picc
[**2187-9-17**] 05:41 25.1* 29.6 2.4*
Brief Hospital Course:
The patient was admitted overnight on [**8-25**] after fall down a
flight of stairs. He was initially found unresponsive and taken
to [**Hospital **] hospital. Intubation was attempted in the field but
was unsuccessful. He was intubated at [**Hospital1 **] and then
transferred to [**Hospital1 18**] for further care. On arrival to [**Hospital1 18**] it
was noted that he had a EDH over the left temporal lobe, SDH
over the right frontal and temporal lobes, diffuse SAH, as well
as extensive fractures through the left temporal, sphenoid, and
parietal bones. He was admitted to the ICU for monitoring.
On the morning of [**8-25**] during rounds his exam was poor and
continued with a GCS of 3 off sedation. As a result of his exam,
an ICP bolt was placed at the bedside by Dr. [**Last Name (STitle) **]. After
placement of the bolt and waiting 5 minutes for the [**Location (un) 1131**] to
settle it was noted that his ICP was sustaining in the low 50's.
Measures were undertaken in order to medically treat his
increased ICP including hyperventilation to a PCO2 below 30, 23%
saline, and mannitol. Initially these measures lowered his ICP
to the low 20's however his pressures soon elevated again and it
was decided that he would be taken to the operating room
emergently for a bilateral hemicraniectomy and partial right
temporal lobe resection.
In the OR it was noted that his brain was under high pressure
and the bone flaps were left off after surgery in order to allow
for swelling. He tolerated the surgery without complications
and his vital signs remained stable throughout the procedure.
Post-operatively he was taken back to the ICU for monitoring and
placed in a pentobarbital coma. A Vigeleo was placed for
monitoring of cardiac status during the pentobarbital coma
however EEG was not placed. On [**8-26**] his exam remained poor
while being monitored in the ICU. He had a weak cough and
sluggish corneals on exam and did not respond to painful
stimuli. He still was induced in a pentobarbital coma at this
time. Upon exam his craniectomy sites were very tense.
An MRI of the head was done on the 25th which showed acute
infarction/contusion of the R temporal lobe, supratentorial
hemorrhage and foci of hemorrhage in the inferior left
cerebellar hemisphere, and a punctate hemorrhage in the genu of
the right corpus callosum suggestive of [**Doctor First Name **].
ON [**8-27**], the decision was made to d/c the pentobarb and to
obtain a proper exam. His status was monitored by daily Head
CTs, which improved silghtly each day and did not demonstrate
any acute hemorrhage or infarct. He developed transient fevers
beginning on [**8-28**]. His blood, urine, and sputum cultures were
all negative, and serially followed.
His neurological exam improved slightly beginning on [**8-30**],
as his pupils were reactive and he began to withdraw his
extremities. Because he still had transient fevers with no
known source, a CT of his Chest, Abd, and Pelvis was performed.
This revealed
1. Small filling defect in a subsegmental branch supplying the
left lower
lobe consistent with a small subsegmental pulmonary embolus.
2. Bilateral consolidation at the lung bases, likely aspiration;
however,
cannot exclude pneumonia.
3. Interval resolution of opacity at the right upper lobe
suggesting
resolution of prior atelectasis.
4. Soft tissue structure in anterior mediastinum similar in
size; however,
now decreased density suggesting likely aging/evolving
hematoma.
5. Slightly prominent single mediastinal lymph node
[**9-1**] Pt underwent placement of PEG, tracheostomy and IVC filter.
Further, bilateral lower extremity dopplers were obtained and
showed R femoral DVT. A head ct was obtained and showed no new
changes and consistent with post operative changes. The patient
was started on a heparin IV GTT on [**2187-9-3**] with a goal ptt of
40-60.
[**9-4**] Pt remained on heparin IV GTT and and did reach his goal of
a ptt greater than 40 on this day. He remained on 1500 units/hr
and PTT were checked q8. His exam on this day was weak eye
opening, attempts to localize RUE, no movement in LUE and
withdraws BLE. He was started on Vancomycin, ciprofloxacin and
flagyl over the weekend for treatment of pneumonia. His sutures
were removed on this day and his incision was clean, dry and
intact.
[**9-5**]: Pt WBC count noted to increase this day to 24.3. His
cultures have been negative to this date. An LP was obtained in
interventional radiology as it could not be completed at the
bedside. CSF gram stain showed no poly's and no microrganisms
and the cell count was WNL.
[**9-6**]: A head ct with and without contrast was obtained and this
showed no obvious signs of intracranial infectious process, and
no new hemorrhage since begining anticoagulation.
[**9-7**]: Pt remained stable. Flagyl was discontinued per ID rec's
unless spikes new temperature.
8/6-9: Pt remained afebrile and remained on a heparin drip for
coumadin bridge. Pt PTT remained therapeutic and INR on this day
1.3. Scheduled to recieve 7.5mg coumadin tonight. His exam
improved over the weekend. He currently follows commands with
RUE, eyes open spontaneously and tracks on exam.
[**2188-9-10**]: Transfered to step down unit on this day. Heparin GTT
continued in therapeutic range. His INR remained at 1.7, and
10mg of Coumadin was given. SBP's were at times in the 220's
which responded well to IV Hydralazine.
[**9-13**]: INR =2.0. Heparin gtt was discontinued and coumadin was
again dosed at 10mg.
[**9-14**]: pt neurologically stable. INR 2.4 . Initial guardianship
paperwork was completed and sent to legal. wrist restraint x1
initiated because of pt pulling at tubes, trach.
[**2092-9-13**]: no acute events. awaiting guardianship & placement.
coumadin dosed at 5mg/day
[**9-17**]: Pt again stable. Final guardianship paperwork completed
and signed. Pt cleared for discharge to acute rehab.
Medications on Admission:
None
Discharge Medications:
.
1. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
2. Acetaminophen 650 mg Suppository Sig: [**2-3**] Suppositorys Rectal
Q6H (every 6 hours) as needed for fever, pain.
3. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for wheeze.
4. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
2-4 puffs Inhalation every four (4) hours as needed for
wheezing. puffs
5. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
6. Senna 8.8 mg/5 mL Syrup Sig: Two (2) Tablet PO BID (2 times a
day) as needed for constipation.
7. Levetiracetam 100 mg/mL Solution Sig: One (1) PO BID (2
times a day).
8. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for prophylaxis.
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day) as needed for HTN.
10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
11. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
12. Oxycodone 5 mg/5 mL Solution Sig: [**2-3**] PO Q4H (every 4
hours) as needed for pain.
13. Sodium Chloride 0.9 % 0.9 % Parenteral Solution Sig: One (1)
ML Intravenous PRN (as needed) as needed for line flush.
14. Furosemide 10 mg/mL Solution Sig: One (1) Injection [**Hospital1 **] (2
times a day).
15. Sodium Chloride 0.9 % 0.9 % Parenteral Solution Sig: One (1)
ML Intravenous Q8H (every 8 hours) as needed for line flush.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
Subdural Hematoma
Epidural hematoma
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable
(intermittently).
Activity Status: Bedbound.
Discharge Instructions:
GENERAL INSTRUCTIONS
WOUND CARE
?????? You or a family member should inspect your wound every day and
report any of the following problems to your physician.
?????? Keep your incision clean and dry.
?????? You may wash your hair with a mild shampoo 24 hours after your
sutures are removed.
?????? Do NOT apply any lotions, ointments or other products to your
incision.
?????? DO NOT DRIVE until you are seen at the first follow up
appointment.
?????? Do not lift objects over 10 pounds until approved by your
physician.
MEDICATIONS
?????? Take all of your medications as ordered. You do not have to
take pain medication unless it is needed. It is important that
you are able to cough, breathe deeply, and is comfortable enough
to walk.
?????? Do not use alcohol while taking pain medication.
?????? Medications that may be prescribed include:
o Narcotic pain medication such as Dilaudid (hydromorphone).
o An over the counter stool softener for constipation (Colace or
Docusate). If you become constipated, try products such as
Dulcolax, Milk of Magnesia, first, and then Magnesium Citrate or
Fleets enema if needed). Often times, pain medication and
anesthesia can cause constipation.
?????? 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.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc, as this can increase your chances of bleeding.
ACTIVITY
The first few weeks after you are discharged you may feel tired
or fatigued. This is normal. You should become a little stronger
every day. Activity is the most important measure you can take
to prevent complications and to begin to feel like yourself
again. In general:
?????? Follow the activity instructions given to you by your doctor
and therapist.
?????? Increase your activity slowly; do not do too much because you
are feeling good.
?????? You may resume sexual activity as your tolerance allows.
?????? If you feel light headed or fatigued after increasing
activity, rest, decrease the amount of activity that you do, and
begin building your tolerance to activity more slowly.
?????? DO NOT DRIVE until you speak with your physician.
?????? Do not lift objects over 10 pounds until approved by your
physician.
?????? Avoid any activity that causes you to hold your breath and
push, for example weight lifting, lifting or moving heavy
objects, or straining at stool.
?????? Do your breathing exercises every two hours.
?????? Use your incentive spirometer 10 times every hour, that you
are awake.
WHEN TO CALL YOUR SURGEON:
With any surgery there are risks of complications. Although your
surgery is over, there is the possibility of some of these
complications developing. These complications include:
infection, blood clots, or neurological changes. Call your
Physician Immediately if you Experience:
?????? Confusion, fainting, blacking out, extreme fatigue, memory
loss, or difficulty speaking.
?????? Double, or blurred vision. Loss of vision, either partial or
total.
?????? Hallucinations
?????? Numbness, tingling, or weakness in your extremities or face.
?????? Stiff neck, and/or a fever of 101.5F or more.
?????? Severe sensitivity to light. (Photophobia)
?????? Severe headache or change in headache.
?????? Seizure
?????? Problems controlling your bowels or bladder.
?????? Productive cough with yellow or green sputum.
?????? Swelling, redness, or tenderness in your calf or thigh.
Call 911 or go to the Nearest Emergency Room if you Experience:
?????? Sudden difficulty in breathing.
?????? New onset of seizure or change in seizure, or seizure from
which you wake up confused.
?????? A seizure that lasts more than 5 minutes.
Important Instructions Regarding Emergencies and After-Hour
Calls
?????? If you have what you feel is a true emergency at any time,
please present immediately to your local emergency room, where a
doctor there will evaluate you and contact us if needed. Due to
the complexity of neurosurgical procedures and treatment of
neurosurgical problems, effective advice regarding emergency
situations cannot be given over the telephone.
?????? Should you have a situation which is not life-threatening, but
you feel needs addressing before normal office hours or on the
weekend, please present to the local emergency room, where the
physician there will evaluate you and contact us if needed.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast.
Completed by:[**2187-9-17**]
|
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icd9cm
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[
[
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icd9pcs
|
[
[
[]
]
] |
12835, 12907
|
5294, 11220
|
340, 412
|
12987, 12987
|
1375, 1375
|
17862, 18123
|
820, 825
|
11275, 12812
|
12928, 12966
|
11246, 11252
|
13140, 16004
|
1874, 5268
|
855, 984
|
16031, 17839
|
280, 302
|
1120, 1356
|
440, 743
|
1392, 1857
|
13002, 13116
|
765, 771
|
787, 804
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,118
| 168,768
|
5367
|
Discharge summary
|
report
|
Admission Date: [**2153-6-7**] Discharge Date: [**2153-6-14**]
Date of Birth: [**2093-10-2**] Sex: F
Service: NEUROSURGERY
Allergies:
Lidocaine / Lipitor / Lovastatin / Haldol / Ativan
Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
Lower extremity Weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: This is a 59 yo F with NSCLC dx in [**3-22**] most recently s/p
once cycle of taxol/[**Doctor Last Name **], COPD, CAD s/p MI, recently started on
tarceva, and notes in the past 2 days, a sudden onset of
discharged on [**2153-5-9**] after an admission for hypotension likely
secondary to dehydration with a mineralocorticoid deficiency and
was started on fludrocort, now presents with lower extremity
weakness after starting on tarceva one week prior. She states
she notes sensation changed up to her knees bilaterally, and
decrease in lower extremity strength but otherwise no
bowel/bladder incontinence, she noted it initially when rising
from a wheelchair two days ago, nonprogressive, no associated
back pain or other symptoms. Her baseline has been ambulation
with a walker.
ROS: chronic cough, productive for rusty sputum past day, o/w
with nausea after starting tarceva, no emesis, no diarrhea,
constipation, no HA, visual changes, eye pain, stable SOB, no
cp, abd pain (sharp, and dull) increased with deep breaths, no
f/c
Past Medical History:
Onc History:
Pt presented to [**Hospital1 18**] on [**2153-3-22**] with hemoptysis. At that time
she was found to have a 8x8x9cm mass in the RUL displacing
segmental bronchi of the RML but no clear invasion. CT guided
biopsy showed non small cell lung CA. She had a PET and an MRI
and found to have a T7 likely metastatic lesion. She underwent
radiation treatment of both her spine mets and lung mass in
[**4-21**]. She is to receive palliative chemo.
.
PMH
-Diverticular bleeds, most recently in [**2152-9-16**].
-Strep pneumoniae pneumonia and sepsis and a prolonged intensive
care unit stay complicated by difficulty extubating, delirium,
and right internal carotid artery cannulization.
-HTN
-hyperlipidemia
-COPD
-panic disorder
-CAD with a MI infarction in [**2144**]. - EF 55% based on echo [**3-20**]
- hypothyroidism
Social History:
She is retired from working in [**Company 2486**]. She smoked two
packs per day for 40 years and quit four years ago. She does not
use alcohol.
Family History:
She has no siblings. Her mother passed away at age 76 of
osteoporosis and severe emphysema. Her father died at age 56 of
lung cancer, though he was a nonsmoker. She has no children. She
is widowed.
Physical Exam:
Physical Exam:
Vitals: 98.1 109 118/80 16 99%2L
Gen: Slightly anxious and mildy tachypneic, able to speak in
full sentences.
HEENT: NC/AT, anicteric, OP clear
NECK: supple, no LAD
CV: tachy, s1 s2 distant heart sound, no murmur/r/g
LUNG: poor air mvt, mild diffuse wheezing
ABD: soft, NT/ND, +bs
EXT: trace bilateral edema
NEURO: alert+ox 3, CNII-XII intact, able to relate history w/o
difficulty.
motor: upper extremity [**4-20**] bilaterally
L/E: RLE 3+/5 prox>distal, LLE [**3-21**], R patellar reflex could not
be appreciated. L DTR 1+. Retained sensation bilaterally in
lower extremities.
U/E- 5/5 strength bilaterally with 2+ DTRs
Rectal: Slightly decreased rectal tone without saddle
anesthesia. Hard brown stool appreciated.
Equivocal babinski's bilaterally.
Pertinent Results:
[**2153-6-7**] 09:45PM GLUCOSE-102 UREA N-10 CREAT-0.5 SODIUM-139
POTASSIUM-2.5* CHLORIDE-92* TOTAL CO2-35* ANION GAP-15
[**2153-6-7**] 09:45PM CALCIUM-8.0* PHOSPHATE-2.7 MAGNESIUM-1.9
[**2153-6-7**] 09:45PM WBC-6.9 RBC-3.75* HGB-9.9* HCT-29.8* MCV-80*
MCH-26.4* MCHC-33.2 RDW-19.7*
[**2153-6-7**] 09:45PM NEUTS-67.2 BANDS-0 LYMPHS-25.5 MONOS-5.7
EOS-1.3 BASOS-0.4
[**2153-6-7**] 09:45PM HYPOCHROM-2+ ANISOCYT-2+ POIKILOCY-2+
MACROCYT-OCCASIONAL MICROCYT-2+ POLYCHROM-NORMAL
[**2153-6-7**] 09:45PM PLT SMR-HIGH PLT COUNT-458*
*
RADIOLOGY Final Report
MR THORACIC SPINE [**2153-6-7**] 6:59 PM
MR THORACIC SPINE
Reason: please assess for cord compression
[**Hospital 93**] MEDICAL CONDITION:
59 YO W with metastatic lung cancer with known T7 spinal lesion
now presents with lower extremity weakness
REASON FOR THIS EXAMINATION:
please assess for cord compression
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 59-year-old with metastatic lung cancer and known T7
spinal lesion. Assess for cord compression.
TECHNIQUE: Multiplanar T1- and T2-weighted images through the
thoracic spine without IV contrast.
COMPARISON: [**2153-3-30**].
There is a large right upper lobe lung mass measuring at least
3.6 x 6.2 cm on scout images. This is consistent with the
patient's known history of lung cancer.
Compression deformity of the T7 vertebral body has progressed
since the prior examination now with marked retropulsion of
fragments and increased soft tissue mass associated with
increased compression of spinal cord. Soft tissue is seen
extending into and essentially obliterating the left neural
foramen and pressing upon the spinal cord causing
moderate-to-severe cord compression. No increased STIR signal
intensity or T2 signal intensity is seen within the cord to
suggest cord edema. Soft tissue mass is also seen extending into
the right neural foramen, but to a lesser extent than the left.
A new linear area along the superior aspect of the T4 vertebral
body is seen, demonstrating decreased T1 and increased STIR
signal intensity. A new 7 x 7 mm rounded somewhat ill-defined
lesion is seen in the posterior right aspect of the T6 vertebral
body concerning for a new metastatic static focus. Decreased T1
signal intensity along the inferior endplate of T6 likely is due
to degenerative changes. Heterogeneously decreased T1 and
increased T2/STIR signal intensity throughout the T8 vertebral
body is also seen and new from the prior examination. There is
also mild-to-moderate anterior wedging of the T8 vertebral body,
also new since the prior study. There has been slightly
increased diffuse T1 signal intensity throughout the vertebral
bodies in the thoracic spine likely related to post-radiation
changes.
Elsewhere in the thoracic spine, the spinal canal appears normal
in caliber. Vertebral body alignment is also normal elsewhere as
is vertebral body height and disc space height.
IMPRESSION:
1. Progression of metastatic disease involving T8 with increased
collapse of the vertebral body and soft tissue component
involving the vertebral body. There is extension of soft tissue
component into both neural foramen, left greater than right, and
moderate-to-severe cord compression without definite cord edema.
2. Probable new metastatic focus in T6 posteriorly on the right.
3. Post-radiation changes throughout the thoracic spine. Signal
abnormalities in the T4 vertebral body is probably due to
insufficiency fracture post-radiation. Signal abnormalities in
T8 are less certain and may be due to new metastatic involvement
or insufficiency fracture.
4. Known right upper lobe lung cancer.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) 7853**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
DR. [**First Name (STitle) 3905**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3906**]
Approved: SAT [**2153-6-9**] 11:57 AM
*
RADIOLOGY Preliminary Report
CHEST (PRE-OP PA & LAT) [**2153-6-9**] 5:34 PM
CHEST (PRE-OP PA & LAT)
Reason: LUNG CANCER;WEAKNESS
[**Hospital 93**] MEDICAL CONDITION:
59 year old woman with T7 metastatic lesion
REASON FOR THIS EXAMINATION:
preop CXR
HISTORY: Metastatic lesion.
PA and lateral radiographs of the chest again demonstrate a
right upper lung mass, similar in appearance when compared to
[**2153-5-4**]. There is no pleural effusion. The left lung is clear.
Cardiomediastinal contours are normal. The osseous structures of
the spine are not well assessed secondary to technique. There is
mild shift of the trachea from the midline to the right. No
pneumothorax.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 6892**]
*
RADIOLOGY Final Report
CT T-SPINE W/O CONTRAST [**2153-6-9**] 9:45 AM
CT T-SPINE W/O CONTRAST
Reason: please do CT T3-T11 with saggital reconstrutions. Thanks
[**Hospital 93**] MEDICAL CONDITION:
59 year old woman with lung Ca mets to T7, s/p radiation.
therapy.
REASON FOR THIS EXAMINATION:
please do CT T3-T11 with saggital reconstrutions. Thanks
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 59-year-old female with lung cancer and mets to T7
status post radiation therapy.
COMPARISONS: MRI thoracic spine dated [**2153-6-7**].
TECHNIQUE: Axial non-contrast CT imaging of the thoracic spine.
FINDINGS: A large mass is seen in the apex of the right lung
consistent with the patient's known history of lung cancer.
Again identified is a pathological compression deformity of the
T7 vertebral body. Elsewhere throughout the thoracic spine, the
spinal canal appears normal in caliber. Vertebral body alignment
as well as vertebral body height and disc space height are also
normal elsewhere throughout the thoracic spine.
IMPRESSION:
1. Large right upper lobe lung mass measuring approximately 7.0
x 4.7 cm, consistent with history of lung carcinoma.
2. Metastatic disease with pathologic compression fracture
involving T7 collapse of the vertebral body and soft tissue
component causing destruction of the posterior vertebral body
with retropulsion. Correlation with recent MR shows that the
cord compression seen on MR [**First Name (Titles) **] [**Last Name (Titles) 21837**] due to soft-tissue
mass.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
DR. [**First Name (STitle) 3905**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3906**]
Approved: SAT [**2153-6-9**] 9:47 PM
*
Brief Hospital Course:
A/P: This is a 59 yo F NSCLC who presented with lower extremity
weakness and was found to haver thoracic cord compression
secondary to her know metastatic lung cancer.
.
The patient has a known T7 metastasis which was previously
treated with XRT. Her MRI on admission demonstrated worsening
cord compression. She was not a a candidate for XRT and thus was
transferred to neurosurgery for laminectomy and decompression.
As part of her pre-op her ASA and heparin were d/c'ed. An Xray
was checked which demonstrated mild tracheal deviation but upon
discussion with the radiologist this was thought to be unchanged
from previous. She was continued on dexamethasone 4 mg IV q 6
hrs and placed on an insulin sliding scale. As part of her
pre-op clearance she was seen by anesthesia.
Patient seen and evaluated by neurosurgery for palliative
resection of T7 lesion and instrumentation. After long
discussion with patient and his oncologist further decided to
proceed with surgery. Patient transferred to neuropsurgery
service and taken to OR on [**6-10**] under general anesthesia for T7
metastatic lesion resection and T4-10 fusion and instrumentation
and facia JP drainplacement without intraoperative
complications. Patient tranferred to neuro ICU immediate postop
for further close monitoring. She remainedintubated overnight
able extuabte succesfully in the morning of postop day one.
Immediate postoperative neurologic exam is she was able follow
commands moving all atremities, able to lift both upper and
lower extremities, sensation intact. Her hematoctrit dropped
29.9 to 23.3 on the postoperative day one which she received one
unit of PRBC, subsequent hct levels are improved. She was some
what tachycardic tried to control with beta-blockers, was on
pressors was able to wean off on postop day one.
Patient transferred to step-down on postop day one in the
afternoon. He tachyacardia was better conrrolled, remained
afebrile. She continued to improve, TLSO brace fitted for
fusion. She transferred to floor status on day two, JP drain
removed, her insicion site dry and clean, no redness or swelling
noted. Her Thoracis PA/lateral radiogaraph reveals posterior
fixation rods are seen. Pedicles screws are seen from T4-5 and
T10-11 levels. Two contiguous mid thoracic compression fractures
are visualized. A large consolidation/mass is present in the
right upper lobe of the lung. There is normal alignment of the
thoracic spine.
Patient fitted for TLSO brace which is at her bed side. Patient
seen and evaluated by PT and recommendd rehabilitition.
.
Her INR was elevated upon admission for unclear reasons. She
was on coumadin in the past but her primary oncologist thought
that this had been stopped. Persual of her [**Month (only) 16**] from the nursing
home did not demonstrate the administration of coumadin. She
received a total of 10mg Vit K SC and 10mg Vit K PO.
.
For the patients NSCLC, Dr. [**Last Name (STitle) **] is holding tarceva for now. The
patient will have a CT torso for tumor staging post-operatively.
The patient received duonebs for shortness of breath and
congestion.
.
She was continued on levothyroxine for hypothyroidism which is
stable. For anxiety she received imipramine and remeron. We
avoided administration of ativan as she has had some paradoxical
side effects.
.
Ms. [**Known lastname 7474**] received potassium repletion of 40mEq PO x 2, 40mEq
IV x 1. Her subsequent chemistry showed correction of her
potassium.
.
Fludrocort was administered for apparent mineralcorticoid
deficiency. Iron supplementation was continued for treatment of
anemia.
.
The patient had a previously documented DNR/DNI status, but
currently requests only DNI, and 1 set of chest compressions.
She will discuss this further with her primary attending.
.
Contact: HCP Dr. [**Last Name (STitle) **] or friend, [**Name (NI) 2013**] [**Name (NI) 1968**] [**Telephone/Fax (1) 21834**] and
[**Name (NI) 21835**] father, pastor [**Name (NI) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 21836**].
Medications on Admission:
- Imipramine HCL 50 mg po qhs
- Levothyroxine 75 mcg po qd
- Ipratropium 17mcg 2puff QID
- Aspirin 81mg QD
- Fludrocortisone 0.1mg QD
-Ferrous Gluconate 300 mg PO TID
- mucinex 600 mg [**Hospital1 **]
- Potassium 25mcg qd liquid
- remeron 30mg qhs
- prilosec 20mg OTC qd
- morphine sulfate 20mg [**Hospital1 **]
- colace 100 mg [**Hospital1 **]
- senna 2 tabs qhs
- tarceva 150mg qd
- crestor 20mg qd
- percocet 5/325 q4-6hr prn
Discharge Medications:
1. Imipramine HCl 25 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
4. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
7. Mirtazapine 30 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
8. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
10. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed.
11. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for rash L breast: until clear.
12. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
14. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
15. Dexamethasone 2 mg Tablet Sig: 1.5 Tablets PO Q8H (every 8
hours) for 1 doses: last dose 6/29 pm then cont next taper dose.
16. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 3 doses: start [**6-15**].then cont next taper dose.
17. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 2 doses: start [**6-16**].then cont next taper dose.
18. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 1 doses: start [**6-17**],then cont next taper dose .
19. Dexamethasone 2 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily)
for 1 doses: start [**6-18**] then stop.
20. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
21. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
Intravenous Q 12H (Every 12 Hours): last dose [**2153-6-22**].
22. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a
day: last dose [**2153-6-22**].
Discharge Disposition:
Extended Care
Facility:
Roscommon
Discharge Diagnosis:
non-small cell lung cancer with spinal cord compression
T7 metastatic lesion
Discharge Condition:
transferred to neurosurgery
stable
Discharge Instructions:
none
Keep your insicion site dry clean, call with drainage, redenss,
swelling, fever>101.5 any neurologic changes.
Please remove one sture on the right side of staples where her
drain site was on [**2153-6-17**].
Followup Instructions:
Follow up with Dr [**Last Name (STitle) 548**] in 20 days from [**2153-6-10**] for removal of
staples . Then make further follow up appointmet at the time of
staple removal.
Follow with your oncologist in [**12-18**] weeks in the office.
Completed by:[**2153-6-14**]
|
[
"V15.82",
"V16.1",
"162.3",
"496",
"401.9",
"198.5",
"336.3",
"412",
"280.9",
"790.92",
"244.9",
"300.00",
"272.4",
"733.13"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.09",
"99.07",
"99.04",
"78.59"
] |
icd9pcs
|
[
[
[]
]
] |
16730, 16766
|
10049, 14075
|
339, 345
|
16887, 16924
|
3454, 4128
|
17186, 17456
|
2447, 2647
|
14572, 16707
|
8395, 8462
|
16787, 16866
|
14101, 14549
|
16948, 17163
|
2677, 3435
|
275, 301
|
8491, 10026
|
373, 1415
|
1437, 2268
|
2284, 2431
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,068
| 165,648
|
40164
|
Discharge summary
|
report
|
Admission Date: [**2180-2-6**] Discharge Date: [**2180-2-15**]
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1390**]
Chief Complaint:
s/p fall, unclear etiology
Major Surgical or Invasive Procedure:
[**2180-2-8**]
Left hip hemiarthroplasty.
History of Present Illness:
89 year old female was taken to OSH after a fall from standing
for unknown
reasons (?mechanical vs. syncopal). Pt subsequently underwent CT
scan which demonstrated a L superior frontoparietal SDH w/ [**2-13**]
mm
midline shift. Pt was also found to have a L hip fx. At that
time, pt was reportedly able to report HPI, moving all
extremities, responding to commands, and was neurologically
nonfocal. Of note, pt has hx of Afib on Coumadin and her INR was
3.3. She received 1U of FFP and 10mg of IV VitK. Shortly
thereafter, pt's speech became less clear/garbled and she was
intubated for concern of herniation. Pt was transferred to [**Hospital1 18**]
for further management and evaluation.
On presentation to the [**Name (NI) **], pt was intubated and on propofol gtt.
After lightening sedation, she was able to respond to commands
and a cursory exam was able to be performed demonstrating no
focal deficits.
Past Medical History:
Afib (on Coumadin), HTN, Hypothyroid, cataracts
Social History:
worked for the IRS, retired in [**2144**]. Widowed, currently lives
alone and has no children. No ETOH, No tobacco
Family History:
Father died from MI at age 52
Physical Exam:
limited [**3-15**] light/moderated sedation and ET tube)
O: T: 97.4 BP: 153/54 HR: 55 R 16 100% CMV 60% 5/5
Gen: Sedated, ET tube in place, pt on propofol gtt. Lightened 5
min prior to exam. Pt able to respond to commands w/ [**6-15**]
symmetric hand grip and [**6-15**] gastrocs bilat. Pupils 3mm and
minimally reactive (artificial lenses in place). EOM intact. No
pronator drift. C-collar in placed. Down going toes bilateral.
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm
Abdominal: Soft
Extr/Back: Traction splint in place distal pulses 2+
bilaterally in the lower extremities
Neuro: Patient is moving all extremities equally
Reflexes: B T Br Pa Ac
Right 2 - 2 2 -
Left 2 - 2 2 -
Pertinent Results:
[**2180-2-5**] 09:56PM WBC-7.9 RBC-3.90* HGB-13.0 HCT-37.8 MCV-97
MCH-33.4* MCHC-34.5 RDW-14.0
[**2180-2-5**] 09:56PM NEUTS-80.6* LYMPHS-14.5* MONOS-3.5 EOS-1.2
BASOS-0.2
[**2180-2-5**] 09:56PM PLT COUNT-218
[**2180-2-5**] 09:56PM PT-18.6* PTT-22.3 INR(PT)-1.7*
[**2180-2-5**] 09:56PM GLUCOSE-187* UREA N-13 CREAT-0.6 SODIUM-138
POTASSIUM-3.1* CHLORIDE-98 TOTAL CO2-25 ANION GAP-18
[**2180-2-5**] Head CT :
1. Mixed density left cerebral convexity subdural hematoma,
reflecting both acute and chronic components, with mild mass
effect exerted upon the adjacent left cerebral hemisphere,
without shift of midline structures.
2. Opacification of the sphenoid sinus, likely relates to
endotracheal
intubation.
[**2180-2-6**] Head CT :
1. Mixed density left cerebral convexity hematoma, with mild
mass effect on the adjacent left frontal lobe, unchanged since
the prior study.
2. Stable opacification of the left sphenoid sinus.
[**2180-2-7**] Cardiac echo :
Preserved left ventricular systolic function. Mild aortic
regurgitation
[**2180-2-7**] Carotid duplex scan :
Findings are consistent with less than 40% stenosis bilaterally.
[**2180-2-8**] Head CT :
Stable appearance of left subdural hematoma with mild mass
effect
on the left frontal lobe. No new interval hyperdense foci to
suggest new
interval hemorrhage.
[**2180-2-8**] Chest CTA :
1. No pulmonary embolus.
2. Cardiomegaly.
3. Small bilateral pleural effusions with associated
atelectasis.
4. Likely pulmonary arterial hypertension, unchanged in terms of
arterial
enlargement.
5. Epicardial lead fragment, retained since at least [**Month (only) 404**]
[**2179**].
[**2180-2-13**] Left arm ultrasound :
Left brachial vein and basilic vein thrombosis along the PICC.
Brief Hospital Course:
Ms. [**Known lastname 39008**] was evaluated by the Trauma team in the Emergency
Room along with the Neurosurgery service. She was intubated
prior to transfer and therefore a full neurologic exam was
difficult. She was transferred to the Trauma ICU for further
management and testing. Although she had an orthopedic injury
requiring surgery, her neurologic status took precedent.
Following admission to the ICU she was gradually extubated from
the respirator and able to breath effectively on her own. She
had no obvious neuro deficits on exam but had some baseline
confusion, probably multifactorial. Her Head Ct was reviewed
and the subdural hematoma was old. A repeat scan done 24 hours
later showed no change. She was subsequently taken to the
Operating Room on [**2180-2-8**] and underwent a left hip
hemiarthroplasty. She tolerated the procedure well and returned
to the PACU in stable condition. She was easily extubated and
again was neurologically intact except for some confusion. This
encephalopathy was possibly due to a UTI, hyponatremia, multiple
changes in hospital settings and possibly medications. Her Head
CT was stable on a 3rd check. Following full recovery from
anesthesia she was transferred to the trauma floor for further
management.
Due to tachypnea and tachycardia on [**2180-2-9**] she returned to the
ICU. A chest CTA was negative for PE. She underwent vigorous
chest PT and incentive spirometry due to bibasilar atelectasis.
Her oxygen saturations improved and on 3L. NC her saturation was
95%. Her sodium was 129 and she was fluid restricted with
subsequent serum sodium 133-137 range. During this time her
blood pressure was elevated and she was placed back on her beta
blocker as well as her [**Last Name (un) **] with prn hydralazine.
Following her return to the Trauma floor she began to make slow
progress. She was seen by the Neurology service as her history
of frequent falls was not explained by a cardiac work up which
included a cardiac echo showing a normal EF and mild aortic
insufficiency along with carotid studies which showed less than
40% stenoses bilaterally of the internal carotid arteries. The
Neurologic evaluation found no disorder that could impair her
walking. They recommended stopping Gabapentin and any
benzodiazepines that might cause her imbalance. Anticoagulation
in the short term will be limited to Lovenox per the routine of
the Orthopedic surgeons however anticoagulation for atrial
fibrillation will be up to the discretion of her PCP. [**Name10 (NameIs) **]
rhythm has generally bee normal sinus rhythm in the 70-80 range
and her Amiodarone continues.Her last Head Ct was on [**2180-2-8**]
and showed no new foci of bleeding. She will need another Head
Ct in 4 weeks for comparison.
On [**2180-2-10**] a left PICC line was placed as assess was a problem
but 48 hours later she developed edema of the left arm and a
duplex scan noted thrombus in the left brachial and basilic
veins. The PICC line was removed, her arm was elevated and non
tender and her treatment will be symptomatic with a follow up
ultrasound in 4 weeks.
The Physical Therapy service evaluated Ms. [**Known lastname 39008**] and found her
to be very deconditioned and recommended rehab for aggressive PT
especially for the left hip prior to her return home. She was
also evaluated by the Speech and Swallow service and found not
to have any difficulty swallowing. Her appetite was poor and
she was given Ensure supplements, placed on calorie counts and
Dronabinol was started.
She developed an E Coli and enterococcal UTI which is currently
being treated with Cipro thru [**2180-2-17**]. Her Foley catheter should
be removed at 12 Md tonight. Ms. [**Known lastname 39008**] states that prior to
admission she had baseline urinary incontinence and used
Depends.
After a long hospital course she was discharged to rehab on
[**2180-2-15**] with the hopes that she will be able to return home if
she progresses well. She will follow up with the Neurosurgery
service, the Orthopedic service and the Trauma service over the
next 4-6 weeks and will continue Lovenox for DVT prophylaxis. Of
note her long acting betablocker ( Toprol 100 mg daily ) should
start today. Prior she was on 25 mg of Lopressor QID.
Medications on Admission:
amiodarone 200', ASA 81', Zetia 10', Coumadin 1', Xanax 0.5',
Neurontin 300', Cozaar 50', Lipitor 40', Synthroid 75', Nexium
40', toprol XL 100'
Discharge Medications:
1. losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
hold for systolic blood pressure <110.
2. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
6. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. dronabinol 2.5 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. enoxaparin 40 mg/0.4 mL Syringe Sig: Forty (40) mg
Subcutaneous DAILY (Daily).
9. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
10. metoprolol succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
11. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours): DC after last dose [**2180-2-17**].
12. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H
(every 8 hours).
13. oxycodone 5 mg/5 mL Solution Sig: Five (5) mg PO Q4H (every
4 hours) as needed for pain.
14. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
S/P fall
1. Acute on chronic SDH
2. Left displaced femoral neck fracture.
3. EColi UTI
4. Left basilic and brachial vein thromboses
5. Encephalopathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane)Weight bearing as tolerated.
Discharge Instructions:
*You were admitted after sustaining a fall and you sustained a
left femoral neck fracture and a CT scan of your head revealed
bruising and a hematoma on your brain which appeared to be old.
You did have surgery for repair of your hip. You also had a
urinary tract infection which has been treated and a clot in
your left arm from a long intravenous catheter which has since
been removed.
Due to your prolonged hospital stay,you are being sent to a
rehab hospital so that you can begin physical therapy prior to
returning home.
You may bear weight as tolerated on your left leg.
At this point you will not resume your Coumadin but you will
need to be on a blood thinner by injection for 4-6 weeks as
determined by the Orthopedic surgeon.
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**6-20**] lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Followup Instructions:
Call the [**Hospital 4695**] Clinic at [**Telephone/Fax (1) 1669**] for a follow up
appointment with Dr. [**Last Name (STitle) 548**] in 4 weeks. You will need a non
contrast Head CT prior to your appointtment. The secretary will
arrange that for you.
Call the [**Hospital **] Clinic at [**Telephone/Fax (1) 1228**] for a follow up
appointment next week. Your staples will be removed at that
time.
Call the Acute Care Clinic at [**Telephone/Fax (1) 600**] for a follow up
appointment in 6 weeks. You will need an ultrasound of your
left arm prior to the visit. The secretary can arrange that for
you.
Completed by:[**2180-2-15**]
|
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"820.03",
"E879.8",
"427.31",
"453.82",
"438.20",
"244.9",
"996.74"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"81.52"
] |
icd9pcs
|
[
[
[]
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9759, 9806
|
4045, 8316
|
276, 320
|
10000, 10000
|
2278, 4022
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12434, 13073
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1482, 1514
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348, 1259
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10015, 10186
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1281, 1331
|
1347, 1466
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
732
| 189,222
|
1514
|
Discharge summary
|
report
|
Admission Date: [**2108-1-2**] Discharge Date: [**2108-1-27**]
Date of Birth: [**2041-10-2**] Sex: F
Service: SURGERY
Allergies:
Cephalexin
Attending:[**First Name3 (LF) 1234**]
Chief Complaint:
Pain in left 3rd toe and foot
Major Surgical or Invasive Procedure:
Placement of dialysis cathether in right subclavian vein.
[**11-9**] - Diagnostic abdominal aortogram and pelvic arteriogram
with unilateral lower extremity runoff, contralateral third
order catheterization, primary balloon angioplasty of the
anterior tibialis x 3. Infusion for thrombolysis of the distal
AT. CPT codes [**Numeric Identifier 4237**], [**Numeric Identifier 4238**], [**Numeric Identifier 8881**],
[**11-10**] - Open third ray amputation left foot
[**11-14**] - Exploration of right groin and repair of bleeding, right
common femoral artery. [**Numeric Identifier 8882**], [**Numeric Identifier 8883**].
[**11-21**] - OPERATION:
1. Open ray amputation left fourth toe.
2. Debridement of skin and subcutaneous tissue, muscle, and
bone.
History of Present Illness:
Ms. [**Known lastname 8884**] is a 66 yo F with a 6-month history of ulcer on her
left 3rd toe. She has been followed by Dr. [**Last Name (STitle) 8885**] of podiatry
in [**Location (un) **]. She reports that she last saw him three weeks ago
and he thought her toe was improving. Two weeks ago, she began
to have increasing pain in her toe and instep, and noticed that
her toe appeared darker. Her cousin, with whom she lives,
noticed her rubbing her toe frequently and encouraged her to see
a doctor, but she did not. One week ago, she noticed redness on
the dorsal aspect of her foot. She finally saw her podiatrist
[**1-2**] and he sent her to the ED. She describes her pain as [**2-4**],
in her 3rd toe and instep of her left foot. Additionally, she
complains of a stinging pain in her great toes bilaterally
secondary to gouty arthritis. She has remained afebrile. She
denies prior foot ulcers or injury, as well as numbness or
tingling in her feet. She notes that she normally moves freely
about her home, and climbs stairs several times a day to do
laundry. She has had recent falls without injury after tripping
over the cord for an electrical blanket. On review of systems,
she has had recent nosebleed and asthmatic symptoms. She denies
HA, dizziness, CP, SOB, fevers/chills, abdominal discomfort,
dysuria, urgency, or muscular weakness. She has had some recent
intentional weight loss.
Past Medical History:
1) Chronic renal insufficiency: [**12-30**] FSGS, s/p nephrectomy,
baseline Cr >3.0
.
2) Type II Diabetes, controlled by diet, HbA1c has always been
less than 6.4%
.
3) Endometrial cancer, stage II/III, s/p TAH/BSO and radiation
.
4) Complete heart block, apparently related to nephrectomy, with
[**Month/Day (2) 4448**] implanted 18 months after surgery
.
5) Colonic adenomas in [**2099**], [**2102**]
.
6) Skull fracture at age 6, [**12-30**] truck [**Last Name (un) 8886**], has mild MR
.
7) Hypercholesterolemia, [**5-2**] total chol 206, LDL 105
.
8) Gout, primarily in big toes BL
.
9) Stress incontinence
.
10) Asthma, no prior hospitalizations, no oral steroids.
.
11) Osteopenia, height loss of 3 inches
.
12) Allergic rhinitis
.
13) Atrial fibrillation/flutter, on warfarin
.
14) Anemia, [**12-30**] renal failure, on Procrit
.
15) Hypertension, controlled on lisinopril, nifedipine
.
16) s/p cholecystectomy
Social History:
Lives with cousin [**First Name8 (NamePattern2) **] [**Name (NI) **]). On Medicare. Has a dog.
Past smoking history but quit in [**2078**]. Occasional EtOH.
Family History:
Father-CA and [**Name2 (NI) **] at age 61, grandmother-breast CA and diabetes,
mother-diabetes, stroke, CAD.
Physical Exam:
Hgt 4'9" Wgt 52.4 kg (max 102 kg 18 years ago) T 98.1 P 69
BP 130/72 RR 18 99% RA
GEN: Appears older than stated age. NAD. AaOx3. Thin hair.
HEENT: Right fronto-temporal scar, convexity. Sclera anicteric.
No conjunctival pallor. MMM. Clear oropharynx. No
thyromegaly or nodules.
CV: IR / IR, nl S1, S2. No M/R/G.
LUNGS: CTAB, clear breath sounds in all fields.
ABD: Flat, soft, NT, ND. No organomegaly or mass.
EXT: Palpable fems b/l, Palp R DP, dopp R PT, L DP/PT
Wounds:
Site: right groin
Type: Surgical
Dressing: Gauze - dry
Site: left foot amp
Description: draining sm amount sang drng.
Care: On VAC @ 125mm/hg / CHANGE DRESSING EVERY TWO DAYS
Site: right groin thrombectomy site
Description: staples intact/eccymotic area,hard to touch/old
dsg. with sang drng sm amount
Site: coccyx
Description: Stage III
Pertinent Results:
Admission Labs:
[**2108-1-2**] 01:35PM BLOOD WBC-16.2*# RBC-3.86* Hgb-11.1* Hct-33.0*
MCV-86 MCH-28.9 MCHC-33.8 RDW-16.7* Plt Ct-280
[**2108-1-2**] 01:35PM BLOOD Neuts-92.6* Bands-0 Lymphs-5.1*
Monos-1.9* Eos-0.3 Baso-0
[**2108-1-2**] 01:35PM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL
Macrocy-NORMAL Microcy-1+ Polychr-NORMAL
[**2108-1-2**] 01:35PM BLOOD Plt Smr-NORMAL Plt Ct-280
[**2108-1-2**] 06:20PM BLOOD PT-31.1* PTT-38.0* INR(PT)-3.3*
[**2108-1-2**] 01:35PM BLOOD ESR-120*
[**2108-1-2**] 01:35PM BLOOD Glucose-141* UreaN-82* Creat-3.9* Na-138
K-4.1 Cl-97 HCO3-27 AnGap-18
[**2108-1-2**] 01:35PM BLOOD Calcium-9.8 Phos-3.3 Mg-2.3
[**2108-1-2**] 03:15PM BLOOD Lactate-1.8
.
Microbiology:
Blood Cultures x 2 ([**1-2**]) No growth
Wound Swab: MSSA, Group B Strep (Levo resistant), and
diptheroids
Urine cultures: ([**1-4**]) No growth
([**1-7**]) <10,000 organisms/ml.
([**1-9**]) YEAST. >100,000 ORGANISMS/ML.
DFA for varicella ([**1-10**]) negative.
.
Studies:
[**1-2**] XR left foot: IMPRESSION: 1. Indistinct cortical contour of
terminal tuft of the left third distal phalanx, concerning for
osteomyelitis, related to an adjacent ulcer.
2. Cystic change in the first metatarsal head is likely
degenerative, related to the hallux valgus deformity, although
the less likely possibility of gout could be considered in the
appropriate clinical setting.
3. [**Month/Day (1) **] calcifications.
.
[**1-3**] Lower Extremity Arterial Doppler: IMPRESSION: Significant
bilateral popliteal/tibial artery occlusive disease with severe
flow deficit to both forefeet.
.
[**1-5**] Venous Dup Extext Bil: FINDINGS: The greater and lesser
saphenous veins are patent bilaterally. Please see digitized
image on PACS for formal sequential vein measurements.
.
[**1-6**] Stress P-MIBI: IMPRESSION: No anginal symptoms with an
uninterpretable EKG for ischemia. Normal pharmacologic
myocardial perfusion study with normal left ventricular wall
motion and cavity size. Compared with the study of [**2100-9-17**], no
significant change.
.
[**1-6**] Dialysis Catheter Placement: IMPRESSION: Successful
placement of right internal jugular tunneled hemodialysis
catheter with tip in the right atrium. The catheter is now
ready for use.
.
[**1-9**] Pre-op CXR IMPRESSION: 1. Small bilateral pleural
effusions with no evidence of parenchymal consolidation. Mild
symettric [**Month/Year (2) 1106**] promince suggests possible fluid overload
related to underlying renal condition.
.
[**1-9**] Pre-op EKG Regular ventricular pacing; Atrial flutter;
Since previous tracing, atrial flutter more apparent.
.
Other pertinent results:
[**2108-1-6**] 07:05AM BLOOD Glucose-133* UreaN-123* Creat-5.5* Na-136
K-4.0 Cl-97 HCO3-23 AnGap-20
[**2108-1-7**] 07:30AM BLOOD Hapto-434*
[**2108-1-3**] 09:30AM BLOOD Triglyc-294* HDL-19 CHOL/HD-8.8
LDLcalc-89
[**2108-1-5**] 06:50AM BLOOD PTH-100*
[**2108-1-7**] 01:15PM BLOOD HBsAg-NEGATIVE HBcAb-NEGATIVE
[**2108-1-9**] 05:55AM BLOOD Vanco-20.4*
[**2108-1-7**] 01:15PM BLOOD HCV Ab-NEGATIVE
[**2108-1-5**] 07:38AM BLOOD pH-7.41
[**2108-1-5**] 07:38AM BLOOD freeCa-1.08*
.
Discharge labs:
[**2108-1-26**] 07:45AM BLOOD WBC-9.3 RBC-2.94* Hgb-8.8* Hct-25.8*
MCV-88 MCH-30.0 MCHC-34.2 RDW-16.3* Plt Ct-278
[**2108-1-27**] 04:56AM BLOOD PT-17.3* INR(PT)-1.6*
[**2108-1-26**] 07:45AM BLOOD Plt Ct-278
[**2108-1-26**] 07:45AM BLOOD Glucose-143* UreaN-34* Creat-2.2* Na-136
K-3.6 Cl-97 HCO3-30 AnGap-13
[**2108-1-26**] 07:45AM BLOOD Calcium-8.3* Phos-3.0 Mg-1.6 UricAcd-4.6
[**2108-1-19**] 11:47 am SWAB Source: Left 4th toe ulcer - deep.
FINAL REPORT 02/28/0
GRAM STAIN (Final [**2108-1-19**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI, IN PAIRS AND
CLUSTERS.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S). SMEAR
REVIEWED; RESULTS CONFIRMED.
WOUND CULTURE (Final [**2108-1-21**]):
STAPH AUREUS COAG +. HEAVY GROWTH.
PENICILLIN SENSITIVITY AVAILABLE ON REQUEST.
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN-------------<=0.25 S
TRIMETHOPRIM/SULFA---- S
ANAEROBIC CULTURE (Final [**2108-1-25**]):
PREVOTELLA SPECIES. MODERATE GROWTH. BETA LACTAMASE
POSITIVE.
Brief Hospital Course:
In the ED, she was seen by podiatry, who probed her wound to
bone, obtained wound and blood cultures, and ordered Chem 10,
CBC, coags, lactate, ESR, and foot xray. She was started on
Unasyn empirically.
.
1) Toe ulcer: Ms. [**Known lastname 8884**] presented with an ulcer that had been
present for six months with fluctuating course, and was found to
be osteomyelitis after being probed to bone, with possible
cellulitis spreading in foot. She was started on vancomycin,
levofloxacin, and Flagyl. A culture of the wound grew
levo-resistant Group B strep, MSSA, and diptheroids.
Levofloxacin was discontinued. [**Known lastname **] insufficiency was
confirmed by doppler of lower extremities and ABIs which showed
significant bilateral popliteal/tibial artery occlusive disease
with severe flow deficit to both forefeet. Additionally, she
was found to have poor proprioception in her toes on admission.
On [**1-10**], a new pungent odor from toe was appreciated. Although
her white count was intermittently elevated, the erythema was
stable, as was her temperature. [**Month/Year (2) **] surgery was then
consulted:
[**Month/Year (2) **] procedures:
[**11-9**] - Diagnostic abdominal aortogram and pelvic arteriogram
with unilateral lower extremity runoff, contralateral third
order catheterization, primary balloon angioplasty of the
anterior tibialis x 3. Infusion for thrombolysis of the distal
AT. CPT codes [**Numeric Identifier 4237**], [**Numeric Identifier 4238**], [**Numeric Identifier 8881**],
[**11-10**] - Open third ray amputation left foot
[**11-14**] - Exploration of right groin and repair of bleeding, right
common femoral artery. [**Numeric Identifier 8882**], [**Numeric Identifier 8883**].
[**11-21**] - OPERATION:
1. Open ray amputation left fourth toe.
2. Debridement of skin and subcutaneous tissue, muscle, and
bone.
.
2) Acute on chronic renal failure: Ms. [**Known lastname 8884**] had had a prior
nephrectomy for secondary FSGS and a perinephric abscess. On
admission, her baseline creatinine was around 3.0-3.5. She was
admitted with a creatinine of 3.9, which rose to 5.5. Lasix was
D/C'ed as there was no evidence of volume overload. All
medications were redosed for inrenal function as needed. She had
had a previous failed attempt at AV fistula formation due to
poor vessel quality, so she then received a central venous
dialysis catheter. Renal team followed her and she was dialyzed
twice while on the medicine service with Procrit, iron, and
calcitriol given at dialysis as needed. The etiology of the
acute renal process was never definitively determined, although
it was thought that there may have been contribution from
medications, volume depletion, or an intrinsic process. There
were signs suggestive of an intrinsic renal process, including
Albumin:Cr of 176 (Serum albumin low at 2.8, LFTs normal) and
granular casts were noted on urinary sediment, suggestive of
ATN. She was continued on an ACE inhibitor to minimize albumin
loss. She was not a regular HD schedule. This will be determined
by Renal. She did get HD [**1-27**]. On [**1-27**] - this was renals
recommendations:
Access - tunneled line no issues, working well at hd
.
Renal function - ESRD
.
Na, bp volume - cont lopressor, lisinopril
.
Potassium - low k diet, 3.5 k bath
.
Acid base - 35 bicarb bath at hd
.
Anemia - epo 10,000 units at HD
.
Ca, phos - Zemplar 1 mcg at hd
.
Renal replacement - hd today 3 1/2 hrs 350 qb goal 1 kg uf
.
3) Orthopnea- Ms. [**Known lastname 8884**] developed positional dyspnea on [**1-8**],
which was though to be likely due to volume overload, as she had
received approximately 1 liter of IV fluids in the preceding day
as renal protection for scheduled angiography. Her oxygen
saturation fell to 92% on room air on [**1-9**], and she was put on
2L oxygen by nasal cannula with improvement to 99%. A CXR was
c/w volume overload. By the afternoon of [**1-9**], her oxygen
saturation was adequate on room air, and she denied further
symptoms.
.
4) Dermatomal vesicular rash- First noted by the patient on [**1-8**]
on chest midline T4, tender to light touch. This was felt to be
concerning for VZV. Acyclovir was started empirically and she
was put on contact precautions. A DFA came back negative for
VZV on [**1-11**], and acyclovir was discontinued. Much improved on
DC.
.
5) Type II Diabetes: Ms [**Known lastname 8884**] has longstanding DM that she
says is controlled by diet alone and her HbA1c has always been
less than or equal to 6.4%, which implies reasonable control.
She says that she is followed by an ophthalmologist at [**Hospital1 18**] and
that she does not have any ocular disease. She strongly denies
neuropathy, although her position sense in her toes did not
appear to be fully intact. Her finger sticks were monitored [**Hospital1 **],
and then changed to QID for tighter control on an insulin
sliding scale.
.
6) 5 point hematocrit drop- From [**1-6**] to [**1-7**], patient's
hematocrit dropped from 29.8 to 24.0. There was no record of
significant blood loss during IR procedure. She had no sign of
hematoma at procedure site. A haptoglobin, LDH, and TBili were
not consistent with a hemolytic process. All stools were guaiac
negative. 2 units pRBCs were given [**1-7**] with an appropriate
response, and she experienced no further drop in hematocrit.
To note pt did have an angiogram on [**11-9**]. On [**11-14**] it was
thought that the pt developed a psueedo anuerysm post cath. Pt
experienced extreme thigh pain / dropped her pressure. Pt was
taken to the the OR emrgently for hematoma evacuation and repair
odf her femoral arery. Pt did recieve PRBC. On Dc HCt is stable
.
7) Asthma: Ms. [**Known lastname 8884**] has had no prior hospitalizations or oral
steroid use for her asthma. She had an exacerbation on [**1-4**] at
night, but responded to albuterol inhaler with no further
exacerbations. She was given albuterol and fluticasone inhalers
daily for control of symptoms.
.
8) Atrial fibrillation/flutter: Ms [**Known lastname 8884**] has a history of
paroxysmal A-fib. She is on warfarin, and was admitted with a
supratherapeutic INR at 3.9 that rose to 4.5. LFTs were normal.
Warfarin was held. She was given vitamin K and 2 units of
fresh frozen plasma with correction of her INR to 1.3. IM
heparin was given for DVT prophylaxis at this point. When her
vascualr issues were completed. Pt restarted on her coumadin On
Dc her INR is 1.6
.
9) Social/financial: Patient expressed concerns regarding
insurance coverage of dialysis and that she has been trying to
get on Medicare. She is on disability and has few financial
resources. Social work was consulted and will follow with
recommendations for outpatient dialysis placement.
.
10) Ms. [**Known lastname 8887**] hypertension was controlled on lisinopril,
nifedipine.
.
11) Hypertriglyceridemia: A lipid panel was ordered which showed
trigglycerides 294, cholesterol 167, and LDL 89. Before
hospital discharge, her PCP should be consulted regarding
whether she would advise adding gemfibrozil.
Medications on Admission:
Albuterol 17 gm, 2 puffs qid PRN cough
Allopurinol 200 mg qday
Atenolol 50 mg qday
Azmacort 100 mcg, 3-4 puffs [**Hospital1 **]
Furosemide 40 mg qday
Lisinopril 5 mg qday
Loratidine 10 mg qday
MVA qday
Nasonex 50 mcg, 2 sprays each nostril qday PRN
Nifedical XL 30 mg qday
Nortryptiline 20 mg qhs
Procrit 10,000 units SQ qweek
Tums 750 mg tid with food
Tylenol 1,000 mg [**Hospital1 **] PRN
Tylenol-Codeine#3 300/30 mg, 1-2 tabs qhs PRN pain
Warfarin 2.5-5.0 mg qday
Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
2. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
3. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
4. Fluticasone 50 mcg/Actuation Aerosol, Spray Sig: One (1)
Spray Nasal DAILY (Daily).
5. Nortriptyline 10 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
6. Acetaminophen-Codeine 300-30 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed.
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
8. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO QTUTHSA
(TU,TH,SA).
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**11-29**] Sprays Nasal
QID (4 times a day) as needed.
11. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
12. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed.
13. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed for pain.
14. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for abd discomfort.
15. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
16. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
18. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed for skin breakdown in abd. skin folds.
19. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
20. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
21. iNSULIN
Insulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
Humalog
Glucose Insulin Dose
0-70 mg/dL 4 oz. Juice and 15 gm crackers 4 oz. Juice
71-150 mg/dL 0 Units 0 Units 0 Units 0 Units
151-200 mg/dL 1 Units 1 Units 1 Units 1 Units
201-250 mg/dL 2 Units 2 Units 2 Units 2 Units
251-300 mg/dL 3 Units 3 Units 3 Units 3 Units
301-350 mg/dL 4 Units 4 Units 4 Units 4 Units
351-400 mg/dL 5 Units 5 Units 5 Units 5 Units
> 400 mg/dL Notify M.D.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 1121**] - [**Location (un) 1456**]
Discharge Diagnosis:
L 4th toe open ulceration / cellulitis
Right groin hematoma post angiogram
DM(II)diet controlled
A. flutter
CRI(3.0)
HTN
Pressure ulcer coccyyx
Discharge Condition:
stable
Discharge Instructions:
VAC DRESSING Discharge Instructions
Introduction:
This will provide helpful information in caring for your wound.
If you have any questions or concerns please talk with your
doctor or nurse. You have an open wound, as opposed to a closed
(sutured or stapled) wound. The skin over the wound is left open
so the deep tissues may heal before the skin is allowed to heal.
Premature closure or healing of the skin can result in
infection. Your wound was left open to allow new tissue growth
within the wound itself. The wound is covered with a VAC
dressing. This will be changed every TWO DAYS.
The VAC:
_ helps keep the wound tissue clean
_ absorbs drainage
_ prevents premature healing of skin
- promotes healing
When to Call the Doctor:
Watch for the following signs and symptoms and notify your
doctor if these occur:
Temperature over 101.5 F or chills
Foul-smelling drainage or fluid from the wound
Increased redness or swelling of the wound or skin around it
Increasing tenderness or pain in or around the wound
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] SURGERY (NHB)
Date/Time:[**2108-2-10**] 2:30
Provider: [**Name10 (NameIs) **] CALL Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2108-2-21**]
9:30
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2108-5-21**]
9:00
Completed by:[**2108-1-27**]
|
[
"V10.42",
"730.07",
"707.03",
"317",
"V15.3",
"E879.8",
"585.6",
"709.8",
"285.21",
"584.5",
"682.7",
"274.9",
"440.24",
"707.15",
"784.7",
"444.22",
"493.92",
"997.2",
"041.00",
"V45.01",
"V09.0",
"041.11",
"V45.73",
"790.92",
"428.0",
"998.11",
"250.00",
"582.1",
"403.91",
"442.3",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"84.11",
"99.10",
"39.95",
"77.88",
"86.22",
"39.50",
"00.40",
"38.95",
"99.04",
"39.41",
"99.07",
"88.48"
] |
icd9pcs
|
[
[
[]
]
] |
18853, 18953
|
8977, 16048
|
299, 1061
|
19141, 19150
|
7231, 7707
|
20226, 20643
|
3636, 3747
|
16565, 18830
|
18974, 19120
|
16074, 16542
|
19174, 20203
|
7724, 8954
|
3762, 4597
|
230, 261
|
1089, 2500
|
4632, 7212
|
2522, 3443
|
3459, 3620
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,682
| 100,636
|
42794
|
Discharge summary
|
report
|
Admission Date: [**2189-1-17**] Discharge Date: [**2189-1-25**]
Date of Birth: [**2138-6-15**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
[**2189-1-19**] Coronary artery bypass graft x4 -- left internal mammary
artery to left anterior descending artery and saphenous vein
grafts to diagonal, obtuse marginal 1, and obtuse marginal 2
History of Present Illness:
Mr. [**Known lastname **] is a 50 year old man who had four days of chest and
left arm pain and was admitted to [**Hospital6 3105**]
after a subsequent cardiac catheterization revealed multi-vessel
coronary artery disease. He was transferred to [**Hospital1 18**] for
surgical evaluation.
Past Medical History:
Hypertension
Diabetes Mellitus
Depression
Anxiety
Benign prostatic hypertrophy
Skin lesion removal of right infraorbital area
s/p TURP
Social History:
Race:hispanic
Last Dental Exam:> 1 year
Lives with:wife
Contact: [**Name (NI) **] [**Last Name (NamePattern1) 91012**] Phone #([**Telephone/Fax (1) 92458**]
Occupation:disability due to depression
Cigarettes: Smoked no [x] yes [] last cigarette [**2172**] Hx:
1.5ppd times 25 years
ETOH: < 1 drink/week [x] [**2-3**] drinks/week [] >8 drinks/week []
Illicit drug use - no
Family History:
No Premature coronary artery disease
Physical Exam:
Pulse:50 Resp:16 O2 sat:100%RA
B/P L:147/81
Height:5"3 Weight:151 lbs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [x] grade I/VI diastolic
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema none
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right:2+ Left:2+
DP Right:2+ Left:2+
PT [**Name (NI) 167**]:2+ Left:2+
Radial Right:2+ Left:2+
Carotid Bruit Right:- Left:-
Pertinent Results:
CT [**2189-1-18**]: No intrathoracic, intra-abdominal, or intrapelvic
pathology
identified.
.
Echo: [**2189-1-19**]: PRE-BYPASS:
The left atrium is dilated. No spontaneous echo contrast or
thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler. Right ventricular chamber size and free wall motion are
normal. There are simple atheroma in the aortic arch. There are
simple atheroma in the descending thoracic aorta. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. No mitral regurgitation is seen.
There is no pericardial effusion. Dr.[**First Name (STitle) **] was notified in
person of the results before surgical incision.
Postbypass: Preserved biventricular systolic function. LVEF 55%.
Intact thoracic aorta. No new valvular findings.
Brief Hospital Course:
As mentioned in the HPI, Mr. [**Known lastname **] was transferred from
outside hospital after cardiac cath revealed severe coronary
artery disease. Upon admission he was medically managed and
underwent pre-operative work-up. On [**1-20**] he was brought to the
operating room where he underwent a coronary arterty bypass
graft x 4. Please see operative note for details. Following
surgery he was transferred to the CVICU for invasive monitoring
in stable condition. His awoke from sedation hemodynamically
stable and was weaned from the ventilator and extubated. He was
started on betablockers, lasix, ASA and statin therapy. CT and
temporary pacing wires were removed per protocol. He was
evaluated by physical tehrpay for strnegth and conditioning. On
3 separate occasions when he was walking on the stairs he became
hypotensive w/ SBP 70's-80's and diaphoretic. His medications
were adjusted and he was given 2 UPRBC for post-op anemia( HCT
22) with stabilization of his hemodynamics. An ECHO was done
without evidence of pericardial effusion. CXR revealed a
moderate left effusion which has responded to diuresis. On POD#
6 he was cleared for dischrge to home and all follow up
instructions and appointments were advised.
Medications on Admission:
lisinopril 20mg daily, lantus 50 units at bedtime, aspirin 81mg
daily, remeron 45mg daily, zocor 80mg daily, relafen 750mg [**Hospital1 **]
PRN, colace 100mg [**Hospital1 **], metformin 1000mg [**Hospital1 **]
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. mirtazapine 15 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
4. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*65 Tablet(s)* Refills:*0*
5. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*2*
6. simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
7. metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
8. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 5 days.
Disp:*5 Tablet(s)* Refills:*1*
9. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO once a day for 5 days.
Disp:*10 Tablet Extended Release(s)* Refills:*1*
10. glargine
take only 10 units of lantus at bedtime and check you
fingerstick before meals and at bedtime
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Coronary artery disease s/p Coronary artery bypass graft x 4
Past medical history:
Hypertension
Diabetes Mellitus
Depression
Anxiety
Benign prostatic hypertrophy
Skin lesion removal of right infraorbital area
s/p TURP
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage.
Edema- none
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**First Name (STitle) **] on [**2189-3-3**] at 1:00pm in the [**Hospital **] medical
office building, [**Hospital Unit Name **]
Cardiologist: Dr. [**Last Name (STitle) 66588**] on [**2189-2-25**] at 10:45am
Wound check: [**Hospital Unit Name **], [**Hospital Unit Name **] on [**2189-1-29**] at 11:00am
Please call to schedule appointments with your
Primary Care Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 696**] in [**4-2**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2189-1-25**]
|
[
"V58.67",
"786.51",
"V15.82",
"401.9",
"285.9",
"511.9",
"356.9",
"250.00",
"414.01",
"458.29",
"276.1",
"414.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.13",
"39.61",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
5739, 5814
|
3119, 4347
|
320, 516
|
6075, 6286
|
2111, 3096
|
7126, 7930
|
1408, 1446
|
4607, 5716
|
5835, 5896
|
4373, 4584
|
6310, 7103
|
1461, 2092
|
270, 282
|
544, 834
|
5918, 6054
|
1008, 1392
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,968
| 161,569
|
17425
|
Discharge summary
|
report
|
Admission Date: [**2169-4-24**] Discharge Date: [**2169-5-4**]
Date of Birth: [**2109-1-18**] Sex: F
Service: Cardiac Surgery
HISTORY OF PRESENT ILLNESS: This 59-year-old white female
who has a history of jaw pain x1 month which was relieved
with sublingual nitroglycerin and had a positive exercise
tolerance test. She was referred for cardiac catheterization
which revealed a 70% distal left main coronary artery
stenosis, 90% left anterior descending artery stenosis, the
left circumflex was diffusely diseased with a 90% OM-2 and
proximal severe disease of the OM-3. The right coronary
artery had a 90% proximal stenosis. The PDA had an 80%
proximal stenosis. Her left ventricle showed severe diffuse
hypokinesis with an ejection fraction of 25%, and she was
admitted for coronary artery bypass graft.
PAST MEDICAL HISTORY:
1. History of a seizure disorder.
2. Status post cerebrovascular accident on [**2152**] with residual
deficit of an unsteady gait.
3. Status post left fem-[**Doctor Last Name **] bypass.
4. History of hypertension.
5. History of hypercholesterolemia.
6. History of noninsulin-dependent diabetes.
SOCIAL HISTORY: She does smoke cigarettes. Does not drink
alcohol and lives with her husband.
ALLERGIES: She has no known allergies.
MEDICATIONS ON ADMISSION:
1. Aspirin 81 mg po q day.
2. Dilantin 400 mg po q hs.
3. Hydrochlorothiazide 25 mg po q day.
4. Univasc 7.5 mg po q day.
5. Glucophage 1,000 mg po q am, 500 mg po q pm.
6. Toprol XL 50 mg po q day.
7. Glyburide 10 mg po q day.
8. Isosorbide 30 mg po q day.
REVIEW OF SYSTEMS: Unremarkable except for her unsteady
gait.
PHYSICAL EXAMINATION: On physical examination, she is a
well-developed and well-nourished white female in no apparent
distress. Vital signs stable, afebrile. HEENT examination
is normocephalic, atraumatic. Extraocular movements are
intact. Oropharynx is benign. Neck is supple, full range of
motion, no lymphadenopathy, or thyromegaly. Carotids are 2+
and equal bilaterally without bruits. Lungs are clear to
auscultation and percussion. Cardiovascular examination:
regular, rate, and rhythm, normal S1, S2 with no murmurs,
rubs, or gallops. Abdomen was soft and nontender with
positive bowel sounds, no masses or hepatosplenomegaly.
Extremities were without clubbing, cyanosis, or edema.
Pulses were 2+ and equal on the carotids, 2+ and equal on the
radials. The right femoral was 2+. The left femoral was 1+,
and the dorsalis pedis was nonpalpable on the right and 1+ on
the left.
Dr. [**Last Name (STitle) 70**] was consulted. Neurology saw the patient
preoperatively. She had a MRA of the head on [**4-25**] which
revealed a large old right PCA territory infarct involving
the posterior temporal lobe and the medial parietal and
occipital lobes as well as the right thalamus. She also had
old bilateral lacunes.
Neurology cleared her for surgery and on [**4-26**], she underwent
a CABG x4 with LIMA to the left anterior descending artery,
reverse saphenous vein graft to the diagonal with a Y to the
OM and the PDA. Cross-clamp time was 84 minutes, total
bypass time 113 minutes. She was transferred to the Surgical
Intensive Care Unit on Neo-Synephrine, dobutamine, and
propofol.
She had a stable postoperative night, she was extubated. Her
dobutamine was weaned off. Then she remained on
Neo-Synephrine. This was weaned off on postoperative day
two, and her chest tubes were discontinued. She did slowly
progress, but she got very confused and agitated and was
delirious. She required Haldol. She eventually became
reoriented, and she also had epicardial pacing wires
discontinued on postoperative day #3.
Postoperative day #5, she had a hepatic appearing lesion in
her lower back and was started on acyclovir. Her mental
status continued to improve, and on postoperative day #7, she
was transferred to the floor in stable condition. She became
fully oriented and had a normal mental status and continued
to improve, and on postoperative day #8, she was discharged
to rehabilitation in stable condition.
LABORATORIES ON DISCHARGE: Hematocrit 34.2, white count
9,900, platelets 488,000. Sodium 142, potassium 4.9,
chloride 102, CO2 26, BUN 17, creatinine 1.0, blood sugar
109.
DISCHARGE MEDICATIONS:
1. Ecotrin 325 mg po q day.
2. Dilantin 400 mg po q hs.
3. Univasc 7.5 mg po q day.
4. Glucophage 1,000 mg po q am, 500 mg po q pm.
5. Toprol XL 75 mg po q day.
6. Glyburide 10 mg po q day.
7. Vioxx 25 mg po q day prn.
8. [**First Name5 (NamePattern1) 233**] [**Last Name (NamePattern1) 1002**] 20 mEq po q day x7 days.
9. Lasix 20 mg po bid x7 days.
10. Colace 100 mg po bid.
11. Acyclovir 800 mg po qid x3 days.
FOLLOW-UP INSTRUCTIONS: She will be followed by Dr. [**Last Name (STitle) **]
in [**11-24**] weeks, Dr. [**Last Name (STitle) **] in two weeks, and Dr. [**Last Name (STitle) 70**] in
six weeks.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 6516**]
MEDQUIST36
D: [**2169-5-4**] 11:15
T: [**2169-5-4**] 11:50
JOB#: [**Job Number 48692**]
|
[
"429.9",
"433.10",
"250.00",
"440.20",
"780.39",
"414.01",
"438.89",
"411.1",
"425.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"37.23",
"88.53",
"88.56",
"36.13",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
4277, 4692
|
1316, 1575
|
1662, 4092
|
4107, 4254
|
1595, 1639
|
176, 833
|
4717, 5190
|
855, 1152
|
1169, 1290
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,099
| 110,827
|
11867+56296
|
Discharge summary
|
report+addendum
|
Admission Date: [**2198-2-8**] Discharge Date: [**2198-2-15**]
Date of Birth: [**2125-1-13**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 398**]
Chief Complaint:
hypoxia
Major Surgical or Invasive Procedure:
[**Location (un) **] tracheal canula change and debridement of granulation
tissue
History of Present Illness:
This is a 73 year old gentleman with a PMH significant for
tracheobronchomalacia and severe central OSA s/p trach placed in
[**5-26**] with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] button in [**11-27**], obesity hypoventilation
syndrome s/p, asthma, c-spine injury with left diaphragmatic
paralysis, pulmonary HTN, diastolic CHF, followed by Dr.
[**Last Name (STitle) **], who is transferred from the PACU s/p trach revision
with post-operative hypoxia with oxygen saturations to the
60-70% range.
.
Patient underwent flexible bronchoscopy on [**2197-10-27**] demonstrating
supraglottic tissues which were collapsing over the epiglottis
creating obstruction with mild degree of granulation tissue
around the [**Location (un) **] tube. This afternoon, he underwent
[**Location (un) **] tracheal canula change and debridement of granulation
tissue. In the PACU, his oxygen saturations were in the 60-70%
range on room air. Patient was awake, alert, and without
acute complaints. Patient was transferred to the MICU for
monitoring of oxygenation status overnight.
.
Upon transfer to the MICU, patient appears comfortable and is
breathing comfortably with oxygen saturations of 87% on RA. He
has no acute complaints at this time.
Past Medical History:
1. OSA s/p trach [**5-26**], [**Location (un) **] button [**11-27**]
2. Asthma
3. HTN
4. DM2
5. Hyperlipidemia
6. PUD
7. CHF - diastolic heart failure (documented on Echo in [**2192**])
8. Pulmonary hypertension
9. History of PEA arrest
10. Obesity hypoventilation syndrome
Social History:
Lives with his wife, used to work in Demolition,
Never smoked, no EtOh, no IVDU.
Family History:
Father had an MI at 49, Mother with MI at 44,
Brother with MI at 75.
Physical Exam:
VS: Temp: 96.7, BP: 139/76 HR: 76 RR: O2sat: 87% RA
GEN: pleasant, NAD
HEENT: PERRL, EOMI, anicteric, dry mucous membranes
RESP: expiratory wheezes bilaterally
CV: RR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no pedal edema
SKIN: no rashes/no jaundice/no splinters
NEURO: AAOx3. 5/5 strength throughout
Pertinent Results:
[**2198-2-8**] 09:41PM GLUCOSE-151* UREA N-17 CREAT-1.0 SODIUM-140
POTASSIUM-4.3 CHLORIDE-95* TOTAL CO2-38* ANION GAP-11
[**2198-2-8**] 09:41PM CALCIUM-9.1 PHOSPHATE-4.8*# MAGNESIUM-1.7
[**2198-2-8**] 09:41PM WBC-7.6 RBC-5.75 HGB-17.0 HCT-53.1* MCV-93
MCH-29.7 MCHC-32.1 RDW-13.5
[**2198-2-8**] 09:41PM PLT COUNT-121*
.
[**2198-2-15**] 04:42AM BLOOD WBC-4.8 RBC-5.24 Hgb-15.6 Hct-46.2 MCV-88
MCH-29.8 MCHC-33.7 RDW-12.9 Plt Ct-134*
[**2198-2-15**] 04:42AM BLOOD Glucose-172* UreaN-24* Creat-0.8 Na-133
K-4.1 Cl-91* HCO3-38* AnGap-8
[**2198-2-15**] 04:42AM BLOOD Calcium-9.2 Phos-3.3 Mg-1.8
[**2198-2-14**] 04:00AM BLOOD Type-ART Temp-36.7 Rates-/16 Tidal V-250
PEEP-5 FiO2-30 pO2-79* pCO2-63* pH-7.38 calTCO2-39* Base XS-8
Intubat-INTUBATED
EKG: [**2198-2-6**]: Sinus rhythm. A-V conduction delay. Non-specific
lateral ST-T wave changes as recorded [**2197-7-7**]. Otherwise, no
diagnostic interim change.
.
Imaging:
Chest radiograph ([**2197-2-6**]): FINDINGS: The lung volumes are
relatively low. There is unchanged marked cardiomegaly with
large diameter pulmonary vessels, suggesting mild-to-moderate
overhydration. No pleural effusions. No focal parenchymal
opacity suggesting pneumonia. Normal appearance of the
mediastinal and hilar contours.
Brief Hospital Course:
In regards to vent settings: [**Location (un) 7188**] with bag attachement,
current setting (1 liter oxygen) and an oxygen flow rate up to 6
liters/minute. We didn't test higher flow rates. [**Location (un) 7188**] with
vent settings PS 5, PEEP 5, and the minimal FiO2 needed to get
sats 90-94%. We can't set a BUR as we would on BiPAP ST, but if
the low MV alarm sounds, the ventilator will switch to SIMV
mode.
.
To Do: Needs teaching about trach care and vent management prior
to safe return to home.
.
Hospital Course:
#. Hypoxia: Likely multifactorial as patient with known
tracheobronchomalacia and severe OSA, asthma, pulmonary
hypertension, and diastolic CHF. Lack of fever, leukocytosis,
symptoms, or chest radiographic evidence of opacities argues
against PNA. With evidence of mild volume overload on chest
radiograph was given some lasix in attempt to diuresis with mild
improvement in hypoxia and increase in bicarb. IP recommended a
sleep study to assess for central sleep apnea after a witnessed
episode of apnea while in the ICU.
He had a tracheostomy tube placed on the monring of [**2-10**]. He
required mechanical ventilation for a short time afterwards
while the sedating medications wore off. He underwent the sleep
study the night of [**2-10**] which was inconclusive. Vent settings
were titrated with multiple sleep studies and he ultimately did
well on trach colalr during the day and PSV 5/5 FiO2 30% on
[**Location (un) 7188**] ventilator at nighttime. He should continue on these
vent settings while sleeping and will need teaching about how to
suction, deflate and inflate cuff and use ventilator. Goal PCO2
at nighttime remained around 60.
#. Asthma: Continued albuterol nebs.
.
#. Diastolic CHF: On last echo in [**2194**], patient found to have
severe symmetric left ventricular hypertrophy. With evidence of
volume overload on chest radiograph was diuresed until
bicarbonate increased and then discontinued diuresis.
#. HTN: Stable, continued home hydrochlorothiazide, metoprolol,
nifedipine, and lisinopril.
#. DM: Stable, held home oral antiglycemic medications and
covered with insulin sliding scale overnight. Restarted home
regimen on discharge.
#. Hyperlipidemia: Continued lovastatin 20mg PO daily.
#. PUD: Stable, on PPi.
Comm: patient
[**Name2 (NI) 7092**]: FULL code
Medications on Admission:
- ALBUTEROL SULFATE - 2.5 mg/0.5 mL Solution for Nebulization -
1
(One) ampoule inhaled via nebulizaiton every eight (8) hours
- ALBUTEROL SULFATE - 90 mcg HFA Aerosol Inhaler - [**1-21**] puffs
Q4-6
prn
- FREESTYLE GLUCOMETER - - as directed for blood sugar
monitoring dx code 250.00
- GLIPIZIDE [GLUCOTROL XL] - 5 mg Tablet Extended Rel 24 hr - 1
Tab(s) by mouth once a day
- HYDROCHLOROTHIAZIDE - 25 mg Tablet - 1 Tablet(s) by mouth once
a
day
- LISINOPRIL - 40 mg Tablet - 1 Tablet(s) by mouth once a day
- LOVASTATIN - 20 mg Tablet - 1 Tablet(s) by mouth once a day
take
in the evening
- METFORMIN - 500 mg Tablet Sustained Release 24 hr - 1 (One)
Tablet(s) by mouth once a day Take in the morning with Glipizide
- METOPROLOL SUCCINATE [TOPROL XL] - 100 mg Tablet Sustained
Release 24 hr - 1 Tablet Sustained Release 24 hr(s) by mouth
once
a day
- NIFEDIPINE - 90 mg Tablet Sustained Release - 1 Tablet(s) by
mouth once a day
Discharge Medications:
1. [**Location (un) 7188**] Ventilator
Pressure support 5
PEEP 5
Back up rate 10
Oxygen 30%
Diagnosis: Tracheobronchomalacia, obstructive sleep apnea
2. albuterol sulfate 2.5 mg/0.5 mL Solution for Nebulization
Sig: One (1) amp Inhalation every 6-8 hours as needed for
shortness of breath or wheezing.
3. Glucotrol XL 5 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO once a day.
4. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
5. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. lovastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime.
7. metformin 500 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
8. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
9. nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
10. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
11. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Tracheomalacia
Central sleep apnea
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the ICU for low oxygen levels after a
tracheostomy revision. You were followed by the sleep doctors
and had a sleep study. Weigh yourself every morning, [**Name8 (MD) 138**] MD if
weight goes up more than 3 lbs. You will have teaching about
your ventilator and how to manage your trahheostomy at the
facility you are being discharged to.
There were no changes made to your medication regimen other
thanthe addition of heparin SC while you are at a rehab facility
to prevent blood clots.
It was a pleasure taking part in your care.
Please follow up as below and call the doctor if you have any
issues with your breathing or tracheostomy.
Followup Instructions:
Department: MEDICAL SPECIALTIES
When: FRIDAY [**2198-5-11**] at 9:00 AM
With: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3300**] RRT/DR [**First Name (STitle) **] [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: MEDICAL SPECIALTIES
When: FRIDAY [**2198-5-11**] at 9:00 AM
With: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3300**] RRT/DR [**First Name (STitle) **] [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Name: [**Known lastname 6725**],[**Known firstname **] Unit No: [**Numeric Identifier 6726**]
Admission Date: [**2198-2-8**] Discharge Date: [**2198-2-15**]
Date of Birth: [**2125-1-13**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 6727**]
Addendum:
1. [**Location (un) 5040**] Ventilator
Pressure support 5
PEEP 5
Back up rate 10
Oxygen 30%
Diagnosis: Tracheobronchomalacia, obstructive sleep apnea
2. albuterol sulfate 2.5 mg/0.5 mL Solution for Nebulization
Sig: One (1) amp Inhalation every 6-8 hours as needed for
shortness of breath or wheezing.
3. Glucotrol XL 5 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO once a day.
4. hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
5. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. lovastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime.
7. metformin 500 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
8. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
9. nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
10. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
11. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
Discharge Medications:
1. [**Location (un) 5040**] Ventilator
Pressure support 5
PEEP 5
Back up rate 10
Oxygen 30%
Diagnosis: Tracheobronchomalacia, obstructive sleep apnea
2. albuterol sulfate 2.5 mg/0.5 mL Solution for Nebulization
Sig: One (1) amp Inhalation every 6-8 hours as needed for
shortness of breath or wheezing.
3. Glucotrol XL 5 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO once a day.
4. hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
5. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. lovastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime.
7. metformin 500 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
8. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
9. nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
10. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
11. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 609**] for the Aged - MACU
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6728**] MD [**MD Number(1) 3662**]
Completed by:[**2198-2-15**]
|
[
"416.8",
"519.4",
"327.21",
"519.19",
"327.23",
"428.33",
"428.0",
"250.00",
"997.39",
"V85.38",
"493.20",
"E879.8",
"278.03",
"V46.11",
"519.09"
] |
icd9cm
|
[
[
[]
]
] |
[
"97.23",
"31.5",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
12700, 12923
|
3830, 4336
|
310, 393
|
8456, 8456
|
2546, 3807
|
9292, 11509
|
2091, 2162
|
11532, 12677
|
8398, 8435
|
6182, 7120
|
4353, 6156
|
8607, 9269
|
2177, 2527
|
263, 272
|
421, 1678
|
8471, 8583
|
1700, 1976
|
1992, 2075
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,942
| 188,564
|
25924
|
Discharge summary
|
report
|
Admission Date: [**2174-2-10**] Discharge Date: [**2174-2-23**]
Date of Birth: [**2144-1-6**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 1561**]
Chief Complaint:
Tracheal stenosis
Major Surgical or Invasive Procedure:
tracheal resection and reconstruction.
Bronchoscopy
History of Present Illness:
The patient is a 30-year-old woman with a past medical history
significant for resection of her thyroid at age 16 and abdominal
hysterectomy three years ago. For both of these, she required
general endotracheal anesthesia. She was in her usual state of
health until the spring of [**2173**] when she passed out from unknown
causes and required intubation for 5 days. An extensive work-up
was unrevealing. About 2 weeks post discharge she developed a
harsh progressive cough. This progressed to dyspnea and stridor
and was evaluated by ear, nose, and throat specialist. She was
found to have subglottic granulation tissue and underwent
resection of this. Postoperatively, she developed respiratory
distress and required intubation. She was subsequently found to
have tracheal stenosis and underwent placement of a
tracheostomy. At that time, a CT scan demonstrated 43-mm long
area of stenosis extending from the cervical trachea down to the
arch of the aorta. She was treated with ablative therapy, which
included cryotherapy and laser therapy. Ultimately, a silicone
Dumon stent was placed and maintained for 4 months. Ultimately,
it was removed on [**2173-11-4**], and she subsequently
developed recurrent stenosis. She was evaluated by you at this
point and ultimately had a temporary silicone stent replaced.
She now presents for surgical consideration. Other than the two
episodes of intubation for surgical procedures, she has no other
history of airway diseases. She has never had any trauma to her
airways. She has no known collagen vascular diseases. She denies
history of airway infections or lung infections in the past. She
has no current chest pain, no dyspnea at present, no current
stridor, no hemoptysis, no neurological or no musculoskeletal
complaints.
The patient underwent rigid brochoscopy on [**12-31**], which showed a
4.3 cm
area of stenosis in the mid upper trachea. There was
approximately 1.8 cm of disease, but salvageable trachea just
below the cricoid. The area of severe stenosis started at 1.8 cm
below the cricoid and extended from 4.3 cm until normal trachea
was encountered. There was 4.5 cm of normal trachea from the
distal portion of the stenosis to the carinal spur.
Past Medical History:
hypertension, depression and previous hysterectomy in [**2170**]. She
underwent thyroidectomy for thyroid cancer at age 16
Social History:
The patient underwent a divorce approximately 2 years ago and
has been diagnosed and treated for depression thereafter. She
does not smoke or use illicit drugs. She has a 4- and 6-year-old
child at home and is engaged.
Family History:
Significant for type 2 diabetes and a great aunt who had thyroid
cancer. No family members have history of airway disorders or
collagen vascular diseases or autoimmune diseases.
Physical Exam:
She is a well-appearing female in no apparent distress and is
mildly overweight. She weighs 190.6 pounds and is 66 inches
tall. Her vital signs demonstrate a blood pressure 123/81, pulse
104 and regular, heart rate 70, and
respiratory is 20, and oxygen saturation 96% on room air. Her
pupils are equal, round, and reactive. Her sclerae are
anicteric. Cervical exam reveals no supraclavicular or cervical
adenopathy. Her neck is not particularly long, but it also is
not short. Her larynx is well above the sternal notch with a
significant amount of cervical trachea. Lungs are clear to
auscultation bilaterally equal. There is no wheezing, no audible
stridor. Heart is regular without murmur. Thorax is symmetrical
without lesions or scars. She does have a cervical scar from her
previous thyroid surgery. Abdomen is benign without masses or
tenderness. Extremities show no clubbing or edema. Neurologic is
grossly nonfocal with intact and appropriate mental status.
Pertinent Results:
[**2174-2-11**] 12:30AM BLOOD WBC-6.1# RBC-3.61* Hgb-11.0* Hct-29.2*
MCV-81* MCH-30.3 MCHC-37.5* RDW-13.9 Plt Ct-220
[**2174-2-11**] 12:30AM BLOOD Plt Ct-220
[**2174-2-11**] 12:30AM BLOOD PT-11.8 PTT-25.1 INR(PT)-0.9
[**2174-2-11**] 12:30AM BLOOD Glucose-97 UreaN-13 Creat-0.6 Na-138
K-5.0 Cl-105 HCO3-24 AnGap-14
CXR:
PA AND LATERAL CHEST: The cardiomediastinal and hilar contours
are normal. The lungs are clear. No pleural abnormality is seen.
A slight contour abnormality is seen in the right lateral wall
of the trachea just above the level of the clavicular heads. The
central airways are otherwise unremarkable.
IMPRESSION: Slight contour abnormality of the proximal trachea,
as above.
Brief Hospital Course:
Pt was admitted on [**2174-2-10**] and taken to the OR for tracheal
resection and reconstruction on [**2174-2-11**]. A rigid bronch was
performed and her tracheal stent was removed. There was a
circumferential stenosis measuring 4.5 cm and commencing 1.8 cm
from the cricoid and 4.2 cm from the carinal spur. A tracheal
resection and reconstruction was performed at that level of the
trachea.
Immediately pt was admitted to the ICU for pulmonary hygiene and
airway managemnt.
Her post op course was otherwise uneventful but given risk of
anastomtic dehiscience her guardian stitch was kept in place
until POD # 10. A bronch was performed on POD # 11 which showed
normal healing suture line and granulation tissue.
She was d/c'd to [**Location (un) **] airport to fly home to MI. She will
follow up with her home pulmonologist and schedule a bronch in
one month and 6months.
At the time of discharge, pt's pain was well controlled on
percocet and motrin and she was [**Last Name (un) 1815**] regular diet and
ambulating on room air w/o resp difficulty.
Medications on Admission:
Levothyroxine 137.5mcg PO QD, Prevacid 30mg PO QD PRN
Discharge Medications:
1. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*100 Tablet(s)* Refills:*0*
2. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Tracheal resection and reconstruction.
Discharge Condition:
good
Discharge Instructions:
Call Dr.[**Name (NI) 1816**] office [**Telephone/Fax (1) 170**] if you experience
wheezing, chest pain, shortness or breath, productive cough,
fever, or chills.
You may see your chiropractor after two months.
Do not extend your neck. No lifting objects greather than 10
pounds or anything over your head.
Followup Instructions:
see your pulmonologist for a bronchoscopy in one month and again
in 6 months.
Completed by:[**2174-2-23**]
|
[
"V10.87",
"519.1",
"997.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.5",
"33.22",
"31.75",
"98.15"
] |
icd9pcs
|
[
[
[]
]
] |
6364, 6370
|
4932, 5986
|
346, 400
|
6453, 6460
|
4213, 4909
|
6813, 6922
|
3032, 3211
|
6090, 6341
|
6391, 6432
|
6012, 6067
|
6484, 6790
|
3226, 4194
|
289, 308
|
428, 2634
|
2656, 2780
|
2796, 3016
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,045
| 186,185
|
39888
|
Discharge summary
|
report
|
Admission Date: [**2138-2-21**] Discharge Date: [**2138-2-27**]
Date of Birth: [**2063-12-17**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Statins-Hmg-Coa Reductase Inhibitors
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
progressive dyspnea on exertion
Major Surgical or Invasive Procedure:
Redo sternotomy aortic valve replacement and replacement of
ascending aorta [**2138-2-21**]
History of Present Illness:
73 year old female s/p AVR in [**2125**] with progressively worsening
dyspnea on exertion over last several years. Most recent Echo
shows severe prosthetic AV
stenosis and dilated asc. aorta 4.5 cm. She is now referred for
Redo AVR.Pt reports no changes in her physical condition since
clinic visit [**2138-1-14**] other than worsening DOE and fatigue.
Past Medical History:
Hypertension
Dyslipidemia
Renal insufficiency
Colon cancer
Obesity
Anemia
Tissue AVR [**2125**]
Colectomy x 2
Varicose vein stripping right leg
Hernia repair
Tonsillectomy
Social History:
Lives: alone
Occupation: works at [**Company 87741**]: quit [**2107**]
ETOH: occasional glass of wine
Family History:
non-contributory
Physical Exam:
Pulse: 75 Resp: 18 O2 sat: 98%
B/P LEFT: 110/85
Height: 65" Weight: 180 lbs
General: Well-developed female in no acute distress
Skin: Warm[X] Dry [X] intact [X]
HEENT: NCAT[X] PERRLA [X] EOMI [X]
Neck: Supple [X] Full ROM [X]
Chest: Lungs clear bilaterally [X] healed MSI
Heart: RRR [X] Irregular [] Murmur 4-5/6 SEM
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+
[X] healed mid-line incision
Extremities: Warm [X], well-perfused [X] Edema
Varicosities: None [X]
Neuro: Grossly intact
Pulses:
Femoral Right: Left:
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit:SEM transmitted (B), pulses 2+ (B)
Pertinent Results:
Admission Labs:
[**2138-2-21**] 07:41AM HGB-12.3 calcHCT-37
[**2138-2-21**] 07:41AM GLUCOSE-113* LACTATE-1.4 NA+-138 K+-4.5
CL--107
[**2138-2-21**] 11:45AM PT-15.3* PTT-27.3 INR(PT)-1.3*
[**2138-2-21**] 11:45AM PLT COUNT-114*#
[**2138-2-21**] 11:45AM WBC-16.7*# RBC-2.57*# HGB-7.7*# HCT-23.6*#
MCV-92 MCH-30.1 MCHC-32.8 RDW-14.8
[**2138-2-21**] 01:25PM UREA N-24* CREAT-1.2* SODIUM-142
POTASSIUM-4.7 CHLORIDE-112* TOTAL CO2-22 ANION GAP-13
Discharge Labs:
[**2138-2-25**] 05:00AM BLOOD WBC-7.6 RBC-3.31* Hgb-10.1* Hct-30.2*
MCV-91 MCH-30.5 MCHC-33.4 RDW-16.5* Plt Ct-179
[**2138-2-25**] 05:00AM BLOOD Plt Ct-179
[**2138-2-24**] 12:16AM BLOOD PT-13.4 PTT-21.8* INR(PT)-1.1
[**2138-2-27**] 04:55AM BLOOD UreaN-26* Creat-1.4* Na-139 K-4.2 Cl-97
[**2138-2-25**] 05:00AM BLOOD Glucose-96 UreaN-29* Creat-1.2* Na-137
K-3.9 Cl-98 HCO3-33* AnGap-10
Radiology Report CHEST (PORTABLE AP) Study Date of [**2138-2-24**] 2:51
AM
[**Hospital 93**] MEDICAL CONDITION: 74 year old woman with POD#3 s/p
redo AVR, asc aorto replacement
Final Report: Allowing for differences in penetration, there has
been no significant change since the prior chest x-ray.
Perihilar edema is still present and atelectasis at the left
base is again seen.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: *1.4 cm 0.6 - 1.1 cm
Left Ventricle - Ejection Fraction: 50% >= 55%
Aorta - Annulus: 1.9 cm <= 3.0 cm
Aorta - Ascending: *4.4 cm <= 3.4 cm
Aortic Valve - Peak Velocity: *4.5 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *80 mm Hg < 20 mm Hg
Aortic Valve - Valve Area: *0.8 cm2 >= 3.0 cm2
Findings
RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.
LEFT VENTRICLE: Mild symmetric LVH. Normal regional LV systolic
function. Low normal LVEF.
RIGHT VENTRICLE: RV not well seen.
AORTA: Normal aortic diameter at the sinus level. Mildly dilated
ascending aorta. Normal aortic arch diameter. Simple atheroma in
descending aorta.
AORTIC VALVE: Severely thickened/deformed aortic valve leaflets.
Bioprosthetic aortic valve prosthesis (AVR). Severe AS (area
0.8-1.0cm2). Mild to moderate ([**2-9**]+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild to
moderate ([**2-9**]+) MR.
TRICUSPID VALVE: Tricuspid valve not well visualized.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
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
Prebypass
No atrial septal defect is seen by 2D or color Doppler. There is
mild symmetric left ventricular hypertrophy. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is low normal (LVEF 50-55%). The ascending
aorta is mildly dilated. There are simple atheroma in the
descending thoracic aorta. The aortic valve leaflets are
severely thickened/deformed. A bioprosthetic aortic valve
prosthesis is present. There is severe aortic valve stenosis
(valve area 0.8-1.0cm2). Mild to moderate ([**2-9**]+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild to moderate ([**2-9**]+) mitral regurgitation is seen.
Dr. [**Last Name (STitle) **] was notified in person of the results on [**2137-2-21**]
at 900am.
Post bypass
Patient is A paced and receiving an infusion of Norepinephrine
and Epinephrine. Very poor views post bypass. Bioprosthetic
valve seen in the aortic position on the ME LAX view. Appears
well seated. No aortic insufficiency seen in this view. Unable
to obtain gradients across the aortic valve. Mild to moderate
mitral regurgitation persists.
Brief Hospital Course:
Admitted same day surgery and underwent redo sternotomy, aortic
valve replacement and replacement of ascending aorta. See
operative report for further details. She received cefazolin
for perioperative antibiotics and post operatively was
transferred to the intensive care unit for management. In the
first twenty four hours she was weaned from sedation, awoke
neurologically intact and was extubated without complications.
She continued to do well and in the evening post operative day
one went into rapid atrial fibrillation treated with
betablockers and amiodarone, which she converted back to normal
sinus rhythm. She continued to progress and was transferred to
the floor on post operative day three for the remainder of her
stay. Chest tubes and pacing wires were removed per cardiac
surgery protocol. On post operative day 4 she went into rapid
atrial fibrillation for a second episode and was treated with
additional Amiodarone and increased doses of Lopressor. She
converted to sinus rhythm with PAC's and remained in sinus
rhythm for greater than 24 hours before discharge. Physical
therapy worked with her on strength and mobility. At the time of
discharge, her incisions were healing well, she was ambulating
in the halls with assistance and she was tolerating a full oral
diet. She continued to do well and was ready for discharge home
with services on post operative day 6 with all appropriate
follow up appointments made.
Medications on Admission:
Lisinopril 20 mg daily
Paroxetine 10 mg daily
Lorazepam 0.5 mg prn
Aspirin 81 mg daily
Diphenoxylate-atropine 2.5-0.025 mg daily
Calcium plus Vitamin D daily
Magnesium oxide 500mg daily
iron daily
Discharge Medications:
1. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. paroxetine HCl 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
5. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): please take 400 mg daily until [**3-6**] then decrease to
200 mg daily and follow up with cardiologist .
Disp:*50 Tablet(s)* Refills:*0*
6. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
7. lorazepam 0.5 mg Tablet Sig: [**2-9**] Tablet PO Q8H (every 8
hours) as needed for anxiety .
8. potassium chloride 10 mEq Tablet Sustained Release Sig: Two
(2) Tablet Sustained Release PO once a day for 2 weeks.
Disp:*28 Tablet Sustained Release(s)* Refills:*0*
9. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 2
weeks.
Disp:*14 Tablet(s)* Refills:*0*
10. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
12. diphenoxylate-atropine 2.5-0.025 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] VNA
Discharge Diagnosis:
Aortic stenosis s/p AVR
Post operative atrial fibrillation
Hypertension
Dyslipidemia
renal insufficiency
Anemia
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with tylenol
Incisions:
Sternal - healing well, no erythema or drainage
Edema 1+ pedal edema bilat
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr [**First Name (STitle) **] [**Name (STitle) **] [**3-20**] at 1:15 pm [**Telephone/Fax (1) 170**]
Cardiologist: Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] - [**3-7**] at 3 pm
Please call to schedule appointments with your
Primary Care Dr [**First Name4 (NamePattern1) 518**] [**Last Name (NamePattern1) 6700**] in [**5-13**] weeks [**Telephone/Fax (1) 6699**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2138-2-27**]
|
[
"441.2",
"427.31",
"272.4",
"403.90",
"E878.2",
"V10.05",
"585.9",
"424.1",
"997.1",
"E878.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.45",
"39.61",
"35.21"
] |
icd9pcs
|
[
[
[]
]
] |
8982, 9037
|
5832, 7278
|
337, 431
|
9193, 9377
|
1911, 1911
|
10301, 10943
|
1146, 1164
|
7526, 8959
|
2877, 5809
|
9058, 9172
|
7304, 7503
|
9401, 10278
|
2379, 2840
|
1179, 1892
|
265, 299
|
459, 814
|
1927, 2363
|
836, 1010
|
1026, 1130
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,952
| 164,466
|
27999
|
Discharge summary
|
report
|
Admission Date: [**2147-11-30**] Discharge Date: [**2147-12-12**]
Date of Birth: [**2081-1-14**] Sex: F
Service: MEDICINE
Allergies:
Compazine / Penicillins
Attending:[**First Name3 (LF) 3556**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
Central Venous Access
History of Present Illness:
66 F with Hx of AAA repair [**6-17**] c/b pancreatitis and bladder Ca
with right nesphrectomy and cystectomy and ileal conduit [**9-17**]
admitted with pancreatitis and ARF. Pt states that she has had
nausea and abdominal pain for approximately the last 8 weeks
since her bladder surgery. Increased intensity in the last 2
weeks with nausea/emesis (no blood) with occasional diarrhea.
Pain does not radiate to her back. No appetite and decreased PO
intake since surgeries. Denied any new medications or EtOH.
Denies F/C, SOB, CP.
Past Medical History:
muscular invasive transitional cell cancer of bladder, s/p CTX
carboplatium and [**Company **] last cycle [**2147-6-14**]
leukopenia with associated thrombocytopenia secondary to CTX
anxiety/depression
coronary artery disease s/p angioplasty w stenting
AAA
HTN
biliary dyskensia by HIDA scan [**6-17**]
s/p Cystectomy, Ileal conduit, Right nephrectomy.
Social History:
Social History: Liives with niece. widowed. No EtOH. quit
tobacco [**2138**] but smoke 2-3ppd x 20+ years.
Family History:
+ diabetes
Physical Exam:
VS: 97.2 81 131/66 18 100% on 2L
NAD, AAOx3, speaking in full sentences, no asterixis
dry MM, OP-dry, EOMI, PERRL.
FROM, no LAD
RR with distant heart sounds
Diffuse rhonchi, no crackles, no wheezes
Soft, mildly tender in epigastric region but received pain meds.
no voluntary guarding, no rebound pain. Able to sit up without
much difficulty, +BS
Per ED, rectal quaiac +, normal tone.
no rashes, le edema.
Pertinent Results:
Admit Labs
[**2147-11-29**] 08:25PM BLOOD WBC-7.4 RBC-3.14* Hgb-10.2* Hct-28.0*
MCV-89 MCH-32.4* MCHC-36.4* RDW-15.6* Plt Ct-209
[**2147-11-29**] 08:25PM BLOOD Neuts-80* Bands-1 Lymphs-8* Monos-11
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2147-11-29**] 08:25PM BLOOD Glucose-143* UreaN-128* Creat-5.9*#
Na-137 K-2.9* Cl-104 HCO3-9* AnGap-27*
[**2147-11-29**] 08:25PM BLOOD Calcium-8.4 Phos-4.6* Mg-1.5*
[**2147-11-29**] 08:25PM BLOOD ALT-9 AST-10 AlkPhos-143* Amylase-270*
TotBili-0.4
[**2147-11-30**] 03:57AM BLOOD LD(LDH)-126
[**2147-11-29**] 08:25PM BLOOD Lipase-692*
[**2147-11-30**] 03:57AM BLOOD PT-13.1 PTT-26.7 INR(PT)-1.1
[**2147-11-30**] 03:57AM BLOOD calTIBC-153* VitB12-758 Folate-6.4
Hapto-196 Ferritn-888* TRF-118*
[**2147-11-29**] 11:45PM URINE Color-Straw Appear-Hazy Sp [**Last Name (un) **]-1.012
[**2147-11-29**] 11:45PM URINE Blood-LG Nitrite-NEG Protein-30
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-9.0* Leuks-SM
[**2147-11-29**] 11:45PM URINE RBC-0-2 WBC-0-2 Bacteri-MOD Yeast-NONE
Epi-0-2
[**2147-11-29**] 11:45PM URINE Hours-RANDOM Creat-76 Na-58
[**2147-11-29**] 11:45PM URINE Osmolal-416
.
Micro
[**2147-12-8**] 9:39 am BLOOD CULTURE
AEROBIC BOTTLE (Final [**2147-12-11**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
COAG NEG STAPH does NOT require contact precautions,
regardless of
resistance Oxacillin RESISTANT Staphylococci MUST be
reported as
also RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
FINAL SENSITIVITIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ =>16 R
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ 2 S
.
[**2147-12-8**] 3:14 pm CATHETER TIP-IV Source: R CVL.
**FINAL REPORT [**2147-12-10**]**
WOUND CULTURE (Final [**2147-12-10**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. >15 colonies.
COAG NEG STAPH does NOT require contact precautions,
regardless of
resistance.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ =>16 R
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ 2 S
.
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2147-12-1**]):
REPORTED BY PHONE TO [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 68172**] [**2147-12-1**] 9:45AM.
CLOSTRIDIUM DIFFICILE.
FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA.
Reference Range: Negative.
A positive result in a recently treated patient is of
uncertain
significance unless the patient is currently
symptomatic
(relapse).
.
.
Diagnostic Imaging
.
[**12-11**] TTE:
The left atrium is elongated. There is mild symmetric left
ventricular
hypertrophy. Overall left ventricular systolic function is
normal (LVEF>55%). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. The left ventricular inflow
pattern suggests impaired relaxation. There is a
trivial/physiologic pericardial effusion.
.
[**12-8**] CT Abd/Pelvis w/ contrast
1. No definite abnormalities identified to explain the
patient's symptoms. No CT findings of bowel perforation,
colitis, or pancreatitis.
2. Mild pulmonary edema and small bilateral pleural effusions.
.
[**12-7**] MR Abdomen
1. Interval resolution of peripancreatic fluid seen around the
tail of the pancreas. Unremarkable appearance to the pancreas.
2. Stable abdominal aortic aneurysm.
3. Slightly atypical appearance to the right post-nephrectomy
site with a
thickened circumferential area that encases bulk fat. This most
likely
represents packing material used during the operation.
.
[**12-4**] CT Abd/Pelvis w/ contrast
1. Bilateral new small pleural effusions with associated
atelectasis.
2. Smaller postsurgical abdominal aortic aneurysm with
atheromatous plaque.
3. Diverticulosis of sigmoid, without diverticulitis.
4. Small amt of layering high density material in gallbladder
representing layering sludge, polyp, or stone.
.
[**11-30**] Renal U/S
No evidence of renal obstruction. Normal-appearing renal
vasculature.
.
[**11-29**] Abd U/S
No evidence for common bile duct dilation, and moderately
distended and sludge containing gallbladder but otherwise
unremarkable without cholelithiasis.
Brief Hospital Course:
66 YO F with multiple medical problems recently including AAA
[**6-17**] c/b pancreatitis, right nephrectomy and cystecomy with
ilealconduit in [**9-17**], and MI s/p cardiac stenting in [**10-18**]
initially admitted to the MICU with pancreatitis and ARF.
.
1. Pancreatitis - possible acute on chronic given chronic nausea
and poor po tolerance in past; calcium not elevated, lipids not
grossly elevated, no clear drug-related etiology, and U/S failed
to reveal CBD dilation; CT abd did reveal GB sludge. Surgery
was consulted, but deferred surgical management pending clinical
decline. Pt was treated with NPO and copious resuscitation via
IVF per routine, and was advanced as tolerated over the course
of her stay. F/u MR abd revealed interval resolution of
peripancreatic fluid around the tail of the pancreas, which
correlated w/ pt's clinical improvement. By discharge, pt's
LFTs and amylase/lipase were greatly improved, and she was
tolerating full meals w/o nausea, vomiting, or pain.
.
2. ARF - pt presented with BUN/Cr of 128/5.9 (well above normal
baseline) with hypokalemia, hypocalcemia and hypophosphatemia.
Pt responded well to fluid resuscitation, although FENA of 5%
was not suggestive of prerenal etiology; no muddy brown casts
were appreciated. BUN/Cr continued to trend down to normal, and
renal U/S was unremarkable. In setting of chronic HTN, pt will
need continued f/u for possible underlying chronic renal
disease, but her ARF was largely prerenal based on
post-resuscitative improvement.
.
3. CAD - stable throughout course; continued lopressor, avapro,
hydralazine but will held tricor/zocor given active pancreatitis
at admission. Echo revealed preserved EF and normal anatomy.
.
4. GI bleed - patient found to be guaiac positive on admission,
no further evidence of bleeding. Pt was maintained on PPI, HCTs
were rechecked and were stable, and stools were guiac negative
for the remainder of her course.
.
5. Line Infection - Pt transferred back to the MICU on [**12-8**]
because of fevers and concern for sepsis. Central line and
blood cultures grew multi-resistant coag negative staph
sensative to vanc; PICC was placed under IR for long-term vanc
(at least 2 weeks) given bacteremia and AAA vascular graft.
Pt's other cultures remained negative, she responded well to
vanc (afebrile, normotensive), and was discharged with IV vanc
with close PCP f/u and weekly BUN/Cr and trough checks.
.
6. C-Diff Positive Stool - pt was asymptomatic with normal WBC
and was afebrile when test posted as positive; pt began oral
vanc and will continue as outpatient with close PCP f/u.
.
7. HTN - when NPO, utilized IV metoprolol and hydralazine for
control; once ARF resolved and tolerating po's, continued oral
lopressor, avapro, hydralazine with moderate success. Will need
continued outpatient maint.
.
8. AAA - no active issues, but due to recent graft, pt's
positive BCX was treated aggressively with vanc and close follow
up.
.
At discharge, pt's PCP was notified regarding extended course of
both IV and oral vancomycin; PCP welcomed [**Name Initial (PRE) **]/u w/in the week of
D/C for appropriate laboratory monitoring and clinical
reevaluation.
Medications on Admission:
Avapro 300'
hydralazine 25"'
tricor 160'
paxil 10'
zocor 10'
ditropan 10'
meds confirmed with niece:
isosorbide 60'
Plavix 75'
metoprolol 100mg [**Hospital1 **]
protonix 40mg daily
ranitidine 150 mg daily
clonidine patch q wed or q sunday
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QMON (every Monday).
Disp:*4 Patch Weekly(s)* Refills:*2*
3. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 23 days: may substitute with liquid preparation;
finish [**2148-1-4**].
Disp:*92 Capsule(s)* Refills:*0*
4. Paroxetine HCl 10 mg/5 mL Suspension Sig: Twenty (20) mg PO
DAILY (Daily).
Disp:*qs mL* Refills:*2*
5. Irbesartan 300 mg Tablet Sig: One (1) Tablet PO daily ().
Disp:*30 Tablet(s)* Refills:*2*
6. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) g
Intravenous Q 24H (Every 24 Hours) for 9 days: Please
discontinue dosing on [**2147-12-21**].
Disp:*qs mL* Refills:*0*
7. PICC Line Care
PICC Line care per CCS Protocol.
8. Outpatient Lab Work
Please draw Vancomycin Trough Level and BUN/Cr weekly.
9. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours.
Disp:*90 Tablet(s)* Refills:*2*
10. Tricor 160 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
11. Paxil 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
12. Zocor 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
13. Ditropan 5 mg Tablet Sig: Two (2) Tablet PO once a day.
Disp:*60 Tablet(s)* Refills:*2*
14. Isosorbide Mononitrate 60 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*
15. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO
twice a day.
Disp:*60 Tablet(s)* Refills:*2*
16. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
17. Ranitidine HCl 150 mg Capsule Sig: One (1) Capsule PO once a
day.
Disp:*30 Capsule(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
Primary Diagnoses
1. Pancreatitis
2. Central Venous Catheter Infection
3. Acute Renal Failure
4. Anemia
5. C. Diff Positive Stool
Secondary
1. HTN
2. AAA Graft
3. CAD
Discharge Condition:
Stable
Discharge Instructions:
Please return to the hospital if you experience fevers, chills,
shortness of breath or chest pain.
You will be discharged on an antibiotic, Vancomycin, to be taken
IV for a total of 2 weeks from discharge (ending on [**2147-12-21**]),
and for 23 more days orally.
Please continue all of your other medications as prescribed,
keep all appointments, and follow up with your primary physician
for [**Name Initial (PRE) **] recheck within 1 week of discharge.
Call your doctor or return to the Emergency Department right
away if any of the following problems develop:
* If you are vomitting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomitting,
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.
* You have shaking chills, or a fever greater than 100.4 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
Followup Instructions:
Please follow up with your primary care physician [**Name Initial (PRE) 176**] 1 week
of discharge.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]
Completed by:[**2147-12-21**]
|
[
"577.0",
"V44.6",
"401.9",
"285.9",
"996.62",
"311",
"250.92",
"008.45",
"593.9",
"V15.82",
"412",
"V10.51",
"584.9",
"V45.82",
"414.01",
"792.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.6",
"99.15",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
12799, 12882
|
7394, 10575
|
301, 325
|
13094, 13103
|
1858, 7371
|
14273, 14534
|
1403, 1416
|
10865, 12776
|
12903, 13073
|
10601, 10842
|
13127, 14250
|
1431, 1839
|
247, 263
|
353, 886
|
908, 1263
|
1295, 1387
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,447
| 160,384
|
6624
|
Discharge summary
|
report
|
Admission Date: [**2165-7-23**] Discharge Date: [**2165-8-16**]
Date of Birth: [**2095-7-11**] Sex: F
Service: SURGERY
Allergies:
Sulfasalazine
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Abdominal pain, admitted for ERCP
Major Surgical or Invasive Procedure:
1. ERCP
2. Biliary bypass (choledochal duodenostomy).
3. Open cholecystectomy.
4. Extensive adhesiolysis.
History of Present Illness:
History of Present Illness: Pt is a 70 year old woman with a
PMHx significant for CBD stones and strictures and stents
admitted for abdominal pain and planned ERCP. For the past 2
weeks she has not felt well with increased abdominal pain, worse
after meals. No bloody stools. No N/V. She has been constipated
intermittently. She describes the pain as sharp, and localizes
it to her epigastric region. She had fevers to 101 at home with
chills. She was taken by her daughter to [**Hospital3 **] where
she had rigors and a temp of 99. Her WBCs were found to be
22,000. Creat was slightly elevated at 1.4 in the setting of
presumed dehydration. T Bili was 0.26 and LFTs were nl except
for Alk Phos elevated to 139. She was given Levo and Flagyl and
transferred to [**Hospital1 18**] for ERCP planned for tomorrow.
.
As for her CBD history, she underwent ERCP and stenting in
[**Month (only) 1096**] in [**State 4565**] initially for acute CBD obstruction.
Then she had more symptoms and underwent an ERCP in [**Month (only) 958**] of
this year and the CBD was dilated with a suggestion of a filling
defect or a stricture in its distal portion on initial
cholangiogram and a villious like polyp was found in the distal
CBD which corresponded to the stricture on
cholangiogram/flouroscopy. This was biopsied and brushings were
also taken and was found to be negatice for malignant cells. A
biliary stent was placed successfully in the in the CBD across
the stricture. In [**Month (only) 547**], she had another ERCP with replacement
of the plastic stent with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] biliary stent after
baloon dilation. Brushings from this ERCP yielded "atypical
ductal cells and atypical columnar cells in groups and singly.
While this may represent reactive changes, a neoplasm cannot be
entirely excluded."
.
In the ED she was given Vicodin and admitted.
Past Medical History:
Macular degeneration (legally blind)
HTN
Migraines
CBD obstruction with multiple stent/dilation ERCPs
Hyperlipidemia
PUD
Pernicious anemia
Hyperthyroidism
Anxiety
Heart Murmur
s/p Appendectomy
s/p C-section x 2
s/p TAH
s/p Gastric celiac aneurym repair in [**2157**]
s/p ventral hernia repair in [**2158**]
Social History:
Lives alone in [**Location (un) 620**]. Divorced. Drinks 4-5 drinks/week never
more than 1/day. Ex-smoker x 25 pack years. Quit in [**2133**].
Retired psychologist.
Family History:
Father with lung ca
Mother with leukemia
Physical Exam:
PE: 98.1 99/75 92 19 96% O2 Sats RA wt 133
Gen: WD female in NAD resting in bed
HEENT: Clear OP, MMM
NECK: Supple, No LAD, No JVD
CV: RR, NL rate. NL S1, S2. [**1-12**] HSM, No rubs or [**Last Name (un) 549**]
LUNGS: CTA, BS BL, No W/R/C
ABD: Soft, Epigastric tenderness [**3-16**], No g/r. ND. NL BS. No
HSM.
EXT: No edema. 2+ DP pulses BL
SKIN: No lesions
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout. [**1-8**]+ reflexes,
equal BL.
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
[**2165-8-15**] 06:58AM BLOOD WBC-12.1*
[**2165-8-13**] 04:27AM BLOOD WBC-14.5* RBC-3.74* Hgb-10.9* Hct-31.8*
MCV-85 MCH-29.1 MCHC-34.2 RDW-15.2 Plt Ct-387
[**2165-8-13**] 04:27AM BLOOD Glucose-95 UreaN-10 Creat-0.6 Na-139
K-3.3 Cl-105 HCO3-27 AnGap-10
[**2165-8-14**] 09:45AM BLOOD K-3.8
[**2165-8-9**] 04:34AM BLOOD ALT-26 AST-71* AlkPhos-66 Amylase-31
TotBili-0.3
[**2165-8-9**] 04:34AM BLOOD Lipase-48
[**2165-8-7**] 02:27PM BLOOD CK-MB-8 cTropnT-0.03*
[**2165-8-7**] 09:49PM BLOOD CK-MB-8 cTropnT-0.06*
[**2165-8-14**] 09:45AM BLOOD Phos-3.7
[**2165-8-13**] 04:27AM BLOOD Calcium-7.7* Phos-2.5* Mg-2.0
.
ERCP BILIARY&PANCREAS BY GI UNIT [**2165-7-24**] 3:26 PM
IMPRESSION: Large stricture in the distal part of common bile
duct with proximal dilatation of CBD.
.
CT ABDOMEN W/CONTRAST [**2165-7-26**] 1:23 PM
IMPRESSION:
1. No CT signs of pancreatitis or pancreatic necrosis.
2. Pancreatic and intra-hepatic/extra-hepatic ductal dilatation.
Distended gallbladder without surrounding inflammatory changes
is likely related to NPO status, please correlate clinically.
3. Three-cm infrarenal aortic aneurysm with moderate amount of
atherosclerotic aortic disease and mural thrombus.
4. There is suggestion of interstitial lung disease. If
indicated clinically, HRCT could better differentiate dependent
changes from peripheral/basilar interstitial lung disease.
.
MRI ABDOMEN W/O & W/CONTRAST [**2165-7-27**] 9:57 A
IMPRESSION:
1. Focal high-grade stenosis involving the proximal celiac
artery without obvious collateral formation (similar in
appearance to recent CT). Remaining mesenteric vasculature is
widely patent.
2. Infrarenal abdominal aorta demonstrates fusiform dilation,
atherosclerosis, and eccentric thrombus, unchanged.
3. Circumferential low T2 signal surrounding the distal common
bile duct in the region of the patient's known CBD stent, likely
associated with the stenosis in this region. Diffuse mild main
pancreatic duct dilatation is unchanged.
.
Cardiology Report ECG Study Date of [**2165-7-31**] 10:15:50 AM
Sinus rhythm upper limit normal rate
Left axis deviation - possible left anterior fascicular block
Inferior + anterior T wave change are nonspecific
Since previous tracing of [**2165-7-18**], no significant change
Read by: [**Last Name (LF) **],[**First Name3 (LF) 900**] A.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
99 112 110 396/452.28 59 -35 11
.
Cardiology Report ECHO Study Date of [**2165-8-1**]
Conclusions:
The left atrium is normal in size. The estimated right atrial
pressure is
0-5mmHg. There is mild (non-obstructive) focal hypertrophy of
the basal
septum. The left ventricular cavity size is normal. There is
mild to moderate
regional left ventricular systolic dysfunction with
inferior/inferolateral
akinesis. Tissue Doppler imaging suggests an increased left
ventricular
filling pressure (PCWP>18mmHg). Right ventricular chamber size
and free wall
motion are normal. The ascending aorta is mildly dilated. The
aortic valve
leaflets (3) are mildly thickened. There is no aortic valve
stenosis. Trace
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened.
Moderate (2+) mitral regurgitation is seen. There is borderline
pulmonary
artery systolic hypertension. There is no pericardial effusion.
.
SPECIMEN SUBMITTED: GALLBLADDER (1).
Procedure date Tissue received Report Date Diagnosed
by
[**2165-8-7**] [**2165-8-7**] [**2165-8-12**] DR. [**Last Name (STitle) **]. LOMO/cma??????
Previous biopsies: [**Numeric Identifier 25328**] COMMON BILE DUCT BIOPSIES
DIAGNOSIS:
Gallbladder:
Chronic cholecystitis.
.
Cardiology Report ECG Study Date of [**2165-8-11**] 3:28:28 PM
Sinus rhythm. Occasional premature atrial contractions. Diffuse
ST-T wave
abnormalities which are non-specific. Low QRS voltage in limb
leads. Compared
to tracing of [**2165-8-28**] there is no significant diagnostic change.
Read by: [**Last Name (LF) **],[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 10592**]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
88 138 98 [**Telephone/Fax (2) 25329**] -6 -11
.
FOOT AP,LAT & OBL BILAT [**2165-8-12**] 1:11 PM
FOOT AP,LAT & OBL BILAT
Reason: Assess gout
[**Hospital 93**] MEDICAL CONDITION:
70 year old woman with acute gouty arthritis
REASON FOR THIS EXAMINATION:
Assess gout
BILATERAL FEET, SIX VIEWS
INDICATION: Acute gouty arthritis. Evaluate gout.
FINDINGS: No comparisons. No acute fracture or dislocation is
seen. Hallux valgus deformity is seen on the left with mild
degenerative change of the first MTP joint. Dorsal soft tissue
swelling is seen over the feet bilaterally. A tiny focal erosion
of the first metatarsal head is seen on the left. Mineralization
in the distal aspect of the right Achilles tendon likely
reflects enthesopathy. Soft tissues are otherwise unremarkable.
IMPRESSION:
Focal erosion of the medial aspect of the first metatarsal head
on the left could represent gouty erosion. Prominent soft tissue
swelling involving the dorsal soft tissues of both feet.
Brief Hospital Course:
Postprandial pain - could most likely be from recurrent CD
strictures on unkown etiology No gallstone or ca has been
diagnosed to date. Hence surgery was consulted and they
recommend a biliary bypass procedure next week. (Dr [**Last Name (STitle) **].
Pain was controlled with morphine immediate release. ERCP
results as above.
Given the post prandial nature of pain - MRA abdomen was done
that showed a tight stenosis of proximal celiac artery. Vascular
surgery was consulted and they did not feel further
interventions were needed for this.
Septicemia/cholangitis/cholecystitis - Treated with antibiotics
x ..... days. Blood cultures neg at discharge and patientwas
afebrile for many days prior to discharge.
Post-ERCP pancreatitis - developed after ERCP. Treated with
bowel rest and analgesia with good recovery.
ARF: Presumed secondary to dehydration. Creatinine improved to
normal on fluids.
AAA - incidentally seen on CT abd - will defer to PCP for follow
up of the CT scan in another 3 months to assess increase in
size.
ILD - also incidentally seen on CT scan. Not hypoxic. Again will
defer to PCP for arranging appropriate followup.
Hyperlipidemia: On statin
PUD: started on PPI.
Hx of hyperthyroidism: Presumed hypothytroid s/p tx. - Continue
Levothyroxine. Should get repeat TSH (mildly high here) in 4-
weeks with PCP.
Full code.
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================================================================
She was then transfered to the Surgery Service and on [**2165-8-7**]
went to the OR for:
1. Biliary bypass (choledochal duodenostomy).
2. Open cholecystectomy.
3. Extensive adhesiolysis.
Post-op Hypotension: She remained in the SICU overnight due to
hypotension. She receive several fluid boluses with good
response.
Pain: She had an epidural on POD 1. The epidural became
dislodged and she was then started on a Dilaudid PCA. She had
good pain control with the PCA. She was demanding to remain on
the PCA for pain control, mostly complaining of foot pain
related to the gout. She was then transitioned to PO pain meds
once tolerating a diet.
GI/ABD: She was NPO, with IVF and a NGT. The NGT was D/C'd POD
5. She was started on sips on POD and her diet was slowly
advanced. She was tolerating a regular diet and had +BM prior to
discharge.
The drain was removed on POD 9 without incident. There was some
redness around the drain site. The staples were also removed and
steri strips applied. The incision had some mild erythema.
Gout: She was followed by Rheumatology for an acute gouty flare.
She was started on Colchicine, but this was switched for
Naproxen. Allopurinol should not be given at this time and will
be started in the future by the Rheumatologist, which she needs
to see in clinic.
She had significant LE edema and was taking Lasix and HCTZ for
continued diuresis.
PT: She was seen by PT and it was recomended she go to rehab.
Medications on Admission:
Lipitor 20 mg orally once a day
Depakote 500 mg orally once a day
levothyroxine 25 mcg once a day
cyclobenzaprine the dose she does not know
bupropion 150 mg orally once a day
triamterene and hydrochlorothiazide one tablet orally once a day
Colace for constipation
Lorazepam 0.5mg 3x/day for anxiety
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours.
3. Lorazepam 0.5 mg Tablet Sig: .25 mg PO Q4H (every 4 hours) as
needed.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Divalproex 500 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO HS (at bedtime).
6. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO BID (2 times a day).
8. Triamterene-Hydrochlorothiazid 37.5-25 mg Capsule Sig: One
(1) Cap PO DAILY (Daily).
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Naproxen 250 mg Tablet Sig: Three (3) Tablet PO Q12H (every
12 hours): Gout.
11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
13. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed.
14. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Medical Center - [**Hospital1 3597**]
Discharge Diagnosis:
post-ERCP pancreatitis
Biliary stricture
Discharge Condition:
Good
Tolerating a diet
Incision C,D,I
Gout flare is most bothersome. Continue with Naproxen. No
Allopurinol now, Rheumatology will add later after flare has
diminished.
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomitting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomitting,
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. Continue with your Gout medication and follow-up
with Rheumatology.
* Continue to amubulate several times per day.
Followup Instructions:
Please follow-up with Dr [**Last Name (STitle) **] - [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 23793**] (clinic) in [**3-10**]
weeks. Call [**Telephone/Fax (1) 476**] to schedule an appointment.
Follow-up with Dr. [**Last Name (STitle) 1940**] ([**Telephone/Fax (1) 2306**].
Please follow-up with Rheumatology in [**1-8**] weeks. Call ([**Telephone/Fax (1) 25330**] to schedule an appointment.
Completed by:[**2165-8-16**]
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42,327
| 162,230
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30881
|
Discharge summary
|
report
|
Admission Date: [**2135-7-14**] Discharge Date: [**2135-8-18**]
Date of Birth: [**2066-11-25**] Sex: M
Service: MEDICINE
Allergies:
Vidaza / vancomycin
Attending:[**First Name3 (LF) 3913**]
Chief Complaint:
Fatigue
Major Surgical or Invasive Procedure:
bone marrow biopsies
History of Present Illness:
This is a 68 yo M with a history of MDS RAEB type 1 with
myelofibrosis s/p Cycle 1 decitabine ending [**2135-6-9**], COPD,
chronic decubitus ulcers, and neutrophilic dermatosis who has
been admitted for further evaluation of weakness.
The patient was recently admitted from [**Date range (1) 73067**] with fever.
During this admission, he was found to have a pan-S E. coli,
Vancomycin sensitive enterococcus, and [**First Name5 (NamePattern1) 564**] [**Last Name (NamePattern1) 563**] blood
stream infection. He had a TTE which did not show signs of
endocarditis and a dilated eye exam which did not show [**Female First Name (un) 564**]
endophthalmitis. He received a two week course of Vancomycin
and Cefepime and a plan was made for thirty days of Fluconazole
(first negative blood culture for yeast [**2135-6-19**]). There was also
concern for a multifocal pneumonia in the RUL on chest imaging
during the [**Date range (1) 73067**] admit. The patient underwent BAL on
[**2135-7-1**], with negative cultures. Lastly, he was found to have a
transaminitis and hyperbilirubinemia of unclear etiology during
his last admission (ALT 226, AST 235, T Bili 11.3). These lab
abnormalities resolved without GI intervention.
The patient was discharged on [**7-5**] to home, which is his
daughter's home in [**Location (un) 3844**]. The patient reports initially
feeling well, but then over the last five days, started to
experience decrease appetite and fatigue. Initially, he thought
the decrease in appetite was secondary to a change in taste
caused by Fluconazole; thus, he stopped taking the Fluconazole
for a few days. He felt better, but then noticed return of the
symptoms. The fatigue increased to the point that he started
using a walker at home and even started to notice difficulty
getting up from the bed. He denies any fevers, chills,
vomiting, new rash, blurry vision, shortness of breath, chest
pain, or headache. He has chronic nausea and diarrhea, which
have continued. He has also noticed a new pain below his right
rib cage which is worse with inspiration.
Past Medical History:
1. Myelodysplastic syndrome [dx [**2130**], until [**8-/2134**] treated with
only procrit and RBC transfusion, then in [**8-27**] started on
azacitidine (Vidaza)] w/ adverse reaction, now treated with
decitabine. Evidence of transformation to AML.
2. s/p right hemicolectomy with end ileostomy/mucous fistula for
ischemic bowel perforation ([**2134-9-28**])
3. s/p back surgeries (multiple)
4. paroxysmal atrial fibrillation (dx [**9-/2134**])
5. COPD
6. Carpal tunnel syndrome
7. Left knee surgery
8. History of VRE positive peritoneal fluid in [**2133**]
Social History:
- Retired, used to work for chemical company in office setting
- Lives with daughter in [**Name (NI) 3597**] NH
- Significant ETOH use, stopped seven years ago
- 60 pack year history of tobacco use
Family History:
- Sister - died scleroderma
- Brother - died ETOH abuse
- Daughter - Marfan's with cardiac problems
- Mother - died lung ca
- Father - died [**Name2 (NI) 8751**]
Physical Exam:
VS: T 96.4, BP laying 109/47 HR 69, BP sitting 111/43 HR 75, BP
standing 108/45 HR 79, RR 20, O2 98% RA
GEN: AOx3, NAD
HEENT: PERRLA. dry mucous membranes. no LAD. neck supple. No
cervical or supraclavicular LAD
Cards: RRR with 2-3/6 sytolic murmur. no gallops/rubs.
Pulm: CTAB no crackles or wheezes
Abd: BS+, soft, minimal RUQ tenderness to palpation under the
last rib, no rebound/guarding. Patient has dressing covering
abdominal wound, which is < 2cm. No erythema. He has a colostomy
bag in the R abdomen with liquid stool.
Extremities: wwp, trace LLE edema. DPs 2+.
Skin: + bruising, no visible rash
Neuro: CNs II-XII intact. Patient has intact sensation
throughout.
Pertinent Results:
ADMISSION LABS:
[**2135-7-14**] 02:30PM BLOOD WBC-2.0* RBC-2.94* Hgb-8.9* Hct-24.7*
MCV-84 MCH-30.4 MCHC-36.1* RDW-14.2 Plt Ct-27*
[**2135-7-14**] 02:30PM BLOOD Neuts-40* Bands-6* Lymphs-30 Monos-2
Eos-10* Baso-0 Atyps-2* Metas-2* Myelos-0 Blasts-8*
[**2135-7-15**] 07:10AM BLOOD PT-15.2* PTT-29.1 INR(PT)-1.3*
[**2135-7-14**] 02:30PM BLOOD UreaN-44* Creat-1.1 Na-139 K-5.0 Cl-105
HCO3-26 AnGap-13
[**2135-7-14**] 02:30PM BLOOD Calcium-10.2 Phos-4.8* Mg-2.0
[**2135-7-14**] 02:30PM BLOOD ALT-44* AST-36 LD(LDH)-196 AlkPhos-89
TotBili-0.9
.
[**2135-8-18**] 12:16AM BLOOD WBC-2.6* RBC-2.73* Hgb-8.3* Hct-23.3*
MCV-85 MCH-30.3 MCHC-35.5* RDW-13.8 Plt Ct-17*
[**2135-8-18**] 12:16AM BLOOD Neuts-25* Bands-6* Lymphs-32 Monos-8
Eos-1 Baso-0 Atyps-0 Metas-10* Myelos-1* Promyel-2* Blasts-15*
[**2135-8-18**] 02:20PM BLOOD Plt Ct-31*#
[**2135-8-18**] 12:16AM BLOOD Fibrino-325
[**2135-8-18**] 12:16AM BLOOD Gran Ct-1144*
[**2135-8-18**] 12:16AM BLOOD Glucose-82 UreaN-23* Creat-0.9 Na-135
K-3.9 Cl-94* HCO3-37* AnGap-8
[**2135-8-10**] 06:15PM BLOOD cTropnT-0.32*
[**2135-8-10**] 05:50AM BLOOD CK-MB-2 cTropnT-0.36*
[**2135-7-21**] 06:52AM BLOOD Lipase-20
[**2135-8-18**] 12:16AM BLOOD Calcium-8.7 Phos-3.0 Mg-1.9
[**2135-7-30**] 07:02AM BLOOD calTIBC-88* Ferritn-6126* TRF-68*
[**2135-7-15**] 07:10AM BLOOD TSH-1.7
[**2135-7-16**] 07:26AM BLOOD Cortsol-19.2
[**2135-8-11**] 06:58AM BLOOD Type-[**Last Name (un) **] pO2-153* pCO2-59* pH-7.43
calTCO2-40* Base XS-12
[**2135-8-10**] 06:46PM BLOOD Type-[**Last Name (un) **] pO2-121* pCO2-62* pH-7.41
calTCO2-41* Base XS-12 Comment-GREEN TOP
[**2135-8-10**] 06:08AM BLOOD Type-[**Last Name (un) **] pO2-168* pCO2-64* pH-7.39
calTCO2-40* Base XS-11
[**2135-8-3**] 11:34PM BLOOD Type-ART Temp-39.4 pO2-68* pCO2-54*
pH-7.30* calTCO2-28 Base XS-0
[**2135-8-11**] 06:58AM BLOOD Glucose-91 Lactate-0.9 Cl-92*
URINE CULTURE (Final [**2135-7-26**]):
ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML..
URINE CULTURE (Final [**2135-7-19**]):
KLEBSIELLA PNEUMONIAE. 10,000-100,000 ORGANISMS/ML..
Piperacillin/tazobactam sensitivity testing available
on request.
STAPH AUREUS COAG +. 10,000-100,000 ORGANISMS/ML..
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Brief Hospital Course:
68yo man with MDS/AML admitted for weakness/fatigue, diarrhea
(high ostomy output), and dehydration. He completed cycle #1
decitabine [**2135-6-9**]. This was complicated by recently admitted
from [**Date range (1) 73067**] with fever. During this admission, he was found
to have a pan-S E. coli, Vancomycin sensitive enterococcus, and
[**First Name5 (NamePattern1) 564**] [**Last Name (NamePattern1) 563**] blood stream infection requiring
hospitalization [**2135-6-12**] and treatment with cefepime/vancomycin
x2wks, and fluconazole x30 days (1st negative blood culture for
yeast [**2135-6-19**]). TTE and ophthalmic exam for [**Female First Name (un) 564**]
endophthalmitis were both negative. Also, imaging showed RUL
infiltrate. BAL [**2135-7-1**] had negative cultures. Transaminitis
and hyperbilirubinemia of unclear etiology (ALT 226, AST 235, T
Bili 11.3) resolved without GI intervention. He was admitted
with fatigue.
.
# Weakness/fatigue: Possibly due to dehydration vs. progressive
disease vs. infection (recurrence of recent multi-organism
sepsis) vs. post-chemo effect (unlikely with decitabine). He
received IV fluids. TSH and cortisol were normal. Blood and
urine cultures were sent: urine culture grew and IV fluids
given. Blood, fugnal, and urine cultures sent. He was treated
with empiric antibiotics and his weakness appeared to improve.
The patient was able to ambulate around the [**Hospital1 **] with PT and
walker assistance, but deteriorated once again, requiring ICU
admission (see below). However, his weakness waxed and waned
thoughout the hospital course, and did not completely resolve by
the time of discharge.
.
# Abdominal pain and diarrhea: The patient presented with high
ostomy output. He was started on IV hydration and a low residue
diet. C. diff toxin and stool culture were sent and were
negative. He also complained of RUQ pain, with positive
[**Doctor Last Name 515**] sign. However USS and HIDA scan only showed gall
bladder sludge and GI and surgery were reluctant to place a
percutaneous biliary drain or perform ERCP given the high risk
of sepsis int his frail neutropenic patient. In addition to the
focal RUQ pain, the patient also complained of diffuse,
migratory abdominal pain. He was treated with empiric
antibiotics to treat for gram negative, positive and fungal
infections, and his symptoms improved. CT abdomen also revealed
epiploic appendagitis, which may have been the cause of his
diffuse abdominal pain.
.
# Urinary tract infections: Urine cultures from [**2135-7-16**] grew
MRSA and klebsiella pneumoniae; urine cultures from [**2135-7-23**] grew
enterococcus, and the patient presented with abdominal pain and
hypotension. On both occasions, appropriate antibiotics were
started, and the patient's urinary symptoms and culture
positivity resolved.
.
Respiratory distress: On admission, the patient had CXR and CT
findings of a diffuse infiltrative process. Over the course of
his hospitalization, the patient had variable degrees of
respiratory distres; sometimes requiring increasing amounts of
oxygen for satisfactory blood oxygen saturation. He frequently
developed pulmonary edema, which was however responsive to
lasix. He underwent a thoracentesis to drain pulmonary effusion
on [**2135-8-3**]. However, he became tachypneic and desaturated and
was transferred to the ICU for flash pulmonary edema. In the
ICU, his oxygen saturation improved on high flow oxygen. He was
treated with nebulizers and oxygen and transferred back to the
floor shortly thereafter. On the floor he developed some
pleuritic chest pain, but this resolved with oxycodone and
cardiac enzymes were negative. CT chest prior to discharge
showed that his chest infiltrates were improving.
.
# MDS: s/p decitabine finished cycle #1 [**2135-6-9**]. On
readmission, his peripheral blood morphology was concernign for
MDS, but bone marrow biopsy on [**2135-7-17**] showed only 8% blasts.
Nevertheless, over the course of this hospitalization, the
patient continued to have non-specific weakness, and remained
pancytopenic. Bone marrow biopsy was repeated on [**2135-8-11**] and
showed a hypercellular marrow consistent with RAEB-2. Mr.
[**Known lastname **] will requrie close outpatient followup and readmission
for cycle 2 of decitabine chemotherapy.
.
# Anemia and thrombocytopenia: likely secondary to MDS and
chemotherapy. The patient required frequent blood and platelet
trasnfusions during his hospitalization.
Medications on Admission:
1. furosemide 40 mg-Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
3. morphine 30 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO at bedtime.
4. oxycodone 5 mg Tablet Sig: Two (2) Tablet PO 8:00AM, 12:00PM,
4:00PM, and 8:00PM as needed.
5. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours)
as needed for Pain.
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
7. zinc sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
8. multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
9. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. prochlorperazine maleate 5 mg Tablet Sig: 1-2 Tablets PO
every eight (8) hours as needed for nausea.
11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation: This can be
purchased over the counter.
12. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation: This can be purchased over the
counter.
Discharge Medications:
1. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
Disp:*60 Tablet(s)* Refills:*2*
2. fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
Disp:*60 Tablet(s)* Refills:*2*
3. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours).
Disp:*90 Tablet(s)* Refills:*2*
4. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours).
Disp:*60 Tablet(s)* Refills:*2*
5. morphine 30 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO Q8H (every 8 hours).
Disp:*90 Tablet Extended Release(s)* Refills:*2*
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
8. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. prochlorperazine maleate 5 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
11. Oxygen
O2 at 2L continously with pulse dose system for portability. Dx
COPD/PNA
12. oxycodone 5 mg Tablet Sig: One (1) Tablet PO four times a
day as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 4480**] Rehab Home Care
Discharge Diagnosis:
1. Pneumonia
2. myelodysplastic syndrome
3. anemia
4. thrombocytopenia
5. urinary tract infection
6. COPD
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Mr. [**Known lastname **], You were admitted to [**Hospital1 1170**] because of weakness and fatigue with high ostomy output.
We found that you had a pneumonia and you were treated. We
found that you had an infection of you gastrointestional track,
which has been treated. We found you had a urinary tract
infection, which has been treated. You also had a bone marrow
biopsy that reveal that you continue to have a myelodysplastic
syndrome.
Medication changes:
Stop taking Furosemide
Stop taking Lorazepam
Stop taking Omeprazole
Change to MS Contin 30mg by mouth every 8 hours
Start taking Oxycodone 5mg by mouth every 6 hours as needed for
pain
Start taking Ciprofloxacin 500mg by mouth every 12 hours
Start taking metronidazole 500mg by mouth every 8 hours
Continue taking the Acyclovir 400 by mouth three times daily
Continue taking Ascorbic Acid 500mg by mouth daily
Continue taking Docusate 100mg by mouth two times daily
Continue taking Fluconazole 200mg 2 tablets daily
Continue taking a multivitamin daily
Continue taking Prochlorperzaine maleate 5mg 1-2 tablets by
mouth every six hours as needed for nausea
Continue taking Senna 1 table twice a day as needed for
constipation
Stop taking Zinc Slfate 220mg daily
Followup Instructions:
please follow up on Sunday, [**2135-8-21**] for lab work.
Department: HEMATOLOGY/[**Year (4 digits) 3242**]
When: THURSDAY [**2135-8-25**] at 10:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7779**], MD [**Telephone/Fax (1) 3241**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/[**Hospital Ward Name 3242**]
When: THURSDAY [**2135-8-25**] at 10:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9574**], NP [**Telephone/Fax (1) 3241**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/[**Hospital Ward Name 3242**]
When: THURSDAY [**2135-8-25**] at 10:30 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3920**], RN [**Telephone/Fax (1) 3241**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2135-8-29**]
|
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3,952
| 111,515
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5061
|
Discharge summary
|
report
|
Admission Date: [**2126-9-25**] Discharge Date: [**2126-10-1**]
Date of Birth: [**2071-6-27**] Sex: M
Service: MEDICINE
Allergies:
Tapazole
Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
Unresponsive, hypoglycemia
Major Surgical or Invasive Procedure:
Intubation [**2126-9-25**]
History of Present Illness:
45 year old male with a history of type 1 diabetes, chronic
kidney disease, and multiple episodes of hypoglycemia found
unresponsive at home by a friend.
On EMS arrival, cool and unresponsive but with pulse and
spontaneously breathing. FSBG 19, given 1amp D50 and 1mg
glucagon. Narcan without improvement. [**Month/Day/Year 4045**] to ED.
In the ED, vitals T 32.5, 65, 144/63, 17. Temp improved to 34.1
on bair hugger. Labs notable for WBC 18.3 without bands, Hct
25.2, AG 14, BUN 129, Cre 6.5, LFTs with mild transaminitis, CK
467, MB/MBI 12/2.6, TnT 0.13, lactate 1.6, serum and urine tox
screens negative. FSBG 109, remained normoglycemic while in ED.
U/A with mod bact, [**1-30**] WBC. Exam 'clamped down', cool, grossly
edematous, no evidence trauma, no gag, unresponsive to painful
stimuli, shivering. ABG 7.26/60/156. Intubated for airway
protection (reportedly very difficult due to edema). Given given
ativan and started on propofol gtt for ?seizure history. CXR
with no acute process. CT head negative. Not placed in C-collar
or spine imaging series given no concern for traumatic injury.
Covered with vanc 1gm IV, CTX 2gm IV. Admit to ICU.
Further history from the patient now that extubated and A&Ox3.
States that he awoke at 5:30am and ate breakfast, taking all his
meds including lasix, glargine and humulog. Went back to bed
around 8:30am then awoke later to go to the bathroom. The last
thing he remembers he was going back to bed. Denies seizure
history. Reports ultrabrittle diabetes with FSBG ranging 4 to
1300 at times. Had been feeling well the day prior and the
morning of admission. No cough, CP, SOB, nausea, diarrhea,
fevers, chills. No recent med changes or new meds. Denies h/o
prostate problems or change in urinary stream or frequency.
Past Medical History:
Diabetes type 1 (since age 16 on insulin, followed by Dr.
[**Last Name (STitle) 10088**]
-frequent hypoglycemic episodes
-high level of anti-insulin Ab
-complicated by nephropathy
-complicated by retinopathy (s/p right eye laser surgery,
repeated [**8-3**])
Vascular disease
Chronic renal insufficiency (baseline Cre ~4, followed by Dr. [**Name (NI) 5626**] at [**Last Name (un) **])
Hypertension
Hyperlipidemia
Anemia
Denies h/o seizure, heart problems (although sees cardiologist
Dr. [**Last Name (STitle) 20854**] at NEBH)
Graves' Disease
Diastolic CHF with LVH
Social History:
Lives with parents. Works in construction. No alcohol, drugs, or
tobacco.
Family History:
Mother has DM2 and RA. Maternal Aunt also c DM2. Nephew c DM1
Physical Exam:
T 35.1 HR 92 BP 129/68 RR 23 SaO2 100% on A/C 550x14x5, 60% FiO2
General: Intubated, sedated
HEENT: pinpoint pupils, scleral edema, anicteric
Neck: supple, trachea midline, no thyromegaly or masses, no LAD
Cardiac: RRR, s1s2 normal, soft SEM RUSB, no r/g, unable to
assess JVD
Pulmonary: diminished BS right base, crackles on left, no wheeze
Abdomen: +BS, soft, nontender, nondistended, no HSM
Extremities: warm, 2+ DP pulses, 1+ bilateral pitting tibial
edema
Neuro: Unable to assess due to sedation
Pertinent Results:
[**2126-9-25**] CT HEAD W/O CONTRAST:
FINDINGS: There is no evidence for edema, hemorrhage, mass
effect, or territorial infarction. There is no shift of midline,
and there is preservation of the normal [**Doctor Last Name 352**]-white matter
differentiation. The ventricles and sulci are normal in caliber
and configuration. There are no fractures. There is mucosal
thickening of the left and right maxillary sinuses as well as
the ethmoid sinuses and nasal passages, which could be related
to patient's intubated status. Patient is status post right lens
surgery. There are extensive vascular calcifications of the
carotid and vertebral arteries.
IMPRESSION: No acute intracranial process.
[**2126-9-25**] CHEST (PORTABLE AP):
FINDINGS: The ET tube has its tip approximately 45 mm from the
carina. The NG tube has its tip projected over the stomach.
There is apparent cardiomegaly which may partly be due to AP
projection. The lungs are clear.
[**2126-9-25**] RENAL U.S.:
The right kidney measures 10.7 cm, and the left kidney measures
10.1 cm. The parenchymal echogenicity is somewhat increased,
suggestive of chronic renal disease. There is no evidence of
stones, mass, or hydronephrosis. The bladder demonstrates Foley
catheter instrumentation, but is otherwise unremarkable. There
is a small amount of perihepatic ascites.
IMPRESSION:
1. Echogenic kidneys suggest chronic renal disease.
2. No evidence of stones, mass, or hydronephrosis.
3. Small amount of perihepatic ascites.
MICROBIOLOGY:
[**2126-9-30**] URINE URINE CULTURE-FINAL <10,000 organisms
[**2126-9-25**] MRSA SCREEN MRSA SCREEN-FINAL negative
[**2126-9-25**] SEROLOGY/BLOOD RAPID PLASMA REAGIN TEST-FINAL
negative
[**2126-9-25**] BLOOD CULTURE Blood Culture, Routine-FINAL no growth
[**2126-9-25**] BLOOD CULTURE Blood Culture, Routine-FINAL no growth
ADMIT AND DC HEMATOLOGY:
[**2126-9-25**] 11:15AM BLOOD WBC-18.3* RBC-3.12* Hgb-8.6* Hct-25.2*
MCV-81* MCH-27.7 MCHC-34.2 RDW-15.9* Plt Ct-230
[**2126-10-1**] 06:40AM BLOOD WBC-10.0 RBC-2.55* Hgb-7.1* Hct-20.3*
MCV-80* MCH-28.0 MCHC-35.1* RDW-15.5 Plt Ct-157
ADMIT AND DC CHEMISTRY:
[**2126-9-25**] 11:15AM BLOOD Glucose-86 UreaN-129* Creat-6.5* Na-141
K-4.5 Cl-102 HCO3-25 AnGap-19
[**2126-10-1**] 06:40AM BLOOD Glucose-243* UreaN-149* Creat-6.7* Na-134
K-4.7 Cl-99 HCO3-23 AnGap-17
[**2126-9-25**] 11:15AM BLOOD ALT-76* AST-46* CK(CPK)-467* AlkPhos-66
TotBili-0.2
[**2126-9-30**] 06:30AM BLOOD ALT-36 AST-26
[**2126-10-1**] 06:40AM BLOOD LD(LDH)-357* TotBili-0.2
CARDIAC ENZYMES:
[**2126-9-25**] 11:15AM BLOOD cTropnT-0.13*
[**2126-9-25**] 11:15AM BLOOD CK-MB-12* MB Indx-2.6
[**2126-9-25**] 05:33PM BLOOD CK-MB-13* MB Indx-3.3 cTropnT-0.12*
[**2126-9-25**] 08:38PM BLOOD CK-MB-16* MB Indx-3.6 cTropnT-0.13*
MISCELLANEOUS:
[**2126-9-25**] 11:15AM BLOOD VitB12-1454*
[**2126-9-26**] 04:21AM BLOOD calTIBC-267 Ferritn-42 TRF-205
[**2126-10-1**] 06:40AM BLOOD Hapto-156
[**2126-9-26**] 04:21AM BLOOD TSH-3.5
[**2126-9-26**] 04:21AM BLOOD Free T4-1.2
[**2126-9-25**] 11:15AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2126-9-30**] 12:50PM BLOOD THIOPURINE METHYLTRANSFERASE (TPMT),
ERYTHROCYTES-14.8 U/mL RBC
Brief Hospital Course:
# Unresponsiveness:
Patient was initially with concern for protecting airway and
thus was intubated. Hypoglycemia alone was most likely
explanation for initial unresponsive state. On night of
presentation patient had intermittently low fingersticks
requiring 1 amp of D50 on 2 separate occasions. At presentation
tox screens negative and patient did not arouse to narcan
administration. ROMI??????d with 3 sets of cardiac enzymes (elevated
enzymes likely due to CRI). CT head negative for intracranial
bleeding at presentation. Patient spontaneously awoke and
self-extubated in the MICU. After ensuring stabilization of
vital signs, he was transferred to the medical floor on night of
[**9-26**].
# Hypoglycemia / Diabetes:
After initial night in the MICU with several D50
administrations, the patient had no more hypoglycemia while
hospiatlized. Patient was subjected to Q2H fingersticks on the
floor to monitor for and acute drops in blood sugar; however,
the patient was never below mid-100s. Moreover, his blood sugar
climbed over 400 overnight every night after leaving the MICU
and coming to the medical floor (apart from night prior to
discharge when sugars remained under 300). Patient received
multiple doses of insulin overnight to keep sugars from climbing
over 400 (up to 20+ [**Location **]) and there was a concern for
stacking due to patient's poor renal function; however, the
patient's blood sugar never dropped. Given this information, the
patient's glargine doses were gingerly titrated up throughout
hospitalization until he had a night with no sugars over 300. He
discharge glargine dose was 8U in the AM and 6U in the PM.
# Insulin Receptor Autoantibody Syndrome:
Recently diagnosed with autoantibodies to the insulin receptor
and started on oral prednisone for immune suppression as an
outpatient; however, patient admitted that he only started
consistently taking the prednisone a few days prior to
admission. He had been frightened about side effects of
prednisone, most notably, the hypertension. Rheumatology
consulted on [**2126-9-26**] and they started patient on prednisone
20 mg twice daily in the hospital. Discussion with rheum consult
also revealed possibility that hypoglycemia could be attributed
to insulin autoantibodies that spontaneously release a large
pool of insulin rather than antibodies to the insulin receptor
itself. Regardless, given patient's uncontrolled hypertension
and hyperglycemia, dose of prednisone was reduced to 15 mg twice
daily and patient was started on azathioprine prior to
discharge. Allopurinol was decreased to 50 mg QOD in setting of
starting azathioprine. In order to adjust dosing of azathioprine
as an outpatient, a THIOPURINE METHYLTRANSFERASE (TPMT) level
was drawn and returned as 14.8 U/mL RBC after the patient was
discharged. He was scheduled to see his rheumatologist, Dr.
[**Last Name (STitle) 20863**], the week following discharge.
# Chronic kidney disease:
Patient presented with Cr of 6.5 up from his previous baseline
of 5.5 to 6.0; however, this dose not represent a significant
worsening of GFR. Nephrology was consulted and reported that the
patient had been approached about dialysis and about having a
fistula placed in preparation, but he had thus far refused the
idea of initiating preparation for dialysis. Nephrology consult
did feel that patient would benefit from a kidney and pancreas
transplant evaluation, thus he was set up to see Dr. [**Last Name (STitle) **]
the week following discharge.
# Hypertension:
Patient presented with an impressive outpatient regimen of
minoxidil, clonidine, metoprolol, diltiazem, doxazosin, and
furosemide. He had recently been discontinued from the ACE
inhibitor monapril in the outpatient setting for unclear
reasons. While hospitalized, his blood pressures initially
ranged from 160s to 190s systolic. His minoxidil and metoprolol
doses were increased as an inpatient. As his refractory
hypertension was thought to be partially associated with volume
status, the patient was started on [**Hospital1 **] 60 mg IV furosemide with
appropriate diuresis and a reduction in his edema. He was
discharged on oral furosemide at a dose of 80 mg [**Hospital1 **].
# Anemia:
Stable from previously. Likely secondary to CKD. Patient would
likely benefit from starting epo therapy; however, there are
reports from his nephrologist that he has been resistant to this
intervention. The epo clinic at [**Last Name (un) **] was called and patient
was provided with their number in order to set up a screening
appointment. Also, as his iron saturation was found to be 6.7%,
he was initiated on iron replacement therapy as an inpatient.
# Primary care:
Patient currently has no primary care and desperately needs a
physician to tie together his complicated medical presentation
and his multiple specialist visits. He has been arranged to see
Dr. [**First Name (STitle) 20866**] [**Name (STitle) 20867**] in [**Hospital 191**] clinic the week following
discharge.
Medications on Admission:
allopurinol 100mg po QOD
Lantus 3 [**Hospital1 **]
Humulog sliding scale
Lasix 30mg daily
Doxazosin 4mg qhs
Diltiazem 180mg [**Hospital1 **]
clonidine 0.3mg/hr q week
Toprol 100mg po daily
Toprol 50mg po QHS
Minoxidil 5mg po daily
calcitriol 0.25mg po daily
nephrocaps daily
sevelamer 800mg po tid
calcium carbonate 500mg po BIDWM
crestor 20mg po daily
colace
senna
Levothyroxine 75mcg daily
Discharge Medications:
1. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
2. Humalog 100 unit/mL Solution Sig: Administer by sliding
scale. units Subcutaneous four times a day.
3. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
4. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO BID (2 times a day).
5. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QFRI (every Friday).
6. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
7. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
9. Minoxidil 2.5 mg Tablet Sig: Two (2) Tablet PO twice a day.
Disp:*120 Tablet(s)* Refills:*2*
10. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BIDWM (2 times a day (with meals)).
12. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
15. Insulin Glargine 100 unit/mL Solution Sig: Six (6) units
Subcutaneous at bedtime.
16. Allopurinol 100 mg Tablet Sig: one half Tablet PO EVERY
OTHER DAY (Every Other Day).
Disp:*15 Tablet(s)* Refills:*2*
17. Furosemide 80 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
18. Prednisone 5 mg Tablet Sig: Three (3) Tablet PO twice a day.
Disp:*180 Tablet(s)* Refills:*2*
19. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO twice a day.
Disp:*60 Tablet Sustained Release 24 hr(s)* Refills:*2*
20. Azathioprine 50 mg Tablet Sig: one half Tablet PO DAILY
(Daily).
Disp:*15 Tablet(s)* Refills:*2*
21. Sevelamer HCl 800 mg Tablet Sig: Two (2) Tablet PO TID with
meals.
Disp:*180 Tablet(s)* Refills:*2*
22. Insulin Glargine 100 unit/mL Solution Sig: Six (6) units
Subcutaneous at bedtime.
23. Insulin Glargine 100 unit/mL Solution Sig: Eight (8) units
Subcutaneous Every morning.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
1. Hypoglycemia
Secondary Diagnoses:
2. Diabetes Mellitus
3. Chronic Kidney Disease
4. Hypertension
5. Anemia
6. Insulin autoantibodies
Discharge Condition:
afebrile, hemodynamically stable, blood sugars in 200s
Discharge Instructions:
You were admitted to the hospital after you were found
unreponsive at home. You were found to have a very low blood
sugar level. Your kidney function was found to be worse. You
were intubated and treated with glucose. Your blood sugars
improved and your breathing tube was removed. You were evaluated
by Rheumatology and instructed to take prednisone 15 mg by mouth
daily. They also started you on another medication called
azathioprine 25 mg daily.
Once you were transferred to the floor from the intensive care
unit, you were observed on the floor due to concern for high
blood pressure and low blood sugar. The doctors [**First Name8 (NamePattern2) **] [**Last Name (Titles) **] have
adjusted your Lantus and sliding scale insulin dosing as per the
attached flowsheet.
You have a complicated medication regimen and we have made
several changes and additions to your medication list. Please
review the attached medication list very carefully. Specifically
we have added the following medications:
1) Prednisone 15 mg by mouth twice a day
2) Azathioprine 25 mg by mouth once a day
3) Ferrous sulfate 325 mg daily
We have made changes to the following medications:
1) Glargine (Lantus) insulin 8 U in morning and 6 U at bedtime.
2) Metoprolol XL 100 mg in morning and 100 mg at bedtime.
3) Sevelamer 1600 mg three times a day with meals
4) Furosemide 80 mg by mouth twice a day
5) Allopurinol 50 mg by mouth every other day
6) Minoxidil 5 mg by mouth twice a day
You should follow-up this hospitalization with several doctor
visits:
1) We have arranged for you to see a transplant kidney doctor,
Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 60**]) [**Last Name (NamePattern1) **]. on [**2126-10-7**] at
1:00 PM in order to be evaluated for the possibility of a
transplant to improve your health
2) You have an appointment with Dr. [**Last Name (STitle) 20863**] in rheumatology
([**Telephone/Fax (1) 2226**]) on [**2126-10-8**] at 12:30 PM
3) You have an appointment with your new primary care physician
at [**Name9 (PRE) 191**] on [**2126-10-10**] at 3:30 PM
4) You should call Dr.[**Name (NI) 4849**] to make an appointment to
follow-up on your kidney function.
5) We have contact[**Name (NI) **] the anemia clinic at [**Name (NI) **] so that you can
be evaluated by them. They should be calling you for an
appointment; however, you may also call [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1968**] [**Doctor First Name 20868**] at
[**Telephone/Fax (1) 20869**].
Should you have any fever, chills, chest pain, diaphoresis, low
blood sugars, lightheadedness, or feeling that you may pass out,
please call your physician or report to the emergency room
immediately.
Followup Instructions:
1) We have arranged for you to see a transplant kidney doctor,
Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 60**]) [**Last Name (NamePattern1) **]. on [**2126-10-7**] at
1:00 PM in order to be evaluated for the possibility of a
transplant to improve your health
2) You have an appointment with Dr. [**Last Name (STitle) 20863**] in rheumatology
([**Telephone/Fax (1) 2226**]) on [**2126-10-8**] at 12:30 PM
3) You have an appointment with your new primary care physician
at [**Name9 (PRE) 191**] on [**2126-10-10**] at 3:30 PM
4) You should call Dr.[**Doctor Last Name 4849**] to make an appointment to
follow-up on your kidney function.
5) We have contact[**Name (NI) **] the anemia clinic at [**Name (NI) **] so that you can
be evaluated by them. They should be calling you for an
appointment; however, you may also call [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1968**] [**Doctor First Name 20868**] at
[**Telephone/Fax (1) 20869**].
Completed by:[**2126-10-6**]
|
[
"428.30",
"403.91",
"585.6",
"518.81",
"285.21",
"428.0",
"584.9",
"250.83"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
14319, 14325
|
6616, 11607
|
296, 325
|
14524, 14581
|
3421, 5913
|
17327, 18322
|
2819, 2884
|
12049, 14296
|
14346, 14346
|
11633, 12026
|
14605, 17304
|
2899, 3402
|
14402, 14503
|
5930, 6593
|
230, 258
|
353, 2123
|
14365, 14381
|
2145, 2711
|
2727, 2803
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,799
| 120,131
|
1914+1915+55331
|
Discharge summary
|
report+report+addendum
|
Admission Date: [**2202-3-29**] Discharge Date: [**2202-4-1**]
Service: MEDICINE
Allergies:
Penicillins / Aspirin / Nsaids / Erythromycin Base / Bactrim Ds
/ Atenolol / Heparin Agents / Nitroglycerin / Iodine Containing
Agents Classifier
Attending:[**Doctor First Name 1402**]
Chief Complaint:
mild HA, fatigue
Major Surgical or Invasive Procedure:
Pacer lead replacement
History of Present Illness:
86yo woman w h/o severe AS, CAD s/p CABG and recent DES->RCA and
LCx, tachy-brady syndrome s/p dual lead placement [**3-26**] who
presented to the ED w/ c/o HA and palpitations. She was
discharged yesterday and had been feeling well. Awoke this am at
3am then had [**2-21**] SSCP without radiation. Much milder than her
prior MIs and not assoc with any diaphoresis/N/V. She did report
mild diffuse HA. HA and CP occurred intermittenly until 10:30 am
so she called cards and came to device clinic.
.
Per device note, Interrogation showed good battery function.
Atrial sensing/vent pacing 20%, atrial pacing/vent pacing 78%
time. Underlying rhythm was variable nodal escape between 35-50
w occas sinus beats. EKG showed 1:1 conduction w Vrate of 60.
Further pacer interrogation showed undersensing the P-wave w
atrial [**Last Name (un) 36**] 0.5mV and a capture threshold 3.75 volts. Pt sent in
for admission and atrial lead revision in am.
.
In the ED: HR 60 BP stable. CXR showed no change in lead.
.
Currently, she is CP and HA free. She reports fatigue. No pain
at site of pacer. No groin pain. No syncopal sx. No recent F/C.
.
On review of systems, as above.
Past Medical History:
# Atrial fib: c/b tachy-brady syndrome s/p dual chamber [**Hospital 10014**] [**Last Name (un) 10661**] DR [**Numeric Identifier 10663**]/14/08. Now on amio and metop
# CAD s/p 2V CABG (SVG->LAD, SVG->ramus)Dr. [**Last Name (STitle) 70**] [**7-/2198**]
- s/p STEMI [**12/2198**] and PCI from distal LMCA into prox LAD(TO of
SVG->LAD)
- DES->RCA,LCx [**2202-3-12**]
- on asa and plavix
# Severe Aortic Stenosis ([**2-/2202**] [**Location (un) 109**] 0.6 cm2, peak grad 66 mmhg)
# Aortic regurg seen on last echo
.
# HTN
# Hypercholesterolemia
# Mild Mitral Regurgitation
# Breast Ca s/p Bilateral Mastectomies approx [**2159**], and [**2172**],
XRT
# Rectal Cancer s/p LAR in [**2192**]
# Radiation induced L axillary sarcoma, s/p XRT and resection
[**2199**]
# OA
# Osteoporosis
# h/o colon polyps- adenomas, last screened [**2200**]
# s/p Right THR
# s/p spinal fusion
# h/o HIT
# Acute cholecystitis s/p Lap Chol [**11/2199**]
Social History:
Widowed, lives indepently in [**Location (un) **]. She performs all ADLs
except for grocery shopping, where package lifting requires
help. She does not drive. 2 daughters are [**Name2 (NI) 2759**] and live locally.
No tobacco, history of alcohol abuse.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
VS: 98.6 122/58 60 14 99% RA
Gen: elderly NAD.
Neuro: AAO x3. CN ii-xii intact. strength 5/5 distal upper
bilat. [**5-17**] bilat lower. [**Last Name (un) 36**] intact light touch.
HEENT: PERRLA MM dry
NECK: JVP 12 cm
Cards: RRR rate 60. PPM dressing c/d/i. III/VI early systolic
murmur at LUSB and II/VI blowing diastolic murmur.
Chest: scloliosis deformity
Lungs: decreased BS at bases bilat
Abd: BS+ NTND no masses
Groin: 2+ pulses bilat w no bruits
Ext: WWP. trace edema bilat. 1+ DP pulses.
Skin: No stasis dermatitis, ulcers, scars
Pertinent Results:
ECG in ED: AV paced, LBBB pattern. Rate 65 w occas APCs.
CXR: FINDINGS: In the interim, there is essentially no change in
the position of the right atrial lead which still terminates in
the right atrium. There is slight worsening of a small left
pleural effusion. The patient is significantly dextroscoliotic.
The patient is status post median sternotomy. The right lung is
clear. Heart is mildly enlarged.
IMPRESSION:
1. Stable right atrial lead location.
2. Slight increase in the small left pleural effusion.
[**2202-3-31**] CXR:
Preliminary Report
REASON FOR EXAMINATION: Evaluation of pacemaker lead placement.
Portable AP chest radiograph compared to [**2202-3-29**].
The right-sided pacemaker is in unchanged position with its
leads terminating in right atrium and right ventricle. There is
a slight increase in the left currently moderate pleural
effusion. Small right pleural effusion is unchanged. The lungs
are hyperinflated with no new consolidations demonstrated. The
patient is not on failure. Severe kyphoscoliosis is again
noted, unchanged, as well as chronic left apical fibrotic
changes most likely related to previous granulomatous exposure.
[**2202-3-31**] 05:10AM BLOOD WBC-4.7 RBC-3.04* Hgb-10.0* Hct-29.6*
MCV-97 MCH-32.9* MCHC-33.9 RDW-14.2 Plt Ct-220
[**2202-3-28**] 05:23AM BLOOD WBC-5.6 RBC-3.06* Hgb-10.1* Hct-29.7*
MCV-97 MCH-33.0* MCHC-34.0 RDW-14.3 Plt Ct-158
[**2202-3-29**] 06:40PM BLOOD Neuts-81* Bands-0 Lymphs-7* Monos-9 Eos-3
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2202-3-29**] 06:40PM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-1+
Macrocy-1+ Microcy-NORMAL Polychr-NORMAL Ovalocy-1+
Schisto-OCCASIONAL Tear Dr[**Last Name (STitle) **]1+ Acantho-1+
[**2202-3-31**] 05:10AM BLOOD Plt Smr-NORMAL Plt Ct-220
[**2202-3-29**] 06:40PM BLOOD PT-12.3 PTT-30.1 INR(PT)-1.0
[**2202-3-31**] 05:10AM BLOOD Glucose-94 UreaN-32* Creat-1.1 Na-134
K-4.6 Cl-101 HCO3-25 AnGap-13
[**2202-3-28**] 05:23AM BLOOD Glucose-83 UreaN-45* Creat-1.1 Na-136
K-4.5 Cl-100 HCO3-26 AnGap-15
[**2202-3-30**] 05:10AM BLOOD CK(CPK)-54
[**2202-3-29**] 06:40PM BLOOD CK(CPK)-94
[**2202-3-30**] 05:10AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2202-3-29**] 06:40PM BLOOD cTropnT-<0.01
[**2202-3-30**] 05:10AM BLOOD Calcium-8.5 Phos-3.4 Mg-2.2
Brief Hospital Course:
ATRIAL LEAD UNDERSENSING: 86yo woman w hx of severe AS, CAD s/p
CABG and recent DES->RCA and LCx, tachy-brady syndrome s/p dual
lead placement [**3-26**] here with HA, intermittent CP and reports of
palpitations. She went to device clinic and was found to have a
resolution of her symptoms with an increase of her pacer rate.
She was sent to the hospital for atrial lead repositioning /
replacement. While inpatient her pacer was interrogated and
there was a clear reproduction of symptoms with rates that were
slower (in the 30s) and a resolution of the symptoms with faster
rates. Her atrial lead was undersensing and she was being AV
paced. She underwent an EP study, they were unable to
reposition the lead so she had the atrial lead replaced which
was then functioning well. Sent out on levofloxacin for 2 days
for skin ppx with pacer placement.
ANGINA: the patient has chronic angina, 1 episode inpatient
lasting less than 10 minutes- self limited, and mild. Increased
her lopressor slightly from 12.5mg po bid to 12.5mg po tid.
Plan to uptitrate antianginals as outpatient.
Medications on Admission:
Amiodarone 400mg [**Hospital1 **] until [**4-2**] then taper
ASA 325 daily
Plavix 75 daily
Lisinopril 5 daily
Vit D
CaCo3
Atorvastatin 80 daily
Lasix 20 daily
tylenol prn
Metop 25 [**Hospital1 **]
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO once a day.
7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
Disp:*45 Tablet(s)* Refills:*2*
8. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): continue as previous: take 2 tabs twice daily until
[**4-2**], then 2 tabs once daily until [**4-9**], then 1 tab daily.
9. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO once a day
for 2 days: start taking on [**4-2**].
Disp:*2 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary Diagnosis:
Undersensing Atrial pacing lead
Sick sinus syndrome
Paroxysmal Atrial Fibrillation
Conversion Pause
Severe Aortic Stenosis
Discharge Condition:
stable
Discharge Instructions:
You were admitted to adjust one of your pacer leads. This was
replaced.
Please call your doctor or return to the emergency room if your
symptoms return or worsen, you have chest pain that is worse
than your usual stable angina or that lasts longer than your
stable angina. In addition call your doctor or return to the
emergency room if you have any other symptoms that concern you.
Followup Instructions:
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2202-4-5**]
1:30
Provider: [**First Name8 (NamePattern2) 1409**] [**Last Name (NamePattern1) **], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 250**]
Date/Time:[**2202-4-28**] 1:30
Provider: [**First Name11 (Name Pattern1) 20**] [**Last Name (NamePattern1) 21**], M.D. Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2202-5-4**] 12:30
In addition please follow up with your Cardiologist Dr. [**Last Name (STitle) **]
within 3 weeks of your discharge from the hospital.
Please also follow up with Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] [**Telephone/Fax (1) 250**] within
6 weeks of your discharge from the hospital.
Admission Date: [**2202-4-2**] Discharge Date: [**2202-5-8**]
Service: CARDIOTHORACIC
Allergies:
Penicillins / Aspirin / Nsaids / Erythromycin Base / Bactrim Ds
/ Atenolol / Heparin Agents / Nitroglycerin / Iodine Containing
Agents Classifier
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest pain, shortness of breath
Major Surgical or Invasive Procedure:
[**2202-4-28**] Open Tracheostomy and Placement of Percutaneous
Endoscopic Gastrostomy Tube.
[**2202-4-14**] Redo Sternotomy, Aortic Valve Replacement(19mm CE
Pericardial Valve), and Single Vessel Coronary Artery Bypass
Grafting(vein graft to left anterior descending).
[**2202-4-7**] Cardiac Catheterization
History of Present Illness:
Mrs. [**Known lastname 2916**] is a 86 year old woman with severe aortic stenosis
(valve area 0.6cm, peak gradient 66mmHg) and coronary artery
disease s/p CABG and recent DES to RCA, LCx w/ 80%
stenosis-unable to intervene who presented with right-sided
chest pressure, which is her typical anginal equivalent. In
brief, angina resolved by time she reached ED, but she had EKG
with deepening ST depressions in lateral leads. Cardiac
biomarkers were negative. CXR showed pulmonary edema and
bilateral effusions. She was admitted for further evaluation and
treatment.
Past Medical History:
# Coronary Artery Disease s/p 2V CABG [**2198**](SVG to LAD, SVG to
Ramus), History of STEMI [**12/2198**], s/p PCI of Left Main [**12/2198**],
s/p PCI/DES to RCA and LCX in [**2-/2202**]
# Aortic Stenosis/Insufficiency
# Atrial Fibrillation, with history of tachy-brady, s/p PPM
Placement
# Hypertension
# Hypercholesterolemia
# Mild Mitral Regurgitation
# Breast Ca s/p Bilateral Mastectomies approx [**2159**], and [**2172**],
XRT
# Rectal Cancer s/p LAR in [**2192**]
# Radiation induced L axillary sarcoma, s/p XRT and resection
[**2199**]
# OA
# Osteoporosis
# History of colon polyps- adenomas, last screened [**2200**]
# s/p Right THR
# s/p spinal fusion
# History HIT
# Acute cholecystitis s/p Lap Chol [**11/2199**]
Social History:
Widowed, lives indepently in [**Location (un) **]. She performs all ADLs
except for grocery shopping, where package lifting requires
help. She does not drive. 2 daughters are [**Name2 (NI) 2759**] and live locally.
No tobacco, history of alcohol abuse.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
ADMIT EXAM
VS: T 93.7 BP 153/39 HR 61 RR 21 O2 93% 2L
Gen: elderly woman, grimacing, shallow, labored breathing with
mild use of accessory muscles. AAOx3.
HEENT: MM slightly dry, JVP elevated to jaw.
CV: [**4-18**] late peaking harsh systolic murmur @ USB and [**2-17**]
diastolic murmur. Nl S1 and S2. RRR.
Chest: Dullness at bases bilaterally L>R with mild crackles
above, occ. inspiratory wheeze. Pacer site- dressing c/d/e, no
hematoma
Abd: soft, moderately distended, with reproducible epigastric
pain
EXT: R arm 1+ pitting edema, LE with 2+ pitting edema above
knees.
Neuro: CNII-XII intact, moving all 4 ext., with nl. sensation.
Pertinent Results:
PREOP LABS:
[**2202-4-2**] 09:40AM BLOOD WBC-6.0 RBC-3.13* Hgb-10.6* Hct-30.5*
MCV-98 MCH-33.9* MCHC-34.7 RDW-14.2 Plt Ct-335
[**2202-4-2**] 09:40AM BLOOD PT-11.3 PTT-30.0 INR(PT)-0.9
[**2202-4-2**] 09:40AM BLOOD Glucose-92 UreaN-40* Creat-1.5* Na-132*
K-5.3* Cl-98 HCO3-26 AnGap-13
[**2202-4-2**] 09:40AM BLOOD CK(CPK)-31
[**2202-4-2**] 09:40AM BLOOD cTropnT-<0.01
[**2202-4-3**] 02:10AM BLOOD Albumin-3.1* Calcium-8.2* Mg-2.2
[**2202-4-13**] 02:31PM BLOOD %HbA1c-5.5
[**2202-4-7**] Cardiac Cath:
1. Limited resting hemodynamics demonstrated an elevated right
and left
heart filling pressures with an RVEDP of 18 mm Hg and an LVEDP
of 34 mm
Hg. The cardiac index was low at 2.17 L/min/m2 via the Fick.
2. Hemodynamics demonstrated a mean gradient of 17 mm Hg across
the
aortic valve. The aortic valve area was 0.6 cm2. Hemodynamics
demonstrated equalization of the left ventricle and femoral
diastolic
pressures indicating significant aortic regurgitation. A
echocardiogram
obtained in the cath lab demonstrated moderate - severe (3+)
aortic
regurgitation. Decision made not to perform the aortic
vavlvuloplasty.
[**2202-4-7**] Echocardiogram:
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets are severely thickened/deformed.
Significant aortic stenosis is present (not quantified). There
is probably moderate to severe (3+) aortic regurgitation is seen
(Pressure half time 200 ms, holodiastolic flow reversal in the
descending aorta). The aortic regurgitation jet is eccentric and
difficult ot assess visually. The mitral valve leaflets are
mildly thickened. Mild to moderate ([**1-13**]+) mitral regurgitation
is seen. The tricuspid valve leaflets are mildly thickened.
[**2202-4-13**] Carotid Ultrasound:
Duplex evaluation was performed of bilateral carotid arteries.
There is no significant plaque seen bilaterally. The velocities
are 96, 74, and 56 cm/sec in the ICA, CCA, and ECA respectively.
This is consistent with no stenosis.
[**2202-4-14**] Intraop TEE:
Pre Bypass -
The left atrium is dilated. No spontaneous echo contrast or
thrombus is seen in the body of the left atrium or left atrial
appendage. There is symmetric left ventricular hypertrophy.
There is mild to moderate regional left ventricular systolic
dysfunction with with focal septal hypokinesis as well as
overall global hypokinesis (EF 45%). The right ventricular
cavity is mildly dilated with normal free wall contractility.
There are complex (>4mm) atheroma in the aortic arch. There is
severe aortic valve stenosis (area <0.8cm2). Severe (4+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild mitral regurgitation.
Post Bypass -
A well-seated bioprosthetic valve is seen in the aortic position
with normal leaflet motion and gradients (mean gradient = 5
mmHg, peak 11 mmHg). No aortic regurgitation is seen. There is a
mild perivalvular leak in between the right and left coronary
cusps. Overall left ventricular function is similar. No aortic
dissection is seen. All findings discussed with surgeons at the
time of the exam.
POSTOP LABS:
Brief Hospital Course:
Mrs. [**Known lastname 2916**] was admitted under cardiology with congestive heart
failure. She ruled out for myocardial infarction. She was noted
to have acute renal insufficiency, likely prerenal etiology for
which the ACE inhibitor was discontinued. EP interrogation of
her pacemaker revealed normal function. She continued on
Amiodarone for atrial fibrillation. She experienced increasing
dyspnea and oxygen requirements which prompted transfer to the
CCU for initiation of Lasix drip and CPAP. Her oxygenation
gradually improved but she remained critical. Given that she was
a poor surgical candidate, it was decided to attempt aortic
valvuloplasty. Aortic valvuloplasty was aborted however
secondary to hemodynamic and echocardiographic evidence of
severe aortic insufficiency. Cardiac surgery was therefore
consulted for redo aortic valve replacment surgery. After
extensive discussion with the patient and her family, it was
decided to proceed high risk redo operation. Please see result
section preoperative workup. Of note, preop HIT assays were
negative for PF4 Heparin antibodies. On [**4-14**], Dr. [**First Name (STitle) **]
performed redo sternotomy, aortic valve replacement and coronary
artery bypass grafting surgery. For surgical details, please see
seperate dictated operative note. Following the operation, she
was brought to the CVICU for invasive monitoring. Initial
postoperative course was complicated by shock and coagulopathy.
She required significant pressor support and multiple blood
products. She also required re-exploration on postoperative day
zero. Due to a prolonged critical condition and failure to wean
from mechanical ventilation, tube feedings were initiated. She
concomitantly became oliguric despite fluid and volume
resuscitation. She was unresponsive to Natrecor and Lasix drip.
The renal service was consulted, and CVVH was eventually
initiated. Due to eventual mechanical problems with CVVH,
hemodialysis was temporarily required. Over several days, her
urine output improved as did volume status. She gradually
transitioned back to Lasix drip with adequate response, and
dialysis was no longer required. From a cardiac standpoint, she
maintained stable hemodynamics and eventually weaned from
inotropic support. Despite some improvement in renal function,
she continued to remain ventilator dependent. A right sided
chest tube was placed on [**4-25**] for worsening right pleural
effusion. On [**4-26**], she failed extubation trial. The
Thoracic service was therefore consulted and performed open
tracheostomy and placement of PEG tube on [**4-28**] without
complication. Following placement of tracheostomy, she went on
to develop worsening lethargy, altered mental status, and a
rising BUN. Stools were concomitantly noted to be guaiac
positive. She was transfused with PRBCs to maintain hematocrit
near 30% and all narcotics were discontinued. Rectal tube was
placed for persistent dark liquid stools. Over several days, her
mental status improved. Rising BUN was attributed to guaiac
positive stools. On [**5-5**], she developed an acute abdomen for
which she needed intervention by the general surgery team. Given
her current conditon and her age and fraility the family decided
not to proceed with this and after a long discussion with them
she was made CMO. A morphine drip was initiated and the
ventilator was withdrawn after discussion with Dr. [**First Name (STitle) **]. She
expired at 12:15 AM on [**5-6**] with her family at her bedside.
Medications on Admission:
Furosemide 20 mg PO DAILY
Aspirin 325 mg PO DAILY
Lisinopril 5 mg PO DAILY
Clopidogrel 75 mg PO DAILY
Vitamin D 400U DAILY
Calcium Carb 500MG DAILY
Lopressor 12.5MG PO TID
Amiodarone 400MG PO BID
Levofloxacin 250MG PO DAILY
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Coronary Artery Disease
Aortic Stenosis/Insufficiency
s/p redo sternotomy/AVR/CABG
s/p tracheostomy/PEG placement
Chronic Diastolic Congestive Heart Failure
Acute on Chronic Renal Insufficiency
Atrial Fibrillation
Postoperative Respiratory Failure
Postoperaive Bleeding/Coagulopathy
Discharge Condition:
expired
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2202-5-21**] Name: [**Known lastname 1484**],[**Known firstname 1485**] Unit No: [**Numeric Identifier 1486**]
Admission Date: [**2202-4-2**] Discharge Date: [**2202-5-8**]
Date of Birth: [**2115-5-12**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Aspirin / Nsaids / Erythromycin Base / Bactrim Ds
/ Atenolol / Heparin Agents / Nitroglycerin / Iodine Containing
Agents Classifier
Attending:[**First Name3 (LF) 265**]
Addendum:
Correction of dates/addendum to brief hospital course:
Pt. developed acute abdomen on [**5-7**]. Decision made with family
not to aggressively pursue treatment. Made CMO and expired at
12:20 AM on [**2202-5-8**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 49**] - [**Location (un) 50**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 266**]
Completed by:[**2202-5-28**]
|
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icd9cm
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icd9pcs
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|
11465, 11720
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107
| 182,383
|
4831
|
Discharge summary
|
report
|
Admission Date: [**2121-11-30**] Discharge Date: [**2121-12-5**]
Date of Birth: [**2052-4-2**] Sex: M
Service: MEDICINE
Allergies:
cefazolin / Penicillins
Attending:[**First Name3 (LF) 1899**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
hemodialysis
History of Present Illness:
69 year old male per OMR h/o ESRD, failed renal tx, s/p
thrombectomy of AV fistula, CHF, CAD s/p stents presenting with
shortness of breath. Onset was 2 hours prior when he returned
from church and sat down on his couch. He reported it felt
similar to past CHF exacerbations in that it was sudden in
onset, exacerbated by activity, no relieving factors. He denied
fevers or chills, reported positive nonproductive cough,
positive subjective lower extremity edema that is symmetric,
positive unintentional weight gain of approximately 10 pounds
over the past few weeks, no chest pain, no headache or change in
vision, no abdominal pain, no dysuria or urinary frequency, no
focal tingling or weakness. no change in medication.
.
In the ED, his initial 02sat was mid-80s on a NRB mask. He was
started on bipap. His initial labs were notable for a K+ 8.2, Cl
91, BUN/Cr 82/12.1, pro BNP 3760, trop 0.08. After insulin,
dextrose, albuterol and calcium, his repeat K+ was down to 6.0.
His EKG showed NSR at 60, 1 deg AVB, LAD, NO hyper acute T
waves. He was able to be taken off BiPap and at the time of
transfer, his 02sat was 98% on 4LPM via NC.
.
On arrival to the MICU, his HR was 63, BP 155/67, Sp02 98% on
2LPM via NC
.
Past Medical History:
PAST MEDICAL HISTORY:
- [**7-/2121**]: Rx allergy: Cephalosporins (cefazolin), s/p graft
embolect
- Subdural Hematoma: ER [**Hospital1 18**] [**6-18**]
- ESRD s/p kidney transplant and rejection, now on hemodialysis
- Glomerulonephritis
- CAD: cardiac cath [**2119-9-26**]: completely occluded LCx
(unchanged since [**2113**]), 50% lesion LAD (vs 30% prior) &
completely stenotic RCA
- Cath [**2119-9-28**] s/p 2 Xience DES to RCA after rotablation of
heavily calcified artery
- Hyperparathyroidism
- Anemia
- Gout
- Hyperlipidemia
- Hypertension
- Eosinophilia (? 2o Strongloides)
- Multiple lung nodules of unknown etiology
- Hypogonadism
- Obesity
- Bronchospasm
- Hx PPD positive but ruled out for pulmonary TB recently
- chronic SDH s/p [**2119**]
- [**2121-8-25**] Left IJ tunnelled catheter placement
.
PAST SURGICAL HISTORY:
- Cardiac catherization on [**2119-9-28**] s/p 2 Xience DES to RCA
after rotablation of heavily calcified artery.
- [**2113**] - Left brachial artery to cephalic vein primary AV
fistula.
- [**2114**] - Revision of AV fistula with ligation of side branches
- [**2114**] - Creation of left upper arm arteriovenous graft,
brachial
to axillary.
- [**2115**] - Thrombectomy with revision of left arm arteriovenous
(AV) graft
- [**2115-4-11**] Cadaveric kidney transplant, right iliac fossa. (Dr.
[**First Name (STitle) **]
- [**2117-8-13**] - Right upper arm brachial - axillary graft (Dr.
[**First Name (STitle) **]
- [**2119**] - RUE AVG Fistulogram, angioplasty of intragraft
partially occluding clot
- [**2120**] - RUE AVG Thrombectomy, fistulogram, arteriogram, 8-mm
balloon angioplasty of outflow stenoses.
Social History:
-Tobacco: smoked for a few years as a teenager
-EtoH: denies
-Illicits: denies
-Lives alone w Cat; has three sons that are not very involved in
his life; walks with a cane. Has VNA once a month and meals on
wheels.
-Previously worked as a zoo keeper [**Last Name (NamePattern1) 20122**] Zoo
Family History:
-No history of kidney disease, + history for DM, HTN
Physical Exam:
Vitals: T: BP: 155/67 P: 63 R: 18 O2: 97% on 2LPM via NC
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
Pertinent Results:
[**2121-12-2**] 06:44AM BLOOD WBC-9.1 RBC-4.51* Hgb-11.8* Hct-38.9*
MCV-86 MCH-26.2* MCHC-30.4* RDW-18.0* Plt Ct-218
[**2121-12-1**] 08:34AM BLOOD WBC-9.1 RBC-4.29* Hgb-11.3* Hct-36.7*
MCV-85 MCH-26.2* MCHC-30.7* RDW-18.0* Plt Ct-220
[**2121-12-1**] 12:01AM BLOOD WBC-14.2*# RBC-4.74 Hgb-12.8* Hct-40.3
MCV-85 MCH-27.0 MCHC-31.7 RDW-18.1* Plt Ct-303
[**2121-11-30**] 05:10PM BLOOD WBC-8.5 RBC-4.53* Hgb-12.1* Hct-39.0*
MCV-86 MCH-26.8* MCHC-31.1 RDW-17.9* Plt Ct-256
[**2121-11-30**] 05:10PM BLOOD Neuts-79.9* Lymphs-17.3* Monos-1.3*
Eos-0.7 Baso-0.9
[**2121-12-2**] 06:44AM BLOOD Plt Ct-218
[**2121-12-1**] 08:34AM BLOOD Plt Ct-220
[**2121-12-1**] 08:34AM BLOOD PT-11.8 PTT-20.8* INR(PT)-1.0
[**2121-12-2**] 06:44AM BLOOD Glucose-94 UreaN-42* Creat-7.3*# Na-139
K-4.6 Cl-93* HCO3-27 AnGap-24*
[**2121-12-1**] 08:34AM BLOOD Glucose-90 UreaN-53* Creat-9.0*# Na-140
K-4.5 Cl-92* HCO3-29 AnGap-24*
[**2121-12-1**] 12:01AM BLOOD Glucose-125* UreaN-36* Creat-5.8*# Na-139
K-3.3 Cl-92* HCO3-27 AnGap-23*
[**2121-11-30**] 05:10PM BLOOD Glucose-155* UreaN-82* Creat-12.1* Na-137
K-8.2* Cl-91* HCO3-24 AnGap-30*
[**2121-12-1**] 08:34AM BLOOD CK-MB-2 cTropnT-0.10*
[**2121-12-1**] 12:01AM BLOOD CK-MB-2 cTropnT-0.07*
[**2121-11-30**] 05:10PM BLOOD CK-MB-2 cTropnT-0.08* proBNP-3760*
[**2121-12-2**] 06:44AM BLOOD Calcium-8.2* Phos-8.7* Mg-2.0
[**2121-12-1**] 08:34AM BLOOD Calcium-8.0* Phos-8.8*# Mg-1.9
Echocardiography [**12-1**]:
Conclusions
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is normal (LVEF>55%). There is no ventricular
septal defect. The diameters of aorta at the sinus, ascending
and arch levels are normal. The aortic valve leaflets (3) are
mildly thickened. There is a minimally increased gradient
consistent with minimal aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Trivial mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. The pulmonary artery systolic pressure could not be
determined. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2121-1-25**],
LV systolic function is now more vigorous.
Chest x-ray [**11-30**]:
IMPRESSION: Mild interstitial pulmonary edema, slightly improved
from the
prior study.
[**2121-12-3**] 06:58AM BLOOD WBC-10.9 RBC-4.48* Hgb-11.9* Hct-37.9*
MCV-85 MCH-26.6* MCHC-31.4 RDW-18.3* Plt Ct-243
[**2121-12-4**] 07:00AM BLOOD WBC-10.5 RBC-4.39* Hgb-12.3* Hct-39.0*
MCV-89 MCH-28.0 MCHC-31.5 RDW-18.4* Plt Ct-189
[**2121-12-3**] 06:58AM BLOOD Plt Ct-243
[**2121-12-4**] 07:00AM BLOOD Plt Ct-189
[**2121-12-3**] 05:05PM BLOOD Glucose-123* UreaN-41* Creat-7.2*# Na-143
K-4.1 Cl-93* HCO3-29 AnGap-25*
[**2121-12-4**] 07:00AM BLOOD Glucose-91 UreaN-55* Creat-9.1*# Na-142
K-4.9 Cl-92* HCO3-30 AnGap-25*
[**2121-12-3**] 09:10PM BLOOD CK-MB-2 cTropnT-0.15*
[**2121-12-4**] 07:00AM BLOOD CK-MB-2 cTropnT-0.15*
[**2121-12-3**] 05:05PM BLOOD CK-MB-2 cTropnT-0.16*
[**2121-12-3**] 06:58AM BLOOD Albumin-4.1 Calcium-7.9* Phos-11.2*#
Mg-2.3
[**2121-12-3**] 05:05PM BLOOD Calcium-8.3* Phos-6.7*# Mg-2.1
[**2121-12-4**] 07:00AM BLOOD Calcium-8.2* Phos-9.3*# Mg-2.3
Brief Hospital Course:
# Respiratory distress: Pt reported to the ED with a sudden
onset of shortness of breath. In the ED, he was initially
desatting to the 80s on a NRB, was put on Bipap, improved quite
rapidly and was eventually able to be weaned down to a NC and
was stable on 2L upon arrival in the MICU. His 02 sat was
continuously monitored. An echocardiography was done (EF>55%),
the results of which are above.
.
#Chest pain: Pt developed left sided chest pain, accompanied by
diaphoresis and mild dyspnea while moving around on [**2121-12-3**].
Pain resolved after about half an hour with sublingual
nitroglycerin and maalox and simethicone. EKG at the time
showed new ST depressions and T wave inversion in I, aVL.
Troponins were cycled and were 0.16, 0.16, 0.15. In the
morning, repeat EKG showed persistent T wave inversions, but
resolution of ST depression. The overall picture was consistent
with an NSTEMI. The patient underwent a nuclear stress test
which showed normal myocardial uptake and preserved EF of 59%.
He did not undergo catheterization as his stress test was
normal.
.
# Hyperkalemia - emergent hemodialysis at the bedside was
performed and the repeat K+ after dialysis was 3.3.
.
# ESRD - received emergent hemodialysis at the bedside and
resumed on his regular schedule.
.
# CAD - he was continued on his ASA, beta blocker, statin, and
plavix. He had a repeat echo, the results of which are above.
His cardiac enzymes were trended.
.
# Gout - continued allopurinol
.
# Hyperlipidemia - continued statin
.
# Hypertension - continue beta blocker
.
.
Transitional Care Issues:
Has outstanding blood cultures that needs to be followed up on.
Medications on Admission:
- albuterol
- allopurinol
- cinacalcet (sensipar)
- clopidogrel
- fluticasone
- metoprolol succinate
- nitroglycerin
- oxycodone-acetaminophen
- pravastatin
- sevelamer carbonate
- ASA
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 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
3. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
4. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. pravastatin 20 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
8. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) inhalation Inhalation twice a day as
needed for shortness of breath or wheezing.
10. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO every 4-6 hours as needed for pain.
11. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
12. sevelamer carbonate 800 mg Tablet Sig: Four (4) Tablet PO
TID W/MEALS (3 TIMES A DAY WITH MEALS).
13. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual as required: as required for chest pain.
14. fluticasone 50 mcg/Actuation Spray, Suspension Sig: [**2-9**]
sprays Nasal once a day: each nostril.
15. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary: pulmonary edema, hyperkalemia
Secondary: end stage renal failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known firstname 20204**],
It was a pleasure to look after you at the [**Hospital1 827**]. You were admitted with difficulty breathing.
We found that your potassium level was high. You were admitted
to the ICU and given oxygen. We also treated you with
hemodialysis to remove potassium and fluid. your breathing
improved and you are back at your baseline [**Last Name (un) 14836**] at the time of
discharge. The renal team will coordinate further dialysis at
your outpatient facility.
We made no changes to your home medications.
Please followup with your doctors, see below.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Department: ADVANCED VASC. CARE CNT
When: THURSDAY [**2122-1-8**] at 10:00 AM
With: [**Name6 (MD) 5536**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 5537**]
Building: [**Street Address(2) 7298**] ([**Location (un) 583**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Department: PULMONARY FUNCTION LAB
When: THURSDAY [**2122-1-22**] at 2:10 PM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: MEDICAL SPECIALTIES
When: THURSDAY [**2122-1-22**] at 2:30 PM
With: DR. [**Last Name (STitle) 11071**]/DR. [**Last Name (STitle) **] [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 1905**]
|
[
"278.00",
"410.71",
"252.00",
"996.81",
"274.9",
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"285.21",
"403.11",
"428.33",
"V10.05",
"276.7",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
11095, 11153
|
7750, 9310
|
292, 307
|
11271, 11271
|
4288, 7727
|
12126, 13093
|
3548, 3602
|
9636, 11072
|
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|
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2414, 3223
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3617, 4269
|
245, 254
|
9336, 9401
|
335, 1557
|
11286, 11398
|
1602, 2391
|
3239, 3532
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,726
| 111,899
|
24032
|
Discharge summary
|
report
|
Admission Date: [**2191-8-9**] Discharge Date: [**2191-8-17**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5827**]
Chief Complaint:
CHF exacerbation
Major Surgical or Invasive Procedure:
none
History of Present Illness:
89 yo male with a PMHx of CHF, HTN, chronic lymphedema/venous
stasis was admitted to [**Hospital1 18**] with worsening SOB "for a long
time." Over the last day, his SOB at NH increased. A CXR had CHF
findings and the patient got 140 po lasix (via 3 doses) with
good urine output. Despite this, he continued to be SOB. O2 sat
by ems was 74 on 4L; this increased to 96% on NRB. He was given
40 iv lasix and 3 sl nitro by ems with slight improvement and
transferred to [**Hospital1 18**]. No cp/f/c/n/v. Per patient, + for
orthopnea and increasing SOB
Past Medical History:
-CHF
-multiple falls
-HTN
-BPH
-Chronic Lymphedema
-Venous stasis (w/ LLE stasis ulcer)
-PEripheral Neuropathy
Social History:
Txferred from [**Hospital3 2558**].
Family History:
NA
Physical Exam:
On admission:
T:97.6 BP:113/82 P: 94 RR: 15 O2 sats:98% NRB
Gen: Pleasant elderly gentleman slightly SOB with speaking
HEENT: JVD not visible.
CV: +s1+s2 +diastolic murmur along L sternal border
Resp: Crackles at bases bilaterally. No wheezing
Abd: +BS Soft NT ND
Ext: L>R leg with lymphedema. Non pitting edema.
Pertinent Results:
Labs on Admission:
[**2191-8-9**] 08:07PM BLOOD WBC-9.2 RBC-4.65 Hgb-15.0 Hct-43.5 MCV-94
MCH-32.2* MCHC-34.5 RDW-16.6* Plt Ct-237
[**2191-8-9**] 08:07PM BLOOD Neuts-77.4* Lymphs-16.6* Monos-4.3
Eos-1.5 Baso-0.2
[**2191-8-9**] 08:07PM BLOOD Plt Ct-237
[**2191-8-9**] 08:07PM BLOOD Glucose-154* UreaN-24* Creat-2.0* Na-139
K-6.4* Cl-102 HCO3-27 AnGap-16
[**2191-8-9**] 08:07PM BLOOD CK(CPK)-195*
[**2191-8-9**] 08:07PM BLOOD CK-MB-2
[**2191-8-9**] 08:07PM BLOOD cTropnT-0.05*
[**2191-8-10**] 04:06AM BLOOD CK(CPK)-140
[**2191-8-10**] 04:06AM BLOOD CK-MB-3 cTropnT-0.07*
[**2191-8-9**] 08:07PM BLOOD Calcium-9.3 Phos-3.9 Mg-2.3
[**2191-8-10**] 02:45AM BLOOD Type-ART pO2-82* pCO2-48* pH-7.40
calTCO2-31* Base XS-3
[**2191-8-9**] 10:26PM BLOOD Lactate-1.8
*
Studies:
CHEST (PORTABLE AP) [**2191-8-9**] 9:43 PM
FRONTAL CHEST RADIOGRAPH: Study is slightly limited by motion
artifact. Cardiac and mediastinal contours appear grossly
unremarkable allowing for portable technique. Increased
interstital opacities are noted, consistent with
mild-to-moderate CHF. No focal consolidations are seen. No
definite pleural effusions identified.
IMPRESSION: Slightly limited by motion artifact.
Mild-to-moderate CHF.
*
BILAT LOWER EXT VEINS [**2191-8-10**] 12:42 PM
FINDINGS: Grayscale and color Doppler imaging of the common
femoral, superficial femoral, and popliteal veins were performed
bilaterally. The right common femoral vein only partially
compresses and likely has non- occlusive thrombus within. The
superficial femoral vein does not compress and no demonstrable
flow is seen within. The right popliteal vein compresses and
demonstrates normal flow.
Likely non-occlusive thrombus is also identified within the left
common femoral vein though normal compressibility and flow is
seen within the left superficial femoral and popliteal veins.
IMPRESSION: Non-occlusive thrombus within the common femoral
vein bilaterally. Occlusive thrombus likely within the right
superficial femoral vein.
*
ECHO [**2191-8-10**]
Conclusions:
The left atrium is mildly dilated. The right atrium is
moderately dilated. No atrial septal defect is seen by 2D or
color Doppler. The estimated right atrial pressure is 11-15mmHg.
There is mild symmetric left ventricular hypertrophy with normal
cavity size and regional/global systolic function (LVEF>55%).
There is no ventricular septal defect. The right ventricular
cavity is moderately dilated. Right ventricular systolic
function is borderline normal. Interventricular septal motion is
normal. The ascending aorta is mildly dilated. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild to moderate ([**11-23**]+) 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 a
trivial/physiologic pericardial effusion.
IMPRESSION: Normal LVEF. Dilated RV with borderline normal
systolic function. Moderate to severe pulmonary hypertension.
These findings suggest chronic pulmonary hypertension. No
findings of acute, massive pulmonary embolism are suggested.
*
Brief Hospital Course:
*
A/P: 89 yo male with hx of CHF, HTN and venous stasis/lymphedema
with CHF exacerbation
.
# CHF Exacerbation/Hypoxia: now resolved thought to be due to
CHF exacerbation. PT had CTA which was negative for PE. Pt
started on Levofloxacin for question of pneumonia. Pt received
Lasix daily with good result.
.
#. [**Name (NI) 61151**] Pt had bilateral superficial femoral thrombosis. Pt was
started on a heparin gtt with bridge to coumadin with goal INR
2.5 - 3.0. Currently at goal on discharge.
.
# Fever: Pt had one upon admission, thought to be [**12-24**] pneumonia,
treated with 5 day course of Levofloxacin. [**8-9**] blood culture
pending, [**8-9**] urine culture contaminated but negative for
Legionella Ag. [**8-12**]- sputum cultures 4+ GP cocci in
pairs/chains, 2+ GN rods, 2+ GP rods
.
Medications on Admission:
-lasix 80mg daily
-prilosec 40mg daily
-aspirin 325mg daily
-diltiazem SA 120mg daily
- fluticasone nasal spray 50mcg
-KCl 40mEq daily
-Therapeutic-N one tab daily
-Spiriva 18mcg daily
-colchicine 0.6mg daily
-mirtazapine 15mg daily
-acular ls 0.4% each eye [**Hospital1 **]
-labetalol 100mg [**Hospital1 **]
-artificial tears
-tylenol PRN
-MOM PRN
-NTG PRN
-duonebs PRN
Discharge Medications:
1. Fluticasone 50 mcg/Actuation Aerosol, Spray Sig: One (1)
Spray Nasal DAILY (Daily).
2. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
3. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed.
5. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Inhalation Q6H (every 6 hours) as needed.
6. Erythromycin 5 mg/g Ointment Sig: One (1) Ophthalmic QID (4
times a day).
7. Labetalol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Ketorolac Tromethamine 0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
9. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
10. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
12. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
13. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
14. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. Outpatient Lab Work
Please check INR [**8-18**], [**8-22**], [**8-25**]
If INR>3.0 will need coumadin dose adjusted and pt should follow
up with his PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 335**] [**Last Name (NamePattern1) 5351**].
Pt will need help with administration of nebulizers and other
medicaitons.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
CHF exacerbation
Discharge Condition:
Improved
Discharge Instructions:
You were admitted to the hospital for a CHF exacerbation. You
were initially treated with some supplemental oxygen and Lasix
to imrove your urine output. In addition, a study showed that
you clots in your veins in the legs and you were started on
heparin and than transitioned to Coumadin.
You will need to get routine checks of your INR which will help
monitor your coumadin level. You will need to be checked in 2
days and then every 3 days thereafter.
If you are feeling short of breath or having any chest pain,
please return to the ED for further management
Followup Instructions:
You will see Dr [**First Name8 (NamePattern2) 335**] [**Last Name (NamePattern1) 5351**] while at [**Hospital3 2558**]
|
[
"401.9",
"459.81",
"486",
"356.9",
"600.00",
"428.0",
"457.1",
"453.41"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7423, 7493
|
4688, 5488
|
278, 284
|
7554, 7565
|
1419, 1424
|
8178, 8300
|
1066, 1070
|
5910, 7400
|
7514, 7533
|
5514, 5887
|
7589, 8155
|
1085, 1085
|
222, 240
|
312, 862
|
1438, 4665
|
884, 997
|
1013, 1050
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,294
| 197,862
|
37308
|
Discharge summary
|
report
|
Admission Date: [**2131-4-2**] Discharge Date: [**2131-4-10**]
Date of Birth: [**2086-9-5**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3190**]
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
Anterior release T10-L4
Anterior lumbar interbody fusion L4-S1
Posterior fusion T3-S1
History of Present Illness:
Ms. [**Known lastname 83948**] has a long history of back and leg pain due to her
scoliosis. She has attmepted conservative therapy including
physical therapy and has failed. She now presents for surgical
intervention.
Past Medical History:
As above
Social History:
Denies
Family History:
N/C
Physical Exam:
A&O X 3; NAD
RRR
CTA B
Abd soft NT/ND
BUE- good strength at deltoid, biceps, triceps, wrist
flexion/extension, finger flexion/extension and intrinics;
sensation intact C5-T1 dermatomes; - [**Doctor Last Name 937**], reflexes
symmetric at biceps, triceps and brachioradialis
BLE- good strength at hip flexion/extension, knee
flexion/extension, ankle dorsiflexion and plantar flexion,
[**Last Name (un) 938**]/FHL; sensation intact L1-S1 dermatomes; - clonus, reflexes
symmetric at quads and Achilles
Pertinent Results:
[**2131-4-9**] 06:10AM BLOOD WBC-7.5 RBC-2.67* Hgb-7.8* Hct-22.8*
MCV-86 MCH-29.2 MCHC-34.1 RDW-13.3 Plt Ct-180
[**2131-4-8**] 04:25AM BLOOD WBC-8.6 RBC-2.74* Hgb-8.4* Hct-22.9*
MCV-84 MCH-30.6 MCHC-36.6* RDW-13.3 Plt Ct-138*
[**2131-4-7**] 12:50PM BLOOD Hct-26.9*
[**2131-4-7**] 04:04AM BLOOD WBC-6.0 RBC-3.38* Hgb-10.2* Hct-27.9*
MCV-83 MCH-30.0 MCHC-36.3* RDW-14.2 Plt Ct-144*
[**2131-4-6**] 02:46PM BLOOD WBC-3.8* RBC-3.73* Hgb-10.9* Hct-30.9*
MCV-83 MCH-29.3 MCHC-35.3* RDW-13.8 Plt Ct-126*
[**2131-4-4**] 05:30AM BLOOD WBC-5.3 RBC-3.93* Hgb-11.6* Hct-34.3*#
MCV-87 MCH-29.5 MCHC-33.8 RDW-13.8 Plt Ct-121*
[**2131-4-9**] 06:10AM BLOOD Glucose-110* UreaN-9 Creat-0.5 Na-139
K-3.8 Cl-100 HCO3-36* AnGap-7*
[**2131-4-6**] 08:51PM BLOOD Glucose-131* UreaN-16 Creat-0.5 Na-138
K-4.5 Cl-102 HCO3-32 AnGap-9
[**2131-4-4**] 05:30AM BLOOD Glucose-120* UreaN-8 Creat-0.7 Na-139
K-4.2 Cl-105 HCO3-27 AnGap-11
Brief Hospital Course:
Ms. [**Known lastname 83948**] was admitted to the [**Hospital1 18**] Spine Surgery Service on
[**2131-4-2**] and taken to the Operating Room for an anterior release
T10-L4 through an thoracotomy approach. Please refer to the
dictated operative note for further details. The surgery was
without complication and the patient was transferred to the PACU
in a stable condition. She has a chest tube placed at the time
of this surgery. TEDs/pnemoboots were used for postoperative DVT
prophylaxis. Intravenous antibiotics were given per standard
protocol. Initial postop pain was controlled with a PCA. On HD#2
([**2131-4-3**]) she returned to the operating room for a scheduled
L4-S1 anterior lumbar interbody fusion as part of a staged
3-part procedure. Please refer to the dictated operative note
for further details. The second surgery was also without
complication and the patient was transferred to the PACU in a
stable condition. Postoperative HCT was stable. She
subsequently returned to the OR for a scheduled T2-S1 posterior
fusion with instrumentation. A bupivicaine epidural pain
catheter placed at the time of the posterior surgery remained in
place until postop day one. She spent the night in the SICU for
hemodynamic monitoring and she was transfered to the floor
thereafter. She received multiple blood products and tolerated
the procedures well. She was kept NPO until bowel function
returned then diet was advanced as tolerated. The patient was
transitioned to oral pain medication when tolerating PO diet.
Foley was removed on POD#2 from the third procedure. She was
fitted with a TLSO brace for ambulation. Physical therapy was
consulted for mobilization OOB to ambulate. Hospital course was
otherwise unremarkable. On the day of discharge the patient was
afebrile with stable vital signs, comfortable on oral pain
control and tolerating a regular diet.
Medications on Admission:
None
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. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
Disp:*60 Tablet Sustained Release 12 hr(s)* Refills:*0*
4. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4
hours) as needed for paimn.
Disp:*100 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Scoliosis
Acute post-op blood loss anemia
Discharge Condition:
Good
Discharge Instructions:
You have undergone the following operation: ANTERIOR/POSTERIOR
Lumbar Decompression With Fusion
Immediately after the operation:
-Activity: You should not lift anything greater than 10 lbs for
2 weeks. You will be more comfortable if you do not sit or stand
more than ~45 minutes without getting up and walking around.
-Rehabilitation/ Physical Therapy:
o2-3 times a day you should go for a walk for 15-30 minutes as
part of your recovery. You can walk as much as you can tolerate.
oLimit any kind of lifting.
-Diet: Eat a normal healthy diet. You may have some constipation
after surgery. You have been given medication to help with this
issue.
-Brace: You have been given a brace. This brace is to be worn
when you are walking. You may take it off when sitting in a
chair or while lying in bed.
-Wound Care: Remove the dressing in 2 days. If the incision is
draining cover it with a new sterile dressing. If it is dry then
you can leave the incision open to the air. Once the incision is
completely dry (usually 2-3 days after the operation) you may
take a shower. Do not soak the incision in a bath or pool. If
the incision starts draining at anytime after surgery, do not
get the incision wet. Cover it with a sterile dressing. Call the
office.
-You should resume taking your normal home medications. No
NSAIDs.
-You have also been given Additional Medications to control your
pain. Please allow 72 hours for refill of narcotic
prescriptions, so please plan ahead. You can either have them
mailed to your home or pick them up at the clinic located on
[**Hospital Ward Name 23**] 2. We are not allowed to call in or fax narcotic
prescriptions (oxycontin, oxycodone, percocet) to your pharmacy.
In addition, we are only allowed to write for pain medications
for 90 days from the date of surgery.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
Followup Instructions:
With Dr. [**Last Name (STitle) 363**] in 10 days
Completed by:[**2131-4-19**]
|
[
"721.3",
"285.1",
"455.6",
"627.9",
"338.18",
"737.30",
"737.34",
"E878.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"77.79",
"81.06",
"84.51",
"81.62",
"81.63",
"81.08",
"81.05",
"81.64",
"81.04",
"84.52"
] |
icd9pcs
|
[
[
[]
]
] |
4736, 4742
|
2203, 4079
|
327, 415
|
4828, 4835
|
1276, 2180
|
6814, 6894
|
736, 741
|
4134, 4713
|
4763, 4807
|
4105, 4111
|
4859, 4958
|
756, 1257
|
4994, 5187
|
278, 289
|
5223, 5678
|
5690, 6791
|
443, 664
|
686, 696
|
712, 720
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,038
| 125,008
|
22061
|
Discharge summary
|
report
|
Admission Date: [**2162-12-4**] Discharge Date: [**2162-12-8**]
Date of Birth: [**2090-10-5**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 495**]
Chief Complaint:
diarrhea, fatigue
Major Surgical or Invasive Procedure:
Paracentesis
Central Venous Line
Tracheal Intubation
History of Present Illness:
Mr [**Known lastname 15942**] is a 72 year old man with known alcoholic
cirrhosis, who refused transplant evaluation last year, and who
comes today with a five day history of diarrhea and weakness. He
and his daughter say he was in his usual state of health until
earlier this week, the daughter thinks around Tuesday. He began
to have diarrhea which he said was not bloody or black. Earlier
this week (Thursday?) he was in the bathtub and was feeling so
weak that he could not get out and stayed there for hours. He
says that he also fell down some stairs; he hit his buttocks and
back but denies any head trauma. He has more recently been
having shaking chills, including this morning when his chills
were at their worst yet. Further review of systems is detailed
below.
When he presented to the [**Hospital1 18**] ED, his initial vitals were: T
100.4; BP 112/57; HR 72; RR 18; O2 99% on 3L NC. In the
emergency department he had an x-ray which showed no pulmonary
edema or consolidation, and a clean UA. His blood pressures
dipped down into the 80s and low 90s, at which point the sepsis
protocol was initiated. From 11:40 AM to 14:40 her received 4 L
of NS as well as a fifth liter running at 200 cc/hr which was
mostly complete by the time he arrived in the MICU. Additionally
at 15:30 levophed drip was started. He was started on
antibiotics with zosyn 4.5 mg IV and vancomycin 1 gram IV, each
as one-time doses given at 1320 (zosyn) and 1550 (vanco).
Additionally, early in his stay, he also received zofran 4 mg IV
x1 and Tylenol 1g PO. By report GI recommended 150 grams of
albumin but the ED was not able to give this. A central venous
line was placed with an appropriate central line checklist
placed in the chart.
ROS: Constitutional: Fatigue, Weight loss, gained weight overall
but daughter and pt feel he has lost weight in other areas
besides his distended abdomen
Ear, Nose, Throat: Dry mouth, No(t) Epistaxis
Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t)
Orthopnea
Respiratory: No(t) Cough, No(t) Dyspnea
Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t)
Emesis, Diarrhea
Genitourinary: Foley
Integumentary (skin): Jaundice
Heme / Lymph: Anemia
Neurologic: No(t) Headache
Pain: No pain / appears comfortable
Past Medical History:
Cirrhosis; turned down evaluation for transplant in [**5-/2161**];
grade II esophageal varices seen in EGD [**7-29**] along with portal
hypertensive gastropathy but no gastric varices
Past EtOH abuse
Type II DM, last HgbA1c 6.7
Hypertension
Social History:
no tobacco, no illicits, patient denies alcohol but per
daughters think patient still drinks
Family History:
non-contributory
Physical Exam:
T: 36 ??????C HR: 72 BP: 118/61 RR: 19 SpO2: 95% 3LNC
General Appearance: gaunt face, thin other than quite distended
abdomen
Eyes / Conjunctiva: PERRL, No(t) Conjunctiva pale, jaundice
Head, Ears, Nose, Throat: Normocephalic, Mucus membranes dry;
back of OP dark color of red without any apparent blood or fluid
Cardiovascular: (S1: Normal), (S2: Normal), distant heart sounds
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Diminished), (Left DP pulse:
Diminished), cool feet in context of levophed
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Clear : , No(t) Crackles : , No(t) Bronchial: , No(t) Wheezes :
, No(t) Rhonchorous: )
Abdominal: Soft, Non-tender, Bowel sounds present, Distended,
markedly distended; angiomas; caput at umbilicus; bulging
flanks;
Extremities: Right: 1+, Left: 1+
Musculoskeletal: Muscle wasting, facial wasting
Skin: Warm, Jaundice, mostly warm except feet/LE which were
cool; scattered ecchymoses on back
Neurologic: Attentive, Follows simple commands, Responds to:
Verbal stimuli, Oriented (to): Hospital, [**Hospital3 **], [**Location (un) 86**],
[**Month (only) 1096**], "[**2162**]", Movement: Not assessed, Tone: Not assessed,
very slight asterixis
Pertinent Results:
ON ADMISSION:
[**2162-12-4**] 12:15PM BLOOD WBC-15.3*# RBC-3.39* Hgb-12.4* Hct-33.5*
MCV-99* MCH-36.5* MCHC-36.9* RDW-15.6* Plt Ct-110*
[**2162-12-4**] 12:15PM BLOOD Neuts-84* Bands-6* Lymphs-1* Monos-9
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2162-12-4**] 12:15PM BLOOD PT-24.1* PTT-34.5 INR(PT)-2.3*
[**2162-12-4**] 12:15PM UreaN-43* Creat-1.7* Na-129* K-4.2 Cl-99
HCO3-21* AnGap-13
[**2162-12-4**] 10:05PM Calcium-7.0* Phos-4.0 Mg-2.3
CREATININE TREND
[**2162-12-4**] 10:05PM UreaN-43* Creat-1.8* Na-133 K-4.7 Cl-104
HCO3-22
[**2162-12-5**] 09:13AM UreaN-54* Creat-2.5* Na-133 K-4.9 Cl-101
HCO3-17*
[**2162-12-6**] 03:58AM UreaN-68* Creat-3.3* Na-130* K-4.4 Cl-100
HCO3-16*
[**2162-12-7**] 03:18AM UreaN-88* Creat-4.8* Na-127* K-4.4 Cl-97
HCO3-16*
LFTS
[**2162-12-4**] 12:15PM ALT-74* AST-136* AlkPhos-108 TotBili-7.2*
DirBili-4.4* IndBili-2.8
[**2162-12-5**] 09:13AM ALT-67* AST-126* LD(LDH)-283* AlkPhos-87
TotBili-9.9*
[**2162-12-6**] 03:58AM ALT-54* AST-90* AlkPhos-68 TotBili-9.8*
[**2162-12-6**] 03:34PM ALT-52* AST-80* AlkPhos-68 TotBili-11.2*
[**2162-12-7**] 03:18AM ALT-49* AST-76* AlkPhos-70 TotBili-12.9*
IRON STUDIES
[**2162-12-4**] 12:15PM BLOOD Iron-55 calTIBC-135* Hapto-25*
Ferritn-903* TRF-104*
[**2162-12-6**] 03:58AM BLOOD AFP-<1.0
[**2162-12-5**] 09:13AM BLOOD Ethanol-NEG
LACTATE TREND
[**2162-12-4**] 11:59AM BLOOD Lactate-3.1*
[**2162-12-4**] 03:55PM BLOOD Lactate-2.0
[**2162-12-4**] 05:25PM BLOOD Glucose-71 Lactate-2.1*
[**2162-12-4**] 06:14PM BLOOD Lactate-1.9
[**2162-12-4**] 07:33PM BLOOD Lactate-2.0
[**2162-12-5**] 10:31PM BLOOD Lactate-2.0
CULTURES:
[**2162-12-4**] 12:15 pm BLOOD CULTURE 4/4 bottles
Blood Culture, Routine (Preliminary):
KLEBSIELLA PNEUMONIAE. FINAL SENSITIVITIES.
GRAM NEGATIVE ROD #2.
GRAM NEGATIVE ROD #3. 3RD MORPHOLOGY.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 2 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
ASCITES
Cultures 12/13 and [**12-5**] with no growth to date
[**12-5**] Albumin <1 and cytology negative for malignant cells
[**12-5**] WBC RBC Polys Lymphs Monos Mesothe Macrophages Totprot
Glucose LDH
95* 235* 20* 5* 72* 3* 1.7
131 54
[**12-4**] 148* 85* 34* 24* 26* 16* 1.6
84
[**12-5**] Urine Culture: no growth
[**2162-12-5**] 3:29 pm STOOL CONSISTENCY: FORMED Source:
Stool.
**FINAL REPORT [**2162-12-7**]**
FECAL CULTURE (Final [**2162-12-7**]): NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final [**2162-12-7**]): NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final [**2162-12-6**]):
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
FECAL CULTURE - R/O VIBRIO (Final [**2162-12-7**]): NO VIBRIO
FOUND.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2162-12-6**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
RADIOLOGY
[**2162-12-4**] CXR: No evidence of pneumonia or volume overload.
Atelectasis at the left lung base.
[**2072-12-4**]: ABD X-RAY There is gas seen in several featureless
loops of likely small bowel within the mid abdomen. No dilated
loops of colon is identified. Findings are non-specific. There
is no free intra-abdominal gas. Degenerative changes are seen at
the lumbar spine and of the hips bilaterally.
[**2162-12-4**] LIVER/GALLBLADDER US
1. Gallbladder wall edema without pericholecystic fluid or
son[**Name (NI) 493**]
[**Name2 (NI) 515**] sign. Cholelithiasis with gallbladder wall sludge.
Overall,
findings equivocal for acute cholecystitis and if persistent
clinical concern for acute cholecystitis, a HIDA scan is
recommended.
2. Right hepatic lobe heterogeneously echogenic vascular mass as
described
above, raising concern for hepatocellular carcinoma in the
setting of
cirrhosis, was noted on the CT abdomen from [**2161-4-13**],
however, direct comparison in size cannot be made due to
technique-related differences. MR characterization is
recommended.
3. Cirrhosis, splenomegaly, ascites indicating portal
hypertension.
ECG [**2162-12-4**]: Sinus rhythm. Findings are within normal limits.
Compared to the previous tracing of [**2160-9-3**] there is no
significant diagnostic change.
Brief Hospital Course:
72 year old man with known alcoholic cirrhosis, esophageal
varices, type II diabetes and hypertension, who presented with
diarrhea, fevers and chills, and severe weakness; consistent
with sepsis. Patient was empirically started on vancomycin,
zosyn, ciprofloxacin and flagyl. Patient grew [**3-26**] gram negative
rods in blood eventually speciated as pan-sensitive klebsiella.
Unclear source of bacteremia as urine culture was negative and
patient did not have CXR consistent with pneumonia. Patient did
have mildly wall thickening of gall bladder, although there was
no ductal dilation, but patient was also in worsening liver and
renal failure and a very poor surgical candidate. Patient also
had low HCT and guaiac positive stool suggesting he may have had
a GI bleed with translocation of organisms precipitating his
presentation. Repeat cultures on antibiotics were negative. The
patient's acute renal failure was initially attributed to
prerenal etiology or peritonitis. Peritoneal fluid and
paracentesis were negative for infection. Volume resuscitation
with fluid and albumin did not improve creatinine or urine
output. Patient was felt to have type 1 hepatorenal syndrome and
was treated with octreotide and midodrine. In the setting of
attempted the volume resuscitation, despite a paracentesis that
removed 3 liters of fluid, the patient's respiratory status
declined. The patient was intubated for hypoxemic respiratory
failure. Given worsening end-stage cirrhosis with rising
bilirubin and ultrasound negative for obstruction, renal failure
attributed to hepatorenal syndrome and patient's prior refusal
for any transplant evaluation, CVVHD or HD to attempt to improve
renal/volume status was futile. Over the course of the
admission, the patient became more confused attributed to his
hepatic encephalopathy. Discussion with family regarding the
patient's poor prognosis resulted in the family changing his
goals of care to comfort measures. The liver service worked
closely with the MICU service in coordinating this patient's
care. The patient died [**2162-12-8**] with family at his bedside. The
family, including all of his daughters, declined an autopsy.
Medications on Admission:
Aldactone 1.5 tablets by mouth once daily
Furosemide 80 mg oral
Glipizide 5 mg oral
Nadolol 40 mg PO
One Touch Ultra
Oxazepam 15 mg oral HS PRN
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Endstage Liver Disease due to Alcoholic Cirrhosis
Acute Renal Failure, Likely Hepatorenal syndrome
Cardiac Arrest
Discharge Condition:
Death
Discharge Instructions:
N/A
Followup Instructions:
N/A
|
[
"572.3",
"787.91",
"038.49",
"789.59",
"572.2",
"250.00",
"518.81",
"456.21",
"571.2",
"584.9",
"786.3",
"995.92",
"401.9",
"572.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91",
"38.93",
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
11742, 11751
|
9340, 11518
|
340, 395
|
11909, 11917
|
4380, 4380
|
11969, 11976
|
3071, 3089
|
11714, 11719
|
11772, 11888
|
11544, 11691
|
11941, 11946
|
3104, 4361
|
6070, 9317
|
283, 302
|
423, 2677
|
4394, 6026
|
2699, 2945
|
2961, 3055
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,524
| 190,249
|
53044
|
Discharge summary
|
report
|
Admission Date: [**2142-5-9**] [**Month/Day/Year **] Date: [**2142-5-15**]
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
Left hemiparesis, left neglect.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
87yo woman with HTN, Hyperlipidemia, CAD, recent
ERCP with biliary stent placement aditted to the medicine servie
[**5-9**] with UTI who now presents with acute onset left hemiparesis
and left sided neglect. She was last seen well at ~11:17pm [**5-10**]
when medicine nightfloat coverage was called to evaluate the pt
for slumping against a wall in the bathroom. Medicine
nightfloat's exam at that time found the pt was fluent, using
both hands to roll toilet paper ([**Name8 (MD) **] RN), able to ambulate back
to bed. Brief neurologic exam at that time was absent for any
facial palsy. At 3am the RN noted left sided weakness and called
medicine resident to re-evalute. Code Stroke was called.
Neurology Resident examination at this time revealed NIHSS of 13
for left arm > leg hemiparesis, profound left sided
neglect/inattention, facial droop, slight dysarthria. Pt was
brought for STAT head CT/CTA/CT perfusion revealing proximal R
ICA occlusion just prior to bifurcation with prolonged MTT on
perfusion images in R MCA territory. Neurosurgery was contact[**Name (NI) **]
for possible IA intervention given that the pt was at ~5hrs
since
time last seen normal. Unfortunately given the location of the
ICA thrombus the risk of distal embolization causing total MCA
occlusion with mechanical and IA TPA clot disruption was high.
Per discussion with Dr. [**First Name (STitle) **] (neurosurgery) and Dr. [**First Name (STitle) **]
(stroke neurology), medical therapy was deemed most beneficial.
At present, the patient denies any headache, she is unaware of
her left sided deficit. She denies weakness, numbness, tingling.
She denies any pain, f,c, CP, SOB, nausea.
Past Medical History:
Coronary Artery Disease s/p stent placement; MI in [**1-/2140**]
S/p appendectomy
S/p cataract surgery
Transient isolated third nerve palsy- ([**2140**]) thought [**2-10**]
diabetes, resolved fully by the time the pt was seen by Dr.
[**Last Name (STitle) 4253**] at [**Hospital1 18**] neurology.
Diabetes
Lumbar spinal stenosis
CAD- s/p stents, MI [**1-/2140**]
Hypertension
Hypercholesterolemia
s/p ventral hernia repair
s/p ERCP with biliary stent placement, new afib documented with
this admission, coumadin held s/p procedure.
Social History:
Lives at home alone, daughter lives nearby, quit smoking 65
years back prior to which she was not a heavy smoker, no
alcohol.
Family History:
Non contributory
Physical Exam:
Vitals: T 98, BP 140/70, P 71, R 12, Sat 99% 2LNC
Gen- well appearing, older woman, R gaze preference
HEENT- NCAT, aniceric, OP clear
Neck- no carotid bruits bilat
CV- RRR, no MRG
PULM- CTA B
ABD- soft, nt, nd, bs +
Extrem- no CCE
NEUROLOGIC EXAM:
MS- alert and oriented to month, pt's age. Follows midline and
appendicular commands (severely neglecting left hemibody). Her
speech is mildly dysarthric, fluent. Naming intact. She neglects
the left side of the cookie theft picture.
CN- PERRL 4-->3mm bilaterally, conjugate right gaze preference,
but EOM's are full without nystagmus. left UMN facial paresis,
Motor- left arm is [**1-13**], left leg is [**2-13**], right arm is
antigravity
x 10 seconds, right leg is antigravity x 10 seconds. No
adventitious movements.
Sensory- neglects left side. Intact on R.
Coordination- unable to test on left, itact FNF on right.
Reflexes- brisk on left, 2+ on right.
Left toe is upgoing, right toe is downgoing.
Pertinent Results:
Admission labs:
145 108 16 AGap=15
---+---+----<167
4.0 26 0.8
CK: 124 MB: 4 Trop-T: <0.01
Ca: 9.1 Mg: 2.1 P: 3.9
ALT: 19 AP: 101 Tbili: 0.7 Alb:
AST: 17
WBC 6.7, Hb 12.6, Hct 36.3, Plt 185
[**2142-5-13**] Radiology HIP UNILAT MIN 2 VIEWS LEFT
Degenerative changes, no #
[**2142-5-12**] Radiology CHEST (PORTABLE AP) [**Last Name (LF) 162**],[**First Name3 (LF) **] APPROVED
Stable cardiomegaly and elevation of the left hemidiaphragm.
Calcification projecting over the heart. Localization of this
finding may be obtained with a lateral view
[**2142-5-12**] Radiology CT HEAD W/O CONTRAST
Evolving right MCA infarct, without significant mass effect at
this time. No hemorrhage
[**2142-5-11**] Cardiology ECHO [**2142-5-11**] [**Last Name (LF) **],[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 975**]
The left atrium is mildly dilated. There is moderate symmetric
left ventricular hypertrophy. The left ventricular cavity size
is normal. Left ventricular systolic function is hyperdynamic
(EF 70-80%). Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). Transmitral Doppler
and tissue velocity imaging are consistent with Grade II
(moderate) LV diastolic dysfunction. Right ventricular chamber
size and free wall motion are normal. The ascending aorta is
mildly dilated. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. There is severe
mitral annular calcification. Mild (1+) mitral regurgitation is
seen. [Due to acoustic shadowing, the severity of mitral
regurgitation may be significantly UNDERestimated.] The
tricuspid valve leaflets are mildly thickened. The supporting
structures of the tricuspid valve are thickened/fibrotic. There
is moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
*** Compared with the findings of the prior study (images
reviewed) of [**2142-4-24**], the findings are similoar
[**2142-5-11**] Radiology CTA HEAD W&W/O C & RECONS
1. Large area of right MCA territory ischemia, without definite
evidence of acute infarction on the included images. However,
small areas of acute infarction or infarction in areas in
territories outside the included images cannot be assessed on
the present study. MR of the head can be considered, for better
evaluation.
2. Large intraluminal filling defect, in the right distal common
carotid, common carotid bifurcation, and proximal cervical
internal carotid artery, as well as a tiny filling defect in the
cavernous right internal carotid artery, related to thrombosis.
3. Patent mid and distal cervical, intracranial internal
carotid, anterior and middle cerebral arteries.
4. Mild stenosis, without flow-limiting stenosis or
hemodynamically significant in the left common carotid, as well
as at the cavernous internal carotid arteries
[**2142-5-9**] Cardiology ECG [**2142-5-11**] [**Last Name (LF) 162**],[**First Name3 (LF) **]
Sinus bradycardia. Peaked P waves with rightward P wave axis
consistent with right atrial enlargement. There is slight ST
segment depression and T wave inversion in leads I and aVL, more
prominent as compared with prior tracing of [**2142-4-22**]. The rate
has slowed. Non-conducted atrial ectopy is no longer recorded.
A-V conduction delay persists. No diagnostic interim change.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
50 228 76 456/438 74 -7 119
[**2142-5-9**] Radiology CT HEAD W/O CONTRAST [**Last Name (LF) 21753**],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
APPROVED
1. No acute intracranial process.
2. Likely chronic lacunar infarct in the left thalamus. Please
note that MRI with diffusion-weighted imaging is more sensitive
for detection of acute brain ischemia
Brief Hospital Course:
NEURO 87yo woman with HTN, Hyperlipidemia, CAD, recent ERCP with
biliary stent placement aditted to the medicine service [**5-9**]
with UTI who developed acute onset left hemiparesis and left
sided neglect. Her neurologic exam is notable for left
hemiparesis, profound left sided neglect and anosognosia. NCHCT
negative, but CTA/perfusion with large R ICA thrombus and
prolonged MTT in R MCA territory. Mechanism was probably
cardioembolic as she has atrial fibrillation and was not on
heparin or coumadin and INR was sub therapeutic. She was not
considered for IV tPA as she was out of three hour window.
Interventionlist Dr [**First Name (STitle) **] was contact[**Name (NI) **] for potential IA
intervention but she was not considered for IA intervention as
right common carotid was completely occluded and there was
significant concern that introduction of a catheter may cause
dislodgement of the clot with distal embolization. Admitted to
the NeuroICU for with a large close observation of her
neurological status.
* She neurologically completed her R MCA stroke, her hemiparesis
became a diffuse grade 4 whereas at first it was strongly
dependent on the level of neglect. She continued to have a
fluctuating mental status but often was alert. She had
extinction to double sided stimulation, and a persistent
neglect, motor impersistence and inattention. Her speech was
hypophonic.
* She was started on Heparin and transitioned to warfarin given
the cardioembolic nature of the stroke (atrial fibrillation).
Heparin gtt was at 600 units per hour at the time of [**Name (NI) **]
and PTT goal should be 50-70 until INR is therapeutic (2 to 3).
She will follow-up with Dr. [**First Name8 (NamePattern2) 2530**] [**Name (STitle) **] in Neurology after
[**Name (STitle) **].
CARDIO Her bloodpressures were stable without further
interventions or changes in her bloodpressure medications. She
had intermittent Afib but did not go into RVR. Her ECHO and EKG
were stable, see "results". She should continue aspirin 81mg
daily given CAD.
ABD She was able to eat thickened liquids and pureed solids, and
was allowed to advance her diet. There were no signficant GI
issues. She was placed on a bowel regimen.
ID No issues. Afebrile throughout.
Medications on Admission:
Clopidogrel 75mg daily
Lisinopril 40mg daily
Aspirin 81mg daily
Bactrim DS [**Hospital1 **]
[**Hospital1 **] Medications:
1. Heparin (Porcine) in NS Intravenous
2. Warfarin 5 mg Tablet Sig: One (1) Tablet PO QPM (once a day
(in the evening)).
3. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
5. Aspirin 81mg po daily.
[**Hospital1 **] Disposition:
Extended Care
Facility:
[**Hospital3 7**]
[**Hospital3 **] Diagnosis:
Large R MCA territory stroke
[**Hospital3 **] Condition:
Fair. Neurologic examination notable for mild left hemiparesis
and left hemineglect.
[**Hospital3 **] Instructions:
You have been admitted with a large R sided stroke, with
neurological deficits on the L side of your body. The cause for
this is most likely your irrgeular heart which may have produced
a clot, and for this reason you will need to take Coumadin.
Please take all your medications excactly as directed and please
attend all your follow-up appointments.
Please report to the nearest ER or call 911 or your PCP
immediately when you experience recurrence of weakness,
numbness, tingling, problems with speech, language, walking,
thinking, headache, or difficulties arousing, or any other signs
or symptoms of concern.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 285**]
Date/Time:[**2142-6-5**] 3:20
Please follow-up with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **]
from Rehab.
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 162**], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2142-6-18**] 2:30
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
|
[
"434.91",
"V45.82",
"250.00",
"401.9",
"781.8",
"342.90",
"414.01",
"412",
"599.0",
"427.31",
"724.02",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7627, 9873
|
306, 314
|
3742, 3742
|
11263, 11781
|
2726, 2744
|
9899, 9993
|
2759, 2993
|
235, 268
|
10377, 11240
|
10023, 10347
|
342, 2013
|
3759, 7604
|
3010, 3723
|
2035, 2567
|
2583, 2710
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,099
| 109,904
|
12724
|
Discharge summary
|
report
|
Admission Date: [**2186-10-31**] Discharge Date: [**2186-11-3**]
Date of Birth: [**2114-1-8**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Doctor First Name 1402**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
coronary catheterization - stents x 2 to graft to OM2 and LAD.
History of Present Illness:
72 yo M h/o 3VD s/p CABG in [**2171**] (cath in [**2181**] with chronically
occluded SVG to OM1), HTN, hyperlipidemia, COPD, DM (diet
controlled), and CRI presents as tx from [**Hospital3 1443**] for
CP. The CP began Mon morning ([**10-30**]) while the pt was in bed. He
describes one week of angina with increasing frequency that
responded to nitro 1-2 tabs SL. The angina was generally
associated with exertion, though some episodes occurred while
the patient was in bed. He called EMT's on Monday because the
pain did not respond to nitro SL x 3. At [**Hospital3 1443**] he
was found to have EKG with ST depression in inferior and
anterior leads and a trop I of 0.47 (0.04 ULN). He had an
episode of CP at OSH that resolved with SL nitro x 1. He was
tx'd to [**Hospital1 18**] for coronary cath on [**10-31**]. On the morning of
[**10-31**] he went to cath and was stented in his graft to OM2 and
his LAD distal to the LIMA touch down with good restoration of
flow. (SVG to OM1 remained occluded.) EKG changes were resolving
but not gone. After catheterization, when the sheath was pulled,
the pt had a vagal episode that did not resolve with atropine
promptly. He was started on dopa for pressure and was taken back
to the cath lab as he developed substernal CP in the face of EKG
changes re-emerging. In the cath lab he was noted to have patent
stents. No further intervention was done.
.
The patient had a Creat of 2.0 from OSH - he received 180cc
contrast in first cath and 30cc in second cath.
Past Medical History:
PMH:
- CAD s/p CABG after MI in [**2171**] with LIMA to LAD, SVG to OM1 and
SVG to OM2 - [**2181**] cath found OM1 graft to be occluded and not
amenable to PCI.
- Hyperlipidemia
- COPD: asthma
- DM, diet controlled (pt denies)
- obesity
- AFlutter [**2183**]
- CRI (baseline Creat 2.0)
- Bilateral cataract surgery
.....
PSH:
- [**2171**] CABG ([**Hospital1 18**])
- [**5-21**] colon surgery (?resection). No malignancy per pt - done
at [**Hospital3 1443**]).
- appy
.....
Allergies: NKDA
Social History:
SHx: Machinist - retired. 50 pck yr hx smoking quit in [**2171**]
after MI and CABG. EtOH only very occasionally. Ambulates
independantly,
uses a cane prn. Lives in [**Location 1468**] with wife, [**Name (NI) 2013**], and son,
[**Name (NI) 401**].
......
FHx: Father died of MI age 71, 2 sisters have "heart problems."
Physical Exam:
Gen: NAD, in bed comfortable.
VS: 113/58, 80, AF.
Head: EOMI, NCAT
Neck: No bruits, thick neck, poorly visualized JVD, Supple.
Lungs: Crackles bilaterally laterally.
Heart: RRR, S1 and S2 present, II/VI SEM at USB
Abd: soft, NTND +BS, no HSM
Groin: R groin with gauze in place, small ooze, no bruit, no
hematoma. L groin with gauze (s/p angioseal) with some oozing,
no bruit, no hematoma.
Extr: Pulses dopplerable bilat at DP and PT. Toes cool
bilaterally, legs and feet warm. No skin color changes.
Pertinent Results:
Day of Admission:
[**2186-10-31**] 05:24PM BLOOD WBC-14.7*# RBC-4.28* Hgb-13.1* Hct-36.5*
MCV-85 MCH-30.7 MCHC-36.0*# RDW-13.8 Plt Ct-256
[**2186-10-31**] 08:30AM BLOOD INR(PT)-1.2
[**2186-10-31**] 05:24PM BLOOD PT-12.8 PTT-25.2 INR(PT)-1.1
[**2186-10-31**] 05:24PM BLOOD Glucose-135* UreaN-30* Creat-1.7* Na-136
K-3.7 Cl-96 HCO3-30 AnGap-14
[**2186-10-31**] 05:24PM BLOOD Calcium-8.5 Phos-3.8 Mg-1.9
[**2186-11-1**] 04:10AM BLOOD %HbA1c-6.2* [Hgb]-DONE [A1c]-DONE
.
Cardiac Enzymes:
[**2186-10-31**] 05:24PM BLOOD CK(CPK)-50
[**2186-10-31**] 10:50PM BLOOD CK(CPK)-80
[**2186-11-1**] 04:10AM BLOOD CK(CPK)-65
[**2186-10-31**] 05:24PM BLOOD CK-MB-NotDone cTropnT-0.45*
[**2186-10-31**] 10:50PM BLOOD CK-MB-NotDone cTropnT-0.54*
[**2186-11-1**] 04:10AM BLOOD CK-MB-NotDone cTropnT-0.63*
.
Day of Discharge:
[**2186-11-2**] 07:05AM BLOOD WBC-10.0 RBC-3.53* Hgb-10.7* Hct-30.2*
MCV-86 MCH-30.4 MCHC-35.5* RDW-13.9 Plt Ct-206
[**2186-11-2**] 07:05AM BLOOD Glucose-119* UreaN-33* Creat-1.9* Na-139
K-3.8 Cl-98 HCO3-33* AnGap-12
.
.
EKG: [**10-31**] - pre-cath:
Sinus bradycardia. Inferolateral T wave inversions with ST
segment depression consistent with an acute ischemic process.
Compared to the previous tracing of [**2183-5-4**] no definite change.
Cardiac Cath #1:
COMMENTS:
1. Selective coronary angiography revealed a right dominant
system with
three vessel native CAD, a patent LIMA, a chronically occluded
SVG to
OM1 and a stenotic SVG to OM2. The LMCA had diffuse mild
disease. The
LAD had a subtotal ostial occlusion and was totally occluded
after the
first septal branch. The distal vessel filled by a patent LIMA
but
there was an 80% native LAD lesion after the touchdown of the
LIMA.
There was a very distal 80% apical lesion. The Lcx had severe
diffuse
disease throughout its length and in its branches. It was
occluded
after the OM2. The distal vessel filled via left to left and
right to
left collaterals. The SVG to Om1 was known to be occluded. The
SVG to
OM2 had a distal 90% lesion within the SVG. The native LAD and
this SVG
were stented (see below).
2. Limited hemodynamics revealed normal central aortic blood
pressures.
3. Left ventriculography was not performed.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Patent LIMA to LAD.
3. Occluded SVG to OM1
4. 90% stenosis of SVG to OM2.
.
.
Cardiac cath #2:
Stents Patent
.
.
EKG [**11-1**] - post-cath:
Sinus bradycardia. First degree atrio-ventricular conduction
delay.
P-R interval 0.24. Lateral T wave inversion with ST segment
depression.
Compared to the previous tracing of [**2186-10-31**] repolarization
abnormalities are
somewhat less prominent.
.
.
Echocardiogram (Post-Cath):
Conclusions:
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size, and systolic function are normal
(LVEF>55%). Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen. The pulmonary artery systolic pressure could not be
determined. There is no pericardial effusion.
IMPRESSION: Preserved global biventricular systolic function..
Mild mitral regurgitation.
Brief Hospital Course:
# Cardiac: 72 yo M with known CAD, s/p NSTEMI/ +troponin.
Admitted for cath from OSH. During cath, had 2 vessel
intervention (LAD and graft to OM2). Afterward, during sheath
pull, developed severe and symptomatic hypotension and chest
pain. Pt was taken for re-look procedure. The stents were found
to be patent. Overnight had dopamine weaned and BP remained low
normal. The patient was initially very confused but gradually
became more oriented overnight. HCT was stable. The next day,
metoprolol was started at low dose for cardioprotection and the
pat tolerated this well. The patient was known to have
extensive 3VD, so was followed with daily ekg that showed
resolution of small ischemic area. Echo showed a preserved EF,
small focal WMA, and no effusion. CE's trended down (CK) while
troponins increased. The patient diuresed well after the volume
load in the cath lab and was euvolemic at discharge. The
patient has a history in his chart of A flutter and had an
episode of narrow complex tachycardia at this hospitalization
that probably represented AT. This never recurred. The patient
was treated for diastolic heart failure with intermittent
diuresis diet control, wt and BP monitoring.
.
# Hypotension: The pt was hypotensive after catheterization and
was on dopamine for pressor for 12 hours. Thereafter pressures
were low stable. Metoprolol was started at a low dose and
titrated up as BP tolerated. The patient was changed back to
atenolol on discharge at a lower dose than on admission. His BP
was to be checked regularly so that his atenolol could be
titrated up as an outpatient. Imdur was also restarted as an
OP. Diltiazem was held and the pt was instructed to f/u with
PMD to restart this medication and titrate other BP meds as his
BP returned to his previous state of controlled hypertension.
.
# ? Cholesterol Emboli - on the day after cath, the pt was
thought to have had mottled toes that were cool. Interventional
cards was called and suggested a vascular consult. Vascular
recommended no treatment for this symptom. By two days
post-cath, there was no further evidence of emboli nor tissue
damage.
.
# PVD - Vascular suggested at w/u for PVD given the pt's history
of claudication. LE dopplers showed ABI > 1 but some slowed
flow to LLE. The pt was instructed to f/u with vascular surgery
to follow his symptoms and ABI's.
.
# CRI: The patient is noted to have a baseline creat in 2.0. Was
1.8 at OSH. Likely etiology was DM and HTN.
- Bicarb infusion per protocol was given prior to cath, but held
post-cath as pt was volume overloaded.
- Observed Creat/BUN for 72 hours. Dye load was relatively large
given 2 caths (210cc). No acute contrast nephropathy developed.
There was no evidence of cholesterol emboli to the kidneys.
.
# Gout: The patient developed L MTP joint tenderness two days
after catheterization. He has a history of gout but did not
recall being treated for this. He was treated with colchicine
for the acute flair. He would likely benefit from long-term
allopurinol therapy, as his serum uric acid was elevated to over
10 and he has had repeated episodes.
.
# Leukocytosis: Pt had an elevated WBC in setting of cath x 2 on
day of admission. This was thought to be due to demargination
from stress, however, to be sure of this diagnosis she was given
a UA and UCx, which were negative for infection. BCx and CXR
were also negative for infection..
.
# MS changes - The pt arrived in the CCU after cath with MS
changes - trying to get out of bed, generally disoriented. These
symptoms improved with time, and were likely were due to
atropine.
.
# Hyperlipidemia
- Continued lipitor at home dose.
.
# COPD
- Continued advair and albuterol at home doses.
.
# DM
- HbA1C was <7. Pt was placed on SSI but sugars were well
controlled.
.
# Ppx: The patient was maintained on sq heparin throughout the
hospitalization.
Medications on Admission:
Home Meds:
ASA 325 mg po daily
atenolol 100 mg po QD
lipitor 80 mg po daily
HCTZ 25 mg po daily
Imdur 60 mg po daily
diltiazem CD 120 mg po daily
bumex 1 mg po daily
advair 100/50
albuterol 2 puffs
flovent 220 mcg
colace 100 mg po BID
--------
Meds on Tx:
mucomyst started at OSH
heparin gtt started at OSH
integrilin gtt at OSH
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): To prevent stent closure.
Disp:*90 Tablet(s)* Refills:*4*
2. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual Q5MIN () as needed for chest pain: Take
one tablet under tongue for chest pain. Wait 5 minutes and
repeat as needed. Take a total of 3 tablets and if pain does
not resolve, seek medical attention.
Disp:*20 Tablet, Sublingual(s)* Refills:*0*
3. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day: For
blood pressure. .
Disp:*30 Tablet(s)* Refills:*0*
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Imdur 60 mg Tablet Sustained Release 24HR Sig: One (1) Tablet
Sustained Release 24HR PO once a day.
6. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day:
To reduce cholesterol.
7. Bumex 1 mg Tablet Sig: One (1) Tablet PO once a day: To
prevent water retention.
8. Albuterol 90 mcg/Actuation Aerosol Sig: [**12-18**] puff Inhalation
once a day as needed for shortness of breath or wheezing.
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO Q2H (every 2
hours) as needed for gout: In case of gout pain - take one
tablet every 2 hours until the pain resolves or you develop
diarrhea. Do not take more than 7 doses.
Disp:*7 Tablet(s)* Refills:*0*
11. Flovent 220 mcg/Actuation Aerosol Sig: One (1) spray
Inhalation once a day.
Discharge Disposition:
Home With Service
Facility:
Greater [**Location (un) 1468**] VNA
Discharge Diagnosis:
NSTEMI
s/p 2 stents
HTN
hypercholesterolemia
PVD
gout
CKD
COPD
Discharge Condition:
Good - free of chest pain.
Discharge Instructions:
You were admitted with chest pain and taken to the coronary cath
lab. You received 2 stents. Afterward, you had more chest pain
and returned to the cath lab where it was found that the stents
were in place.
You are being discharged and will have a nurse come to your home
to help you with your medications and to monitor your blood
pressure and pulse.
You should follow up with your primary care doctor, Dr. [**Last Name (STitle) **]
within 2-3 weeks. You can call him to make an appointment by
calling: [**Telephone/Fax (1) 39260**].
You should follow up with your cardiologist, Dr. [**Last Name (STitle) 5686**],
within 4 weeks. You can schedule an appointment at
[**Telephone/Fax (1) 11554**].
You should follow up with vascular surgery for an appointment to
evaluate your leg pain. The circulation to your legs is
somewhat impaired and the vascular surgeon will assess your
blood flow to determine what the best therapy will be to reduce
your pain. You have an appointment with Dr. [**Last Name (STitle) 39261**] on [**11-22**] at 4:15pm. You can call if you need to change your
appointment: ([**Telephone/Fax (1) 1798**].
Followup Instructions:
Dr. [**Last Name (STitle) **] within 2-3 weeks. -Pt's atenolol dose was decreased and
diltiazem has been held as he was hypotensive in the hospital.
These medications should be adjusted based on BP readings as an
outpatient. He was previously on 100mg atenolol and 120mg
diltiazem.
Pt may benefit from allopurinol therapy as an outpatient.
Dr. [**Last Name (STitle) 5686**] within 4 weeks.
Dr. [**Last Name (STitle) 39261**] - [**11-22**], 4:15pm
Completed by:[**2186-11-4**]
|
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icd9cm
|
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[
[]
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[
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icd9pcs
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[
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12498, 12565
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420, 1924
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,382
| 163,918
|
746
|
Discharge summary
|
report
|
Admission Date: [**2132-12-8**] Discharge Date: [**2132-12-14**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
cardiac catheterization
History of Present Illness:
Ms [**Known lastname 5448**] is an 89yo pt with h/o CAD s/p RCA stent in [**2124**],
a-fib on warfarin and dofetilide, who presented to OSH on
[**2132-12-7**] with CHF exacerbation. BNP was 326 (1-100). CT ruled
out PE but showed extensive metastatic disease to pleura.
Initial tropI was negative but the 2nd tropI was positive at
1.43 at 7AM and 1.79 at 12:30PM. EKG showed e/o possible prior
septal infarct, no acute ST changes. Cardiology saw her and felt
that, given her age and comorbidity (breast cancer w/mets), she
is not suitable for further intervention and recommended medical
management. Pt was started on nitro patch. However, her primary
cardiologist (Dr. [**Last Name (STitle) **] felt otherwise and was willing to cath
her, so she was transferred to [**Hospital1 18**] for catheterization. Per
report, she had an episode of chest pain that responded to nitro
this afternoon. Also, after speaking with medical team at OSH,
the discussion was had about her code status and decision was
made DNR.
.
At home, pt reports passing out 5 days ago. She was getting into
bed, felt SOB, lost consciousness for a couple of minutes. She
reports hitting her head on the left side of her forehead on a
thick rug. Her sons were with her. Episode of SOB while watching
TV as well as +Substernal pressure, rating [**7-13**], no radiation.
No assoc lightheaded, diaphrosis, SOB, n/v, palpitations. No
orthopnea, pedal edema, wt gain. +PND 5 days ago. She denies
headaches, dyarthia, vision changes, numbness/tingling, focal
muscle weakness, gait disturbance.
.
On arrival to [**Hospital Ward Name 121**] 5, patient denied any chest pain. However,
she had frequent runs of polymorphic VT, 5-30 seconds each.
Patient was transferred to CCU emergently, given Mg infusion,
started on isoproterenol gtt, which broke the torsades.
Throughout this episode, her BP was stable with SBP in the 110s,
and she remained asymptomatic except for some brief nausea.
.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery. Pt denies fever, chills, cough, hemoptysis,
abdominal pain, diarrhea, constipation, BRBPR, melena, myalgias,
joint pains. All of the other review of systems were negative.
Past Medical History:
-Breast Cancer with mets to pleura: On hormonal therapy for
breast ca, no chemo or xrt.
-CAD s/p PCI and stent placed 3 years ago
-CHF
-HTN
-HL
-PAF
-s/p hysterectomy
-s/p knee replacement
Social History:
Pt lives with her son. She quit smoking 40 years ago, 1ppd x 2
years. Glass of wine once in awhile.
Family History:
Father with MI at 58 yo.
Physical Exam:
VS: T98.2, 134/79, 89, 18, 95% on 5L
GENERAL: elderly female in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink. MMM.
NECK: Supple without LAD, JVP of 9 cm.
CARDIAC: Irregularly irregular. 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. 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 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
LABS ON ADMISSION ([**2132-12-8**]):
.
HEMATOLOGY:
[**2132-12-9**] 12:44AM BLOOD WBC-10.0# RBC-3.59* Hgb-10.5* Hct-29.7*
MCV-83 MCH-29.1 MCHC-35.2* RDW-14.0 Plt Ct-322
.
[**2132-12-9**] 12:44AM BLOOD PT-14.7* PTT-22.5 INR(PT)-1.3*
.
CHEMISTRY:
[**2132-12-9**] 12:44AM BLOOD Glucose-145* UreaN-32* Creat-1.1 Na-139
K-3.8 Cl-102 HCO3-26 AnGap-15
[**2132-12-9**] 12:44AM BLOOD Calcium-9.1 Phos-3.9 Mg-1.9
.
[**2132-12-10**] 05:32AM BLOOD ALT-17 AST-37 LD(LDH)-407* CK(CPK)-185*
AlkPhos-62 TotBili-1.0
.
[**2132-12-9**] 12:44AM BLOOD CK-MB-7 cTropnT-0.21* CK-147
[**2132-12-9**] 09:48AM BLOOD CK-MB-8 cTropnT-0.22* CK-156
[**2132-12-9**] 09:54PM BLOOD CK(CPK)-167*
[**2132-12-10**] 05:32AM BLOOD CK(CPK)-185*
.
[**2132-12-9**] 09:48AM BLOOD Triglyc-128 HDL-68 CHOL/HD-2.5 LDLcalc-73
[**2132-12-10**] 05:32AM BLOOD TSH-0.32
.
LABS ON DISCHARGE:
.
HEMATOLOGY:
[**2132-12-14**] 07:40AM BLOOD WBC-5.6 RBC-3.53* Hgb-10.0* Hct-29.8*
MCV-85 MCH-28.3 MCHC-33.6 RDW-13.4 Plt Ct-328
[**2132-12-14**] 07:40AM BLOOD PT-24.7* PTT-70.8* INR(PT)-2.4*
.
CHEMISTRY:
[**2132-12-14**] 07:40AM BLOOD Glucose-96 UreaN-25* Creat-0.8 Na-140
K-4.1 Cl-103 HCO3-27 AnGap-14
[**2132-12-14**] 07:40AM BLOOD Calcium-9.1 Phos-3.4 Mg-2.0
.
MICROBIOLOGY:
C.diff negative
.
RADIOLOGY:
CXR ([**2132-12-9**]):
IMPRESSION:
1. Right upper lobe 3.6 x 4.6 cm opacity and right suprahilar
3.5 x 3.8 cm
opacity that still could represent pneumonia, however are
concerning for
possible malignancy.
2. Right pleural effusion.
3. Mild congestive heart failure.
.
.
CARDIOLOGY:
.
Cardiac Cath ([**2132-12-9**])
BMS placed to R-PDA
.
TTE ([**2132-12-10**]):
The left atrium is elongated. The interatrial septum is
aneurysmal. No atrial septal defect is seen by 2D or color
Doppler. There is mild symmetric left ventricular hypertrophy.
The left ventricular cavity size is normal. No masses or thrombi
are seen in the left ventricle. Overall left ventricular
systolic function is mildly depressed (LVEF= 40-45 %) with mid
to distal septal and inferior/infero-lateral hypokinesis. There
is no ventricular septal defect. Right ventricular chamber size
and free wall motion are normal. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. Mild (1+) aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. Mild
(1+) mitral regurgitation is seen. The tricuspid valve leaflets
are mildly thickened. There is moderate pulmonary artery
systolic hypertension. There is a trivial/physiologic
pericardial effusion.
.
Brief Hospital Course:
In summary, Ms [**Known lastname 5448**] is an 89yo w CAD and a-fib (formerly on
warfarin and dofetilide), who presented originally to OSH w SOB,
was transferred to [**Hospital1 18**] for cath for NSTEMI, course complicated
by polymorphic VT.
.
# CORONARIES: Pt w known CAD and prior stenting, now p/w NSTEMI
at OSH, s/p cath at [**Hospital1 18**] with bare metal stent to R-PDA. Pt
denies CP/SOB. On heparin drip for NSTEMI at first, then on
heparin to coumadin bridge for a-fb. TTE shows reduced EF. On
discharge, hemodynamically stable, on aspirin, clopidogrel,
beta-blocker, valsartan and atorvastatin.
.
# RHYTHM: History of afib, on coumadin and on dofetilide at
home. Had frequent runs of polymorphic VT with no symptoms on
floor, broke with isoproterenol gtt. Likely induced by
dofetilide in setting of cardiac ischemia and reduced renal
clearance (Cr 1.1, unclear baseline). Now off dofetilide and
isoproterenol, s/p run of afib with RVR after cath. Metoprolol
used as rate control. Though bradycardia might increase the risk
of ectopic ventricular arrhythmias, it is likely not the cause
of the VT on this admission (VT caused by ischemia/dofetilide).
For afib, pt rate-controlled w metoprolol and anticoagulated w
warfarin w INR goal of [**1-6**]. Therapeutic on discharge, regular
followup recommended. Pt monitored on tele, electrolytes
repleted as needed - K>4.0, Mg >2.0.
.
# PUMP: Likely new diagnosis of systolic CHF, though unclear
whether h/o chronic CHF, unknown EF. Pt does not appear
overloaded on exam. Echo with EF 40-45% with mid to distal
septal and inferior/lateral hypokinesis s/p cath. Beta blocker,
[**Last Name (un) **], furosemide 40mg po daily.
.
# Breast cancer: with mets to pleura. On hormonal therapy; no
chemo or xrt. Per conversation with oncologist coverage, OK to
not restart aromatase inhibitor (side effect of cardiac
ischemia) as inpatient. Per Dr [**Last Name (STitle) **], restarted aromatase on
discharge. Followup w oncologist recommended.
.
# HTN: stable BP, valsartan held while inpatient, restarted on
discharge.
.
# CODE: FULL, confirmed with patient
.
# Contact: [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 5449**]
Medications on Admission:
Pt does not remember, pharmacy: Rite Aide ([**Location (un) 5450**], NH) -
[**Telephone/Fax (1) 5451**]
.
Warfarin 2mg PO daily
Dofetilide 500 mg [**Hospital1 **]
Metoprolol tartrate 50 mg daily (checked w pharmacist)
Lipitor 10 mg daily
Diovan 160 mg daily
Lasix 40 mg daily
Aromasin 25 mg daily
Percocet 1 pill a day PRN
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): to keep your heart stent open.
Disp:*30 Tablet(s)* Refills:*0*
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): for your cholesterol.
Disp:*30 Tablet(s)* Refills:*2*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO once a day as needed for pain: do not take if sedated or if
driving.
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
for your heart failure.
Disp:*30 Tablet(s)* Refills:*2*
6. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
for your heart and blood pressure.
Disp:*30 Tablet(s)* Refills:*2*
7. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day: dose
may change based on your INR, a blood test; follow Dr.[**Name (NI) 5452**]
instructions .
Disp:*75 Tablet(s)* Refills:*2*
8. Outpatient [**Name (NI) **] Work
PT, INR, check twice weekly (Monday, Thursday) after discharge
fax result to Dr. [**Last Name (STitle) **], fax number [**Telephone/Fax (1) 5453**].
9. Aromasin 25 mg Tablet Sig: One (1) Tablet PO once a day.
10. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: 1.5
Tablet Sustained Release 24 hrs PO once a day.
Disp:*45 Tablet Sustained Release 24 hr(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
VNA of [**Location (un) **]
Discharge Diagnosis:
Non-ST elevation MI
Polymorphic Ventricular Tachycardia
.
Systolic heart failure, acute on chronic
hypertension
hyperlipidemia
Discharge Condition:
Hemodynamically stable, afebrile
Discharge Instructions:
You were admitted to [**Hospital1 18**] due to a heart failure exacerbation
and were found to have a heart attack. You had a cardiac
catheterization and a stent placed in one of your heart's blood
vessels.
.
You also had an irregular heart rhythm of your heart, called
polymorphic ventricular tachycardia. You were treated with
medication to correct this and your dofetilide was stopped.
.
Your coumadin levels were adjusted during your stay. You will
need to get [**Hospital1 **] work, and have the results sent to Dr. [**Last Name (STitle) **] to
adjust your coumadin level. Please have your blood work checked
twice a week (Monday and Thursday) until you see Dr. [**Last Name (STitle) **]. You
will be given a [**Last Name (STitle) **] order to take to your local [**Last Name (STitle) **] or have your
visiting nurse draw your labs. Please have results faxed to Dr [**Name (NI) 5454**] office @ [**Telephone/Fax (1) 5453**].
.
Your medicaions were changed, please take your medications as
instructed.
Diovan was decreased to 80mg daily
Toprol XL was changed to 75mg daily
Dofetilide was stopped
Norvasc was stopped
Lipitor was changed to 80mg
Warfarin (coumadin) is continued at 2mg daily
Clopidogrel (plavix) was started
Aspirin continued
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: do not drink more than 2liters of fluids per
day
.
Seek medical attention if you have chest pain, shortness of
breath, groin pain or bleeding, or any other concerning symptom.
Followup Instructions:
Dr [**Last Name (STitle) **] - Please call ([**Telephone/Fax (1) 5455**] and make an appointment for
in 2 weeks from discharge. He may adjust your coumadin levels
before that.
.
Please call Dr. [**Last Name (STitle) 5456**] (PCP) at [**Telephone/Fax (1) 5457**] to call and make an
appointment to discuss your stay.
.
Completed by:[**2132-12-14**]
|
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62,551
| 183,851
|
51943
|
Discharge summary
|
report
|
Admission Date: [**2151-3-22**] Discharge Date: [**2151-4-10**]
Date of Birth: [**2069-10-2**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
scheduled bronchoscopy
Major Surgical or Invasive Procedure:
Bronchoscopy
Intubation x2
Arterial line
Central venous line (IJ)
History of Present Illness:
Ms [**Known lastname 107532**] is an 81 year old woman with past medical history
significant for chronic low back pain, coronary artery disease,
hypertension, hyperlipidemia, and question of vasculitis,
transferred to medicine from PACU after undergoing bronchoscopy
for workup or a right lower lobe mass and developing a new
oxygen requirement.
.
Briefly, Ms [**Known lastname 107532**] began having a chronic cough and some
hemoptysis this past [**Month (only) **]. Workup for this included a CT
scan, which revealed a large (6cm) cavitary lesion. She
underwent extensive evaluation for possible metastatic disease
including head MRI, PetCT and bronchoscopy, however although Pet
revealed markedly FDG avid
right lower lobe mass with a satellite nodule, transbronchial
biopsy and washings were non diagnostic. Patient was electively
admitted today to have repeat rigid bronchoscopy with FNA of
lymph nodes under ultrasound guidance. Patient was extubated
without difficulty however she remained hypoxic and is still
requiring supplemental oxygen.
.
Patient denies any pain, but reports being slightly disoriented
still. Has a heavy cough and reports some difficulty breathing,
no nausea.
.
In the PACU, 137/68 96 93% on 50% face tent. Patient was given
Lasix 20mg IV and was admitted to MICU team for further
management.
Past Medical History:
CAD
Diastolic Dysfunction
Low anterior resection [**2146**] for complicated diverticular disease
HTN
Hyperlipidemia
Vasculitis?
Lower extremity neuropathy
Social History:
Ex smoker, 20 pack year history. Denies alcohol or drug use.
Lives with room mate, is originally from [**Country 4754**].
Family History:
No family history of lung cancer
Sister with breast cancer
Physical Exam:
On admission
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
Pertinent Results:
[**2151-3-22**] 11:36PM BLOOD WBC-19.8* RBC-3.55* Hgb-8.8* Hct-29.9*
MCV-84 MCH-24.7* MCHC-29.3* RDW-15.0 Plt Ct-616*
[**2151-3-22**] 11:36PM BLOOD PT-14.0* PTT-29.3 INR(PT)-1.2*
[**2151-3-22**] 11:36PM BLOOD Glucose-100 UreaN-15 Creat-1.0 Na-139
K-3.2* Cl-102 HCO3-26 AnGap-14
[**2151-3-22**] 11:36PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2151-3-22**] 11:36PM BLOOD Calcium-10.4* Phos-3.1 Mg-1.6
[**2151-3-25**] 02:13AM BLOOD calTIBC-215* Ferritn-1419* TRF-165*
Brief Hospital Course:
# Respiratory Distress: Initial respiratory distress was thought
to be likely a result of post-bronchoscopy fluid overload. No
pneumothorax seen. Patient initially did well on oxygen by
facemask with diuresis, but on [**3-22**] patient had increased
respiratory distress associated with ventricular tachycardia,
and was intubated for hypoxic respiratory failure. Patient
initially received empirical levaquin for presumed CAP, but
antimicrobials were empirically broadened to Vanco/Cefepime on
[**3-22**]. BAL during bronchoscopy on [**3-22**] was unremarkable. She was
extubated the following day, but had respiratory distress again
on [**3-25**] requiring reintubation. She was transferred to the [**Hospital Unit Name 153**]
where her respiratory status improved with diuresis and
antibitiocs transiently but ultimately she could not be weaned
from the Vent. Several family meetings were held during the
course of her hospitalization, and with lack of progress and
continued dependence on mechanical ventialtion, consistent with
the patients previsously expressed wishes that long term
mechanical ventilation was not acceptable quality of life, she
was terminally extubated.
.
# Ventricular Tachycardia. Possibly triggered by
hypoxia/respiratory distress. 4 episodes over ~30 minutes which
responded to amiodarone (150 x 2 and then 0.5 mg/min drip) and
respiratory support. Was intubated and started on amiodarone
drip with no more episodes. She did not require DC
cardioversion. Completed amiodarone drip but continued to have
NSVT, which resolved following repositioning of a central venous
catheter on [**3-26**].
# RLL mass: Squamous cell on bronch biopsy. Patient was
transferred to the [**Hospital Ward Name **] on [**3-25**] for radiation therapy.
RadOnc deferred therapy.
.
# NSTEMI/CAD: Ruled in by troponin (peaked at 0.25) on [**3-22**] with
flat CK. Started on heparin drip until troponin plateaud. TTE
showed anterior wall motion abnormalities and depressed EF with
MR 2+. Cardiology deferred cath given her overall status.
# CHF: has known diastolic CHF. Presented to [**Hospital Unit Name 153**] with florid
pulmonary edema and effusions. This was related to new, acute
systolic dysfunction from anterior NSTEMI compounded by 2+MR
.
# Hypercalcemia: Albumin only 2.2 so corrected calcium actually
>12. With appropriately low PTH this is likely from malignancy
related tumor factors. Patient received lasix and pamidronate. .
Medications on Admission:
Lasix 20 mg daily
Lisinopril 20/HCTZ 12.5 mg a day
Inderal 20 mg q.i.d. (for tremor)
Gemfibrozil 600 mg b.i.d
Simvastatin 20 mg a day
Omeprazole 20 mg a day
Caltrate 600 mg a day
Iron 65 mg a day
Aspirin 81 mg a day
Protonix 40 mg a day
Alprazolam 0.25 mg q.i.d. p.r.n.
Lyrica 150 mg a day
Darvocet p.r.n.
SLNG as needed
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
Completed by:[**2152-8-8**]
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82,641
| 118,720
|
18635
|
Discharge summary
|
report
|
Admission Date: [**2138-2-4**] Discharge Date: [**2138-2-8**]
Date of Birth: [**2076-9-24**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 594**]
Chief Complaint:
abdominal pain, nausea, and diarrhea
Major Surgical or Invasive Procedure:
left internal jugular central venous line placement
endotrachial intubation
radial arterial line placement
nasogastric intubation
History of Present Illness:
61 year old male with hepatitis C +/- alcoholic cirrhosis
complicated by encephalopathy, ascites and nonbleeding varices
who was recently started on HCV treatment on [**2137-10-18**] with Pegasys
90 mcg weekly, ribavirin 800 mg
daily, and boceprevir 800 mg t.i.d. (start date for boceprevir
was [**2137-11-27**]). He has had a viral response to therapy (HCV RNA
undetectable by week 10 of treatment). His course has been
complicated by thrombocytopenia and leukopenia.
.
He presented to [**Hospital3 **] hospital with four days of abdominal
pain, nausea, vomiting and confusion. His labs were notable for
WBC 1.1 with 68% bands, hematocrit of 41, T.bili of 5.5, D.Bili
of 3.3.
CT scan at OSH showed showed large amount of acites, gallstones,
sludge in the gallbladder and thickened colon concerning for
inflammatory colitis. He was given vancomycin/zosyn at OSH and
transferred to [**Hospital1 18**] ED for concern for cholangitis.
.
In the [**Hospital1 18**] ED, initial vitals were 97.4 98/66, 80, 23, 92% RA.
EKG showed atrial fibrillation with no ST-T changes. CXR showed
concern for multifocal pneumonia vs fluid overload. Labs notable
for neutropenia, thromboctyopenia, direct bilirubenemia,
creatinine of 2.0 and lacate of 7. Bedside cardiac ultrasound
showed no pericardial effusion though poor squeeze. RUQ US with
dopplers showed known ascites, patent vasculature and normal
CBD. Review of CT abdomen by radiologist with transplant surgery
resident showed no concern for colitis. Diagnostic paracentesis
showed WBC of 400 with 83% polys (326 PMNs). He was fluid
resuscitated with 12.5g/250 cc of albumin and transferred to
MICU for further evaluation and management. Vitals prior to
transfer were 101.2 111/78 85 95%RA 30
.
On arrival to the MICU, he reports no other complaints .
Past Medical History:
HCV genotype 1 complicated by cirrhosis which in turn was
complicated by encephalopathy, ascites and esophageal varices
grade II
Alcohol abuse
Type 2 DM
Subpleural nodules
On HCV therapy [**2137-10-18**] with Pegasys 90 mcg weekly, ribavirin 800
mg daily, and boceprevir 800 mg t.i.d. (start date for
boceprevir
was [**2137-11-27**]). He has had a viral response to therapy (HCV RNA
undetectable by week 10 of treatment).
Social History:
Mr. [**Known lastname **] [**Last Name (Titles) 546**] at [**Location (un) 38380**] Skilled Nursing Facility and was
thinking about pursuing independent housing. No current tobacco
or alcohol use. He gave up using drugs 30 years and did use
crystal meth and marijuana in the past.
Family History:
non-contributory
Physical Exam:
General: Awake, answering some questions appropriately.
HEENT: PERRL, anicteric sclera.
CV: S1S2 RRR w/o m/r/g??????s.
Lungs: CTA on anterior exam. No crackles or wheezing.
Ab: Distended, diffusely tender, possibly moreso in the R>LUQ
than the LQs. Could not appreciate HSM [**3-13**] distension.
Ext: Chronic vascular changes, no clubbing.
Neuro: Awake, oriented x self, ??????hospital??????, ??????the day after
[**Holiday **]??????, thinks the year is ??????two??????. No focal motor deficits on
general exam.
Pertinent Results:
Admission labs:
[**2138-2-4**] 12:25AM BLOOD WBC-0.7*# RBC-3.66* Hgb-13.1* Hct-41.5
MCV-113* MCH-35.9* MCHC-31.7 RDW-17.4* Plt Ct-25*
[**2138-2-4**] 12:25AM BLOOD Neuts-47* Bands-27* Lymphs-9* Monos-3
Eos-0 Baso-0 Atyps-0 Metas-14* Myelos-0 NRBC-1*
[**2138-2-4**] 12:25AM BLOOD PT-20.0* PTT-45.7* INR(PT)-1.9*
[**2138-2-4**] 04:49AM BLOOD Fibrino-134*
[**2138-2-4**] 12:25AM BLOOD Glucose-62* UreaN-27* Creat-2.0* Na-137
K-4.1 Cl-107 HCO3-15* AnGap-19
[**2138-2-4**] 12:25AM BLOOD ALT-56* AST-118* AlkPhos-94 TotBili-6.3*
DirBili-4.0* IndBili-2.3
[**2138-2-4**] 04:49AM BLOOD CK-MB-3 cTropnT-<0.01
[**2138-2-4**] 12:25AM BLOOD Albumin-2.4* Calcium-8.3* Phos-4.3 Mg-1.6
[**2138-2-4**] 12:31AM BLOOD Glucose-55* Lactate-7.0*
Last labs before made CMO:
[**2138-2-6**] 04:12AM BLOOD WBC-14.2* RBC-2.88* Hgb-10.6* Hct-32.8*
MCV-114* MCH-36.7* MCHC-32.2 RDW-17.8* Plt Ct-14*
[**2138-2-6**] 04:12AM BLOOD Plt Smr-RARE Plt Ct-14*
[**2138-2-6**] 09:03AM BLOOD Fibrino-122*
[**2138-2-6**] 04:12AM BLOOD Glucose-73 UreaN-57* Creat-4.7* Na-131*
K-4.5 Cl-101 HCO3-13* AnGap-22*
[**2138-2-6**] 04:12AM BLOOD ALT-83* AST-150* AlkPhos-31*
TotBili-13.0*
[**2138-2-6**] 04:12AM BLOOD Calcium-8.7 Phos-6.0* Mg-2.1
[**2138-2-6**] 04:37AM BLOOD Type-ART Temp-38.3 Rates-/30 PEEP-8
pO2-83* pCO2-22* pH-7.38 calTCO2-14* Base XS--9
Intubat-INTUBATED Vent-SPONTANEOU
[**2138-2-6**] 12:27AM BLOOD Lactate-6.9* K-4.8
[**2138-2-6**] 12:27AM BLOOD freeCa-1.02*
Pertinent Studies:
CT abd/pelvis:
IMPRESSION:
1. Moderate nonhemorrhagic ascites without pneumoperitoneum or
extraluminal
contrast to suggest perforation.
2. Cholelithiasis.
TTE:
The left atrium is mildly dilated. The right atrium is
moderately dilated. No atrial septal defect is seen by 2D or
color Doppler. There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>55%). There is no ventricular septal defect. The
right ventricular cavity is dilated with normal free wall
contractility. The aortic root is mildly dilated at the sinus
level. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. Mild (1+) mitral regurgitation is seen.
There is mild pulmonary artery systolic hypertension. There is
no pericardial effusion.
Brief Hospital Course:
61 year old male with hepatitis C +/- alcoholic cirrhosis
complicated by encephalopathy, ascites and nonbleeding varices
admitted with four days of abdominal pain, diarrhea, N/V, fever,
lactic acidosis, and neutropenia. Developed GNR sepsis in the
setting of SBP.
# GNR Sepsis secondary to SBP: pt admitted to MICU with fevers,
confusion, acidosis, neutropenia and abdominal pain. Could not
identify or get in touch with health care proxy on admission.
Pt was very confused, so treated aggressively empirically.
Diagnostic para performed; PMNs were 332. Started
vancomycin/zosyn for empiric treatment of fevers in the setting
of neutropenia. Pt was hemodynamically unstable so CVL was
placed and he was started on pressors. He subsequently became
somnolent with poor respiratory effort and was intubated the
evening of admission. Reviewing the data from OSH, their CT A/P
read was concerning for colititis but radiologist at [**Hospital1 **]
disagreed. RUQ US with doppler, CT abdomen and alkaline
phosphatase were normal making biliary source and portal vein
thrombosis unlikely. Due to negative imaging and unidentifiable
source, diagnosis of spontaneous bacterial peritonitis was made.
Zosyn switched to cefepime due to non-response. Received day 1
of albumin for prophylaxis for HRS (see below). Blood cultures
and ascitic fluid grew GNR's on hospital day 2, so vanc was
stopped. Sensitivities showed organisms pan-sensitive to all
but cipro so cefepime was stopped and ceftriaxone started on Day
2. Renal function declined in the setting of sepsis and he
became anuric the evening of admission. Potassium began to
trend up. Renal was consulted and recommended starting CVVH.
Despite multiple attempts to contact her previously, were not
able to get in touch with HCP until hospital day 2 after
intubation. At that time, she stated that patient would not have
wanted to be DNR/DNI, that he did not want to live supported by
machines, and that he did not like seeing doctors [**Name5 (PTitle) **] [**Name5 (PTitle) 20483**]
medical care in general. Decision was made by presumed HCP not
to pursue CVVH, knowing this could hasten his death, because it
would not be in line with his wishes. NH says she is only
contact - no family nearby, nor do they do have any names or
contact numbers for any family. However, they did not have a
verified proxy form and, in fact, faxed a full code order signed
by patient in [**Month (only) **]. HCP came to hospital; was tearful. Stated
she did not think he would want this, she has known him 25
years, he is [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] scientist and would not want to be kept
alive on machines. Discussed lack of proxy form and lack of
other family contacts with HCP and ethics team. Per ethics, Ms.
[**Name13 (STitle) **] was seen as the most appropriate healthcare proxy
given the available data. After writing a letter to the
patient's brother, and attempting unsuccessfully to find a phone
number for the patient's estranged children, the decision was
made to withdraw aggressive care in concert with Ms. [**Name13 (STitle) **]
understanding of what Mr. [**Known lastname **] wishes would be under such
circumstances. Additionally, Mr. [**Known lastname **] became so acutely ill
with multiorgan system failure that even with aggressive
interventions, the team's medical opinion was that his
likelihood of surviving his illness was exceedingly low such
that such aggressive care would represent futile treatment. As
such, given Ms. [**Name13 (STitle) **] perception of what his wishes would
be, the Ethics consult's recommendation to use her as the
presumptive HCP, and our medical opinion that aggressive care
would ultimately be futile, Mr. [**Known lastname **] was made CMO and extubated
on [**2138-2-7**] and passed away on [**2138-2-8**].
# Neutropenia/thrombocytopenia: Due to HCV treatment with
interferon/ribavirin. Held interferon/ribavirin/boceprevir,
maintained on neutropenic precautions initially, but WBC
improved on day 2 of admission.
# Acute kidney injury: Likely due to septic shock. Pt also has
liver failure and HRS could be component as well. Renal
consulted and recommended CVVH but HCP declined this.
# ESLD: MELD of 27. Known ascites/encephalopathy/nonbleeding
varices. Nadolol was held for concern for sepsis. Rifaximin and
lactulose continued for encephalopathy until patient was made
CMO.
# Atrial fibrillation: Holding nadolol in setting of sepsis. Not
on anticoagulation due to thrombocytopenia and varices.
Medications on Admission:
1. Novolin sliding scale as directed.
2. Lantus 33 units at bedtime.
3. Vitamin D 1,000 units daily.
4. Xifaxan 550 mg twice a day.
5. Acetaminophen 325 mg tablets as needed so long as it is less
than 2,000 mg in 24 hours.
6. Colace 100 mg twice daily.
7. Tramadol 50 mg two tablets at bedtime as needed.
8. Lactulose titrated to three to four soft bowel movements a
day.
9. Loratadine 10 mg tablets one tablet daily.
10. Magnesium oxide 400 mg twice a day.
11. Daily multivitamin.
12. Nadolol 20 mg tablets a day.
13. Omeprazole 20 mg tablet two tablets by mouth twice daily.
14. Pegasys 90 mcg injection every Friday.
15. Potassium chloride 20 mEq daily.
16. Ribavirin 200 mg capsules two capsules twice daily (800 mg
total).
17. Amelioride 20 mg daily.
18. Wellbutrin 75 mg tablets twice daily.
19. Ciprofloxacin 250 mg one tablet daily for SBP prophylaxis.
20. Fluoxetine 20 mg capsules two capsules daily (40 mg total
daily).
21. Lasix 80 mg daily.
22. Victrelis 400 mg t.i.d.
Discharge Medications:
None, passed away
Discharge Disposition:
Expired
Discharge Diagnosis:
Spontaneous Bacterial Peritonitis
Discharge Condition:
Deceased
Discharge Instructions:
Followup Instructions:
|
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icd9cm
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[
[
[]
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[
"96.04",
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icd9pcs
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[
[
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11628, 11637
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6015, 10553
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497, 2290
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,212
| 164,451
|
42848
|
Discharge summary
|
report
|
Admission Date: [**2172-10-21**] Discharge Date: [**2172-10-27**]
Date of Birth: [**2127-11-29**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 10593**]
Chief Complaint:
requesting detox
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 6633**] is a 44 year-old Spanish-speaking gentleman, with a
PMH history of alcoholism and poor health care maintenance
presents with EtOH withdrawal. Patient is requesting detox, at
the encouragement of his PCP (Dr. [**First Name (STitle) 3510**] at [**Location (un) 2274**]). Reports
that he has been "drinking a lot" for a long time. Typically, he
drinks 1 24-beer case per days, with additional rum
occasionally. He has been drinking about this much daily for
the past 14 years. His last drink was at 8 pm yesterday
evening. He has [**Last Name (un) **] tried to detox before. He has only gone
a few hours without drinking in the past. When he does stop for
a few hours, he becomes tremulous. He has no history of
seizures. He does black out drinking sometimes. He is unable
to give a reason for why he drinks. He denies any anxiety or
depression. He denies any suicidal ideation.
.
ROS was positive for swelling on the back of his right wrist.
No known trauma associated with right wrist. Also, positive for
recent upper respiratory cold symptoms. He also has non-bloody
diarrhea chronically, with 3-4 BMs daily. He has vomiting [**11-24**]
times per month. This is also not bloody. Patient is unable to
see out of his right eye. Two weeks ago, he was hospitalized at
another hospital (unable to recall which) because he was unable
to urinate. He was treated with "pills," but does not know what
his diagnosis was. Patient admits to cocaine use about once per
month, with last use 2 months ago.
.
In the ED, initial vs were: 98.3 92 173/121 20 99%. Noted to be
tremulous on exam. Patient was given 2LNS, IV thiamine, diazepam
20mg total, multivitamin. Vitals prior to transfer were 98.7
152/91 66 16 97% room air.
.
On the floor, the patient was still tremulous. His initial
vital signs were 99.9 170/110 66 20 98%RA. He was pleasant and
able to provide details of his history.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness. Denies shortness of
breath. Denies chest pain or tightness, palpitations. Denies
nausea, hematemesis, hematochezia, melena, constipation or
abdominal pain. No recent change in bowel or bladder habits. No
dysuria or hematuria. Denies arthralgias or myalgias.
Past Medical History:
- alcohol abuse: note in Atrius regarding a history of alcohol
withdrawal with tremors
- cocaine abuse
Social History:
Came to US from [**Male First Name (un) 1056**] 23 years ago. Lives in [**Location **] area
with his [**Last Name (LF) **], [**First Name3 (LF) **]. He works in maintenance. never
married. Not in any relationships now. He has [**11-24**] cigarettes
"occasionally." Has two snorts of cocaine about once per month,
last use two months ago. Alcohol history as described in HPI.
Family History:
non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 99.9 170/110 66 20 98%RA
General: Latino male, looks stated age, alert, oriented, NAD,
pleasant
HEENT: Sclera anicteric, injected conjunctivae bilaterally,
+cataracts bilaterally, MMM, EOMI, clear orophayrnx
Neck: supple, JVP not elevated, no LAD
Lungs: CTAB
CV: RRR, Nl S1/S2, No MRG
Abdomen: Soft, non-tender, non-distended, normoactive bowel
sounds, no hepatosplenomagaly, no caput medusa
Ext: Right wrist with soft tissue swelling on dorsum. Unable to
flex right wrist secondary to soft tissue swelling. Warm, well
perfused, 2+ pulses, no clubbing or cyanosis. Trace bipedal
edema.
Skin: No spider angiomata, no palmar erythema. Skin breakdown
on anterior shins.
Neuro: Obvious tremors all over body. +asterixis.
.
DISCHARGE PHYSICAL EXAM:
VS - 98.3 140/90 60 18 96%RA
GENERAL - NAD, not agitated
HEENT - NC/AT, MMM, oropharynx clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - bruises, dried excoriations on anterior shins
NEURO - awake, A&Ox2 (does not know exact date, knows he's in
hospital in [**Location (un) 86**])
Pertinent Results:
ADMISSION LABS:
[**2172-10-21**] 08:15AM BLOOD WBC-6.7 RBC-4.67 Hgb-15.4 Hct-46.2
MCV-99* MCH-32.9* MCHC-33.3 RDW-13.7 Plt Ct-125*
[**2172-10-21**] 08:15AM BLOOD Neuts-73.2* Lymphs-15.7* Monos-5.5
Eos-4.8* Baso-0.9
[**2172-10-21**] 08:15AM BLOOD Glucose-126* UreaN-10 Creat-1.0 Na-139
K-4.2 Cl-99 HCO3-29 AnGap-15
[**2172-10-21**] 08:15AM BLOOD ALT-60* AST-76* AlkPhos-72 TotBili-1.2
[**2172-10-21**] 08:15AM BLOOD Calcium-9.7 Phos-4.6* Mg-1.8
[**2172-10-21**] 08:15AM BLOOD Ethanol-21*
[**2172-10-21**] 11:20AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
DISCHARGE LABS:
[**2172-10-26**] 06:48AM BLOOD WBC-6.0 RBC-4.47* Hgb-14.8 Hct-44.7
MCV-100* MCH-33.2* MCHC-33.1 RDW-13.4 Plt Ct-166
[**2172-10-25**] 06:45AM BLOOD PT-12.8* INR(PT)-1.2*
[**2172-10-26**] 06:48AM BLOOD Glucose-87 UreaN-14 Creat-0.9 Na-138
K-3.8 Cl-99 HCO3-29 AnGap-14
[**2172-10-26**] 06:48AM BLOOD ALT-52* AST-50* TotBili-1.2
[**2172-10-23**] 04:03AM BLOOD Lipase-16
[**2172-10-26**] 06:48AM BLOOD Calcium-9.5 Phos-4.6* Mg-2.0
[**2172-10-25**] 06:45AM BLOOD VitB12-1177* Folate-12.9
.
IMAGING:
[**2172-10-21**] Wrist, 3 views
FINDINGS: AP, oblique, lateral, and navicular views of the right
wrist were
obtained. No evidence of acute fracture or dislocation is seen.
No
significant degenerative change is seen. There is no concerning
osteoblastic or lytic lesion. No radiopaque foreign body is
seen. Suggestion of soft tissue swelling is noted over the
dorsum of the wrist.
IMPRESSION: No acute fracture or dislocation.
[**2172-10-26**] RUQ ultrasound:
FINDINGS: The liver demonstrates diffuse increase in
echogenicity. No focal liver lesions or biliary dilatation is
seen. The common bile duct is normal, measuring 4 mm. The
gallbladder is normal. The main portal vein has normal
hepatopetal flow. The head and body of the pancreas appear
normal, but the pancreatic tail is obscured by overlying bowel
gas. The right and left kidneys are normal, measuring 10.6 and
12.1 cm, respectively. No hydronephrosis, stones, or renal
masses are seen. The spleen is normal measuring 9.8 cm. There is
no ascites. The imaged portions of the aorta and IVC are normal.
IMPRESSION: Echogenic liver consistent with fatty infiltration.
However,
other forms of liver disease including advanced liver disease
such as hepatic fibrosis or cirrhosis cannot be excluded in this
study. No focal liver lesions.
Brief Hospital Course:
Mr. [**Known lastname 6633**] is a 44 year-old Spanish-speaking gentleman, with a
PMH history of alcoholism and poor health care maintenance
presents for alcohol detox.
.
.
ACUTE ISSUES
# Alcohol withdrawal: Patient has an extensive past history of
alcohol abuse, without efforts to detox in the past. Motivation
and commitment to current detox was unclear. On admission, he
exhibited signs of withdrawal with borderline fever, borderline
tachycardia, hypertension, tremulousness and asterixis. His
risk factors for DT's include history of sustained drinking and
age greater than 30. While on the inpatient medicine floor, he
continued to have significant tremors. Over 24 hours after
admission, he required diazepam 70 mg, per CIWA scale. He
became agitated and was transferred to the MICU out of concern
for delirium tremens. Once in the ICU patient was initially
managed with precedex, then switched to haldol and clonidine to
control agitation. On transfer back to the floor, he did not
require haldol or clonidine initially and CIWA was < 10.
However, on [**2172-10-26**], he again became agitated with CIWA 11 and
tremulous and demanded to leave the hospital. He was seen by
psychiatry who felt that he did not have capacity as he was not
able to state understanding of risks of leaving the hospital.
He was monitored overnight and discharged the next day when he
was no longer agitated and able to answer questions
appropriately. He was no longer tremulous. He was A & O x 2,
knew that he was in a hospital but did not know date. Per
family, this was his baseline mental status. He worked with PT
who felt that he had no PT needs. He also met with social work
and was given resources to outpatient detox facilities. He was
kept on thiamine, folic acid, and multivitamin throughout
hospital admission and discharged on these supplements.
.
# Hypertension, benign: Patient was persistently hypertensive
during this admission. it was likely multifactorial with some
element of catecholamine-induced hypertension in alcohol
withdrawal with likely underlying essential hypertension, given
that diastolic was persistently elevated. Since last cocaine
use was two months ago, acute cocaine intoxication is less
likely. After he completed acute withdrawal, he was started on
amlodipine 5mg daily for HTN.
.
# Macrocytosis - Blood tests showed macrocytosis, but no anemia.
Likely secondary to chronic alcohol use and malnutrition.
Vitamin B12 was elevated, folate was wnl.
.
CHRONIC ISSUES:
# Alcohol abuse: Patient has a long history of sustained alcohol
abuse and questionable commitment to current detox plan.
Thrombocytopenia, mild transaminitis and mild total
bilirubinemia consistent with alcohol abuse. RUQ ultrasound was
performed showing echogenic liver c/w fatty infiltration but
could not exclude fibrosis or cirrhosis. There were no focal
liver lesions. The patient was counseled about the importance of
committing to abstinence. He was provided with resources
regarding outpatient programs at [**Hospital 12091**] Health Center and
several Spanish-speaking AA groups.
.
# Right wrist swelling: Exam was most consistent with ganglion
cyst. There had been concern for fracture (with unknown trauma
history); no evidence of join inflammation. Wrist x-ray
revealed soft tissue swelling. Swelling was monitored. Pt
reported no pain, stated that there was some discomfort on
extension of the hand.
.
# Poor healthcare maintenance: Patient without good healthcare
follow-up, but in need of extra support, given substance abuse.
TRANSITIONAL ISSUES
# He had elevated LFTs. Abdominal ultrasound showed fatty
infiltration, but could not exclude more advanced liver disease
such as cirrhosis. Would recommend continued follow-up of liver
disease.
Medications on Admission:
none
Discharge Medications:
1. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Alcohol withdrawal
.
Secondary diagnoses:
Substance abuse
Essential hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure taking care of you in the hospital. You were
admitted for detox from alcohol. You were briefly admitted to
the ICU for a medication to help with agitation. You were also
started on a medication to help with blood pressure control.
You met with our social worker who provided you with resources
that can help you if you choose to stop drinking alcohol. We
encourage you to continue with your abstinence. However, please
remember that abruptly stopping all alcohol intake can be
dangerous, even life-threatening. Please consult with a doctor
if you choose to stop drinking alcohol in the future.
The following changes were made to your medications:
1) START amlodipine 5mg daily
2) START thiamine 100mg daily
3) START multivitamin, 1 tablet daily
4) START folic acid 1mg daily
Followup Instructions:
Name: [**First Name5 (NamePattern1) 85678**] [**Last Name (NamePattern1) 92538**]
Location: [**Hospital1 641**]
Department: Internal Medicine
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 11962**]
Appointment: Tuesday [**2172-11-3**] 11:15am
*This is a follow up appointment of your hospitalization. You
will be reconnected with your primary care physician after this
visit.
Completed by:[**2172-10-29**]
|
[
"287.5",
"263.9",
"571.0",
"291.0",
"289.89",
"401.1",
"305.60",
"782.4",
"727.41",
"303.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"94.62"
] |
icd9pcs
|
[
[
[]
]
] |
11299, 11305
|
7053, 9547
|
325, 331
|
11448, 11448
|
4634, 4634
|
12423, 12894
|
3221, 3239
|
10885, 11276
|
11326, 11326
|
10856, 10862
|
11599, 12400
|
5241, 7030
|
3279, 4011
|
11387, 11427
|
2306, 2680
|
269, 287
|
359, 2287
|
4650, 5225
|
11345, 11366
|
11463, 11575
|
9563, 10830
|
2702, 2806
|
2822, 3205
|
4036, 4615
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,281
| 122,492
|
12172
|
Discharge summary
|
report
|
Admission Date: [**2164-2-7**] Discharge Date: [**2164-2-15**]
Date of Birth: [**2103-6-10**] Sex: M
Service: NEUROSURGERY
CHIEF COMPLAINT: Headache.
HISTORY OF PRESENT ILLNESS: This is a 60 year old white
male, flight attendant, who presents with acute onset of
worst headache of his life developed while leaning over to
He went to the [**Hospital6 33**] in [**Location (un) **] where a CT
scan was positive for subarachnoid blood in the medial left
superior cerebellar area raising the question of a superior
cerebellar artery versus a posterior communicating artery
aneurysm versus an arteriovenous malformation. The patient
was transferred to the [**Hospital1 69**]
Upon arrival, the patient was awake, alert and oriented times
three. He was moving all extremities. He complained of a
mild to moderate photophobia and headache. At the outside
hospital, the patient had received Dilantin 1 gram
intravenously as a loading dose and also received Morphine
Sulfate times two for headache.
PAST MEDICAL HISTORY: Previous medical history was positive
for a previous history of subarachnoid hemorrhage in [**2153**],
reportedly in the same area of the brain. No surgery was
done at that time. The patient had a mild right hemiparesis
that resolved over five weeks with aggressive physical
therapy and rehabilitation at that time. The initial
subarachnoid hemorrhage in [**2153**], did occur while the patient
was on Coumadin for report of previous deep vein thrombosis.
Previous medical history also includes a past history of deep
vein thrombosis times two. He is currently on Enteric Coated
Aspirin for this. He also has a past history of
gastroesophageal reflux disease times two years, a positive
history of polymyalgia rheumatica times two years, and he is
status post varicose vein ligation of the right lower
extremity.
MEDICATIONS ON ADMISSION: He is currently on Protonix for
the gastroesophageal reflux disease, Prednisone for the
polymyalgia rheumatica. He also takes Calcium and Vitamin D
as well as one 325 mg Enteric Coated Aspirin tablet per day.
SOCIAL HISTORY: His heart sounds includes the fact the
patient is a flight attendant with U.S. Air. He quit smoking
sixteen years prior to admission but has a twenty pack year
history of smoking. He drinks approximately three glasses of
wine or scotch per day.
PHYSICAL EXAMINATION: On physical examination, the patient
was a well developed, well nourished white male who appeared
in no acute distress. He was afebrile. Vital signs revealed
blood pressure 157/91, respiratory rate 16, heart rate 70
normal sinus rhythm, oxygen saturation 100% on two liters
nasal cannula at the time of admission. He was awake, alert
and oriented times three. He was normocephalic and
atraumatic of the cranium. The pupils are equal, round, and
reactive to light and accommodation. Extraocular movements
were intact with bilateral end point fine nystagmus noted.
Peripheral fields were full to confrontation. The neck was
slightly tender and rigid and stiff with a mild reduced range
of motion. The lungs were clear. The heart was regular in
rhythm without murmurs, rubs or gallops. Abdominal
examination showed bowel sounds to be positive in all four
quadrants. The abdomen was nontender and nondistended
without hepatosplenomegaly or costovertebral angle
tenderness. Extremities were without cyanosis, clubbing or
edema. On neurologic examination, the patient was awake,
alert and oriented times three. He was conversant with
fluent appropriate speech. Smile was equal. The face was
symmetric. There was no drift of the upper extremities. He
was moving all extremities with full range of motion and full
strength 5/5 in all major muscle groups bilaterally. Sensory
examination was intact. Deep tendon reflexes were intact
throughout and equal bilaterally. The toes were downgoing
bilaterally. Finger to nose and heel to shin were within
normal limits. There was no dysmetria noted and no clonus.
LABORATORY DATA: At the time of admission, laboratories
showed a hematocrit of 46.2, white blood cell count of 9.6,
platelet count 204,000. Coagulation studies revealed
prothrombin time 13.2, partial thromboplastin time 26.3 and
INR 1.1. Chem7 was within normal limits as was a calcium,
total bilirubin, alkaline phosphatase, and liver enzymes.
Review of the CT scan from [**Hospital6 33**] showed
positive blood in the left superior cerebellar area
consistent with a subarachnoid hemorrhage.
IMPRESSION: The impression at the time of admission was that
of a 60 year old white male with a new onset of headache and
radiographic findings consistent with subarachnoid
hemorrhage. The patient was considered to be grade I for
subarachnoid hemorrhage and was admitted to the neurosurgery
service with Dr. [**Last Name (STitle) 1132**] as the attending physician.
HOSPITAL COURSE: A CT angiogram was performed on the night
of admission which raised the question of a small
arteriovenous malformation and due to the clinical and
radiographic findings, the patient was taken to the angiogram
suite for formal diagnostic angiogram on the morning of
[**2164-2-8**], where an angiogram confirmed the presence of an
arteriovenous malformation.
The patient was maintained in the Neurosurgical Intensive
Care Unit during the early phase of his hospitalization where
blood pressure was controlled to keep the systolic blood
pressure within normal limits.
The patient was taken back to the angiogram suite on
[**2164-2-10**], where the patient underwent an angiogram and
NBCA adhesive embolization of one of the superior cerebellar
feeder vessels to the arteriovenous malformation.
Postangiographic physical examination showed some mild
decreased strength in the right arm and, for this reason, the
patient was taken for an urgent head CT scan which showed no
area of infarct or bleed. He was maintained on Heparin until
[**2164-2-13**]. His right arm strength gradually improved without
further sequelae.
He was transferred to the floor on [**2164-2-13**], and an
echocardiogram was obtained on [**2164-2-14**], to assess heart
function and the conclusions of this echocardiogram were
pending at the time of dictation of the summary.
DISCHARGE PLAN: The patient is to be discharged to
rehabilitation facility for aggressive physical therapy and
occupational therapy with plans to be followed by Dr. [**Last Name (STitle) 1132**]
in the clinic in approximately two weeks time and additional
consideration for future angiogram and possible stage II
embolization to be entertained in the future.
CONDITION ON DISCHARGE: Stable.
MEDICATIONS ON DISCHARGE:
1. Percocet 5/325 mg one to two tablets p.o. q4hours p.r.n.
2. Lopressor 25 mg p.o. b.i.d. with instructions to hold the
Lopressor for a systolic blood pressure of less than 120 or a
heart rate less than 60.
3. Multivitamins one per day.
4. Ativan 1 mg p.o. q8hours p.r.n.
5. Zantac 150 mg p.o. b.i.d.
6. Tylenol 650 mg p.o. q4hours for mild pain or for fever
over 101.0 degrees Fahrenheit.
7. Thiamine 100 mg p.o. q.d.
8. Folate 1 mg p.o. q.d.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D., Ph.D. 14-133
Dictated By:[**Doctor Last Name 7311**]
MEDQUIST36
D: [**2164-2-14**] 16:42
T: [**2164-2-14**] 18:09
JOB#: [**Job Number **]
|
[
"430",
"787.02",
"V12.51",
"530.81",
"725",
"V15.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.41",
"99.29",
"88.42"
] |
icd9pcs
|
[
[
[]
]
] |
6668, 7355
|
1889, 2100
|
4896, 6247
|
2388, 4878
|
161, 172
|
201, 1019
|
6264, 6608
|
1042, 1862
|
2117, 2365
|
6633, 6642
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,689
| 130,498
|
37072+37578
|
Discharge summary
|
report+report
|
Unit No: [**Numeric Identifier 83569**]
Admission Date: [**2174-10-25**]
Discharge Date: [**2174-11-2**]
Sex: M
Service: TRA
ADDENDUM: This is an addendum to the previously dictated
Discharge Summary for Mr. [**Known lastname **].
The patient required prolonged mechanical ventilation prior
to expiring because of his initial brain injury. He had a
central neurologic traumatic etiology for his acute
respiratory failure. He had ongoing cerebral edema due to his
intracerebral hemorrhage. His cerebral edema was clinically
significant. Therefore to be added to the discharge
diagnosis:
Acute respiratory failure due to intracerebral hemorrhage and
central neurologic trauma.
[**First Name11 (Name Pattern1) 518**] [**Last Name (NamePattern4) **], MD
Dictated By:[**Last Name (NamePattern4) 17555**]
MEDQUIST36
D: [**2174-12-2**] 09:00:46
T: [**2174-12-4**] 19:20:36
Job#: [**Job Number 83570**]
Admission Date: [**2174-10-25**] Discharge Date: [**2174-11-2**]
Service: SURGERY
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
85M who fell off of a step stool outside of his home. There was
+ LOC. He was taken to [**Hospital 8641**] hospital where he was intubated.
He was found to have multiple intraparenchymal hemorrhages and
transferred to [**Hospital1 18**] for further management.
Past Medical History:
CHF, A-Fib, Pacemaker [**1-24**] bradycardia, Gastritis, Hep C,
Osteoporosis
Social History:
N/A
Family History:
N/A
Physical Exam:
N/A
Brief Hospital Course:
Mr. [**Known lastname **] was transferred to [**Hospital1 18**] after sustaining multiple
intracranial hemorrhagic lesions after a fall off of a step
stool at his home. He was admitted to the Trauma ICU. His
neuro exam was poor on arrival and did not improve over time.
Repeat head CTs showed stable intracranial hemorrhages.
Ventilatory support was required for many days. Neurosurgery
reported that his chance for a meaningful recovery were very
small. A family meeting was held and they elected to withdraw
care as the patient would not have desired to be supported by
artificial means. He was extubated and expired shortly
thereafter.
Medications on Admission:
n/a
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
n/a
Discharge Condition:
n/a
Discharge Instructions:
n/a
Followup Instructions:
n/a
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
|
[
"873.42",
"E881.0",
"802.4",
"802.0",
"070.70",
"V45.01",
"801.25",
"V58.61",
"733.00",
"802.6",
"348.5",
"518.5",
"807.03",
"427.31",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"08.81",
"57.32",
"96.6",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
2397, 2406
|
1670, 2315
|
1186, 1192
|
2453, 2458
|
2510, 2644
|
1621, 1627
|
2369, 2374
|
2427, 2432
|
2341, 2346
|
2482, 2487
|
1642, 1647
|
1138, 1148
|
1220, 1484
|
1506, 1584
|
1600, 1605
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,357
| 175,175
|
40831
|
Discharge summary
|
report
|
Admission Date: [**2170-5-8**] Discharge Date: [**2170-5-17**]
Date of Birth: [**2093-7-30**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
Polytrauma - found down likely after fall from ladder
Major Surgical or Invasive Procedure:
Intubation ([**2170-5-10**])
Left paravertebral catheter placed ([**2170-5-11**])
Left chest tube placed ([**2170-5-11**])
History of Present Illness:
76 yo male with hx of dementia, CAD, recent falls transferred
from an OSH after sustaining an unwitnessed fall on [**Location (un) 7453**]. Patient was found down in the garden and does not
recall event. At OSH, patient was found to have a SDH and SAH as
well as multiple rib fx. Patient was transferred to [**Hospital1 18**] for
further management. Upon arrival here, patient was pan scanned
and seen by neurosurgery. He was loaded with keppra. His TLS
spine was cleared but his c-spine is still in a collar. Patient
also has significant EtOH hx per report, though EtOH negative
here. Per further discussion with the family it seemed as
though there was a ladder nearby and he may have fallen and then
tried to walk home before collapsing. His toxicology screen on
admission was negative.
INJURIES:
Sm L PTX and apical HTX
L medial rib fxs [**12-17**]
L prox rib fxs [**1-14**] at trans proc artic
L tentorial and inf sagittal sinus SDH
L fronto-parietal SAH
L clavicular fx close to scapula
Mildly displaced fracture of inferior left scapula
Past Medical History:
PMH: CAD, MI, infrarenal AAA (5x4.6cm), congenital single R
kidney, h/o past falls
PSH: Cardiac stents
Social History:
Lives in [**Hospital3 4298**] with his girlfriend [**Name (NI) **]. [**Name2 (NI) **] a
daughter and three grandchildren. History of heavy EtOH and
tobacco.
Family History:
Non-contributory
Physical Exam:
(on admission)
Gen: C-spine collar,lethargic but easily arousable, cooperative
with exam
HEENT: few abrasians
Neck: Hard Collar
Lungs: Decreased breath sounds on the left with occ. Wheeze
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Lethargic but arousable
Orientation: Oriented to self only, spells first and last name,
confused to place, time, president
Pertinent Results:
CT head ([**2170-5-8**]): Left tentorial and parafalcine subdural
hemorrhage and left frontal and parietal subarachnoid
hemorrhage. Punctate amount of intraventricular hemorrhage
within the left occipital [**Doctor Last Name 534**].
CT cspine ([**2170-5-8**]): No acute fracture or malalignment; no
significant canal stenosis.
CT torso ([**2170-5-8**]): Small left hemopneumothorax with extensive
left-sided rib fractures including segmental fractures of ribs
two through six, as well as rib eight. Mildly displaced
fracture of the inferior body of the left scapula. Comminuted
left distal clavicular fracture. 4.8 x 4.6 cm infrarenal aortic
aneurysm. Mild pulmonary edema with bibasilar atelectasis.
CT head ([**2170-5-9**]): Partial interval resorption and/or
redistribution of left frontal lobe subarachnoid hemorrhage.
Tiny layering hemorrhage within the occipital horns of the
lateral ventricles is new on the right and increased on the
left. New right frontal lobe hyperdensity could be represent
redistributed SAH or a small focus of parenchymal hemorrhage at
the grey-white matter junction, perhaps secondary to diffuse
axonal ("shear") injury. SDH overlying the left leaflet of the
tentorium cerebelli is unchanged, while parafalcine SDH is
decreased.
CT head ([**2170-5-11**]): No new acute intracranial hemorrhage or major
vascular territory infarction. Interval
redistribution/resorption of subarachnoid and subdural
hemorrhage. Probable minimal increase in blood products within
the occipital [**Doctor Last Name 534**] of the left lateral ventricle. Possible shear
injury involving the posterior corpus callosum. Consider MRI for
further evaluation as clinically indicated.
MRI head ([**2170-5-12**]): Subarachnoid and subdural blood products
identified as on the prior CT. Signal changes in the splenium of
corpus callosum, left frontal lobe as well as susceptibility
abnormalities along the [**Doctor Last Name 352**]-white matter junction are
suggestive of diffuse axonal injury. No territorial infarcts are
seen.
CXR ([**2170-5-17**]): ET tube is in standard placement, no less than 7
cm from the carina, although it is at the level of the lower
margin of the clavicles. Pulmonary edema superimposed on
residual abnormalities in both lungs due to ARDS and multifocal
pneumonia has improved slightly since earlier today. Small right
pleural effusion is likely. Heart size is top normal and
mediastinal veins are still distended. No pneumothorax.
Nasogastric tube passes into the stomach and out of view.
Brief Hospital Course:
[**5-9**]: The patient was admitted to the Trauma ICU from the ED. He
was initially maintained on an oxygen facemask. Neurosurgey was
consulted for his SAH and SDH and felt reimaging the next day
was appropriate and surgical intervention was not intubated at
that time. His head CT was repeated and showed just
redistribution of blood.
[**5-10**]: Epidural placement was attempt for discomfort and
difficulty breathing but the patient was unable to tolerate
procedure. His respiratory status worsened with desaturations
despite 100% O2 facemask and he was ultimately intubated for
airway protection.
[**5-11**]: A left sided paravertebral catheter was placed to help with
pain control given desaturations on CPAP ventilator mode. His
post-placement CXR demonstrated worsening of his previously seen
left sided pneumothorax and a left sided chest tube was placed
with 300cc of old blood out and improvement in his pneumothorax.
[**5-12**]: A repeat head CT was obtained given change in mental status
which was unrevealing, and neurology was consulted. A head MRI
was obtained which demonstrated moderate [**Doctor First Name **]. The patient was
minimally responsive at that time and mental status failed to
significantly improve throughout the rest of his
hospitalization. Sputum cultures were sent which demonstrated
H.influenza and moderate streptococcus pneumonia, and he was
started on levaquin. He continued to spike fevers and was
changed to vanco and zosyn. Free water flushes were added for
hypernatremia.
[**5-13**]: A family meeting was held and the patient was made DNR with
no further escalation in care. He respiratory status continued
to decline with inability to tolerate CPAP and thick secretions.
[**5-14**]: Propofol was added for dysynchrony on the ventilator -
sedatives had previously been held for concern for depressed
mental status. Discussions were made to hold a family meeting
on Thursday [**5-17**].
[**5-15**]: His paravertebral catheter was dc'ed and fentanyl and
oxycodone were added. His chest tube was dc'ed. His tube feeds
were held for high residuals.
[**5-16**]: His respiratory status continued to worsen despite
diuresis. He continued to be unable to tolerate tube feeds.
[**5-17**]: A family meeting was held with the patient's daughter,
grandchildren and girlfriend. The decision was made to make the
patient CMO with terminal extubation. The patient expired
shortly thereafter.
Medications on Admission:
Asa 325mg po
Prozac 80
Neurontin 900 tid
Clonazepam 1 tid
Risperidone 0.25 [**Hospital1 **]
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Death
Discharge Condition:
Death
Discharge Instructions:
Death
Followup Instructions:
Death
|
[
"E881.0",
"518.5",
"852.00",
"V49.86",
"414.01",
"276.0",
"860.4",
"300.4",
"486",
"810.03",
"852.39",
"V45.81",
"294.8",
"807.07",
"518.0",
"V66.7",
"441.4",
"753.0",
"811.09"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.04",
"96.6",
"03.90",
"33.23",
"96.04",
"96.72",
"33.29"
] |
icd9pcs
|
[
[
[]
]
] |
7513, 7522
|
4894, 7343
|
356, 480
|
7571, 7578
|
2337, 4871
|
7632, 7640
|
1877, 1895
|
7485, 7490
|
7543, 7550
|
7369, 7462
|
7602, 7609
|
1910, 2178
|
263, 318
|
508, 1557
|
2193, 2318
|
1579, 1685
|
1701, 1861
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,343
| 194,072
|
33428
|
Discharge summary
|
report
|
Admission Date: [**2186-11-17**] Discharge Date: [**2186-11-27**]
Date of Birth: [**2122-2-2**] Sex: M
Service: NEUROSURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics) / Diamox Sequels / Septra /
Acetazolamide / sulfacetamide / Penicillins / Quinolones /
Codeine / ciprofloxacin
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Mental status change/ new brain mass
Major Surgical or Invasive Procedure:
Left temporal craniotomy for tumor resection.
History of Present Illness:
This is a 64 year old male who lives in a nursing facility who
has been having
difficulties with speech for the past two weeks, but in the last
two days has had confusion. He was sent to an outside hospital
to rule out stroke. A head CT showed a left temporal mass, an
MRI was done which confirmed a large
left temporal mass with extensive vasogenic edema and midline
shift.
Past Medical History:
history of DM2 with neuropathy and retinopathy-uncontrolled
history of coronary artery disease s/p CABG'sx3 [**2177**]
history of peripheral vascular disease s/p left 5th toe, left
fem-AK [**Doctor Last Name **] with PTFE, s/p left AK [**Doctor Last Name **]-PT w arm vein+STSG [**12-27**]
history of retinopathy s/p eye surgery
history of gall bladder disease s/p cholecstectomy
Social History:
lives alone
denies tobacco use
occasional ETOH use
Family History:
N/C
Physical Exam:
Neuro:
Mental status: Awake and alert, cooperative with exam
Orientation: Oriented to person, place, and date with choices
given for yes/no answers
Recall: unable to assess
Language: Aphasic, word finding difficulty, stutters
Cranial Nerves:
I: Not tested
II: L pupil surgical, R pupil 2mm reactive. Unable to fully
assess visual fields- pt legally blind per records, R eye
appears
to have some vision on exam
III, IV, VI: ? whether EOM is restrictive on right vs. unable to
follow command
V, VII: Facial sensation intact and R facial
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Mild tremor to RUE. Strength full power [**3-24**] to BUE. LLE
amputated, RLE weak antigravity- min distal strength. No
pronator
drift.
Sensation: Intact to light touch
Coordination: Unable to follow
Neurological exam on the day of discharge:
A&Ox3
R pupil reactive, L surgical ptosis
BUE [**3-24**]
Moves BLE
Incision: c/d/i
Pertinent Results:
[**2186-11-17**] 08:51PM PT-26.5* PTT-41.7* INR(PT)-2.5*
[**2186-11-17**] 08:51PM PLT COUNT-229
[**2186-11-17**] 08:51PM NEUTS-90.1* LYMPHS-8.5* MONOS-0.9* EOS-0.3
BASOS-0.3
[**2186-11-17**] 08:51PM WBC-10.4 RBC-3.96* HGB-13.2* HCT-37.1* MCV-94
MCH-33.3* MCHC-35.6* RDW-13.4
[**2186-11-17**] 08:51PM CALCIUM-8.9 PHOSPHATE-2.4* MAGNESIUM-2.0
[**2186-11-17**] 08:51PM estGFR-Using this
[**2186-11-17**] 08:51PM GLUCOSE-157* UREA N-15 CREAT-0.9 SODIUM-136
POTASSIUM-4.7 CHLORIDE-103 TOTAL CO2-23 ANION GAP-15
[**2186-11-17**] 10:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2186-11-17**] 10:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.011
[**2186-11-17**] Non Contrast Head CT from outside hospital
CT C/A/P:
1. No CT evidence of a primary neoplasm within chest, abdomen or
pelvis.
2. Small left pleural effusion with adjacent area of compressive
atelectasis.
3. Numerous sigmoid and descending colon diverticula without
associated
inflammatory changes.
4. Extensive coronary artery calcifications.
5. Hepatic hypodensities are too small to characterize and most
likely
represent cysts or hamartomas.
Echo:
The left atrium is moderately dilated. 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 is normal. with borderline normal free wall
function. The aortic root is mildly dilated at the sinus level.
The aortic valve leaflets are mildly thickened (?#). No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Physiologic mitral
regurgitation is seen (within normal limits). The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
IMPRESSION: Suboptimal image quality due to body habitus. Left
ventricular systolic function is probably normal, a focal wall
motion abnormality cannot be excluded. The right ventricle is
not well seen but is probably normal in size with borderline
systolic function. No significant valvular abnormality. Normal
estimated pulmonary artery systolic pressure.
CT HEAD W/O CONTRAST [**2186-11-24**]
Post-surgical changes related to large left temporal lobe mass
biopsy, as
detailed above, with small amount of pneumocephalus, which is
likely
post-surgical. There is persistent stable rightward shift of
normally midline structures by 6 mm
Brief Hospital Course:
On [**11-18**] the patient was admitted the the intensive care unit
under Neurosurgery. prior to admission the patient was given
Dexamethasone 10mg and upon arrival to this hospital was given
another dose of Dexamethasone 10mg. The patient was started on
Decadron 6 mg every 6 hours. The INR was 2.5. Coumadin and
Plavix were held. Social Work was consulted for coping and
family support A wound consult was placed for the right lower
extremity venous satsus. Neuro- oncology and radiology oncology
were consulted.
On [**11-19**], The Decadron was decreased to 4mg every 6hrs. The
patient exam was stable and the patient was transferred to the
Step Down unit with neurological assessments ordered for every 2
hours. The INR was 2.1. Pre-operative workup was initiated
including EKG, UA, CXR.The vascular surgery team was notified
that the patient was admitted to the hospital and the right
lower extremity was evaluated by the team. Upon assessment at
the bedside, the vascular team felt that the grafts were patent
and there was no intervention warranted from their perspective.
[**11-21**] A CT of the chest, abdomen and pelvis was performed which
did not reveal any other cancerous lesions.
[**11-23**] patient was found to have a UTI and was started on
ceftriaxone, cultures were sent to check sensitivities. An Echo
was performed at the bedside for pre-operative clearance.
[**11-24**] patient was taken to the OR for a left frontal Craniotomy
for tumor biopsy. Intraoperatively, case was uncomplicated and
patient was tranferred to the floor.
On [**11-25**], family discussion was held and patient was made comfort
measures. He was transferred to the floor and remained stable.
He was discharged to a nursing home for hospice care on [**11-26**].
Medications on Admission:
Medications prior to admission:
Coumadin 3mg QD, Plavix 75mg QD, Flonase 50mcg QD, Insulin SS,
Lantus 50 units QHS, Hydroxyzine 25mg PRN, Lisinopril 5mg QD,
MVI
daily, Omeprazole 20mg QD, Zocor 20mg QHS, Ergocalciferol 50,000
unit daily, Minocycline 100mg [**Hospital1 **], Miralax 17gm [**Hospital1 **],
Prednisolone
acetate 1% [**Hospital1 **], Senna, Tearisol 2gtt [**Hospital1 **], Timolol 0.5% [**Hospital1 **],
Tylenol PRN, Zyprexa 2.5mg QHS, Brimonidine 0.15% TID
Discharge Medications:
1. cefpodoxime 200 mg Tablet Sig: Two (2) Tablet PO every twelve
(12) hours for 4 days. Tablet(s)
2. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for Pain/fever. Tablet(s)
3. hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for anxiety.
4. olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
5. white petrolatum-mineral oil 56.8-42.5 % Ointment Sig: One
(1) Appl Ophthalmic PRN (as needed) as needed for dry eyes.
6. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H
(every 8 hours).
7. timolol maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
8. prednisolone acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
9. levetiracetam 250 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
10. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
11. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
12. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
13. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily) as needed for constipation.
14. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q8hrs ()
for 99 doses.
15. insulin glargine 100 unit/mL Solution Sig: One (1)
Subcutaneous HS (at bedtime).
16. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
17. 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.
18. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] LivingCenter - [**Location (un) 8545**]
Discharge Diagnosis:
left temporal brain mass
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 are being discharged to a nursing facility for comfort care
measures and hospice care. ****Please remove sutures on
[**2186-12-4**]*****
Followup Instructions:
You can follow up with Dr. [**First Name (STitle) **] as needed. Please call
[**Telephone/Fax (1) 1669**]
Completed by:[**2186-11-27**]
|
[
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"357.2",
"599.0",
"250.52",
"V58.61",
"272.4",
"V58.67",
"459.81",
"414.00",
"V49.75",
"V45.81",
"427.31",
"369.4",
"250.62",
"707.03",
"191.2",
"348.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.14"
] |
icd9pcs
|
[
[
[]
]
] |
9189, 9271
|
5071, 6836
|
444, 492
|
9340, 9340
|
2494, 5048
|
9681, 9819
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1385, 1390
|
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|
6862, 6862
|
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1405, 1412
|
6894, 7335
|
367, 406
|
520, 897
|
1648, 2475
|
9355, 9492
|
919, 1300
|
1316, 1369
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,223
| 168,113
|
41984
|
Discharge summary
|
report
|
Admission Date: [**2170-7-26**] Discharge Date: [**2170-8-15**]
Date of Birth: [**2145-12-15**] Sex: M
Service: PLASTIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 36263**]
Chief Complaint:
Self inflicted Left forearm laceration
Major Surgical or Invasive Procedure:
[**2170-7-26**]
1. Irrigation and debridement of the left forearm down to bone
with excision of necrotic muscle.
2. Exploration of the wound with neurolysis of the median and
radial nerve.
3. Ligation of a small tributary of the radial artery.
.
[**2170-7-27**]
1. Washout, debridement, dressing change to left forearm wound.
.
[**2170-7-30**]
1. Irrigation and debridement with removal of necrotic muscle.
2. Application of vacuum-assisted closure device measuring 20 x
20 cm.
.
[**2170-8-2**]
Irrigation and debridement of left forearm skin, subcutaneous
tissue, fascia, and muscle.
.
[**2170-8-8**]
1. Irrigation, washout, debridement of nonviable skin,
subcutaneous tissue and muscle, left forearm.
2. Flexor digitorum superficialis to flexor pollicis longus
tendon transfer, left forearm.
3. Local advancement bipedicled flaps x2. Total of 60 sq cm.
4. Split-thickness skin graft from right side of left forearm
132 sq cm.
History of Present Illness:
24M transferred from OSH by med flight after a near drowning
episode. Found by EMS in fresh water pond after severely
degloving his left forearm with a boxcutter. Unclear whether he
walked or jumped into the pond. Was initially responsive and
breathing spontaneously, decompensated at OSH ED and was
intubated. Hypoxic and hypotensive despite 6L crystalloid and 2U
PRBCs. Received 2g ancef, tetanus at OSH. Hypothermic to 31C in
the ambulance. Hypotensive w/SBP in 80s and bradycardic in the
50s en route and on arrival to [**Hospital1 18**]. Received 3 add'l units
PRBCs. Placed in C-spine precautions given unclear hx and
refractory hypotension w/bradycardia, CT neg for spinal cord
injury. Hct 27 after transfusion.
Past Medical History:
paranoid schizophrenia dx [**2163**]; +auditory hallucinations,
negative symptoms; hx mult anti-psychotics
Social History:
Lives on Cape, was very bright and smart, attended community
college, studied bhuddism, is a pacificist. family very
supportive.
Family History:
Non-contributory
Physical Exam:
Upon presentation to [**Hospital1 18**]:
Gen: Intubated, sedated
CV: Pulse RRR
Resp: intubated
LUE: There are two deep longitudinal volar lacerations that
extend from the wrist to approximately 5 cm distal to the elbow
crease. The wounds penetrate fascia and the entire superfical
musculature of the volar forearm is visible. The wound is
contaminated with debris. There is significant bleeding
although
no discrete arterial injury. Median and ulnar nerves are not
clearly visible. Upon removal of the tourniquet, biphasic
dopperable signals of radial and ulnar artery at the wrist are
present.
Pertinent Results:
[**2170-7-26**] 11:10PM GLUCOSE-147* UREA N-23* CREAT-0.8 SODIUM-140
POTASSIUM-3.8 CHLORIDE-116* TOTAL CO2-15* ANION GAP-13
[**2170-7-26**] 11:10PM ALT(SGPT)-20 AST(SGOT)-18 ALK PHOS-22* TOT
BILI-0.6
[**2170-7-26**] 11:10PM ALBUMIN-1.7* CALCIUM-5.6* PHOSPHATE-3.7
MAGNESIUM-1.5*
[**2170-7-26**] 11:10PM DIGOXIN-LESS THAN
[**2170-7-26**] 11:10PM WBC-9.0 RBC-2.93* HGB-9.2* HCT-26.1* MCV-89
MCH-31.5 MCHC-35.4* RDW-14.0
[**2170-7-26**] 11:10PM PLT COUNT-42*
[**2170-7-26**] 11:10PM PT-20.1* PTT-49.3* INR(PT)-1.8*
[**2170-7-26**] 11:10PM FIBRINOGE-69*
[**2170-7-26**] 11:09PM TYPE-ART PO2-502* PCO2-33* PH-7.28* TOTAL
CO2-16* BASE XS--9
[**2170-7-26**] 11:09PM GLUCOSE-134* LACTATE-3.7* NA+-134* K+-3.8
CL--115*
[**2170-7-26**] 11:09PM HGB-8.9* calcHCT-27
[**2170-7-26**] 11:09PM freeCa-0.80*
[**2170-7-26**] 10:20PM GLUCOSE-153* LACTATE-5.3* NA+-134* K+-4.5
CL--111 TCO2-15*
[**2170-7-26**] 10:10PM UREA N-26* CREAT-1.1
[**2170-7-26**] 10:10PM estGFR-Using this
[**2170-7-26**] 10:10PM LIPASE-18
[**2170-7-26**] 10:10PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2170-7-26**] 10:10PM WBC-UNABLE TO
[**2170-7-26**] 10:10PM PTT-UNABLE TO
[**2170-7-26**] 08:50PM URINE HOURS-RANDOM
[**2170-7-26**] 08:50PM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2170-7-26**] 08:50PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.011
[**2170-7-26**] 08:50PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-100 KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2170-7-26**] 08:50PM URINE RBC-<1 WBC-<1 BACTERIA-FEW YEAST-NONE
EPI-<1
[**2170-7-26**] 08:50PM URINE RBC-<1 WBC-<1 BACTERIA-FEW YEAST-NONE
EPI-<1
[**2170-7-26**] 08:50PM URINE MUCOUS-RARE
[**2170-8-15**] 01:20PM BLOOD WBC-6.1 RBC-2.73* Hgb-8.6* Hct-25.2*
MCV-92 MCH-31.4 MCHC-34.0 RDW-16.6* Plt Ct-412
[**2170-8-15**] 01:20PM BLOOD Plt Ct-412
[**2170-8-15**] 01:20PM BLOOD Glucose-127* UreaN-16 Creat-0.6 Na-141
K-3.7 Cl-105 HCO3-27 AnGap-13
[**2170-8-15**] 01:20PM BLOOD ALT-38 AST-27 AlkPhos-89 TotBili-0.2
[**2170-8-15**] 01:20PM BLOOD Calcium-8.7 Phos-2.3* Mg-1.9
.
MICROBIOLOGY:
[**2170-8-1**] 11:33 am TISSUE Site: ARM
DEEP FOREARM WOUND EXTRA ANC AND AER SWABS RECEIVED SAME
SITE.
**FINAL REPORT [**2170-8-5**]**
GRAM STAIN (Final [**2170-8-1**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final [**2170-8-5**]):
Reported to and read back by DR. [**First Name (STitle) **], J [**2170-8-2**] 10:47AM.
AEROMONAS SPECIES. RARE GROWTH.
sensitivity testing performed by Microscan. CEFEPIME
<=2MCG/ML.
BACTRIM (=SEPTRA=SULFA X TRIMETH) <=2/38MCG/ML.
MEROPENEM <=1MCG/ML. AMPICILLIN/SULBACTAM ([**Male First Name (un) **])
>16/8MCG/ML.
PSEUDOMONAS AERUGINOSA. RARE GROWTH.
Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
AEROMONAS SPECIES
| PSEUDOMONAS AERUGINOSA
| |
AMIKACIN-------------- 8 S
AMPICILLIN/SULBACTAM-- R
CEFEPIME-------------- S <=1 S
CEFTAZIDIME----------- <=1 S 2 S
CEFUROXIME------------ <=4 S
CIPROFLOXACIN--------- <=0.5 S <=0.25 S
GENTAMICIN------------ 4 S <=1 S
IMIPENEM-------------- =>8 R
LEVOFLOXACIN---------- <=1 S
MEROPENEM------------- S 0.5 S
PIPERACILLIN/TAZO----- S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- S
ANAEROBIC CULTURE (Final [**2170-8-5**]): NO ANAEROBES ISOLATED.
.
RADIOLOGY:
Radiology Report CT HEAD W/ CONTRAST Study Date of [**2170-7-26**] 8:49
PM
IMPRESSION: No acute intracranial process.
.
Radiology Report CT C-SPINE W/O CONTRAST Study Date of [**2170-7-26**]
8:50 PM
IMPRESSION: No acute fracture or dislocation.
.
Radiology Report CT ABD & PELVIS WITH CONTRAST Study Date of
[**2170-7-26**] 8:51 PM
IMPRESSION: Evaluation is slightly limited by artifact from the
arms down by
the patient's side.
1. High-density fluid within the right paracolic gutter,
concerning for
blood. Small focus of gas along the hepatic flexure- unclear
whether
definitively intra- or extraluminal, but may be extraluminal.
Above findings
raise concern for possible bowel injury.
2. Small amount of free fluid within the abdomen and periportal
edema is
likely secondary to aggressive resuscitation.
3. Small amount of pneumomediastinum.
4. OG tube within the stomach. Side port is just inferior to the
GE junction
and could be slightly advanced.
5. Nodularity with tree-in-[**Male First Name (un) 239**] opacities in the left upper lobe
is most
likely infectious or inflammatory in nature.
.
Radiology Report PELVIS (AP ONLY) Study Date of [**2170-7-26**] 9:26 PM
IMPRESSION: Very superior iliac wings not included on the
images. Contrast
seen within the urinary bladder from recent CT. No evidence of
acute fracture or dislocation.
.
Radiology Report WRIST(3 + VIEWS) LEFT Study Date of [**2170-7-26**]
9:26 PM
IMPRESSION: Extensive left forearm laceration, with probable
retained foreign bodies, but no acute fracture.
.
OTHER REPORTS:
Cardiology Report ECG Study Date of [**2170-7-27**] 2:36:18 AM
Sinus rhythm at lower limits of normal rate. Vertical axis. Low
precordial
voltage. No previous tracing available for comparison. Clinical
correlation is suggested.
.
Neurophysiology Report EEG Study Date of [**2170-8-7**]
IMPRESSION: This is a normal awake and sleep EEG. No focal
abnormalities or epileptiform features were seen. No
electrographic
seizures were recorded.
.
Cardiology Report ECG Study Date of [**2170-8-7**] 7:08:36 PM
Sinus rhythm. Since tracing #1 T wave amplitude has improved.
Otherwise,
findings are unchanged.
Brief Hospital Course:
He was admitted to the Acute Care team and was evaluated by
Ortho Hand due to the large left upper extremity laceration with
exposed muscle. He was taken urgently to the operating room for
irrigation and debridement of the left forearm down to
bone with excision of necrotic muscle; exploration of the wound
with neurolysis of the median and radial nerve and ligation of a
small tributary of the radial artery. He was transferred to the
Trauma ICU postoperatively for close hemodynamic monitoring. On
[**7-27**] he was taken back to the operating room by Ortho Hand for
further washout, debridement and dressing change. The patient
subsequently went back to OR for multiple washout and
debridements of his left forearm wound and application of
vacuum-assisted closure device. He underwent a trauma tertiary
survey and no other issues were identified. On [**2170-8-1**] patient
was transferred to the Plastic Surgery service. On [**2170-8-8**],
patient underwent irrigation, washout, debridement of nonviable
skin, subcutaneous tissue and muscle of the left forearm; Flexor
digitorum superficialis to flexor pollicis longus tendon
transfer, left forearm; Local advancement bipedicled flaps x2;
Split-thickness skin graft from right side of left forearm. He
tolerated the procedure well. A bolster was applied to left
forearm skin graft site and a JP drain was in place. His right
thigh skin graft donor site was left open to air. The bolster
dressing was removed on Sunday, [**2170-8-12**] revealing pink and
viable skin graft over both forearm sites with 100% take. There
was no drainage noted, no evidence of hematoma. The JP drain
was removed for scant drainage output. The skin graft sites
were dressed daily with xeroform, gauze fluffs, kerlix and ace
wraps and splint reapplied.
MENTAL/PSYCH: Psychiatry was consulted immediately due to the
nature of his trauma, he was placed on 1:1 sitter and
recommended for in patient psychiatric placement once medically
stable. Zyprexa and Ativan prn were initially recommended. A
section 12 was put into place and patient could not leave
against medical advice. Patient was severely psychotic,
paranoid and with suicidal ideation upon admission. He was
initially refusing care and medications. Psychiatry worked
closely with patient and teams to assist with management of this
psychotic patient. A 1:1 sitter was maintained during this
patients entire inpatient stay on a regular floor. The zyprexa
was discontinued on [**2170-8-5**] and patient was started on
Iloperidone on recommendation of Psych service. The patient was
compliant with taking the medication and titrated up to a
standing dose of Iloperidone 10 mg PO/NG [**Hospital1 **]. The patient had
continued psychosis and paranoia but became more compliant with
care and staff after continuing to take the Fanept medication.
On [**2170-8-6**], patient's mother reported that she witnessed
patient's eyes rolling back in his head and various hand
movements. For this purpose, an EEG was obtained and compaired
to a previous EEG from outside facility. This showed a normal
awake and sleep EEG. No focal abnormalities or epileptiform
features were seen. No electrographic seizures were recorded.
The patient was followed closely by psychiatry service during
the remainder of his stay and was compliant with taking his
medication. Upon discharge, the patient was asking appropriate
questions about his care and his discharge status and was
compliant and involved with all aspects of his care.
ID: Patient was initially started and maintained on Unasyn IV on
[**2170-7-26**]. A deep tissue swab of the left forearm was obtained
during debridement and washout on [**2170-8-1**]. This culture
eventually yielded 'aeromonas' and 'pseudomonas'. Unasyn was
discontinued at this point and patient was started on Ampicillin
and Ciprofloxacin. These were eventually discontinued on
[**2170-8-15**].
NEURO/PAIN: On [**2170-8-1**] the Acute Pain Service placed a left
supraclavicular catheter for post-operative pain control for
frequent dressing changes. The catheter provided excellent pain
control and was discontinued on [**2170-8-6**]. The patient was then
given dilaudid IV prn and oxycodone PO prn for additional pain
control. When wound was covered with skin grafts, the patient
eventually required no pain medications including tylenol.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored. ECG x 3 were
unremarkable.
PULM: The patient was stable from a pulmonary standpoint; vital
signs were routinely monitored.
GI/GU: Post-operatively, the patient was given IV fluids until
tolerating oral intake. His diet was advanced when appropriate,
which was tolerated well. He was also started on a bowel regimen
to encourage bowel movement. Intake and output were closely
monitored.
Medications on Admission:
None
Discharge Medications:
iloperidone 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 69**] - [**Location (un) 86**]
Discharge Diagnosis:
1) Left forearm open wound
2) Paranoid schizophrenia
Discharge Condition:
Mental Status: Paranoid thoughts and statements at times.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Followup Instructions:
-You should continue taking your current medication.
-Elevate your left arm as much as possible and maintain it in a
the splint and dressing that is currently in place.
-Please keep your left arm dry
- If your left arm begins to worsen after discharge with an
acute increase in swelling or pain, please call Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
office at ([**Telephone/Fax (1) 36264**].
- You should keep your right thigh donor site open to air and
leave the yellow xeroform dressing in place to dry out. Do not
get this area wet.
- Your left arm skin graft and repair sites will be dressed with
a xeroform dressing to graft areas, fluffed gauzes covered with
kerlix and then ace wrap. Your splint should be warn at all
times.
Followup Instructions:
Please follow up with Plastic Surgery, Hand Clinic: ([**Telephone/Fax (1) 15940**] [**Hospital Ward Name 516**], [**Hospital Ward Name 23**] Building, [**Location (un) **]
Please follow up in the Hand Clinic on the next TUESDAY, after
you are discharged home or to another facility. You must call
([**Telephone/Fax (1) 2007**] to make an appointment. The clinic is open from
8-12pm most Tuesdays. The clinic is located on the [**Hospital Ward Name 516**],
[**Hospital Ward Name 23**] Building, [**Location (un) **]. Please make sure that you obtain a
referral from your insurance company prior to your clinic
appointment.
Completed by:[**2170-8-15**]
|
[
"287.5",
"994.1",
"922.2",
"338.18",
"295.30",
"285.1",
"991.6",
"E956",
"E954",
"458.9",
"881.10"
] |
icd9cm
|
[
[
[]
]
] |
[
"83.45",
"83.75",
"86.69",
"86.72",
"96.71",
"38.83",
"04.49"
] |
icd9pcs
|
[
[
[]
]
] |
14071, 14141
|
9064, 13921
|
344, 1275
|
14238, 14238
|
2969, 9041
|
15221, 15878
|
2316, 2334
|
13977, 14048
|
14162, 14217
|
13947, 13953
|
14412, 14412
|
2349, 2950
|
266, 306
|
1303, 2023
|
14253, 14388
|
2045, 2153
|
2169, 2300
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,904
| 189,889
|
28334
|
Discharge summary
|
report
|
Admission Date: [**2155-10-16**] Discharge Date: [**2155-10-28**]
Date of Birth: [**2100-7-20**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6169**]
Chief Complaint:
new R leg weakness
Major Surgical or Invasive Procedure:
radiation therapy
History of Present Illness:
55 y/o M with PMHx of recent dx of MM c/b cord compression s/p
T1-T8 laminectomy/decompression surgery on [**9-17**] with residual
bilat LE weakness, s.viridans abscess s/p 4 wks of Unasyn, COPD,
here with exacerbation of his RLE weakness along with hypoxia in
the ED. Pt states that he noticed the insidious onset of SOB
over the past week. He has noticed difficulty maintaining his
respirations over the past week, but denies any air hunger or
inabililty to expire completely. He denies any f/chills, cough,
sputum production or change in his sputum. He denies any CP,
orthopnea, PND, or other heart failure sx's. He has been
immobilized due to his recent back surgery and spinal
instability.
Today, he feels SOB, but denies air hunger, fatigue, wheezing,
or inability to expire completely. He denies any CP, f/chills,
N/V/abd pain. Admits to baseline back pain. No calf
pain/tenderness.
.
In the ED, VS were: Tc 99.1, HR111, BP107/74, RR22, 96%RA ->
92%RA and started on 4L O2. Sats improved to 98% on 4L. Pt
received Dilaudid 1mg x1, Ativan 0.5mg IV x1. He was evaluated
by neurosurgery in the ED who determined that there was no acute
change to his neurological exam & no acute neurosurgical issue.
He was admitted to medicine for further w/u and treatment of his
hypoxia.
Past Medical History:
1. Recent dx of multiple myeloma, dx'ed on CT guided bx of
posterior mediastinal mass s/p Decadron treatment at last
admission
2. spinal cord compression s/p T1-T8 laminectomy/decompression
on [**9-17**]
3. s/p strep viridans abscess; recently completed 4 wks of IV
Unasyn
4. Hypercalcemia of malignancy s/p Pamidronate at last admission
5. COPD, 80 pk/yr smoker
6. Hypercholesterolemia
7. s/p Appendectomy
8. Hernias, s/p multiple repairs with current umbilical hernia
9. Sebaceous cysts
10. Lipomas
11. s/p Arthroscopic knee surgery
Social History:
> 1ppd x40 years; separated from wife 4 months ago after 35
years of marriage.
Family History:
Mother with DM and died of colon CA at 64
Father with emphysema
Physical Exam:
VS: Tc:97.7 BP: 142/78 HR: 104 RR: 20 O2sat: 94%4L
GEN: Male in mild resp distress with tachypnea. No accessory
muscle use or intercostal retractions noted.
HEENT: NCAT, EOMI. O/P clear
NECK: Mild increase in JVP to 7cm
RESP: Lungs relative[**Name (NI) **] CTAB. No c/w/r noted throughout all
fields. Limited by effort and inability to move from supine
position.
CV: Tachycardic, nml s1,s2. No m/r/g.
ABD: Obese, soft, nontender, nondistended. No rebound/guarding.
EXT: No edema bilat. + venodynes. No C/C. DP 2+ bilat. R arm
with PICC line in place with erythema. No cords palpated
bilat; [**Last Name (un) 5813**] sign (-) bilat.
NEURO: AAOx3. CNII-XII intact. UE strength 5/5 bilat. RLE with
inability to dorsoflex. Plantarflexion intact. Knee
flexors/extendors [**2-9**] bilat, worse on R.
Pertinent Results:
C-spine CT ([**2155-10-15**]):
No fracture or subluxation. Within the upper cervical vertebral
levels (C2-C4), there is no apparent indentation on the contour
of the thecal sac; however, there is very limited evaluation
below that level. There is mild spinal canal stenosis at those
levels.
.
T-spine CT ([**2155-10-15**]):
Interval marked progression of compression fracture deformity
involving the T4/5 vertebral bodies, with interval increase in
marked focal kyphotic angulation, retropulsion of osseous
fragments, and marked narrowing of the spinal canal at that
level. Postsurgical changes from prior laminectomy are also
again seen in this area. These findings are concerning for
interval cord compression, especially in the setting of
patient's new symptomatology.
.
L-spine CT ([**2155-10-15**]):
No new fracture or subluxation is identified. Degenerative
changes and compression deformities involving L1-L2 are similar
in comparison to the prior MRI exam of [**2155-9-17**].
.
CT angio chest ([**2155-10-16**]):
No pulmonary embolism. Progression of thoracic vertebral
compression fractures with retropulsion of fragments concerning
for cord compression. Bibasilar consolidations, left greater
than right, raise the question of aspiration.
[**2155-10-16**] 04:48AM GLUCOSE-94 UREA N-18 CREAT-0.4* SODIUM-136
POTASSIUM-4.0 CHLORIDE-101 TOTAL CO2-28 ANION GAP-11
[**2155-10-16**] 04:48AM CALCIUM-8.4 PHOSPHATE-3.8 MAGNESIUM-2.0
[**2155-10-16**] 04:48AM WBC-8.0 RBC-3.42* HGB-10.0* HCT-29.4* MCV-86
MCH-29.3 MCHC-34.1 RDW-17.6*
[**2155-10-16**] 04:48AM PLT COUNT-179
[**2155-10-16**] 03:19AM TYPE-ART PO2-88 PCO2-41 PH-7.44 TOTAL CO2-29
BASE XS-3
[**2155-10-15**] 04:58PM LACTATE-1.1
[**2155-10-15**] 04:50PM CRP-2.4
[**2155-10-15**] 04:50PM SED RATE-30*
[**2155-10-15**] 04:50PM PT-12.2 PTT-23.1 INR(PT)-1.1
[**2155-10-27**] 12:00AM BLOOD WBC-7.9 RBC-4.03* Hgb-11.4* Hct-35.0*
MCV-87 MCH-28.4 MCHC-32.7 RDW-18.1* Plt Ct-170
[**2155-10-27**] 12:00AM BLOOD Plt Ct-170
[**2155-10-27**] 12:00AM BLOOD Glucose-116* UreaN-14 Creat-0.3* Na-134
K-4.6 Cl-98 HCO3-29 AnGap-12
[**2155-10-27**] 12:00AM BLOOD Calcium-8.5 Phos-3.2 Mg-2.0
Brief Hospital Course:
In the ED, the patient was evaluated by neurosurgery for new
cord compression. A CT scan of the spine was performed (since
he has been historically unable to tolerate an MRI without
sedation and intubation) which showed worsening of his T4/T5
compression fracture, expulsion of bony fragments into the
spinal canal, and new compression of the cord at this level.
Per the neurosurgery consult, the patient was not a surgical
candidate since he already had baseline bowel/bladder
incontinence and left leg weakness from his prior cord
compression, and surgery would be very unlikely to improve this
baseline.
Upon arrival to the floor, there was concern that he had
worsened hypoxia, and a CT angiogram was performed which showed
no PE; it did however show bibasilar opacities consistent with
aspiration (though he has never been febrile). He remained on
2L nasal cannula which is his baseline.
For his cord compression, his oncologist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1557**] was
called who recommended starting dexamethasone 40mg PO daily.
Radiation oncology began an 8-dose treatment cycle of XRT to his
thoracic spine on [**2155-10-16**]. He was transferred to the oncologic
medicine service for the remainder of his admission. His
dexamethasone was tapered first to 16mg for the remainder of
his XRT treatments then to 8mg afterwards with plans to taper
upon follow up with Dr. [**First Name (STitle) 1557**].
A pain consult was obtained to assist with his chronic pain
control and they recommended starting a Dilaudid PCA on top of
his chronic pain medications. Although initially obtaining good
control of his pain, he became increasingly oversedated and had
an episode of decreased respiratory rate and obtundation which
required transfer to ICU for 2d, dsepite discontinuation of PCA.
He did well in ICU and was transferred back to the oncologic
service with decreased methadone (30 tid)dosing and PRN
dilaudid, on which he has been stable.
Mr. [**Known lastname **] has an underlying anxiety disorder which prevented
him from placing TLSO brace at times as well as increased his
level of pain. We started him on venlafaxine and dc'd his
citalopram with hopes of addressing his baseline anxiety and he
will be discharged with dose of 75mg with plans to increase to
150mg 2d after his discharge
A wound care consult was obtained for his prior neurosurgical
wound and his decubitus ulcers. They recommended wet-to-dry
dressing to his surgical wound and local wound care with
micoazole for his pressure ulcers.
A neurology consult was obtained to evaluate if his aspiration
could be due to his cord compression causing diaphragmatic
hemiparesis or some other neurolgic defect.
Inspiration/expiration CXRs were obtained which showed good
movement of his diaphragm.
.
MEDS on transfer:
Hydromorphone 0.25 mg IVPCA Lockout Interval: 6 minutes Basal
Rate: 0 mg(s)/hour 1-hr Max Limit: 2.5 mg(s)
Insulin SC (per Insulin Flowsheet)
Ipratropium Bromide Neb 1 NEB IH Q6H
Acetylcysteine 20% 600 mg PO BID 4 doses
Lactulose 30 ml PO TID
Acetaminophen 650 mg PO Q4H
Lidocaine 5% Patch 1 PTCH TD QD Apply to back for 12h every day.
Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN
Lorazepam 0.5 mg PO Q4-6H:PRN anxiety
Allopurinol 300 mg PO DAILY
Amitriptyline HCl 25 mg PO HS
Megestrol Acetate 800 mg PO
Citalopram Hydrobromide 10 mg PO DAILY
Methadone HCl 40 mg PO Q 8H
Dexamethasone 40 mg PO DAILY
Metoprolol 12.5 mg PO BID
Docusate Sodium 100 mg PO BID
Miconazole Powder 2% 1 Appl TP [**Hospital1 **]
Gabapentin 600 mg PO Q8H
Pantoprazole 40 mg PO
Heparin 5000 UNIT SC TID
Senna 1 TAB PO BID
Simvastatin 40 mg PO
Hydromorphone 4 mg PO Q4H
.
STUDIES:
.
C-spine CT ([**2155-10-15**]):
No fracture or subluxation. Within the upper cervical vertebral
levels (C2-C4), there is no apparent indentation on the contour
of the thecal sac; however, there is very limited evaluation
below that level. There is mild spinal canal stenosis at those
levels.
.
T-spine CT ([**2155-10-15**]):
Interval marked progression of compression fracture deformity
involving the T4/5 vertebral bodies, with interval increase in
marked focal kyphotic angulation, retropulsion of osseous
fragments, and marked narrowing of the spinal canal at that
level. Postsurgical changes from prior laminectomy are also
again seen in this area. These findings are concerning for
interval cord compression, especially in the setting of
patient's new symptomatology.
.
L-spine CT ([**2155-10-15**]):
No new fracture or subluxation is identified. Degenerative
changes and compression deformities involving L1-L2 are similar
in comparison to the prior MRI exam of [**2155-9-17**].
.
CT angio chest ([**2155-10-16**]):
No pulmonary embolism. Progression of thoracic vertebral
compression fractures with retropulsion of fragments concerning
for cord compression. Bibasilar consolidations, left greater
than right, raise the question of aspiration.
.
A/P: 55 yo man with MM and recent cord compression with residual
weakness admitted with new cord compression causing paresis of
right leg/foot now getting XRT.
.
# Cord compression- Neurosurg eval appreciated, unlikely to be a
surgical candidate given low likely of regaining function.
currently getting spine XRT, plan is for 8 total doses. today
will be dose #5. Exam relatively unchanged, continued [**3-17**]
pain, sl. improved, decreased PO narcotic breakthrough
requirement.
- TLSO brace when OOB
- Rad/Onc following; continue XRT, dexamethasone 4q6h
- pain service following. Cont methadone, dilaudid pca, po
dilaudid prn, neurontin, elavil, tylenol and lidocaine patch.
Have decreased dilaudid dosing to 2-4mg po q3-4h from 4-10mg
q3-4h. Appreciate pain service recs.
- anxiolysis may also aid with pain control
.
# Multiple Myeloma: holding systemic tx. until XRT finished
- 4mg dexamethasone q6h
- fotmonthly pamidronate (history of hypercalcemia) yesterday
- renal function has been good
- plan to start prednisone/melphalan vs. IV cyclophosphamide on
monday s/p last XRT treatment
.
# COPD: CT angio neg for PE and ?basilar consolidation. Per
reports has emphysema and 2L O2 baseline requirement
- Cont supplemental O2 at his baseline 2L
- aspiration precautions
- albuterol/ipratropium per outpatient regimen
.
# Anxiety/Dx: increasing anxiolytics as pt. with increased
anxiety, especially given steroids.
- started clonazepam as longer acting [**Doctor Last Name 360**] with ativan PRN. As
pt. with AMS last night and on many mood altering meds, will
decrease dose from 1 [**Hospital1 **] to 0.5 [**Hospital1 **], d/c trazadone.
- started effexor 37.5 for GAD/Dx. will increased if tolerated
q4d. Started [**10-21**]. cont. citalopram. consider d/cing as
effexor titrated up.
.
# Anemia: chronic inflammation/bone marrow infiltration
- cont to monitor, at baseline.
.
# Hyperlipidemia: cont statin
# FEN - cardiac po diet, replete lytes as needed.
# Ppx - teds and SC heparin. decub ulcer prophylaxis (air
mattress), PPI, bactrim while on steroids.
# Full Code
# Contact: [**Name (NI) **] (son) [**Telephone/Fax (1) 68782**]; [**Name (NI) 68783**] (wife) [**Telephone/Fax (1) 68784**]
# Dispo: pending XRT, initiation of chemo
Medications on Admission:
Zocor 40'
Senna/Colace
Lidoderm patch
Albuterol/Atrovent IH
Allopurinol 300'
Amitriptyline 25 qhs
Neurontin 300'''
Lactulose 30'''
Megace 800"
Lovenox 40 SC qD
Methadone 30mg PO q8
Dilaudid 4mg PO q4
Protonix
Celexa 10'
Unasyn 3g IV q8 completed yesterday
Pamidronate 90mg q4 wks
Discharge Medications:
1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
3. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Megestrol 40 mg/mL Suspension Sig: Twenty (20) ml PO BID (2
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. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mls
Injection TID (3 times a day).
7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
8. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical QD ().
9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours).
10. Toprol XL 25 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
11. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO MWF (Monday-Wednesday-Friday).
12. Methadone 10 mg Tablet Sig: Three (3) Tablet PO Q 8H (Every
8 Hours).
13. Mineral Oil-Hydrophil Petrolat Ointment Sig: One (1)
Appl Topical TID (3 times a day) as needed.
14. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: [**4-16**]
MLs PO Q6H (every 6 hours) as needed.
15. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
16. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
17. Nortriptyline 25 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
18. Insulin Regular Human 100 unit/mL Solution Sig: as directed
units Injection ASDIR (AS DIRECTED).
19. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4
to 6 hours) as needed for anxiety.
20. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
21. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day).
22. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
23. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID
(2 times a day).
24. Lactulose 10 g/15 mL Syrup Sig: Forty Five (45) ML PO TID (3
times a day).
25. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q4H (every 4 hours) as needed.
26. Venlafaxine 75 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO DAILY (Daily) for 2 days:
continue for 2 days, then increase to 150mg qday.
27. Venlafaxine 150 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO once a day: start on [**10-31**].
28. Gabapentin 300 mg Tablet Sig: Three (3) Capsule PO three
times a day.
29. oxygen
continuous oxygen at 2-4L titrated to keep o2 sats >93%
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
cord compression
multiple myeloma
Discharge Condition:
alert and cognitively intact; hemodynamically stable; tolerating
po; unable to reposition himself in bed or get up without
assistance; satting >93% on 3L
Discharge Instructions:
Take all medications exactly as prescribed.
.
Attend all follow-up appointments as below
.
Neurosurgery: Watch incision for redness, drainage, bleeding,
swelling any discharge, fever greater than 101.5 call Dr [**Name (NI) 14232**] office. No heavy lifting greater than 10lb.
Should wear TLSO whenever out of bed.
Followup Instructions:
Dr. [**First Name (STitle) 1557**] (Oncology): Tuesday, [**2155-11-13**] 1:30 PM. [**Hospital Ward Name 23**] 7,
[**Hospital3 **] Hospital.
.
Dr.[**Name (NI) 9034**] office will call you about when and if you need to
follow up. If you have not heard from their office by next
week, call
[**Last Name (NamePattern1) 439**], [**Hospital3 **] Hospital.
.
Dr. [**Last Name (STitle) **] (Primary Care): Schedule an appointment to
establish primary care at [**Telephone/Fax (1) **].
|
[
"733.13",
"300.00",
"492.8",
"285.22",
"707.03",
"737.41",
"338.3",
"336.3",
"V58.65",
"787.6",
"788.30",
"203.00",
"786.09",
"307.89",
"E937.9",
"344.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"92.29"
] |
icd9pcs
|
[
[
[]
]
] |
15667, 15739
|
5431, 8251
|
336, 356
|
15816, 15973
|
3256, 5408
|
16336, 16817
|
2344, 2410
|
12964, 15644
|
15760, 15795
|
12659, 12941
|
15997, 16313
|
2425, 3237
|
278, 298
|
384, 1673
|
1695, 2232
|
2248, 2328
|
8269, 12633
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,167
| 111,095
|
22889
|
Discharge summary
|
report
|
Admission Date: [**2169-3-3**] Discharge Date: [**2169-5-6**]
Date of Birth: [**2120-6-9**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
Right upper quadrant pain with jaundice s/p PTCA stent placement
Major Surgical or Invasive Procedure:
[**2169-3-3**] cholecystectomy, common bile duct excision, left hepatic
lobectomy, Roux-en-Y hepaticojejunostomy, repair of right
hepatic artery with inferior mesenteric vein interposition and
graft
[**2169-3-10**] exploratory laparotomy, evacuation of ascites, wound
closure of dehisence
[**2169-3-18**] exploratory laparotomy, evacuation of intraabdominal
hematoma and blood, ligation of the right hepatic artery.
[**2169-4-12**] Open tracheostomy.
History of Present Illness:
This patient is a 48 year old male with a past medical history
of hepatits C and herniated lumbar disc who was found to have
biliary obstruction during work-up for right upper quadrant pain
with jaundice. The patient underwent PTCA on [**2169-2-17**] with
dilation of a stricture ant the confluence o fthe right and left
hepatic ducts. The stricture was biopsied and showed chronic
infalmmation with fibrosis. The patient now presents for hepatic
resection with Roux-en-Y hepaticojejunostomy.
Past Medical History:
HepC ([**2157**])
Herniated disk
Recurrent sinus infection
Social History:
35+ pk/yr Hx of tobacco use
Denies EtOH
Works for rehab company
Physical Exam:
T 98.4 HR 84 BP 147/80 SpO2 97%RA
RRR, normal S1 and S2
CTA b/l
Abdomen soft, NT/ND with +bowel sounds. PTCA tubes in place and
draining.
Extremeties warm/well-perfused
Brief Hospital Course:
The patient was admitted to the hospital and was taken to the
operating room on [**2169-3-3**] for a cholecystectomy, common bile
duct excision, left hepatic lobectomy, Roux-en-Y
hepaticojejunostomy. The case was complicated by hepatic artery
dissection and required repair of right hepatic artery with
inferior mesenteric vein interposition and graft. The patient
tolerated this procedure well but was transferred to the PACU
intubated and in guarded condition. The patient was admitted to
the SICU, where, after a prolonged hospital course, he expired
on [**2169-5-6**]. The hospital course will be dictated by systems.
Neuro:
Patient remained sedated post-operatively. His pain was
controlled with morphine. POD 7, PO pain medications were given.
Following return to OR for wound dehisence, post-op pain was
controlled with morphine. POD [**9-4**] patient noted to be anxious
but responsive with well-controlled pain. POD 15/8 patient
attempted to get out of bed to go to bathroom unassisted. Got
dizzy and fell. No neurological sequelae from fall. POD 16/9/1
morphine stopped, dilaudid started for improved pain control.
POD 23/16/8 began propofol wean to off in attempt to extubate.
When re-intubated that day, patient was again sedated. POD
41/34/27/2 propofol drip weaned, patient started on fentanyl
drip and haldol prn.
Cardiovascular:
Patient was tachycardic immediately post-op, and was felt to be
septic secondary to pancreatitis. He was placed on neosynephrine
to maintain blood pressure. He was monitored carefully and
agressively hydrated post-operatively. MAP was kept >65. On
post-op day #2, the patient was taken off pressors. POD 6 beta
blockade started for mild hypertension/tachycardia. POD [**10-6**]
sustained tachycardia w/o changes on EKG noted, likely secondary
to anxiety and pain. POD [**1-8**] tachycardia noted to be improving
with stable BP's. POD 15/8 patient noted to be tachycardic after
slipping and falling. Moved to SICU and became
tachycardic/hypotensive. Taken to OR on [**2169-3-18**] emergently for
GI bleeding. Right hepatic artery ligated in OR. POD 16/9/1
patient noted to be tachycardic with stable BP. Patient
continued to remain tachycardic thereafter. On POD 38/31/23
patient became hypotensive. neosynephrine started to maintain
blood pressure. POD 46/39/31/7 TTE demonstrates no evidence of
vegetations in heart. POD 48/41/33/9 blood pressure begins to
decrease. Beta-blockade held. POD 53/46/38/14 patient found to
be hemodynamically unstable, unresponsive to fluid boluses,
developing signs of shock. Pressors started. POD 63/56/48/24
patient becomes hemodynamically unstable. He is made CMO by his
family and expires on [**2169-5-6**].
Respiratory:
The patient was initially supported by ventilator immediately
after surgery. This was weaned and patient extubated by POD#3.
Incentive spiromety encouraged. POD 7/0, extubated after return
to OR for wound dehisence. POD [**11-6**] patient noted to have some
respiratory distress though responsive to diuresis. POD 18/5
noted to be short of breath and diaphoretic shortly before
emergent return to OR [**2169-3-18**] for GI bleeding. Patient remained
intubated after procedure. Attempted to wean starting POD
17/10/2. POD 22/15/7 CPAP trials began but failed. POD 23/16/8
sedation weaned and on POD 24/17/9 patient self-extubated. Later
that day, due to increased work of breathing and fatigue,
patient was re-intubated. Daily chest xrays continued to
demonstrate atelectasis with pulmonary edema. POD 28/21/13 CT
guided thoracocentesis performed due to difficulty weaning from
vent. POD 39/32/25 patient undergoes open tracheostomy after
failing to wean from ventillatory support. POD 54/47/39/15
patient in septic shock with large right plerual effusion found
on CXR. This is tapped via ultrasound guidance. Patient remains
ventilator dependent until death on [**2169-5-6**].
Gastrointestinal:
The patient was kept NPO immediately after surgery with T-tubes
to gravity. Total bilirubin noted to be 3.4. On post-op day #2,
ultrasound showed patent hepatic artery and vein. POD 4
ultrasound repeated and showed right anterior portal vein
reverlsal of flow. LFT's checked and found to be improving with
exception of stable bilirubin at 5.2. Patient taken to OR on
[**2169-3-10**] for wound dehisence. On examination, found to have
intraluminal clot, dilated stomach and proximal small bowel,
marked ascited and approx. 500cc old hematoma. Total bilirubin
noted to be 4.1. GI service consulted. POD [**10-6**], noted to be
stable, sips started. POD [**11-6**], small amount of BRBPR, passing
flatus. POD [**12-8**], ultrasound noted to show patent hepatic flow.
POD [**1-8**] through POD 17/4, continued GI bleeding. POD 18/5 taken
to OR on [**2169-3-18**] for continued GI bleeding. Right hepatic artery
ligated in OR. Total bilirubin noted to rise from 3.2 to 6.5 on
POD 19/6/1. On POD 21/14/6, CT scan obtained, showing moderate
amount of intra-abdominal ascites, patchy areas of nonperfusion
involving segments 5, 6 and 8 of the liver, and a patent right
portal vein. PTCA drain placed to decompress the right biliary
duct system. Total bilirubin noted to fall from 6.5 to 5.9. POD
25/18/10 CT abdomen failed to demonstrate evidence of
intra-abdominal infection. Stable amount of ascites. Patent
poral vein noted. Total bilirubin noted to be 5.5. POD 34/27/19
trophic tube feeds started. Total bilirubin noted to be 7.3. POD
37/30/22 CT scan obtained which showed unchanged appearance of
the hepatic parenchyma with areas of infarction and unchanged
size and appearance of three intraperitoneal fluid collections.
Total bilirubin noted to be 6.4. POD 38/31/23 Dobhoff feeding
tube placed. POD 42/36/28/3 CT scan performed, showing little
change in the appearance of multiple fluid collections and
drains. Total bilirubin noted to be 9.1. POD 44/37/29/5 Total
bilirubin found to be 10.7. Cholangiogram performed, which
showed existing right biliary internal external drain in place
with tip in the
jejunum, no intrahepatic biliary ductal dilatation and contrast
leak seen at the anastomotic site. POD 45/38/30/6 Tube feeds
advanced to goal. Total bilirubin found to be 13.1. POD
47/40/32/8 tube feeds advanced to goal. Total bilirubin 16.1.
POD 51/44/11 repeat CT scan shows stable fluid collections,
necrosis of liver. Total bilirubin found to be 17.8. POD
53/46/38/13 bilirubin continues to rise, now to 18.9.
Transaminases noted to be rising as well. POD 54/47/39/15
patient in septic shock, bilirubin climbing to 20.2. POD
62/55/47/23 biliary catheter drainage is assessed due to rising
bilirubin to 23.1. The catheter is exchanged and there is found
to be large persistent leak at the anastamotic site. Patient
expires next day due to multi-system organ failure.
Hematalogic:
Serial hematocrits were obtained, as were coags. Heparin was
held initially. On post-op day #1, the patient was transfused 2
units of PRBC's and 2 units of FFP for hematocrit of 27 and PTT
on 107. Aspirin and plavix started on POD 3. On POD 4,
hematocrit found to be 23. Transfused 4 units PRBC's to HCT 30.
POD 7 hematocrit found to be 23.3. 2 units PRBC's given. [**2169-3-10**]
Patient returned to OR for wound dehisence, 4 units PRBC's 1
unit FFP given intraop. ASA/plavix held post-op. POD [**9-4**] serial
HCT noted to be stable. POD [**10-6**] 1 unit PRBC's given for HCT
27.2. POD [**11-6**], 2 units PRBC's given for HCT 27.8. POD [**12-8**]
continued GI bleeding, transfused 4 units PRBC's, 1 unit
platelets, 1 unit cryo, 2 units FFP. POD [**1-8**] 5 units PRBC's
transfused. POD 13/6 required 6 units PRBC's, 7 units platelets,
3 units FFP, 2 units cryo for continued bleeding. POD 15/8,
patient slipped and fell. After falling, serial HCT showed drop
from 32 to 26. 4 units PRBC's and 2 units platelet transfused.
Patient taken to OR [**2169-3-18**] where he received 10 units PRBC's, 7
units FFP, 4 units platelets, 3 units cryo. POD 18/11/3, HCT 28,
transfused 1 unit PRBC's to HCT 30.5. POD 20/13/5 transfused 2
units PRBC's to keep HCT>30. POD 21/14/6 transfused 1 unit
PRBC's. POD 29/18/10 HCT 28.1, transfused 1 unit PRBC's. POD
32/25/17 CT scan demonstrated left inferior epigastric artery
pseudoaneurysm, which was injected with thrombin. POD 33/26/18
HCT dropped to 24. Patient transfused 2 units PRBC's, 2 units
FFP. CT scan obtained to r/o hemorhage and failed to show
evidence of bleed. POD 40/34/26/1 transfused 1 unit PRBC's for
persistent ooze around tracheostomy collar. POD 42/36/28/3
neosynephrine weaned. TTE obtained, demonstrating mild LVH.
Beta-blockade restarted. POD 57/50/42/18 in the setting of
multi-system organ failure, diffuse bleeding noted. 2 units
PRBC's transfused, 1 unit platelets transfused. POD 60/53/45/21
levophed weaned off. Patient expires soon after.
Fluids/Electrolytes/Nutrition:
Patient was kept NPO after surgery with aggressive IV hydration.
Albumin infusion was started immediately post-operatively to
maintain level greater than 2.5. TPN started on POD#3. POD 4
clear liquid diet started. POD 6 diet advanced to regular diet.
POD [**9-4**] patient kept NPO, TPN continued. POD 19/6/1 patient kept
NPO, TPN continued. POD 23/16/8 albumin infusions stopped. POD
34/27/19 trophic tube feeds started. TPN continued. POD 38/31/23
Dobhoff feeding tube placed. POD 42/36/28/3 tube feeds started.
POD 47/40/32/8 tube feeds advanced to goal. TPN discontinued.
Endocrine:
Patient was maintained on RISS.
Genitourinary:
Urine output was initially good. Electrolytes were checked daily
and repleted PRN. A foley catheter was placed and kept to
gravity. Patient began to autodiurese on POD3. On POD4, lasix
10mg started to help diuresis. POD 6 foley catheter was removed.
POD [**9-4**] lasix continued for diuresis. POD 16/9/1 lasix continued
for diuresis after OR. POD 24/17/9 diamox started. POD 27/20/12
lasix drip started. POD 30/23/15 lasix drip discontinued due to
falling BP. POD 34/27/19 Urology service consulted for
hematuria. This was found to be self-limited. POD 52/45/37/13
creatinine bumped to 1.6, lasix drip held. POD 54/47/39/15
patient in septic shock, renal consulted to start CVVH. This is
continued until expiration on [**2169-5-6**].
Tubes/Lines/Drains:
On post-op day #1, the PA line was changed because of
infiltration of propofol into the PA catheter sheath. On POD#4,
the Swan line was changed to triple-lumen catheter, NG tube
removed. POD 7/0, NGT, foley catheter replaced intraop. POD 14/7
ultrasound showing biliary tube had been pulled back into
peritoneum. POD 18/5 blood noted in JP drain prior to emergent
return to OR [**2169-3-18**]. JP drain placed above liver, JP drain
placed near biliary anastamosis. POD 17/10/2 left cordis changed
to triple lumen catheter. POD 23/16/8 CVL changed over wire. POD
24/17/9 NGT removed with self-extubation but replaced when
patient re-intubated. POD 28/21/13 central lines changed and
re-sited. POD 42/36/28/3 RIJ CVL changed over wire. POD
53/46/38/14 a cordis/swan-ganz catheter is placed for
monitoring.
Infectious Diseases:
Patient was initially placed on Zosyn for prophylaxis. On
post-op day #2, the patient spiked a temperature and was
pan-cultured. Blood culture showed [**2-5**] positive for gram
positive cocci. Vancomycin was started. On POD 4, Zosyn
discontinued and meropenem started. POD 5, levofloxacin and
fluconazole started for coag negative staph and [**Female First Name (un) **] growing
from peritoneal fluid. POD [**11-6**] fluconazole stopped. POD 15/8,
patient spiked temp to 103. Unclear if related to transfusion of
blood products. Caspofungin started, vancomycin and meropenem
continued. Patient started spiking fevers daily after [**2169-3-18**].
POD 20/13/5 gram positive rods found in sputum cx. POD 21/14/6
peritoneal fluid from [**2169-3-20**] growing lactobacillus. POD 22/15/7
Flagyl added for coverage. POD 27/16/8 PTC drainage growing
psudomonas and enterobacter. POD 26/19/12 paracentesis
performed, fluid growing lactobacillus. Sputum culture from same
day grew pseudomonas. ID service consulted. POD 30/23/15
paracentesis performed, cultures grow psudomonas, enterococcus,
lactobacillus. POD 32/25/17 patient underwent CT guided drainage
of a left subdiaphragmatic and left lower quadrant collection.
Cultures grow lactobacillus. POD 33/26/18 antibiotics changed to
vancomycin, piperacillin, Flagyl and caspofungin. POD 36/29/21
wound swab growing psudomonas. POD 37/30/22 subdiaphragmatic
fluid collection aspirated via CT guidance. Flagyl was
discontinued and patient started on clindamycin for
lactobacillus coverage. POD 41/34/27/2 ambisome started for
disseminated fungal disease. POD 41/35/27/2 sputum growing
pseudomonas. POD 42/36/28/3 CT scan performed, showing little
change in the appearance of multiple fluid collections and
drains. POD 45/38/30/8 blood culture growing pseudomonas. POD
47/40/32/8 clindamycin discontinued in favor of Zosyn. POD
48/41/33/9 vancomycin discontinued, amikacin started. POD
49/42/34/10, colistin started. POD 53/46/38/14 patient begins to
develop multi-system organ failure in setting of resistant
pseudomonas. POD 61/51/46/22 patient started on cefipime.
Wound:
Immediately after surgery, the wound was noted to be clean and
intact. POD 4 wound noted to be cellulitic. POD6 wound opened,
no purulence. Wet-to-dry dressings applied. POD 7 patient
reported bloody drainage from wound after fit of coughing. Wound
probed and found to have dehisced. Patient taken to OR on [**2169-3-10**]
for washout of wound and closure. POD 29/21/14 abdominal wound
found to be infected again. POD 37/30/18 wound VAC placed.
Medications on Admission:
Protonix 40mg PO Qdaily.
Discharge Disposition:
Expired
Discharge Diagnosis:
Multisystem organ failure secondary to pseudomonas infection
Hepatic necrosis and failure secondary to ligated hepatic artery
Discharge Condition:
Expired
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
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29,299
| 162,468
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34731
|
Discharge summary
|
report
|
Admission Date: [**2192-9-14**] Discharge Date: [**2192-10-10**]
Date of Birth: [**2137-2-23**] Sex: M
Service: MEDICINE
Allergies:
Ceftriaxone
Attending:[**First Name3 (LF) 1666**]
Chief Complaint:
Somnolence and Fevers
Major Surgical or Invasive Procedure:
-PICC line placement x 2
-NG Tube placement
-[**Last Name (un) 1372**]-intestinal Tube Placement
-Lumbar Puncture
-Mechanical Ventilation
History of Present Illness:
Mr. [**Known lastname 19484**] is a 55M with a PMH s/f morbid obesity, type II DM,
and OSA who presented to [**Hospital **] Hospital with altered mental
status after being found by a family member. According to the
patient's daughter who lives with him, he was in his USOH until
the night prior to admission to [**Location (un) **] on [**9-13**]. On [**9-13**] he
slept in unusually late into the afternoon. His daughter
finally went into his bedroom to wake him up, and reports that
patient was too lethargic to arouse completely. He would
intermittently wake up and speak in meaningful sentances, other
times he would be non-sensical and drift off into sleep. She
also reports he seemed to have weakness on his left lower
extremity, and complained of back and left leg pain.
.
At [**Location (un) **] he was found to be febrile to 101, hyperglycemic with
a fingerstick of 600, hypertensive in the 150-200 range, and
somnolent. He was treated with 20 units of insulin, but did not
have an anion gap. He reportedly did not respond to narcan. A
foley was placed and drained 1650cc of urine. His O2
saturations dropped to 88-91% on RA, requiring NRB. A head CT
showed "no evidence of gross ICH, hypodensities are noted in the
bilateral thalami which may represent infarcts of indeterminate
age, recommend correlation with MRI". A CXR was negative for
any acute pulmonary pathology. A d-dimer waws elevated to 1.55(
0.22-0.44); ABG 7.42/39/77/23
.
On arrival to our ED, his inital vital signs were 103 axillary,
182/100 (170-200/90-100), 103, 99% NRB. His fingerstick was in
the 300s with no anion gap on his electrolytes. His mental
status was severely declined, he was minimally responsive to
painful stimuli, and had a reduced gag reflex. The ED called
anesthesiology, who placed a nasotracheal airway. A serum tox
screen was negative. An EKG was wnl, as were cardiac enzymes.
An infectious work-up was started including a CXR, UA, lumbar
puncture, urine and blood cultures. Lumbar puncture showed no
leukocytes, and a mildly elevated protein. He had a CT torso
with contrast, which preliminarily is negative for PE, and shows
some pelvic lymphadenopathywith ? asymmetric sclerosis of the
sacroiliac joints. The patient was empirically started on
vancomycin and ceftriaxone for meningitis coverage.
Past Medical History:
Type II DM
OSA (not on CPAP)
"Fluid overload"
Social History:
Works in real estate, and owns several small businesses. Remote
smoking history, quit ~10 years ago. No alcohol or drug use
Family History:
No sudden cardiac death, mother with "a cardiomyopathy" and CHF
Physical Exam:
T=99.7... BP=139/76... HR=82... RR=12... O2=95% on PSV 11/5
pulling Tv of 900, FiO2 40%
GENERAL: Morbidly obese, intubated, sedated
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. Pupils miotic and sluggish bilaterally.
CARDIAC: Regular rhythm, normal rate, no murmurs or gallops
LUNGS: Coars ventilated breath sounds anteriorly
ABDOMEN: Obese, NABS, NT/ND
EXTREMITIES: Bilateral [**2-15**]+ pitting edema to the knees, good
pulses x4
SKIN: No rashes/lesions, ecchymoses.
NEURO: Pupils sluggish bilaterally and miotic, doll's eye
equivocal, corneal reflexes intact. Babinski's down-going
bilaterally. Responds to noxious stimuli in all four
extremities with purposeful movement.
Pertinent Results:
Admission Labs:
[**2192-9-14**] 03:10PM %HbA1c-12.8*
[**2192-9-14**] 06:17AM TYPE-ART TEMP-37.6 PO2-100 PCO2-46* PH-7.37
TOTAL CO2-28 BASE XS-0 INTUBATED-INTUBATED
[**2192-9-14**] 06:17AM LACTATE-1.1
[**2192-9-14**] 04:48AM VoidSpec-QNS, [**Doctor Last Name **]
[**2192-9-14**] 02:57AM COMMENTS-GREEN TOP
[**2192-9-14**] 02:57AM LACTATE-0.9
[**2192-9-14**] 02:10AM CEREBROSPINAL FLUID (CSF) PROTEIN-53*
GLUCOSE-192
[**2192-9-14**] 02:10AM CEREBROSPINAL FLUID (CSF) WBC-0 RBC-129*
POLYS-0 LYMPHS-0 MONOS-0
[**2192-9-14**] 02:10AM CEREBROSPINAL FLUID (CSF) WBC-10 RBC-4580*
POLYS-46 LYMPHS-53 MONOS-1
[**2192-9-14**] 12:40AM GLUCOSE-341* UREA N-9 CREAT-0.8 SODIUM-136
POTASSIUM-5.4* CHLORIDE-101 TOTAL CO2-23 ANION GAP-17
[**2192-9-14**] 12:40AM estGFR-Using this
[**2192-9-14**] 12:40AM ALT(SGPT)-31 AST(SGOT)-46* CK(CPK)-259* ALK
PHOS-63 TOT BILI-0.3
[**2192-9-14**] 12:40AM LIPASE-135*
[**2192-9-14**] 12:40AM cTropnT-<0.01
[**2192-9-14**] 12:40AM CK-MB-8
[**2192-9-14**] 12:40AM ALBUMIN-4.1 CALCIUM-8.6 PHOSPHATE-3.9
MAGNESIUM-1.9
[**2192-9-14**] 12:40AM TSH-0.35
[**2192-9-14**] 12:40AM DIGOXIN-<0.2* THEOPHYL-<0.8*
[**2192-9-14**] 12:40AM PHENOBARB-<1.2* PHENYTOIN-<0.6* LITHIUM-0.3*
VALPROATE-<3.0*
[**2192-9-14**] 12:40AM ASA-NEG ETHANOL-NEG CARBAMZPN-<1.0*
ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2192-9-14**] 12:40AM URINE HOURS-RANDOM
[**2192-9-14**] 12:40AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2192-9-14**] 12:40AM WBC-9.2 RBC-5.57 HGB-14.1 HCT-42.4 MCV-76*
MCH-25.4* MCHC-33.3 RDW-13.5
[**2192-9-14**] 12:40AM NEUTS-81.7* LYMPHS-12.6* MONOS-5.2 EOS-0.3
BASOS-0.3
[**2192-9-14**] 12:40AM PLT COUNT-280
[**2192-9-14**] 12:40AM PT-13.6* PTT-21.4* INR(PT)-1.2*
[**2192-9-14**] 12:40AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.025
[**2192-9-14**] 12:40AM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG
GLUCOSE-1000 KETONE-50 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2192-9-14**] 12:40AM URINE RBC-21-50* WBC-0-2 BACTERIA-MOD
YEAST-NONE EPI-0-2.
.
.
Pertinent Labs:
[**2192-9-23**] 02:48AM BLOOD WBC-10.8 RBC-5.06 Hgb-13.1* Hct-38.8*
MCV-77* MCH-26.0* MCHC-33.8 RDW-12.8 Plt Ct-247
[**2192-9-27**] 05:46AM BLOOD WBC-9.8 RBC-4.56* Hgb-11.3* Hct-35.1*
MCV-77* MCH-24.9* MCHC-32.3 RDW-13.4 Plt Ct-531*
[**2192-10-2**] 10:27AM BLOOD WBC-8.0 RBC-4.54* Hgb-11.0* Hct-35.7*
MCV-79* MCH-24.3* MCHC-30.9* RDW-12.8 Plt Ct-618*
[**2192-10-7**] 06:30AM BLOOD WBC-8.6 RBC-4.49* Hgb-11.4* Hct-34.2*
MCV-76* MCH-25.4* MCHC-33.3 RDW-13.5 Plt Ct-445*
[**2192-9-19**] 03:09AM BLOOD Neuts-68 Bands-0 Lymphs-21 Monos-8 Eos-1
Baso-0 Atyps-2* Metas-0 Myelos-0
[**2192-9-22**] 04:58AM BLOOD Neuts-63.6 Lymphs-24.9 Monos-8.7 Eos-2.2
Baso-0.7
[**2192-9-21**] 03:32AM BLOOD PT-14.5* PTT-25.7 INR(PT)-1.3*
[**2192-9-23**] 02:48AM BLOOD PT-14.7* PTT-28.5 INR(PT)-1.3*
[**2192-9-16**] 05:14AM BLOOD ESR-38*
[**2192-9-23**] 10:45AM BLOOD ESR-45*
[**2192-9-23**] 02:48AM BLOOD Ret Aut-1.6
[**2192-9-21**] 03:32AM BLOOD Glucose-264* UreaN-16 Creat-0.8 Na-137
K-3.8 Cl-99 HCO3-28 AnGap-14
[**2192-9-27**] 05:46AM BLOOD Glucose-91 UreaN-22* Creat-0.7 Na-135
K-4.1 Cl-97 HCO3-30 AnGap-12
[**2192-10-7**] 06:30AM BLOOD Glucose-119* UreaN-25* Creat-0.7 Na-138
K-3.9 Cl-100 HCO3-26 AnGap-16
[**2192-9-22**] 04:58AM BLOOD ALT-25 AST-28 LD(LDH)-236 AlkPhos-56
TotBili-0.3
[**2192-9-22**] 07:32PM BLOOD CK(CPK)-204*
[**2192-9-23**] 02:48AM BLOOD CK(CPK)-455*
[**2192-9-30**] 04:47AM BLOOD ALT-24 AST-20 AlkPhos-74 Amylase-61
TotBili-0.4
[**2192-9-30**] 04:47AM BLOOD Lipase-48
[**2192-9-22**] 11:01AM BLOOD CK-MB-2 cTropnT-0.02*
[**2192-9-22**] 07:32PM BLOOD CK-MB-2 cTropnT-0.02*
[**2192-9-23**] 02:48AM BLOOD CK-MB-2 cTropnT-0.02*
[**2192-9-22**] 04:58AM BLOOD Calcium-8.7 Phos-5.5*# Mg-2.1
[**2192-9-26**] 03:13AM BLOOD Calcium-8.4 Phos-4.4 Mg-2.1
[**2192-10-4**] 05:43AM BLOOD Calcium-8.9 Phos-5.2* Mg-2.1
[**2192-9-15**] 04:00AM BLOOD Triglyc-205* HDL-38 CHOL/HD-4.2
LDLcalc-82
[**2192-9-16**] 05:14AM BLOOD CRP-156.6*
[**2192-9-23**] 02:48AM BLOOD CRP-138.2*
[**2192-9-23**] 10:45AM BLOOD CRP-146.8*
[**2192-9-22**] 11:01AM BLOOD PSA-0.2
[**2192-9-30**] 05:06AM BLOOD Vanco-19.1
[**2192-10-4**] 05:43AM BLOOD Vanco-15.3
[**2192-10-5**] 08:05AM BLOOD Vanco-13.7
[**2192-9-14**] 12:40AM BLOOD Digoxin-<0.2* Theophy-<0.8*
[**2192-9-14**] 12:40AM BLOOD Phenoba-<1.2* Phenyto-<0.6* Lithium-0.3*
Valproa-<3.0*
[**2192-9-14**] 12:40AM BLOOD ASA-NEG Ethanol-NEG Carbamz-<1.0*
Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2192-9-15**] 12:29PM BLOOD Type-[**Last Name (un) **] pO2-51* pCO2-45 pH-7.41
calTCO2-30 Base XS-2
[**2192-9-18**] 01:26PM BLOOD Type-ART pO2-77* pCO2-38 pH-7.42
calTCO2-25 Base XS-0
[**2192-9-21**] 10:07AM BLOOD Type-ART pO2-75* pCO2-39 pH-7.48*
calTCO2-30 Base XS-5
[**2192-9-21**] 10:50AM BLOOD Type-[**Last Name (un) **] pO2-39* pCO2-44 pH-7.45
calTCO2-32* Base XS-5
[**2192-9-23**] 10:48AM BLOOD Type-MIX Temp-39.0 pO2-63* pCO2-34*
pH-7.51* calTCO2-28 Base XS-3 Comment-GREEN TOP
[**2192-9-23**] 07:23PM BLOOD Type-[**Last Name (un) **] Temp-38.3 O2 Flow-3 pO2-35*
pCO2-45 pH-7.45 calTCO2-32* Base XS-6 Intubat-NOT INTUBA
Comment-NASAL [**Last Name (un) 154**]
[**2192-9-28**] 08:56AM BLOOD Type-ART Temp-38.6 pO2-78* pCO2-45
pH-7.46* calTCO2-33* Base XS-6 Intubat-NOT INTUBA
[**2192-9-28**] 08:56AM BLOOD Lactate-0.9
[**2192-9-20**] 11:21AM BLOOD Lactate-2.1*
[**2192-9-23**] 10:48AM BLOOD K-3.7
.
U/A on [**2192-10-10**]
Color yellow Clear SpecGr 1.025 pH 5.0 Urobil Neg Bili Neg
Leuk
Neg Bld Lg Nitr Neg Prot Neg Glu 1000 Ket 50 RBC 21-50 WBC
0-2 Bact
Mod Yeast None Epi 0-2
.
OSH Pertinent Imaging:
.
CT head OSH: no evidence of gross ICH, hypodensities are noted
in the bilateral thalami which may represent infarcts of
indeterminate age, recommend correlation with MRI
.
CT torso OSH:
-no dissection
-no central or segmental PE, limited by patient size
-Bibasilar consolidations ?atelectasis vs. aspiration vs. PNA
-Fatty liver
-Asymmetric sclerosis of the sacroiliac joints with multiple
enlarged pelvic lymph nodes ?septic arthritis of sacroiliac
joint, recommend
.
[**Hospital1 18**] Pertinent Imaging:
.
MRI.EEG ([**2192-9-14**])
Impression: This is an abnormal routine EEG due to slow
background
activity. This finding suggests either a moderate encephalopathy
or
severe drowsiness. Medications, metabolic disturbances,
infection and
hypoxia are among the most common causes. There were no areas of
prominent focal slowing and there were no epileptiform features
seen.
.
CT Chest/Abd/Pelvis ([**2192-9-14**])
IMPRESSION:
1. Bibasilar pulmoanry infiltrates most likely secondary due to
aspiration.
2. Left sacroileiitis
.
Head MRI/MRA/MRV ([**2192-9-14**])
There are bilateral acute thalamic infarcts, left greater than
right, the
left-sided infarct extends into the superior mid brain/cerebral
peduncle and midbrain tegmentum. There are no imaging findings
of herpes simplex
encephalitis. There is no pathologic intracranial enhancement.
Scattered ethmoid opacification is noted bilaterally. There is
also scattered fluid in the right mastoid air cells.
MRV of the brain demonstrates no evidence of venous sinus
thrombosis. MRA of the brain demonstrates a PICA termination of
the right distal vertebral
artery. Basilar artery appears to be patent. The left PCA
appears to be
supplied via the left PCOM in a fetal distribution. The left PCA
appears to be slightly smaller compared to the right but no
evidence for acute occlusive lesion is seen. A CTA can be
performed for further evaluation if clinically indicated. There
is no pathologic intracranial enhancement.
IMPRESSION:
Acute bilateral thalamic and left midbrain infarct.
No significant lesions seen in the remaining brain.
.
Bilateral LENIs ([**2192-9-15**])
There is a normal 2D grayscale and color Doppler appearance of
bilateral lower extremity veins including the common femoral,
superficial femoral, and popliteal veins. No DVT within either
lower extremity.
.
TTE: ([**2192-9-15**])
The left atrium is mildly dilated. There is moderate symmetric
left ventricular hypertrophy. The left ventricular cavity size
is normal. 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 root is
mildly dilated at the sinus level. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic regurgitation. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no
pericardial effusion.
No vegetation seen (cannot definitively exclude).
.
Neck MRI/MRA ([**2192-9-15**])
The study is moderately motion degraded. The origin of the right
vertebral
artery is not well visualized. Within limits of the exam, no
hemodynamically significant stenosis is seen. The right
vertebral artery is hypoplastic and appears to terminate as the
PICA. The carotid arteries demonstrate no hemodynamically
significant stenosis.
IMPRESSION:
Technically limited study, no definite evidence for high-grade
stenosis. No evidence for dissection.
.
Pelvic MRI/MRA: ([**2192-9-15**])
FINDINGS: There are prominent signal abnormalities consisting of
hypointensity on all sequences involving the anterior inferior
SI joints
bilaterally, left greater than right with the sacral aspect
appearing more
involved than the iliac aspect. There is very faint edema
involving the more superior aspects and probable faint
enhancement, though no pre-contrast or subtraction sequences are
available to confirm. CT demonstrates the low-intensity areas to
correspond to areas of sclerosis. There are no definite erosions
or joint effusions. Small osteophytes are noted. There are no
adjacent focal fluid collections about the SI joints or
involving the imaged psoas musculature; however, there is edema
involving the left paraspinous musculature only partially imaged
at the most superior aspect of the study of uncertain clinical
significance. Prominent subcutaneous edema at this level is also
noted. Several borderline enlarged iliac chain and obturator
internus lymph nodes are seen on the left. No other focal area
of marrow edema. No fractures.
IMPRESSION:
1) Bilateral sacroiliitis, consisting primarily of sclerosis
with faint edema and enhancement about the superior aspect and
small osteophytes. No erosions or effusions. Given these
findings, a degenerative process with altered biomechanics is
favored over an inflammatory etiology, though correlate with
clinical presentation and lab values.
2) Ill-defined edema involving the left paraspinal musculature,
incompletely imaged on this study, of unclear etiology and
clinical significance.
3) Left iliac chain and obturator internus lymphadenopathy.
.
TEE: ([**2192-9-17**])
The left atrium and right atrium are normal in cavity size. No
spontaneous echo contrast or thrombus is seen in the body of the
left atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. The interatrial septum is mildly
dynamic with color flow evidence of right-to-left flow with deep
inspiration/snoring across the area of a secundum ASD/PFO. Left
ventricular wall thicknesses and cavity size are normal. Overall
left ventricular systolic function is normal (LVEF>55%). The
ascending, transverse and descending thoracic aorta are normal
in diameter and free of atherosclerotic plaque to 50 cm from the
incisors. 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 evidence of any mass or thrombus on
the mitral or aortic vavlve. The tricuspid valve appears
structurally normal with trace trivial regurgitation. There is
no pericardial effusion.
Impression: A small secundum ASD with a right-to-left shunt
during deep inspiration/snoring. No evidence of thrombus or
valvular endocarditis
.
RIGHT UPPER EXTREMITY VENOUS ULTRASOUND: ([**2192-9-24**])
The examination is somewhat limited due to patient body habitus.
[**Doctor Last Name **]-scale, color, and Doppler images of the right internal
jugular, subclavian, axillary, brachial, basilic, and cephalic
veins show normal flow, compressibility, augmentation, and
waveforms. No intraluminal thrombus is identified.
IMPRESSION: Limited examination. No deep venous thrombosis
identified in
right upper extremity.
.
[**Last Name (un) 1372**]-Intestinal Tube Placement: ([**2192-10-5**])
PROCEDURE: The right nostril was anesthetized with lidocaine
jelly, and the throat with Hurricane spray. An 8 French
[**Location (un) 2174**]-[**Doctor First Name 1557**] feeding tube was introduced using fluoroscopic
guidance and passed beyond the pylorus and beyond the ligament
of Treitz. An injection of Conray confirms the tip
placement in the proximal jejunum. The patient tolerated the
procedure well
and there were no immediate complications.
IMPRESSION: Successful placement of 8 French [**Location (un) 2174**]-[**Doctor First Name 1557**]
feeding tube
into the proximal jejunum.
.
.
BEDSIDE SWALLOW EVALUATIONS:
([**2192-9-20**])
Mr. [**Known lastname 19484**] appeared with s/sx of aspiration on thin liquids as
evidenced by throat clearing and delayed cough. He appeared with
some difficulty with ground solid trial possibly [**3-17**] signs and
sensation of pharyngeal residue. Suggest patient begin a po diet
of nectar thick liquids and puree consistencies at this time.
Recommend supervision to assist with feeding and monitor swallow
safety. Suggest keeping dobhoff in place as patient begins po to
ensure toleration of diet and adequate intake. We will continue
to follow to see how he is tolerating and if his diet may safely
be advanced early next week. I do feel he will continue to
improve as his overall medical status and alertness continues to
improve.
This swallowing pattern correlates to a Dysphagia Outcome
Severity Scale (DOSS) rating of level 3, moderate dysphagia.
RECOMMENDATIONS:
1. Continue use of tube feeds as primary means of nutrition and
hydration at this time.
2. Initiate po intake of nectar thick liquids and puree
consistencies.
3. Pills may be crushed with puree or via tube feeds.
4. 1:1 supervision with po.
5. Alternate bites and sips.
6. Patient seated upright as much as possible.
7. We will continue to follow to see how he is tolerating and if
his diet may safely be advanced early next week.
.
Repeat Bedside Swallw Evaluation: ([**2192-10-3**])
HISTORY:
Returned today to re-evaluate this 55 y/o male with h/o morbid
obesity, DM II, OSA, who initially presented to OSH after being
found by family member with altered mental status, lethargy,
fever, lower extremity weakness and c/o back and leg pain. At
OSH
patient was found to be hyperglycemic and hypertensive requiring
a NRB. Patient was transferred to [**Hospital1 18**] on [**2192-9-14**] for further
management. Upon arrival to ED patient was noted with worsening
mental status and was subsequently intubated nasotracheally.
Further w/u revealed acute thalamic stroke (bilateral) and right
pontine infarct resulting in right-sided hemiparesis. Patient
being treated for aspiration pna.
Patient was extubated [**2192-9-17**] and we were consulted to evaluate
patient's oral and pharyngeal swallowing function and r/o
aspiration while eating and drinking. We attempted to see him on
[**2192-9-19**], however patient was significantly lethargic and
unarousable. We returned today to reattempt the bedside swallow
evaluation. On [**2192-9-20**] he passed his bedside swallowing
evaluation for nectar thick liquids and pureed solids. He was
seen on [**2192-9-24**] and recommended for diet upgrade to thin liquids
and continued puree consistencies. We returned [**9-27**] and the pt
had overt coughing with thin liquids and was downgraded to
nectar
thick liquids and pureed solids. He continued to require tube
feeds via the Dobbhoff, as he was too lethargic to take in
enough
PO. We returned today to repeat the evaluation and RN reported
he
had been fully awake all day, taking in a good amount PO without
signs of aspiration.
EVALUATION:
The examination was performed while the patient was seated
upright in the chair on CC 7.
Cognition, language, speech, voice:
Pt was awake, alert and oriented x 3, able to stay awake
throughout the evaluation. Language was fluent but speech was
mildly dysarthric. He was able to follow all commands today but
with occasional slow response time.
Teeth: wfl
Secretions: wfl in the oral cavity
ORAL MOTOR EXAM:
Mild right sided weakness and facial droop with reduced ROM on
the right. Lip seal was adequate bilaterally. Tongue was at
midline with functional strength and ROM. Palatal elevation was
symmetrical, - gag.
SWALLOWING ASSESSMENT:
The pt was seen with ice chips, thin liquids (tsp, cup), thin
liquids with a chin tuck, nectar thick liquids (tsp, straw,
consecutive), pureed solids, ground solids in apple sauce and
small bites of cracker. He was awake enough to focus on keeping
solid boluses on the left side of the oral cavity and pocketing
was minimal with all consistencies. He had overt coughing with
thin liquids with his head slightly reclined in the chair, that
was eliminated when he was able to use the chin tuck. However,
he
continues to be lethargic and was unable to consistently lift
his
head to tuck his chin. Coughing was consistently present when
not
using the chin tuck and he admitted to the sensation of
aspiration. O2 SATs remained stable during the evaluation.
Laryngeal elevation was timely and wfl to palpation.
SUMMARY / IMPRESSION:
Mr. [**Known lastname 19484**] was significantly more awake today than during
previous evaluations and was able to take in larger amounts PO.
He continues to have aspiration with thin liquids, but it can be
prevented with the use of a chin tuck while up in the chair.
However, most meals are given in bed [**3-17**] limited tolerance of
sitting in the chair, and the risk for aspiration is greater in
a
reclined position on the bed. as such, he should remain on
nectar
thick liquids but can be advanced to moist, ground solids. He
should be encouraged to keep the bolus on the left, and will
still need to alternate between bites and sips. Please crush
meds
and give with purees. When most awake and seated fully upright
in
the chair, he can take a small amount of thin liquids using a
chin tuck outside of meals.
He will benefit from continued nutrition follow up to determine
if his PO intake is adequate now that he is more awake and his
diet can be advanced slightly. If his intake continues to be
poor, he may still need to have the PEG placed for supplemental
nutrition and hydration before d/c. We will continue to follow
him.
This swallowing pattern correlates to a Dysphagia Outcome
Severity Scale (DOSS) rating of 4, mild to moderate dysphagia.
RECOMMENDATIONS:
1. Suggest a PO diet of nectar thick liquids and moist, ground
solids.
2. Continue strict 1:1 supervision during meals.
3. Alternate between bites and sips and encourage the pt to keep
the bolus on the left side of his mouth.
4. Check the oral cavity before lying him down.
5. Between meals and only when seated fully upright in the
chair,
he can take small amounts of thin liquids using a chin tuck.
6. Continued nutrition input to wean tube feeds as PO intake
increases. If intake continues to be limited, he may still need
to have a PEG placed before d/c.
7. We will continue to follow during his admission. Pt will
benefit from speech therapy services s/p d/c.
.
Social Work Consult: ([**2192-10-3**])
SW met with pt's dtr today for coping support. Dtr, [**Name (NI) **], is
about to enter her senor year at [**University/College 34597**]. She reports she
has been living at home with pt in their own home in [**Location (un) **],
MA. Dtr reports she is the one who found pt and called 911.
Dtr
reports pt is divorced, ex-wife lives in AZ and is supportive to
dtr but no contact with pt. Dtr shares that she and her aunt
(pt's sister) have been making decisions on behalf of pt and
that
dtr is very grateful for and appreciative of aunt's involvement.
She shares aunt has experience with hospital system, as she was
primary care taker for pt's mother.
Dtr reports she is coping well under circumstances. She notes
understandable difficulty coping with the unknowns of the
future,
particularly wondering to what extent pt will recover. She
expresses concerns about logistics - ie, pt owns adn operates a
liquor store and she is unsure about the future of this. She
shares that pt's father lives near them and is handling the
logistics but notes he is elderly and wonders how this is
impacting him.
Dtr shares she is well-supported by her aunt and her fiance, but
notes limited family support. She is hoping that pt will be able
to go to rehab near her college (she is hoping for NE [**Hospital1 **].
Dtr
and aunt also weighing decision re: PEG. Dtr wanting this as a
last resort option, fearing that if he gets one he will never
swallow on his own.
SW explained sw role and function and provided emotional support
to dtr.
A/P
Dtr appears to be coping well under circumstances. She is
heavily relying on aunt for guidance and is very appreciative
and
respectful of aunt's input. It seems as though pt and aunt
could
use further education re: PEG tube placement to help them make
their decision. They could also benefit from regular updates
from team.
Brief Hospital Course:
Mr. [**Known lastname 19484**] is a 55M with a PMH s/f type II DM who is presenting
with acute onset of somnolence in the setting of fevers and
hyperglycemia
1)Bilateral Thalamic CVA and Left Peduncle CVA: The patient was
found at home by a family member and was found to be extremely
somnolent. The pt presented to an OSH and the CT head showed
infarcts bilaterally in the thalamus. The pt was then
transferred to [**Hospital1 18**] for further work-up. In the EP and LP was
performed and the pt was empirically started on antibiotics to
treat bacterial meningitis. These were later d/c on the basis of
CSF fluid analysis and culture. Neurology was consulted an EEG
was consistent with a global encephalopathy. An MRI was obtained
which confirmed the above infarcts, and in addition diagnosed
the patient was a Left Cerebral Peduncle infarct. These were
thought to be embolic in nature. The patient was briefly started
on a heparin drip but this was stopped after neurology reviewed
the films more closely. Both TTE and TEEs were obtained that did
not demonstrate any valvular lesions. His carotid studies did
not show evidence stenosis or data compatible with an unstable
plaque. Pt seen repeatedly by speech and swallow (details listed
above), due to difficulty swallowing and questionable aspiration
PNA on admission. In regards to his deficits, the patient was
discharged able to move both his left upper and lower
extremities, able to grip with his right hand, and able to
slightly wiggle his right toes. The pt was able to speak, was
oriented to his daughters name on occasion, able to state yes/no
correctly as to his location, but did not know the date. The
patient worked consistently with PT while as an in-patient
working on Bed mobility, balance training, transfer training and
patient/family education.
.
2)Fever of Unknown Etiology: The patient spiked fevers
throughout his hospitalization, from a Tm of 103 on admission,
often as high as 101F in the PM, for a period of over three
weeks.
.
The patient has also had HRs between 90-120 throughout his
hospital stay without identified etiologies of his sinus
tachycardia.
.
When patient was first admitted, he was empirically treated for
bacterial meningitis given a fever and changes in mental status;
but in light of his CSF fluid data, the regimen was stopped. CT
torso at the OSH also showed pelvic lymphadenopathy with a
question of septic arthritis at the sacroiliac joint. He
underwent an MRI pelvis here which suggested that this
inflammation around the sacroiliac joint was chronic in nature
and not osteomyelitis. Several days into admission, the patient
was started on Ceftriaxone and Flagyl for presumed aspiration
pneumonia. He then started to spike fevers almost every day.
Repeat CXR suggested a new infiltrate so his antibiotic regimen
was changed to Vancomycin and Zosyn to treat for hospital
acquired pneumonia. A PICC line was placed for access. He also
had a CTA and LE Dopplers which were negative for PE and DVT.
.
The patient completed a 8 day course of Zosyn for presumed
Hospital Acquired PNA, and a 7 day course for fungal UTI. The
patient also had a full 14 day course of Vancomycin (plus 2 days
at subtherapeutic levels) for a suspected line infection from
[**2192-9-22**]. One should note that the BCx from [**9-22**], as well as one
from [**10-3**], were positive 1/2 bottles for Coag Neg Staph
(Oxacillin Resistant from the [**10-3**] one), with subsequent
surveillance all showing no growth to date.
.
Other etiologies for the patients FUO included drug fevers [**3-17**]
to Vancomycin, Sacral Ileitis, and centralized possible
hypothalamic involvement of the patients stroke. On the final
day of admission the patient was noted to have a slight increase
in his WBC from 8.6 to 11.8 in the setting of a clogged Foley
catheter. U/A was negative for bacterial infection (see attached
results), Urine cultures were sent and were pending at the time
of discharge, and will be followed up by the primary team.
.
3)Respiratory: Patient was intubated in ED with a nasopharyngeal
tube in place. As his mental status improved, he was extubated
successfully. He required CPAP at night given his underlying
OSA. The patient remained on CPAP at night once transferred to
the floor. The patient had episodes of somnolence during the day
when not on CPAP, and thus he was desaturate, but given a hx of
presumed OSA, the patients saturations would increase once
awaken. The patient was discharged on
.
4)Type II DM: The patient presented on Metformin as an
outpatient. His hemoglobin A1C~12. He was initially started on
NPH which was titrated up significantly, especially given his
body habitus. The patient initially had very labile sugars.
Given persistently elevated blood sugars, he was started on an
insulin drip with improvement. [**Last Name (un) **] was consulted to help
manage his diabetes given his large insulin requirements. The
patient was placed on Lantus 100 units/[**Hospital1 **], which was later
decreased 80 [**Hospital1 **], then 55 [**Hospital1 **], and finally 40 [**Hospital1 **] upon discharge
(once TF's were running at 20/hr).
.
5)Nutrition: Patient was unable to take PO upon admission due to
somnolence and inability to swallow. An NG tube was placed for
TF. [**Last Name (un) **] was consulted given his labile blood glucose levels.
The patient was eventually stabilized on tube feeds in
conjunction with ground solids and thick purees. The patient was
initially started on a rate of 40/hr, this was decreased to
20/hr, with the appropriate changes made to his insulin
regimen. The team emphasized that a long term solution the
patients decreased PO intake, and need for nutrition, would be
to place a PEG. GI consulted and stated that a percutaneous PEG
could not be placed due to the patients fat pad. The family
repeatedly stated that they were against placement of a PEG. On
the day of discharge the patient has a PEG and/or Dobhoff tube
in place for 25 days. The patient had calorie count done on [**10-9**]
showing 50gm total of protein (34gm food, 16gm supplement) and
1175 calories (725 food, 450 supplement).
.
6)UTI?: On the final day of the patients hospital course, prior
to discharge the patient was noted to have an increase in his
WBC from 8.6 to 11.8 in the setting of a clogged foley catheter.
U/A was negative for bacterial infection (see attached results).
Urine cultures were sent and were pending at the time of
discharge, and will be followed up by the primary team.
Medications on Admission:
Metformin500mg [**Hospital1 **]
Insulin
Lasix 20mg daily
Discharge Medications:
1. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day) as needed.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed.
7. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
8. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
9. Acetaminophen 160 mg/5 mL Solution Sig: One (1) PO Q6H
(every 6 hours) as needed for fever.
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
11. Insulin Glargine 100 unit/mL Cartridge Sig: One (1) 40
Subcutaneous twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Primary Diagnosis
-Bilateral Thalamic and Left Peducle Cerebrovascular Accident
-Hospital Acquired PNA
-Urinary Tract Infection
-Central Line Infection
-Urinary Tract Infection
Discharge Condition:
Stable. Patient on tube feeds at 20/hr, able to take ground
solid PO and thicks with dysphagia. Patient able to move left
upper and lower extremity. Patient able to speak.
Discharge Instructions:
You were admitted to hospital after suffering a stroke while at
home. While in hospital you were treated for a number of
suspected infections including a urinary tract infection,
pneumonia, and a potential line infection. In addition, your
blood sugars were very high and you were seen by the [**Hospital **]
clinic that made a number of recommendations to your Diabetes
Regimen.
.
A number of changes have been made to your medications as listed
in the discharge summary. Specifically note the initiation of an
insulin regimen that must be followed closely.
.
Please return to hospital if you experience worsening in your
ability to move your left arm and left leg, repeated high
fevers, chills, chest pain, worsening shortness of breath or
loss of consciousness.
Followup Instructions:
Follow-up at [**Hospital **] Rehabilitation Center
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1672**] MD, [**MD Number(3) 1673**]
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|
3013, 3078
|
31916, 32800
|
32916, 33095
|
31834, 31893
|
33314, 34080
|
3093, 3806
|
234, 258
|
464, 2784
|
3841, 5914
|
5930, 25279
|
2806, 2854
|
2870, 2997
|
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