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76,165
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48278
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Discharge summary
|
report
|
Admission Date: [**2116-8-20**] Discharge Date: [**2116-8-24**]
Date of Birth: [**2053-4-14**] Sex: F
Service: MEDICINE
Allergies:
Erythromycin Base / Lactose
Attending:[**Doctor First Name 1402**]
Chief Complaint:
AFib with RVR
Major Surgical or Invasive Procedure:
Electrical cardioversion x 2 in ED on arrival
History of Present Illness:
Ms. [**Known lastname 101707**] is a 63 yo F with history of liver transplant and
paroxysmal Afib, admitted from the ED with AFib with RVR and
tenuous blood pressure. The patient initialy presented to [**Hospital1 **]
[**Location (un) 620**], where she was unsuccessfully electrically cardioverted
twice (50 J and 100 J with INR 3.4) and given lopressor 5 mg IV
x 1. She was transferred here for further management.
In the ED here, VS were T 101, heart rate of 120-140. She was
given hydrocortisone 100 mg IV (for presumed adrenal
insufficiency with chornic prednisone for liver transplant) as
well as lopressor 5 mg IV and calcium gluconate. Cardioversion
was again attempted with 200 J and then 300 J. Her blood
pressure dropped after a dilt drip was started, and then she was
tried on amio drip which also dropped her pressures. She has
received a total of 6L IVF. She was supposed to go to the CCU,
but they have no beds currently.
She denies preceeding viral symptoms including HA, fever,
chills, myalgias, cough, rhinorrhea. She developed two "spells"
of non-bloody vomiting today and has loose stools, but not frank
diarrhea and no ill contacts. She denies feeling unwell over
the last few days. She reports acute onset of paroxysmal AFib
over the last few weeks, which is worsening of her AFib, and is
scheduled for an ablation at the end of the month with Dr.
[**Last Name (STitle) **].
Past Medical History:
Liver transplant [**2095**], [**1-21**] primary biliary cirrhosis (vs.
atresia-- records contradict)
Paroxysmal Afib
Hypertrophic cardiomyopathy, normal EF
Ascending aortic aneurysm, 4.2 x 4.3 cm in [**3-28**]
Hypertension
Thyroid colloid cyst
Stable Lung nodules
Rosacea
Retroperitoneal adenopathy
Skin cancer
Raynaud's syndrome
Cellulitis of thumb and left lower extremity
Keratosis on Left LE which has tract
Hernia repair
Portal shunt
C-section
Social History:
distant smoker; denies ETOH and IVDU; married with two sons;
elementary school social worker
Family History:
non-contributory
Physical Exam:
GEN: comfortable in bed, NAD
HEENT: JVP8cm H2O, MMM,OP clear, decent dentition
LUNGS: crackles at bases that clear with cough
COR: irreg irregular, tachycardic, no murmurs appreciated
Abd: + Bs, soft, NTND
Ext: No edema, WWP
Pertinent Results:
ADMISSION LABS:
[**2116-8-20**] 01:12PM BLOOD WBC-5.3 RBC-5.17 Hgb-15.7 Hct-46.7 MCV-90
MCH-30.4 MCHC-33.6 RDW-14.7 Plt Ct-92*
[**2116-8-20**] 01:12PM BLOOD Neuts-83.5* Lymphs-8.3* Monos-5.8 Eos-1.6
Baso-0.8
[**2116-8-20**] 01:12PM BLOOD PT-33.2* PTT-33.0 INR(PT)-3.4*
[**2116-8-20**] 01:12PM BLOOD Glucose-103* UreaN-14 Creat-0.6 Na-144
K-3.2* Cl-111* HCO3-24 AnGap-12
[**2116-8-20**] 01:12PM BLOOD CK(CPK)-118
[**2116-8-20**] 01:12PM BLOOD cTropnT-<0.01
[**2116-8-21**] 04:22AM BLOOD Calcium-7.8* Phos-2.7 Mg-2.4
[**2116-8-20**] 01:12PM BLOOD TSH-1.2
[**2116-8-20**] 01:12PM BLOOD TSH-1.2
LABS: notable for K 3.2 (repleted in ED), Cr 0.6 (0.9 at BIDN),
TSH pending, INR 3.4
.
MICROBIOLOGY:
[**2116-8-20**] BCx x 2: pending
[**2116-8-20**] UCx: pending
[**2116-8-20**] UA: neg LE, neg nit, WBC 0-2
.
ADMISSION ECG: atrial fibrillation, LVH, QTc 450ms
.
ADMISISON CXR (at [**Location (un) 620**]):
AP supine view of the chest. Mild cardiomegaly is again seen,
though it is probably exaggerated by supine positioning. The
aorta is calcified and slightly tortuous, as before. There is
no evidence of pulmonary edema, pulmonary consolidation, or
pleural effusion.
.
[**2116-8-20**] CT ABD:
1. No intra-abdominal infectious process is identified.
2. Status post liver transplant with unremarkable appearance of
the liver. Extensive portosystemic collaterals.
3. Multiple renal hypodensities, a few of them have minimally
enlarged since the earlier study, including an uncharacterized
9mm left renal hypodensity. Recommended a non-emergent renal
ultrasound for further assessment of the above lesions. A stable
right renal angiomyolipoma.
4. Uncomplicated fat-containing ventral abdominal wall hernia.
.
cMRI [**2116-7-31**]
Impression:
1. Mildly increased left ventricular cavity size with focal
hypertrophy of the distal third and true apex portions of the
left ventricle with normal regional left ventricular systolic
function. The LVEF was normal at 72%. The effective forward LVEF
was mildly decreased at 43%.
2. Normal right ventricular cavity size and systolic function.
The RVEF was normal at 71%.
3. Mild aortic regurgitation. Moderate to severe mitral
regurgitation. Mild tricuspid regurgitation.
4. The indexed diameter of the ascending aorta was moderately
increased. The indexed diameters of the descending thoracic
aorta and main pulmonary artery diameter index were mildly
increased.
5. Moderate biatrial enlargement.
6. Normal size and orientation of the pulmonary veins without MR
evidence of anomalous pulmonary venous return or pulmonary vein
stenosis.
7. Dilated IVC. Several subcentimeter foci in the right kidney
which probably represents cysts.
.
DISCHARGE LABS:
.
[**2116-8-24**] 09:20AM BLOOD WBC-3.9* RBC-5.02 Hgb-14.9 Hct-46.9
MCV-94 MCH-29.7 MCHC-31.8 RDW-14.7 Plt Ct-122*
[**2116-8-24**] 09:20AM BLOOD Plt Ct-122*
[**2116-8-24**] 09:20AM BLOOD PT-21.0* PTT-29.8 INR(PT)-2.0*
[**2116-8-24**] 09:20AM BLOOD Glucose-99 UreaN-16 Creat-0.7 Na-140
K-3.7 Cl-104 HCO3-28 AnGap-12
[**2116-8-24**] 09:20AM BLOOD ALT-43* AST-53* LD(LDH)-218 AlkPhos-128*
TotBili-1.1
[**2116-8-24**] 09:20AM BLOOD Calcium-8.9 Phos-3.7 Mg-1.7
[**2116-8-24**] 09:20AM BLOOD tacroFK-PND
[**2116-8-21**] 04:22AM BLOOD tacroFK-9.1
.
PENDING:
[**8-24**] Tacro level
Brief Hospital Course:
63 yoF s/p liver transplant with refractory AFib/RVR.
#. ATRIAL FIBRILLATION with RVR: On admission, the patient was
found to be in AFib with RVR. She was given Lopressor in the
ED, and then two attempts at cardioversion were unsucessful.
She was started on a Dilt drop and subsequently amiodarone gtt
and her SBP was in the 80s-90s. She was admitted to the MICU,
where she was continued on an amiodarone gtt and received 6L of
IVFs. She remained stable and was transferred to the floor on
[**2116-8-21**]. Her Disopyramide and amiodarone gtt were discontinued
and she was started on Amiodarone 200 mg TID. Her Atenolol was
also uptitrated to 75 mg daily. She spontaneously converted to
NSR on the evening of [**8-23**] with HRs in the 50s, BPs 120s/70s. EP
saw the patient and determined that her rhythm control regimen
should be amiodarone 200 mg TID x 1 week, 200 [**Hospital1 **] x 1 week, 200
qd thereafter, along with atenolol 50 qd for rate control. She
is scheduled to have a pulmonary vein isolation with Dr.
[**Last Name (STitle) **] on [**9-17**], after which the amiodarone should be
discontinued.
.
# Anticoagulation: Patient's INR supertherpaeutic at 4.8 at time
of admission. Dose was decreased from 4 to 1. INR 2 at time of
discharge. Will d/c patient on 2 mg daily wih instructions to
get INR checked later this week.
.
#. HYPOTENSION: Resolved with volume recuscitation. This was
likley from por CO with RVR and loss of atrial kick. By the
time of discharge, patient's BPs were in the 120s/70s.
.
#. s/p LIVER TRANSPLANT: Primary liver doctor is at [**Hospital 36653**]
Clinic, Dr. [**First Name (STitle) **] at ([**Telephone/Fax (1) 13527**]. Her dosing of medications
was confirmed: CellCept [**Pager number **] mg b.i.d.,Prednisone 4 mg daily,
and Prograft 1 mg b.i.d.
- Prograft level on [**8-21**] 9.1, level [**8-24**] pending at time of
discharge
.
#. HTN: Resume ACE-I and atenolol
.
#. HYPERTROPHIC CARDIOMYOPATHY: normal EF; no evidence of CHF
exacerbation noted.
.
#. FULL CODE
Medications on Admission:
Atenolol 50 mg daily
Disopyramide 300 mg b.i.d.
CellCept [**Pager number **] mg b.i.d.
Prednisone 5 mg daily
Quinapril 40 mg b.i.d.
Prograf 1 mg b.i.d.
Coumadin as directed
Vitamin C 500 mg b.i.d.
Colace
Magnesium oxide 400 mg b.i.d.
Multivitamin
Calcium
Discharge Medications:
1. Mycophenolate Mofetil 500 mg Tablet Sig: Three (3) Tablet PO
BID (2 times a day).
2. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
3. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
5. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO TID x 4 days,
[**Hospital1 **] x 7 days, QD thereafter.
Disp:*40 Tablet(s)* Refills:*1*
6. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
7. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Quinapril 40 mg Tablet Sig: One (1) Tablet PO twice a day.
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
11. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO twice a
day. Tablet(s)
Discharge Disposition:
Home
Discharge Diagnosis:
1. Paroxysmal Atrial Fibrillation with RVR
2. Nonobstructive hypertrophic cardiomyopathy
3. Hypertension
4. Primary Biliary Cirrhosis s/p liver transplant
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
|
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29,338
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44233
|
Discharge summary
|
report
|
Admission Date: [**2162-6-10**] Discharge Date: [**2162-6-17**]
Date of Birth: [**2089-8-16**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 66189**] is a 72 yo male with ESRD on HD, IDDM, chronically
ventilated since prior CVA, who is transferred from [**Hospital 100**] Rehab
with fevers beginning on [**5-26**]. At [**Hospital 100**] Rehab he was started
empirically on PO metronidazole for suspected c. difficile
colitis, but all c. diff toxins returned negative. Tmax was
101.2 on [**6-5**], and he was started empirically on vancomycin and
zosyn. Since then, he has had persistent low-grade fevers of
99.4-100.2. Urine, stool, and blood cultures have been no
growth to date. Sputum cultures have repeated grown pseudomonas
aeurginosa (sensitive to zosyn, ceftaz; intermediate to
cefepime). WBC increased from 9.8 on [**5-25**] to 23 on [**5-27**]. It
has subsequently remained elevated in the range of 14-19.
In [**2161-12-12**], his functional status declined, had difficulty
walking and required transport to dialysis. He had heart attack
and underwent cabg at [**Hospital1 2177**] in [**2162-1-12**], post-operatively had
stroke, L sided hemiparesis but could still talk, though had
aphasia, went to [**Hospital1 **]. At [**Hospital1 **] developed sacral decubs,
developed sepsis in [**Month (only) 958**] and he want to [**Hospital1 2177**]. We was intubated
and septic in ICU at [**Hospital1 2177**] and the was discharged to [**Hospital 100**] Rehab
still requiring mechanical ventilation. He had a trach placed at
[**Hospital1 2177**]. At [**Hospital 100**] Rehab over the past months, he would nod his head
to queestion. Has not been able to talk.
Review of medical records revals a nonproductive cough and
minimal secretions from the trach. There was no other report of
localizing symptoms. [**Name8 (MD) **] RN, patient does not make urine but
has been straight-cathed daily to drain bladder pus. Stools are
well-formed.
Past Medical History:
1. Diabetes mellitus, Type II. Diagnosed 40 years ago,
complicated by nephropathy, neuropathy (sensory and autonomic
leading to urinary retention) and retinopathy (s/p bilat
vitrectomies, L eye blindness).
2. ESRD secondary to diabetic nephropathy + chronic allograft
insufficiency s/p R cadaveric kidney transplant, complicated by
postinfectious GN (negative [**Doctor First Name **], ANCA, low complemt), signs of
chronic rejection (sclerotic glomeruli, interstitial fibrosis
3/[**2158**]). On dialysis starting [**2148**].
3. Anemia
4. Hypertension
5. Neurogenic bladder
6. BPH s/p TURP [**2157**].
5. PVD s/p left popliteal-dorsalis pedis bypass with saphenous
vein graft
6. Chronic osteomyelitis of C-spine and bilateral feet, s/p
bilateral transmetatarsal amputations (R foot [**2145**], L foot
[**2157**]).
7. HSV stomatitis/genital
8. Recurrent UTI
9. s/p right MCA stroke [**1-19**]
10. blindness in right eye
11. Respiratory failure, chronically vented on CPAP 15/5, FiO2
35%
Social History:
Immigrated from [**Country **] in [**2141**]. Retired from being a civil
engineer at age 47 because of ??????health issues.?????? Currently lives
with wife and 38 [**Name2 (NI) **] daughter. Denies alcohol, tobacco, drugs.
Family History:
Mother and brother with DM Type 2.
Physical Exam:
VS: T 98.1, BP 102/61, HR 90, RR 19, SpO2 99% on FiO2 35%
Gen: minimally responsive, grimacing to noxious stimuli
Neck: trach in place, no purulent secretions
CV: RRR, [**2-17**] murmur best auscultated at apex
Resp: lungs CTA
Abdomen: PEG clean, dry, intact; soft, + BS
Extrem: s/p bilateral partial foot amputations, diffuse muscle
wasting in lower extremities; scar tissue with functioning AV
fistula in LUE; midline in antecubital fossa of RUE; increased
rigidity of RUE; flacid LUE
Skin: full thickness decubitus ulcer covered with feces
Pertinent Results:
[**2162-6-10**] 08:30PM BLOOD WBC-8.9# RBC-3.40* Hgb-10.3* Hct-32.8*
MCV-97 MCH-30.3 MCHC-31.5 RDW-17.4* Plt Ct-331#
[**2162-6-10**] 08:30PM BLOOD Neuts-77.2* Lymphs-14.1* Monos-3.7
Eos-4.5* Baso-0.5
[**2162-6-17**] 03:13AM BLOOD WBC-7.8 RBC-3.36* Hgb-10.5* Hct-32.8*
MCV-98 MCH-31.2 MCHC-32.0 RDW-17.2* Plt Ct-356
[**2162-6-10**] 08:30PM BLOOD PT-15.7* PTT-35.9* INR(PT)-1.4*
[**2162-6-10**] 08:30PM BLOOD Glucose-159* UreaN-37* Creat-2.3*# Na-141
K-3.9 Cl-103 HCO3-30 AnGap-12
[**2162-6-17**] 03:13AM BLOOD Glucose-223* UreaN-46* Creat-3.2* Na-137
K-4.1 Cl-99 HCO3-27 AnGap-15
[**2162-6-10**] 08:30PM BLOOD ALT-104* AST-173* AlkPhos-264*
TotBili-0.3
[**2162-6-15**] 05:27AM BLOOD ALT-37 AST-39 LD(LDH)-128 AlkPhos-161*
TotBili-0.3
[**2162-6-11**] 04:00AM BLOOD Lipase-12
[**2162-6-10**] 08:30PM BLOOD Albumin-2.6* Calcium-9.0 Phos-2.6* Mg-1.7
[**2162-6-17**] 03:13AM BLOOD Calcium-9.7 Phos-3.7 Mg-2.2
[**2162-6-14**] 05:38PM BLOOD Cortsol-5.6
[**2162-6-14**] 06:15PM BLOOD Cortsol-14.7
[**2162-6-14**] 06:45PM BLOOD Cortsol-16.3
[**2162-6-12**] 03:00AM BLOOD Vanco-25.9*
[**2162-6-15**] 05:27AM BLOOD Vanco-23.2*
[**2162-6-10**] 07:12PM BLOOD Type-ART PEEP-5 FiO2-35 pO2-42* pCO2-42
pH-7.49* calTCO2-33* Base XS-7 Vent-SPONTANEOU
[**2162-6-10**] 08:32PM BLOOD Type-ART Temp-37.8 PEEP-5 FiO2-35
pO2-118* pCO2-44 pH-7.47* calTCO2-33* Base XS-8
Intubat-INTUBATED Vent-SPONTANEOU
[**2162-6-12**] 03:10AM BLOOD Type-ART Temp-37.2 Rates-25/ Tidal V-500
PEEP-5 FiO2-35 pO2-125* pCO2-42 pH-7.44 calTCO2-29 Base XS-4
Intubat-INTUBATED Vent-IMV Comment-TRACH
[**2162-6-16**] 03:20AM BLOOD Type-ART pO2-116* pCO2-46* pH-7.43
calTCO2-32* Base XS-5 Intubat-INTUBATED
[**2162-6-10**] 07:12PM BLOOD Lactate-2.2*
[**2162-6-10**] 08:32PM BLOOD Lactate-1.3
[**2162-6-10**] 10:43PM BLOOD Lactate-1.0
[**2162-6-10**] 08:32PM BLOOD freeCa-1.17
.
MICROBIOLOGY:
[**2162-6-16**] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-FINAL
negative
[**2162-6-15**] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-FINAL
negative
[**2162-6-14**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2162-6-14**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2162-6-13**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2162-6-13**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2162-6-12**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2162-6-12**] URINE URINE CULTURE-FINAL no growth
[**2162-6-11**] BLOOD CULTURE Blood Culture, Routine-FINAL no growth
[**2162-6-10**] [**2162-6-10**] 6:30 pm SPUTUM Source: Endotracheal.
GRAM STAIN (Final [**2162-6-10**]):
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2162-6-13**]):
OROPHARYNGEAL FLORA ABSENT.
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 8 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN--------- 2 I
GENTAMICIN------------ 4 S
MEROPENEM------------- 1 S
PIPERACILLIN---------- 32 S
PIPERACILLIN/TAZO----- 64 S
TOBRAMYCIN------------ <=1 S
LEGIONELLA CULTURE (Final [**2162-6-17**]): NO LEGIONELLA
ISOLATED.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
[**2162-6-10**] BLOOD CULTURE Blood Culture, Routine-no growth
.
CHEST (PORTABLE AP) [**2162-6-10**] 6:53 PM
FINDINGS: No recent views for comparison. The patient has
undergone a CABG procedure with intact sternal sutures.
Tracheostomy tip lies approximately 3.3 cm above the carina.
Pacemaker device with single lead extending to the right
ventricle. No evidence of pneumothorax. Apical pleural
thickening is seen, as on the study of [**2160-6-27**]. There is some
haziness to the lower hemithoraces raising the possibility of
layering pleural effusion. Bibasilar atelectatic change is seen.
.
BILAT UP EXT VEINS US [**2162-6-11**] 8:42 AM
CLINICAL HISTORY: Questionable right upper extremity DVT.
Evaluation of the deep venous system in the right upper
extremity was performed utilizing grayscale images, Doppler
flow, compression, and augmentation. There is mild eccentric
thickening in the wall of the right internal jugular vein which
raises a possibility of an element of chronic thrombosis in this
region. The right internal jugular vein, however, is patent and
compressible. The right subclavian, axillary, and brachial veins
are unremarkable. A PICC line is noted in the brachial vein.
Evaluation of the deep venous system in the left upper extremity
was also performed. The study demonstrates left internal
jugular, subclavian, axillary, and brachial veins to be patent.
There is a left-sided brachial AV fistula likely representing
patient's dialysis fistula. Note was made of thrombosis of the
left basilic vein, which is a superficial vein in the forearm.
IMPRESSION:
1. No evidence of acute DVT in either upper extremity.
2. Mild eccentric thickening in the right internal jugular vein
which may reflect a non-occlusive old/chronic thrombus.
3. Thrombosis of the left basilic vein which is a superficial
vein.
4. Left brachial arteriovenous dialysis fistula.
.
ABDOMEN U.S. (COMPLETE STUDY) PORT [**2162-6-11**] 8:41 AM
IMPRESSION:
1. Cholelithiasis and minimal gallbladder wall thickening. Since
the gallbladder does not appear to be distended, these findings
are unlikely to reflect cholecystitis. If there is a clinical
concern for cystic duct obstruction, a nuclear HIDA scan can be
performed for further evaluation.
2. Incidental bilateral pleural effusions.
.
[**2162-6-11**] TTE
The left atrium is normal in size. The interatrial septum is
aneurysmal. 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. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. No
masses or vegetations are seen on the aortic valve. No 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 estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
IMPRESSION: No evidence of endocarditis. Normal global
biventricular systolic function. Mild mitral regurgitation.
Compared with the prior study (images reviewed) of [**2160-6-27**], an
interatrial shunt could not be demonstrated on the current
study. Pericardial effusion has resolved. The other findings are
similar.
.
CT CHEST W/O CONTRAST [**2162-6-13**] 4:14 PM
IMPRESSION:
1. Large non-hemorrhagic non-loculated bilateral pleural
effusions. The effusions are symmetric in size bilaterally.
2. Gallstones. Possible cysts within the body and also within
the head and proximal tail of the pancreas, which could be
further assessed with MR of the abdomen.
3. Bilateral atrophic kidneys.
.
CHEST (PORTABLE AP) [**2162-6-16**] 2:50 AM
The tracheostomy tip is at the midline, terminating 6.5 cm above
the carina. The pacemaker leads terminate in the right
ventricle, unchanged. The cardiomediastinal silhouette is
stable. There is no change in mild vascular enlargement and
large bilateral pleural effusions, right more than left, as well
as bibasilar areas of atelectasis.
Brief Hospital Course:
72 year old male with ESRD on HD, chronically ventilated since
prior CVA, who was transferred from [**Hospital 100**] Rehab with fevers
beginning on [**5-26**], course complicated by hypotension. Hospital
course by problem:
.
# Fevers/Hypotension/Adrenal Insufficiency: The patient remained
afebrile since admission. He was continued on vanc/zosyn which
had been started at his NH, and ciprofloxacin was added as he
was found to have a sacral ulcer contaminated with stool. He had
the area cleaned, a rectal tube placed to avoid contamination,
and the wound evaluated by wound nurse who recommended wund care
and dressing changes. Despite antibiotics, he remained
hypotensive, requiring IV pressors. Blood and stool culture data
were unrevealing (some blood cultures are still pending at time
of discharge). Sputum culture was positive for pseudomonas
though this was felt to be due to colonization. Chest xray and
CT did not suggest pneumonia. He does have chronic bilateral
effusions, not loculating, which had been tapped at his prior
hospitalization at [**Hospital1 2177**]. He had a TTE which was negative for
vegetation. He had a RUE US to evaluate for DVT as a possible
source of infection (given that he was noted to have a R SCV
clot on [**Hospital1 2177**] records) which was negative for DVT. His recurrent
intermittent fevers prior to admission were felt to most likely
be due to seeding of his sacral ulcer with stool. Given the
patient's persistent hypotension on broadspectrum antibiotics,
with no evidence of active infection, the patient had a cortisol
stimulation test which was consistent with adrenal insufficiency
(cortisol level 5, bumped to less than 19). He was started on
hydrocortisone [**6-14**] and subsequently remained stable off of IV
pressors, in fact becoming hypertensive to the SBP 170s.
Hydrocortisone was changed to prednisone 40mg daily on [**6-16**], to
begin a slow 2 week taper, with plan to repeat a cortisol
stimulation test as an outpatient. On [**6-16**] his antibiotics were
discontinued as he had completed a 10 day course of antibiotics
since his last febrile episode. He remained afebrile
subsequently for >24hrs. His PCP should follow up on remaining
culture data and evaluate for ability to wean off of steroid
supplementation. A repeat cortisol stimulation test should be
performed in 2 weeks.
.
# HTN: The patient was hypertensive to SBPs 170s on [**6-17**]. He had
HD to remove 3L which brought his BP down to 146/61.
.
# Sacral decubitus ulcer: Ulcer was found to be contaminated
with feces, which is why he was treated with cipro. Rectal tube
was placed and wound evaluated by wound nurse. Please see wound
care instructions for further management. Continue rectal back
and q72h dressing changes.
.
# ESRD: Patient received HD according to his regular Tues,
Thurs, Sat schedule by AV fistula in LUE.
.
# Respiratory failure: Patient is chronically vented. He was
weaned to CPAP and PS with PEEP 5/ PS 5. He may tolerate a trial
of trach mask.
.
# DM2: He was continued pm Glargine qHS (increased to 14u due to
steroids) + RISS. This may need to be adjusted as steroids are
weaned.
.
# FEN: He was continued on Nutren Renal @ 40 cc/hour.
.
# PPx: SQ heparin, PPI.
.
# Access: RUE midline inserted [**5-1**], changed [**6-5**].
.
# Code status: Full code, confirmed with HCP.
.
# Communication: HCP is daughter [**Name (NI) 4457**] [**Name (NI) 66189**] (daughter):
[**Telephone/Fax (1) 94885**].
Dispo: [**Hospital 100**] Rehab.
Medications on Admission:
Zosyn 2.25 grams q12 hours (start date [**6-5**])
Vancomycin 1 gram qHD M,Th,Sat
Acetic acid 1% irrigation daily
Combivent 6 puffs QID
ASA 81 mg daily
Lantus 7 un qHS
RISS
Lactobacillus 2 tab [**Hospital1 **]
Reglan 5 mg q8 hours
MVI 5 ml daily
Omeprazole 20 mg daily
Simvastatin 20 mg qHS
Codeine sulfate 7.5 mg q8 hours PRN
Lorazepam 0.25 mg q6 hours PRN
Zofran 4 mg IM PRN
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1) mL
Injection TID (3 times a day).
2. Chlorhexidine Gluconate 0.12 % Mouthwash [**Hospital1 **]: Fifteen (15) ML
Mucous membrane [**Hospital1 **] (2 times a day): only use if is on
mechanical ventilation.
3. Simvastatin 10 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY
(Daily).
4. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Metoclopramide 10 mg Tablet [**Hospital1 **]: 0.5 Tablet PO TID (3 times a
day).
6. Therapeutic Multivitamin Liquid [**Hospital1 **]: Five (5) ML PO DAILY
(Daily).
7. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
8. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol [**Last Name (STitle) **]: Six
(6) Puff Inhalation Q4H (every 4 hours).
9. Insulin Glargine 100 unit/mL Cartridge [**Last Name (STitle) **]: Fifteen (15)
units Subcutaneous at bedtime.
10. Humalog 100 unit/mL Cartridge [**Last Name (STitle) **]: as directed as directed
Subcutaneous four times a day: glucose
0-60: give [**1-13**] amp D50; 61-180: give 0;
181-240: give 6 units;
241-320: give 8 units;
321-400: give 10 units;
>400: [**Name8 (MD) 138**] MD.
11. Prednisone 5 mg Tablet [**Name8 (MD) **]: as directed Tablet PO once a
day: [**6-18**], [**6-19**]: 40mg. [**6-20**], [**6-21**], [**6-22**], [**6-23**]: 30mg. [**6-24**], [**6-25**],
[**6-26**], [**6-27**]: 20mg. [**6-28**] change to 10mg daily, continue until
evaluated by PCP .
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary
1. adrenal insufficiency
2. sacral pressure ulcer
3. end stage renal disease on hemodialysis
Secondary
1. hypertension
2. chronic respiratory failure
3. type 2 diabetes
4. chronic anemia
5. status post right MCA stroke
Discharge Condition:
able to open eyes, occasionally mouths words, squeezes hand
(inconsistently), afebrile, trached
Discharge Instructions:
You were admitted to the hospital for persistent low grade
fevers and hypotension. No source of infection was found,
however, it was felt that a possible source of infection was
your sacral ulcer which was found to be contaminated by stool.
You were continued on vanc/zosyn, and a third antibiotic,
ciprofloxacin was added to your regimen to cover for stool
organisms. You remained afebrile throughout your stay in the
hospital but you required IV pressors for several days despite
antibiotics. You had a cortisol stimulation test which showed
that you had adrenal insufficiency so you were started on high
dose hydrocortisone. After this your blood pressure remained
stable and you no longer required pressors. You were
transitioned to oral prednisone which should be tapered slowly
over 2 weeks as your blood pressure tolerates. You should follow
up with your PCP and have [**Name Initial (PRE) **] repeat cortisol stim test in 2
weeks. You completed a 10 day course of antibiotics which ended
[**6-16**] and remained afebrile.
.
You received hemodialysis according to your normal schedule.
.
Please continue to take your medications as prescribed. Continue
to go to your regularly scheduled dialysis sessions. Please
follow wound care instructions to maintain the area of your
ulcer clean and dry. Your CPAP settings were gradually weaned to
[**5-17**]. You may benefit from a trial of trach mask.
.
If you develop fever or any other concerning symptoms, please
call your doctor or come to the hospital.
Followup Instructions:
Continue hemodialysis on Tuesday, Thursday, Saturday schedule.
Repeat cortisol stimulation test in 2 weeks by PCP.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
Completed by:[**2162-6-17**]
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13,735
| 190,148
|
30247
|
Discharge summary
|
report
|
Admission Date: [**2147-1-24**] Discharge Date: [**2147-2-6**]
Date of Birth: [**2067-2-11**] Sex: M
Service: SURGERY
Allergies:
Demerol
Attending:[**First Name3 (LF) 6346**]
Chief Complaint:
Abdominal pain, retroperitoneal air on imaging, transfer from
outside hospital
Major Surgical or Invasive Procedure:
CT guided drainage of abdominal abscess
History of Present Illness:
79 yo male with lower abdominal pain for 2 weeks prior to
admission and 6 days prior to admission he started have nausea
and vomiting and pain radiating to the back. The patient was
seen for dehydration at an outside institution and discharged ro
rehab for back pain. Today the patient came back to [**Hospital3 **]
for the same issues. Had a CT scan chest/ABD and pelvis
revealing pneumoperitoneum, pneumomediastinum and
retroperitoneal air with a 5x4 cm abscess in the left lower
abdomen with fat stranding and multiple diverticula. He was
transferred for evaluation.
Past Medical History:
1. Hypertension
2. Hypercholesterolemia
3. Coronary Artery Disease status post CABG [**64**] years ago and
multiple stents placed at different times last one more than 3
years.
4. Pacemaker
5. Gastritis
Social History:
Lives with his wife on the [**Location (un) 448**] of a three story complex.
His son lives on the [**Location (un) 1773**]. He denies any tobacco
history. Denies alcohol use and denies IV drug use. Previously
to being sick 2 weeks prior to admission he was independant and
his wife is in good health.
Family History:
NC
Physical Exam:
Physical on Admission:
PE T 99.0 HR 98 BP 144/70 RR 16 O2Sat 98% on 3L NC
Lungs CTA
heart RRR
ABD soft localized tenderness to palpation lower
quadrants
ext clammy no edema
Rectal exam: no masses, heme negative
Pertinent Results:
Admission Labs
-----------------
[**2147-1-24**] 06:00PM BLOOD WBC-20.4* RBC-4.78 Hgb-13.7* Hct-41.1
MCV-86 MCH-28.6 MCHC-33.3 RDW-15.7* Plt Ct-267
[**2147-1-24**] 06:00PM BLOOD Neuts-90.3* Bands-0 Lymphs-6.9* Monos-2.3
Eos-0.2 Baso-0.4
[**2147-1-24**] 06:00PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2147-1-24**] 06:00PM BLOOD PT-15.7* PTT-39.0* INR(PT)-1.4*
[**2147-1-24**] 06:00PM BLOOD Glucose-121* UreaN-36* Creat-0.9 Na-127*
K-5.9* Cl-92* HCO3-26 AnGap-15
[**2147-1-24**] 10:24PM BLOOD ALT-24 AST-25 AlkPhos-100 Amylase-64
TotBili-0.7
[**2147-1-24**] 10:24PM BLOOD Lipase-22
[**2147-1-25**] 03:48AM BLOOD Albumin-2.4* Calcium-8.3* Phos-2.7 Mg-2.4
Discharge Labs
-----------------
[**2147-2-6**] 03:24AM BLOOD WBC-5.6 RBC-3.71* Hgb-10.8* Hct-33.0*
MCV-89 MCH-29.1 MCHC-32.8 RDW-18.3* Plt Ct-195
[**2147-2-6**] 03:24AM BLOOD Plt Ct-195
[**2147-2-6**] 03:24AM BLOOD Glucose-117* UreaN-22* Creat-0.5 Na-136
K-3.9 Cl-104 HCO3-26 AnGap-10
[**2147-2-6**] 03:24AM BLOOD Calcium-8.1* Phos-3.7 Mg-2.0
[**2147-2-5**] 05:21AM BLOOD calTIBC-181* Ferritn-101 TRF-139*
[**2147-2-6**] 03:24AM BLOOD Vanco-16.9
EXAMINATION: CT-guided drainage of abdominal collection
INDICATION: Diverticulitis. Non-contrast CT abdomen.
FINDINGS: Some consolidation is noted in the left base. Free air
is noted in the mediastinum posterior to the heart and
anteriorly in the right base. A [**Hospital1 **]-lead pacemaker is in situ.
Below the diaphragm, the liver and spleen are unremarkable given
this is a non-contrast CT. The gallbladder is normal. The
pancreas is atrophic consistent with the patient's age. The
adrenals are normal. The left kidney is normal. There is a
punctate density in the lower pole of the left kidney which is
not causing any obstruction. Within the peritoneal cavity, there
is a significant amount of free air, which is noted anterior to
the transverse colon and also on the left side. There is
thickening of the wall of the sigmoid colon with some
intraluminal narrowing and diverticulitis is noted in this area.
There appears to be a connection to a collection which has a
contrast air level and this measures 5.3 cm in transverse by 3.8
cm in AP diameter. This may represent a walled-off collection
secondary to perforation from diverticulitis. Further inferiorly
in the rectum, further thickening of the wall is noted with more
intraluminal narrowing.
IMPRESSION: Free air within the mediastinum and within the
peritoneum with diverticulitis of the sigmoid colon and rectum
with collection noted adjacent to the sigmoid colon which may be
secondary to perforation.
CT-GUIDED DRAINAGE OF DIVERTICULAR ABSCESS.
FINDINGS: Informed written consent was obtained. Timeout with
double patient identifiers was performed. Using local
anesthetic, aseptic technique and ultrasound guidance, a
12-French Flexima catheter was inserted into the collection.
Approximately 50 mL of fecal and fluid was aspirated. The
procedure was well tolerated. No complications. The attending,
Dr. [**First Name (STitle) **], was present and actively participated throughout
the procedure. Moderate sedation was provided by administering
divided doses of 2 mg of Versed and 75 mcg of fentanyl
throughout the total intraservice time of approximately 35
minutes during which the patient's hemodynamic parameters were
continuously monitored. A post-procedural CT was performed which
revealed a pigtail catheter in good location and resolution of
the previously noted diverticular abscess.
IMPRESSION: Status post successful drainage of diverticular
abscess in the left side of the pelvis
CT PELVIS W/CONTRAST [**2147-1-30**] 12:03 PM
CT ABDOMEN W/CONTRAST; CT CHEST W/CONTRAST
Reason: Evaluate drainage of abscess, also please do spine
reconstru
Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
79 year old man with perforated diverticulitis s/p CT guided
drainage of peritoneal abscess, also with back pain.
REASON FOR THIS EXAMINATION:
Evaluate drainage of abscess, also please do spine
reconstructions. Please administer gastrograffin PO contrast.
CONTRAINDICATIONS for IV CONTRAST: None.
CLINICAL HISTORY: 79-year-old male with perforated
diverticulitis status post CT-guided drainage of peritoneal
abscess. Patient now with back pain. Evaluate for abscess.
COMPARISON: [**2147-1-25**].
TECHNIQUE: Contrast enhanced multidetector CT acquired axial
images of the chest, abdomen, and pelvis from the thoracic inlet
to the pubic symphysis. Coronal and sagittal reformatted images
were obtained.
CT OF THE CHEST WITH INTRAVENOUS CONTRAST: The lung show
bilateral ground- glass opacity and small left pleural effusion
likely secondary to edema. The heart, great vessels are within
normal limits. There is no pericardial effusion. The airways are
patent to the subsegmental level. Free air is noted within the
anterior mediastinum likely related to recent intra-abdominal
procedure. There is no axillary or mediastinal lymphadenopathy.
CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: Low-density lesions
are seen within the liver, too small to characterize, however
most likely represent cysts. The gallbladder, spleen, pancreas,
adrenal glands are within normal limits. Kidneys enhance and
excrete contrast symmetrically. Hypodensities are seen within
bilateral kidneys, too small to characterize, likely
representing cysts. Free intraabdominal free air is identified,
which has decreased compared to [**2147-1-25**]. A drainage
catheter is present with tip adjacent to the sigmoid colon in
the area of previously noted abscess. No large fluid collection
is evident. There is no retroperitoneal or mesenteric
lymphadenopathy.
CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: The bladder, distal
ureter, rectum are unremarkable. The prostate is enlarged.
Contrast is seen within the prosthatic urethra, which may be
seen in the setting of prior TURP. There is no pelvic
lymphadenopathy.
BONY WINDOWS: There is scoliosis of the lumbar spine with
leftward convexity. Multilevel degenerative changes are present,
notably disc space narrowing and endplate sclerosis at L1-L2,
not significantly changed from [**2147-1-25**]. An area of
hypoattenuation is seen within the T12 vertebral body, which
likely represents a hemangioma.
IMPRESSION:
1. Compared to prior CT from [**2147-1-25**], there is
improvement in the appearance of the diverticular abscess. The
drainage catheter remains in appropriate location.
2. Bilateral ground-glass opacity within the lungs and small
left pleural effusion, most likely representing edema.
3. Hypodense lesions within the liver too small to characterize,
likely representing cysts.
4. Multilevel degenerative changes throughout the thoracolumbar
spine notably endplate sclerosis and disc space narrowing at
L1-L2. Incidental
note of a hemangioma at the T12 vertebral body.
CT L-SPINE W/O CONTRAST
Reason: evaluate for fracture. Please also image sacrum.
[**Hospital 93**] MEDICAL CONDITION:
79 year old man with low back pain.
REASON FOR THIS EXAMINATION:
evaluate for fracture. Please also image sacrum.
CONTRAINDICATIONS for IV CONTRAST: None.
HISTORY: 79 y/o man with low back pain, evaluate for fracture,
specifically of the sacrum.
Routine CT of the lumbar spine with sagittal and coronal
reconstructions.
No comparisons.
Sagittal images demonstrate degenerative end plate sclerosis of
L1/L2. There is multilevel loss of disc height. Schmorl's nodes
are seen at L4 and L3. Axial images at L1/L2 demonstrate mild
spondylotic disc bulge with mild central canal stenosis.
Bilateral facet hypertrophy is noted, causing mild foraminal
narrowing.There are large anterior osteophytes at this level.
At L2/L3, there is a diffuse spondylotic disc bulge with mild
right foraminal narrowing. There is a developmentally small
canal at this level with short pedicles.
At L3/L4, there is a diffuse spondylotic disc bulge extending to
both foramina with bilateral foraminal narrowing. There is also
moderate central canal stenosis on a developmental basis with
superimposed degenerative changes of the facet and ligamentum
flavum as well as disc bulge.
At L4/L5, there is a diffuse spondylotic disc bulge and
bilateral facet and ligamentum flavum hypertrophy. There is mild
central canal stenosis and moderate left foraminal narrowing
from disc bulge.
At L5/S1, there is diffuse spondylytic disc bulge without
significant central or foraminal narrowing.
There is scoliosis of the lumbar spine to the left.
IMPRESSION:
Multilevel spondylotic changes as detailed above.
Brief Hospital Course:
[**Known firstname 122**] [**Known lastname 61554**] was admitted to [**Hospital1 18**] on [**2147-1-24**] under the care
of Dr. [**First Name (STitle) 2819**]. WBC count was 20.4 Outside CT scan revealed
pneumoperitoneum, pneumomediastinum, and retroperitoneal air
with a 5.4 cm abscess in the left lower abdomen. He was made
NPO. IV fluids were initiated. Ampicillin/Levofloxacin/Flagyl
were started for empiric coverage.
At HD 1 the LLQ abscess was percutaneously drained in radiology
with 90cc feculent material returned. A 12fr pigtail catheter
was left in place for continued drainage.
At HD 3 he was doing well. WBC was 8.5 and urine output was WNL.
The abscess culture was positive for GPC;GPR;GNR and yeast.
Fluconazole was added to therapy.
At HD 4 he remained NPO. A PICC line was placed and TPN started
for nutritional support. Abscess culture was speciated as staph
coag +; enterococcus; [**Female First Name (un) **] albicans; viridans streptococci.
His hospital course was complicated by severe back pain which
limited his mobility. Neuro exam was negative for radicular
signs, loss of rectal tone, sensory deficits, or true weakness.
Pain medications and muscle relaxants were provided.
Neurosurgery was consulted and recommended CT of the L-S spine
which showed multilevel spondylotic changes. MRI was not
possible due to pacemaker.
At HD 14 he was doing well. WBC count was 5.6. Repeat CT scan
showed improvement of the diverticular abscess. He was afebrile
and tolerating a regular diet. Pigtail drain remained in place
with nominal drainage. His back pain was improved with pain
medications, muscle relaxants, and physical therapy. He was
discharged to a rehabilitation center for IV antibiotics, drain
care, and physical therapy. He was to schedule a repeat L-spine
CT scan in 4 weeks and follow up with Dr. [**Last Name (STitle) 548**] in 5 weeks. He
was to follow up with Dr. [**First Name (STitle) 2819**] in [**1-7**] weeks. He was continued
on 5 weeks fo Levofloxacin/Flagyl/Vancomycin/Fluconazole.
Medications on Admission:
1. Gabapentin 300mg PO Daily
2. Toprol 50mg PO Daily
3. Nexium 40mg PO Daily
4. Plavix 75mg PO Daily
5. Folic acid daily
6. Isosorbide 120mg PO BID
7. Enalapril 5mg PO BID
8. Enteric Coated Aspirin 325mg PO daily
9. nytro 4mg prn
10. Darvocet n-100 prn
Discharge Medications:
1. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Isosorbide Dinitrate 40 mg Tablet Sustained Release Sig:
Three (3) Tablet Sustained Release PO BID (2 times a day).
4. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 5 weeks.
5. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 5 weeks.
6. Fentanyl 50 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours) as needed for chronic back
pain.
7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Enalapril Maleate 10 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
9. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig:
Five Hundred (500) mg Intravenous Q8H (every 8 hours) for 5
weeks.
10. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
Gram Intravenous Q 12H (Every 12 Hours) for 5 weeks.
11. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
as needed for stents.
12. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for Pain.
13. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
14. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO NOON (At
Noon).
15. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO QAM (once
a day (in the morning)).
16. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours) as needed for pain.
17. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two
(2) ML Intravenous DAILY (Daily) as needed: 10 ml NS followed by
2 ml of 100 Units/ml heparin (200 units heparin) each lumen
Daily and PRN. Inspect site every shift. .
18. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day): [**Month (only) 116**] discontinue when patient is
walking 2-3 times per day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Abdominal abscess secondary to perforated diverticulitus
Degenertive Osteoarthritis
Acute Discitis
HTN
Hypovolemia
Malnutrition
Discharge Condition:
Good
Discharge Instructions:
Discharge Instructions: Please return or contact for:
* Fever (>101 F) or chills
* Persistent Pain
* Nausea or vomiting
* Numbness or tingling at face or hands
* Redness or drainage from incision site
* Any other concerns
Followup Instructions:
1. Please follow up with Dr. [**First Name (STitle) 2819**] in 2 weeks. Call ([**Telephone/Fax (1) 35203**] to make an appointment.
2. Please get a repeat CT scan of your L-spine in 4 weeks. To
schedule please call [**Telephone/Fax (1) 327**].
3. Please follow up with Dr. [**Last Name (STitle) 548**] one week after getting your
repeat CT scan so in 5 weeks. Call ([**Telephone/Fax (1) 88**] to make an
appointment.
Completed by:[**2147-2-7**]
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66,002
| 126,815
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28980
|
Discharge summary
|
report
|
Admission Date: [**2196-7-5**] Discharge Date: [**2196-8-16**]
Date of Birth: [**2150-10-18**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 800**]
Chief Complaint:
Fevers, chills x 3 days; myalgias, fatigue x 2 weeks
Major Surgical or Invasive Procedure:
Mechanical Ventilation (intubation/extubation)
Tracheostomy
PEG tube placement
Bronchoscopy
History of Present Illness:
Mr. [**Known lastname **] is a 45 year old male with history of hypertension who
presents from home with fevers, chills, myalgias and SOB. Mr.
[**Known lastname **] saw his PCP on three weeks ago with similar complaints. He
had fatigue, shortness of breath, nonproductive cough and a
burning sensation with deep breathing. No fevers at that time.
At that time symptoms were attributed to mild flu and he was
instructed to take tylenol and drink plenty of fluids. Symptoms
persisted since then and worsened this past Saturday. He had
increased myalgias and new fevers up to 102. He was so fatigued
that he had trouble getting out of bed. Shortness of breath was
worse at night. Symptoms felt similar to prior pneumonia. On
Sunday he was prescribed a Zpack and inhaler over the phone.
This morning he went again to see his PCP and was referred here
for evaluation. His boyfriend has also had a dry cough but no
other symptoms. No recent travel outside of the US - recently
went to [**State 531**].
.
In ED, vital signs were T 102.6, BP 149/108, HR 140, RR 22,
O2sat 93% on RA. Labs were unremarkable, negative lactate, aside
from anemia. CXR notable for left upper lobe pneumonia. He was
given 2L IVF and HR improved. He was also given Levofloxacin for
pneumonia and ibuprofen for fever. Vital signs prior to transfer
were HR 102, BP 128/75, 95% on 2L NC. Patient is admitted for
recurrent pneumonia.
.
Currently, he continues to be short of breath with prolonged
talking. He gets extremely fatigued with ambulating to the
bathroom and notes pain when taking deep breaths. He feels that
his lungs have "gone from basketball size to [**First Name8 (NamePattern2) **] [**Location (un) 2452**]".
.
Of note, patient has history of multiple pneumonias. He had PNA
2 years ago, 19 years ago and a severe bronchitis 4 years ago.
ROS: Denies night sweats, headache, vision changes, rhinorrhea,
congestion, sore throat, abdominal pain, nausea, vomiting,
diarrhea, constipation, BRBPR, melena, hematochezia, dysuria,
hematuria.
Past Medical History:
Hypertension
Social History:
Patient denies any tobacco use. He drinks 2-4 drinks every 3
weeks. No drug use. Endorses healthy diet. In a sexual
relationship with a male partner and endorses safe sexual
practive. Last HIV test 3 years ago (per patient and partner)
was negative.
Family History:
Mother with history of multiple bronchitis and frequent
congestion, unclear etiology. Father with history of MI,
hypertension.
Physical Exam:
VS - Tm 99.7, Tc 96.0, HR 85 (79-93), BP 120/78 (102-125/58-97),
RR 18, O2 97% on Trach Mask
Gen: NAD, alert and oriented X3, sitting up in bed shaving
Neck: trach with trach mask in place. Trach site
clean/dry/intact
CV: RRR, no murmurs/gallops/rubs, normal S1/S2
Pulm: Clear to auscultation bilaterally, no rhonchi/rales - very
mild wheeze in left upper lobe anteriorly
Abd: +BS, soft, non-tender/distended, PEG site clean/dry/intact
- slight erythema on right side
Ext: no cyanosis/ecchymosis/edema, PICC site in right
antecubital
Pertinent Results:
[**2196-7-5**] 05:50PM WBC-9.3 RBC-4.17* HGB-13.0* HCT-38.1* MCV-91
MCH-31.3 MCHC-34.2 RDW-13.4
[**2196-7-5**] 05:50PM NEUTS-76.1* LYMPHS-18.4 MONOS-4.1 EOS-1.0
BASOS-0.4
[**2196-7-5**] 05:50PM PLT COUNT-322
[**2196-7-5**] 05:50PM ALBUMIN-2.9*
[**2196-7-5**] 05:50PM ALT(SGPT)-94* AST(SGOT)-88* LD(LDH)-431* ALK
PHOS-146* TOT BILI-0.2
[**2196-7-5**] 05:50PM GLUCOSE-109* UREA N-15 CREAT-0.9 SODIUM-133
POTASSIUM-4.0 CHLORIDE-101 TOTAL CO2-23 ANION GAP-13
[**2196-7-8**] @ 1600: HIV viral load 61,600 copies
CXR [**7-5**]: IMPRESSION: Patchy ill-defined opacities within both
lungs, most pronounced within the left mid and upper lung field,
which could represent areas of infection. Asymmetric pulmonary
edema may also be possible, and followup radiographs are
recommended.
CXR [**7-7**]: IMPRESSION: Significant worsening of the multifocal
airspace opacities throughout the lungs with relative sparing of
the apices is likely related to multifocal infection. Early
followup is recommended.
CT chest [**7-8**]: No pulmonary edema. Widespread pulmonary
parenchymal abnormality including areas of consolidation and
ground-glass change, suspicious for an infectious process given
rapidity of change is seen on recent radiographs. Other
etiologies such as hypersensitivity pneumonitis or vasculitis
are considered much less likely.
Brief Hospital Course:
Mr. [**Known lastname **] is a 45 year old male with history of hypertension who
presents after a couple weeks of malaise and acute onset of
fevers, chills, and shortness of breath over 3 days with newly
diagnosed HIV on [**7-8**] and worsening PNA seen on CT suggestive of
PCP.
.
# RESPIRATORY FAILURE: Patient with fevers, chills,
nonproductive cough and CXR with left mid and upper lung field
PNA. His PORT score was 80 on admission and he has maintained a
normal WBC count with a left shift throughout his hospital
course. He has a history of PNA in the past, elevated ESR, CRP,
LFTs, and low albumin so question if there was a question of an
element of immunocompromise or anatomical defect resulting in
frequent infection. Sexually active with men, HIV test negative
2 years ago and reports sex with condoms. HIV antibody
positive, viral load 61,600 copies on [**7-8**].
.
He was started empirically on [**Month/Day (4) **] (day 1 [**7-5**]) for a
community acquired pneumonia; however, his oxygen requirement
escalated [**7-7**] from 3 to 5 Liters to maintain his oxygen
saturation in the low 90s. At this time he was also started on
vanco/cefepime in addition to the [**Month/Year (2) **]. Sputum induced on
[**7-8**] was positive for Pneumocystis jirovecii (carinii), yeast,
and normal oropharygeal flora and negative for Legionella. Urine
legionella was negative. CT scan obtained on [**7-9**] showed diffuse
ground glass opacities consistent with PCP. [**Last Name (NamePattern4) **] [**7-8**], Bactrim IV
was started, as well as Prednisone 40 mg [**Hospital1 **] x 5 days, given low
PaO2 in the setting of PCP. [**Name10 (NameIs) **], [**Name11 (NameIs) **]/cefepime were
discontinued. ID was consulted on [**7-9**] and recommended holding
off on HAART at this time. Further work-up revealed a negative
RPR and past exposure/current immunity to HBV and HAV.
.
His respiratory status was generally stable until [**7-10**] when his
hypoxemia worsened, and he required 100% high flow O2 and NC. In
the setting of this ARDS physiology, prednisone was subsequently
increased to 40 PO BID from 60mg PO Qam per ID. PaO2 was stable,
but worsening hypercarbia required intubation on [**7-11**] on volume
assist control with ARDS tidal volume. By [**7-12**], he met SIRS
criteria for tachycardia and fever, and steroids were increased
to 40 mg Q6hrs. The likely etiology was secondary pneumona vs.
worsening PCP, [**Name10 (NameIs) **] no clear source was isolated. Antibiotics
were extended to cipro, cefepime, and vancomycin. However,
sputum cultures from [**7-11**], [**7-12**], and [**7-15**] only grew sparse
oropharyngeal flora and yeast. Steroids were weaned back to 40mg
daily by [**7-15**] and abx were decreased to just [**Month/Day (4) **] for coagulase
negative staph aureus bacteria, with discontinuation of [**Month/Day (4) **] by
[**7-18**].
.
Given persistent ARDS physiology and inability to wean him from
vent, CT was performed on [**7-18**], which revealed new left lower
lobe opacity not seen at admission. However, sputum sample on
[**7-18**] grew just few yeast, and mini-BAL on [**7-19**] grew only
10-100,000 yeast, with a negative viral culture.
.
He developed thickened secretions, leukocytosis, persistent
fever, and worsening hypoxia by [**7-24**] concerning for ventilator
associated pneumonia, so he was started on vancomycin, cefepime,
cipro x 8 days for VAP (completed on [**7-31**]). Steroids were
decreased to 20 mg daily given lack of evidence to suggest
utility of high dose steroids in severe PCP beyond acute
presentation and concern that steroids could be harmful in the
setting of second pneumonia. However, sputum samples continued
to reveal only yeast and normal oropharyngeal flora, and bronch
could not be performed due to hypoxia/high PEEP requirement.
.
CXR and clinical picture began to stablize/improve by [**7-27**].
There was concern that weaning from ventilation was being
limited by ET tube placement and/or obstruction with secretions,
bronchoscopy was performed on [**7-27**], with the removal of thick
secretions but no frank ET obstruction. An associated BAL
revealed >100,000 yeast but no other microorganisms, although he
had already received multiple abx doses by the time of the BAL.
By [**8-3**], Bactrim was decreased to prophylactic dosing and
prednisone was tapered off. MAC prophylaxis with Azithromycin
was started on [**8-4**].
.
PEEP was difficult to wean, but by [**7-29**], tracheostomy and g-tube
were placed. His respiratory status and CXRs were stable to
improved until he spiked a fever on [**8-3**]. CXR on [**8-5**] slight
improvement in the atelectasis/airspace opacities in the LLL and
with stable multifocal airspace opacities in the remaining
lungs. Sputum cultures from [**8-3**] grew sparse oropharyngeal
flora, and cx from [**8-5**] was pending. Given that the CXR
opacities could also represent pulmonary edema, an echo was
ordered for [**8-5**]. Upon call out from MICU, patient was breathing
well with trach and trach mask in place. Patient had routine
nebulized Albuterol/Ipratropium and respiratory therapy/care
while on the floor. He also had chest physical therapy while on
the floor. Patient continued to saturate well (99-100% on
humidified Trach Mask) on the floor.
- Patient continues to saturate well with humidified trach
mask/trach in place.
- Continue chest physical therapy
- Continue Albuterol and Ipratropium nebulizers q6hrs
.
# SEDATION/AGITATION MANAGEMENT: Intubated on [**7-11**] with Fentanyl
and Midazolam. Propofol and Cisatracurium were added on [**7-12**] due
to inadequate sedation; these agents were discontinued on [**7-13**].
Subsequent dysynchrony resolved with increased sedation. Zyprexa
was started on [**7-23**] for agitation. Sedation became greatly
limited by episodic tachycardia and HTN in the setting of
anxiety and agitation, requiring intermittent restarting/
discontinuing of Fentanyl drip and frequent adjustment/bolus
doses of Midazolam, Methadone, and Zyprexa doses. Maximum dose
of Zyprexa was reached, so it was discontinued and Quetiapine
was started. Diazepam NG was added to enable weaning from
Midazolam drip, all with moderate success. Clonidine was added
for duel function as antihypertensive and sedative. Adequate
anti-anxiety/agitation control was achieved with Midazolam
boluses prn and standing Quetiapine, Diazepam, Clonidine, and
Methadone by [**8-5**]. Upon call out from the MICU, patient
continued to elicit anxiety. Of note, he was continued on
albuterol nebulizers throughout this time. His anxiety was
managed with Diazepam 7mg qHS/5mg q12hrs PRN, Fluoxetine 10mg
daily, Seroquel 75mg qHS/25mg qHS PRN.
- Continue Diazepam 7mg qHS/5mg q12hrs PRN, Fluoxetine 10mg
daily, Seroquel 75mg qHS/25mg qHS PRN
.
# FEVER/TACHYCARDIA/LEUKOCYTOSIS: T102, HR 124, WBC 12.4 (WBC 21
on [**7-11**])meeting SIRS criteria on [**7-12**], as per above. The likely
etiology was secondary pneumona vs. worsening PCP, [**Name10 (NameIs) **] no clear
source was isolated. He experienced episodes of hypotension
requiring pressors. Antibiotics were extended to cipro,
cefepime, and vancomycin and extraneous lines were removed. His
abx coverage was decreased to just vancomycin after blood
culture from [**7-12**] grew out 1 bottle of coag negative staph, but
vanco was discontinued on [**7-18**] due to the low suspicion for
CoNSA bacteremia in stable clinical setting. WBC were within
normal limits by [**7-15**], but he continued to spike intermittent
fevers, including up to 104 on [**7-24**] resulting in extraction of
PICC line, all associated with negative blood cultures. The
etiology of these spikes was thought to be due to underlying HIV
in the setting of low WBC.
.
Spike to T 101 on [**8-3**] prompted blood cx, urine cx, sputum cx,
and C. difficile (UCx negative, all others pending.) CXR from
[**8-5**] showed stable to improving parenchymal opacities. Abdominal
CT was also performed on [**8-5**] given elevated liver and
pancreatic enzymes, and prelim read showed no acute abdominal
processes.
.
Blood cultures were negative from [**2118-7-5**], [**7-15**], [**7-16**], [**7-17**], [**7-21**],
[**7-24**], 8/17,[**7-30**] with BCx from [**8-3**] and [**8-5**] pending. Blood
culture for fungus and AFB were negative on [**7-21**]. Urine cultures
performed with temp spikes were persistently negative, last on
[**8-3**]. Stool samples have been consistently negative for C.
difficile (last negative on [**9-16**] pending); microsporidium,
cryptosporidium, giardia (last on [**7-23**]); salmonella, shigella,
campylobacter (last on [**7-31**]). Stool was negative for ova and
parasites on [**7-23**] and for enteric gram negative rods on [**7-31**].
Cultures for extracted catheters were negative on [**7-24**] and [**7-29**].
Upon call out to the floor from the MICU, patient's foley was
discontinued and urinalysis showed no signs of urinary tract
infection. He did continue to [**Location 69856**] CBC as well as
Stool Culture/Cdiff/O and P sent. Patient was switched from
Bactrim to Atovaquone on [**2196-8-16**] for possible drug fevers with
plans to transition patient to Dapsone. Because there was
concern for metheomoglobulinemia, G6PD labs were ordered first.
At time of discharge, this was still pending, so the switch from
Atovaquone to Dapsone was held until patient sees Dr. [**Last Name (STitle) **] as an
outpatient.
- Will follow-up on Stool Cultures/O and P/Cdiff
- Patient is to follow-up with Dr. [**Last Name (STitle) **] if his low-grade fevers
persist despite being on Dapsone
.
# BP LABILITY: His outpatient regimen of Lisinopril and HCTZ
were held due to the development of hypotension in the setting
of SIRS by [**7-12**]. He required pressors (norepinephrine,
phenylephrine, vasopressin) due to a worsening septic picture.
He was off all pressors by [**7-16**].
He began to develop HTN on [**7-24**], with SBP to 250s systolic and
associated tachycardia to 160s, which normalized of BP following
hydralazine bolus followed by labetalol bolus then labetalol
drip. Head CT on [**7-25**] showed no acute intracranial process
associated with his HTN.
He began to experience hypotensive episodes overnight on [**7-25**]
with MAPs in low 60's in the setting of increased sedation
requirements, antihypertensive medications, and attempts to
optimize respiratory status by maintaining negative fluid
balance. MAPs were improved with IVF and low-dose Levophed,
which was discontinued by [**7-26**].
Attempts to wean sedation resulted in intermittent spikes in BP
and HR, which were somewhat improved after trach placement. He
continued to experience intermittent, volume-responsive drops in
BP while being weaned from sedation. He last received pressors
after a hypotensive episode during GJ-tube placement in the
setting of sedation on [**8-3**]; pressors were discontinued when
sedation was lifted. His blood pressure was subsequently
maintained on Clonidine patch, started [**8-3**], and IVF boluses as
needed for intermittent hypotension in the setting of extensive
autodiuresis. There was concern for possible adrenal
insufficiency given urine sodium wasting and hypotension, with
cortisol from [**8-5**] pending.
.
By the time patient was called out of the MICU, his blood
pressure was stable on Clonidine patch. He was not restarted on
his home medications of HCTZ and Lisinopril.
- Continue Clonidine patch
.
# TACHYCARDIA: The patient was tachycardic to the 120s with
walking [**7-7**]. He was started on IV fluids as he is likely
dehydrated secondary to infection, fever, and dehydration. At
the time of admission to the ICU, his HR was 140s. HR worsened
with fever and anxiety, especially in the setting of the
development of SIRS with fever and tachycardia on [**7-12**]. Improved
when afebrile and with appropriate sedation. Patient remained
borderline tachycardic (HR low 90s) on the floor, after being
called out of the MICU. It was thought this was due to his
inhalers and anxiety component. Patient's inhalers were changed
from 6 puffs to 4, in discussion with Pharmacy, but continued as
standing doses in discussion with attending Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and
Respiratory Therapy.
- Continue above regimen for anxiety. Despite side effect of
tachycardia, patient should continue on Albuterol nebulizers
.
# ANEMIA: Fe-deficiency anemia at presentation. Started on iron
supplementation. However, his Hct continued to drop throughout
his stay from 38.1 at presentation to consistently below 30 by
[**7-12**]. The etiology of his ongoing anemia was low production in
the setting of HIV +/- stress response, frequent phlebotomy, and
subptimal nutrition. On [**7-21**], his peripheral smear was notable
for metamyelocytes typical of HIV, and hematology recommended
that there was no need for bone marrow biopsy given these
results.
.
On [**8-2**], his Hct dropped acutely from 22 to 19.7. The likely
etiology was cumulative effect of the above causes. There were
no signs of acute blood loss or end-organ failure or hemolysis
(LDH and total bilirubin were within normal limits). WBC and
plts also down. He received 1 unit of PRBC with appropriate
increase in Hct to 22 and stable Hct thereafter. His Hct was
25.8 on [**2196-8-15**], which was stable since his call out from MICU.
.
# TRANSAMINITIS. Ddx includes viral hepatitis from HIV +/-
medication effect (Bactrim). LFTs had been chronically elevated
but trending down since [**2193**]. Tylenol levels negative at
admission. Hep serologies show past exposure and current
immunity to HBV and HAV. PCR for CMV was negative on [**7-10**].
Transaminases peaked at ALT 108, AST 106, and alkaline
phosphatase 267 on [**7-29**]. LDH peaked at 503 on [**7-17**] and again at
407 on [**7-25**], and stabilized thereafter to admission level. Tbili
remained within normal limits throughout. Liver and gallbladder
ultrasound showed no focal liver abnormalities and a normal
gallbladder on [**7-11**] but gallbladder wall irregularity at the
level of the fundus, potentially respresenting HIV
cholangiopathy, was noted on [**7-22**]. CT on [**7-18**] and [**7-25**]
identified a small amount of sludge vs. small stones in the
gallbladder, but by [**7-27**], there continued to be no convincing
ultrasound evidence of acute cholecystitis or biliary ductal
dilatation. Given elevated lipase, an abdominal CT was performed
on [**8-5**] was (prelim read) negative as per above. Tylenol use was
minimized at 2-3g. doses as needed for fever.
.
# ELEVATED LIPASE: Lipase was within normal limits at the time
of admission but peaked at 389 on [**7-30**] following propofol use in
the setting of extubation. CT of the abdomen on [**7-18**] and [**7-25**]
failed to appreciated pancreatitis. Lipase peaked at 420 again
after GJ tube placement on [**8-3**] (no propofol was used.) Given
frequently elevated lipase and transaminases with negative work
up, further work up was minimized. To assess fevers and elevated
lipase, an abdominal CT was performed on [**8-5**], which was (prelim
read) negative, as per above. After call out from MICU, patient
no longer eliciting abdominal pain. Lipase levels were not
checked. There was a question as to whether his Truvada could be
also contributing to the elevated lipase, which should be worked
up as outpatient in discussion with Infectious Disease.
- Patient is to discuss with Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **] of
Infectious Disease regarding his Truvada as a cause of his
elevated lipase. This can be worked-up as outpatient.
.
# URINE ELECTROLYTES. Urine sodium noted on wasting with Na 163
on [**7-25**] during autodiuresis. FeNA last 1.4 on [**8-4**], with
associated UNa 169 and UOsm 485. Creatinine WNL, good UOP.
Unclear etiology at this point, potentially due to solute
diuresis. As per above, there was concern for adrenal
insufficiency in the setting of low BP, but patient was ruled
out with cortisol stimulation test.
.
# ANXIETY: likely [**1-11**] new diagnosis. Subsequent difficulty
sleeping. SW consult, Klonopin started. Anxiety resulted in
difficulty weaning vent and sedation. As per above, adequate
anti-anxiety/agitation control was achieved with Midazolam
boluses prn and standing Quetiapine, Diazepam, Clonidine, and
Methadone by [**8-5**]. Patient was continued on Diazepam 7mg qHS/5mg
q12hrs PRN, Fluoxetine 10mg daily, Seroquel 75mg qHS/25mg qHS
PRN while on the floor.
- Continue anxiolytic regimen per above
.
# POOR GI MOTILITY: NG tube with tube feeds were initiated
following intubation. High tube feed residuals with no BM were
noted by [**7-14**]. A bowel regimen including lactulose enema was
given, producing a bowel movement by [**7-16**]. A post-pyloric Dobhoff
was placed on [**7-18**]. Tube feeds were resumed [**7-20**] but TF material
was found coming from his mouth the same day, and NG suction
revealed 450 cc residuals. Imaging revealed that the Dobhoff was
not post-pyloric and lipase increased, so TPN was started on
[**7-23**] ending tube advancement. After Dobhoff was advanced, tube
feeds were restarted on [**7-26**] and slowly advanced without
significant residuals. Given his history of poor GI motility and
high tube feed residuals with pre-pyloric feeds, GJ tube was
placed on [**8-3**], with tube feeds started on [**8-4**]. Speech and
Swallow evaluation on [**2196-8-16**] cleared patient for Thin Liquids,
Regular Solids with re-evaluation by nutrition and
speech/swallow as outpatient when patient can be weaned off his
G-tube.
- Continue TPN until can be weaned
- Continue Thin Liquids/Regular Solids Diet
- Patient can take pills whole with water or in puree
- Nutrition Consult and Speech and Swallow Eval when weaning
patient off PEG tube
- Continue oral care every 8 hours
.
# HIV: New diagnosis of HIV during this admission. Viral load
61,600 copies on [**7-8**]. Started on darunavir, ritonavir, and
truvada on [**7-30**], with stable LFTs. When ARDS picture improved,
bactrim was dosed at prophylactic doses for PCP [**Last Name (NamePattern4) **] [**8-3**], and
azithromycin prophylaxis for MAC were started. Patient was
switched from bactrim to dapsone on [**2196-8-16**] after concerns that
the bactrim was causing drug fever. Patient is to follow-up with
Dr. [**First Name (STitle) **] [**Name (STitle) **] in Infectious Disease as well as Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
- Continue Darunavir, Ritonavir and Truvada.
- Patient is to follow-up with Drs [**First Name (STitle) **] [**Name (STitle) **] and [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
.
# FEN: GJ-tube placement with TFs started on [**8-4**]. Electrolytes
repleted as needed, as per above. Glycemic control was
discontinued due to glucose levels consistently <150. Speech and
Swallow evaluated the patient prior to MICU call out and felt he
was not yet stable to take anything by mouth. They cleared him
on [**2196-8-16**] as per above.
- Continue TPN until patient can be weaned
- Continue Thin Liquids/Regular Solids Diet
- Patient can take pills whole with water or in puree
- Nutrition Consult and Speech and Swallow Eval when weaning
patient off PEG tube
- Continue oral care every 8 hours
.
# PPX: heparin SC, pneumoboots.
.
# CODE: Full
Medications on Admission:
Lisinopril 40mg daily
HCTZ 25mg daily
Azithromycin (started Sunday)
Been using tylenol 2 tablets every 2-3 hours
Discharge Medications:
1. Folic Acid 1 mg Tablet [**Date Range **]: One (1) Tablet PO DAILY (Daily).
2. Docusate Sodium 50 mg/5 mL Liquid [**Date Range **]: Ten (10) mL PO BID (2
times a day).
3. Lactulose 10 gram/15 mL Syrup [**Date Range **]: Thirty (30) ML PO Q12 ()
as needed for constipation.
4. Chlorhexidine Gluconate 0.12 % Mouthwash [**Date Range **]: Fifteen (15) ML
Mucous membrane [**Hospital1 **] (2 times a day).
5. Nystatin 100,000 unit/mL Suspension [**Hospital1 **]: Five (5) ML PO QID
(4 times a day).
6. Oxycodone 5 mg/5 mL Solution [**Hospital1 **]: Five (5) mL PO Q4H (every 4
hours) as needed for for pain.
7. Fluoxetine 10 mg Capsule [**Hospital1 **]: One (1) Capsule PO DAILY
(Daily).
8. Acetaminophen 160 mg/5 mL Solution [**Hospital1 **]: 325-650 mg PO Q6H
(every 6 hours) as needed for fevers or pain.
9. Lidocaine HCl 10 mg/mL (1 %) Solution [**Hospital1 **]: 2.5 MLs Injection
DAILY (Daily) as needed for hiccups.
10. Diazepam 2 mg Tablet [**Hospital1 **]: 3.5 Tablets PO HS (at bedtime).
11. Ritonavir 80 mg/mL Solution [**Hospital1 **]: 1.25 mL PO DAILY (Daily).
12. Clonidine 0.1 mg/24 hr Patch Weekly [**Hospital1 **]: One (1) Patch
Weekly Transdermal QWED (every Wednesday).
13. Azithromycin 600 mg Tablet [**Hospital1 **]: Two (2) Tablet PO 1X/WEEK
(WE): Infection (MAC) prophylaxis until CD4 count >200.
14. Emtricitabine-Tenofovir 200-300 mg Tablet [**Hospital1 **]: One (1)
Tablet PO DAILY (Daily).
15. Darunavir 400 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY
(Daily).
16. Quetiapine 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO HS (at
bedtime) as needed for agitation.
17. Quetiapine 25 mg Tablet [**Hospital1 **]: Three (3) Tablet PO QHS (once a
day (at bedtime)).
18. Fluconazole 200 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q24H (every
24 hours) for 2 weeks: Until [**2196-8-24**] for full 2 week course.
19. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR PO BID (2 times a day).
20. Diazepam 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q12H (every 12
hours) as needed for anxiety.
21. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension [**Last Name (STitle) **]:
15-30 MLs PO QID (4 times a day) as needed for heartburn.
22. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Last Name (STitle) **]: Four (4) puffs Inhalation Q6H (every 6 hours)
as needed for shortness of breath or wheezing.
23. Ipratropium Bromide 0.02 % Solution [**Last Name (STitle) **]: Four (4) puffs
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
24. Dapsone 100 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary: Pneumocystis (carinii) jiroveci Pneumonia, HIV/AIDS
Secondary: Hypertension
Discharge Condition:
Improved. Vital signs are stable. Patient's respiratory status
is stable.
Discharge Instructions:
-You were admitted with fevers/chills and developed respiratory
difficulties. You were diagnosed with Pneumocystic jiroveci
pneumonia (PJP, formerly known as PCP) and HIV/AIDS. During your
stay in the MICU, you required intubation and medications to
maintain your blood pressure. You have since been treated for
PJP pneumonia and started on HIV/AIDS medications. You have been
given a tracheostomy for breathing and PEG tube for nutrition.
-It is important that you continue to take your medications as
directed. We made the following changes to your medications
during this admission:
START:
For HIV/AIDS
* Emtricitabine-Tenofovir (200-300 mg Tablet) once daily
* Darunavir 800 mg daily
* Ritonavir (80 mg/mL Solution) 1.25 mL (100mg) daily
For MAC/PJP(PCP)/[**Female First Name (un) 564**] prophylaxis
* Azithromycin 1200 mg weekly, every Wednesday: For infection
(MAC) prophylaxis until CD4 count >200
* Fluconazole 200 mg Tablet daily for 2 weeks (until [**2196-8-24**])
* Dapsone 100mg daily
For oral thrush -
* Chlorhexidine Gluconate (0.12 % Mouthwash) 15 mL oral swish
twice daily
* Nystatin (100,000 unit/mL Suspension) 5 mL four times oral
swish four times a day
For anxiety
* Fluoxetine 10 mg Capsule daily
* Quetiapine 75mg by NG tube before bedtime daily
* Diazepam 7 mg at bedtime
* Quetiapine 25 mg Tablet before bed as needed for anxiety
* Diazepam 5 mg twice daily as needed for anxiety
For hypertension
* Clonidine (0.1 mg/24 hr) patch weekly, every Wednesday
For respiratory/breathing
* Albuterol Sulfate (0.083% Solution for Nebulization) 4 puffs
every 6 hours * Ipratropium Bromide (0.02 % Solution for
Nebulization) 4 puffs every 6 hours
For pain
* Oxycodone (5 mg/5 mL Solution) 5 mL every 4 hours as needed
for pain
* Acetaminophen (liquid) 325-650mg every 6 hours as needed for
pain (not to exceed 2 grams daily for liver health)
Other meds:
* Folic Acid 1 mg Tablet daily
* Lansoprazole (30 mg Tablet, Rapid Dissolve) twice daily for
heartburn
.
-Contact your doctor or come to the Emergency Room should your
symptoms return. Also seek medical attention if you develop any
new fever, chills, trouble breathing, chest pain, nausea,
vomiting or unusual stools.
Followup Instructions:
Please make an appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] within 1-2 weeks.
You can reach his office at: ([**Telephone/Fax (1) 3346**].
Location: [**Location (un) **]. [**Location (un) **], [**Numeric Identifier 4774**]
** Please discuss with Dr. [**Last Name (STitle) **] if you continue to have
low-grade fevers on Dapsone. You were switched from Bactrim to
Dapsone because of concern that the Bactrim was causing your
low-grade fevers (drug fever).
** Please discuss whether your Truvada is elevating your lipase
(a measurement of your pancreas function)
.
Please also make an appointment within 1-2 weeks to see Dr. [**First Name (STitle) **]
[**Name (STitle) **] in Infectious Disease. She has been following you during
this admission and you can reach her office at: ([**Telephone/Fax (1) 4170**]
** Please discuss with Dr. [**Last Name (STitle) **] if you continue to have
low-grade fevers on Dapsone. You were switched from Bactrim to
Dapsone because of concern that the Bactrim was causing your
low-grade fevers (drug fever).
** Please discuss whether your Truvada is elevating your lipase
(a measurement of your pancreas function)
.
You have an appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in Internal
Medicine on [**10-17**] at 11:00 am. You can reach his office at:
[**Telephone/Fax (1) 7477**].
.
You also have an appointment with Dr. [**First Name (STitle) **] [**Name (STitle) 7376**] in Orthopedic
Surgery on [**10-20**] at 9:30am. You can reach their office at:
[**Telephone/Fax (1) 1228**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]
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49,603
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Discharge summary
|
report
|
Admission Date: [**2123-3-15**] Discharge Date: [**2123-3-17**]
Date of Birth: [**2084-5-13**] Sex: M
Service: MEDICINE
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 8487**]
Chief Complaint:
AMS
Major Surgical or Invasive Procedure:
Lumbar Puncture
History of Present Illness:
39 y/o M with PMH of type 1 DM, depression, and bipolar who is
brought in by EMS with altered MS. [**Name13 (STitle) **] is unable to give
history. Per ED history the patient was feeling poorly for the
last few days. His family reports that he felt like he had the
flu on sat. night, however they are unable to give further
history. Per the ED the patient has had diarrhea and vomiting as
well as cough over last few days, however the family is unable
to verify this information. His family was unable to get a hold
of him this afternoon and a friend went over to check on him. He
was found to be confused and brought to the ED for further
evaluation.
On arrival to the ED VS were T 102, HR 120, BP 166/86 RR 22 100%
on unknown amount of oxygen. He was found to be confused and
agitated and was intubated for airway protection. He was given
fentanyl 100mcg, Etomidate 20mg, succ 120mg IV and vecuronium
100mg IV. He was noted to have L gaze deviation and R beating
nystagmus. LP was performed that showed 9500 WBC (91% polys),
250 RBC, 1140 prot and glu 6. He was given dexamethasone 10mg
IV, acyclovir 700mg IV, ampicillin 2gm IV, vancomycin 1gm IV and
ceftriaxone 2gm IV. He also received 4L IVF, versed 2mg IV x 3,
tylenol 1gm, propofol gtt and insulin gtt. Neuro was consulted
given his neuro findings. Head CT showed no acute bleed and
prominant ventricles. CTA head was normal. Labs were notable for
WBC 21.8 with 8% bands and INR 1.8. Glu was elevated to 522. He
was admitted to the ICU for further management.
On arrival to the ICU the patient is intubated and sedated. ROS
is unable to be obtained. Noted to be tachycardic to 160s and
hypertensive to 227/111. T was 101.9. He was given 5mg IV
labetolol , tylenol and continued on IVF.
Past Medical History:
IDDM since age 3
Depression, h/o suicide attempt 2 years ago by hanging
CRI, unknown baseline
Bipolar
recent back injury
Social History:
Married, separated from wife. Have 10 year old child. Lives
alone in [**Location (un) 745**]. Previously worked as mechanic, out of work due
to back injury. Current smoker, 1ppd x 20+ years. H/o oxycodone
and EtOH abuse, has been sober for over 2 years. No h/o IVDU.
Family History:
mother - bipolar
[**Name (NI) 9876**] - DM
Physical Exam:
On admission
VITAL SIGNS: T 101.9 BP 227/111 HR 126 RR 19 O2 100% on vent
GENERAL: Intubated, sedated
HEENT: superficial abrasions on forehead, pupils non-reactive,
R>L. No conjunctival pallor. No scleral icterus. ETT and OG tube
in place.
CARDIAC: Tachy, irregular, No murmurs, rubs or [**Last Name (un) 549**] audible.
LUNGS: CTA anteriorly
ABDOMEN: NABS. Soft, ND. No HSM
EXTREMITIES: No edema, 2+ dorsalis pedis/ posterior tibial
pulses, R elbow with surrounding erythema and possible effusion
SKIN: No rashes, multiple tattoos, no rash
NEURO: Sedated, babinski unequivocal, pupils unreactive,
withdraws to painful stimuli.
Pertinent Results:
[**2123-3-17**] 07:42AM BLOOD WBC-22.0* RBC-3.72* Hgb-10.9* Hct-33.8*
MCV-91 MCH-29.2 MCHC-32.3 RDW-14.3 Plt Ct-236
[**2123-3-15**] 09:41PM BLOOD Neuts-53 Bands-43* Lymphs-2* Monos-0
Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-0
[**2123-3-16**] 04:03PM BLOOD PT-15.5* PTT-26.8 INR(PT)-1.4*
[**2123-3-16**] 03:23AM BLOOD Fibrino-638*
[**2123-3-15**] 09:41PM BLOOD FDP-40-80*
[**2123-3-17**] 07:42AM BLOOD Glucose-246* UreaN-23* Creat-1.2 Na-162*
K-3.8 Cl-132* HCO3-25 AnGap-9
[**2123-3-16**] 03:23AM BLOOD ALT-18 AST-26 LD(LDH)-190 CK(CPK)-220*
AlkPhos-45 TotBili-0.4
[**2123-3-16**] 03:23AM BLOOD CK-MB-7 cTropnT-0.14*
[**2123-3-17**] 07:42AM BLOOD Calcium-9.0 Phos-2.9 Mg-2.3
[**2123-3-15**] 09:41PM BLOOD Hapto-267*
[**2123-3-17**] 07:42AM BLOOD Osmolal-340*
[**2123-3-15**] 02:15PM BLOOD Ammonia-64*
[**2123-3-15**] 02:15PM BLOOD Acetone-TRACE
[**2123-3-15**] 02:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2123-3-15**] 02:30PM BLOOD Glucose-498* Lactate-7.4*
[**2123-3-15**] 06:35PM BLOOD freeCa-1.11*
[**2123-3-15**] 05:14PM CEREBROSPINAL FLUID (CSF) WBC-9500 RBC-250*
Polys-91 Lymphs-2 Monos-7
[**2123-3-15**] 05:14PM CEREBROSPINAL FLUID (CSF) TotProt-1140*
Glucose-6
[**2123-3-15**] 05:14PM CEREBROSPINAL FLUID (CSF) CYTOMEGALOVIRUS -
PCR-Test
[**2123-3-15**] 05:14PM CEREBROSPINAL FLUID (CSF) HERPES SIMPLEX VIRUS
PCR-PND
[**2123-3-15**] 02:15PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.031
[**2123-3-15**] 02:15PM URINE Blood-LG Nitrite-NEG Protein-TR
Glucose-1000 Ketone-50 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2123-3-15**] 02:15PM URINE RBC-[**2-25**]* WBC-0-2 Bacteri-FEW Yeast-NONE
Epi-0
Brief Hospital Course:
39 y/o M with PMH of type 1 DM, depression, and bipolar who is
brought in by EMS with altered MS, found to have pneumococcal
meningitis.
#. Meningitis: Pt's initial presentation was that of DKA and
altered mental status. He had focal neurologic changes on exam
as well as increased ICP on LP. Lumbar puncture and preliminary
blood cultures confirmed pneumococcal meningitis. Etiology of
this was unknown, as pt and family denied any drug use and had
negative tox screen, but pt was likely predisposed to severe
infection due to longstanding diabetes type 1. He was
intubated, treated with pressors, dexamethasone, vancomycin,
ampicillin, ceftriaxone and acyclovir and was followed by ID and
neuro. Head CT showed severe intracranial edema and EEG showed
no signs of seizure. Given pt's severe meningitis and
displacement of grey-white junction, central DI (sodium to
160s), hypothermia, lack of reflexes, pt was though to have
minimal likelihood of recovery. He was evaluated by the organ
bank, who ruled him out as a donor given his high risk
bacteremia. Family was informed and after parents arriving, pt
was made CMO and extubated. He passed away from pulmonary arrest
at 3:10pm on [**3-17**]. Autopsy was offered but refused.
Medications on Admission:
Insulin, unknown
Zestril, unknown dose
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Pneumococcal Meningitis
Discharge Condition:
Deceased
Discharge Instructions:
None
Followup Instructions:
None
Completed by:[**2123-3-17**]
|
[
"403.90",
"585.9",
"V66.7",
"272.4",
"286.9",
"584.9",
"250.33",
"327.23",
"296.80",
"427.0",
"320.1",
"780.65"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"38.91",
"03.31",
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
6285, 6294
|
4930, 6166
|
300, 317
|
6361, 6371
|
3250, 4907
|
6424, 6459
|
2538, 2583
|
6256, 6262
|
6315, 6340
|
6192, 6233
|
6395, 6401
|
2598, 3231
|
257, 262
|
345, 2093
|
2115, 2238
|
2254, 2522
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,805
| 143,452
|
36791
|
Discharge summary
|
report
|
Admission Date: [**2140-8-20**] Discharge Date: [**2140-9-20**]
Date of Birth: [**2083-3-17**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
57M assaulted and stabbed in the back who presented to [**Hospital1 18**]
unconscious. He was coded in the ED and taken to the operating
room for exploration.
Major Surgical or Invasive Procedure:
[**2140-8-20**] Exploratory laparotomy w/ liver packing; right
thoracosotmy. Re-exploration and left arm faciotomy.
[**2140-8-22**] Unpacking of liver and closure w/ [**State 19827**] patch.
[**2140-8-29**] Closure of abdomen, liver biopsy and placment of G-J
tube.
[**2140-9-2**] Tracheostomy for prolonged respiratory toilet.
History of Present Illness:
This was an unidentified Asian male who entered via the
emergency room on the night of [**2140-8-19**] after suffering what
appeared to be a single stab wound to the right midback. He
apparently had called 911 on his own. He was alive when he was
initially encountered by the paramedics but en route he lost all
vital signs. He had been asystolic for at least 2 to 4 minutes,
receiving closed chest compressions when he arrived in the
emergency room. He was coded in the ED requiring 4 units of
blood and taken to the operating room for exploration.
Thoracotomy and exploratory laparotomy found diaphragm injury.
During the ex-lap, his liver was described as having a
"micronodular appearance. The liver was completely intact. The
gallbladder and porta were intact." His abdomen was left open
and packed. His course was complicated by right hemothorax with
pulmonary vein compression, shock bowel, and left hand
compartment syndrome. His left hand compartment syndrome
required fasciotomies and carpal tunnel release on [**2140-8-20**]. He
also became septic from Ventilator Associated Pneumonia (VAP)
from [**8-23**] until [**8-26**] with sputum and BAL growing Ecoli, and
negative blood cultures. On [**2140-9-2**] he had a tracheostomy
performed for prolongued respiratory toilet.
Past Medical History:
Asthma
Hepatitis B positive
Alcohol abuse
Social History:
Lives in [**State 760**], no health insurance, married, lives with
his wife who will manage his care until he will follow up in
clinic.
Family History:
non contributory
Physical Exam:
PHYSICAL EXAM upon discharge:
O: T:98.7 BP: 105/65 HR:83 R 16 O2Sats 96% R/A
Gen: WD/WN, comfortable, NAD.
HEENT: NCAT
Pupils: 4mm to 2mm bil. round, brisk reaction EOMs: full.
No nystagmus. scleral icterus
Neck: Supple, healing trach wound, almost closed
Lungs: CTA bilaterally (anterior fields).
Cardiac: RRR. no murmurs
Abd: Soft,flat, NT, BS+
Extrem: Warm and well-perfused. Left arm with multiple healing
wounds and incrustations.
Neuro:
Mental status: Awake and alert x3 , cooperative with exam.
Normal
affect. Orientation: Oriented to person, place, and date.
Pertinent Results:
[**2140-8-20**] 09:13PM GLUCOSE-123* UREA N-7 CREAT-0.4* SODIUM-144
POTASSIUM-4.5 CHLORIDE-114* TOTAL CO2-23 ANION GAP-12
[**2140-8-20**] 09:13PM CALCIUM-8.7 PHOSPHATE-4.6* MAGNESIUM-1.6
[**2140-8-20**] 09:13PM WBC-1.6* RBC-3.79* HGB-11.3* HCT-31.8* MCV-84
MCH-29.9 MCHC-35.7* RDW-14.6
[**2140-8-20**] 09:13PM PLT COUNT-104*
[**2140-8-20**] 09:13PM PT-13.7* PTT-39.6* INR(PT)-1.2*
[**2140-8-20**] 08:38PM TYPE-ART RATES-20/ PEEP-8 PO2-107* PCO2-35
PH-7.37 TOTAL CO2-21 BASE XS--3 INTUBATED-INTUBATED
VENT-CONTROLLED
[**2140-8-20**] 08:38PM freeCa-1.18
[**2140-8-20**] 06:36PM TYPE-ART PO2-147* PCO2-42 PH-7.34* TOTAL
CO2-24 BASE XS--2
[**2140-8-20**] 06:36PM LACTATE-4.0*
[**2140-8-20**] 06:30PM GLUCOSE-124* UREA N-7 CREAT-0.5 SODIUM-146*
POTASSIUM-4.6 CHLORIDE-116* TOTAL CO2-22 ANION GAP-13
***
[**2140-8-20**]: Chest/Abd/Pelvis CT with contrast: Large right-sided
hemothorax with area of active extravasation likely coming from
either the diaphragm or a right-sided erector spinae vessel.
Leftward mild shift of mediastinal structures with compression
of the pulmonary veins. 2. Areas of active
extravasation from liver injury and associated intraperitoneal
hematoma. 3. Hyperenhancing bowel concerning for shock bowel.
[**2140-8-26**]: Abd/Pelvis CT with contrast - Focally thick walled,
markedly edematous small bowel. Findings may represent small
bowel ischemia, although other considerations include focal
enteritis. No pneumatosis or portal venous gas. 2. Open
abdominal wall. The small bowel distal to the edematous bowel
abuts the mesh material anteriorly. 3. Small focus of high
density posterior to the liver adjacent to packing material.
Adjacent hematoma is similar in size to the initial CT. 4.
Intermediate density perihepatic fluid about the dome and
posterior liver with small foci of gas. This may be developing
fluid collection or abscess or packing material. 6. Linear
hypodensity of the right hepatic lobe concerning for laceration.
7. Bibasilar pulmonary opacities with tree-in-[**Male First Name (un) 239**] pattern at the
right lung base concerning for infection/aspiration. 8. Small
bilateral pleural effusions.
[**2140-9-1**]: Chest/Abd/Pelvis CT with contrast - Diffuse ground-glass
opacities with areas of consolidation, consistent with acute
respiratory distress syndrome (ARDS). 2. Interval improvement in
perihepatic fluid.
[**2140-9-6**]: CXR - Tracheostomy and left subclavian catheters remain
in place. Diffuse areas of airspace consolidation are seen
bilaterally, again consistent with multifocal pneumonia.
Indistinctness of pulmonary vessels suggests some elevated
pulmonary venous pressure, possibly related to overhydration.
[**2140-9-15**] 1:47 PM SWALLOWING VIDEOFLUOROSCOPY: Oropharyngeal
swallowing videofluoroscopy was performed in conjunction with
the speech and swallow division. Multiple consistencies of
barium were
administered. Barium passed freely through the oropharynx and
esophagus
without evidence of obstruction. There was no gross aspiration
or
penetration.
Brief Hospital Course:
HPI: 57M assaulted and stabbed in the back. He presented to
[**Hospital1 18**] unconscious. He was coded in the ED and taken to the
operating room for exploration. Bilateral chest tube were
placed and liver injury was packed during exploratory laparotomy
on [**2140-8-19**]. His initial course was complicated by left hand
compartment syndrome, right hemothorax with pulmonary vein
compression and shock bowel.
Upon arrival to the TSICU, it was noted that his hand was
edematous and dusky.
On serial examinations, his hand became more edematous and had
open bullae which were draining serous fluid. Plastic surgery
was involved and recommended fasciotomies of his left hand and
forearm when surgery planned to re-explore and re-pack his
abdomen. This procedure took place on [**2140-8-20**]. Surgical notes
noted a large amount of blood in the liver, likely as a result
of hepatic venous injury or hepatic injury that had been
previously undetected. The liver appeared cirrhotic but intact.
Plastic hand surgery performed a compartmental release with
fasciotomies. Over the course of the first 5 postoperative days
the patient received more than 20 PRBCs plus FFP.
He remained intubated in the SICU. His abdominal wound remained
open until [**2140-8-22**] and was subsequently closed with a [**State 19827**]
patch. During the course of his SICU stay, the patient was
febrile with altered mental status and sepsis requiring
phenylephrine. Infectious workup was done and yielded gram
negative rods on BAL. Hepatitis serology showed hepatitis B
infection. He had interval placement of J and G-tube for
nutrition. The patient was extubated on [**2140-8-31**] but then
re-intubated on [**2140-9-1**] because of increased O2 requirement.
For long term ventilation, trach consent was obtained and trach
was placed on [**2140-9-2**]. He still had fever spikes in the ICU
which did not show an obvious source of infection. Empiric
antibiotic therapy was discontinued per ID consult on [**2140-9-9**].
The patient was transferred to the floor [**2140-9-13**] and exhibited
a stable condition. He underwent video swallow studies upon
arrival to the floor which showed improved swallow function and
by time of discharge he was tolerating oral food well.
Mr. [**Known firstname **] [**First Name8 (NamePattern2) **] [**Known lastname **] underwent extensive rehab placement search.
Because of his none health insurance status he was finally
discharged on [**2140-9-21**] to his home in [**State 760**]. Follow up
appointments are planned at our clinic for next week.
Discharge Medications:
1. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) ML's PO BID
(2 times a day).
Disp:*200 ml* Refills:*0*
2. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime as
needed for constipation.
Disp:*20 Tablet(s)* Refills:*0*
3. Clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QWED (every Wednesday) for 2 weeks.
Disp:*2 Patch Weekly(s)* Refills:*0*
4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*20 Tablet(s)* Refills:*2*
5. Methadone 5 mg Tablet Sig: One (1) Tablet PO see other
instructions for 5 days: Methadone 5mg
[**2140-9-20**] 10mg TID
[**2140-9-21**] 5mg TID
[**2140-9-22**] 5mg TID
[**2140-9-23**] 5mg [**Hospital1 **]
[**2140-9-24**] 5mg [**Hospital1 **]
[**2140-9-25**] 5mg once
then discontinue.
Disp:*15 Tablet(s)* Refills:*0*
6. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO four times
a day as needed for pain for 2 weeks.
Disp:*30 Tablet(s)* Refills:*0*
7. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
s/p Multiple stab wound assault with
-Myocardial injury
-Compartment syndrome left hand
-Right pneumothorax
-Liver injury
Discharge Condition:
Hemodynamically stable, pain adequately controlled.
Discharge Instructions:
Wound care: You should not shower until your follow-up
appointment with Dr. [**Last Name (STitle) **]. This is to keep your abdominal wound
dry. You have been instructed on proper wound care. Please
continue to care for your wounds as directed.
Abdominal wound: Please clean with saline and put on gauze -
moist to dry as instruced by your nurse. Please change your
dressing twice a day.
Left arm/hand: Daily dressing changes with Xeroform to wound on
back of hand and on forearm volar side. Please continue to
exercise your left arm - aggressive physical therapy for left
arm in full range of motion (elbow, wrist, fingers) at least 10
minutes 3 times a day.
Please take your medications as prescribed until your follow-up
appointments.
Please call your doctor or return to the hospital if you
experience any of the following: signs and symptoms of
infection, including fevers, chills, increased redness,
swelling, discharge from your wounds, chest pain, shortness of
[**Last Name (LF) 1440**], [**First Name3 (LF) 691**] nausea or vomiting or any other symptoms that you
may find concerning.
Followup Instructions:
You have agreed that you will return to [**Hospital1 **] to
follow-up for your injuries. Please follow-up below as
directed:
LIVER:
It is important that you follow up with the liver clinic. You
should call ([**Telephone/Fax (1) 1582**] to make an appointment with Dr.
[**Last Name (STitle) 497**]. You should make this appointment to be within 2 weeks
after your discharge.
PLASTICS:
It is important that you follow up with the Plastics Hand
clinic. You should call [**Telephone/Fax (1) 3009**] to make this appointment
for next week. They have clinic during Tuesdays. It is
important that you contact them as soon as possible after your
discharge to make an appointment for next Tuesday. They are
aware of your case.
TRAUMA:
You should follow up with Dr. [**Last Name (STitle) **], the trauma surgeon within
one week from your discharge. This is to follow up for your
hospitalization as well as to remove your G-tube. It is
important that you call [**Telephone/Fax (1) 600**] as soon as possible to
schedule this appointment. If possible, try to obtain an
appointment next Tuesday so that you can overlap with your
plastics outpatient appointment.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
Completed by:[**2140-9-20**]
|
[
"E966",
"995.91",
"958.4",
"998.59",
"759.6",
"511.9",
"868.13",
"860.3",
"998.32",
"459.2",
"958.91",
"E878.8",
"876.0",
"038.9",
"864.11",
"E849.7",
"576.8",
"875.0",
"518.81",
"354.0",
"E849.8",
"070.30",
"997.31",
"862.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"96.72",
"54.62",
"44.39",
"96.6",
"37.12",
"38.91",
"99.60",
"34.04",
"50.12",
"33.24",
"83.14",
"31.1",
"04.43",
"39.98",
"54.61",
"96.04",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
9706, 9712
|
6054, 8626
|
475, 808
|
9890, 9944
|
2986, 6031
|
11090, 12410
|
2359, 2377
|
8649, 9683
|
9733, 9869
|
9968, 9968
|
2392, 2392
|
275, 437
|
2422, 2841
|
9980, 11067
|
836, 2123
|
2856, 2967
|
2145, 2188
|
2204, 2343
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,384
| 170,995
|
9773
|
Discharge summary
|
report
|
Admission Date: [**2136-6-22**] Discharge Date: [**2136-7-9**]
Date of Birth: [**2099-9-10**] Sex: F
Service: SURGERY
Allergies:
Penicillins / Tetracyclines / Succinylcholine / Clozaril /
Calcium Channel Blocking Agents-Benzothiazepines /
Beta-Adrenergic Blocking Agents
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
Infected Hemodialysis femoral catheter
Major Surgical or Invasive Procedure:
Transhepatic Catheter placement
History of Present Illness:
34 y/o female with ESRD secondary to IgA nephropathy who had
been admitted to [**Hospital3 5506**] with fevers. She had
previously been treated for 3 weeks with Bactrim for MRSA
cultured from her femoral catheter site on [**2136-4-21**]. Fevers were
as high as 102.1, in the ER she was 99.5. C/O nausea but no
vomiting, also no CP, SOB, cough or diarrhea. At Hemodialysis
she was found to have pus at the dialysis catheter insertion
site, and received a gram of Vancomycin at dialysis. She was
then transferred to [**Hospital1 18**] for furthermanagement due to past
difficulties with dialysis access management.
Past Medical History:
PAST MEDICAL HISTORY:
1. ESRD due to IgA nephropathy
2. Schizoaffective disorder
3. Depression
4. Anemia
5. GERD
6. Cardiomyopathy
7. Hypothyroidism
8. GI bleed
9. Coagulase negative staph infection
10. RLE DVT
PAST SURGICAL HISTORY:
s/p L upper & lower AV fistula - failed
s/p R AV fisula basilic v transposition - failed
s/p R forearm AV graft - failed
s/p PD catheter '[**27**] - failed
central venous stenosis - R brachiocephalic v.
occlusion of inominate v.
s/p R arm brachial->axilla AV graft ([**2133-10-9**])
s/p thrombectomy & angioplasty of outflow stenosis ([**2133-10-11**])
s/p thrombectomy ([**2133-10-23**])
s/p thrombectomy and revision of R arm AV graft ([**2133-11-12**])
s/p thrombectomy of R arm AV graft ([**2133-11-16**], [**2133-12-15**])
s/p excision of infected R arm AV graft ([**2133-12-25**])
Social History:
Lives at [**Location (un) **] Health and Rehab center, unemployed, no
tobacco, alcohol, or recreational drug use.
Family History:
Non-contributory.
Physical Exam:
VS: 99.3, 144/95, 87, 22, 100% on 2L
Gen: NAD, blank facies, withdrawn but A+Ox3, flat affect
HEENT: MMM, tongue beefy, no erythema in throat
CV: RRR
Lungs: CTA bilaterally
Abd: Soft, non-tender, non-distended
Ext: No C/C/E, warm. Upper extremities bilaterally have scars
from previous access attempts. Right femoral tunneled line in
place with frank pus.
Incisions: Well healed
Pertinent Results:
On Admission: [**2136-6-22**]
WBC-7.8 RBC-2.78* Hgb-9.7* Hct-28.5* MCV-103* MCH-35.0*#
MCHC-34.2 RDW-14.4 Plt Ct-264
PT-15.0* PTT-33.4 INR(PT)-1.3*
Glucose-95 UreaN-45* Creat-7.7*# Na-135 K-3.9 Cl-92* HCO3-27
AnGap-20
Calcium-9.1 Phos-2.5* Mg-2.3
On Discharge:[**2136-7-9**]
WBC-6.3 RBC-2.83* Hgb-9.0* Hct-27.5* MCV-97 MCH-31.7 MCHC-32.7
RDW-18.3* Plt Ct-279
PT-33.2* PTT-36.7* INR(PT)-3.6*
Glucose-78 UreaN-29* Creat-6.6*# Na-134 K-4.1 Cl-100 HCO3-24
AnGap-14
Calcium-8.2* Phos-2.7 Mg-2.4
Brief Hospital Course:
Patient admitted with infected femoral hemodialysis catheter.
She received hemodialysis T-TH-S at the [**Hospital **] [**Hospital **] clinic.
CT examination of the abdomen and pelvis revealed no suspicious
areas of abscess collection.
A Left femoral temporary line was placed for hemodialysis and
she was started on IV Vanco and Gentamycin. She continued with
fevers as high as 103.4.
An ECHO was performed and ruled out endocarditis, showing Normal
study, No valvular pathology or pathologic flow identified.
Blood cultures drawn daily, the ones from [**6-24**] grew Staph Coag
Positive and an ID consult was called. Gentamycin was taken off
regimen and daily blood cultures were followed, which have all
been no growth since initial positive culture.
On [**6-27**], the patient was transferred to the SICU for
hypotension, this was following hemodialysis. She received a
bolus and was otherwise okay, ECG was WNL in sinus.
On [**6-29**] she had guaiac positive stool and coffee ground emesis.
[**Hospital1 **] Protonix was started.
Flagyl was added to regimen in addition to the Vanco, for
persistent loose stools.
Patient vasculature was scanned in preparation for line
placement, and extensive clot was found. She started on a
heparin drip and was subsequently converted to Warfarin therapy
with goal inr of 2.0 to 2.5.
On [**2136-7-1**] patient underwent successful placement of a
transhepatic tunneled hemodialysis catheter (14.5 French, 27 cm
cuff to tip) via the left hepatic vein, with tip cranial to the
cavoatrial junction. The catheter was ready for immediate use.
This catheter was used for all subsequent hemodialysis. Flow
rates are listed on Hemodialysis run sheet as 350.
Patient had an episode of SVT, this was following a day on
Levophed for pressure support while in the SICU. Seen by
Cardiology; ECHO performed on [**7-4**] showing
"Compared with the prior study (images reviewed) of [**2136-6-25**],
the findings are
similar. Biventricular systolic function remains normal and no
intracardiac
thrombi are seen."
Repeat CT on [**7-4**] did not show any abdominal fluid collections.
There was some anasarca, and lymphadenopathy remained unchanged.
Cefepime was started on [**7-6**] for broad coverage given persistent
fevers. This does not need to be continued in the outpatient
setting as she will continue on Vanco at Hemodialysis and Flagyl
for a full 6 weeks duration.
Patient was transferred back to the surgical floor on [**2136-7-7**],
she remained stable until her discharge back to the skilled
nursing facility.
Medications on Admission:
ChlorproMAZINE 100 mg PO QHS, Lisinopril 20', Cinacalcet 90',
Metoprolol 50", Clonazepam 0.75", Metoclopramide 5''', colace
100", nIFEdipine 10 QHD, Epoetin Alfa, Nephrocaps T',
Fluphenazine 62.5 mg IM/SC QTues, Ropinirole 1.5', Fluphenazine
5 mg PO QAM, Fluphenazine 10 mg PO QPM, Tiotropium Bromide 1 CAP
IH DAILY, Foate T", Lanthanum 1000'''
Discharge Medications:
1. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
4. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day).
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Cinacalcet 30 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
8. Ropinirole 1 mg Tablet Sig: 1.5 Tablets PO QPM (once a day
(in the evening)).
9. Chlorpromazine 25 mg Tablet Sig: Four (4) Tablet PO QHS (once
a day (at bedtime)).
10. Fluphenazine Decanoate 25 mg/mL Syringe Sig: 2.5 Injection
1X/WEEK (TU).
11. Fluphenazine HCl 10 mg Tablet Sig: One (1) Tablet PO QPM
(once a day (in the evening)).
12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for headache.
13. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Inhalation Q6H (every 6 hours) as needed.
14. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed.
15. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours): Continue for 6 week total ending [**8-10**].
16. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
17. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
18. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed.
19. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO Q8H
(every 8 hours) as needed.
20. Warfarin 1 mg Tablet Sig: One (1) Tablet PO at bedtime.
21. Vancomycin 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous HD PROTOCOL (HD Protochol): Through [**2136-8-10**] at
hemodialysis.
22. Insulin Regular Human 100 unit/mL Solution Sig: sliding
scale Injection every six (6) hours: 61-149 0 Units
150-199 2 units
200-249 4 units
250-299 6 units
300-349 8 units
>350 [**Name8 (MD) 138**] MD.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 169**] Center
Discharge Diagnosis:
Infection of femoral hemodialysis catheter: Bacteremia
ESRD on hemodialysis
Thrombus: Occlusive thrombus in the left groin involving the
left external iliac vein, the proximal greater saphenous vein,
and the left internal iliac vein.
Discharge Condition:
Fair
Discharge Instructions:
Please call the [**Hospital 1326**] clinic/Access center if the patient
has fevers >101.4, chills, nausea vomiting (more than baseline)
or diarrhea.
Hemodialysis catheter is a trans-hepatic catheter sitting in the
cavo-atrial junction. For Dialysis use only. Patient may get out
of bed with this catheter in place. Assure dressing is in place
at all times.
Followup Instructions:
[**First Name4 (NamePattern1) 4850**] [**Last Name (NamePattern1) **] (Infectious Disease) [**2140-8-2**]:00 AM.
Needs weekly CBC, Chem 10, vanco trough FAX to [**Hospital **] clinic:
[**Telephone/Fax (1) 1419**]
PT/INR per facility protocol for Coumadin Therapy
Completed by:[**2136-7-9**]
|
[
"583.9",
"244.9",
"295.70",
"041.11",
"453.8",
"996.62",
"996.73",
"458.21",
"425.4",
"790.7",
"403.91",
"585.6",
"427.1",
"453.41"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"38.95",
"88.61",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
8169, 8221
|
3075, 5620
|
439, 473
|
8499, 8506
|
2561, 2561
|
8911, 9204
|
2127, 2147
|
6016, 8146
|
8242, 8478
|
5646, 5993
|
8530, 8888
|
1388, 1979
|
2162, 2542
|
2821, 3052
|
361, 401
|
501, 1115
|
2575, 2808
|
1159, 1365
|
1995, 2111
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,654
| 139,683
|
45614
|
Discharge summary
|
report
|
Admission Date: [**2154-5-6**] Discharge Date: [**2154-5-9**]
Date of Birth: [**2082-1-21**] Sex: F
Service: MEDICINE
Allergies:
lisinopril / [**Last Name (un) **]-Angiotensin Receptor Antagonist
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Angioedema
Major Surgical or Invasive Procedure:
Nasogastric Intubation
Mechanical Ventilation
History of Present Illness:
72 yo with history of ESRD, anemia, HTN, presented with tongue
swelling. The patient was recently started on lisinopril last
week by her PCP. [**Name10 (NameIs) **] patient had reported to her outpatient
PCPs office within a few days of starting lisinopril and was
found to have unilateral facial swelling. The family was
concerned, however her PCP instructed the patient to continue to
take lisinopril. The day following, the patient's son took her
to a dentist. The dentist thought her teeth were not the
culprit of the swelling. Per her son, she denied any symptoms
other than facial swelling. The patient presented to the ED
because of difficulty speaking and swallowing.
.
In the ED, initial VS were 97.2 70 130/55 18 100%. Her exam was
significant for profoundly swollen tongue obstructing her
airway, drooling and having difficulty phonating. Anesthesia
was consulted for urgent airway. Her labs returned with Crn of
3.4, K of 5.2. She received an epi pen, 50mg IV benadryl, 120mg
IV hydrocortisone, inhaled racemic epi, 20mg IV famotidine.
Nasaltracheal intubation was performed with cocaine for
anesthetic purposes. She was started on propofol for sedation.
One PIV was placed and a second placed prior to transfer. Her
VS in the OR and PACU have been stable. She is coming to the
MICU for continued monitoring.
Past Medical History:
-Hypertension
-Hyperuricemia/gout
-Stage IV CKD - baseline 2.8
-Anemia ([**1-30**] CKD)
-Renal osteodystrophy
-Osteoarthritis
-Uterine fibroids
-s/p excision cyst from R breast
-s/p unilateral salpingo-oophorectomy after ectopic pregnancy
-s/p tonsillectomy
Social History:
Takes care of [**Age over 90 **] yo mother and 50 year old daughter with down's
syndrome.
- Tobacco: 1 pack cigarettes every 1 1/2 days
- Alcohol: daily use
- Illicits: Per OMR denies
Family History:
Mother alive at 91 (had two MI's; age unknown); father died of
lung cancer.
Physical Exam:
On Admission:
General: intubated sedated with nasotracheal intubation in
place
HEENT: extremely edematous tongue taking up the whole
oropharynx and coming out of the mouth, sclera anicteric, MMM,
mild exopthalmous, OGT in place
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
On discharge:
AVSS
HEENT: No edema
Lungs: CTAB
Pertinent Results:
Admission labs:
[**2154-5-6**] 09:50AM BLOOD WBC-6.5 RBC-3.88* Hgb-12.0 Hct-36.0
MCV-93 MCH-31.0 MCHC-33.5 RDW-17.6* Plt Ct-244
[**2154-5-6**] 09:50AM BLOOD PT-11.8 PTT-27.0 INR(PT)-1.0
[**2154-5-6**] 09:50AM BLOOD Glucose-112* UreaN-41* Creat-3.7* Na-139
K-5.2* Cl-104 HCO3-21* AnGap-19
[**2154-5-6**] 04:43PM BLOOD Calcium-8.8 Phos-6.2* Mg-2.7*
[**2154-5-6**] 05:53PM BLOOD Type-[**Last Name (un) **] pO2-121* pCO2-37 pH-7.30*
calTCO2-19* Base XS--7
.
[**2154-5-6**] CXR:
1. Probable left lower lobe pneumonia, new since [**2152-3-22**].
2. Satisfactory placement of medical devices.
3. A vertical linear lucency traversing the right lung is most
likely due to a skin fold and could be clarified by a followup
radiograph, and ensuring the absence of skin folds adjacent to
the detector.
.
Discharge labs:
[**2154-5-9**] 06:20AM BLOOD WBC-9.9 RBC-3.04* Hgb-9.2* Hct-27.7*
MCV-91 MCH-30.4 MCHC-33.4 RDW-17.7* Plt Ct-205
[**2154-5-9**] 12:45PM BLOOD Hct-32.0*
[**2154-5-6**] 04:43PM BLOOD Neuts-85.6* Lymphs-11.4* Monos-1.2*
Eos-1.3 Baso-0.6
[**2154-5-9**] 06:20AM BLOOD Plt Ct-205
[**2154-5-9**] 06:20AM BLOOD Glucose-104* UreaN-54* Creat-3.0* Na-145
K-2.7* Cl-109* HCO3-20* AnGap-19
[**2154-5-9**] 12:45PM BLOOD Na-141 K-3.5 Cl-106
[**2154-5-9**] 06:20AM BLOOD Calcium-7.9* Phos-4.4# Mg-2.3
[**2154-5-6**] 04:43PM BLOOD C4-37
Brief Hospital Course:
72F ESRD, anemia, HTN, admitted for angioedema secondary to
lisinopril that required [**Last Name (un) **]-tracheal intubation that improved
with steroids.
ACTIVE ISSUES
# Angioedema: Likely secondary to lisinopril given time course
as patient started medication the week prior to presentation.
Patient required [**Last Name (un) **]-tracheal intubation in operating room.
Patient was intubated from [**2154-5-6**] - [**2154-5-8**]. She sucessfully
passed spontaneous breathing trial and was extubated. Allergy
was consulted. Patient was initially treated with IV solumedrol
Q8H and IV benadryl Q8H. Patient was also treated with
famotidine. A C4 level was checked and was normal. Patient's
angioedema improved and she was extubated. Steroids were
changed to prednisone 60 mg daily for 3 days. The benadryl was
continued to oral PRN dosing. Patient was called out from ICU
to medicine floor. On the floor the pt had no swelling and was
discharged with 2 additional days of PO Prednisonde.
.
# Aspiration Pneumonitis: Patient likely has aspiration event
during episode of angioedema. Her sputum culture grew gram
positive cocci in pairs, chains and clusters, gram negative
diplococci, and gram negative rods. Patient also developed
leukocytosis while in ICU. This may have been secondary to
steroids, but we were also concerned for infection. Started
vancomycin and zosyn in MICU to cover for VAP. Repeat CXR showed
complete resolution of her symptoms and antiobiotics were
.
# Acute on Chronic renal failure: Likely secondary to AIN from
lisinopril or volume depletion from decreased PO intake from
inability to swallow. Patient had positive urine Eos. She was
continued on her home calcitriol and sodium bicarbonate. Her
creatinine improved to 3.0 on discharge (baseline 2.8)
.
INACTIVE ISSUES:
# Anemia: At baseline, continued outpatient darbopoetin.
Guaiac negative.
.
# HTN: Initially patient's nifedipine was held in MICU. When
sedation was weaned and patient was extubated, blood pressures
were more elevated. Patient was restarte on home nifedipine.
.
TRANSITIONAL ISSUES:
The pt is the caregiver of her 95 mother. The pt uses a cane
when walking outside. The pt was discharged with home PT after
inpatient physical therapy deemed that she reuired additional
strength training and physical therapy at home following her
hospitalization that included intubation. This was set up prior
to discharge. Joy Ferrara (VNA) is the contact individual that
set up home services.
.
# Code: Full (discussed with son)
Medications on Admission:
ALLOPURINOL 100 mg daily
CALCITRIOL 0.5 mcg 1 on odd days, 2 on even days
DARBEPOETIN 40mcg/mL once a month
FOLIC ACID 6 mg daily
LISINOPRIL 5 mg daily
NIFEDIPINE 90 mg QHS
FERROUS GLUCONATE 324 mg [**Hospital1 **]
MULTIVITAMIN daily
SODIUM BICARBONATE 650 mg TID
Discharge Medications:
1. prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily) for 2 days.
Disp:*6 Tablet(s)* Refills:*0*
2. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO EVERY
OTHER DAY (Every Other Day).
3. calcitriol 0.25 mcg Capsule Sig: Four (4) Capsule PO EVERY
OTHER DAY (Every Other Day).
4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. folic acid 1 mg Tablet Sig: Six (6) Tablet PO DAILY (Daily).
6. allopurinol 100 mg Tablet Sig: One (1) Tablet PO once a day.
7. sodium bicarbonate 650 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
8. nifedipine 90 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO DAILY (Daily).
9. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO twice a day.
10. darbepoetin alfa in polysorbat 40 mcg/0.4 mL Syringe Sig:
One (1) Injection once a month.
11. Eye Drops Ophthalmic
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary Diagnosis
- Angioedema
- Aspiriation Pneumonitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital following an adverse reaction
from Lisinopril. You were intubated to protect your airway and
given steroids to decrease the swelling in your throat. The
swelling resolved and you were given oral prednisone.
.
We have started the following medication:
1) Prednisone 60mg Daily for two days
Followup Instructions:
Please call to make an appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
[**Telephone/Fax (1) 3581**] in the next 1-2 weeks.
Department: WEST [**Hospital 2002**] CLINIC
When: FRIDAY [**2154-5-24**] at 10:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 17762**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: WEST [**Hospital 2002**] CLINIC
When: WEDNESDAY [**2154-8-21**] 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: WEST [**Hospital 2002**] CLINIC
When: WEDNESDAY [**2154-10-16**] at 11:00 AM
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) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
|
[
"507.0",
"995.1",
"288.60",
"E942.9",
"274.9",
"E932.0",
"276.8",
"276.7",
"787.99",
"285.21",
"584.9",
"715.90",
"403.90",
"276.50",
"588.0",
"585.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
8113, 8170
|
4366, 6164
|
335, 383
|
8271, 8271
|
3015, 3015
|
8769, 10113
|
2249, 2327
|
7219, 8090
|
8191, 8250
|
6930, 7196
|
8422, 8746
|
3822, 4343
|
2342, 2342
|
2961, 2996
|
6471, 6904
|
285, 297
|
411, 1747
|
6181, 6450
|
3031, 3806
|
2356, 2947
|
8286, 8398
|
1769, 2028
|
2044, 2233
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,375
| 108,627
|
10344
|
Discharge summary
|
report
|
Admission Date: [**2153-9-18**] Discharge Date: [**2153-9-19**]
Date of Birth: [**2116-9-12**] Sex: M
Service: SURGERY
Allergies:
Amoxicillin / Lamictal
Attending:[**First Name3 (LF) 1**]
Chief Complaint:
Thyroidectomy
Major Surgical or Invasive Procedure:
Total thyroidectomy involving the substernal resection via
cervical approach
History of Present Illness:
37 yo Male with history of bipolar disorder presented for total
thyroidectomy [**9-18**] for multinodular goiter that was causing
tracheal narrowing, transferred to MICU after thyroidectomy to
monitor his airway. Patient noted to have feel a choking
sensation in neck approximately 3 years ago. His PCP at the time
felt this was due to GERD and was given Prilosec which did not
help. He never felt a mass in his neck, and due to his body
habitus never visualized anything. [**Last Name (un) **] the course of three years
he lost 85 pounds due to his own efforts. He continually felt a
choking sensation when he exercised, layed flat, and even
talked. He had a full pulmonary work up and was told exercise
induced asthma may be the culprit. Given albuterol which had no
effect.
His PCP referred him to ENT ([**8-29**]) recently due to large
tonsils that she noticed. ENT saw no concern with tonsils, but
noticed the large mass in his neck. Within two weeks of this
finding, he was referred for surgery of his thyroid mass. During
his pre-op clearance, a bronchoscopy was done that showed no
endotracheal narrowing. All was external compression from his
goiter.
Past Medical History:
Bipolar Disorder: Stable on current regimen
Gout: Indomethicin PRN. Has not had a flare-up since [**1-8**]
H/O Dermoid Cyst in Brain as a child that has since resolved.
Hemorrhoids
Hernia Repair x2 as child
Social History:
Lives alone in [**Hospital1 **]. Worked as a computer network
administrator, currently unemployed and actively looking for a
job. Has worked in Imaging at [**Hospital1 2025**] in the past. Former smoker,
quit 2 1/2 years ago after 25-30 pack/year history. Social
Drinker.
Family History:
Mother: ?thyroid disease, DMT2;
Father: COPD (smoker)
Maternal GM: CAD s/p CABG; Maternal GF: PCA at age [**Age over 90 **].
Physical Exam:
ON PRESENTATION, Pre-Operatively:
per Surgical team
ON ARRIVAL TO ICU, Post-Operatively:
VITAL SIGNS:
T=96.5 BP=112/62 HR=83 RR=16 O2= 99% 3 Liters
.
GENERAL: Pleasant, well appearing male in NAD
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. Constricted pupils and PERRLA/EOMI. MMM. OP
clear. Anterior neck C/D/I
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**].
LUNGS: CTAB, good air movement biaterally.
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: No edema, 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.
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
[**2153-9-18**] 02:04PM freeCa-1.21
[**2153-9-18**] 02:04PM HGB-14.6 calcHCT-44
[**2153-9-18**] 02:04PM GLUCOSE-103 LACTATE-1.9 NA+-139 K+-4.0
CL--105 TCO2-23
[**2153-9-18**] 02:04PM TYPE-[**Last Name (un) **] PH-7.42 INTUBATED-INTUBATED
[**2153-9-18**] 03:12PM HCT-37.7*
[**2153-9-18**] 03:12PM CALCIUM-9.1 MAGNESIUM-1.8
[**2153-9-18**] 03:12PM POTASSIUM-3.9
Pathology Examination
Thyroid, total thyroidectomy:
a. Follicular carcinoma with angioinvasion, see synoptic
report.
b. Papillary micro-carcinoma (slide C).
Brief Hospital Course:
The patient's operative course was c/b 500-600 cc of blood loss
and no transfusion needed. Patient was extubated after his
surgery with no tracheomalacia or stridor noted. He was
hemodynamically stable post-op and it was noted that he was not
a difficult intubation.
Upon arrival to the ICU, patient was conversing well and stated
he hasn't breathed this well in years. He was hemodynamically
stable.
His diet was slowly advanced, and he tolerated lunch well. He
was started on 200mcg daily of levothryoxine for thyroid hormone
replacement and discharged in stable condition.
Medications on Admission:
Topamax 50 mg [**Hospital1 **]
Azithromcyin 250 mg daily [**1-1**] sinusitis...Last dose was [**9-17**]
Ibuprofen prn (has not had any in 10 days)
Discharge Medications:
1. Topiramate 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
2. Levothyroxine 100 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
3. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2)
Tablet, Chewable PO BID (2 times a day) for 2 weeks.
Disp:*56 Tablet, Chewable(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation for 2 weeks.
Disp:*30 Capsule(s)* Refills:*0*
5. Morphine 15 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for pain for 1 weeks.
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Large substernal goiter with tracheal compression
Discharge Condition:
stable
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
*Avoid lifting objects > 5lbs until your follow-up appointment
with the surgeon.
*Avoid driving or operating heavy machinery while taking pain
medications.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to ambulate several times per day.
Incision Care:
-Your steri-strips will fall off on their own. Please remove any
remaining strips 7-10 days after surgery.
-You may shower, and wash surgical incisions.
-Avoid swimming and baths until your follow-up appointment.
-Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
*Avoid driving while taking pain medication.
*Continue taking stool softeners with pain medication to prevent
constipation.
*You may feel tingling around your lips, arms & legs. Take TUMS
(2 tabs four times for a few days until tingling goes away).
emergency room if unable to reach MD.
*You may return to work once you feel comfortable.
*Avoid physical/strenuous activity until you feel comfortable.
*You may shower. Avoid swimming or bath for 5-7 days.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] 4 weeks.
Call [**Telephone/Fax (1) 9**] for an appointment.
|
[
"296.80",
"278.01",
"274.9",
"241.0",
"327.23",
"519.19"
] |
icd9cm
|
[
[
[]
]
] |
[
"06.4"
] |
icd9pcs
|
[
[
[]
]
] |
5036, 5042
|
3633, 4213
|
293, 372
|
5136, 5145
|
3064, 3610
|
7128, 7243
|
2101, 2227
|
4410, 5013
|
5063, 5115
|
4239, 4387
|
5169, 6311
|
6326, 7105
|
2242, 3045
|
240, 255
|
400, 1565
|
1587, 1795
|
1811, 2085
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,661
| 119,226
|
51570
|
Discharge summary
|
report
|
Admission Date: [**2173-1-8**] Discharge Date: [**2173-2-7**]
Date of Birth: [**2106-3-28**] Sex: M
Service: MEDICINE
Allergies:
morphine / Peach
Attending:[**First Name3 (LF) 11466**]
Chief Complaint:
bilateral lower extremity erythema
Major Surgical or Invasive Procedure:
PICC placement
Endotracheal intubation
Sigmoid resection, Hartmann and end colostomy
Central line placement
arterial line placement
History of Present Illness:
[Per admission H&P]
66-year-old male with history of COPD (Gold moderate in '[**72**],
DLCO 45%) and NSCLC s/p cyberknife [**6-23**], prostate ca s/p
prostatectomy '[**69**], who presented to the ED today c/o 4 days of
bilateral lower extremity redness and swelling as well.
Mr [**Known lastname 3444**] states that he was in his usual state of chronic
illness, but overall good health until tuesday night when he
realized that his right foot was "leaking like someone peeing in
the bed." The next morning when he awoke he noticed that his
right leg was swollen much more than the left and that there was
liquid weeping from his right heel. He thought that he should
come to the emergency department but new that his "home-maker"
was coming on friday so he decided to wait until then. He noted
that he couldn't get a sock on his right foot so he put on a
"hospital bootie" that he kept "pushing down" eventually causing
an ulcer/skin tear.
When his home make came to see him today, and they decided
together to take an ambulance.
In the ED inital vitals were 99.1 118 97/55 20 99%. In the ED
the patient stated that he felt short of breath because he was
anxious about his legs but denied chest pain. He was given
duonebs. He denies any change in his sputum which he states is
"always dirty" and thats why he sees Dr. [**Last Name (STitle) **]. He doesn't
feel more short of breath than he did at home.
Exam was notable for bilateral lower extremity pitting edema
right significantly larger than left. Warmth and minimal
erythema were noted along the dorsal aspect of the right foot.
CXR was performed and revealed a bilateral upper lobe pneumonia
and given the patients frequent interactions with the health
care system and underlying bronchiectasis he was started on
vanc/cefepime for HCAP as well as ?cellulitis.
Lower extremity doppler was performed and revealed a
non-occlusive clot involving the right calf, common femoral and
possible the illiac. Heparin bolus and drip was initiated in
the ED. There was concern for overlying cellulitis.
Blood pressures were noted to be soft 93/51 a fluid bolus was
given and the decision was made to admit to the ICU.
On the floor he is in great spirits and arrives with normal
vitals.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
-Stage I NSCLC dxd [**10-24**], s/p Cyberknife treatment [**6-23**],
followed by rad onc
-Asthma/COPD: PFTs [**7-25**]: mod [**Last Name (un) **]. vent defect, DLCO 45% of
predicted, FEV1-66% of predicted
-osteoporosis
-hip fractures
-Anemia/Thrombocytopenia
-H. Pylori + s/p tx
-ETOH pancreatitis
-Neuropathy
-Osteoporosis
-Prostate CA prostatectomy ([**4-21**]) with no biochemical rec
urrence. At time of surgery, nodes neg, but extracapsular
extension into L NV bundle. Chemotherapy and radiation were
recommended but pt elected against them. Recent PSA neg, recent
bone scan neg.
-h/o aspergillus [**Country 11730**] growing out of sputum, + galactomanan
(treated with vori)
-?[**Doctor First Name **]
- Bronchiectasis
Social History:
Initially born in [**Doctor First Name 26692**] and moved to the [**Location (un) 86**] area in
[**2126**]. He was an Air Force sergeant stationed in Okinawa. Was
not in [**Country 3992**] despite OMR notes to the contrary. He is a
retired truck driver of 35 years. He lives alone, currently
with the help of a homemaker. He smoked intermittently while
truck driving for 35 years, a few cigarettes a day, but had a
15-year stretch of one pack per day smoking. Quit last year. No
alcohol use currently, he said he quit seven years ago, but
never drank heavily. No drug use. Not sexually active.
Family History:
Father died of MI at age 72, mother died of CVA
at age 72, has seven siblings, all healthy.
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
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
On Discharge:
XXX
Pertinent Results:
==================
LABORATORY RESULTS
==================
On Admission:
WBC-17.9* RBC-3.76*# Hgb-9.6*# Hct-31.6* MCV-84RDW-16.5* Plt
Ct-223#
---Neuts-86* Bands-2 Lymphs-7* Monos-4 Metas-1* Myelos-0
PT-15.9* PTT-22.9 INR(PT)-1.4*
Glucose-106* UreaN-31* Creat-1.3* Na-135 K-4.8 Cl-106 HCO3-14*
Albumin-2.0* Calcium-7.8* Phos-2.4* Mg-1.5* Iron-15*
ALT-12 AST-24 LD(LDH)-305* AlkPhos-84 TotBili-0.2
calTIBC-103* Ferritn-1680* TRF-79*
Urine: Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.013 Blood-NEG
Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG
Urobiln-NEG pH-5.0 Leuks-NEG URINE RBC-<1 WBC-2 Bacteri-FEW
Yeast-NONE Epi-<1 TransE-<1
On discharge:
XXX
Other Important Studies:
calTIBC-103* Ferritn-1680* TRF-79*
============
MICROBIOLOGY
============
Blood Culture [**1-8**] and [**1-9**]: No Growth to Date
Urine Culture [**1-8**]: No Growth
Urine Legionella Antigen [**1-12**]: Negative
Sputum Cultures 11/26 and [**1-12**]: Extensively contaminated with
upper airway flora and not run.
===============
OTHER STUDIES
===============
ECG ([**2173-1-8**]):
Sinus tachycardia. Low voltage in the limb leads. Q waves in
leads V1-V2
suggest possible prior anteroseptal myocardial infarction. No
diagnostic
change from tracing of [**2172-5-8**]
Chest Radiograph (PA and Lat) ([**2173-1-8**]):
IMPRESSION: Worsening right upper lobe and new left lung,
predominantly upper lobe opacity, concerning for pneumonia.
Bilateral Lower Extremity Ultrasounds ([**2173-1-8**]):
IMPRESSION:
1. Partially occlusive DVT in the right lower extremity
extending from the
posterior tibial veins up to at least the right common femoral
vein. Proximal extent of the DVT is not seen, but most likely
extends into the right iliac vein(s). Peroneal veins not
completely visualized.
2. No DVT in the left lower extremity.
TTE ([**2173-1-11**]):
onclusions
Poor image quality.The left atrium is normal in size. 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 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. Right ventricular chamber size and free wall
motion are normal. The aortic valve is not well seen. There is
no aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve appears structurally normal with trivial mitral
regurgitation. The pulmonary artery systolic pressure could not
be determined. There is no pericardial effusion.
RUQ Ultrasound ([**2173-1-14**]):
Normal examination of the liver and gallbladder. Midline
obscured by bowel gas, as described above.
CT A/P ([**2173-1-15**]):
1. No evidence for intra-abdominal abscess or colitis. Diffusely
distended
colon with large amount of stool.
2. Right lower lobe consolidation, concerning for pneumonia.
Follow up CT
after treatment is recommended to evaluate for underlying
malignancy, which cannot be excluded in the setting of
infection.
3. Hypoenhancing right renal lower pole, concerning for
infection or infarct.
4. New peripheral wedge-shaped hypodensity in the spleen, likely
representing infarct.
5. Right common femoral and iliac vein thrombosis compatible
with findings of prior ultrasound.
Right foot plan filmss ([**2173-1-20**]):
No radiographic findings of osteomyelitis in the right foot.
KUB ([**2173-1-21**]):
Single bedside frontal view of the abdomen again shows a
markedly dilated sigmoid colon with stool seen throughout the
large bowel. No free
intraperitoneal air is seen.
Gastrografin enema ([**2173-1-22**]):
Sigmoid volvulus. Intraabdominal free air present consistent
with bowel perforation.
Brief Hospital Course:
66M presenting to the emergency department with bilateral lower
extremity edema found to have pseudomonas pneumonia and RLE DVT
complicated by hypotension presumed due to septic shock. He had
persistent abdominal pain and distension in the setting of
chronic narcotic-associated constipation. He was found to have a
sigmoid volvulus and underwent urgent exploratory laparotomy
with sigmoid colectomy and end colostomy.
.
# Septic Shock:
Patient was admitted to the [**Hospital Unit Name 153**] when he was noted to be
hypotensive with SBP in the low 90s. Hypotension resolved with
Volume resucitation and antibiotics. PE with obstructive shock
was felt to be unlikely given rapid correction with volume
resuscitation and ECHO showed no right heart strain. Blood
cultures remained negative.
.
Course further complicated by abdominal pain and distension,
found to have sigmoid volvulus w perforation, now s/p
sigmoidectomy with ostomy on [**2173-1-22**]. Was in SICU post-op,
hypotensive on phenylephrine and was weaned off pressors, and
called out [**2173-1-25**].
.
While on the medicine floor, the patient was normotensive,
maintained on ciprofloxacin for Pseudomonas pneumonia and flagyl
for intra-abdominal pathology; also maintained on voriconazole
given his history of aspergillosis in the setting of his new
pneumonia. The patient was having his NGT pushed further in
when he had acute desaturation, as per report went as low as the
50s on RA. Put on NC, and then NRB; upon transfer to MICU, was
satting mid 80s on NRB and was hypotensive with systolics in the
mid 80s.
.
On arrival to the MICU, pt was on NRB, tachypneic with talking.
Reports feeling comfortable, denying any chest pain. The
patient was initially on NRB, but then required intubation for
acute decompensation and increased work of breathing. After
being intubated, the patient became hypotensive and ultimately
required four pressors. The patient's antibiotics were
broadened to vancomycin, meropenem, ciprofloxacin, voriconazole.
PO Vanc and IV Flagyl were also added on for empiric treatment
for Cdifficile given septic picture but later discontinued when
C. diff PCR was negative. The patient's PICC line was also
pulled. ID continued to follow the patient while he was in the
unit. His pressor requirement was weaned, and antibiotics pared
down. Because of gross volume overload from volume
resuscitation, the patient was initiated on CVVH.
.
#Septic shock:
Patient had multiple sources for infection as listed below.
Patient's vasopressor requirements remained high and was unable
to be weaned. Patient expired while on 2 pressors.
.
# Pneumonia:
Patient noted to have productive cough with xray findings and
leukocytosis suggestive of PNA. While he did not meet the
strict criteria for HCAP, he did have frequent interactions with
the healthcare system and seemed to be at risk for CA MRSA, and
his bronchiectasis makes him a good set-up for Pseudomonas. He
did eventually grow mycobacterium kansasii and pseudomonas. He
was continued on his home voriconazole (for h/o aspergillosis)
and additionally treated cefpodoxime from [**Date range (1) 106889**] then
ciprofloxacin for pseudomonas. Patient continued to require
mechanical ventilation for hypoxia and hemodynamic instability.
# RLE DVT:
Patient presented with significant lower extremity swelling R>L
likely due to his large DVT. As noted above obstructive shock
from PE thought unlikely to be primary driver of hypovolemia as
rapid improvement with fluids and no signs of right heart strain
on echo. Given lack of evidence of right heart compromise and
other more likely etiologies of hypoxemias further work up for
PE was not performed as it was felt unlikely to affect
management. Given history of malignancy and recent treatment
with voriconazole low molecular weight heparin was felt to be
optimal anticoagulation and this was started. He became
supratherapeutic on INR and further anticoagulation was held
while he was in the MICU.
.
# Hypoxemia/COPD/Aspergillosis:
The patient has COPD as well as bronchiectasis and history of
aspergillosis. Etiology of hypoxemia felt to be multifactorial
due to underlying COPD, bronchiectasis, and scarring from
aspergillus that was poorly able to compensate for additional VQ
mismatch from pneumonia. He as continued on an aggressive
inhaler regimen. Systemic steroids to optimize COPD were
deferred given concern for serious infection.
.
# Acute renal failure:
Patients creatine was elevated at 1.3 on admission. Pre-renal
etiology was felt to be most likely given concentrated urine
with sp. Gravity 1.013 and FeNa 1%. Creatinine improved to 0.8
following fluid resuscitation for intial sepsis in the [**Hospital Unit Name 153**].
Unfortunately, when he developed his second episode of septic
shock, he became anuric in the MICU and required CVVH to remove
volume and correct electrolyte abnormalities. patient required
CVVH while in the MICU for volume overload. He did not tolerate
fluid removal and would become hypotensive requiring somewhat
frequent fluid boluses.
.
# Sigmoid volvulus:
Over the course of his admission, the patient developed
abdominal pain and distension in the setting of chronic
narcotic-associated constipation. Imaging was consistent with
constipation and ileus, for which the patient was treated with
an aggressive bowel regimen both orally and rectally, with
little effect. A gastrografin enema obtained on HD 15 revealed a
sigmoid volvulus with associated free air. The patient was
taken to the operating urgently and underwent exploratory
laparotomy, sigmoid colectomy, and end colostomy (please see
operative report for further details). Postoperatively, he
remained intubated in the setting of significant pulmonary
history, and was admitted to the Surgical ICU. Later that
evening he was extubated and remained stable from both a
respiratory and hemodynamic standpoint. He was continued on
ciprofloxacin/Flagyl and his outpatient voriconazole. His pain
was controlled with a dilaudid PCA. He was transferred to the
floor on POD 3. Remained stable while in the MICU.
.
Anemia:
Patient came in above his baseline of the low 20s with a hct in
the 30s, likely representing hemoconcentration. This then fell
closer to baseline. Iron studies were sent and not consistent
with iron deficiency as ferritin >1000. Therefore, iron was
stopped particularly given association of iron overload and
aspergillus.
.
# goals of care: While in the MICU, multiple family meetings
were held and it was decided by the HCP, the patient's daughter
[**Name (NI) **] [**Name (NI) **], that the patient be DNR. On [**2173-2-7**] a final
family meeting was held and was determined to make the patient
CMO. He was terminally extubated and expired shortly after
extubation. Patient was pronounced at 18:21 on [**2173-2-7**]
.
Medications on Admission:
ALBUTEROL SULFATE - 90 mcg HFA Aerosol Inhaler - 2 puffs inhaled
four times daily as needed for shortness of breath
FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 500 mcg-50 mcg/Dose
Disk
with Device - 1 whiffs inhaled twice a day
FOLIC ACID - 1 mg Tablet - 1 Tablet(s) by mouth daily
IPRATROPIUM BROMIDE [ATROVENT HFA] - 17 mcg/Actuation HFA
Aerosol
Inhaler - 2 puffs inhaled twice daily
IPRATROPIUM-ALBUTEROL - 0.5 mg-3 mg (2.5 mg base)/3 mL Solution
for Nebulization - 1 vial nebulized every 6 hours as needed for
shortness of breath
LIPASE-PROTEASE-AMYLASE [CREON] - 12,000 unit-[**Unit Number **],000 unit-[**Unit Number **],000
unit Capsule, Delayed Release(E.C.) - [**3-19**] Capsule(s) by mouth
three times a day
MEGESTROL [MEGACE ES] - 625 mg/5 mL Suspension - 625 mg(s) by
mouth twice a day
MIRTAZAPINE - 30 mg Tablet - 1 Tablet(s) by mouth daily at
bedtime
OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 (One)
Capsule(s) by mouth twice a day
OXYCODONE - 5 mg Tablet - 2 Tablet(s) by mouth every six hours
as
needed for pain may sedate, please do not drive or drink alcohol
with pills
OXYCODONE [OXYCONTIN] - (Prescribed by Other Provider) (Not
Taking as Prescribed: Need to hold while on Voriconozole) - 30
mg
Tablet Extended Release 12 hr - 1 Tablet(s) by mouth three times
a day
TRAZODONE - 100 mg Tablet - 1 Tablet(s) by mouth daily
VORICONAZOLE - 200 mg Tablet - 1 Tablet(s) by mouth twice a day
.
Medications - OTC
FERROUS SULFATE - 325 mg (65 mg iron) Tablet - 1 Tablet(s) by
mouth daily
MULTIVITAMIN - Tablet - 1 Tablet(s) by mouth daily
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary Diagnosis:
Health Care Associated Pneumonia complicated by septic shock
Right Lower Extremity Deep Venous Thrombosis
Chronic obstructive Pulmonary Disease
Secondary Diagnoses:
Invasive aspergillosis
Anemia
Osteopenia
Pancreatic Insufficiency
Discharge Condition:
expired
Discharge Instructions:
n/a
Followup Instructions:
n/a
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Discharge summary
|
report
|
Admission Date: [**2175-3-31**] Discharge Date: [**2175-4-4**]
Date of Birth: [**2095-5-27**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 602**]
Chief Complaint:
Lower GI Bleed
Major Surgical or Invasive Procedure:
1. Blood transfusion
2. Interventional radiology tagged red blood cell scan with
attempted percutaneous ablation.
History of Present Illness:
Mr. [**Known lastname **] is a 79 y/o male with a history of atrial
fibrillation on coumadin, CKD stage III, COPD, chronic
venostasis, systolic CHF (EF of 45%-50%) who presented to [**Hospital1 **]
[**Location (un) 620**] with several episodes of bright red blood per rectum. He
first noted some bleeding while he was on vacation in
[**State 2748**] the day PTA. He started having some abdominal
discomfort overnight and went to the bathroom where he had an
episode of bright red blood per rectum. Later on the following
day he had multiple other episodes of BRBPR and decided to
return to [**State 350**] and presented to [**Hospital1 **] [**Location (un) 620**]. At [**Hospital1 **]
[**Location (un) 620**], in the ED he was noted to be pale and having massive
bright red blood per rectum. His hematocrit was noted to be 41
upon presentation which dropped to 27.5 approximately 6 hours
later. His INR was 3.2 and his creatinine was 1.7. He was
transferred to [**Hospital1 18**] for further evaluation and IR intervention.
He received 2 units of FFP and 1 unit of packed red blood cells
prior to discharge.
.
Of note he presented in [**Month (only) **] to [**Hospital1 **] [**Location (un) 620**] with a similar
episode of lower GI bleed. He had a colonsocpy on [**2175-11-18**] which
showed persistent active bleeding with diffuse clots suggestive
of diverticular bleed in the setting of anticoagulation with
coumadin and was transferred to the intensive care unit. The
patient's INR was reversed with FFP and he also received vitamin
K. He also required blood transfusion. He received a total of 4
units of packed red blood cells and 8 units of FFP.
.
On arrival to the MICU, paient was noted to be awake and alert.
His vitals were stable on arrival and he was mentating well.
Ultrasound of his internal jugular showed collapse suggestive of
volume depletion. There was an emergency release of 3 units of
packed red blood cells and 2 untis of FFP.
Past Medical History:
1. History of lower GI bleed with recurrent diverticular bleed.
2. Atrial fibrillation on Coumadin.
3. CKD stage III.
4. Hypothyroid.
5. Hyperlipidemia.
6. COPD.
7. Chronic venostasis.
8. Gout.
9. Hypertension.
10. BPH.
11. Prostate cancer.
12. CHF with an EF of 45%.
13. Status post appendectomy.
14. Glaucoma.
15. Bilateral neuropathy from leg edema.
16. History of gastric polyp.
17. Schatzki ring.
18. He is status post pacemaker. The pacemaker was placed due to
atrial fibrillation and bradycardia.
Social History:
He denies a history of smoking. He drinks alcohol occasionally.
Denies history of alcohol abuse. He lives at home. He is
independent.
Family History:
Abdominal hernia repair, right knee replacement, appendectomy.
Physical Exam:
Physical Exam on admission:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry MM, 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, some wheezes noted
bilaterally, no rales or ronchi
Abdomen: hyperactive bowel sounds, soft, non-tender, slighlty
distended, no organomegaly
GU: foley in place
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
Pertinent Results:
I) Admission Labs
[**2175-3-31**] 04:40PM BLOOD WBC-6.1 RBC-3.26* Hgb-9.0* Hct-30.4*
MCV-93 MCH-27.5 MCHC-29.5* RDW-16.3* Plt Ct-182
[**2175-3-31**] 04:40PM BLOOD Neuts-73.2* Lymphs-16.2* Monos-6.5
Eos-3.0 Baso-1.0
[**2175-3-31**] 05:45PM BLOOD PT-15.6* PTT-30.2 INR(PT)-1.5*
[**2175-3-31**] 04:40PM BLOOD Glucose-94 UreaN-37* Creat-1.3* Na-143
K-4.5 Cl-107 HCO3-25 AnGap-16
[**2175-3-31**] 04:40PM BLOOD CK-MB-4 cTropnT-<0.01
[**2175-3-31**] 04:40PM BLOOD Calcium-8.3* Phos-3.2 Mg-2.3
[**2175-3-31**] 08:02PM BLOOD freeCa-1.03*
[**2175-3-31**] 04:54PM BLOOD Lactate-1.3
II) Microbiology:
[**2175-3-31**] 4:24 pm MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2175-4-3**]**
MRSA SCREEN (Final [**2175-4-3**]): No MRSA isolated.
III) Imaging:
Tagged RBC Scan [**3-31**]:
Hemorrhage beginning at 1 minute, likely within the sigmoid
colon
IV) Studies:
CT-Angiogram [**4-1**]:
FINDINGS:
No active extravasation seen from arteriograms performed in the
superior
mesenteric and inferior mesenteric arteries.
IMPRESSION: Successful uncomplicated superior mesenteric and
inferior mesenteric arteriograms with no active extravasation.
V) Discharge/Notable Labs
CBC
[**2175-4-4**] 06:20AM BLOOD WBC-5.9 RBC-3.25* Hgb-9.3* Hct-30.7*
MCV-95 MCH-28.6 MCHC-30.2* RDW-16.6* Plt Ct-134*
[**2175-4-3**] 06:15AM BLOOD WBC-6.0 RBC-3.29* Hgb-9.3* Hct-31.5*
MCV-96 MCH-28.2 MCHC-29.5* RDW-15.8* Plt Ct-173
[**2175-4-2**] 05:20AM BLOOD WBC-5.8 RBC-3.24* Hgb-9.3* Hct-30.1*
MCV-93 MCH-28.6 MCHC-30.9* RDW-16.1* Plt Ct-122*
[**2175-4-1**] 05:54AM BLOOD WBC-6.7 RBC-3.32* Hgb-9.5* Hct-31.1*
MCV-94 MCH-28.7 MCHC-30.6* RDW-15.8* Plt Ct-143*
.
Coags:
[**2175-4-4**] 06:20AM BLOOD PT-14.5* PTT-29.5 INR(PT)-1.4*
[**2175-4-3**] 06:15AM BLOOD PT-13.3* PTT-27.5 INR(PT)-1.2*
[**2175-4-2**] 05:20AM BLOOD PT-12.9* PTT-26.4 INR(PT)-1.2*
[**2175-4-1**] 05:54AM BLOOD PT-12.8* PTT-28.5 INR(PT)-1.2*
Chemistry:
[**2175-4-4**] 06:20AM BLOOD Glucose-86 UreaN-35* Creat-1.6* Na-145
K-3.5 Cl-106 HCO3-34* AnGap-9
[**2175-4-3**] 06:15AM BLOOD Glucose-87 UreaN-32* Creat-1.5* Na-144
K-3.3 Cl-105 HCO3-34* AnGap-8
[**2175-4-2**] 05:20AM BLOOD Glucose-94 UreaN-32* Creat-1.3* Na-144
K-3.6 Cl-108 HCO3-26 AnGap-14
[**2175-4-4**] 06:20AM BLOOD Calcium-8.2* Phos-3.2 Mg-2.1
VI) Pending Studies:
None
Brief Hospital Course:
79 year-old male with atrial fibrillation on coumadin, chronic
kidney disease, 5 months s/p massive lower GI bleed secondary to
diverticular disease transferred from [**Hospital1 **] [**Location (un) 620**] for massive
lower gastrointestinal bleed most likely due to sigmoid
diverticulosis.
Issues addressed during hospitalization:
1. Acute blood loss anemia
2 Diverticular bleeding
3. Chronic systolic heart failure with EF 45%.
4. Hypertension
5. Atrial Fibrillation s/p PPM
The patient presented to [**Hospital1 **]-[**Location (un) 620**] after
experiencing a large lower GI bleed while gambling at a casino
in [**Location (un) **]. Upon arrival to [**Hospital1 **]-[**Location (un) 620**], the patient stepped
out of the car and his pants were soaked with blood. He was
transfused 4 units of packed red blood cells as well 3 units of
FFP and vitamin K for an INR of 3.2. He was transferred to [**Hospital1 18**]
for possible surgical or interventional radiology intervention.
Upon arrival to [**Hospital1 18**], he continued to have painless rectal
bleeding. The patient was admitted to the ICU where he received
3 additional units of red blood cells. Surgical and GI services
were consulted who recommended a tagged RBC scan which was
notable for extravasation in the sigmoid. IR attempted to
percutaneously embolize the bleed, but could not find any
bleeding during the procedure. The procedure was then aborted.
He received 3 more units of red cells to maintain a hematocrit
greater than 30. Of note, despite the recurrent bleeding he did
not have any hemodynamic instability.
His bleeding ceased without intervention by hospital day 2
and his hematocrit remained stable for 4 consecutive days. On
hospital day 3, his metoprolol and lasix were resumed and his
blood pressure remained stable. The patient never had any
episodes of shortness of breath, chest pain, or reported
palpitations.
Prior to discharge, an discussion was held with GI, the
patient's primary care physician (Dr [**First Name8 (NamePattern2) **] [**Name (STitle) **]), outpatient
cardiologist (Dr. [**Last Name (STitle) **] and outpatient gastroenterologist (Dr.
[**First Name8 (NamePattern2) **] [**Name (STitle) 23804**]), and Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2819**] from general surgery
about the option of surgical intervention for his diverticular
disease and the need to weigh the risks of surgery, including
possibility of total abdominal colectomy given degree of
diverticular disease, bleeding on anticoagulation, and stroke
off anticoagulation. After hearing of the available options and
the relative risks of each, the patient decided that he would
like to hold on surgery and continue with anticoagulation to
reduce his stroke risk. He understood his persistent risk of
bleeding and stated that should he re-bleed again, he would
consider surgery more strongly. He was therefore discharged home
to restart his Coumadin without a bridge and to have a stress
test for further risk stratification in the event that he does
elect to have a surgical intervention in the future. He will
also follow up with General Surgery, GI, Cardiology, and his
PCP.
Medication changes: None.
The patient was discharged with follow-up with:
1) PCP
2) Cardiology
3) GI
4) General Surgery
Transitional Issues:
1. Anticoagulation: discussion of risks vs. benefits in the
setting of atrial fibrillation and 2 episodes of massive lower
GI bleeds in the past year.
2. INR monitoring
3. Stress testing for pre-operative risk stratification
(arranged with Dr. [**Last Name (STitle) **] .
4. Surgical consultation with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2819**]
Medications on Admission:
1. Toprol-XL 25 mg p.o. daily.
2. Lasix 80 mg p.o. daily.
3. Aspirin 81 mg p.o. daily.
4. Timolol 0.5% eye drops in both eyes daily.
5. Pravastatin 20 mg p.o. daily.
6. Allopurinol 300 mg p.o. daily.
7. Levothyroxine 100 mcg p.o. daily.
8. Coumadin 1 mg p.o. daily.
Discharge Medications:
1. Toprol XL 25 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO once a day.
2. furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. timolol maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
5. pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
7. allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Coumadin 1 mg Tablet Sig: One (1) Tablet PO once a day: Start
on Wednesday [**2175-4-5**], Goal INR [**2-10**] .
1. Toprol XL 25 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO once a day.
2. furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. timolol maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
5. pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
7. allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Coumadin 1 mg Tablet Sig: One (1) Tablet PO once a day: Start
on Wednesday [**2175-4-5**], Goal INR [**2-10**] .
Discharge Disposition:
Home
Discharge Diagnosis:
1. Massive lower gastrointestinal bleed
2. Difuse diverticular disease
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 in the setting of massive painless, lower
gastro-intestinal tract bleeding. We believe that your bleeding
episode was caused by your diverticulosis. You received 7 units
of blood on the day you were admitted. In the 4 days that
followed your blood counts remained stable. You were also found
have a slightly increased INR at 3.2 (this is the value that in
monitored while you are taking Coumadin) and you were given
vitamin K. Having a high INR puts you at increased risk for
bleeding. Your bleeding resolved without further intervention.
There is no guarantee that you won't have additional
episodes of re-bleeding. Going forward it is very important that
you closely monitor your INR or coumadin level so that your
blood does not become too thin. You must also monitor for early
signs of bleeding; these include increased amounts of bright red
blood in your stool, lightheadedness or fast heart rate which
may be felt a palpitations.
We have made several appointments with cardiology, GI, your
primary care doctor and surgery to help guide your further
management in preventing another GI bleed.
We have made no changes to your medications.
1. You should RESTART your COUMADIN, at 1mg per day on [**2175-4-5**].
You will see Dr. [**First Name (STitle) **], your parimary care doctor, tomorrow
[**2175-4-5**] and your INR will be checked at this visit. He will
advise you on future doses of this medication.
It is important that you have your coumadin levels monitored by
your primary care physician on [**Name Initial (PRE) **] very frequent basis to avoid
over-anticoagulation. You may also want to discuss the risks and
benefits of coumadin therapy.
If you experience any of the warning symptoms discussed above
and listed below please call your primary care physician and go
to the nearest emergency department.
Several follow-up visits have been scheduled for you. Please
review these as listed below.
Followup Instructions:
Name: [**Last Name (LF) **], [**First Name3 (LF) **] Z. MD, PHD
Location: [**Hospital1 **] HEALTHCARE - [**Location (un) **]
Address: [**Street Address(2) 10534**], [**Location (un) **],[**Numeric Identifier 10535**]
Phone: [**Telephone/Fax (1) 9347**]
Appt: Tomorrow, [**4-5**] at 2:30pm
Dr. [**Last Name (STitle) **] has requested a Nuclear Stress Test to be performed
prior to your appointment with him. You will be called from
[**Hospital1 18**] [**Location (un) 620**] to schedule this appointment. If you do not
receive at call by tomorrow [**2175-4-5**], please call ([**Telephone/Fax (1) 99596**] to schedule this test.
Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) 122**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital1 18**] [**Location (un) 620**]--CARDIAC SERVICES
Building: [**Street Address(2) 3001**] ([**Location (un) 620**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Parking on Site
Appt: [**4-12**] at 3:45pm
Name: [**Last Name (LF) **],[**Name (NI) **] MD --Gastroenterology
Address: [**Apartment Address(1) 58580**], [**Location (un) **],[**Numeric Identifier 18724**]
Phone: [**Telephone/Fax (1) 3259**]
Appt: [**4-20**] at 3:45pm
Department: SURGICAL SPECIALTIES
When: MONDAY [**2175-5-1**] at 10:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8318**], MD [**Telephone/Fax (1) 2998**]
Building: [**Street Address(2) 3001**] ([**Location (un) 620**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Parking on Site
|
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"244.9",
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"600.00",
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"355.8",
"427.31",
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icd9cm
|
[
[
[]
]
] |
[
"88.47"
] |
icd9pcs
|
[
[
[]
]
] |
11585, 11591
|
6143, 9335
|
318, 434
|
11706, 11706
|
3813, 6120
|
13858, 15417
|
3116, 3181
|
10173, 11562
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|
263, 280
|
462, 2416
|
3224, 3794
|
11721, 11833
|
2438, 2944
|
2960, 3100
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,700
| 174,160
|
24935
|
Discharge summary
|
report
|
Admission Date: [**2136-10-24**] Discharge Date: [**2136-12-28**]
Date of Birth: [**2095-9-15**] Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
Transfer for exacerbation of chronic cirrhosis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Pt is a 41 y/o man w/ a hx of alcoholic cirrhosis c/b ascites,
portal hypertension, and hepatic encephalopathy who presented w/
an exacerbation of his liver failure over the past 2 months. He
also had an episode of s. viridans bacteremia in [**9-7**] that was
treated w/ 4wk of vancomycin and 2wk of gentamycin. He was
admitted to an outside hospital on [**9-5**] w/ bacteremia as above,
[**9-21**] w/ prerenal azotemia, and [**10-20**] w/ complaints of SOB and
fatigue. He was found during his last admission to have a large
R pleural effusion along with elevated LFTs. He was treated
empirically with avelox at the outside hospital and was given
diuretics. A thoracentesis was planned but did not occur [**3-7**]
his elevated INR. He was transferred to [**Hospital1 18**] for further
management of his acute on chronic liver failure and for w/u of
its etiology.
Upon arrival, the patient was mildly confused taking long time
periods to answer questions and needing some redirection to
focus on the question at hand. According to the patient, his
liver function has been declining for approximately the past 3
months. He reports that he has had increasing edema in his LE
despite treatment and that he has been increasingly jaundiced of
late. He states that he has not been able to think as well as
he used to think. He denies any CP, SOB, N/V, diarrhea, HA,
palpatations, or pruritis. He denies any recent viral illness
or sick contacts. [**Name (NI) **] has not traveled recently and has not has
had any of his medications changed recently. He denies taking
any herbal supplements.
Past Medical History:
1. alcoholic cirrhosis c/b ascites and encephalopathy
2. s viridans bacteremia s/p 4wk vanco 2wk gent
3. ARF [**3-7**] aminoglycoside toxicity
Social History:
Pt is married w/ 2 children. He lives in [**Location 5450**] and works
as a salesman for Staples. He has a hx of alcohol abuse w/ his
last drink in [**Month (only) 116**]. He denies smoking, drug use, or tattoos.
Family History:
Pt w/ diabetes in his mother and father. Father died of "kidney
and pancreas problems".
Physical Exam:
Gen: Jaundiced appearing man lying in bed in NAD
HEENT: EOMI, PERRLA, MMM, O/P clear, + icterus
Skin: + jaundice, - rashes
CV: RRR, S1/S2 intact, -M/R/G
Lungs: dullness to percussion w/out BS on the lower half of the
R lung, otherwise CTA
Abd: S/NT, distended, -HSM, +BS, mild asterixis
Ext: -C/C, 2+ pitting edema to the mid-thigh in the LE
Neuro: AAOx2 (not date), patient not able to do serial 7s past
86
Brief Hospital Course:
41 y/o man with h/o alcoholic cirrhosis who presented after
being admitted to an outside hospital with SOB and fatigue. Was
found to have a R pleural effusion and worsening of his LFTs. No
tap was performed [**3-7**] elevated INR.
He had a long hx of cirrhosis with worsening of his condition
over the past several months. He presented w/ encephalopathy and
severe jaundice with unclear cause of sudden decrease in liver
fxn. Possible causes included infection, toxin, thrombosis of
veins. Blood and urine cultures were negative. An US of the
liver w/ doppler revealed a cirrhotic liver without focal
lesions with nearly no flow within the main and left portal
veins, and no detectable flow within the right portal vein.
Massive varices within the abdomen with evidence of splenorenal
shunting. Massive splenomegaly. Small amount of perihepatic
ascites, which was not sufficient
to tap. Nondistended gallbladder with gallbladder wall edema,
indicative of liver disease and right pleural effusion.
Labs were significant for + [**Last Name (un) 15412**] and IgG. He was followed by the
Hepatology service who initiated transplant workup. The
Transplant service was consulted on [**2137-10-27**] and a transplant
workup was completed. CT of the abdomen demonstrated a cirrhotic
liver with no mass lesion demonstrated. Patent but narrow
caliber portal vessels. Thin linear hypodensity within the main
portal vein likley representing some nonocclusive thrombus.
Hepatic veins were patent. Features of portal hypertension
including splenomegaly, moderate amount of intra-abdominal
ascites and portosystemic collaterals were described.
He remained in the hospital for management of worsening liver
failure with hepatorenal syndrome. He became coagulopathic
requiring daily transfusions with platelets, FFP, cryo and PRBCs
per Hepatology recommendation to keep plt>20, inr<4, hct>25,
fibrin >150. Encephalopathy wax and waned. This was managed
with lactulose and rifaximin. He was followed by social work,
psychiatry, nutrition and physical therapy. His MELD score
ranged in the 40s. He did not receive a liver transplant despite
being at the top of the list. He was transferrred to the SICU
with neurology consultation for worsening encephalopathy. He was
intubated. A CT demonstrated a spontaneous subdural hematoma.
He was coagulopathic and due to his contraindication to
transplant, his family met with the team and decided to make him
CMO. He expired on [**2137-12-28**].
Medications on Admission:
avelox 400mg
aldactone 25 tid
ambien prn
lasix 20
mvi
folate
Discharge Medications:
none
Discharge Disposition:
Home
Discharge Diagnosis:
End Stage Liver Disease secondary to Alcoholic Cirrhosis
Discharge Condition:
expried [**2137-12-31**]
Discharge Instructions:
n/a
Followup Instructions:
n/a
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2137-5-17**]
|
[
"303.90",
"570",
"452",
"284.8",
"571.2",
"572.2",
"486",
"572.3",
"275.0",
"275.42",
"518.81",
"432.1",
"286.7",
"511.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.06",
"96.72",
"38.91",
"99.05",
"96.6",
"38.93",
"96.04",
"99.07",
"45.13",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
5525, 5531
|
2904, 5385
|
319, 325
|
5632, 5658
|
5710, 5871
|
2367, 2457
|
5496, 5502
|
5552, 5611
|
5411, 5473
|
5682, 5687
|
2472, 2881
|
233, 281
|
353, 1952
|
1974, 2118
|
2134, 2351
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,295
| 109,267
|
5430+55673
|
Discharge summary
|
report+addendum
|
Admission Date: [**2157-11-16**] Discharge Date: [**2157-12-5**]
Date of Birth: [**2084-6-29**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 17683**]
Chief Complaint:
Anal squamous cell carcinoma
Major Surgical or Invasive Procedure:
Abdominal peroneal resection, gracilus flap closure
History of Present Illness:
This is a 73 year old man with hx of HIV/AIDS who presents with
extensive squamous cell anal cancer who presents for
resection/[**Month (only) **]
Past Medical History:
1) HIV/AIDS
2) DM Type II
Social History:
Pt lives with partner in [**Name (NI) 3615**], but they are staying in
[**Hospital1 8**] as he is getting radiation therapy. Homosexual male.
Denies IVDU, EtOH, Tob.
Family History:
Non contributory
Physical Exam:
126/68 72 97.0 18 99%ra
NAD
MMM
CTA-B
RRR
soft, non-tender abdomen
rectal: some tenderness
Pertinent Results:
[**2157-11-16**] 09:25PM GLUCOSE-130* UREA N-13 CREAT-1.0 SODIUM-139
POTASSIUM-4.5 CHLORIDE-108 TOTAL CO2-23 ANION GAP-13
[**2157-11-16**] 09:25PM ALT(SGPT)-17 AST(SGOT)-26 ALK PHOS-64 TOT
BILI-3.9*
[**2157-11-16**] 09:25PM ALBUMIN-3.5 CALCIUM-8.7 PHOSPHATE-5.5*#
MAGNESIUM-1.5*
[**2157-11-16**] 09:25PM WBC-5.9# RBC-2.91* HGB-12.4* HCT-33.3*
MCV-114* MCH-42.7* MCHC-37.3* RDW-15.0
[**2157-11-16**] 06:25PM TYPE-ART PO2-105 PCO2-37 PH-7.40 TOTAL CO2-24
BASE XS-0 COMMENTS-NOT SPECIF
[**2157-11-16**] 06:25PM GLUCOSE-132* LACTATE-1.3 NA+-136 K+-4.0
CL--108
[**2157-11-16**] 06:25PM HGB-10.8* calcHCT-32
[**2157-11-16**] 06:25PM freeCa-1.21
[**2157-11-16**] 02:26PM TYPE-ART PO2-176* PCO2-36 PH-7.43 TOTAL
CO2-25 BASE XS-0
[**2157-11-16**] 02:26PM HGB-12.0* calcHCT-36 O2 SAT-98
[**2157-11-16**] 12:00PM freeCa-1.20
[**2157-11-16**] 10:12AM freeCa-1.19
Brief Hospital Course:
After uneventful [**Month (only) **] and gracilis flap closure by plastics, the
patient kept in the pacu overnight, he was kept intubated post
op, but extubeabted next AM. He was kept on a kinair mattress
with no leg abduction or sitting. He was kept on Vanco and
Zosyn as perioperative antibiotics. HIV meds were restarted on
POD 3. He was transfered to the T/SICU due to nausea/vomiting
with hypoxia and tachypnea. He did well in the unit, his
hypoxia resolved and after two days in the unit he was
transfered back to the floor. Enterostomal therapy was
consulted to teach and care for his new ostomy, this went well
without complications. On [**11-22**] JP #1 was discontinued. NG
tube was d/c'ed on [**11-22**] as well. Foley was d/c'ed on day of
transfer to rehab. He went to rehab without issue
Medications on Admission:
15. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
BID (2 times a day). 6. Ipratropium Bromide 0.02 % Solution Sig:
One (1) Inhalation Q6H (every 6 hours).
7. Emtricitabine 200 mg Capsule Sig: One (1) Capsule PO qAM ().
8. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours).
9. Atazanavir Sulfate 100 mg Capsule Sig: Three (3) Capsule PO
QPM (once a day (in the evening)).
10. Ritonavir 100 mg Capsule Sig: One (1) Capsule PO QPM (once a
day (in the evening)).
11. Zidovudine 100 mg Capsule Sig: Three (3) Capsule PO Q12H
(every 12 hours).
12. Tenofovir Disoproxil Fumarate 300 mg Tablet Sig: One (1)
Tablet PO QPM (once a day (in the evening)).
Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily
Discharge Medications:
1. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
ml Injection [**Hospital1 **] (2 times a day).
2. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
3. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
4. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
5. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for to buttocks region.
6. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
7. Emtricitabine 200 mg Capsule Sig: One (1) Capsule PO qAM ().
8. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours).
9. Atazanavir Sulfate 100 mg Capsule Sig: Three (3) Capsule PO
QPM (once a day (in the evening)).
10. Ritonavir 100 mg Capsule Sig: One (1) Capsule PO QPM (once a
day (in the evening)).
11. Zidovudine 100 mg Capsule Sig: Three (3) Capsule PO Q12H
(every 12 hours).
12. Tenofovir Disoproxil Fumarate 300 mg Tablet Sig: One (1)
Tablet PO QPM (once a day (in the evening)).
13. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed.
14. Morphine Sulfate 8 mg/mL Syringe Sig: 1-5mg Injection Q4H
(every 4 hours) as needed for breakthrough pain.
15. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
BID (2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Anal squamous cell carcinoma
Diabetes
HIV/AIDS
Discharge Condition:
good
Discharge Instructions:
Notify MD if you experience incresing pain, fever > 101.4,
bleeding or other concering signs. Resume taking all of your
pre procedure medications
Followup Instructions:
in [**1-11**] weeks with Dr. [**Last Name (STitle) **], call her office for an
appointment
[**Name6 (MD) 843**] [**Name8 (MD) 844**] MD [**MD Number(1) 845**]
Completed by:[**2157-11-24**] Name: [**Known lastname **],[**Known firstname **] Unit No: [**Numeric Identifier 3672**]
Admission Date: [**2157-11-16**] Discharge Date: [**2157-12-5**]
Date of Birth: [**2084-6-29**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3673**]
Addendum:
The patient was scheduled for discharge on [**11-24**], but due to low
urine output, hypotension, and abdominal distension, the patient
required transfer to the intensive care unit on [**11-25**]. A
central line was placed for further management, including
central venous pressure monitoring. Plastic surgery continued
to follow the patient while in the unit. The patient's fluid
status was watched closely and nephrology was consulted, as it
was thought that he was in acute renal failure secondary to
dehydration. The patient's creatinine improved with time, and
by the time of discharge on [**12-5**], his creatinine was 0.9. He
was transferred back to the floor on [**12-1**] where he continued to
do well. He was discharged to acute rehab at [**Hospital1 **] on [**12-5**].
Major Surgical or Invasive Procedure:
Abdominal perineal resection, gracilus flap closure
Past Medical History:
1) HIV/AIDS
2) DM Type II
Social History:
Pt lives with partner in [**Name (NI) 3674**], but they are staying in
[**Hospital1 15**] as he is getting radiation therapy. Homosexual male.
Denies IVDU, EtOH, Tob.
Family History:
Non contributory
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 14**] & Rehab Center - [**Hospital1 15**]
Discharge Diagnosis:
Anal squamous cell carcinoma
Diabetes
HIV/AIDS
Discharge Condition:
good
Discharge Instructions:
Notify MD if you experience incresing pain, fever > 101.5,
bleeding or other concerning signs. Resume taking all of your
pre-procedure medications
Followup Instructions:
in 1 week with Dr. [**Last Name (STitle) **], General Surgery, call her office for
an appointment
in 1 week with Dr. [**First Name (STitle) 3675**], call his office for an appointment
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(1) 3676**]
Completed by:[**2157-12-5**]
|
[
"250.00",
"571.5",
"584.5",
"197.5",
"458.29",
"276.5",
"042",
"V15.3",
"198.82",
"276.0",
"276.6",
"560.1",
"154.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"59.8",
"99.15",
"99.04",
"86.89",
"96.07",
"38.93",
"48.5",
"60.62",
"86.74",
"86.67"
] |
icd9pcs
|
[
[
[]
]
] |
7045, 7126
|
1870, 2682
|
6700, 6754
|
7217, 7223
|
971, 1847
|
7419, 7726
|
7004, 7022
|
3495, 4876
|
7147, 7196
|
2708, 3472
|
7247, 7396
|
857, 952
|
277, 307
|
427, 575
|
6776, 6803
|
6819, 6988
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,734
| 154,629
|
538
|
Discharge summary
|
report
|
Admission Date: [**2110-8-26**] Discharge Date: [**2110-8-30**]
Date of Birth: [**2053-7-14**] Sex: F
Service: VASCULAR
HISTORY OF PRESENT ILLNESS: The patient is a 57 year old
female with multiple medical problems who presented with
gangrene of the right lower extremity, required admission for
pain control, intravenous antibiotics and ultimately for
right below the knee amputation.
PAST MEDICAL HISTORY:
1. Coronary artery disease, status post coronary artery
bypass graft, complicated by sternal wound infection.
2. History of Methicillin resistant Staphylococcus aureus
bacteremia in [**2109-8-3**].
3. Diet controlled diabetes mellitus.
4. Hypertension.
5. Hypercholesterolemia.
6. Significant tobacco use.
7. History of wound abscess in the right lower extremity
which grew out Methicillin resistant Staphylococcus aureus.
8. Status post AV fistula in [**2105**].
9. Status post coronary artery bypass graft times three that
was complicated by the sternal wound infection, [**8-3**], by Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1537**].
10. Status post right femoral to below knee popliteal bypass
with PTFE done in [**3-4**], followed by a right first toe
amputation completed in [**3-4**].
11. History of cesarean section.
12. Questionable history of Penicillin allergy, but she does
state otherwise that she has no known drug allergies.
MEDICATIONS ON ADMISSION:
1. Nephrocaps one tablet p.o. once daily.
2. Norvasc 5 mg twice a day.
3. Gabapentin 300 mg q Monday, Wednesday and Friday after
hemodialysis.
4. Tramadol 50 mg p.o. twice a day p.r.n.
5. Trazodone 100 mg q.h.s.
6. Medroxyprogesterone 2.5 mg once daily.
7. Albuterol MDI.
8. Pantoprazole 40 mg p.o. once daily.
9. Calcitriol 0.25 mcg once daily.
10. Aspirin 81 mg p.o. once daily.
11. Epogen 20,000 units q Monday, Wednesday and Friday with
hemodialysis as well as using MSIR 50 mg q12hours.
The patient was admitted with increasing right lower
extremity pain and low grade temperature. Her admission
white count was noted to be 10.4 with a left shift,
hematocrit 40.0 with a platelet count of 244,000.
Prothrombin time was 13.7 and INR was 1.3 with a partial
thromboplastin time of 28.0. She was on dialysis with a
blood urea nitrogen and creatinine of 74 and 6.9,
respectively. She had an admission potassium of 7.6 which
was repeated in the Emergency Department and shown to be 8.0.
Hyperkalemia was emergently treated with calcium chloride,
bicarbonate, dextrose, insulin, Lasix as she does make some
urine, as well as emergent hemodialysis and Kayexalate.
Upon the day of admission, she went to dialysis and received
her hemodialysis. Her potassium postdialysis was 4.1. She
was otherwise feeling OK except complaining of persistent
right lower extremity pain.
PHYSICAL EXAMINATION: Her admission examination was notable
for a temperature of 100.1, pulse 90, blood pressure 158/60,
respiratory rate 18, oxygen saturation 94% in room air. She
was a cachectic female who appeared older than her stated
age. The pupils are equal, round, and reactive to light and
accommodation. Extraocular movements are intact. The sclera
were anicteric. She had no jugular venous distention and no
carotid bruit. The heart was regular with no gallop. The
lungs were clear but decreased throughout. The abdomen was
soft, nontender, scaphoid, no hepatosplenomegaly, no
pulsatile masses and no bruit. She had palpable femoral
pulses bilaterally. Popliteal pulses were not palpable.
Distal pulses in the right lower extremity were absent. She
had some dry and wet gangrene involving the right forefoot
with a failed right first toe amputation site that clearly
had some purulent exudate.
She was admitted for intravenous antibiotics and started on
Vancomycin, Levofloxacin and Flagyl for her hemodialysis.
Over the next couple days, she was resuscitated adequately
and ultimately on [**2110-8-26**], she went to the operating room
and received a right below the knee amputation.
Postoperatively she did well. She was ruled out by enzymes
and kept on telemetry times 24 hours and was uneventful. Her
postoperative white blood cell count was 9.6 and hematocrit
was 41.8. Platelet count was 157,000. Blood urea nitrogen
and creatinine were 58 and 6.3 with a potassium of 5.3. Her
phosphate was noted to be elevated at 11.8. Therefore, in
hospital medications, she had her Calcitriol stopped and she
was started on Amphojel and PhosLo. The Amphojel was
continued for a total of three days of therapy, starting on
[**2110-8-28**], and to end on [**2110-8-31**]. Over the next couple days,
her pain was appropriately controlled with Dilaudid PCA
although the patient demanded that the Dilaudid did not work
for her. Therefore, she was requesting Morphine. This was
given concomitantly and resulted in some mental status
changes and confusion which quickly resolved upon removal of
her narcotic. She had a foot culture from [**2110-8-25**], that
grew out Methicillin resistant Staphylococcus aureus. Blood
cultures from [**2110-8-24**], were negative. By postoperative day
number four, she continued on triple antibiotics. Her
temperature maximum was 100.1, but a current of 97.4, pulse
82, blood pressure 130/70, respiratory rate 18, 96% oxygen
saturation in room air. Her fingerstick was mildly elevated
but she was noncompliant and was not taking a diabetic or
renal diet. She was taking adequate p.o. Her white blood
cell count at discharge was 9.4. Her blood urea nitrogen and
creatinine were 52 and 6.3 with a potassium of 4.8 and
bicarbonate of 21.
At this time, her stump which had been resected back to the
level of the proximal one third of the right lower extremity
was clean, dry and intact with staples in place, no erythema,
no exudate, no evidence of hematoma and the flaps were warm.
She was deemed stable and appropriate for discharge by Dr.[**Name (NI) 4436**] service.
MEDICATIONS ON DISCHARGE:
1. Nephrocaps one tablet p.o. once daily.
2. Vancomycin to be dosed at time of dialysis times two
weeks, dose for trough values less than 15.0.
3. Norvasc 5 mg p.o. twice a day.
4. Gabapentin 300 mg q Monday, Wednesday and Friday after
hemodialysis.
5. Tramadol 50 mg p.o. twice a day p.r.n.
6. Trazodone 100 mg p.o. q.h.s.
7. Medroxyprogesterone 2.5 mg p.o. once daily.
8. Albuterol MDI q4hours p.r.n.
9. Pantoprazole 40 mg p.o. once daily.
10. Calcitriol 0.25 mcg p.o. once daily to be on hold until
followed up by her nephrologist.
11. Aspirin 81 mg p.o. once daily.
12. Folic Acid 1 mg p.o. once daily.
13. Epogen 20,000 units q Monday, Wednesday and Friday with
hemodialysis.
14. MSIR 50 mg p.o. q12hours.
15. Dilaudid 2 to 4 mg p.o. q3-4hours p.r.n. breakthrough
pain.
16. Colace and Pericolace for stool softening agents.
FOLLOW-UP: The patient should follow-up with Dr. [**Last Name (STitle) 1391**] in
approximately two to three weeks for skin clip removal. She
will have right lower extremity remain in knee immobilizer
with a dry dressing and ace wrap to above knee region to help
immobilize and straighten her leg. She should take part in
aggressive physical therapy and learn how to do transfers and
so forth. Ultimately she will require outpatient sitting for
prosthesis, however, the stump cannot be used until
designated by Dr. [**Last Name (STitle) 1391**]. Typically this occurs within six
to eight weeks postoperatively. The patient is deemed
appropriate and stable for discharge.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4417**]
Dictated By:[**Last Name (NamePattern4) 4437**]
MEDQUIST36
D: [**2110-8-30**] 10:13
T: [**2110-8-30**] 10:32
JOB#: [**Job Number 4438**]
cc:[**Last Name (NamePattern1) 4439**]
|
[
"293.0",
"276.7",
"250.70",
"E935.2",
"585",
"440.24",
"401.9",
"250.40"
] |
icd9cm
|
[
[
[]
]
] |
[
"84.15",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
5971, 7801
|
1432, 2815
|
2838, 5945
|
170, 409
|
431, 1406
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,399
| 156,844
|
17223
|
Discharge summary
|
report
|
Admission Date: [**2158-10-21**] Discharge Date: [**2158-11-18**]
Date of Birth: [**2127-3-9**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Bactrim / Vancomycin And Derivatives / Cellcept
Attending:[**First Name3 (LF) 3326**]
Chief Complaint:
Diarrhea
Major Surgical or Invasive Procedure:
Endotracheal intubation
Attempted cardiopulmonary resuscitation
History of Present Illness:
31 y/o man with a PMH of relapsed AML who has received alloSCT
x2 from his brother who presents today after a week of
progressive diarrhea x 6 days with fevers today. Today c/o > 20
episodes copious non-bloody, yellow green watery diarrhea. He
also c/o increased fatigue x 1 dy. He has also noticed increased
ankle edema x 1 dy. In ED found to be febrile to 101.7.
Yellow/green nausea and emesis x T. his dysuria has resolved
completely. Does not report back pain. Of note ROS also positve
for a cough and low grade fevers x1 week for which he was
started on levoquin/inhalers on [**2158-10-16**]. He has noticed that
his breathing is slightly more labored w/o inhaler but denies
increasing dyspnea on exetion, PND, chest discomfort, or
orthopnea. Does not report abdominal pain. Strict adherence to
neutropenic diet. His father has been sick but does not have
diarrhea. No recent travel.
.
meds in ED: On DOA
Today 20:55 Magnesium Sulfate 2g
Today 20:59 NS (Mini Bag Plus) 100mL Bag 1
Today 21:23 Acyclovir 200mg Cap 2
Today 21:23 Metoprolol 50mg Tab
Today 21:23 Prednisone 10mg Tablet
Today 21:24 Levofloxacin 500mg Tablet
Today 21:24 Dolasetron Mesylate 12.5mg Vial
Today 21:39 Phenazopyridine HCl 100mg
Past Medical History:
AML as above
s/p Cholecystectomy [**10/2157**]
h/o pleural effusions b/t. tapped in [**10-26**]
.
His AML course is significant for diagnosis of AML in [**2151**] and
underwent an alloBMT. His course was complicated by severe
chronic cutaneous GVHD causing a scleroderma-like process. This
was treated with photopheresis, pentostatin, and Rituxan. In
[**4-/2158**] he was noted to have blasts in his peripheral blood
counts and he was re-admitted for reinduction with VP-16 and
Ara-C followed by a second allogeneic transplantation with
bu/cy. This transplant was complicated by b/l pleural effusions,
pericarditis, and infection. He was d/c on [**9-16**]. He was then
admitted again on [**11-4**] with hemorrhagic cystitis which
resolved with ditropan, pyridium and narcotics.
Social History:
He lives with parents and brother. Is a nursing student. Denies
tob, EtOH, or illicits.
Family History:
No hx of oncolologic dx. CAD in grandparents.
Physical Exam:
T 97.8 BP 93/54 HR 116 RR 20 O2Sat 95% CMV Vt 550x16 PEEP 5 FIO2
100%
Gen: sedated but responsive
HEENT: EOMI, PERRL, intubated
Neck: -LAD
Chest: diffuse ronchi throughout
CV: Tachy RR, S1/S2 intact, -M/R/G
Abd: S/distended, +BS in all four quadrants, scrotal edema
Ext: generalized anasarca, +3 pitting edema in UE and LE
Pertinent Results:
REPORTS:
.
CXR [**2158-11-17**]:
IMPRESSION: Pulmonary edema, bibasilar atelectasis and
effusions.
Superimposed infection cannot be excluded.
CT head [**2158-11-16**]:
CT OF THE HEAD WITH AND WITHOUT IV CONTRAST: There are no
enhancing masses,
hydronephrosis, intracranial hemorrhage, shift of normally
midline structures,
major vascular territorial infarct, or mass effect. The
[**Doctor Last Name 352**]-white matter
differentiation is preserved. There is an air-fluid level in
the right
maxillary sinus. The osseous structures are unremarkable.
CT chest/abd/pelvis [**2158-11-16**]:
IMPRESSION:
The study is technically limited due to streak artifacts arising
from the
overlying patient's arms.
1. Slight increase in ascites when compared to the prior study.
2. Increase in anasarca.
3. Decrease in pericardial effusions.
4. Increase in pulmonary effusions.
5. New bilateral pulmonary infiltrates, left larger than right.
These likely
represent infectious infiltrates.
TTE [**2158-11-16**]:
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
normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal.
3.The aortic valve leaflets (3) appear structurally normal with
good leaflet
excursion. No aortic regurgitation is seen.
4.The mitral valve appears structurally normal with trivial
mitral
regurgitation.
5.There is a small pericardial effusion. The effusion appears
circumferential.
The effusion is echo dense, consistent with blood, inflammation
or other
cellular elements. There are no echocardiographic signs of
tamponade.
TTE [**2158-11-13**]:
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
normal
(LVEF>55%).
3. Right ventricular chamber size is normal.
4.The aortic valve leaflets (3) appear structurally normal with
good leaflet
excursion. No masses or vegetations are seen on the aortic
valve. No aortic
regurgitation is seen.
5.The mitral valve leaflets are mildly thickened. No mass or
vegetation is
seen on the mitral valve. Trivial mitral regurgitation is seen.
6.There is a small pericardial effusion. There are no
echocardiographic signs
of tamponade.
MR CALF W&W/O CONTRAST [**2158-11-10**]:
IMPRESSION: Diffuse edema bilaterally with a moderate right
knee effusion.
Crescenteric fluid around the gastrocnemius muscle bellies,
worse on the right
than left. No drainable collections seen.
CT ABDOMEN W/CONTRAST [**2158-10-31**]:
IMPRESSION:
1. Interval marked increase in size of pericardial effusion
compared to
recent study of [**2158-8-23**].
2. Persistent bilateral pleural effusions with associated
atelectasis.
3. Interval development of wall edema involving the entire
length of colon
and distal ileum. Differential diagnosis includes infectious and
inflammatory
etiologies . Ischemia is unlikely and distribution would be
atypical for
graft versus host disease and neutropenic enterocolitis.
[**10-26**]: CXR
IMPRESSION:
1. Large pericardial effusion, increased from the prior study.
2. Bilateral pleural effusions, right greater than left,
increased from the prior study.
.
[**10-26**]: ECHO:
1. Left ventricular wall thickness, cavity size, and systolic
function are normal (LVEF>55%). Regional left ventricular wall
motion is normal.
2. There is a moderate sized pericardial effusion. There is
significant,
accentuated respiratory variation in mitral/tricuspid valve
inflows,
consistent with impaired ventricular filling.
3. Compared with the findings of the prior study of [**2158-8-28**], the
size of the pericardial effusion has increased and the signs of
tamponade are new.
.
LABS:
[**2158-11-18**] 04:32AM BLOOD WBC-12.5* RBC-3.06* Hgb-9.9* Hct-31.5*
MCV-103* MCH-32.3* MCHC-31.4 RDW-25.5* Plt Ct-22*
[**2158-11-18**] 04:32AM BLOOD Neuts-62 Bands-17* Lymphs-7* Monos-6
Eos-0 Baso-0 Atyps-0 Metas-4* Myelos-4* NRBC-25*
[**2158-11-18**] 04:32AM BLOOD Plt Ct-22*
[**2158-11-18**] 04:32AM BLOOD PT-13.5* PTT-25.4 INR(PT)-1.2
[**2158-11-17**] 02:40AM BLOOD Fibrino-294
[**2158-11-15**] 11:20PM BLOOD Gran Ct-[**Numeric Identifier 42090**]*
[**2158-11-18**] 09:23AM BLOOD Glucose-142* UreaN-52* Creat-0.9 Na-174*
K-4.3 Cl-110* HCO3-GREATER TH
[**2158-11-18**] 04:32AM BLOOD Glucose-189* UreaN-60* Creat-1.1 Na-136
K-4.2 Cl-110* HCO3-19* AnGap-11
[**2158-11-18**] 04:32AM BLOOD ALT-18 AST-38 LD(LDH)-1409* AlkPhos-102
TotBili-2.5*
[**2158-11-18**] 09:23AM BLOOD Calcium-5.8* Phos-2.7 Mg-1.1*
[**2158-11-18**] 04:32AM BLOOD Albumin-2.0* Calcium-7.8* Phos-3.7
Mg-1.5*
[**2158-11-18**] 04:32AM BLOOD Cyclspr-590*
[**2158-11-18**] 09:29AM BLOOD Type-ART pO2-250* pCO2-31* pH-7.80*
calHCO3-50* Base XS-26 Intubat-INTUBATED
[**2158-11-18**] 08:37AM BLOOD Type-ART Temp-36.6 Tidal V-550 PEEP-10
FiO2-60 pO2-93 pCO2-33* pH-7.31* calHCO3-17* Base XS--8
-ASSIST/CON Intubat-INTUBATED Vent-SPONTANEOU
[**2158-11-18**] 09:29AM BLOOD K-3.7
[**2158-11-18**] 06:28AM BLOOD Lactate-1.6
.
MICRO:
[**2158-11-16**] PLEURAL FLUID GRAM STAIN-FINAL; FLUID
CULTURE-PENDING; ANAEROBIC CULTURE-PENDING; FUNGAL
CULTURE-PENDING; ACID FAST SMEAR-FINAL; ACID FAST
CULTURE-PENDING; VIRAL CULTURE-PENDING
[**2158-11-15**] BLOOD CULTURE AEROBIC BOTTLE-PENDING; ANAEROBIC
BOTTLE-PENDING
[**2158-11-15**] BLOOD CULTURE AEROBIC BOTTLE-PENDING; ANAEROBIC
BOTTLE-PENDING
[**2158-11-15**] BLOOD CULTURE AEROBIC BOTTLE-PENDING; ANAEROBIC
BOTTLE-PENDING
[**2158-11-14**] BLOOD CULTURE AEROBIC BOTTLE-PENDING; ANAEROBIC
BOTTLE-PENDING
[**2158-11-13**] Immunology (CMV) CMV Viral Load: negative
[**2158-11-11**] CATHETER TIP-IV WOUND CULTURE-FINAL {STAPH AUREUS
COAG +}
[**2158-11-10**] URINE URINE CULTURE: negative
[**2158-11-10**] BLOOD CULTURE AEROBIC BOTTLE-FINAL {STAPH AUREUS COAG
+}; ANAEROBIC BOTTLE-FINAL {STAPH AUREUS COAG +}
[**2158-11-10**] BLOOD CULTURE AEROBIC BOTTLE-FINAL {STAPH AUREUS COAG
+}; ANAEROBIC BOTTLE-FINAL {STAPH AUREUS COAG +, STAPH AUREUS
COAG +}
[**2158-11-9**] BLOOD CULTURE AEROBIC BOTTLE-FINAL {STAPH AUREUS COAG
+}; ANAEROBIC BOTTLE-FINAL {STAPH AUREUS COAG +}
[**2158-11-9**] BLOOD CULTURE AEROBIC BOTTLE-FINAL {STAPH AUREUS COAG
+}; ANAEROBIC BOTTLE-FINAL {STAPH AUREUS COAG +}
[**2158-11-6**] Immunology (CMV) CMV Viral Load: negative
[**2158-11-2**] PLEURAL FLUID GRAM STAIN-FINAL; FLUID CULTURE-FINAL;
ANAEROBIC CULTURE-FINAL: negative
Brief Hospital Course:
[**Hospital Unit Name 153**] course:
31 y/o man with a PMH of relapsed AML who has received alloSCT
x2 from his brother who was initially admitted for diarrhea and
fevers as well as increased dyspnea and orthopnea. While in
hospital patient with pericardial effusion s/p
pericardiacentesis [**2158-10-27**], plueral effusions s/p thoracentesis
x 2 most recent on [**2157-11-16**], MRSA bacteremia, GI bleed,
increased LFTs. Most recenlty patient noted to have increased
tacypnea on [**11-15**] and episode of choking/vomiting while
drinking. Patient was started on cefepime/flagyl to cover for
possible aspiration PNA. CXR showed increase pleural effusion
and patient underwent thoracentesis on [**2158-11-16**]. Patient got 40
IV lasix earlier in the day and put out 1L and O2Sat improved
the previous night. On day of transfer to [**Hospital Unit Name 153**] patient was found
to be in respiratory distress O2 sat low 80s and intubated. VBG
showed 7.08/69/43. He was transferred to the [**Hospital Unit Name 153**], intubated,
and placed on CMV 550/16/5/100%. FIO2 decreased to 70%.
The ddx for his worsening respiratory status was worsening PNA,
new aspiration PNA, or PE. Post-thoracentesis CT showed
remaining large effusion and infiltrates. Cefepime, flagyl, and
daptomycin were continued. Decision made not to do CTA, since
anticoagulation contraindicated given profound thrombocytopenia,
which was thought to be [**12-28**] HUS/TTP from CSA.
In the [**Hospital Unit Name 153**], his MAPs were in the 50s. FENa found to be 0.2%,
indicating prerenal state. Fluid boluses were given, which were
minimally effective. Serial ABGs were done overnight. His
oxygenation status improved, and his FIO2 was decreased to 60%
around 8:30AM on [**11-18**]. At 9:30AM, team was called to bedside
for hypotension. Found to be in PEA arrest. Code called.
Throughout the code, pt was intermittently in PEA, VT/VF, and
asystole, and treated appropriately with epinephrine,
amiodarone, atropine, and defibrillation as indicated. ABG was
done, which was 7.80/31/250 with K 3.7. Family was present at
bedside at code. Consideration given to bedside
pericardiocentesis due to recent evidence of pericardial
effusion on TTE; however, pt remained in VF and asystole, and
was deferred. After 30 minutes, decision made by ICU team and
family to stop code. Death was pronounced at 9:40am. Autopsy was
requested.
CCU Course:
On DOA, patient was found to have a pericardial effusion on CT
scan and a TTE was suggestive of tamponade. For this reason, the
patient was transferred to the CCU.
# PERICARDIAL EFFUSION
- Etiology likely underlying Malignancy
- On acceptance to the CCU, patient had pulsus [**2-28**] mmHg; JVP
elevated at 9 cm
.
- On HOD#2, patient was taken to cath lab and thre was no
evidence of tamponade physiology -> hence a pericardiocentesis
was not done.
- considered Reecho for pericardial fluid status in 1 week.
- despite no intervention, patient felt clinically improved on
HOD#3.
- HR had been in sinus rhythm with occasional tachycardia on
Tele.
- Since patient had no other urgent cardiac issues, he was
transferred back to the [**Month/Day (1) 3242**] team.
.
# DYSPNEA
- Etioplogy thought to be combination of bilateral pleural
effusions and pericardial effusion/echocardiographic tamponade
- post procedure, no complaints of dyspnea
- considered thoracentesis for diagnostic/therapeutic purposes
.
# DIARRHEA
- Etiology unclear; was investigated by [**Month/Day (1) 3242**] service.
Differential includes infectious diarrhea vs GVHD. Patient
started on Flagyl and IV steroids (? GVHD).
- Improved diarrhea in evening of [**10-27**]
- CDiff neg x 3
- CMV negative on [**10-16**]
- NPO, IVF
- Repleteed electrolytes PRN
- received Loperamide standing
.
# FEVERS:
- Concerning for infection
- CXR without evidence of PNA, with B/L effusions
- f/u stool cultures and blood cultures
- F/u UA/UCx
- PICC without clinical signs of infection
.
# AML
- [**Month/Year (2) 3242**] followed
- Continude Acyclovir/Levoquin/Ursodiol/Cyclosporine/
Diflucan/Prednisone
- Monitored lytes
- Allogenic transplant precautions
- Monitored fever curve and CIS
.
[**Month/Year (2) 3242**] course:
31y/o man w/ AML s/p his second allo-SCT who presented w/ one
week of diarrhea and fevers. Pt subsequently had new oxygen
requirement, was found to have signs of tamponade by echo, and
was transferred to the CCU. Right heart cath did not show
tamponade, and pt was transferred back to the [**Month/Year (2) 3242**] service. Pt
subsequently had episode of hypotension, accompanied by fever
and continued R leg pain. Pt then grew 4/4 bottles of MRSA from
blood. Pt then had acute episode of SOB of unclear etiology,
and was intubated and transferred to the ICU for mechanical
ventilation.
.
#) Episode of hypotension: Likely secondary to sepsis, given
positive blood cx's and fever. Possible sources included PICC, R
leg, or GI tract. PICC line was pulled and cath tip grew MRSA.
Pt subsequently grew MRSA from blood, which was treated with
daptomycin.
- pt given 1 L NS, cefepime, and daptomycin at time of
hypotension. BP subsequently normalized.
- transfused PRN
- R leg CT was negative for bleed. R leg MRI negative for
pathology, except for edema. Ortho was consulted, and leg pain
improved with brace and ROM exercises.
- cefepime and daptomycin were started (pt has PCN and Vanc
allergy), given new fevers and decreased BP
- stat portable CXR shows increased size of R pleural effusion,
but no pneumothorax that could be causing hypotension
- repeat echo did not show endocarditis or signs of tamponade
.
#) Diarrhea: Pt presented with voluminous diarrhea, thought
likely due to GVH. Pt's diarrhea improved markedly, although
gradually, with both steroid treatment and with flagyl. Ddx
included infectious diarrhea- cidff, other bacterial pathogens,
vs GVHD. Pt had hx significant for GVH.
- abd CT scan showed edema/inflammation of the entire colon, and
involvement of [**11-27**] of the ileum. Likely consistent with
infection (per radiology, would be atypical for GVH).
- GI consulted, recommended flex sig, however pt refused
procedure.
- crypto and microsporidia were negative
- stool O&P was negative
- C.dif toxin B was negative
- C.diff negative x 3
- pt had one day of levo/flagyl on admission, subsequently d/c'd
as pt was afebrile. flagyl re-started for 2 wk course of empiric
therapy for C.dif, given radiologic findings and GI
recommendations.
- pt was also treated with solumedrol and cyclosporine for
presumed GVH
- weekly CMV viral loads were negative
- pt tolerated clear liquids with occasional toast, with only
minimal diarrhea.
- CSA was continued throughout the admission, dosed by level
.
#) Fevers: Pt was afebrile during most of the admission,then
spiked a fever accompanied by episode of hypotension. Pt grew
4/4 bottles MRSA from blood.
- cxr demonstrated BL effusions w/o evidence of infection, L
pleural fluid from prior thoracentesis demonstrates transudative
process.
- picc site was tender, and PICC was subsequently pulled
.
#) AML: Pt was not neutropenic.
- acyclovir/CSA were continued
- continude ursodiol (was being held [**12-28**] difficulty taking
pills)
- allogenic x-plant precautions
- monitored fever curve
.
#) SOB: Pt had been having increasing oxygen requirement, and
had acute episode of SOB prior to transfer to CCU. Appears to
have resolved during stay in CCU. Chest CT showed large
pericardial effusion, and BL pleural effusions. Although echo
was consistent with tamponade, right heart cath did not show
tamponade. Repeat abdominal CT showed larger pericardial
effusion. Subsequent CT's showed decreasing size of pericardial
effusions.
- pt underwent multiple thoracenteses during the admission, and
1 L serosanguinous fluid was removed each time
- per pulm recs, both pleurodesis and pleurex were considered
- CXR showed rapid reaccumulation of pleural effusions
- pericardial effusion decreased in size according to last chest
CT
.
#) HTN: pt had been hypertensive during the admission (with BP
140's/110's). Unclear if pt has hx of htn (he says he was on
metoprolol for "irregular heart rhythm."). Also unclear etiology
of decreased pulse pressure (? related to pericardial effusion).
HTN possibly secondary to cyclosporine.
- metoprolol 25mg tid was given, with increased dose to 50 tid
- nifedipine 10mg tid switched to nifedipine 30mg CR qd, and
nifedipine then held in setting of hypotension
.
#) Thrombocytopenia: Pt had decreased platelets from 100 to 50
overnight during stay in CCU (he had been started on Hep SC for
ppx).
- Ddx includes recurrence of AML, TTP, or drug induced. Several
schistocytes were seen on peripheral smear.
- HIT Ab was negative
- decreased platelets also might be secondary to flagyl (however
continued flagyl given possible infectious colitis, and pt's
intolerance of vanco)
- towards the end of the admission, there was more concern for
TTP given pt's rising LDH, decreasing platelets, and worsening
mental status. Stopping the pt's cyclosporine was considered,
however the CSA was continued because pt was believed to be at
risk for worsening GVH.
.
#) Elevated LFT's/bili/LDH: Concerning for liver GVH vs. VOD.
LDH had been rising, then trended down, then began to increase.
Possibly due to liver GVH vs. pulmonary process (pt had known
pleural and pericardial effusions). TTP also a possibility
given decreased platelets.
- pleural fluid LDH much less than serum LDH, suggesting liver
or hemolytic source of elevated serum LDH
- RUQ u/s was negative for clot
- bili peaked at about 4.3, then began to stabilize around 3
- fluconazole was held secondary to rising bili
.
#) Edema: Pt had significant LE edema, likely secondary to low
albumin, GVH, and high volume needed for antibiotics and TPN.
- avoided aggressive diuresis given concern for tamponade and
sepsis
.
#) FEN: pt was originally NPO, given concern for gut GVH. pt
was then started clear liquids, and this was well tolerated.
This was subsequently switched back to NPO as pt's mental status
deteriorated, given concern for aspiration.
.
#) Code: Pt was full code throughout the admission.
Medications on Admission:
Folic Acid 1 mg qd
Pantoprazole 40 mg qd
Oxycodone 5 mg q 4 hrs prn
Triamcinolone prn
Cyclosporine liquid form (neoral) 200 mg [**Hospital1 **]
Ditropan 5 mg qd
Pyridium 200 mg [**Hospital1 **]
Acyclovir 400 mg tid
Ursodiol 300mg [**Hospital1 **]
Zolpidem 5 mg qhs prn
Ativan 1 mg prn
Metoprolol 50 mg [**Hospital1 **]
Fluconazole 200 mg qd
Prednisone 5 mg 3T qam and T qhs
Levoquin 500 mg po qd started [**2158-10-17**] for low grade temps and
cough along with advair and combivent- plan was to f/u with Dr.
[**First Name (STitle) 1557**] this Tuesday to confirm duration of course.
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Recurrent acute myelogenous leukemia, pneumonia, pleural and
pericardial effusions, cardiopulmonary arrest
Discharge Condition:
Deceased
Discharge Instructions:
N/A
Followup Instructions:
N/A
Completed by:[**2158-11-19**]
|
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77,487
| 144,009
|
9476
|
Discharge summary
|
report
|
Admission Date: [**2198-11-17**] Discharge Date: [**2198-11-23**]
Date of Birth: [**2123-1-24**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4891**]
Chief Complaint:
hematemesis
Major Surgical or Invasive Procedure:
[**2198-11-17**] EGD
[**2198-11-19**] EGD
[**2198-11-21**] EGD with enteroscopy
[**2198-11-23**] Left thumb Incision and Drainage
History of Present Illness:
Mr. [**Known lastname 32226**] is a 75 year old male with CAD s/p CABG, systolic
heart failure and chronic kidney disease history. He reports
having vertiginous episode for 30 seconds with subsequent
vomiting of 200 cc of dark red blood. He does not report chest
pain, shortness of breath, lightheadedness, syncope, presyncope,
melena or BRBPR. He has never had hematemesis. He reports
using ibuprofen for past three days for his gout.
In the ED, initial VS were: 97.2 62 127/52 18 100%RA. NG
lavage showed coffee ground with bright red blood which was not
cleared with lavage. 2 units of PRBC have been typed and
crossed. Started pantoprazole 80 + gtt. 2 18 IV. Last vitals:
72 134/70 18 100%RA.
On arrival to the MICU, he reports feeling well.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
- Coronary artery disease
* CABG ([**2187**]): LIMA to LAD/Vein to OM/Vein to distal circ/Vein
to D2
- Hypertension
- Chronic kidney disease, stage III-IV
- Congestive heart failure
* EF 35-40% ([**2191**]), moderate LVH, mild AS
- Hypercholesterolemia
- Spinal stenosis
* s/p lumbar laminectomy and fusion L3-L5 ([**2191**])
- S/p hip replacement ([**2184**])
- S/p hemorrhoidectomy
- Diabetes mellitus
* A1c 6.3 ([**2196**])
- Osteoarthritis
Social History:
The patient currently at rehab since his last discharge. He
usually lives with his wife and two sons. [**Name (NI) **] ambulates
with a walker. Quit smoking 12 years ago. Smoked 100 ppy
history.
Family History:
Brother had rheumatic fever.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T: BP: P: R: 18 O2:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
Discharge Physical Exam:
Vitals: Tc 97.9 Tm 99.2 BP 135-153/55-66 HR 56-66 RR 18 O2sat
99(RA).
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: RRR, normal S1 + S2, II/VI systolic ejection murmur best
heard at RUSB
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, no tophus or evidence of inflammed joints
Neuro: CNs2-12 intact, motor function grossly normal
Pertinent Results:
ADMISSION LABS:
[**2198-11-17**] 08:05AM BLOOD WBC-8.9 RBC-4.18* Hgb-12.0* Hct-36.0*
MCV-86 MCH-28.7 MCHC-33.3 RDW-14.8 Plt Ct-171
[**2198-11-17**] 08:05AM BLOOD Neuts-70.0 Lymphs-21.4 Monos-6.0 Eos-2.1
Baso-0.5
[**2198-11-17**] 08:05AM BLOOD PT-11.3 PTT-32.7 INR(PT)-1.0
[**2198-11-17**] 08:05AM BLOOD Glucose-179* UreaN-70* Creat-2.0* Na-141
K-4.8 Cl-102 HCO3-28 AnGap-16
[**2198-11-17**] 08:05AM BLOOD ALT-51* AST-33 AlkPhos-116 TotBili-0.3
[**2198-11-17**] 08:05AM BLOOD Albumin-3.6
[**2198-11-17**] 12:32PM BLOOD Calcium-8.3* Phos-3.0 Mg-2.1
[**2198-11-17**] 08:13AM BLOOD Hgb-11.8* calcHCT-35
[**2198-11-17**] 09:18AM URINE Color-Straw Appear-Hazy Sp [**Last Name (un) **]-1.011
[**2198-11-17**] 09:18AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-LG
[**2198-11-17**] 09:18AM URINE RBC-1 WBC-54* Bacteri-NONE Yeast-NONE
Epi-2
[**2198-11-17**] 09:18AM URINE CastHy-28*
[**2198-11-17**] 09:18AM URINE Mucous-RARE
.
IMAGING:
FINDINGS: Mild cardiomegaly is again noted. Lung volumes are
low, likely
exaggerating pulmonary vasculature which is mildly prominent. No
focal
consolidation or pneumothorax is detected. There is possibly a
small left
pleural effusion. An esophageal catheter is incompletely
evaluated due to
exposure. Sternal wires are noted.
IMPRESSION: Low lung volumes with cardiomegaly and possible
small left
pleural effusion. Incomplete evaluation of esophageal catheter,
which
possibly terminates in the mid esophagus. Per discussion with
Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 14740**] by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7867**] by telephone at 21:02 on
[**2198-11-17**], this tube may possibly be in place intentionally
within the mid esophagus. If gastric placement is desired,
advancing the tube is recommended if not contraindicated for
this patient.
.
EGD ([**2198-11-17**]): Esophagus: Normal esophagus.
Stomach: Excavated Lesions A few non-bleeding localized erosions
were noted in the antrum. Cold forceps biopsies were performed
for histology.
Duodenum: Normal duodenum.
Impression: Erosions in the antrum (biopsy)
Otherwise normal EGD to third part of the duodenum
.
EGD ([**2198-11-19**]):
Irregular z line was noted. Biopsies of this area was obtained.
(biopsy)
Normal mucosa in the whole stomach
Normal mucosa in the whole duodenum
Otherwise normal EGD to third part of the duodenum
.
Small Bowel Enteroscopy ([**2198-11-21**]):
Esophagitis
Normal mucosa in the whole stomach
Normal mucosa in the whole duodenum
Normal mucosa in the proximal jejunum
Otherwise normal EGD to jejunum
.
Thumb Xray ([**2198-11-23**]):
FINDINGS:
Three views of the left thumb demonstrate thumb within a splint.
There are
degenerative changes at the first IP joint with osteophytes and
joint space
narrowing. There are also severe osteoarthritic changes at the
first CMC with intra-articular bodies and large osteophytes with
joint space narrowing and cystic change. It is unclear as to
whether there is a superimposed fracture at the base of the
first metacarpal or background degenerative changes. No acute
fracture identified in the distal aspect of the thumb.
Hematology labs:
[**2198-11-20**] 12:44PM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-1+
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-1+ Tear
Dr[**Last Name (STitle) 833**]
[**2198-11-20**] 12:44PM BLOOD Ret Aut-1.4
[**2198-11-20**] 12:44PM BLOOD LD(LDH)-171
[**2198-11-21**] 07:02AM BLOOD VitB12-509 Folate-13.1 Ferritn-52
[**2198-11-20**] 12:44PM BLOOD calTIBC-276 Hapto-142 TRF-212
Micro:
[**2198-11-19**] 6:55 am SEROLOGY/BLOOD
**FINAL REPORT [**2198-11-21**]**
HELICOBACTER PYLORI ANTIBODY TEST (Final [**2198-11-21**]):
NEGATIVE BY EIA.
(Reference Range-Negative).
[**2198-11-23**] 8:58 am THUMB ABSCESS Source: L 1st digit.
GRAM STAIN (Final [**2198-11-23**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CHAINS.
WOUND CULTURE (Preliminary):
BETA STREPTOCOCCUS GROUP B. MODERATE GROWTH.
ANAEROBIC CULTURE (Preliminary):
Labs on Discharge:
[**2198-11-23**] 07:01AM BLOOD WBC-8.9 RBC-3.29* Hgb-9.6* Hct-28.2*
MCV-86 MCH-29.1 MCHC-33.9 RDW-15.6* Plt Ct-169
[**2198-11-23**] 07:01AM BLOOD Glucose-166* UreaN-29* Creat-1.3* Na-141
K-4.0 Cl-106 HCO3-27 AnGap-12
[**2198-11-23**] 07:01AM BLOOD Calcium-8.7 Phos-3.2 Mg-2.0
Brief Hospital Course:
PRIMARY REASON FOR ADMISSION:
Mr. [**Known lastname 32226**] is a 75 year old male with coronary artery disease
(CAD) status post bypass surgery (CABG), chronic systolic heart
failure and chronic kidney disease admitted with hematemesis.
ACTIVE DIAGNOSES:
# Hematemesis: Patient was originally admitted to the ICU where
he was started on pantoprazole drip, but did not require
transfusions to maintain and hematocrit greater than 30. He did
have a hematocrit drop from 36 to 31 one day after admission,
but his hct stabilized after the drop and did not require any
transfusion while in the MICU. Patient remained hemodynamically
stable in the ICU. No clear source of bleeding was seen on EGD,
but full view was precluded by food in the stomach. Upon
transfer to the flor, he was tolerating food well. Repeat EGD
the day after transfered showed no source of bleeding, no
ulcers. Yet, hematocrit continued to drop to 26, but the
patient was asymptomatic. The initial drop since admission may
reflect re-equilibration of the hematocrit, which did not change
during the acute blood loss. Due to the drop in hct, however, a
third EGD was performed, now with push enteroscopy, showing
esophagitis but no other abnormalities. Esophagus was very
friable and bled with touch by scope, thus may be source of
patient's guaiac + stools. Patient's hct stabilized around 26.
the 10pt drop since admission was explained by reequilibration
as well as improper bone marrow response. Retic index is low,
and by iron studies, patient is mildly iron deficient.
Hemolysis labs are negative. B12 and folate levels are good.
RBC morphology shows evidence of some teardrop cells, suggesting
possible MDS. Patient probably also does not have enough
reserve from iron deficiency, epo deficiency, ?MDS or
thalassemia (of Italian descent and has documented anemia for
long time), to generate a response to acute blood loss. Patient
received 1 unit of blood onthe floor for symptomatic anemia
(dizziness), which increased his hct 1pt. Per hematology,
inpatient workup for thalassemia or MDS would be confounded by
iron deficiency, so should continue supplementation and pursue
outpatient work-up. Patient was continued on iron
supplementation and prilosec 20 [**Hospital1 **] (higher dose may cause
marrow suppression). We strongly recommended that the patient
avoid all forms of NSAIDs, and educated the patient and his wife
regarding the expected risks of taking these or other
acid-increasing medications or foods. They expressed
understanding regarding this plan and recommendations.
#. CAD/systolic heart failure: His blood pressure medications
were held in the ICU given the concern for development of acute
blood loss hemorrhage. Upon transfer to the floor, he was
restarted on home carvedilol, lisinopril, spironolactone, and
his blood pressure remained around 130s-150s systolic. His home
diuretics were held as his hct did not stabilize. He received
one dose of IV lasix after the blood transfusion for increased
peripheral edema.
# HTN. Antihypertensives were originally held in the ICU due to
recent hematemesis. Upon transfer to the floor, patient was
restarted on lisinopril and carvedilol per home regimen and
blood pressure remained in the SBP 130s-150s.
# Left thumb felon. On the day prior to discharge, patient's
left thumb was noted to be swollen, tender, and erythematous.
Per his wife, he has had an infection of his thumb before
requiring I&D. He was started on Zosyn and Doxycycline and Hand
Surgery was consulted. He was diagnosed with a felon and his
thumb was I&D'd, the pus sent for culture. He was discharged on
14 days of doxycycline with instructions for dressing changes
for his thumb, and of note, he and his wife deferred visiting
nurse services, but noted they were familiar with dressing
changes from his prior finger infection. He was provided with
follow-up information regarding hand/plastics follow-up.
CHRONIC DIAGNOSES:
# Gout. Patient has hx of gout per his PCP. [**Name10 (NameIs) 32267**] aspirations
have always been negative for septic arthritis. Patient states
he currently has pain in the small joints of his hands
consistent with previous gout flares. He was continued on
colchacine per his home regimen.
# DMII. Most recent HgbA1c was 6.3% in [**2197-4-15**]. Patient takes
glipizide at home and not on insulin. In house, he was
maintained on a ISS and his glipizide was held.
.
# OSA. Patient has O2 sats in the high 90s during the day, but
dips to the mid-80s at night while sleeping. He snores and has
been told before by wife that he has brief episodes of apnea.
Patient was told he should receive outpatient sleep study.
TRANSITIONAL ISSUES:
Patient will follow up with his PCP and in [**Name9 (PRE) **] Surgery clinic,
appointments set up for week after discharge. He was also
encouraged to pursue an outpatient sleep study to work up sleep
apnea. All recommendations were discussed at the bedside by the
medical team, and with the patient's wife [**Name (NI) **] present. Their
questions were addressed to their satisfaction.
Emergency Contact: [**Name (NI) **] (wife and HCP) [**Telephone/Fax (1) 32268**]
Medications on Admission:
carvedilol 12.5 mg po BID
Colchicine 0.6 mg po BID
furosemide 80 mg po qam and 40 mg po qpm
glipizide 5 mg po qdaily
lisinopril 40 mg po qdaily
omeprazole 20 po qdaily
spironolactone 12.5 mg po qdaily
Discharge Medications:
1. carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
2. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
3. furosemide 40 mg Tablet Sig: 1-2 Tablets PO twice a day:
Please take 2 tablets in the morning and 1 tablet in the
evening.
4. spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
5. glipizide 5 mg Tablet Sig: One (1) Tablet PO once a day.
6. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO Q 12H (Every
12 Hours).
7. Iron (ferrous sulfate) 325 mg (65 mg iron) Tablet Sig: One
(1) Tablet PO once a day.
8. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
9. doxycycline hyclate 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours) for 14 days.
Disp:*28 Capsule(s)* Refills:*0*
10. Augmentin 875-125 mg Tablet Sig: One (1) Tablet PO every
twelve (12) hours for 14 days.
Disp:*28 Tablet(s)* Refills:*0*
11. Betadine Skin Cleanser 7.5 % Soap Sig: One (1) swab Topical
once a day: please use to clean wound/dressing changes.
Disp:*1 bottle* Refills:*0*
12. Protonix 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO twice a day.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
Hematemesis
Anemia
Left thumb felon
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 32226**],
.
You were admitted to the hospital because you were vomiting
blood. The GI doctors looked at your esophagus, stomach, and
small intestine but did not find a source of the bleeding. You
were treated with antacids and we monitored the levels of your
blood to make sure you did not need blood transfusions. Since
you blood level dropped a little more a few days into your
hospital stay, you received two more endoscopies, both of which
found no active source of bleeding, but a very friable esophagus
from inflammation. Your blood level stabilized later during
your hospital course.
You were also found to have swelling and tenderness in your left
thumb. We started you on antibiotics for an infection. Hand
surgeons evaluated your thumb as well, drained some pus, and
dressed the wound.
Please note that the following changes have been made to your
medications:
- Please START taking Omeprazole 20mg twice a day for the next 8
weeks
- Please START taking Doxycycine and Augmentin twice a day for a
total of 14 days (until [**12-6**])
- Please START Ascorbic acid (Vitamin C)
- Aspirin was listed on your medication list, but your wife
stated that you were NOT taking this, so we are taking this off
your medication list
- Please follow the following instructions for dressing
changes:
Dilute betadine soaks three times a day and replace dressing
afterwards, keep wick in until follow-up in Hand Clinic.
***Sometimes people have bleeding in their stomachs when they
take extra pain medications such as ibuprofen (Motrin, Advil,
Aleve) or aspirin. You should try to avoid these when possible.
If you need to take them for pain (like your gout), you should
only take the pain medications with food and do not exceed 2400
mg per day.
WOUND CARE for left thumb abscess drainage wound: soak in 50%
betadyne and 50% saline three times a day for half an hour and
wrap in gauze afterwards (has appointment with hand surgery on
[**11-28**])
Followup Instructions:
Please follow-up with the following appointments:
Department: [**Hospital1 18**] HAND CLINIC
When: TUESDAY [**2198-11-27**] at 9:30 AM
With: DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 32269**]
Specialty: Orthopedic Surgery
Department: [**Hospital **] MEDICAL GROUP
When: WEDNESDAY [**2198-11-28**] at 1:45 PM
With: DR. [**First Name8 (NamePattern2) 132**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 133**]
Specialty: Internal Medicine
Building: [**Street Address(2) 3375**] ([**Location (un) **], MA) [**Location (un) 858**]
Campus: OFF CAMPUS Best Parking: On Street Parking
Completed by:[**2198-11-26**]
|
[
"V58.64",
"V45.81",
"327.23",
"274.9",
"V45.4",
"585.4",
"V43.64",
"578.0",
"285.1",
"428.22",
"681.01",
"428.0",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.04",
"45.16",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
14951, 14957
|
8300, 8540
|
319, 451
|
15054, 15054
|
3766, 3766
|
17207, 17879
|
2404, 2434
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13733, 14928
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14978, 15033
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|
15204, 17184
|
2474, 3096
|
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|
1257, 1705
|
267, 281
|
7895, 7947
|
8000, 8277
|
479, 1238
|
3782, 7860
|
7981, 7981
|
15069, 15180
|
8558, 12989
|
1727, 2172
|
2188, 2388
|
3121, 3747
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,979
| 190,669
|
4134
|
Discharge summary
|
report
|
Admission Date: [**2173-1-16**] Discharge Date: [**2173-1-23**]
Date of Birth: [**2098-12-13**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 14037**]
Chief Complaint:
respiratory failure
Major Surgical or Invasive Procedure:
s/p intubation
History of Present Illness:
74yo man with history of COPD presented to [**Hospital1 18**] ED with
history of increasing dyspnea, cough with no fevers or chills
for several days. He had been seen by his PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 5762**] a few
days prior to admission with similar complaints. He had also
been having productive cough with green sputum. He had denied
any fevers, chills, nausea/vomiting, chest pain. There was not
clear orthopnea, PND,
or increased lower extremity edema.
.
Initial vitals of 98.9, 136, 144/77, 36, 89% on 100% NRB.
On exam, he was in respiratory distress, tachypneic to 30's,
tachycardic, and saturating only 89% on 100% NRB mask. His chest
xray demonstrated bilateral infiltrates (official read as
pulmonary edema), and he was intubated for respiratory failure.
Intubation done with succ/etomidate. He was given bolus of
fentanyl and versed for sedation. His initial abg after
intubation was 7.29/64/179 -> then 7.31/40/71.
.
In ED, he was given 10mg decadron, ceftriaxone 1g, levaquin
500mg, 3L in total of NS, had two 18g peripheral IVs placed, and
received
fentanyl and versed. He was also noted to have asymmetric lower
extremity swelling with right > left. A lower extremity doppler
ultrasound demonstrated an extensive right DVT from the
superficial femoral vein down to the popliteal vein. He was
started on heparin IV.
Past Medical History:
1. Hypertension.
2. Seizure disorder since birth, last seizure five years
ago. Generalized tonoclonic seizures.
3. Status post colovesical fistula repair in [**2164**].
4. History of diverticulitis.
5. COPD, 120 pack yr smoking history.
Social History:
Recently widowed. He is a retired
restaurant worker and has grown children. The patient smoked
four packs per day for thirty years before quitting in [**2144**].
He denies alcohol use or other drug use.
Family History:
The patient describes several relatives on
his father's side of the family who suffered Alzheimer's
disease. No family history of coronary artery disease,
cancer or diabetes mellitus.
Physical Exam:
vitals: 96.8, 94 sinus, 124/78, 24, 100%
vent: [AC 550 x 14, 8 peep, fio2 0.6]
gen: intubated, sedated; opens eyes, following commands to voice
heent: PERRLA, mucous membranes moist
cv: RRR, no m/r/g; elevated JVD
resp: Basilar crackles bilaterally
abd: soft, nabs, non-tender
extr: asymmetric LE swelling with 1+ in RLE, 0 in LLE
neuro: moving all extremities equally; responding to voice
Pertinent Results:
CHEST AP: The heart size and mediastinal contours are
unremarkable. There is a moderate pulmonary edema with possible
small bilateral pleural effusions. No focal areas of
consolidation are visualized.
IMPRESSION: Moderate pulmonary edema.
.
ekg: Sinus tachycardia ta 107bpm, leftward axis, RBBB,
occasional
pvc's, inverted T waves in III, aVF, V1-2
Brief Hospital Course:
.
1. Hypoxic/hypercarbic respiratory failure - Secondary to a
combination of pulmonary edema, PNA, PE, and COPD. Patient
required intubation, however, was extubated on [**2173-1-16**]. His
respiratory status stabilized during his admission. He remained
hemodynamically stable. At discharge he was on 5LNC - he is on
home O2 at baseline.
.
2. Pneumonia - He was treated empirically with levofloxacin x 5
days. Urine Legionella Ag negative.
.
3. Right DVT/bilateral PE: Initially on heparin gtt, was also
started on Coumadin in preparation for discharge. On discharge
INR was slightly supra therapeutic at 4.0. His INR will be
followed weekly by his PCP.
.
4. Hypertension/demand ischemia: TWI on EKG, known RBBB, pos
enzymes (peak trop 0.68), trending down. No symptoms of angina.
- TTE with EF > 55%; no LV wall motion abnormalities. He was
started on a beta blocker, and was continued on ASA and a
statin.
.
5. Normochromic, normocytic anemia: B12 and folate both WNL. Pt
has low normal Fe levels and low TIBC and transferrin. Ferritin
is elevated. ? anemia of chronic disease vs iron deficiency.
Patient continues to refuse colonoscopy. HCT stable.
Medications on Admission:
Atenolol
Primidone 250mg TID
Mucinex
Home oxygen at 2L nc
Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol Sig: Four (4) Puff
Inhalation Q4-6H (every 4 to 6 hours) as needed.
Disp:*qs qs* Refills:*6*
2. Primidone 250 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Disp:*qs Cap(s)* Refills:*2*
6. Captopril 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a
day).
Disp:*135 Tablet(s)* Refills:*2*
7. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
Disp:*135 Tablet(s)* Refills:*2*
8. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
10. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
12. Continuous home oxygen
Please supply continuous oxygen by NC at 2-4L/min
13. Coumadin 2 mg Tablet Sig: One (1) Tablet PO at bedtime: Take
one pill tonight ([**2173-1-23**]) and tomorrow night ([**2173-1-24**]) and
follow up with Dr. [**Last Name (STitle) 5762**] on [**2173-1-25**] for further instructions.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary diagnosis
1. Pneumonia
2. Pulmonary Embolism
3. COPD exacerbation
.
Secondary diagnoses
1. COPD
2. HTN
3. seizure disorder
4. hx of diverticulitis
Discharge Condition:
good
Discharge Instructions:
Please take all of you medications as prescribed.
**
Please call you doctor or go to the emergency room if you have
more shortness of breath, chest pain, you cannot eat or drink,
develop fevers/chills, fall and hit your head, or any other
symptoms that are conserning to you.
Followup Instructions:
Please go to Dr.[**Name (NI) 14038**] office on [**2173-1-25**] to have you blood
(INR) checked.
.
Please make an appointment with Dr. [**Last Name (STitle) 5762**] in one week
|
[
"415.19",
"428.0",
"491.21",
"285.9",
"780.39",
"518.81",
"401.9",
"486",
"453.41"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
6172, 6230
|
3250, 4412
|
337, 354
|
6429, 6436
|
2874, 3227
|
6761, 6941
|
2261, 2448
|
4520, 6149
|
6251, 6408
|
4438, 4497
|
6460, 6738
|
2463, 2855
|
278, 299
|
382, 1752
|
1774, 2023
|
2039, 2245
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,187
| 168,390
|
53101
|
Discharge summary
|
report
|
Admission Date: [**2168-12-29**] Discharge Date: [**2169-1-2**]
Date of Birth: [**2120-12-11**] Sex: F
Service: MEDICINE
Allergies:
Morphine / Histamine H2 Inhibitors / Heparin Agents
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
Increasing abdominal girth
Major Surgical or Invasive Procedure:
4u FFP
Paracentesis
History of Present Illness:
47 female with h/o HCV cirrhosis compocated by encephalopathy,
ascites, and h/o portal vein thrombosis (right anterior portal
vein) and portalcaval shunt (reversed flow in main portal vein)
presents from liver clinic with increasing abdominal girth. She
also described sob, nausea, worsening lower ext edema. She
denied abd pain, fevers, chills. She was admitted for a large
volume paracentesis but her INR on admission was 3.8. She
received 4units of FFP which decreased her INR to 2.2 and then 2
more units during the tap. She then had 6L of non-bloody ascitic
fluid removed without complication. She received 36gm of albumin
following the tap. Her BP on admission was 120/70 and remained
stable following the tap. Over the next several hours, pt
complained of abd pain but this resolved on its own without
medication. In the am, she was found to have a hct of 24, down
from 32 and plts 35, down from 72. She received 2units of plts
and 1unit of PRBCs. Her BP was then noted to be decreased at
80/40 which improved mildly to 90/30 with 1.5L of NS. Temp noted
to be low at 94 and she was placed on bear hugger which improved
temp to 96.7. Her mental status also had decreased from
admission and her urine output was minimal, 225cc over the past
12 hours. Creatinine this am was 1.9 from 0.9 yesterday.
.
Previous hospital course (per H&P):
She was recently hospitalised from [**11-28**]/-[**12-8**] for abdominal
discomfort at which time she underwent paracentesis that ruled
out SBP and relieved her abdominal pain. She also underwent US
that revealed patent portal and hepatic vessels. While her
discharge summary maintains that she was continued on
Furosemide/ Spirinolactone/Propranolol, the patient did not
receive any scripts on discharge and as a result did not take
these medications. Also, due to worsening renal function, she
was started on octreotide/ midodrine/albumin for hepatorenal
syndrome (Cr 3.3 at its worst) which resolved prior to her
discharge. The hospitalisation was also significant for mild DIC
for which she received cryoglobulins and UTI (+ Enterococcus and
+Klebsiella). She received a 7 day course of amoxicillin for
which Enterococcus was sensitive but Klebsiella unknown.
Past Medical History:
HCV cirrhosis c/b esophageal varices, ascites, partial portal
vein thrombosis
h/o gastritis
morbid obesity
recent cholecystitis [**5-15**]
h/o EtOH abuse
sickle cell trait
Social History:
Patient denies etoh and tobacco use. She has a history of heavy
alcohol use. Lives alone [**Location (un) 1773**] apartment; son and mother
nearby
Family History:
None
Physical Exam:
Physical Exam: T 95, BP 120/70, HR 82, RR 20, 96%RA Wt 301.6lb
HEENT: + scleral icterus. No thrush.
Neck: No [**Doctor First Name **], normal thyroid contour
Lungs: CTAB
Cardiac: RRR, no murmurs
Abdomen: obese, soft, mildly distended dull to percussion
throughout, no tenderness, liver non-palpable due to large
volume of ascited
Extremities: [**2-11**]+ pretibial edema extending above knee R>L,
no asterixis. No palmar erythema
Pertinent Results:
[**2168-12-29**] 10:10AM BLOOD WBC-8.1 RBC-3.69* Hgb-11.0* Hct-32.4*
MCV-88 MCH-29.8 MCHC-33.9 RDW-26.0* Plt Ct-72*#
[**2168-12-29**] 10:10AM BLOOD Neuts-68.3 Bands-0 Lymphs-19.8 Monos-10.6
Eos-1.1 Baso-0.2
[**2168-12-29**] 10:10AM BLOOD Hypochr-1+ Anisocy-2+ Poiklo-2+
Macrocy-2+ Microcy-NORMAL Polychr-NORMAL Ovalocy-OCCASIONAL
Target-OCCASIONAL Schisto-OCCASIONAL Tear Dr[**Last Name (STitle) 833**]
[**2168-12-29**] 10:10AM BLOOD PT-23.0* PTT-63.2* INR(PT)-3.8
[**2168-12-29**] 10:10AM BLOOD Glucose-76 UreaN-17 Creat-0.8 Na-129*
K-3.9 Cl-101 HCO3-19* AnGap-13
[**2168-12-29**] 10:10AM BLOOD ALT-33 AST-65* AlkPhos-70 TotBili-30.3*
DirBili-20.8* IndBili-9.5
[**2168-12-29**] 10:10AM BLOOD Albumin-3.1*
[**2168-12-29**] 10:10AM BLOOD Ammonia-39
.
RADIOLOGY
1. Small cirrhotic liver with what appears to be a portocaval
shunt.
2. Moderate ascites.
3. Cholelithiasis without evidence of acute cholecystitis.
4. No hydronephrosis.
5. Borderline splenomegaly.
.
Brief Hospital Course:
A/P: 48 yo morbidly obese woman with HCV cirrhosis c/b
encephalopathy, esophageal varices and partial vein thrombosis
(but no hx of SBP) presents with increasing abdominal girth
likely secondary to ascites. Admitted for diagnostic/therapeutic
paracentesis and then transferred to the ICU for hypotension,
confusion and anemia.
.
# Liver cirrhosis: MELD score of 34 on admission. Pt became
more encephalopathic during her hospital course. She was not a
transplant candidate due to her obesity. A family meeting was
held on hospital day #4 which included the pt's closest family
members, her hepatologist, Dr. [**Last Name (STitle) 10285**], her PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] and
the ICU team. After it was explained that the pt's prognosis
was very poor given that she was not a transplant candidate, the
decision was made by the family and the medical team to withdraw
care. The pt was made comfortable and she expired several hours
later.
.
# Recurrent ascites: On the medical floor, pt had a large volume
paracentesis (6 liters) followed by replacement with albumin.
She had no evidence of SBP.
.
# Hypotension: Pt became hypotensive following the large volume
paracentesis despite replacement with albumin. This was thought
to be [**1-12**] the large volume tap verses sepsis though she had no
other evidence of sepsis. She was placed on pressors to
maintain a MAP>55. Once the decision was made to withdraw care,
the pressors were discontinued.
.
# Anemia: Hct dropped following the tap and there was concern
for bleed into her abdomen. She received one unit of PRBCs. CT
of the abdomen and pelvis showed no evidence of bleed. Her
hematocrit remained stable at 24-26 following the acute drop.
.
# ARF: Creatinine has increased from 0.9 on admission to 1.9 on
admission to ICU. Urine lytes with Na of 10 indicating either
pre-renal or hepatorenal. Fluid challenge with 36gm of albumin,
one unit of PRBCs and 2L of NS. Will check creatinine this
afternoon. Pt previously diagnosed with hepatorenal and was
started on midodrine, octreotide and albumin; these were
continued. Her creatinine continued to increase, likely due to
her worsening liver failure.
.
Pt expired during this admission after family discussion to make
her comfort care only.
Medications on Admission:
Rifaximine 200mg tid
Lactulose 30cc qid titrated to 3-4BM/day
Protonix 40mg po qd
Discharge Medications:
none
Discharge Disposition:
Home
Discharge Diagnosis:
none
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
|
[
"458.9",
"572.4",
"456.21",
"584.9",
"282.5",
"278.01",
"571.5",
"276.1",
"285.9",
"452",
"070.70"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"99.07",
"38.93",
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
6893, 6899
|
4437, 6731
|
340, 362
|
6947, 6956
|
3446, 4414
|
7009, 7016
|
2975, 2981
|
6863, 6870
|
6920, 6926
|
6757, 6840
|
6980, 6986
|
3011, 3427
|
274, 302
|
390, 2597
|
2619, 2793
|
2809, 2959
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,608
| 180,052
|
38864+58237
|
Discharge summary
|
report+addendum
|
Admission Date: [**2199-3-13**] Discharge Date: [**2199-4-2**]
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
[**2199-3-14**] Cardiac Catheterization
[**2199-3-26**]:
1. Aortic valve replacement with a 21-mm St. [**Male First Name (un) 923**] Epic
tissue valve.
2. Coronary artery bypass grafting x4 with a left internal
mammary artery to left anterior descending artery, and
reverse saphenous vein grafts to the posterior
descending artery, obtuse marginal artery and the
diagonal artery.
History of Present Illness:
[**Age over 90 **] year old man with HTN, HL, DM, [**Last Name (un) **] who presented to [**Hospital1 **] with chest pain s/p a fall. He had been developing
worsening right sided chest pain since a mechanical fall on [**3-11**]
(no LOC). Paitent described sensation as right sided "chest
deadness" worse at night and with activity. Sensation woke him
on the morning of [**3-12**] after 2 hours of sleep. On the morning of
admission his chest pain was worse and he had dyspnea, prompting
his presentation to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].
.
There, he was found to have EKG changes, CK 542, TropI 15.7, Cr
1.8, BNP 1040. He was started on Lasix and an NTG gtt and
transferred her for futher eval. A head CT was done that was
negative for bleed.
Transferred to [**Hospital1 18**] CCU and
underwent cardiac catherization [**3-14**] which showed 3VD, and
patient
underwent successful PCI and stent of RCA. Patient medically
treated with BIPAP and lasix gtt and transferred to inpatient
floor on [**2199-3-16**]. On [**2199-3-17**] patient triggered on floor x2 with
acute SOB, RAF,and confusion. Again medically treated with
lasix,
lopressor and amiodarone (converted to sinus rhythm on [**2199-3-18**]).
Triggered again on [**2199-3-19**] for respiratory distress, poor
oxygenation and transferred back to CCU for aggressive diuresis.
Consulted today for surgical evaluation for AVR/CABG.
Past Medical History:
aortic stenosis
Coronary artery disease s/p Aortic valve replacement
(tissue)/coronary artery bypass x4 [**2199-3-26**]
Non- ST elevation myocardial infarction [**2199-3-11**] bare metal
stent to right coronary artery
hypertension
hyprelipidemia
non-insulin dependent diabetes mellitus
chronic kidney disease
left eye cataract
chronic systolic heart failure
benign prostatic hypertrophy
pernicious anemia
pre-op Atrial Fibrillation
Social History:
Retired [**Location (un) 86**] Bomb Squad Chief, Policeman, Marine. Lives with
daughter (HCP) and son(s).
-Tobacco history: 25pk yrs, 40yrs ago
-ETOH: denies.
Family History:
Father had stroke in 80s. Patient denies other FHX of DM or CV
disease in parents or 2 sisters. [**Name (NI) **] family history of early MI,
arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise
non-contributory.
Physical Exam:
VS: T=96.1 BP=101/61 HR=99 RR=18 O2 sat=92-98 on high-flow
mask.
Wt = 170lbs/77kg
GENERAL: NAD. Oriented. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Facial abrasions worse on right side. CNs intact.
NECK: Supple with JVP of [**11-18**] cm. + Hepatojugular reflex.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No r/g. II/VI systolic ejection
loudest at USB. II/VI at apex. No thrills, lifts. No S3 or S4.
Minimal chest wall tenderness to palpation on right. No
obvious deformities or echymoses
LUNGS: Kyphosis. Poor air movement. Bilateral bibasilar
crackles. No wheezes, egophany.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: Pretibial edema to knee bilaterally.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Neuro: Grossly intact to light tough, pinpoint sensation,
strength, plantar reflex,
PULSES:
Right: Carotid 2+ Femoral 1+ DP 2+ PT 2+ Radial 1+
Left: Carotid 2+ Femoral 1+ DP 2+ PT 2+ Radial 1+
Pertinent Results:
[**2199-4-1**] 04:43AM BLOOD WBC-6.2 RBC-3.58* Hgb-10.4* Hct-31.7*
MCV-89 MCH-29.1 MCHC-32.8 RDW-15.8* Plt Ct-124*
[**2199-3-31**] 05:12AM BLOOD WBC-6.6 RBC-3.61* Hgb-10.2* Hct-31.6*
MCV-88 MCH-28.3 MCHC-32.3 RDW-16.0* Plt Ct-128*
[**2199-3-30**] 11:45PM BLOOD Hct-31.7*#
[**2199-3-14**] Cardiac Catheterization
1. Coronary angiography of this right dominant system revealed
three
vessel coronary artery disease. The LMCA had mild nonobstructive
disease. The mid LAD was occluded after a diagonal branch with
70%
stenosis. The LAD was heavily calcified. The LCx was occluded
proximally, with an occluded OM. The RCA had a 90% proximal
stenosis
with diffuse disease distally.
2. Resting hemodynamics demonstrated mildly elevated right and
moderately elevated left sided filling pressures (RVEDP 15 mm
Hg, PWCP
mean 23 mm Hg, respectively). There was moderate pulmonary
arterial
hypertension (PASP 49 mm Hg). The systemic arterial blood
pressure was
low-normal (SBP 105 mm Hg) with sinus tachycardia. The cardiac
index was
depressed at 1.9 l/min/m2. The systemic vascular resistance was
high
normal (1422 dynes-sec/cm5). The pulmonary vascular resistance
was
elevated (267 dynes-sec/cm5).
3. Successful PCI of the proximal RCA with a 3.0x12mm Vision
BMS,
post-dilated to 3.5mm proximally.
4. Unsuccessful attempts to cross the LAD with Choice PT ES and
Choice
PT [**Name (NI) 9165**] Int wires. Further attempts were deferred to spare
additional
radiation and contrast exposure.
[**2199-3-26**] Cardiac Catheterization
Pre-Bypass:
The left atrium is moderately dilated. No mass/thrombus is seen
in the left atrium or left atrial appendage.
Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is moderately depressed (LVEF= 30-35 %).
[Intrinsic left ventricular systolic function is likely more
depressed given the severity of valvular regurgitation.]
Right ventricular chamber size is normal. with normal free wall
contractility.
There are simple atheroma in the ascending aorta. The descending
thoracic aorta is mildly dilated. There are simple atheroma in
the descending thoracic aorta.
There are three aortic valve leaflets. The aortic valve leaflets
are moderately thickened. There is critical aortic valve
stenosis (valve area <0.8cm2). There is little movement of the
left coronary cusp, and the right and non-coronary cusps don't
move at all. .No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. An eccentric,
anteriorly directed jet of Moderate (2+) mitral regurgitation is
seen.
Moderate [2+] tricuspid regurgitation is seen.
There is severe pulmonary artery systolic hypertension.
There is no pericardial effusion.
Dr. [**Last Name (STitle) **] was notified in person of the results on [**2199-3-26**] at
0845.
Post-Bypass
The patient is in SR on Epinephrine infusion.
The aortic valve prosthesis is well seated with no leak and no
AI. Residual mean gradient = 14.
MR [**First Name (Titles) **] [**Last Name (Titles) 86253**] improved, still moderate.
Biventricular systolic fxn is much the same as pre-bypass, with
EF 30 - 35%.
Aorta intact.
[**2199-3-19**] Carotid Ultrasound
There is less than 40% stenosis within the internal carotid
arteries bilaterally.
Brief Hospital Course:
[**Age over 90 **] yo M with diabetes, hyperlipedemia, and hypertension without
past known CV disease presents with chest discomfort and ST
depression consistent with NSTEMI.
.
# NSTEMI:
Patient with TIMI score of 5, presented with elevated cardiac
biomarkers (CK peak 1683 with Trop 9.6) and resolved chest pain.
Patient denied past CV disease, though his EKG suggestted prior
inferior MI. He was started on a heparin drip on presentation.
He was loaded with clopidogrel, placed on aspirin and
atorvastatin high dose. [**3-13**] preliminary transthoracic
echocardiogram decreased EF, severe aortic stenosis (estimated
aortic valve area ~0.8 cm2), moderate to severe mitral
regurgitation, mild to moderate tricuspid regurgitaiton, as well
as moderate regional left ventricular systolic dysfunction with
inferior and inferolateral akinesis/hypokinesis. He was taken
for cardiac catheterization on [**2199-3-15**] the morning after
presentation, during which a 90% stenosed proximal RCA lesion
was stented with a bare metal stent. Chronic 70% mid LAD
stenosis and old TO prox LCX also noted. Pressures: RA=13,
RV=57m PCWP=22, PA=47/20. CO=3.6, CI=1.9. ECHO [**3-15**] shows
moderate regional left ventricular systolic dysfunction with
inferior and inferolateral akinesis/hypokinesis. Patient
remained chest pain free after the procedure, but required
continued respiratory support.
Patient was taken for Cardiothoracic surgery CABGx4 and AVR on
[**2199-3-26**] and then transfered to the cardiac surgical service.
Per operative report atrial and ventricular pacing wires were
placed. The heart resumed beating on its own. The lungs were
ventilated. He came off bypass without difficulties. The aortic
valve appeared to be well-seated. The left ventricular function
remained the same at 30% to 35%.
.
#SOB, mild hypoxia.
Patient was noted to have murmurs concerning for aortic stenosis
and mitral regurgitation. Patient determined to have acute
pulmonary edema clinically and radiographically in the setting
of compromised cardiac function. Recent fall may be related to
AS. Lack of effusions suggest acute evolution and NSTEMI
contribution. Pneumonia ruled out by chest xray findings,
physical exam, in addition to lack of fever, cough, or other
symptoms. Patient was diuresed initially with PO and IV
furosemide and then was transitioned to a drip.
.
#Atrial Fibrillation. Patient had transient atrial fibrillation
after his catheterization. He was loaded on amiodarone twice
for recurrent atrial fibrillation and then transitioned to 200
mg PO BID. He is also on low dose metoprolol.
.
#Acute kidney injury in the setting of chronic disease.
Patient's chronic renal disease is likely due to diabetes and
hypertension with [**Date Range 5348**] function of 1.2-1.4. Patient's
creatinine increased slightly to 2.6 after catheterization and
diuresis. This was likely due to compromised cardiac output as
patient recieved load a 43 mL visipaque contrast load and renal
function gradually improved following diuresis.
.
#Diabetes. His hgbA1C was 9.1 during admission. Patient's
metformin was held in the setting of kidney injury and
hospitalization. He had a large insulin requirement of 18-24
units of basal glargine along with 20-40 units of humalog daily.
.
#Hypertension. Patient is now normotensive likely due to mild
cardiogenic shock. Continue beta blocker. Restart Nefidipine
PRN.
-Hold ACEi given compromised kidney function.
.
#Trauma to face, after fall onto right side 2days prior to
presentation. Patient denies LOC, altered sensorium, weakness,
palpitations, preceding chest pain, and postictal state.
Patient is neurologically intact on exam. No broken bones
visible on CXray. Etiology is mechannical or related to aortic
stenosis.
.
#Anemia. Patient has [**Date Range 5348**] pernictious anemia. Treated with
B12 by PCP. [**Name10 (NameIs) **] Hct 36-39 prior to presentation decreased
during admission while on heparin. Patient had 2 occult
positive stools on [**3-17**] and [**3-25**] without frank blood. Patient's
IV heparin was held on [**3-25**] and was transfused 2 units prior the
day prior to cardiac surgery on [**3-26**]. Patient was transfused
5units RBCs, 2-3U FFP, and 2-3U platelets in the procedure. He
required several more units on the floor. After the procedure
he was taken off of clopidogrel and heparin was not restarted.
Mr. [**Name14 (STitle) 86254**] was taken to the operating room on [**2199-3-26**] for
aortic valve replacement with a 21-mm St. [**Male First Name (un) 923**] Epic tissue
valve, Coronary artery bypass grafting x4 with a left internal
mammary artery to left anterior descending artery, and reverse
saphenous vein grafts to the posterior descending artery, obtuse
marginal artery and the diagonal artery. Postoperatively he
remained intubated and was admitted to the CVICU after surgery
on [**3-26**] on titrated nitroglycerin, epinephrine, and propofol
drips. He awoke neurological intact and was extubated on POD #1.
He was weaned from vasoactive medications and begun on
betablocker and stain therapy and was diuresed toward his
pre-operative weight. On POD# 2 he was transferred from the ICU
to the stepdown unit. He was evaluated by physical therpay for
strength and [**Hospital 86255**] rehab was recommended. He was
cleared for discharge to rehab on POD#6 by Dr. [**Last Name (STitle) **].
Medications on Admission:
([**Location (un) 86256**] [**Company 4916**])
-Metformin 500mg [**Hospital1 **]
-Quinopril 40mg QD
-Nefidipine 60mg QD
-Lipitor 20mg QD
-Tolazamide 250mg [**Hospital1 **]
meds at transfer to Csurg:
Aspirin 325 mg daily
Atorvastatin 80mg daily
Plavix 75mg daily
Colace 100mg twice a day
Heparin 5000 units sc TID
Amiodarone 400mg twice a day
Insulin sliding scale regular
Lantus 22 units sc every am
Albuterol/Atrovent nebulizers IH every 6 hours as needed
Lasix IV 5-15mg/hr to maintain urine output >40cc/hr
Lopressor 25mg twice a day
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain/fever.
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
5. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
6. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 400mg [**Hospital1 **] x 1 week, then 200mg [**Hospital1 **] x 1 week,then 200mg
daily until further instructed.
9. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
11. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
12. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
13. Insulin Glargine 100 unit/mL Solution Sig: One (1)
Subcutaneous Q pm: 22units with dinner.
14. Insulin Lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous four times a day: Humalog sliding scale attached.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
aortic stenosis
Coronary artery disease s/p Aortic valve replacement
(tissue)/coronary artery bypass x4 [**2199-3-26**]
Non- ST elevation myocardial infarction [**2199-3-11**] bare metal
stent to right coronary artery
hypertension
hyprelipidemia
non-insulin dependent diabetes mellitus
chronic kidney disease
left eye cataract
chronic systolic heart failure
benign prostatic hypertrophy
pernicious anemia
pre-op Atrial Fibrillation
Discharge Condition:
alert and oriented
sternal pain controlled with percocet
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Please call to schedule appointments
Primary Care Dr.[**Last Name (STitle) 22552**] in [**2-9**] weeks
Wound check appointment - [**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse
will schedule
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8583**], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2199-5-1**]
1:00
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2199-5-6**]
1:00
Completed by:[**2199-4-1**] Name: [**Known lastname 13644**],[**Known firstname 33**] Unit No: [**Numeric Identifier 13645**]
Admission Date: [**2199-3-13**] Discharge Date: [**2199-4-2**]
Date of Birth: [**2108-11-12**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 135**]
Addendum:
The patient was discharged to rehab yesterday- however was
returned to [**Hospital1 8**] immediately, by transport EMTs, citing
deplorable conditions at the rehab. Family members visited
alternative facilities, and it was decided to send the patient
to [**Hospital **] rehab today. He was started on an ACE inhibitor
and metolazone was added for increased diuresis. Follow up
instructions remain the same. Additionally, the patient was
found to be MRSA+ by nasal swab. This has been added to the
medical history and the patient should be in an isolation room
on contact precautions at [**Name (NI) **] Rehab.
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain/fever.
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
5. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
6. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 400mg [**Hospital1 **] x 1 week, then 200mg [**Hospital1 **] x 1 week,then 200mg
daily until further instructed.
9. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
11. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
12. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
13. Insulin Glargine 100 unit/mL Solution Sig: One (1)
Subcutaneous Q pm: 22units with dinner.
14. Insulin Lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous four times a day: Humalog sliding scale attached.
15. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day).
16. Metolazone 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 13108**] - [**Location 205**]
Discharge Diagnosis:
aortic stenosis
Coronary artery disease s/p Aortic valve replacement
(tissue)/coronary artery bypass x4 [**2199-3-26**]
Non- ST elevation myocardial infarction [**2199-3-11**] bare metal
stent to right coronary artery
+MRSA nasal swab
hypertension
hyprelipidemia
non-insulin dependent diabetes mellitus
chronic kidney disease
left eye cataract
chronic systolic heart failure
benign prostatic hypertrophy
pernicious anemia
pre-op Atrial Fibrillation
Followup Instructions:
Please call to schedule appointments
Primary Care Dr.[**Last Name (STitle) 13646**] in [**2-9**] weeks
Wound check appointment - [**Hospital Ward Name **] 6 ([**Telephone/Fax (1) 2440**]) - your nurse
will schedule
Provider: [**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern4) 137**], MD Phone:[**Telephone/Fax (1) 1477**] Date/Time:[**2199-5-1**]
1:00
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1582**], MD Phone:[**Telephone/Fax (1) 337**] Date/Time:[**2199-5-6**]
1:00
[**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern4) 137**] MD [**MD Number(2) 138**]
Completed by:[**2199-4-2**]
|
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"272.4",
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"414.01",
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"584.9",
"281.0",
"428.0",
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"410.71",
"785.51",
"V58.67",
"041.12",
"250.40",
"920",
"518.82",
"403.90",
"396.2",
"V15.82",
"E888.9",
"799.02",
"366.9",
"585.9",
"583.81",
"600.00",
"428.23"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.68",
"38.91",
"36.15",
"00.45",
"37.22",
"93.90",
"36.06",
"88.56",
"89.64",
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"99.05",
"99.04",
"35.21",
"99.07",
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] |
icd9pcs
|
[
[
[]
]
] |
19424, 19493
|
7504, 12890
|
278, 680
|
15489, 15548
|
4195, 7481
|
19988, 20661
|
2789, 3016
|
17662, 19401
|
19514, 19965
|
12916, 13456
|
15572, 16066
|
3031, 4176
|
228, 240
|
708, 2138
|
2160, 2594
|
2610, 2773
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,040
| 198,386
|
34618
|
Discharge summary
|
report
|
Admission Date: [**2148-1-7**] Discharge Date: [**2148-1-10**]
Date of Birth: [**2083-7-6**] Sex: M
Service: SURGERY
Allergies:
Allopurinol / Ibuprofen / Colchicine
Attending:[**First Name3 (LF) 598**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
ERCP with sphincterotomy [**2148-1-7**]
History of Present Illness:
HPI: 64M w/ sudden onset of nausea, vomiting, abdominal pain
at 2PM, hours after consuming a normal lunch. The pain was so
terrible for the patient that within two hours, he presented to
his nearest hospital for evaluation. There they found him to
have RUQ and epigastric tenderness with labs and imaging that
were concerning for septic cholecystitis. He was transferred
here for definitive care and the development of sepsis with
hypotension (MAP 50's). Here he has signs, symptoms, and labs
that are concerning for cholangitis. He has RUQ/epigastric
tenderness, jaundice in the form of mild scleral icterus, and
has
required substantial, continued fluid to maintain his blood
pressure with a map > 60.
Past Medical History:
PMHx: CRI (1.2), sebaceous cyst, CAD s/p 4 coronary stents,
Social History:
former EtOH (quit in [**Month (only) 116**])
No tobacco
Lives with wife
Family History:
NC
Physical Exam:
PHYSICAL EXAMINATION: upon admission: [**2148-1-7**]
Temp:98.4 HR:100 BP:104/56 Resp:18 O(2)Sat:97
Constitutional: moderately ill appearing
HEENT: icteric
supple
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm
Abdominal: Soft, RUQ TTP
Extr/Back: No cyanosis, clubbing or edema
Skin: No rash, Warm and dry
Neuro: Speech fluent
Psych: Normal mood, Normal mentation
Heme/[**Last Name (un) **]/[**Last Name (un) **]: No petechiae
Pertinent Results:
[**2148-1-9**] 06:00AM BLOOD WBC-7.6 RBC-4.48* Hgb-12.4* Hct-36.0*
MCV-80* MCH-27.7 MCHC-34.5 RDW-14.7 Plt Ct-150
[**2148-1-8**] 03:13AM BLOOD WBC-10.4 RBC-4.07* Hgb-11.1* Hct-32.7*
MCV-80* MCH-27.3 MCHC-33.9 RDW-14.8 Plt Ct-159
[**2148-1-7**] 02:50AM BLOOD Neuts-67 Bands-21* Lymphs-7* Monos-4
Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0
[**2148-1-9**] 06:00AM BLOOD Plt Ct-150
[**2148-1-8**] 03:13AM BLOOD Plt Ct-159
[**2148-1-8**] 03:13AM BLOOD PT-16.3* PTT-32.1 INR(PT)-1.4*
[**2148-1-9**] 06:00AM BLOOD Glucose-128* UreaN-12 Creat-1.3* Na-138
K-3.4 Cl-104 HCO3-22 AnGap-15
[**2148-1-8**] 03:13AM BLOOD Glucose-115* UreaN-18 Creat-1.6* Na-139
K-4.2 Cl-110* HCO3-19* AnGap-14
[**2148-1-7**] 03:07PM BLOOD Glucose-116* UreaN-19 Creat-1.6* Na-144
K-3.0* Cl-110* HCO3-23 AnGap-14
[**2148-1-7**] 02:50AM BLOOD Glucose-137* UreaN-18 Creat-2.1* Na-142
K-4.1 Cl-106 HCO3-19* AnGap-21*
[**2148-1-9**] 06:00AM BLOOD ALT-87* AST-57* AlkPhos-204* Amylase-51
TotBili-3.6*
[**2148-1-8**] 03:13AM BLOOD ALT-126* AST-129* LD(LDH)-172
AlkPhos-150* TotBili-3.6* DirBili-3.0* IndBili-0.6
[**2148-1-7**] 02:50AM BLOOD ALT-249* AST-585* AlkPhos-236*
TotBili-3.2*
[**2148-1-9**] 06:00AM BLOOD Lipase-24
[**2148-1-9**] 06:00AM BLOOD Calcium-8.9 Phos-1.9* Mg-1.8
[**2148-1-7**] 03:20PM BLOOD Lactate-2.9*
[**2148-1-7**] 09:28AM BLOOD Lactate-3.2*
[**2148-1-7**]: EKG:
Baseline artifact. Sinus rhythm. No previous tracing available
for
comparison
[**2148-1-7**]: Ultrasound:
IMPRESSION:
1. No cholelithiasis. No son[**Name (NI) 493**] evidence of acute
cholecystitis.
2. Diffusely echogenic liver most compatible with diffuse fatty
liver. Other forms of liver disease or advanced form of liver
disease such as fibrosis and cirrhosis cannot be excluded
[**2148-1-7**]: ERCP:
Impression: Periampullary diverticulum
Stones at the middle third of the common bile duct. Otherwise
normal biliary tree. A biliary sphincterotomy was performed.
Both stones were successfully extracted.
(sphincterotomy, stone extraction)
Otherwise normal ercp to third part of the duodenum
[**2148-1-7**] 3:05 am BLOOD CULTURE
Blood Culture, Routine (Preliminary):
GRAM NEGATIVE ROD(S).
Aerobic Bottle Gram Stain (Final [**2148-1-9**]):
GRAM NEGATIVE ROD(S).
REPORTED BY PHONE TO [**Last Name (LF) **], [**First Name3 (LF) **] ON [**2148-1-9**] AT 6:52 PM.
Brief Hospital Course:
Mr. [**Known lastname 21693**] was evaluated by the Acute Care service in the
Emergency Room and admitted to the ICU for treatment of
cholangitis with hypotension. He required significant volume
resuscitation and pressor support along with antibiotics.. His T
Bili was 3.2 along with elevated transaminase. After his
hemodynamics were stable he underwent an urgent ERCP on [**2148-1-7**]
to rule out biliary tree obstruction. He tolerated the ERCP with
sphincterotomy well. He maintained stable hemodynamics and his
pain was much less. He remained NPO for an additional 12 hours
and then began a clear liquid diet. A blood culture from [**2148-1-7**]
grew gram negative rods for which he was covered with Zosyn.
Following transfer to the Surgical floor he continued to make
good progress. His LFT's were checked daily and were slowly
trending down. His diet was gradually advanced to regular and
again was well tolerated. He remained afebrile and his WBC was
down to 6K. He was up and walking independently and his T Bili
was down to 2.0.
He will need a cholecystectomy in the near future but will
currently recover from this episode of cholangitis and be booked
at a later date. He was discharged to home on [**2148-1-10**] and will
follow up in the [**Hospital 2536**] Clinic in [**3-8**] weeks.
Medications on Admission:
[**Last Name (un) 1724**]: omeprazole 20', asa, ativan 2 qhs, niaspan
Discharge Medications:
.
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever pain.
2. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours): thru [**2148-1-16**].
Disp:*12 Tablet(s)* Refills:*0*
3. metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day): thru [**2148-1-16**].
Disp:*18 Tablet(s)* Refills:*0*
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
5. Niaspan Extended-Release 500 mg Tablet Sustained Release Sig:
One (1) Tablet Sustained Release PO once a day.
6. aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day: start
Saturday.
Discharge Disposition:
Home
Discharge Diagnosis:
Cholangitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You are being discharged after you were admitted to the hospital
for abdominal pain with nausea and vomitting. You were found to
have cholangitis and you underwent an ERCP. You were found to
have stones in the biliary tree which were extracted. You are
now preparing for discharge home with the following
instructions:
resume your regular diet, increase liquids
walking as tolerated
resume your pre-hospital medications
complete the course of antibiotics
Please return to the emergency room if you experience:
chest pain
abdominal pain
nausea/vomitting
abdominal distention
fever
weakness
Followup Instructions:
Please follow-up with the Acute Care Service in [**3-8**] weeks. You
can schedule this appointment by calling #[**Telephone/Fax (1) 600**]
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]
Completed by:[**2148-1-10**]
|
[
"414.01",
"440.20",
"574.51",
"585.9",
"V45.82",
"576.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.88",
"51.85"
] |
icd9pcs
|
[
[
[]
]
] |
6255, 6261
|
4143, 5449
|
308, 350
|
6317, 6317
|
1771, 3862
|
7096, 7374
|
1279, 1283
|
5569, 6232
|
6282, 6296
|
5475, 5546
|
6468, 7073
|
1298, 1298
|
3906, 4120
|
1321, 1323
|
254, 270
|
378, 1089
|
1337, 1752
|
6332, 6444
|
1111, 1173
|
1189, 1263
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,551
| 138,087
|
34118
|
Discharge summary
|
report
|
Admission Date: [**2187-7-3**] Discharge Date: [**2187-7-20**]
Date of Birth: [**2120-3-30**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 473**]
Chief Complaint:
Duodenal and Ampullary Adenoma
Major Surgical or Invasive Procedure:
1. Pancreatoduodenectomy (Whipple procedure).
2. Open cholecystectomy.
3. Extensive lysis of adhesions.
History of Present Illness:
Mr. [**Known lastname **] is a 67-year-old
man who comes from a family with a deep history of both
colorectal cancer and polyposis as well as duodenal
adenomatous disease, some family members of which have
undergone duodenectomy. He has recently presented with
endoscopic evidence of a progressive duodenal and ampullary
adenoma, which is extending up into the inferior bile duct.
It cannot be removed endoscopically and has adenomatous
disease has been biopsy proven. There has been no pancreatic
or biliary ductal or duodenal obstruction. In light of this,
he is referred for consideration of elective
pancreatoduodenectomy,
The patient states that he was originally diagnosed with
familial
adenomatous polyposis back in the [**2138**] to [**2148**] where he
underwent a total abdominal colectomy for polyposis syndrome.
Since then he has done quite well. He had been following a
gastroenterologist. However, he had been lost to followup for
approximately 8 years. He recently sought the care of Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 78664**] at [**Hospital3 17921**] Center for an abdominal pain syndrome
that he has been having. He states that the pain is sharp in
nature, located in his periumbilical region and worsens with
eating. He denies any nausea or vomiting associated with this.
He denies any hematemesis or coffee-ground emesis. He denies
any
bright-red blood per rectum or diarrhea. He does state that he
has been experiencing the symptomatology for quite some time.
Based on this, he underwent imaging as well as an endoscopy. I
do not have the results of the imaging but the endoscopy did
show
a 1.5 cm polyp at the ampulla. Based on this he was referred to
us for further evaluation and management of his ampulla.
Past Medical History:
His medical history is again significant for a likely diagnosis
of familial adenomatous polyposis, hypertension, coronary artery
disease, chronic obstructive pulmonary disease (COPD), arthritis
and peripheral vascular disease.
PAST SURGICAL HISTORY
His past surgical history is significant for coronary artery
bypass graft (CABG) and carotid endarterectomy.
Social History:
SOCIAL HISTORY
His social history is significant for positive tobacco. He
smokes half pack per day, no alcohol and no IV drugs use, and no
intranasal cocaine use.
Family History:
His family history is significant for his maternal grandfather
that was affected with colorectal cancer, mother that was
affected with polyposis, brother that was affected with
colorectal cancer, 2 daughters that are affected with polyposis,
a grandson that is affected with polyposis, a brother that was
lost to colorectal cancer and a son that is also affected with
polyposis.
Physical Exam:
On examination today he appeared in no distress, he was alert
and
oriented x 3. His vital signs were stable. He is afebrile. On
exam HEENT pupils are equal, round and reactive to light,
extraocular muscles were intact. The mucus membranes were
moist.
Neck was supple. There was no jugular venous distention (JVD).
His chest was clear to auscultation, bilaterally. Heart was
regular rate and rhythm. The abdomen is soft, nontender and
nondistended with normoactive bowel sounds. The extremities
have
no cyanosis, erythema or edema. Neurologically, cranial nerves
II-XII were grossly intact, no focal deficits.
Pertinent Results:
[**2187-7-3**] 04:10PM BLOOD WBC-10.5 RBC-4.07* Hgb-12.8* Hct-37.2*
MCV-91 MCH-31.5 MCHC-34.5 RDW-13.9 Plt Ct-155
[**2187-7-7**] 05:50AM BLOOD WBC-10.8 RBC-4.04* Hgb-13.1* Hct-36.1*
MCV-89 MCH-32.6* MCHC-36.4* RDW-14.2 Plt Ct-208
[**2187-7-8**] 06:30AM BLOOD Glucose-117* UreaN-23* Creat-0.8 Na-138
K-4.1 Cl-103 HCO3-26 AnGap-13
[**2187-7-5**] 02:00AM BLOOD CK-MB-30* MB Indx-1.9 cTropnT-0.18*
[**2187-7-5**] 10:38AM BLOOD CK-MB-31* MB Indx-2.3 cTropnT-0.36*
[**2187-7-5**] 04:25PM BLOOD CK-MB-24* MB Indx-1.9 cTropnT-0.40*
[**2187-7-6**] 01:24AM BLOOD CK-MB-11* cTropnT-0.23*
[**2187-7-8**] 06:30AM BLOOD Calcium-8.1* Phos-3.0 Mg-2.1
.
Cardiology Report ECG Study Date of [**2187-7-4**] 11:57:18 PM
Read by: [**Last Name (LF) 2889**],[**First Name3 (LF) 2890**] K.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
94 158 94 [**Telephone/Fax (2) 78665**]3
.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2187-7-5**] 7:37
PM
FINDINGS: In comparison with study of [**7-4**], there is little
change.
Persistent blunting of the left costophrenic angle consistent
with pleural
fluid and atelectatic changes. Similar, though less marked
changes are seen
on the right. The pulmonary vessels appear somewhat less
prominent, possibly
reflecting some improvement in pulmonary venous pressure status.
Catheters
remain in place.
IMPRESSION: Little change except for possibly some improvement
in pulmonary vascular status.
.
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 78666**]Portable TTE
(Complete) Conclusions
The left atrium is elongated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is mildly
depressed (LVEF= 40-50 %) secondary to hypokinesis of the
inferior and posterior walls. There is no ventricular septal
defect. The right ventricular cavity is dilated with borderline
normal free wall function. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. Trace aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. There is
no mitral valve prolapse. Mild (1+) mitral regurgitation is
seen. The estimated pulmonary artery systolic pressure is
normal. There is no pericardial effusion.
.
[**2187-7-12**] 06:10AM BLOOD WBC-10.6 RBC-3.10* Hgb-9.7* Hct-28.3*
MCV-91 MCH-31.3 MCHC-34.3 RDW-13.9 Plt Ct-287
[**2187-7-19**] 04:30AM BLOOD Glucose-88 UreaN-18 Creat-0.6 Na-134
K-4.2 Cl-105 HCO3-21* AnGap-12
[**2187-7-11**] 03:00AM BLOOD CK(CPK)-72
[**2187-7-11**] 03:00AM BLOOD CK-MB-NotDone cTropnT-0.14*
[**2187-7-19**] 04:30AM BLOOD Calcium-7.6* Phos-3.1 Mg-1.9
[**2187-7-15**] 05:28AM BLOOD calTIBC-178* Ferritn-918* TRF-137*
[**2187-7-15**] 05:28AM BLOOD Triglyc-173*
.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2187-7-17**] 2:11
PM
IMPRESSION:
1. PICC terminates in the lower SVC.
2. Bibasilar atelectasis.
3. Vague opacity in the right middle lobe may represent
additional
atelectasis or pneumonia.
.
Radiology Report CT ABDOMEN W/CONTRAST Study Date of [**2187-7-10**]
11:04 AM
IMPRESSION:
1. Unremarkable post-operative appearance with no evidence for
abscess.
2. Moderate gastric distension without evidence for obstruction.
.
Radiology Report ABDOMEN (SUPINE & ERECT) Study Date of [**2187-7-12**]
11:35 AM
IMPRESSION: Paucity of bowel gas, nonspecific bowel gas pattern.
NG tube
with side port in esophagus needs further advancement.
Brief Hospital Course:
This is a 67 year old male with ampullary polyp who went to the
OR on [**2187-7-3**] for:
1. Pancreatoduodenectomy (Whipple procedure).
2. Open cholecystectomy.
3. Extensive lysis of adhesions.
He followed the "Whipple" pathway.
Pain: He had an epidural for pain control and was followed by
APS. The epidural, per the pathway, was removed on POD 4. He was
transitioned to a PCA and then oral pain medications once
tolerating a diet.
Post-op Pulmonary Edema: He was Triggered for O2 sat 88 on 2L;
60yr h/o smoking, COPD; CXR showed slightly more vascular
congestion; EKG essentially normal; ABG NL with O2 in 70s; given
nebs, venti mask; and was transferred to the ICU as his cardiac
enzymes were rising. He had a cardiology consult who felt this
was not a MI, but rather a pulmonary overload (demand ischemia)
issue.
[**7-6**] Echo: LVEF 40-50% hypokinesis inf/post walls, trace AR, 1+MR
He was started on ASA and his Lopressor was titrated up.
On [**2187-7-9**], a CXR revealed an area of patchy opacification that
is developed in the right mid to lower zone. Levofloxacin was
started for possible pneumonia.
On POD 7, he complained of chest pain and had some EXG changes.
Again cards was called, but felt that this was a normal variant
and his "chest pain" was likely reflux.
GI/ABD: He was NPO, with a NGT and IVF. The NGT, per the
pathway, was removed on POD 3. His diet was slowly advanced as
she had return of bowel function. He was tolerating clears
liquids by POD 5. On POD 6, a JP Amylase was measured and was
1254 The drain was left in place. A repeat JP Amylase on [**7-17**]
was [**Numeric Identifier 78667**]. The drain was converted to passive drainage.
For clinical concerns, a CT was obtained to rule out
abscess/leak.
[**7-10**]: CT abd: No evidence for abscess, moderate gastric
distension. He then had emesis on POD 9. A NGT was placed and
put out a large amount of bilious fluid. He was started on TPN.
He also had some redness and bogginess on his right flank near
the drain site. Vancomycin was started and a week was completed.
After 3 days of the NGT, it was removed and again his diet was
advanced. The TPN was weaned down and he was tolerating regular
food and reported +flatus and +BM thru the ostomy prior to
discharge.
His abdomen was soft, nondistended and the incision with staples
was C/D/I. The staples were removed prior to discharge and steri
strips placed. There were no signs of infection.
Medications on Admission:
metoprolol 50mg SR', omeprazole 20mg EC', lisinopril 10mg',
vytorin 10/40mg'
.
Discharge Medications:
1. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day) as needed.
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
5. 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*
6. 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:*2*
7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed.
Disp:*45 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 269**] Home Health & Hospice
Discharge Diagnosis:
duodenal and ampullary adenoma
Post-op Pulmonary Edema; hypoxemia; Demand Ischemia
Post-op Delayed Gastric Emptying
Malnutrition
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.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting, diarrhea
or other reasons.
* Signs of dehydration include dry mouth, rapid heartbeat or
feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
.
* Take all new meds as ordered.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
* Continue to increase activity daily
* Monitor your incision for signs of infection.
* You may shower and wash, no tub baths or swimming.
* Continue with drain care. Empty and record daily output.
Change dressing/appliance as needed.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 468**] on [**2187-8-13**] at 10:15. Call
[**Telephone/Fax (1) 2835**] with questions or concerns.
Completed by:[**2187-7-20**]
|
[
"211.3",
"410.71",
"496",
"E878.8",
"E849.7",
"568.0",
"799.02",
"211.2",
"263.9",
"575.11",
"428.0",
"997.1",
"577.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.59",
"38.93",
"96.6",
"52.7",
"99.15",
"51.22",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
10907, 10978
|
7386, 9827
|
343, 449
|
11151, 11158
|
3869, 7363
|
12712, 12889
|
2834, 3215
|
9957, 10884
|
10999, 11130
|
9853, 9934
|
11182, 12689
|
3230, 3850
|
273, 305
|
477, 2253
|
2275, 2636
|
2652, 2818
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,564
| 182,690
|
34560
|
Discharge summary
|
report
|
Admission Date: [**2189-11-15**] Discharge Date: [**2189-11-20**]
Date of Birth: [**2143-1-22**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4393**]
Chief Complaint:
hematemesis
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
Mr. [**Known lastname 3234**] is a 46 year-old male with end-stage liver disease
secondary to alcohol abuse and chronic hepatitis C, never
treated due to ongoing ETOH use, previously complicated by
bleeding esophageal varices status post banding, portal
hypertension, non-bleeding gastric varices, portal vein thrombus
(not anticoagulated because of compliance issues and continued
alcohol use). He developed abdominal pain yesterday morning
which was followed by about 3 episodes of bright red vomitus,
which he quantifies at a half [**Last Name (un) 79352**]. He also had several
episodes of melena daily starting yesterday. On the morning
of presentation, he had 3 episodes of bright red blood per
rectum with continued diffuse abdominal pain. He endorses chills
but denies cough, dysuria or headache/confusion. He has been
lightheaded at times but denies chest pain or palpitations. His
last EGD [**9-/2189**] showed portal gastropathy and gastric fundal
varix. He has been compliant with his Nadolol.
.
Upon presentation to the ED, his initial VS were T 99.3, HR82,
BP133/76, RR16, Sat100RA. On exam, he had diffuse abdominal pain
worse in the RLL (s/p appendectomy). Also with G+ black stool,
no ascites, mild baseline tremor, w/ mild asterixis, oriented X
3. He was found to have a hematocrit to 27 from a baseline in
the low to mid 30s. He refused NGT. He received 2LNS, IV PPI
bolus and gtt, along with octreotide gtt, 10unit vitamin K, and
ciprofloxacin. He was crossmatched 4 units, got a unit of
platelets for plt 40, a unit of FFP (INR 2.1), and will be sent
with a pRBCs. Lactate elevated to 2.4. Prior to transfer to
the MICU, his VS were T98.6 P83 BP107/65 RR14 99RA.
.
On arrival to the MICU, his initial VS were:T100.2 P91 BP105/68
RR15 Sat98RA. He was comfortable in no acute distress, noting
only diffuse abdominal pain. No recent hematemesis since
arriving from the MICU. States that he has been drinking [**7-15**]
[**Month/Day (3) 17963**] nightly, with last drink on friday. Otherwise denying
fevers, chills, dysuria, hematuria, malaise, weakness, weight
gain, increased girth. No recent NSAIDs or anticoagulants.
He's been compliant with nadolol.
.
Of note, he was admitted for consideration of TIPS in [**6-/2189**]
after routine HCC screening CT revealed a portal vein thrombus.
The decision was made not to proceed with either TIPS or
anticoagulation due to ongoing ETOH abuse and suspected
inabiltiy to comply with coumadin.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
.
Past Medical History:
-Cirrhosis c/b esophageal varices, no h/o ascites
-HCV, chronic
-EtOH abuse, ongoing
-portal vein thrombosis [**6-/2189**], not anticoagulated
Social History:
Lives w son. Facilities [**Name2 (NI) **].
EtOH: 6-8 [**Name2 (NI) 17963**] nightly
Smoking: 30py, now [**2-8**] cigarettes per day
Drugs: h/o IV use (heroin), denies recent use
Family History:
noncontributory
Physical Exam:
On Admission:
Vitals: T100.2 P91 BP105/68 RR15 Sat98RA
General: jaundice, Alert, orientedx3, resting comfortably, no
acute distress
HEENT: 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: mild tenderness to palpation diffusely, but soft,
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: answering questions appropriately, AAOx3, moving all
extremities
.
Discharge PE:
Vitals: 99.0, 94/56, 70, 99%RA
General: Alert, orientedx3, resting comfortably, no acute
distress
HEENT: 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, nontender, nondistended, +BS
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: answering questions appropriately, AAOx3, moving all
extremities
.
Pertinent Results:
Admission labs:
[**2189-11-15**] 01:40PM BLOOD WBC-3.6* RBC-2.74* Hgb-9.0* Hct-27.1*
MCV-99* MCH-32.7* MCHC-33.1 RDW-19.6* Plt Ct-40*
[**2189-11-15**] 08:00PM BLOOD WBC-2.3* RBC-2.03*# Hgb-6.5*# Hct-20.1*#
MCV-99* MCH-31.9 MCHC-32.2 RDW-20.1* Plt Ct-44*
[**2189-11-16**] 12:50AM BLOOD Hct-25.0*
[**2189-11-15**] 01:40PM BLOOD PT-22.2* PTT-37.8* INR(PT)-2.1*
[**2189-11-15**] 08:00PM BLOOD PT-22.4* PTT-40.4* INR(PT)-2.1*
[**2189-11-16**] 05:51AM BLOOD PT-20.2* PTT-36.2* INR(PT)-1.8*
[**2189-11-15**] 01:40PM BLOOD Glucose-107* UreaN-11 Creat-0.6 Na-138
K-3.9 Cl-104 HCO3-29 AnGap-9
[**2189-11-16**] 05:51AM BLOOD Glucose-77 UreaN-8 Creat-0.7 Na-140 K-3.3
Cl-108 HCO3-25 AnGap-10
[**2189-11-16**] 03:03PM BLOOD Glucose-97 UreaN-7 Creat-0.6 Na-138
K-3.0* Cl-103 HCO3-25 AnGap-13
[**2189-11-15**] 01:40PM BLOOD ALT-33 AST-102* LD(LDH)-284* AlkPhos-134*
TotBili-5.4* DirBili-2.5* IndBili-2.9
[**2189-11-16**] 05:51AM BLOOD ALT-23 AST-68* AlkPhos-86 TotBili-4.3*
[**2189-11-17**] 05:13AM BLOOD ALT-27 AST-78* AlkPhos-88 TotBili-4.7*
[**2189-11-15**] 01:40PM BLOOD Albumin-2.4* Calcium-8.1* Phos-2.8
Mg-1.5*
[**2189-11-16**] 05:51AM BLOOD Calcium-7.0* Phos-3.2 Mg-1.2*
[**2189-11-16**] 03:03PM BLOOD Calcium-7.3* Phos-3.6 Mg-2.2
.
Discharge labs:
[**2189-11-18**] 06:05AM BLOOD WBC-2.5* RBC-3.24* Hgb-10.1* Hct-30.9*
MCV-95 MCH-31.2 MCHC-32.8 RDW-20.4* Plt Ct-51*
[**2189-11-19**] 06:00AM BLOOD WBC-3.3* RBC-3.15* Hgb-10.1* Hct-30.5*
MCV-97 MCH-32.0 MCHC-33.1 RDW-20.9* Plt Ct-44*
[**2189-11-20**] 07:00AM BLOOD WBC-3.6* RBC-3.12* Hgb-9.7* Hct-30.2*
MCV-97 MCH-31.2 MCHC-32.3 RDW-20.6* Plt Ct-45*
[**2189-11-18**] 06:05AM BLOOD PT-23.7* INR(PT)-2.2*
[**2189-11-19**] 06:00AM BLOOD PT-24.9* PTT-38.6* INR(PT)-2.4*
[**2189-11-20**] 07:00AM BLOOD PT-25.9* INR(PT)-2.5*
[**2189-11-17**] 05:13AM BLOOD Glucose-105* UreaN-10 Creat-0.7 Na-137
K-3.0* Cl-102 HCO3-28 AnGap-10
[**2189-11-18**] 06:05AM BLOOD Glucose-80 UreaN-5* Creat-0.5 Na-130*
K-3.1* Cl-96 HCO3-26 AnGap-11
[**2189-11-19**] 06:00AM BLOOD Glucose-75 UreaN-6 Creat-0.6 Na-132*
K-3.4 Cl-101 HCO3-24 AnGap-10
[**2189-11-20**] 07:00AM BLOOD Glucose-88 UreaN-7 Creat-0.6 Na-133 K-3.5
Cl-102 HCO3-25 AnGap-10
[**2189-11-17**] 05:13AM BLOOD ALT-27 AST-78* AlkPhos-88 TotBili-4.7*
[**2189-11-18**] 06:05AM BLOOD ALT-29 AST-83* AlkPhos-87 TotBili-4.6*
[**2189-11-20**] 07:00AM BLOOD ALT-28 AST-72* AlkPhos-116 TotBili-3.3*
[**2189-11-18**] 06:05AM BLOOD Albumin-2.4* Calcium-7.2* Phos-2.6*
Mg-1.4*
[**2189-11-19**] 06:00AM BLOOD Calcium-7.3* Phos-2.3* Mg-1.6
[**2189-11-20**] 07:00AM BLOOD Albumin-2.5* Calcium-7.3* Phos-3.4
Mg-1.5*
.
Abdomenal US: [**11-16**] (prelim)
Portal veins are patent, however there is reversal of flow
throughout the
portal system and of the splenic vein. Left lobe lesion stable
in size c/w
[**2189-9-7**]. Cirrhosis, no sig ascites.
Gallstones in gb neck, borderline gb thickness likely [**3-11**]
cirrhosis. no
son[**Name (NI) 493**] murphys, cbd normal caliber. No bil dil.
.
EGD:
Esophagus:
Other Scar from prior banding seen in lower esophagus.
Stomach:
Lumen: A small size hiatal hernia was seen.
Mucosa: Erythema and congestion of the mucosa were noted in the
whole stomach. These findings are compatible with portal
gastropathy.
Protruding Lesions A single large varix was was seen in the
stomach fundus. There were no stigmata of recent bleeding,
however given the amount of blood and lack of other findings,
decision made to inject with glue. 3 cc glue injected for
hemostasis with success.
Other Blood and clots seen in the stomach fundus and body. It
was too thick to suction.
Duodenum: Normal duodenum.
Impression: Small hiatal hernia
Scar from prior banding seen in lower esophagus.
Blood and clots seen in the stomach fundus and body. It was too
thick to suction.
Erythema and congestion in the whole stomach compatible with
portal gastropathy
Gastric varices (injection)
Otherwise normal EGD to third part of the duodenum
Brief Hospital Course:
Mr. [**Known lastname 3234**] is a 46yo M with end stage liver disease due to
chronic hepatitis C and ETOH intake, portal hypertension, portal
vein thrombosis, here with upper GIB of likely variceal origin.
.
# UPPER GI BLEED: Patient presented after several episodes of
bloody hematemesis and melena. Admission HCT below baseline at
27 from 30-35. In the MICU, received 2unit plt and 2FFP. Urgent
EGD demonstrated a single large varix was was seen in the
stomach fundus. There were no stigmata of recent bleeding,
however given the amount of blood and lack of other findings,
decision made to inject with 3 cc glue for hemostasis with
success. Patient monitored in the MICU for goal HCT~25, INR<2,
Plt>50 on octreotide and ppi ggt. Patient continued on Abx for
ppx. Per Liver, if instability ensue, next step would be TIPS.
The patient was transferred to the ET service, and while on the
floor, his vital signs and crit were stable. The patient was
continued on nadolol and upon discharge, the patient's
ceftriaxone for UGIB ppx was discontinued. The patient was
instructed how important it is to stop drinking alcohol. He was
seen by social work and given information for outpatient
resources to help him to stop drinking.
.
# END STAGE LIVER DISEASE. Related to chronic hepatitis C and
ETOH. Abd US with evidence of stable cirrhosis. Dopplers with
reversal of flow secondary to cirrhosis rather than clot.
Nadolol was initially held, but once patient was on the
[**Doctor Last Name 3271**]-[**Doctor Last Name 679**] service, the patient was restarted on Nadolol. The
patient was instructed about the importance of stopping
drinking, as his liver disease is continuing to progress. While
in the unit, the patient was showing some signs of
encephalopathy, as he was becoming confused. He was started on
Lactulose while in the unit. However, on transfer to the
floor, the patient's mental status had cleared up and returned
to baseline. The patient was discharged on lactulose PRN for
confusion.
.
# ETOH ABUSE: Patient with 6-8nightly drinks; he was initially
started on CIWA protocol for ETOH withdrawal. He was also
continued on IV folate, thiamine, and multivitamin. THe patient
was seen by social work regarding his alcohol abuse. The
importance of alcohol cessation was reiterated.
.
# PORTAL VEIN THROMBOSIS: Never anticoagulated due to
noncompliance and ongoing ETOH abuse. Please continued to
follow this as an outpatient.
.
Transitional Issues:
.
# outpatient follow-up: The patient is scheduled for an
outpatient colonoscopy and EGD. He also has follow up at the
liver center, as well as with his PCP.
Medications on Admission:
Nadolol 40 mg daily
Omeprazole daily
MVT daily
Discharge Medications:
1. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID:PRN
as needed for confusion.
Disp:*3 bottles* Refills:*0*
2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. nadolol 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
5. thiamine HCl 50 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
primary diagnosis:
upper gastrointestinal bleed
alcholic cirrhosis
Hepatitis C infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 3234**],
.
It was a pleasure taking care of you while you were hospitalized
at [**Hospital1 18**]. You were admitted to the hospital because you were
vomiting blood. You were taken to the intensive care unit and
an emergent scope was done and a camera was out down into your
stomach. We found that you had a bleed blood vessel (varix)
that was causing you to vomit up blood. We injected your varix
with glue and the bleeding has stopped.
.
You have been stable since the procedure and you have not bled.
.
It is VERY important that you stop drinking. The reason you
have your varix and these dilated blood vessels is because your
heavy alcohol drinking has caused your liver to become sick.
The more you drink, the sicker your liver is going to get and
the more likely you will have another bleed.
.
It is also very important that you follow up in the liver clinic
and with your primary care doctor. You also are scheduled for
for a colonoscopy and upper endoscopy on Tuesday, [**12-8**] a
8 AM in the [**Hospital Ward Name 1950**] building, [**Location (un) 10043**].
.
We made the following changes to your medications:
START Lactulose 30 ml as needed for when you are confused
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] L.
Location: [**Hospital6 **]
Address: [**Hospital1 **], [**Hospital1 **],[**Numeric Identifier 12842**]
Phone: [**Telephone/Fax (1) 45347**]
Appointment: THURSDAY [**11-26**] AT 11:45AM
.
Department: LIVER CENTER
When: WEDNESDAY [**2189-12-2**] at 11:20 AM
With: DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
.
COLONOSCOPY/EGD
TUESDAY, [**12-8**] at 8AM
[**Hospital Ward Name 1950**] Building, [**Location (un) **]
[**Hospital Ward Name 516**], [**Location (un) 830**]
Please call [**Telephone/Fax (1) 2422**] with any questions
.
Department: LIVER CENTER
When: WEDNESDAY [**2189-12-16**] at 12:20 PM
With: DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 4407**]
Completed by:[**2189-11-29**]
|
[
"285.1",
"578.0",
"571.2",
"572.8",
"452",
"456.8",
"305.00",
"303.90",
"070.54"
] |
icd9cm
|
[
[
[]
]
] |
[
"44.43"
] |
icd9pcs
|
[
[
[]
]
] |
12057, 12063
|
8822, 11272
|
318, 323
|
12196, 12196
|
4881, 4881
|
13584, 14790
|
3670, 3687
|
11550, 12034
|
12084, 12084
|
11479, 11527
|
12347, 13473
|
6123, 8799
|
3702, 3702
|
11293, 11453
|
13502, 13561
|
2841, 3291
|
4357, 4862
|
267, 280
|
351, 2822
|
4897, 6107
|
12103, 12175
|
3716, 4343
|
12211, 12323
|
3313, 3458
|
3474, 3654
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,538
| 140,085
|
46853+58950
|
Discharge summary
|
report+addendum
|
Admission Date: [**2195-8-18**] Discharge Date: [**2195-8-26**]
Date of Birth: [**2130-4-10**] Sex: F
Service: [**Company 191**]
HISTORY OF PRESENT ILLNESS: The patient is a 65-year-old
woman with multiple medical problems including coronary
artery disease, status post coronary artery bypass graft in
[**2171**], breast cancer treated with lumpectomy and chemotherapy
and radiation therapy, idiopathic thrombocytopenic purpura in
splenectomy, portal vein thrombosis, and known grade III
esophageal varices who presents now with a 3-day history of
black tarry stools and nausea times one day.
The patient denies bright red blood per rectum. Denies
vomiting or hematemesis. She was noted to be more lethargic
by her family on the night prior to admission and was taken
was noted to have a blood pressure of 156/75, and an
electrocardiogram that showed rapid atrial fibrillation to
the 160s, and inferolateral ST depressions.
She was transferred to [**Hospital1 69**]
for further management. In the Emergency Room she was found
to be in sinus tachycardia with a rate of 102 and blood
pressure 122/61. The patient complained of right-sided chest
pain which resolved one sublingual nitroglycerin. The
patient also was complaining of nausea. Electrocardiogram
showed persistent inferolateral ST changes. Nasogastric
lavage was done which revealed small specs of blood clots,
but no active bleeding. Hematocrit was 19.9.
The patient was transferred to the Medical Intensive Care
Unit for observation overnight. The [**Hospital 228**] Medical
Intensive Care Unit course was notable for a transfusion of 4
units of packed red blood cells with appropriate bump in
hematocrit to 30. The patient was placed on Protonix,
propranolol, and Octreotide drip. The patient also ruled in
for a non-Q-wave myocardial infarction with a peak creatine
kinase of 863 which then trended downward and with slow
resolution of electrocardiogram changes. The patient's
atrial fibrillation spontaneously converted to sinus rhythm.
The patient did have one episode of nonsustained ventricular
tachycardia in the post myocardial infarction period. The
patient's esophagogastroduodenoscopy was delayed in the
setting of her non-Q-wave myocardial infarction. Cardiology
deferred catheterization in the setting of gastrointestinal
bleed.
The patient was transferred to the Medical floor for further
management.
REVIEW OF SYSTEMS: On review of systems, the patient denied
fevers, chills, nausea, vomiting, shortness of breath. The
patient did continue feeling lightheaded when going from
lying to sitting. The patient did have mild right upper
quadrant tenderness, but no rebound or guarding. She
reported continued black stools, but no dysuria and no chest
pain.
PAST MEDICAL HISTORY:
1. Coronary artery disease, status post coronary artery
bypass graft in [**2171**]. Status post exercise MIBI in [**2194-9-14**]; a 9-minute [**Doctor First Name **] protocol, 62% maximum heart rate,
no anginal type symptoms with possible ischemic
electrocardiogram changes (0.5-mm to 1-mm ST depressions in
V5 through V6) at exercise which resolved with rest. An
ejection fraction of 47%, and mild reversible perfusion
defect in the inferior wall and apex, and mild global
hypokinesis.
2. Hypercholesterolemia.
3. Breast cancer, status post lumpectomy in [**2188**], also
treated with chemotherapy and radiation therapy. The patient
was on tamoxifen until [**2194-3-15**].
4. Idiopathic thrombocytopenic purpura in [**2188**] in the
setting of chemotherapy for breast cancer.
5. Status post splenectomy, which pathology revealed
noncaseating granulomas consistent with sarcoidosis.
6. Sarcoidosis diagnosed in [**2164**] complicated by
hypercalcemia treated with steroids.
7. Diastolic dysfunction.
8. Admitted for dyspnea on exertion in [**2194-9-14**].
9. Status post transthoracic echocardiogram which showed
mild concentric left ventricular hypertrophy,
moderate-to-severe mitral regurgitation, ejection fraction of
greater than 55%. No regional wall motion abnormalities.
Mild pulmonary artery systolic hypertension.
10. Portal vein thrombosis in [**2188**] treated initially with
Coumadin.
11. Osteoporosis.
12. Status post cholecystectomy in [**2189**].
13. Esophageal varices presumed secondary to portal vein
thrombosis, status post esophagogastroduodenoscopy in [**2194-9-14**] showing grade III varices in middle and lower third
of the esophagus which were nonbleeding.
14. Helicobacter pylori negative in [**2194-9-14**].
15. A 3.8-cm infrarenal aortic aneurysm incidentally noted
on CAT scan from [**2194-9-14**].
16. Status post Escherichia coli sepsis in [**2194-8-15**].
MEDICATIONS ON ADMISSION: (Home medications include)
1. Atenolol 50 mg p.o. q.d.
2. Lipitor 20 mg p.o. q.d.
MEDICATIONS ON TRANSFER:
1. Propranolol 60 mg p.o. b.i.d.
2. Octreotide drip 50 mcg per hour.
3. Lipitor 20 mg p.o. q.d.
4. Protonix 40 mg p.o. q.d.
ALLERGIES: The patient allergic to ERYTHROMYCIN and
CEFTAZIDIME; the patient gets thrombocytopenic with
CEFTAZIDIME.
SOCIAL HISTORY: The patient lives with her husband. The
patient has four sons. She quit smoking eight years ago and
drinks alcohol socially.
FAMILY HISTORY: Both father and mother died from heart
problems.
PHYSICAL EXAMINATION ON ADMISSION: Temperature 97.5, blood
pressure 114 to 133/51 to 63, respirations 18, satting 99% on
2 liters. In general, the patient was pleasant, slightly
tired, but alert and oriented times three. HEENT revealed
oropharynx was slightly dry. Neck had jugular venous
distention to 8 cm. Cardiovascular had a regular rate and
rhythm, normal S1 and S2. No murmurs. Respiratory with
crackles heard halfway up on the right and at the base on the
left. No wheezing. Abdomen was soft with moderate
distention, mild right upper quadrant tenderness. No
hepatomegaly. Extremities had no clubbing, cyanosis or
edema. Right femoral line in place.
RADIOLOGY/IMAGING: Chest x-ray showed cardiomegaly with
slight left ventricular decompensation.
Abdominal ultrasound showed portal vein thrombosis with
diffuse increase of hepatic echogenicity compared to the
study done on [**2194-9-17**].
Electrocardiogram showed normal sinus rhythm with normal
intervals, normal axis, Q wave in III, poor R wave
progression, ST depressions in V5 and V6; ischemic changes
improved from previous electrocardiogram.
HOSPITAL COURSE:
1. GASTROINTESTINAL: The patient received Octreotide drip
for 72 hours, continued on Protonix and propranolol. The
patient's hematocrit remained stable at 30 and did not
require any further transfusions.
Upper endoscopy revealed multiple grade III varices in the
middle and distal third of the esophagus. Three bands were
placed.
2. CORONARY ARTERY DISEASE: The patient ruled in for a
non-Q-wave myocardial infarction with a peak creatine kinase
of 863. Her creatine kinases began to trend down, and her
electrocardiogram changes resolved. This was likely
secondary to demand ischemia from her gastrointestinal bleed.
Aspirin was held secondary to her gastrointestinal bleed.
The patient was on propranolol and started on an ACE
inhibitor. Her Lipitor was continued.
Cardiac catheterization will eventually have to be done as an
outpatient.
3. CONGESTIVE HEART FAILURE: The patient's post myocardial
infarction echocardiogram showed an ejection fraction of 45%
and 4+ mitral regurgitation and tricuspid regurgitation. The
patient was diuresed with Lasix p.r.n. The patient will
need to receive a follow-up echocardiogram in two to three
months to evaluate her congestive heart failure status and to
evaluate the need for valve repair, as echo revealed 4+ MR.
4. ELECTROPHYSIOLOGY: The patient's atrial fibrillation
from outside hospital spontaneously converted to normal sinus
rhythm. The patient had one episode of nonsustained
ventricular tachycardia within the post myocardial infarction
24-hour period. The patient's only other telemetry events
was a brief episode of atrial tachycardia.
5. HEMATOLOGY: The patient's INR was elevated, and the
patient was treated with vitamin K. Hypercoagulability
workup was sent, and those results were pending at the time
of this dictation.
Ultrasound on this admission did reveal continued portal vein
thrombosis. It will need to be decided as an outpatient
whether this will need to be treated with anticoagulation, once
her additional esophageal varices are banded.
The patient was not anticoagulated while in the hospital
secondary to her recent gastrointestinal bleed.
6. STUDIES: Abdominal ultrasound revealed
minimal-to-moderate ascites. The patient did not want a
paracentesis during this hospitalization. Some upper
abdominal distention was also secondary to bowel gas and not
accounted for by ascites.
7. LIVER FUNCTION TESTS: The patient had a mild increase in
liver function tests likely secondary to hepatic congestion,
status post myocardial infarction. The patient's liver
function tests did return to normal values.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4446**]
Dictated By:[**Name8 (MD) 7112**]
MEDQUIST36
D: [**2195-8-30**] 12:19
T: [**2195-9-3**] 12:48
JOB#: [**Job Number 43097**]
Name: [**Known lastname 15911**], [**Known firstname 5461**] Unit No: [**Numeric Identifier 15912**]
Admission Date: [**2195-8-18**] Discharge Date: [**2195-8-26**]
Date of Birth: [**2130-4-10**] Sex: F
Service: [**Company 112**]
CONTINUATION OF HOSPITAL COURSE:
LEUKOCYTOSIS: The patient had persistent elevation of the
white blood cell count without a left shift. There was no
evidence of infection and this was likely a stress response,
status post myocardial infarction and gastrointestinal bleed.
CONDITION ON DISCHARGE: Fair.
DISCHARGE STATUS: The patient was discharged to home.
DISCHARGE MEDICATIONS:
1. Propanolol 70 mg p.o. b.i.d.
2. Protonix 40 mg p.o. b.i.d.
4. Lisinopril 10 mg p.o. q.d.
5. Simethicone 80 mg p.o. q.i.d.
FOLLOW UP:
1. The patient has a follow up appointment in the
gastrointestinal clinic with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**2195-9-14**]
at 1:20 PM.
2. Follow up esophagogastroduodenoscopies with further
banding by Dr. [**Last Name (STitle) 4829**] are scheduled for [**2195-9-23**] at
11 AM and [**2195-10-7**] at 10:30 AM. Prior to these
esophagogastroduodenoscopies with banding, the patient should
be n.p.o. after midnight except for medications in the
morning.
3. The patient will also need to follow up with her new
primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 302**] [**Last Name (NamePattern1) 303**], for discussion of
cardiac and primary care.
DISCHARGE DIAGNOSES:
1. Status post upper gastrointestinal bleed secondary to
esophageal varices.
2. Status post non-Q wave myocardial infarction.
SECONDARY DIAGNOSES:
1. Coronary artery disease, status post coronary artery
bypass grafting.
2. Diastolic dysfunction with mitral regurgitation and
tricuspid regurgitation on echocardiogram.
3. History of breast cancer, status post lumpectomy,
radiation therapy and chemotherapy.
4. Status post splenectomy for idiopathic thrombocytopenia
in the setting of chemotherapy for breast cancer.
5. History of portal vein thrombosis.
6. History of grade 3 esophageal varices, likely secondary
to portal vein thrombosis.
7. Hypercholesterolemia.
8. Sarcoidosis.
[**Name6 (MD) 1034**] [**Name8 (MD) 1035**], M.D. [**MD Number(1) 1036**]
Dictated By:[**Name8 (MD) 353**]
MEDQUIST36
D: [**2195-8-30**] 12:25
T: [**2195-9-3**] 12:18
JOB#: [**Job Number 15913**]
|
[
"789.5",
"272.0",
"410.71",
"428.0",
"424.0",
"397.0",
"452",
"427.31",
"456.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"42.33"
] |
icd9pcs
|
[
[
[]
]
] |
5259, 5330
|
10842, 10971
|
9948, 10078
|
4738, 4823
|
9596, 9837
|
10992, 11769
|
10089, 10821
|
2433, 2770
|
174, 2412
|
5345, 6433
|
4848, 5096
|
2793, 4711
|
5113, 5241
|
9862, 9925
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,976
| 188,314
|
15971
|
Discharge summary
|
report
|
Admission Date: [**2144-12-29**] Discharge Date: [**2145-1-1**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Cardiac Catheterization- Left Main Drug-Eluting Stent
Intra-arterial Balloon pump
History of Present Illness:
[**Age over 90 **] year old male with CAD, PVD presented to [**Location (un) 511**] [**Hospital 45759**]
Hospital on [**12-24**] with chest pain that awoke him from sleep. He
described pain as going from shoulder to shoulder. No
associated shortness of breath, nausea or diaphoresis. He
called his daughter who brought him to OSH. He has 4 to 5 month
history of similar pains which typically start while lying in
bed and resolves in [**9-26**] minutes after sitting up and
occasionally requiring sl nitroglycerin. He states the pain has
been more frequent in the past several weeks. It used to occur
once/month and has been occuring once/week for the past month.
At OSH ruled in with maximum Troponin 1.67, EKG showed ST
depression with TW inversions in V3-V6, TW inversions in I, aVL,
II, III, aVF. Diagnostic cath at OSH showed 90% distal left
main, no signifcant LAD disease, 90% mid Left circumflex, 100
proximal RCA, total occlusion of right superficial femoral
artery. He was transferred to [**Hospital1 18**] for interventional
catheterization.
Past Medical History:
CAD s/p PCI x 2
severe PVD
hypercholesterolemia
hypothyroidism
chronic low back pain
AFib s/p ablation
s/p cholecystectomy
s/p bilateral carotid endartectomies
s/p left popliteal graft
s/p left knee arthroscopy
s/p lumbar decompression '[**34**]
s/p left leg thrombectomy
Social History:
previous 30 pack-year tobacco, quit 40 yrs ago. Occasional
EtOH. Lives with daughter.
Family History:
Non-contributory
Physical Exam:
T 96.9 HR 65 BP 130/40 RR 18 98%/2L n.c.
Gen: Comfortable, no acute distress
HEENT: PERRL, EOMI, OP clear, MMM
Neck: no JVD
CV: S1, S2, RRR, 2/6 systolic murmur at base
Pulm: CTAB
Abd: (+) bowel sounds, soft, obese, nontender
Ext: bilateral venous stasis changes, no edema, warm,
well-perfused, 1+DP.
groin sites without hematoma or bruit. Left groin ecchymosis.
Pertinent Results:
Admission Labs:
[**2144-12-29**] 08:15PM BLOOD WBC-8.3 RBC-3.53* Hgb-11.8* Hct-32.1*
MCV-91 MCH-33.4* MCHC-36.7* RDW-13.8 Plt Ct-202
[**2144-12-29**] 08:15PM BLOOD PT-13.8* PTT-89.5* INR(PT)-1.3
[**2144-12-29**] 08:15PM BLOOD Glucose-160* UreaN-29* Creat-1.4* Na-136
K-4.5 Cl-99 HCO3-29 AnGap-13
[**2144-12-30**] 07:09PM BLOOD CK(CPK)-114
[**2144-12-30**] 07:09PM BLOOD CK-MB-4
[**2144-12-29**] 08:15PM BLOOD Calcium-8.9 Phos-2.8 Mg-2.2
.
Cardiac catheterization:
PROCEDURE DATE: [**2144-12-30**]
INDICATIONS FOR CATHETERIZATION:
NSTEMI.
Chest pain.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Successful stenting of the LMCA/LAD.
COMMENTS:
1. Limited angiography of the left coronary artery showed a 90%
distal
LMCA stenosis involving the ostial LAD and an 80% mid LCX
stenosis with
a distal LCX occlusion. The RCA was known to be occluded and not
imaged.
2. Resting hemodynamics showed central aortic hypertension.
3. Successful PTCA and stenting of the distal LMCA into the LAD
with a
3.5 mm Cypher drug-eluting stent.
.
Day of discharge labs
[**2145-1-1**] 06:45AM BLOOD WBC-9.7 RBC-3.32* Hgb-10.9* Hct-29.5*
MCV-89 MCH-32.8* MCHC-37.0* RDW-13.9 Plt Ct-179
[**2145-1-1**] 06:45AM BLOOD PT-12.4 PTT-24.8 INR(PT)-1.0
[**2145-1-1**] 06:45AM BLOOD Glucose-104 UreaN-22* Creat-1.3* Na-137
K-4.1 Cl-102 HCO3-26 AnGap-13
Brief Hospital Course:
Initial impression: [**Age over 90 **] year old female with CAD, peripheral
[**Age over 90 1106**] disease with rest chest pain. High-risk by positive
enzymes (troponin max 1.67 on [**12-24**], reference 0-0.4). ECG with
ST depressions with TWI in V3-V6, TWI in I, aVL, II, III, aVF.
Diagnostic catheterization showed 90% distal left main disease,
with no significant LAD, 90% mid left circumflex, 100% distal
left circumflex, 100% proximal right coronary artery, with left
ventriculogram EF 40%, LV mildly dilated. Inferobasal and
inferior wall akinesis, with total occlusion of RSFA. Based on
this initial catherization report, patient was transferred to
[**Hospital1 18**] for intervention. HOSPITAL COURSE BY SYSTEM:
1) Cardiovascular: Coronary angiography at [**Hospital1 18**] on [**2144-12-30**]
demonstrated LMCA 95%, distal LAD ostial 90%, left circumflex
moderate prox, 80% mid, 100% ostial RCA. Patient received a
left-main coronary artery Cypher [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] 1 and was transferred to
the CCU post-catheterization for intra-aortic balloon pump to
optimize coronary hemodynamics. Patient was monitored in CCU for
1 day (where he was transfused 1 unit of packed RBCs) and
transferred back to floor, chest pain free and hemodynamically
and electrically stable, which he remained through the remainder
of his hospitalization. He was continued on his accupril,
ecotrin, imdur, lasix, lipitor, plavix, toprol XL. Plan was to
continue plavix and ASA x 9 months then ASA indefinitely.
Although patient had a history of atrial fibrillation, he was in
normal sinus rhythm for the entire admission, and coumadin was
restarted after his CCU stay for goal INR [**1-15**]. Patient will be
followed in outpatient cardiology and will have re-look cardiac
catheterization for left main disease in [**2-15**] weeks.
2) Heme: It was felt by the CCU inpatient team that the
patient's coumadin could be restarted without heparin bridge
upon discharge from CCU. He will be anticoaguled for goal INR
[**1-15**].
3) Endocrine: Continued synthroid for hypothyroidism.
5) Prophy: Anticoagulated with ASA, plavix and coumadin on
discharge. On PPI throughout.
FULL CODE
Medications on Admission:
Accupril 10 qd
Eccotrin 325 qd
Indur 60 qd
Lasix 40 qd
Lipitor 40 qd
MOM 30 qd prn
Plavix 75 qd
Synthroid 75 mcg
Toprol XL 75 [**Hospital1 **]
Morphine prn
Nitropaste 1" q8h
Discharge Medications:
1. Quinapril 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig:
Three (3) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*90 Tablet Sustained Release 24HR(s)* Refills:*2*
9. Warfarin 5 mg Tablet Sig: One (1) Tablet PO every other
night: alternate with 2.5mg tab.
10. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO every other
night: alternate with 5mg tab .
11. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1)
Sublingual once a day as needed for chest pain: take 1 tab every
5 mintues as needed for chest pain, up to 3 times, if no relief
call 911. .
Disp:*30 tabs* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
1.non-ST elevation MI
Discharge Condition:
good. chest pain free
Discharge Instructions:
Please report chest pain, shortness of breath, palpitations, or
other medical issues to your primary physician.
You have been discharged on a new medicine called plavix. This
is to help prevent clot formation in your new stent. Please take
as prescribed below. You are also prescribed nitroglycerin to
take as needed for chest pain. Take one tab every 5 minutes, up
to 3 times, for relief of pain. If pain not relieved call 911
for emergent evaluation.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] in [**12-14**] weeks. Call [**Telephone/Fax (1) 2394**] to
schedule an appointment.
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] SURGERY (NHB)
Date/Time:[**2145-2-23**] 10:00
Completed by:[**2145-1-4**]
|
[
"272.0",
"443.9",
"414.01",
"244.9",
"427.31",
"410.71"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.61",
"37.22",
"00.45",
"88.55",
"00.66",
"36.07",
"88.52",
"00.40"
] |
icd9pcs
|
[
[
[]
]
] |
7357, 7415
|
3647, 4341
|
273, 357
|
7481, 7505
|
2288, 2288
|
8008, 8350
|
1867, 1885
|
6075, 7334
|
7436, 7460
|
5877, 6052
|
2855, 3624
|
7529, 7985
|
4369, 5851
|
1900, 2269
|
2818, 2838
|
223, 235
|
385, 1451
|
2304, 2785
|
1473, 1746
|
1762, 1851
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,131
| 156,448
|
19911+57094
|
Discharge summary
|
report+addendum
|
Admission Date: [**2140-3-21**] Discharge Date: [**2140-4-2**]
Date of Birth: [**2071-10-30**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This is a 68 year old gentleman
with a history of Parkinson's disease and a recent prolonged
complicated admission, status post motor vehicle accident
where he was hit by a car as a pedestrian who returned with
fever, shortness of breath and hypotension from
rehabilitation. He was admitted on [**2140-1-15**] to
[**2140-3-12**] after being struck by a car. In that
admission he had a complicated course including a right
fibular fracture and right acetabular fracture and multiple
left rib fractures and left perisplenic hematoma and left
common femoral vein deep vein thrombosis and had a inferior
vena cava filter placed on [**2140-1-6**]. He also had
evidence of right lower extremity skin necrosis in the thigh
and cellulitis which was debrided and had a skin graft from
his thigh. Also during that hospitalization, he had an
exploratory laparotomy which showed left retroperitoneal,
perinephric hematoma, also complicated by pancreatitis status
post endoscopic retrograde cholangiopancreatography and
sphincterotomy and Methicillin-resistant Staphylococcus
aureus pneumonia which was treated with Vancomycin. He was
discharged on [**1-10**] to [**Hospital1 **]. He was there two to
three days prior to representation at [**Hospital6 649**]. He developed fevers, tachypnea and shortness
of breath at that rehabilitation and was sent back in for
further evaluation. On admission he had evidence of a right
lower lobe pneumonia. He was started on Flagyl for concern
for aspiration pneumonia. He was given a dose of Azotreanam
at the rehabilitation and was started on Vancomycin given his
history of Methicillin-resistant Staphylococcus aureus.
Review of systems was positive for fevers, shortness of
breath, cough which was nonproductive with a rare yellowish
sputum. He had dark brown diarrhea, positive back pain since
his accident. No abdominal pain. He was taking p.o., no
coughing after eating. No nausea, vomiting or dysuria. In
the Emergency Room, he was noted to have temperature to 101.5
with systolic blood pressure of 84, respiratory rate between
30 to 40 and 87% saturations on room air. He was given 3
liters of normal saline. His blood pressure came up to
133/86. A central line was placed in his right internal
jugular vein. He was given Ceftriaxone and admitted to the
Medicine Intensive Care Unit.
PAST MEDICAL HISTORY: Past medical history includes 1.
Parkinson's disease since [**2121**]; 2. Hypertension; 3. Status
post motor vehicle accident trauma, being hit as a
pedestrian; 4. Prostate cancer, status post prostatectomy.
ALLERGIES: Zosyn and Levaquin.
MEDICATIONS ON ADMISSION: Sinemet, Senna, Atrovent,
Albuterol, Seroquel, Ultram, Entacapone with the Sinemet,
cream Glycerine, Lactulose, Colace, multivitamin, Tylenol,
Fragmin, Prevacid, Flagyl started on [**3-20**], Azotreanam
started on [**3-21**] and then Vancomycin given one dose on
[**3-21**].
SOCIAL HISTORY: Negative tobacco or alcohol. He was an
engineer on a ship with positive asbestosis exposure,
currently at rehabilitation. He has a wife and daughter in
the nearby town.
FAMILY HISTORY: Negative for coronary artery disease,
diabetes and coronary artery disease or cancers.
PHYSICAL EXAMINATION ON ADMISSION: Notable for temperature
101.5, blood pressure 181/76, heart rate 109, respiratory
rate 30, saturations 95% on 3 liters of nasal cannula. In
general, he was an elderly Russian-speaking only male,
tachypneic. Head, eyes, ears, nose and throat, flat neck
veins, pupils equal, round and reactive to light, anicteric
sclera, moist mucous membranes, left subclavian triple lumen
with some secondary erythema but no tenderness, warmth or
fluctuance. Chest with bronchial breath sounds and rhonchi
of the left base with right bibasilar rales. Heart was
tachycardiac with heart sounds obscured by rapid breath
sounds. Abdomen was soft with a healed midline scar,
nontender. Extremities, trace to 1+ patchy edema in
bilateral lower extremities. Well granulation tissue over
graft on his right lower extremity. Back, left Stage 1
decubitus ulcer over his left buttocks, no surrounding
cellulitis. Rectal, guaiac negative. Neurological, cogwheel
rigidity, alert and oriented.
LABORATORY DATA: Laboratory data on admission revealed white
count 17.5, hematocrit 28.6, platelets 292. Sodium 140,
potassium 4.1, chloride 104, bicarbonate 27, BUN 26,
creatinine 0.9, glucose 99, lactate 2.1, INR 1.4. Urinalysis
was hazy with a specific gravity of 1.029, 30 protein, 15
ketones, trace leukocyte esterase, large blood, 11 to 20 of
red blood cells, treated by white blood cells, moderate
bacteria. Cultures were pending on admission. An
echocardiogram in [**2140-1-4**] with normal ejection
fraction, no wall motion abnormality, no valvular disease.
Chest x-ray with left lower lobe opacity.
HOSPITAL COURSE: This is a 68 year old gentleman with
Parkinson's disease, status post recent long complicated
hospital course, status post a motor vehicle accident who
presented with fevers, shortness of breath and hypotension.
1. Sepsis - The patient's likely sources were considered to
be pneumonia, urinary tract infection and diarrhea, given his
history of Clostridium difficile colitis. Also a source
could have been decubitus ulcer. The patient was admitted to
the Intensive Care Unit and started on broad spectrum
antibiotics, including Vancomycin, Ceftriaxone for pneumonia,
and Flagyl to cover for Clostridium difficile. The patient's
previous left subclavian central line was pulled and sent for
cultures. He had a new right internal jugular central line
placed. He continued to have aggressive intravascular
repletion with intravenous fluids to which he responded,
presumably initially hypovolemic secondary to diarrhea,
fevers, tachypnea. Chest x-ray confirmed left lower lobe
collapse, consolidation which has increased in prominence
since the previous study. He does have a known elevated
right hemidiaphragm and this was stable from the previous
chest x-ray. However, the patient was treated as a
nosocomial pneumonia with his recent hospitalization. As he
was coming from the nursing home, the patient was treated
broadly with goal to complete a 14 day course of Vancomycin
and Ceftriaxone of which he started on [**3-21**], and which
will be completed on [**4-4**]. Blood cultures drawn on the
day of admission and follow up cultures remained negative.
The patient's stool was positive for Clostridium difficile
and sputum was positive for Methicillin-resistant
Staphylococcus aureus and the patient is to complete the two
week courses of both, and both will be completed on [**4-4**].
His leukocytosis from an admission of 17,000 did trend down
during the course of his stay with antibiotics. His
hypotension through the course of the Medicine Intensive Care
Unit stay and on the floor was fluid-responsive and remains
stable. Eventually he was restarted on his outpatient
hypertensive regimen.
2. Respiratory distress - The patient was noted to have some
episodes of respiratory distress in the Medicine Intensive
Care Unit, he was treated with BiPAP as he was hypercapnic
and this did help improve his ventilatory status. He
tolerated BiPAP well. He was eventually weaned just to BiPAP
nightly. He continued to retain carbon dioxide with a rise
in bicarbonate throughout the course of his stay and this was
considered likely secondary to a persistent carbon dioxide
retention. His respiratory distress and hypercapnia were
attributed to his pneumonia. Eventually also evidence of
right lower lobe pneumonia and right lower lobe collapse
likely was more susceptible secondary to his elevated right
hemidiaphragm which was chronic and more susceptible to
atelectasis in light of his hypotension and mental status
issues. His respiratory status remained stable on the floor.
He was continued on oxygen by nasal cannula at a rate of 3
liters. He tolerated this well with stable saturations
around 96%. He was continued on nebulizers q. [**5-10**] with good
results and continued to produce good cough efforts, although
still gaining back strength. He was continued on BiPAP at
settings of 10 and 5 with three to four liters of bleeding
over night with good result. This is to be continued at
rehabilitation. His chest x-ray confirmed small right
pleural effusion which was stable in size and improving
through the course of his stay as was the respiratory status.
No plans were made to tap as it was considered increasing
risk for thoracentesis than to just continue treatment. Again
the patient has completed a two week course of Ceftriaxone
and Vancomycin for nosocomial acquired pneumonia at the
nursing home and his course will be completed on [**4-4**].
The patient had a mid line placed in his right forearm to
complete the rest of his antibiotics at rehabilitation.
3. Clostridium difficile colitis - The patient again had
stool samples which were positive for Clostridium difficile
and the patient was again restarted on Flagyl to complete a
two week course which he will complete on [**4-4**]. Otherwise
his diarrhea improved throughout the course of his stay with
treatment and this was stable at the time of discharge.
4. Wound care - The patient does have a Stage 1 to 2 Grade
sacral decubitus ulcer, continue wound care at rehabilitation
as had been appropriate. Continue to ambulate and improve
the patient's nutritional status to help wound healings.
5. Parkinson's disease - He was stable from his Parkinson's
issues on his home medications of Sinemet and Entacapone.
Continue his home brands in five times a day dosing of
Entacapone and Parkinson's was stable here.
6. Altered mental status - Noted in Medicine Intensive Care
Unit to have some change in mental status. This was
attributed to multiple factors including overuse of
intravenous Morphine. Once this was cut back his mental
status and agitation improved. Also the patient was started
on b.i.d. dosing of Seroquel which he tolerated well with
improvement in his mental status. He was also started on prn
doses of Zyprexa which he did not require as he remained
stable. For a short time he was on a 1:1 sitter which was
discontinued as the patient was stable and was not agitated
further. For altered mental status, the patient was
restarted on smaller doses of Percocet for pain control and
he tolerated this well without altered mental status. He
continued to improve and was back to baseline per family. He
did recognize them alert and oriented, even per interpreter,
except did note that the patient continued to have some
strange dreams which have been chronic issues with him and
his Parkinson's disease per family and are unchanged from his
baseline. So, his altered mental status was likely delirium
from infectious causes and over-narcotics. Concern was also
related to hypercarbia, however, this was stable, his pCO2
and his mental status improved.
6. Acid base - The patient initially with respiratory
acidosis which improved with BiPAP, however, secondary to
prolonged respiratory acidosis, compensated with a metabolic
alkalosis, the patient was alkalinizing his urine
appropriately and his metabolic alkalosis was attributed in
part to post hypercarbic respiratory acidosis and post
hypercarbic metabolic alkalosis in response to his
hypercarbic state. Also, compounding that was a contraction
alkalosis and he remained stable in terms of his acid base
status and we will continue to follow his bicarbonates in his
chemistries. However, his blood gases remained stable with
pCO2 ranging from 50s and with some respiratory distress up
to 70s, however, persistently in the 50s. This may be his
new baseline. His bicarbonate was stable at 38 at the time
of discharge.
7. Atrial fibrillation - He did have new onset atrial
fibrillation while in the Intensive Care Unit. He was
cardioverted and loaded on Amiodarone and remained stable in
sinus throughout the rest of his stay.
8. Left thigh pain - Originally, known fractures of the
right acetabulum and right femur and has had extensive
necrosis of his right thigh, status post debridement and
status post skin graft placement in [**Last Name (LF) 404**], [**First Name3 (LF) **] the surgical
team. However, per patient this intermittent cramping type
pain has been with him over the past month and he describes
it as an intermittent cramping type pain. The patient was
started back on Percocets with good relief. He was also
started back on anti-inflammatories like Ultram and also
started on Quinine to help with leg cramps and for concern of
possible neuropathic pain was started on low doses of
Neurontin which can be titrated up at rehabilitation.
9. Nutrition - The patient passed a video speech and swallow
evaluation with no evidence of aspiration and originally had
been on nectar-thickened liquids after having been on tube
feeds in the Medicine Intensive Care Unit. However, as he
showed no signs of aspiration, he was started on regular
consistency diet with thin liquids which he tolerated well,
however, just required assistance in terms of feeding. The
patient admitted he had very little appetite but when
encouraged to eat and drink Boost supplemental drinks, he
would, knowing that the alternative to poor p.o. intake was a
possible feeding tube. He agreed with continuing to try and
family agreed trying to encourage p.o. intake as they wanted
to avoid placing an nasogastric tube or possible gastrostomy
tube if his nutritional intake does not increase. The
patient's electrolytes were followed closely and were
repleted as needed.
10. Right lower extremity deep vein thrombosis - The patient
had a right lower extremity deep vein thrombosis after his
fracture, and had an inferior vena cava filter placed at the
time in [**2140-1-4**]. He was continued on his Lovenox here
and started on Coumadin to be titrated up with goal INR
between 2 and 3. His Lovenox should be discontinued once he
reached his goal INR.
11. Hypertension - Although throughout much of his stay, he
was slightly hypotensive, by the time of discharge he was
started back on his home regimen of Metoprolol but to
continue at low doses.
DISCHARGE DIAGNOSIS:
1. Sepsis.
2. Pneumonia.
3. Pleural effusion.
4. Urinary tract infection.
5. Clostridium difficile colitis.
6. Parkinson's disease.
7. Status post deep vein thrombosis.
8. Delirium.
9. Atrial fibrillation.
10. Failure to thrive.
DISCHARGE MEDICATIONS:
1. Entacapone 200 mg p.o. five times a day.
2. Multivitamin one p.o. q. day.
3. Acetaminophen 325 mg one to two p.o. q. 4-6 hours.
4. Albuterol nebulizers one neb q. 2 hours prn.
5. Albuterol nebulizers, one neb inhaled q. 4 hours.
6. Atrovent nebulizers, one neb q. 6 hours.
7. Carbidopa/Levodopa 25-250 mg p.o. five times a day.
8. Zyprexa rapid release 5 mg tablet, one p.o. q. day prn
agitation.
9. Metoprolol 25 mg p.o. b.i.d., hold for systolic blood
pressures less than 110.
10. Pantoprazole 40 mg p.o. q. day
11. Seroquel 50 mg p.o. b.i.d.
12. Lovenox 80 mg p.o. subcutaneously q. 12 until INR is
greater than 10.
13. Warfarin 5 mg tablets, p.o. q.h.s. to be titrated to goal
INR between 2 to 3.
14. Ultram 50 mg p.o. q.i.d.
15. Quinine 260 mg p.o. b.i.d.
16. Guaifenesin 10 ml p.o. q. 6 hours.
17. Percocet 5/325 mg one p.o. q. 4 hours prn pain.
18. Colace 100 mg p.o. b.i.d.
19. Senna 1 tablet p.o. b.i.d.
20. Flagyl 500 mg p.o. t.i.d. to be completed [**4-4**].
21. Vancomycin 1 gm q. 12 hours to be completed [**4-4**].
22. Ceftriaxone 1 gm q. 24 hours to be completed [**4-4**].
23. Neurontin 100 mg p.o. q. 8 hours to be titrated up as
tolerated.
DISCHARGE FOLLOW UP/INSTRUCTIONS: The patient is to follow
up with his primary care physician in seven to ten days after
discharge from rehabilitation. The patient is to follow up
with the Trauma Clinic as was previously recommended. The
patient is to follow up with the Plastic Surgery Team as was
previously recommended. The patient is to continue with
aggressive pulmonary toilet and suctioning, supplemental
oxygen, BiPAP at night with settings of 10 and 5, to be
continued with aggressive physical therapy in rehabilitation.
The patient is to continue to be encouraged to take p.o.
intake to improve nutritional status.
DISPO: Prior to transfer to rehab, the patient was scheduled for
monitoring and continued hospital level treatment over the
weekend to assess for stability. He became acutely dyspneic with
worsening respiratory acidosis and hypoxemic, and was transferred
to the ICU. Please see a subsequent d/c addendum for further
details.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5613**], M.D. 12- AHU
Dictated By:[**Name8 (MD) 264**]
MEDQUIST36
D: [**2140-4-1**] 14:32
T: [**2140-4-1**] 16:11
JOB#: [**Job Number 53741**]
Name: [**Known lastname 9966**], [**Known firstname 4794**] Unit No: [**Numeric Identifier 9967**]
Admission Date: [**2140-3-21**] Discharge Date: [**2140-4-21**]
Date of Birth: [**2071-10-30**] Sex: M
Service:
This is an addendum to his prior dictation summary up until
[**4-2**] and will comprise his MICU course from [**4-3**] until [**4-20**].
In summary, this is a 68-year-old gentleman with a history of
Parkinson's disease and hypertension with recent prolonged
hospitalization at [**Hospital1 536**]
status post motor vehicle accident as pedestrian struck by a
motor vehicle, who was transferred to the ICU following an
extended hospital course from [**3-21**] to [**3-/2065**] for progressive
hypercarbic and hypoxic respiratory failure. Please see
complete dictation summary as stated above for details of
hospitalization prior to this dictation summary.
However, in brief, the patient was transferred to the ICU on
the evening of Sunday, [**4-3**] with progressive
hypercarbic and hypoxic respiratory failure. He was being
treated on the floor intermittently receiving BiPAP when he
was noted to have oxygen desaturations in the 80s and became
increasingly agitated. There was some mild improvement with
suctioning and diuresis, however, he became increasingly
delirious with tachypnea, altered mental status, and
hypotension.
An ABG was performed on the 28th showing a gas on 100% face
mask of 7.31, 84, and 60. Prior gas which was 7.32, 81, and
53. Consequently, the patient was semiurgently intubated and
transferred to the ICU for continued medical care with
multiple medical problems.
1. Respiratory failure: Patient has had a long history of
respiratory failure stemming from complications related to
his motor vehicle accident in [**2140-1-4**], and was
originally admitted for progressive hypercarbic respiratory
failure. Patient's respiratory failure was multifactorial
comprising of poor respiratory mechanics secondary to chest
wall trauma, diaphragmatic weakness, bibasilar
consolidations, question of obstructive-sleep apnea,
infection with possible pneumonia nosocomial versus
aspiration pneumonia with progressive increasing of his pCO2
over two-week period of this recent hospitalization.
Prior to admission to the ICU, patient was attempted to be
treated with BiPAP, however, repeatedly failed, and did not
tolerate the procedure. In the ICU, he remained intubated
and demonstrated progressive improvement in his respiratory
status from [**3-/2065**] until the time of discharge.
On presentation there was a question of aspiration pneumonia
or nosocomial pneumonia, which was treated with a 10-day
course of antibiotics. He was progressively weaned from the
ventilator with trials of pressure support and spontaneous
breathing trials improving his strength and stamina along
with aggressive chest and physical therapy. For part of his
course, his extubation was limited by increased secretion,
where he would tolerate spontaneous breathing trials with
subsequent secretion development and then require return to
pressure support ventilation.
Finally, it was determined that tracheostomy tube placement
would be the best indication for .......... However, after
consult with the IP service followed by ENT, it was noticed
the patient had a low-lying trachea, and that placement of a
tracheostomy tube would not be possible without resection of
manubrium.
Consequently, the plan was to give him a trial of extubation
on Saturday, [**4-16**], however, the patient self extubated
on the night of Friday, [**4-15**]. He was followed closely
with repeat blood gases showing pH of approximately 7.4, pCO2
in the middle to high 40s with adequate oxygenation. Initial
attempts were made to use BiPAP at night using 10 and 5 and
then 12 and 8 settings, however, the patient did not tolerate
this procedure. The intention of the BiPAP was to provide
respiratory support at night to rest him in order to
facilitate his continued extubation.
However, at day four of extubation, the patient continued to
do remarkably well and has not required BiPAP at night.
Consequently, his discharge plan includes the following: To
continue to follow him for evidence of respiratory failure,
though he appears stable at this time. He is generally
improved in is strength and ability to tolerate spontaneous
breathing trials prior to extubation. He no longer has
evidence of pneumonia or infection, and his chest x-rays on
left lung have repeatedly improved, though he still has
evidence of an elevated right hemidiaphragm.
Consequently, he will not need BiPAP at night and the patient
has not tolerated it, and he will need continued chest
physical therapy for treatment.
2. Pneumonia: It was felt based on the patient's chest x-ray
and his clinical presentation that he may have had either an
aspiration or nosocomial-acquired pneumonia. During his stay
in the ICU, culture data was repeatedly negative. He was
treated with a 10-day course of vancomycin, ceftaz, and
clindamycin. Currently he remains afebrile without
leukocytosis. He did have a recent sputum sample from the
[**4-13**] showing MRSA and cephalosporin-resistant
Klebsiella. However, it was thought that these were
colonizers and not actual agents of infection, and he was not
restarted on any antibiotics. However, it would be prudent
to consider reculture and starting antibiotics if he were to
clinically deteriorate.
3. Clostridium difficile colitis: The patient had a history
of Clostridium difficile colitis. He completed a two-week
course of Flagyl without further events.
4. Change in mental status: Patient has had repeated
episodes of well-documented change in mental status. During
his ICU stay here, he was initially treated with Seroquel 50
b.i.d. with prn Haldol, Ativan, and narcotics additionally,
he received Flexeril three days prior to discharge with
associated delta MS.
Consequently, having spoken with neurologist, it was
suggested that we discontinue Haldol as this can have
delirious effects on Parkinson's disease and can contribute
to confusion. Additionally, Flexeril, benzodiazepines, and
narcotics were discontinued, and should be minimized on his
discharge. He will be discharged on Seroquel 50 b.i.d. and
would suggest prn Zyprexa if needed for acute management of
agitation.
5. Bright red blood per rectum: During his stay in the ICU,
he had one episode of bright red blood per rectum after
passage of a hard-formed stool. Subsequent stools were
guaiac negative. He did not have any additional episodes.
It was thought he possibly had a hemorrhoid versus fissure,
and he has responded well to stool softeners without
additional events.
6. Eosinophilia: The patient continues to have eosinophilia
counts approximately 8-10%. This was felt to be related to
antibiotic use. There are no obvious signs of parasitic or
other infection. This should be continued to be followed,
but it is felt likely related to medication effect.
7. Pain control: The patient intermittently complains of
cramping leg pain. Was treated with narcotics. However,
narcotics were felt to have a delirious effect on mental
status, and he now is well controlled on Morphine with NSAIDs
prn as needed for pain.
8. Hypertension: Patient has reported hypertension at
baseline. He was well controlled in-house with Lopressor 50
t.i.d.
9. DVT: Patient has a known history of DVT with IVC filter
placement. He continued on Lovenox 80 mg subq b.i.d. for
therapeutic prophylaxis. If it is desired, he can consider
transition to Coumadin in the outpatient setting.
10. Atrial fibrillation: The patient had an episode of
atrial fibrillation prior to his transfer to the ICU. He
remained in normal sinus rhythm throughout his stay. He will
continue on Lopressor 50 t.i.d. for hypertension and for rate
control.
11. FEN: The patient had a PEG tube placed on [**4-12**], which
was intended to coincide with placement of a tracheostomy
tube. However, tracheostomy tube failed as stated above.
Patient is now tolerating p.o., though minimal, he has
repeatedly passed swallow evaluations, and as patient's
strength and mental status improves, would suggesting
discontinuing the PEG tube encouraging full p.o. diet.
12. Parkinson's disease: Patient has a history of
Parkinson's disease that he is treated with Sinemet on 5x a
day dosing 250 mg tablets, he receives dosing at 7 a.m., 10
a.m., 1 p.m., 4 p.m., 7 p.m. Additionally he receives
entacapone 200 mg tablet 5x a day with his Sinemet. Patient
will need to be continued to followed by his outpatient
neurologist and should have a scheduled appointment in the
near future.
13. Deconditioning: Patient is extremely deconditioned
following his extensive hospitalization from [**1-15**],
on [**3-12**] was subsequently discharged and readmission
to [**Hospital1 8**] on [**3-21**]. He will need aggressive Physical Therapy.
He suffered multiple fractures of his lower extremities, had
skin grafting on his left following a severe cause of
cellulitis. Please continue Physical Therapy as indicated
for assistance with ambulation and activities of daily
living.
DISCHARGE CONDITION: Patient was stable on discharge. He is
breathing comfortably on 4 liters nasal cannula, which is
required for appropriate oxygenation. He is tolerating p.o.
intake with nutritional supplementation via PEG tube. His
mental status has improved over the last 24-48 hours by
minimizing his medications.
DISCHARGE STATUS: Patient is to be discharged to [**Hospital6 2696**] for an extended period of time.
DISCHARGE DIAGNOSES:
1. Sepsis, multifactorial.
2. Hypercarbic respiratory failure.
3. Hypoxic respiratory failure.
4. Pneumonia.
5. Clostridium difficile colitis.
6. Delirium, change in mental status.
7. Complications of Parkinson's disease.
8. Pain: Status post motor vehicle accident.
9. Bright red blood per rectum/gastrointestinal bleed.
10. Eosinophilia.
11. Deep venous thrombosis.
12. Complications of Parkinson's disease.
13. Failure to thrive.
DISCHARGE MEDICATIONS:
1. Seroquel 50 mg p.o. b.i.d.
2. Metoprolol 50 mg p.o. t.i.d.
3. Senna one tablet p.o. b.i.d. prn constipation.
4. Colace 100 mg p.o. b.i.d, hold for loose stool.
5. Dermagen ointment one applicator TP b.i.d. prn.
6. Albuterol 1-2 puffs inhalation q.4. q.i.d.
7. Ipratropium bromide MDI two puffs inhalation q.i.d.
8. Tylenol liquid 650 mg p.o. q.4-6h. prn fever and pain.
9. Lansoprazole 30 mg q.d. via PEG.
10. Ascorbic acid 500 mg p.o. b.i.d.
11. Enoxaparin 80 mg subq q.12.
12. Sinemet 25/250 5x a day at 7 a.m., 10 a.m., 1 p.m., 4
p.m., and 7 p.m.
13. Multivitamin one cap p.o. q.d.
14. Entacapone 200 mg tablets 5x a day 7 a.m., 10 a.m., 1
p.m., 4 p.m., and 7 p.m.
15. Ibuprofen prn pain.
16. Zyprexa prn anxiety/agitation.
DISCHARGE INSTRUCTIONS:
1. The patient is to be discharged to [**Hospital6 9892**].
2. The patient should follow up with his primary neurologist
for continued management of his Parkinson's disease.
3. Patient should contact his primary care doctor within one
week to set a follow-up appointment and discuss his
complicated course at [**Hospital3 **] and continued medical care.
4. Patient should continue to be followed by Orthopedics for
management of his multiple lower extremity fracture sites.
[**First Name4 (NamePattern1) 963**] [**Last Name (NamePattern1) 964**], M.D. [**MD Number(1) 965**]
Dictated By:[**Last Name (NamePattern1) 4517**]
MEDQUIST36
D: [**2140-4-20**] 13:50
T: [**2140-4-20**] 13:58
JOB#: [**Job Number 9979**]
(cclist)
|
[
"995.92",
"008.45",
"486",
"518.81",
"707.0",
"599.0",
"038.9",
"518.0",
"276.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"43.11",
"96.72",
"99.04",
"96.6",
"96.04",
"38.93",
"33.22"
] |
icd9pcs
|
[
[
[]
]
] |
26173, 26580
|
3276, 3385
|
26601, 27036
|
27059, 27790
|
14365, 14604
|
2794, 3070
|
5007, 14344
|
27814, 28576
|
160, 2499
|
3400, 4989
|
22622, 26151
|
2522, 2767
|
3087, 3259
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,768
| 130,903
|
12850
|
Discharge summary
|
report
|
Admission Date: [**2162-11-26**] Discharge Date: [**2162-11-26**]
Date of Birth: [**2092-3-3**] Sex: M
Service: MEDICINE
Allergies:
Lipitor
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
[**Hospital 15305**] transfer from outside hospital
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt is a 70 yo M w/ h/o CAD, CHF (EF 5-10% from recent ECHO), s/p
rigth right nephrectomy who presents from outside hospital with
sepsis. Pt was originally admitted to [**Hospital1 2436**] on [**2162-11-23**]
with fevers, and [**Location (un) 2452**] colored urine. Initially felt to have a
UTI and treated with levoquin. Also had elevated LFT's but RUQ
US was normal at this point. Continued to spike fevers, and
changed abx to Zosyn out of concern for biliary sepsis. However
Ct chest,abd pelvis unremarkable. He then had worsening acute
renal failure. He was given fluids and then developed
respiratory compromise. Ultimately he required intubation. Blood
pressures continued to drop and required pressors. [**Last Name (un) **] stim was
60 with no response. Ultimately required 3 pressors. Repeat RUQ
US showed GB thickening. A percutaneous cholecystectomy was
placed. Found to have gram negative bacilli in biliary fluid.
Despite aggressive care continued to have worsening renal
failure, required pressors, became anuric, and difficulty to
oxygenate on vent. Therefore transferred to [**Hospital1 18**] for possible
CVVH and further intensive care.
Past Medical History:
MI s/p 3 stents
Right nephrectomy
Hiatal hernia
Social History:
Lives with wife. Former [**Name2 (NI) 1818**]
Family History:
NC
Physical Exam:
T 101.3 BP 134/70 HR 140 RR 21 O2sats 95%
Vent settings: AC TV 600 RR 20 FiO2 100% PEEP 10
Gen: Sedated, non-responsive
HEENT: Pupils constricted but reactive, equal. + scleral
icterus, + scleral edema, + ETT
Neck: no LAD
Lungs: Crackles at bases
Heart: Tachy, no m/r/g
Abd: Distended, hypoactive bowel sounds, + biliary drain w/ dark
gree bile
Ext: no edema, ext. cool, + mottling
Neuro: non-resposive
Lines: Left subclavian, right femoral Aline
Pertinent Results:
[**2162-11-26**] 08:31PM TYPE-ART TEMP-37.2 PEEP-10 PO2-105 PCO2-39
PH-7.18* TOTAL CO2-15* BASE XS--13 INTUBATED-INTUBATED
VENT-CONTROLLED
[**2162-11-26**] 08:22PM GLUCOSE-121* UREA N-40* CREAT-5.2* SODIUM-135
POTASSIUM-4.0 CHLORIDE-103 TOTAL CO2-14* ANION GAP-22*
[**2162-11-26**] 08:22PM ALT(SGPT)-145* AST(SGOT)-120* LD(LDH)-294*
CK(CPK)-127 ALK PHOS-114 AMYLASE-297* TOT BILI-2.1*
[**2162-11-26**] 08:22PM LIPASE-125*
[**2162-11-26**] 08:22PM CK-MB-15* MB INDX-11.8* cTropnT-1.38*
[**2162-11-26**] 08:22PM ALBUMIN-2.4* CALCIUM-6.3* PHOSPHATE-4.8*
MAGNESIUM-1.6
[**2162-11-26**] 08:22PM WBC-21.6* RBC-3.40* HGB-10.9* HCT-30.7*
MCV-90 MCH-32.2* MCHC-35.6* RDW-15.1
[**2162-11-26**] 08:22PM PT-13.7* PTT-30.0 INR(PT)-1.3
[**2162-11-26**] 08:22PM FIBRINOGE-622*
Brief Hospital Course:
When patient arrived to floor he was on three pressors at max
dosages. He was required full ventilatory support with FiO2 of
100%. On attempting to transition him from transort meds to our
meds his BP would drop from the low 100's to 60's. During this
time we bolused him 2 L of IVF and continued pressor support.
Initially ABG should acidosis of 7.18 and Bicarb of 15. His
pressors returned to low 100's after fluid boluses but then
would have transient episodes of hypotension. Initially labs
came back with worsening renal failure, elevated trop, hypoca,
hyperphos, leukocytosis. A discussion was held with family given
poor prognosis as patient was in sepsis with multi-organ failure
including heart, lungs, lkidneys, liver. He was anuric. EF at
OSH was 5-10%. Contact[**Name (NI) **] renal about possible CVVH> They
recommended trying lasix, zaroxyln, bicarb gtt. Pt was given
bicarb and calcium and increased his minute ventilation to blow
off CO2. However despite this patient worsened. His BP dropped
into the 50's despite maximizing three pressors. HE then went
into PEA arrest. CPR started. He was given epineprine 1mg times
2 and atropine 1mg times 2 with no response. After 11 minutes of
CPR and coding the patient he was pronounced dead at 2221
(1021pm).
Medications on Admission:
Meds on admission to OSH:lescol, zetia, effexor, terazosin,
flomax, mavik, cardia, percocet
.
Meds on admission to [**Hospital1 18**]:
Levophed 0.5
Dopamine 20
Vasopressin 2.4
cefepime, gent, heparin sc, protonix, propofol, fentanyl, alb,
atrovent
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Sepsis
Hypotension
Heart Failure
Cholangitis
Respiratory Failure
Cardiac Arrest
Discharge Condition:
Expired [**2162-11-26**] at 2221
Discharge Instructions:
NA
Followup Instructions:
NA
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"995.92",
"414.01",
"V45.73",
"412",
"428.0",
"276.4",
"V45.82",
"518.81",
"427.5",
"785.51",
"576.1",
"V10.52",
"584.9",
"458.9",
"038.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"38.91",
"38.93",
"99.60"
] |
icd9pcs
|
[
[
[]
]
] |
4556, 4565
|
2959, 4228
|
328, 334
|
4688, 4722
|
2155, 2936
|
4773, 4914
|
1668, 1672
|
4527, 4533
|
4586, 4667
|
4254, 4504
|
4746, 4750
|
1687, 2136
|
237, 290
|
362, 1517
|
1539, 1589
|
1605, 1652
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,500
| 199,196
|
29081
|
Discharge summary
|
report
|
Admission Date: [**2188-2-5**] Discharge Date: [**2188-2-15**]
Date of Birth: [**2126-3-18**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2969**]
Chief Complaint:
Barrett's esophagus
Major Surgical or Invasive Procedure:
transhiatal esophagectomy
History of Present Illness:
Most recent EGD showed 3cm Barrett's esoph and superifical adeno
Ca
Past Medical History:
Crohn's, IDDM
Social History:
denies tobacco, ETOH
Family History:
siblings with ca of breast, lung, colon, and DM
Physical Exam:
AAOx3 NAD
RRR
CTAB
soft NT/ND
incisions c/d/i
no c/c/e
Pertinent Results:
[**2188-2-11**] 06:20AM BLOOD WBC-9.9 RBC-3.14* Hgb-10.8* Hct-32.3*
MCV-103* MCH-34.2* MCHC-33.3 RDW-14.2 Plt Ct-257
[**2188-2-5**] 02:24PM BLOOD WBC-10.5# RBC-3.62* Hgb-12.7* Hct-37.4*
MCV-103* MCH-35.1* MCHC-34.0 RDW-13.8 Plt Ct-267
[**2188-2-5**] 02:24PM BLOOD PT-13.2* PTT-24.2 INR(PT)-1.2*
[**2188-2-11**] 06:20AM BLOOD Glucose-122* UreaN-16 Creat-0.7 Na-147*
K-3.4 Cl-110* HCO3-30 AnGap-10
[**2188-2-5**] 02:24PM BLOOD Glucose-160* UreaN-16 Creat-1.0 Na-142
K-4.0 Cl-109* HCO3-21* AnGap-16
[**2188-2-11**] 06:20AM BLOOD Calcium-7.9* Phos-3.6# Mg-2.2
[**2188-2-5**] 02:24PM BLOOD Calcium-8.4
[**2188-2-7**] 04:29AM BLOOD Type-ART pO2-80* pCO2-46* pH-7.41
calTCO2-30 Base XS-3
[**2188-2-5**] 08:59AM BLOOD Type-ART pO2-121* pCO2-40 pH-7.40
calTCO2-26 Base XS-0 Intubat-INTUBATED Vent-CONTROLLED
[**2188-2-7**] 03:48AM BLOOD Lactate-1.0
[**2188-2-5**] 12:36PM BLOOD freeCa-1.11*
[**2-12**] Video Swallow
IMPRESSION: No evidence of extravasation or stricture.
Path
MACROSCOPIC
Specimen Type: Esophagogastrectomy.
Tumor site: Distal esophagus, at the gastroesophageal junction.
Tumor Size
Greatest dimension: 1.1 cm. Additional dimensions: 0.9 cm
MICROSCOPIC
Histologic Type: Adenocarcinoma.
Histologic Grade: G1: Well differentiated.
EXTENT OF INVASION
Primary Tumor: pT1: Tumor invades lamina propria.
Regional Lymph Nodes: pN0
Lymph Nodes
Number examined: 7.
Number involved: 0.
Distant metastasis: pMX: Cannot be assessed.
Margins
Proximal margin: Uninvolved by invasive carcinoma.
Distal margin: Uninvolved by invasive carcinoma.
Circumferential (adventitial) margin: Uninvolved by
invasive carcinoma.
Distance of invasive carcinoma from closest margin: 8 mm.
Specified margin: Adventitial.
Lymphatic (Small Vessel) Invasion: Absent.
Venous (Large vessel) invasion: Absent.
Brief Hospital Course:
Pt underwent a transhiatal esophagectomy and a feeding
jejunostomy on [**2-5**] without complications. He extubated without
difficulty and went to the CSRU post op. he had a pleual
effusion on CXR which resolved thoughout the hospital course.
Pulmonary did not think it was significant enough to drain. He
was transferred to the floor where he worked well with PT. Of
note his voice was hoarse and ENT was consulted who noted a
paralyzed L vocal cord. This will be followed up on. Tube
feeds were also advanced as well and were tolerated. Video
swallow showed no stricture or leak. Pt had some coughing
intially with clears but eventually tolerated them and fulls
well. Other hispital course was uneventful and pt was in good
condition to discharge home with home health aid on day fo
discharge.
Medications on Admission:
Liptor, insulin, prilosec
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed.
Disp:*400 ML(s)* Refills:*0*
2. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One
(1) tab PO once a day.
Disp:*30 * Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Gentiva
Discharge Diagnosis:
DM2, Crohn's, Barrett's, tonsillectomy
transhiatal esophagectomy
Discharge Condition:
good
Discharge Instructions:
Call Dr.[**Name (NI) **] office [**Telephone/Fax (1) 170**] if you have chest pain,
shortness of breath, fever, chills, difficulty swallowing,
nausea, vomiting, diarrhea.
continue with tube feedings as ordered and soft solid diet.
If your feeding tube stitches break, secure tube with tape and
call the office [**Telephone/Fax (1) 170**]. If the feeding tube falls out,
call the office [**Telephone/Fax (1) 170**] and come immediately to the
hospital or to your local emergency room to have it replaced.
Followup Instructions:
*****CALL THE OFFICE AND MAKE A SPECIFIC APPOINTMENT FOR THE PT
PER DR.[**Doctor Last Name **] WISHES******
+/- SWALLOW STUDY PER DR. [**Last Name (STitle) **] [**Telephone/Fax (1) 4741**]
|
[
"151.0",
"530.81",
"997.3",
"272.0",
"276.2",
"555.9",
"250.00",
"V58.67",
"530.85",
"511.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"46.39",
"50.12",
"42.42"
] |
icd9pcs
|
[
[
[]
]
] |
3724, 3762
|
2575, 3381
|
340, 368
|
3872, 3878
|
695, 2552
|
4430, 4622
|
556, 605
|
3457, 3701
|
3783, 3851
|
3407, 3434
|
3902, 4407
|
620, 676
|
281, 302
|
396, 465
|
487, 502
|
518, 540
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,542
| 140,308
|
29808
|
Discharge summary
|
report
|
Admission Date: [**2128-3-23**] Discharge Date: [**2128-4-10**]
Date of Birth: [**2047-3-11**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
hilar mass in segment IV of liver
Major Surgical or Invasive Procedure:
[**2128-3-23**] Diagnostic laparoscopy conversion to
exploratory laparotomy, common bile duct excision Roux-en-Y
hepaticojejunostomy, intraoperative ultrasound
History of Present Illness:
81 y.o. male who presented with a 9-month history of abnormal
liver function tests, painless jaundice, pruritis. After
extensive workup was
performed, he finally presents for exploratory laparotomy for
resection of hilar mass in segment IV of liver. CA [**39**]-9 was
elevated to ~ 6,000. Initially had trans ampullary stent placed
which was replaced with PTC drains. He presented for elective ex
lap with possible Left hepatic lobectomy.
Past Medical History:
CAD
GERD, HTN
myelodysplastic syndrome with refractory anemia, On Epoietin
Social History:
Lives in own home with wife
Social ETOH
non-smoker
Retired chemical engineer
Family History:
Non-Contributory
Pertinent Results:
On Admission: [**2128-3-23**]
WBC-36.0*# RBC-3.05* Hgb-10.7* Hct-31.8* MCV-104* MCH-35.1*
MCHC-33.7 RDW-14.9 Plt Ct-347
PT-14.7* INR(PT)-1.3*
Glucose-139* UreaN-15 Creat-0.7 Na-136 K-4.1 Cl-108 HCO3-22
AnGap-10
ALT-120* AST-131* AlkPhos-733* TotBili-2.4* CK(CPK)-95
Lipase-14
[**2128-4-1**] TSH-1.5
[**2128-4-1**] T4-6.1
.
ON DISCHARGE:
[**2128-4-10**] 05:35AM BLOOD WBC-11.9* RBC-3.23* Hgb-10.2* Hct-29.1*
MCV-90 MCH-31.6 MCHC-35.1* RDW-17.4* Plt Ct-184
[**2128-4-9**] 08:14PM BLOOD Hct-30.6*
[**2128-4-9**] 12:50PM BLOOD WBC-13.3* RBC-3.23* Hgb-10.5* Hct-29.2*
MCV-90 MCH-32.5* MCHC-36.0* RDW-17.3* Plt Ct-178
[**2128-4-9**] 05:39AM BLOOD PT-11.1 PTT-24.8 INR(PT)-0.9
[**2128-4-10**] 05:35AM BLOOD Glucose-77 UreaN-16 Creat-0.8 Na-131*
K-3.9 Cl-101 HCO3-24 AnGap-10
[**2128-4-7**] 04:33AM BLOOD ALT-20 AST-21 AlkPhos-230* TotBili-0.9
[**2128-4-4**] 02:21AM BLOOD Lipase-53
[**2128-4-9**] 05:39AM BLOOD Calcium-7.5* Phos-2.7 Mg-1.8
.
RADIOLOGY Final Report
CT ABDOMEN W/CONTRAST [**2128-4-9**] 6:28 PM
CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST
Reason: PO AND IV CONTRAST; eval for enterocutaneous fistula or
pseu
Field of view: 39 Contrast: [**Hospital 13288**]
[**Hospital 93**] MEDICAL CONDITION:
80M s/p exploratory laparoscopy, roux-en-y hepaticojejunostomy,
cholecystectomy for unresectable cholangioCA s/p wound infection
with open wound.
REASON FOR THIS EXAMINATION:
PO AND IV CONTRAST; eval for enterocutaneous fistula or
pseudoaneurysm.
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 80-year-old male status post exploratory
laparoscopy, Roux-en-Y hepaticojejunostomy, and cholecystectomy
for unresectable cholangiocarcinoma. Now with wound infection.
Please evaluate for fistula or pseudoaneurysm.
COMPARISON: [**2128-3-29**].
TECHNIQUE: MDCT-acquired axial imaging from the lung bases to
the pubic symphysis after administration of oral and intravenous
contrast.
CT OF THE ABDOMEN WITH IV CONTRAST: Visualized lung bases
demonstrate small bilateral pleural effusions and adjacent
atelectasis.
A large amount of free intraperitoneal air remains, which this
far out from the patient's surgical procedure is highly unusual.
There is mild-to-moderate ascites around the liver, and
throughout the abdomen. There has been interval placement of
percutaneous biliary tube, which enters the mid abdomen and
transits the biliary system, through the patient's known
cholangiocarcinoma, terminating with its tip in a loop of small
bowel in the region of what appears to be the patient's
hepaticojejunostomy loop. Heterogeneous low- attenuation mass in
segment IV, consistent with known cholangiocarcinoma is
unchanged.
Previously noted pneumobilia has resolved. The pancreas and
spleen are unremarkable. Patient is status post cholecystectomy.
The stomach and intra- abdominal loops of bowel are
unremarkable. No discrete fluid collection or abscess is
identified. Previously noted surgical drains have been removed.
The adrenal glands, kidneys, and ureters are unremarkable.
Midline anterior abdominal wall incision site, with surgical
staples appears to have worsened in the interval, and there is
now evidence of breakdown of the subcutaneous tissues in the
anterior abdominal wall, as well as a small amount of
inflammatory stranding and fluid. The deep fascia appears to be
intact, and there is no communication between any loop of bowel.
CT OF THE PELVIS WITH IV CONTRAST: The rectum, sigmoid colon and
pelvic loops of bowel are unremarkable. Air is seen within a
somewhat distended urinary bladder, which may be related to
prior instrumentation. There is a small amount of free pelvic
fluid. There is no abnormal pelvic or inguinal lymphadenopathy.
OSSEOUS STRUCTURES: No suspicious osteolytic or sclerotic
lesions are seen.
IMPRESSION:
1. Continued evidence of large volume of free intraperitoneal
air is concerning in a patient this far out from surgical
procedure.
2. No evidence of discrete fluid collection or abscess.
3. Interval removal of surgical drains, and interval placement
of biliary catheter extending through the patient's known
cholangiocarcinoma, and terminating in a loop of small bowel in
what appears to be the patient's hepaticojejunostomy.
4. Infiltrative cholangiocarcinoma in segment IV is unchanged
from prior exams.
5. Moderate ascites throughout the abdomen.
6. Interval degradation of anterior abdominal wall wound
adjacent to incision site, with evidence of inflammatory change
and fluid in the anterior abdominal wall, but no breakdown of
the deep fascia. No definite fistula is identified.
Above findings were reviewed in person with the surgical team at
the time of study interpretation on [**2128-4-9**].
Brief Hospital Course:
He was taken to the OR for diagnostic laparoscopy with
conversion to exploratory laparotomy, common bile duct excision
and Roux-en-Y hepaticojejunostomy. Surgeon was Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **]. Intraoperative ultrasound was performed which
demonstrated a large mass in the medial segment of the left
lobe. An End-to-side hepaticojejunostomy was done over the
10-French [**Location (un) 3825**] stents which were changed out from the pigtail
catheters. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 406**] drain was placed near this anastomosis.
Please see operative report for further details. He was
extubated in the PACU.
He did well postop with pain controlled by dilaudid. LFTs
trended down. On pod 3 he experienced new onset AFIB requiring
IV lopressor for rate control. Enzymes were cycled and negative.
Cardiology was consulted. Recommendations included increasing
beta blocker and consideration of coumadin. Given
risks/prognosis coumadin was deferrred. Aspirin was initiated.
Ibutilide was used x2 to help cardiovert him to prevent need for
anticoalulation. This was successful. Urine output was on the
low side averaging 10-25cc/hour.
Diet was advanced without nausea or vomiting. On [**3-29**] a tube
cholangiogram was done demonstrating right moderate narrowing at
the anastomosis, likely representing post-operative edema
without anastomotic leak. The Left cholangiogram demonstrated
diffuse ductal dilatation with lack of opacification of the
central ducts and retraction and malpositioning of the
left-sided biliary catheter. No anastamotic leak was noted, but
contrast extravasated in the left subcapsular region was noted
likely related to contrast leaking via sideholes of the catheter
outside of the biliary system. A CT was done to evaluate for
collection. No evidence of oral contrast extravasation was noted
to indicate the presence of a leak. Large volume intra-abdominal
free air, stranding in the region of the porta hepatis, and
small intra-abdominal ascites were noted consistent with recent
surgery. There was a small amount of pneumobilia.
He returned to IR for successful balloon dilation of the central
left biliary ducts with improved patency and drainage into the
small bowel. The left biliary catheter was exchanged for an 8
French internal- external biliary catheter.
.
On [**3-31**] he returned to the SICU for recurrent afib. BB, CCB and
neo were used to keep map >65. He converted back to SR. An echo
showed LVEF of >55%. There was a mild resting left ventricular
outflow tract obstruction. Cardiology recommend amiodarone. IV
amiodarone was started then this was converted to po amiodarone.
Recommendations included amiodarone 400mg [**Hospital1 **] x1 week then 400mg
qd x 14 days then 200mg qd and goal of euvolemia.
.
On [**4-2**] the right PTC was capped and the JP was removed. The
next day he received 2 units of PRBC for hct of 24.3. He
experienced hypotension with melena with hct drop to 21.3. Fluid
bolus was given. Heart rate was in 80's in afib. He transferred
back to the SICU where he received another 2 units of PRBC. GI
was consulted for melena. A tagged RBC study was done revealing
no active GI bleeding. EGD revealed no upper GI bleed. Purulent
drainage was noticed from his abdominal wound and it was opened
at the bedisde in the SICU and wet-to-dry dressings were
applied.
On [**2128-4-6**], the patient made a decision to be made DNR/DNI. A
family meeting was held on [**2128-4-7**] to discuss the decision with
his family. On [**2128-4-8**], he was stable to be transferred to the
floor. His fole was discontinued, however, was required to be
replaced due to difficulty voiding. A CT scan was performed on
[**2128-4-9**] for determine a possible enterocutanous fistula, none
was detected. He was trasnfused 1 unit PRBC and had a single
bloody bowel movement. Serial hcts did not demonstrate a acute
decrease in his hct and he was deemed stable for discharge home
with transition to hospice care on [**2128-4-10**].
Medications on Admission:
Atenolol 25mg',Ranitidine 150 mg PO BID, Lisinopril 20mg',
Cholestyramine 4gm [**Hospital1 **], ASA 81mg x 2 QD (CLARIFY)
.
Discharge Medications:
1. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
Disp:*45 Tablet(s)* Refills:*0*
2. walker
please provide rolling walker
3. commode
please provide commode-adjustable
4. 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:*2*
5. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
Disp:*270 Tablet(s)* Refills:*2*
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day
for 14 days.
Disp:*28 Tablet(s)* Refills:*0*
8. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day:
Start after you finish the amiodarone 400mg Daily for 14 days.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 6136**] Homecare services
Discharge Diagnosis:
unresectable cholangiocarcinoma
afib
GI bleeding
Discharge Condition:
Stable
Discharge Instructions:
Please call Dr.[**Name (NI) 670**] office if fevers, chills, nausea,
vomiting, inability to take medications, unable to eat,
increased abdominal pain, incision redness/bleeding/drainage
from incision/drain sites.
.
Please continue wet-to-dry dressings to your abdominla wound
changed twice a day.
.
Please follow-up as directed.
.
Please take medications as prescribed.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2128-4-16**] 2:10
.
Please call PCP to schedule follow appointment in next [**11-18**]
weeks.
|
[
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"576.2",
"575.11",
"578.1",
"155.0",
"196.2",
"238.75",
"788.20",
"V64.41",
"997.4",
"530.81",
"427.31",
"401.9",
"198.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.29",
"51.22",
"51.69",
"87.51",
"51.98",
"45.13",
"40.3",
"99.04",
"54.21",
"51.37",
"99.06",
"99.69",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
11082, 11150
|
5907, 9954
|
347, 508
|
11243, 11252
|
1224, 1224
|
11670, 11900
|
1187, 1205
|
10129, 11059
|
2431, 2577
|
11171, 11222
|
9980, 10106
|
11276, 11647
|
1564, 2394
|
274, 309
|
2606, 5884
|
536, 977
|
1238, 1550
|
999, 1076
|
1092, 1171
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,287
| 110,985
|
19145+57024+57025
|
Discharge summary
|
report+addendum+addendum
|
Admission Date: [**2150-5-13**] Discharge Date: [**2150-5-27**]
Date of Birth: [**2072-4-21**] Sex: F
Service:
REASON FOR TRANSFER: Second orthopedic opinion status post
hip fracture.
HISTORY OF PRESENT ILLNESS: This is a 75-year-old female
with multiple medical problems including coronary artery
disease, congestive heart failure and chronic obstructive
pulmonary disease who initially presented to the [**Hospital3 417**]
Hospital on [**2150-4-25**], after suffering a
left hip fracture (displaced subcapital fracture). This
occurred as a result of a mechanical fall, apparently related
to left leg weakness the patient attributed to her diabetic
neuropathy. On admission to [**Hospital3 417**] she was placed in
Bucks traction while various medical workup occurred in
preparation for planned unipolar hemiarthroplasty. She was
given a course of amoxicillin for "bronchitis." Urine grew
Klebsiella and E. coli although the patient reported "chronic
UTIs" and it is unclear whether she had thrombocytopenia
(platelets 60's) so the Hematology Service was consulted.
They felt she should be transfused with platelets before and
after the surgery. The Cardiology Service was consulted and
felt she could safely undergo hip arthroplasty without
further preoperative coronary evaluation. Unfortunately,
although medically cleared for surgery, the patient by that
time had developed a significant coccygeal decubitus ulcer.
She was transferred to [**Hospital1 **] Rehab on [**4-29**] for
aggressive wound care in the hopes that hip surgery could be
performed around the end of [**Month (only) **].
At [**Hospital1 **] Rehab careful wound care of the
coccygeal decubitus ulcer was provided. She completed her
seven day course of amoxicillin. Chest x-ray on [**4-30**]
showed a left infiltrate with effusion, and borderline
congestive heart failure. Follow-up x-rays showed worsening
of the infiltrate and effusion and aspiration pneumonia was
suspected, so Flagyl was begun on [**5-7**]. Her TSH was
elevated (felt to be secondary to amiodarone) and her
Synthroid was increased from 12.5 mcg to 25 mcg q. day. On
[**5-8**] the Orthopedic Service saw her and discontinued the
Bucks traction.
She was transferred here today for second opinion regarding
the hip surgery. The patient is very eager to have the hip
repaired and complains mostly of hip pain and related leg
muscle spasm. She denies dyspnea or chest pain. She has had
a cough that she says is old and chronic; minimal sputum
production was reported. Her appetite is poor and she has
been receiving TPN. She says that she "ate a little bit"
yesterday for the first time in days. The coccygeal ulcer
does not bother her currently.
PAST MEDICAL HISTORY:
1. Coronary artery disease, status post coronary artery
bypass graft times three in [**2135**]. The exact coronary anatomy
at that time is unknown.
2. Congestive heart failure, ejection fraction 20%.
Confirmed by echocardiogram.
3. Chronic obstructive pulmonary disease (not currently on
any inhalers).
4. Mitral regurgitation confirmed by echocardiogram.
5. Amiodarone induced hypothyroidism.
6. Atrial fibrillation, currently in sinus rhythm status
post cardioversion not on Coumadin at the time of admission.
7. Left subcapital displaced hip fracture [**2150-4-19**].
8. Diabetes mellitus type 2 of unknown duration.
9. Chronic renal insufficiency likely secondary to diabetic
nephropathy. Baseline creatinine [**12-22**].
10. Hypertension.
11. Gout.
12. Rheumatoid arthritis.
13. Coccygeal decubitus ulcer.
14. Gastroesophageal reflux disease.
15. Lactose intolerance.
16. Intermittent claudication.
17. Colon cancer status post partial colectomy.
18. Right carotid bruit (no history of transient ischemic
attack or stroke).
19. Thrombocytopenia.
ALLERGIES: Atorvastatin, Cipro, clarithromycin,
procainamide, macrolides, quinolones, NSAIDS, Latex
(reactions undocumented).
MEDICATIONS ON TRANSFER:
1. Allopurinol 300 mg p.o. q. day.
2. Amiodarone 200 mg p.o. q. day.
3. Artificial tears two drops O.U. t.i.d.
4. Vitamin C 500 mg p.o. b.i.d.
5. Lovenox 30 mg subcu q. day.
6. Epo 40,000 units subcu q. Wednesday.
7. Iron sulfate 300 mg p.o. b.i.d.
8. RISS 5 ml/200 mg p.o. b.i.d.
9. Synthroid 25 mcg p.o. q. day.
10. Nexium 40 mg q. day.
11. Chondroitin 500 mg p.o. b.i.d.
12. Metamucil one packet p.o. b.i.d.
13. Flomax 0.4 mg p.o. q. hs.
14. Milk of magnesia p.r.n.
15. Senna two tabs p.o. b.i.d.
16. Multivitamin one p.o. q. day.
17. Flagyl 500 mg IV q. 8h. day No. five of seven.
18. Zinc sulfate 200 mg p.o. q. day.
19. Tylenol p.r.n.
20. Alprazolam 0.25 mg p.o. q. 3h. p.r.n.
21. Guaifenesin b.i.d.
22. Percocet one tab p.o. q. 4h. p.r.n.
23. Peripheral parenteral nutrition.
FAMILY HISTORY: Significant for lung cancer relative unknown
at time of dictation at present.
SOCIAL HISTORY: Married times 58 years. Has five children,
one in [**State 4260**], one in [**Location (un) 3844**] and three locally. She has
a 40 pack year history of tobacco use. Occasional alcohol
use. Able to climb 13 stairs to enter her apartment on
[**Location (un) 1773**]. No elevator. DNR/DNI per report.
PHYSICAL EXAMINATION ON ADMISSION: Temperature 97.7 degrees,
blood pressure 140/60, pulse 54, respiratory rate 22,
oxygenation 98% on two liters. General: Alert, pleasant,
elderly female lying very still in bed. HEENT: Pupils
equal, round and reactive to light and accommodation.
Extraocular movements intact. Anicteric sclerae. Moist
mucus membranes. Chest: Bilateral basilar crackles, left
greater than right. No wheeze. Scattered rhonchi that clear
with cough. Cardiovascular: Faint S1, S2. Regular, no
murmurs heard. Abdomen soft, non-tender, non-distended.
Positive bowel sounds. Extremities: Two plus pitting edema
to buttocks bilaterally. Dorsalis pedis pulses not palpable.
Several scattered dark non-tender distal bullae approximately
3-4 mm diameter on toes bilaterally. Not present on upper
extremity. No cyanosis or clubbing. Back not examined.
Plan to examine when more staff available to turn patient to
examine decubitus ulcer. Photographs in chart from [**Hospital1 33995**] documented. Neuro examination:
Cranial nerves II through XII grossly intact. Alert and
oriented times three. Motor examination limited by hip
fracture. Sensation grossly intact to light touch.
LABORATORY [**5-12**] FROM OUTSIDE HOSPITAL: PT 14.2, INR 1.3,
sodium 138, potassium 4.2, chloride 107, bicarb 18, BUN 56,
creatinine 2.7, glucose 137, calcium 7.7, magnesium 2.3,
phosphorus 2.6, triglycerides 117. Albumin 14.
[**5-11**]: White blood cell count 6.2, hematocrit 32.6,
platelet count 153,000. Alk phos 185,000. Total bilirubin
0.42. ALT 36, CK 96, LDH 222, total protein 5.1, albumin
2.4.
Micro: Clostridium difficile negative on [**5-6**] and [**5-8**]. Urine culture negative on [**5-11**].
ELECTROCARDIOGRAM: [**4-29**]: Normal sinus rhythm of 64 beats
per minute, right axis deviation, intraventricular conduction
delay, poor R-wave progression, T-wave inversion in leads V5
through V6 and 1 and aVL. No ST segment deviation.
RADIOLOGY: Chest x-ray on [**5-7**]: Left lower lobe
infiltrate with effusion. Right lung clear. Cardiomegaly.
HOSPITAL COURSE: [**2150-5-13**]: The patient was admitted to
the Medicine Service and was hemodynamically stable. Was
complaining of feeling tired and not able to sleep with some
pain in her back over the location of the decubitus ulcer.
Labs on the first day at [**Hospital1 188**]: White count 7.3, hematocrit 34.5, platelet count
149,000. The Chem-7 was 137, 4.4, 107, 17, 59, 2.4 and 109.
A chest x-ray at [**Hospital1 69**] showed
cardiomegaly with congestive heart failure and pulmonary
edema. Moderate left effusion, small right effusion. No
pneumothorax. An orthopedic consult was obtained on the date
of admission with Dr. [**First Name (STitle) 1022**] being the attending surgeon. At
that time it was Dr.[**Name (NI) 2989**] opinion that the patient would not
be a candidate for surgery until her decubitus ulcer
infection was controlled. The patient would be started on
deep venous thrombosis prophylaxis and Nutrition would be
consulted along with Psychiatry secondary to the patient's
dysthymia regarding her medical condition.
[**2150-5-14**]: A Psychiatry consultation was obtained. At
that time it was recommended that the patient be started on
Remeron at 7.5 mg to help with her anxiety and depressed
mood. The patient's lung examination was concerning for
crackles half the way up on the left and one-third up on the
right. Given this finding along with the chest x-ray
findings, it was recommended that the CHF Service would
consult. Dr. [**First Name (STitle) **] was asked to consult. On this date it was
felt that the patient would be able to have the surgery and
was actually typed, screened and cross-matched for two units
of packed red blood cells in preparation for surgery.
[**2150-5-15**]: Dr. [**First Name (STitle) **] spoke with the patient's outpatient
cardiologist who reported the patient is not usually in
congestive heart failure and this was probably an acute
exacerbation secondary to increased fluids due to the
patient's poor p.o. intake. The patient was started on 60 mg
of intravenous Lasix on the morning of [**5-15**] and 80 mg of
intravenous Lasix in the p.m. with only 300 cc of diuresis.
At this time it was felt that the patient was a poor
operative candidate and the surgery would have to be
postponed. Of note, there was also some concern about the
patient's dysrhythmias. The patient had had left bundle
branch block according to her outpatient cardiologist and
also had a history of atrial fibrillation status post
cardioversion and on the [**5-15**] the patient was found
to be in right bundle branch block. Due to the acute
exacerbation of congestive heart failure it was felt that the
patient was at high risk for re-entering rapid atrial
fibrillation and a Cardiology consult was obtained. The
Cardiology consult felt that the patient would benefit from
nesiritide as well as Lasix and transferred to ______ Two or
Three (Cardiology floors) when available. The goal for
diuresis would be one to two liters per day and to follow the
oxygenation lung examination and chest x-ray. Of note, wound
care per protocol was applied to the decubitus ulcer.
[**2150-5-16**]: The patient's code status was changed to
DNR/DNI by Dr. [**First Name (STitle) **] after speaking with the patient and her
husband. The patient had minimal diuresis of 250 cc
overnight with Lasix. The patient was continued on
amiodarone for atrial fibrillation. The coccygeal ulcer
continued to be dressed appropriately. The patient developed
a new issue of hyperglycemia. The insulin sliding scale was
adjusted accordingly.
[**2150-5-17**]: The patient was transferred to the Cardiology
floor (Far three) and nesiritide drip was started at 0.01
mcg/kg/min. The patient's diuresis was slightly improved at
400 cc in two hours on nesiritide and Lasix 80 mg IV times
one. The patient's lung examination had not improved.
Repeat chest x-ray showed persistent congestive heart failure
with effusions as described above. The patient's nesiritide
drip was increased to 0.15 mcg/kg. At this point the patient
was becoming increasingly frustrated with the progress of her
medical conditions. Psychiatry continued to follow and felt
that Remeron might be contributing to her sedation and that
her depression might be secondary to her multiple medical
conditions. Substantial discussion was conducted regarding
the need for intracardiac monitoring while the patient was
being diuresed. The patient, however, was extremely
reluctant to undergo additional interventions such as
Swan-Ganz catheter placement and was actually scheduled for
the Operating Room on [**2150-5-18**], despite her poor
oxygenation at 99% on five liters nasal cannula and poor
diuresis (CHF). Upon further discussion, the patient agreed
to go to the Coronary Care Unit for intracardiac monitoring
during her diuresis and on [**2150-5-18**], she was transferred
to the Coronary Care Unit. Chest x-ray findings suggested a
potential aspiration pneumonia.
A transthoracic echocardiogram was obtained that showed an
ejection fraction of less than 20%, moderate dilation of the
right atrium. Left ventricle: Mild symmetric left
ventricular hypertrophy, severe left ventricular systolic
dysfunction. Left wall motion: The following resting
regional left ventricular wall motion abnormalities were
seen: Basal inferior - akinetic; mid inferior - akinetic;
basal inferolateral - akinetic; mid inferolateral - akinetic;
inferior apex - akinetic; lateral apex - akinetic. Right
ventricle dilated. Moderate global. Right ventricular free
wall hypokinesis. Aorta: Aortic root is normal diameter.
Aortic valve leaflets are mildly thickened. Mitral valve:
Valve leaflets mildly thickened, 3+ mitral regurgitation.
In the Coronary Care Unit a pulmonary artery catheter was
placed in the left subclavian with CVP 25, PA pressure 57/28,
pulmonary capillary wedge pressure 30, cardiac output 6.6,
cardiac index 3.9, SVR 21. The patient was on strict I's and
O's, daily weights, daily chest x-ray. Due to the patient's
decreased SVR, the patient was pan cultured for a question of
sepsis. Orthopedics continued to follow the patient in the
Coronary Care Unit. A Nutrition consult was obtained due to
the patient's poor p.o. intake. The decubitus ulcer
continued to be dressed per standard protocol.
[**2150-5-19**]: The patient continued to be hemodynamically
stable, was breathing at 97% on three liters with an
increased pulmonary artery pressure at 64/30.
[**2150-5-20**]: The patient's levofloxacin and Flagyl was
discontinued after cultures showed no growth and the chest
x-ray was most consistent with congestive heart failure. The
patient was started on hydralazine 25 q.i.d. p.o. for
afterload reduction. At this point the patient's only
antibiotic was vancomycin 750 mg IV q.o.d. renally dosed.
[**2150-5-21**]: A Podiatry consult was obtained to evaluate
the patient's risk of infection secondary to open bullae on
her distal extremities with decreased sensation in the
setting of diabetes preoperatively. At this time the patient
was on hydralazine 25 q.i.d., Lasix 10 mg drip per hour,
metolazone 5 mg b.i.d. and nesiritide 0.02 mcg/kg/min, _____
25 q.i.d. The patient responded well and was negative one
liter over 24 hours. Due to the fact that the Swan-Ganz
catheter was no longer needed but central access was still
desired, the patient had her subclavian line changed using
the Seldinger technique to a triple lumen catheter in the
usual sterile fashion. Of note, at this time the patient's
platelet count was 81,000, creatinine 3.2. Possibly as a
result of the decreased platelets and/or uremic platelets, it
was difficult to attain adequate hemostasis post procedure,
therefore, lidocaine with epinephrine was injected at the
site. After applying direct pressure for 30 minutes, finally
after lidocaine with epinephrine adequate hemostasis was
achieved.
[**2150-5-22**]: Due to the fact the patient's pulmonary artery
pressures had declined and central intracardiac monitoring
was no longer required, the patient was transferred to the
floor on Natrecor drip at 0.02 mcg/kg/min, hydralazine 20
q.i.d., Lasix 20 mg drip per hour.
[**2150-5-23**]: The patient's Natrecor and Lasix drip were
discontinued as it was felt by the primary team as well as
the CHF Service that the patient was back to her baseline dry
weight of 65.5 kilograms and her lung examination had
improved. This was confirmed by chest x-ray as well. Of
note, the patient's hematocrit had dropped to 29.5 and she
was transfused one unit of packed red blood cells. The
patient was made NPO after midnight in anticipation of the
repair of her left minimally displaced subcapital femur
fracture on [**2150-5-24**].
[**2150-5-24**]: A left hip hemiarthroplasty was performed.
Surgeon [**Doctor Last Name 12528**] under general anesthesia with an estimated
blood loss of 250 cc. Intraoperatively the patient received
one unit of packed red blood cells and [**Pager number **] cc of lactated
Ringer's. The patient completed the surgery without
complications and was hemodynamically stable and transferred
to the Post Anesthesia Care Unit.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**MD Number(1) 1009**]
Dictated By:[**Last Name (NamePattern1) 1811**]
MEDQUIST36
D: [**2150-5-27**] 19:49
T: [**2150-5-27**] 21:39
JOB#: [**Job Number 52243**]
Name: [**Known lastname **], [**Known firstname 7488**] L Unit No: [**Numeric Identifier 9733**]
Admission Date: [**2150-5-12**] Discharge Date: [**2150-5-31**]
Date of Birth: [**2072-4-21**] Sex: F
Service: [**Hospital1 248**] MEDICINE
ADDENDUM: The patient returned to the floor on the evening
of [**2150-5-24**], postoperative day number zero, status post a
left hip arthroplasty. Her hospital course was significant
for the following issues.
1. STATUS POST LEFT HIP ARTHROPLASTY: The patient was
continued on morphine for pain control. Neurovascular
examinations were done regularly and the patient was
continued on Lovenox for DVT prophylaxis. PT was consulted,
but the patient was difficult to motivate and seemed
unwilling to take part in her recovery, stating that she was
unable to walk. Physical therapists were able to get the
patient out of bed but she was unable even to tolerate her
own weight.
2. CONGESTIVE HEART FAILURE: The patient continued to be
fluid-overloaded despite diuretics. At the time of this
dictation, she had no episodes of shortness of breath.
However, she was continued on the hydralazine, metolazone for
afterload reduction. She was placed on a 1.5 gram sodium
diet, 100 cc fluid restriction. Her blood pressure remained
in the 100-120/30-50 range.
3. CHRONIC RENAL INSUFFICIENCY: The patient's creatinine
postoperatively was 3.6. IV fluids were held given the
concern of fluid overload. Over the following week, the
patient's creatinine continued to increase.
A Renal consult was obtained. A renal ultrasound showed no
obstruction. Urine electrolytes demonstrated evidence of
prerenal azotemia with a fractional excretion urea around
35%. The patient's creatinine continued to increase despite
stopping diuretics. At the time of this dictation, the
patient may require hemodialysis for fluid overload.
4. ESOPHAGEAL ULCERS: The patient's ulcers continued to
heal. B.i.d. dressing changes were continued. There was no
evidence of osteomyelitis or infection.
5. INCREASED WHITE BLOOD COUNT: The patient's white blood
count increased on postoperative day number one and it
continued to increase on postoperative day number two to a
high of 18. Antibiotics which had been started in the
coronary care unit were discontinued since there was no
obvious source of infection and the pain medications were
changed to Percocet to Oxycodone in order not to hide a
fever.
The following day, the white count decreased and returned to
baseline over the next few following days with no evidence of
infection seen. The patient continued to be afebrile during
this course.
6. FLUIDS, ELECTROLYTES, AND NUTRITION: A Nutrition consult
was obtained postoperatively. It was determined that the
patient was not taking adequate calories. Tube feeds and a
percutaneous endoscopic gastrostomy was considered. However,
the patient refused both of these and chose instead to try to
increase her p.o. intake which remained to be less than
optimal at the time of this dictation.
7. PSYCHIATRY/DEPRESSION: The patient continued to be
depressed and not take an active role in her recovery. A
Psychiatry consult was obtained and an ECT consult was
obtained to determine whether this patient would be eligible
for electroconvulsive therapy. Psychiatry consult
recommended starting a stimulant. Dextroamphetamine was
started.
At the time of this dictation, it is unclear whether the
patient will need ECT if the trial of stimulants does not
improve the patient's motivation.
8. HYPOTHYROIDISM: The patient is hypothyroid. There is a
question as to whether this may be contributing to her
depression; however, her dose of levothyroxine had been
adjusted prior to admission. Her TSH levels did not reflect
this change in dose. This should be checked in another week
or so. It should then reflect a change in dose.
9. ANEMIA: Postoperatively, the patient continued to be
somewhat anemic and required blood transfusion on [**2150-5-26**] as
well as 2 units on [**2150-5-28**] to maintain a hematocrit greater
than 30. There was no obvious source of bleeding. The
patient's decrease in hemoglobin could be attributable to
changes in fluid status. The patient's increased white count
may be attributable to urinary tract, although a U/A and
urine culture did not show specific etiology. The patient
was noted to have [**Female First Name (un) 1441**] in her urine and was given one dose
of Diflucan and should be changed.
Discharge status and discharge diagnoses will be described in
the dictation to occur at a later date.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) **]
Dictated By:[**Last Name (NamePattern1) 2685**]
MEDQUIST36
D: [**2150-5-31**] 06:15
T: [**2150-5-31**] 18:58
JOB#: [**Job Number 9734**]
Name: [**Known lastname **], [**Known firstname 7488**] L Unit No: [**Numeric Identifier 9733**]
Admission Date: [**2150-5-12**] Discharge Date: [**2150-6-9**]
Date of Birth: [**2072-4-21**] Sex: F
Service: [**Hospital1 **]
ADDENDUM: The [**Hospital 1325**] hospital course up until [**2150-5-31**] was previously dictated.
The patient continued to have worsening congestive heart
failure despite the use of afterload reducers. She was
continued on hydralazine, nesiritide, and Lasix. She was
placed on a low-sodium diet and 1000-cc fluid restriction.
Her creatinine also continued to rise.
A Renal consultation was obtained to consider hemodialysis
but the patient refused. The patient also had poor oral
intake, but the patient declined a nasogastric tube or
percutaneous endoscopic gastrostomy tube for tube feeding.
A family meeting was held to determine if further more
aggressive intervention could be performed on her behalf, but
the family decided to withdraw care, and the patient was
comfort measures only. She expired on the morning of [**2150-6-9**].
DISCHARGE DIAGNOSES:
1. Left hip arthroplasty.
2. Congestive heart failure.
3. Chronic renal insufficiency.
4. Esophageal ulcers.
5. Increased white blood cell counts.
6. Depression.
7. Hypothyroidism.
8. Anemia (requiring blood transfusions).
[**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern1) 181**], M.D.
Dictated By:[**Name8 (MD) 9735**]
MEDQUIST36
D: [**2150-6-9**] 15:35
T: [**2150-6-9**] 18:21
JOB#: [**Job Number 9736**]
|
[
"707.0",
"820.8",
"496",
"428.20",
"426.4",
"E888.9",
"403.91",
"584.9",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"00.13",
"38.93",
"81.51"
] |
icd9pcs
|
[
[
[]
]
] |
4775, 4854
|
22724, 23194
|
7282, 22703
|
234, 2727
|
5213, 7264
|
3965, 4758
|
2749, 3940
|
4871, 5198
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,044
| 116,475
|
43856
|
Discharge summary
|
report
|
Admission Date: [**2144-12-30**] Discharge Date: [**2145-1-21**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 134**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Percutaneous aortic valvuloplasty
Placement of a bare metal stent in the saphenous vein graft
History of Present Illness:
This is an 86 yo male with a history of CAD (s/p CABG), chronic
Afib, CHF, critical AS who was transferred to [**Hospital1 18**] for
evaluation for aortic valvular repair. In early [**Month (only) 404**], he was
at [**Hospital6 **] for an acute CHF exacerbation, where
he ruled in for an MI by enzymes. At [**Hospital1 **] on [**2144-12-28**], he
underwent catheterization which showed 85% stenosis of his
SVG-OM1, but a patent LIMA-LAD. He was transferred to the [**Hospital1 18**]
for aortic valve replacement.
.
In preparation for surgery, he was being followed by nephrology
for chronic kidney disease. It was felt that the patient had a
20% chance of needing dialysis following CABG. He was also
being followed by Heme-onc for chronically elevated INR, which
was felt to be secondary to chronic warfarin use.
.
On the morning of admission, he became tachypneic, the rate of
his AFib increased and he developed substernal chest pain. His
O2 requirement increased to 92% on 2L (98% RA yesterday). Over
the past few days, he has been on a decreased dose of lasix,
only receiving 40 PO daily when his home regimen was 40mg po
BID.
.
On transfer to the CCU he converted to sinus rhythm after
receiving lasix, metazolone, and metoprolol 7.5 mg IV. He
reported improved SOB and CP after converting.
.
Past Medical History:
CAD - MI & CABG [**2127**]
CHF -- systolic dysfunction (EF 35 - 40%)
Chronic Afib
critical AS
NSVT s/p AICD [**1-28**]
HTN
DM
LBBB
CRI
TIA & CVA
Social History:
Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse. Patient is a former
barber.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
ADMISSION PHYSICAL EXAM
.
VS: T: 96.7 , BP: 91/61 , HR: 110s (Afib) -> 80s , RR:20 , O2
94% on 3L NC
.
Gen: WDWN elderly male with obvious respiratory distress with
some difficulty speaking. Pleasant.
HEENT: NCAT. Sclera anicteric. OP clear.
Neck: Supple with JVP to mid neck with bed at 45%.
CV: irregularly irregular. Murmurs difficult to appreciate.
Chest: Poor air movement ~ 1/3 up bases. No wheezing.
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: 2+ pretibial edema.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
ADMISSION LABS:
[**2144-12-30**] 04:50PM BLOOD WBC-8.4 RBC-3.45* Hgb-10.4* Hct-30.9*
MCV-90 MCH-30.0 MCHC-33.5 RDW-14.0 Plt Ct-164
[**2144-12-30**] 04:50PM BLOOD PT-17.7* PTT-75.8* INR(PT)-1.6*
[**2144-12-30**] 04:50PM BLOOD Plt Ct-164
[**2144-12-30**] 04:50PM BLOOD Glucose-160* UreaN-84* Creat-3.2* Na-136
K-4.8 Cl-97 HCO3-30 AnGap-14
[**2144-12-30**] 04:50PM BLOOD ALT-33 AST-28 LD(LDH)-300* AlkPhos-95
Amylase-83 TotBili-0.5
[**2144-12-30**] 04:50PM BLOOD Albumin-3.2*
[**2144-12-31**] 07:30AM BLOOD Calcium-9.1 Phos-5.0* Mg-3.0*
[**2144-12-30**] 04:50PM BLOOD %HbA1c-6.9*
.
IMAGING:
[**2144-12-30**] Admission CXR-- PA & Lateral
Mild atelectasis at the left lung base with moderate
cardiomegaly
.
[**2145-1-15**] Cardiac Catheterization (see cath report for further
details)
1. Three vessel coronary artery disease. Patent LIMA.
SVG->OM/PDA
stenosis.
2. Pulmonary edema.
3. Critical aortic stenosis.
4. Successful stenting of the SVG-OM/PDA with a bare metal
stent.
5. Successful aortic valvuloplasty.
Brief Hospital Course:
AORTIC STENOSIS
On admission, Mr. [**Known lastname 94178**] EF was ~35-40% with moderate mitral
regurgitation and critical aortic stenosis (valve area of 0.6
and mean gradient of 58). Surgical aortic valve replacement was
deferred on this admission because of the patient's worsening
renal function and multiple comorbidities, placing him at high
risk for complications with an open heart surgery. A
percutaneous aortic valvuloplasty was performed on [**2145-1-15**]
without complication.
ATRIAL FIBRILLATION
He has known chronic atrial fibrillation, with a baseline LBBB.
Upon arrival to the CCU, Mr. [**Known lastname **] was found to be in AFib with
a rapid ventricular rate, which induced hypoxia and chest pain.
After intravenous furosemide and metoprolol, the patient quickly
returned to his baseline rhythm of atrial fibrillation with a
rate in the 70's, and his shortness of breath and chest pain
improved. A chest X ray showed pulmonary edema, which slowly
improved over the hospital course with continued diruesis. He
was kept on heparin throught the admission for anticoagulation
and was bridged to Coumadin at the end of his hospital stay.
CORONARY ARTERY DISEASE
Mr. [**Known lastname **] had a CABG in [**2127**] with SVG to the OM1 and LIMA to
the LAD. His cath on [**2145-1-15**] showed patent LAD and 85% stenosis
of the SVG; thus, a bare metal stent was placed in the SVG to
OM1. He was continued on aspirin and plavix for anti-platelet
therapy.
HYPERTENSION
He was continued on metoprolol succinate and amlodipine with
good control of his blood pressure. His home ACE inhibitor was
held in the setting of ARF.
ACUTE ON CHRONIC RENAL FAILURE
Although his baseline Cr is unknown, his Cr was 3.2 on
admission, elevated from the 2.2 - 2.4 that he was running at
the outside hospital prior to transfer. The aucte on CKD was
likely secondary to contrast nephropathy and a pre-renal state.
The renal service was consulted and felt there was no indication
for acute dialysis. His kidney function improved somewhat by
the time of discharge with management of his CHF and volume
status (see above). His home ACE inhibitor was held in the
setting of ARF.
URINARY TRACT INFECTION
Mr. [**Known lastname **] was found to have Klebsiella in is urine cultures
from [**2143-12-31**], which was treated with cirpofloxacin. Repeat urine
culture on [**2145-1-13**] grew Klebsiella and Enterococcus; he was
again treated with ciprofloxacin (shown to be sensitive on
culture). The foley catheter was pulled on [**1-20**] prior to
discharge.
Medications on Admission:
Medications pateint was on prior to admission to [**Hospital1 **]:
toprol XL 100mg
lisinopril 40mg daily
glyburide 10mg daily
hydralazine 20mg TID
furosemide 40mg [**Hospital1 **]
norvasc 5mg daily
doxazosin 4mg daily
ASA 81mg daily
warfarin 5mg daily
hectorol 0.5mcg daily
.
medications on Transfer to ICU:
-metoprolol xl 100mg daily
-doxasozin 4mh qhs
-doxercalciferol 0.5mcg dialy
-colace 100mg [**Hospital1 **]
-lasix 40mg Po daily
-insulin ss
- glipizide 10mg [**Hospital1 **]
-epoietin alpha 4000U SC MWF
-IV heparin
-diltiazem 30mg PO QID
-ipratropium Q6hr
Discharge Medications:
1. Doxercalciferol 0.5 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever, headache, pain.
3. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
5. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
6. Glipizide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Warfarin 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Dosage to be adjusted according to INR (goal 2.0 - 3.0).
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
9. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 3 days: Continue through [**2145-1-24**].
10. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) Injection
QMOWEFR (Monday -Wednesday-Friday).
11. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
12. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed.
14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
15. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
16. Insulin Lispro 100 unit/mL Solution Subcutaneous
17. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): Dosage will need to be adjusted according to daily
weights to keep his weight even.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 1294**]
Discharge Diagnosis:
Primary Diagnoses:
Aortic Stenosis, s/p percutaneous valvuloplasty
Systolic congestive heart failure
Atrial fibrillation
Acute on chronic renal failure
Urinary tract infection
Secondary Diagnoses:
Hypertension
Diabetes
Coronary Artery Disease
Discharge Condition:
Stable-- patient less short of breath than on admission; still
with some fatigue but also improved. Patient deconditioned from
prolonged hospital stay, but able to work with physical therapy
and being discharged to a rehab facility.
Discharge Instructions:
Please follow the rehabilitation program at the rehab facility
that you are going to after your discharge from the hospital.
You should call your primary care doctor if you develop fever,
pain with urination, worsening shortness of breath, or fluid
retention.
Your fluid levels need to be closely monitored while you are at
the rehab facility and then later when you go home. They should
adjust your lasix dosage so that you do not gain weight and do
not become short of breath.
Subcutaneous insulin dosage to be adjusted according fingerstick
glucose.
Followup Instructions:
Please see your cardiologist and primary care doctors within the
next 1 - 2 weeks for follow-up of your heart problems.
|
[
"414.01",
"428.20",
"599.0",
"414.02",
"250.00",
"584.9",
"424.1",
"427.31",
"428.0",
"585.9",
"403.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"37.22",
"00.40",
"00.66",
"00.45",
"35.96",
"36.06"
] |
icd9pcs
|
[
[
[]
]
] |
8541, 8615
|
3753, 6311
|
282, 377
|
8903, 9139
|
2721, 2721
|
9744, 9867
|
2046, 2128
|
6926, 8518
|
8636, 8813
|
6337, 6903
|
9163, 9721
|
2143, 2702
|
8834, 8882
|
223, 244
|
405, 1709
|
2737, 3730
|
1731, 1877
|
1893, 2030
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,560
| 169,834
|
41310+58436
|
Discharge summary
|
report+addendum
|
Admission Date: [**2135-6-12**] Discharge Date: [**2135-6-18**]
Date of Birth: [**2065-1-14**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
[**2135-6-13**] Aortic valve replacement (23 mm Pericardial)
pericardial patch repair of aortotomy.
History of Present Illness:
This 70 year old female with a history of aortic stenosis has
been followed closely by her cardiologist. She has had
worsening exertional dyspnes. In the past, she had undergone a
balloon valvuloplasty for her aortic valve which did provide
significant improvement in her symptoms. However, her symptoms
have now worsened and she is admitted for surgical management.
She is a CoreValve study pt.
Past Medical History:
Aortic stenosis
Morbid obesity
Sleep apnea
chronic obstructive pulmonary disease on home O2
obstructive sleep apnea on CPAP
Hyperlipidemia
Pulmonary Hypertension
Osteoarthritis
Hyperparathyroidism
Status post parathyroidectomy
h/o Lobular carcinoma in situ of the right breast ([**2123**])
Diverticular disease
Gastroesophageal reflux disease
Osteoporosis
Depression
Stress incontinence
Sinusitis
Restless leg syndrome
rheumatic fever
Hepatitis B
s/p Hysterectomy
s/p Cervical neck fusion (C3-C5)
s/p tonsillectomy
s/p cholecystectomy
s/p Multiple sinus polylpectomies
Social History:
Lives with: Alone.
Occupation: Retired.
Tobacco: Denies hx of tobacco.
ETOH: Occasional ETOH.
Family History:
noncontributory
Physical Exam:
Pulse: 90 Resp: 26 O2 sat: 92% RA
B/P Right: 136/75 Left: 136/75
Height: Weight: 104.2 kg
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]with hx of cervical fusion.
Chest: Shallow respirations with decreased BS at the bases b/l.
+Expiratory wheezes b/l.
Heart: RRR [x] Irregular [] Murmur: IV/VI SEM.
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]. [x[ obese.
Extremities: Warm [x], well-perfused [] Edema [x] 2+ LE edema
with chronic venous stasis changes. Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 1+ Left: 1+
PT [**Name (NI) 167**]: NP Left: NP
Radial Right: 2+ Left: 2+
Carotid Bruit: Right/Left:+radiation of murmur.
Pertinent Results:
[**2135-6-18**] 04:00AM BLOOD WBC-7.4 RBC-2.77* Hgb-8.5* Hct-25.9*
MCV-93 MCH-30.9 MCHC-33.1 RDW-15.4 Plt Ct-175#
[**2135-6-18**] 04:00AM BLOOD Glucose-92 UreaN-28* Creat-0.8 Na-139
K-3.9 Cl-100 HCO3-35* AnGap-8
[**2135-6-12**] 12:55PM BLOOD ALT-12 AST-19 LD(LDH)-171 AlkPhos-59
Amylase-43 TotBili-0.7
[**2135-6-18**] 04:00AM BLOOD proBNP-1548*
[**2135-6-18**] 04:00AM BLOOD Calcium-8.4 Phos-2.9 Mg-1.9
[**2135-6-12**] 02:48PM BLOOD %HbA1c-5.7 eAG-117
TTE Conclusions
Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is normal (LVEF>55%). The right ventricular
cavity is mildly dilated with borderline normal free wall
function. A bioprosthetic aortic valve prosthesis is present.
The transaortic gradient is normal for this prosthesis. Trace
aortic regurgitation is seen.
IMPRESSION: limited views. Normal global LV function. Mildly
dilated/hypokinetic RV. The aortic valve prosthesis is not well
seen but has normal gradients and only trace regurgitation.
Electronically signed by [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2135-6-15**] 17:34
Brief Hospital Course:
She was admitted for surgical evaluation and on [**6-13**] was brought
to the Operating Room and underwent aortic valve replacement
with repair of aorta, see operative report for further details.
She received cefazolin for perioperative antibiotics and was
transferred to the intensive care unit for post operative
management. That evening she was weaned from sedation, awoke
neurologically intact and was extubated without complications.
She was started on betablockers and [**Last Name (un) **] for blood pressure
management. On post operative day one she was transfused for
postoperative anemia and started on diuretic. She was
transferred to the floor on post operative day one. Her chest
tubes and pacing wires were removed per protocol. She recieved 2
units of packed red blood cells for post -op anemia and was
placed on iron supplements.She was mainatined on CPAP for her
history of OSA. She was evaluated by physical therapy for
strength and conditioning and rehab was recommended. On POD 4
,she went into A fib that converted to SR. Amiodarone was
started, but no Coumadin per Dr. [**Last Name (STitle) 914**]. She continued to make
good progress and was cleared for discharge to [**Location (un) **] Health
[**Hospital **] rehab on POD #5. F/u appts were advised. She is a CoreValve
study pt.
Medications on Admission:
Albuterol Sulfate 90 mcg HFA aerosol inhaler two puffs p.r.n.
Sensipar 30 mg tablet one p.o. daily
Citalopram 20 mg tablet one p.o. daily
Famotidine 20 mg tablet one p.o. daily
Fluticasone 50 mcg spray suspension one spray intranasally daily
Fluticasone/Salmeterol 500/50 mcg - dose disk with device one
puff b.i.d.
Losartan 50 mg tablet one p.o. daily
Singulair 10 mg tablet one p.o. daily
Ropinirole 2mg qHS
Theophylline 200 mg standard release tablet one p.o. daily
Spiriva 18 mcg capsule inhalation device one puff daily
Torsemide 20 mg tablet one p.o. daily
Aspirin 81 mg p.o. daily
Calcium 500 mg tablet one p.o. daily
Loratadine 10 mg tablet one p.o. daily
Multivitamin one p.o. daily
augmentin 875mg [**Hospital1 **]
Buproprion 100mg daily
Discharge Medications:
1. ranitidine HCl 150 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) for 1 months.
3. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO DAILY (Daily) as needed for constipation.
4. loratadine 10 mg Tablet Sig: One (1) Tablet PO qd ().
5. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal DAILY (Daily).
7. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. cinacalcet 60 mg Tablet Sig: One (1) Tablet PO once a day.
9. ropinirole 1 mg Tablet Sig: Two (2) Tablet PO QPM (once a day
(in the evening)).
10. bupropion HCl 100 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
11. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
6-10 Puffs Inhalation Q4H (every 4 hours) as needed for sob
wheezing .
12. theophylline 400 mg Tablet Extended Release Sig: 0.5 Tablet
Extended Release PO DAILY (Daily).
13. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day): one IH
[**Hospital1 **].
14. losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap(s)IH Inhalation DAILY (Daily).
16. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
17. guaifenesin 600 mg Tablet Extended Release Sig: Two (2)
Tablet Extended Release PO BID ().
18. hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours): hold for SBP < 100.
19. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): check LFTs in one month.
20. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb IH Inhalation Q4H (every 4 hours):
with chest PT.
21. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
22. tramadol 50 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for pain.
23. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 400 mg [**Hospital1 **] for 6 days through [**6-23**]; then 400 mg daily
[**6-24**] through [**6-30**]; then 200 mg daily ongoing.
24. furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day.
25. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Healthcare Center - [**Location (un) **]
Discharge Diagnosis:
Aortic stenosis
s/p Aortic valve replacement-CoreValve study pt.
postop A Fib
Obstructive Sleep apnea on CPAP
Chronic obstructive pulmonary disease on home oxygen
Hyperlipidemia
Pulmonary Hypertension
Osteoarthritis
Hyperparathyroidism
h/o Lobular carcinoma in situ of the right breast
Diverticular disease Gastroesophageal reflux disease
Depression
Stress incontinence
Restless leg syndrome
Rheumatic fever
Hepatitis B
Obesity
s/p tonsillectomy
s/p cholecystectomy
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**
You have a percutaneous cholecystostomy tube in place. If you
should have any problems
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr [**Last Name (STitle) 914**] ([**Telephone/Fax (1) 170**]) on [**7-12**] at 1:45pm
Cardiologist: Dr.[**Name (NI) 89934**] office nurse will contact patient
after discharge.(voicemail for them to call [**Doctor First Name **] back)
Please call to schedule appointments with:
Primary Care Dr [**Last Name (STitle) 89935**] in [**5-17**] weeks ([**Telephone/Fax (1) 89936**])
**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:[**2135-6-18**] Name: [**Known lastname **],[**Known firstname 1013**] Unit No: [**Numeric Identifier 14237**]
Admission Date: [**2135-6-12**] Discharge Date: [**2135-6-18**]
Date of Birth: [**2065-1-14**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 1543**]
Addendum:
appt with Dr. [**Last Name (STitle) 14238**] [**7-18**] @ 1:20 PM has been scheduled
Discharge Disposition:
Extended Care
Facility:
[**Hospital 382**] Healthcare Center - [**Location (un) 382**]
[**First Name11 (Name Pattern1) 33**] [**Last Name (NamePattern4) 1544**] MD [**MD Number(2) 1545**]
Completed by:[**2135-6-18**]
|
[
"278.01",
"416.8",
"V70.7",
"997.79",
"272.4",
"333.94",
"427.31",
"496",
"311",
"V12.09",
"733.00",
"424.1",
"327.23",
"440.0",
"716.90",
"997.1",
"287.5",
"E878.2",
"285.9",
"V85.41",
"E849.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.56",
"38.97",
"35.21",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
11140, 11388
|
3689, 4997
|
317, 419
|
8842, 9022
|
2410, 3666
|
10032, 11117
|
1567, 1584
|
5795, 8226
|
8353, 8821
|
5023, 5772
|
9046, 10009
|
1599, 2391
|
258, 279
|
447, 846
|
868, 1439
|
1455, 1551
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,052
| 155,123
|
51077
|
Discharge summary
|
report
|
Admission Date: [**2182-3-7**] Discharge Date: [**2182-3-15**]
Date of Birth: [**2108-5-19**] Sex: F
Service: MEDICINE
Allergies:
Sulfonamides / Iodine
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Respiratory failure
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
73 yoF w/ h/o HTN, hyperchol, and prior TIAS initially presented
to ED [**2182-3-6**] following episode of sudden onset transient
slurred speech and paresthesias of lip (sbp at home 190s). In
[**Name (NI) **], pt evaluated by neuro, had MRI (-) for acute stroke. [**2182-3-7**]
a.m., pt had episode of N/V followed by tachypnea and increased
work of breathing. Received lasix 40 mg IV X 1, nitro gtt and
was placed on BiPAP for suspected CHF. However, sbp decreased to
60s (no improvement following d/c of nitro gtt). She was
intubated, started on levophed and gtt. CTA (-) for PE, showing
diffuse ground glass opacities and bibasilar opacities (c/w
pulmonary edema and aspiration). Pt then sucessfully extubated.
Transferred to the floor [**3-11**] and doing well at this time
Past Medical History:
1) HTN
2) Hypercholesterolemia
3) h/o pancreatitis
4) lumbar radiculopathy s/p laminectomy
5) s/p bilateral hip replacements
6) h/o aspiration PNA
Social History:
No tobacco or ETOH use. Mother of 8 children. Very involved
family.
Family History:
NA
Physical Exam:
On transfer from MICU to floor.
97.1 135/64 66 15 97% 4L NC
Gen- Awake. Pleasant. Alert. NAD.
HEENT: PERRL. EOMI. MMM.
Cardiac- RRR. S1 S2. No murmers.
Pulm- Faint crackles at right base.
Abdomen- Soft. NT. ND. Positive bowel sounds.
Extremitis- 1+ bilateral LE edema.
Pertinent Results:
[**2182-3-15**] 04:50AM BLOOD WBC-3.0* RBC-4.02* Hgb-12.7 Hct-36.2
MCV-90 MCH-31.7 MCHC-35.2* RDW-14.1 Plt Ct-110*
[**2182-3-11**] 04:15AM BLOOD Neuts-89.1* Bands-0 Lymphs-6.6* Monos-3.8
Eos-0.3 Baso-0.2
[**2182-3-15**] 04:50AM BLOOD Plt Ct-110*
[**2182-3-15**] 04:50AM BLOOD Glucose-93 UreaN-8 Creat-0.8 Na-139 K-4.2
Cl-107 HCO3-27 AnGap-9
[**2182-3-15**] 04:50AM BLOOD Calcium-8.5 Phos-2.8 Mg-2.0
[**2182-3-6**] 08:20PM BLOOD %HbA1c-5.6
[**2182-3-6**] 04:30PM BLOOD Triglyc-136 HDL-61 CHOL/HD-4.0
LDLcalc-155*
[**2182-3-7**] 09:29PM BLOOD TSH-6.5*
[**2182-3-7**] 09:29PM BLOOD Cortsol-34.0*
MRA BRAIN W/O CONTRAST ([**2182-3-6**])
FINDINGS: There is no area of restricted diffusion. Again noted
are multiple foci and confluent areas of T2 hyperintensity in
the periventricular and deep white matter of the cerebral
hemispheres which have increased in the interval. There is
convex margin of the superior aspect of the pituitary gland and
mild glandular enlargement, which is not significantly changed
compared to prior examination. There is no mass effect, shift of
the normally midline structures, or hydrocephalus.
IMPRESSION:
1. No evidence of acute infarct.
2. Progression of patient's known chronic small vessel ischemic
infarcts.
3. Unchanged pituitary gland enlargement, compatible with a
small tumor.
HEAD MRA: 3D time of flight imaging of the anterior and
posterior cerebral circulations was obtained. Comparison was
made to prior study dated [**2181-7-29**].
FINDINGS: There is no hemodynamically significant stenosis or
aneurysmal dilatation of the visualized vasculature.
IMPRESSION: Unremarkable head MRA.
CHEST (PA & LAT) ([**2182-3-6**]):
FINDINGS:
The heart is normal in size. The aorta is slightly tortuous and
unfolded. The lungs appear clear. There is no pleural effusion.
Pulmonary vasculature is within normal limits. There is no
pneumothorax. Biapical pleural scarring is unchanged. A clip is
seen medially in the superior mediastinum along the left
paratracheal margin. The osseous structures demonstrate mild
degenerative changes throughout the thoracic spine.
IMPRESSION:
No radiographic evidence of acute cardiopulmonary process. No
CHF.
The study and the report were reviewed by the staff radiologist.
Echo ([**3-8**]):
Findings:
LEFT ATRIUM: Normal LA size.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Normal LV wall thickness. Small LV cavity.
Hyperdynamic LVEF. No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic root diameter.
AORTIC VALVE: Three aortic valve leaflets. Mildly thickened
aortic valve
leaflets. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular
calcification. Mild thickening of mitral valve chordae.
Calcified tips of
papillary muscles. Trivial MR. Prolonged (>250ms) transmitral
E-wave decel time. LV inflow pattern c/w impaired relaxation.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
Mild PA
systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR. Normal main PA. No Doppler evidence for PDA
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: The patient appears to be in sinus rhythm.
Left pleural
effusion.
Conclusions:
The left atrium is normal in size. Left ventricular wall
thicknesses are
normal. The left ventricular cavity is small. Left ventricular
systolic
function is hyperdynamic (EF 70-80%). Right ventricular chamber
size and free wall motion are normal. There are three aortic
valve leaflets. The aortic valve leaflets are mildly thickened.
No aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Trivial mitral regurgitation is seen. The left
ventricular inflow pattern suggests impaired relaxation. There
is mild pulmonary artery systolic hypertension. There is no
pericardial
effusion.
CT abdomen and pelvis ([**3-10**]):
FINDINGS: Evaluation of the lung bases demonstrates bilateral
pleural effusions and atelectasis. This is less severe than on a
prior examination although the entire lungs are not evaluated on
today's exam.
The liver and spleen are unremarkable. A calcified stone and
sludge are identified within the gallbladder. There is no
evidence of intra or extrahepatic biliary ductal dilatation. The
pancreas is slightly fatty replaced, but otherwise unremarkable.
No adrenal lesions are present. There is a 4.6 cm exophytic cyst
in the left kidney. No other renal masses are identified. The
kidneys enhance symmetrically and are without evidence of
perinephric stranding or hydronephrosis. There are no dilated
loops of small bowel to suggest an obstruction. Contrast is
visualized throughout the distal bowel and colon. Scattered left
sided and sigmoid diverticula are present without evidence of
diverticulitis. No significant lymphadenopathy is present. Note
is made of atherosclerotic calcifications and a clacified
splenic artery aneurysm.
Evaluation of the deep pelvis is slightly limited due to
artifact from the indwelling bilateral hip arthroplasties. No
discrete fluid collection is identified. The bladder is
collapsed with a Foley catheter within it.
Evaluation of the bone windows demonstrates no osseous blastic
or lytic lesions. Degenerative changes are present throughout
the spine. An area of soft tissue density is identified with in
the atrophied left paraspinous muscles of L5-S1. This is better
evaluated on the prior CT and MRI of the lumbar spine. It is
nonspecific and may represent post-surgical changes.
IMPRESSION:
Bilateral pleural effusions with adjacent atelectasis.
No intra-abdominal fluid collections are identified to suggest
an abscess. Evaluation of the deep pelvis is slightly limited as
described above.
Carotid US ([**3-12**]):
HISTORY: TIA.
There is no appreciable plaque or wall thickening involving
either carotid system. The peak systolic velocities bilaterally
are normal, as are the ICA to CCA ratios. There is normal
antegrade flow in both vertebral arteries.
IMPRESSION:
Widely patent common and internal carotid arteries bilaterally.
Sputum culture ([**3-10**]):
GRAM STAIN (Final [**2182-3-10**]):
<10 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH
OROPHARYNGEAL FLORA.
RESPIRATORY CULTURE (Final [**2182-3-12**]):
SPARSE GROWTH OROPHARYNGEAL FLORA.
Brief Hospital Course:
A/P: 73 y/o female with PMH significant for HTN, previous TIAs,
and hypercholesterolemia admitted through ED on [**3-6**] following
an episode of slred speech and lip paresthesias. MRI was
negative for acute CVA. On the morning of [**3-7**], the pt had an
episode of nausea and vomiting followed by increased work of
breathing and decrease in SBP to the 60s. Pt required intubation
and was started on levophed. She was transferred to the MICU at
that time. CTA was negative for PE but showed bilateral
consollidations concerning for aspiration PNA. Pt was treated
and successfully extubated. She was transferred to the floor on
[**3-11**]. She is currently being treated emperically with levo and
flagyl.
1. Respiratory failure- Pt experienced an episode of respiratory
failure on [**3-7**]. This occurred following an episode of nausea
and vomiting. At that time, the pt developed increased work of
breathing and tachypnia. CXR showed florid CHF so the pt was
diuresed with lasix 40 mg IV and started on a nitro drip. She
was also placed on BiPap. However, her SBP decreased to the 60s
at that time and the pt required intubation. She was also
started on pressors for her hypotension at that time. A CTA was
concerned given a concern for PE but this was negative. Imaging
did show bilateral lower lobe infiltrates consistent with
probable aspiration PNA. Pt was started on emperic levo, flagyl,
and ceftriaxone at that time. Pt was extubated without problem
on [**3-11**]. Following transfer to the floor, pt's respiratory
status has been stable. At this time, she has an oxygen
saturation in the mid 90s on room air. She does not desaturate
with ambulation. The ceftriaxone was discontinued on [**3-12**] and
the pt will complete a 14 day course of levo and flagyl. Blood
cultures have been negative to date and sputum cultures grew
only oropharyngeal flora. Of note, pt had bedside swallow eval
on [**3-11**] which she passed without difficulty. No further choking
epsisodes with eating.
2. [**Name (NI) **] Pt with probable aspiration PNA as above. In addition, pt
developed rigoring, transient leukopenia, and hypertension in
the MICU on [**3-10**]. At that time, she was experiencing severe
back and leg pain. A CT was obtained that diverticulosis and
fluid at L4-L5 of the spinal processes. However, there were no
findings thought to account for her symtpoms. Blood clutures
were sent which are negative to date. A TTE was obtained to
evaluate for possible valvular disease/endocarditis. It showed
no significant abnormality and no vegitation. As the pt remained
afebrile on the floor with negative blood cultures and no new
murmer, a TEE was not obtained. The vancomycin was discontinued.
She has been stable from an ID standpoint while on the floor.
3. [**Name (NI) **] Pt was hypotensive in the MICU in settion of
probable aspiration PNA/concern for SIRS. She was treated with
levophed for approximately 2 days. It was weaned off at that
time and the pt required one IV fluid bolus but otherwise
maintained stable BP. On [**3-10**], in the setting of back and leg
pain, the pt devloped hypertesion. She was started back on low
doses of her home BP meds and those have slowly been titrated
upward since that time. She is now back on her home dose of
HCTZ, avapro, and beta blocker. BP is well controlled at the
time of discharge.
4. Neuro- On admission, pt had transient dysarthria and facial
numbness most probably due to a TIA. Neuro consult was obtained.
Head CT and MRI were negative for evidence of acute infarct.
Carotid US was obtained [**3-12**] which showed widely patent
arteries. TIA may have been in setting of poorly controlled
hypertension. As pt had this episode and has had TIAs in the
past, an appointment was made for her to follow up with
neurology following discharge.
5. [**Name (NI) 14984**] Pt's dose of lipitor was increased to
40 mg during admission.
6. [**Name (NI) 3674**] Pt with slow trend down of Hct over admission but
stable over last few days. No obvious source of bleeding.
Guiacing all stools which have been negative. She did not
require transfusion.
7. FEN- Cardiac diet as tolerated. Electrolytes repleated as
needed throughout admission.
8. Proph- SC heparin; PPI; bowel regimen
9. [**Name (NI) 54454**] PT and OT consults were obtained during admission.
\
10. Code- Full
11. [**Name (NI) 2638**] Pt's daughter [**Name (NI) **] [**Name (NI) 4640**] is her health care
proxy. [**Name (NI) **] number is [**Telephone/Fax (1) 106085**] and cell number is
[**Telephone/Fax (1) 106086**].
Medications on Admission:
1. Lipitor 20 mg daily
2. HCTZ 12.5 mg daily
3. Toprol 75 mg daily
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Irbesartan 150 mg Tablet Sig: 1.5 Tablets PO qd ().
Disp:*45 Tablet(s)* Refills:*2*
5. Hydrochlorothiazide 25 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 10 days.
Disp:*30 Tablet(s)* Refills:*0*
7. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 10 days.
Disp:*10 Tablet(s)* Refills:*0*
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
9. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
10. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary diagnosis:
Aspiration pneumonia
Secondary diagnosis:
Respiratory failure
Hypotension in setting of PNA
Hypertension
Hypercholesterolemia
TIAs
Discharge Condition:
Stable. Breathing comfortably on room air.
Discharge Instructions:
1. Please keep all follow up appointments.
2. Please take all medications as prescribed.
3. Seek medical attention for chest pain, shortness of breath,
abdominal pain, inability to eat, or any other concerning
symtpoms.
Followup Instructions:
1. Please follow up with your primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 172**]
on Monday [**4-1**] at 1:15.
2. Please follow up in neurology clinic with Dr. [**Last Name (STitle) **] on [**4-2**] at 2:15. His office is on the [**Location (un) **] of the [**Hospital Ward Name 23**]
Clinical Building. Call [**Telephone/Fax (1) 44**] before your appointment to
update your personal information.
|
[
"272.0",
"518.0",
"518.81",
"562.10",
"428.30",
"435.9",
"401.9",
"507.0",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
14091, 14149
|
8128, 12672
|
300, 313
|
14344, 14388
|
1704, 8105
|
14658, 15092
|
1391, 1395
|
12790, 14068
|
14170, 14170
|
12698, 12767
|
14412, 14635
|
1410, 1685
|
241, 262
|
341, 1120
|
14232, 14323
|
14189, 14211
|
1142, 1290
|
1306, 1375
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,229
| 146,900
|
14076+56503
|
Discharge summary
|
report+addendum
|
Admission Date: [**2167-6-9**] Discharge Date: [**2167-6-25**]
Date of Birth: [**2123-6-18**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Respiratory failure
Major Surgical or Invasive Procedure:
Intubation (OSH)
History of Present Illness:
43 yo female with h/o bipolar disorder and hypothyroidism who
was transferred from [**Hospital1 **] for respiratory failure.
Per boyfriend, pt had been very awake for 4-5 days. Yesterday
AM, he was unable to arouse her from sleep and she was still
sleeping on return from work. This AM, he still was unable to
rouse her and noted urinary incontinence, so he called EMS. No
observed tonic clonic movements or bowel incontinence; no h/o
seizure d/o. He was concerned for overdose given some
unidentified, empty pill bottles found near her, h/o overdose
8-9 years ago , and recent multiple stressors including ongoing
psych med adjustments, recent cholecystectomy, and strained
relationship with parents although.
.
In the OSH [**Name (NI) **], pt had a RR of 6 and was desatting to 70-80s on
arrival. Urine tox positive for benzos and methadone. Pt
received Narcan. She developed hypoxemic respiratory failure
with ABG 7.525/33.4/46 requiring intubation. CT torso showed
left lung consolidation with volume loss and distal left
mainstem bronchus narrowing. She was given Zosyn and K 40-60 mEq
for hypokalemia and transferred here for further evaluation.
.
In our ED, initial vs were: T 98 rectal, HR 105 with PVCs, BP
120/60, RR 30, O2sats in low 90s. Pt sedated with propofol on
arrival but overbreathing vent. She was suctioned with
improvement in O2sat to 100% on AC 500/16/6/100%. Labs notable
for WBC of 17.9 with 91.6%N. Read here of OSH CT chest noted
mediastinal shift to the left with left lung atelectasis;
hypodense material in the airways, mostly at the left lung base;
and pericardial effusion. Pt was given a dose of vancomycin IV.
She also received 1L NS IV for lactate 3.2 and 40m Eq K for K
3.2. On transfer, pt afebrile with HR 101, BP 110/64, RR 20s,
and O2 sat 100% on above vent settings with ABG 7.48/34/109.
.
On the floor, pt sedated.
Past Medical History:
- Bipolar disorder
- Hypothyroidism
- EtOH neuropathy
- H/o overdose 8-9 years ago as above
Social History:
Lives with long-time boyfriend; had part-time job as
phlebotomist in past. Per boyfriend, 1.5 ppd of cigarettes x 25
years, h/o EtOH abuse but none in [**5-11**] years, h/o cocaine 10
years ago; no h/o IVDU.
Family History:
Both parents alive. Mother with CHF.
Physical Exam:
EXAM ON ADMISSION
Vitals: T 98.4, BP 116/72, P 97, R 25, O2 98% on
General: No acute distress, intubated and sedated
HEENT: Sclera anicteric, MMM, oropharynx clear, +ETT, +OGT
Neck: Supple, JVP not elevated, no LAD
Lungs: Bronchial breath sounds R>L, no wheezes, rales, rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: Foley
Ext: Extremities mildly cool, well perfused, 2+ pulses, no
clubbing, cyanosis or edema
ON DISCHARGE
pt alert and oriented x3. Confused at times (could not remember
what city she lived in).
Pertinent Results:
[**2167-6-9**] 09:45PM BLOOD WBC-17.9* RBC-4.19* Hgb-13.0 Hct-38.7
MCV-92 MCH-31.1 MCHC-33.6 RDW-16.7* Plt Ct-280
[**2167-6-9**] 09:45PM BLOOD Neuts-91.6* Lymphs-5.9* Monos-1.4*
Eos-0.9 Baso-0.1
[**2167-6-11**] 02:26AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-2+
Macrocy-1+ Microcy-NORMAL Polychr-NORMAL Ovalocy-OCCASIONAL
Burr-2+
[**2167-6-9**] 09:45PM BLOOD PT-13.7* PTT-28.1 INR(PT)-1.2*
[**2167-6-9**] 09:45PM BLOOD Glucose-131* UreaN-16 Creat-0.8 Na-140
K-3.2* Cl-102 HCO3-25 AnGap-16
[**2167-6-10**] 01:09AM BLOOD Albumin-3.2* Calcium-7.8* Phos-2.6*
Mg-1.9
[**2167-6-9**] 09:45PM BLOOD ALT-21 AST-42* AlkPhos-86 TotBili-0.8
[**2167-6-9**] 09:45PM BLOOD Lipase-20
[**2167-6-9**] 09:52PM BLOOD Lactate-3.2* K-3.2*
.
[**2167-6-10**] 01:09AM BLOOD TSH-54*
[**2167-6-11**] 02:26AM BLOOD Free T4-<0.10*
[**2167-6-12**] 03:13AM BLOOD Cortsol-26.6*
.
[**2167-6-9**] 09:45PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2167-6-9**] 09:45PM URINE bnzodzp-POS barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-POS
.
[**2167-6-24**] 06:24AM BLOOD TSH-80*
[**2167-6-24**] 06:24AM BLOOD T4-4.1* Free T4-0.73*
.
[**2167-6-10**] 1:08 am SPUTUM Source: Endotracheal.
RESPIRATORY CULTURE (Final [**2167-6-12**]):
SPARSE GROWTH OROPHARYNGEAL FLORA.
STAPH AUREUS COAG +. MODERATE GROWTH.
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN------------- 0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
.
[**2167-6-9**] OSH CT chest:
1. Left lung collapse with leftward shift of the mediastinal
structures.
Hypodense material within the airways of the left lung, mostly
within the left lung base which could be aspirated material or
mucous impaction. Bronchoscopy is recommended for further
evaluation.
2. Small to moderate-sized pericardial effusion.
3. Ill-defined nodular opacities in the right lower lobe which
could indicate small airway disease or aspiration.
.
[**2167-6-13**] CT Thorax:
1. Residual dense consolidation in the left lower lobe.
2. Patchy consolidation in the left upper lobe but increased
aeration of the left upper lobe compared to prior study.
3. Patchy atelectasis in the right upper and lower lobes.
4. Small pleural effusions which have developed since the prior
study
bilaterally. Moderate pericardial effusion which has increased
from prior
study.
5. Small amount of free fluid in the gallbladder fossa and in
the pelvis.
.
[**2167-6-23**] Video Swallow Eval:
[**2167-6-23**] Chest xray: FINDINGS: The NG tube passes along the
expected route of the esophagus, into the stomach. Comparison to
the previous study shows the left lower lobe atelectasis has
cleared. The right lower lobe border is not seen but the lungs
are clear with no mass, consolidation, pneumothorax or pleural
effusion. Heart and mediastinal structures are normal.
IMPRESSION: Satisfactory position of the NG tube. The lungs are
clear.
Brief Hospital Course:
43 yo female with h/o bipolar disorder and hypothyroidism who
presented to OSH with increased lethargy and hypoxemic
respiratory failure requiring intubation and found to have left
lung collapse.
.
# Respiratory failure: Bronchoscopy on admission without
evidence of obstructive lesion. Left lung collapse thought to be
secondary to consolidative pneumonia with copious secretions.
Respiratory cultures grew out pansensitive MSSA, and initial
broad coverage with vanc, zosyn, and levofloxacin pared down to
zosyn and then to nafcillin. Multiple bronchs done given
persistent copious sputum with gradual improvememt in purulent
secretions seen in left lung, pt eventually extubated s
complication. PICC placed for long-term administration of abx,
pt recieved total of 14day course, last day: [**2167-6-23**].
.
# Hypothyroidism: Poorly controlled per PCP records with concern
in past that pt may have been abusing medications for weight
control. She last filled her prescription for armourthyroid in
[**12-12**] per her pharmacy. Here, TSH level was 54 with a free T4 of
<0.1. Thought to be myxedematous per Endo but not myxedema coma.
Cortisol level normal. Given synthroid with loading dose of 300,
then 75mcg IV daily. On the day of discharge pt was transitioned
to PO synthroid (100 mcg). Most recent TSH was 80 and free T4
0.73.
.
# Altered mental status: Pt initially responsive only to pain.
This was thought [**1-5**] to untreated hypothyrodism v. polypharmacy
v. underlying bipolar disorder v severe infection. No h/o
seizure disorder per OSH records. Utox positive for methadone
and benzos; pt did receive narcan at OSH. Altered mental status
persisted on arrival. Started on synthroid per endo recs for
myxedema. Her home psych meds of topiramate and divalproex were
restarted, her seroquel, clonazepam, provigil, and zolpidem were
initally held pending improvement. Seroquel and clonazepam
subsequently restarted at lower dose per psych recs. Seroquel
was then d/ced as pt's home psychiatrist confirmed pt was no
longer on this medication and it appeared to lengthen her QT. As
pt improved clinically, she went from somnolent to delirious.
Her delirium improved daily. Hopefully pt will continue to
improve back to her baseline, though cannot exclude the
possibility of anoxic brain injury [**1-5**] her respiratory status
prior to admission. Pt was occasionally agitated at night.
Agitation was treated initially with haldol but because of her
improving mental status and lengthening QT, this was changed to
occasional prn ativan 0.5mg which had good effect. Would
definitely AVOID haldol and seroquel in the future.
.
# CHEST PAIN: pt had one short episode of chest pain which
resolved c nitroglycerin. Pt's EKG was found to have 1mm ST
depression in V3-5 (most prominent in EKGs from [**2167-6-22**] at
9:30am) and pt was ruled out with three sets of negative enzymes
(trop 0.03, 0.02, 0.02). Pt will follow-up with cardiology as
outpt to determine the need for stress testing. Pt was started
on asa 81mg, though cardiology may decide to discontinue.
.
# Ileus: Pt developed large bowel ileus without evidence of
small bowel obstruction (perhaps [**1-5**] hypothyroid?). Placed on
bowel rest with OG tube to suction with aspiration of feculant
matter. Resolved after several days with aggressive bowel
regimen. Pt discharged on reglan which pt should be able to
discontinue as her hypothyroid resolves.
.
# Metabolic acidosis: Pt c nonanion gap metabolic acidosis,
likely [**1-5**] normal saline. Type 1 or 2 RTA was considered as pt
was also hypokalemic. However, pt's urine lytes and urine pH
were not completely consistent with either type of RTA.
.
# Pericardial effusion: TTE showed only small pericardial
effusion (appeared moderate on chest CT) with no evidence of
tamponade. Pt did not have elevated pulsus paridoxus.
.
# FEN/SWALLOW EVAL: Pt initially received tube feeds. Speech and
swallow did a video evaluation which showed some aspiration risk
so pt was started on thickened liquids and pureed solids. Pt
should follow up for further evaluation while at rehab.
.
# Prophylaxis: Subcutaneous heparin
.
# Communication: No HCP. Boyfriend [**Name (NI) 449**] [**Name (NI) 41978**] [**Telephone/Fax (1) 41979**] H,
[**Telephone/Fax (1) 41980**]. Father [**Name (NI) 9241**] [**Name (NI) 1169**] [**Telephone/Fax (1) 41981**] (currently
fighting; mother in hospital). Sister [**Name (NI) **] in [**Name (NI) **] [**Telephone/Fax (1) 41982**]
H, [**Telephone/Fax (1) 41983**] C. Also has 4 stepbrothers.
Medications on Admission:
In bag with patient:
- Propoxyphene-APAP 1 tab q8h prn
- Divalproex ER 1000mg qhs
- Topirimate 200mg [**Hospital1 **]
- Provigil 200mg tid
- Seroquel 300mg 2-3 tabs qhs
- Zolpidem 10mg qhs prn
- Clonazepam 1 mg 5x/day
.
Per Rite-Aid ([**Telephone/Fax (1) 41984**]):
- Seroquel 300mg 2-3 tabs qhs
- Divalproex ER 500mg 2 tab qhs
- Topimax 200mg 1 tab [**Hospital1 **]
- Darvocet 1 tab q8h prn
- Clonazepam 1mg 5x/day
- Provigil 200mg 1 tab tid
- Armourthyroid 90 mg 1 tab [**Hospital1 **] (last filled 6 m ago)
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day): please only give if patient is
not out of bed qshift.
2. Topiramate 100 mg Tablet Sig: Two (2) 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. Divalproex 125 mg Capsule, Sprinkle Sig: Two (2) Capsule,
Sprinkle PO QID (4 times a day).
5. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
8. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Vaginal HS (at
bedtime) for 4 days.
9. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
11. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS
(4 times a day (before meals and at bedtime)): Please
discontinue if pt having more than 1 BM per day.
12. Multi-Vitamin W/Minerals Capsule Sig: One (1) Capsule PO
once a day.
13. Synthroid 100 mcg Tablet Sig: One (1) Tablet PO once a day.
Tablet(s)
14. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for headache. Tablet(s)
15. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for severe agitation.
16. Outpatient Lab Work
Please check a valproate level on friday [**2167-6-27**] and call the
result to Dr [**Last Name (STitle) 15095**] (her psychiatrist) at [**Telephone/Fax (1) 41985**], please
verbally confirm with her doctor (or his representative) that
her valproate dose is appropriate.
Please check TSH and free T4 on [**2167-7-8**] and [**2167-7-22**] and call the
result to Dr [**Last Name (STitle) 3540**] (her endocrinologist) at [**Telephone/Fax (1) 1803**], please
verbally confirm that her doctor (or his representative) that
the synthroid dose is appropriate.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2857**] - [**Location (un) **] [**Doctor First Name **] - [**Location (un) 4047**]
Discharge Diagnosis:
primary diagnosis: MSSA pneumonia, hypothyroid
secondary diagnoses: bipolar disorder
Discharge Condition:
fair
Discharge Instructions:
FOR PATIENT:
You were admitted to the hospital because of a very bad
pneumonia. You initially went to the intensive care unit where
you had a breathing tube to help you breathe and you received
antibiotics. You were also found to have very low thyroid
hormone as you had not been taking your thyroid medicine at
home. We restarted you on a new thyroid medicine called
synthroid. You were also started on a cream for yeast infection
(which you were found to have) and daily aspirin.
We aren't sure what happened right before you came to the
hospital, and you can't remember either, but it is possible that
you took too much of one of your medicines or perhaps took
medicines that had been prescribed for someone else. It is very
important that you take your medicines exactly as prescribed and
that you do not take any medicines that were prescribed for
anyone but you.
We asked you if it was possible that you took extra medicine in
order to purposefully harm yourself but you assured us that this
was not the case. If you feel like you are at risk of harming
yourself in the future please call your psychiatrist or go to
the emergency room.
Lastly, you developed a short period of chest pain while you
were in the hospital. We are going to have you see a
cardiologist and are also starting you on a baby aspirin per
day. When you see the cardiologist he or she may want to stop
the aspirin or change your medicines.
You were seen by swallowing specialists at the hospital and they
felt that your swallowing may be a little impaired. For now, you
should drink thickened liquids and eat pureed solids. Your rehab
will reevaluate your swallowing abilities and hopefully you will
be able to eat normal food very soon.
Please call your doctor or return to the hospital if you are
having chest pain, shortness of breath, fevers or for any other
symptoms which are concerning to you.
FOR REHAB:
PLEASE DO NOT GIVE SEROQUEL AS PT DEVELOPED LONG QT (QTc of 512)
ON SEROQUEL ALONE. Would also be wary of other antipsychotics.
If acutely agitated can give ativan 0.5.
Please give the following medicines: Heparin (Porcine) 5,000
unit/mL Solution Sig: One (1) Injection TID (3 times a day):
please only give if patient is not out of bed qshift.
Topiramate 100 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Divalproex 125 mg Capsule, Sprinkle Sig: Two (2) Capsule,
Sprinkle PO QID (4 times a day).
Clonazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
Miconazole Nitrate 2 % Cream Sig: One (1) Appl Vaginal HS
(at bedtime) for 4 days.
Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO DAILY (Daily).
Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS
(4 times a day (before meals and at bedtime)): Please
discontinue if pt having more than 1 BM per day.
Multi-Vitamin W/Minerals Capsule Sig: One (1) Capsule PO
once a day.
Synthroid 100 mcg Tablet Sig: One (1) Tablet PO once a day.
Tablet(s)
Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every
6 hours) as needed for headache. Tablet(s)
Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for severe agitation
Please check a valproate level on friday [**2167-6-27**] and call the
result to Dr [**Last Name (STitle) 15095**] (her psychiatrist) at [**Telephone/Fax (1) 41985**], please
verbally confirm with her doctor (or his representative) that
her valproate dose is appropriate.
Please check TSH and free T4 on [**2167-7-8**] and [**2167-7-22**] and call the
result to Dr [**Last Name (STitle) 3540**] (her endocrinologist) at [**Telephone/Fax (1) 1803**], please
verbally confirm that her doctor (or his representative) that
the synthroid dose is appropriate.
Please monitor vital signs per routine and call Dr [**Last Name (STitle) 16646**], her
PCP, [**Name10 (NameIs) **] concerning values (HR >105 or <65, BP >160/90 or BP
<95/55, oxygen saturation <93% on RA) at [**Telephone/Fax (1) 27258**].
Please continue to treat pt's unstagable decubitus ulcers, on
both hips, per nursing notes. Site: Left hip
Description: 3x2 unstagable pressure ulcer on L hip. wound bed
is yellow. Surrounding skin is intact.
Care: cleanse with wound cleanser. Apply mepilex q3 days and PRN
Pt needs PT, OT, speech and swallow and social work involvement.
Followup Instructions:
You should call your psychiatrist's office, Dr [**Last Name (STitle) 15095**], as soon
as you are discharged from rehab. His phone number is
[**Telephone/Fax (1) 41985**].
You should see your primary care doctor, Dr [**Last Name (STitle) 16646**]. as soon as
you are discharged from rehab. His phone number is [**Telephone/Fax (1) 27258**].
You have an appointment with the following endocrinologist (who
will follow your thyroid) at [**Hospital3 **] Deaconness in the
[**Hospital Ward Name 23**] building: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 1803**]
Date/Time:[**2167-7-13**] 11:00
You have an appointment with the following cardiologist: [**Doctor First Name 900**]
[**Name8 (MD) 901**], M.D. Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2167-7-13**] 1:40
Completed by:[**2167-6-26**] Name: [**Known lastname 2518**],[**Known firstname 6360**] A Unit No: [**Numeric Identifier 7582**]
Admission Date: [**2167-6-9**] Discharge Date: [**2167-6-25**]
Date of Birth: [**2123-6-18**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 175**]
Addendum:
Expected rehab length of stay is less than 30 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7340**] - [**Location (un) **] [**Doctor First Name **] - [**Location (un) 4186**]
[**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern1) 181**] MD [**MD Number(1) 182**]
Completed by:[**2167-7-3**]
|
[
"518.0",
"965.00",
"518.81",
"E849.0",
"423.9",
"933.1",
"965.02",
"296.80",
"304.23",
"564.00",
"482.41",
"560.1",
"244.9",
"E950.0",
"276.2",
"E915",
"357.5",
"507.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"96.72",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
19753, 20031
|
6306, 7651
|
332, 350
|
13691, 13698
|
3329, 6283
|
18450, 19730
|
2592, 2630
|
11393, 13417
|
13583, 13583
|
10859, 11370
|
13722, 18427
|
2645, 3310
|
13651, 13670
|
273, 294
|
378, 2236
|
13602, 13630
|
7666, 10833
|
2258, 2351
|
2367, 2576
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,138
| 161,176
|
25931
|
Discharge summary
|
report
|
Admission Date: [**2176-12-13**] Discharge Date: [**2176-12-18**]
Service: MEDICINE
Allergies:
Nembutal Sodium / Penicillins
Attending:[**First Name3 (LF) 1055**]
Chief Complaint:
CC:[**CC Contact Info 64473**]
Major Surgical or Invasive Procedure:
bronchoscopy
History of Present Illness:
HPI: This is a [**Age over 90 **] year old woman with PMH significant for mild
dementia and macular degeneration who presented to [**Hospital3 **] following an "choking" episode this morning. The
paramedics described that she had a primary respiratory arrest
at the scene followed by a cardiac arrest, which they believe to
be PEA arrest that resolved with oxygen only. The heimlich
maneuver and CPR were performed followed by intubation at the
scene. The RN note indicates that she was pulseless. The RN note
indicates that defibrillation was attempted at 75 joules
followed by a strong pulse; there is no other record of a shock.
The pt was transported to [**Hospital6 **] with stable VS.
There she was described to the family as "almost dead" but was
"brought back."
.
At [**Hospital6 **], the pt was transferred to the MICU
where the CXR demonstrated mediastinal emphysema and
subcutaneous air. Bronchoscopy demonstrated tear of right
lateral aspect of her membranous trachea or bronchus
intermedius. She was transferred from the [**Hospital1 34**] MICU to the to
[**Hospital1 18**] MICU for interventional pulmonary assessment.
.
ROS: The patient says she has pain with breathing in her chest.
She denies abdominal pain.
.
Past Medical History:
PMH:
Alzheimer's dementia
macular degeneration
vertigo
hypothyroidism
depression with anxiety and delusions
A fib
Social History:
SH: She resided at [**Hospital1 **] house for the last 2 years. She is
reportedly alert and oriented x 3 at baseline according to her
son, and is able to carry on a conversation about family events.
No alcohol, tobacco, or other drug use.
Family History:
non-contributory
Physical Exam:
PE: V: T 99 BP 104/81 P 77 RR 17 97% 2L NC
Gen: Elderly female, responsive to voice, in NAD
HEENT: Pupils contricted bilaterally, OP clear
Resp: crackles at bases R>L
CV: RRR no mrg
Abd: soft NT, ND +BS
Ext: warm, no cyanosis, clubbing, edema. 2+ DP bilaterally
Neuro: pupils small bilaterally. moves all extremities to
command
Skin: no rashes crepitance inferior to right clavicle
.
Pertinent Results:
OSH labs:
12.9 \13.0/212
/38.5\
.
141 108 18
-----------< 245
3.9 22 0.9
.
ALT 45 ALT 50 T bili 0.6
Troponin <0.01 TP 5.7 Alb 3.5 Alk phos 123
UA negative, culture pending
.
EKG - NSR, RBBB, old.
.
CXR (reports from [**Hospital3 **]) -
1) right mainstem bronchus intubation
2) subcutaneous air with mediastinal air, R lung clear, left
pleural effusion with possible pneumonia. Possible
pneumomediastinum.
3) CHF with interstitial edema
4) large amount of subcutaneous emphysema present with mild
interstitial edema, right cehst tube in place
.
[**2176-12-18**] 05:15AM BLOOD WBC-6.7 RBC-3.98* Hgb-12.1 Hct-34.3*
MCV-86 MCH-30.5 MCHC-35.4* RDW-14.3 Plt Ct-177
[**2176-12-17**] 06:10AM BLOOD WBC-7.1 RBC-3.79* Hgb-11.2* Hct-32.6*
MCV-86 MCH-29.7 MCHC-34.5 RDW-14.4 Plt Ct-162
[**2176-12-16**] 05:45AM BLOOD WBC-7.3 RBC-3.80* Hgb-11.2* Hct-31.9*
MCV-84 MCH-29.4 MCHC-35.0 RDW-14.1 Plt Ct-158
[**2176-12-15**] 12:24PM BLOOD Hct-33.3*
[**2176-12-14**] 12:03AM BLOOD WBC-11.9* RBC-4.64 Hgb-13.9 Hct-39.8
MCV-86 MCH-30.0 MCHC-34.9 RDW-14.0 Plt Ct-178
[**2176-12-14**] 12:03AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-1+
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-1+
[**2176-12-18**] 05:15AM BLOOD Plt Ct-177
[**2176-12-16**] 05:45AM BLOOD Plt Ct-158
[**2176-12-16**] 05:45AM BLOOD PTT-38.6*
[**2176-12-15**] 06:27AM BLOOD Plt Ct-142*
[**2176-12-14**] 12:03AM BLOOD Plt Ct-178
[**2176-12-14**] 12:03AM BLOOD PT-11.8 PTT-26.9 INR(PT)-0.9
[**2176-12-18**] 05:15AM BLOOD Glucose-106* UreaN-14 Creat-0.6 Na-143
K-4.4 Cl-110* HCO3-25 AnGap-12
[**2176-12-17**] 06:10AM BLOOD Glucose-123* UreaN-16 Creat-0.7 Na-140
K-4.0 Cl-110* HCO3-25 AnGap-9
[**2176-12-15**] 06:27AM BLOOD Glucose-89 UreaN-12 Creat-0.7 Na-142
K-4.1 Cl-111* HCO3-24 AnGap-11
[**2176-12-14**] 12:03AM BLOOD Glucose-37* UreaN-15 Creat-0.8 Na-144
K-3.8 Cl-110* HCO3-25 AnGap-13
[**2176-12-15**] 06:27AM BLOOD LD(LDH)-235
[**2176-12-18**] 05:15AM BLOOD Calcium-8.8 Phos-2.6* Mg-1.8
[**2176-12-17**] 06:10AM BLOOD Calcium-8.5 Phos-2.7 Mg-1.9
[**2176-12-16**] 05:45AM BLOOD Calcium-8.3* Phos-2.9 Mg-2.4 Iron-31
[**2176-12-15**] 06:27AM BLOOD Calcium-8.8 Phos-2.4* Mg-1.6
[**2176-12-14**] 12:03AM BLOOD Calcium-8.9 Phos-2.6* Mg-1.8
[**2176-12-14**] 01:57AM BLOOD Type-ART pO2-74* pCO2-39 pH-7.34*
calHCO3-22 Base XS--4
[**2176-12-15**] CT
IMPRESSION: 1) No mediastinal fluid collection seen. No
distinct tear of the trachea or bronchial walls identified.
Sensitivity of detection for
tracheobronchial wall injury is low, given the presence of
extensive
pneumomediastinum.
2) Endotracheal soft tissue could represent hematoma or
hypertrophic mucosa.
3) Collapse of the left lower lobe as well as portions of the
right lower lobe and lingula that may reflect retained
secretions or aspiration.
Brief Hospital Course:
A/P: [**Age over 90 **] year old woman with h/o dementia and A fib here with
pneumomediastinum s/p intubation attempt.
.
1) Tracheobronchial tree laceration with [**Hospital 64474**]
transfer to the [**Hospital1 18**] MICU, the patient continued to breath
spontaneously without evidence of obstruction. There was no need
for intubation. Her chest tube was removed on [**2176-12-14**]. She has
been healing well at the site since that time. Per
interventional pulmonology, the airway would likely
spontaneously heal on its on without the need for intervention
or stenting. The pt was stable from a respiratory standpoint and
is to be transferred to the floor. She continued to breath
comfortably while on the wards with oxygen given via nasal
cannula for pt comfort. She is to have a follow-up bronchoscopy
in [**10-18**] days aas an out-patient.
.
2) dementia with more depressed mental status: On admission the
patient had a waxing/[**Doctor Last Name 688**] mental status. this was felt to be
likely [**2-7**] to her anesthesia with her pain medication as well
as the ICU environment contributing. Her electrolytes were WNL.
She was continued on her home zyprexa and trazodone, though at
lower doses given her altered mental status. After arriving to
the floor, the patient's mental status steadily improve. She
became more lucid and interactive, at her baseline as described
by her family.
.
3) pain: The pt was complaining to pain focused in her
chest/sternum. This was likely due to chest compressions in
code. CT chest did nor reveal rib fracture. She was given
tylenol standing ATC with prn morphine. She reported that her
pain was well-controlled on this regimen.
.
4) ? aspiration pneumonia/pneumonitis--A CXR demonstrated a new
LLL consolidation. A video swallow study performed at [**Hospital1 18**]
demonstrated that the pt is not demonstrating any signs or
symptoms of aspiration or oropharyngealdysphagia at bedside with
thin liquids and pureed solids. The patient was started on a
regular diet of thin liquids/pureed solids and tolerated this
diet well. She was started on a 7 day course of levo/flagyl for
treatment of presumed aspiration pna.
.
5) hypothyroidism--The pt's TSH was checked and found to be high
at 22. Her synthroid was increased from 75 mcg daily to 87.5 mcg
daily.
.
6) PAF hx: The pt was in sinus rhythm during this admission with
a well-controlled rate. She was on no anti-coagulation as an
out-patient. Issues of anti-coagulation should be readdressed on
transfer.
.
7) glucose control - The patient was initially placed on an
insulin sliding scale for tight control in the MICU. On trasnfer
to the floor her ISS and FSs were d/c'd.
.
8) proph - The pt was continued on colace, SQH, PPI throughout
the admission
.
9) FEN: The pt initially received PPN and was NPO on admission.
However, following the video swallow study she received a
regular diet as above.
.
10) Code - The pt is full code. This was discussed with the HCP
(de facto HCP daughter, [**Name (NI) 2411**] as pt's parents and husband are
deceased). Her son-in-law, [**Name (NI) **] is involved in decision making
in conjunction with [**Doctor First Name 2411**].
.
11) communication - with [**Doctor First Name 2411**] (daughter and HCP) [**Telephone/Fax (1) 64475**]
cell, [**Telephone/Fax (1) 64476**] (home)
.
12) Dispo-- transfer back to [**Hospital6 **].
Medications on Admission:
Meds (at [**Hospital1 **] house)
ASA 81 mg po qd
Cosopt 1 OU QD
levothyroxine 75 mcg po qd
propranolol 20 mg po bid
meclizine 12.5 po bid
zyprexa 2.5 mg po QAM, 7.5 mg po qpm
tranzodone 50 mg po qhs
trazodone 50 mg po Q4H PRN
vitamin b12 1000 po qd
MOM 30 ml po Q4H prn
tylenol 650 mg po q4h prn
loperamide 2 mg po q4h prn
dulcolax 10 mg po qd prn
artificial tears
diet: house, ground low lactose with eggs daily
.
All: penicillin, hyosciamine, promethazine, pentobarbital
.
Discharge Medications:
1. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
2. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic QD ().
4. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
7. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-7**]
Drops Ophthalmic PRN (as needed).
8. Levofloxacin 250 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours) for 6 days.
9. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
10. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
11. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
12. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
13. Levothyroxine 175 mcg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
14. Morphine 2 mg/mL Syringe Sig: One (1) Injection Q2H (every
2 hours) as needed for pain.
15. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO three
times a day for 7 days: day 1= [**12-14**].
Discharge Disposition:
Extended Care
Facility:
southshor
Discharge Diagnosis:
Primary: pneumomediastinum, tracheal laceration
Secondary: atrial fibrillation, Alzheimer's dementia, macular
degeneration, hypothyroidism, depression, anxiety
Discharge Condition:
Stable. The patient is breathing comfortably and her mental
status appears to be at baseline as described by her family.
Discharge Instructions:
The patient continue to take her medications as prescribed.
She should follow-up with her appointments as below. She should
have
The pt should not recive any positive pressure ventilatory
assist as this may exacerbate the bronchial laceration.
Intubation should be avoided if at all possible.
The patient should continue to eat according to the following
recommendations:
1.Pureed solids, thin liquids, po meds crushed in purees.
2.Assist with feeding, but allow for independent feeding as
much as possible.
3.Maintain aspiration precautions.
Followup Instructions:
Dr. [**Last Name (STitle) **] from Interventional Pulmonary will contact the patient
with her out-patient bronchoscopy appointment in [**10-18**] days.
In the meantime, the pt should not recive any positive pressure
ventilatory assist as this may exacerbate the bronchial
laceration. Intubation should be avoided if at all possible.
|
[
"244.9",
"E879.8",
"998.81",
"786.59",
"331.0",
"294.10",
"507.0",
"427.31",
"874.02",
"519.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.22"
] |
icd9pcs
|
[
[
[]
]
] |
10374, 10410
|
5178, 6058
|
270, 285
|
10615, 10738
|
2392, 5155
|
11353, 11690
|
1954, 1972
|
9066, 10351
|
10431, 10594
|
8567, 9043
|
10762, 11330
|
1987, 2373
|
200, 232
|
313, 1543
|
6073, 8541
|
1565, 1681
|
1697, 1938
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,211
| 175,976
|
28903
|
Discharge summary
|
report
|
Admission Date: [**2117-7-17**] Discharge Date: [**2117-7-25**]
Date of Birth: [**2060-9-28**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Transfer from OSH for further work-up of interstitial lung
disease.
Major Surgical or Invasive Procedure:
Intubation.
History of Present Illness:
56 y.o. man with hx of osteoarthritis, HTN, hyperlipidemia
admitted from [**Hospital3 **] hospital where he has been undergoing
workup of severe unexplained dyspnea. Patient says that he last
felt genuinely well back in [**2116-8-22**]. At that time he was
able to ride a stationary bike for [**3-31**] miles without undue SOB.
In [**2116-9-22**], he developed a red rash on his forehead, his
knuckles, and his shins, he developed aches in his wrists,
fingers, shoulders, and knees, R > L, and he began to feel a
little tired. Patient thought he might have Lyme and tired to
"ride it out" for about 2 months. The tired feeling persisted so
he went to his PCP where he tested negative for Lyme. It's
somewhat unclear but the rash resolved except for on his fingers
and he received a 2 week course of doxycycline.
.
He next came to medical attention in early [**Month (only) 116**] when he noticed
he had some SOB. He had a CXR and was diagnosed with PNA and
treated with 10 days of moxifloxacin. A repeat CXR showed
unresolving PNA and he received 10 more days of moxifloxicin. He
didn't really improve and in [**Month (only) 205**] he had an episode while
traveling. He says he was walking accross a hotel lobby when he
"ran out of gas" and felt like he couldn't support the weight of
his suitcase or take another step. He says that he stood there
until he was helped by a friend to a seat where he recovered
after about 30 minutes. He reports some dry non-productive
coughing associated with the episode but felt the SOB was the
[**Last Name **] problem. [**Name (NI) **] became concerned after this episode and saw a
pulmonologist. He has since been undergoing work-up for his
dyspnea.
The work-up was interrupted by a cholecystectomy about two weeks
ago.
.
Pt says that the dyspnea has been very slowly progressive since
it began, better in cold environments and when he lays down,
worse when sitting, with any exertion, or in humidity; Of note,
he says that he has begun to feel slightly better over the past
2-3 days with slightly better air movement.
.
ROS: 35 # weight loss in past month, increase in constipation
(1-2x per day, now QOD or less), no urinary complaints, +
nausea, no vomiting, no congestion or nasal discharge; no new
rashes
Past Medical History:
L ACL repair in [**8-/2114**]
Osteoarthritis
HTN
Hyperlipidemia
hx of scarlet and rheumatic fevers as child
s/p appendectomy in [**2095**]
Social History:
Married, works in retail sales; travels 3 x per year to [**State 2690**].
Hx of tobacco use 1 PPD x 30 years, quit 7 years ago; Infrequent
alcohol x "his whole life"; smoked marijuana in the past but
says he never used it regularly; Has had sex with a prostitute ~
30 years ago but says he used protection and has no other HIV
risk factors - has never been tested.
Family History:
Brother with [**Name2 (NI) **]; Mother is 85 without significant disease
Physical Exam:
VS: Temp: 96 BP: 124/85 HR: 98 RR: 22 O2sat: 100% on NRB
GEN: man lying in bed, breathing with slight effort
HEENT: PERRLA, EOMI, MMM, neck supple
RESP: fine dry crackles in lower [**11-23**] lung fields, decreased air
movement
chest
CV: regular, nl s1, s2, no m/r/g, + crepitus in chest wall, R>L
ABD: soft, NT, ND, + BS, no HSM, well-healed surgical scars
EXT: no edema, trace DP pulses, +2 popliteal pulses
Skin: + Gottron's sign on hands BL
Pertinent Results:
Labwork on admission:
[**2117-7-17**] 09:31PM WBC-8.9 RBC-5.09 HGB-13.6* HCT-40.8 MCV-80*
MCH-26.7* MCHC-33.3 RDW-14.6
[**2117-7-17**] 09:31PM PLT COUNT-378
[**2117-7-17**] 09:31PM PT-10.9 PTT-26.6 INR(PT)-0.9
[**2117-7-17**] 09:31PM GLUCOSE-129* UREA N-18 CREAT-0.5 SODIUM-130*
POTASSIUM-4.8 CHLORIDE-92* TOTAL CO2-31 ANION GAP-12
[**2117-7-17**] 09:31PM CALCIUM-8.4 PHOSPHATE-2.6* MAGNESIUM-2.8*
.
Wedge biopsies of lung, right lower lobe:
a. Acute and organizing pneumonitis superimposed over a
background of chronic interstitial pneumonitis with interstitial
fibrosis and honeycomb change.
b. Special stains for fungi and pneumocystis are negative.
Note: An infectious process (viral or bacterial) superimposed
over chronic interstitial lung disease such as usual
interstitial pneumonia or fibrosing non-specific interstitial
pneumonitis should be considered.
.
CHEST (PORTABLE AP) [**2117-7-24**] 12:17 PM
CHEST: Compared to the prior chest x-ray of two hours before
there is increasing opacities in both lungs against the
background of interstitial lung disease. These appearances
suggest failure. Right pneumothorax is again seen essentially
unchanged in size since the prior chest x-ray.
IMPRESSION: New onset pulmonary edema.
Brief Hospital Course:
56 yoM with past medical history of osteoarthritis,
hypertension, hyperlipidemia admitted from [**Hospital3 **] Hospital for
further work-up of his severe dyspnea. The patient had
interstital lung disease diagnosed by biopsy, likely secondary
to dermatomyositis vs. other collagen vascular disease. Patient
developed a pneumothorax seven days into his hospitalization and
required intubation. On Day 3 of intubation, the patient could
not be oxygenated despite FiO2 100% and high pressures with
O2sats to 60-70s. Family decided to make him CMO and he was
extubated and passed within 20 minutes.
Medications on Admission:
Lipitor
Lisinopril
Discharge Medications:
None.
Discharge Disposition:
Expired
Discharge Diagnosis:
Deceased.
Discharge Condition:
Deceased.
Discharge Instructions:
Deceased.
Followup Instructions:
Deceased.
|
[
"253.6",
"518.81",
"512.1",
"272.0",
"515",
"710.3",
"401.9",
"288.8",
"715.90",
"564.00",
"E932.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04",
"38.93",
"34.09",
"99.28",
"34.04",
"38.91",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
5760, 5769
|
5064, 5660
|
383, 396
|
5822, 5833
|
3792, 3800
|
5891, 5903
|
3236, 3310
|
5730, 5737
|
5790, 5801
|
5686, 5707
|
5857, 5868
|
3325, 3773
|
276, 345
|
424, 2674
|
3814, 5041
|
2696, 2837
|
2853, 3220
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,736
| 196,052
|
32001
|
Discharge summary
|
report
|
Admission Date: [**2140-1-4**] Discharge Date: [**2140-1-11**]
Date of Birth: [**2082-10-29**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
mild DOE
Major Surgical or Invasive Procedure:
AVR (29 porcine) Replac Asc Aorta (30 Gelweave graft)[**1-4**]
/Reexploration for bleeding [**1-4**]
History of Present Illness:
57 yo M with h/o AI and minimal DOE followed by echo. Most
recent echo showed severe AI and bicuspid AV, dilated aorta and
preserved LVEF. Referred for surgery.
Past Medical History:
AI, Hep C, Anemia, COPD
Social History:
works with extruding company
lives with wife
etoh: case of beer per week
quit tobacco [**2118**]
Family History:
NC
Physical Exam:
hr 65 bp 131/51
NAD
Lungs CTAB
Heart RRR 4/6 DM t/o->neck
Abdomen benign
Extrem warm, no edema
Mild LLE varicosities
Pertinent Results:
[**2140-1-8**] 07:05AM BLOOD WBC-8.2 RBC-3.05* Hgb-10.0* Hct-28.4*
MCV-93 MCH-32.8* MCHC-35.2* RDW-14.3 Plt Ct-167
[**2140-1-8**] 07:05AM BLOOD Plt Ct-167
[**2140-1-5**] 12:33PM BLOOD PT-14.2* PTT-29.4 INR(PT)-1.2*
[**2140-1-7**] 07:25AM BLOOD Glucose-112* UreaN-9 Creat-0.9 Na-143
K-3.7 Cl-103 HCO3-28 AnGap-16
[**Known lastname 74966**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 74967**] (Complete)
Done [**2140-1-4**] at 2:55:15 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Last Name (Prefixes) 413**], [**First Name3 (LF) 412**]
Division of Cardiothoracic [**Doctor First Name **]
[**First Name (Titles) **] [**Last Name (Titles) **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2082-10-29**]
Age (years): 57 M Hgt (in): 68
BP (mm Hg): 122/80 Wgt (lb): 147
HR (bpm): 75 BSA (m2): 1.79 m2
Indication: Intraoperative TEE for AVR, ascending aortic
replacement
ICD-9 Codes: 786.05, 440.0, 424.1, 424.0
Test Information
Date/Time: [**2140-1-4**] at 14:55 Interpret MD: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5740**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Suboptimal
Tape #: 2007AW3-: Machine: 3
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Inferolateral Thickness: *1.4 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: *7.5 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 25% to 30% >= 55%
Aorta - Annulus: *3.8 cm <= 3.0 cm
Aorta - Sinus Level: *4.7 cm <= 3.6 cm
Aorta - Ascending: *4.2 cm <= 3.4 cm
Aorta - Descending Thoracic: *3.6 cm <= 2.5 cm
Aortic Valve - Pressure Half Time: 240 ms
Findings
LEFT ATRIUM: Dilated LA. All four pulmonary veins identified and
enter the left atrium.
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: Mild symmetric LVH. Severely dilated LV cavity.
Severely depressed LVEF. [Intrinsic LV systolic function likely
depressed given the severity of valvular regurgitation.]
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Moderately dilated aortic sinus. Moderately dilated
ascending aorta. Moderately dilated descending aorta Simple
atheroma in descending aorta. No 2D or Doppler evidence of
distal arch coarctation.
AORTIC VALVE: Bicuspid aortic valve. Mildly thickened aortic
valve leaflets. Aortic leaflet prolapse. No AS. Severe (4+) AR.
Eccentric AR jet directed toward the anterior mitral leaflet.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild MVP.
Mitral leaflets fail to fully coapt. Mild mitral annular
calcification. Eccentric MR jet. Moderate (2+) 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. Suboptimal image
quality. The patient appears to be in sinus rhythm. Results were
Conclusions
PRE-BYPASS:
1. The left atrium is dilated. No atrial septal defect is seen
by 2D or color Doppler.
2. There is mils symmetric left ventricular hypertrophy. The
left ventricular cavity is severely dilated. Overall left
ventricular systolic function is severely depressed (LVEF= 25-30
%). [Intrinsic left ventricular systolic function is likely more
depressed given the severity of valvular regurgitation.]
3. Right ventricular chamber size and free wall motion are
normal.
4. The aortic root is moderately dilated at the sinus level. The
ascending aorta is moderately dilated. There is a section of the
descending thoracic aorta, just distal to the aortic arch that
appears moderately dilated. There are simple atheroma in the
descending thoracic aorta and the aortic arch.
5. The aortic valve is bicuspid. The aortic valve leaflets are
mildly thickened. There is no aortic valve stenosis. Severe (4+)
aortic regurgitation is seen. The aortic regurgitation jet is
eccentric, directed toward the anterior mitral leaflet.
6. The mitral valve leaflets are mildly thickened. There is mild
mitral valvular prolapse. An eccentric, anteriorly directed jet
of Moderate (2+) mitral regurgitation is seen.
7. There is no evidence of PDA or coarctation.
POST-BYPASS:
Patient removed from cardiopulmonary bypass on a phenylephrine
infusion.
1. There is a bioprosthetic aortic valve that is well seated
with no evidence of paravalvular leak or valvular aortic
regurgitation. Mean gradient across the valve is 8.6mmHg with a
maximum around 20 mm Hg.
2. Biventricular function is unchanged with LVEF 25-30%.
3. Degree of mitral regurgitation is also unchanged.
4. Aortic contours are intact post-decannulation.
5. The ascending aortic graft can not be visualized.
Brief Hospital Course:
He was taken to the operating room on [**1-4**] where he underwent
an AVR & replacement of ascending aorta. He was transferred to
the ICU in stable condition. He was taken back to the operating
room later that same day for bleeding and was found to have
chest wall bleeding. He was returned to the ICU. He was
extubated on POD #1. He was transferred to the floor on POD #2.
He was noted to have an air leak on his left pleural chest tube;
it was left in while his meiastinal tubes were removed. It was
placed to water seal on POD # 3, but he had a pneumothorax on
CXR. The tube was again placed to water seal on POD # 4, CXR
revealed a left apical ptx. This remained, but the airleak
resolved. The tube was ultimately removed on POD #6 when the
airleak resolved. Repeat CXR showed slight increase in ptx. He
remained in the hospital another day. Repeat CXR showed
decrease in left apical ptx., he has remained hemodynamically
stable, and is ready to be discharged home.
Medications on Admission:
norvasc 5', lisinopril 10'
Discharge Medications:
1. Atorvastatin 10 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. Folic Acid 1 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:*50 Tablet(s)* Refills:*0*
5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 7 days.
Disp:*30 Tablet(s)* Refills:*0*
9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours)
for 7 days.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
10. 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*
11. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO
twice a day.
Disp:*60 Tablet(s)* Refills:*2*
12. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
home health and hospice
Discharge Diagnosis:
AI now s/p AVR/replacement of ascending aorta
Hep C, Anemia, COPD
Discharge Condition:
Good.
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions, creams or powders to incisions.
No lifting more than 10 pounds or driving until follow up with
the surgeon.
[**Last Name (NamePattern4) 2138**]p Instructions:
Dr. [**Last Name (Prefixes) **] 2 weeks
Dr. [**Last Name (STitle) 39975**] 4 weeks
Dr. [**Last Name (STitle) **] 6 weeks
Completed by:[**2140-1-11**]
|
[
"424.1",
"746.4",
"512.1",
"E878.2",
"441.2",
"427.31",
"998.11",
"496",
"070.54"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.03",
"39.61",
"35.21",
"38.45"
] |
icd9pcs
|
[
[
[]
]
] |
8634, 8688
|
6144, 7121
|
330, 433
|
8798, 8806
|
957, 6121
|
800, 804
|
7198, 8611
|
8709, 8777
|
7147, 7175
|
8830, 9086
|
9137, 9289
|
819, 938
|
282, 292
|
461, 623
|
645, 670
|
686, 784
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,796
| 141,386
|
11368
|
Discharge summary
|
report
|
Admission Date: [**2155-9-16**] Discharge Date: [**2155-9-22**]
Date of Birth: [**2078-9-11**] Sex: M
Service: [**Hospital Unit Name 196**]
CHIEF COMPLAINT: Sent to the Emergency Department for chest
pain during a stress test.
HISTORY OF PRESENT ILLNESS: This is a 77-year-old male with
a history of coronary artery disease status post coronary
artery bypass graft surgery, insulin dependent-diabetes
mellitus, congestive heart failure, chronic atrial
fibrillation, and chronic renal insufficiency, who is sent to
the Emergency Department after having chest pain and
bilateral arm weakness during his stress test. He did not
have any associated nausea, vomiting, or diaphoresis. He did
not experience any palpitations. He describes the chest pain
as more heaviness rather than chest pain.
PAST MEDICAL HISTORY:
1. Atrial fibrillation on Coumadin.
2. Coronary artery disease status post coronary artery bypass
graft surgery.
3. Insulin dependent-diabetes mellitus.
4. Anemia.
5. Gout.
6. Systolic congestive heart failure with an ejection
fraction of less than 20%.
7. Status post pacemaker ICD placement.
8. Chronic renal insufficiency.
ALLERGIES: Morphine causing nausea.
MEDICATIONS ON ADMISSION:
1. Gemfibrozil 600 mg twice a day.
2. Lasix 20 mg daily.
3. Altace 5 mg daily.
4. Coumadin 5 mg daily except Sundays 2.5 mg.
5. Digoxin 0.125 mg Monday, Wednesday, [**Last Name (LF) 2974**], [**First Name3 (LF) 1017**].
6. Allopurinol 150 mg daily.
7. Colchicine 0.5 mg q day.
8. Folic acid 1 mg daily.
9. Zebeta 5 mg.
10. Aspirin 325 mg daily.
11. Humalog insulin-sliding scale.
12. NPH insulin, 18 units in the morning, 5 units hs.
SOCIAL HISTORY: No tobacco, occasional alcohol [**3-10**] drinks
per month, retired systems engineer.
PHYSICAL EXAMINATION: Temperature 98.7, heart rate 64, blood
pressure 112/50, respiratory rate 18, and oxygen saturation
is 99% on 2 liters. General: Alert and oriented in no acute
distress. HEENT: Pupils are equal, round, and reactive to
light. Supple neck. Jugular venous distention approximately
10 cm above the sternal notch. Cardiovascular examination:
regular, rate, and rhythm, no murmurs, rubs, or gallops.
Lungs: Faint crackles at the bases bilaterally. Abdomen is
soft, nontender, nondistended. Extremities: No edema.
Neurologic is alert and oriented. Cranial nerves II through
XII are grossly intact. Strength are [**6-9**] bilaterally in
upper and lower extremities.
LABORATORY VALUES: White blood cell count 5.6, hematocrit
37.3, platelets 124, MCV 100, INR 2.4. Sodium 135, potassium
5.7, chloride 107, bicarb 16, BUN 97, creatinine 2.7, glucose
224. Digoxin 0.8.
ELECTROCARDIOGRAM: Showed bigeminy with V-paced beats
alternating with intrinsic beats, left bundle branch block,
no acute changes, no ST-T wave changes.
CHEST X-RAY: Showed stable cardiomegaly without evidence of
acute cardiopulmonary disease.
Stress test revealed extensive reversible ischemic changes
with an ejection fraction of 19%. MIBI revealed severe
global hypokinesis with large inferior wall and moderate
anterior apical defects, severe systolic dysfunction with
septal hypokinesis with an ejection fraction of 19%.
HOSPITAL COURSE:
1. Chest pain/positive stress test: The patient underwent
cardiac catheterization which revealed severe native vessel
coronary artery disease with one patent saphenous vein graft
to OM graft with two focal stenoses, markedly elevated right
and left sided filling pressures, successful stenting of the
right coronary artery, ostial saphenous vein graft lesion,
and distal saphenous vein graft lesion. An intra-aortic
balloon pump was placed prophylactically secondary to the
patient's severe systolic dysfunction. The patient was
transferred to the CCU for monitoring, and was transferred to
the floor after only a short stay.
The patient was given Mucomyst and IV fluid hydration prior
to catheterization in light of his chronic renal
insufficiency.
2. Systolic congestive heart failure: The patient was
admitted on daily Lasix, ACE inhibitor, digoxin, and a beta
blocker. His diuretics and ACE inhibitor were held initially
secondary to his acute on chronic renal insufficiency. On
discharge, the patient was restarted on his ACE inhibitor,
however, his daily Lasix will be held until his follow-up
appointment with his cardiologist, Dr. [**Last Name (STitle) **]. The patient
will measure his weights daily, and will notify Dr.[**Name (NI) 23312**]
office if his weight increases more than five pounds.
3. Acute on chronic renal insufficiency: The patient has
chronic renal insufficiency with a baseline creatinine of 1.5
to 1.8, which is likely secondary to diabetic nephropathy.
On admission, the patient's creatinine was 2.7. The
patient's Lasix, ACE inhibitor, Allopurinol, and colchicine
were all held because they were felt to be major contributors
to his acute renal failure. The renal team was consulted.
It was felt that the patient's acute on chronic renal failure
was secondary to a large component of prerenal hypovolemia as
well as renal tubular acidosis type IV.
The patient was started on sodium bicarbonate 650 mg twice a
day, and was given IV fluid hydration including normal saline
with bicarbonate. The patient's creatinine responded well to
IV hydration and holding of nephrotoxic medications and on
the day of discharge, his creatinine had returned to his
baseline at 1.5. The patient will continue to take sodium
bicarbonate as an outpatient. He will also be taking his
daily ACE inhibitor and daily Allopurinol. He will not take
his colchicine unless he has an acute flare of gout.
4. Diabetes mellitus: The patient was continued on his fixed
doses of NPH, and was placed on an insulin-sliding scale.
CONDITION ON DISCHARGE: Fair.
DISCHARGE STATUS: Home.
DISCHARGE INSTRUCTIONS: Please follow up with your primary
care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] within 1-2 weeks. Please follow
up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] as previously scheduled, [**10-23**]. Please have your INR checked in [**4-8**] days as Coumadin
dose may need to be adjusted. Your goal INR should be
between [**3-10**]. Please have the results called to your primary
care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **].
DISCHARGE DIAGNOSES:
1. Unstable angina.
2. Coronary artery disease.
3. Systolic congestive heart failure.
4. Insulin dependent diabetes.
5. Chronic renal insufficiency.
6. Acute renal failure.
7. Renal tubular acidosis type IV.
8. Hyperkalemia.
9. Anemia.
10. Gout.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg daily.
2. Plavix 75 mg daily.
3. Gemfibrozil 600 mg twice daily.
4. Folic acid 1 mg daily.
5. Digoxin 125 mcg Monday, Wednesday, [**Last Name (LF) 2974**], [**First Name3 (LF) 1017**].
6. Sodium bicarbonate 650 mg twice daily.
7. Coumadin 5 mg daily.
8. Ramipril 5 mg daily.
9. Allopurinol 150 mg daily.
10. Toprol XL 50 mg daily.
[**First Name8 (NamePattern2) 2064**] [**Last Name (NamePattern1) **], M.D. [**MD Number(2) 2139**]
Dictated By:[**Last Name (NamePattern1) 9609**]
MEDQUIST36
D: [**2155-9-22**] 15:01
T: [**2155-9-24**] 06:06
JOB#: [**Job Number 36407**]
|
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17,372
| 135,863
|
11248
|
Discharge summary
|
report
|
Admission Date: [**2141-10-22**] Discharge Date: [**2141-10-28**]
Service: MICU
CHIEF COMPLAINT: Lightheadedness.
HISTORY OF PRESENT ILLNESS: This is a 77 year old male
with a past medical history significant for coronary artery
disease status post coronary artery bypass graft, atrial
fibrillation, and Hepatitis C, who was brought to [**Hospital1 346**] after a pre-syncopal episode while
having a bowel movement this morning at 02:30 in the morning.
The patient was found by his family on the toilet; he felt
woozy. He did not fall; he did not lose consciousness. He
was recently admitted to the [**Hospital **] Hospital two weeks ago for
weakness. He was evaluated for heart failure. Amiodarone
was stopped at that time secondary to liver toxicity and a GI
evaluation which consisted of an upper GI study which was
normal. During that study, he was found to have ascites.
The patient complains of intermittent epigastric abdominal
pain, non-radiating, with each bowel movement.
PAST MEDICAL HISTORY:
1. Atrial fibrillation.
2. Coronary artery disease status post five-vessel coronary
artery bypass graft with a redo in [**2139**].
3. Hepatitis C with recent ascites.
4. Pacemaker.
5. Congestive heart failure; ejection fraction approximately
15%.
ALLERGIES: To eggs, he gets short of breath and to contrast,
he gets a fever.
MEDICATIONS:
1. Aspirin 325 mg p.o. q. day.
2. Captopril 25 mg p.o. three times a day.
3. Colace 100 mg p.o. twice a day.
4. Spironolactone 300 mg p.o. q. day.
5. Lasix 20 mg p.o. q. day.
6. Nitroglycerin patch, 0.4 mg.
SOCIAL HISTORY: He lives with his wife. [**Name (NI) **] denies any
tobacco, alcohol or intravenous drug use.
FAMILY HISTORY: Significant for coronary artery disease.
PHYSICAL EXAMINATION: Temperature 95.6 F.; blood pressure
80s to 90/40; heart rate 150 to 175; respiratory rate 16; O2
99% on three liters. In general, he is a cachectic somnolent
man. HEENT examination: Oropharynx is clear. Pupils
equally round and reactive to light. Extraocular movements
are intact. Neck is supple. Full range of motion; no
jugular venous distention. Cardiovascular examination:
Irregularly irregular, tachycardic, no murmurs, gallops or
rubs. Pulmonary examination: Decreased breath sounds
bilateral bases, right greater than left. Decreased fremitus
at the right base, no egophony. Abdomen examination: Mildly
distended. Diffusely tender. No guarding, no rebound.
Guaiac positive stool. The lavage via the nasogastric tube
was negative. Liver span is 12 cm. Extremities: No
cyanosis, clubbing or edema. Neurologic examination:
Cranial nerves II through XII are intact. The patient is
alert and oriented times three. Skin examination, no
jaundice, no spider hemangiomas.
LABORATORY: Laboratory data on arrival at the Emergency Room
on [**10-22**] at 3 a.m., white count 5,900, 37 neutrophils,
52 lymphs, 7 monos, 3 eos. Hematocrit 38.8, platelets 120.
PT 15.3, PTT 33.3, INR 1.5. SMA-7, 128, 5.0, 97, 17, 29,
1.2, glucose 101, calcium 8.9, phosphorus 3.5, magnesium 2.1.
CK #1 drawn in the Emergency Room was 67, troponin less than
0.3.
An EKG on arrival showed atrial fibrillation at 80 beats per
minute, left ventricular hypertrophy, Q wave in V2 through
V5, ST elevations in V2.
A CT scan of the abdomen was performed that showed bilateral
pleural effusions, right greater than left, large amount of
ascites, showed a cirrhotic liver, showed minimum aortic
dissection above the bifurcation of 2.8 cm.
Chest x-ray showed bilateral effusions, enlarged cardiac
silhouette, cephalization of vasculature.
At 5 a.m., EKG showed a heart rate of 150 beats per minute,
in ventricular tachycardia with Qs anteriorly and laterally.
There was still left ventricular hypertrophy.
ASSESSMENT: This is a 77 year old man who presented to the
Emergency Department for lightheadedness. While in the
Emergency Department, he experienced bright red blood per
rectum. The NG lavage was negative. He was found to be
alternating between atrial fibrillation and ventricular
tachycardia. He was transferred to the Medical Intensive
Care Unit for further observation.
HOSPITAL COURSE:
1. Gastrointestinal: The cause of the bright red blood
per rectum is most likely a lower GI source. The
possibilities include ischemia and diverticulitis. The
patient will be placed on Protonix. He will be kept NPO;
hematocrits will be checked q. four hours and a call will be
sent to the Blood Bank.
2. Cardiovascular: He has a history of atrial
fibrillation. He is currently not anti-coagulated. He has a
pacer placed recently at the VA. He has congestive heart
failure with an ejection fraction of 15%. The plan would be
to restart amiodarone, however, given the patient's recent
toxicity, Cardiology will be consulted to: 1) Identify the
intrinsic rhythm of his heart and identify the rhythm of the
pacemaker and, 2) make recommendations for anti-arrhythmic
therapy.
3. Infectious Disease: The patient became febrile on
transfer to the Medical Intensive Care Unit. Blood cultures,
urine cultures will be sent. A thoracentesis will be
performed if the patient spikes again and if another source
for infection is not found.
Over the next few days, at first the patient required more
oxygen and the patient's blood pressure remained low, which
is close to his normal of 90s over 60s. The GI bleeding
resolved. The cardiac work-up consisted mostly of obtaining
prior history that showed that prior EP studies had
demonstrated aberrant atrial tachycardia with no inducible
ventricular tachycardia. The patient then progressed to
tachy/brady syndrome which led to a permanent pacemaker and
he is currently AV paced at 80.
The patient's ascites remained stable. The patient was
transiently started on Neo-Synephrine to maintain blood
pressure. By hospital day number four, [**10-24**], the
patient had guaiac negative bowel movements. He was no
longer on pressors. He was feeling better. The patient was
continued on antibiotics of Ciprofloxacin and Flagyl which
was started empirically on the first temperature spike. He
was transferred to the Floor on hospital day number four,
[**10-24**].
The patient remained on the Floor for two days and was
transferred back to the Medical Intensive Care Unit on
[**10-26**], secondary to hypoxia. This is secondary to a
worsening pneumonia complicated by congestive heart failure.
On [**10-27**], the patient was intubated for worsening
hypoxia and respiratory distress. The patient's blood
pressure decreased at that point in time. Possible
contributing factors included sepsis from the pneumonia,
medication induced from the anesthetics used to sedate the
patient and low cardiac output secondary to the patient's 15%
ejection fraction.
A Swan-Ganz catheter was placed and that demonstrated good
cardiac output for this patient of 5 liters per minute. This
probably represents a hyperdynamic heart for this patient
given his reduced ejection fraction and a line was also
placed, an OG tube was placed. Levophed was maxed out.
Neo-Synephrine was also started overnight from [**10-27**]
until [**10-28**]. On [**10-28**], the patient's family
arrived. While seeing him, the patient went into an
supraventricular tachycardia at the rate of 170. The patient
was on 100% oxygen and was maintaining a blood pressure in
the systolics of 60s and at that time the Medical Team
thought further treatment would not benefit the patient.
The family saw the patient and concurred and care was
withdrawn. Approximately ten minutes later, the patient was
pronounced dead on [**2141-10-28**]. An autopsy was refused
by the family. The patient was not discharged; he was
declared deceased on [**2141-10-28**], at 12:55 p.m.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**], M.D. [**MD Number(1) 2438**]
Dictated By:[**Last Name (NamePattern1) 8228**]
MEDQUIST36
D: [**2142-1-30**] 19:17
T: [**2142-2-2**] 10:11
JOB#:
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43,126
| 124,079
|
23428
|
Discharge summary
|
report
|
Admission Date: [**2124-3-1**] Discharge Date: [**2124-8-17**]
Date of Birth: [**2067-4-22**] Sex: M
Service: MEDICINE
Allergies:
Bactrim
Attending:[**First Name3 (LF) 3913**]
Chief Complaint:
CLL with [**Doctor Last Name 6261**] Transformation, admitted for Allo SCT
Major Surgical or Invasive Procedure:
Hickmann Placement & Removal
Central Venous Line Placement and removal x3
PICC Placement and removal x2
Sigmoidoscopy with biopsy
Paracentesis
History of Present Illness:
Mr. [**Known lastname **] is a 56-year-old male with history of CLL with P53
mutation, s/p FCR and PCR, and Campath [**2123-7-9**], with recent new
onset ([**2122-12-21**])left cervical lymph node enlargment which upon
biopsy revealed large cell ([**Doctor Last Name 6261**]) transformation, s/p [**Hospital1 **]
([**Date range (1) 60068**]), s/p ESHAP ([**Date range (1) 35870**]/09) ([**Date range (1) 60070**]) admitted now
for an ablative Cytoxan/Busulfan matched ([**7-27**]) unrelated donor
peripheral stem cell transplant.
.
The patient reports fatigue and anorexia since previous
admission with decreased taste sensation. He is otherwise
feeling well. On review of systems, he denies any fever, chills,
nausea, vomiting, chest pain, SOB, diarrhea, constipation,
dysuria, abdominal pain, weakness, numbness, or tingling. He
reports anxiety and fear entering transplant, but he has
accepted that it is the next step in his therapy and he is
ready.
Past Medical History:
Past Medical History:
Hypertension
Hypercholesterolemia (diet controlled)
S/p tonsillectomy
CLL (see below)
.
Past Oncologic History (Per [**Hospital **] Clinic Note):
Pt presented with his disease back in [**10/2119**] with an elevated
white count and LDH. He was without any splenomegaly or any
cytopenias at that time. He did have some bulky lymphadenopathy.
Over the course of six months, his white count began to rise and
essentially doubled to approximately 130,000 with a rising in
his LDH of up to 1400, and he also was noted to have worsening
palpable lymphadenopathy. He then completed four cycles of FCR
therapy, which he completed back in 09/[**2119**]. He had an excellent
response to therapy and was monitored off treatment for
approximately two years. He then presented in [**7-/2122**] with a
rising white count, approximately 50% lymphocytes,
and a mildly elevated LDH. He also had some mild worsening
palpable lymphadenopathy. He then received four cycles of PCR,
but did not have much in the way of response and his treatment
regimen was switched to R-CVP of which he received two cycles.
He did again not have a significant response, though continued
to have an excellent performance status, and he was ultimately
switched to Campath therapy. He did have resolution of his
lymphocytosis, and his white count has come down nicely, but did
not have much in the way of response in terms of reducing his
bulky lymphadenopathy. He had received chemotherapy initially
through 06/[**2122**]. We had decided to observe him off treatment,
and ultimately, we had decided to move forward with an
allogeneic stem cell transplant; however, back at the end of the
summer, his donor had backed out. He also had return of his
disease, and we reinitiated Campath regimen. This, however,
ultimately was cut short on [**2123-7-7**] due to question of an
infection versus PE for which he was ruled out. He has been
followed closely by ID and has been treated on Augmentin since
that time through therapy. He then was restarted back on Campath
and completed six weeks of treatment dose as previously his
cycles have been interrupted. He again had normalization of his
white count and also no longer had any lymphocytosis. However,
he again did not have much in the way of significant response to
his lymphadenopathy. He then eventually had developed an
enlarging left cervical node which was biopsied and was found to
have [**Doctor Last Name **] transformation. He was admitted on [**2124-1-5**] for
[**Hospital1 **]. This [**Hospital1 **] was overall well tolerated. He completed his
first course of ESHAP on [**2124-2-2**], and tolerated this well.
.
Four cycles of FCR (Fludarabine, Cytoxan,
Rituxan) completed on [**2120-8-15**], four cycles of PCR
(Pentostatin, Cytoxan, Rituxan) completed on [**2122-10-1**], two
cycles of R-CVP completed on [**2123-3-11**], Campath treatment
subcutaneously initiated on [**2123-4-14**] and stopped on [**2123-4-30**],
reinitiated on [**2123-6-23**] and stopped on [**2123-7-7**], restarted
on [**2123-10-11**] and completed approximately six weeks of therapy
which he completed on [**2123-12-3**]. Reinitiated therapy due to
[**Doctor Last Name 6261**] transformation with [**Hospital1 **] treatment (Continuous
infusion of etoposide, Adriamycin, and Vincristine on days [**11-21**],
Oral prednisone on days [**11-22**], and Cytoxan on day 5) in 02/[**2123**].
D/t inadequate disease response from [**Hospital1 **] regimen was switched
to ESHAP (Bolus of Etoposide on days [**11-21**], Cisplatin continuous
infusion on days [**11-21**], Methylprednisolone IV on days [**11-22**],
Cytarabine 2g/m2 IV over 2 hours on day 5 only).
Social History:
Has been married for 30 years. He works as a software engineer.
He does not smoke and drinks occasional alcohol He has one
daughter who is 20-years-old.
Family History:
Notable for father who died of prostate cancer, with question of
lung involvement at the end. His mother had a history of MS and
one of his brothers is obese. An uncle with pancreatic cancer
and an aunt with breast cancer.
Physical Exam:
ON ADMISSION:
VS- 97.1 114/70 80 18 98%@RA
Gen: awake, alert, no acute distress, pleasant
HEENT: mucous membranes moist, always with a different [**Location (un) 86**]
sports hat, today Bruins.
Neck: Non-tender, neck supple, no JVD, no thyromegaly
CV: S1 & S2 regular without murmur
Lungs: Clear to auscultation bilaterally, no
wheezes/rales/rhonchi
Abd: soft, non-tender or distended, no HSM, BS present
Ext: No edema, 2+ DP pulses bilaterally
Neuro: AOx3, CN2-12 intact grossly, strength 5/5 diffusely,
sensation intact diffusely, coordination intact bilaterally.
FTN/HTS intact, negative Romberg's sign.
ON DISCHARGE:
T: 97.0 BP: 119/92 HR: 86 RR: 18 SP02: 98%RA
General: Quite, slow movements, no acute distress
HEENT: Moist mucous membranes, no palpable LAD, neck is supple
CARDIAC: Regular rate and rhythm; normal S1 and S2
RESP: Clear to auscultation bilaterally; no wheezes, rales,
rhonchi
ABDOMEN: +BS, non-tender, non-distended
EXTREMITY: 1+ edema bilaterally; full range of movement
SKIN: Slightly ashen/icteric
Pertinent Results:
Please note, there are 5 months worth of labs in our system.
Please find below the admission labs, and below them, the
discharge labs.
.
ADMISSION LABS:
[**2124-3-1**] 09:25AM BLOOD WBC-14.0* RBC-3.19* Hgb-10.0* Hct-28.0*
MCV-88 MCH-31.2 MCHC-35.5* RDW-19.3* Plt Ct-117*#
[**2124-3-1**] 09:25AM BLOOD Neuts-33* Bands-2 Lymphs-55* Monos-5
Eos-0 Baso-1 Atyps-1* Metas-3* Myelos-0
[**2124-3-1**] 09:25AM BLOOD Hypochr-NORMAL Anisocy-2+ Poiklo-NORMAL
Macrocy-1+ Microcy-1+ Polychr-1+
[**2124-3-1**] 09:25AM BLOOD PT-12.0 INR(PT)-1.0
[**2124-3-1**] 09:25AM BLOOD Gran Ct-5320
[**2124-3-1**] 09:25AM BLOOD UreaN-23* Creat-1.1 Na-147* K-4.1 Cl-106
HCO3-28 AnGap-17
[**2124-3-1**] 09:25AM BLOOD ALT-27 AST-33 LD(LDH)-604* AlkPhos-103
TotBili-0.3 DirBili-0.1 IndBili-0.2
[**2124-3-1**] 09:25AM BLOOD Calcium-9.1 Phos-3.2 Mg-1.6 UricAcd-4.5
.
DISCHARGE LABS:
Na 131, K 3.7, Cl 101, HC03 18 (stable), BUN 24, Cr. 0.5,
Glucose 172, WBC 6.7, Hgb 9.0, Hct 26.9, Plt 95, Ca 8.2, Mg 1.9,
Phos 2.2. LFTS (trending down) ALT 214, AST 93, LDH 668, Alk
Phos 421.
Urine culture [**8-14**]: <10,000 organisms. U/A: Bili small,
bacteria few (most likely contaminated), protein trace, glucose
300, nitrates negative, leukocytes negative.
Other results:
.
Last CMV VL [**2124-8-14**] Negative.
.
ID RESULTS:
-Cdiff negative x4 since [**6-25**]
-[**2124-7-22**] cryptococcal Ag negative
-[**2124-7-20**] Peritoneal fluid negative, Gstain and Cx, Fungal,
anaerobes, AFB all negative
-[**2124-7-14**] CSF negative Gstain, Cx, Crypto, fungal, Ag
-[**2124-7-12**] stool Cx all negative
--VRE bacteremia, s/p linezolid x 2 weeks
- Strep milleri bacteremia, treated, and resolved, TTE [**4-21**] no
vegetation. There is a note that HHV6 was positive at the same
time as patient developed evanescent rash, which was attributed
to HHV6. Repeat serum viral load was negative a week later.
-BK viruria >390 million ([**4-24**]) with bladder spasms, but then
symptoms resolved.
.
Last positive Cx's we have on record are:
Final [**2124-5-17**]: ENTEROCOCCUS FAECIUM.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # [**Numeric Identifier 60071**]
[**2124-5-11**].
Anaerobic Bottle Gram Stain (Final [**2124-5-14**]):
GRAM POSITIVE COCCI IN CHAINS.
.
Aerobic Bottle Gram Stain (Final [**2124-5-15**]):
GRAM POSITIVE COCCI.
IN PAIRS AND CHAINS.
.
Culture taken from colon:
Time Taken Not Noted Log-In Date/Time: [**2124-5-10**] 6:22 pm
TISSUE COLON.
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
TISSUE (Final [**2124-5-13**]):
ENTEROCOCCUS SP.. SPARSE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ =>32 R
LINEZOLID------------- 2 S
PENICILLIN G---------- =>64 R
VANCOMYCIN------------ =>32 R
ANAEROBIC CULTURE (Final [**2124-5-16**]):
BACTEROIDES FRAGILIS GROUP. SPARSE GROWTH.
BETA LACTAMASE POSITIVE.
ACID FAST CULTURE (Final [**2124-7-10**]): NO MYCOBACTERIA
ISOLATED.
ACID FAST SMEAR (Final [**2124-5-11**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
FUNGAL CULTURE (Final [**2124-5-26**]): NO FUNGUS ISOLATED.
[**2124-4-15**] 12:05 pm BLOOD CULTURE
**FINAL REPORT [**2124-4-18**]**
Blood Culture, Routine (Final [**2124-4-18**]):
STREPTOCOCCUS ANGINOSUS (MILLERI) GROUP. FINAL
SENSITIVITIES.
CLINDAMYCIN RESISTANT @ > 2MCG/ML.
ERYTHROMYCIN RESISTANT @>4MCG/ML.
Sensitivity testing performed by Sensititre.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STREPTOCOCCUS ANGINOSUS (MILLERI)
GROUP
|
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- R
PENICILLIN G---------- 0.06 S
VANCOMYCIN------------ 1 S
Anaerobic Bottle Gram Stain (Final [**2124-4-16**]):
REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] @ 1035AM [**2124-4-16**].
GRAM POSITIVE COCCI IN CHAINS.
The following are significant reports from the last 5 months.
However, due to volume of reports, this list is not inclusive.
[**2124-7-21**] CXR
FINDINGS: In comparison with study of [**7-12**], there is a slightly
better
inspiration with continued enlargement of the cardiac silhouette
and widening of the mediastinum due to extensive mediastinal
lipomatosis. Lungs are clear and there is no vascular
congestion.
CENTRAL CATHETER REMAINS IN PLACE.
[**2124-7-19**] Doppler u/s abdomen
FINDINGS: Transabdominal ultrasound with Doppler demonstrates
patent hepatic veins including the right middle and left hepatic
veins. There is appropriate direction of flow. No thrombus is
seen. Patient evaluation is limited due to patient's inability
to breath-hold. The main portal vein was seen to be patent with
appropriate direction of flow on the earlier study. The hepatic
artery was not visualized. Moderate ascites throughout the
abdomen, unchanged from prior study.
IMPRESSION: Limited evaluation. Hepatic veins are patent with
appropriate
direction of flow with no thrombus seen.
[**2124-7-18**] CT abdomen pelvis
FINDINGS: The lung bases demonstrate increased atelectasis when
compared to prior study of [**2124-5-11**]. In addition, there are
bilateral pleural
effusions, left greater than right, both slightly increased in
size since the prior study. The heart size is normal. The
spleen, gallbladder, pancreas, adrenal glands, stomach are
within normal limits. Both kidneys demonstrate parapelvic cysts
bilaterally. Otherwise, the kidneys both enhance and excrete
contrast symmetrically bilaterally. A small hyperdensity is
noted within the right lobe of the liver (2:22), unchanged in
size and appearance since at least [**2124-3-17**]. Multiple small
retroperitoneal and mesenteric lymph nodes are again noted, none
meeting CT criteria for pathologic enlargement. There is no free
air.
There is a moderate amount of ascites, which has increased in
amount since the CT of [**5-11**]. In addition, there is a
significant amount of soft tissue edema throughout the entire
subcutaneous tissues of the abdomen, which has greatly increased
also since the prior study.
There is persistent mild bowel wall thickening at the ileum that
apperas
moreso in the terminal ileum, not significantly changed. Fatty
change in the wall of the terminal ileum also is stable. In some
of the areas of wall thickening there is striated enhancement,
but the mucosal enhancement is only mildly increased and this is
in collapsed bowel. No distended bowel shows wall thickening
with striated enhancement. There are mildly dilated loops of
jejunum and proximal ileum without a transition pint. Previously
described possible edema of the gastric antrum/pylorus is not
apparent on today's study.
CT OF THE PELVIS WITH IV CONTRAST: The rectum and prostate are
within normal limits. Air within the bladder is likely due to
recent placement of a Foley catheter. A large amount of free
fluid is noted within the pelvis, increased since the prior
study. There is no pelvic or inguinal lymphadenopathy. There is
a small left sided fat containing inguinal hernia.
BONE WINDOWS: No suspicious osseous lesions are seen. Left
eighth rib
deformity consistent with old healed fracture, unchanged.
IMPRESSION:
1. Increased ascites within the abdomen and pelvis. Bilateral
pleural
effusions, left greater than right, also slightly increased
since the prior study. Anasarca.
2. Persistent mild ileal wall thickening and with fatty
deposition in the
terminal ileal wall, unchanged. No convinving active ileitis at
this time
with the findings likely reflecting chronic changes from graft
versus host
disease. No obstruction, but likely mild small bowel ileus.
[**2124-7-15**] MRI head
FINDINGS: The diffusion images, which are adequate for
interpretation,
demonstrate no acute infarct. There is no mass effect or midline
shift. The remaining images are limited by motion demonstrate no
obvious midline shift or hydrocephalus. There are no obvious
areas of enhancement seen on motion limited axial images but
evaluation is limited. Subtle areas of high signal on both basal
ganglia region on post-gadolinium axial images are artifactual
from pulsation artifacts.
IMPRESSION: Limited study due to motion. Diffusion images which
are adequate for interpretation demonstrate no acute infarct.
Other images, which are limited demonstrate no obvious
abnormalities, but for better evaluation if clinically
indicated, a repeat study can be obtained with sedation.
[**2124-7-3**] RUE U/S
FINDINGS:
RIGHT UPPER EXTREMITY VENOUS ULTRASOUND:
The right internal jugular vein is patent. The proximal right
subclavian vein at the level of the internal jugular vein is
patent. Just distal to the internal jugular vein, the subclavian
vein is thrombosed. The vein is
distended with echogenic clot and demonstrates absence of flow
and
compressibility. The axillary vein is now only partially
thrombosed, with
minimal flow seen around the echogenic clot. There is partial
compressibility. The basilic vein is patent.
One of the paired brachial veins remains thrombosed with
echogenic clot
distending the lumen and absence of flow and compressibility.
The other
brachial vein is patent. The cephalic vein remains completely
thrombosed
without compressibility or flow.
The left subclavian vein is patent.
IMPRESSION:
1. Interval improvement in degree of the right upper extremity
thrombosis,
now with only partial clot in the right axillary vein, and flow
in the basilic
vein.
2. Persistent thrombosis of the superficial veins of the right
upper
extremity, with thrombosis of one of the paired brachial veins
and the
axillary vein.
[**2124-6-15**] ECHO
Findings
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Normal LV wall thickness. Small LV cavity.
Overall normal LVEF (>55%). No resting LVOT gradient. No VSD.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. Normal aortic arch diameter.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. No
masses or vegetations on aortic valve, but cannot be fully
excluded due to suboptimal image quality.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. No
masses or vegetations on mitral valve, but cannot be fully
excluded due to suboptimal image quality. Normal mitral valve
supporting structures. No MS. Mild (1+) MR. LV inflow
uninterpretable due to tachycardia and/or fusion of spectral
Doppler E and A waves
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. No masses or vegetations are seen on the tricuspid valve,
but cannot be fully excluded due to suboptimal image quality.
Normal tricuspid valve supporting structures. No TS. Normal PA
systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR. No vegetation/mass on pulmonic valve.
Normal main PA. No Doppler evidence for PDA
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
Conclusions
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity is small.
Overall left ventricular systolic function is normal (LVEF 70%).
There is no ventricular septal defect. Right ventricular chamber
size and free wall motion are normal. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic regurgitation. No masses or vegetations are seen on
the aortic valve, but cannot be fully excluded due to suboptimal
image quality. The mitral valve leaflets are mildly thickened.
There is no mitral valve prolapse. No masses or vegetations are
seen on the mitral valve, but cannot be fully excluded due to
suboptimal image quality. Mild (1+) mitral regurgitation is
seen. No masses or vegetations are seen on the tricuspid valve,
but cannot be fully excluded due to suboptimal image quality.
The estimated pulmonary artery systolic pressure is normal. No
vegetation/mass is seen on the pulmonic valve. There is no
pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2124-5-12**], no major change.
IMPRESSION: Suboptimal image quality. No obvious vegetations
seen
If clinically suggested, the absence of a vegetation by 2D
echocardiography does not exclude endocarditis.
[**2124-7-21**] FLOW CYTOMETRY PERIPHERAL BLOOD
FLOW CYTOMETRY REPORT
FLOW CYTOMETRY IMMUNOPHENOTYPING
The following tests (antibodies) were performed: HLA-DR, FMC-7,
Kappa, and CD antigens 3, 5, 10, 19, 20, 23, 38, 45.
RESULTS:
Three color gating (CD45 versus light scatter) is used to
determine population of interest.
B cells are extremely scant in number, however, appear
polytypic.
T cells comprise 90% of lymphoid gated events.
INTERPRETATION
Non-specific T cell dominant lymphoid profile; diagnostic
immunophenotypic features of involvement by a non-Hodgkin B-cell
lymphoma are not seen in specimen. Correlation with clinical
findings is recommended. Flow cytometry immunophenotyping may
not detect all lymphomas due to topography, sampling or
artifacts or sample preparation.
[**2124-7-20**] FLOW CYTOMETRY ASCITES
FLOW CYTOMETRY REPORT
FLOW CYTOMETRY IMMUNOPHENOTYPING
The following tests (antibodies) were performed: HLA-DR, FMC-7,
Kappa, Lambda, and CD antigens 3, 5, 10, 19, 20, 23, 38, 45.
RESULTS:
Three color gating is performed (light scatter vs. CD45) to
optimize lymphocyte yield.
B cells are scant in number precluding evaluation of clonality.
T cells comprise 90% of lymphoid gated events.
INTERPRETATION
Non-specific T cell dominant lymphoid profile; diagnostic
immunophenotypic features of involvement by a non-Hodgkin B-cell
lymphoma are not seen in specimen. Correlation with clinical
findings is recommended. Flow cytometry immunophenotyping may
not detect all lymphomas due to topography, sampling or
artifacts or sample preparation.
[**2124-6-26**] FLOW CYTOMETRY OF CSF FLUID
The following tests (antibodies) were performed: Kappa, Lambda,
and CD antigens 19, 45.
RESULTS:
Three color gating is performed (light scatter vs. CD45) to
optimize lymphocyte yield.
B cells are scant in number precluding evaluation of clonality.
T cells comprise 99% of lymphoid gated events.
INTERPRETATION
Non-specific T cell dominant lymphoid profile; diagnostic
immunophenotypic features of involvement by lymphoma are not
seen in specimen. Correlation with clinical findings is
recommended. Flow cytometry immunophenotyping may not detect all
lymphomas as due to topography, sampling or artifacts of sample
preparation.
[**2124-5-29**] SKIN BX
DIAGNOSIS:
1. Skin, right forearm, biopsy (A-B):
Interface and superficial perivascular dermatitis with marked
dyskeratosis, dermal melanophages, and extravasated
erythrocytes, see note.
Note: The degree of dyskeratosis (some at basal layer), lack of
eosinophils, and finding of lymphocyte-keratinocyte satellitosis
favor graft versus host disease, if clinically appropriate. The
histologic differential diagnosis includes a drug eruption..
This case was discussed with Dr. [**Last Name (STitle) **] on [**2124-5-30**].
2. Skin, left upper back, biopsy (C):
Interface and superficial perivascular dermatitis with marked
dyskeratosis, dermal melanophages, and extravasated
erythrocytes, see note.
Note: The degree of dyskeratosis (some at basal layer), lack of
eosinophils, and finding of lymphocyte-keratinocyte satellitosis
favor graft versus host disease, if clinically appropriate. The
histologic differential diagnosis includes a drug eruption.
This case was discussed with Dr. [**Last Name (STitle) **] on [**2124-5-30**].
[**2124-5-18**] GI BX
DIAGNOSIS:
Terminal ileum, biopsy:
Granulation tissue and ulcer bed with crystalline material. See
note.
Note: No intact intestinal epithelium is seen. The crystalline
material is morphologically consistent with sodium polystyrene
sulfonate (Kayexalate), which is reported to be associated with
gastrointestinal tract ulcers. Reactive atypia is noted within
the granulation tissue, however, no definite viral inclusions
are identified. An immunohistochemical stain for
cytomegalovirus is in process and results will be reported as an
addendum. Severe acute graft versus host disease cannot be
excluded based on the morphologic findings. The case was
reviewed with Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) 7108**], who concurs. The findings were
discussed with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on [**2124-5-19**].
ADDENDUM:
Immunohistochemical stain for CMV is negative.
[**2124-3-30**] - SIGMOIDOSCOPY - Impression: Diverticulosis of the
sigmoid colon
Normal mucosa in the sigmoid colon (biopsy)
Otherwise normal sigmoidoscopy to descending colon at 50 cm
.
[**2124-3-30**] - PATHOLOGY - GI BIOPSIES (2 JARS)
DIAGNOSIS:
Colonic mucosa biopsies, two:
A. Sigmoid: Colonic mucosa, no diagnostic abnormalities
recognized.
B. Rectum: Colonic mucosa with rare crypt cell apoptosis, see
note.
Note: These findings are not diagnostic for GVHD. Immunostain
for CMV is negative.
.
[**2124-4-12**] - PATHOLOGY - Skin, abdomen:
- Interface dermatitis with dyskeratotic keratinocytes, and mild
superficial perivascular lymphocytic infiltrate consistent with
graft versus host disease, see note.
Note: The histological differential diagnosis includes a
reaction to drugs. The current specimen shows
lymphocyte-keratinocyte satellitosis and marked apoptic bodies
at the interface level, and no eosinophilia is noted. The
keratinocytic dyskeratosis is predominantly seen at the basal
keratinocytes level, and no dermal edema is seen. Overall, a
diagnosis of graft versus host disease (GVHD) is favored, if
compatible with the clinical presentation.
.
MICROBIOLOGY TESTS:
[**2124-4-15**] BLOOD CULTURE Blood Culture, Routine-FINAL
{STREPTOCOCCUS ANGINOSUS (MILLERI) GROUP}; Anaerobic Bottle Gram
Stain-FINAL
Anaerobic Bottle Gram Stain-FINAL INPATIENT
FINAL SENSITIVITIES.
CLINDAMYCIN RESISTANT @ > 2MCG/ML.
ERYTHROMYCIN RESISTANT @>4MCG/ML.
Sensitivity testing performed by Sensititre.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STREPTOCOCCUS ANGINOSUS (MILLERI)
GROUP
|
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- R
PENICILLIN G---------- 0.06 S
VANCOMYCIN------------ 1 S
Anaerobic Bottle Gram Stain (Final [**2124-4-16**]):
[**2124-4-16**] BLOOD CULTURE -FINAL {STREPTOCOCCUS ANGINOSUS
(MILLERI) GROUP}
[**2124-4-18**] BLOOD CULTURE -FINAL NO GROWTH.
Brief Hospital Course:
Mr. [**Known lastname **] is a 56-year-old male with history of CLL with large
cell transformation who was admitted for a scheduled allogeneic
MUD SCT on [**2124-3-10**]. His course was complicated by febrile
neutropenia and acute GVHD involving the intestinal tract, liver
and skin. He was discharged to [**Hospital1 **] in stable condition
with symptomatic improvement.
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[**Date range (3) 60072**]
# Allo BMT - Day 0: [**2124-3-10**] from MUD ([**7-27**], mismatch at one
HLA-A allele). The patient underwent a Busulfan/Cytoxan
conditioning regimen which did not cause neutropenia and he
tolerated it with only mild diarrhea. His initial transplant
proceeded without incident. The patient was started on
Acyclovir, Fluconazole and Ursodiol per protocol on Day -2.
Cyclosporine was started Day -1 and monitored by level.
Methotrexate was given per protocol on Days +1, and then again
on Day +7 (delayed due to concern of transaminitis - see below),
and day +11. He received inhaled pentamidine on a monthly basis
([**3-29**] and [**4-30**]). He was started on atovaquone for PCP
prophylaxis on [**4-8**]. Fungal prophylaxis was switched micafungin
while the patient had fever & neutropenia. The patient was on
voriconazole for a short period of time, but changed back to
micafungin due to concern of exacerbating chemotherapy induced
liver toxicity.
.
# Acute GVHD - The patient course was complicated by acute GVHD
which started as a blanching rash on [**3-20**]. The patient was
treated empirically for GVHD with steroids, which improved his
rash, but when the steroids were tapered the patient developed
severe watery diarrhea, up to 2L a day at times. The
gastroenterology service was consulted and on [**3-30**] the patient
had a flexible sigmoidoscopy. Biopsies of the sigmoid and rectum
were non-diagnostic but consistent with GVHD. Stool cultures
for bacterial and viral pathogens and for C. diff were negative.
The steroids were again tapered as the patient's diarrhea
improved, however, the patient developed a morbilliform rash and
his diarrhea worsened. Dermatology biopsied the rash, and the
pathology was consistent with GVHD. His skin rash evolved into
desquamation and bullae and his diarrhea symptoms flared when
steroids doses were tapered. The patient was treated with
high-dose (2mg/kg) methylprednisone, cellcept, cyclosporine and
Remicade x 2 ([**4-14**] and [**4-22**]). He also developed liver
involvement with GVHD. His TBili was elevated to max of 2.7 on
[**4-24**]. After his second dose of remicade, his symptoms improved
and a very slow steroid taper was reattempted. Steroid taper
was ultimately unsuccessful with patient requiring
methylprednisolone 25 mg in am and 20 mg in pm.
It was thought that the skin rash may have been worsened by
cefepime. The cefepime was switched to meropenem and derm was
once again consulted on [**5-31**]. Derm took a biopsy which showed
results consistent with GVHD and unlikely for drug reaction.
.
# Fevers and neutropenia - The patient developed fevers in the
setting of neutropenia post transplant on [**3-13**] and was treated
with broad spectrum antibiotics and antifungal coverage.
Cultures remained negative and no source was identified. C diff
was negative on multiple occasions throughout this
hospitalization. His counts recovered ([**3-22**]) and antibiotics were
discontinued.
.
# VRE bacteremia - The patient developed bloody diarrhea and
underwent colonoscopy for evaluation ([**5-18**]). He was
hemodynamically stable at this time. The colonscopy was negative
as was an EGD. The following evening the patient developed a
fever to 102 and blood cultures grew VRE bacteremia. He was
started on linezolid and cefepime. His IJ was removed as was his
PICC line for access. The fevers resolved as did the bacteremia.
.
# Fevers - The patient again became febrile on [**5-31**]. He had no
symptoms and his vital signs remained stable. The patient was
continued on meropenem, linezolid and flagyl was added to cover
potential c. diff. He consistently cultured negative. His PICC
was removed with no resolution of the fevers. His IJ was removed
on [**6-9**]. Following this his fevers resolved.
.
# HHV6 infection: The patient spiked a fever [**3-27**] when he was
no longer neutropenic and he developed a splotchy and evanescent
rash, which disappeared within 24 hours. A serum HHV6 viral
load was eventually positive, and HHV6 was felt to be the likely
cause of the patient??????s rash. Repeat testing a week later for
HHV6 was negative.
.
# Strept Milleri Bacteremia: On [**4-15**] blood cultures were drawn
as the patient appeared unwell and had borderline low blood
pressures. The patient was not neutropenic at this time. Blood
cultures eventually grew Strep milleri. The patient was treated
with vancomycin initially and then switched to ceftazadime and
flagyl and then to cefepime per ID recommendations. TTE was
negative for endocarditis. The patient was deemed to high risk
to undergo TEE so it was determined that he would complete a 4
week course from the first negative blood culture on [**4-18**] (D/C ON
[**5-15**]).
.
# BK virus: In early [**Month (only) **], while the patient was on multiple
immunosuppressant medications for GVHD, he developed dysuria,
difficulty voiding and hematuria. There was initially concern
about urinary retention; however, once the foley was placed the
patient only had a small amount drained from the bladder. Urine
bacterial cultures were negative, but urine studies were
positive for BK virus. He eventually developed BK viremia. The
patient suffered from painful bladder spasms as a result of his
BK virus. Urology service was consulted to assist with bladder
spasm control. His bladder spasms were symptomatically managed
with flomax, detrol, pyridium and a morphine PCA. ID was
consulted and they recommended treatment with intravesicular
cedofivir. In addition, the patient was given IVIG on [**5-6**] to
help boost his Ig levels in the setting of such high levels of
immunosuppression. Urology recommended an outpatient cystoscopy
after discharge for further evaluation of microscopic hematuria.
.
# Decreased Mental Status - In Mid [**2124-5-17**], patient had
waxing/[**Doctor Last Name 688**] mental status: AOx2, missing date, with a mild
decrease in his mental status. On [**6-13**] the patient's mental
status worsened. He was able to follow simple commands but not
complex commands. He was also complaining of some visual
halluciantions and made some coherent but nonsensical
statements. An MRI was conducted which showed no pathology that
would account for the mental status change. Neurology was
consulted. It was thought that the most likely cause was
metabolic encephalopathy secondary to one of his medications. In
the past he has had similar symptoms in response to cyclosporin.
At that time he was given a cyclosporin holiday and changed to
tacrolimus with a recovery of his mental status to baseline. He
is also on steroids and mycophenolate and received etanercept.
#) Hypertension: The patient has a history hypertension that is
generally exacerbated by steroids. His anti-hypertensive
medications required frequent adjustment during this
hospitalization. His Diltiazem was changed to Nifedipine due to
concern regarding hepatotoxicity. His metoprolol dose was
increased. On [**6-11**] nifedipine was stopped due to low blood
pressures.
.
#) Anascarca: The patient's severe GVHD caused an inflammatory
state with required aggressive fluid replacement. The patient
developed severe anascarca and ascites and had an approximately
40lb weight gain secondary to GVHD. Once his GVHD stabilized,
he was diuresed with lasix which at one point caused prerenal
acute renal failure with a creatinine peak of 1.7. However,
this resolved with fluids. Patient currently has 1+ edema
bilaterally in both legs, but no other symptoms of fluid
overlaod.
.
#) Superficial venous clots: On [**4-14**], the patient developed
superficial venous clots in his left cephalic and basilic veins
near a PICC line site. He did not have any DVT.
.
#) GERD: The patient was started on a PPI on [**3-28**] due to
increased symptoms of "heartburn" in the setting of high dose
steroids. He was discharged with omeprazole 20mg.
.
#) Access: The patient had multiple central lines at various
times during this hospitalization, which were required as the
patient was unable to take POs. He had a Hickmann tunnelled
catheter which was removed because it was non-functional. He
also had right PICC x2 (the first of which was removed due to a
superficial phlebitis), a left IJ, a right subclavian (removed
when the patient was bacteremic) and a right IJ. He currently
has no central access.
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[**Hospital Unit Name 153**] (Intensive Care Unit) course ([**Date range (2) 60073**])
.
# Hypothermia / MS changes: Multiple possible etiologies in the
immunocompromised pt s/p BMT, concern for sepsis given elevated
lactate (although unclear as to what pt's baseline lactate level
is given malignancy and adenopathy, was stable at 3.0 on
transfer) and resp alkalosis. Pt had recent VRE bacteremia,
after central line placement, the midline was removed and sent
for culture. MRI shows possible embolic infarcts which raises
concern for endocarditis as another possible source of sepsis.
TSH was low normal ruling out hypothyroid myxedema. Concern for
meningitis or other central process given persistent resp
alkalosis. Additional concern for med toxicity given hx of MS
changes with cyclosporine. LP was performed and suggestive of
possible aseptic meningitis, etiologies include HSV and other
viruses (CMV, HHV, number of others sent out) vs malignancy
related as 99% lymphs on tap vs drug (chemo/immunosup) toxicity.
Ammonia level normal. BMT/heme thought that the CSF lymphs were
not likely malignant. ID recommended coverage for empiric HSV
with foscarnet (due to better coverage of HSV 6). ID also
recommended, f/u galactomannan, B-D-glucan as another survey for
invasive fungal infection without need for broader fungal
coverage now. We initially placed the patient on Linezolid,
cipro, Meropenem, flagyl, Micafungin, foscarnet and Atovaquone
(pt not taking since NPO), but then d/c'd cipro once it was felt
that pseudomonas was unlikely. The pt reported having some loose
stools but C. diff was negative and empiric flagyl treatment was
d/c'd. Atovaquone was restarted when pt able to PO clear liquid
diet. Otherwise, with this treatment the patient became
normothermic with temps >96, with improved mental status, and
hemodynamically stable (never with need for
intubation/pressors).
.
# Anemia: HCT 22 from 26, now stable 23. Not likely dilutional
(Plts, WBC increased). [**Month (only) 116**] be related to blood draws vs
bleeding. 2U pRBC given. Hemolysis/DIC labs negative. Continue
to monitor daily labs.
.
Upon discharge from [**Hospital Unit Name 153**]: [**2124-6-20**]:
#GVHD - The patient continued to have copious diarrhea since his
discharge from the [**Hospital Unit Name 153**]. The patient was restarted on
etanercept on [**6-28**]. This was held for several days when the
patient appeared septic on [**7-12**], however, was restarted on
[**2124-7-15**] after the patient's condition improved, and then finally
d/c'd again the week after. The diarrhea improved significantly
on tincture of opium, however this caused the patient to become
confused. He was switched to lomotil which has alleviated the
diarrhea somewhat. He continues to be on cellcept 1500mg [**Hospital1 **],
budesonide 3mg tid, and methylprednisolone.
.
#MS changes - The patient had multiple episodes of hypothermia
to as low as [**Age over 90 **]F, with associated mental status changes. During
his most recent episode on [**2124-7-12**], his blood pressure also
dropped to 90/60, and he was started on meropenem and daptomycin
because of the possibility of sepsis. The patient's blood
pressure improved with boluses and antibiotics. MRI head was
negative, and LP glucose, protein were normal. However, it was
thought that the daptomycin was potentially causing a further
elevation in his bilirubin, and this was stopped on [**7-15**].
.
#Adenovirus - The patient was found to have >100,000 copies of
adenovrius in his blod on [**6-28**]. CSF was sent from [**6-26**] which
also showed evidence of adenovirus. However, repeat level on
[**7-6**] showed decreasing adenovirus levels and cidofivir was not
started. A repeat LP was performed on [**2124-7-14**], HHV-6, CMV,
Enterovirus, viral culture, HSV PCR, EBV PCR, [**Male First Name (un) 2326**], Adenovirus
pending. Blood adenovirus level also re-sent.
.
#RUE clot - The patient was found to have a RUE clot [**12-20**] picc
line, however his last U/S showed some resolution. He was not
on anticoag due to hx of GI bleeds, following clinically.
.
#GI bleed - Since leaving the unit, the patient has had several
GI bleeds, first on [**6-29**] after supratherapeutic PTT, more
recently on [**7-11**]. Both episodes were managed conservatively
with fluids given that the likely etiology was graft vs. host
disease.
.
#Ascites/edema - The patient was placed on lasix 20bid to
improve his overall anasarca and ascites.
=
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=
=
=
=
=
=
=
=
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================================================================
From [**2124-7-17**] to [**2124-8-17**] (Date of Discharge)
1. GVHD: By the beginning of [**Month (only) **], the pt did not have any
GVHD associated rash and he was not having any significant
amount of diarrhea, however he did have increases in his LFT's
and total bilirubin (as below) that were associated with altered
mental status, increased somnolence and decreased responsiveness
(see below, AMS). GVHD was in the differential of this liver
dysfunction. He continued on immunosuppressive regimen of
cellcept, Budesonide, Methylprednisolone and enterecept.
Enterecept was eventually discontinued and doses of other
immunosuppressive were readjusted in accordance with liver
function. He was also started on Rituxan once per week and had
received [**1-19**] doses by the time of discharge. By d/c his LFT's
were still increased, with a Tbili holding steady in the 6's.
The amt of diarrhea changed from day to day but was typically
[**12-22**] loose stools per day, occasionally with frank blood, and
occasionally with guiac + but not frankly bloody. On discharge,
patient was kept on Methylprednisone 25mg AM/20mg PM, Cellcept
750mg every 8 hours and budesonide 3mg TID. He will receive one
more dose of Rituxan on [**8-19**].
.
2. Increased Tbili: This was thought to be GVHD vs drug effect.
The Tbili steadily increased in late [**Month (only) 216**] until early
[**Month (only) **], when it peaked at 9.6 and this was concurrent with
his altered mental staus (as below). Acyclovir was d/c'd. Pt was
to get an MRI abdomen but was unable to sit still long enough to
get it, therefore was sent for CT abdomen with and without
contrast [**2124-7-18**], which showed an interval increase in his
ascites, increase in his pleural effusions L>R, and chronic
ileal wall thickening c/w GVHD. Hepatology was consulted and a
paracentesis was performed in early [**Month (only) **] that was
essentially non-diagnostic, ascites cultures were negative, and
the picture was essentially consistent with portal hypertension.
Rifaxamin was started. Liver Bx was recommended but was not
performed because by this time the pt was clinically improving,
waking up, and AMS was resolving. However, despite the improved
mental status, his LFT's and Tbili continued to increase and
peaked at 9.6 before they again began to decline again and were
steadily in the 6's on d/c. He began to clinically improve, his
scleral icterus got better and no liver Bx was ever performed.
Rifaxamin was stopped without consequence. Acyclovir was added
on and continued at discharge.
.
3. Altered Mental Status: The first week of [**Month (only) **], the
patient was noted to be very somnolent, confused and saying
nonsensical things. Concurrent with this was hypothermia and
hypotension. This was thought to be mostly due to hepatic
encephalopathy. An LP performed on [**7-14**] was non diagnostic and
all viral studies from that procedure were negative. MRI head
[**7-14**] was also non diagnostic. Neuro was consulted and
recommended a 24hr bedside EEG to evaluate for subclinical
seizures, however he eventually began to dramatically turn
around though and became more awake, was conversational, able to
express himself, was requesting food, and EEG was not felt to be
necessary. His mental status steadily cleared up although it was
noted that he would have occasional delirium, would be a little
restless at night (he had actually pulled out a central venous
line one night, another was placed, but he then pulled that one
out several days later), saying odd things in the morning before
he fully woke up, and sundowning a little at night. At baseline,
he is lethargic but appropriate early in the morning, will
follow commands, but later in the day after he has fully woken
up he is very appropriate, concerned about his care, his health
and his plan.
.
4. Hypothermia and Hypotension--Seen to be occasionally
hypotensive to the 90's, which responded to fluid boluses, and
hypothermic to a low of 93.8. Was put on a warmer. The pt's
Metoprolol was d/c'd and his bp's began to improve from high
90's/low 100's to the 110's. Temperature began to improve as
well. By the time the pt's mental status improved, his blood
pressures and hypothermia were no longer an issue. His vital
signs remained stable and hypothermia/hypoTN were not an issue
for several weeks leading up to discharge. In fact, the pt's
blood pressure and heart rate began to increase the week after
Metoprolol was d/c'd and was added back in with a decrease in bp
and pulse seen. He was d/c'd on Metoprolol 12.5 TID with steady
vitals.
.
5. GIB--While he was AMS, pt was not having active GI bleed or
diarrhea issues, but after he woke up he began having loose BM's
with obvious dark red blood. For the next several weeks in
[**Month (only) **], the pt would occasionally have dark red stools, which
required occasional PRBC transfusion, but never compromised him
from a hemodynamic standpoint. He also received occasional
platelets --> During [**Month (only) **], the pt required 6U of PRBC's and
5 of platelets. GI was consulted but felt the pt not stable for
colonoscopy as the large ammount of ascites fluid would lead to
infection. They also felt that he had been scoped within the
past several months and no change would be seen since his
clinical condition was not much changed. By the time of
discharge the pt's Hct was stable, he was having occasional
guiac + stools but not felt to be compromised by them.
.
6. Adenoviremia: Patient was found to have >100,000 copies of
adenovrius in his blood on [**6-28**], also with adenovirus in CSF
from [**6-26**]. Repeat level on [**7-6**] showed decreasing adenovirus
levels at approx. 3000 and cidofivir was not started. A repeat
LP was performed on [**2124-7-14**], HHV-6, CMV, Enterovirus, viral
culture, HSV PCR, EBV PCR, [**Male First Name (un) 2326**], Adenovirus were all negative.
Blood adenovirus level was present and found to be positive at
titer approx. 1900. A repeat measurement later in [**Month (only) **]
showed a titer of 696, and no specific therapy was started.
.
7. RUE clot: Found to have RUE clot of several months duration
but not anti-coagulated due to h/o GIB's. On [**2124-7-24**] pt's R hand
and forearm seen to be acutely grossly swollen, L hand normal,
however by the afternoon the pt's R arm returned to its normal
size without any interventions. It was questioned whether he was
sleeping on that arm which led to its swelling. In any event,
the patient was unable to be anticoagulated to the GIB's.
.
8. Anasarca: The pt was grossly edematous up to his abdomen.
After Metoprolol was d/c'd and hypotension resolved, Lasix was
increased to 40mg IV bid with appropriate response. He continued
to put out urine and as his anasarca steadily decreased his
Lasix was tapered. By the point of discharge, his legs were
drastically reduced from earlier, with barely any baseline
swelling even being noticeable. His Lasix was stopped.
.
9. Nutrition: The patient was started on TPN while his mental
status was poor and he was not eating, but by the time he began
to wake up he was requesting food. TPN was continued for
several weeks even after he had woken up, and eventually was
totally stopped, as the pt was increasingly taking good PO
solids and liquids. He had also pulled out two central lines by
this point and did not have access for TPN anyways. So he was
given a trial to take PO on his own, which he has done well with
by the time of discharge.
.
10. BK viruria: The pt was noted to have RBC's in his UA during
[**Month (only) **] and thus a BK virus assay was sent, which came back >5
million copies. No specific therapy was initiated. Follow up
UA's then showed that the RBC's were zero. Given recent
complaints of dysuria, another BK virus was sent and results are
pending.
.
11. Mood: The pt had appropriately depressed moods at various
points and was very desolate that he had been in bed 5 mos,
couldn't move his legs, and didn't feel he was making progress.
Remeron was tried for several nights (to increase his sleep at
night and stimulate his appetite) but was thought to increase
restlessness/confusion at night, then was stopped. He was never
tried on any other stimulant or antidepressant. His mood would
likely get better as his clinical condition, mobility, and
overall status improve, and this was repeatedly explained to
him.
.
12. Disposition: The pt basically needs aggressive
rehabilitation at this point, as he has major proximal LE muscle
wasting and myopathy likely due to long term steroid use. He has
good distal LE strength, but cannot stand or lift his legs very
well. If steroids can be tapered, he may be able to regain his
strength. We were attempting to use Rituxan in an attempt to
wean steroids. He is eating and drinking well and needs to be
encouraged to eat and drink. If food and drink is put in front
of him he will eat it.
Medications on Admission:
Acyclovir 400 mg PO Q8H
Allopurinol 300 mg Tablet PO DAILY
Augmentin 500mg PO TID
Atenolol 100 mg PO Daily
Fluconazole 200 mg PO Q24H
Diltiazem HCl 240 mg PO DAILY
Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H
Pentamidine 300mg inh qm x 6m (last dose [**2124-2-10**])
Compazine 10mg PO q6-8 PRN nausea
Ativan 0.5-1mg PO q4-6 PRN nausea, anxiety, insomnia
Discharge Medications:
1. Nystatin 100,000 unit/mL Suspension Sig: Ten (10) ML PO QID
(4 times a day).
2. Saliva Substitution Combo No.2 Solution Sig: One (1) ML
Mucous membrane QID (4 times a day).
3. Oral Wound Care Products Gel in Packet Sig: One (1) ML
Mucous membrane QID (4 times a day) as needed for mouth pain.
4. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itching.
5. White Petrolatum-Mineral Oil Cream Sig: One (1) Appl
Topical QID (4 times a day) as needed for GVHD.
6. Atovaquone 750 mg/5 mL Suspension Sig: One (1) PO DAILY
(Daily).
7. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED): Please see attached sliding
scale.
8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for wheeze.
9. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
10. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO QSUN ([**Doctor First Name **]).
11. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO ASDIR (AS
DIRECTED).
12. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO
ASDIR (AS DIRECTED).
13. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
14. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
15. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
16. Budesonide 3 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO TID (3 times a day).
17. Mycophenolate Mofetil 500 mg Tablet Sig: 1.5 Tablets PO Q 8H
(Every 8 Hours).
18. Potassium & Sodium Phosphates 280-160-250 mg Powder in
Packet Sig: One (1) Powder in Packet PO ONCE (Once) for 1 doses.
19. Micafungin 100 mg Recon Soln Sig: One (1) Recon Soln
Intravenous DAILY (Daily).
20. Rituximab 10 mg/mL Concentrate Sig: Seven Hundred-Fifteen
(715) MG Intravenous Give dose #4 (last dose) on [**2124-8-19**] for 1
doses: Please give 715mg on [**2124-8-19**].
21. Methylprednisolone Sodium Succ 40 mg/mL Recon Soln Sig:
Twenty Five (25) MG Injection QAM : Please give 25mg of
methylprednisolone sodium succ every morning.
22. Methylprednisolone Sodium Succ 40 mg/mL Recon Soln Sig:
Twenty (20) MG Injection Q PM: Please give 20MG of
methylprednisolone sodium succ every night.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary/active diagnoses on discharge:
1. CLL s/p [**Doctor Last Name 6261**] Transformation
2. Allogeneic Stem Cell Transplant [**2124-3-10**]
3. Chronic Graft versus Host disease of the liver, GI system,
and skin
4. Chronic GI bleed
5. Chronic Anemia
6. Thrombocytopenia
7. Hypertension
8. BK viruria
9. Adenoviremia
10. Extensive RUE deep venous thromboses
Discharge Condition:
By the time of discharge, the pt's chronic graft versus host
disease was stable, his chronic GI bleed was not hemodynamically
compromising, the pt had been working with PT to increase his
strength and mobility, was taking good PO foods and liquids,
vital signs were stable, and was medically cleared for
discharge.
Discharge Instructions:
You have been admitted to the hospital for an allogeneic stem
cell transplant on [**2124-3-10**]. Please see discharge summary for
COMPLETE SUMMARY of your hospital course since [**2124-3-1**].
.
Please see attached for COMPLETE LIST of your current
medications. This was RECONCILED with admission list.
.
If you experience fever >100, shortness of breath, chest pain,
abdominal pain, headache, pain with urination, weight loss, or
any other concerning symptom, please call Dr. [**Last Name (STitle) **] or 911
immediately.
Followup Instructions:
Patient will need complete CBC with differential and complete
chemistry (Chem 10) within 24-48 hours of discharge on [**8-18**].
Please fax results to Dr. [**Last Name (STitle) **] at: [**Telephone/Fax (1) 21962**].
.
DR. [**Last Name (STitle) **] AND [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]: [**2124-8-21**] at 12:30pm. [**Telephone/Fax (1) 3241**] or
[**Telephone/Fax (1) 3237**].
.
Dr. [**Last Name (STitle) **], MD Phone:[**Telephone/Fax (1) 3241**] Date/Time:[**2124-9-18**] 10:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9574**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 3241**]
Date/Time:[**2124-9-18**] 10:30
.
Urology for blood in urine: Wednesday [**9-20**] at 4pm [**Hospital Ward Name 23**] [**Location (un) **].
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28,292
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Discharge summary
|
report
|
Admission Date: [**2153-4-6**] Discharge Date: [**2153-4-23**]
Date of Birth: [**2089-11-17**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Aortic Valve Endocarditis
Major Surgical or Invasive Procedure:
[**2153-4-12**] 1. Re-do sternotomy and aortic root replacement with a 21
mm Homograft with coronary button reimplantation. 2. Coronary
artery bypass grafting x1, with a reversed saphenous vein graft
from the aorta to the distal right coronary artery.
History of Present Illness:
The patient is a 63 year-old male w/ CAD s/p CABG with AVR in
[**7-16**], DM2, HTN, ESRD on HD, and Hep C cirrhosis presenting to
OSH w/ high grade fever and altered mental status. The patient
was found to have high grade MRSA bacteremia and was treated
with tailored therapy with vancomycin since adm'n there on
[**2153-3-25**]. Source was thought to be left foot osteomyelitis
(suggested by bone scan). TTE and TEE were negative for any
vegetations. Altered mental status was thought to be from
infection, and improved dramatically with antibiotic treatment.
The patient was transferred here in stable condition for further
evaluation of his left foot as his prior podiatry care was here.
On ROS, the patient denies CP, SOB, dizziness, palpitations,
N/V/D, abd pain, dysuria.
Past Medical History:
1. Coronary artery disease, remote MI in his 40s in the setting
of cocaine use - left main and two-vessel coronary disease
diagnosed on cardiac cath from [**2152-7-31**] in the setting of non-ST
elevation MI (peak CK 190, MB 20, troponin T 4.5). CABG on
[**2152-7-31**]: LIMA to LAD, SVD-D1, SVD-OM1-OM3 with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 914**].
2. Moderate aortic stenosis status post 23 mm [**Initials (NamePattern4) 7624**] [**Last Name (NamePattern4) 12640**]
AvR
on [**2152-7-31**].
3. Diabetes, type 2 with neuropathy, nephropathy, and
retinopathy by notes, but not on insulin or other oral agents
4. End-stage renal disease on hemodialysis Monday, Wednesday,
and Friday.
5. Hypertension x 10 years.
6. Hypercholesterolemia.
7. Hepatitis C with reported child's A cirrhosis, Grade I
Varices by EGD [**2150**], no varices on last EGD [**2151**].
8. Gout.
9. Charcot deformity of the feet with left exostectomy, ulcer
excision, and bone stimulator removal on [**2152-7-18**].
10. Left forearm fistula placement [**6-13**].
Social History:
He is a single without children and lives with his nephew and
wife. [**Name (NI) **] has remote history of smoking which he cannot quantify
but quit 20 years ago. He previously drank [**2-11**] drinks two times
a week but denies current alcohol. He denies prior intravenous
drug use, but has a history of cocaine used in the past. He is
retired, used to own a sub shop.
Family History:
Parents are both deceased. Father, late 60s of unknown cause;
mother, age 65 of myocardial infarction. He has two brothers,
one who had a myocardial infarction age 45 and underwent CABG.
Other brother has no significant medical
history. There is no family history of sudden cardiac death or
cardiomyopathy.
Physical Exam:
Admission Physical Exam:
T 98 HR 72 BP 135/82 RR 16 O2 97%/RA
GEN: NAD
Skin: no petechaie, no rashes
HEENT: EOMI, PERRL, no LAD, MMM
Neck: supple, no thyromegaly
Heart: RRR, 3/6 systolic murmur in aortic area, nl S1 S2
Chest: CTABL
Abd: soft, NT/ND, no HSM, BS +
Extr: no edema. L heel ulcer with no probing to bone, no
erythema or drainage
Neuro: AAO x 2. no focal neuro deficit
Pertinent Results:
[**2153-4-6**] 10:47PM BLOOD WBC-11.5*# RBC-4.14* Hgb-11.6* Hct-35.2*
MCV-85 MCH-28.0 MCHC-33.0 RDW-17.3* Plt Ct-256
[**2153-4-6**] 10:47PM BLOOD Neuts-79.9* Lymphs-14.7* Monos-4.7
Eos-0.4 Baso-0.3
[**2153-4-6**] 10:47PM BLOOD Glucose-206* UreaN-27* Creat-5.9* Na-136
K-4.4 Cl-97 HCO3-25 AnGap-18
[**2153-4-6**] 10:47PM BLOOD PT-15.0* PTT-26.9 INR(PT)-1.3*
[**2153-4-6**] 10:47PM BLOOD ALT-40 AST-36 LD(LDH)-298* CK(CPK)-21*
AlkPhos-133* Amylase-104* TotBili-0.5
[**2153-4-8**] 07:00AM BLOOD ESR-57*
[**2153-4-8**] 07:00AM BLOOD CRP-106.6*
[**2153-4-6**] L FOOT XRAY: New osseous destructive changes about the
mid foot - metatarsal articulation are consistent with
osteomyelitis.
[**2153-4-9**] TEE: No spontaneous echo contrast or thrombus is seen in
the body of the left atrium/left atrial appendage or the body of
the right atrium/right atrial appendage. No atrial septal defect
is seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy with normal cavity size and global
systolic function (LVEF>55%). There are simple atheroma in the
aortic arch.and descending thoracic aorta. A well-seated
bioprosthetic aortic valve prosthesis is present. There is a
1.2x0.7cm mobile echodensity attached to the aortic side of the
posterior aortic valve leaflet c/w a vegetation (see clip #[**Clip Number (Radiology) **]).
No aortic regurgitation is seen. The posterior aortic root is
somewhat thickened and heterogeneous with areas of echolucency
suggestive of an aortic root abscess. No flow is seen into this
area. The mitral valve leaflets are structurally normal. No mass
or vegetation is seen on the mitral valve. Mild (1+) mitral
regurgitation is seen.
[**2153-4-10**] Abdominal Ultrasound:The liver again demonstrates a
coarsened echotexture appearance. No focal masses were
identified. There is no biliary dilatation and the common duct
measures 0.4 cm. The portal vein is patent with hepatopetal
flow. The gallbladder is normal without evidence of stones. The
spleen is again noted to be enlarged measuring 15.4 cm. The
kidneys are again noted to be atrophic but there is no
hydronephrosis identified. No ascites is seen. IMPRESSION:
Cirrhosis but no focal hepatic lesions identified. Splenomegaly.
No ascites is seen.
[**2153-4-12**] Head CT Scan: There is no evidence of hemorrhage, edema,
mass, mass effect, or acute vascular territorial infarction. The
ventricles and sulci are moderately prominent, most consistent
with age-related involutional change. There is no fracture.
Visualized paranasal sinuses are normally aerated.
Brief Hospital Course:
Admitted to the podiatry service on [**2153-4-6**] from [**Hospital **]
Hospital with fevers, MRSA bacteremia, felt due to a lfet foot
wound. He was readily transferred to the medical service due to
his complicated medical history. He developed heart block, and
underwent placement of a temporary screw-in pacmaker on [**2153-4-9**].
He then had a surgical debridement of his left foot. On [**4-12**] he
was noted to have recurrent positive blood cultures, an dmental
status changes,a nd was taked to the OR urgently for an
AVR/homograft. Please see operative report for details of
surgical procedure.
Post-op, he required vasopressors and inotropes, which were
weaned off by POD # 3. He remained on mechanical ventilation,
and was extubated on POD # 4. He was also on CVVH until he was
transitioned to hemodialysis, which was started on POD # 6. The
neurology service was consulted due to ongoing delirium, which
they attributed to metabolic issues. He initially failed his
swallow eval due to his mental status, but he later passed as
his mental status cleared over the next few days. On post-op
day # 6, he was transferred to the telemetry floor.
He had remained hemodynamically stable over the next few days,
and discharge planning was in progress. On [**4-23**], am, he had
complained of "not feeling well", with no specific complaints.
Hi vital signs were stable, and he was transported to the
dialysis unit for his usual treatment. Prior to initiation of
dialysis, he had a cardiac arrest. The code team was called,
and CPR was initiated. He was intubated, and transported to the
CVICU, where he was noted to be in EMD. CPR and ACLS protocol
was continued with poor response. His chest was opened, and
there was no spontaneous heart movement, and no blood in the
pericardial space. The resuscitation was stopped after approx.
30 minutes, and he was pronounced at 0908.
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
MRSA endocarditis now s/p redo sternotomy, bental
homograft(21mm), reimplantation of LMCA/SVG-diag/SVG-OM1-OM2,
CABGx1(SVG-RCA)
foot osteomyelitis
s/p CABG/AVR(tissue) [**7-16**], DM, HTN, ESRD on HD-L forearm
fistula, and Childs A Hep C cirrhosis, charcot arthropathy,
polyneuropathy, multiple foot ulcers, L foot osteo.
Discharge Condition:
expired
Discharge Instructions:
Followup Instructions:
Completed by:[**2153-4-23**]
|
[
"250.40",
"V45.81",
"403.91",
"996.61",
"585.6",
"421.0",
"790.7",
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"426.0",
"412",
"998.0",
"272.0",
"357.2",
"041.11",
"250.60",
"730.17",
"V12.09",
"V17.3",
"427.31",
"707.15"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.21",
"78.68",
"39.95",
"39.61",
"37.78",
"36.11",
"89.60",
"88.72",
"77.68",
"88.49",
"38.45",
"37.91",
"37.76",
"77.48"
] |
icd9pcs
|
[
[
[]
]
] |
8167, 8176
|
6222, 8116
|
346, 600
|
8543, 8553
|
3641, 6199
|
8605, 8633
|
2914, 3225
|
8139, 8144
|
8197, 8521
|
8579, 8579
|
3265, 3622
|
281, 308
|
628, 1407
|
1429, 2506
|
2522, 2898
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,406
| 171,510
|
46970+46971
|
Discharge summary
|
report+report
|
Admission Date: [**2170-1-26**] Discharge Date: [**2170-3-4**]
Date of Birth: [**2107-10-30**] Sex: F
Service: MED ICU
OF NOTE: The patient has been in the hospital for over six
weeks at the time of this dictation. This dictation is being
pieced together from notes of multiple caregivers and will be
a broad review of her hospital course from [**1-26**] until
[**2170-3-4**]. The rest of this dictation will be completed
by the house officer taking over her care on [**2170-3-5**].
HISTORY OF PRESENT ILLNESS: The patient is a 52 year old
female with a history of congestive heart failure, diabetes
mellitus, hypertension, atrial fibrillation, obesity and
peripheral vascular disease on Coumadin who presents with
bright red blood per rectum since about midnight on the day
prior to admission. The patient experienced periumbilical
abdominal pain followed by watery non-bloody diarrhea all
afternoon.
The patient was recently admitted to the [**Hospital Unit Name 196**] Service from
[**1-4**] until [**1-16**] with congestive heart failure
and a non-ST elevation myocardial infarction and new onset of
rapid atrial fibrillation where she was treated with a
Diltiazem drip. The patient was started on Coumadin at that
time. The patient had an elevated creatinine during that
admission which was thought to be secondary to over diuresis,
so her Lasix dose was decreased.
Since the day prior to admission, the patient denies any
chest pain, palpitations or shortness of breath, but does
report some lightheadedness. The patient also reports nausea
and vomiting with two episodes of non-bloody emesis with food
particles. The patient does report having bloody stools
greater than ten years ago when she was drinking heavily, but
that had never been worked up.
She denies a colonoscopy or esophagogastroduodenoscopy in the
past. The patient takes Daypro chronically. The patient is
still with some abdominal pain and bright red blood per
rectum. Her nasogastric lavage was negative.
PAST MEDICAL HISTORY:
1. Congestive heart failure with an echocardiogram in
[**2169-12-13**], with one plus mitral regurgitation, two plus
tricuspid regurgitation, normal wall motion and ejection
fraction.
2. Diabetes mellitus.
3. Hypertension.
4. Cerebrovascular accident with seizure disorder.
5. Morbid obesity.
6. Peripheral vascular disease status post left femoral to
popliteal bypass in [**2164**].
7. Hypercholesterolemia.
8. Atonic bladder.
9. Right total knee replacement in [**2163**].
10. History of Methicillin resistant Staphylococcus aureus in
her left knee.
11. Major depression.
12. History of atrial fibrillation in [**2169-12-13**].
13. Coronary artery disease status post non-ST elevation
myocardial infarction in [**2169-12-13**] with a cast at that
time showing a 50% ostial lesion with no intervention done.
14. Chronic renal insufficiency with a creatinine of between
1.2 and 1.5.
15. Osteoarthritis.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS ON ADMISSION:
1. Albuterol Multiple dose inhaler.
2. Protonix 40 mg p.o. q. day.
3. Risperidone 2 mg p.o. twice a day.
4. Zoloft 10 mg p.o. twice a day.
5. Metoprolol 200 mg p.o. twice a day.
6. Lisinopril 20 mg p.o. q. day.
7. Doxepin 10 mg p.o. twice a day.
8. Aspirin 325 mg p.o. q. day.
9. Iron sulfate 225 mg p.o. q. day.
10. Sublingual Nitroglycerin as needed.
11. Senna as needed.
12. Colace.
13. Lasix 80 mg p.o. twice a day.
14. Coumadin 10 mg p.o. q. h.s.
15. Insulin 70/30, 70 units at breakfast and 25 units at
night.
16. Daypro one tablet p.o. q. day.
SOCIAL HISTORY: The patient lives alone. She has a tobacco
history of 30 pack year, half pack per day. No alcohol, but
has a past history of alcohol abuse. She has Visiting Nurses
Association services.
FAMILY HISTORY: Diabetes mellitus.
PHYSICAL EXAMINATION: On admission, blood pressure 186/70
with a heart rate of 65; respirations 18 with 98% on room
air. In general, she is morbidly obese. HEENT examination:
Pupils are equal, round and reactive to light. Extraocular
movements intact. Anicteric. Oropharynx is clear.
Cardiovascular: She had regular rate and rhythm, distant.
Pulmonary: Clear to auscultation bilaterally. Abdomen is
morbidly obese. Periumbilical tenderness. Extremities with
non-pitting edema.
LABORATORY: On admission, white blood cell count of 12.9,
hematocrit of 42.2 which was up from 32.8 on [**1-16**].
Platelets 298; 89% neutrophils, 7% lymphocytes, 2% monocytes,
1% eosinophils. PT 17.2, PTT 24.7, INR 1.9. Sodium 141,
potassium 4.6, chloride 105, bicarbonate 21, BUN 55 up from
51 and creatinine of 2.0, up from 1.8, all from [**1-22**]
that was increased. Glucose 245, troponin 0.5.
Urinalysis showed a specific gravity of 1.009, small blood,
moderate leukocyte esterase, two red blood cells, 35 white
blood cells, many bacteria.
EKG was normal sinus rhythm at 68, normal axis, normal
intervals, T wave inversions in II, III, AVF, V4 through V6.
T wave inversions in I. No ST changes. Q wave in III and
AVF. Compared with [**1-18**] where there were T waves from
lead V4 through V6 which are new.
ASSESSMENT: This is a 52 year old female on Coumadin for
atrial fibrillation, who presents with bright red blood per
rectum.
HOSPITAL COURSE:
1. GASTROENTEROLOGY: The patient originally had been
admitted with bright red blood per rectum. She had had a
flexible sigmoidoscopy upon admission on [**2170-1-26**],
which showed signs that may have been consistent with early
ischemic colitis. At that time, she was treated with
Levofloxacin and Flagyl empirically and was being followed
both by the Gastrointestinal and Surgery Services.
Because of an elevation in her creatinine for an acute on
chronic picture, a CT scan without contrast was done. The CT
scan at that time was a limited study given that there was no
intravenous contrast. There was one loop of distended small
bowel without wall thickening and a loss of transverse
colonic haustration, also without wall thickening, a
nonspecific finding, and ischemia could not be excluded.
There was no free intraperitoneal air and no portal air.
There was an area of narrowing with wall thickening in the
splenic flexure which may represent peristalsis but a
constricting lesion also could not be excluded.
These findings were thought to be concerning, but because a
more specific study with contrast could not be performed at
the time she was continued to be treated empirically on
antibiotics; since she was hemodynamically stable, she was
followed without any further intervention. There was a plan
to have a follow-up CT scan with contrast to further
appreciate the cause of her bright red blood per rectum while
she was on her Coumadin, however, that was complicated by a
PEA arrest, so the study could not be done.
The patient's further gastrointestinal course was essentially
that she was kept off Coumadin while she had been placed on a
heparin drop for her paroxysmal atrial fibrillation. This
was also discontinued in her setting of her continued drop in
hematocrit. She had a follow-up flexible sigmoidoscopy done
which showed findings consistent with melanosis coli, but
there were no clear reasons why she had suffered from bright
red blood per rectum. It was thought that when she was more
stable and her acute medical issues were resolved and she was
out of the Intensive Care Unit, that she would benefit from a
full colonoscopy and/or a video study to further evaluate her
gastrointestinal tract.
Of note, the patient also was noted to have an elevated
alkaline phosphatase and LDH, and the etiology of this was
not clear. It was thought that she was likely suffering from
an infiltrative process. An ultrasound was done of the
gallbladder which showed stable cholelithiasis but no
evidence of cholecystitis. It was thought that this may be a
secondary infiltrative process from her acute illness in the
Intensive Care Unit and no further interventions were done.
At that time of this dictation, the patient's bright red
blood per rectum had resolved; she was guaiac negative and
her hematocrit was stable.
2. CARDIOLOGY: The patient was status post recent non-ST
elevation myocardial infarction with a catheterization and no
intervention. She had also been recently treated for atrial
fibrillation and was on Coumadin. During her
hospitalization, the patient again developed atrial
fibrillation and had been cardioverted into normal sinus
rhythm.
During the setting of her acute illnesses, the patient again
developed atrial fibrillation. She was started on an
amiodarone drip, a Diltiazem drip and heparin drip at that
time. The patient's Diltiazem drip was weaned off and she
was started on p.o. Diltiazem. Her amiodarone drip was also
converted to 400 mg p.o. q. day. Her heparin drip was
discontinued as she was having difficulties with a
gastrointestinal bleed, so she remained without
anti-coagulation as this was the reason she was hospitalized
and with anti-coagulation, she continued to bleed.
The patient thus failed the initial cardioversion in the
setting of another acute illness and was kept on amiodarone.
At the time of this dictation, she was in continued atrial
fibrillation and was rate controlled on Amiodarone, Diltiazem
and Lopressor. The patient's outpatient Lopressor dose was
200 mg p.o. twice a day and her medications are being
titrated up as her blood pressure tolerates.
3. PEA arrest: The patient had two episodes of PEA arrest
during her hospitalization. The first PEA arrest occurred
during her CT scan when she was administered intravenous
contrast. There were no case studies showing any relation
between receiving intravenous contrast and developing PEA
arrest, however, it was also in the setting of the patient
lying down flat. The patient has a history of obesity
hypoventilation syndrome and obstructive sleep apnea, so it
is not unreasonable to presume that perhaps there was a
hypoxic component to her PEA arrest. She was resuscitated
with two of epinephrine, two of Atropine and two of
bicarbonate. initially she was in asystole and then PEA with
a narrow complex bradycardia which was taken to be notable.
She had been extubated a few days after her initial PEA
arrest only to suffer a second episode of PEA arrest and was
re-intubated to protect her airway again. The second PEA
arrest was two minutes and she was resuscitated and had
subsequent hypotension requiring transient pressors.
The patient at the time of this dictation, did not suffer any
more episodes of PEA arrest.
4. PULMONARY: The patient is a very obese woman and likely
suffers from an obesity hypoventilation syndrome with
obstructive sleep apnea. She had been intubated twice in the
setting of a PEA arrest. After her second extubation, the
patient had been stable until she again was noted to have
respiratory distress and was re-intubated for this reason.
The patient remained intubated for about three weeks and was
finally weaned to CPAP overnight and nasal cannula during the
day without effect.
In order to treat the patient's obstructive sleep apnea, it
is important that she sit relatively high with her head of
bed elevated 45 degrees, so that the girth of her abdomen is
not weighing upon her chest wall and subsequently causing
more difficulties in her breathing status. The patient is
also someone who benefits from CPAP at night to keep her
alveoli open in the setting of having a large chest wall.
5. INFECTIOUS DISEASE: The patient, at the time of her
third intubation in the setting of respiratory distress, was
found to have a metabolic acidosis and it was felt that she
was in respiratory distress secondary to compensation from
the underlying acidosis. A full work-up was done to find the
etiology of her sepsis, which had required pressors and she
had a pan-CT of her body to look for any signs or symptoms of
infection including pneumonia, abdominal abscess, colitis.
She had a lower extremity CT scan to see if she had any
evidence of seeding infection to her knee where she had prior
surgery; however, the CT scans were essentially negative and
it was not clear exactly the source of her sepsis. However,
it was noted that the patient had increasing sputum so she
was treated with a two week course of a treatment of
Vancomycin for a ventilator acquired pneumonia.
After the patient was extubated for the third time, she also
developed a VRE urinary tract infection and a Methicillin
resistant Staphylococcus epidermidis sepsis. She was placed
on Linezolid. At the time of this dictation, she is still
currently on this treatment.
6. RENAL: The patient's kidney function essentially
remained relatively stable throughout her hospitalization.
She had a few episodes of acute on chronic renal
insufficiency which subsided with treatment of her underlying
sepsis and her underlying fluid status. The patient had no
further complications and tolerated increasing levels of
diuresis with Lasix.
7. HEMATOLOGY: The patient had an anemia upon admission
thought secondary to her blood loss from her bright red blood
per rectum. She required occasional transfusions with goal
transfusion of hematocrit of greater than 27.
8. ENDOCRINE: The patient had a history of diabetes
mellitus and she was kept on an insulin drip for most of her
hospital stay given that the goal fingersticks were between
80 and 120 in the acute care setting. She was finally
transitioned over to her 70/30 insulin dose that she takes at
home without any further problems.
Of note, the patient had an elevated prolactin level and some
galactorrhea. Endocrine was consulted and felt that in
relation to her acute settings, this was a minor issue and to
follow-up as an outpatient to assure that this has been
resolved.
9. NEUROLOGICAL/PSYCHIATRIC: The patient had a history of
depression but her anti-depressants were held in the setting
of a change in mental status and lethargy. At the time of
this dictation, Psychiatry was being consulted regarding when
to initiate her anti-depressants.
The patient was also noted to have fair weakness while she
was in the Intensive Care Unit. Neurology was consulted and
felt that she had a critical care myopathy and neuropathy,
which should be resolved when treatment of her underlying
medical condition was also treated. No further intervention
was done.
Of note, the patient also had an elevated sedimentation rate
and CRP and we were unclear if it was contributing to her
weakness or her overall slow recovery after extubation.
Rheumatology was consulted and they felt it was unlikely to
be a rheumatological process and suggested to keep the
patient off steroids as the risks of steroids were greater
than any benefit and to keep the patient off steroids
empirically if no clear reasons for steroids was identified.
10. ACCESS: At the time of this dictation, the patient had
a PICC line placed at the bedside by Interventional
Radiology. The PICC line had been placed with some
difficulty, however, it is a working PICC that can withdraw
blood and can have medication administered. It was placed on
[**2170-2-27**].
11. OPHTHALMOLOGY: The patient was noted to have increasing
erythema and edema around both of her eyes, but especially
noted on the left. She was seen by Ophthalmology who felt
that she had an exposure keratopathy as well as a corneal
abrasion and she was treated with Ciprofloxacin and
Erythromycin Ointments to help prevent any further infection.
The remainder of this Discharge Summary will be dictated by
the House Officer taking over this patient's care. The
remainder of the Discharge Summary will include the patient's
discharge medications and complete list of her discharge
diagnoses.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 99620**]
Dictated By:[**Name8 (MD) 99621**]
MEDQUIST36
D: [**2170-3-4**] 16:47
T: [**2170-3-4**] 18:44
JOB#: [**Job Number 99622**]
Admission Date: [**2170-1-26**] Discharge Date: [**2170-3-15**]
Date of Birth: [**2107-10-30**] Sex: F
Service:
ADDENDUM: This is an Addendum to the previous Discharge
Summary for admission [**2170-1-26**] and date of discharge
[**2170-3-15**].
HOSPITAL COURSE BY ISSUE/SYSTEM (CONTINUED): The patient was
transferred to the floor on [**2170-3-7**] because she was
stable.
1. PULMONARY ISSUES: Continued continuous positive airway
pressure overnight. Head of bed to 45 degrees at all times.
Inhalers and nebulizers as needed for her obesity
hypoventilation syndrome and obstructive sleep apnea.
2. INFECTIOUS DISEASE ISSUES: The patient was treated with
10 days with linezolid for vancomycin-resistant enterococcus
urinary tract infection and methicillin-resistant
Staphylococcus epidermidis bacteremia. Her cultures remained
negative with no growth to date. A wound care nurse [**First Name (Titles) **]
[**Last Name (Titles) 4221**] for her decubitus ulcers, and she was continued on
Baricaire bed to promote wound healing.
3. CARDIOVASCULAR SYSTEM/ATRIAL FIBRILLATION: The patient
was rate controlled on metoprolol, diltiazem, and amiodarone.
Anticoagulation was held secondary to the gastrointestinal
bleed. Hypertension was controlled with beta blocker. She
was continued on aspirin 81 mg p.o. q.d., and there were no
events on telemetry, which was eventually discontinued.
4. GASTROINTESTINAL ISSUES: The patient has a history of
gastrointestinal bleeds with melanosis coli and question of
ischemic colitis on admission. There was no further evidence
of bleeding, and she was felt to be high risk to pursue
colonoscopy on. She was to continue proton pump inhibitor.
5. ANEMIA ISSUES: Continued to check the patient's
hematocrit and transfuses as needed for a hematocrit of less
than 30 because of her history of coronary artery disease.
6. NEUROPSYCHIATRIC ISSUES: The patient's mental status
was stable. She continued to be held from her psychiatric
medications.
7. ENDOCRINE ISSUES: For her diabetes, she was begun on
NPH-10 100 units subcutaneously q.a.m. 40 units
subcutaneously q.p.m. and a regular insulin sliding-scale.
8. OPHTHALMOLOGIC ISSUES: For exposure keratopathy, she
was seen by Ophthalmology who recommended erythromycin
eyedrops, and lubrication drops.
9. FLUIDS/ELECTROLYTES/NUTRITION ISSUES: The patient
continued to be nothing by mouth because of aspiration risks.
She was tolerating tube feeds at goal.
Both Gastroenterology and Interventional Radiology were
[**Last Name (Titles) 4221**] again regarding possibly placing a percutaneous
endoscopic gastrostomy tube in this patient. After careful
review of her hospital course and her data, it was felt that
there was still a small window for access, but is not
transhepatic, transcolonic, or through the costal area.
Similarly, Interventional Radiology was unable to find a
window to place the percutaneous endoscopic gastrostomy tube.
Therefore, percutaneous endoscopic gastrostomy tube placement
was deferred. Instead, the patient had a Dobbhoff tube
placed, and tube feeds were continued.
10. ACCESS ISSUES: Her peripherally inserted central
catheter line remained in place.
11. PROPHYLAXIS ISSUES: She was continued on a proton pump
inhibitor and subcutaneous heparin.
DISCHARGE DISPOSITION/STATUS: Discharge to [**Hospital3 1761**] facility for continued pulmonary
rehabilitation and swallowing rehabilitation.
DISCHARGE DIAGNOSES:
1. Pulseless electrical activity arrest times two.
2. Respiratory arrest.
3. Atrial fibrillation.
4. Acute blood loss anemia.
5. Ischemic colitis.
6. Melanosis coli.
7. Vancomycin-resistant enterococcus urinary tract
infection.
8. Methicillin-resistant Staphylococcus epidermitis
bacteremia.
9. Ventilator-associated pneumonia.
10. Exposure keratopathy.
11. Morbid obesity.
12. Obesity hypoventilation syndrome.
13. Obstructive sleep apnea.
14. Elevated prolactin.
CONDITION AT DISCHARGE: Condition on discharge was stable.
MEDICATIONS ON DISCHARGE:
1. Polyvinyl alcohol drops as needed.
2. Lansoprazole 30 mg p.o. q.d.
3. Heparin 5000 units subcutaneously q.8h.
4. Diltiazem 120 mg p.o. q.i.d.
5. Ipratropium bromide inhaler as needed.
6. Albuterol nebulizers as needed.
7. Acetaminophen as needed.
8. Amiodarone 400 mg p.o. q.d.
9. Multivitamin one p.o. q.d.
10. Zinc sulfate p.o. q.d.
11. Vitamin C p.o. q.d.
12. Erythromycin eyedrops q.d.
13. Nystatin oral suspension q.i.d.
14. Metoprolol 150 mg p.o. t.i.d.
15. Aspirin 81 mg p.o. q.d.
16. NPH insulin 100 units subcutaneously q.a.m. and 40 units
subcutaneously q.p.m.
17. Regular insulin sliding-scale.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 99620**]
Dictated By:[**Last Name (NamePattern1) 2918**]
MEDQUIST36
D: [**2170-3-14**] 18:32
T: [**2170-3-14**] 19:53
JOB#: [**Job Number 99623**]
|
[
"557.0",
"285.1",
"428.0",
"780.39",
"427.31",
"599.0",
"427.5",
"584.9",
"790.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"45.24",
"96.71",
"00.14",
"45.25",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
3818, 3838
|
19521, 20019
|
20097, 21007
|
3031, 3592
|
5295, 19499
|
3861, 5278
|
20034, 20070
|
536, 2015
|
2037, 3005
|
3610, 3800
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,329
| 171,635
|
45175
|
Discharge summary
|
report
|
Admission Date: [**2144-3-8**] Discharge Date: [**2144-3-18**]
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Fever and diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
83 yo F with h.o dementia, CAD s/p CABG, DM, seizure disorder,
hyperntension, who presented to ED with diarrhea and fever. She
was admitted to [**Hospital1 18**] in [**Month (only) **] and treated for pneumonia. She was
discharged to rehab at [**Hospital1 599**] and was discharged from [**Hospital1 599**] to
home on Wednesday. She is helped by a home health aide. Pt is
demented and could not provide any history, she denies all
complaints including abd pain, chest pain, sob, dysuria. Per her
aid and husband over the telephone, they say that she has had
diarrhea since Wed, 3 episodes on day of admission, with mucous
and traces of blood x one day. They also note she had nausea and
vomited 2x on day of admission, ne hemetemesis. They do not
believe she had abd pain. They are not sure if she was recently
on antibiotics and per the d/c summary was not sent out on
antibiotics but only treated for a few days during that
hospitalization. Per the home nurse, she has been declining over
the past weeks. She said that it would not be unusual for
[**Known firstname 96555**] to not realize she was in the ER.
Past Medical History:
DM type 2
CAD s/p 2 vessel CABG and PCI to LIMA-LAD in '[**23**]
Carotid stenosis s/p stent to L ICA in '[**36**]
Atrial septal defect
TIA/CVA
Chronic kidney disease, baseline cr 1.6-2.1
Stroke Induced Seizures
HTN
Hyperlipidemia
Cervical Spondylosis
Lumbar Radiculopathy
Depression
CHF EF 20% 8/04, mildly dil LA, small ASD w/ L->R flow, mild
LVH, near akinesis distal [**1-17**] ventricle, mildly hypokinetic
basal anterior septal and inferolatral walls. Mild global RV
free wall hypokinesis. trace AR, 1+ MR, 3+ TR. Mild pulmonary
artery systolic hypertension
.
PSH:
S/p cataract repair
s/p LUE fx repair
s/p CABG '[**23**]
Social History:
SH:
Retired math professor [**First Name (Titles) **] [**Last Name (Titles) **], married and lives at [**Location 96556**] with
husband. [**Name (NI) 4906**] is primary HCP and son is secondary HCP.
Denies present or past tobacco, no EtoH. Pt has 24h home health
aid. Per health aid she is wheelchair bound. Son- [**Name (NI) **] phone #
[**Telephone/Fax (1) 96553**]; Nurse [**First Name8 (NamePattern2) **] [**Last Name (Titles) 1356**] #[**Telephone/Fax (1) 96554**].
Family History:
Non- contributory
Non- contributory
Physical Exam:
PE:
101.3, 99, 154/45, 20, 98%RA
GENL: pleasantly demented
HEENT: PERL, EOMI, OP clear, no LAD
CV: RRR +systolic murmur
Lungs: CTA with crackles at bases
Abd: soft, nt, nd, +bs, no HSM
Ext: trace edema, 1+ pedal pulses.
Neuro: awake, oriented to self only, follwed some simple
commands. moves all extremities
Pertinent Results:
Abd CT: Marked wall thickening of the rectosigmoid colon,
surrounded by
fat stranding, suspicious for infectious versus inflammatory
colitis. The
abnormality is in similar area compared to the prior study,
therefore,
chronicity of the finding is uncertain. Clinical correlation is
recommended. Multiple small gallstones.
[**2144-3-9**] 06:20AM BLOOD WBC-21.1* RBC-3.30* Hgb-9.8* Hct-29.0*
MCV-88 MCH-29.7 MCHC-33.8 RDW-14.9 Plt Ct-369
[**2144-3-9**] 06:20AM BLOOD Neuts-79* Bands-17* Lymphs-2* Monos-2
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2144-3-9**] 06:20AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2144-3-9**] 06:20AM BLOOD Plt Smr-NORMAL Plt Ct-369
[**2144-3-9**] 06:20AM BLOOD Glucose-202* UreaN-29* Creat-1.1 Na-136
K-3.5 Cl-106 HCO3-17* AnGap-17
[**2144-3-9**] 06:20AM BLOOD TSH-1.6
[**2144-3-8**] 10:20PM BLOOD K-4.9
Brief Hospital Course:
83 yo F with dementia, CAD, CVA and seizure d/o, admitted with
diarrhea x 3 days and fever. Pts floor course was notable for
elevated WBC with left shift,low grade fever initially (99.2).
She was made NPO and found to be C diff +. CT abd showed
rectosigmoid thickening with fat stranding. Given NS a 75 cc/hr
over the course of the day with little UOP. Overnight on [**3-9**],
the patient triggered for low BP (80/50) at 10:12 pm. VS were
104, 80/50, 20, 99.2, 94%. Given 250 cc bolus with improvement
in BP. Another trigger called at 6 am on [**3-10**]. HR 104,
120/doppler, 20, 97.1, 98% 1L, UOP 10 cc/6-7 hrs. PO vanco was
added. Surgery was consulted and recommended transfer to the ICU
for closer monitoring.
.
In the ICU, renal was consulted. A renal ultrasound showed no
significant abnormalities but ascites. A KUB showed C. difficile
but no toxic megacolon and a uretherogram showed ATN. The
patient was given 100 mg IV lasix in the unit and diuresed well.
She was continued on IV Lasix until her creat came back down to
baseline of 1.0. In addition, after fluid recusitation pt became
anasarcic which improved with diuresis. Pt should continue lasix
80mg PO for approximately 2 weeks or until her edema resolved.
Her creat and potassium should be followed while she is on this
dose of lasix.
.
After addition of PO Vancomycin and aggressive IVF pt's BP
stablitized. Nutrition was maintained with TPN while pt still
nauseous. Diet advanced slowly and pt tolerated this well. Pt
should receive full 2 week course of abx. PICC line placed for
IV Flagyl for 4 additional days of treatment.
.
Pt was found to be anemic with GUIAC neg stools prior to
placement of recal tube. Pt had trace amounts of bright red
blood after recal tube removed which resolved. Iron studies were
normal. Baseline HCT is 27-30. Pt is on epogen. Pt dropped HCT
to 24 during admission and was transfused one unit PRBC with
appropriate response. Pt should have HCT rechecked in 2 days.
.
CVA/seizure d/o: Pt was continued on her depakote per outpt
dose. Depakote level can also be checked in 2 days.
.
DM: While pt NPO, she was maintained on insulin sliding scale.
Glyburide restarted after pt tolerating PO.
.
Psych: per son, pt has been diagnosed with depression and
schitzoaffective d/o. Cont zoloft.
.
HTN: Pt switched to IV Lopressor while NPO and started back on
PO Lopressor once tolerating PO. Will change to PO Lopressor
instead of Toprol XL as outpatient as Metoprolol can be crushed.
.
FEN: Pt was on TPN until able to tolerate PO diet. Pt can have
only Nector thickened liquids and ground solids. Meds should be
crushed when able and pt should be assisted to eat with
aspiration precautions.
.
Code: Patient is a full code per son. This was discussed with
the family.
Medications on Admission:
Glyburide
Depakote 125 [**Hospital1 **]
Toprol xl 50 mg daily
ASA 81 mg daily
Zoloft 25 mg QD
Albuterol IH
Atrovent IH
RISS
Pantoprazole
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] of [**Location (un) 55**]
Discharge Diagnosis:
C.Diff colitis
Dementia
ATN
Anemia
Hypertentiosn
Discharge Condition:
Stable.
Discharge Instructions:
Please return to the hospital if you develop:
Chest pain, shortness of breath, diarrhea, severe
nausea/vomiting, fevers or any other concerning symptoms.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 2204**] in [**12-16**] weeks.
|
[
"585.9",
"424.0",
"276.2",
"780.39",
"401.9",
"276.51",
"438.89",
"789.5",
"295.70",
"584.5",
"V45.81",
"294.8",
"272.4",
"428.0",
"008.45",
"250.00",
"397.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"38.93",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
6777, 6849
|
3826, 6589
|
236, 242
|
6942, 6952
|
2920, 3803
|
7154, 7235
|
2539, 2576
|
6870, 6921
|
6615, 6754
|
6976, 7131
|
2591, 2901
|
178, 198
|
270, 1383
|
1405, 2034
|
2050, 2523
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,232
| 190,398
|
30477
|
Discharge summary
|
report
|
Admission Date: [**2158-3-17**] Discharge Date: [**2158-3-30**]
Date of Birth: [**2111-9-10**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins / Codeine
Attending:[**Known firstname 1267**]
Chief Complaint:
left shoulder pain
Major Surgical or Invasive Procedure:
[**3-24**] Replacement of ascending aorta (26mm hemashield dacron
graft)
History of Present Illness:
46 yo M with h/o bicuspid aortic valve went to OSH ED with 1 day
of left shoulder pain and left arm and hand numbness. CT chest
showed 5.1 cm ascending aorta.
Past Medical History:
chronic shoulder pain, +opiate abuse, +tob, aortic dilitation
Social History:
1.5 ppd x 20years
- etoh
- drug use
operates heavy machinery
Family History:
NC
Physical Exam:
Appears in pain
Lungs CTAB
CV RRR 2/6 SEM
Abd soft NT, no organomegaly
extrem wihtout edema
L shoulder and hand tender, with limited range of motion
palpable pulses throughout
Pertinent Results:
[**2158-3-29**] 06:45AM BLOOD Hct-22.3*
[**2158-3-28**] 06:25AM BLOOD WBC-11.0 RBC-2.41* Hgb-7.7* Hct-23.2*
MCV-96 MCH-31.9 MCHC-33.3 RDW-15.6* Plt Ct-218#
[**2158-3-27**] 02:43AM BLOOD WBC-12.5* RBC-2.13* Hgb-7.1* Hct-20.3*
MCV-95 MCH-33.5* MCHC-35.1* RDW-14.2 Plt Ct-142*
[**2158-3-28**] 06:25AM BLOOD Plt Ct-218#
[**2158-3-26**] 12:25AM BLOOD PT-13.6* PTT-28.5 INR(PT)-1.2*
[**2158-3-29**] 06:45AM BLOOD UreaN-11 Creat-0.8 K-4.1
[**2158-3-28**] 06:25AM BLOOD Glucose-153* UreaN-14 Creat-0.8 Na-140
K-3.6 Cl-105 HCO3-26 AnGap-13
CXR [**3-27**]
Compared with one day earlier and allowing for technical
differences, I doubt significant interval change. Again seen are
patchy opacities throughout both lungs and left lower lobe
collapse and/or consolidation, with obscuration of the medial
portion of the left hemidiaphragm. The patient is status post
sternotomy, with skin staples. The cardiomediastinal silhouette
is widened but unchanged. No gross effusion is identified. A
right IJ sheath is present, stable in position. No pneumothorax
is detected.
Brief Hospital Course:
He was seen by orthopedics for his shoulder pain. Aspiration was
performed and was negative. Shoulder MRI showed Mild
tendinopathy of the supraspinatus tendon without tear. He was
seen by psychiatry for a question of drug seeking behavior, with
recommendations to add ativan and consult the pain service, who
recommended neurontin, and NSAIDs, and increased narcotics.
Cardiac catheterization on [**3-20**] shoee no flow limiting CAD. He
was seen by neurology for transient visual loss, a Head and neck
CTA was negative, and carotid u/s was negative as well. He was
cleared by dental for surgery. He was taken to the operating
room on [**2158-3-24**] where he underwent a replacement of his
ascending aorta. He was taken back to the operating room later
that same day for bleeding. He was extubated later that same
day. He continued to be seen by pain service post op and a PCA
was started. He was transferred to the floor on POD #3. Pain
service recommended PO pains meds of neurontin, motrin, percocet
and long acting oxycodone. He received 1 unit PRBCs for an HCT
of 20. He was seen in consulatation by electrophysiology for
some pauses and bradycardia to the 30s which were felt to be
vagal, recommendations included [**Doctor Last Name **] of hearts monitor and EP
follow up as outpatient. He was also seen by opthamology post op
again for transient right eye blurriness. Exam was negative and
artificial tears were prescribed. He was ready for discharge
home on POD #6.
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:*0*
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
6. 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*
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*0*
9. Nicotine 2 mg Gum Sig: One (1) Gum Buccal Q1H (every hour) as
needed.
Disp:*QS 1 month* Refills:*0*
10. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*0*
11. Tizanidine 2 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) as needed.
Disp:*50 Tablet(s)* Refills:*0*
12. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
13. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
Disp:*14 Tablet Sustained Release 12 hr(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Ascending aortic aneurysm
chronic shoulder pain
opiate abuse
tobacco abuse
aortic dilatation
Discharge Condition:
Good.
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions, creams or powders to incisions.
No heavy lifting or driving until follow up with surgeon.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**First Name3 (LF) **] R [**Telephone/Fax (1) 72413**] Follow-up appointment
should be in 1 week
Provider: [**Name10 (NameIs) **],[**Known firstname 1112**] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 170**] Follow-up appointment
should be in 1 month
Dr. [**Last Name (STitle) **] 4-6 weeks
Completed by:[**2158-4-4**]
|
[
"441.2",
"305.1",
"746.4",
"E878.2",
"719.41",
"998.11",
"428.30"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"39.61",
"38.45",
"88.54",
"37.23",
"39.41",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
5158, 5233
|
2042, 3519
|
306, 381
|
5370, 5378
|
964, 2019
|
5664, 6030
|
748, 752
|
3575, 5135
|
5254, 5349
|
3545, 3552
|
5402, 5641
|
767, 945
|
248, 268
|
409, 569
|
591, 654
|
670, 732
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,107
| 131,162
|
18470+56955
|
Discharge summary
|
report+addendum
|
Admission Date: [**2187-10-25**] Discharge Date: [**2187-11-2**]
Date of Birth: [**2109-9-12**] Sex: M
Service: MEDICINE
Allergies:
Heparin Agents
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Altered Mental status, respiratory failure
Major Surgical or Invasive Procedure:
-hemodialysis
-PICC placement
History of Present Illness:
78 y/o gentleman with CAD, systolic CHF EF 20%,
ischemic/hemorrhagic CVA, ESRD/HD, recurrent PNA presents with
respiratory failure and altered mental status. History obtained
from wife and two daughters. [**Name (NI) **] experienced an ischemic
stroke which converted to hemorrhagic in [**2187-5-22**] and was
admitted to [**Hospital1 112**]. He then had respiratory failure, recurrent PNA
(including MRSA and Klebsiella), unable to wean off vent and
trach placement. He was transfered to [**Hospital1 392**]. His last PNA was
one month ago and was treated with vanc/cefepime for two weeks.
Patient was transfered to [**Hospital 38**] rehab yesterday. He was at
his usual baseline yesterday. He has residual left sided
weakness from stroke. He is alert and oriented x 3, able to
read/write and do math problems. [**Name (NI) **] was recently weaned off of
vent.
This morning his duaghter found him to be less responsive. His
oxygen saturation decreased to 80s with systolic BP to 80s later
on prior to HD session. He was transfered to [**Hospital3 13347**]. He was found to have WBC to 40s with bandemia to 30s. He
was given Vancomycin IV, cefepime and flagyl per verbal report
from ED. He was transfered to [**Hospital1 18**] as there was no beds
available there.
When patient arrived to [**Hospital1 18**] his vitals were T 98.3 BP 102/58
HR 95 RR 20 100 % CMV. His BP then dropped to 80s requiring 1 L
NS. He was started on low dose midazolam as he was 'fighting the
vent' per ED signout.
On arrival to the ICU his vitals were T 99.1 HR 92 BP 95/42 100%
CMV/AS FiO2 50% PEEP 5 TV 400. He was not able to provide any
history. According to family patient has experienced increased
bowel movements today. He did not compain of any fever, chills,
nightsweats, chest pain, abdominal pain, nausea, vomitting,
headache, change in vision, hearing, new weakness, numbness
yesterday. He was able to recognize his family in the ED today
after the antibiotics but less responsive after midazolam drip.
Past Medical History:
CVA [**2174**] ? [**2179**]. In [**2187-5-22**] ischemic converted to hemorrhagic.
- CAD s/p MI
- systolic CHF EF 20%
- ESRD/HD
- Type 2 DM
- Dyslipidemia
- h/o TB approx 30 years ago was treated
- Stage 3 decub ulcer
- chronic thrombocytopenia
- failed speech and [**Last Name (LF) **], [**First Name3 (LF) 282**] placed
Social History:
Patient lived at home prior to stroke in [**5-29**] with his wife.
[**Name (NI) **] three daughter living nearby. 30 pack year history quit
approx 40 years ago. No ETOH.
Family History:
Noncontributory
Physical Exam:
Vitals: T 99.1 HR 92 BP 95/42 100% CMV/AS FiO2 50% PEEP 5 TV
400.
Gen: Patient unable to give any history. Not responding to
verbal stimuli. Cachectic. Spontaneously moved left upper
extremity.
HEENT: Pupils round and minimally reactive to light, MMM, OP
clear
Heart: S1S2 RRR, distant heart sounds
Lungs: Crackles in bilat lower half of lung fields, coarse
breath sounds bilaterally.
Abdomen: [**Name (NI) 282**] tube in place. Hypoactive BS. Soft ND.
Ext: Sacral decubitus ulcer. No edema. WWP.
Neuro: Plantars down going. Reflexes 1+ bilaterally.
Pertinent Results:
[**2187-10-25**] 10:10PM BLOOD WBC-40.4* RBC-3.20* Hgb-9.5* Hct-30.1*
MCV-94 MCH-29.7 MCHC-31.5 RDW-16.5* Plt Ct-99*
[**2187-10-26**] 05:53PM BLOOD WBC-23.1* RBC-3.45*# Hgb-11.0*#
Hct-30.5*# MCV-89 MCH-31.9 MCHC-36.1*# RDW-16.5* Plt Ct-80*
[**2187-10-28**] 02:47AM BLOOD WBC-17.2* RBC-3.28* Hgb-9.9* Hct-29.8*
MCV-91 MCH-30.3 MCHC-33.3 RDW-16.3* Plt Ct-66*
[**2187-10-30**] 02:11AM BLOOD WBC-8.9 RBC-3.11* Hgb-9.4* Hct-28.7*
MCV-92 MCH-30.3 MCHC-32.9 RDW-15.9* Plt Ct-66*
[**2187-11-1**] 02:51AM BLOOD WBC-6.7 RBC-3.02* Hgb-9.3* Hct-28.2*
MCV-94 MCH-30.7 MCHC-32.9 RDW-16.3* Plt Ct-56*
[**2187-11-2**] 04:12AM BLOOD WBC-6.2 RBC-2.87* Hgb-8.5* Hct-26.4*
MCV-92 MCH-29.7 MCHC-32.4 RDW-15.5 Plt Ct-53*
[**2187-10-25**] 10:10PM BLOOD Neuts-85* Bands-10* Lymphs-1* Monos-4
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2187-10-27**] 04:07AM BLOOD Neuts-88.6* Lymphs-4.3* Monos-6.4 Eos-0.5
Baso-0.1
[**2187-11-1**] 02:51AM BLOOD Neuts-53 Bands-6* Lymphs-14* Monos-18*
Eos-4 Baso-1 Atyps-1* Metas-2* Myelos-1*
[**2187-11-2**] 04:12AM BLOOD Neuts-50 Bands-10* Lymphs-14* Monos-15*
Eos-3 Baso-0 Atyps-4* Metas-3* Myelos-1*
[**2187-10-25**] 10:10PM BLOOD PT-15.5* PTT-34.0 INR(PT)-1.4*
[**2187-10-26**] 04:57AM BLOOD PT-16.6* PTT-38.6* INR(PT)-1.5*
[**2187-10-27**] 04:07AM BLOOD PT-16.4* PTT-38.8* INR(PT)-1.5*
[**2187-10-30**] 02:11AM BLOOD PT-16.9* PTT-37.8* INR(PT)-1.5*
[**2187-11-2**] 04:12AM BLOOD PT-14.1* PTT-33.2 INR(PT)-1.2*
[**2187-10-25**] 10:10PM BLOOD Glucose-249* UreaN-143* Creat-3.7*
Na-131* K-5.4* Cl-95* HCO3-18* AnGap-23*
[**2187-10-26**] 05:53PM BLOOD Glucose-145* UreaN-20 Creat-0.9# Na-137
K-2.9* Cl-99 HCO3-27 AnGap-14
[**2187-10-27**] 04:07AM BLOOD Glucose-173* UreaN-37* Creat-1.5* Na-137
K-3.3 Cl-100 HCO3-27 AnGap-13
[**2187-10-29**] 02:00AM BLOOD Glucose-70 UreaN-93* Creat-3.0* Na-136
K-4.0 Cl-103 HCO3-22 AnGap-15
[**2187-10-31**] 03:53AM BLOOD Glucose-128* UreaN-63* Creat-2.3* Na-136
K-4.3 Cl-102 HCO3-24 AnGap-14
[**2187-11-1**] 02:51AM BLOOD Glucose-143* UreaN-32* Creat-1.5* Na-138
K-4.7 Cl-105 HCO3-27 AnGap-11
[**2187-11-2**] 04:12AM BLOOD Glucose-233* UreaN-58* Creat-2.3* Na-135
K-3.4 Cl-102 HCO3-25 AnGap-11
[**2187-10-26**] 04:57AM BLOOD LD(LDH)-189 CK(CPK)-69 TotBili-0.5
[**2187-10-26**] 11:45AM BLOOD CK(CPK)-82
[**2187-10-26**] 04:57AM BLOOD CK-MB-NotDone cTropnT-3.75*
[**2187-10-26**] 11:45AM BLOOD CK-MB-NotDone cTropnT-3.75*
[**2187-10-26**] 04:57AM BLOOD Calcium-8.6 Phos-6.4* Mg-2.5
[**2187-10-27**] 04:07AM BLOOD Calcium-8.2* Phos-1.8* Mg-1.7
[**2187-10-29**] 02:00AM BLOOD Calcium-8.2* Phos-4.8*# Mg-1.9
[**2187-10-31**] 03:53AM BLOOD Calcium-8.4 Phos-4.3 Mg-2.4
[**2187-11-2**] 04:12AM BLOOD Calcium-8.0* Phos-4.9*# Mg-1.8
[**2187-10-30**] 02:11AM BLOOD calTIBC-91* Ferritn-GREATER TH TRF-70*
[**2187-10-25**] 10:16PM BLOOD Temp-38.0 Rates-20/5 Tidal V-400 PEEP-5
FiO2-100 pO2-396* pCO2-36 pH-7.37 calTCO2-22 Base XS--3
AADO2-296 REQ O2-54 -ASSIST/CON Intubat-INTUBATED
[**2187-10-27**] 08:05AM BLOOD Type-ART Temp-37.1 Rates-18/2 Tidal V-400
PEEP-5 FiO2-50 pO2-206* pCO2-34* pH-7.50* calTCO2-27 Base XS-4
Intubat-INTUBATED Vent-CONTROLLED
[**2187-10-28**] 03:03AM BLOOD Type-ART pO2-192* pCO2-32* pH-7.49*
calTCO2-25 Base XS-2
[**2187-10-30**] 02:24PM BLOOD Type-ART Temp-38.1 Rates-/22 Tidal V-350
PEEP-5 FiO2-40 pO2-171* pCO2-39 pH-7.43 calTCO2-27 Base XS-2
-ASSIST/CON Intubat-INTUBATED
[**2187-10-27**] 9:01 pm SPUTUM Site: ENDOTRACHEAL
ENDOTRACHEAL.
GRAM STAIN (Final [**2187-10-27**]):
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Preliminary):
OROPHARYNGEAL FLORA ABSENT.
KLEBSIELLA PNEUMONIAE. MODERATE GROWTH.
WARNING! This isolate is an extended-spectrum
beta-lactamase
(ESBL) producer and should be considered resistant to
all
penicillins, cephalosporins, and aztreonam. Consider
Infectious
Disease consultation for serious infections caused by
ESBL-producing species.
KLEBSIELLA PNEUMONIAE. SPARSE GROWTH.
SENT TO [**Hospital1 4534**] LABORATORIES FOR COLISTIN SUSCEPTIBILITY.
STAPH AUREUS COAG +. RARE GROWTH.
Please contact the Microbiology Laboratory ([**5-/2485**])
immediately if
sensitivity to clindamycin is required on this
patient's isolate.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations
Rifampin
should not be used alone for therapy.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
| KLEBSIELLA PNEUMONIAE
| | STAPH AUREUS
COAG +
| | |
AMIKACIN-------------- 16 S =>64 R
AMPICILLIN/SULBACTAM-- =>32 R =>32 R
CEFAZOLIN------------- =>64 R =>64 R
CEFEPIME-------------- R 32 R
CEFTAZIDIME----------- R =>64 R
CEFTRIAXONE----------- R
CEFUROXIME------------ R =>64 R
CIPROFLOXACIN--------- =>4 R =>4 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ =>16 R =>16 R <=0.5 S
LEVOFLOXACIN---------- =>8 R
MEROPENEM-------------<=0.25 S
OXACILLIN------------- =>4 R
PENICILLIN G---------- =>0.5 R
PIPERACILLIN/TAZO----- =>128 R =>128 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TOBRAMYCIN------------ =>16 R =>16 R
TRIMETHOPRIM/SULFA---- =>16 R =>16 R <=0.5 S
VANCOMYCIN------------ <=1 S
[**2187-10-29**] 5:27 pm SPUTUM Site: ENDOTRACHEAL
Source: Endotracheal.
**FINAL REPORT [**2187-10-31**]**
GRAM STAIN (Final [**2187-10-29**]):
[**9-15**] PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
RESPIRATORY CULTURE (Final [**2187-10-31**]):
RARE GROWTH OROPHARYNGEAL FLORA.
KLEBSIELLA PNEUMONIAE. RARE GROWTH.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
[**Numeric Identifier 50803**]
[**2187-10-27**].
KLEBSIELLA PNEUMONIAE. RARE GROWTH 2ND MORPHOLOGY.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
[**Numeric Identifier 50803**]
[**2187-10-27**].
CXR [**10-25**]:
FINDINGS: Portable AP view of the chest in supine position was
obtained.
There is a right-sided dual-lumen hemodialysis catheter with the
tip in the
right atrium. Tracheostomy tube is seen. The cardiac silhouette
is enlarged.
The aorta is tortuous and calcified. Bilateral pleural
effusions, left
greater than right. Retrocardiac opacity may represent a
combination of
atelectasis and pleural effusion. There are diffuse interstitial
abnormalities with patchy areas of more nodular opacities. There
is no
pneumothorax.
IMPRESSION: The constellation of findings may represent acute on
chronic
process such as pulmonary edema in a patient with chronic
interstitial lung
disease; however, superimposed infection or other entities
cannot be excluded.
PA and lateral views of the chest after appropriate treatment is
recommended.
CT would also be helpful if clinically indicated.
=========================================
.
Micro results from [**Hospital6 **].
.
[**2187-9-27**] Sputum
Klebsiella Pneumoniae resistant to Amikacin, amp, amp/sulbacam,
aztreonam, cefazolin, cefepime, ceftazidime, ceftriaxone, cipro,
gent, topramycin, bacrim. Sensitive to Cefotetan, imipenem,
[**Doctor Last Name **]/tazo.
.
Staph aureus: MRSA sensitive to linezolid, tetracycline,
bactrim, vanco
.
Klebsiella Pneumoniae Strain #2. Reisistant to Amikacin, amp,
amp/sulbactam, cefazolin, ceftazidime, cipro, genta, [**Doctor Last Name **]/tazo,
tobramycin, bactrim. Sensitive to aztreonam, cefepime,
cefotetan, ceftriaxone, imipenem.
Brief Hospital Course:
78 y/o gentleman with CAD, systolic CHF EF 20%,
ischemic/hemorrhagic CVA, ESRD/HD, recurrent PNA presents with
septic shock, respiratory failure and altered mental status.
.
# Sepsis/pneumonia: Patient has known pneumonia with MRSA and
klebsiella in the past. Known to have VRE in the past. On
presentation patient had crakles on exam, sputum production,
leukocytosis, bandermia, and abnormal CXR consistent with
pneumonia. Blood, urine, sputum, and stool cultures were drawn,
and he was started empirically on vancomycin and meropenem. Also
given reports of loose stools he was started on empiric oral
vancomycin and IV flagyl. Patient was noted to have decubitus
ulcer and a scabbed, dried vescicled rash in a dermatomal
pattern (R T10) that appeared consistent with healing zoster.
Neither of these was felt to be significantly contributing to
his clinical picture. His [**10-27**] Sputum culture grew Klebsiella
with 2 separate lines isolated which was originally both
sensitive to amikacin and meropenem. On further testing one
line was found to be resistant to meropenem and anikacin. At
this time, it is thought that one of his Klebsiella species was
ESBL sensitive to Meropenem. The other Klebsiella strain which
was resistant to Meropenem, likely due to intrinsic
carbapenemase activity but is not ESBL so it could potentially
be sensitive to some beta lactams although resistance pattern
did show resistence to Unasyn and Zosyn. ID Did not recommend
any further antibiotic therapy at this time. MRSA was also added
to [**10-27**] sputum. He was continued on Meropenem and vancomycin
(although vancomycin was discontinued on [**10-30**] and restarted
[**11-2**] once MRSA added to [**10-27**] sputum culture. Fevers have
largely subsided and leukocytosis decreased as has sputum
production. Transient reports of hypotension during admission
were found to be associated to positioning of A-line and/or
post-HD hypotension (fluid responsive) so unlikely to be due to
sepsis. His oral vancomycin and IV flagyl were discontinued on
[**10-29**] once C difficile toxin A&B were negative in 3 separate
samples. He will need to complete a 14 day course of vancomycin
to finish on [**2187-11-16**]. A two week course of meropenem should
continue until [**11-9**]. His vancomyin will need to be dosed per HD
protocol. Due to Mr [**Known lastname **] multiple resistant pathogens a private
room and strict contact precautions should be maintained. Please
trend LFTS weekly for side effects of meropenem.
.
# AMS: Likely secondary to sepsis and midazolam administration.
The patient's mental status improved per family (who was at
bedside daily) since admission with treating infection as above.
At time of discharge, patient was at his most recent baseline
according to his family.
.
# Hypoxia: Most likely due to pneumonia. The patient was
maintained on assist control for most of his admission, with
daily trials at pressure support. His respiratory status
improved with administration of antibiotics. At the time of
discharge he was still unable to wean from assist control. He
will need to work on weaning as an outpatient.
.
# CHF: patient has known ischemic cardiomyopathy with last
known EF 20%. His only CHF med at the time of admission was
variable doses of carvedilol. On admission his dose was
initially decreased to 12.5 mg [**Hospital1 **] and then uptitrated to 25 mg
[**Hospital1 **]. He was also started on a trial of Isordil and hyralazine.
However, he had periods of low blood pressures, particularly
after HD. Renal was concerned that these medications were
limiting their ability to perform ultrafiltration so these
medications were discontinued. His carvedilol am dose was held
on HD days. In the future, you could consider initiating a low
dose ace inhibitor or [**Last Name (un) **].
.
# CAD: Normal CK at OSH and elevated tropinin in the setting of
renal failure. EKG changes are most likely due to LVH with
strain pattern. No clear ischemic changes. He ruled out for MI
with serial cardiac enzymes. His ischemic cardiomyopathy was
managed as above. He was continued on baby aspirin, statin, and
beta blocker. In the future, if he has recurrent ischemia,
caution will need to be taken with any anticoagulation and
antiplatelet therapies given his history of heparin allergy and
recent hemorrhagic stroke.
.
# ESRD/HD: He continued on HD throughout his hospital admission
Q monday, wednesday, friday. He tolerated 3-4 L of
ultrafiltration per day. After some HDs, he had periods of low
BP which were felt to be due to over ultrafiltration and he
responded to IV fluid boluses. His last HD session was on the
day of discharge [**11-2**].
.
# Diarrhea: On admission elevated WBC and bandemia raised
concern for C difficile in the setting of recent antibiotics. As
above, he was started on empiric oral vancomycin and IV flagyl
which were discontinued on [**10-29**] once his stool cultures were
negative for C difficile x 3.
.
# atrial flutter: patient had no prior history of atrial
fibrillation and atrial flutter. He went into atrial flutter
after having a temp on [**10-31**]. He was well rate controlled with
variable block and ventricular responses in the 70s. He
spontaneously converted to NSR on [**11-1**]. On [**11-2**], during
dialysis he had some periods of sinus bradycardia into the 40s.
However, a line tracing showed excellent blood pressures despite
bradycardia with SBPs in 130s. It is possiblehe has some
element of sick sinus sindrome/tachy brady syndrome. At this
time he is asymptomatic. We are continuing his beta blocker at
the current dose. If he has episodes of bradycardia with
decreased BP, one could consider decreasing his carvedilol dose.
He is a poor anticoagulation candidate given his history of
stroke and allergy to heparin. Can consider increasing aspirin
to full dose. However this was not done prior to discharge
given his baseline thrombocytopenia.
.
# chronic thrombocytopenia: levels fluctuated throughout
hospital course but remained reasonably stable without evidence
of bleeding with the exception of his zoster site. His aspirin
dose was maintained at 81 mg due to this. Also given his
abnormal differentials and chronic anemai during his hospital
admission hematology was consulted. They did not think any
further treatment needed to be pursued with the exception of
supportive care but he will follow up with Hematolgy as an
outpatient. Please trend platelets at rehab and replete for
plts < 20 or if actively bleeding
.
# Diabetes: he was continued on lantus and humalog insulin
sliding scale.
.
# seizure disorder: likely secondary to his preceding stroke. He
had no seizure activity during his admission and he was
continued on his regular dose keppra.
.
# Decubitus ulcer: Improving per daughter. Wound care was
consulted and he had no evidence of infection throughout his
hospital admission. Wound care recs: pressure redistribution per
pressure ulcer guidliens. Turn and reposition q2h off back.
After cleaning pat dry and apply wound gel. No sting barrier
wipe to perinum, allow to dry. Plase NS [**Last Name (un) 26535**] (barely damp) on
ulcer, cover with dry gauze, abd pad. Secure with tape
.
# herpes zoster: patient was noted to have R sided herpes zoster
on admission in T10 distribution. Over the course of admission,
vesicles unroofed and scabbed. He had increased ecchymoses
surrounding rash felt to be due to chronic thrombocytopenia. It
continued to resolve during his admission. No treatment was
pursued. Wound should be cleared daily with commercial cleanser
and left open to air when possible.
.
# Code: Full code, no central lines after discussing with family
(wife [**Name (NI) **] [**Name (NI) **], daughters [**Name (NI) **] and [**Name (NI) 21212**])
.
# Contact: Wife [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 50804**], Daughter [**Name (NI) **] [**Telephone/Fax (1) 50805**], [**Name2 (NI) 21212**] [**Telephone/Fax (1) 50806**]
Medications on Admission:
albuterol ipratropium q6h
carvedilol 25 mg daily
carvedilol 25 mg on sun, mon, wed, and fri
chlorhexindine
clortrimazoel topical
NPH novolin 4 units qhs
levetiracetam 750 mg [**Hospital1 **]
mvi
nystatin swish and spit
omeprazole 20 mg daily
acetaminophen prn
albuterol nebs prn
bisacodyl prn
Discharge Medications:
1. Chlorhexidine Gluconate 0.12 % Mouthwash [**Hospital1 **]: Fifteen (15) ML
Mucous membrane [**Hospital1 **] (2 times a day) as needed.
2. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
3. Calcium Carbonate 500 mg Tablet, Chewable [**Last Name (STitle) **]: One (1)
Tablet, Chewable PO TID (3 times a day).
4. Acetaminophen 160 mg/5 mL Solution [**Last Name (STitle) **]: Six [**Age over 90 1230**]y
(650) mg PO Q6H (every 6 hours) as needed.
5. Albuterol 90 mcg/Actuation Aerosol [**Age over 90 **]: Six (6) Puff
Inhalation Q4H (every 4 hours).
6. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Age over 90 **]: Six (6)
Puff Inhalation Q4H (every 4 hours).
7. Aspirin 81 mg Tablet, Chewable [**Age over 90 **]: One (1) Tablet, Chewable
PO DAILY (Daily).
8. Nystatin 100,000 unit/mL Suspension [**Age over 90 **]: Ten (10) ML PO QID
(4 times a day) as needed for thrush: give until thrush clears.
9. Atorvastatin 10 mg Tablet [**Age over 90 **]: One (1) Tablet PO DAILY
(Daily).
10. Levetiracetam 250 mg Tablet [**Age over 90 **]: Three (3) Tablet PO BID (2
times a day).
11. Carvedilol 12.5 mg Tablet [**Age over 90 **]: Two (2) Tablet PO BID (2
times a day): hold for SBP < 100, HR < 60, please hold am dose
on dialysis days .
12. 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.
13. Vancomycin in Dextrose 1 gram/200 mL Piggyback [**Age over 90 **]: One (1)
gram Intravenous HD PROTOCOL (HD Protochol): previously on [**10-26**]
to [**10-30**], restarted [**11-2**]. Complete 2 week continuous course to
[**11-16**] .
14. Meropenem 500 mg Recon Soln [**Month/Year (2) **]: One (1) Recon Soln
Intravenous Q24H (every 24 hours): give dose AFTER dialysis, on
HD days. Complete two week course on [**11-9**].
15. Insulin Lispro 100 unit/mL Solution [**Month/Year (2) **]: see ISS units
Subcutaneous four times a day: As directed by HISS.
16. Lantus 100 unit/mL Solution [**Month/Year (2) **]: Six (6) units Subcutaneous
at bedtime: use in conjunction with humalog ISS.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary:
1. Klebsiella pneumonia
2. MRSA pneumonia
3. ESRD on dialysis
4. herpes zoster
5. stage 3 decubitus ulcer
6. acute on chronic respiratory failure
7. Anemia
8. Paroxsymal Atrial flutter
9. Thursh
Secondary:
1. chronic systolic heart failure
2. history of cerebrovascular accident
3. thrombocytopenia
4. seizure disorder
5. diabetes
6. hyperlipidemia
7. CAD
Discharge Condition:
Nonverbal. Interactive with family. Ventilator dependent with
trach and [**Hospital1 282**]. HR and BP stable.
Discharge Instructions:
You were admitted to the hospital for a change in your mental
status. You were found to have a pneumonia and were treated
with strong antibiotics. You will need to continue on these
antibiotics as prescribed below. We were unable to wean you off
the ventilator, this process will continue at rehab.
Please follow up with your regular doctors as below.
The following perninant changes were made to your medications:
Started on Meropenem to be taken for 2 week course until [**11-9**]
for pneumonia.
Started on Vancomycin to be taken for 2 week course to end on
[**11-16**]
If you develop worsening fevers, increased ventilator
requirement, abdominal pain, diarrhea, worsening mental status,
chest pain, focal weakness, or any other worrisome symptoms
please seek urgent medical attention.
Followup Instructions:
Please call your primary care provider [**Last Name (NamePattern4) **]. [**First Name (STitle) 39968**] at
[**Telephone/Fax (1) **] to schedule a follow up appointment after discharge
from rehab or sooner should the need arise.
.
As you requested here is the number of the Cardiology department
at [**Hospital1 69**]. Please call
[**Telephone/Fax (1) 62**] to schedule a new patient appointment.
.
Please continue with your regular dialysis schedule.
.
Please follow up with Hematology as below:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 647**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2187-11-8**] 3:00
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3014**], RN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2187-11-8**]
3:00
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2187-11-2**] Name: [**Known lastname **],[**Known firstname 909**] POY Unit No: [**Numeric Identifier 9448**]
Admission Date: [**2187-10-25**] Discharge Date: [**2187-11-2**]
Date of Birth: [**2109-9-12**] Sex: M
Service: MEDICINE
Allergies:
Heparin Agents
Attending:[**Last Name (NamePattern4) 3776**]
Addendum:
Of note, records obtained from [**Hospital6 9449**] Hospital from
original hospitalization in [**6-29**] indicate patient was positive
for VRE on screening swab. He also then had a MSSA pneumonia
diagnosed on sputum sample from [**6-26**].
Records were obtained from [**Hospital6 9230**] from
hospitalization [**9-29**]. Patient had MRSA in sputum as well as two
Klebsiella species. Please see results section for full details.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 14**] & Rehab Center - [**Hospital1 15**]
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 593**] [**Name8 (MD) 304**] MD [**MD Number(1) 594**]
Completed by:[**2187-11-2**]
|
[
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"428.0",
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icd9cm
|
[
[
[]
]
] |
[
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"38.93",
"39.95",
"87.44"
] |
icd9pcs
|
[
[
[]
]
] |
25496, 25748
|
11802, 19761
|
326, 357
|
22768, 22881
|
3534, 7104
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23724, 25473
|
2931, 2948
|
20105, 22256
|
22379, 22747
|
19787, 20082
|
22905, 23701
|
2963, 3515
|
7145, 11779
|
244, 288
|
385, 2381
|
2403, 2728
|
2744, 2915
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,522
| 149,005
|
38298
|
Discharge summary
|
report
|
Admission Date: [**2117-5-14**] Discharge Date: [**2117-6-15**]
Service: NEUROSURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
Cervical Spine Fracture
Major Surgical or Invasive Procedure:
[**2117-5-17**]: C6-T1 posterior instrumented fusion
[**2117-5-19**]: C7 corpectomy with allograft and plate
[**2117-5-26**] re-intubation
[**2117-5-27**]: tracheostomy
PEG placement
History of Present Illness:
[**Known firstname 85342**] [**Known lastname 53905**] is an 85 year old woman who presented as a
transfer from [**Hospital3 4107**] for evaluation of cervical spine
fractures.The patient stated that she was walking up the stairs
in her basement the afternoon of admission when she fell
backwards at the top after missing the handrail. She fell
approximately 15 stairs. She did not loose conciousness but
reported left shoulder pain. She was finally found by her
husband who called EMS and had her brought to [**Hospital3 **].
There, she was found to have a burst fracture of C7, a C6 facet
fracture and a possible fracture of T1. She was referred to
[**Hospital1 18**] for further treatment.
At admission, she denied any headache, changes in vision. She
had pain in her left shoulder and upper back. She had no chest
pain, no shortness of breath, no abdominal pain. She denied any
numbness or tingling. She had not had bowel or bladder
incontinance. All other ROS where negative.
Past Medical History:
Diabetes
Renal insufficiency (chronic, unknown baseline GFR)
Chronic Anemia
History of ankle fractures
s/p Right knee replacement [**2116**]
s/p unknown right shoulder surgery "years ago"
s/p 2 c-sections and TAH
Social History:
Married. Lives with her husband. Denies tobacco, alcohol or
drugs.
Family History:
not obtained
Physical Exam:
On Admission:
T: 97.4 BP: 144/56 HR: 64 R 20 O2Sats 100%
Gen: NAD.
HEENT: hard collar in palce. Tenderness over the left shoulder,
and upper Tspine.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2. 3/6 SEM at LUSB
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Rectal: normal tone, + frank blood
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, "[**Hospital1 756**]", and date.
Motor:
D B T WE WF IP Q H AT [**Last Name (un) 938**] G
R 5 5 4 5 5 5 5 5 5 5 5
L 3(pain) 5 5 5 5 5 5 5 5 5 5
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Reflexes: Brisk Right bicep, brachioradialis, 1+ triceps, 2+
left
UE. Absent patella and ankle jerks bilaterally.
Toes downgoing bilaterally
On Discharge
wounds are well healed. Motor exam appears full - no deficits
appreciated. She is hard of hearing but nods to questions and
follows commands.
Pertinent Results:
[**2117-5-14**] L Shoulder Xray- no fracture or dislocations
Pelvix Xray- read pending, no obvious fracture
[**2117-5-14**] Pelvis X-ray
No acute fracture or dislocation.
[**2117-5-14**] Chest X-ray:
1. Minimal irregularity right anterior seventh rib, which could
represent a fracture. Correlation with the site of patient's
pain
is recommended. 2. No acute cardiopulmonary abnormality.
MRI C-spine [**2117-5-15**]
. Severe hyperflexion sprain injury with associated rupture of
the intra-
and supraspinous ligaments, dorsally, and associated multiple
spinous process
fractures, as on the prompting CT.
2. Unstable fracture with both anterior and posterior column
involvement,
including interfacetal dislocation with "perched" facet on the
right, and
fracture involving the C7 inferior articulating facet, on the
left.
3. Though there is associated 6-mm anterolisthesis of C6 on C7,
with acutely angulated kyphosis, effacement of the ventral CSF
and angulation of the cord, there is no definite evidence of
cord contusion (N.B. Unfortunately, a DWI sequence was not
performed).
4. The processes above, including the burst fracture of C7,
likely fractured osteophyte originating from the inferior
endplate of C6, as well as the interfacetal dislocation combine
to markedly encroach on the right neural foramen, impinging upon
the exiting right C7 nerve root, correlating with the patient's
acute symptoms. There is no significant narrowing of the
contralateral neural foramen demonstrated on either examination,
and there is mo finding to specifically suggest nerve root
avulsion.
5. No evidence of injury at any other level of the imaged
cervicothoracic
spine.
[**2117-5-14**] 07:13PM GLUCOSE-202* UREA N-42* CREAT-1.6* SODIUM-141
POTASSIUM-4.8 CHLORIDE-105 TOTAL CO2-28 ANION GAP-13
[**2117-5-14**] 07:13PM WBC-15.5* RBC-4.00* HGB-11.1* HCT-34.0*
MCV-85 MCH-27.7 MCHC-32.6 RDW-15.3
[**2117-5-14**] 07:13PM NEUTS-88.6* LYMPHS-5.7* MONOS-4.6 EOS-0.5
BASOS-0.7
[**2117-5-14**] 07:13PM PLT COUNT-209
[**2117-5-14**] 07:13PM PT-12.6 PTT-24.6 INR(PT)-1.1
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt
Ct
[**2117-6-14**] 04:13 5.9 3.08* 8.8* 28.1* 91 28.6 31.3 16.0 223
DIFFERENTIAL Neuts Lymphs Monos Eos Baso
[**2117-6-11**] 16:54 78.9* 8.4* 8.4 3.8 0.5
[**2117-6-14**] 04:13 Plt:223
[**2117-6-11**] 16:54 FIBRINOGEN 332
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2117-6-15**] 05:57 105* 91* 3.2* 143 3.4 105 27 14
[**2117-6-14**] 04:13 ALT:21 AST:21 CK:71 Alk Phos:194*
TotBili 1.0
Source: Line-art
CPK ISOENZYMES CK-MB cTropnT
[**2117-6-11**] 16:54 3 0.07
Calcium Phos Mg
[**2117-6-15**] 05:57 9.5 3.7 2.2
Brief Hospital Course:
This is an 85 year old female s/p fall while walking up stairs.
She states that she missed the top of the hand rail and fell
backwards down 15 steps. She presented to [**Hospital3 4107**] where
CT c-spine showed multiple cervical fractures and the patient
was transferred to [**Hospital1 18**] for further neurosurgical workup. She
presented with right tricep weakness. She was admitted to
neurosurgery and an MRI of the c-spine was obtained. She was
found to have a C7 burst fracture as well as facet fractures.
MRI imaging was performed and she was scheduled for surgery.
Pre-op eval showed UTI and cipro was started on [**5-16**]. She
underwent a C6-T1 posterior instrumented fusion with Dr [**Last Name (STitle) 548**] on
5.17 and was transported to the ICU intubated after surgery.
She remained intubated in the ICU and had poor urine output
post-operatively. On [**5-19**] she went to the OR with Dr. [**Last Name (STitle) 548**] for
a C7 corpectomy with allograft and plate and was transported
back to the SICU post-operatively. She tolerated the procedure
well. Upon returning to the SICU she was noted to have
tachycardia with hypotension which appeared rate related. She
received lopressor and was placed on a diltiazem drip. Her vital
signs remained stable on [**5-20**] while on the diltiazem drip and
she moved all four extremtiies and was interactive via head
nods.
On [**5-21**] the patient had CXR showing a potential
pneumomediastinum. She had a Chest CT as well as a bronchoscopy
and BAL and no study could definitively find a source. She was
also started on triple antibiotics as empiric coverage for
potential esophageal rupture. Her INR increased to 2.6 and she
received vitamin K as well as started on TPN with Vitamin K due
to the potential that her increased INR was from malnutrition.
On 5.23 she was increasingly fluid volume overloaded and
received 20 of IV Lasix with good effect. Also on the 23rd she
had a drainage bag placed to her weeping left hand wound from a
previous IV placement.
She was able to be weaned from ventilator and extubated [**5-25**] but
then increasing respiratory difficulties prompted re-intubation
morning of [**5-26**]. On [**5-27**] she remained intubated on CMV and a
trach was placed due to her unstable respiratory status.
On the weekend of [**5-30**] and [**5-31**] she began to develop uremia and
acute renal failure, as well as elevated LFTs. Renal was
consulted for the possibility of placing the patient on
dialysis. A MRCP was performed which did not reveal any
retained stones or cholelithiasis. And further work up was held
as her renal issues took precedence though there were no acute
surgical issues and LFTs should be followed in the future.
On [**6-2**] a hemodialysis catheter was placed and she was started on
continuous [**Last Name (un) **]-venous hemodialysis. She diueresed nicely with
this. Her wounds continued to be well healed. her mental
status continued to be depressed with only intermittent
following of commands.
She continued on CVVH until [**6-6**] and diuersis of her positive
fluid balance was acheived and she became more interactive.
After the discontinuation of the CVVH her mental status began to
decline again and she was now intermittently following commands.
She remained stable and is being medically managed by the SICU
with renal service input including management of lasix drip for
diuersis. On [**6-10**] she was OOB to chair and working with PT. She
was titrated on medications for her anxiety which helped with
ventalator weaning. On [**6-11**] she spent 12 hours on trach mask and
on [**6-12**] was OOB to chair and much more interactive following
commands with bilateral grasps and wiggling toes to command.
On [**6-13**] she continued to be OOB to chair with trach mask on and
becoming more interactive. on [**6-14**] she was following more
commands and mouthing words and saying her own name. She has
also [**Doctor First Name **] titrated with beta blockers for heart rate.
Medications on Admission:
Arasep 60mg
Insulin (unknown dose), takes in AM
Discharge Medications:
1. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
3. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for mouth care.
4. Ipratropium Bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q6H (every 6 hours).
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) as needed for anxiety.
7. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Insulin Regular Human Injection
9. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
11. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily) for 30 days.
12. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
13. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Ten (10) ML
Intravenous PRN (as needed) as needed for line flush.
14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
15. Therapeutic Multivitamin Liquid Sig: One (1) Tablet PO
DAILY (Daily).
16. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Four (4) mg
Injection Q8H (every 8 hours) as needed for nausea.
17. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Cervical ligamentous injury
C7 fracture/perched facet
6-mm anterolisthesis of C6 on C7
acute renal failure
respiratory distress
atrial fibrillation
elevated Liver function tests with common bile duct dilitation
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
?????? Do not smoke
?????? Keep wound clean / take daily showers
?????? No pulling up, lifting> 10 lbs., excessive bending or
twisting for two weeks.
?????? Limit your use of stairs to 2-3 times per day
?????? Take pain medication as instructed; you may find it
best if taken in the a.m. when you wake for morning stiffness
and before bed for sleeping discomfort
?????? Do not take any anti-inflammatory medications such as
Motrin, Advil, aspirin, Ibuprofen etc. for 3 months.
?????? Increase your intake of fluids and fiber as pain
medicine (narcotics) can cause constipation
Followup Instructions:
PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR.
[**Last Name (STitle) **] TO BE SEEN IN 6 WEEKS.
YOU WILL NEED XRAYS PRIOR TO YOUR APPOINTMENT
Follow up with:
PCP
GI for follow up for elevated LFTs
Renal for kidney functioning
Completed by:[**2117-6-15**]
|
[
"998.81",
"585.9",
"285.21",
"276.6",
"997.1",
"427.31",
"805.07",
"518.81",
"805.06",
"576.2",
"263.9",
"250.00",
"805.2",
"584.5",
"599.0",
"V43.65",
"E880.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"81.03",
"34.91",
"03.09",
"81.02",
"03.53",
"38.93",
"81.62",
"33.24",
"96.04",
"84.51",
"44.32",
"80.51",
"99.15",
"33.22",
"31.1",
"39.95",
"96.72",
"38.95"
] |
icd9pcs
|
[
[
[]
]
] |
11216, 11288
|
5660, 9665
|
247, 432
|
11543, 11543
|
2887, 5637
|
12373, 12656
|
1791, 1805
|
9763, 11193
|
11309, 11522
|
9691, 9740
|
11723, 12350
|
1820, 1820
|
184, 209
|
460, 1452
|
1835, 2128
|
11558, 11699
|
1474, 1689
|
1705, 1775
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,260
| 124,707
|
8610+55969
|
Discharge summary
|
report+addendum
|
Admission Date: [**2181-2-15**] Discharge Date: [**2181-3-1**]
Date of Birth: [**2101-12-26**] Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
MVA
Major Surgical or Invasive Procedure:
[**2181-2-18**]: Placement of right External Ventricular Drain
History of Present Illness:
Mr. [**Known lastname **] (Eu Crit [**Doctor First Name **]) is a 79 yo M with h/o CAD s/p CABG,
HTN, HL who presents after MVC with IVH.The patient was driving
and apparently hit a telephone pole. He remembers driving but
cannot remember any events leading up to the crash, or any
abnormal symptoms. He was brought to OSH ED where head CT showed
IVH. He was transferred to [**Hospital1 18**] where he was hypertensive on
arrival SBP>200. In the ED he received labetalol and phenytoin.
Trauma was consulted. R wrist had laceration, irrigated and will
be monitored only by plastics. FAST showed a question of LUQ
cyst, so CT abdomen was done. Neurosurgery was consulted for
IVH.
The patient is currently denying headache, N/V, vision
changes,numbness, weakness or tingling.
Past Medical History:
CAD s/p CABG x 4 ~10yrs ago
HTN
HL
?COPD
hernia repair
Social History:
lives with wife who has [**Name (NI) 11964**]. h/o tobacco use.
Family History:
NC
Physical Exam:
PHYSICAL EXAM:
Gen: NAD
HEENT: xanthelasma on face, sclera anicteric
CV: RRR, no m/r/g
PULM: CTAB
AB: NT/ND
EXT: well perfused
NEURO:
Alert and oriented x 3. Able to recite days of week backward
easily. Language intact for naming, comprehension, no
dysarthria.
No neglect.
CN I- not tested
II- PERRL 4 to 3mm
III, IV, VI- EOMI without nystagmus
V- facial sensation intact to light touch
VII- facial musculature full strength and symmetric
IX, X, [**Doctor First Name 81**]- palate elevates symmetrically, tongue protrudes in
midline
MOTOR- 5/5 strength at bilateral delt, [**Hospital1 **], tri, finger
ext/flexors, IP, ham, quad, TA and gastroc. Upward drift on
pronator drift on L.
SENSATION- intact to light touch and joint position sense
DTR: 2+ at [**Hospital1 **], brachiorad, tri. 0 at patella, achilles. Toes
downgoing, no clonus.
COORDINATION: intact FNF
Discharge:
Gen: pleasant, awake, NAD
HEENT: incision intact with nylon suture, eyes clear
Neck: supple, no thyromegaly
CV; RR, S1 s2 nl, no murmurs
Pulm: CTAB, no w/c/r
abd: obese, but soft, + BS, incision with steri, mild ecchymosis
Ext: right hand with wrap, no c/c/e
Neuro: AAOX3, PERRL, left droop at nasolabial fold, PERRL, EOM
intact, Strength intact throughout, sensory intact throughout,
coordination intact, gait not tested
Pertinent Results:
CTA Head and neck: [**2-15**]
Intraventricular hemorrhage and ? small left tentorial subdural
hemorrhage.
CTA head and neck: [**2-15**]
Preliminary read 3D recons pending. Occlusion of the R
ICA.Dimminutive flow in the right ACA and MCA; could be
collaterals. No flow in the V1 right vertebral, dimminutive flow
in right V2. Cannot determine chronicty - no prior or history to
compare.
LABS:
PLT 183
INR 1.0
WBC 9.2
H/H 17.6/52.0
CT Head [**2-16**] - Overall stable extent of intraventricular
hemorrhage and probable concurrent subdural hemorrhage along the
tentorium cerebelli. Stable ventricular size. No new hemorrhage
Chest CT [**2-16**] -
1. No acute rib fracture.
2. 6-cm mass-like lesion along the right basilar lateral region,
with
heterogeneous attenuation, not acute hematoma, could be neoplasm
or unusual rounded atelectasis.
3. Heterogeneous collection medial to the right middle lobe,
could represent an old hematoma or postinfectious phlegmon.
Recommend correlation with prior history of trauma.
4. Moderate volume loss of right hemithorax with pleural
thickening, of
uncertain chronicity and etiology.
5. Status post CABG, with significant coronary artery
calcifications
involving all three vessels.
6. Simple cholelithiasis without acute cholecystitis.
Ct head [**2-18**] - 1. Interval development of hydrocephalus.
2. Stable appearance of intracranial hemorrhage with interval
redistribution
of clot
CT head [**2-19**] - 1. Unchanged hydrocephalus with intraventricular
hemorrhage. New right frontal approach ventriculostomy catheter.
2. Small subarachnoid hemorrhage in the right parietal lobe
CT head [**2-20**] - 1. Unchanged hydrocephalus with intraventricular
hemorrhage. New right frontal approach ventriculostomy catheter.
2. Small subarachnoid hemorrhage in the right parietal lobe
CT head [**2-22**] - Mildly decreased ventriculomegaly. See details
above. The tip of the catheter
is in the septum pellucidum close to the left foramen of [**Last Name (un) 2044**],
unchanged
CT head [**2-25**] - Status post removal of ventricular drain with
interval mild
prominence of the ventricles compared to most recent CT head. An
interval
increase in amount of free air in the right frontal and temporal
[**Doctor Last Name 534**] of the ventricle. Similar focus of subarachnoid hemorrhage
along the right occipital and pariteal gyri. Similar
intraventricular hemorrhage.
CT head [**2-26**] - Resolving intraventricular hemorrhage and nearly
resolved right subarachnoid hemorrhage. Persistent air in the
right lateral ventricle status post removal of ventriculostomy
catheter.
CT head [**2-26**] - 1. The new right frontal approach
intraventricular catheter terminates in the left frontal [**Doctor Last Name 534**].
Minimal decrease in the size of the lateral ventricles.
2. Minimal new blood adjacent to the catheter tip.
3. Unchanged residual blood in the right lateral ventricle
atrium and in few right parietal sulci
KUB [**2-28**] - Distended loops of large and small bowel gas-filled
in keeping
with ileus.
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to [**Hospital1 18**] Neurosurgery service after an
IVH caused an MVA. CTA ruled out aneurysm. CT chest was done for
rib pain and this showed multiple lung abnormalities. the family
was informed and they agreed. On [**2-17**], patient was seen to be
neuro intact. On [**2-18**], in am rounds, he was seen to move all
extremities, but non verbal with no eye opening, no commands. A
stat head ct revealed hydrocephalus and an abg showed no CO2
retention. He was then transferred to the ICU and an EVD was
placed and leveled at 10.
On [**2-19**], a repeat head CT shows decreased IVH, but ventricles
were still plump. EVD at 10 with low ICP pressures. His exam was
improved, he was A&Ox3 and full strength throughout, but still
somewhat lethargic. He remained int he ICU for neuro monitoring.
On [**2-20**], patient reported nausea, he was seen to be more
lethargic and confused, a repeat head CT was done which showed
slight 1mm increase in 3rd ventreicle.
On [**2-21**] his mental status improved and his EVD was raised to 20.
His Aspirin and SQH were started. His ICP's remained low and his
EVD was clamped on the morning on [**2-22**]. CT in the afternoon
showed no increase in ventricular size. The drain remained
clamped. Pulmonology saw the patient for his newly discovered
lung lesions and they recommended a PET CT and CT guided FNA
with outpatient clinic follow up. Overnight, patient's EVD
became disconnected. Exam was unchanged and the drain was
reconnected sterily.
On [**2-23**], patient was alert and oriented x3, follows all commands
and full strength. His EVD remained clamped overnight and
patient's exam remained intact. His EVD was removed and he was
transferred to step down. PT consult was placed.
Over the weekend, patient was seen to have drainage from EVD
site. A dressing was placed and was saturated on Sunday morning.
A repeat head CT showed increase in ventricle size. On [**2-26**],
patient exam worsened, he was more lethargic and difficult to
arouse. He was taken to the OR for VP shunt placement. In OR,
opening pressure was observed to be 38. Shunt was placed with
the assistance of general surgery and no complication were
observed. Post operatively, patient was more alert and ansering
questions appropriately. Head CT was stable and he was
transferred to the floor. On [**2-27**], patient was stable, PT was
consulted and he was being screened for rehab.
[**2-28**] patient developed illeus which was confirmed on KUB. He was
made NPO and an agressive bowel regimen was initiated. On [**3-1**]
he had four bowel movements. He was hypertensive to a systolic
blood pressure in the 190's and norvasc was added.
Medications on Admission:
Lipitor dose unknown
BP meds unknown
Spiriva
Advair
ASA 81 mg
Discharge Medications:
1. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
2. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
[**12-3**] Disk with Devices Inhalation [**Hospital1 **] (2 times a day).
3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
4. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. docusate sodium 50 mg/5 mL Liquid Sig: Two (2) PO BID (2
times a day).
6. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. labetalol 100 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
8. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
9. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for oral thrush.
11. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
12. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day) as needed for constipation.
13. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
14. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. megestrol 40 mg Tablet Sig: One (1) Tablet PO QID (4 times a
day).
16. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
17. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: [**12-3**] Inhalation Q4H (every 4 hours) as needed
for wheeze/SOB.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 **] Hospital
Discharge Diagnosis:
Intraventricular hemorrhage
Hydrocephalus
Subarachnoid hemorrhage
Dysphagia
Type II AtrioVentricular block- Wenckebach
Right Lower lobe mass
Ileus
Incontinence
Hypertension
Oral thrush
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Activity Status: Out of Bed with assistance to chair or
wheelchair.
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.
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.
[**Last Name (STitle) 739**], 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.
Pulmonary follow up:
You will need a PET CT of your chest. This will be done in
Nuclear medicine on Thursday [**2181-3-1**] at 11:45am. This is located
on [**Location (un) **] of the [**Hospital Ward Name 23**] building on the [**Hospital Ward Name **] of [**Hospital1 **]. A
preparation list and directions should be picked up before this
appointment.
You have an appointment with a pulmonologist: Dr. [**Last Name (STitle) **] in
the pulmonary clinic ([**Telephone/Fax (1) 612**]) on [**3-8**], at 9:00am. you
need to arrive at 8:30 for pulmonary function testing. this
location is [**Hospital Ward Name 23**] Building, [**Hospital Ward Name 516**], [**Location (un) 436**].
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2181-3-1**] Name: [**Known lastname **],[**Known firstname 389**] Unit No: [**Numeric Identifier 5338**]
Admission Date: [**2181-2-15**] Discharge Date: [**2181-3-1**]
Date of Birth: [**2101-12-26**] Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1698**]
Addendum:
PET CT scan to be done prior to rehab today.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 **] Hospital
[**Name6 (MD) **] [**Name8 (MD) 1041**] MD [**MD Number(2) 1709**]
Completed by:[**2181-3-1**]
|
[
"V45.81",
"331.4",
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"431",
"882.0",
"426.12",
"305.1",
"788.20",
"560.1",
"162.5",
"787.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"02.34",
"86.59",
"02.39"
] |
icd9pcs
|
[
[
[]
]
] |
13278, 13454
|
5765, 8455
|
312, 377
|
10473, 10473
|
2695, 5742
|
11693, 12037
|
1354, 1358
|
8568, 10169
|
10265, 10452
|
8481, 8545
|
10724, 11670
|
1388, 2676
|
12048, 13255
|
269, 274
|
405, 1179
|
10488, 10700
|
1201, 1257
|
1273, 1338
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,154
| 109,127
|
32609
|
Discharge summary
|
report
|
Admission Date: [**2141-4-24**] Discharge Date: [**2141-5-3**]
Date of Birth: [**2083-4-23**] Sex: M
Service: PLASTIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 7733**]
Chief Complaint:
Left forearm swelling
Major Surgical or Invasive Procedure:
s/p multiple incision and drainage, left forearm split thickness
skin graft (donor site - L thigh) with wound vac application:
.
[**2141-4-24**]
1. Decompression fasciotomy, left arm, with epimysiotomy of
all muscle groups.
2. Decompression fasciotomy, left forearm, epimysiotomy of
all muscle groups.
3. Left open carpal tunnel release.
4. Application of vacuum-assisted closure dressing.
.
[**2141-4-26**]
1. Dressing change, debridement left forearm, soft tissue
only.
2. Pulse irrigation and application of vac dressing.
.
[**2141-4-27**]
1. Irrigation and debridement of left arm wound 40 x 15 cm.
2. Placement of vacuum-assisted sponge 14 x 15 cm.
.
[**2141-4-29**]
1. Irrigation and debridement, left arm wound.
2. Partial wound closure, left arm.
3. VAC dressing change.
.
[**2141-5-1**]
1. Debridement left forearm.
2. Split-thickness skin graft left forearm (30 cm x 9.0
cm).
3. Application of VAC dressing.
History of Present Illness:
58M otherwise healthy who developed atruamatic L elbow pain 4
days prior, which he states started on his funny bone. It made
it difficult to move his elbow, and it has gotten progressively
worse. Last night he was seen at an outside hospital where he
had an Xray and labs. He was told he had an "orthopedic problem"
and was referred to a clinic and given pain medication.
Overnight
he developed fever (Tmax 103) and shaking chills, in addition to
N/V. The pain has continued to worsen and now he can barely move
his arm. He is unable to flex or extend his wrist or his elbow
secondary to pain. EMS was called this morning for worsening
symptoms and lightheadedness. In the field he was found to be
hypotensive to the 70s. On arrival to the ED he was
normotensive.
.
He denies recent trauma or similar pain in his elbow. He denies
a known bite or abrasion over his left forearm. He denies any
wounds in the area recently. He denies abdominal pain, chest
pain or shortness of breath. He states he had cold symptoms last
week, which are improving. He has a history of bursitis in this
elbow approximatey 2 years ago, which resolved on it's own.
Past Medical History:
Esophageal ulcer (negative biosy)
.
PSH: s/p transphenoid pituitary tumor removal
Social History:
No Tob/EtOH/IVDU. Works at a desk job
Family History:
N/C
Physical Exam:
PE:
99.2-->103 100 110/62 16 99% RA
General: A&O x 3, Calm, Resting in bed.
EXT: He is uncomfortable with any movement of LUE. Skin over
medial aspect of extensor surface of forewarm erythematous and
edematous. No fluctuance noted. Tenderness over that area to
light touch. Compartment tense. Elbow held at approximately 80
degrees able to extend minimally with severe pain. Pain with
wrist extension and flexion. Grasp weak [**2-15**] pain. Capillary
refill <2 secs in all extremities. No bony tenderness in elbow.
No apparent joint effusion or significant bursa swelling.
Radial,
Median, Ulnar SILT. 2+ radial pulses.
Pertinent Results:
Pathology Examination
Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 76008**],[**Known firstname **] [**2083-4-23**] 58 Male [**Numeric Identifier 76009**] [**Numeric Identifier 76010**]
Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]
Gross Description by: DR. [**Last Name (STitle) **]. [**Hospital1 **]/dif
.
SPECIMEN SUBMITTED: TENOSYNOVIUM CARPAL CANAL LEFT (1 VIAL),
Forearm Fascia, Tenosynovium Carpal Canal , Forearm muscle.
Procedure date Tissue received Report Date Diagnosed
by
[**2141-4-24**] [**2141-4-25**] [**2141-4-27**] DR. [**Last Name (STitle) **]. [**Doctor Last Name 2336**]/ttl
Previous biopsies: [**Numeric Identifier 76011**] GI BX (6 jars)
DIAGNOSIS:
I. Tenosynovium, carpal canal (A):
Fibrous tissue with edema and acute inflammation; focal necrosis
and bacterial forms.
II. Left forearm fascia (B-E):
1. Fibroadipose and fascial type tissue with extensive necrosis
and acute inflammation.
2. Tissue Gram's stain reveals numerous Gram's positive cocci.
III. Left forearm muscle (F-G):
1. Fibrous tissue and skeletal muscle with extensive necrosis
and acute inflammation.
2. Tissue Gram's stain reveals numerous Gram's positive cocci.
IV. Tenosynovium carpal canal (H):
Fibroadipose tissue with edema and acute inflammation; focal
necrosis and bacterial forms.
.
[**2141-4-24**]
LEFT ELBOW THREE VIEWS; FOREARM, TWO VIEWS
FINDINGS: No fracture or dislocation identified. No effusions,
subcutaneous
gas or radiopaque foreign body identified. No suspicious blastic
or lytic
lesions.
IMPRESSION: No acute process. No fracture or dislocation.
.
Final Report
CT SCAN OF THE LEFT ARM PERFORMED ON [**2141-4-24**]
Comparison with a radiograph from same day.
IMPRESSION: Diffuse edema in the left forearm, which is notable
in the deep fascial compartments which raises concern for
compartment syndrome. Please correlate clinically. No soft
tissue gas or drainable fluid collection.
.
[**2141-4-24**] 7:30 pm SWAB LEFT FOREARM FASCIA.
**FINAL REPORT [**2141-4-28**]**
GRAM STAIN (Final [**2141-4-24**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
WOUND CULTURE (Final [**2141-4-26**]):
BETA STREPTOCOCCUS GROUP A. MODERATE GROWTH.
ANAEROBIC CULTURE (Final [**2141-4-28**]): NO ANAEROBES ISOLATED.
[**2141-4-24**] 8:30 pm TISSUE LEFT FOREARM FAT.
**FINAL REPORT [**2141-4-28**]**
GRAM STAIN (Final [**2141-4-24**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
TISSUE (Final [**2141-4-27**]):
BETA STREPTOCOCCUS GROUP A.
SPARSE GROWTH OF TWO COLONIAL MORPHOLOGIES.
ANAEROBIC CULTURE (Final [**2141-4-28**]): NO ANAEROBES ISOLATED.
.
[**2141-4-24**] 7:30 pm TISSUE LEFT FOREARM FASCIA #2.
**FINAL REPORT [**2141-4-28**]**
GRAM STAIN (Final [**2141-4-24**]):
Reported to and read back by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 76012**] #[**Numeric Identifier 76013**] @2210,
[**2141-4-24**].
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
TISSUE (Final [**2141-4-27**]):
BETA STREPTOCOCCUS GROUP A. SPARSE GROWTH.
IDENTIFICATION PERFORMED ON CULTURE # [**Numeric Identifier 76014**]
([**2141-4-24**]).
ANAEROBIC CULTURE (Final [**2141-4-28**]): NO ANAEROBES ISOLATED.
.
[**2141-4-24**] 7:30 pm TISSUE LEFT FOREARM FASCIA #1.
**FINAL REPORT [**2141-4-28**]**
GRAM STAIN (Final [**2141-4-24**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
TISSUE (Final [**2141-4-27**]):
BETA STREPTOCOCCUS GROUP A. MODERATE GROWTH.
IDENTIFICATION PERFORMED ON CULTURE # [**Numeric Identifier 76014**]
[**2141-4-24**].
ANAEROBIC CULTURE (Final [**2141-4-28**]): NO ANAEROBES ISOLATED.
.
[**2141-4-24**] 8:45 pm TISSUE TENOSYNOVIUM CARPAL CANAL - L.
**FINAL REPORT [**2141-4-28**]**
GRAM STAIN (Final [**2141-4-24**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
TISSUE (Final [**2141-4-27**]):
BETA STREPTOCOCCUS GROUP A. RARE GROWTH.
SENSI REQUESTED BY DR. [**Last Name (STitle) **],[**Doctor First Name 2482**] [**2141-4-26**].
Sensitivity testing performed by Sensititre.
CLINDAMYCIN. <=0.12MCG/ML.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
BETA STREPTOCOCCUS GROUP A
|
CLINDAMYCIN----------- S
ERYTHROMYCIN----------<=0.25 S
PENICILLIN G----------<=0.06 S
VANCOMYCIN------------ <=1 S
ANAEROBIC CULTURE (Final [**2141-4-28**]): NO ANAEROBES ISOLATED
.
[**2141-4-27**] 11:41 pm TISSUE LEFT UPPER EXTREMITY.
**FINAL REPORT [**2141-5-2**]**
GRAM STAIN (Final [**2141-4-28**]):
THIS IS A CORRECTED REPORT [**2141-4-30**].
Reported to and read back by DR [**Last Name (NamePattern4) 76015**] [**2141-4-30**] 330PM.
3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND IN SHORT
CHAINS.
PREVIOUSLY REPORTED AS ([**2141-4-28**]).
3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND IN SHORT
CHAINS.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
Reported to and read back by [**First Name5 (NamePattern1) 76016**] [**Last Name (NamePattern1) 76017**] 0335 ON
[**2141-4-28**].
TISSUE (Final [**2141-5-1**]):
BETA STREPTOCOCCUS GROUP A. HEAVY GROWTH.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
[**Numeric Identifier 76018**]
([**2141-4-24**]).
ANAEROBIC CULTURE (Final [**2141-5-2**]): NO ANAEROBES ISOLATED.
.
[**2141-5-1**] 3:36 pm SWAB LEFT FOREARM.
GRAM STAIN (Final [**2141-5-1**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary):
.
ECHO - [**2141-4-27**]:
Conclusions
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). Transmitral and tissue
Doppler imaging suggests normal diastolic function, and a normal
left ventricular filling pressure (PCWP<12mmHg). There is no
ventricular septal defect. 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 (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
IMPRESSION: Normal regional and global left ventricular systolic
function. Borderline normal RV function. No significant valvular
abnormality seen
.
Final Report
PORTABLE CHEST [**2141-4-30**]
CLINICAL INFORMATION: Infection, PICC placement.
FINDINGS:
Frontal view of the chest demonstrates a right-sided PICC
terminating at the cavoatrial junction. There is a patchy
airspace consolidation at the right lung base. There is
atelectasis at the left lung base. There is mild
eventration of the right hemidiaphragm. Remainder of the lungs
is relatively clear. Heart and mediastinum are stable.
[**2141-4-24**] 09:25AM BLOOD WBC-27.5* RBC-4.92 Hgb-15.4 Hct-44.1
MCV-90 MCH-31.3 MCHC-35.0 RDW-12.1 Plt Ct-351
[**2141-4-24**] 02:27PM BLOOD WBC-21.6* RBC-4.21* Hgb-13.3* Hct-38.4*
MCV-91 MCH-31.6 MCHC-34.7 RDW-12.1 Plt Ct-259
[**2141-4-24**] 09:56PM BLOOD WBC-23.7* RBC-4.16* Hgb-13.3* Hct-37.9*
MCV-91 MCH-31.9 MCHC-35.1* RDW-12.4 Plt Ct-302
[**2141-4-25**] 02:21AM BLOOD WBC-21.3* RBC-3.63* Hgb-11.4* Hct-33.0*
MCV-91 MCH-31.4 MCHC-34.6 RDW-12.3 Plt Ct-249
[**2141-4-25**] 05:00PM BLOOD WBC-23.2* RBC-3.91* Hgb-12.4* Hct-35.6*
MCV-91 MCH-31.8 MCHC-35.0 RDW-12.6 Plt Ct-290
[**2141-4-26**] 04:46AM BLOOD WBC-29.0* RBC-3.89* Hgb-12.2* Hct-35.3*
MCV-91 MCH-31.3 MCHC-34.5 RDW-12.4 Plt Ct-307
[**2141-4-27**] 03:24AM BLOOD WBC-29.5* RBC-3.59* Hgb-11.4* Hct-32.2*
MCV-90 MCH-31.7 MCHC-35.4* RDW-12.6 Plt Ct-302
[**2141-4-28**] 01:32AM BLOOD WBC-15.8* RBC-3.72* Hgb-11.5* Hct-33.9*
MCV-91 MCH-31.0 MCHC-34.1 RDW-12.7 Plt Ct-289
[**2141-4-29**] 05:45AM BLOOD WBC-15.3* RBC-3.88* Hgb-12.0* Hct-35.4*
MCV-91 MCH-31.0 MCHC-34.1 RDW-12.9 Plt Ct-355
[**2141-4-30**] 05:50AM BLOOD WBC-15.3* RBC-3.65* Hgb-11.4* Hct-33.1*
MCV-91 MCH-31.2 MCHC-34.4 RDW-13.2 Plt Ct-309
[**2141-5-1**] 05:52AM BLOOD WBC-14.1* RBC-3.69* Hgb-11.6* Hct-33.8*
MCV-92 MCH-31.5 MCHC-34.4 RDW-13.5 Plt Ct-329
[**2141-5-2**] 04:30AM BLOOD WBC-12.3* RBC-3.72* Hgb-11.5* Hct-34.3*
MCV-92 MCH-31.0 MCHC-33.6 RDW-13.6 Plt Ct-383
[**2141-4-24**] 09:25AM BLOOD Neuts-77* Bands-19* Lymphs-2* Monos-2
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2141-4-25**] 02:21AM BLOOD Neuts-80* Bands-9* Lymphs-4* Monos-3
Eos-0 Baso-0 Atyps-2* Metas-2* Myelos-0
[**2141-4-25**] 05:00PM BLOOD Neuts-97* Bands-1 Lymphs-1* Monos-1*
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2141-4-26**] 04:46AM BLOOD Neuts-89* Bands-5 Lymphs-2* Monos-4 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2141-4-28**] 01:32AM BLOOD Neuts-76* Bands-1 Lymphs-15* Monos-3
Eos-0 Baso-0 Atyps-3* Metas-1* Myelos-1*
[**2141-4-29**] 05:45AM BLOOD Neuts-59 Bands-8* Lymphs-13* Monos-4
Eos-2 Baso-0 Atyps-2* Metas-8* Myelos-4*
[**2141-5-1**] 05:52AM BLOOD Neuts-60 Bands-2 Lymphs-23 Monos-7 Eos-1
Baso-0 Atyps-0 Metas-4* Myelos-2* Promyel-1*
[**2141-5-2**] 04:30AM BLOOD Neuts-66 Bands-5 Lymphs-18 Monos-7 Eos-2
Baso-0 Atyps-1* Metas-1* Myelos-0
[**2141-4-24**] 09:25AM BLOOD ESR-51*
[**2141-4-26**] 12:51PM BLOOD ESR-78*
[**2141-4-24**] 09:25AM BLOOD PT-13.5* PTT-20.4* INR(PT)-1.2*
[**2141-4-24**] 09:56PM BLOOD PT-15.7* PTT-31.2 INR(PT)-1.4*
[**2141-4-25**] 02:21AM BLOOD PT-16.2* PTT-31.8 INR(PT)-1.4*
[**2141-4-25**] 10:46PM BLOOD PT-14.3* PTT-30.0 INR(PT)-1.2*
[**2141-4-27**] 03:24AM BLOOD PT-13.0 PTT-26.2 INR(PT)-1.1
[**2141-4-28**] 01:32AM BLOOD PT-13.4 PTT-24.4 INR(PT)-1.1
[**2141-4-24**] 09:25AM BLOOD Glucose-97 UreaN-23* Creat-1.8* Na-137
K-4.4 Cl-96 HCO3-23 AnGap-22*
[**2141-4-24**] 02:27PM BLOOD Glucose-94 UreaN-20 Creat-1.4* Na-138
K-4.2 Cl-104 HCO3-19* AnGap-19
[**2141-4-24**] 09:56PM BLOOD Glucose-100 UreaN-20 Creat-1.2 Na-138
K-4.7 Cl-104 HCO3-20* AnGap-19
[**2141-4-25**] 02:21AM BLOOD Glucose-90 UreaN-17 Creat-1.0 Na-135
K-4.3 Cl-105 HCO3-20* AnGap-14
[**2141-4-25**] 05:00PM BLOOD Glucose-167* UreaN-17 Creat-1.2 Na-133
K-4.3 Cl-94* HCO3-23 AnGap-20
[**2141-4-25**] 10:46PM BLOOD Glucose-111* UreaN-20 Creat-1.1 Na-132*
K-4.4 Cl-100 HCO3-26 AnGap-10
[**2141-4-26**] 04:46AM BLOOD Glucose-134* UreaN-20 Creat-1.1 Na-130*
K-4.4 Cl-98 HCO3-28 AnGap-8
[**2141-4-26**] 12:51PM BLOOD Glucose-89 UreaN-20 Creat-1.0 Na-134
K-4.2 Cl-100 HCO3-25 AnGap-13
[**2141-4-27**] 03:24AM BLOOD Glucose-97 UreaN-17 Creat-0.9 Na-135
K-3.6 Cl-101 HCO3-26 AnGap-12
[**2141-4-28**] 01:32AM BLOOD Glucose-94 UreaN-20 Creat-0.8 Na-139
K-3.3 Cl-105 HCO3-27 AnGap-10
[**2141-4-30**] 05:50AM BLOOD Glucose-135* UreaN-12 Creat-0.8 Na-139
K-3.9 Cl-107 HCO3-26 AnGap-10
[**2141-5-1**] 05:52AM BLOOD Glucose-97 UreaN-17 Creat-0.9 Na-139
K-4.5 Cl-106 HCO3-26 AnGap-12
[**2141-4-24**] 09:25AM BLOOD CK(CPK)-154
[**2141-4-25**] 02:21AM BLOOD ALT-334* AST-204* LD(LDH)-200
AlkPhos-198* TotBili-2.6*
[**2141-4-25**] 05:00PM BLOOD ALT-300* AST-151* LD(LDH)-240
CK(CPK)-562* AlkPhos-203* TotBili-2.7*
[**2141-4-25**] 10:46PM BLOOD CK(CPK)-581*
[**2141-4-27**] 03:24AM BLOOD ALT-173* AST-93* AlkPhos-298*
TotBili-3.1* DirBili-2.4* IndBili-0.7
[**2141-4-28**] 01:32AM BLOOD ALT-152* AST-176* AlkPhos-369*
TotBili-1.8*
[**2141-4-29**] 05:45AM BLOOD ALT-144* AST-153* LD(LDH)-381*
AlkPhos-427* TotBili-1.1
[**2141-5-2**] 04:00PM BLOOD ALT-90* AST-77* LD(LDH)-282* AlkPhos-331*
TotBili-0.6
[**2141-4-27**] 03:24AM BLOOD GGT-138*
[**2141-4-29**] 05:45AM BLOOD Lipase-122*
[**2141-4-24**] 02:27PM BLOOD Calcium-7.1* Phos-3.2 Mg-1.3*
[**2141-4-24**] 09:56PM BLOOD Calcium-7.3* Phos-5.1*# Mg-2.4
[**2141-4-25**] 02:21AM BLOOD Albumin-2.3* Calcium-7.0* Phos-3.5#
Mg-2.1
[**2141-4-25**] 05:00PM BLOOD Albumin-2.6* Calcium-7.4* Phos-2.6*
Mg-2.4
[**2141-4-25**] 10:46PM BLOOD Calcium-7.7* Phos-2.7 Mg-2.6
[**2141-4-26**] 04:46AM BLOOD Calcium-7.8* Phos-3.2 Mg-2.7*
[**2141-4-27**] 03:24AM BLOOD Calcium-7.6* Phos-2.5* Mg-2.5
[**2141-4-29**] 05:45AM BLOOD Calcium-7.5* Phos-3.8 Mg-2.0
[**2141-4-30**] 05:50AM BLOOD Calcium-7.4* Phos-4.7* Mg-1.9
[**2141-5-1**] 05:52AM BLOOD Calcium-7.9* Phos-4.3 Mg-2.0
[**2141-4-29**] 05:45AM BLOOD Free T4-0.92*
[**2141-4-27**] 03:24AM BLOOD TSH-0.20*
[**2141-4-29**] 05:45AM BLOOD TSH-1.8
[**2141-4-25**] 05:00PM BLOOD Vanco-8.8*
[**2141-4-24**] 09:48AM BLOOD Lactate-7.2*
[**2141-4-24**] 11:31AM BLOOD Lactate-3.9*
[**2141-4-24**] 09:58PM BLOOD Lactate-4.9*
[**2141-4-25**] 02:50AM BLOOD Lactate-3.8*
Brief Hospital Course:
This is a 58 year-old Male who initially presented with 3-days
of left forearm swelling, redness and pain associatd with fevers
for one day. He noted the onset of bilateral axilla erythema for
2-weeks after having upper respiratory symptoms including
congestion and cough. Three days prior to presentation, the
patient developed severe left arm pain and erythema, targeting
elbow and forearm, associated with intermittent paresthesias of
the left hand. He then reported the onset of high fever, nausea
and vomiting on the night prior to arrival. He presented to the
[**Hospital1 18**] ED where his labs were notable for a lactate of 7.2, he
had evidence of mild renal insufficiency with a creatinine of
1.8 and a WBC to 27.5. He received 4L of IVF's. X-ray of the
extremity was performed and was negative for gas. CT of the
extremity was performed which showed deep fascial edema
concerning for impending compartment symdrome, without gas.
NEURO/PAIN: The patient was maintained on IV pain medication in
the immediate post-operative periods and transitioned to PO
narcotic medication with adequate pain control on POD#9 from his
initial surgical procedure. The patient remained neurologically
intact and without change from baseline. The patient remained
alert and oriented to person, location and place.
CARDIOVASCULAR: The patient remained hemodynamically stable
intra-op and in the immediate post-operative period. He did,
however, develop intermittent, paroxysmal atrial fibrillation
following his first surgical procedure with rapid ventricular
repsonse refractory to medical treatment initially with
Lopressor and Diltiazem. He Cardiology had been consulted,
recommending an Amiodarone gtt which was discontinued following
his initial procedure and following an oral loading dose. He
remains on Amiodarone, and will follow-up with cardiology as an
outpatient. He had no further episodes of atrial fibrillation
from POD#[**5-22**]. Vitals signs were closely monitored via telemetry.
He remained hemodynamically stable throughout his stay.
RESPIRATORY: The patient was extubated POD#1 from his initial
procedure, successfully. The patient had no episodes of
desaturation or pulmonary concerns. The patient denied cough or
respiratory symptoms. Pulse oximetry was monitored closely and
the patient maintained adequate oxygenations. He was extubated
without issue following his washout and debridements in the
operating room.
GASTROINTESTINAL: The patient was NPO following their procedure
and transitioned to sips and a clear liquid diet on POD#0 from
each procedure, again being made NPO past midnight for his
following procedure. The patient experienced no nausea or
vomiting. The patient was transitioned to a regular diet on
POD#[**8-22**] and IV fluids were discontinued once adequate PO intake
was established.
GENITOURINARY: The patient's urine output was closely monitored
in the immediate post-operative period. A Foley catheter was not
required and the patient was able to successfully void without
issue. The patient's intake and output was closely monitored for
> 30 mL per hour output. The patient's creatinine was 1.8, with
evidence of acute renal insufficiency on admission, however,
this improved with adequate hydration. His creatinine normalized
to 0.9 prior to discharge.
HEME: The patient remained hemodynamically stable and did not
require transfusion. The patient's coagulation profile remained
normal. The patient had no evidence of bleeding from their
incision. His hematocrit remained stable.
ID: The patient was admitted with concerns of acute compartment
syndrome versus necrotizing fasciitis. For this, he was
emergently brought to the operating room for left forearm
fasciotomy and VAC placement. At the time of his procedure,
infectious disease physicians were notified and he was
empirically begun on IV Vancomycin, Clindamycin and Zosyn. His
OR wound cultures initially speciated Beta Streptococcus group
A, as did all following cultures. He was taken to the operating
room on HOD#2, 3, 5 and 7 for subsequent debridements and
washouts with a final procedure on [**2141-5-1**] consisting of a left
forarm I&D, split thickness skin graft from the left thigh and
VAC placement. Infectious disease specialists continued to
follow the patinet, as his antibiotics were tapered to IV
Ceftriaxone 2 g IV Q24 hours. His WBC on admission was 27 and
fell steadily to around a WBC 12 prior to discharge. Serial arm
and hand examinations were continuously performed, yielding
steady improvement. His arm remained elevated, in a volar
resting splint and sling, in an elevated position at all times.
ENDOCRINE: The patient's blood glucose was closely monitored in
the post-op period with Q6 hour glucose checks. Blood glucose
levels greater than 120 mg/dL were addressed with an insulin
sliding scale.
PROPHYLAXIS: The patient was maintained on heparin 5000 units SQ
TID for DVT/PE prophylaxis and encouraged to ambulate
immediately post-op. The patient also had sequential compression
boot devices in place during immobilization to promote
circulation. The patient was encouraged to utilize incentive
spirometry, ambulate early and was discharged in stable
condition.
Medications on Admission:
nexium
Discharge Medications:
1. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day): Apply to underarms.
Disp:*1 Bottle* Refills:*1*
2. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO daily ().
3. ceftriaxone in dextrose,iso-os 2 gram/50 mL Piggyback Sig:
One (1) Intravenous Q24H (every 24 hours) for 5 days: last dose
[**2141-5-8**].
Disp:*5 solutions* Refills:*0*
4. 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.
5. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours)
as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
6. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
Disp:*45 Tablet(s)* Refills:*1*
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*30 Capsule(s)* Refills:*2*
8. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever: Max 12/day. Do not exceed
4gms/4000mgs of tylenol per day.
9. Outpatient Lab Work
Please draw the following labs on [**2141-5-8**]:
1) CBC w/diff
2) BUN/Cr
3) LFTs
Please fax results to Dr.[**Name (NI) 23346**] office, fax #: [**Telephone/Fax (1) 76019**]
Discharge Disposition:
Home With Service
Facility:
Critical Care Systems
Discharge Diagnosis:
Necrotizing fasciitis, left arm: BETA STREPTOCOCCUS GROUP A
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Your wound vac to your left arm skin graft site should stay
intact until Tuesday, [**5-9**], when you. Please keep suction
at 125 mmHg.
.
You may maintain your left arm in a sling for comfort and you
should always wear your orthoplast splint. You should continue
to actively move your fingers so that they don't become stiff.
.
You should continue to leave your left thigh donor site open to
air to dry it out. The yellow dressings should stay in place
and dry out like a scab. Do not get this area wet until cleared
by Dr. [**Last Name (STitle) 5385**].
.
Please follow up with your primary care physician within one
week of discharge. You had an occurrence of atrial fibrillation
while an inpatient, and you are being discharged on Lopressor.
This needs to be managed by your PCP.
.
Medications:
1. Resume your regular medications unless instructed otherwise
and take any new meds as ordered.
2. You may take your prescribed pain medication for moderate to
severe pain. You may switch to Tylenol or Extra Strength Tylenol
for mild pain as directed on the packaging. Please note that
Percocet and Vicodin have Tylenol as an active ingredient so do
not take these meds with additional Tylenol.
3. Take prescription pain medications for pain not relieved by
tylenol.
4. Your antibiotic will be given IV until [**2141-5-8**] when you will
receive your last dose.
5. Take Colace, 100 mg by mouth 2 times per day, while taking
the prescription pain medication. You may use a different
over-the-counter stool softener if you wish.
6. Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
.
Call the office IMMEDIATELY if you have any of the following:
1. Signs of infection: fever with chills, increased redness,
swelling, warmth or tenderness at the surgical sites, or unusual
drainage from the incision(s).
2. A large amount of bleeding from the incision(s) or drain(s).
3. Fever greater than 101.5 oF
4. Severe pain NOT relieved by your medication.
.
Return to the ER if:
* If you are vomiting and cannot keep in fluids or your
medications.
* If you have shaking chills, fever greater than 101.5 (F)
degrees or 38 (C) degrees, increased redness,swelling or
discharge from incision, chest pain, shortness of breath, or
anything else that is troubling you.
* Any serious change in your symptoms, or any new symptoms that
concern you.
Followup Instructions:
You have a follow up appointment with Dr. [**Last Name (STitle) 5385**]: ([**2141**]
for this Tuesday, [**2141-5-9**] at 3:30PM to have wound vac dressing
removed. Dr. [**Last Name (STitle) 5385**] is located at:
[**Apartment Address(1) 76020**]
[**Location (un) 55**], [**Numeric Identifier 3883**]
.
Please schedule a follow up with your Primary Care Provider to
[**Name9 (PRE) 76021**] the need for your 'lopressor' medication used to help
prevent the recurrence of 'atrial fibrillation' that you
experienced while you were in the hospital. [**Last Name (LF) 76022**],[**First Name3 (LF) 8694**] C.
[**Telephone/Fax (1) 2115**]
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 7738**]
|
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icd9cm
|
[
[
[]
]
] |
[
"86.28",
"83.02",
"83.09",
"83.45",
"04.43",
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"86.69",
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icd9pcs
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[
[
[]
]
] |
23675, 23727
|
17136, 22336
|
325, 1261
|
23831, 23831
|
3273, 10061
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263, 287
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10093, 10108
|
1289, 2434
|
10141, 17113
|
23846, 23958
|
2456, 2539
|
2555, 2596
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
741
| 133,898
|
20617
|
Discharge summary
|
report
|
Admission Date: [**2104-4-25**] Discharge Date: [**2104-4-29**]
Date of Birth: [**2072-6-17**] Sex: M
Service: [**Company 191**]
HISTORY OF PRESENT ILLNESS: The patient is a 31-year-old man
with history of diabetes for about six years, who presented
with nausea and vomiting. The patient states that he was in
his usual state of health until the morning prior to
admission when he woke up and had nausea and vomiting. He
continued to have extensive vomiting throughout the rest of
the day stating he vomited approximately 20 times. He had
mild improvement by the evening prior to admission, however,
upon awaking on the day of admission, he again had severe
nausea and vomiting. He is unable to take any p.o. foods or
liquids.
He also stated that his vomitus had coffee ground-like
material in it. He denies any bright red blood in the
vomitus. The patient denies any use of drugs or alcohol
several days prior to these symptoms. He denies any unusual
foods. He denies any recent travel. He also denies any
abdominal pain or diarrhea. Patient states that since he
started vomiting, he has had a very bad sore throat. He
denies any cough or shortness of breath. He states that he
has been taking his insulin regularly. He states that he
only checks his fingersticks every other day or so, and has
not checked it since the nausea and vomiting began. The
patient states that he does not regularly see a doctor nor he
does he have regular followup for his diabetes.
He denies any complications of diabetes except for erectile
dysfunction. He denies any numbness or tingling in the
extremities. He denies any visual changes.
PAST MEDICAL HISTORY:
1. Diabetes mellitus type 1 (diagnosed approximately six
years ago). Patient is on stable insulin regimen as below.
He has no known complications, although he does complain of
erectile dysfunction currently.
2. Lyme's disease: Diagnosed six years ago and treated.
Patient presented with arthritis symptoms.
3. Attention-deficit disorder.
4. History of oral herpes ulcers.
MEDICATIONS ON ADMISSION:
1. Insulin: 8 units of NPH and 8 units of regular before
breakfast and before dinner.
2. Ritalin 20 mg q.d.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient works as a fisherman and lives
in [**Hospital1 6687**]. He smokes approximately [**2-12**] cigarettes per
week and has been doing so for five years. He drinks alcohol
only occasionally on the weekends. He has occasional
marijuana use. The patient is heterosexual and is in a
monogamous relationship. He does have a history of
unprotected sexual intercourse.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAM ON ADMISSION: Vital signs: Temperature 100.1,
blood pressure 121/54, pulse 112, respiratory rate 24, and O2
saturation is 100% on room air. In general, the patient is a
middle-age man in no apparent distress. Is well appearing.
HEENT exam is significant for erythema in the oropharynx with
dry mucous membranes. Pupils are equal, round, and reactive
to light. Sclerae are anicteric and noninjected. Tympanic
membrane examination: Cerumen was noted in the left ear
canal with clear right ear canal. Lung exam was clear to
auscultation bilaterally. Heart exam showed tachycardia with
a regular rate, normal S1, S2 and no murmurs. Abdomen was
benign. The patient had emesis, which was Gastroccult
positive. Extremities showed no edema with good distal
pulses. Neurologic exam was intact. Rectal exam showed no
stool in the vault with normal prostate and normal rectal
tone.
LABORATORIES ON ADMISSION: CBC showed a white count of 36
with a differential of 81% neutrophils, 2% bands, and 12%
lymphocytes, hematocrit was 47.9, platelets 561. Chem-7
notable for a sodium of 141, potassium 5.8, chloride of 93,
bicarbonate of 9, BUN of 23, and creatinine of 1.6 with a
glucose of 730. The anion gap was 39.
Arterial blood gas was 7.09/19/158. Coagulation studies were
within normal limits. Lactate was 4.6. Free calcium was
1.2.
Chest x-ray did not show any acute processes.
EKG showed normal sinus rhythm at 111 beats per minute with
normal axis and normal intervals with no ST-T wave changes.
SUMMARY OF HOSPITAL COURSE BY ISSUE:
1. Diabetic ketoacidosis: The patient was admitted with a
diagnosis of diabetic ketoacidosis. He was admitted to the
ICU. He was given extensive IV fluid hydration with normal
saline. He was also started on insulin drip with q.1h.
fingersticks. Once his blood glucose went below 200, insulin
drip and hydration, patient's IV fluids were changed to D5
[**1-11**] normal saline to prevent hypoglycemia as he was continued
on insulin drip.
The exact etiology of the patient's diabetic ketoacidosis was
unclear. [**Name2 (NI) **] has no severe infection. However, he did have
question of gastroenteritis, and as stated below, he has
possibility of Candidal esophagitis, although this would not
be expected to cause him to go into diabetic ketoacidosis.
Cultures did not show any evidence of infection.
Patient received his insulin drip for approximately 24 hours.
At that point, his anion gap was closed. After he began to
eat, the insulin drip was shut off, and the patient was
placed on a standing regimen of insulin. The initial regimen
was NPH in the morning and evening with the sliding scale of
regular insulin. This was suggested after the patient was
called out of the ICU and put on the regular floor.
Initially the patient had elevated blood sugars in the 200s.
However, his insulin regimen was increased giving him 34
units of NPH in the morning with 10 units of regular and 15
units of NPH with 8 units of regular before dinner. On this
regimen, the patient's blood sugars were well controlled in
the low 100's even after he resumed a somewhat normal diet.
The patient's anion gap remained closed during the rest of
the hospitalization.
In terms of general diabetes management, the patient was
consulted by Nutrition for diabetic diet teaching. He was
also counseled by his physicians on the importance of tight
blood sugar control and close followup with his outpatient
primary care provider.
2. Upper GI bleed: The patient had evidence of upper GI
bleed given coffee-ground emesis and Gastroccult-positive
emesis. GI was consulted, and an EGD was performed. The EGD
showed erosive esophagitis with possibility of Candidal
esophagitis. There was also evidence of gastritis in the
fundus and stomach body. The patient's hematocrit remained
stable during the hospital admission. His Candidal
esophagitis was treated with three days of fluconazole and
nystatin swish and swallow.
He continued to have significant pharyngeal pain upon
swallowing either liquids or solids. This was thought to be
due to a combination of erosive esophagitis from extensive
emesis that he had several days prior to admission and the
Candidal esophagitis. The patient received minimal relief
with viscus lidocaine or nystatin. He was therefore put on
IV Morphine so that he could eat, and his blood sugars could
be better stabilized.
Prior to discharge, he was transitioned over to p.o. Morphine
and tolerated this well. He was discharged with p.o.
narcotics with continued pain management so that he can eat
regularly. It was expected that his symptoms of pain would
resolve on its own as his esophagitis resolves.
3. Acute renal failure: Patient's acute renal failure was
thought to be due to hypovolemia from his diabetic
ketoacidosis. Once he was volume repleted with IV fluids,
his creatinine returned to baseline.
4. Nutrition: As stated above, the patient had a Nutrition
consult for diabetic diet teaching. Because of his
odynophagia, he was placed on a diet of puree solids and
diabetic shakes. He tolerated this well reasonably well when
he was taking pain medication.
5. Candidal esophagitis: The patient was treated for
Candidal esophagitis as stated above with fluconazole and
nystatin swish and swallow. Though it was possible that
patient's Candidal esophagitis was secondary to poorly
controlled diabetes, there is also concern for HIV especially
the potential etiology for the diabetic ketoacidosis.
Patient also wished to have HIV testing even though he was
low risk. HIV antibody was sent and was negative. Patient
was given post-test counseling, and advised that if he feels
that he is at risk, then he should be tested.
6. Code status: Patient was full code on admission and at
discharge.
DISCHARGE STATUS: The patient was discharged to home.
DISCHARGE CONDITION: Patient is in good condition. He is
afebrile, stable and tolerating p.o.
DISCHARGE DIAGNOSES:
1. Diabetic ketoacidosis.
2. Diabetes mellitus type 1.
3. Candidal esophagitis.
4. Acute renal failure.
DISCHARGE MEDICATIONS:
1. Nystatin swish and swallow 5 mL p.o. t.i.d. for three more
days after discharge.
2. Protonix 40 mg p.o. q.d.
3. Insulin NPH 34 units in the morning and 15 units in the
p.m. before breakfast and dinner.
4. Insulin regular 10 units before breakfast and 8 units
before dinner.
5. Vicodin 5-500 mg tablet one tablet one p.o. q.4-6h. as
needed for pain for seven days.
6. Insulin syringe.
7. Lancets.
8. Test strips.
DISCHARGE INSTRUCTIONS AND FOLLOW-UP PLANS: Patient was
instructed to adhere to a strict diabetic diet. Is
recommended that he continue to take soft puree solids until
his odynophagia improves. He was instructed to call his
doctor or return to the hospital if he is unable to eat and
take fluids.
With regards to his insulin regimen, the patient was
instructed to check his blood sugars by fingerstick at least
4x a day before meals and at bedtime, occasionally after
meals. He was told to do this vigorously for approximately
two weeks and then his diabetic control could be reassessed
when he visits his PCP. [**Name10 (NameIs) **] patient was aware of symptoms he
gets before becoming hypoglycemic and is aware that he needs
to take [**Location (un) 2452**] juice if he does have these symptoms.
The patient will follow up with his new primary care
provider, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Hospital3 **]. He is
instructed to call [**Telephone/Fax (1) 250**] to make an appointment at the
first available date. He will be referred to the [**Last Name (un) **]
Diabetes Center by his PCP.
[**First Name4 (NamePattern1) 247**] [**Last Name (NamePattern1) 248**], M.D. [**MD Number(1) 54834**]
Dictated By:[**Name8 (MD) 5709**]
MEDQUIST36
D: [**2104-4-30**] 10:33
T: [**2104-5-1**] 10:48
JOB#: [**Job Number 55098**]
|
[
"112.84",
"088.81",
"250.11",
"578.9",
"711.80",
"276.5",
"584.9",
"305.1",
"314.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
8537, 8612
|
2638, 2670
|
8633, 8738
|
8761, 9204
|
2080, 2228
|
9222, 10614
|
175, 1657
|
3585, 8515
|
1679, 2054
|
2245, 2621
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,944
| 189,874
|
10278+56128
|
Discharge summary
|
report+addendum
|
Admission Date: [**2141-3-21**] Discharge Date: [**2141-3-29**]
Date of Birth: [**2063-7-22**] Sex: F
Service: TRANSPLANT SURGERY
HISTORY OF THE PRESENT ILLNESS: Mrs. [**Known lastname **] is a 77-year-old
female with a past medical history significant for a
cadaveric renal transplantation performed on [**2140-11-30**]
secondary to glomerulonephritis whose postoperative course
was complicated by delayed graft functioning requiring three
weeks of hemodialysis. The patient was recently treated at
the [**Hospital6 256**] last month for a
sputum culture which grew atypical mycobacteria. The patient
had an additional sputum culture taken on [**2141-2-18**]
which grew Scedosporium, however, this result was not known
at the time of discharge. The patient states that she had a
one day history of increasing dyspnea and orthopnea along
with one episode of bilious emesis before presenting to an
outside hospital the day prior to admission. She denied any
change in urinary output, frequency, or color but does state
that she has been developing persistently increasing ankle
swelling. The patient was admitted to this institution for a
brief period at the beginning of this month for a CHF
exacerbation. At the outside hospital, the patient received
40 mg of IV Lasix, 1 amp of sodium bicarbonate, 1 amp of
dextrose, and 1 amp of calcium gluconate for a potassium of
6.0. She was then transferred to this institution on 6
liters of supplemental oxygen via a nasal cannula.
At the time of presentation, the patient denied fevers,
chills, abdominal pain, cough, chest pain, or palpitations.
She was admitted to this institution for the treatment of
acute CHF.
PAST MEDICAL HISTORY:
1. Status post cadaveric renal transplantation.
2. End-stage renal disease secondary to glomerulonephritis.
3. Hypertension.
4. Chronic atrial fibrillation.
5. Hypothyroidism.
6. Status post open cholecystectomy.
7. Status post right inguinal hernia repair.
8. History of COPD.
9. Atypical mycobacterium pneumonia.
10. Osteoporosis.
11. Scedosporium pneumonia.
12. Congestive heart failure.
ADMISSION MEDICATIONS:
1. Prednisone 5 mg p.o. q.d.
2. Prograf 1 mg p.o. b.i.d.
3. Os-Cal 500 mg p.o. b.i.d.
4. Alendronate 35 mg p.o. q. week.
5. Coumadin 1.5 mg p.o. q.d.
6. Synthroid 175 micrograms p.o. q.d.
7. Metoprolol 75 mg p.o. b.i.d.
8. Lasix 20 mg p.o. b.i.d.
9. Protonix 40 mg p.o. q.d.
10. Bactrim single-strength one tablet p.o. q.d.
11. Rifabutin 300 mg p.o. q.d.
12. Ethambutol 750 mg p.o. q.d.
13. Clarithromycin 500 mg p.o. b.i.d.
14. Albuterol inhaler.
15. Amiodarone 200 mg p.o. q.d.
ALLERGIES: The patient has allergies to penicillin and
codeine.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature
96.5, heart rate 91, blood pressure 100/48, respiratory rate
18, oxygen saturation 95% on 6 liters. General: The patient
is a pleasant female who is able to speak in full sentences
and is sitting upright. HEENT: The oropharynx was clear
with moist mucous membranes. The neck has JVD to
approximately 12 cm. There were no masses or bruits. Heart:
Regular in rate and rhythm. Lungs: Inspiratory crackles
bilaterally at the bases with decreased breath sounds.
Abdomen: Soft, nontender, nondistended, with a well-healed
scar. Extremities: There was 2+ pedal edema but were warm.
LABORATORY/RADIOLOGIC DATA: WBC 12.7, hematocrit 30.3,
platelet count 251,000, potassium 6.0, creatinine 4.7. The
urinalysis was negative.
An AP and lateral view of the chest demonstrated moderately
acute heart failure with no effusions.
An EKG demonstrated peak T waves with Q waves in the inferior
leads.
HOSPITAL COURSE: The patient was admitted to the institution
under the care of Dr. [**First Name (STitle) **] on the Transplant Surgery
Service. She was treated aggressively with Lasix
intravenously for diuresis. Her cardiac enzymes were
negative times three. The elevated creatinine was concerning
for a problem with the transplanted kidney and a transplanted
ultrasound was, therefore, obtained. This study was normal,
demonstrating flow in the renal artery and renal vein. The
patient was recently seen in the [**Hospital 1326**] Clinic where a
kidney biopsy was performed on [**2141-3-19**]. At
approximately one day into her hospitalization, these results
returned as significant for mild acute cellular rejection.
She was, therefore, treated with five doses of Solu-Medrol
intravenously and then placed on a prednisone taper. The
patient was also maintained on her tacrolimus for
immunosuppression.
Given her worsening pulmonary function at the time of
presentation and her history of pneumonia, she was seen by
the Pulmonary consult service. On hospital day number two,
the patient had a CAT scan of the chest which demonstrated
improvement in her previously seen lesions. A CT of the head
was obtained to rule out invasive fungal disease. This
result was negative.
On hospital day number four, the patient had a bronchoscopy
with bronchoalveolar lavage. This test was consistent with
Scedosporium pneumonia. Per the recommendations of the
Infectious Disease Service, the patient was started on
voriconazole for the fungal pneumonia. She was also
maintained on Clarithromycin, ethambutol and Rifabutin for a
total of six months to treat her atypical Mycobacterium
pneumonia. The patient's Amiodarone was held given its
interaction with Voriconazole. The patient's CMV viral load
was negative as was her cryptococcus antigen.
After being aggressively treated with intravenous Lasix, the
patient's creatinine diminished from 4.4 at the time of
admission to 2.5 at the time of discharge. On hospital day
number six, the patient became acutely short of breath with
oxygen saturations in the 70% range and was immediately
transferred to the Intensive Care Unit for a CHF
exacerbation. A chest x-ray obtained at this time
demonstrated bilateral pleural effusions. There were no EKG
changes and her cardiac enzymes were negative. She did spend
one complete day in the Intensive Care Unit for observation
and aggressive diuresis and was returned to the floor on
hospital day number seven.
The patient remained asymptomatic throughout her stay and was
discharged to home with supplemental oxygen on hospital day
number nine.
DISCHARGE DIAGNOSIS:
1. End-stage renal disease.
2. Congestive heart failure exacerbation.
3. Atrial fibrillation.
4. Hypothyroidism.
5. Status post cholecystectomy.
6. Status post cadaveric renal transplantation.
7. Status post inguinal hernia repair.
8. History of mild acute cellular rejection on [**2141-3-19**].
9. Atypical Mycobacterium pneumonia.
10. Scedosporium pneumonia.
11. Osteoporosis.
12. Chronic obstructive pulmonary disease.
13. Hypothyroidism.
14. Hypertension.
DISCHARGE MEDICATIONS:
1. Os-Cal 500 mg p.o. b.i.d.
2. Synthroid 175 micrograms p.o. q.d.
3. Lasix 40 mg p.o. b.i.d.
4. Protonix 40 mg p.o. b.i.d.
5. Metoprolol 75 mg p.o. t.i.d.
6. Bactrim single-strength one tablet p.o. q. other day.
7. Renagel 800 mg p.o. t.i.d.
8. Clarithromycin 500 mg p.o. b.i.d. times five more months.
9. Ethambutol 750 mg p.o. q.d. times five more months.
10. Rifabutin 300 mg p.o. q.d. times five more months.
11. Coumadin 1.5 mg p.o. q.d.
12. Voriconazole 300 mg p.o. q.d. times four weeks.
13. Prednisone 5 mg p.o. q.d.
14. Tacrolimus 1 mg p.o. b.i.d.
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: The patient was discharged to home
with a visiting nurse [**First Name (Titles) **] [**Last Name (Titles) **] with home oxygen therapy,
physical therapy, blood draws.
FOLLOW-UP PLANS: The patient was instructed to follow-up
with Dr. [**First Name (STitle) **] at the [**Hospital 1326**] Clinic in approximately
two to three weeks. She was instructed to follow-up sooner
if she developed shortness of breath, chest pain, severe leg
swelling, abdominal pain, fevers, or if she had any other
questions or concerns. The patient was also instructed to
follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**] from the Transplant [**Hospital **] Clinic
in approximately two weeks following discharge.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 1331**]
Dictated By:[**Last Name (NamePattern1) 26023**]
MEDQUIST36
D: [**2141-3-28**] 04:50
T: [**2141-3-29**] 19:47
JOB#: [**Job Number 34187**]
Name: [**Known lastname 1012**], [**Known firstname 2868**] Unit No: [**Numeric Identifier 6013**]
Admission Date: [**2141-3-21**] Discharge Date: [**2141-3-30**]
Date of Birth: [**2063-7-22**] Sex: F
Service:
ADDENDUM: Briefly, the patient is a 77 year-old female who
had undergone a cadaveric renal transplant in [**2139-12-30**] who was admitted with congestive heart failure
exacerbation who has been diagnosed with [**Doctor First Name **] approximately a
month prior to admission who is admitted with congestive
heart failure exacerbation and found to have Scedosporium
Pneumonia. Infectious disease consult was on board and the
day prior to discharge they recommended to discontinue
Voriconazole and to start the patient on Itraconazole 200 mg
po q 12 hours. The patient remained under treatment for [**Doctor First Name **].
The patient was discharged on [**2141-3-30**] with her
leukocytosis gradually decreasing. Oxygenation relatively
decent given her home O2 requirement. The patient remained
afebrile. The patient was also advised to restart on her
Amiodarone, which she had not been taking during this
hospitalization.
DISCHARGE DIAGNOSES:
1. Renal failure status post kidney transplant.
2. Congestive heart failure exacerbation.
3. Mild acute cellular rejection of transplanted kidney.
4. Scedosporium pneumonia.
5. Mycobacterium avium pneumonia.
DISCHARGE MEDICATIONS ADDENDED:
1. Synthroid 175 micrograms po q day.
2. Protonix 40 mg po q day.
3. Bactrim single strength one tablet po q.o.d.
4. Ethambutol 500 mg po q.d. for five more months to
complete a course of six months.
5. Biaxin 250 mg po q.d. for five months to complete a
course of six months.
6. Rifabutin 150 mg po q.d. for five months to complete a
course of six months.
7. Itraconazole 200 mg po b.i.d.
8. Lasix 40 mg po b.i.d.
9. Lopressor 75 mg po t.i.d.
10. Tacrolimus 2 mg po b.i.d. to be adjusted during follow
up.
11. Norvasc 5 mg po q.d.
12. Coumadin 1.5 mg po q.h.s.
13. CellCept [**Pager number **] mg po b.i.d.
14. Prednisone 10 mg po q.d. for two days.
15. Percocet 5/325 mg half tablet po q.h.s.
16. Amiodarone 200 mg po q.d.
FOLLOW UP: The patient is to follow up with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] at the Transplant Center as instructed and is to have
a blood draw every Monday and Thursday and to have the
results faxed to the Transplant Center. The patient is also
to see Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 25**] from the Transplant Infectious
Disease Department as scheduled.
DISCHARGE STATUS: Discharged to home with services.
DISCHARGE CONDITION: Good.
[**First Name8 (NamePattern2) 399**] [**Last Name (NamePattern1) 400**], M.D. [**MD Number(1) 401**]
Dictated By:[**Last Name (NamePattern1) 6014**]
MEDQUIST36
D: [**2141-3-30**] 08:47
T: [**2141-3-31**] 06:23
JOB#: [**Job Number 6015**]
|
[
"428.0",
"496",
"996.81",
"427.31",
"031.0",
"244.9",
"484.7",
"584.9",
"E878.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"33.24",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
7437, 7605
|
11134, 11419
|
9641, 10629
|
6813, 7381
|
6320, 6790
|
3669, 6299
|
2133, 2710
|
10641, 11112
|
7623, 9620
|
2725, 3651
|
1709, 2110
|
7406, 7413
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,532
| 111,610
|
54530
|
Discharge summary
|
report
|
Admission Date: [**2195-10-15**] Discharge Date: [**2195-10-22**]
Date of Birth: [**2138-12-16**] Sex: F
Service: SURGERY
Allergies:
seasonal
Attending:[**First Name3 (LF) 1234**]
Chief Complaint:
Abdominal aortic aneurysm, status
post stent graft repair with enlargement and continued
endoleak
Major Surgical or Invasive Procedure:
[**2195-10-15**]: Explant of aortobi-iliac endovascular stent
graft, conversion open with aortobi-iliac 16-8 mm Dacron.
History of Present Illness:
56F with h/o AAA, who first presented with acute symptomatic
aneurysm approximately a year ago. We placed a stent graft
which stopped her pain and stopped the aneurysm from increasing
in size. However, she developed very large, persistent type 2
endoleak. We attempted to treat this with
a number of factors including realigning the graft but
thought there might be a type 3 leak, a proximal cuff,
extension iliac limbs, lumbar embolization and actually
translumbar sac embolization. The aneurysm continued to grow
and there were no other treatment options other than open
explant and repair. A long discussion was had with the patient
and her family, who understood the risks including death,
bleeding, intestinal damage, kidney damage.
Past Medical History:
symptomatic AAA (s/p endovascular repair on [**2194-8-2**])
- c/b type Ib endoleak right CIA (s/p endograft repair [**2194-9-2**])
- c/b type Ib endoleak left CIA (s/p endograft repair [**2195-5-12**])
- c/b type II endoleak (s/p coil embolization [**2195-8-11**])
- HTN, anemia, h/o hematuria, obesity, vertigo, ventral hernia,
h/o positive PPD, Diverticulosis c/b diverticular bleed x4 -
first one in [**2185**] requiring sigmoidectomy with colostomy
(now s/p Hartmann's takedown), diverticulitis, pancreatitis,
anemia, +H Pylori - [**4-27**], Colonoscopy [**2195-4-21**] - Previous
ileo-colonic anastomosis of the colon Diverticulosis of the
sigmoid colon Polyp in the rectum (polypectomy)
.
Social History:
lives with family, independent in ADLs
Tobacco - denies
ETOH - denies
Ilicit substances - denies
Family History:
Non-contributory
Physical Exam:
Gen: WDWN female in NAD
Card: RRR
Lungs: Cta bilat
Abd: Soft, non tender, non distended. Incision c/d/i
Extremities: warm, edematous
Pulses:
fem/ [**Doctor Last Name **]/ dp/ pt
R: p d d p radial - dopplerable
L: p d p p
Pertinent Results:
[**2195-10-15**] 6:40 pm MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2195-10-18**]**
MRSA SCREEN (Final [**2195-10-18**]): No MRSA isolated.
Weight
Admission: 81.65kg
[**10-20**] 97.7kg
[**10-21**] 91.9kg
[**10-22**] 86.6kg
[**2195-10-22**] 03:28AM BLOOD WBC-8.4 RBC-3.61* Hgb-10.4* Hct-30.1*
MCV-83 MCH-28.7 MCHC-34.5 RDW-17.2* Plt Ct-281
[**2195-10-22**] 03:28AM BLOOD Glucose-99 UreaN-13 Creat-0.8 Na-141
K-3.8 Cl-96 HCO3-37* AnGap-12
[**2195-10-22**] 03:28AM BLOOD Calcium-9.2 Phos-4.4 Mg-1.8
Brief Hospital Course:
Ms. [**Known lastname 111557**] was admitted on [**10-15**] and underwent explant of
aortobi-iliac endovascular stent graft, conversion open with
aortobi-iliac 16-8 mm Dacron. She tolerated the procedure well
and was transfered to the CVICU post-operatively. She was
transfused several units of packed red blood cells for acute
blood loss anemia. She was started on metopolol 25mg twice daily
for cardioprotection and blood pressure control. Her weight was
up approximately 20kg post operatively, and she was diuresed
accordingly. Pain was controlled with an epidural and later oral
medications. She was monitored closely with good blood pressure
and pain control. On [**10-18**] she was transfered to the VICU where
she continued to be monitored. She tolerated a regular diet and
was placed on nutritional supplements. She continued to be
diuresed aggressively, with a weight of 86.6kg on the day of
discharge, which is 5kg up from admission weight. She worked
with PT and OT and continued to make steady progress. She is
discharged home on [**10-22**] in stable condition. She will continue on
furosemide and potassium at home for a few days for further
diuresis. She will have a VNA checking weights several times per
week. She will see her PCP in [**Name Initial (PRE) **] week to follow up. She will
follow up with Dr. [**Last Name (STitle) **] in a two weeks for staple removal.
Medications on Admission:
1. Ferrous Sulfate 325 mg PO DAILY
2. Multivitamins 1 TAB PO DAILY
3. Vitamin B Complex 1 CAP PO DAILY
4. Vitamin D 1000 UNIT PO DAILY
5. Amlodipine 5 mg PO DAILY
6. Aspirin 325 mg PO DAILY
7. Hydrochlorothiazide 25 mg PO DAILY
8. Lisinopril 20 mg PO DAILY
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
2. Aspirin 325 mg PO DAILY
3. Ferrous Sulfate 325 mg PO DAILY
4. Hydrochlorothiazide 25 mg PO DAILY
5. Lisinopril 20 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Vitamin B Complex 1 CAP PO DAILY
8. Vitamin D 1000 UNIT PO DAILY
9. Metoprolol Tartrate 25 mg PO BID
RX *metoprolol tartrate 25 mg 1 tablet(s) by mouth twice a day
Disp #*30 Tablet Refills:*0
10. Oxycodone-Acetaminophen (5mg-325mg) [**2-16**] TAB PO Q4H:PRN pain
RX *oxycodone-acetaminophen [Endocet] 5 mg-325 mg [**2-16**] tablet(s)
by mouth q4-6h Disp #*50 Tablet Refills:*0
11. Furosemide 20 mg PO DAILY Duration: 3 Days
RX *furosemide 20 mg 1 tablet(s) by mouth once a day Disp #*3
Tablet Refills:*0
12. Potassium Chloride 10 mEq PO DAILY Duration: 3 Days
with furosemide
RX *potassium chloride [Klor-Con 10] 10 mEq 1 po by mouth once a
day Disp #*3 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Abdominal aortic aneurysm, status
post stent graft repair with enlargement and continued
endoleak.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Division of [**Location (un) **] and Endovascular Surgery
Abdominal Aortic Aneurysm (AAA) Surgery Discharge Instructions
You were admitted for explantation of your aortic stent grafts,
and open repair. Post operatively you were significantly fluid
overloaded and your weight was up significantly. We started you
on furosemide (lasix) to help diurese this fluid. You will
continue to take furosemide at home for a short period of time.
We would like you to see your PCP in the next week to follow up.
Because this medication takes fluid off, it can make your
potassium low. We have started you on potassium supplement as
well. You should take 1 potassium pill with each dose of
furosemide. You will have a visiting nurse to check your
weight, and help you with your meds.
We have also started you on an additional blood pressure
medication, metoprolol 25mg twice daily. You should continue
to take this and monitor your bps closely. Again, you should
see your PCP to follow up with this.
WHAT TO EXPECT:
1. It is normal to feel weak and tired, this will last for [**7-24**]
weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? You may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have incisional and leg swelling:
?????? Wear loose fitting pants/clothing (this will be less
irritating to incision)
?????? Elevate your legs above the level of your heart with 2-3
pillows every 2-3 hours throughout the day and at night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
??????
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one enteric coated aspirin daily, unless otherwise
directed
ACTIVITIES:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? You should get up every day, get dressed and walk, gradually
increasing your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (let the soapy water run over incision, rinse
and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area
CALL THE OFFICE FOR : [**Telephone/Fax (1) 63033**]
?????? Redness that extends away from your incision
?????? A sudden increase in pain that is not controlled with pain
medication
?????? A sudden change in the ability to move or use your leg or the
ability to feel your leg
?????? Temperature greater than 101.5F for 24 hours
?????? Bleeding from incision
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2195-11-3**] 9:30 Staples will be removed at this visit
Dr. [**Last Name (STitle) **] Thursday [**10-29**] 2:10pm
Completed by:[**2195-10-22**]
|
[
"E878.2",
"285.1",
"440.0",
"996.1",
"998.11",
"557.0",
"278.00",
"276.8",
"V45.72",
"441.4",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.90",
"38.44",
"17.56",
"00.40"
] |
icd9pcs
|
[
[
[]
]
] |
5584, 5641
|
2995, 4387
|
369, 491
|
5784, 5784
|
2404, 2972
|
9371, 9653
|
2114, 2132
|
4695, 5561
|
5662, 5763
|
4413, 4672
|
5935, 9348
|
2147, 2385
|
232, 331
|
519, 1263
|
5799, 5911
|
1286, 1983
|
1999, 2098
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,643
| 173,237
|
4812
|
Discharge summary
|
report
|
Admission Date: [**2101-4-16**] Discharge Date: [**2101-4-19**]
Date of Birth: [**2039-3-10**] Sex: M
Service: FENARD INTENSIVE CARE UNIT MEDICINE
CHIEF COMPLAINT: Increasing shortness of breath and
difficulty suctioning at nursing home through trache.
HISTORY OF PRESENT ILLNESS: Patient is a 62-year-old male
with a history of severe congestive obstructive pulmonary
disease, coronary artery disease, status post recent
admission to the Medical Intensive Care Unit on the [**Hospital Ward Name 12053**] of [**Hospital1 69**] for a
congestive obstructive pulmonary disease flare between [**2101-4-1**] and [**2101-4-8**] at which time a tracheostomy was
placed for failure to wean from ventilator x2, who presents
from [**Hospital3 672**] Hospital with problems suctioning his
tracheostomy tube and possible shortness of breath.
During patient's previous admission to [**Hospital1 **],
he had a course of azithromycin, was treated with steroids,
nebulizer treatments, CTA was negative for pulmonary embolus.
Upon arrival in the Emergency Room, the patient was evaluated
by ENT, and a fiberoptic scope revealed patent airways and a
normal tracheostomy. Patient was also treated with
Solu-Medrol and albuterol/Atrovent nebulizer treatments.
On initial presentation, the patient denied chest pain,
nausea, vomiting, fevers, chills, or any other associated
symptoms.
PAST MEDICAL HISTORY:
1. Congestive obstructive pulmonary disease status post
multiple admissions with severe obstructive defect on
pulmonary function tests.
2. Status post tracheostomy placement [**2101-4-7**] for
failure to wean from vent.
3. Coronary artery disease status post myocardial infarction
[**2101-1-25**]. Cardiac catheterization on the 23rd did
not show any significant obstructive disease. Echocardiogram
on [**2099-4-5**] showed an ejection fraction of 60%.
4. Reactive airways.
5. Hypertension.
6. Low back pain status post L1-L2 diskectomy.
7. Hyperlipidemia.
8. Tracheostomy in place [**2101-4-7**].
9. G tube in place [**2101-4-7**].
10. Bursitis.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ARRIVAL:
1. Tums 500 mg po bid.
2. Aspirin 325 mg po q day.
3. Lipitor 10 mg po q day.
4. Lisinopril 2.5 mg q day.
5. Prednisone taper currently 30 mg po q day.
6. Ativan prn.
7. Protonix 40 mg q day.
8. SubQ Heparin [**Hospital1 **].
9. Levaquin 500 mg po q day.
SOCIAL HISTORY: The patient has a 20+ pack year smoking
history, quit 28 years ago. Lives with his wife and has two
daughters. [**Name (NI) **] is coming from [**Hospital3 672**] Hospital.
PHYSICAL EXAMINATION: On examination, the patient has the
following vent settings: pressure support of 10, PEEP of 5,
FIO2 of 50%, tidal volume of 600. Temperature 99.1, blood
pressure 105/55, heart rate 100 and regular, respirations 12,
and oxygen saturation of 99%. In general, the patient was
alert and oriented times three. At rest, appears comfortable
without using any accessory respiratory muscles, however,
with movement, he is noted to have pursed-lip breathing.
HEENT: Normocephalic, atraumatic. Extraocular movements are
intact. Pupils are equal, round, and reactive to light.
Sclerae are anicteric. Moist mucous membranes. No teeth.
Neck is supple, no lymphadenopathy, no stridor. Lungs:
Decreased breath sounds throughout, no wheezes, crackles, or
rhonchi were appreciated. Heart is tachycardic, S1, S2
normal, no murmurs, rubs, or gallops were noted. Abdomen is
soft, nontender, nondistended, positive bowel sounds
throughout. G tube is in place and is clean around the
insertion site. Back: No CVAT and no spinal tenderness.
Extremities: No clubbing, cyanosis, or edema. Skin: No
sacral breakdown. Neurologically, the patient is alert and
oriented times three. Cranial nerves II through XII are
intact. Motor is [**5-9**]. Sensory is [**5-9**] throughout. Access:
The patient has a right internal jugular line. Tracheostomy
tube and J tube, and G tube, and Foley in place.
INITIAL LABORATORY VALUES: On [**2101-4-15**]: White blood
cell count of 14.7 with a differential of 81 neutrophils, 14
lymphocytes, 34 monocytes, hematocrit of 35.6, platelets of
371, PT is 12.8, PTT is 39.2, INR is 1.1. Sodium 135,
potassium 4.3, chloride 97, bicarbonate 28, BUN 28,
creatinine 0.9, glucose 122.
Chest x-ray shows emphysematous changes, otherwise no acute
cardiopulmonary process.
HOSPITAL COURSE: Patient was admitted to the Fenard
Intensive Care Unit for management of his congestive
obstructive pulmonary disease and respiratory status.
1. Pulmonary: History of severe congestive obstructive
pulmonary disease with tracheostomy in place status post
seven day course of Levaquin at [**Hospital3 672**] Hospital.
The patient was continued on prednisone taper, nebulizer
treatments, and switched to trache mask ventilation requiring
50% oxygen at 10 liters.
The patient's pulmonary status remained stable throughout the
entire hospital course. Remained afebrile without any
evidence of pneumonia or congestive obstructive pulmonary
disease flare.
2. Psychiatry: The patient is noted to be somewhat anxious
and depressed. He was started on Zoloft 50 mg po q day as
well as Ativan as needed. Patient was advised that he might
not note marked improvement in his symptoms for a few weeks.
3. Fluids, electrolytes, and nutrition: The patient was
continued on his tube feeds per his nursing home protocol,
and started on po which he tolerated very well during his
hospital stay. His electrolytes remained stable, and did not
require IV fluid resuscitation.
4. Prophylaxis: The patient was continued on subQ Heparin as
well as proton-pump inhibitor.
5. Access: The patient's central venous line was
discontinued. Peripheral line was placed. G tube and trache
remained in place.
6. Code status: The patient is full code.
7. Communication: Ongoing with patient's wife and two
daughters. The patient's two daughters visited the patient
on a regular basis. Wife's phone number is [**Telephone/Fax (1) 19018**].
DISPOSITION: Discharged to rehabilitation.
CONDITION ON DISCHARGE: Stable.
DIAGNOSES:
1. Mechanical tracheostomy difficulty.
2. Congestive obstructive pulmonary disease.
3. Anxiety disorder.
4. Depression.
DISCHARGE MEDICATIONS:
1. Albuterol/Atrovent metered-dose inhaler 2-4 puffs q6h.
2. Lorazepam 0.5 mg po bid.
3. Prednisone 20 mg po q day q a prolonged taper over the
next week.
4. Sertraline hydrochloride 25 mg po q day.
5. Lorazepam 0.5 mg po q4-6h prn.
6. Pantoprazole 40 mg po q24h.
7. Heparin subQ 5,000 units q12h.
8. Lactulose 30 cc po q8h prn constipation.
9. Lisinopril 2.5 mg po q day.
10. Atorvastatin 10 mg po q hs.
11. Sublingual nitroglycerin 0.3 mg sublingual prn.
12. Aspirin 325 mg po q day.
13. Calcium carbonate 500 mg [**Hospital1 **].
14. Colace 100 mg po bid.
15. Tylenol 325-650 mg po q4-6h prn.
16. Ipratropium bromide nebulizer q6h prn.
17. Albuterol nebulizer q6h prn.
[**Name6 (MD) **] [**Last Name (NamePattern4) 5837**], M.D. [**MD Number(1) 5838**]
Dictated By:[**Name8 (MD) 20162**]
MEDQUIST36
D: [**2101-4-19**] 08:25
T: [**2101-4-19**] 08:33
JOB#: [**Job Number 20163**]
|
[
"401.9",
"V44.0",
"272.0",
"300.00",
"412",
"414.00",
"V44.1",
"309.0",
"491.21"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"33.21",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
6272, 7192
|
4412, 6083
|
2598, 4394
|
186, 276
|
305, 1392
|
1414, 2382
|
2399, 2575
|
6108, 6249
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,229
| 158,678
|
34025
|
Discharge summary
|
report
|
Admission Date: [**2186-9-27**] Discharge Date: [**2186-10-2**]
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
lethargy, headache
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname **] is a [**Age over 90 **] year-old right-handed man with a history
including broca's aphasia in the setting of remote stroke,
dementia, polycythemia [**Doctor First Name **], and recent admission ([**Date range (1) 13693**])
for
small right subdural hematoma who is referred to the ED after he
was discovered to have acute expansion of the lesion in the
setting of headache and somnolence.
.
According to the patient's daughter, he was relatively well
until
[**2186-9-22**]. On that date, he reportedly stood up from a chair,
turned around, and then fell backwards, striking his head
(without loss of consciousness). He was initially evaluated at
[**Hospital1 **] where a non-contrast CT of the head
demonstrated
a small right subdural hematoma. He was admitted to the
geriatrics service for evaluation of syncope (as a potential
cause of the fall). He was discharged home on [**2186-9-24**].
.
The patient's family had been staying with him 24/7 since
discharge until [**2186-9-26**] at about 11 pm. He apparently went
downstairs to the front desk in his pyjamas at about 6 am on the
morning of evaluation to seek help (although the details are
unclear). It is unknown if he suffered interval falls. His
daughter arrived at about 8 am. At that time, he was grasping
his head and complaining of headache. He seemed sleepier than
usual. At noon, the VNA arrived. She recommended the patient
present to the ED. The family, instead, contact[**Name (NI) **] the PCP who
coordinated an outpatient non-contrast CT of the head. He was
referred to the ED when the imaging showed acute progression of
hemorrhage, which is now bilateral and associated with sulcal
effacment and shift.
.
At baseline, the patient lives in an "independent" living
facility. However, his three children and aides provide almost
continuous care. His children do the pills, laundry, and
organize medications. He needs help into the shower but can
then
bathe himself. He is able to dress himself. He is able to feed
himself. He walks with the assistance of others and was
discharged with a cane on [**2186-9-24**]. Due to presumed remote
infarcts "in the language area" he has broca's aphasia. He is
oriented to self, birthday, and general location but not year at
baseline, and has memory deficits.
Past Medical History:
1. Dementia.
2. Myeloproliferative disorder
3. Gout. He is currently on allopurinol. He reports no active
symptoms.
4. History of stomach cancer. He reports a stomach cancer
discovered in [**2176**], which also revealed lymphoma cells on
biopsy.
5. Bilateral hearing loss. He does wear bilateral hearing
aids,but is having some difficulty accommodating them.
6. Macular degeneration. He underwent right eye surgery for
this several years ago and the vision has improved since then.
7. Osteoarthritis
8. Hypercholesterolemia.
9. Hypothyroidism.
Social History:
Lives in an senior independent living facility. His daughter
comes by often to help him. His other children call him to
remind him to take his meds and go to dinner. Was a heavysmoker
but quit at 40. No EtOH. No illicits
Family History:
M - had significant dementia in her 80s
3 kids - all healthy
Physical Exam:
At admission:
General: sleeping, sitting upright. when awakend holds front of
head.
HEENT: Normocepahlic, staples. no scleral icterus noted. Mucus
membranes dry, no lesions noted in oropharynx. left lid
dehiscence.
Neck: right carotid bruit
Cardiac: Regular rate, II/VI systolic murmur.
Pulmonary: Lungs clear to auscultation bilaterally.
Abdomen: Round. Normoactive bowel sounds. Soft. Non-tender,
non-distended.
Extremities: Warm, well-perfused.
Skin: no rashes or concerning lesions noted.
MSK: stooped posture with limited head rotation
NEUROLOGIC EXAMINATION:
Mental Status:
* Degree of Alertness: awakens easily to voice and maintains
wakefulness without continuous stimulation.
* Orientation: Oriented to person, place ("hospital")
* Attention: Names days of week forwards with substitution of
"tuesday" for thursday. able to recite days backwards from
saturday to wednesday. verbal perseveration.
* Memory: Able to correctly identify birthdate.
* Language: Language is non-fluent with some paraphasic errors.
Repetition is intact ("today is a sunny day"). Comprehension
appears intact; pt able to correctly follow midline and
appendicular commands. Pt able to name thumb, knuckles.
[**Location (un) **]
(happy birthday) intact. writes "happy - 3 upside down "u"s -
birthday."
* Calculation: unable to calculate number of quarters in $1.50
("4")
* Praxis: No evidence of apraxia (able to mimic brushing teeth)
* Frontal Release signs: positive grasp
Cranial Nerves:
* I: Olfaction not evaluated.
* II: PRL 3 to 2mm and brisk.
* III, IV, VI: EOM with limited upgaze, without nystagmus.
* V: Facial sensation intact to light touch in the V1, V2, V3
distributions.
* VII: No facial droop, facial musculature symmetric.
* VIII: Hearing intact to voice.
* IX, X: Palate elevates symmetrically.
* [**Doctor First Name 81**]: 5/5 strength in trapezii bilaterally.
* XII: Tongue protrudes in midline.
Motor:
* Bulk: generalized atrophy
* Tone: increased throughout (inc tone vs paratonia).
* Drift: No pronator drift.
* Adventitious Movements: No tremor or asterixis noted.
Strength:
* Left Upper Extremity: 4+ Delt, 5 Biceps, 4+ Triceps, 5 Wrist
Ext, 5 Wrist Flex, 4+ Finger Ext, 5 Finger Flex
* Right Upper Extremity: breakable Delt, 5 Biceps, breakable
Triceps, 5 throughout Wrist Ext, Wrist Flex, Finger Ext, Finger
Flex
* Left Lower Extremity: 4 Iliopsoas, 5 Quad, 4 Ham, 5 Tib Ant,
5
Gastroc, breakable Ext Hollucis Longis
* Right Lower Extremity: 4+ Iliopsoas, 5 Quad, 4+ Ham, 5 Tib
Ant,
5 Gastroc, 5 Ext Hollucis Longis
Reflexes:
* Left: 2 throughout Biceps, Triceps, Bracheoradialis, 2+
Patellar, 0 Achilles
* Right: 2 thoughout Biceps, Triceps, Bracheoradialis, 2+
Patellar, 0 Achilles
* Babinski: flexor right, extensor left
Sensation:
* Temperature: intact to cold sensation in hands, feet, face
* Vibration: difficult to assess
* Proprioception: decreased at level of great toe; unable to
answer with proximal testing
Coordination
* Finger-to-nose: intact bilaterally
Gait:
* Description: pt declined
At discharge:
Neuro exam: drowsy, eyes intermittently closed even while awake.
Requires frequent verbal/tactile stimuli to maintain alertness.
(Responds better to daughters than staff). Follow simple
commands. Little verbal output, inconsistently produces [**2-13**]
words appropriately, some phonemic errors evident. Pupils 2.5 to
2 with light bilatterally. Right facial droop. Motor exam has
varied over his course (some volitional component) but today has
[**6-15**] in bilateral deltoids, triceps, and biceps. [**5-16**] in bilateral
IPs. Wide based unsteady gait with use of cane.
Pertinent Results:
[**2186-9-27**] 06:00PM WBC-27.8* RBC-4.97 HGB-14.2 HCT-43.5 MCV-88
MCH-28.6 MCHC-32.7 RDW-17.0*
[**2186-9-27**] 06:00PM NEUTS-82* BANDS-0 LYMPHS-5* MONOS-10 EOS-2
BASOS-1 ATYPS-0 METAS-0 MYELOS-0
[**2186-9-27**] 06:00PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL
[**2186-9-27**] 06:00PM PLT SMR-NORMAL PLT COUNT-183
[**2186-9-27**] 06:00PM PT-14.9* PTT-36.6* INR(PT)-1.3*
[**2186-9-27**] 06:00PM LIPASE-18
[**2186-9-27**] 06:00PM ALT(SGPT)-11 AST(SGOT)-16 ALK PHOS-110 TOT
BILI-0.5
[**2186-9-27**] 06:00PM GLUCOSE-115* UREA N-39* CREAT-2.0* SODIUM-139
POTASSIUM-4.8 CHLORIDE-105 TOTAL CO2-22 ANION GAP-17
[**2186-9-27**] 09:40PM URINE RBC-<1 WBC-1 BACTERIA-FEW YEAST-NONE
EPI-0
[**2186-9-27**] 09:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
[**2186-9-27**] NCHCT - R frontal SDH (about 15 mm in largest diameter)
with sulcal effacement, layering of hem in L occipital [**Doctor Last Name 534**],
subacute SDH along R post convexity, about 6 mm midline shift to
left, interval development of left anterior and middle cranial
fossae subdural hematomas
ECG:
Normal sinus rhythm. Tracing is within normal limits and
unchanged from
previous tracing of [**2186-9-22**].
Read by: [**Last Name (LF) **],[**First Name8 (NamePattern2) 2206**] [**Doctor Last Name **]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
75 148 86 388/414 55 -2 45
Portable CXR:
FINDINGS: There is a tortuous aorta with atherosclerotic
calcifications.
Otherwise, mediastinal contours are unremarkable. There are low
lung volumes bilaterally, exagerating the appearance of the hila
and pulmonary vasculate. Heart size is top normal. There is a
retrocardiac opacity, which likely represents combination of
atelectasis and possibly a small left effusion. No pneumothorax
evident.
IMPRESSION:
1. No overt evidence of fluid overload.
2. Retrocardiac opacity, likely combination of atelectasis and
possibly small pleural effusion.
[**9-28**] Repeat NonContrast Head CT:
FINDINGS: There is a hyperdensity along the convexity of the
right frontal, parietal, and temporal lobes with some areas of
hypodensity that is consistent with an acute on chronic subdural
hematoma. This extra-axial collection is unchanged in thickness,
extent, and mass effect compared to prior study. It extends from
the vertex to the middle cranial fossa. There is effacement of
the adjacent sulci and a shift in the normally midline
structures 6 mm to the left, this is unchanged from prior study.
There is also a small hyperdense extra-axial collection in the
LEFT frontal and temporal lobe convexities, consistent with a
small acute subdural hematoma. It is less dense and slightly
smaller in size compared to most recent study on [**2186-9-27**].
The subarachnoid hemorrhage seen in the left temporal lobe on
prior study is unchanged in appearance. The small
intraventricular hemorrhage in the left occipital [**Doctor Last Name 534**] of the
left lateral ventricle is unchanged and less dense, consistent
with normal evolution of hemorrhage. There is no new hemorrhage.
No interval development of acute infarction, edema, or
herniation. There is slight periventricular white matter
hypodensity, likely the sequela of chronic small vessel ischemic
disease.
A few retention cysts are noted in the right maxillary sinus.
osseous details are better assessed on prior study.
IMPRESSION:
1. Bilateral subdural hematomas, right greater than left. The
right subdural hematoma along the frontal, parietal, temporal
convexity is unchanged. The left subdural hematoma in the
frontotemporal area is slightly smaller in size.
2. No new hemorrhage or infarction.
3. Stable slight shift of midline structures without evidence of
herniation.
4. Stable equivocal left temporal subarachnoid hemorrhage.
5. Stable left occipital intraventricular hemorrhage.
EEG:
IMPRESSION: This is an abnormal EEG due to the sudden appearance
of
generalized, rhythmic slowing suggestive of electrographic
seizure. No
clear clinical correlate was seen, though occasional facial
twitching
during this period was evident. Separately, the slow background
activity with bifrontal slowing may represent the presence of a
bifrontal subcortical lesion, diffuse areas of bilateral
subcortical
dysfunction and/or increased intracranial pressure.
Brief Hospital Course:
[**Age over 90 **] yo M h/o polycythemia [**Doctor First Name **], HL, prior gastric lymphoma,
suspected dementia and suspected prior stroke with nonfluent
aphasia admitted overnight with increasing headache and
somnolence, found to have interval increased in prior traumatic
SDH (from [**9-22**]) with intraventricular extension and new SDHs.
The patient was felt to not need neurosurgical intervention by
NSurg given the family's desire to avoid major surgeries such as
a hemicraniectomy. The patient had fallen on [**9-22**] and suffered a
head injury without loss of consciousness, resulting in a small
frontal SDH. Over several days, he developed a worsening
headache and became more lethargic and sleepy. He was brought to
[**Hospital1 18**] and was found to have the extension of his prior
hemorrhages and new hemorrhages. He was kept in the TSICU
overnight without any major
change in neurologic status. Given discussions with the family,
they decided against aggressive interventions including
hemicraniectomy to drain the SDH. The patient was transferred to
the stroke neurology floor. A routine EEG was done that showed
EEG seizure activity (no clear clinical correlate) for which the
patient was started on Keppra 250mg po bid (renally dosed). The
patient's headache pain regimen was modified as well. Of note,
the patient takes in very little nutrition. The patient was
transferred to [**Hospital 100**] Rehab on [**2186-10-2**] with the understanding
that his nutrition will continued to be evaluated at rehab.
Palliative care has also been involved with his stay here and we
hope that palliative care continues to care for him as well at
rehab.
Medications on Admission:
- hydroxyurea 500 mg Capsule Sig: One (1) Capsule PO every day
except Sunday.
- simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
- allopurinol 100 mg Tablet Sig: One (1) Tablet PO once a day.
- ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1)
Tablet
PO once a day.
- oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours)
as needed for pain.
- Vitamin D 1,000 unit Tablet Sig: One (1) Tablet PO once a
day.
- pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
- Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation or if using oxycodone.
Discharge Medications:
1. hydroxyurea 500 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
2. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Four (4) mg
Injection Q8H (every 8 hours) as needed for nausea.
5. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
7. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
8. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
9. acetaminophen 500 mg/5 mL Liquid Sig: 1000 (1000) mg PO Q6H
(every 6 hours): Please give at 0000, 0600, 1200, and 1800.
10. tramadol 50 mg Tablet Sig: 0.5 Tablet PO three times a day:
Please give at 0900, 1500, and 2100.
11. levetiracetam 250 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
12. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO qMN: Please give at
midnight with acetaminophen every night. .
13. docusate sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day).
14. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
Subdural Hemorrhage
Intraventricular Hemorrhage
Seizure
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Neuro exam: drowsy, eyes intermittently closed even while awake.
Requires frequent verbal/tactile stimuli to maintain alertness.
(Responds better to daughters than staff). Follow simple
commands. Little verbal output, inconsistently produces [**2-13**]
words appropriately, some phonemic errors evident. Pupils 2.5 to
2 with light bilatterally. Right facial droop. Motor exam has
varied over his course (some volitional component) but today has
[**6-15**] in bilateral deltoids, triceps, and biceps. [**5-16**] in bilateral
IPs. Wide based unsteady gait with use of cane.
Discharge Instructions:
It was a pleasure caring for you during your stay. You were
admitted to the hospital for evaluation of your sleepiness. It
was discovered that your previous subdural hematoma after falls
weeks prior had expanded. After discussion with the
neurosurgical team, your family decided against a large
hemicraniectomy. If In [**4-14**] weeks you would like to see
neurosurgery in clinic to determine if a smaller surgery, a Burr
hole, would be appropriate to help remove the blood, please call
the number listed below to make an appointment in their clinic.
On imaging, it appears that the bleeding has remained stable
during your stay. It there is any large increase in sleepiness,
there is a chance more bleeding has occurred and you should seek
medical attention if so desired. Otherwise palliative care was
involved in your stay and we hope they continue to work with you
in rehab. We have scheduled a pain regimen that seems to be
helping with your headache. Your nutrition has been of concern
given that you take in very little food in. We hope that rehab
continues to work on improving your nutrition during your stay.
Followup Instructions:
Please see neurosurgery in clinic:
Neurosurgery Appointment Line
([**Telephone/Fax (1) 88**]
Please see Dr. [**Last Name (STitle) **] in the [**Hospital 878**] clinic, [**Hospital1 18**] [**Hospital Ward Name 5074**], [**Hospital Ward Name 23**] Bldg, [**Location (un) **]. Phone:[**Telephone/Fax (1) 2574**]
Date/Time: Friday, [**2186-12-1**] at 1:30pm
Previously scheduled appointments:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name12 (NameIs) 280**] Phone:[**Telephone/Fax (1) 719**]
Date/Time:[**2186-10-2**] 8:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2847**], MD Phone:[**Telephone/Fax (1) 719**]
Date/Time:[**2186-12-14**] 10:30
|
[
"238.4",
"272.4",
"V15.82",
"274.9",
"E888.9",
"852.21",
"438.11",
"294.8",
"244.9",
"585.9",
"V49.86",
"V10.79",
"780.39"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
15240, 15325
|
11560, 13221
|
279, 285
|
15424, 15424
|
7162, 9213
|
17315, 18030
|
3450, 3512
|
13926, 15217
|
15346, 15403
|
13247, 13903
|
16172, 17292
|
3527, 4072
|
6570, 7143
|
221, 241
|
313, 2627
|
5012, 6556
|
9222, 11537
|
15439, 16148
|
4096, 4096
|
2649, 3195
|
3211, 3434
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,148
| 145,980
|
38155
|
Discharge summary
|
report
|
Admission Date: [**2147-7-27**] Discharge Date: [**2147-8-25**]
Date of Birth: [**2114-4-23**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 7591**]
Chief Complaint:
Tonsillar swelling
Major Surgical or Invasive Procedure:
Bone marrow biopsies
Central line placement
History of Present Illness:
The patient is a 33 year old male with no significant past
medical history who presents from an OSH with enlarged tonsils
and CBC with white count of 79. He states that in mid-[**Month (only) **] he
had a sore throat and noticed a voice change. He went to his
PCP, [**Name10 (NameIs) **] [**Name Initial (NameIs) **] strep throat culture which was negative, and was
diagnosed with a tonsillar abscess. He was prescribed an
antibiotic on [**2147-7-8**] and took it for several days, but did not
improve. He returned to his PCP who prescribed Clindamycin and
steroids. However, he continued to not feel well and had
temperatures to 101.5 with cervical LAD. He returned to his PCP
who ordered blood tests. He was told they were abnormal and was
seen by an oncologist at the outside hospital. He had a
peripheral smear done at the OSH and was transferred to the BMT
service.
.
Prior to the enlarged tonsils, he states that he had been
feeling well. However, he did see his dentist a few weeks ago
who noted that he had some gum hypertrophy and bleeding, which
he states they were concerned about. He says that he had seen a
PCP regularly in the past and had had normal blood tests.
.
Currently, he continues to have a sore throat and difficulty
with talking and swallowing. He said that he has been trying to
drink water. He has had several small, loose stools which he
attributes to the antibiotics. Otherwise, he has no complaints.
.
ROS: Endorses fever and loose stools, but denies chills, night
sweats, headache, vision changes, rhinorrhea, congestion, sore
throat, cough, shortness of breath, chest pain, abdominal pain,
nausea, vomiting, diarrhea, constipation, BRBPR, melena,
hematochezia, dysuria, hematuria.
.
Past Medical History:
Appendectomy [**2142**] (complicated by ruptured appendix)
Knee surgery on R & L knees
.
Social History:
Pt works as a recruiter from home. He lives with several
roommates. He denies exposure to chemicals or toxins.
Smoking: None
Alcohol: He has alcohol socially on weekends, with up to 10
drinks at a time.
Drugs: Denies illicit drug use.
.
Family History:
Father - deceased from motorcycle accident
Mother - alive and healthy
2 Half-sisters - alive and healthy
Grandparents - deceased, no known cancer history
.
No known bleeding disorder, leukemia, lymphoma or other cancer
in the family.
.
Physical Exam:
Admission Physical Exam:
VS - Temp 100.1, BP 139/84, HR 113, R 20, O2-sat 98% RA
GENERAL - well-appearing man in NAD, comfortable, pleasant
gentleman
HEENT - PERRLA, sclerae anicteric, MMM, + tonsillar hypertrophy,
touching
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - no increased work of breathing, CTAB, no wheezes or
crackles
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, +splenomegaly, no rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact
.
Discharge Physical Exam:
VS: T 97.3, BP 106/70, HR 60, RR 17, SpO2 98% on RA
Gen: Young male in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva without
pallor or injection. MMM, OP clear.
Neck: Supple, full ROM. No JVD. No significant cervical
lymphadenopathy.
CV: RRR with normal S1, S2. No M/R/G. No thrills or lifts. No
S3 or S4.
Chest: Respiration unlabored, no accessory muscle use. CTAB
without crackles, wheezes or rhonchi.
Abd: Normal bowel sounds. Soft, NT, ND. No organomegaly noted.
Ext: WWP. Digital cap refill <2 sec. No C/C/E. Distal pulses
intact radial 2+, DP 2+, PT 2+.
Skin: No stasis dermatitis, ulcers, rashes, or other lesions.
Neuro: CN II-XII grossly intact. Normal gait. Normal language.
.
.
Pertinent Results:
Admission Labs:
[**2147-7-27**] 05:49PM BLOOD WBC-94.8* RBC-2.72* Hgb-8.9* Hct-24.4*
MCV-90 MCH-32.8* MCHC-36.5* RDW-16.1* Plt Ct-74*
[**2147-7-27**] 11:00PM BLOOD WBC-68.7* RBC-2.73* Hgb-8.9* Hct-24.9*
MCV-91 MCH-32.4* MCHC-35.6* RDW-16.3* Plt Ct-64*
[**2147-7-28**] 06:20AM BLOOD WBC-63.7* RBC-2.77* Hgb-9.0* Hct-25.7*
MCV-93 MCH-32.6* MCHC-35.1* RDW-16.8* Plt Ct-57*
.
[**2147-7-27**] 05:49PM BLOOD Neuts-0 Bands-0 Lymphs-13* Monos-0 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0 Blasts-87* Other-0
[**2147-7-27**] 11:00PM BLOOD Neuts-2* Bands-0 Lymphs-10* Monos-1*
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 Blasts-87* NRBC-1* Other-0
[**2147-7-28**] 06:20AM BLOOD Neuts-0* Bands-0 Lymphs-16* Monos-4 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0 Blasts-80* NRBC-1* Other-0
.
[**2147-7-27**] 05:49PM BLOOD Hypochr-2+ Anisocy-OCCASIONAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2147-7-27**] 11:00PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2147-7-28**] 06:20AM BLOOD Hypochr-NORMAL Anisocy-2+ Poiklo-1+
Macrocy-1+ Microcy-1+ Polychr-NORMAL Spheroc-2+ Ovalocy-1+
.
[**2147-7-27**] 05:49PM BLOOD PT-15.0* PTT-24.5 INR(PT)-1.3*
[**2147-7-28**] 06:20AM BLOOD PT-15.9* PTT-24.2 INR(PT)-1.4*
.
[**2147-7-27**] 05:49PM BLOOD Fibrino-261
[**2147-7-28**] 06:20AM BLOOD Fibrino-183
[**2147-7-28**] 06:20AM BLOOD FDP-160-320*
.
[**2147-7-28**] 06:20AM BLOOD Gran Ct-0*
.
[**2147-7-27**] 05:49PM BLOOD Glucose-149* UreaN-14 Creat-1.3* Na-134
K-3.3 Cl-95* HCO3-30 AnGap-12
[**2147-7-27**] 11:00PM BLOOD Glucose-155* UreaN-14 Creat-1.3* Na-139
K-3.6 Cl-97 HCO3-33* AnGap-13
[**2147-7-28**] 06:20AM BLOOD Glucose-131* UreaN-16 Creat-1.2 Na-140
K-4.0 Cl-100 HCO3-33* AnGap-11
.
[**2147-7-27**] 05:49PM BLOOD ALT-27 AST-21 LD(LDH)-394* AlkPhos-61
TotBili-0.5
[**2147-7-27**] 11:00PM BLOOD ALT-27 AST-19 LD(LDH)-359* AlkPhos-52
TotBili-0.3
[**2147-7-28**] 06:20AM BLOOD ALT-24 AST-19 LD(LDH)-387* AlkPhos-53
TotBili-0.4
.
[**2147-7-27**] 05:49PM BLOOD Albumin-4.3 Calcium-9.5 Phos-3.1 Mg-1.9
[**2147-7-27**] 11:00PM BLOOD Calcium-9.0 Phos-4.0 Mg-1.9 UricAcd-4.3
[**2147-7-28**] 06:20AM BLOOD Calcium-8.7 Phos-5.9*# Mg-2.0 UricAcd-4.5
.
[**2147-7-27**] 09:39PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.002
[**2147-7-27**] 09:39PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
.
.
Discharge Labs:
[**2147-8-25**] 12:00AM BLOOD WBC-3.9* RBC-3.33* Hgb-9.9* Hct-28.5*
MCV-86 MCH-29.8 MCHC-34.7 RDW-15.8* Plt Ct-638*
[**2147-8-25**] 12:00AM BLOOD Neuts-32* Bands-0 Lymphs-26 Monos-41*
Eos-0 Baso-1 Atyps-0 Metas-0 Myelos-0
[**2147-8-25**] 12:00AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-NORMAL
Polychr-OCCASIONAL Ovalocy-OCCASIONAL
[**2147-8-25**] 12:00AM BLOOD PT-13.7* PTT-26.2 INR(PT)-1.2*
[**2147-8-25**] 12:00AM BLOOD Gran Ct-1245*
[**2147-8-25**] 12:00AM BLOOD Glucose-87 UreaN-19 Creat-0.9 Na-141
K-4.4 Cl-104 HCO3-30 AnGap-11
[**2147-8-25**] 12:00AM BLOOD ALT-45* AST-30 LD(LDH)-245 AlkPhos-124
TotBili-0.4
[**2147-8-25**] 12:00AM BLOOD Albumin-3.8 Calcium-9.0 Phos-4.5 Mg-2.3
UricAcd-5.2
.
.
Reports:
CT neck [**2147-7-28**]:
IMPRESSIONS:
1. Markedly enlarged tonsils and nasopharyngeal lymphoid
tissues, markedly narrowing the airway for a segment of several
centimeters. At its narrowest, the airway measures approximately
6 mm.
2. 6-mm focal hypodensity in the left tonsil, concerning for
abscess or developing abscess. No evidence of extension in to
the peritonsillar space at this time.
3. Extensive, pronounced cervical lymphadenopathy throughout
levels II through IV, with lymph nodes measuring up to 2 cm.
4. Mild paranasal sinus disease.
.
.
[**2147-7-28**]: BONE MARROW ASPIRATE AND CORE BIOPSY.
DIAGNOSIS:
ACUTE MYELOID LEUKEMIA WITH MONOCYTIC DIFFERENTIATION. SEE NOTE.
Note: please correlate with cytogenetics findings.
MICROSCOPIC DESCRIPTION
Peripheral Blood Smear: ([**2147-7-27**])
The smear is adequate for evaluation. Erythrocytes are markedly
decreased and exhibit moderate anisopoikilocytosis with rare
dacrocytes and red cell fragments present. A rare nucleated red
blood cell is seen on scan. The white blood cell count appears
markedly increased. White cells predominantly consist of large
immature forms with moderate basophilic cytoplasm occasional
vacuoles, [**Doctor Last Name **] chromatin and prominent nucleoli suggestive of
immature monocytic precursors. Platelet count appears markedly
decreased. Differential count shows 2% neutrophils, 6%
lymphocytes, 92% blasts and promonocytes.
Aspirate Smear:
The aspirate material is adequate for evaluation and exhibits
near total replacement by blasts and promonocytes. Occasional
maturing normal hematopoietic elements including maturing
myeloids, rare erythroids and megakaryocytes are seen.
Differential (300 cells) shows: 94% blasts and promonocytes, 3%
bands/neutrophils, 9% lymphocytes, 3% erythroid.
Clot Section and Biopsy Slides:
The biopsy material is adequate for evaluation. The overall
cellularity is 90%-100% and is almost entirely comprised of
immature forms with modest cytoplasm vesicular nuclei and
variably prominent nucleoli. Rare background myeloid and
erythroid precursors are present. Megakaryocytes are markedly
decreased.
Special Stains:
Iron stain is adequate of evaluation. Storage iron is markedly
decreased. Sideroblasts are absent. However, erythroblasts are
rare making it difficult to evaluate for sideroblasts.
Cytogenetics studies: Pending
Flow cytometry studies: See separate note.
.
.
[**2147-7-28**]: FLOW CYTOMETRY REPORT
FLOW CYTOMETRY IMMUNOPHENOTYPING
The following tests (antibodies) were performed: CD2, CD3, CD4,
CD5, CD7, CD8, CD10, CD13, CD14, CD15, CD19, CD20, CD33, CD34,
CD41, CD11c, CD56, CD64, HLA-DR, Kappa, Lambda, CD71, Glyc A,
CD45, CD117.
RESULTS:
Three color gating is performed (light scatter vs. CD45) to
optimize blast yield. Cell marker analysis demonstrates that the
majority of the cells isolated from this bone marrow express
immature antigens CD34, HLA-DR, myeloid associated antigens
CD33, CD15, CD117, CD11c, CD64, CD56, CD71, lymphoid associated
antigen CD7, are CD10 (cALLa) negative, and are negative for
CD5, CD19, CD20, CD3, CD13, CD14, CD41, Glycophorin A.
Blast cells comprise 94% of total gated events.
INTERPRETATION
Immunophenotypic findings consistent with involvement by acute
myeloid leukemia with monocytic differentiation. Please refer to
case S10-27409S for morphologic evaluation.
.
.
[**2147-8-10**]: BONE MARROW ASPIRATE AND CORE BIOPSY.
DIAGNOSIS:
MARKEDLY HYPOCELLULAR BONE MARROW CONSISTENT WITH CHEMOTHERAPY
INDUCED ABLATION. DIAGNOSTIC FEATURES OF INVOLVEMENT BY ACUTE
LEUKEMIA ARE NOT PRESENT.
MICROSCOPIC DESCRIPTION
Peripheral Blood Smear:
The smear is adequate for evaluation. Erythrocytes are
decreased and show mild poikilocytosis. Rare ovalocytes and red
cell fragments are seen on scan. The white blood cell count
appears markedly decreased. Platelet count appears markedly
decreased. Differential count shows 0% neutrophils, 0% bands,
0% monocytes, 100% lymphocytes, 0% eosinophils, 0% basophils. A
limited 50 cell differential was performed.
Aspirate Smear:
The aspirate material is adequate for evaluation and is markedly
hypocellular. A limited 100 cell differential shows 90%
lymphocytes, 8% plasma cells, and 2% immature erythroid
precursors. Numerous background histiocytes with ingested
debris are present.
Clot Section and Biopsy Slides:
The biopsy material is adequate for evaluation. The overall
cellularity is <5% and comprised predominantly of lymphocytes
and plasma cells. Background histiocytes with ingested debris
and diffuse amorphous eosinophilic deposits are seen. There is
focal bone remodeling with osteoblastic activity.
.
.
[**2147-8-17**]: BONE MARROW ASPIRATE AND CORE BIOPSY:
DIAGNOSIS:
Hypercellular bone marrow with maturing erythroid-dominant
trilineage hematopoiesis
5% blasts highlighted by CD34, see note.
Note: CD34 highlights blasts, approximately about 5% of marrow
cellularity. These are mostly scattered. CD117 highlights a
population of early myeloid cells. CD68 (and CD4) highlights
monocytes. Glycophorin highlights all the red cell precursors as
sheets and large aggregates, including the atypical blast-like
cells. Thus the findings overall represent robust erythroid
regeneration. Blasts are seen, and the differential diagnosis
includes marrow regeneration, and residual leukemia; based on
the scattered nature and recovering counts the former is
favored. Clinical correlation is recommended. Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]
informed of the impression.
MICROSCOPIC DESCRIPTION
Peripheral Blood Smear:
The smear is adequate for evaluation. Erythrocytes are decreased
and show mild poikilocytosis with occasional microcytes,
dacrocytes, rare spherocytes and nucleated red cells seen. The
white blood cell count appears markedly decreased. Platelet
count appears markedly decreased. Occasional large forms are
seen. Rare giant forms are present. Limited 50 cell differential
count shows 7% monocytes, 90% lymphocytes, 0% eosinophils, 0%
basophils, 3% others including 2% nucleated red cells, 1% blast.
Aspirate Smear:
The aspirate material is inadequate for evaluation due to lack
of spicules.
Clot Section and Biopsy Slides:
The biopsy material is adequate for evaluation. The overall
cellularity is estimated to be 50-60%. Scant large foci
hypocellular areas are present consistent with recent
chemotherapy effect. There are small clusters of myeloblasts.
The dominant picture is erythroid predominant hematopoiesis. The
M:E ratio estimate is decreased. Erythroid precursors are
relatively increased and exhibit normoblastic maturation.
Myeloid elements are markedly decreased and show left shift.
Megakaryocytes are markedly increased, include several abnormal
forms in loose and tight clusters. Marrow clot section is not
submitted. Touch prep examined. Scattered marrow stromal cells
and hematopoietic precursors are seen, however, the morphology
is suboptimal to evaluate due to preparation artifacts.
.
.
TTE (Complete) Done [**2147-8-21**] at 9:40:59 AM
Conclusions
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic regurgitation. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
.
.
Brief Hospital Course:
The patient is a 33 year old male with no significant past
medical history who presented from an OSH with enlarged tonsils
and CBC with white count of 79. Bone marrow biopsy on [**2147-7-27**]
established a new diagnosis of AML, monocytic type.
.
# AML, monocytic type: He initially presented with leukocytosis
from OSH and a 2 week history of enlarged tonsils treated with
Clindamycin for possible pharyngeal abscess. A BMB was done on
[**2147-7-27**], demonstrating AML, likely monocytic type. He was
started on Hydrea and hydration on the evening of [**2147-7-27**], which
brought his white count down. His course was complicated by
further tonsilar enlargement and difficulty breathing through
his mouth with voice change from the night of [**7-27**] to [**7-28**]. He
was evaluated by ENT who did not see any drainable abscess, but
started him on Dexamethasone and he was transferred to the ICU
for airway management. He was also started empirically on
Vancomycin, Aztreonam, and Meropenem for possible infectious
causes of airway narrowing. He required desensitization for
Meropenem given his history of penicillin allergy. Prior to ICU
placement, he was started on 7+3 induction chemotherapy on
[**2147-7-28**].
.
He improved on Dexamethasone and no intubation was required. He
was discharged to the floor and taken off steroids. He
continued to have persistent throat swelling, cervical area
lymphadenopathy and neck pain. CT of the neck that afternoon
showed interval enlargement of a left tonsillar phlegmonous
collection to 4.3 x 6.2 x 6.4 cm with ongoing severe airway
narrowing, and he was returned to the ICU for airway monitoring.
In terms of his ongoing AML management he had started his 7+3
regimen and was on day 4 of his chemotherapy with
Cytarabine/Anthracycline when he was sent to the ICU for the 2nd
time. His 7+3 induction was complicated by DIC, and his labs
were trended for several days. During this time, he required
several bags of cryo, platelets, and PRBC transfusions. He
returned to floors on [**2147-8-1**] on a steroid taper. No further
airway complications were encountered.
.
He finished his 7+3 induction, and repeat bone marrow biopsy on
day 14 showed a markedly hypocellular bone marrow consistent
with chemotherapy induced ablation and no features of
involvement by acute leukemia. He required several platelet
transfusions and PRBC transfusions throughout this time due to
his pancytopenia. By Day 21, his CBC continued to show
pancytopenia, with nucleated RBCs on peripheral smear and a
slight increase in platelet count from baseline. Concern for
returning leukemia prompted a day 21 ([**2147-8-17**]) bone marrow
biopsy which showed hypercellular marrow with maturing
erythroid-dominant trilineage hematopoiesis and 5% blasts
highlighted by CD34. This was interpreted as favoring bone
marrow recovery rather than recurrent leukemia. His CBC began
to improve over the next few days, with his ANC rapidly starting
to normal after [**2147-8-21**]. He was discharged on [**2147-8-25**] with normal
platelets, steadily increasing Hct, and granulocyte count 1245.
.
# DIC: He began to go into DIC on the evening of [**2147-7-28**]. He was
scheduled for DIC labs Q4H. He received several transfusions of
cryo and platelets. On [**7-29**], he was switched to q6H DIC labs.
By [**8-1**], he had recovered and DIC labs were stopped. No further
complications of DIC were encountered during his stay.
.
# Tonsillar Enlargement: The patient came in after recently
completing a course of clindamycin for a possible pharyngeal
infection. With his development of worsening pharyngeal edema
on [**2147-7-28**], he was started empirically on Vancomycin and
Aztreonam, with later addition of Clindamycin. CT neck
demonstrated a 6 mm mass concerning for abscess. ID was
consulted, and Meropenem was started with desensitization in the
MICU given his history of Penicillin allergy. ENT could not
identify a drainable abscess. He was given Dexamethasone which
improved his swelling. Steroids were stopped briefly and the he
required readmission to the MICU for airway monitoring.
Dexamethasone was restarted, and tapered appropriately on the
floor. No further airway complications were encountered.
Clindaymcin and Aztreonam were stopped, and he was continued on
Vancomycin, Meropenem, and Micafungin for the duration of his
chemotherapy induced neutropenia. The antibiotics were
discontinued as his white count recovered. He remained afebrile
and asymptomatic as the antibiotics were stopped, and was
feeling well at discharge.
.
Medications on Admission:
Recently on Clindamycin and steroids.
No other home or OTC medications.
Discharge Medications:
1. Acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Acute Myelogenous Lymphoma
Secondary Diagnoses:
Neutropenic Fever
Pharyngeal Edema
Discharge Condition:
All vital signs stable. Afebrile and asymptomatic.
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for treatment of your recently
diagnosed acute myelogenous leukemia. Initially, you had
difficulty swallowing, enlarged tonsils, and a high white blood
cell count. You were given chemotherapy medications in order to
treat the leukemia, and bone marrow biopsies were performed in
order to evaluate your response to the chemotherapy. The most
recent biopsy showed a good response to the treatment and
regeneration of the normal bone marrow cells. At the time of
discharge, your blood counts were quickly returning back to
their normal range.
For part of your hospital stay, you were sent to the Intensive
Care Unit for part due to swelling in your throat and concern
that your airway could become obstructed. You were treated with
IV antibiotics and this improved over time. You were kept on a
regimen of several strong antibiotics during most of your stay.
Prior to discharge, these antibiotics were stopped, and you did
not develop any new fevers or symptoms of infection.
After discharge, you should continue taking Acyclovir for
prophylaxis
Followup Instructions:
A followup appointment has been scheduled with your Oncologist,
Dr [**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) 410**], for [**2147-8-28**] at 10:00AM.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 3749**], MD Phone:[**Telephone/Fax (1) 3241**]
Date/Time:[**2147-8-28**] 10:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 12633**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2147-8-28**] 10:00
|
[
"288.03",
"787.29",
"E933.1",
"787.91",
"478.25",
"205.00",
"284.1",
"475",
"286.6",
"528.01",
"780.61"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.25",
"41.31"
] |
icd9pcs
|
[
[
[]
]
] |
19939, 19945
|
15098, 19688
|
292, 338
|
20092, 20144
|
4151, 4151
|
21404, 21886
|
2468, 2706
|
19811, 19916
|
19966, 19966
|
19714, 19788
|
20295, 21381
|
6563, 15075
|
2746, 3354
|
20034, 20071
|
233, 254
|
366, 2084
|
4167, 6547
|
19985, 20013
|
20159, 20271
|
2106, 2197
|
2213, 2452
|
3379, 4132
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,407
| 127,491
|
38917
|
Discharge summary
|
report
|
Admission Date: [**2158-6-30**] Discharge Date: [**2158-7-6**]
Date of Birth: [**2115-3-1**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4393**]
Chief Complaint:
hematemesis
Major Surgical or Invasive Procedure:
EGD x2
History of Present Illness:
43 yo M alcohol abuse, HCV cirrhosis,
esophageal varices, DM2 and multiple admissions for variceal
banding who presents from hematemesis. Of note, pt was last
hospitalized in [**2158-3-25**] for variceal bleed. EGD from that
admission showed four grade II - III varices with stigmata of
recent bleeding. Four bands placed. Significant old blood and
clot in the stomach. Otherwise normal EGD to third part of the
duodenum. He was due for follow-up EGD in [**2158-4-25**] but was lost
to follow-up. Presented to clinic this morning after hematemsis
this morning, and sent to ED for further management.
.
In the ED, initial vs were: T 99 P 109 BP 147/80 RR 17 O2 sat.
100% 2-3L. He reported abdominal pain in LUQ, and abdominal
bloating. He denied fever, cp, sob, and diarrhea/melena. Two 16
G IV's were placed. He was started on pantoprazole drip and
octreotide. GI evaluated with plan to scope in MICU. Hct was 33.
.
On the floor, he was intubated and scoped by hepatology. Per
report, varices were seen with old blood in stomach. Plan was to
wait to see if blood cleared, re-scope, evaluate for
gastric/duodenal ulcers, and possibly band varices.
.
Review of systems:
Pt intubated. ROS per HPI.
Past Medical History:
EtOH Abuse
Cirrhosis
Hepatitis C: No prior treatment
Diabetes Mellitus 2 - 20 + years
Tobacco Use
Depression
Hypertension
GERD
Pancreatitis
Diverticulitis
Hemorrhoids
Atypical chest pain
Social History:
He is an unmarried Hispanic male presently living at the [**Doctor Last Name 2048**]
McGuinnis House, where he used to live in the past. He went to
live with his mother until recently when he returned to the
[**First Name8 (NamePattern2) 2048**] [**Last Name (NamePattern1) **] House. He does not have any social support as
per himself. He still drinks alcohol almost on daily basis but
at least 3 times a week with at least [**12-28**] 40 oz. beers each
time. He
denies any current use of illicit drugs, but has remote history
of IVDU. He has smoked 1 pack per day for at least 20 years.
Family History:
No history of bleeding disorders or abdominal bleeding. Both
parents still living.
Physical Exam:
T 98.4, HR 77-83, BP 143-152/63-76, RR 20, Sat 100% RA
Gen: NAD.
HEENT: NC/AT. Anicteric. MMM. No oral lesions. OP clear.
Neck: Supple.
Chest: CTAB.
CV: RRR. Normal s1 and s2. No M/G/R.
Abd: +BS. Soft. Tender in LUQ with no R/G. Liver and spleen not
palpated.
Ext: WWP. Radial and DP pulses 2+ bilaterally.
Neuro: A+Ox3. PERRL 6mm->5mm. Strength 5/5 throughout. Mild
tremor. No asterixis.
Pertinent Results:
[**2158-6-30**] 01:10PM BLOOD WBC-4.1 RBC-4.44* Hgb-10.4* Hct-32.6*
MCV-73*# MCH-23.5*# MCHC-31.9 RDW-20.5* Plt Ct-130*
[**2158-7-2**] 05:03PM BLOOD Hct-26.3*
[**2158-7-3**] 02:54PM BLOOD Hct-28.8*
[**2158-6-30**] 01:10PM BLOOD PT-16.2* PTT-32.7 INR(PT)-1.4*
[**2158-7-1**] 10:20AM BLOOD Fibrino-174
[**2158-6-30**] 01:10PM BLOOD Glucose-233* UreaN-13 Creat-0.6 Na-138
K-3.8 Cl-99 HCO3-30 AnGap-13
[**2158-6-30**] 01:10PM BLOOD ALT-207* AST-304* AlkPhos-166*
TotBili-1.1
[**2158-7-1**] 12:10AM BLOOD ALT-160* AST-247* LD(LDH)-245 AlkPhos-109
TotBili-2.3*
[**2158-7-2**] 03:32AM BLOOD DirBili-0.6*
[**2158-7-2**] 05:20PM BLOOD Amylase-36
[**2158-7-1**] 12:10AM BLOOD Albumin-3.2* Calcium-7.7* Phos-4.2 Mg-1.9
[**2158-7-2**] 03:32AM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
[**2158-6-30**] 01:26PM BLOOD Glucose-223* Lactate-2.8* Na-140 K-3.8
Cl-95* calHCO3-34*
[**2158-7-2**] 06:31PM BLOOD Glucose-170* Lactate-1.3 calHCO3-28
[**2158-7-1**] 02:33PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.022
[**2158-7-1**] 02:33PM URINE Blood-MOD Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
[**2158-7-1**] 02:33PM URINE RBC-29* WBC-2 Bacteri-NONE Yeast-NONE
Epi-0
[**2158-7-1**] 02:33PM URINE CastHy-2*
[**2158-7-2**] 05:04PM URINE bnzodzp-POS barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
..
ECG [**2158-6-30**]: Sinus tachycardia. Intra-atrial conduction defect.
Not significantly different from previous tracing of [**2158-4-8**].
...
CXR [**2158-6-30**]: IMPRESSION: No acute cardiopulmonary abnormality.
...
EGD [**2158-6-30**]: Grade II varices at the lower third of the
esophagus, banded x2.Blood in the fundus of the stomach. No
gastric varices. Normal appearing duodenum.
Brief Hospital Course:
Assessment and Plan: Mr. [**Known lastname **] is a 42 yo male w/hx of alcohol
abuse, HCV cirrhosis, DM2, and multiple variceal bleeds s/p
banding who presents with hemetemesis.
.
MICU Course: The patient presented with hematemesis. He was
given fluids through 2 large bore IV's, typed and screened, and
followed with serial hematocrits. He was initially transfused
1unit PRBCs upon arrival to the MICU. He was intubated for
airway protection and given ceftriaxone, octreotide and started
on a ppi. Had EGD per hepatology with two esophageal varices
banded. Hct remained stable and patient was successfully
extubated. Continued on ceftriaxone and octreotide for total of
5 days. Otherwise, placed on PO meds including nadolol,
carafate, ppi, and simethicone. Pt was monitored for withdrawal
and placed on a CIWA scale with valium. He was repleted with
thiamine, folate, and MVI. He received insulin per sliding
scale and his home lantus dose, although this was reduced after
an episode of hypoglycemia. Patient required several doses of
oxycodone and morphine for episodes of abdominal pain that is
chronic and intermittent for him.
.
On the floor he remained stable. He was hemodynamically stable
and his hematocrit was monitored closely and it stabilized in
the low to mid thirties. He was taken off of octreotide and
ceftriaxone. An abdominal ultrasound was checked for chronic
abdominal pain and was positive for cirrhosis and splenomegaly,
but no acute process. He was counseled extensively on the
quitting drinking alcohol. He was offered services but
declined. His hematocrit remained stable and on discharge was
34.1. He was discharged on a PPI and sucralfate. It was
stressed to him that he needed to keep his appointments and to
have close follow-up with the hepatology clinic.
Medications on Admission:
1. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
6. Lantus 100 unit/mL Solution Sig: Seventy Two (72) units
Subcutaneous once a day.
Disp:*60 ml* Refills:*2*
7. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
Disp:*120 Tablet(s)* Refills:*2*
8. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for pain.
Disp:*14 Tablet(s)* Refills:*0*
9. Truetest Test Strips Strip Sig: One (1) In [**Last Name (un) 5153**] four
times a day.
Disp:*500 strips* Refills:*2*
10. Lancets,Ultra Thin Misc Sig: One (1) Miscellaneous four
times a day.
Disp:*500 lancets* Refills:*2*
11. Quetiapine 300 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. Paroxetine HCl 30 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
13. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
Disp:*90 Capsule(s)* Refills:*0*
14. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day) as needed for titrate to 3 BM/day.
Disp:*1 bottle* Refills:*2*
15. Cortisone 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a
day).
Disp:*1 tube* Refills:*2*
16. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
19. Humalog 100 unit/mL Solution Sig: 20 units plus sliding
scale Subcutaneous three times a day: with meals, take 20 units
Humalog and additional per sliding scale:
201-250: 0 units
251-300: 2 units
301-350: 4 units
351-400: 6 units
>400: 8 units.
Disp:*100 ml* Refills:*2*
Discharge Medications:
1. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO four times a
day.
Disp:*120 Tablet(s)* Refills:*2*
2. Quetiapine 300 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*
3. Paroxetine HCl 30 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*2*
5. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
Disp:*2700 ML(s)* Refills:*2*
6. Nadolol 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
8. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for abdominal cramps.
Disp:*120 Tablet, Chewable(s)* Refills:*0*
9. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO twice a day for
5 days.
Disp:*10 Tablet(s)* Refills:*0*
13. Lantus 100 unit/mL Solution Sig: Fifty (50) units
Subcutaneous at bedtime: Please inject 0.5ml under the skin at
bedtime.
Disp:*qs ml* Refills:*2*
14. Humalog 100 unit/mL Solution Sig: per insulin sliding scale
Subcutaneous QACHS: Per the insulin sliding scale provided with
your paper work.
Disp:*qs ml* Refills:*2*
15. Truetest Test Strips Strip Sig: One (1) strip
Miscellaneous four times a day.
Disp:*120 strips* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Variceal Bleed
.
Secondary:
Alcohol abuse
Alcohol and Hepatitis C induced cirrhosis
Depression
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for severe bleeding in your esophagus
resulting in vomiting blood. You were given a blood transfusion
and transferred to the ICU. In the ICU you were placed on
medications to help stop the bleeding and protect your
intestines from more bleeding. You had a breathing tube placed
to help with them look in your stomach with a camera. They
found the source of bleeding and 2 blood vessels that were
enlarged. They placed bands on those blood vessels to prevent
them from bleeding. After the procedure, the breathing tube was
removed. You were put on your home medications, and you were
stable in the ICU. You were then transferred to the liver
service. There, your blood counts were monitored and they
stayed stable. On discharge you were much improved, with no
signs of continued bleeding.
.
Please take the following medications:
Nadolol 40mg by mouth daily
Folic Acid 1mg by mouth daily
Thiamine 100mg by mouth daily
Gabapentin 400mg by mouth 3 times a day
Lactulose 30ml by mouth 3 times a day with a goal of [**1-26**] bowel
movements a day.
Lisinopril 5mg by mouth daily
Multivitamins 1 tablet by mouth daily
Paroxetine 30mg by mouth daily
Pantoprazole 40mg by mouth daily
Quetiapine extended-release 300mg by mouth daily
Simethicone 40 mg by mouth 4 times a day as needed for abdominal
cramps
Sucralfate 1gm by mouth 4 times a day
Lantus 50 units under the skin at night
Humalog according to the insulin sliding scale in your paper
work
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Apartment Address(1) **] (ST-3) GI ROOMS Date/Time:[**2158-7-20**] 2:00
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **] Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2158-7-20**]
2:00
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2158-8-9**] 1:50
.
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2158-8-9**] 1:50
* Please discuss with him about increasing your Nadolol for
management of bleeding from the esophagus
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 4407**]
Completed by:[**2158-7-7**]
|
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"782.1",
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"456.20",
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] |
icd9cm
|
[
[
[]
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[
"42.33",
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
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325, 333
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10637, 10637
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361, 1511
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,283
| 189,862
|
38502
|
Discharge summary
|
report
|
Admission Date: [**2115-7-8**] Discharge Date: [**2115-7-26**]
Date of Birth: [**2045-9-26**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1363**]
Chief Complaint:
RUL and LLL masses, respiratory failure, VAP / post-obstructive
pneumonia
Major Surgical or Invasive Procedure:
endotrachial intubation, bronchoscopy
History of Present Illness:
The pt is a 69-yo woman smoker with hypertension,
hypothyroidism, rheumatoid arthritis, and a recently diagnosed
RUL lung mass, who was admitted to OSH after PEA in Radiology.
The pt was undergoing an elective outpatient lung biopsy (TTNBx)
of her newly-diagnosed large RUL mass on [**2115-7-4**], and during the
procedure she became cyanotic, unresponsive, and pulseless. CPR
was initiated and the pt regained NSR, was intubated, and was
transiently on dopamine. Per the anesthesia report, there was
significant blood within the mouth prior to intubation and in
the airways thereafter. She underwent bronchoscopy and was then
found to have near-occlusion of the LLL bronchus with an
endobronchial tumor that extends into the left main stem
bronchus, with evidence of endobronchial bleeding from the right
side, and also evidence of an endobronchial lesion distant into
the RUL apical segments. The decision was made to transfer her
to [**Hospital1 18**] for IP evaluation for possible endobronchial stenting.
.
During the hospitalization, the pt spiked a fever to 101.4F
yesterday with leukocytosis to 28.7, and was started on
Vancomycin, Imipenem, and Ciprofloxacin to cover for possible
post-obstructive pneumonia and VAP. BAL culture returned with
Staph aureus sensitive to Ciprofloxacin, with other culture data
negative to date. She continues to have respiratory failure
requiring mechanical ventilation, on AC 500x12/40%/5. She also
underwent flexible bronchoscopy on Friday [**2115-7-5**] that showed
minimal residual bleeding, clots, and LLL obstruction.
Preliminary biopsy results from the RUL Bx are c/w small cell
carcinoma.
.
On arrival to [**Hospital1 18**] MICU, the pt remains intubated and sedated.
With regards to her recent diagnosis, she reportedly had weight
loss of 25 pounds over the preceding 3-6 months, and SOB.
Past Medical History:
Rheumatoid arthritis
Hypothyroidism
Hypertension
Large RUL mass diagnosed [**2115-6-26**]
s/p tonsillectomy
s/p cholecystectomy
s/p appendectomy
s/p dilatation & curettage
s/p lumbar laminectomy
s/p gastric stapling
s/p thyroidectomy
Social History:
Used to work in retail. Widowed, husband died of pancreatic
cancer. Four children, one of whom has cerebral palsy.
- Tobacco: Smokes a pack a day of [**State 622**] Slims.
- Alcohol: Denies.
- Illicits: Unknown.
Family History:
Non-contributory. One brother, alive and well. A paternal aunt
with breast cancer.
Physical Exam:
On Admission:
Vitals: T: 98.0F, BP: 182/64, P: 80, R: 35, O2: 96%
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
On admisssion:
.
[**2115-7-8**] 09:27PM BLOOD WBC-23.4* RBC-3.16* Hgb-8.8* Hct-27.4*
MCV-87 MCH-27.7 MCHC-32.0 RDW-16.6* Plt Ct-150
[**2115-7-8**] 09:27PM BLOOD Neuts-98.2* Lymphs-1.0* Monos-0.7* Eos-0
Baso-0
[**2115-7-8**] 09:27PM BLOOD PT-13.1 PTT-26.3 INR(PT)-1.1
[**2115-7-8**] 09:27PM BLOOD Glucose-130* UreaN-22* Creat-0.7 Na-138
K-4.2 Cl-108 HCO3-24 AnGap-10
[**2115-7-8**] 09:27PM BLOOD ALT-11 AST-14 LD(LDH)-386* AlkPhos-171*
Amylase-36 TotBili-1.1
[**2115-7-8**] 09:27PM BLOOD Albumin-2.1* Calcium-8.4 Phos-2.7 Mg-1.8
[**2115-7-8**] 10:31PM BLOOD Type-ART pO2-67* pCO2-37 pH-7.39
calTCO2-23 Base XS--1
[**2115-7-8**] 10:31PM BLOOD Lactate-1.3
[**2115-7-8**] 10:31PM BLOOD freeCa-1.23
.
CXR [**7-8**]: AP chest reviewed in the absence of prior chest
radiographs:
.
A relatively homogeneous 8-cm wide right upper lobe lung lesion
is most likely a mass. More heterogeneous opacification in the
right lung looks right middle and lower lobe pneumonia, but
would obscure other smaller lung nodules. Less distinct left
perihilar and infrahilar opacification could also be pneumonia.
Bilateral pleural effusions are small. ET tube and nasogastric
tube are in standard placements. Heart size is normal. Poor
definition of the left bronchial tree suggests retained
secretions. The hila are not particularly enlarged. Right
internal jugular line ends in the mid SVC and a nasogastric tube
ends in the upper stomach. No pneumothorax.
.
Prior imaging should be obtained in order to assess the
chronicity and likely explanation for widespread pulmonary
abnormalities.
.
TTE:
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is top
normal/borderline dilated. Overall left ventricular systolic
function is mildly to moderately depressed (LVEF= 40-45 %) with
inferior hypokinesis. The aortic valve leaflets are mildly
thickened (?#). There is a possible vegetation on the aortic
valve. There is no valvular aortic stenosis. The increased
transaortic velocity is likely related to increased stroke
volume due to aortic regurgitation. Severe (4+) 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. Torn mitral chordae are
present. An eccentric, posterior directed jet of Mild (1+)
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. There is mild pulmonary artery systolic
hypertension. There is a small pericardial effusion. There are
no echocardiographic signs of tamponade.
.
IMPRESSION: Severe aortic regurgitation with possible aortic
valve endocarditis. Mildly to moderately reduced LVEF.
.
CTA chest/abd/pelvis:
1. Right upper lobe lung mass with bilateral hilar and
mediastinal adenopathy. Contralateral left hilar adeonpathy
causes
obliteration of the left lower lobe artery and moderate
narrowing of the left lower segment airways. This is concerning
for metastatic lung cancer. The mass is amenable to CT-guided
biopsy
.
2. Ill defined ground glass lung opacities likely represent
infection or
edema, although underlying neoplasm cannot be excluded. Followup
after
therapy can help exclude underlying tumor.
.
3. Moderate bilateral pleural effusions. Diffuse anasarca.
.
4. No evidence of aortic dissection.
.
TEE:
.
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 mass or thrombus is seen in
the right atrium or right atrial appendage. 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. The ascending
aorta is mildly dilated. There are complex (>4mm, non-mobile)
atheroma in the aortic arch. The aortic valve leaflets (3) are
mildly thickened with a focal 4mm nodule, but no vegetations or
abscess. Moderate to severe (3+) centrally directed aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. No
vegetation/mass is seen on the pulmonic valve. There is no
pericardial effusion.
.
IMPRESSION: Diffuse aortic leaflet thickening with focal nodule
atypical for a vegetation. No abscess seen. Moderate to severe
centrally directed aortic regurgitation. Mild mitral
regurgitation.. Mildly dilated ascending aorta. Complex plaque
(>4 mm) in aortic arch.
.
CXR [**7-10**]:As compared to the previous radiograph, the tip of the
endotracheal tube still projects 5.2 cm above the carina. The
course and position ofthe right internal jugular vein catheter
is unchanged. Unchanged course of the nasogastric tube, the tip
of the tube is not visualized on the image.
.
Unchanged large right apical tumor, unchanged extensive
bilateral areas of
parenchymal opacities with complete consolidation of the
retrocardiac lung
areas. No newly appeared focal parenchymal opacities, no
pneumothorax.
.
CXR [**7-12**]: 1. ETT tube in standard position. No pneumothorax.
2. Decreased mild pulmonary edema with unchanged small left
pleural effusion.
.
CXR [**7-24**] :Collapse of the left lung is new, and is probably due
to retained secretions because the left bronchial airway is
opacified before the takeoff of the upper lobe bronchus. Right
lung shows improvement in basal consolidation and the right
upper lobe mass is slightly smaller suggesting interval
treatment, either radiation or chemotherapy.
.
Pathology [**7-17**]: Right upper lobe, CT-guided core biopsies
(S10-2992, [**2115-7-4**]; [**Hospital3 85667**], [**Location (un) 2498**],
MA):
Small cell lung carcinoma.
Note:
Enclosed immunohistochemical stains show that tumor cells stain
positive for cytokeratin 7 and neuron-specific enolase; cells
are negative for cytokeratin 20, TTF-1, chromogranin and
synaptophysin. LCA (CD45) highlights background lymphocytes. The
histomorphologic and immunophenotypic findings are consistent
with small cell lung carcinoma. Please correlate with clinical
and radiologic findings.
Right upper lobe, touch preparations of biopsy cores (NG10-549,
[**2115-7-4**]):
Positive for malignant cells, consistent with small cell
lung carcinoma
Note:
See core biopsy result (S10-2992) for definitive diagnosis.
Left lower lobe, bronchial brushings (NG10-550, [**2115-7-5**]):
Positive for malignant cells, consistent with squamous cell
carcinoma.
Left lower lobe, bronchial washings (NG10-552, [**2115-7-5**])
Suspicious for squamous cell carcinoma.
.
Bone Scan [**2115-7-22**]: No evidence of interosseous metastases
.
CT Head W/ and W/out contrast [**2115-7-18**]: No evidence of
metastatic disease.
.
Bone Scan [**7-24**]: no evidence of interosseous metastases
Brief Hospital Course:
69-yo woman smoker with newly-diagnosed RUL and LLL masses, who
suffered hemoptysis and PEA arrest while undergoing outpatient
RUL Bx, transferred intubated to [**Hospital1 18**] with respiratory failure,
VAP / post-obstructive pneumonia, treated for newly dx'd small
cell lung cancer. After transfer to the floor she was made
DNR/DNI. She had several episodes of atrial fibrillation with
RVR, respiratory distress secondary to COPD, heart failure
causing pulmonary edema, and anxiety. She was treated with
nebulizer treatments and diuretics. The patient passed on
[**2115-7-26**] after going into Afib with RVR. She was given metoprolol
for rate control but was unable to maintain her blood pressure.
Chemical cardioversion with amiodarone was attempted and failed.
The paient passed of cardiopulmonary arrest.
.
#. RUL and LLL masses - Newly-diagnosed, underwent RUL Bx at OSH
on [**2115-7-4**] with prelim Bx report c/w small cell lung carcinoma.
Also noted to have LLL endobronchial lesion with obstruction on
bronchoscopy, transferred to [**Hospital1 18**] for evaluation for possible
endobronchial stenting. Interventional pulmonary was consulted
and performed a bedside bronchoscopy that showed collapse of the
left lower lobe airways. Stent placement was held given risk of
worsening VQ mismatch and pt was treated symptomatically and for
PNA as below. The final pathology showed two primary cancers,
both small cell lung cancer and non-small cell lung cancer. She
received one cycle of carboplatin-etoposide therapy with
interval response on chest x-ray. A bone scan showed no
evidence of interosseous metastases. A CT of the head was also
without evidence of metastases.
.
# Acute aortic insufficiency - A cardiac echo performed here
showed that the patient had 4+ aortic insufficiency, which was
new when compared to the report of an echo performed at [**Hospital1 9191**] on [**2115-7-4**]. Urgent CTA was performed, which showed no
evidence of dissection. TEE was performed which showed no
evidence of endocarditis. She was managed medically with BP
control.
.
#. Pneumonia - Pt with fever and elevated WBC at OSH, started on
vancomycin, imipenem and cipro to cover for VAP and/or
post-obstructive pneumonia. The patient's sputum from [**7-9**] grew
out MSSA, and therefore the patient's antiboitic regimen was
narrowed to nafcillin.
.
#. Respiratory failure - The patient was placed on mechanical
ventilation after her PEA arrest. She was successfully
extubated on [**2115-7-12**]. The patient was continued on steroids to
treat her obstructive lung disease, also tx'd with abx and nebx.
.
#. PEA arrest - Occurred at OSH on [**2115-7-4**] during RUL Bx, as pt
became cyanotic, unresponsive, and pulseless. Per anesthesia,
noted to have blood within mouth prior to intubation and in
airways. Likely hypoxic PEA arrest.
.
# Atrial fibrillation - The patient was intermittently in
atrial fibrillation. She was treated with AV nodal blocking
agents for rate control. Anti-coagulation was considered but
the patient refused. On occasion the patient had a rapid
ventricular response.
.
# Aspiration - The patient had an aspiration events and was
made NPO after a video swallow demonstrated that she was not
safe to eat or swallow pills.
.
# Hypokalemia - The patient's potassium was chronically low and
difficult to replete due to her malignancy, likely ACTH
production, and diuretics required for her volume overload. Her
electrolytes were checked frequently and repleted as needed.
.
#. Hypertension - continued on home diltiazem. Metoprolol,
lisinopril, and hydralazine were added and uptitrated for BP
control.
.
#. Hypothyroidism - she was continued on home levothyroxine
.
#. Psych - continued on home Venlafaxine, alprazolam and
mirtazapine
.
# The patient was DNR/DNI.
Medications on Admission:
- albuterol inhaler
- alprazolam 0.5mg PO QHS
- beclomethasone dipropionate 7.3gm inhaled [**Hospital1 **]
- cholecalciferol 2000units PO daily
- diltiazem 240mg PO daily
- levothyroxine 50mcg PO daily
- mirtazapine 15mg PO QHS
- Percocet 5/325mg PO Q4hrs PRN pain
- prednisone 10mg PO daily
- simvastatin 40mg PO daily
- venlafaxine 225mg PO BID
.
Medications on Transfer:
- Combivent 6 puffs inhaled QID
- Lovenox 30mg SQ daily
- Metamucil 1pkt PO QHS
- Vancomycin 1gram IV Q12hrs
- Ciprofloxacin 400mg IV Q12hrs
- Solu-Medrol 40mg IV Q8hrs
- Imipenem 500mg IV Q6hrs
- Chlorhexidine gluconate
- Levothyroxine 50mcg PO daily
- Diltiazem 60mg PO QID
- Venlafaxine XR 225mg PO BID
- Acetaminophen 650mg PO Q4hrs PRN fever
- Midazolam
- Morphine
Discharge Medications:
NA
Discharge Disposition:
Expired
Discharge Diagnosis:
NA
Discharge Condition:
NA
Discharge Instructions:
NA
Followup Instructions:
NA
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 1368**]
|
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9,454
| 108,877
|
47710
|
Discharge summary
|
report
|
Admission Date: [**2136-7-4**] Discharge Date: [**2136-7-16**]
Service: MEDICINE
Allergies:
Pronestyl / Quinidine / Clonidine / A.C.E Inhibitors /
Spironolactone / Flagyl / Levaquin / Compazine / Keflex
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
vomiting, diarrhea
Major Surgical or Invasive Procedure:
left IJ central venous catheter; PICC
History of Present Illness:
HPI: 86 y/o F h/o CAD, CHF, DM, AFib on coumadin, and chronic c.
diff colitis on PO vanco a/w vomiting and diarrhea x 2 days. She
began having more frequent formed BM's approx. 1 week PTA, at
which time the patient's daughter increased vancomycin from 250
mg daily to QID. However it is unclear whether this was given as
there was a new home health aide caring for the patient. 2 days
PTA she developed anorexia and nausea associated with poor oral
intake, had a few episodes of non-bloody vomiting and [**9-30**]
non-bloody episodes of diarrhea. Notably, she has not vomited
during past bouts of C. diff. She has not had fever, chills, URI
symptoms, abdominal pain, sick contacts, recent antibiotics
(other than PO vanco) or recent travel.
.
Over the past two weeks, she had had a [**12-21**] lb. weight gain and
has felt more lethargic, reportedly similar to how she has
during past episodes of fluid retention. Per the home health
aide, the patient has had more labored breathing and O2sats in
the low 90s on room air, requiring oxygen in the daytime, a rare
occurence for her. The daughter reports increasing her dose of
lasix to as much as 160 mg daily in an attempt to remove some
fluid. The patient has stable chronic 5-pillow orthopnea and
uses 2 L oxygen at night. She has not had dizziness,
lightheadedness, CP, palpitations, cough, SOB, or DOE. She was
seen in cardiology clinic the day prior to admission, at which
time routine labs revealed BUN 38/Cr 2.1/K 5.9. She was
instructed by her cardioligst's office to stop taking the [**Last Name (un) **],
potassium, and diuretics and to come to the ED.
.
In the ED, initially afebrile HR 83 BP 100/48 RR 20 O2sat 96% RA
100% 4LNC. She was reportedly guaiac negative. K+ peaked at 6.9
(D50 & insulin given) f/b 5.2. WBC 11.3 with 83% PMNs, no bands.
Lactate 5.5 f/b 4.1. INR 3.4. A left IJ was placed. She was
given just 1 L NS in light of severe systolic dysfunction. SBP
never dropped below 100, MAP ranged 55-78, with HR 50's-70's.
CVP ranged 6-11 cmH20, ScvO2 65-78. She had minimal urine
output. She was treated with IV flagyl for presumed C. diff
colitis, and IV ampicillin and cefepime for +U/A. CXR revealed
bilat effusions R>L and cephalization c/w CHF. Abd/pelvis CT w/o
contrast preliminarily showed intraperitoneal free fluid and
colonic wall thickening predominantly on the right c/w
third-spacing or infectious colitis. She was transferred to the
ICU for observation and further management of CHF and ARF.
.
In the ICU, patient had a TTE which showed worsening of her EF
to 15%, pulmonary hypertension, and severe aortic stenosis. On
[**7-8**], patient was started on hydralazine to decrease afterload.
On [**7-9**], lasix and albumin were added, and patient's UOP
increased to 40 cc/h. Patient's progress notes were reviewed.
Past Medical History:
1. CAD - s/p PCI with BMS [**8-20**]
2. CHF (LVEF 25% 10/06)
3. Rheumatic, multivalvular disease (mod AS, mod-severe AR)
4. Afib
5. CHB s/p pacemaker placement
6. IDDM
7. Hyperlipidemia
8. Dementia
9. HTN
10. h/o GI bleed
11. Hypothyroidism
12. Temporal arteritis
13. s/p R CEA
14. chronic c. diff colitis
15. CKD - b/l Cr. ~1.6
Social History:
Lives at home in [**Location (un) 745**], MA with 24[**Hospital 8018**] home health aid.
Daughter is very involved in her care as well. Retired
secretary/homemaker. Husband died in [**2131**]. She does not smoke
or drink ETOH.
Family History:
unknown.
Physical Exam:
V/S - T 95.9 HR 79 BP 143/39 RR 28 96% 2L CVP 7
GEN - Somnolent, but arousable; appears comfortable lying in bed
HEENT - PERRL; poor dentition; OP clear with dry MM
NECK - JVP to angle of jaw; L IJ with blood-stained dressing
CV - RRR nl S1S2 +S3 IV/VI syst ejec murmur @ base
PULM - decr. BS @ bases, no w/r/r
ABD - soft NTND +BS no rebound, guarding
EXT - warm, dry +distal pulses trace LE edema
NEURO - oriented to person, birthdate, hospital; not oriented to
month, year, president, [**Location 27224**]
Pertinent Results:
CXR - There is multichamber cardiomegaly with bibasilar
effusions and some upper lobe venous diversion. The findings are
suggestive of congestive heart failure. A left-sided unipolar
cardiac pacemaker is seen with the tip projected over the right
ventricle. There are degenerative changes noted in the thoracic
spine.
.
CT ABD/PELVIS w/o contrast (prelim) - large right pleural
effusion and small left effusion with right lower lobe opacity
could reflect atelectasis or pneumonia; intraperitoneal free
fluid and colonic wall thickening predominantly on the right,
could reflect third spacing other differential includes
infectious colitis, including C diff. Study not equipped for
evaluation of bowel ischemia due to lack of IV contrast which
remains in the differential
.
TTE [**7-5**] - The left atrial volume is markedly increased
(>32ml/m2). The right atrium is markedly dilated. No atrial
septal defect is seen by 2D or color Doppler. There is mild
symmetric left ventricular hypertrophy with normal cavity size.
There is severe regional left ventricular systolic dysfunction
with akinesis of the inferior wall, mild hypokinesis of the
basal inferolateral, lateral and anterolateral segments and
severe hypokinesis of the other segments. There are three aortic
valve leaflets. The aortic valve leaflets are severely
thickened/deformed. There is severe aortic valve stenosis (area
<0.8cm2). Moderate (2+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. The mitral valve shows
characteristic rheumatic deformity. Mild to moderate ([**12-21**]+)
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. There is severe pulmonary artery systolic hypertension.
Significant pulmonic regurgitation is seen. There is a small
posterior pericardial effusion. There are no echocardiographic
signs of tamponade. Echocardiographic signs of tamponade may be
absent in the presence of elevated right sided pressures.
Compared with the prior study (images reviewed) of [**2134-9-21**],
overall LV systolic function may be slightly worse. The
esitmated pulmonary artery systolic pressures are now higher.
The degrees of valvular abnormalities are similar. There is a
small pericardial effusion seen on the current study that was
present on the prior but not mentioned in the report.
Brief Hospital Course:
A/P: 86 y/o F h/o CAD, CHF, DM, AFib hypertherapeutic on
coumadin, and chronic c. diff colitis on recently elevated dose
of PO vanco a/w vomiting and diarrhea with evidence of colitis,
and acute on chronic renal failure in the setting of escalating
diuresis.
.
#Acute on chronic renal failure - Patient presented with acute
on chronic renal failure. Her Cr has been steadily improving,
and yesterday, her Cr was 1.4 (baseline). Patient's UOP has been
increasing, and she put out 700 cc yesterday.
- Goal UOP >20-30 cc/h
- Holding K
- Continue Lasix 40 mg PO BID
- Begin Metolazone 2.5 mg daily
.
#Acute on chronic systolic heart failure - TTE revealed worsened
valve and LV function c/w exam [**9-24**]; substantial pleural
effusions but no respiratory compromise. CEs negative, ECG
unchanged, no new findings on TTE so unlikely recent ischemic
event precipiated this decompensation.
- Continue BB and [**Last Name (un) **], Lasix, and Metolazone
- Titrate O2 to maintain sat >92%.
- Continue digoxin
.
# possible Burisitis- patient with reproducible pain with
lifting left leg, but not with bending left knee localized to
top of femur, likely musculoskeletal, ordered x-rays soft
tissue/ bone to reassure daughter (no like pain in right leg)
- femur xr showed degenerative changes, f/u as outpt
.
#. UTI: Patient had a U/A yesterday which showed moderate
leukocytes, small blood, few bacteria, and <1 epi. Patient had
foley removed.
- unclear i/o's since pt is incontinent, but foley was removed
earlier due to possible UTI
- cipro given d [**2-20**]
.
# Bilat pleural effusion/RLL opacity - likely transudative
effusions in the setting of decompensated CHF, cannot exclude
underlying PNA but low suspicion since no fever or leukocytosis;
stable resp. status on minimal O2 requirement
-no indictation for ABX for now (esp. in light of h/o c. diff)
-blood Cx still pending
.
#N/V/D - suspect viral etiology as has not had vomiting with
prior episodes of c. diff; no c/o pain, benign abdominal exam,
and supratherapeutic INR makes ischemia/thrombosis less likely;
lactate trending down. [**Month/Day (4) **] negative x3.
- Continue PO vanco qday.
.
#Anemia - Hct 32, b/l ~38; no s/sx bleeding but GI tract most
likely source; has polyps on prior colonoscopies; on Fe
replacement for chronic anemia, likely element of ACD as well.
Hct today was 27.1.
- Transfuse for Hct <21%
- Monitor daily Hct
- Guiac stools \, on d.c, guiac negative, h/h has significant
lab variation, no clincal problems
.
#AFib - V-paced
-holding coumadin with supratherapeutic INR
.
#DM -
-[**12-21**] basal insulin + RISS while NPO, f/b full dose NPH when
eating
.
#CAD - no ischemic changes on EKG and negative troponins x3
-cont. ASA, B-blocker
.
#HTN -
- Cont. carvedilol and restart [**Last Name (un) **] for HTN, afterload reduction
.
#Hypothyroidism
- Cont. thyroxine
- TSH, free T4 WNL
.
# SW issues/ elder abuse - Her daughter would like for her to
live with her again and will be hiring two caretakers to watch
over the patient. There will be a family meeting on Monday
morning with the Social Worker and team to reinforce the fact
that the patient's meds should not be changed arbitrarily.
- However, her daughter thought this was a [**Name (NI) **] flair, and
increased her Flagyl to TID instead of qday (without medical
authorization). She had also increased the patient's furosemide
without medical consent (to ~80 [**Hospital1 **]).
.
#F/E/N-slightly better PO intake
- Cardiac diet, with supplements
- Monitor lytes [**Hospital1 **]
- Encourage PO entake. [**Month (only) 116**] require tube feeds if caloric intake
does not increase
.
#PPx - PPI, INR ok, supratheraputic heparin, D/c'ed , no need
for bowel regimen
.
#Access - 2 PIV, PICC (d/c'ed PICC on 7.28)
.
#Contact - Daughter [**First Name8 (NamePattern2) **] [**Known lastname 100724**] [**Telephone/Fax (1) 100725**]
.
#CODE STATUS - FULL
.
# Disposition: To Rehab. Patient is unable to pivot while
working with PT and will require more than 2 caretakers.
- outpatient f/u, PCP [**Name9 (PRE) **],[**First Name3 (LF) 251**] [**Name Initial (PRE) **]. [**Telephone/Fax (1) 100755**], appt for
tues, [**7-24**] 11:20am
- [**Doctor Last Name **] cardiology f/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 696**] [**10-18**] 11:40 [**Telephone/Fax (1) 62**]
Medications on Admission:
ASA 81 mg daily
CALCIUM-CHOLECALCIFEROL 500 mg (1,250 mg)-400 unit- [**Unit Number **] daily
CALCITONIN 200 U 1 spray once a day
CARVEDILOL 6.25 mg [**Hospital1 **]
COUMADIN 5 mg daily
DIGOXIN .0625 mg daily
DONEPEZIL 10 mg daily
FERROUS SULFATE 325 mg daily
FUROSEMIDE 60 mg daily
INSULIN NPH - 12 units once a day
INSULIN LISPRO [HUMALOG] daily before breakfast per SS
LATANOPROST [XALATAN] - 0.005 % - 1 drop both eyes at bedtime
LEVOTHYROXINE 112 mcg daily
LIPITOR 10 mg daily
LOSARTAN 25 mg daily
METOLAZONE 2.5 mg daily
POTASSIUM CHLORIDE 70 mEq
PROTONIX 40 mg daily
SACCHAROMYCES BOULARDII - 500 mg [**Hospital1 **]
SERTRALINE [ZOLOFT] 75 mg qHS
VANCOMYCIN 250 mg daily (was increased to 250 mg QID)
Discharge Medications:
1. Outpatient Physical Therapy
Please evaluate and treat as needed.
2. Mattress [**Last Name (un) 100756**]
Please provide mattress [**Last Name (un) **] that fits home hospital bed to
help alleviate and avoid skin breakdown
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] Family & [**Hospital1 1926**] Services
Discharge Diagnosis:
Primary: Acute renal failure, chronic renal disease,
1. CAD - s/p PCI with BMS [**8-20**]
2. CHF (LVEF 25% 10/06)
3. Rheumatic, multivalvular disease (mod AS, mod-severe AR)
4. Afib
5. CHB s/p pacemaker placement
6. IDDM
7. Hyperlipidemia
8. Dementia
9. HTN
10. h/o GI bleed
11. Hypothyroidism
12. Temporal arteritis
13. s/p R CEA
14. chronic c. diff colitis
15. CKD - b/l Cr. ~1.6
Discharge Condition:
stable
Discharge Instructions:
You have been admitted for vomiting, diarrhea and chest pain.
You were also found to be in worsened kidney failure. You were
treated with fluid, medications and antibiotics. Once improved
you are now being discharged home for further recovery. We
discussed that you may benefit from a short stay at rehab, but
you have opted to go home with 24 hour care which is reasonable
as well. You will continue to have VNA and home PT services at
home.
Your medications have been adjusted while inpatient. Take all
medications as prescribed. Most importantly, you should be on
Lasix 40 mg by mouth twice daily and Metolazone 2.5 mg by mouth
daily.
All medication changes must be confirmed by medical specialist.
Do not adjust medications on your own.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1.5L
Please keep all outpatient appointments.
Return to the hospital if you notice fevers,
Followup Instructions:
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 1114**], M.D. Date/Time:[**2136-7-24**] 11:20
Provider: [**Name10 (NameIs) **] FERN, RNC Date/Time:[**2136-7-31**] 11:00
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 1114**], M.D. Date/Time:[**2136-10-10**] 11:20
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 696**], MD Date/Time: [**2136-10-18**] at 11:40
Completed by:[**2136-7-16**]
|
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"427.31",
"416.8",
"272.4",
"428.23",
"285.21",
"585.9",
"V58.61",
"511.9",
"446.5",
"008.45"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
12164, 12250
|
6838, 11157
|
335, 374
|
12676, 12684
|
4379, 6815
|
13694, 14145
|
3826, 3836
|
11914, 12141
|
12271, 12655
|
11183, 11891
|
12708, 13671
|
3851, 4360
|
277, 297
|
402, 3204
|
3226, 3565
|
3581, 3810
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,368
| 154,337
|
5999
|
Discharge summary
|
report
|
Admission Date: [**2107-8-16**] Discharge Date: [**2107-8-22**]
Date of Birth: [**2067-4-5**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Doxepin / Haldol
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 805**] is a 40F with history of bipolar disorder, anxiety,
prior suicide attempts and polysubstance abuse who presented to
ED approximately one hour after taking sixty 100 mg tabs of
chlorpromazine. Also reported using crack cocaine recently, but
denied other ingestions.
In the ED, initial VS were 97.9 130 150/118 16 99% RA. Patient
reports she was "upset." Was vomiting on arrival, but mentating
well. Refused administration of activated charcoal. Was
started on IVF with 2L NS, and initial EKG showed sinus
tachycardia with normal QRS and QTc. Labs notable for Cr 1.2 (up
from baseline 1.0). Urine tox screen positive for cocaine.
Serum tox screen positive for EtOH (level 148) and tricyclics
(though this can be positive for Chlorpromazine ingestion).
Patient was seen by Toxicology who recommended IVF, serial EKGs
to monitor QRS/QTc for prolongation, possible intubation if
worsening mental status, seizure precautions, and frequent
monitoring of temperature. While in ED, became hypotensive to
70s/30s. R IJ placed. Was started on pressors with
norepinephrine, but MAPs remained in low 60s, and she was also
then started on phenylephrine. Per ED, has continued to mentate
well. Admitted now to ICU for close monitoring, and given
patient on pressors.
On arrival to the MICU, patient's VS were:
HR 100, BP 114/68 on 0.05mcg/kg/min norepi and 0.6mcg/kg/min
phenylepherine, RR 19, sat 100%.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies shortness of breath, cough, or wheezing.
Denies chest pain, chest pressure, palpitations. Denies
constipation, abdominal pain, diarrhea, dark or bloody stools.
Denies dysuria, frequency, or urgency. Denies arthralgias or
myalgias. Denies rashes or skin changes.
Past Medical History:
Asthma
Eczema
S/p miscarriage ([**10-5**])
Reports h/o seizures while on doxepin
PAST PSYCHIATRIC HISTORY (Per [**Last Name (LF) **], [**Name6 (MD) **] [**Name8 (MD) **], M.D., [**2105-6-17**]):
* Diagnoses of borderline personality disorder, and reported
diagnoses of MDD and PTSD
* Many previous hospitalizations, most recently at the CSU last
month
* Reports many past suicide attempts, many overdoses and once
lying down in traffic
* Reports past assaultive behavior, and admits to being banned
from several shelters for this
Social History:
The patient began drinking alcohol at age 11. She began using
other
substances at approximately age 21 and since that time has used
cocaine, methadone, and benzodiazepines. Most recent drug use
this past Friday (crack cocaine). She denies ever experiencing
withdrawal seizures. She lives with her father in [**Location (un) 686**].
Family History:
* Father was an alcoholic
* Sister with depression
* Denies other psychiatric history
Physical Exam:
Admission PE
Vitals: HR 100, BP 114/68 on 0.05mcg/kg/min norepi and
0.6mcg/kg/min phenylepherine, RR 19, sat 100%.
General: lethargic, oriented x 3, no acute distress but reports
being sleepy
HEENT: Sclera anicteric, MMM, oropharynx clear, Pupils 1 mm
bilaterally, reactive. Fasciculations of tongue.
Neck: supple, JVP not elevated, no LAD
CV: tachycardic rate, regular rhythm, normal S1 + S2, no
murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: foley in place
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: would not participate, but A&O x 3, moving all 4 limbs
spontaneously.
Pertinent Results:
ADMISSION LABS
[**2107-8-16**] 03:30AM WBC-8.0# RBC-4.91 HGB-13.9 HCT-40.5 MCV-83
MCH-28.4 MCHC-34.4 RDW-15.6*
[**2107-8-16**] 03:30AM NEUTS-26* BANDS-0 LYMPHS-70* MONOS-1* EOS-2
BASOS-1 ATYPS-0 METAS-0 MYELOS-0
[**2107-8-16**] 03:30AM GLUCOSE-140* UREA N-12 CREAT-1.2* SODIUM-138
POTASSIUM-3.5 CHLORIDE-105 TOTAL CO2-19* ANION GAP-18
[**2107-8-16**] 03:30AM CALCIUM-8.6 PHOSPHATE-3.3 MAGNESIUM-1.9
[**2107-8-16**] 03:57AM LACTATE-4.0*
[**2107-8-16**] 08:30AM LACTATE-2.8*
[**2107-8-16**] 09:52AM FIBRINOGE-206
[**2107-8-16**] 09:52AM PT-11.1 PTT-28.0 INR(PT)-1.0
[**2107-8-16**] 03:57AM BLOOD Type-[**Last Name (un) **] Temp-37.1 pO2-83* pCO2-34*
pH-7.34* calTCO2-19* Base XS--6
[**2107-8-16**] 03:30AM BLOOD ASA-NEG Ethanol-148* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-POS
.
CXR [**2107-8-19**]
Lungs are clear. Cardiomediastinal silhouette and hilar
contours are
unremarkable. There is no pneumothorax or pleural effusion.
Previous central
line has been removed. A severe dextroscoliosis again exists.
IMPRESSION: No evidence of pneumothorax or pneumonia.
Brief Hospital Course:
40F w/ PMH bipolar disorder, anxiety, multiple prior suicide
attempts and polysubstance abuse who presented to ED
approximately one hour after taking sixty 100 mg tabs of
chlorpromazine course complicated by hypotension requiring
vasopressors and ICU stay
ACTIVE ISSUES
#Chlorpromazine overdose:
In the ED, toxicology consult was consulted. She was initially
hypotensive and was fluid resuscitated as well as started on
pressors. Before transfer to the MICU, she was weaned off
pressors. The patient was monitored for anticholinergic effects,
CNS depression, seizures, hypotension, and cardiotoxicity with
serial EKGs, telemetry, and serial lactates. Neither her QRS
nor QTc became prolonged and she did not have any evidence of
arrythmias. She was weaned off pressors and was hemodynamically
stable.
.
# Orthostatic hypotension
After resolution of the patients initial episode of hypotension,
her blood pressures again dropped into the SBP 90-100 range.
Her orthostatics were positive and she was given IV fluids. A
CXR was checked for complications related to her ICU stay
(pneumothorax) and this was negative. The patient had stable
BP's after this (her baseline is in the 90s per her), and she
had no symptoms of orthostasis and was eating and drinking well
and urinating normal amounts/volumes.
.
#Psychiatric illness, substance abuse:
Given degree of overdose and prior psychiatric history, there
was strong suspicion of suicide attempt. Pt was also actively
using cocaine and prostituing herself. By report, she is
effectively homeless although she refused to participate with
interview on admission to ICU. Psychiatry was consulted for
evaluation and she was recommended for a dual diangosis
inpatient program once medically stable. They felt that she
could be restarted on her home medications, but after talking
with pharmacy, we felt it was best to hold them for 24 hrs.
Social work was consulted for assistance with housing situation.
The BEST team is involved with placing the patient. A bed on
[**Hospital1 **] 4 became available and after medical clearance she was
discharged from inpatient medical [**Hospital1 **] to [**Hospital1 **] 4 for
ongoing inpatient psychiatric care.
.
INACTIVE ISSUES
# Asthma-given 1 dose of albuterol and fluticasone for episode
of cough on the night of her admission.
.
Transitional Issues
-urine culture pending from [**2107-8-20**] needs following for final
result.
Medications on Admission:
Home Medications - unclear, based on [**Name (NI) **] [**2104**]
-hydroxyzine pamoate [Vistaril] 50 mg capsule, 2 Capsule(s) by
mouth three times a day as needed for As needed for Anxiety
Discharge Medications:
1. traZODONE 200 mg PO HS
2. HydrOXYzine 25 mg PO Q6H:PRN anxiety
3. ChlorproMAZINE 100 mg PO BID
4. Nicotine Patch 21 mg TD DAILY
5. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob
6. Calcium Carbonate 500 mg PO QID:PRN indigestion
7. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] 4
Discharge Diagnosis:
sucide attempt
borderline personality disorder
Major Depressive Disorder
Post traumatic stress disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You presented to [**Hospital1 18**] after a medication overdose. You had low
blood pressure and were sent to the ICU for treatment. Your
heart was closely monitored there and did not shows signs of
adverse affects. On the medical floors, you had some low blood
pressure and unsteadiness when getting up from bed. You were
given IV fluids and you improved.
Followup Instructions:
Please follow up with the following:
1) PCP-[**Name10 (NameIs) 138**] to schedule an appointment in [**11-29**] weeks
Dr. [**First Name (STitle) 216**]
Phone: [**Telephone/Fax (1) 2010**]
Fax: [**Telephone/Fax (1) 4004**]
2) Psychiatry-per the inpatient Psyc team on [**Hospital1 **] 4
|
[
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"969.1",
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"285.9",
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icd9cm
|
[
[
[]
]
] |
[
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
8089, 8134
|
5113, 7540
|
302, 308
|
8282, 8282
|
4002, 5090
|
8817, 9107
|
3121, 3208
|
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|
8155, 8261
|
7566, 7756
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3223, 3983
|
1786, 2198
|
251, 264
|
336, 1767
|
8297, 8409
|
2220, 2753
|
2769, 3105
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,890
| 195,132
|
30021
|
Discharge summary
|
report
|
Admission Date: [**2130-8-27**] Discharge Date: [**2130-8-30**]
Date of Birth: [**2069-12-11**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2751**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname **] is a 60 year old woman with h/o MS, osteoporosis,
presenting from [**Hospital1 1501**] with one week of shortness of breath, and
desat to the 80s.
.
Per staff at the facility, the patient has been SOB for the past
week. On the afternoon of admission, she was noted to have O2
sat in 80s on room air. ?fever, but no cough, n/v/headache,
pain.
.
In the ED, initial vs were: T 98.0 P 74 BP 100/72 RR 24 O2sat
90%2LNC. Pt was given Vanc/Levaquin initially for concern for
PNA. However, CXR was unremarkable. The patient became
hypotensive to the mid80s. CTA showed massive PEs involving all
lobes with right heart strain. The patient was started on
Heparin gtt initially, but then it was held, and she was given
TPA. Prior to transfer, vitals were: SBP 95, HR 80s, RR 26, 100%
4LNC.
.
On the floor, the patient remains hemodynamically stable. She is
currently comfortable and has no complaints. She had a recent
cellulitis near her suprapubic catheter and finished a course of
Keflex on [**2130-8-21**].
.
Review of systems:
(+) Per HPI
(-) Denies chills, night sweats, recent weight loss or gain.
Denies headache, sinus tenderness, rhinorrhea or congestion.
Denies cough. 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:
MS x 38 years
urge incontinence, suprapubic catheter placed [**6-29**]
osteoporosis
fatigue
depression/anxiety
Social History:
Lives at [**Hospital1 1501**] since [**3-29**]. Worked in healthcare in various office
jobs x25 years.
- Tobacco: prior use
- Alcohol: none
- Illicits: none
Family History:
Father with DM and neuropathy. Mother with DM, PD, s/p PPM. Pt
has an identical twin sister with no MS.
Physical Exam:
Vitals: T 95.6 BP 100/60 P 86 R 17 O2: 96% 4LNC
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: suprapubic foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: AOx3, CN II-XII intact, 4+/5 LE strength
Pertinent Results:
[**2130-8-27**] 09:45PM PT-14.5* PTT-58.3* INR(PT)-1.3*
[**2130-8-27**] 10:54AM PTT-26.9
[**2130-8-27**] 05:00AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.021
[**2130-8-27**] 05:00AM URINE BLOOD-LG NITRITE-NEG PROTEIN-25
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2130-8-27**] 05:00AM URINE RBC-[**12-9**]* WBC-[**3-24**] BACTERIA-FEW
YEAST-NONE EPI-[**3-24**]
[**2130-8-27**] 05:00AM URINE HYALINE-[**3-24**]*
[**2130-8-27**] 02:20AM COMMENTS-GREEN TOP
[**2130-8-27**] 02:20AM LACTATE-1.3 K+-4.5
[**2130-8-27**] 02:10AM GLUCOSE-125* UREA N-23* CREAT-0.9 SODIUM-136
POTASSIUM-5.2* CHLORIDE-102 TOTAL CO2-23 ANION GAP-16
[**2130-8-27**] 02:10AM estGFR-Using this
[**2130-8-27**] 02:10AM WBC-10.5 RBC-4.35 HGB-12.7 HCT-37.7 MCV-87
MCH-29.1 MCHC-33.6 RDW-14.2
[**2130-8-27**] 02:10AM NEUTS-68.1 LYMPHS-26.5 MONOS-4.2 EOS-0.7
BASOS-0.5
[**2130-8-27**] 02:10AM PLT COUNT-198
[**2130-8-27**] 02:10AM PT-13.2 PTT-23.7 INR(PT)-1.1
.
Imaging:
CTPA [**2130-8-27**]: IMPRESSION:
1. Massive PE involving all pulmonary lobes, with evidence of
right heart
strain.
2. Scattered pulmonary ground-glass opacities could represent
developing
infarcts, less likely infection/inflammation or atelectasis.
3. Multinodular thyroid can be further evaluated by ultrasound
on a
nonemergent basis, if clinically indicated.
The study and the report were reviewed by the staff radiologist.
.
CXR [**2130-8-27**]: No acute cardiopulmonary process.
[**2130-8-30**] 06:35AM BLOOD WBC-6.4 RBC-3.47* Hgb-10.7* Hct-29.9*
MCV-86 MCH-30.8 MCHC-35.8* RDW-14.1 Plt Ct-201
[**2130-8-30**] 06:35AM BLOOD PT-32.0* PTT-135.8* INR(PT)-3.2*
[**2130-8-29**] 09:50PM BLOOD PT-23.0* PTT-80.9* INR(PT)-2.2*
[**2130-8-29**] 07:25AM BLOOD Glucose-99 UreaN-10 Creat-0.7 Na-139
K-4.0 Cl-108 HCO3-26 AnGap-9
[**2130-8-27**] 5:00 am URINE Site: NOT SPECIFIED
**FINAL REPORT [**2130-8-30**]**
URINE CULTURE (Final [**2130-8-30**]):
STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA.
>100,000 ORGANISMS/ML..
sensitivity testing performed by Microscan.
TIMENTIN = RESISTANT > 64 MCG/ML.
CHLORAMPHENICOL SENSITIVE < = 8 MCG/ML.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STENOTROPHOMONAS (XANTHOMONAS)
MALTOPHILIA
|
CEFTAZIDIME----------- =>16 R
LEVOFLOXACIN---------- <=1 S
TRIMETHOPRIM/SULFA---- <=2 S
[**2130-8-28**] 2:33 pm URINE Source: Catheter.
**FINAL REPORT [**2130-8-29**]**
URINE CULTURE (Final [**2130-8-29**]): NO GROWTH.
Brief Hospital Course:
#. PEs: Pt with massive bilateral PEs involving all lobes and R
heart strain. She was initially started on Heparin gtt. This was
held in the ED and TPA was given. Hypotension and hypoxia now
improved - pt is hemodynamically stable. Etiology unclear - may
be because pt sedentary [**2-21**] to MS or the ESTRING which was
recently started (vaginally). No known malignancies. Active T&S
was maintained prior to transfer to floor as were two peripheral
large bore IVs. Started on coumadin [**8-28**] and will likely need
life time anticoagulation as she sedentary due to MS. She
improved quickly with normal hemodynamics. On [**2130-8-30**] INR =
3.2. IV Heparin was discontinued and Warfarin was moved to 4mg
qhs to start evening of [**2130-8-30**]. PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 12872**] and pt's N{
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4643**] were informed (phone/email) about current treatment
plan. They will take over INR monitoring and make sure that
ESTRING is removed upon arrival to [**Hospital1 1501**]. (Pt preferred ESTRING
removal to be done there).
.
#. MS: Pt with MS c/b fatigue, urge incontinence, has suprapubic
catheter in place. The patient's outpatient medications were
continued, including baclofen, oxybutinin, neurontin, and
provigil prn. Urinalysis showed no pyuria, no leukocyte
esterace, no nitrite but urine cultures were sent and returned
>100K Stenotophomonas Maltophilia. Pt was afebrile and without
any new symptoms. I assume this is contamination vs.
colonization. Repeat UCx showed no growth.
.
#. Osteoporosis: Stable on outpatient fosamax and vitamin D.
.
#. Psych: Stable on outpatient Buspar, and Zoloft.
Medications on Admission:
Fosamax 70 mg PO qweekly
Vitamin D 50K PO qweekly
Oxybutynin Chloride ER 10 mg PO daily
MVI PO daily
Colace 200 mg PO daily
Baclofen 20 mg PO TID, 10mg PO daily prn
Neurontin 600 mg PO qAM, 300mg qPM and qhs
Provigil 200 mg PO BID prn fatigue
BUSpar 15mg PO BID
Zoloft 100mg PO Daily
.
Discharge Medications:
1. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
3. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
4. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. Sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. Baclofen 10 mg Tablet Sig: Two (2) Tablet PO QID (4 times a
day).
7. Baclofen 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as
needed for pain.
8. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO QAM (once a
day (in the morning)).
9. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
11. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO 1X/WEEK (TH).
12. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QMON (every
Monday).
13. Buspirone 5 mg Tablet Sig: Three (3) Tablet PO BID (2 times
a day).
14. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for fever.
15. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4
PM.
Discharge Disposition:
Extended Care
Facility:
[**First Name8 (NamePattern2) 3075**] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for living
Discharge Diagnosis:
Massive Pulmonary Embolus
Multiple Sclerosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted with fast heart rate and low blood pressure,
and diagnosed with massive pulmonary embolism. This was treated
with IV thrombolytics and IV and then oral blood thinners to
therapeurtic levels. You should continue on Warfarin with
monitoring as directed by your medical team.
You were advised to have the ESTRING taken out and indicated a
preference to have your nurse practitioner do this once you are
back at your health facility.
Followup Instructions:
per Dr. [**Last Name (STitle) 12872**] who is aware.
|
[
"241.0",
"415.19",
"340",
"300.4",
"733.00",
"041.85",
"599.0",
"788.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.10"
] |
icd9pcs
|
[
[
[]
]
] |
8879, 9020
|
5607, 7312
|
320, 326
|
9109, 9109
|
2865, 5584
|
9760, 9816
|
2155, 2260
|
7648, 8856
|
9041, 9088
|
7338, 7625
|
9285, 9737
|
2275, 2846
|
1401, 1808
|
277, 282
|
354, 1382
|
9124, 9261
|
1852, 1965
|
1981, 2139
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,747
| 191,979
|
13070+56424
|
Discharge summary
|
report+addendum
|
Admission Date: [**2139-11-30**] Discharge Date: [**2139-12-5**]
Date of Birth: [**2064-1-10**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
hypercalcemia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is a 75yo woman with h/o CLL with Leptomeningeal
involvement, on bendamustine and rituximab; who presents with
one week of increasing fatigue and weakness. She was
hospitalized from [**10-28**] to [**2139-11-5**] with fatigue, visual
hallucinations, and hypercalcemia during which time, she was
treated with Bendamustine and Rituxan with symptomatic
improvement. Her hypercalcemia was treated with IVF, calcitonin
and pamindronate with resolution. The patient was discharged to
[**Hospital 1319**] rehab, where she states her strength increased
significantly with PT over a three week period. She states that
she was able to ambulate well with walker. One week ago she left
rehab and went to her stay with her son. Over this period she
states that she has had increasing weakness, largely in the
lower extremities, to the point where she has difficulty walking
to the commode.
.
ROS
+ diarrhea: Patient was hospitalized from [**Date range (3) 39961**] for
C.diff colitis and has been continued on po flagyl since. She
states that her diarrhea initially improved but within the past
one to two weeks has noted re-emergence of watery stools [**4-21**]
x/day, although in smaller amounts than with previous infection.
She was recently seen by Dr [**Last Name (STitle) **] and started on po vancomycin
on [**2139-11-25**]. She denies associated abdominal pain, nausea,
vomiting, melana, hematochezia.
+ urinary frequency, which the patient attributes to lasix
- fevers, chills, nightsweats, headache, diplopia, paresthesias
-sore throat, cough, shortness of breath
- chest pain, palpitations, orthopnea
- dysuria, hematuria, foul smelling urine
.
Past Medical History:
PAST ONCOLOGIC HISTORY:
ONCOLOGIC HISTORY:
-CLL diagnosed in [**2131**]. She had been
primarily followed by Dr. [**First Name (STitle) 4223**] at [**Location (un) **] Hematology
Oncology and transferred her care here several months ago.
- Originally presented in [**2131-12-17**]: elevated white blood
cell count of 24,000 and a monoclonal IgG kappa paraproteinemia.
Flow cytometry studies revealed findings consistent with CLL.
She did not have a bone [**Year (4 digits) 15482**] biopsy done. There was no
evidence of lymphadenopathy and she did not have anemia or
thrombocytopenia. She was deemed as low risk, RAI stage 1 and
remained asymptomatic for a number of years.
- Early [**2136**], WBC levels started to rise and presumably she
had either symptoms or cytopenias. Started on Rituxan in
[**2136-5-17**], and received a total of 8 weekly doses.
- Course of fludarabine, cyclophosphamide, and Rituxan
x 6 cycles from [**2136-10-17**] to [**2137-3-17**] with remission
- Became symptomatic with fevers and a cough and re-started
therapy in [**2138-1-17**] with 2 more cycles of FCR. At this
time, her WBC was around 300,000. Her WBC count subsequently
decreased to 72,000
- WBC 200,000 by [**2138-5-17**]. Torso CT at [**Hospital6 33**] on
[**2138-6-26**] showed progressive upper abdominal and mesenteric
adenopathy and splenomegaly. A bone [**Date Range 15482**] done on [**2138-7-16**]
showed
a monoclonal kappa B-cell population co-expressing CD5 and CD23
per flow cytometry. Started on bendamustine and Rituxan, which
she apparently tolerated well but only achieved a partial
response.
- In [**2138-10-17**] she suffered a detached retina so no treatment
for her CLL.
- In [**2139-1-17**] received 2 cycles of CVP.
- Repeat CT on [**2139-4-8**] which showed interval enlargement of
her axillary, retroperitoneal, periaortic, mesenteric, and iliac
adenopathy and a diffusely enlarged spleen. On [**2139-4-16**] severe
cellulitis/nec fasc in her L arm transferred to [**Hospital1 24300**] for a fasciotomy.
- Dyspneic with significant hepatosplenomegaly and a white count
of 424K. Received 2 cycles of R-[**Hospital1 **] and white count declined
from 424K down to a low of 70K as well as reduction in the size
of her organomegaly. Then received R-CVP. But again increase in
her white count and size of her spleen, therefore she was
started on a regimen of Campath which correlated with fever,
cough, and a large
hematoma at the injection site.
- [**2139-9-17**] had CT demonstrating pancolitis and proctitis. CDiff
treated with IV Flagyl, po vancomycin, IVIG, IV tigecycline.
- Bendamustine 100 mg/m2 on [**9-27**] and [**9-28**]. Rituxan 375 mg/m2 on
[**9-30**]. During her admission she was experiencing weakness in her
legs, therefore an LP was performed. Flow on her CSF revealed
atypical lymphocytes highly suspicious for CNS involvement by
her known CLL. She was given a dose of IT Depocyt 50 mg on
[**2139-10-4**].
- No chemo since
.
OTHER MEDICAL HISTORY:
# Detached retina treated at [**Hospital 13128**] Institute
# SVT/Atrial Tachycardia
# Hyperlipidemia
# Osteoporosis
# CAD s/p RCA stent in [**2128**], EF 60% in [**5-27**]
# s/p Hysterectomy in [**2130**]
# Hx of breast biopsy, benign
# History of bladder prolapse [**2130**]
# Toes turn blue in cold weather - seen by vascular surgery
several times and told that this is not a vascular problem
# C. diff colitis [**9-/2139**]
# MDR pseudomonas UTI [**10/2139**]
Social History:
Divorced in the [**2108**]. Retired nurse.
- Smoking Hx: Short interval at age 18-21, never since.
- Alcohol Use: rare use.
- Recreational Drug Use: none.
Family History:
One son had [**Name (NI) 4278**] lymphoma at age 25. Daughter has lupus.
No other known cancer history.
Physical Exam:
ADMISSION EXAM:
VS: P 98 BP 109/57 RR 18 T 97.8 Pain Score 0/10 %O2 Sat 99
HEENT: Shows no pharyngeal lesions.
NECK: Supple with bilateral cervical, supraclavicular, and
axillary adenopathy.
CHEST: Clear to auscultation and percussion.
CARDIAC: Regular rate and rhythm without murmurs, rubs, or
gallops.
ABDOMEN: Soft, nontender with a liver edge palpated about 4
fingerbreadths below the costal margin. Splenic edge palpated
about 2 fingerbreadths below the left costal margin.
EXTREMITIES: Show chronic 1 to 2+ edema.
.
DISCHARGE EXAM:
Unchanged
Pertinent Results:
ADMISSION LABS:
[**2139-11-30**] 09:35AM BLOOD WBC-213.9* RBC-2.75* Hgb-10.0* Hct-28.5*
MCV-106* MCH-35.9* MCHC-34.3 RDW-22.3* Plt Ct-51*
[**2139-11-30**] 09:35AM BLOOD Neuts-2* Bands-0 Lymphs-97* Monos-1*
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2139-12-1**] 06:55AM BLOOD PT-13.0 PTT-31.4 INR(PT)-1.1
[**2139-11-30**] 09:35AM BLOOD UreaN-17 Creat-0.6 Na-137 K-4.2 Cl-101
HCO3-27 AnGap-13
[**2139-11-30**] 09:35AM BLOOD ALT-17 AST-48* LD(LDH)-559* AlkPhos-87
TotBili-0.5
[**2139-11-30**] 09:35AM BLOOD Albumin-4.0 Calcium-12.0* Phos-3.1 Mg-1.6
UricAcd-7.2*
[**2139-12-1**] 05:22PM BLOOD IgG-644* IgA-17* IgM-30*
.
DISCHARGE LABS:
[**2139-12-4**] 04:34AM BLOOD WBC-223.6* RBC-2.88* Hgb-10.4* Hct-28.6*
MCV-99* MCH-36.0* MCHC-36.3* RDW-24.4* Plt Ct-22*
[**2139-12-4**] 04:34AM BLOOD Neuts-4* Bands-0 Lymphs-89* Monos-2 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0 Other-5*
[**2139-12-4**] 04:34AM BLOOD PT-18.6* PTT-33.5 INR(PT)-1.7*
[**2139-12-4**] 04:34AM BLOOD Glucose-161* UreaN-52* Creat-0.8 Na-135
K-4.1 Cl-104 HCO3-20* AnGap-15
[**2139-12-4**] 04:34AM BLOOD ALT-278* AST-456* AlkPhos-97 TotBili-0.7
[**2139-12-4**] 04:34AM BLOOD Calcium-8.4 Phos-5.4* Mg-1.8
.
IMAGING:
CXR [**2139-11-30**]:
IMPRESSION: PA and lateral chest compared to [**10-20**] and 13:
Lung volumes are still low, particularly on the left where
linear opacities are due to subsegmental atelectasis. There are
no findings to suggest pneumonia or pulmonary edema, no pleural
effusion or indication of central adenopathy. Heart size normal.
Lateral view suggests a lower thoracic vertebral body is
unchanged from at least [**10-20**].
.
Abdominal XR [**2139-12-3**]:
FINDINGS: One supine and one left lateral decubitus image of the
abdomen show multiple air-filled loops of dilated small bowel
measuring up to 3.9 cm. There is a small about of air seen
within the colon extending into the rectum. These findings are
concerning for an early complete or partial small-bowel
obstruction. There is no evidence of free air. There are
significant degenerative changes of the lumbar spine, with a
mild curvature that may be related to positioning.
IMPRESSION: Dilated loops of small bowel are concerning for a
partial versus early complete small-bowel obstruction.
.
MICROBIOLOGY:
BCX negative
C diff negative
CMV negative
Urine culture
[**2139-12-2**] 2:51 pm URINE Source: Catheter.
**FINAL REPORT [**2139-12-5**]**
URINE CULTURE (Final [**2139-12-5**]):
ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ R
LINEZOLID------------- 2 S
NITROFURANTOIN-------- 128 R
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ =>32 R
Brief Hospital Course:
The patient is a 75 yo woman with refractory CLL with CNS
involvement who presented to clinic with weakness, fatigue, and
diarrhea. She was found to be hypercalcemic and admitted for
treatment. The patient's calcium level at the time of admission
was 12. She was started on IVF, given one dose of Pamindronate
90mg IV and 4 doses of Calcitonin 200 sq q12h. She responded
well, with calcium drop to 10 within 24 hours.
.
Infectious work-up also performed for generalized symptoms and
increasing WBC. CXR was negative for pneumonia. Blood and urine
cultures taken. The patient had a h/o MDR pseudomonas UTI
sensitive to ciprofloxacin, which was continued. Preliminary
results of Urine culture grew Enterococcus, and the patient was
started on Vancomycin on HD 2. (This was later discontinued when
the patient was noted to have reduced urine output). The patient
also had a h/o severe C Diff colitis in the past and complained
of worsening diarrhea at the time of admission. She was
continued on Flagyl and started on PO vancomycin.
The patient was continued on PPX: cipro, acyclovir, fluconazole,
bactrim.
.
On the morning of HD 3, the patient was triggered for hypoxia
and shortness of breath. Evaluation revealed patient in mild
respiratory distress with oxygen saturation of 95% on 2L NC. CXR
revealed no significant pulmonary congestion and no pleural
effusions. She responded well to furosemide 20mg IV x1.
The patient has a h/o CLL refractory to multiple treatment
regimens. She last received bendamustine and rituximab on [**11-2**].
On the day of admission she had a WBC count of 213 (from 144 the
week prior), LDH of 560, and uric acid of 7.2. These findings
were concerning for rapid progression of disease. Chemotherapy
with Rituxan was started on [**2139-12-3**].
[**Hospital Unit Name 13533**]:
On the evening of HOD #3, the patient developed hypotension with
SBP in 60s as well as bradycardia in the 40s. Concern was for
beta blocker and/or calcium channel blocker toxicity given that
patient had received 240mg diltiazem and 45mg IV metoprolol over
the day. Glucagon bolus and drip were started, and she was given
calcium gluconate 2g IV and 1mg atropine with improvement in HR
to 60s. She was started on a phenylephrine drip and transferred
to the [**Hospital Unit Name 153**]. In the [**Hospital Unit Name 153**] a dopamine drip was started.
Ciprofloxacin was stopped and she was started vanc/cefepime IV
for empiric coverage of hospital-acquired pathogens, given
patients immune compromise secondary to CLL and new hypotension
concerning for septic shock. EKG was unremarkable. She was
quickly able to be weaned of phenylephrine within 12 hours.
.
Goals of care: During the patinet'[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 153**] stay, a family meeting
was held with Dr. [**Last Name (STitle) **], her primary hematologist. Prognosis
and treatment options were discussed. The patient expressed her
desire to withhold further treatment and instead focus on her
quality of life and be discharged at home with hospice care.
Hospice care was arranged and patient was able to be discharged
home. She was treated with one dose of fosfomycin prior to
discharge for VRE bacturia. Vancomycin and flagyl were
discontinued as there was no evidence of c. diff toxin on any of
her stool samples. All other prophylactic antibiotics were
continued per patient wish.
Medications on Admission:
ACYCLOVIR - (Prescribed by Other Provider) - 400 mg Tablet - 1
Tablet(s) by mouth every eight (8) hours
ALLOPURINOL - (discharge med) - 300 mg Tablet - 1 Tablet(s) by
mouth DAILY (Daily)
CLONAZEPAM - 0.5 mg Tablet - 1 (One) Tablet(s) by mouth twice a
day as needed for anxiety.
DILTIAZEM HCL - (Prescribed by Other Provider; Dose adjustment
-
no new Rx) - 240 mg Capsule, Extended Release - 1 Capsule(s) by
mouth once a day
FLUCONAZOLE - (Dose adjustment - no new Rx) - 100 mg Tablet - 2
Tablet(s) by mouth once a day.
FUROSEMIDE [LASIX] - (discharge med) - 20 mg Tablet - 1
Tablet(s) by mouth once a day
LACTULOSE - (per [**Hospital3 **]) - 10 gram/15 mL Solution -
20gm by mouth as needed for constipation
LORAZEPAM - (Dose adjustment - no new Rx) - 0.5 mg Tablet - 1
(One) Tablet(s) by mouth every six (6) hours as needed for as
needed for anxiety
METOPROLOL SUCCINATE - (discharge med) - 100 mg Tablet Extended
Release 24 hr - 2 Tablet(s) by mouth twice a day
METRONIDAZOLE - (discharge meds) - 500 mg Tablet - 1 Tablet(s)
by mouth every eight (8) hours
NYSTATIN - (discharge med) - 100,000 unit/mL Suspension - 5
Suspension(s) by mouth four times a day
OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 (One)
Capsule(s) by mouth once a day
SULFAMETHOXAZOLE-TRIMETHOPRIM - (Prescribed by Other Provider;
Dose adjustment - no new Rx) - 800 mg-160 mg Tablet - 0.5 (One
half) Tablet(s) by mouth DAILY (Daily)
VANCOMYCIN [VANCOCIN] - 250 mg Capsule - 2 (Two) Capsule(s) by
mouth four times a day.
Medications - OTC
ACETAMINOPHEN - (Prescribed by Other Provider) - 325 mg Tablet
-
[**1-18**] Tablet(s) by mouth every six (6) hours as needed for pain
B COMPLEX VITAMINS [VITAMIN B COMPLEX] - (OTC) - Tablet - 1
Tablet(s) by mouth once a day
BENZOCAINE-MENTHOL-CETYLPYRID [CEPACOL SORE THROAT] - (OTC) -
15
mg-2.6 mg Lozenge - [**1-18**] Lozenge(s) prn as needed for Throat pain
CALCIUM CARBONATE [OYSTER SHELL CALCIUM 500] - (per [**Hospital3 **]) - 500 mg calcium (1,250 mg) Tablet - 1 Tablet(s) by mouth
twice a day
CHOLECALCIFEROL (VITAMIN D3) - (per [**Hospital3 **]) - 400 unit
Capsule - 2 Capsule(s) by mouth once a day
GLYCERIN (ADULT) - (per [**Hospital3 **]) - ADULT Suppository -
1
Suppository(s) rectally as needed for constipation
MULTIVITAMIN - (OTC) - Tablet - 1 (One) Tablet(s) by mouth
once a day
SENNOSIDES - (OTC; Dose adjustment - no new Rx) - 8.6 mg Tablet
- 1 (One) Tablet(s) by mouth twice a day as needed for
constipation
Discharge Medications:
1. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
2. allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain, fever.
5. nystatin 100,000 unit/mL Suspension Sig: Ten (10) ML PO QID
(4 times a day) as needed for thrush, mouth pain for 2 weeks.
6. sodium chloride 0.65 % Aerosol, Spray Sig: [**1-18**] Sprays Nasal
QID (4 times a day) as needed for dry nostrils.
7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule 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.
10. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
11. fluconazole 200 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
NVNA
Discharge Diagnosis:
CLL
Hypercalcemia
Beta-Blocker overdose
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
It was a pleasure taking care of you at [**Hospital3 **].
.
You came in with high calcium. Your course was complicated and
you decided to go home with hospice and concentrate on your
comfort. We were more than happy to help you get home.
.
The following changes were made to your home medications:
- STOP flagyl and Vancomycin
Followup Instructions:
Please call Dr. [**Last Name (STitle) **] on Monday to provide an update.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
Completed by:[**2139-12-23**] Name: [**Known lastname **],[**Known firstname **] Unit No: [**Numeric Identifier 7202**]
Admission Date: [**2139-11-30**] Discharge Date: [**2139-12-5**]
Date of Birth: [**2064-1-10**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1807**]
Addendum:
Pt was monitored for tumor lysis during her admission, with lab
values consistent with tumor lysis syndrome. However, given her
goals of care, she was not treated and eventual decision was
made to stop checking blood work.
Discharge Disposition:
Home With Service
Facility:
NVNA
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1809**]
Completed by:[**2140-2-7**]
|
[
"E942.4",
"277.88",
"799.4",
"293.0",
"285.22",
"112.0",
"287.5",
"733.00",
"300.00",
"276.2",
"275.42",
"286.7",
"414.01",
"427.89",
"272.4",
"E942.6",
"204.10",
"458.29"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.25"
] |
icd9pcs
|
[
[
[]
]
] |
17637, 17822
|
9221, 12613
|
288, 295
|
16281, 16281
|
6328, 6328
|
16816, 17614
|
5632, 5738
|
15137, 16139
|
16218, 16260
|
12639, 15114
|
16464, 16745
|
6959, 9198
|
5753, 6282
|
16763, 16793
|
6298, 6309
|
234, 250
|
323, 1979
|
6344, 6943
|
16296, 16440
|
2001, 5442
|
5458, 5616
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,452
| 145,688
|
4588
|
Discharge summary
|
report
|
Admission Date: [**2134-12-13**] Discharge Date: [**2134-12-20**]
Date of Birth: [**2080-11-23**] Sex: M
Service: MEDICINE
Allergies:
Reglan / Protonix
Attending:[**First Name3 (LF) 6195**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
Endotracheal intubation
Central venous line placement
Cardiac Catheterization
History of Present Illness:
54M with DM1, gastroparesis/neuropathy, s/p renal transplant in
[**2119**] now on PD, CAD, CHF with EF 45% who presents with
dehydration, L foot infection, and confusion, brought in by his
wife. Pt was noted to have a L foot was red starting on
Saturday, worsened today. He had walked around in new shoes all
day Friday at the races. No drainage per wife. [**Name (NI) **] fevers or
chills. Wife also felt that he was dehydrated--he was nauseous
starting Saturday and had poor po intake. This AM he was
confused. FS was 40 and was given [**Location (un) 2452**] juice and a packet of
sugar. His wife drove him to the [**Name (NI) **]. FS on arrival was 308.
.
He was recently started on Keflex on [**2134-11-18**] by his PCP for
infected left second toe x 10 days. This was stopped after 2
days and the redness of the foot resolved. He re-started the
Keflex yesterday. He also had an episode of diarrhea today. No
abd pain. Last PD was on Saturday; the fluid looked clear. No
headaches, CP, SOB, per wife.
.
In the ED, initial VS: 98.4, 101/27, 83, 14, 92% on RA. BP
acutely dropped to 80/42. Pt was noted to be lethargic. Exam was
sig. for bibasilar rales. PD site looked c/d/i. LLE is
erythematous. Pt was intubated for prophylatically for
increasing IVF needs. He has received 3L NS. CXR was not sig.
EKG showed lateral STDs. Trop is elevated at 0.76, CK 125,
CKMB12, and MBI 9.6. Pt received Vanc/Zosyn/Flagyl and
dexamethasone 10 mg. Current VS are: 98.5, 104/58 on levophed of
0.08, 69. CVP 13. Head CT is pending.
.
ROS: As above.
Past Medical History:
# Insulin dependent diabetes type I - complications of
neuropathy, retinopathy, gastroparesis (somewhat responsive to
erthromycin)
# Renal transplant, [**2119**], now on PD since [**5-27**] - followed by Dr
[**First Name (STitle) 805**]
# CAD - 3VD, DES to OM [**3-26**], following MI (deferred placing
multiple stents d/t excessive dye load in setting of renal
insufficiency).
# Systolic CHF: ECHO from [**1-25**]--EF 45-50%, akinesis of basal
inferior wall and hypokinese of the mid and basal inferolateral
wall.
# Polycythemia [**Doctor First Name **]
# PVD
# HTN
# h/o Osteomyelitis of R 5th metatarsal in [**2128**]
# Eosinophilic gastritis
# Stoke in [**2123**] with right hand weakness, resolved on its own
Social History:
Patient lives with his wife. [**Name (NI) **] is a retired auto mechanic. Per
wife, no smoking, alcohol, and any illicit drug use.
Family History:
One sister has a congenital [**Last Name 4006**] problem. Mother and another
sister with bipolar disorder on lithium.
Physical Exam:
ADMISSION PHYSICAL EXAM
Tmax: 36.6 ??????C (97.8 ??????F)
Tcurrent: 36.6 ??????C (97.8 ??????F)
HR: 63 (63 - 67) bpm
BP: 122/71(84) {95/57(66) - 122/71(84)} mmHg
RR: 16 (16 - 21) insp/min
SpO2: 100%
General Appearance: No acute distress, Overweight / Obese
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Endotracheal tube, NG tube
Lymphatic: Cervical WNL, Supraclavicular WNL
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Absent)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Crackles : bibasilar)
Extremities: Right lower extremity edema: Absent, Left lower
extremity edema: Absent
Skin: Not assessed
Neurologic: Attentive, Follows simple commands, Responds to:
Verbal stimuli, Movement: Not assessed, Sedated, Tone: Not
assessed
Pertinent Results:
Admission labs [**2134-12-13**]:
WBC-6.8 RBC-3.54* HGB-10.2* HCT-30.1* MCV-85 MCH-28.7 MCHC-33.8
RDW-16.6*
NEUTS-64.9 LYMPHS-18.8 MONOS-6.6 EOS-9.1* BASOS-0.7
PLT COUNT-181
GLUCOSE-284* UREA N-58* CREAT-6.9* SODIUM-132* POTASSIUM-4.0
CHLORIDE-96 TOTAL CO2-20* ANION GAP-20
ALT(SGPT)-10 AST(SGOT)-27 CK(CPK)-125 ALK PHOS-101 TOT BILI-0.4
LIPASE-9
Cardiac enzymes:
[**2134-12-13**] CK(CPK)-125 CK-MB-12* MB Indx-9.6* cTropnT-0.76*
[**2134-12-13**] CK(CPK)-243* CK-MB-27* MB Indx-11.1* cTropnT-1.09*
[**2134-12-14**] CK(CPK)-266* CK-MB-34* MB Indx-12.8* cTropnT-1.27*
[**2134-12-14**] CK(CPK)-215* CK-MB-31* MB Indx-14.4* cTropnT-1.67*
[**2134-12-15**] CK(CPK)-115 CK-MB-15* MB Indx-13.0* cTropnT-1.11*
[**2134-12-16**] CK(CPK)-276* CK-MB-11* MB Indx-4.0 cTropnT-0.71*
Discharge labs [**2134-12-20**]:
WBC-6.4 RBC-3.03* Hgb-8.5* Hct-26.0* MCV-86 MCH-28.1 MCHC-32.7
RDW-17.4* Plt Ct-232
Glucose-157* UreaN-39* Creat-5.9* Na-142 K-2.9* (corrected to
3.4) Cl-105 HCO3-26 AnGap-14
Calcium-7.4* Phos-4.7* Mg-1.9
Microbiology:
[**2134-12-13**] Blood culture negative
[**2134-12-13**] Urine culture negative
[**2134-12-13**] PD fluid culture negative
GRAM STAIN (Final [**2134-12-14**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
WOUND CULTURE (Final [**2134-12-16**]):
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.
Please contact the Microbiology Laboratory ([**8-/2431**])
immediately if
sensitivity to clindamycin is required on this
patient's isolate.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- 0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
[**2134-12-16**] Blood culture- pending (negative to date)
[**2134-12-17**] C diff negative
Imaging:
[**2134-12-13**] EKG:
Sinus rhythm. Right bundle-branch block. Left anterior
fascicular block. Left atrial abnormality. Compared to the
previous tracing of [**2134-3-19**] the ischemic appearing lateral ST-T
wave changes have improved which may be
pseudonormalization. The rate has increased. The QRS has
widened. There is now right bundle-branch block. Clinical
correlation is suggested.
[**2134-12-13**] CXR: Mild stable cardiomegaly with no acute
cardiopulmonary process.
[**2134-12-13**] CT head:
1. No acute intracranial abnormality.
2. Chronic infarcts of the left frontal lobe, as well as likely
chronic
lacunar infarcts in the left basal ganglia and pons.
[**2134-12-14**] Echo:
There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. LV systolic function appears
depressed (ejection fraction 40 percent) secondary to
hypokinesis of the inferior septum and lateral wall;, and
akinesis of the posterior wall. Tissue Doppler imaging suggests
an increased left ventricular filling pressure (PCWP>18mmHg).
There is no ventricular septal defect. Right ventricular chamber
size and free wall motion are normal. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present.
Mild (1+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2134-1-21**], the left ventricular ejection fraction is
further reduced secondary to increased hypokinesis of the
inferior, posterior, and lateral walls, suggesting
restenosis/thrombosis of the circumflex artery stent.
[**2134-12-14**] EKG:
Sinus bradycardia with slowing of the rate as compared to the
previous tracing of [**2134-12-13**]. Right bundle-branch block is no
longer recorded. There is left anterior fascicular block. Prior
posterolateral myocardial infarction cannot be excluded. The Q-T
interval has increased and is quite prolonged as compared with
tracing of [**2134-3-19**]. In the absence of right bundle-branch block
the T waves are now inverted in leads V2-V6 and may represent
active anterolateral ischemic process. Followup and clinical
correlation are suggested.
[**2134-12-14**] Cardiac cath:
1. Coronary angiography of this right dominant system revealed
severe
three vessel coronary artery disease. The LMCA had a distal
calcific 60%
lesion. The LAD was severely diseased, with a mid-vessel 80%
stenosis
into a twin LAD with a proximal 90% stenosis in the diagonal
portion and
an 80% stenosis in the LAD portion. The LCx had 70% in-stent
restenosis
of the prior stent, with a distal 40% lesion. The RCA was
severely
calcified with a mid-vessel 80% stenosis and proximal PDA 60-90%
lesions.
2. Resting hemodynamics demonstrated mildly elevated right and
left
sided filling pressures (RVEDP 14 mm Hg, PCWP mean 17 mm Hg).
There was
mild pulmonary hypertension (PASP 40 mm Hg). The systemic
arterial blood
pressure was normal on levophed 0.04 mcg/min IV. The systemic
and
pulmonary vascular resistances were normal on levophed (SVR 1025
and PVR
112 dynes-sec/cm5). The cardiac index was normal on pressors (CI
3.0
l/min/m2).
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Mild biventricular diastolic dysfunction.
3. Mild pulmonary hypertension.
4. Cardiac index normal on levophed.
[**2134-12-14**] L Foot x-ray:
1. Fracture across the proximal aspect of the left fifth
metatarsal shaft
with callus formation and irregularity of the fracture margins,
likely
representing a subacute fracture.
2. No specific features for osteomyelitis or subcutaneous gas.
[**2134-12-16**] CTA Chest:
1. No pulmonary embolus. No aortic dissection.
2. Bilateral pleural effusions with associated atelectasis.
3. Nodular and ground-glass opacification in both lower lobes
and prominant mediatinal and hilar nodes are nonspecific for an
infective/inflammatory process. Correlate clinically.
4. Pulmonary artery enlargement consistent with pulmonary artery
hypertension.
5. Vascular (Aortic, celiac axis and splenic artery)
calcifications including dense three-vessel coronary artery
calcifications.
6. Moderate ascites.
7. Bilateral gynecomastia.
8. Mediastinal lipomatosis.
Brief Hospital Course:
#Multifactorial shock - Suspected source was left foot
ulcer/cellulitis. This was treated with IV fluids, vasopressors
(discontinued [**12-15**]), and empiric vanc/cipro/zosyn, and
stress-dose corticosteroids. Wound swab from a LLE ulcer grew
MSSA and antibiotics were changed to nafcillin on [**12-17**] and
changed to Unasyn on [**12-18**] for better coverage of gram negatives
and anaerobes given his history of type 1 diabetes. He was sent
home on Keflex for a total 14 day course of antibiotics. Blood
cultures were negative from admission and are no growth to date
from [**12-16**].
#Hypoxemic respiratory failure - Secondary to septic shock.
Treated with mechanical ventilation until extubation on [**12-15**].
CTA [**12-16**] negative for PE.
#Subendocardial ischemia/type II MI - Peak CKMB 34 and troponin
1.67 on [**12-14**]. TTE [**12-14**] showed LVEF 40%, further reduced
secondary to increased hypokinesis of the inferior, posterior,
and lateral walls, suggesting restenosis/thrombosis of the
circumflex artery stent. Cardiac cath [**12-14**] showed 3VD, BiV
diastolic dysfunction, mild pulmonary hypertension, and a normal
cardiac index (on levophed). No intervention was performed.
Cardiac surgery consultated was obtained but plans for surgery
deferred pending resolution of acute medical issues. Continued
aspirin and plavix. Metoprolol started [**12-18**] and continued at
discharge. His simvastatin was increased to 80mg daily.
#ESRD c/b failed renal transplant on PD: Continued with PD.
Continued cyclosporine at home dose to prevent acute rejection.
Stress dose steroids tapered to home dose of prednisone on
[**12-17**]. He was followed by renal transplant and told to continue
his home PD regimen on discharge.
#DM1: Hyperglycemia treated with insulin gtt while he was in the
MICU on steroids. This was transitioned to basal & sliding scale
insulin when steroids tapered. He was continued on his home
dose of basal insulin and sliding scale while on the floor.
#Chronic systolic CHF: Echo findings, as above. [**Month (only) 116**] benefit
from starting ACEi but this was not done prior to discharge.
#Hypokalemia: Had some hypokalemia on day of discharge which
improved with po potassium supplementation. He is to follow up
with his PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) **] in the next couple days for lab work
to monitor his electrolytes.
Medications on Admission:
Keflex 250 mg TID, 4 doses
Cyclosporine 25 mg daily
Prednisone 5 mg daily
Plavix 75 mg daily
ASA 81 mg daily
Simvastatin 10 mg daily
Renagel 800mg TID with [**First Name (STitle) 16429**]
Calcitriol 0.50 mcg daily
Colace 100 mg [**Hospital1 **]
Humalog ISS
Lantus 20 units in AM, not this AM or yesterday
Discharge Medications:
1. Keflex 500 mg Capsule Sig: One (1) Capsule PO twice a day for
6 days.
Disp:*12 Capsule(s)* Refills:*0*
2. Sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID
W/[**Hospital1 **] (3 TIMES A DAY WITH [**Hospital1 **]).
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Cyclosporine 25 mg Capsule Sig: One (1) Capsule PO Q24H
(every 24 hours).
6. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
7. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
8. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Calcitriol 0.25 mcg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
10. Insulin
Please continue your 20 units of Lantus in the morning and your
Humalog sliding scale.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1. Septic shock
2. Cellulitis
Secondary:
1. Type 1 DM
2. End stage renal disease
Discharge Condition:
Stable
Discharge Instructions:
You were admitted to the hospital with an infection in your L
foot that progressed to shock. You were in the intensive care
unit and had to be on a breathing tube and medicine to support
your blood pressure. You improved with antibiotics and no
longer required these supports. You were sent to a regular
floor bed and continued to improve. Please follow-up with Dr.
[**First Name (STitle) **] your PCP [**Name9 (PRE) 1639**] to check your electrolytes as your
potassium was low today. Please resume your home peritoneal
dialysis schedule of 4 daily cycles every 6 hours with 1.5%
dextrose for 3 cycles and 1 cycle with 2.5% dextrose.
The following medications were added to your regimen:
1. Keflex, an antibiotic, please take this for 6 days
2. Increase simvastatin to 80mg daily
Please return to the ED or call your doctor if you experience
fever or chills, chest pain, difficulty breathing, severe pain,
redness or swelling in your foot.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2134-12-21**] 1:00
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 722**], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2135-1-17**] 8:15
Provider: [**First Name8 (NamePattern2) 161**] [**Name11 (NameIs) 162**] [**Name8 (MD) 163**], MD Phone:[**Telephone/Fax (1) 921**]
Date/Time:[**2135-1-26**] 2:30
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6198**] MD, [**MD Number(3) 6199**]
|
[
"428.0",
"611.1",
"250.61",
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"585.6",
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"272.8",
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"250.51",
"426.4",
"536.3",
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"276.8",
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icd9cm
|
[
[
[]
]
] |
[
"96.71",
"54.98",
"88.56",
"37.23",
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icd9pcs
|
[
[
[]
]
] |
14422, 14428
|
10704, 13106
|
293, 372
|
14563, 14572
|
3886, 4234
|
15567, 16188
|
2842, 2961
|
13462, 14399
|
14449, 14542
|
13132, 13439
|
9649, 10681
|
14596, 15544
|
2976, 3867
|
4251, 6751
|
242, 255
|
400, 1940
|
6760, 9632
|
1962, 2678
|
2694, 2826
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,259
| 195,659
|
7402+55832
|
Discharge summary
|
report+addendum
|
Admission Date: [**2106-9-2**] Discharge Date: [**2106-9-8**]
Date of Birth: [**2026-12-30**] Sex: F
Service: VSU
CHIEF COMPLAINT: Left BKA ischemia.
HISTORY OF PRESENT ILLNESS: This is a 79-year-old well known
to the vascular service recently admitted for workup of a
left BKA ischemia. She underwent anaphylaxis during planned
angiogram of the left axillofemoral bypass. This required
intubation in ICU with ventilatory support. She was
ultimately discharged to home on [**2106-8-27**] for
outpatient workup of her left stump ischemia. She returns
today, brought by her daughter, for concern of worsening
ischemia. She has used a new left leg prosthesis.
Subsequently has worse pain and "black stump." Denies fevers,
chills, rest pain, chest pain, shortness of breath or
abdominal pain.
PAST MEDICAL HISTORY: Peripheral vascular disease, status
post right femoral peroneal bypass, status post common
femoral artery thrombectomy, status post left
axillobifemoral, status post profunda, status post left
ilioprofunda with PTFE, aortic insufficiency, history of
hypertension controlled, history of type 2 diabetes diet
controlled, coronary artery disease, status post myocardial
infarction, status post CABG remote, history of
hypothyroidism on no supplement at this time.
PAST SURGICAL HISTORY: Includes hysterectomy.
ALLERGIES: KEFZOL causes anaphylaxis. SULFA causes
anaphylaxis, and ANGIO CONTRAST causes anaphylaxis.
MEDICATIONS: Include Lopressor 50 mg b.i.d., nifedipine 50
mg XR daily, Isordil 30 mg daily, Lipitor 10 mg daily,
Tylenol p.r.n., aspirin 325 mg daily, Lasix 40 mg b.i.d.,
Plavix 75 mg daily, Pletal 100 mg b.i.d., chlorpropamide 100
mg daily, Percocet p.r.n.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: She denies alcohol, drug or tobacco use.
PHYSICAL EXAMINATION: Vital signs: 99.8, 78, 14, blood
pressure of 114/53, oxygen saturation 96% on room air.
General appearance: This is a pleasant female in no acute
distress. HEENT exam is unremarkable. Chest is clear to
auscultation bilaterally. Heart has a regular rate and
rhythm. Abdominal exam is obese, nontender, nondistended.
Extremity exam shows left stump with slightly purpuric and
cool. Pulse exam shows palpable radials bilaterally. The
femoral on the right is 2+, popliteal is 2+, DP is
monophasic, PT is 1+. On the left; the femoral is 1+, the
popliteal is absent, and the axillary graft is biphasic.
HOSPITAL COURSE: The patient was initially evaluated in the
emergency room. Vascular was consulted. The patient was
admitted to the vascular service for continued care. IV
heparinization was begun. On [**2106-9-2**] the patient
underwent a left axillary femoral jump graft to the profunda
femoris with [**Doctor Last Name 4726**]-Tex. The patient tolerated the procedure
well and was transferred to the PACU in stable condition. Her
admitting hematocrit was 31.6. Postoperative hematocrit was
24.2. She was transfused. BUN was 27. Creatinine was 0.1.
These remained unchanged. Her potassium was repleted.
Postoperatively, her dressings were clean, dry, and intact.
The stump was warm. The axillary graft was triphasic. The
patient continued to do well and then was transferred to the
VICU for continued monitoring and care. Her post transfusion
hematocrit was 36.4 after 2 units. Heparin drip was continued
and coumadinization was instituted. The patient was diuresed,
and she remained in the VICU.
On postoperative day 2, the patient continued to do well. IV
heparinization continued. Coumadinization was continued, and
her coagulation parameters were monitored and anticoagulant
dosing was adjusted. Physical therapy was requested to see
the patient in anticipation for discharge planning. Rehab was
their recommendation. Family and patient were adamantly
against this. The patient was reevaluated and felt that she
could be discharged with home PT.
On postoperative day 3, the patient's diet was advanced as
tolerated. T-max was 100.7 to 98.9. The patient had some
nausea. EKG was obtained which was negative for ischemic
changes. Beta blockade was increased.
DISCHARGE STATUS: The remaining hospital course was
unremarkable, and the patient was discharged to home on
postoperative day 6.
DISCHARGE INSTRUCTIONS: The patient's INR should be
monitored 3 times a week the initial. Goal INR is 2.0 to 2.5.
INR on [**9-7**] was 2.7. The patient did have some diarrhea
and was empirically started on Flagyl. The patient should
follow up with Dr. [**Last Name (STitle) **] in 2 weeks' time. The INR
results should be called to his office nurse; [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at
[**Telephone/Fax (1) 27201**]. The patient may ambulate essential distances.
No heavy lifting. [**Month (only) 116**] take showers. No tub baths.
DISCHARGE MEDICATIONS: Isosorbide 30 mg t.i.d., atorvastatin
10 mg daily, aspirin 325 mg daily, Lasix 40 mg b.i.d., Plavix
75 mg daily, chlorpropamide 125 mg daily,
oxycodone/acetaminophen 5/325 tablets 1 to 2 q.6h. p.r.n.
(for pain), potassium and sodium phosphate packet 1 b.i.d.,
acetaminophen 325-mg tablets 1 to 2 q.4-6h., Lopressor 75 mg
b.i.d., Flagyl 500 mg t.i.d. for a total of 2 weeks, Coumadin
2.5 mg daily. Monitor INR. Goal of 2.0 to 2.5.
DISCHARGE DIAGNOSES:
1. Ischemic left below-the-knee amputation.
2. Type 2 diabetes with neuropathy.
3. History of hypothyroidism.
4. History of coronary artery disease.
5. Status post myocardial infarction.
6. Status post coronary artery bypass grafting.
7. History of peripheral vascular disease.
8. Status post right femoral peroneal.
9. Status post left common femoral thrombectomy.
10. Status post left axillobifemoral.
11. Status post left ilioprofunda femoris with PTFE.
12. Status post axillobifemoral jump graft to the
profunda
femoral artery with [**Doctor Last Name 4726**]-Tex on [**2106-9-2**].
13. Postoperative blood loss anemia, corrected.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 5697**]
Dictated By:[**Last Name (NamePattern1) 2382**]
MEDQUIST36
D: [**2106-9-7**] 14:58:12
T: [**2106-9-7**] 16:00:22
Job#: [**Job Number 27202**]
Name: [**Known lastname 4677**],[**Known firstname 4678**] Unit No: [**Numeric Identifier 4679**]
Admission Date: [**2106-9-2**] Discharge Date: [**2106-9-8**]
Date of Birth: [**2026-12-30**] Sex: F
Service: SURGERY
Allergies:
Sulfa (Sulfonamides) / Cefazolin
Attending:[**First Name3 (LF) 1546**]
Addendum:
[**2106-9-8**] coumadin held 8/24,[**9-9**] with instructions to began 1mgm
@ HS [**2106-9-10**] ( Friday), alternating with 2.5mgm qod starting
[**2106-9-11**]. INR should be drawn [**9-9**] and results called to PCP
[**Name Initial (PRE) 4682**].goal INR 2.0-2.5
d/c to home stable
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 328**] VNA
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1548**] MD [**MD Number(1) 1549**]
Completed by:[**2106-9-8**]
|
[
"V45.81",
"412",
"440.20",
"357.2",
"424.1",
"285.1",
"250.60",
"244.9",
"401.9",
"V49.75"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.29",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
6871, 7081
|
1730, 1748
|
5269, 6848
|
4817, 5248
|
2446, 4226
|
4251, 4793
|
1323, 1713
|
1830, 2428
|
153, 173
|
202, 814
|
837, 1299
|
1765, 1807
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,734
| 186,879
|
611+612
|
Discharge summary
|
report+report
|
Admission Date: [**2109-8-7**] Discharge Date: [**2109-8-17**]
Date of Birth: [**2053-7-14**] Sex: F
Service:
DR.[**Last Name (STitle) **],[**First Name3 (LF) 275**] E. 02-248
Dictated By:[**Dictator Info **]
MEDQUIST36
D: [**2109-8-17**] 13:51
T: [**2109-8-22**] 08:45
JOB#: [**Job Number 4718**]
Admission Date: [**2109-8-7**] Discharge Date: [**2109-8-17**]
Date of Birth: [**2053-7-14**] Sex: F
Service: CARDIOTHORACIC
HISTORY OF PRESENT ILLNESS: This is a 56 year-old woman who
had a preop electrocardiogram for a spinal surgery that was
notable for ischemic changes. She underwent a stress
echocardiogram on [**7-5**] that demonstrated inferior wall
near akinesis. On [**8-2**] she underwent a cardiac
catheterization that revealed a 50% occlusion of her LAD and
a 90% occlusion of her left circumflex as well as a 100%
occlusion of the RCA. She had an echocardiogram that
demonstrated an ejection fraction of approximately 40%. The
decision was made that the patient should undergo a coronary
artery bypass surgery.
MEDICATIONS ON ADMISSION: Rocaltrol 0.625 mg q.d.,
Nephrocaps 1 mg po q.d., Lipitor 10 mg po q.d., Provera 2.5
mg po q.d., Premarin 0.625 mg q.d., Norvasc 5 mg po b.i.d.,
Gabapentin 100 mg po t.i.d. and Dilaudid 4 mg po q.i.d.
PAST MEDICAL HISTORY: 1. Stable angina. 2. Type 2 insulin
dependent diabetes mellitus on hemodialysis and neuropathy.
3. Hypertension. 4. Hypercholesterolemia. 5.
Degenerative joint disease at the L4-L5 interspace.
HOSPITAL COURSE: The patient was admitted on [**2109-8-7**] to the [**Hospital Unit Name 196**] Service. On [**8-8**] the patient
underwent an uncomplicated coronary artery bypass graft times
three with the left internal mammary coronary artery to the
left anterior descending coronary artery, saphenous vein
graft to the obtuse marginal 1, and the saphenous vein graft
to the right posterior descending coronary artery. The
patient tolerated the procedure well and was transported to
the CSRU intubated and in stable condition.
Immediately postoperative, the patient was able to answer
questions and follow commands. She was weaned off of the
ventilator and extubated. Her chest tube was notable for a
small air leak initially. On postoperative day one she was
started on Lopressor as well as aspirin. She was weaned from
the Levophed and started on a renal diet. Her pleural chest
tube was left in place and the Renal Service was consulted
for management of her dialysis. At that time she was being
atrially paced at 80 over a normal sinus rhythm at 60. Her
Levophed was discontinued and she was weaned from the
Milrinone. She underwent hemodialysis. On postoperative day
two the patient's heart rate was in the 80s with sinus rhythm
with a blood pressure of 118/67. Her pacemaker was
subsequently turned off as it was competing with her
underlying rhythm. She was stable and was transferred to the
floor.
On the floor the [**Hospital 228**] hospital course was uneventful.
She remained afebrile with good pain control and maintaining
a sinus rhythm. She experienced some nausea and some emesis
associated with her potassium supplements. Her blood sugars
were well controlled, but she was somewhat anorexic. She
also began complaining of some mild mid epigastric tenderness
on postoperative day five associated with some nausea. She
was also noted to have an elevated white blood cell count of
24,000, as well as mildly elevated transaminase and alkaline
phosphatase levels. She underwent a KUB, which was notable
for her colon being full of stool. She also had a right
upper quadrant ultrasound that was negative for biliary
disease processes. She was begun on a regimen of Cascara and
Milk of Magnesia with subsequent large bowel movements with
relief of her abdominal pain. She was noted to have a
somewhat swollen right lower extremity, which was the site of
the saphenous vein graft and concern for a possible deep
venous thrombosis as the etiology of the increased white
blood cell count prompted a venous duplex ultrasound. The
result of this study was negative for deep venous thrombosis.
By postoperative day nine the patient had remained afebrile
and her white count had steadily declined to 17,400. The
patient was subsequently discharged with instructions to
return to clinic and/or the Emergency Department if she
should become ill.
PHYSICAL EXAMINATION ON DISCHARGE: The patient was afebrile
with stable vital signs. She was in no acute distress, alert
and oriented. Her lungs were clear. Her sternum was stable.
Her incision was clean, dry and intact. Her heart had a
regular rate and rhythm and a 2/6 systolic ejection murmur at
the base. Her belly was soft, nontender, nondistended. Her
extremities were warm and well profused and her incision was
clean, dry and intact. She had a small amount of swelling on
her right lower extremity.
DISCHARGE MEDICATIONS: Lopressor 12.5 mg po b.i.d., Percocet
one to two tablets po q 3 to 4 hours prn pain, Colace 100 mg
po b.i.d., ECASA 81 mg po q.d., Ibuprofen 400 mg po t.i.d.,
Gabapentin 100 mg po t.i.d., Amiodarone 400 mg po b.i.d.
times seven days and then 400 mg po q.d., Nephrocaps one
tablet q.d., Premarin 0.625 mg po q.d., Rocaltrol 0.5 mg po
q.d., Provera 2.5 mg po q.d.
The patient was subsequently discharged in stable condition
with instructions to return to the clinic or the Emergency
Department if she was feeling ill and to follow up with Dr.
[**Last Name (STitle) 1537**] in one weeks time as well as her primary care physician
[**Last Name (NamePattern4) **]. [**First Name (STitle) **] in one to two weeks time. She is sent home with
plans for [**Location (un) 86**] VNA to come in and check on her for home
safety and cardiopulmonary evaluation.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern1) 3801**]
MEDQUIST36
D: [**2109-8-17**] 14:19
T: [**2109-8-22**] 08:46
JOB#: [**Job Number 4719**]
|
[
"443.9",
"414.01",
"722.93",
"411.1",
"585",
"357.2",
"250.61",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"39.95",
"37.22",
"88.56",
"39.61",
"36.12"
] |
icd9pcs
|
[
[
[]
]
] |
4971, 6104
|
1129, 1331
|
1573, 4452
|
4467, 4947
|
525, 1102
|
1354, 1555
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,605
| 160,759
|
54392
|
Discharge summary
|
report
|
Admission Date: [**2136-3-27**] Discharge Date: [**2136-4-1**]
Date of Birth: [**2075-2-22**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5037**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
Arthrocentesis of right knee
History of Present Illness:
61 year old male with history of prostate CA, Kidney transplant
on Immunosuppresants presented to ED with shaking chills and
fever. Also having dizziness. No nausea/vomiting. Also with
diarrhea, which he has had since his transplant, no blood in
stool. He also has new onset erythema LLE to abdomen over the
last three hours since he took Zyvox. No cough, no SOB, no
abdominal pain. He does note that he has had increased knee
pain for the last month. The pain is worse on the right than
the left and worse with movement. His baseline blood pressure
is 100/60.
.
In the ED he became hypotensive to 77/48 got 1L NS bolus and BP
returned to 122/54. He had a temperature to 102.4. He was
treated with Cefepime, Tylenol, Benadryl, and Hydrocortisone.
Right femoral line was placed under sterile conditions. he was
transferred to MICU for further monitoring.
Past Medical History:
- ESRD, secondary to polycystic kidney disease
- CRI, baseline creatinine 1.8 - 2.0
- cadaveric renal transplant in [**2118**] which failed
- cadaveric renal transplant on [**2131-3-4**]
- chronic immunosuppression, due to post-transplant meds
- s/p b/l nephrectomy
- s/p ileal loop / urostomy -- ilial conduit neobladder
- status post radical prostatectomy for prostate cancer
- status post Tenckhoff removal secondary to fungal peritonitis
- CMV gastroenteritis
- h/o multiple squamous cell cancers
- h/o fistula in RUE
- h/o chronic venous stasis
- h/o ventral hernia
- MRSA wound infection at the site of his kidney transplant [**3-17**]
- Prostate CA metastatic to spine
Social History:
Retired electrical engineer, had indoor pool company. Has not
been working for 6 years due to illness. Lives with wife, three
sons. [**Name (NI) **] smoking, occassional beer.
Family History:
No parent with kidney problems or heart disease
Physical Exam:
On Admission to MICU:
Vital signs: Temp 99.8, BP 105/56, HR 102, RR 14, 95% on RA
Gen alert, oriented cooperative male in NAD
HEENT: PERRL, EOMI, MM dry, OP clear
Lungs: clear to auscultation bilaterally
CV: tachycardic, nl S1S2 2/6 SEM at LLSB
Abd: ileal loop bag in place with yellow urine, soft,
non-tender, non-distended with numerous scars, positive BS
Ext: 3+ edema with chronic venous stasis changes, right knee
swollen with fluid collection in bursa also present on left, no
erythema or warmth, right arm AV fistula
Neuro: intact
Pertinent Results:
[**2136-3-27**]
CT Abd/Pelvis:
There is bibasilar atelectasis. Again, there are innumerable low
attenuations throughout the liver, unchanged. There are several
areas of high attenuation adjacent to the falciform ligament.
There are stones within the gallbladder. The pancreas, spleen,
and both adrenal glands are unchanged. Surgical clips are seen
within the right nephrectomy bed. There is atherosclerotic
calcification of the descending aorta and multiple branches.
There are no pathologically enlarged mesenteric or
retroperitoneal lymph nodes. The appendix is normal. No definite
soft tissue in the right nephrectomy bed. The patient is status
post left nephrectomy. There are scattered stable small soft
tissue densities in the left nephrectomy bed, likely
representing small lymph nodes. There are diverticuli within the
descending colon. No evidence of diverticulitis. There is no
free air or free fluid. The patient is status post ileostomy.
CT OF THE PELVIS WITHOUT IV CONTRAST: A calcified atrophic renal
transplant seen within the right pelvis. A transplant kidney is
seen in the left pelvis, without evidence of hydronephrosis or
renal stones.Penile prosthesis noted.
Right femoral line lies in the right common femoral
vein.Diverticuli throughout the sigmoid colon. There is a
minimal amount of stranding in the region of the distal sigmoid
colon. Early diverticulitis cannot be excluded. There is no free
fluid or abscess. There are clips within the pelvis. There is a
stable calcified density in the pelvis.
.
No lymphadenopathy.
.
BONE WINDOWS: No suspicious lesions. Degenerative changes within
the spine.
.
REFORMATTED IMAGES: No focal abscess.
.
IMPRESSION:
.
1. Diverticulosis.Minimal stranding adjacent to the distal
sigmoid diverticuli. Early diverticulitis cannot be excluded.
2. Cholelithiasis.
3. Multiple hepatic cysts.
.
[**3-27**]: EKG:
[**2136-3-28**] 03:43AM BLOOD Calcium-7.8* Phos-4.1 Mg-1.4*
[**2136-3-28**] 10:37AM BLOOD Calcium-8.2* Phos-3.1 Mg-2.2
.
[**2135-3-28**]: CXR:
IMPRESSION: No acute cardiopulmonary process.
.
[**3-27**]: Knee Films:
RIGHT KNEE: Three views of the right knee reveal appropriate
anatomic osseous alignment without evidence of fracture or
dislocation. On the sunrise projection, there is a 7-mm
subchondral cyst within the medial facet of the patella. This is
not seen on the other views. There is no joint effusion. There
is vascular calcification.
.
LEFT KNEE: Three views of the left knee reveal appropriate
anatomic osseous alignment without evidence of fracture,
dislocation, or joint effusion. No osseous erosions identified.
There is vascular calcification.
.
IMPRESSION:
1. No evidence of fracture or effusion.
2. Vascular calcification.
.
CBC:
[**2136-3-27**] 03:10PM BLOOD WBC-8.9 RBC-5.02 Hgb-13.1* Hct-38.6*
MCV-77* MCH-26.2* MCHC-34.0 RDW-15.6* Plt Ct-133*
[**2136-3-27**] 03:10PM BLOOD Neuts-86.9* Bands-0 Lymphs-8.8* Monos-4.1
Eos-0.1 Baso-0.1
[**2136-3-28**] 03:43AM BLOOD WBC-5.8 RBC-3.84* Hgb-10.4* Hct-30.0*
MCV-78* MCH-27.1 MCHC-34.8 RDW-16.0* Plt Ct-119*
[**2136-3-28**] 07:57AM BLOOD Hct-32.4*
.
COAGS:
[**2136-3-27**] 03:10PM BLOOD PT-11.3 PTT-20.7* INR(PT)-1.0
[**2136-3-28**] 03:43AM BLOOD PT-12.5 PTT-25.0 INR(PT)-1.1
.
SMA 7:
[**2136-3-27**] 03:10PM BLOOD Glucose-111* UreaN-88* Creat-2.7* Na-139
K-3.2* Cl-96 HCO3-25 AnGap-21*
[**2136-3-28**] 03:43AM BLOOD Glucose-221* UreaN-88* Creat-2.7* Na-140
K-2.8* Cl-102 HCO3-27 AnGap-14
[**2136-3-28**] 10:37AM BLOOD Glucose-205* UreaN-85* Creat-2.7* Na-140
K-3.0* Cl-102 HCO3-25 AnGap-16
[**2136-3-28**] 03:43AM BLOOD Calcium-7.8* Phos-4.1 Mg-1.4*
[**2136-3-28**] 10:37AM BLOOD Calcium-8.2* Phos-3.1 Mg-2.2
.
LFTS:
[**2136-3-27**] 03:10PM BLOOD ALT-15 AST-28 AlkPhos-88 Amylase-79
TotBili-0.5
[**2136-3-27**] 03:10PM BLOOD Lipase-33
.
IMMUNOSUPPRESSANTS:
[**2136-3-27**] 03:10PM BLOOD FK506-8.6
[**2136-3-28**] 07:26AM BLOOD rapmycn-7.2
[**2136-3-28**] 07:26AM BLOOD FK506-12.7
.
LACTATES:
[**2136-3-27**] 03:20PM BLOOD Lactate-2.8*
[**2136-3-27**] 07:11PM BLOOD Lactate-1.8
KNEE (AP, LAT & OBLIQUE) BILAT [**2136-3-28**] 11:41 AM
RIGHT KNEE: Three views of the right knee reveal appropriate
anatomic osseous alignment without evidence of fracture or
dislocation. On the sunrise projection, there is a 7-mm
subchondral cyst within the medial facet of the patella. This is
not seen on the other views. There is no joint effusion. There
is vascular calcification.
LEFT KNEE: Three views of the left knee reveal appropriate
anatomic osseous alignment without evidence of fracture,
dislocation, or joint effusion. No osseous erosions identified.
There is vascular calcification.
IMPRESSION:
1. No evidence of fracture or effusion.
2. Vascular calcification.
US EXTREMITY NONVASCULAR LEFT [**2136-3-29**] 3:00 PM
IMPRESSION:
Symmetric unremarkable appearing bursa within the hip
bilaterally. No focal soft tissue collection or abscess
identified in the left hip in the region of the patient's
discomfort.
[**2136-3-30**] 2:05 PM
CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST
IMPRESSION:
1. Diverticulosis, without evidence of diverticulitis.
2. Cholelithiasis.
3. Multiple hepatic cysts.
US EXTREMITY NONVASCULAR RIGHT [**2136-3-30**] 9:51 AM
Ultrasound was performed adjacent to the right knee. The study
reveals a large approximately 4 x 2 cm simple fluid collection
lateral to the right knee joint. No septations or debris are
noted within this fluid collection.
IMPRESSION: Simple fluid collection adjacent to right knee. The
differential would include either [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 4675**] cyst or a large knee
effusion.
JOINT FLUID ANALYSIS WBC HCT,Fl Polys Bands Lymphs Monos Other
[**2136-3-30**] 03:17PM 40 6*1 58* 1* 28 12 1*2
Source: Knee
1 SPUN HEMATOCRIT PERFORMED
2 CSF LINING CELL
JOINT FLUID Crystal Shape Locatio Birefri Comment
[**2136-3-30**] 03:17PM FEW NEEDLE I/E1 NEG c/w monoso2
Source: Knee
1 Intra/ExtraCellular
2 c/w monosodium urate crystals
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2136-4-1**] 07:10AM 3.3* 4.16* 11.3* 32.8* 79* 27.1 34.4
15.8* 121*
[**2136-3-31**] 07:00AM 3.8* 4.03* 10.9* 31.8* 79* 27.1 34.4
15.8* 130*
[**2136-3-30**] 05:18AM 3.6* 4.03* 10.8* 31.6* 78* 26.9* 34.3
15.9* 123*
[**2136-3-29**] 05:30AM 5.3 4.33* 11.3* 34.0* 79* 26.0* 33.1
15.8* 125*
[**2136-3-28**] 07:57AM 32.4*
[**2136-3-28**] 03:43AM 5.8 3.84* 10.4* 30.0* 78* 27.1 34.8 16.0*
119*
[**2136-3-27**] 03:10PM 8.9 5.02 13.1* 38.6* 77* 26.2* 34.0 15.6*
133
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2136-4-1**] 07:10AM 105 73* 2.9* 142 3.4 103 28 14
[**2136-3-31**] 07:00AM 116* 73* 2.6* 141 3.3 104 28 12
[**2136-3-30**] 05:18AM 165* 77* 2.7* 141 3.2* 104 271 13
1 NOTE UPDATED REFERENCE RANGE AS OF [**2135-8-12**]
[**2136-3-29**] 04:40PM 3.8
[**2136-3-29**] 05:30AM 111* 80* 2.7* 142 2.8*1 104 272 14
1 VERIFIED BY REPLICATE ANALYSIS
NOTIFIED L. CAZAU @0827 [**2136-3-29**]
2 NOTE UPDATED REFERENCE RANGE AS OF [**2135-8-12**]
[**2136-3-28**] 10:37AM 205* 85* 2.7* 140 3.0* 102 251 16
1 NOTE UPDATED REFERENCE RANGE AS OF [**2135-8-12**]
[**2136-3-28**] 03:43AM 221* 88* 2.7* 140 2.8*1 102 272 14
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2136-4-1**] 07:10AM 8.9 3.5 1.5* 12.0*
DRUGS FK506 rapmycn
[**2136-4-1**] 07:10AM 8.01 4.0
Brief Hospital Course:
61 year old male with history of metastatic prostate cancer,
APKD s/p kidney transplant on immunosupression presenting with
fever, chills, hypotension and L hip cellulitis.
.
#. Fever, Hypotension, L hip cellulitis - resolved with fluids.
Likely from early sepsis. CT abdomen/pelvis showed possible
early diverticulitis. In the ICU, patient was placed on
vancomycin (history of MRSA wound infection in past) and zosyn
and stress dose steroids. He was normotensive and did not
require pressors and was afebrile. He was transferred to the
floor team the subsequent AM. On the floor he had shaking
chills and fever initially and reported that he had received a
lupron shot 1 week PTA and now had new erythema on his Left hip
that was tender. An ID consult was called and they recommended
rapid tapering of his steroids to his home dose, imaging of the
L hip, a repeat CT abd/pelvis, a TTE to assess his murmur, and
an ultrasound of a fluid pocket on the lateral side of his right
knee. The U/S of the L hip was negative for abscess, a CT on
day of discharge on preliminary read showed no evidence of
osteomyelitis or effusion. Oncology followed the patient
in-house, and felt that it was unlikely that the patient's left
hip erythema was secondary to the lupron shot. They recommended
d/c'ing the patient's casodex and will consider switching the
patient to zoladex as an outpatient. A repeat CT of the
abd/pelvis showed no evidence of diverticulitis. In discussion
with the renal attending, ID felt that a TTE could be considered
as an outpatient. The ultrasound of the fluid pocket on the
lateral side of his right knee revealed a fluid pocket that
could be part of a knee effusion. Rheum was consulted and they
performed an arthrocentesis which was positive for gout, but
negative for septic arthritis. Blood cultures showed no growth
to date at time of discharge, CXR was negative, urine culture
negative, stool cultures negative, and CMV VL negative. He
defervesced by HD3 and was switched from vanc and zosyn to
linezolid for an additional 2 day course at time of discharge.
He received 1 dose of linezolid as an inpatient without a
reaction. He will follow-up with Dr. [**Last Name (STitle) 4920**] within 2 weeks.
- consider TTE as outpatient
- follow-up final read of Left hip CT
.
#. Kidney transplant - patient was followed by the renal
transplant team as an inpatient. His creatinine was 2.7 on
admission and was stable until discharge, when it was at 2.9.
The renal team felt that his renal function was at baseline. He
was continued on his home dose of FK506 and Rappamune while his
levels were monitored QD.
.
#. Prostate CA - metastatic
Oncology followed the patient in-house, and felt that it was
unlikely that the patient's left hip erythema was secondary to
the lupron shot. They recommended d/c'ing the patient's casodex
and will consider switching the patient to zoladex as an
outpatient.
.
#. Knee pain - secondary to gout. Rheumatology performed an
arthrocentesis which returned wtih birefrigent intra and
extra-cellular crystals. His uric acid was found to be elevated
at 12.0. He was given 1 dose of colchicine for acute gout, but
this was d/c'ed the following day by the renal team. His
prednisone was increased to 20 mg PO QD x 5 days, after which he
would return to his home dose of 10 mg QD. Rheumatology was
called on day of discharge, and they felt that allopurinol
should not be started in the setting of an acute flare, and that
the steroids were an appropriate treatment. Rheumatology will
call the patient and arrange for outpatient follow-up.
- Tylenol for pain while on linezolid
- Continue Vicodin prn for knee pain after finishing linezolid
course
- consider allopurinol as outpatient
Medications on Admission:
1. Rapammune 2 mg qHS
2. Prograf 2 mg [**Hospital1 **]
3. Prednisone 10mg QD
4. Bactrim SS QOD
5. Rocalcitrol M-W-F
6. Neurontin 300 mg [**Hospital1 **]
7. Lasix 80mg daily
8. MVI qAM
9. Casodex qAM
10. Lupron injections each 23 days
11. Vicoden prn
12. Tylenol prn
Discharge Medications:
1. Sirolimus 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
2. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO BID (2 times
a day).
3. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO Every other day.
4. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO EVERY
OTHER DAY (Every Other Day).
5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
6. Multivitamin Capsule Sig: One (1) Cap PO QAM (once a day
(in the morning)).
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Prednisone 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
for 3 days: 20 mg/day for 3 days then return to your regular
dose of 10 mg/day on Thursday [**4-5**].
Disp:*6 Tablet(s)* Refills:*0*
10. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 2 days: do not take your vicodin for pain while on
linezolid, take tylenol instead.
Disp:*3 Tablet(s)* Refills:*0*
11. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain for 7 days: take tylenol instead of vicodin for
pain while on linezolid.
12. Vicodin 5-500 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for pain: do not take while taking linezolid .
Discharge Disposition:
Home
Discharge Diagnosis:
Left hip cellulitis
Gout
Hypotension
Discharge Condition:
stable
Discharge Instructions:
1. Please take all medications as prescribed.
2. Please keep all follow-up appointments.
3. Please seek medical attention if you develop fevers, chills,
new rashes, shortness of breath, chest pain, worsened hip or
knee pain or have any other concerning symptoms.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2695**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2136-4-26**] 12:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4380**], MD Phone:[**Telephone/Fax (1) 3237**]
Date/Time:[**2136-4-27**] 11:00
Please follow-up with Dr. [**Last Name (STitle) 4920**] at [**Telephone/Fax (1) 60**] within 2 weeks.
You will be called by rheumatology, Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] regarding
possible rheumatology follow-up and starting allopurinol. If
you do not receive a call within 1 week, please call
[**Telephone/Fax (1) 2756**] and ask to have her paged.
[**Name6 (MD) 2105**] [**Name8 (MD) 2106**] MD [**MD Number(2) 5038**]
Completed by:[**2136-4-1**]
|
[
"198.5",
"V42.0",
"038.9",
"682.6",
"V10.46",
"585.6",
"274.9",
"255.4",
"995.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.91",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
15625, 15631
|
10197, 13945
|
326, 357
|
15712, 15721
|
2786, 10174
|
16032, 16844
|
2162, 2211
|
14261, 15602
|
15652, 15691
|
13971, 14238
|
15745, 16009
|
2226, 2767
|
275, 288
|
385, 1250
|
1272, 1950
|
1966, 2146
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,047
| 140,219
|
21138
|
Discharge summary
|
report
|
Admission Date: [**2108-7-2**] Discharge Date: [**2108-7-20**]
Date of Birth: [**2059-5-20**] Sex: M
Service: [**Doctor First Name 147**]
Allergies:
Tetracyclines / Demerol / Verapamil / Ativan / Iodine; Iodine
Containing
Attending:[**First Name3 (LF) 473**]
Chief Complaint:
Infected necrotic acute on chronic pancreatitis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
49 yo male with history of multiple episodes of pancreatitis,
developed symptoms of recurrence the week of [**5-23**]. He was
admitted to [**Hospital **] Hospital for management ([**Date range (1) 56064**]).
His hospital course at [**Hospital1 **] was significant for the
following:
1. Pancreatic necrosis with 2 abscesses percutaneously drained.
VRE and yeast was grown from the drainage. Pt underwent a
course of Linezolid and fluconazole. Drain #2 was dc'd on [**5-27**].
2. Sputum cx with stenotrophomonas treated with a course of
Levofloxacin.
3. Macrocytic anemia thought to be secondary to methotrexate
therapy. Treated with PRBC's and cessation of methotrexate.
4. Massive distention of the cecum with pneumatosis of the right
colon and hemodynamic instability.
Past Medical History:
Neuro:
?????? Depression
?????? Chronic abdominal pain
. Chronic chest pain
Pulm:
?????? Chronic severe interstitial pneumonitis
?????? Asthma
?????? Parital diaphragmatic paralysis
?????? Ventilator dependence at night due with daytime trach collar
CV:
?????? Cor pulmonale(EF [**6-5**] 60%)
?????? Endocarditis
?????? Mitral valve prolapse
?????? Pericarditis
FEN/GI:
?????? GERD s/p Nissen Fundoplication '[**98**]
. Exploratory celiotomy with lysis of adhesions
Social History:
Premorbid occupation was security guard at BU
Lives with wife
[**Name (NI) **] tobacco or ETOH history
Family History:
None
Physical Exam:
Gen: Awake, alert, NAD
Pulm: On trach collar; BS diminshed in the bases; otherwise with
mild rhonchi
CV: RRR;
Abd: Soft, distended, mild pain on palpation. Scattered
ecchymoses unchanged since admission. LLQ rash in dermatomal
distribution thought to have been Shingles.
Ext: Mild edema, improved since early on in admission.
Nontender. Residual plantar tenderness with evidence of tinea
pedis.
Pertinent Results:
[**2108-7-20**] 04:17AM BLOOD WBC-13.9* RBC-2.94* Hgb-9.5* Hct-32.1*
MCV-109*# MCH-32.4* MCHC-29.8* RDW-16.5* Plt Ct-313
[**2108-7-19**] 05:44AM BLOOD WBC-16.3* RBC-3.06* Hgb-9.9* Hct-30.0*
MCV-98# MCH-32.5* MCHC-33.1 RDW-16.6* Plt Ct-279
[**2108-7-17**] 03:26AM BLOOD WBC-19.5* RBC-3.29* Hgb-10.8* Hct-32.0*
MCV-97 MCH-32.7* MCHC-33.7 RDW-16.5* Plt Ct-258
[**2108-7-19**] 05:44AM BLOOD Glucose-151* UreaN-15 Creat-0.4* Na-137
K-4.5 Cl-100 HCO3-29 AnGap-13
[**2108-7-18**] 07:49AM BLOOD Glucose-125* UreaN-13 Creat-0.5 Na-137
K-4.0 Cl-100 HCO3-30* AnGap-11
[**2108-7-18**] 06:00AM BLOOD ALT-31 AST-27 AlkPhos-407* Amylase-39
TotBili-0.5
[**2108-7-18**] 04:13AM BLOOD ALT-34 AST-37 AlkPhos-452* Amylase-45
TotBili-0.6
[**2108-7-18**] 06:00AM BLOOD Lipase-17
[**2108-7-18**] 04:13AM BLOOD Lipase-18
[**2108-7-20**] 04:17AM BLOOD Calcium-8.7 Phos-7.2*# Mg-2.2
[**2108-7-19**] 05:44AM BLOOD Calcium-8.8 Phos-4.1 Mg-2.4
[**2108-7-18**] 07:49AM BLOOD Calcium-9.1 Phos-3.2# Mg-2.2
[**2108-7-16**] 04:29PM BLOOD Type-ART O2-45 pO2-89 pCO2-46* pH-7.44
calHCO3-32* Base XS-5 Intubat-INTUBATED Vent-IMV
[**2108-7-9**] 03:09PM BLOOD Type-ART Temp-36.6 Rates-/18 O2-50 pO2-90
pCO2-44 pH-7.44 calHCO3-31* Base XS-4 Intubat-INTUBATED
[**2108-7-7**] 05:42AM BLOOD Type-ART Temp-35.6 Rates-[**10-18**] Tidal V-600
PEEP-8 O2-45 pO2-61* pCO2-40 pH-7.49* calHCO3-31* Base XS-6
Intubat-INTUBATED Vent-IMV
[**2108-7-18**] 12:08 pm SPUTUM Source: Endotracheal.
GRAM STAIN (Final [**2108-7-18**]):
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Preliminary):
? OROPHARYNGEAL FLORA ABSENT.
YEAST. SPARSE GROWTH.
GRAM POSITIVE BACTERIA. SPARSE GROWTH.
BEING ISOLATED FOR FURTHER IDENTIFICATION.
[**2108-7-17**] 10:00 am MRSA SCREEN Site: RECTAL
**FINAL REPORT [**2108-7-19**]**
MRSA SCREEN (Final [**2108-7-19**]): NO STAPHYLOCOCCUS AUREUS
ISOLATED.
[**2108-7-17**] 10:00 am BLOOD CULTURE PICC.
AEROBIC BOTTLE (Pending):
ANAEROBIC BOTTLE (Pending):
[**2108-7-16**] 5:51 pm CATHETER TIP-IV Source: LEFT SUBCLAVIAN.
**FINAL REPORT [**2108-7-18**]**
WOUND CULTURE (Final [**2108-7-18**]): No significant growth.
[**2108-7-15**] 9:17 pm SPUTUM Site: ENDOTRACHEAL
GRAM STAIN (Final [**2108-7-15**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
RESPIRATORY CULTURE (Preliminary):
OROPHARYNGEAL FLORA ABSENT.
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup will be performed appropriate to the isolates
recovered from
this site.
WORK UP PER DR. [**First Name (STitle) **] ([**Numeric Identifier 47824**]) ID FELLOW [**2108-7-18**].
NON-FERMENTER, NOT PSEUDOMONAS AERUGINOSA. HEAVY
GROWTH.
GRAM NEGATIVE ROD #2. HEAVY GROWTH.
FURTHER IDENTIFICATION TO FOLLOW.
GRAM NEGATIVE ROD #3. MODERATE GROWTH.
FURTHER IDENTIFICATION TO FOLLOW.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
NON-FERMENTER, NOT PSEUDOMONAS
AERUGINOSA
| GRAM NEGATIVE ROD #2
| | GRAM NEGATIVE
ROD #3
| | |
[**2108-7-15**] 9:16 pm BLOOD CULTURE
AEROBIC BOTTLE (Pending):
ANAEROBIC BOTTLE (Pending):
[**2108-7-6**] 9:18 pm FLUID,OTHER PANCREATIC DRAINAGE.
**FINAL REPORT [**2108-7-11**]**
GRAM STAIN (Final [**2108-7-7**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
FLUID CULTURE (Final [**2108-7-11**]):
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup is performed appropriate to the isolates recovered
from the
site (including a screen for Pseudomonas aeruginosa,
Staphylococcus
aureus and beta streptococcus).
ENTEROCOCCUS SP.. MODERATE GROWTH.
SENSITIVE TO LINEZOLID AND SYNERCID. RESISTANT TO
MINOCYCLINE.
STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA. SPARSE
GROWTH.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
| STENOTROPHOMONAS
(XANTHOMONAS) MALTOPH
| |
AMPICILLIN------------ =>32 R
CHLORAMPHENICOL------- 8 S
LEVOFLOXACIN---------- =>8 R
PENICILLIN------------ =>64 R
TRIMETHOPRIM/SULFA---- 2 S
VANCOMYCIN------------ =>32 R
ANAEROBIC CULTURE (Final [**2108-7-11**]): NO ANAEROBES ISOLATED.
[**2108-7-6**] 9:18 pm BLOOD CULTURE Site: A LINE 1 OF 2.
**FINAL REPORT [**2108-7-12**]**
AEROBIC BOTTLE (Final [**2108-7-12**]): NO GROWTH.
ANAEROBIC BOTTLE (Final [**2108-7-12**]): NO GROWTH.
[**2108-7-6**] 9:18 pm BLOOD CULTURE 2 OF 2. L SC.
**FINAL REPORT [**2108-7-12**]**
AEROBIC BOTTLE (Final [**2108-7-12**]): NO GROWTH.
ANAEROBIC BOTTLE (Final [**2108-7-12**]): NO GROWTH.
Brief Hospital Course:
Overall developments may be summarized by system as follows:
(Active issues from the present illness denoted by asterisk)
Neuro:
?????? Depression
?????? Chronic abdominal pain
Pulm:
. *Ventilator dependence at night due with daytime trach
collar
?????? *Hospital acquired pneumonia
?????? Chronic severe interstitial pneumonitis
?????? Asthma
?????? Parital diaphragmatic paralysis
CV:
?????? Cor pulmonale history (EF [**6-5**] 60%)
?????? Endocarditis
?????? Mitral valve prolapse
?????? Pericarditis
FEN/GI:
?????? *Microperforation of cecum with pneumatosis
?????? *Necrotic, infected acute on chronic pancreatitis with
pseudocysts growing VRE and stenotrophomonas;
?????? *Failure to tolerate PO or TF diet due to bloating and pain
?????? GERD s/p Nissen Fundoplication
Heme/ID:
?????? *Sepsis from infected pancreatitis and colonic
microperforation.
?????? *Oral thrush currently on fluconazole
?????? *Shingles of the left lower abdomen s/p course of acyclovir
Additional detail on active issues by system as follows:
Neuro:
Pain was managed with IV agents through the majority of the
admission. In the last week, he was transitioned to his usual
PO regimen. He has tolerated this well. The pt. has described
relief from abdominal cramping with diazepam. This has been
helpful but he has had 2 episodes of delirium as a result. Mr
[**Known lastname 4894**] has been occasionally tearful. Psychiatry was consulted
regarding his depression who recommended continuation of his
Wellbutrin.
Pulm:
The patient's usual schedule of overnight SIMV with daytime
trach mask was resumed by [**7-9**]. He has had a gradual return to
his baseline pulmonary status. Bibasilar consolidation
consistent with aspiration pneumonia was seen on CXR on [**7-2**].
Sputum cultures have yielded gram negative rods difficult to
speciate. This is currently being treated with a course of
Levaquin.
FEN/GI:
The CT findings of cecal dilatation and pneumatosis were
followed with serial abdominal exams and interval CT scans with
consultation from the colorectal surgery team. Microperforation
of cecum was identified on subsequent scans but the overall
appearance improved with time. At present, observation is
recommended for this process.
With respect to the pancreas, the hepatobiliary surgery team has
managed the patient. Linezolid was restarted on arrival and was
discontinued [**7-18**] for a total 4 week course to treat VRE. A
course of Bactrim was also completed to treat Stenotrophomonas
from the drain as well. The pancreatic drain was inadvertanly
lost on [**7-11**]. Interval CT scan on [**7-15**] showed no drainable
collection. At present, the patient's pancreas is considered
stable and may be followed in the standard fashion for
pancreatitis with pseudocysts.
Enteral feeding was attempted via the G-J tube alone, in
combination with PO regulars, and with regulars alone. The
patient has failed to tolerate any combination citing bloating
and pain. It was concluded that enteral feeding at present is
unfeasible. A period of bowel rest of at least 1 month has been
elected with TPN for the interim. The patient may take po clears
for comfort and some meds are given po to minimize daily IVF
volume.
Heme/ID:
Apart from the ID issues discussed above, the patient has also
been treated for shingles based on clinical suspicion
(acyclovir) and oral thrush (currently on fluconazole).
Medications on Admission:
Xanax 0.5 q6 prn
Protonix 40 iv bid
tylenol prn
xopenex nebs q6
heparin sq tid
morphine 480 q3 pg
dulcolax 10 pr
flexeril 10 tid
lidoderm patch *3
zofran 4 q6 prn
prednisone 10 po bid
Discharge Medications:
1. Levalbuterol HCl 0.63 mg/3 mL Solution Sig: One (1) puff
Inhalation q6 ().
2. Lidocaine 5 % Adhesive Patch, Medicated Sig: One (1) Adhesive
Patch, Medicated Topical QD (once a day).
3. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q3-4H () as needed.
4. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q4-6H (every 4 to 6 hours) as needed.
5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
6. Morphine Sulfate 15 mg Tablet Sig: 1-2 Tablets PO Q3-4H () as
needed.
7. Morphine Sulfate 30 mg Cap, 24HR Sust Release Pellets Sig:
One (1) Cap, 24HR Sust Release Pellets PO Q6H (every 6 hours).
8. Hydrocortisone 0.5 % Ointment Sig: One (1) Appl Topical TID
(3 times a day) as needed for pruritis.
9. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
10. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
11. Montelukast Sodium 10 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
12. Prednisone 20 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
13. Fluconazole 100 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 13 days.
14. Insulin Regular Human 100 unit/mL Solution Sig: per sliding
scale units Injection every six (6) hours.
15. Bupropion HCl 150 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO BID (2 times a day).
16. Diazepam 5 mg/mL Solution Sig: Five (5) mg Injection QHS PRN
().
17. Diazepam 5 mg/mL Solution Sig: 2.5-5 mg Injection Q6H (every
6 hours) as needed.
18. Ondansetron HCl 2 mg/mL Solution Sig: Four (4) mg
Intravenous Q3-4H () as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] - [**Location (un) 47**]
Discharge Diagnosis:
Neuro:
??????Depression
??????Chronic abdominal pain
Pulm:
??????Hospital acquired pneumonia*
??????Chronic severe interstitial pneumonitis
??????Asthma
??????Parital diaphragmatic paralysis
??????Ventilator dependence at night due with daytime trach collar
CV:
??????Cor pulmonale history (EF [**6-5**] 60%)
??????Endocarditis
??????Mitral valve prolapse
??????Pericarditis
FEN/GI:
??????*Microperforation of cecum with pneumatosis
??????*Necrotic, infected acute on chronic pancreatitis with
pseudocysts growing VRE and stenotrophomonas;
??????*Failure to tolerate PO or TF diet due to bloating and pain
??????GERD s/p Nissen Fundoplication
Heme/ID:
??????*Sepsis from infected pancreatitis and colonic
microperforation.
??????*Oral thrush currently on fluconazole
??????*Shingles of the left lower abdomen s/p course of acyclovir
. Macrocytic anemia
Discharge Condition:
Fair
Discharge Instructions:
none
Followup Instructions:
On transfer to [**Hospital 47**] [**Hospital 1281**] Hospital:
Family physician: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4427**], MD
Gastroenterology: [**Known firstname **] [**Last Name (NamePattern1) 37454**], MD
Pulmonary: Sew-[**Name6 (MD) **] [**Name8 (MD) **], MD
|
[
"515",
"112.0",
"577.0",
"424.0",
"507.0",
"493.90",
"569.89",
"V44.0",
"577.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"38.91",
"38.93",
"96.71",
"89.64",
"00.14"
] |
icd9pcs
|
[
[
[]
]
] |
13211, 13279
|
7867, 11275
|
398, 404
|
14182, 14188
|
2287, 3857
|
14241, 14536
|
1848, 1854
|
11509, 13188
|
13300, 14161
|
11301, 11486
|
14212, 14218
|
1869, 2268
|
4875, 5847
|
311, 360
|
5877, 5877
|
5905, 7844
|
432, 1209
|
1231, 1711
|
1727, 1832
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,873
| 137,057
|
1036
|
Discharge summary
|
report
|
Admission Date: [**2193-8-29**] Discharge Date: [**2193-9-16**]
Date of Birth: [**2156-6-6**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6088**]
Chief Complaint:
Leg and back pain
Major Surgical or Invasive Procedure:
1. Left L4-L5 Microdiscectomy
2. Exploratory laparotomy with primary repair of inferior vena
cava injury and Dacron interposition graft repair of right
common iliac artery transection.
3. Primary abdominal wall closure with placement of retention
sutures and Ethicon wound bridges.
History of Present Illness:
(Per medical record)
Ms. [**Known lastname **] has had low back pain for the past several months that
has been stable. However, in [**Month (only) 216**] she developed acute onset of
severe pain in her L leg from the buttock region down the leg
and all the way to the end of her foot. There is also a sense of
numbness. She tried epidural steroid injections without much
relief.
Past Medical History:
Gastroparesis
Psoriasis
Anxiety
Social History:
Married. She works as a lawyer and has to travel for work.
Family History:
Noncontributory
Physical Exam:
On pre-op exam:
General: pleasant, appears uncomfortable with walking, though
can
walk from exam room to waiting room and bathroom; avoids bearing
weight on L leg
HEENT: sclerae anicteric
OP: MMM, no ulcers/lesions/thrush
Neck: supple, no LAD
Cardiovascular: RRR, normal S1, S2, no M/G/R
Respiratory: CTA bilat w/o wheezes/rhonchi/rales
Back: no focal tenderness, no CVAT
Gastrointestinal: soft, non-tender, non-distended, no
hepatosplenomegaly
Musculoskeletal: no joint warmth or swelling
Ext: Warm and well perfused, no edema
Skin: no rashes, no jaundice
Neurological: alert, conversant, appropriate, normal speech, no
facial droop. Sensation and reflexes intact in lower extremities
bilaterally, with 5/5 strength in all LE muscle groups including
dorsiflexion of great toes.
Pertinent Results:
On admission:
WBC-21.7*# RBC-3.25* Hgb-9.9* Hct-29.5*# MCV-91 MCH-30.5
MCHC-33.6 RDW-13.6 Plt Ct-317
Neuts-75.8* Lymphs-19.2 Monos-4.0 Eos-0.5 Baso-0.4
PT-16.9* PTT-81.4* INR(PT)-1.5*
Glucose-100 UreaN-13 Creat-0.7 Na-138 K-4.4 Cl-107 HCO3-24
AnGap-11
LD(LDH)-158
Calcium-8.1* Phos-2.8 Mg-2.0
freeCa-1.08*
HIT panel: negative
On discharge:
WBC-12.0* RBC-3.42* Hgb-10.2* Hct-30.6* MCV-89 MCH-29.9
MCHC-33.4 RDW-15.0 Plt Ct-653*
Glucose-127* UreaN-7 Creat-0.7 Na-138 K-4.3 Cl-102 HCO3-27
AnGap-13
Calcium-8.8 Phos-3.9 Mg-2.3
Imaging:
CTA ([**2193-8-30**])
1. Large retroperitoneal hematoma with active extravasation of
contrast from
an arteriovenous fistula between the right common iliac artery
and the left
common iliac vein with pseudoaneurysm formation.
2. Thrombosis of the common iliac artery with reconstitution
immediately
proximal to the bifurcation of widely patent external and
internal iliac
arteries.
3. Embolus into the right anterior tibial artery.
KUB ([**2193-9-8**])
Clips in the midline. Several air-fluid levels in non-distended
small bowel loops. No visible colonic gas. Gas in the rectum is
well
visualized. No evidence of free air.
RUQ U/S ([**2193-9-8**])
1. No evidence of cholecystitis. Sludge-like cholelithiasis.
2. Small amount of fluid in [**Location (un) 6813**] pouch.
Brief Hospital Course:
On [**2193-8-29**] Ms. [**Known lastname **] was admitted to the Neurosurgery Service and
underwent an elective microdisectomy. In the PACU she complained
of right foot numbness and tingling. Her foot was noted to be
cool and mottled, without PT or DP pulses. A stat duplex study
was ordered, which demonstrated decreased arterial flow in the
entire right leg. No embolus or clot was noted. Her leg
proceeded to become less mottled, and the numbness resolved. A
Vascular Surgery consult was requested, with initial
recommendations for close monitoring with serial pulse exams.
For this, she was transferred to the VICU.
Upon arrival to the VICU she was tachycardic to 110. Her
hematocrit decreased to 22 from 29 preoperatively. She
underwent a CTA of her abdomen which demonstrated a
retroperitoneal hematoma with active extravasation from a
possible aortocaval fistula with an arterial pseudoaneursym.
She was urgently taken for angiography on [**2193-8-30**] and found to
have and AV fistula at the level of the right common iliac
artery in association with the inferior vena cava. A
pseudoaneurysm of right common iliac artery was noted, in
addition to significant thrombus of the right common iliac
artery, with reconstitution of the external iliac artery via the
hypogastric. After multiple unsuccessful attempts were made at
accessing the infrarenal abdominal aorta/right common iliac
artery, the decision was made to convert to an open procedure.
Ms. [**Known lastname **] was taken to the operating room where she underwent
exploratory laparotomy, primary repair of an inferior vena cava
injury, and Dacron interposition graft repair of a right common
iliac artery transection. Due to the significant fluid
resuscitation required, her abdomen was packed and left open for
planned closure at a later date. On [**2193-9-2**] she was taken back
to the operating room by the Acute Care Surgery Service for
primary abdominal wall closure and placement of retention
sutures and Ethicon wound bridges.
Postoperatively she remained intubated and was transferred to
the ICU. She was maintained on empiric antibiotic coverage with
vancomycin and zosyn. A HIT panel was sent due to a downward
trend in platelet count in the setting of heparin
administration. This returned negative, and she was started on
a heparin drip on hospital day #6. She was additionally
extubated on this day, which she tolerated well.
Ms. [**Known lastname **] was transferred to the step-down unit, VICU, on
hospital day #7. She continued to experience left lower
extremity weakness/tingling, however, her DP/PT pulses remained
palpable. Physical therapy was consulted. She received one
unit of PRBCs for hematocrit 24.6, with appropriate increase to
27.6. Her heparin drip was stopped and subcutaneous heparin
initiated. Her diet was slowly advanced to regular, however, on
hospital day #9 she began to have episodes of bilious emesis in
the setting of known ileus. She had not yet passed stool, and a
KUB was consistent with ileus with gastric dilatation. A RUQ
ultrasound was negative for cholecystitis. She was made NPO
while awaiting return of bowel function, however she refused
placement of a nasogastric tube. On hospital day #11 she began
to pass copious amounts of diarrhea in conjunction with
abdominal distension and crampy lower abdominal pain. Both
Acute Care Surgery and Gastroenterology were consulted. Stool
was sent for C.Diff, and she was started on oral vancomycin. IV
vancomycin and zosyn were stopped at this time. Three C.Diff
studies returned negative, however, the oral vancomycin was
continued for empiric coverage of C. Dificile.
Slowly, Ms. [**Known lastname 6814**] emesis and diarrhea decreased with the use of
zofran and immodium, and her diet was slowly readvanced. She
tolerated this well. She continued to work with physical
therapy, and her left lower extremity weakness and tingling
resolved. She proceeded to ambulate quite well. She did have
one recurrent episode of numbness/tingling along her left ankle
into the left first toe, and Neurosurgery was called to assess
her. Some decreased sensation was noted along the left ankle,
but strength remained intact. She was asked to have this issue
followed up at her Neurosurgery appointment.
On hospital day #19 Ms. [**Known lastname **] was ambulating well, tolerating a
regular diet, and was having formed stools. She was deemed
appropriate for discharge with close follow-up scheduled for her
retention sutures which remained in place at the time of
discharge.
Medications on Admission:
Gabapentin
Tylenol
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
2. clobetasol 0.05 % Solution Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
Disp:*1 bottle* Refills:*2*
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily). Tablet, Delayed
Release (E.C.)(s)
4. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*1*
5. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO qHS PRN as
needed for anxiety.
Disp:*15 Tablet(s)* Refills:*0*
6. vancomycin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 7 days.
Disp:*26 Capsule(s)* Refills:*0*
7. Tylenol-Codeine #3 300-30 mg Tablet Sig: 1-2 Tablets PO q4-6
hrs PRN as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Home Health Care
Discharge Diagnosis:
1. Radiculopathy due to L4-L5 disc protrusion.
2. Status post L4-L5 discectomy with injury to the right iliac
artery and inferior vena cava.
3. Status post repair of inferior vena cava and Dacron
interposition graft of the iliac artery and open abdomen.
4. Status post closure of open abdominal wound.
5. Diarrhea
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
?????? Keep your wound(s) clean and dry / No tub baths or pool
swimming for two weeks from your date of surgery.
?????? If you have steri-strips in place, they will fall off on their
own or be taken off in the office. You may trim the edges if
they begin to curl.
?????? No pulling up, lifting more than 10 lbs., or excessive bending
or twisting.
?????? Limit your use of stairs to 2-3 times per day.
?????? Have a friend or family member check your incision daily for
signs of infection.
?????? 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. No driving while on
narcotic pain medication.
?????? 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.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Do not smoke.
?????? Please resume all home medications, as well as those new
medications prescribed for you while inpatient. Visting nursing
services will be coming to your home to assist with dressing
changes.
?????? Call your surgeon immediately or go to the Emergency
Department if you experience any of the danger signs listed
below.
Followup Instructions:
1. Follow up with Dr. [**Last Name (STitle) 548**] in 5 weeks; please call to schedule
an appointment: [**Telephone/Fax (1) 2992**].
2. Follow up with Dr. [**Last Name (STitle) **] in [**Hospital 2536**] clinic in 2 weeks for
management of your abdominal retention sutures. Please call
([**Telephone/Fax (1) 6815**] to schedule that appointment.
3. Vascular Surgery Appointment with Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 1490**], MD
Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2193-9-25**] 9:00
|
[
"453.89",
"998.2",
"998.12",
"997.79",
"E878.8",
"285.9",
"560.1",
"E849.7",
"599.0",
"442.2",
"787.91",
"722.10"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.32",
"39.57",
"88.42",
"96.71",
"38.91",
"88.47",
"80.51",
"54.62",
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
8797, 8860
|
3342, 7903
|
331, 615
|
9218, 9218
|
2006, 2006
|
10922, 11452
|
1170, 1187
|
7972, 8774
|
8881, 9197
|
7929, 7949
|
9369, 10899
|
1202, 1987
|
2351, 3319
|
274, 293
|
643, 1023
|
2021, 2336
|
9233, 9345
|
1045, 1078
|
1094, 1154
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,319
| 167,333
|
2153
|
Discharge summary
|
report
|
Admission Date: [**2200-6-14**] Discharge Date: [**2200-6-17**]
Date of Birth: [**2122-3-19**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 10593**]
Chief Complaint:
Cough, dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 11503**] [**Known lastname **] [**Doctor Last Name 11504**] is a 78y/o lady with asthma, DM2, multiple
abdominal surgeries for SBOs after perforated jejunal
diverticulim in [**2191**], and falls with recent Colles' fracture who
presented to the ED due to cough and dyspnea and is admitted to
the MICU due to elevated lactate.
.
Of note, she was recently admitted [**Date range (1) 11505**] for hypotension
after
reported fall (unclear etiology, hypotension resolved), as well
as altered mental status (presumably related to medications
received for her wrist fracture, resolved with Narcan). Of
note, on that presentation she received steroids in the ED
because she was wheezy but they were not continued. She was
initially admitted to the [**Hospital Unit Name 153**] but was transferred to the floor
and was discharged home. No elevated lactate during the
previous admission. No changes were made to her medications.
.
She reports that since discharge, she has felt quite weak. She
has had gradually worsening shortness of breath and wheezing
associted with a cough productive of white sputum. No fever but
has had chills and sweats. Non-exertional chest tightness
associated with the wheezing. Reports worsened symptoms upon
waking up in the AM. She continued using her Advair [**Hospital1 **] as well
as PRN Albuterol inhaler and nebs with minimal improvement. She
had a PCP visit to [**Name Initial (PRE) **]/u her hospitalization on [**6-9**] (6 days ago)
and was started on Prednisone 20mg [**Hospital1 **] x3 days, decreased to
20mg daily three days ago (she did take it this AM). She says
that the dyspnea progressed, and today she tried taking a warm
shower to see if her symptoms got better but instead she felt as
if she was choking to death so she presented to the ED.
.
In the ED, initial VS were: T 98.2, HR 100, BP 148/66, RR 28,
POx 100% RA. On exam, she had scattered wheezes. She received
ASA and SL NTG; EKG was not concerning. Labs were notable for
WBC 15.4 (85.6% PMNs, no bands), Na 130, bicarb 16, and lactate
5.3. CXR showed no acute process. She complained of some mild
abdominal discomfort so given her h/o SBO's she underwent CT
abdomen that also showed no acute process. She received
Vanc/Zosyn, Albuterol/Ipratropium nebs, Insulin 6U for glucose
in the 300's, and Tylenol 1g PO. After 6L normal saline, repeat
lactate was 4.5 so she was admitted to the MICU.
.
On arrival to the MICU, she still feels very short of breath but
can speak in full sentences. Is worried that the Prednisone has
made her [**Doctor Last Name 11506**] without helping much, and that it has made her
blood sugar out of control. Denies any fevers. No rhinorrhea
or sinus congestion. No sick contacts at home. No recent
antibiotics. She has continued left wrist pain from her
fracture. No more abdomnal pain - she says that the pain she
had in the ED was mild dull peri-umbilical pain that she thinks
was related to being hungry, as well as swallowing phlegm - and
did not feel like the pain she had during SBO's. No
constipation/obstipation. When asked if she thinks she has had
poor PO intake recently, she denies. Drinks a lot of water.
.
REVIEW OF SYSTEMS:
(+) Per HPI.
Also notable for continued back pain and left wrist pain, very
poorly controlled FSBS in the setting of Prednisone (up to
400's), continued polyuria related to her DM2 but no dysuria.
Also had mild headache related to coughing frequently but this
has resolved. Has intermittent reflux for which she takes OTC
medications, but none recently.
(-) Denies fever, recent weight loss or gain. Denies headache,
sinus tenderness, rhinorrhea or congestion. Denies palpitations,
or weakness. Denies nausea, vomiting, diarrhea, constipation, or
changes in bowel habits. Denies dysuria or urgency. Denies
arthralgias or myalgias. Denies rashes or skin changes.
Past Medical History:
PAST MEDICAL HISTORY:
DM2 (on oral agents)
HTN
obesity
asthma
OA
jejunal diverticulitis
h/o peritonitis, perforated viscus
chronic back pain
plantar fasciitis
Colles fracture s/p fall [**2200-5-27**]
.
PAST SURGICAL HISTORY:
jujunal diverticulotomy
Ex-lap/LOA
trigger finger
SBR
TAH/BSO, tubal ligation
Social History:
-Home: Originally from PR. Moved here many years ago to raise
her children. She lives alone but her granddaughter stays with
her every night. She has 2 sons here and her daughter lives in
PR.
-Occupation: Retired. Used to work on a chicken factory in [**Location (un) 11507**].
-Tobacco: Never
-EtOH: None. History of use in the past but no heavy use in the
past.
-Illicits: Never
Family History:
NC
Physical Exam:
ADMISSION EXAM:
Vitals: T 98.3 ??????F, HR 86, BP 119/87, RR 17, POx 98% RA
General: Elderly obese lady, oriented x3, no respiratory
distress (no pursed lips, she can speak in full sentences)
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: Diffuse expiratory wheezes throughout all lung fields
bilaterally; no stridor; no rales or rhonchi
Abdomen: (+)bowel sounds; obese, midline scar is well-healed; no
hernia; mildly tender to very deep palpation of LLQ; otherwise
no other tenderness and no rebound
GU: foley in place, draining light yellow urine
Ext: thin, no edema, 2+ DP and PT pulses; LUE with cast in place
Neuro: face symmetric, [**6-14**] biceps, hip flexors; finger-to-nose
intact
DISCHARGE EXAM:
Vitals: T97.9 94-114/53/60, 74-87, 98-99% RA
General: Elderly obese lady, oriented x3, no respiratory
distress (no pursed lips, she can speak in full sentences)
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: Diffuse expiratory wheezes throughout all lung fields
bilaterally; no stridor; no rales or rhonchi
Abdomen: (+)bowel sounds; obese, midline scar is well-healed; no
hernia; mildly tender to very deep palpation of LLQ; otherwise
no other tenderness and no rebound
GU: foley in place, draining light yellow urine
Ext: thin, no edema, 2+ DP and PT pulses; LUE with cast in place
Neuro: face symmetric, [**6-14**] biceps, hip flexors; finger-to-nose
intact
Pertinent Results:
ADMISSION LABS:
[**2200-6-14**] 01:20PM BLOOD WBC-15.4* RBC-3.99* Hgb-12.3 Hct-37.6
MCV-94 MCH-30.9 MCHC-32.8 RDW-13.4 Plt Ct-561*#
[**2200-6-14**] 01:20PM BLOOD Neuts-85.6* Lymphs-7.7* Monos-3.7 Eos-2.6
Baso-0.3
[**2200-6-14**] 07:41PM BLOOD PT-11.0 PTT-23.8* INR(PT)-1.0
[**2200-6-14**] 01:20PM BLOOD Glucose-287* UreaN-27* Creat-1.0 Na-130*
K-4.8 Cl-95* HCO3-16* AnGap-24*
[**2200-6-14**] 01:20PM BLOOD ALT-25 AST-24 LD(LDH)-190 AlkPhos-67
TotBili-0.3
[**2200-6-14**] 07:41PM BLOOD Calcium-7.9* Phos-2.3* Mg-1.5*
[**2200-6-14**] 01:20PM BLOOD Albumin-4.2
[**2200-6-14**] 01:20PM BLOOD cTropnT-<0.01 proBNP-345
[**2200-6-14**] 01:22PM BLOOD Lactate-5.3*
DISCHARGE LABS
[**2200-6-17**] 05:46AM BLOOD WBC-12.9* RBC-3.36* Hgb-10.1* Hct-32.2*
MCV-96 MCH-29.9 MCHC-31.2 RDW-13.7 Plt Ct-445*
[**2200-6-17**] 05:46AM BLOOD Glucose-102* UreaN-18 Creat-0.8 Na-135
K-4.9 Cl-103 HCO3-28 AnGap-9
LACTATE TREND:
[**2200-6-14**] 01:22PM BLOOD Lactate-5.3*
[**2200-6-14**] 03:35PM BLOOD Lactate-4.5*
[**2200-6-14**] 08:41PM BLOOD Lactate-2.6*
MICRO DATA:
[**2200-6-14**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2200-6-14**] BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY [**Hospital1 **]
[**2200-6-14**] URINE URINE CULTURE-FINAL EMERGENCY [**Hospital1 **]
[**2200-6-14**] BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY [**Hospital1 **]
EKG [**2200-6-14**]:
sinus tachycardia, rate 104, RBBB, LAD bifasicular block
(unchanged compared to prior)
.
CXR [**2200-6-14**]:
Low lung volumes. No acute intrathoracic process.
.
CT ABDOMEN/PELVIS W/CONTRAST [**2200-6-14**] [preliminary report]:
1. No CT findings to explain patient's abdominal pain.
Post-surgical changes from prior small bowel anastomoses.
2. Diverticulosis without evidence of diverticulitis.
3. Multiple duodenal and small bowel diverticula.
Brief Hospital Course:
Ms. [**Known lastname 11503**] [**Known lastname **] [**Doctor Last Name 11504**] is a 78y/o lady with asthma, diverticulitis
s/p SBO's with multiple abdominal surgeries, DM2 with Metformin
uptitrated last month, falls with recent Colles' fracture who
presents with continued cough/dyspnea, hyperglycemia, and
elevated lactate.
.
ACTIVE ISSUES:
.
#. SOB/wheezing: Asthma exacerbation, unclear trigger but may be
realted to seasonal allergies. She was continued on prednisone
and given nebulizers. She slowly improved. Her prednisone was
weaned down to 30 mg daily but was not weaned further because of
adrenal insufficiency (see below). She was restarted on her
other home asthma medications. her lisinopril was changed to
losartan for possibility lisinopril was contributing to
cough/wheezing.
.
#. Adrenal insufficiency: She had hypotension during this
admision as well as previous admissions. We held her prednisone
for one day and performed [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 104**] stim test which showed that she
did not appropriately respond. We then consulted endocrinology
who recommended a very slow taper of her prednisone. She was
instructed to contine prednisone 30 mg daily for about 3 weeks
but she should follow up with endocrinology before tapering.
.
# Elevated lactate: Likely from medication and volume depletion.
She reports her metformin was recently uptitrated which may have
been contributing. Her metformin was stopped and she received
IVF and her lactate returned to [**Location 213**].
.
#. Diabetes mellitus type 2: Her metformin and glipizide were
stopped on admission and she was started on insulin sliding
scale. Later her glipizide was restarted and her blood sugars
were relatively well controlled. She was instructed that she
should call her PCP if her blood sugars were high.
.
#. Hypertension, benign: She has been on lisinopil, clonidine
and lasix which were held in the setting of hypotension on
presentation (this was thought to be due, at least in part, to
adrenal insufficiency. No source of infection was identified).
She was later restarted on colidine at a lower dose and her
lisinopril was switched to losartan as above. Her lasix was not
continued on discharge.
.
INACTIVE ISSUES:
.
#. Hyperlipidemia: stable.
-continued Pravastatin
.
#. Depression: stable.
-continued Sertraline
.
#. Insomnia: stable
-continued trazodone PRN
.
#. Pain: reasonably controlled.
Pain from left Colles' fracture and chronic back pain.
-continue home Gabapentin, Morpine and PRN Oxycodone
.
TRANSITIONAL ISSUES:
-[**Month (only) 116**] need insulin if blood sugars elevated on steroids and
without metformin
-Needs to be on long prednisone taper as directed by
endocrinology
-Blood cultures pending at time of discharge
-Would consider outpatient referral to Pulmonary.
Medications on Admission:
ASA 81mg daily
lisinopril 40 mg daily
clonidine 0.1 mg [**Hospital1 **]
pravastatin 40 mg daily
furosemide 20 mg daily
fluticasone-salmeterol 500-50 mcg/dose: 1 inh [**Hospital1 **]
ipratropium bromide 0.02 % neb TID
albuterol sulfate 90 mcg HFA: 1-2 puffs Q4H PRN
morphine 30 mg Extended Release [**Hospital1 **] PRN
oxycodone 15 mg TID PRN
gabapentin 600 mg TID
Valium 5 mg daily PRN anxiety [does not take every day]
Patanol 0.1 % 1 drop both eyes [**Hospital1 **]
metformin 500 mg: 1 tab QAM, 2 tabs QPM
glipizide 10 mg daily
sertraline 50 mg daily [but she does nto take this every day]
trazodone 50 mg QHS PRN insomnia
polyethylene glycol powder daily
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. losartan 100 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
3. clonidine 0.1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
5. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
6. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
every eight (8) hours as needed for wheezing.
7. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
[**2-10**] Inhalation every four (4) hours as needed for shortness of
breath or wheezing.
8. morphine 15 mg Tablet Extended Release Sig: Two (2) Tablet
Extended Release PO Q12H (every 12 hours).
9. oxycodone 5 mg Tablet Sig: Three (3) Tablet PO Q8H (every 8
hours) as needed for pain.
10. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO Q8H (every
8 hours).
11. diazepam 5 mg Tablet Sig: One (1) Tablet PO once a day as
needed for Anxiety.
12. olopatadine 0.1 % Drops Sig: One (1) Ophthalmic [**Hospital1 **] (2
times a day).
13. glipizide 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
16. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily) as needed for
constipation.
17. prednisone 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
Asthma exacerbation
Adrenal insufficiency
Lactic acidosis
Secondary Diagnoses:
Hypertension
Diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mrs. [**Known lastname 11503**] [**Known lastname **] [**Doctor Last Name 11504**],
Thank you for coming to the [**Hospital1 1170**]. You were admitted because you had an asthma
exacerbation. While here you had low blood pressure. This was
caused by a condition called adrenal insufficiency. You
developed this condition because of frequent steroid use for
your asthma. Because of this condition you will need to stay on
prednisone for a longer period of time and to follow up with an
endocrinologist. We also decreased the dose of clonidine you
were taking and stopped the furosemide. Please discuss these
changes with you primary doctor. You should also see a lung
doctor (pulmonologist) for further management of your asthma.
We also stopped your metformin because you developed a condition
called lactic acidosis. Stopping this medication in addition to
starting prednisone may make your blood sugars increase. It is
important to eat a low carbohydrate diet to keep your blood
sugar controlled. If your blood sugars do rise please contact
your primary doctor. Please do not stop any medications until
you have spoken to your doctor.
Medication Recommendations
Please START:
-Prednisone 30 mg daily until your primary doctor [**First Name (Titles) **] [**Last Name (Titles) 11508**]t instruct you to change this dose
-Losartan 100 mg daily
Please CHANGE:
Clonidine to 0.1 mg once daily
Please STOP:
Metformin
Lisinopril
Furosmide
Please continue taking all other medications as you have been
Followup Instructions:
Department: [**Hospital1 7975**] INTERNAL MEDICINE
When: WEDNESDAY [**2200-6-18**] at 10:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10134**], MD [**Telephone/Fax (1) 7976**]
Building: [**Hospital1 7977**] ([**Location (un) 686**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
***If you feel you are unable to make this appt, please call the
office to reschedule.
Department: DIV OF GI AND ENDOCRINE
When: FRIDAY [**2200-6-27**] at 3:20 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 1803**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
****You need to be followed up by a Pulmonologist within 2 weeks
from discharge. The Pulmonary department is working on an appt
for you and will call you at home with an appt. If you dont hear
from them by Thursday afternoon, please call the dept at
[**Telephone/Fax (1) 612**] to book.
|
[
"780.52",
"311",
"530.81",
"493.92",
"338.21",
"401.9",
"278.00",
"V54.12",
"250.02",
"724.2",
"562.10",
"276.50",
"276.2",
"715.90",
"560.9",
"255.41"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
13641, 13647
|
8488, 8818
|
321, 328
|
13812, 13812
|
6649, 6649
|
15491, 16561
|
4980, 4984
|
12019, 13618
|
13668, 13746
|
11337, 11996
|
13963, 15468
|
4483, 4562
|
4999, 5821
|
13767, 13791
|
5837, 6630
|
11051, 11311
|
3571, 4236
|
266, 283
|
8833, 10723
|
356, 3552
|
10740, 11030
|
6665, 8465
|
13827, 13939
|
4280, 4460
|
4578, 4964
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,675
| 163,254
|
41380
|
Discharge summary
|
report
|
Admission Date: [**2151-5-18**] Discharge Date: [**2151-6-1**]
Date of Birth: [**2088-7-30**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 473**]
Chief Complaint:
Pancreatic head mass
Major Surgical or Invasive Procedure:
[**2151-5-18**] - pylorus-sparing pacreaticoduodenectomy (Whipple
procedure)
History of Present Illness:
This is a 62-year old Female who presented initially with
obstructive jaundice. She underwent ERCP at [**Hospital3 417**]
Hospital on [**2151-3-29**] with sphincterotomy, brushings and stent
placement across a mid-biliary duct stricture. Fine-needle
aspiration biopsy performed on [**2151-4-23**] revealed necrotic debris,
with remaining concerns for malignancy given the findings of a
pancreatic head mass on endoscopic ultrasound. She was admitted
electively on [**2151-5-18**] following her pancreaticoduodenectomy
(Whipple procedure).
Past Medical History:
PMH: former smoker (20 pack-year), obesity, Meniere disease,
PSH: tonsillectomy, appendectomy
Social History:
Attests to 0.5 packs-per-day for 40-years (20 pack-year), rare
alcohol use ([**5-4**] drinks/year), denies recreational substance
use
Family History:
non-contributory
Physical Exam:
VITALS: Afebrile, vitals signs stable.
HEENT: Normocephalic, atraumatic. EOMI. PERRL. Nares clear.
Mucous membranes moist. Neck supple without lymphadenopathy.
CVS: Regular rate and rhythm, without murmurs, rubs or gallops.
S1 and S2.
RESP: Clear to auscultation bilaterally without adventitious
sounds. No wheezing, rhonchi or crackles.
ABD: soft, obese-appearing, appropriately tender, non-distended,
with normoactive bowel sounds. No masses or peritoneal signs.
EXTR: no cyanosis, clubbing or edema, 2+ peripheral pulses
INCISION: transverse incision is clean, dry and intact, without
evidence of erythema or drainage. Minimal serosanguinous
drainage noted. Staples open to air with steristrips between.
Pertinent Results:
[**2151-5-24**] 02:44AM BLOOD WBC-9.2 RBC-3.78* Hgb-12.9 Hct-37.6
MCV-99* MCH-34.0* MCHC-34.2 RDW-14.3 Plt Ct-239
[**2151-5-25**] 06:10AM BLOOD Creat-0.6 Na-138 K-3.8 Cl-94*
[**2151-5-24**] 02:44AM BLOOD Calcium-8.5 Phos-3.0 Mg-2.5
[**2151-5-18**] 11:24 am BILE
Fluid should not be sent in swab transport media. Submit
fluids in a
capped syringe (no needle), red top tube, or sterile cup.
GRAM STAIN (Final [**2151-5-18**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2151-5-21**]):
A swab is not the optimal specimen collection to evaluate
body
fluids.
KLEBSIELLA OXYTOCA. RARE GROWTH.
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA OXYTOCA
|
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- 16 I
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
ANAEROBIC CULTURE (Final [**2151-5-22**]): NO ANAEROBES ISOLATED.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
Pathology Examination
Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 89531**],[**Known firstname **] [**2088-7-30**] 62 Female [**-1/2137**] [**Numeric Identifier 90076**]
Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]
Gross Description by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **], DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 90077**]/dif
SPECIMEN SUBMITTED: Gallbladder, omentum, Whipple specimen.
Procedure date Tissue received Report Date Diagnosed
by
[**2151-5-18**] [**2151-5-18**] [**2151-5-26**] DR. [**Last Name (STitle) **]. [**Doctor Last Name 15706**]/vf
DIAGNOSIS:
1. Omentum (A-D): Unremarkable adipose tissue; no malignancy
identified.
2. Gallbladder (E-I): Chronic cholecystitis and cholelithiasis.
One unremarkable lymph node, no malignancy identified.
3. Whipple specimen (J-AD): Pancreatic ductal adenocarcinoma
arising in association with an intraductal pancreatic mucinous
neoplasm; see synoptic report.
Pancreas (Exocrine): Resection Synopsis
Staging according to American Joint Committee on Cancer Staging
Manual -- 7th Edition, [**2148**]
MACROSCOPICL:
Specimen Type: Pancreaticoduodenectomy, partial pancreatectomy.
Tumor Site: Pancreatic head.
Tumor Size
Greatest dimension: 1.2 cm. Additional dimensions: 1.2 cm
x 1.0 cm.
Other organs/Tissues Received: Gallbladder, Omentum.
MICROSCOPIC:
Histologic Type: Ductal adenocarcinoma.
Histologic Grade: G1: Well differentiated.
EXTENT OF INVASION
Primary Tumor: pT3: Tumor extends beyond the pancreas but
without involvement of the celiac axis or the superior
mesenteric artery.
Regional Lymph Nodes: pN0: No regional lymph node metastasis.
Lymph Nodes
Number examined: 4.
Number involved: 0.
Distant metastasis: pMX: Cannot be assessed.
Margins:
Margins uninvolved by invasive carcinoma:
Distance from closest margin: 4 mm. Specified margin:
Posterior margin (black-inked).
Venous/Lymphatic vessel invasion: Absent.
Perineural invasion: Absent.
Additional Pathologic Findings: Chronic pancreatitis,
intraductal papillary mucinous tumor with high-grade dysplasia
involving main and side branch pancreatic ducts.
Clinical: Pancreatic mass.
[**2151-5-24**] AP CHEST:
IMPRESSION: AP chest compared to [**5-23**] and [**5-24**] at 4:37 a.m.:
Small region of heterogeneous opacification at the right lung
base has been present for several days. Whether this is
pneumonia or atelectasis is
indeterminate. Pulmonary vasculature is minimally engorged, and
there is no pulmonary edema. Pleural effusion if any is minimal.
Cardiomediastinal
silhouette is normal. There is no obvious explanation for new
hypoxia.
Brief Hospital Course:
NEURO/PAIN: The patient was maintained on IV pain medication in
the immediate post-operative period and had an epidural catheter
in place in the immediate post-op period; and was transitioned
to PO narcotic medication with adequate pain control on POD#[**4-30**].
The patient remained neurologically intact and without change
from baseline during their stay. The patient remained alert and
oriented to person, location and place.
CARDIOVASCULAR: The patient remained hemodynamically stable
intra-op and in the immediate post-operative period. She did
require a minor amount of Neosynephrine gtt IV
intra-operatively, but this was weaned without post-op
requirement, and she remained hemodynamically stable. The
patient was maintained on IV anti-hypertensive medication in the
immediate post-op period, with transition to their oral home
anti-hypertensives on POD#[**8-3**]. Their vitals signs were closely
monitored. The patient's home anti-hypertensive medications were
resumed on POD#[**8-3**].
RESPIRATORY: he patient was extubated in the immediate post-op
period successfully, but given some hypercarbia and carbon
dioxide retention attributed to underlying smoking history and
likely a COPD component, the patient was 93% on non-rebreather
in the PACU and required re-intubation before transfer to the
surgical ICU for futher monitoring. The patient was weaned to
CPAP and tolerated this well on POD#3, with successful
extubation on POD#3. The patient denied cough or respiratory
symptoms following this, but continued to require supplemental
oxygen. Pulse oximetry was monitored closely and the patient
maintained adequate oxygenation on [**1-29**] liters of nasal cannula
supplementation, requiring home oxygen on discharge to rehab.
Intermittent Lasix IV was given for diuresis.
GASTROINTESTINAL: The patient was NPO following their procedure
and maintained on IV fluids for hydration while NPO. Serial
abdominal exams were performed, and once flatus resumed, the
patient was transitioned to a clear liquid diet and their IV
fluids were hep-locked on POD#7. The patient experienced no
nausea or vomiting. A nasogastric tube was maintained until the
output was minimal, and was removed on POD#3. A regular diet was
initiated on POD#9 and the patient tolerated this well. The
patient was maintained on Octreotide in the post-op period as
well, which was discontinued on POD#9. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1661**]-[**Location (un) 1662**]/[**Doctor Last Name 406**]
drain remained in place post-operatively, anf the output was
greater than 30 cc in a 24-hour period, thus she was discharged
with the drain in place. The [**Location (un) 1661**]-[**Location (un) 1662**] drain had an amylase
level of 18 on POD#8, after the patient tolerated full liquids,
and she was transitioned to diet without issue.
GENITOURINARY: The patient's urine output was closely monitored
in the immediate post-operative period. A Foley catheter was
placed intra-operatively and removed on POD#4, at which time the
patient was able to successfully void without issue. The
patient's intake and output was closely monitored for urine
output > 30 mL per hour output. The patient's creatinine was
stable. A mild transaminitis was noted following her procedure,
which was attributed to clamping of the bile duct during the
procedure. Her LFTs were trended and improved appropriately.
HEME: The patient's post-op hematocrit was stable and trended
closely. The patient remained hemodynamically stable and did not
require transfusion. The patient's coagulation profile remained
normal. The patient had no evidence of bleeding from their
incision.
ID: The patient showed no signs of infection and remained
afebrile in the post-op period. Their white count was stable
post-operatively and their incision was closely monitored for
any evidence of infection or erythema. The patient received only
standard peri-operative antibiotics, and did not require further
antibiotics post-op.
ENDOCRINE: The patient's blood glucose was closely monitored in
the post-op period with Q6 hour glucose checks. Blood glucose
levels greater than 120 mg/dL were addressed with an insulin
sliding scale.
PROPHYLAXIS: The patient was maintained on heparin 5000 units SQ
TID for DVT/PE prophylaxis and encouraged to ambulate
immediately post-op once cleared by physical therapy. The
patient also had sequential compression boot devices in place
during immobilization to promote circulation. GI prophylaxis was
sustained with Protonix/Famotidine when necessary. The patient
was encouraged to utilize incentive spirometry, ambulate early
and was discharged in stable condition to a pulmonary
rehabilitation facility.
Medications on Admission:
Tylenol 1000 mg PO BID, calcium carbonate PRN, Naprosyn PRN
Discharge Medications:
1. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*45 Tablet(s)* Refills:*0*
2. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. ipratropium bromide 0.02 % Solution Sig: One (1) nebulizer
Inhalation Q6H (every 6 hours) as needed for wheeze/sob.
4. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO four times
a day.
5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
6. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation every six (6) hours as needed for shortness
of breath or wheezing.
7. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Discharge Disposition:
Extended Care
Facility:
Life Care Center of [**Location 15289**]
Discharge Diagnosis:
Pancreatic head mass
Post-op respiratory failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to Dr.[**Name (NI) 9886**] surgical service for
evaluation and management of your pancreatic head mass,
following your Whipple procedure. You are now being discharged
in Rehab. Please follow these instructions to aid in your
recovery:
Please call your doctor or go to the emergency department if:
* You experience new chest pain, pressure, squeezing or
tightness.
* You develop new or worsening cough, shortness of breath, or
wheezing.
* You are vomiting and cannot keep down fluids, or your
medications.
* If you are getting dehydrated due to continued vomiting,
diarrhea, or other reasons. Signs of dehydration include: dry
mouth, rapid heartbeat, or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit, or have a
bowel movement.
* You experience burning when you urinate, have blood in your
urine, or experience an unusual discharge.
* Your pain is not improving within 12 hours or is not under
control within 24 hours.
* Your pain worsens or changes location.
* You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
* You develop any other concerning symptoms.
* Please resume all regular home medications, unless
specifically advised not to take a particular medication.
* Please take any new medications as prescribed.
* Please take the prescribed analgesic medications as needed.
You may not drive or operate heavy machinery while taking
narcotic analgesic medications. You may also take acetaminophen
(Tylenol) as directed, but do not exceed 4000 mg in one day.
* Please get plenty of rest, continue to walk several times per
day, and drink adequate amounts of fluids.
* Avoid strenuous physical activity and refrain from heavy
lifting greater than 10 lbs., until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
* Please also follow-up with your primary care physician.
Incision Care:
* Please call your surgeon or go to the emergency department if
you have increased pain, swelling, redness, or drainage from the
incision site.
* Avoid swimming and baths until cleared by your surgeon.
* You may shower and wash incisions with a mild soap and warm
water. Gently pat the area dry.
* If you have staples, they will be removed at your follow-up
appointment.
* If you have steri-strips, they will fall off on their own.
Please remove any remaining strips 7-10 days after surgery.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) 251**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 2835**] Date/Time:[**2151-6-14**]
9:30 [**Hospital Ward Name 23**] 3, [**Hospital Ward Name **]
Please follow up with your primary care physician [**Last Name (NamePattern4) **] [**12-27**] weeks
following discharge.
|
[
"157.0",
"518.5",
"401.9",
"278.00",
"386.00",
"276.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"51.22",
"52.7"
] |
icd9pcs
|
[
[
[]
]
] |
11789, 11856
|
6231, 10937
|
322, 401
|
11949, 11949
|
2016, 3372
|
14561, 14883
|
1255, 1273
|
11047, 11766
|
11877, 11928
|
10963, 11024
|
12100, 14028
|
14044, 14538
|
1288, 1997
|
3405, 6208
|
262, 284
|
429, 969
|
11964, 12076
|
991, 1088
|
1104, 1239
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,481
| 133,892
|
51755
|
Discharge summary
|
report
|
Admission Date: [**2136-1-30**] Discharge Date: [**2136-2-7**]
Date of Birth: [**2060-3-16**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2880**]
Chief Complaint:
shortness of breath, dizziness
Major Surgical or Invasive Procedure:
EP study and ablation of ventricular tachycardia
ICD placement
History of Present Illness:
Ms [**Known lastname 8789**] is a 75-year-old woman with history of hypertension,
hyperlipidemia, prior CAD with two "small heart attacks"
approximately 25 years ago, presenting with episode of shortness
of breath, dizziness and diaphoresis after shoveling snow on
[**1-30**].
.
She reports she was able to shovel snow for 10 minutes but
immediately after she felt "strange". Took a 325mg aspirin but,
continued to have lightheadedness and dizziness. Also had blurry
vision, but denied CP, palpitations, n/v/d. Patient very active
at baseline, goes to GYM almost every day (treadmill x 2 miles
per day) and Tennis 4x's per wk. She has no chest discomfort,
pain or dyspnea with these activities. Patient reports she never
lost consciousness or fell to the groud. No smilar prior event.
.
She denies any prior history of stroke, TIA, deep venous
thrombosis, pulmonary embolism, bleeding at the time of surgery,
myalgias, joint pains, cough, hemoptysis, black stools or red
stools. She denies recent fevers, chills or rigors. She denies
exertional buttock or calf pain. All of the other review of
systems were negative.
.
In the field, EMS found patient mentating, diaphoretic and per
report hypotensive, strips showed wide-complex tachycardia
interpreted as ventricular tachycardia. 50mg IV Lidocaine given
with restoration of sinus rhythm, no documentation on time
interval.
.
In the ED, patient arrived with HR 85, BP 110/p and 100% O2 sat
on ? NRB. Case discussed with cardiology fellow and admitted for
further management. She was initally on a lidocaine gtt.
.
On the floor, VT did not reoccur. Pt had stress test that did
not induce VT. Today pt went for EP study, did not have
ablation, however, had bleeding from groin site that would only
temporarly stop after holding pressure. Vascular team assessed
and placed pressure dressing on groin. VS on admission to CCU
were 149/58, 81, hct stable at 35. No pain or SOB, but is upset
about her complications.
Past Medical History:
-- CAD s/p "small heart attack" x 2 (25 and 23 years ago)
-- Hypertension
-- Hyperlipidemia
-- Renal cancer s/p resection and left nephrectomy 14 years ago
Social History:
Lives with husband, retired social worker. Denies alcohol or
cigarrette use. Very active.
Family History:
No family history of early MI, otherwise non-contributory.
Physical Exam:
VS: 98.1 139/89 65 RR 18 97% RA
GENERAL: elderly woman, upset. Oriented x3.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple, laying down, unable to asses neck veins
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2 with S4.
Chest: Left chest C/I/D, mild tenderness
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits. Hematoma in right
groin, about 3inches, mild tenderness, no active bleeding or
oozing
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:
[**2136-2-7**] 10:30AM BLOOD Hct-27.5*
[**2136-2-7**] 05:10AM BLOOD WBC-6.6 RBC-2.74* Hgb-8.9* Hct-24.6*
MCV-90 MCH-32.4* MCHC-36.1* RDW-14.3 Plt Ct-160
[**2136-2-6**] 05:15AM BLOOD PT-12.5 PTT-24.6 INR(PT)-1.1
[**2136-2-7**] 05:10AM BLOOD Glucose-111* UreaN-15 Creat-0.7 Na-140
K-3.9 Cl-106 HCO3-27 AnGap-11
[**2136-2-4**] 07:40AM BLOOD ALT-27 AST-51* LD(LDH)-200 AlkPhos-46
TotBili-0.5
[**2136-2-7**] 05:10AM BLOOD Calcium-8.5 Phos-3.5 Mg-2.2
LABS ON ADMISSION:
.
[**2136-1-30**] 04:51PM BLOOD WBC-8.0 RBC-4.60 Hgb-15.1 Hct-41.7 MCV-91
MCH-32.7* MCHC-36.1* RDW-13.1 Plt Ct-193
[**2136-1-30**] 04:51PM BLOOD Neuts-75.6* Lymphs-16.4* Monos-6.1
Eos-1.8 Baso-0.2
[**2136-1-30**] 04:51PM BLOOD PT-12.0 PTT-19.9* INR(PT)-1.0
.
[**2136-1-30**] 04:51PM BLOOD Glucose-126* UreaN-25* Creat-1.0 Na-143
K-4.0 Cl-104 HCO3-25 AnGap-18
[**2136-1-30**] 04:51PM BLOOD Calcium-9.5 Phos-4.2 Mg-2.3
.
CARDIAC ENZYMES:
[**2136-1-30**] 04:51PM BLOOD cTropnT-<0.01 CK(CPK)-117
[**2136-1-30**] 11:35PM BLOOD cTropnT-0.08* CK(CPK)-83
[**2136-1-31**] 07:35AM BLOOD cTropnT-0.07* CK(CPK)-82
[**2136-1-31**] 06:55PM BLOOD cTropnT-0.05* CK(CPK)-83
.
URINE:
[**2136-1-30**] 05:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
[**2136-1-30**] 05:00PM URINE RBC-0-2 WBC-0-2 Bacteri-RARE Yeast-NONE
Epi-0-2
.
.
RADIOLOGY:
.
CXR([**1-30**])
No evidence of acute focal pneumonia.
.
CXR [**2-7**]
FINDINGS: In comparison with the study of [**2-6**], the two leads
extend to the apex of the right ventricle and the right atrium
respectively.
.
CXR [**2-6**]
IMPRESSION: Dual-lead ICD with leads appropriately positioned.
No
pneumothorax.
.
Femoral Vascular U/S [**2-2**]
IMPRESSION:
1. No evidence of pseudoaneurysm.
2. Ill-defined hematoma overlies the vascular access site.
.
CT abd/plevis [**2-3**]
IMPRESSION:
1. No retroperitoneal hematoma detected. Subcutaneous
reticulation and
stranding involving the right and left superficial soft tissues
of the thigh
with small hematoma, better evaluated on recent ultrasound
imaging.
2. Multiple hypodensities within the liver and right kidney
which are cystic
and not well characterized on this non-contrast-enhanced study
although
statistically represent cysts.
3. Recommend slightly advancing Foley catheter given residual
air within the
bladder.
4. Trace simple pericardial effusion.
5. Fibroid uterus.
6. Sigmoid colon diverticulosis.
.
CARDIOLOGY:
.
TTE ([**2136-1-31**])
The left atrium is mildly dilated. The estimated right atrial
pressure is 0-5 mmHg. There is mild symmetric left ventricular
hypertrophy with normal cavity size. There is mild to moderate
regional left ventricular systolic dysfunction with
akinesis/thinning of the distal half of the inferolateral and
inferior walls. The remaining segments contract normally (LVEF =
40-45 %). No masses or thrombi are seen in the left ventricle.
Right ventricular chamber size and free wall motion are normal.
The diameters of aorta at the sinus, ascending and arch levels
are normal. The aortic valve leaflets (3) are mildly thickened
but aortic stenosis is not present. Trace aortic regurgitation
is seen. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is no mitral valve prolapse.
Mild (1+) mitral regurgitation is seen. The estimated pulmonary
artery systolic pressure is high normal. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
regional systolic dysfunction c/w prior infarction (LVEF
40-45%). Mild mitral regurgitation most likely due to papillary
muscle dysfunction.
.
ETT w Nuclear Imaging ([**2136-2-1**])
Excellent exercise tolerance. No anginal symptoms with
nonspecific T wave changes. Anterior(V1-V3) ST-T wave changes
uninterpretable for ischemia in the presence of the RBBB. In the
presence
of the RBBB, the anterior(V1-V3) ST-T wave changes are
uninterpretable
for ischemia. Deeper T wave inversion (no J-point depression)
was noted
inferiorly and in the lateral precordial leads (nonspecific
finding).
The rhythm was sinus with frequent multiformed VPDs, infrequent
ventricular couplets and, in post-exercise period, one 5-bt run
of an
acclerated idioventicular rhythm(rate~72-94) was noted. Resting
baseline hypertension. Nuclear report sent separately.
.
NUCLEAR IMAGING - INTERPRETATION:
The image quality is good.
Left ventricular cavity size is normal.
Resting and stress perfusion images reveal a large severe fixed
defect in the lateral wall and a large severe fixed defect in
the inferolateral wall.
Given severe photopenia in the affected segments, wall motion in
these areas cannot be determined, but presumed akinetic.
Otherwise, wall motion is normal.
The calculated left ventricular ejection fraction is 44%.
No comparisons.
Two large severe fixed defects consistent with prior infarction.
Ejection fraction 44%.
.
EKG:
Sinus rhythm. Prior inferolateral myocardial infarction. Right
bundle-branch block. Probable true posterior component as well.
Brief Hospital Course:
Ms [**Known lastname 8789**] is a 75F with hypertension, hyperlipidemia, CAD (old
MIs), admitted with ventricular tachycardia, converted to NSR
with lidocaine, transferred to the CCU s/p failed ablation c/b
groin bleeding.
.
# VENTRICULAR TACHYCARDIA: Pt is has a hx of CAD with prior
inferior infact 25 years prior. She was admitted with
hemodynamically stable monomorphic VT with excertion after
shoveling snow. She was started on lidocain gtt, that was
stopped on [**1-31**]. She underwent stress test on [**2-1**], with no VT
induced. The patient underwnet EP study on [**2-2**], but were unable
to ablate the source of her VT. Post-op her course was
complicated by hematoma and low urine output and monitored in
the CCU. A U/S showed no pseudoaneurysm and an ill-defined
hematoma. She also had a CT-scan on [**2-3**] that did not show RP
bleed. Her Hct dropped to 26, but remained stable. Her urine
output improved with IVF. She was started on amiodarone 200mg
TID on [**2-3**]. She remained stable and while she had occasional
episodes of [**4-15**] beat V-tach on tele she remained asymptomatic.
She underwent successful ICD placement on [**2-6**]. She recieved one
dose of Vancomycin prior to the procedure as well as 12 hours
after placement. The likely source of her VT was thought to
from prior scar from MI. She was discharged on Amiodarone 200mg
[**Hospital1 **] (which will be continued until her cardiology follow-up) and
her prior dose of atenolol 50mg daily. Her nifedipine was
discontinued. She was also started on Keflex x2days. She will
have follow-up with device clinic in one week as well as
follow-up with Dr. [**Last Name (STitle) **] in approx 1 month.
.
# Pump: Her stress MIBI showed wall motion defect, likely from
old MI, EF of 44%. Her metoprolol was held in the setting of
bleeding, but restarted when stable. She was continued on
atenolol and lisinopril as an outpatient.
.
# HTN: Her home nifedipine and atenolol were discontinued on
admission. Additionally, she was started on metoprolol and
continued on her lisinopril. Her BP meds were held after the
procedure due to concerns of bleeding. Her BP ranged between
130-160's during her admission, but improved when she was placed
back on her home medications. She she was stablized and put
back on her home atenolol and lisinopril.
.
# CONTACT: [**Name (NI) 4906**] [**Name2 (NI) **] [**Telephone/Fax (1) 107200**] / ([**Telephone/Fax (1) 107201**]. [**Telephone/Fax (1) **]
([**Telephone/Fax (1) 107202**].
Medications on Admission:
Nifedipine ER 60mg
Lisinopril 20mg daily
Atenolol 50mg daily
Crestor 5mg daily
Fosamax
Calcium
Ocuvite
Discharge Medications:
1. Ocuvite Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
3. Rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 2 days.
Disp:*8 Capsule(s)* Refills:*0*
5. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
6. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
7. Fosamax Oral
8. Calcium Oral
9. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Primary:
Ventricular Tachycardia
CAD s/p MI x 2 (25 and 23 years ago)
Hypertension
Hyperlipidemia
Discharge Condition:
stable, chest pain free, ambulating, O2 sat >95%RA, normotensive
Discharge Instructions:
It was a pleasure taking care of you while you were in the
hospital. You were admitted to [**Hospital1 18**] because of a heart rhythm
problem called ventricular tachycardiac. You were evaluated by
the rhythm specialists and underwent ablation of this rhythm.
Please take all your medications as prescribed. The following
changes were made to your medication regimen.
1. Please stop taking nifedipine
2. You will continue Amiodarone 200mg twice a day
3. You will cont Keflex 500mg every 6 hours for 2 days
4. Please take aspirin 81 mg daily
Please follow up with the appointments below.
Please call your PCP or go to the ED if you experience chest
pain, palpitations, shortness of breath, nausea, vomiting,
fevers, chills, or other concerning symptoms.
Followup Instructions:
You have an appointment with your PCP [**Last Name (NamePattern4) **] [**2-10**] at 1pm
PCP: [**Name10 (NameIs) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 26**] [**Telephone/Fax (1) 6803**]
fax:[**Telephone/Fax (1) 74399**]
*** Please follow-up on the patient's Hct
Please follow-up with your cardiologist Dr. [**Last Name (STitle) 1295**] on
[**2-14**] at 10 AM. You will be seen in the [**Location (un) 1110**] Office.
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2136-2-15**]
9:00
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 677**], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2136-3-28**] 2:00
[**First Name11 (Name Pattern1) 900**] [**Last Name (NamePattern1) 2882**] MD, [**MD Number(3) 2883**]
Completed by:[**2136-2-12**]
|
[
"V10.52",
"272.4",
"998.12",
"427.1",
"401.9",
"412",
"414.01",
"V45.73",
"E878.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.26",
"37.27",
"37.94"
] |
icd9pcs
|
[
[
[]
]
] |
12162, 12211
|
8789, 11294
|
345, 410
|
12353, 12420
|
3736, 4187
|
13227, 14088
|
2704, 2764
|
11448, 12139
|
12232, 12332
|
11320, 11425
|
12444, 13204
|
2779, 3717
|
4637, 8766
|
275, 307
|
438, 2400
|
4201, 4620
|
2422, 2581
|
2597, 2688
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,119
| 142,943
|
23091
|
Discharge summary
|
report
|
Admission Date: [**2103-3-23**] Discharge Date: [**2103-3-26**]
Date of Birth: [**2056-12-24**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 297**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
intubation
arterial line
History of Present Illness:
46 year-old female with history of severe asthma (history of
multiple intubations and tracheotomy in [**2099**]), restrictive lung
disease, and severe tracheal stenosis refusing stent,
obstructive sleep apnea presents with acute onsent SOB. History
in the ED was limited by language and obtundation. ABG in the ED
was 7.30/99/184 therefore she was intubated, given levaquin,
solumedrol, and combivent. She was then transfeffed to the MICU.
Past Medical History:
1) asthma on home O2, history of multiple intubations and
tracheotomy in [**2099**]
2) tracheal stenosis (4mm on expiration) on CT and bronch.
patient refused OR to debride granulation tissue and stenting.
3) restrictive lung disease from obesity
4) obstructive sleep apnea on BiPAP at home (15/5 on 4L oxygen)
5) IDDM on glargine and metformin
6) coronary artery disease: MIBI [**12-18**] showed LVEF 65% w/ mild
inferior hypokinesis and reversible defect in inferior wall and
mid to basal inferior lateral wall
7) vitamin B12 deficiency on monthly injections
8) s/p appendectomy
9) chronic lumbar disc disease
10) psychotic disorder NOS
Social History:
The patient recently moved into her niece's place who has 3
flights of stairs.
She has to carry her oxygen tank to go up the 3 flights of
stairs.
Smoking history but frequencey and duration uncertain.
No clear history of alcohol or illicit drug use.
Family History:
NC
Physical Exam:
Vitals: T= 99.8 HR = 109 , BP = 142/92, RR =24 , SaO2 = 92% on
3L.
General: Obese solmnent female on BIPAP, minimally responsive.
HEENT: Normocephalic and atraumatic head, anicteric sclera,
moist mucous membranes.
Neck: No thyromegaly, no lymphadenopathy, no carotid bruits. no
nuchal rigidity
Chest: Chest rose and fell with equal size, shape and symmetry,
poor insp effort
CV: PMI appreciated in the fifth ICS in the midclavicular line
without heaves or thrills, tachy, RR, normal S1 and S1 no
murmurs rubs or gallops.
Abd: Normoactive BS, NT and ND. No masses or organomegaly
Back: No spinal or CVA tenderness.
Ext: No cyanosis, no clubbing or edema with 2+ dorsalis pedis
pulses bilaterally
Integument: multiple areas of ecchymosis
Pertinent Results:
[**2103-3-23**] 09:10PM TYPE-ART PO2-253* PCO2-69* PH-7.41 TOTAL
CO2-45* BASE XS-15
[**2103-3-23**] 08:15PM URINE HOURS-RANDOM
[**2103-3-23**] 08:15PM URINE HOURS-RANDOM
[**2103-3-23**] 08:15PM URINE GR HOLD-HOLD
[**2103-3-23**] 08:15PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2103-3-23**] 08:15PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.023
[**2103-3-23**] 08:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-1000 KETONE-15 BILIRUBIN-NEG UROBILNGN-1 PH-7.0 LEUK-NEG
[**2103-3-23**] 06:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2103-3-23**] 06:35PM TYPE-ART O2-40 PO2-184* PCO2-99* PH-7.30*
TOTAL CO2-51* BASE XS-17 INTUBATED-NOT INTUBA
[**2103-3-23**] 05:01PM TYPE-ART PO2-232* PCO2-94* PH-7.32* TOTAL
CO2-51* BASE XS-17 INTUBATED-NOT INTUBA
[**2103-3-23**] 05:01PM O2 SAT-99
[**2103-3-23**] 03:45PM GLUCOSE-155* UREA N-11 CREAT-0.4 SODIUM-141
POTASSIUM-4.6 CHLORIDE-93* TOTAL CO2-45* ANION GAP-8
[**2103-3-23**] 03:45PM CK(CPK)-59
[**2103-3-23**] 03:45PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2103-3-23**] 03:45PM CK-MB-NotDone cTropnT-<0.01
[**2103-3-23**] 03:45PM WBC-11.1* RBC-4.03* HGB-11.7* HCT-36.5 MCV-91
MCH-29.1 MCHC-32.1 RDW-13.2
[**2103-3-23**] 03:45PM HYPOCHROM-3+
[**2103-3-23**] 03:45PM PLT COUNT-243
[**2103-3-23**] 03:45PM D-DIMER-202
CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST
Reason: OB with ? Pneumo and hx of COPD- eval for PE vs
Pneumothorax
Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
46 year old woman with
REASON FOR THIS EXAMINATION:
OB with ? Pneumo and hx of COPD- eval for PE vs Pneumothorax
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: Question pneumonia, history of COPD; evaluate for
pulmonary embolism or pneumothorax.
TECHNIQUE: CT of the chest was performed before and after the
administration of IV contrast using the CT pulmonary angiography
protocol. 100 cc of Optiray nonionic contrast was given for this
examination. Nonionic contrast was given for the rapid bolus
required for CT pulmonary angiography.
COMPARISON: [**2103-3-9**].
FINDINGS:
CTA: There is no evidence of pulmonary embolism.
CT OF THE CHEST WITH WITHOUT/WITH CONTRAST: The patient is
intubated. There is bibasilar atelectasis at the dependent
portions of both lungs. There is no evidence of consolidation or
pleural effusion.
Lymph nodes at the upper limits of normal or mildly enlarged are
present at the AP window and right paratracheal regions. The
heart and pericardium appear within normal limits. The pulmonary
artery trunk is somewhat enlarged, measuring 3.2 cm, suggestive
of pulmonary artery hypertension.
Visualized portions of the upper abdominal structures are
unremarkable, and osseous structures also appear within normal
limits.
Coronally and sagittally reformatted images were also reviewed,
demonstrating no significant abnormalities aside from
atelectasis described above.
IMPRESSION
1. No evidence of pulmonary embolism.
2. Bibasilar atelectasis.
3. Enlarged pulmonary artery trunk suggestive of PA
hypertension.
4. Mildly enlarged mediastinal lymph nodes.
CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN
Reason: POST INTUBATION
[**Hospital 93**] MEDICAL CONDITION:
46 year old woman with severe asthma, diastolic CHF, and severe
tracheal stenosis and tracheomalacia now in ED with chest pain
REASON FOR THIS EXAMINATION:
POST INTUBATION
INDICATION: Severe asthma with chest pain. Post intubation.
COMPARISON: Earlier, same day.
FINDINGS: ET tube tip is well positioned approximately 2 cm
above the carina. The heart size and mediastinal contours are
normal. There is minimal atelectasis at the left lung base. Lung
volumes are slightly low. There has been no significant change
in the appearance of the chest since the earlier exam.
IMPRESSION: ET tube in good position.
Brief Hospital Course:
# Respiratory failure: The patient has known tracheal stenosis
and severe asthma. However, it was unclear what caused her to
have such a precipitious decline in respuratoy function. PE and
pneumonia were ruled out. She was intubated in the ED after her
PCO2 was 99 and then rapidly extubated on [**3-24**]. She was
emperically treated with steroids, levofloxacin, and nebulizers.
She continued to use BIPAP at night and her baseline 3L O2
during the day once she was on the floor.
# Tracheomalacia: The patient had previously refused treatement
for this in [**2103-2-17**].
# DM: The patient was maintianed on her home regmin of insulin
once on the floor.
# Schizophrenia: The paitent was ready to be discharged when she
then expressed sucidial ideation - specifically of cutting her
wrists. Initially she could not contract for safety. Psych was
called for an urgent consult and felt that she was safe to be
discharged home with close follow up.
Medications on Admission:
1. Paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q4H (every 4 hours).
4. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4 HOURS ().
5. Quetiapine Fumarate 100 mg Tablet Sig: Two (2) Tablet PO HS
(at bedtime).
6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
8. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Insulin NPH Human Recomb Subcutaneous
11. Insulin Regular Human Subcutaneous
Discharge Medications:
1. Paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q4H (every 4 hours).
4. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4 HOURS ().
5. Quetiapine Fumarate 100 mg Tablet Sig: Two (2) Tablet PO HS
(at bedtime).
6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
8. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Insulin NPH Human Recomb Subcutaneous
11. Insulin Regular Human Subcutaneous
12. Prednisone 5 mg Tablets, Dose Pack Sig: as directed Tablets,
Dose Pack PO once a day: Take 4 tablets on Tuesday
Take 2 tablets on Wednesday
Take 1 tablet on THursday and everyday after that.
Disp:*30 Tablets, Dose Pack(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Uphams Corner Home Care
Discharge Diagnosis:
bronchitis
obstructive sleep apnea
psychotic disorder
tracheomalacia
Discharge Condition:
stable on 3L NC, ambulating
Discharge Instructions:
Call you physician if you have fever greater than 101F, Chest
pain, Dizziness, palpitations, or increases of your shortness of
breath.
Call 911 if you feel that you may hurt yourself or others.
Followup Instructions:
Call your PCP to see him within 1 week.
|
[
"285.9",
"518.84",
"493.22",
"298.9",
"519.1",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
9445, 9499
|
6491, 7442
|
292, 319
|
9611, 9640
|
2511, 4121
|
9882, 9924
|
1734, 1738
|
8337, 9422
|
5857, 5984
|
9520, 9590
|
7468, 8314
|
9664, 9859
|
1753, 2492
|
233, 254
|
6013, 6468
|
347, 788
|
810, 1450
|
1466, 1718
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,026
| 138,617
|
51969
|
Discharge summary
|
report
|
Admission Date: [**2170-4-27**] Discharge Date: [**2170-5-4**]
Date of Birth: [**2087-2-26**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 8587**]
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
[**2170-4-27**]: Left hip TFN with profunda artery repair
acute blood loss anemia
hypocaclemia
hypophosphatemia
hypokalemia
History of Present Illness:
Ms. [**Known lastname 107582**] is an 83 year old female who had a mechanical trip
and fall. She was taken to the [**Hospital1 18**] for further evaluation.
Past Medical History:
1. Congestive heart failure.
2. Coronary artery disease.
3. Diabetes type 2.
4. Remote history of stroke.
5. Hypertension.
6. Gangrenous left first toe.
7. Left SFA
8. s/p aortic valve replacement in [**2163**]
9. depression
Social History:
lives with son, has supportive family. walks with cane. husband
died in [**2169-7-19**].
Family History:
NC
Physical Exam:
Upon discharge:
VS
Gen: 83 yo F in NAD, lying in bed,
HEENT: NCAT. Sclera anicteric, left corneal opacity, OP clear,
no
exudates or ulceration.
Neck: Supple, JVP to mandible at 45 degrees with respiratory
variation
CV: Regular rate, soft I/VI systolic ejection murmur at RUSB,
crisp loud S2, no rubs, no gallops
Chest: Resp. were unlabored, no accessory muscle use. Clear
breath sounds bvilaterally
Abd: Obese, Soft, NTND. No HSM or tenderness. (+) Intertriginous
erythema and white plaque (along pannus)
Ext: 1+ edema to shins, dependent edema on buttocks
Skin: Warm, rash as above, dressing on left hip clean / dry /
intact.
Neuro: Alert and oriented x 3, CNs II-XII grossly intact
Alert and oriented
Cardiac: Regular rate rhythm
Chest: Lungs clear bilaterally
Abdomen: Soft non-tender non-distended
Extremities: LLE +pulses/sensation, externally rotated
Pertinent Results:
[**2170-4-26**] 07:50PM BLOOD WBC-16.3*# RBC-3.67* Hgb-10.4* Hct-32.2*
MCV-88 MCH-28.2 MCHC-32.2 RDW-14.0 Plt Ct-200
[**2170-4-27**] 03:45PM BLOOD WBC-22.4*# RBC-4.19*# Hgb-12.0#
Hct-35.6*# MCV-85 MCH-28.8 MCHC-33.9 RDW-15.1 Plt Ct-187
[**2170-4-29**] 03:18AM BLOOD WBC-12.5*# RBC-3.12*# Hgb-9.1*# Hct-26.3*
MCV-84 MCH-29.3 MCHC-34.8 RDW-16.4* Plt Ct-90*
[**2170-5-1**] 06:50AM BLOOD WBC-9.8 RBC-3.31* Hgb-9.6* Hct-28.2*
MCV-85 MCH-28.9 MCHC-34.0 RDW-17.0* Plt Ct-113*
[**2170-5-2**] 07:00AM BLOOD WBC-8.0 RBC-3.31* Hgb-9.7* Hct-29.2*
MCV-88 MCH-29.4 MCHC-33.3 RDW-16.3* Plt Ct-149*
[**2170-4-27**] 07:35AM BLOOD Calcium-8.4 Phos-5.4*# Mg-2.0
[**2170-5-2**] 07:00AM BLOOD Calcium-8.0* Phos-2.8 Mg-1.9
Brief Hospital Course:
Ms. [**Known lastname 107582**] presented to the [**Hospital1 18**] on [**2170-4-26**] after a fall at
home. She was evaluated by the orthopaedic surgery service and
found to have a left hip fracture. She was admitted to medicine
and cleared for surgery. On [**2170-4-27**] she was taken to the
operating room and underwent a left hip TFN. During the surgery
it was noted that she had a lacerated profunda artery. [**Date Range **]
surgery was called in and she also underwent repair of her
artery. She was estimated to have lost 2.5L of blood and was
transfused a total of 5 units of packed red blood cells. She
was transferred to the ICU post operatively for further care.
She was transfused an additional 1 unit of packed red blood
cells. On [**2170-4-28**] she was transfused with 3 units of packed red
blood cells due to acute blood loss anemia. On [**2170-4-29**] she was
transferred from the ICU to the orthopaedic floor. She was seen
by physical therapy to improve her strength and mobility. On
[**2170-4-30**] she was again transfused with 1 unit of packed red blood
cells. Internal Medicine was re-consulted for post operative
fluid overload. Her ins and outs were closely monitored and Ms.
[**Known lastname 107582**] improved on her home dose Lasix over the last days.
Her hct remained stable. She underwent arteriogram prior to D/C
at the recommendation of the [**Known lastname **] Surgery team which did not
shoe any abnormality. The rest of her hospital stay was
uneventful with her lab data and vital signs within normal
limits and her pain controlled. She was discharged to rehab in
stable condition with the appropriate follow up care
coordinated. She will follow up with [**Known lastname **] Surgery in 1
month with a repeat [**Known lastname 1106**] study obtained prior to this
appointment.
Medications on Admission:
NPH 20U qam and 14U qpm
Metoprolol 50mg [**Hospital1 **]
Lasix 40mg daily
Lipitor 20mg daily
Omeprazole 20mg daily
Plavix 75mg daily
ASA 81mg daily
Citalopram 20mg daily
Potassium 20mEq daily
Folic Acid 1mg [**Hospital1 **]
Ferrous Sulfate 325mg [**Hospital1 **]
Vit B12 500mcg daily
Diclofenac XR 100mg daily
Dorzolamide Timolol drops left eye [**Hospital1 **]
Timolol 0.5% drops right eye daily
Discharge Medications:
1. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
2. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic
DAILY (Daily).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Syringe Injection [**Hospital1 **] (2 times a day).
12. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
13. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
14. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4H (every 4 hours) as needed for pain.
15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
16. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
17. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
s/p fall
Left hip fracture
Acute blood loss anemia
Profunda artery laceration
Hypocalcemia
Hypophosphatemia
Hypomagnesemia
Hypokalemia
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:
Continue to be weight bearing as tolerated on your left leg
Continue your medication as prescribed
If you have any increased redness, drainage, or swelling, or if
you have a temperature greater than 101.5, please call the
office or come to the emergency department.
Physical Therapy:
Activity: As tolerated
Left lower extremity: Full weight bearing
Treatments Frequency:
Keep incision clean and dry
Monitor for signs/symptoms of infection
Staples out 14 days after surgery
Followup Instructions:
Please follow up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP in orthopaedics in 2
weeks, please call [**Telephone/Fax (1) 1228**] to schedule that appointment
Please follow up with Dr. [**Last Name (STitle) **]
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) 3628**] (NHB) Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2170-6-6**] 11:15
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 1490**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2170-6-6**] 12:00
Completed by:[**2170-5-4**]
|
[
"584.9",
"707.15",
"440.24",
"428.0",
"V42.2",
"276.8",
"275.3",
"311",
"275.41",
"V58.67",
"E885.9",
"428.33",
"414.00",
"820.22",
"V12.54",
"958.2",
"275.2",
"V45.81",
"285.1",
"250.00",
"904.0",
"112.3",
"458.29",
"287.5",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.31",
"79.35"
] |
icd9pcs
|
[
[
[]
]
] |
6358, 6428
|
2649, 4479
|
327, 454
|
6607, 6607
|
1923, 2626
|
7295, 7843
|
1021, 1025
|
4927, 6335
|
6449, 6586
|
4505, 4904
|
6790, 7058
|
1040, 1040
|
7076, 7145
|
7167, 7272
|
279, 289
|
1056, 1904
|
482, 641
|
6622, 6766
|
663, 898
|
914, 1005
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,970
| 106,760
|
42432
|
Discharge summary
|
report
|
Admission Date: [**2123-1-27**] Discharge Date: [**2123-2-9**]
Date of Birth: [**2057-8-13**] Sex: F
Service: MEDICINE
Allergies:
Augmentin / Avelox / Plendil / metoprolol / Cefzil / clindamycin
/ lisinopril / Felodipine
Attending:[**First Name3 (LF) 9160**]
Chief Complaint:
Headache, fever
Major Surgical or Invasive Procedure:
PICC line placement
Arterial Line for BP monitoring
Foley Catheter Placement
History of Present Illness:
BRIEF CLINICAL HISTORY: 65yo woman with history of CKDIII,
gastric bypass and strep endocarditis (>12 years ago) presented
with headache and fever to 103. Found to have SAH, MSSA
bacteremia, and native mitral valve endocarditis with septic
emboli to brain. SAH thought to have developed in setting of
mycotic aneurysm, although patient also has polycystic kidney
disease with puts her at higher risk of [**Doctor Last Name **] aneurysm. The
patient was initially stabilized in the neuro ICU with BP
control and serial imaging showing stability of the bleed. The
patient was placed on Cefazolin.
.
On the floor, the patient is feeling well. She only complains of
a waxing and [**Doctor Last Name 688**] headache that has improved. The patient
denies any focal deficits. She is having some diarrhea, C diff
negative, with some Guaic positivity due to irritated
hemorrhoids. The patient's kidney function is improving, and she
is not oliguric.
Past Medical History:
HTN
Rheumatic fever (age of 13)
MR (annual ECHO)
Recurrent UTIs ,some with drug resistent organisms
Gastric bypass (c/b duodenal ulcer at anastomotic site)
strep endocarditis (SBE) (12+ yrs ago), treated with ceftriaxone
CKD III
c.difficile diarrhea (after having been treated with abx for
UTI)
Social History:
Lives with husband. [**Name (NI) 1403**] as COO of health care agency. Denies
Tobacco use
Family History:
no family history of immunosuppression, kidney disease, or SAH
Physical Exam:
PHYSICAL EXAM:
Hunt and [**Doctor Last Name 9381**]: 1 [**Doctor Last Name **]: 3 GCS E:4 V:5 M:6
O: T: 100.5 BP: 147/59 HR: 95 R 18 O2Sats 100% RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 3-2mm EOMs intact
Neck: Supple.
Lungs: CTA bilaterally
Cardiac: RRR
Abd: Soft, NT
Extrem: Warm and well-perfused. No C/C/E.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2
mm bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to finger rub bilaterally.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-1**] throughout. No pronator drift
Sensation: Intact to light touch
Coordination: normal on finger-nose-finger
Handedness Right
DISCHARGE EXAM:
Gen: NAD, AOx3
HEENT: scaling, healing vesicles on mouth, nose, forehead
Heart: 3/6 systolic murmur with radiation into axilla
Lungs: scattered basilar crackles
Abd: obese, soft, NT, ND
Ext: 3+ nonpitting edema, good pulses
Skin: tender Osler nodes on foot, improved
Pertinent Results:
DISCAHRGE LABS
[**2123-2-5**] 05:54AM BLOOD WBC-11.2* RBC-3.22* Hgb-9.3* Hct-29.1*
MCV-91 MCH-28.9 MCHC-32.0 RDW-16.0* Plt Ct-405
[**2123-2-4**] 05:51AM BLOOD Neuts-73.4* Lymphs-11.9* Monos-9.1
Eos-5.1* Baso-0.4
[**2123-1-29**] 02:03AM BLOOD PT-12.2 PTT-26.2 INR(PT)-1.1
[**2123-2-5**] 05:54AM BLOOD Glucose-111* UreaN-76* Creat-3.9* Na-136
K-3.7 Cl-102 HCO3-20* AnGap-18
[**2123-1-29**] 02:03AM BLOOD ALT-35 AST-39 AlkPhos-100 TotBili-0.3
[**2123-2-5**] 05:54AM BLOOD Calcium-8.6 Phos-6.4* Mg-2.3
[**2123-2-2**] 12:30PM BLOOD HIV Ab-NEGATIVE
[**2123-1-31**] 06:10AM BLOOD C3-106 C4-26
[**1-26**] NCHCT: left diffuse SAH, no extension into ventricles, no
midline shift
[**1-27**] NCHCT - stable
[**1-27**] MRI/MRA - No evidence of intracranial aneurysm. No apparent
increase in hemorrhage since CT of [**1-27**]. Apparent atherosclerotic
plaque, dissection, or both in distal cervical L ICA --> on
further review this was just due to tortuosity of carotid
arteries. Also on this scan were some diffusion weighted areas
of possible septic emboli, not picked up on first read.
[**1-27**] CXR - Mild cardiomegaly. Mild vasc. congestion. Nodular
opacity in R base & between 5th-6th R posterior ribs, likely
calcified granulomas. No evidence of PNA.
[**1-28**] renal u/s: several simple cysts, no hydro, enlarged GB with
dilated intra and extrahepatic ducts of unknown significance
[**1-28**] TTE: possible mitral valve vegetation
[**1-29**] TEE: Small posterior mitral valve vegetation. Moderate to
severe mitral regurgitation.
[**1-30**] Head MRI: Two small infarctions in the left posterior
parietal lobe and left cerebellum seen on the previous mr may be
secondary to septic emboli
[**1-30**] CXR: PICC in good position. R and ? L basilar consolidation
MICRO:
- [**1-27**] UCx: Group B strep
- [**1-27**] Blood Cx: coag + staph --> MSSA
- [**2-4**] Head CT: 1. Interval decrease in the amount of left
frontoparietal subarachnoid hemorrhage, now minimal.
2. No new intra- or extra-axial hemorrhage.
3. No mass effect or evidence of herniation.
Brief Hospital Course:
This is a 65 yo F with PMH of HTN, CKD, rheumatic fever, and
subacute bacterial endocarditis of native mitral valve in the
past who presented with headache and fevers, found to have MSSA
bacteremia, mitral valve endocarditis, subarachnoid hemorrhage,
and acute kidney injury.
.
1. Subarachnoid Hemorrhage: Ms. [**Known lastname 6105**] was admitted to the
Intensive care unit after initial evaluation for workup of her
Subarachnoid hemorrhage. Patient underwent an MRI/MRA given her
renal insufficiency. MRA findings did not reveal an underlying
aneurysm. Repeat imaging showed a stable bleed and the patient
did not have any focal neuro deficits nor fluctuations in
consciousness. She had aggressive BP control and close
monitoring. The patient had repeat imaging that showed
reabsorption of the bleeding and no new findings. The patient
will be followed by neurosurgery. When her renal function
improves, she will need a cerebral angiogram to definitively
rule out a small [**Doctor Last Name **] aneurysm. In the meantime, the patient
will have BP control with Labetalol 600mg TID, Hydralazine 25mg
Q6hrs, and HCTZ 25mg Daily. If her BP improves, the patient's
hydralazine can be decreased.
.
2. MSSA Endocarditis: The patient has a h/o mitral valve disease
[**1-28**] rheumatic fever as a child. She has previous SBE of the
mitral valve in the past. The patient presented with fever and
was found to have a MSSA bacteremia with vegetations of her
mitral valve consistent with endocarditis. The patient also has
a loud systolic murmur. The patient was treated initially with
Nafcillin, but this was switched to Cafazolin due to
eosinophilia and diarrhea side effects. The patient will
complete a 6 week course of treatment. She will be followed by
ID as outpatient. After resolution of this acute episode, she
may benefit from cardiac surgery consultation for possible MVR
in the future if complications ensue.
.
3. Acute on Chronic Kidney Disease: The patient had chronic
renal insufficiency that was known, although, the etiology was
unclear. Here, the patient had imaging that was consistent with
polycystic kidney disease. The patient also had nausea,
vomiting, dehydration prior to admission leading to ATN that
caused an acute decline in her GFR. Her Cr rose to a max of 3.9.
Her urine had muddy brown casts. With supportive care, her Cr
came down slightly, although her GFR is still much lower than
her baseline. The patient was never oliguric. Her electrolytes
were never altered, except for slightly low bicarb. The patient
has nephrology follow-up. They will follow her PCKD, for which
she may require dialysis in the future.
.
4. Urinary retention: The patient had trouble voiding after
Foley removal. With time, the patient spontaneously voided,
although a PVR showed 350cc of retained urine. The patient has a
history of chronic UTIs which are likely from her urinary
retention. Her urinary retention has never been worked up, but
she will be seen as an outpatient to determine possible causes
and interventions to prevent chronic UTIs and worsening kidney
function.
.
5. E coli UTI: The patient had an E coli UTI. We are treating
this with a 7 day course of Trimethoprim. Last day of treatment
is [**2-11**].
.
6. Diarrhea: The patient had multiple episodes of loose stool
per day. She had C diff toxin negative x 2. She has a PCR which
was also negative for C. diff. Her diarrhea improved after
coming off of the Nafcillin. Still, she has a slight
leukocytosis and some loose stools. Repeat C diff testing should
be done for concerning symptoms.
.
7. Anemia: The patient came in with a Hct of 30. She has a h/o
iron deficient anemia, for which she is on [**Hospital1 **] iron
supplementation. The patient had some BRBPR with an active
source of bleeding from external hemorrhoids. The patient also
has a h/o marginal ulcer near Roux-and-Y site, so we were
concerned for upper GIB, given dark stools. Her stools were
green, however, and Guaiac negative. She was given 1 unit of
blood for a Hct 24. Her hemodynamics were otherwise stable. Iron
was continued. She is on Protonix. The patient should continue
to be monitored for occult GI bleeding. There may also be a
component of anemia due to poor production from her kidney
disease.
.
TRANITIONAL ISSUES:
1. Repeat Hct within 1 week.
2. Have low threshold to obtain CT scan if she has worsening
headaches or focal neurologic signs/symptoms.
3. She should continue aggressive physical therapy at rehab.
Medications on Admission:
Multivitamin, allopurinol, Calcium, fluticasone, Zyrtec
albuterol sulfate, Pataday 0.2 % Eye Drops , Lasix, Fioricet,
ferrous sulfate, omeprazole, labetalol 300 mg [**Hospital1 **], hydroxyzine
Discharge Medications:
1. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. 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.
3. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
4. Eucerin Cream Sig: One (1) application Topical every four
(4) hours as needed for itching.
5. allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day): Will need to be redosed as kidney
function changes.
6. hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal TID (3
times a day) as needed for hemorrhoids.
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. hydralazine 25 mg Tablet Sig: One (1) Tablet PO every six (6)
hours: Hold for SBP<100.
9. calcium acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
10. labetalol 200 mg Tablet Sig: Three (3) Tablet PO TID (3
times a day): Hold for SBP < 100, HR < 55.
11. trimethoprim 100 mg Tablet Sig: 0.5 Tablet PO Q12H (every 12
hours): Last Day [**2-11**].
12. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: One
(1) Tablet PO every eight (8) hours as needed for headaches.
13. psyllium Packet Sig: One (1) Packet PO TID (3 times a
day) as needed for loose stools.
14. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
15. cefazolin 10 gram Recon Soln Sig: Two (2) grams Injection
Q12H (every 12 hours): This will be a 6 week course. ID will
determine when to stop. Renally dosed.
16. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Subarachnoid Hemorrhage
MSSA mitral valve endocarditis
Acute Kidney Injury
Polycystic Kidney Disease
Urinary Tract Infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital after a subarachnoid
hemorrhage. While you were here, we determined that you also had
bacteria in your blood that attached to your mitral valve. You
also developed worsening kidney function that our renal
colleagues thought was due to dehydration on top of polycystic
kidney disease. We performed multiple images of your head that
showed stability of the bleeding. We treated your infection with
antibiotics, which you will continue as an outpatient. We
monitored your kidney function, which we will continue to work
up as an outpatient with the urologist and nephrologist. Below
are some general recommendations from the neurosurgery
colleagues.
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**].
If you have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
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:
Department: SURGICAL SPECIALTIES
When: MONDAY [**2123-2-22**] at 10:00 AM
With: [**First Name8 (NamePattern2) 161**] [**Name6 (MD) 162**] [**Name8 (MD) 163**], MD [**Telephone/Fax (1) 164**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: RADIOLOGY
When: THURSDAY [**2123-2-25**] at 1:30 PM
With: CAT SCAN [**Telephone/Fax (1) 327**]
Building: CC CLINICAL CENTER [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: NEUROSURGERY
When: THURSDAY [**2123-2-25**] at 2:45 PM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 7746**], MD [**Telephone/Fax (1) 3666**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: [**Hospital 9380**] CLINIC
When: TUESDAY [**2123-3-9**] at 2:00 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 721**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 9162**]
|
[
"E930.0",
"280.9",
"787.91",
"054.9",
"430",
"585.3",
"599.71",
"599.0",
"403.90",
"V13.02",
"041.49",
"444.22",
"276.51",
"455.5",
"394.1",
"753.13",
"V45.86",
"584.5",
"421.0",
"788.20",
"288.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
11937, 12007
|
5512, 9984
|
366, 445
|
12176, 12176
|
3442, 5293
|
14351, 15611
|
1859, 1923
|
10228, 11914
|
12028, 12155
|
10010, 10205
|
12327, 14328
|
1953, 2298
|
3155, 3423
|
311, 328
|
473, 1416
|
2482, 3139
|
5302, 5489
|
12191, 12303
|
1438, 1736
|
1752, 1843
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,636
| 150,008
|
11244+56223
|
Discharge summary
|
report+addendum
|
Admission Date: [**2135-10-11**] Discharge Date: [**2135-10-18**]
Date of Birth: [**2067-5-29**] Sex: M
Service: [**Last Name (un) **]
CHIEF COMPLAINT: Left flank hematoma.
HISTORY OF PRESENT ILLNESS: This is a 68 year-old gentleman
who underwent a right [**Doctor Last Name **] to DP bypass this year and a left
carotid endarterectomy 2 years ago, abdominal aortic aneurysm
repair in [**2131**]. He was discharged recently on [**9-21**] from our
institution. At that time hospital course was remarkable for
acute renal failure requiring renal biopsy, which
demonstrated a cholesterol emboli and vascular disease as the
cause of his renal failure. The patient was begun on
hemodialysis at the time. The biopsy site was complicated by
a hematoma and this was embolized. The patient's subsequently
got an AV fistula for hemodialysis access. He has since
discharged complained of increasing size and left flank pain.
He is now admitted for evaluation and treatment of his flank
hematoma.
MEDICATIONS ON ADMISSION: Digoxin 0.125 mg daily, Prevacid
30 mg daily, Lipitor 20 mg daily, diltiazem 30 mg q.i.d.,
trazodone 80 mg at bedtime, Advair b.i.d.,oxycodone 5 mg.
ALLERGIES: Patient has no known drug allergies.
PAST MEDICAL HISTORY: Peripheral vascular disease status
post right popliteal DP bypass graft, status post left
carotid endarterectomy, status post abdominal aortic aneurysm
repair. Acute renal failure on hemodialysis, left flank
hematoma secondary to renal biopsy embolized with
reoccurrence, history of hypertension controlled, history of
prostate carcinoma.
PAST SURGICAL HISTORY: As indicated in the HPI.
PHYSICAL EXAMINATION: Vital signs aer stable. Patient is
alert and oriented x 3, in no acute distress. Heart is a
regular rate and rhythm without murmur, gallop or rub. Lungs
are clear to auscultation bilaterally. Abdominal exam left
flank hematoma, large 20 by 20 cm mass. The patient has no
guarding or tenderness. Extremity exams full range of motion
of all extremities. The right lower extremity bypass incision
site is clean, dry and intact.
REVIEW OF SYSTEMS: Negative for facial changes, somnolence,
dysphagia, chest pain, dyspnea on exertion, orthopnea, melena
or bright red rectal bleeding.
HOSPITAL COURSE: Patient was admitted to the vascular
service, the hemodialysis service and the renal department
was consulted for management of the patient's hemodialysis,
which is Monday, Wednesday and Friday. The patient is also
on 6000 units of Epogen at dialysis and 3 mcg of Zemplar.
Patient's admitting labs white count was 10.6, hematocrit
30.4, platelets 527,000, INR 2.0, BUN 32, creatinine 4.4, K
3.3, albumin 2.3. Chest x-ray with left lower lobe
atelectasis and a small pleural effusion. Patient underwent
CT of the abdomen with contrast. The study demonstrated
bilateral pleural effusions of the lung bases with left
greater than right. Both have increased in comparison study
of [**9-12**]. There were no pulmonary nodules. The right
kidney is unremarkable. There is a large subcapsular left
renal hematoma extends from the lateral portion of the lower
pole and extends downward with a maximum XY diameter of 11 cm
by 9.6 cm. This is larger then before when it was measured at
8 by 7.3 cm the previous dimensions. The subcapsular hematoma
may connect to a massive left flank hematoma, which measures
20 by 17 cm, which has enlarged in size. This hematoma
extends all the way down to the pelvis. There are multiple
loculations within the left flank hematoma especially
medially and posteriorly in the pelvis. There is displacement
of the aorta to the left renal artery and vein are patent.
There is an infrarenal abdominal aortic aneurysm that
measures 5.2 cm in diameter that is unchanged on comparison
study. There is no mesenteric lymphadenopathy. The pelvic
portion of the study was unremarkable except for evidence of
seeds within the prostate. Patient required FFP 2 units to be
emergently reversed. His warfarin effect was an INR of 2.0.
The evening prior to anticipated surgery for hematoma
evacuation, the patient complained of and exhibited
depression enough to end his life. Psychiatry was consulted.
They felt that the patient had mild symptoms of depression in
the context of severe medical illness. His comments about
suicide were out of frustration about his medical care and
his suicidality has abated now and the plan of action has
been proposed. They do not think the patient was at acute
risk for suicide, but recommended that the patient would
benefit from outpatient either by a psychiatrist or by his
primary care physician. [**Name Initial (NameIs) **] 1 to 1 sitter was discontinued.
His trazodone was discontinued, because the patient was
hypersomnolent and consideration from a stimulant or
antidepressant if depressive symptoms persist or return after
surgery might be indicated
Patient proceeded on [**10-13**] for anticipated surgery. Prior to
surgery he spiked a temperature to 102.8 with atrial
fibrillation with a rate of 180 to 160. Blood, urine cultures
were obtained. He required 2 doses of 5 mg of IV Lopressor to
stabilize his ventricular rate and bring his systolic
hypertension to normotensive. Patient's white count at the
time of this fever was 10.8. CKs were obtained, which were
11, troponins were .03. The urinalysis was contaminated. The
patient's left retroperitoneal hematoma was sent for culture,
which was staph coag positive, moderate growth of 3 colony
morphology, which was sensitive to Clinda, erythromycin,
Levofloxacin, oxacillin. The anaerobic cultures were
negative. The retroperitoneal space was swabbed, which grew
staph coag positive, moderate growth, 3 colony morphologies,
no anaerobes were isolated. Patient underwent an open left
retroperitoneal hematoma evacuation. He tolerated the
procedure well. He was transferred to the PACU in stable
condition. His postoperative crit remained stable at 32. He
continued to do well and was transferred to the VICU for
continued monitoring and care. The patient was extubated in
the operating room and transferred to the PACU, but required
emergent intubation. The patient was transferred to thoracic
intensive care unit continuing postoperative care.
Postoperative day 2 the patient continued to do well. He
remained on PCE vent support. His blood gases were 7.434, 41,
63, 27 and 98%. Patient's white count was 8.7, hematocrit
30.7, platelets 383,000, BUN 26, creatinine 3.3, K 4.1, INR
was 1.6. Anticipated patient would be extubated. SubQ heparin
was begun. Patient was extubated on postoperative day 3,
delined and transferred to the vascular postoperative floor
for continued care. Renal service continued to follow the
patient for hemodialysis needs. Patient was placed on
Vancomycin and this was dosed according to random levels less
than 15. Patient's postoperative course continued to do well.
Incisions were clean, dry and intact. Levofloxacin and Flagyl
that he was on postoperatively was discontinued on
postoperative day 4. Patient was evaluated by physical
therapy who felt that the patient was unsafe to be discharged
to home, because of deconditioning and would benefit from
rehab in order to increase his endurance and strength and
optimize his level of function. Rehab screening was begun.
JPs remained in place and the output was monitored. These
will be discontinued when the drainage is less then 30 cc for
24 hours. Patient will be transferred to rehab when medically
stable and bed available.
DISCHARGE MEDICATIONS: Diltiazem 30 mg q.i.d.,
Fluticasone/Salmeterol 100/50 mcg dosed disc 1 disc device
inhalation b.i.d., acetaminophen 325 mg 2 tablets 1 to 2
every 4 to 6 hours prn, lansoprazole 30 mg every day,
metoprolol 50 mg t.i.d., digoxin 125 mcg every day,
oxycodone/acetaminophen 5/325 1 to 2 every 4 to 6 hours prn
for pain, atorvastatin 20 mg every day, dicloxacillin 500 mg
every day for a total of 2 weeks.
DISCHARGE DIAGNOSES: Left flank hematoma, MSSA positive,
history of renal failure on dialysis Monday, Wednesday and
Friday, history of prostate carcinoma, history of atrial
fibrillation, history of chronic anemia. Postoperative blood
loss anemia transfused.
MAJOR PROCEDURES: Open evacuation of left flank hematoma on
[**2135-10-13**].
DISCHARGE INSTRUCTIONS: Patient should follow up with Dr.
[**Last Name (STitle) 1391**] on [**10-21**]. He should call his office for an
appointment at [**Telephone/Fax (1) 1393**]. Upon discharge from rehab the
patient should follow up with his nephrologist for continue
management of his hemodialysis and his primary care physician
for continued management of his atrial fibrillation and blood
pressure.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2380**], [**MD Number(1) 2381**]
Dictated By:[**Last Name (NamePattern1) 2382**]
MEDQUIST36
D: [**2135-10-18**] 09:29:48
T: [**2135-10-18**] 10:22:14
Job#: [**Job Number 36119**]
Name: [**Known lastname 6449**],[**Known firstname 33**] Unit No: [**Numeric Identifier 6450**]
Admission Date: [**2135-10-11**] Discharge Date: [**2135-10-18**]
Date of Birth: [**2067-5-29**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 231**]
Addendum:
[**2135-10-18**] [**Initials (NamePattern4) 1325**] [**Last Name (NamePattern4) 2021**]-[**Location (un) **] drains will remain in place at
discharge. Please moniter and record each jp drainage/ 24hrs.
Patient is to followup with Dr. [**Last Name (STitle) **] on [**2135-10-21**]. We will
remove drains at that time if 24hrs drainage <30cc.
Patient discharged to rhab for continued care. Stable at d/c.
Discharge Disposition:
Extended Care
Facility:
Country [**Hospital **] Rehabilitation & Nursing Center - [**Location (un) 6451**]
[**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern1) 237**] MD [**MD Number(1) 238**]
Completed by:[**2135-10-18**]
|
[
"518.81",
"998.12",
"E878.8",
"443.9",
"424.1",
"285.1",
"441.4",
"V10.46",
"427.31",
"311",
"403.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"39.95",
"99.07",
"96.71",
"96.04",
"54.0"
] |
icd9pcs
|
[
[
[]
]
] |
9755, 10022
|
7941, 8259
|
7517, 7919
|
1037, 1237
|
2272, 7493
|
8284, 9732
|
1624, 1650
|
1673, 2099
|
2119, 2254
|
174, 196
|
225, 1010
|
1260, 1600
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,183
| 145,164
|
244
|
Discharge summary
|
report
|
Admission Date: [**2141-7-9**] Discharge Date: [**2141-7-13**]
Date of Birth: [**2095-12-8**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
overdose
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
Mr. [**Known lastname 2445**] is a 45 year old man who presented to the [**Hospital1 18**] via
[**Location (un) 86**] EMS. Pt was found by EMS at his home at 10:21pm [**2141-7-8**].
The patient was supine, pt was noted to by awake and alert, BP
120/88, pulse 72. He was noted to have overdosed taking "35
pills" - bottles at the scene included citalopram, risperdal,
doxazosin, and doxepin. A note was found with him saying "I
don't want to do time." He was brought to [**Hospital1 18**] where his VS
were T 98.7 BP 126/79 RR 18 99% RA. Pt was noted to have altered
mental status and a GCS of 12. A foley was placed and 150cc of
urine was obtained. By report, he said he had taken "a bunch of
vicodin" so narcan 5mg was given 5mg given at 12:20am with
little response. At 1:13 am the patient was intubated for airway
protection, but the intubation was difficult and anaesthesia
needed to perform the intubation fiberoptically. In total, the
patient was given 2L NS and 1L D5W with 150meq bicarb. Activated
charcoal was also given. An EKG was performed and was RBB with a
QRS of 136. Tox screen was also positive for cocaine, TCAs and
acetaminophen
Past Medical History:
History of hepatitis B exposure
History of head trauma
History of witdrawal seizure
Social History:
He has a history of polysubstance abuse, abusing both
intravenous and intranasal heroin, as well as cocaine. He has
been on a methadone maintenance program. He has a history of
multiple suicide attempts, including an overdose of zyprexa. He
has been incarcereated twice. He has a history of alcohol abuse
and marijuana and tobacco use.
Family History:
Noncontributory
.
Physical Exam:
VS: T 97 HR 81 BP 110/67 RR 13 Sat 100%
Vent: AC Tv 600 RR 12 PEEP 5 FiO2 0.4 pulling: Mv 6.8 PIP 31
Plat 17 MaP 10
Gen: AA man intubated and sedated. +ETT +foley +PIV x2
HEENT: pupils constricted but reactive, sclerae anicteric
Neck: supple, no masses, trachea midline
CV: Normal s1/s2, RRR, no m/r/g
Pul: CTA bilaterally
Abd: Soft, NT, ND
Ext: No edema, warm, dry, DP 2+ bilaterally, RP 2+ bilaterally.
Neuro: Sedated, withdraws to pain
Pertinent Results:
[**2141-7-8**] 11:45PM BLOOD WBC-11.5* RBC-5.63# Hgb-17.4# Hct-49.3
MCV-88 MCH-30.8 MCHC-35.2* RDW-13.6 Plt Ct-207
[**2141-7-8**] 11:45PM BLOOD Neuts-71.2* Lymphs-23.8 Monos-4.5 Eos-0.3
Baso-0.3
[**2141-7-8**] 11:45PM BLOOD Plt Ct-207
[**2141-7-8**] 11:45PM BLOOD Glucose-83 UreaN-16 Creat-1.3* Na-134
K-8.23* Cl-99 HCO3-25 AnGap-18
[**2141-7-8**] 11:45PM BLOOD ALT-184* AST-688* CK(CPK)-[**Numeric Identifier 2446**]*
AlkPhos-85 Amylase-62 TotBili-1.4
[**2141-7-11**] 02:00AM BLOOD CK-MB-4 cTropnT-<0.01
[**2141-7-10**] 10:19AM BLOOD CK-MB-10 MB Indx-0.1 cTropnT-<0.01
[**2141-7-8**] 11:45PM BLOOD Calcium-9.3 Phos-4.6* Mg-2.3
[**2141-7-8**] 11:45PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-14.1
Bnzodzp-NEG Barbitr-NEG Tricycl-POS
[**2141-7-9**] 04:34AM BLOOD Acetmnp-NEG
[**2141-7-9**] 01:00AM BLOOD K-4.3
[**2141-7-13**] 03:02AM BLOOD WBC-8.1 RBC-4.35* Hgb-13.4* Hct-38.5*
MCV-88 MCH-30.9 MCHC-35.0 RDW-13.5 Plt Ct-188
[**2141-7-13**] 03:02AM BLOOD ALT-106* AST-223* LD(LDH)-356*
CK(CPK)-6223* AlkPhos-65 TotBili-1.0
Brief Hospital Course:
45M w/ history of depression, polysubstance abuse, presenting
after a suicide attempt, overdosing on tricyclics (doxepin) and
also with cocaine intoxication who was sucessfully extubated
with a closing QRS and decreasing CK. Patient's renal function
remained good with excellent urine output. Pt medically cleared
for psych admission.
1. TCA: QRS closed, monitored on tele.
2. Rhabdo: decreasing CK with IV hydration and excellent urine
output.
3. SI: 1:1 sitter and psych consult, pt upset that he did not
succeed with suicide attempt, admit to psych, all TCAs and
sedatives held.
4. left arm swelling: no evidence of compartment syndrome, PIV
pulled from left hand, seen by ortho for possible ulnar
neuropraxia, improving upon discharge. US showed no DVT.
Transferred to psych on section 12 for further eval and readjust
of medications.
Medications on Admission:
BENADRYL 25MG--Take 2 by mouth at bedtime
BENZAMYCINPAK 3-5%--Apply twice a day to face for acne
CELEXA 20MG--Take one by mouth at bedtime
COLACE 100MG--1-2 tabs by mouth every day as needed
DOXEPIN HCL 25MG--One capsule(s) by mouth at bedtime
Doxazosin 1MG--2 tablet(s) by mouth at bedtime
RISPERDAL 0.25MG--Take two tablets before sleep
TRETINOIN 0.025%--Pea sized amt to face and rub in for acne
VIAGRA 50 mg--0.5-1 tablet(s) by mouth once a day as needed for
for sexual activity take 30-60 minutes prior to sexual activity
WESTCORT 0.2%--Twice a day to face for 7 days, then d/c
ZANTAC 150MG--One tablet by mouth twice
Discharge Medications:
1. Benadryl 25 mg Capsule Sig: Two (2) Capsule PO at bedtime as
needed for insomnia for 10 days.
2. Colace 100 mg Capsule Sig: [**11-21**] Capsules PO once a day as
needed for constipation for 10 days.
3. Doxazosin 1 mg Tablet Sig: Two (2) Tablet PO at bedtime for
30 days.
4. Risperdal 0.25 mg Tablet Sig: Two (2) Tablet PO at bedtime as
needed for insomnia for 10 days.
5. Zantac 150 mg Tablet Sig: One (1) Tablet PO twice a day for
30 days.
6. BenzamycinPak [**1-22**] % Gel Sig: One (1) Topical twice a day
for 10 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 69**] - [**Location (un) 86**]
Discharge Diagnosis:
TCA overdose, suicide attempt, depression, h/o withdrawal
seizures, h/o head trauma, h/o cocaine use, h/o hep B exposure
Discharge Condition:
Improved
Discharge Instructions:
Discharge to pyschiatry service, keep your scheduled
appointments, hold your anti-depressant medications until you
see psychiatry.
Followup Instructions:
Please follow up with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 2447**]
within 2-3 days
|
[
"729.81",
"989.9",
"518.81",
"305.60",
"728.88",
"969.0",
"309.28",
"E950.3",
"311"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
5592, 5662
|
3524, 4365
|
323, 336
|
5827, 5838
|
2486, 3501
|
6017, 6140
|
1990, 2010
|
5041, 5569
|
5683, 5806
|
4391, 5018
|
5862, 5994
|
2025, 2467
|
275, 285
|
364, 1513
|
1535, 1621
|
1637, 1974
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,247
| 123,031
|
43535
|
Discharge summary
|
report
|
Admission Date: [**2198-7-4**] Discharge Date: [**2198-7-10**]
Date of Birth: [**2115-1-28**] Sex: M
Service: MEDICINE
Allergies:
Glucotrol
Attending:[**First Name3 (LF) 7333**]
Chief Complaint:
inappropriate rhythm sensing by ICD
Major Surgical or Invasive Procedure:
ICD lead replacement [**7-9**]
cardioversion [**7-9**]
History of Present Illness:
For more details, please see admission note from [**2198-7-4**]. In
brief, this is a 83 y/o male with h/o CAD, s/p MI x 2, s/p CABG
in [**2186**], with history of syncope possibly [**1-8**] to NSVT, s/p ICD
placement for primary prevention in [**2184**]. He presented with
inappropriate sensing of his ICD.
He was hospitalized at [**Hospital1 **] from [**2198-6-29**] to [**2198-7-3**] for a LLL CAP
that did not respond to out-patient treatment with z-pak. He was
treated with PO levaquin 750mg PO q48 (renally dosed) and
improved, with less fever, improved symptoms, and improved
leukocytosis. He was discharged [**7-3**] with one remaining dose of
levaquin ([**2198-7-4**]) and upon arriving home, his remote check
demonstrated 15 NSVT episodes, 6 VT-Mon episodes and one VF
episode since [**2198-4-6**]. He denied any symptoms of palpitations,
lightheadedness, or pre-syncope/syncope. He did not experience
any firing of his ICD. He was called by the device clinic and
told to come in for likely inappropriate sensing of
tachyarrhythmias. He was found to have a faulty lead/lead
fracture and his ICD was turned off and he was admitted to the
[**Hospital1 1516**] service. He was taken to the EP OR today, [**2198-7-9**] for lead
replacement. During the procedure, his RA lead was removed, he
went into atrial fibrillation, is s/p cardioversion, currently
in sinus rhythm. He lost about 1 unit of blood during the
procedure, but is clinically stable. A TEE was done during the
procedure and no evidence of pericardial effusion was found.
.
Of note his original NSVT episode presented with syncope. He has
never had another episode of syncope, and he has never felt his
ICD fire.
.
Past Medical History:
1. CARDIAC RISK FACTORS:
+ Diabetes
+ Dyslipidemia (on statin, on [**3-15**] Chol 109, Triglyc 91, HDL 36,
CHOL/HD 3.0, LDLcalc 55)
+ Hypertension
.
2. CARDIAC HISTORY:
# Inferior MI [**2171**], MI [**2176**]
# Chronic systolic CHF (EF 30-35% by echo [**2198-7-9**])
.
CABG:
- 3 vessel CABG in [**2186**] (LIMA to LAD, SVG to RCA, and SVG to D1,
jump to OM2)
.
PERCUTANEOUS CORONARY INTERVENTIONS:
- [**2187-8-7**]: angioplasty of native small OM distal to SVG insertion
site.
.
PACING/ICD:
- [**2185-10-12**] - ICD placed for nonsustained VT / syncope
- [**2192-9-5**] - Generator change
- [**2195-7-3**] - Generator change, ventricular lead revision,
atrial lead upgrade
- [**2198-7-9**] - ICD lead replacement [**1-8**] inappropriate sensing of ICD
# CAD status post CABGx3 in [**2186**] (first obtuse marginal to left
anterior descending artery, saphenous vein graft to right
coronary artery, and saphenous vein graft to obtuse
marginal/diagonal).
# Cath from [**2191**]: 1. Three vessel native coronary artery
disease. 2. Mild left ventricular diastolic dysfunction. 3.
Patent SVG to Diagonal with patent jump segment to OM2. 4.
Patent LIMA to LAD.
# Stress from [**2191**]: EKG: IMPRESSION: No anginal symptoms or
ischemic EKG changes at the achieved workload. Nuclear report
sent separately. Nuclear: IMPRESSION: 1) Severe myocardial
perfusion defect involving the inferior wall shows partial
reversibility in its apical region. 2) Global hypokinesis with
estimated EF of 35%. Further evaluation by cardiac ECHO is
recommended.
# Chronic systolic CHF EF 35-40% [**2194**]
# Hypertension
# Diabetes mellitus
# Duodenal ulcer
# Status post appendectomy
# Status post implantable cardioverter-defibrillator
placement for nonsustained ventricular tachycardia
# High cholesterol
Social History:
Lives alone, but family lives in upstairs apartment.
Tobacco: smoked from age 16-57, about [**1-9**] ppd
EtOH: Social
Denies illicit drugs
Family History:
NC
Physical Exam:
VS: T=98.7 BP=125/50 HR=92 RR=14 O2 sat=97/RA
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis
of the oral mucosa.
NECK: Supple with JVP of 7 cm.
CARDIAC: Regular with ectopy normal S1, S2. No m/r/g.
LUNGS: Wheezing b/l.
ABDOMEN: Soft, NT, Distended, large ventral hernia.
EXTREMITIES: Surgical site R inguinal region: no bruits
ascultated. 2+ pitting edema to knees bilaterally, R>>L.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Femoral 2+ DP 2+ PT 2+
Left: Femoral 2+ DP 2+ PT 2+
Pertinent Results:
[**2198-7-3**] 06:07AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
[**2198-7-3**] 06:07AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.008
[**2198-7-3**] 06:10AM WBC-6.9 RBC-3.66* HGB-10.8* HCT-32.4* MCV-88
MCH-29.6 MCHC-33.5 RDW-13.2
[**2198-7-3**] 06:10AM CALCIUM-8.5 PHOSPHATE-2.9 MAGNESIUM-1.9
[**2198-7-3**] 06:10AM GLUCOSE-158* UREA N-28* CREAT-1.3* SODIUM-136
POTASSIUM-3.9 CHLORIDE-103 TOTAL CO2-26 ANION GAP-11
CXR: [**7-9**]->Previous consolidation in the right lung has improved
substantially above the level of the minor fissure, but not
below and should be investigated as a unresolving acute
pneumonia. Left infrahilar opacification is probably
atelectasis, but could be consolidation as well, and is more
pronounced today than on [**2198-7-4**]. Mild cardiomegaly is
stable. There is no pulmonary edema or pleural effusion and no
pneumothorax or mediastinal widening. The lower portion of the
chest is excluded from this examination and the tips of 2
transvenous cardiac leads are not imaged. The proximal electrode
of the pacer defibrillator lead is in the SVC and left
brachiocephalic vein. Followup radiographs are needed.
Cardiology team was notified.
CXR: [**7-10**]->Mild-to-moderate cardiac enlargement is stable. Right
lower lobe
consolidation has improved consistent with resolving pneumonia.
Transvenous right atrial and right ventricular pacer leads are
in standard placements. No pneumothorax. No appreciable pleural
effusion or pulmonary edema.
Brief Hospital Course:
This is an 83 year old gentleman with a history of CAD s/p CABG
in [**2186**] and syncope likely [**1-8**] VT s/p ICD in [**2184**], recently
discharged from hospital for community acquired pneumonia, who
presented with a faulty ICD lead.
.
1. ICD lead fracture: The patient lost 1 unit of blood during
his lead replacement procedure, but remained clinically stable.
His hematocrit remained stable and he did not require
transfusion. A CXR was performed and showed that his leads were
properly positioned and he had no pneumothorax. The EP fellow
checked the leads prior to discharge. His post procedural pain
was treated with Tylenol Q6H with Oxycodone available PRN for
breakthrough pain
.
2. Atrial fibrillation: The patient had an episode of Afib
during the lead replacement procedure and was cardioverted back
into sinus rhythm at that time. He remained in sinus rhythm
throughout the remainder of his admission s/p cardioversion. He
was started on Coumadin 5 mg daily and is INR=1.3 on discharge.
His INRs will be followed closely by his outpatient PCP and he
will require a total of 3 months of anticoagulation.
.
3. Community Acquired Pneumonia: The patient was recently
discharged after treatment with 3 days of Levaquin for a
community acquired pneumonia. His CXR on admission looked
significantly worse and he was given vanc/cefepime for 4 days
prior to the procedure being performed. He showed marked
clinical improvement and was afebrile with no leukocytosis. His
antibiotics were switched to cefpodoxime and azithromycin on [**7-9**]
following the procedure. He will continue cefpodoxime for a 7
day course and azithromycin for a 5 day course. His CXR was
dramatically improved on discharge.
.
4. Chronic Systolic and Diastolic Heart Failure with an
EF=35-40% on TTE. He was continued on Coreg, but
lisinopril/HCTZ was held as his blood pressure was initially
marginal and his creatinine was up to 1.5. He will continue on
all 3 medications as an outpatient.
.
5. Coronary Artery Disease s/p CABG. He had no anginal symptoms
throughout the admission. He was continued on simvastatin,
clopidogrel, ASA, and coreg.
.
6. Hypertension. Continue Coreg and Lisinopril/HCTZ as an
outpatient.
.
7. Diabetes - Humalog sliding scale, restarted metformin on
discharge.
.
8. Chronic Kidney Disease - baseline Cr 1.2-1.5 and back down to
Cr=1.3 on discharge. Lisinopril/HCTZ restarted prior to
discharge.
Medications on Admission:
Aerochamber Device USE WITH INHALER GETS MEDICATION DEEPER INTO
LUNGS
Albuterol Sulfate [ProAir HFA] 90 mcg HFA Aerosol Inhaler 2
Puffs(s) inhaled Q 4 hr as needed for sob or wheeze or cough
Carvedilol 25 mg Tablet 1 Tablet(s) by mouth twice a day chf
Clopidogrel [Plavix] 75 mg Tablet 1 Tablet(s) by mouth once a
day hx cad
Codeine-Guaifenesin 100 mg-10 mg/5 mL Liquid 5-10ml Syrup(s) by
mouth every four (4) hours as needed for cough
FOLIC ACID 400 MCG Tablet TAKE ONE BY MOUTH EVERY DAY
Lisinopril-Hydrochlorothiazide 20 mg-25 mg Tablet 1 Tablet(s) by
mouth daily LORAZEPAM 1 mg Tablet take 1 Tablet(s) by mouth
twice a day as needed for prn anxiety, irritability, aggravation
Metformin 1,000 mg Tablet 1 Tablet(s) by mouth once a day dm
Nitroglycerin 0.3 mg Tablet, Sublingual 1 Tablet(s) sublingually
as directed as needed for chest pain
Pantoprazole 40 mg Tablet, Delayed Release (E.C.) 1 Tablet,
Delayed Release (E.C.)(s) by mouth once a day gerd
Simvastatin 80 mg Tablet [**12-8**] Tablet(s) by mouth once a day chol
[**2198-3-20**]
Aspirin 81 mg Tablet, Chewable 1 Tablet(s) by mouth DAILY
(Daily)
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours) as
needed for h/o PUD.
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
6. Folic Acid 400 mcg Tablet Sig: One (1) Tablet PO once a day.
7. Carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day.
8. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO once a day as
needed for insomnia.
9. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*10 Tablet(s)* Refills:*0*
10. Azithromycin 500 mg Tablet Sig: One (1) Tablet PO once a day
for 3 days.
Disp:*3 Tablet(s)* Refills:*0*
11. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
Disp:*30 Tablet(s)* Refills:*2*
12. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO once a day.
13. Lisinopril-Hydrochlorothiazide 20-25 mg Tablet Sig: One (1)
Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: ICD lead fracture, community acquired
pneumonia, chronic systolic and diastolic heart failure, atrial
fibrillation
Secondary Diagnoses:
- Hypertension
- Diabetes mellitus
- Duodenal ulcer
- Status post appendectomy
- Status post implantable cardioverter-defibrillator placement
for nonsustained ventricular tachycardia
Discharge Condition:
stable, afebrile, ambulatory
Discharge Instructions:
You were admitted to the hospital because your defibrillator was
not functioning properly. Your lead was replaced and during the
procedure you went into atrial fibrillation and required
cardioversion. You will be started on Coumadin and finish your
antibiotic course for pneumonia as an outpatient.
Please attend all follow-up appointments listed below.
We made the following medication changes while you were here:
- You will continue on daily Coumadin for 3 months and have your
blood levels checked at the discretion of your primary care
physician
[**Name Initial (PRE) **] [**Name10 (NameIs) **] will complete your antibiotics course for pneumonia (5
more days of cefpodoxime and 3 more days of azithromycin)
Please call your doctor or return to the hospital if you develop
chest pain, difficulty breathing, fevers, palpitations,
lightheadedness, or any other concerning symptom.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Followup Instructions:
Please go and follow up with Dr. [**Last Name (STitle) 12872**] on Thursday [**7-12**] [**2196**] at 3:30 PM to have your coumadin level checked.
You have follow-up scheduled in the device clinic:
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2198-7-30**]
3:00
Please keep the following previously scheduled appointments:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1523**], MD Phone:[**Telephone/Fax (1) 1144**]
Date/Time:[**2198-8-23**] 4:30
|
[
"250.00",
"E876.8",
"E878.1",
"996.01",
"285.29",
"428.0",
"272.4",
"V15.82",
"414.01",
"V45.81",
"486",
"V58.67",
"532.90",
"276.1",
"585.9",
"427.31",
"427.69",
"V45.82",
"428.42",
"996.04",
"412",
"403.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.77",
"37.98",
"37.97",
"99.62"
] |
icd9pcs
|
[
[
[]
]
] |
11032, 11038
|
6260, 8688
|
305, 362
|
11421, 11452
|
4673, 6237
|
12490, 13013
|
4055, 4059
|
9849, 11009
|
11059, 11059
|
8714, 9826
|
11476, 12467
|
4074, 4654
|
11215, 11400
|
2268, 3883
|
230, 267
|
390, 2077
|
11078, 11194
|
2099, 2248
|
3899, 4039
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,469
| 187,656
|
26583
|
Discharge summary
|
report
|
Admission Date: [**2160-10-6**] Discharge Date: [**2160-10-7**]
Date of Birth: [**2107-6-12**] Sex: F
Service: MEDICINE
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
endotracheal intubation
History of Present Illness:
Mrs [**Known lastname **] is a 43 year old with recent diagnosis of metastatic
breast cancer, started on 1st round of chemotherapy today, who
presents from OSH with worsening SOB s/p intubation for resp
fatigue and hypoxia. Around 4-5 weeks ago, she was in her
normal state of good health when she developed shortness of
breath asssociated with back pain. She treated the back pain
with flexerol, it resolved, but the shortness of breath
remained. Two weeks ago, she developed acutely worsening SOB
over a 24hr period, and presented to her [**Known lastname 3390**]. [**Name10 (NameIs) 3390**] directed her
to the ER given concern for PE; CTA-chest per report showing no
embolus but liver nodules concerning for malignancy. Subsequent
biopsy showed adenocarcinoma of unknown origin. No lung lesions
identfied on multiple imaging. MRI of breast on [**2160-10-2**]
revealed mass. Path of tumor showed it to be ER neg, PR neg,
HER-2-neu positive, and oncologist decided to start chemo. Over
the past couple of days prior to admission, per her friends, she
had some confusion, with DOE that made climbing stairs
difficult, and worsening jaundice. No chest pain. Recent
weight gain from baseline 175 to 197 lbs.
On the day of admission, she went to her oncologist's office for
1st round of chemotherapy herceptin and navelbine. She appeared
jaundiced and was not oriented to place. While receiving chemo,
she had chills, nausea and several episodes of emesis. According
to the flow sheets, her oxygen saturations was in the 70s-80s.
No chest pain, no itch. She developed an O2 requirement, EMS
was called, and she was sent to [**Hospital3 **]. Her vitals
were 98.1 108 159/68 28 89% on non-rebreather. She received
zofran, solumedrol 125 IV x 1, benadryl 50 IV x 1, ceftriaxone
1g IV x 1, as well as 1500 cc of IVF. Her labs were as below.
She developed worsening weakness, and she was intubated as it
appeared she was tiring out, in anticipation of transfer to
[**Hospital1 18**] for ICU care.
In the [**Hospital1 18**] ER, her vitals were 99.2 (rectal) 97 142/60 23 99%
on FiO2 1.0 PEEP 4.0. ABG drawn, CXR done. She was admitted
for further workup and care.
Past Medical History:
endometriosis
depression
breast cancer as above
Social History:
lives alone. Neuroanatomy PhD, MBA. Works as coordinator of labs
at [**University/College **] College. No smoking, social EtOH, no drugs.
Family History:
mother: alzheimers died in 70s, father alive in 80s, no
siblings, no children
Physical Exam:
Vitals 99.4 (rectal) 111 135/61 25 98% A/C FiO2 0.6 Vt 600
(pulling 800cc-1L) x rr 20 overbreathing 5-6 PEEP 5 PIP 12
Gen Jaundiced middle aged woman, intubated and sedated, with
multiple ecchymoses
HEENT NC/AT, icteric conjunctivae, PERRL 4->2, blood in
oropharynx and nasopharynx, ET and NG tubes in place
Neck supple, no masses, no submandibular, cervical, or
supraclavicular lymphadenopathy, no carotid bruits, no JVD
Breast no masses, no axillary lymphadenopathy, no nipple
discharge, slight inversion of left nipple
CV tachycardic, nl s1, s2, no m/r/g
Pulm coarse, ventilator transmitted breath sounds anteriorly
Abd absent bowel sounds, belly soft, nt/nd
Ext warm, well perfused, no cyanosis, clubbing or edema
Neuro intubated, sedated
Pertinent Results:
[**2160-10-6**] 09:49PM PT-100* PTT-76.8* INR(PT)-66.1
[**2160-10-6**] 09:49PM PLT SMR-VERY LOW PLT COUNT-37*
[**2160-10-6**] 09:49PM HYPOCHROM-1+ ANISOCYT-3+ POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-OCCASIONAL
OVALOCYT-OCCASIONAL SCHISTOCY-OCCASIONAL FRAGMENT-OCCASIONAL
[**2160-10-6**] 09:49PM NEUTS-97* BANDS-2 LYMPHS-1* MONOS-0 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0 NUC RBCS-11*
[**2160-10-6**] 09:49PM WBC-20.2* RBC-3.82* HGB-11.4* HCT-36.1 MCV-95
MCH-29.9 MCHC-31.6 RDW-21.7*
[**2160-10-6**] 09:49PM TOT PROT-5.5* ALBUMIN-2.8* GLOBULIN-2.7
[**2160-10-6**] 09:49PM LIPASE-71*
[**2160-10-6**] 09:49PM ALT(SGPT)-157* AST(SGOT)-726* ALK PHOS-490*
AMYLASE-50 TOT BILI-9.8*
[**2160-10-6**] 09:49PM GLUCOSE-76 UREA N-23* CREAT-1.1 SODIUM-141
POTASSIUM-4.6 CHLORIDE-105 TOTAL CO2-11* ANION GAP-30*
[**2160-10-6**] 09:54PM LACTATE-12.9*
[**2160-10-6**] 11:48PM LACTATE-14.0*
[**2160-10-6**] 11:48PM TYPE-ART PO2-250* PCO2-23* PH-7.16* TOTAL
CO2-9* BASE XS--18
*
CXR: supine AP. question of opacity at right heart/diaphragmatic
border
.
EKG: tachycardic, sinus, slight rightward axis, poor R wave
progression, incomplete rbbb, t wave inversions in v1-v3
.
Abd/pelvis CT:
1. Moderate amount of intra-abdominal ascites. No bowel
dilatation or bowel wall thickening to suggest bowel ischemia.
2. Small bilateral peripheral nodular opacities at the lung
bases suggest an infectious etiology. Alternatively, this could
represent metastatic disease. Correlation with outside
examinations is recommended.
Head CT: There is a large intraparenchymal hemorrhage on the
right parietal lesion and a smaller one on the right frontal
region. There is dissection into the right lateral ventricular
system. There is substantial displacement of the atrium of the
right lateral ventricle and substantial right to left subfalcine
herniation. There is effacement of sulci and decreased density
of the white matter diffusely consistent with diffuse cerebral
edema. The region of the foramen magnum is not well assessed due
to motion artifact but some transforaminal herniation is
suspected. There is a small amount of blood in the posterior
aspect of the left lateral ventricle. There is mild ventricular
dilatation with slight prominence of the temporal horns.
IMPRESSION: Extensive right-sided parenchymal hemorrhage with
diffuse cerebral edema, a subfalcine herniation and probable
transforaminal herniation.
Brief Hospital Course:
Pt was severely ill on admission to the ICU with a lactic
acidosis, respiratory failure, and hepatic failure. She was
given bicarbonate IV, broad spectrum antibiotics, 4 units of FFP
for DIC. She was minimally sedated on propofol gtt but still
was not responsive to painful stimuli. Because of her lactic
acidosis, she had an abdominal CT to eval for bowel ischemia
which was negative. She also had a head CT given her
unresponsiveness, which demonstrated a large intracerebral
hemorrhage with uncal herniation. At this point, a discussion
was had with her HCP who stated that pt would not have wanted
further invasive measures, such as neurosurgical intervention,
and would rather be made comfortable. She was placed on a
morphine gtt and extubated, and died peacefully with her friends
by her side a few minutes later.
Medications on Admission:
fosamax
fluoxetine
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
metastatic breast cancer
intracerebral hemorrhage
lactic acidosis
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
|
[
"197.7",
"431",
"570",
"789.5",
"276.51",
"276.2",
"174.8",
"518.81",
"286.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.07",
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
7059, 7068
|
6133, 6961
|
316, 341
|
7177, 7186
|
3677, 5215
|
7239, 7246
|
2786, 2865
|
7030, 7036
|
7089, 7156
|
6987, 7007
|
7210, 7216
|
2880, 3658
|
257, 278
|
369, 2544
|
5224, 6110
|
2566, 2615
|
2631, 2770
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,761
| 196,936
|
30291
|
Discharge summary
|
report
|
Admission Date: [**2102-9-16**] Discharge Date: [**2102-9-20**]
Date of Birth: [**2053-3-13**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
Alcohol withdrawal/Suicidality
Major Surgical or Invasive Procedure:
None
History of Present Illness:
49 year old female with h/o depression with prior thoughts of
suicide but no attempts, bipolar disease, [**Hospital 2182**] transferred from
[**Hospital1 **] [**Location (un) 620**] ED with chief complaint of suicidality and ETOH or
substance withdrawal. She called [**Location (un) 9188**] police and on a
recorded line, said she wanted to kill herself in context of
being emotional over her brother's suicide in [**2085**]. Sectioned
for medical care. Admitted to drinking vodka (last drink at
11:30pm on [**9-15**]) but denied taking any pills or IV drugs. Per pt
has had seizures with ETOH withdrawal in past. At OSH, her ETOH
of 360 and was tachy and visual hallucinating -- either
withdrawal at 360 or she has something else on board (cocaine?
meth?) - salicylate and tylenol negative, although she denies
it; or withdrawing from benzos. She has new ECG changes with
tachycardia, inferolaterolateral flipped T's in V3-6, II, II new
from [**Month (only) 958**]. First set of enzymes here pending. Oxy sat of 88 on
room air when asleep, consistent with hx of COPD. Hx includes
bipolar, for which she's on seraquel, lexapro, and klonopin, but
off all meds for one month due to money issues. In OSH, she was
hydrated and given benzos (4 mg. ativan IV and 1 mg. klonopin
po) without change. She was transferred to [**Hospital1 18**] for an ICU bed.
.
In our ED, afebrile, pulse 100-105, BP 110/47, RR 12, 98% on RA.
No tremors, is sleepy but responsive.
Past Medical History:
COPD
depression
bipolar disease
current tobacco use
Social History:
She was working for the [**Hospital1 487**] [**Social Security Number **] security bureau as an
administrator. Stopped working in [**Month (only) 958**]. Her father passed away
in [**2102-2-3**], brother committed suicide in [**2085**]. Patient notes
getting support through family and friends. Does not see a
therapist or psychiatrist. Drinks 1 pint vodka with stress, not
daily. Has had h/o withdrawal and seizures (3 admissions in last
year). Current cigarette smoker of 10 cigarettes a day. Denies
IVDU
Family History:
Mother died of cancer at 63yo, strong FH of depression/psych
problems
Physical Exam:
VS - Temp 98.4F, BP [**11/2062**] , HR 105 , R 17, 97% on 3L
GENERAL - Flat affect, sleeping but easily arousable, normal
speech
HEENT - MMM, o/p clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - +wheezes in all lung fields, moderate air movement
HEART - RR, no M/R/G
ABDOMEN - NABS, soft/NT/ND, no masses
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses
Pertinent Results:
CXR: Lungs are clear except to note biapical scarring slightly
more prominent on the right and left basilar linear scar versus
atelectasis. The cardiomediastinal silhouette and hilar contours
are normal. There is no pleural effusion.
Brief Hospital Course:
49 year old female with h/o depression with thoughts of suicide
without attempts, bipolar disease, COPD and active cigarette use
admitted to ICU for ETOH withdrawal and active suicidality.
.
#. ETOH withdrawal: Was being monitored closely as had h/o of
ETOH withdrawal seizures in past. Patient's last drink was at
11:30pm Friday night [**9-15**]. Patient was tachycardiac with tremors
in unit, no seizures. Currently with slight tachycardia (HR <
100). She was started on Q1hr IV valium, and decreased CIWA to
Valium 10mg PO Q2hr for CIWA>10 with PRN bolus if needed. By
time of transfer to the floor, patient was on Q4hr CIWA and
stable. She was started on MVI, thiamine, folic acid. Patient
discharged on 10 mg Valium q8h prn.
.
#. Active suicidality: history of depression/bipolar disease and
this episode is in context of inquiring about her brother's
death by suicide. Per records, patient has not taken psych meds
for days to one month. She was watched with 1:1 sitter with no
active suicide thoughts. Patient sectioned so not able to leave
AMA, also was seen by psych and plan is to transfer to inpatient
psych bed. Patient currently denies suicidal ideation, however
gives conflicting stories. Please see psychiatry notes for
reference.
.
# UTI- Completed 3 day course of cipro for e coli UTI ([**2102-9-18**]).
.
#. COPD: Continued on nebs, advair and started on nicotine patch
for active smoking.
.
# Cardiovascular??????Patient had TWI in setting of tachycardia.
Ruled out for MI. She was started on daily aspirin and needs
outpatient stress test and fasting lipids.
Medications on Admission:
Seroquel 300mg PO QHS
Lexapro 20mg [**Hospital1 **]
Klonopin prn
Advair 1 puf [**Hospital1 **]
Albuterol MDI prn
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] 4
Discharge Diagnosis:
Primary:
Suicidal Ideation
Alcohol withdrawal
Secondary:
Bipolar disorder
Depression
Discharge Condition:
Stable, ambulating with stable vitals.
Discharge Instructions:
You were admitted for alcohol withdrawal. You were monitored for
this and given Valium for treatment. You are being discharged to
a psychiatry facility for mental health help. You had some EKG
changes on admission but did not have a heart attack. You should
have a stress test as an outpatient.
Please take all your medications as perscribed.
Attend all your follow-up appointments.
Return to the ER if you experience suicidal ideation, homicidal
ideation, chest pain, SOB or other concerning symptoms.
Followup Instructions:
Please see your primary care doctor in [**1-4**] weeks. Dr.
[**Last Name (STitle) **],[**First Name3 (LF) **] J at [**Telephone/Fax (1) 5891**].
Completed by:[**2102-9-20**]
|
[
"496",
"041.4",
"291.81",
"296.80",
"V62.84",
"599.0",
"305.1"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
4939, 4985
|
3195, 4776
|
346, 352
|
5115, 5156
|
2936, 3172
|
5710, 5886
|
2453, 2524
|
5006, 5094
|
4802, 4916
|
5180, 5687
|
2539, 2917
|
276, 308
|
380, 1838
|
1860, 1913
|
1929, 2437
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,293
| 143,604
|
52953
|
Discharge summary
|
report
|
Admission Date: [**2124-12-17**] Discharge Date: [**2124-12-17**]
Date of Birth: [**2052-7-30**] Sex: M
Service: MICU
HISTORY OF PRESENT ILLNESS: The patient is a 70 year-old
gentleman with a previous medical history of hypertension and
coronary artery disease who was in his usual state of health
until the evening prior to admission when he complained of an
intense left temporal headache. The patient felt that this
was consistent with his usual migraine headache pain and
refused per the patient's wife to go to the Emergency
Department for evaluation. The patient was found the
following morning [**2124-12-17**] unresponsive by his wife. The
patient was transported by EMS to [**Hospital3 68**]. On
arrival at [**Hospital3 68**] the patient was found to be
unresponsive though breathing. The patient was intubated for
airway support and respiratory support and received a CT
scan, which showed a large intraparenchymal hemorrhage
extending through most of his frontal parietal and temporal
lobes. This hemorrhage was accompanied by midline shift.
The patient was transferred to the [**Hospital1 190**] for possible neurosurgical intervention. The
patient arrived in the Emergency Room at [**Hospital1 346**] at approximately 10:35 a.m. He was
seen by neurosurgery and neurology who felt that there was no
surgical intervention that could be undertaken that would be
beneficial to the patient.
The patient was found to have fixed dilated pupils that were
midline, minimal corneal reflexes, no gag reflexes and
up going Babinski bilateral as well as no response to painful
stimuli. The neurosurgeons discussed their findings with the
family and explained that neurosurgical intervention would be
of greater harm then benefit to the patient. The patient was
thus transferred to the MICU. A discussion was had with the
patient's family about what the patient would want in such
circumstances. It was explained to the family that the
patient's prognosis was quite grim and the patient was close
to having absolutely no brain stem function per
neurosurgical, neurology and MICU team evaluation. After
discussion the patient's family agreed to extubate the
patient and keep the patient as comfortable as possible with
the understanding that his death was likely to be eminent.
The patient was extubated with his wife at the bedside at
2:35 p.m. The patient was given morphine for comfort. The
patient became asystolic around 2:45 p.m. I was called to
evaluate the patient and found the patient to be lacking
respirations, heart sounds, pulses, unresponsive to sternal
rub and other painful stimuli and pupils were fixed and
dilated in the midline. The patient was pronounced at 15:53
p.m. on [**2124-12-17**] with his wife at the bedside.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], M.D. [**MD Number(1) 292**]
Dictated By:[**Name8 (MD) 8330**]
MEDQUIST36
D: [**2124-12-17**] 18:39
T: [**2124-12-20**] 07:46
JOB#: [**Job Number **]
|
[
"272.0",
"431",
"530.81",
"401.9",
"V45.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
164, 3049
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,676
| 179,400
|
44516+44524+58723
|
Discharge summary
|
report+report+addendum
|
Admission Date: [**2161-2-13**] Discharge Date: [**2161-3-5**]
Date of Birth: [**2119-3-30**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 41 year old
right-handed male CD4 count of 80, viral load of 150 in
[**2160-11-4**] with a past medical history significant for
thoracic spine muscle injury presenting with rapid onset
progressive sensory and motor deficit. The patient notes the
injury to his back in the area between the scapula about
three years prior and has had pain muscle pain in the
vicinity since. He woke up with this type of pain eight days
ago with mild relief of symptoms of Tylenol. The pain has
been worsening over the last couple of days. Initially the
patient describes a band-like compression around his torso
area, this type of band has increased to a point where two
days prior he woke up at 4 in the morning with abdominal
muscle feeling extremely tense. The patient was seen in the
Emergency Room one day prior and was discharged with muscle
spasm therapy. The patient notes that since yesterday
afternoon he has had total numbness from the toes, initially
moving upwards in the last 24 hours. During the course of
the day today he has had onset of weakness in the lower
extremities.
DR.[**Last Name (STitle) 95373**],[**First Name3 (LF) 251**] 12-988
Dictated By:[**Last Name (NamePattern1) 5924**]
MEDQUIST36
D: [**2161-3-5**] 14:52
T: [**2161-3-5**] 16:20
JOB#: [**Job Number 41650**]
Admission Date: [**2161-2-13**] Discharge Date: [**2161-3-5**]
Date of Birth: [**2119-3-30**] Sex: M
Service:
ADDENDUM: This is a continuation of the Discharge Summary
which was cut off.
HISTORY OF PRESENT ILLNESS CONTINUED: On the day of
admission, the patient was seen by his primary care physician
with inability to control his bladder and was noted to have
decreased ankle flexion. The patient denied nausea,
vomiting, shortness of breath, abdominal pain, or chest pain.
The patient described feeling like his muscles were
"seizing" around his torso.
At the time of presentation, the patient complained of
inability to move his left leg and urinary incontinence.
REVIEW OF SYSTEMS: On review of systems, the patient denies
weight loss. Positive for fatigue. He denies fevers,
chills, or night sweats. Positive for anorexia. The patient
denies any visual symptoms. The patient denies any dry mouth
or tinnitus. The patient denies chest pain, orthopnea,
paroxysmal nocturnal dyspnea, shortness of breath, or cough.
The patient complains of some abdominal pain and
constipation. The patient complaints of some urinary
incontinence. Denies frequency, urgency, or pain. He denies
a rash or weight change. Positive numbness, weakness, and
paresthesias in extremities. No dizziness, vertigo,
confusion, or headache. The patient denies depression.
PAST MEDICAL HISTORY: (The patient's has a past medical
history significant for)
1. Human immunodeficiency virus positive times 15 years (on
highly active antiretroviral therapy).
2. L5-S1 herniated disk.
3. Longstanding prior history of tuberculosis exposure.
4. Hepatitis C.
MEDICATIONS ON ADMISSION: The patient's medications included
Combivir, Sustiva, dapsone.
ALLERGIES: The patient has an allergy to SULFA.
SOCIAL HISTORY: The patient smokes one pack per day times 24
years. No ethanol. Remote intravenous drug use. The
patient has two children. He is in process of a divorce.
FAMILY HISTORY: Stroke in maternal grandmother. [**Name (NI) **] central
nervous system tumors.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
revealed the patient's temperature was 97, heart rate was
129, blood pressure was 147/84, respiratory rate was 18,
oxygen saturation was 98% on room air. In general, the
patient was pleasant and interactive. In no acute distress.
Somewhat cachectic. Head, eyes, ears, nose, and throat
examination revealed normocephalic and atraumatic. Mucous
membranes were moist. No thyromegaly. No cervical
lymphadenopathy. The patient was without any carotid bruits.
Pulmonary examination revealed clear to auscultation
bilaterally. No crackles or wheezes. Cardiovascular
examination revealed the patient was tachycardic, but
regular. No murmurs, rubs, or gallops. The abdomen was
soft, nontender, and nondistended. Bowel sounds were
present. Extremities revealed the patient moved all four
extremities. Upper extremity pulses were 2+ and symmetric.
Skin revealed no rash. Mental status examination revealed
the patient was fully alert and oriented. The patient was
able to name, register, and recall. No apraxia or neglect
appreciated. Cranial nerve examination revealed pupils were
equal, round, and reactive to light at 3 mm. Extraocular
movements were intact. No nystagmus. The remainder of
cranial nerve examination was unremarkable. The patient with
normal tone. His strength was full in the upper extremities.
The patient was able to raise right leg against gravity, but
only movement in one plane on the left. No pronator drift.
Deep tendon reflexes were symmetric but absent at the ankles
bilaterally. The patient's toes were upgoing bilaterally.
Sensory examination revealed decrease to soft tissue and
pinprick up to the T6 level. Finger-to-nose and rapid
alternating movements were intact.
RADIOLOGY/IMAGING: The patient was ordered for a STAT
magnetic resonance imaging. The magnetic resonance imaging
showed degenerative joint disease at the L5-S1 level. Of
note, and epidural mass was found posterior to the thecal sac
at the T4 level extending from the area of the T3-T4 disks to
the upper portion of T5. The mass had a superior/inferior
dimension of 3.5 cm. Of particular importance, there was
found to be greater than 50% narrowing of the spinal canal
and moderate compression of the spinal cord. Also of note
was an area of increased signal within the spinal cord at the
T5 level with likely edema. The mass was found to extend to
the right neural foramina at the T4-T5 level. Otherwise, the
patient's cervical and lumbar spine were unremarkable.
HOSPITAL COURSE: The patient was taken emergently to the
operating room where an extensive epidural tumor in the
midthoracic spine (as previously described by magnetic
resonance imaging) was noted. Erosion to the lamina and to
the paraspinous muscles was noted. The tumor was found to be
extremely vascular. Please see the Operative Report for
further details of the thoracic laminectomy for described
tumor.
The patient did well after the operative procedure. He
started to slowly regain strength in the lower extremity.
Pathology with preliminary diagnosis of non-Hodgkin lymphoma.
An Oncology consultation was obtained. The Oncology staff
recommended further staging including a gallium scan,
computed tomography scan of the torso, bowel movement, and
lumbar puncture.
The computed tomography of the chest showed small precarinal
lymph nodes, small lymph node on the left side measuring
1.3 cm X 1.1 cm, and no evidence of hilar lymphadenopathy. A
small granuloma of the right lung base was found. Otherwise,
the scan was unremarkable.
A lumbar puncture was performed showing 1 white blood cells,
3 red blood cells, protein of 29, glucose of 69, LDH of 12.
Differential showed 30% polys, 62% lymphocytes, 10%
monocytes; otherwise unremarkable.
As staging for non-Hodgkin lymphoma was being performed, and
the patient was preparing for discharge and outpatient
management of current diagnosis, the patient was found
overnight (on [**2161-2-23**]) to have two episodes of
liquid maroon-colored stools. The patient had been
completely asymptomatic prior. The patient's hematocrit on
[**2-22**] was 24.5; and on [**2-23**] had fallen to 17.9.
The episodes of dark maroon stools were associated with some
left-sided abdominal pain. The patient denied chest pain,
nausea, and vomiting. The patient received 2 units of packed
red blood cells. The patient received an additional
transfusion to keep his hematocrit greater than 30% and was
started on high-dose proton pump inhibitor.
The patient received an upper endoscopy. The patient's
esophagus was of normal appearance. A single cratered
nonbleeding 1-cm ulcer with a clean base was found in the
stomach body along the greater curvature. No blood was seen
in the stomach. In the duodenum, red blood was seen beyond
the ligament of Treitz in the third and fourth parts of the
duodenum and jejunum. The jejunum was explored to 150 cm at
the starting point of the incisors. No localizing source of
the patient's bleeding was appreciated.
An arteriogram of the superior mesenteric artery, superior
mesenteric artery, and three jejunal branches, celiac and
internal mammary artery inferior mesenteric artery were
without evidence of active bleeding.
The patient's hematocrit did not bump appropriately to the
packed red blood cell infusion. The patient was taken for
intravenous injection of tagged red blood cell scan. The
results showed extravasation of red blood cells into the
patient's jejunum; consistent with a jejunal gastrointestinal
bleed.
The patient was taken back to angiography. This time, active
extravasation of contrast was found from a bleeding jejunal
branch of the superior mesenteric artery in the left lower
quadrant. The bleeding jejunal branches were successfully
coiled with full resolution of the bleeding. However, the
patient's hematocrit continued to tend downward from a post
procedure hematocrit of 28 to a hematocrit of 21 with large
bloody bowel movements.
The patient was taken back for a tagged red blood cell scan
which showed an active bleed in the jejunal branch. The
patient was taken back to angiography. Active extravasation
was seen through areas adjacent to initial coiling of the
small collateral vessels. Additional coiling was placed. No
active extravasation was found after the procedure.
After the episode of second embolization, the patient had one
melanic stool. The patient's hematocrit still continued to
trend downward and inappropriately bump.
The patient received a computed tomography scan of the
abdomen. Impression revealed (1) free intraperitoneal fluid
and (2) small bilateral pleural effusions.
At this point, General Surgery took the patient to the
operating room for exploratory laparotomy with jejunal
resection and primary anastomosis. A 6-cm portion of the
jejunum showed no discrete raised lesions, although several
small mucosal ulceration specimens were sent to Pathology.
The patient tolerated the procedure well. Please see the
General Surgery Operative Report for further details.
The patient was transferred to the Surgical Intensive Care
Unit in stable condition; status post operating room
extubation. The patient tolerated the procedure well.
Secondary to the presence of mucosal erosions, the patient
was started on ganciclovir and fluconazole in the setting of
this immunocompromised host. Preliminary pathology later
returned primary process to be vascular and not infectious.
Both medications were subsequently stopped. The patient was
transfused an additional 2 units of packed red blood cells
postoperatively, and his serial hematocrit levels for the
remainder of hospital course remained stable.
The patient admitted tachycardia is a chronic state. The
patient received an echocardiogram. The wall thickness and
cavity size were normal. Left ventricular ejection fraction
was greater than 55%. The aortic valve and mitral valve were
structurally normal. Normal pulmonary artery pressure;
otherwise, unremarkable.
Pathology of intestinal segment showed multiple fossae
mucosal hemorrhage and necrosis with erosions. No acute
inflammation of the submucosa. Organizing thrombus of
smaller veins in submucosa was appreciated. The stains were
negative for microsporidia and acid-fast bacilli in addition
to cytomegalovirus.
The patient received one dose of R-CHOP chemotherapy; per
Oncology recommendations. The patient then received a 5-day
course of G-CSF.
On transfer to the medical floor, the patient was seen and
examined. His hematocrit levels remained stable. The
patient was found to have scrotal and left lower extremity
thigh and bilateral lower extremity edema. The patient was
on Lasix; diuresis successful. Lasix was stopped. The
patient continued diuresis successfully, and swelling and
edema diminished significantly to the time of discharge.
The patient's diet was slowly advanced, and the patient was
tolerating a full solid diet. The patient worked with
Physical Therapy successfully. The patient continued to be
ambulatory with increasing strength and decreasing fatigue
prior to discharge.
Two days prior to discharge, the patient noted 24 hours of
bowel and bladder incontinence. The patient was sent for an
emergent magnetic resonance imaging which showed no
significant change from the interval. The patient's bowel
and bladder incontinence resolved spontaneously within 12
hours of report.
The magnetic resonance imaging was reviewed by Neurosurgery
and was without evidence of any recurrent or residual
epidural tumor. The thoracic spine appeared well
decompressed. Abnormal marrow signal was appreciated in two
thoracic vertebrae. Again, no abnormality was seen in the
lumbar spine or cervical spine.
CONDITION AT DISCHARGE: The patient's condition on discharge
was stable and approved.
DISCHARGE DIAGNOSES:
1. Human immunodeficiency virus times 15 years (on highly
active antiretroviral therapy).
2. L5-S1 herniated disk.
3. Longstanding prior history of tuberculosis exposure.
4. Epidural mass; status post excision.
5. Non-Hodgkin lymphoma.
6. Hepatitis C.
7. Jejunal bleed; status post resection.
8. Massive red blood cell infusions.
MEDICATIONS ON DISCHARGE:
1. Heparin 5000 units subcutaneously q.12h.
2. Percocet one to two weeks p.o. q.4-6h. as needed.
3. Ativan 0.5 mg p.o. q.8h. as needed.
4. Lopressor 25 mg p.o. b.i.d.
5. Pantoprazole 40 mg p.o. q.d.
6. Tenofovir 300 mg p.o. q.h.s.
7. Lamivudine 300 mg p.o. q.h.s.
8. Efavirenz 600 mg p.o. q.h.s.
9. .................... 300 mg p.o. q.h.s. (times one
additional day).
10. Dapsone 100 mg p.o. q.d.
11. Tramadol 100 mg p.o. q.4-6h. as needed.
12. Aluminum magnesium hydroxide 15 mL to 30 mL p.o. q.i.d.
as needed.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was to follow up with Dr. [**Last Name (STitle) **]
(Hematology/Oncology) on Tuesday, [**2161-3-10**].
2. The patient to follow up with Dr. [**Last Name (STitle) **] (the patient's
primary care physician) and Infectious Disease in one week
following discharge.
3. The patient to follow up with Neurosurgery (Dr. [**Last Name (STitle) 1338**]
in 10 days. The patient was instructed to call telephone
number [**Telephone/Fax (1) **] for an appointment.
4. The patient to follow up with General Surgery (Dr.
[**Last Name (STitle) **] in 10 days. The patient was instructed to call
telephone number [**Telephone/Fax (1) **] for an appointment.
DR.[**Last Name (STitle) **],[**First Name3 (LF) 251**] 12-988
Dictated By:[**Last Name (NamePattern1) 5924**]
MEDQUIST36
D: [**2161-3-5**] 14:56
T: [**2161-3-5**] 16:21
JOB#: [**Job Number 95383**]
Name: [**Known lastname **], [**Known firstname **] S. Unit No: [**Numeric Identifier 15092**]
Admission Date: [**2161-2-13**] Discharge Date: [**2161-3-9**]
Date of Birth: [**2119-3-30**] Sex: M
Service:
Addendum to second to last paragraph of hospital course
sentence two days prior to discharge, the patient noted 24
hours of two paragraphs before condition at discharge.
It should read, one week prior to discharge, the patient
noted 24 hours.
After the MRI paragraph should read, throughout the remainder
of the [**Hospital 1325**] hospital course, the patient continued to
ambulate with Physical Therapy in hallways in which he
continually excelled. The patient reported decreasing
fatigue, increased energy, and felt himself to be clearer
mentally. The patient's pain decreased. Patient's dark
tarry stools eventually clear. The patient was having normal
formed brown bowel movement, no melena or bright red blood.
The patient's hematocrit remained q day throughout the
remainder throughout hospital course.
[**Name6 (MD) 116**] [**Name8 (MD) 117**], M.D. [**MD Number(1) 118**]
Dictated By:[**Last Name (NamePattern1) 896**]
MEDQUIST36
D: [**2161-3-9**] 08:50
T: [**2161-3-9**] 09:10
JOB#: [**Job Number 15093**]
|
[
"428.0",
"722.10",
"202.80",
"578.9",
"078.5",
"042",
"070.51",
"305.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"99.29",
"45.62",
"38.93",
"45.91",
"99.25",
"03.4",
"38.91",
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
3512, 6143
|
13482, 13821
|
13848, 14380
|
3205, 3319
|
6162, 13383
|
14413, 16610
|
13398, 13461
|
2224, 2895
|
159, 2204
|
2918, 3178
|
3336, 3495
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,616
| 103,869
|
4577
|
Discharge summary
|
report
|
Admission Date: [**2123-9-13**] Discharge Date: [**2123-9-20**]
Date of Birth: [**2071-4-12**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Percocet
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Fatigue
Major Surgical or Invasive Procedure:
[**2123-9-13**] - CABGx2 (Left internal mammary artery to the left
anterior descending artery, vein graft to the obtuse marginal
artery); Mitral Valve Replacement (27mm [**Company 1543**] Mosaic Tissue
Valve); Diagnostic Cardiac Catheterization
History of Present Illness:
52 year old female with IDDM and CAD who ruled in for an MI in
[**2123-5-25**]. Work-up revealed severe left main and three vessel
disease. An echo showed moderate mitral valve regurgitation. Her
surgery was originally delayed due to uterine bleeding which was
caused by endometriosis. She now presents for surgical
management of her coronary arerty disease.
Past Medical History:
IDDM
Hyperlipidemia
HTN
PVD s/p Right Fem-[**Doctor Last Name **] Bypass
CAD
MI
Uternine bleeding d/t endometriosis s/p Endometrial ablation.
Depression
Social History:
Married and lives in [**State 108**]. 25 pack year smoking hostory
quitting in [**2123-2-25**]. Denies alcohol use.
Family History:
Noncontributory
Physical Exam:
PE: middle aged female, chronic-ill appearing. lying in bed. NAD
T Afeb BP 112/62 P 68
skin: Warm, dry, No C/C/E
lymph: not palpable at cervical region
HEENT: oral mucosa dry
neck: supple, no JVD, no thymomegaly
chest: lungs CTAB
CVS: RRR, quiet late systolic I/VI murmur
abd: soft, NT, BS normal
ext: No edema bilaterally, distal pulses decreased bilaterally.
Right GSV harvaest. Left appears suitable.
neuro: nonfocal
Pertinent Results:
[**2123-9-13**] ECHO
Pre-CPB: No spontaneous echo contrast is seen in the left atrial
appendage. There is mild symmetric left ventricular hypertrophy.
The left ventricular cavity size is normal. Right ventricular
chamber size and free wall motion are normal. There are simple
atheroma in the descending thoracic aorta. There are three
aortic valve leaflets. The aortic valve leaflets are mildly
thickened. There is mild aortic valve stenosis (area
1.2-1.9cm2). No aortic regurgitation is seen. The mitral valve
leaflets are moderately thickened. Moderate to severe (3+)
mitral regurgitation is seen. The MR jet is directed
posteriorly. Moderate [2+] tricuspid regurgitation is seen.
There is no pericardial effusion.
Post-CPB: Patient is on phenylephrine gtt. A well-seated and
functional mitral prosthesis is seen with no MR [**First Name (Titles) **] [**Last Name (Titles) **]-valvular
leak. Good RV systolic fxn. Moderate LV depression, with EF35 -
40%. Aorta intact. Other parameters as pre-bypass.
[**2123-9-16**] CXR
Small bilateral pleural effusions, greater on the left side, are
unchanged. Left lower lobe retrocardiac opacity consistent with
atelectasis is persistent. There has been mild increase in right
lower lobe opacity consistent with atelectasis. Postoperative
cardiomediastinal silhouette is unchanged. There is no
pneumothorax. Right IJ line and chest tubes have been removed.
Brief Hospital Course:
Mrs. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2123-9-13**] for surgical
management of her coronary artery disease. She was taken
directly to the operating room where she underwent a cardiac
catheterization followed by coronary artery bypass grafting to
two vessels and a mitral valve replacement using a 27mm
[**Company 1543**] Mosaic Tissue Valve. Postoperatively she was
transferred to the cardiac surgical intensive care unit for
monitoring. On postoperative day one, Mrs. [**Known lastname **] awoke
neurologically intact and was extubated. She was transfused a
unit of red blood cells for postoperative anemia. She was slow
to wean from pressors. Eventually she was resumed on her beta
blockade and a statin. On postoperative day three, she was
transferred to the step down unit for further recovery. Mrs.
[**Known lastname **] was gently diuresed towards her preoperative weight. Her
blood sugars were difficult to control and the [**Last Name (un) 387**] diabetes
service was consulted for assistance in her care. Appropriate
changes were made to her insulin regimen. The physical therapy
service was consulted for assistance with her postoperative
strength and mobility. Mrs. [**Known lastname **] had episodes of confusion
postoperatively which slowly resolved during her postoperative
course. Haldol was used as needed with good effect. The [**Last Name (un) **]
diabetes service continued to aggressively manage her blood
sugars as they were labile. Mrs. [**Known lastname **] continued to make steady
progress and was discharged home on postoperative day seven. She
will follow-up with Dr. [**Last Name (STitle) 1290**], her cardiologist and her
primary care physician as an outpatient.
Medications on Admission:
Lantus 40units Qday
humalog s/s
Lipitor 40mg one tablet daily
Capoten 25mg 1 tablet twice a day for hypertension
Paxil 40mg
Neurontin 100mg
Trazodone 100mg 3 po qhs
Klonopin 1mg 1 [**1-26**] po qhs
Aspirin 81mg
Iron once daily
Zetia 10mg one daily
Norethindrone Acetate 5mg one daily
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*30 Capsule(s)* Refills:*0*
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Paroxetine HCl 10 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily). Tablet(s)
5. Insulin Glargine 100 unit/mL Solution Sig: as dir
Subcutaneous at bedtime.
6. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
8. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0*
12. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
13. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for
10 days.
Disp:*40 Capsule, Sustained Release(s)* Refills:*0*
14. Haloperidol 1 mg Tablet Sig: One (1) Tablet PO once a day
for 2 days.
Disp:*2 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VNA of Greater [**Hospital1 189**]
Discharge Diagnosis:
CAD s/p CABG
IDDM
PVD s/p Right Fem-[**Doctor Last Name **] Bypass
HTN
Hyperlipidemia
Uterine bleeding
Hypothyroid
MI
MR
[**Name13 (STitle) 19458**] disease
Discharge Condition:
Good.
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Please shower daily.
No bathing or swimming for 1 month. Use sunscreen on incision if
exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks.
6) No driving for 1 month.
7) Call with any questions or concerns.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 1290**] in 1 month. ([**Telephone/Fax (1) 1504**]
Please follow-up with Dr. [**Last Name (STitle) **] in [**1-26**] weeks.
Please follow-up with Dr. [**Last Name (STitle) 19459**] in 2 weeks. [**Telephone/Fax (1) 19460**]
[**Hospital Ward Name 121**] 2 wound clinic as instructed.
Please call all providers for appointments.
Completed by:[**2123-9-20**]
|
[
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"300.00",
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"424.0",
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"244.9",
"433.10",
"E932.3",
"250.81",
"362.01",
"414.01"
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icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.11",
"88.56",
"36.15",
"35.23",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
6869, 6934
|
3143, 4869
|
283, 530
|
7135, 7143
|
1719, 3120
|
7858, 8262
|
1243, 1260
|
5204, 6846
|
6955, 7114
|
4895, 5181
|
7167, 7835
|
1275, 1700
|
236, 245
|
558, 918
|
940, 1094
|
1110, 1227
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,630
| 104,831
|
23659
|
Discharge summary
|
report
|
Admission Date: [**2125-3-28**] Discharge Date: [**2125-4-6**]
Date of Birth: [**2086-7-21**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 25342**]
Chief Complaint:
found unconcious in front of drug deal outside [**Doctor First Name 60501**] place
Major Surgical or Invasive Procedure:
intubation in micu
History of Present Illness:
Patient is a 38 year old female with h/o etoh abuse, asthma,
seizure d/o was found unresponsive outside [**Doctor First Name **] place.
She was found with empty bottle of tegretol (2 wk supply, bottle
date 4/5/5)
Full bottle of Trazodone 400mg HS (date [**2125-3-17**])
Full bottle of Fluoxitine 80mg daily (date [**2125-3-17**])
Multiple samples of [**Doctor First Name **] in Backpack
Was brought to [**Hospital1 18**], and did not respond to narcan so was
intubated for airway protection. Tox screen + for benzo's and
etoh. Was initially treated with levo/flagyl for emperic
coverage for aspiration pneumonia but then was d/c'd on [**3-31**].
She was extubated on [**4-1**].
Was treated with propafol and then valium for withdrawal in MICU
Now more awake, no n/v/d/cp/sob,patient is not complaining
Past Medical History:
According to [**Hospital3 2568**] notes, Asthma, Seizure DO, diet
controlled DM?
Social History:
lives at pine street inn, long hx of etoh use. Has a husband
(who only wants to be involved if consent is needed etc) and two
teenage children.
Family History:
Family hx: NC
Physical Exam:
O: T 98.9 BP 136/90 P76 RR 20
Gen: NAD, tearful, slightly tremulous
HEENT: anicteric, PERRLA, EOMI
Lungs: mild scattered wheezes otherwise CTA x 2
Heart: S1, S2 no m/r/g
Abd: soft, nd, mild tenderness in suprapubic area
Ext: no c/c/e
bilateral numbness up to knees, +pulses
Pertinent Results:
CXRAY [**4-3**]- neg
[**2125-3-28**] 12:02PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2125-3-28**] 12:02PM ASA-NEG ETHANOL-263* CARBAMZPN-4.7
ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2125-3-28**] 12:02PM ALT(SGPT)-39 AST(SGOT)-67* LD(LDH)-262*
CK(CPK)-177* ALK PHOS-50 AMYLASE-28 TOT BILI-0.3
iron (low nl), b12, folate, ferritin all wnl
Brief Hospital Course:
A/P: Patient is a 38 year old female who was transferred out of
MICU s/p intubation for possible post ictal vs. toxic ingestion.
On admission to the medical service patient was off ativan gtt.
ETOH withdrawal-level 263 on arrival to ED, out of window for
DT's on admission to medicine. She was started on a ciwa scale
and did not require valium after the second day of admission.
She was given folate, MVI, thiamine. At the day of discharge
she was less tremulous and able to walk around with no
withdrawal symptoms.
seizure d/o- had a witnessed grand mal seizure night before
admission, had adequate levels of tegretol at admission.
Unclear etiology of seizure disorder. Is not followed by a
neurologist (she was in the past but does not remember his name)
She was continued on tegretol when admitted to medicine and her
levels were within nl limits.
asthma- nebs prn, will try to send patient with an inhaler when
she leaves
Psych- after their first meeting with the patient, psych did not
think that the patient has capacity to leave, thought patient
may have korsakoff's. However, pt/ot cleared the patient and
the next day psych thought that she was much clearer stating
that their initial concerns may have stemmed from mild
withdrawal symptoms. They thought she was safe to leave the
hospital. She wanted to leave b/c she wanted to see her son off
to the prom. This was corrobarated with the son over the phone.
-I have set her up with an outpatient psych appointment
-I have only given her enough trazadone, and fluoxetine to last
her to her pcp's appointment due to the worry that she may have
overdosed. Initially the patient should be given short
prescriptions for these meds until it is obvious that the
patient is reliable and not overdosing.
-I will continue the trazodone since this is vital for her
seizure d/o
numbness- unclear etiology, did improve over hospitalization, nl
b12, may be diabetes related although fs wnl in micu, should
have continued evaluation and monitor for progression.
HTN- she was well controlled on outpatient clonidine .1 mg
Anemia- normocytic, low nl iron, nl b12/folate
full code this admission
Medications on Admission:
carbamazepine
trazadone
fluoxetine
clonidine
Discharge Medications:
1. Carbamazepine 200 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
Disp:*50 Tablet(s)* Refills:*0*
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-10**]
Puffs Inhalation Q6H (every 6 hours) as needed.
Disp:*qs qs* Refills:*0*
4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
6. Clonidine HCl 0.1 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
Disp:*90 Tablet(s)* Refills:*2*
7. Trazodone HCl 100 mg Tablet Sig: Four (4) Tablet PO at
bedtime for 6 days.
Disp:*24 Tablet(s)* Refills:*0*
8. Fluoxetine HCl 40 mg Capsule Sig: Two (2) Capsule PO once a
day for 6 days.
Disp:*12 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
asthma
seizure d/o
Discharge Condition:
stable
Discharge Instructions:
Please come directly to the ED if you have chest pain, or
shortness of breath.
Please stop drinking alcohol- it may kill you.
Followup Instructions:
Please see a pcp next week as listed below
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Where: [**Hospital6 29**] [**Hospital **] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2125-4-11**] 2:30
Completed by:[**2125-4-11**]
|
[
"966.3",
"292.0",
"780.09",
"780.39",
"250.00",
"303.01",
"401.9",
"E950.4",
"291.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
5434, 5440
|
2290, 4446
|
398, 419
|
5503, 5511
|
1860, 2267
|
5686, 5947
|
1535, 1550
|
4541, 5411
|
5461, 5482
|
4472, 4518
|
5535, 5663
|
1565, 1841
|
276, 360
|
447, 1252
|
1274, 1357
|
1373, 1519
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,467
| 181,508
|
31323
|
Discharge summary
|
report
|
Admission Date: [**2148-11-5**] Discharge Date: [**2148-11-15**]
Date of Birth: [**2104-12-17**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
Fever of unknown origin
Major Surgical or Invasive Procedure:
None
History of Present Illness:
43 year old male firefighter who was struck by an auto which
left him with anoxic encephalopathy, seizure disorder, atrial
fibrillation, and multiple extremity wounds. He returns from
his rehab facility with fevers of unknown origin, which have
persisted despite antibiotic treatment with Vancomycin,
Fluconazole, and Amikacin. Cultures at the rehab facility were
positive for gram negative staphylococcus bacteremia and
acenitobacter in his sputum. Urine and stool cultures were
negative.
Past Medical History:
Polytrauma requiring multiple operative interventions
Anoxic brain injury
Placement of IVC filter, percutaneous gastrostomy, tracheostomy
Social History:
Firefighter
Married with children
Family History:
Noncontributory
Physical Exam:
VS: Temp 100.6, BP 145/68, HR 110, RR 16, O2 sat 100% on 10L
trach mask
GEN: NAD, cachectic, responsive but mildly confused
Lungs: CTA B/L, mild upper airway transmission
Heart: S1S2 RRR, no murmurs, gallops, or rubs.
Abd: Soft, NT/ND, + Bowel sounds. Gtube in place.
Back: 7x7 cm sacral decubitus ulcer with fibrinous base,
nonpurulent.
Ext: B/L LE with vacs intact. R arm cast.
Pertinent Results:
[**2148-11-5**] 02:29AM WBC-16.6* RBC-2.81* HGB-8.9* HCT-26.8* MCV-96
MCH-31.7 MCHC-33.2 RDW-14.2
[**2148-11-5**] 02:29AM GLUCOSE-118* UREA N-12 CREAT-0.3* SODIUM-133
POTASSIUM-4.3 CHLORIDE-100 TOTAL CO2-23 ANION GAP-14
[**2148-11-5**] 02:29AM ALT(SGPT)-300* AST(SGOT)-73* LD(LDH)-151 ALK
PHOS-262* AMYLASE-41 TOT BILI-0.3
[**2148-11-7**] 09:45PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE HAV Ab-NEGATIVE IgM HAV-NEGATIVE
*****[**11-5**] WOUND CULTURE:
WOUND CULTURE (Final [**2148-11-8**]):
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup is performed appropriate to the isolates recovered
from the
site (including a screen for Pseudomonas aeruginosa,
Staphylococcus
aureus and beta streptococcus).
GRAM NEGATIVE ROD(S). MODERATE GROWTH.
PROBABLE ENTEROCOCCUS. MODERATE GROWTH.
PSEUDOMONAS AERUGINOSA. MODERATE GROWTH.
GRAM NEGATIVE ROD #3. SPARSE GROWTH.
*****[**11-5**] SPUTUM CULTURE:
RESPIRATORY CULTURE (Final [**2148-11-10**]):
OROPHARYNGEAL FLORA ABSENT.
ACINETOBACTER BAUMANNII. >100,000 ORGANISMS/ML..
"Note, for Amp/sulbactam, higher-than-standard dosing
needs to be
used, since therapeutic efficacy relies on intrinsic
activity of
the sulbactam component".
SULFA X TRIMETH Sensitivity testing per DR [**First Name (STitle) **]
([**Numeric Identifier 1097**]).
SULFA X TRIMETH PERFORMED BY [**Doctor Last Name **]-[**Doctor Last Name **].
STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA.
10,000-100,000 ORGANISMS/ML..
***** [**11-5**] HEAD CT:
FINDINGS: There is no intracranial hemorrhage, shift of normally
midline structures, or evidence of acute major vascular
territorial infarct. No abnormal enhancement is noted. Compared
to [**2148-8-11**], [**Doctor Last Name 352**]-white matter distinction and cerebral edema
has improved. Surrounding osseous structures demonstrate normal
aeration of the paranasal sinuses and mastoid air cells.
Additionally, subcutaneous swelling has improved compared to
[**Month (only) 205**].
IMPRESSION: No intracranial hemorrhage or edema
***** [**11-5**] CT ABDOMEN/PELVIS:
CT ABDOMEN WITH CONTRAST: Opacification within distal bronchi at
the right base likely represent secretions and the lung bases
are otherwise unremarkable. No focal hepatic lesion is
identified and the gallbladder, pancreas, spleen, and adrenal
glands are within normal limits. The kidneys enhance
symmetrically and excrete contrast normally and there is no
evidence of hydronephrosis or hydroureter. Subcentimeter
hypoattenuating bilateral renal lesions measure up to 7 mm in
size and are too small to further characterize. Intra-abdominal
loops of large and small bowel are unremarkable and there is no
free air, free fluid, or pathologically enlarged mesenteric or
retroperitoneal lymph nodes. A G- tube is present within the
stomach and an IVC filter is in place. The abdominal aorta is of
normal caliber throughout.
CT PELVIS WITH CONTRAST: The rectum, sigmoid colon, seminal
vesicles, prostate are unremarkable. A Foley is present within
the bladder which contains nondependent air. No free fluid or
pathologically enlarged lymph nodes are seen within the pelvis.
Bone windows reveal no worrisome lytic or sclerotic lesions. A
few small foci or air within the subcutaneous tissues just
inferior to the coccyx may represent decubitus ulceration, new
since [**Month (only) 205**].
IMPRESSION:
1. New decubitus ulceration just inferior to and approaching the
coccyx bone. Recommend clinical correlation.
2. Opacification of a few right lower lobe bronchi likely
represent secretions.
3. Hypoattenuating renal lesions are too small to characterize
***** [**11-5**] CHEST XRAY:
FINDINGS: Comparison with the study of [**2148-9-21**], the tracheostomy
tube remains in place. The right central catheter has been
removed.
Specifically, there is no evidence of acute pneumonia
***** [**11-5**] RUQ ULTRASOUND:
FINDINGS: The liver demonstrates no focal or textural
abnormality. There is no intra- or extra-hepatic biliary ductal
dilatation. There is a mild amount of sludge within the
gallbladder with a few tiny hyperechoic foci measuring up to 4
mm which may represent [**Doctor Last Name 5691**]/small stones. The common bile duct
measures 3 mm. The main portal vein demonstrates normal
hepatopetal flow. No free fluid is identified in the right upper
quadrant.
IMPRESSION: Gallbladder sludge with tiny [**Doctor Last Name 5691**]/stones. No
evidence of cholecystitis.
*****[**11-6**] TIB/FIB XRAYS:
IMPRESSION: Status post ORIF of comminuted left tibial plateau
fracture and multiple comminuted right tibial fractures.
Evidence of interval fracture healing without hardware
complication.
*****[**11-6**] B/L VENOUS DUPLEX:
IMPRESSION: No evidence of DVT in both legs.
*****[**11-7**] TRANSTHORACIC ECHO:
The left atrium is normal in size. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%) Tissue Doppler imaging suggests a normal left
ventricular filling pressure (PCWP<12mmHg). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no mitral valve prolapse. The pulmonary artery systolic pressure
could not be determined. There is no pericardial effusion.
IMPRESSION: Normal study. No valvular pathology or pathologic
flow identified.
Compared with the prior study (images reviewed) of [**2148-9-21**],
systolic function is now normal.
Brief Hospital Course:
He was admitted to the Trauma ICU on [**2148-11-5**] for expected
ventilator dependency. He was able to tolerate being off of the
ventilator on trach mask around the clock. A complete fever
workup was initiated, including cultures of the blood, urine,
sputum, stool, and sacral ulcer. His left arm midline that was
inserted at the rehab facility was removed and cultured. His
blood, urine, and stool cultures were negative, and remained
negative on repeat cultures as well. His wound culture was
positive for Pseudomonas and Enterococcus, and sputum was
positive for Acinetobacter and Strophomonas. The infectious
disease service was consulted, and as he was hemodynamically
stable, the decision was made to stop all of his antibiotics.
His fever persisted for several days, during which Xrays of the
chest and a CT of the abdomen and pelvis were performed, and
were negative for sources of infection. Lower extremity
ultrasounds were negative for DVT. As his liver enzymes were
elevated, a RUQ ultrasound was done, which showed gallbladder
sludge but was negative for cholecystitis. Hepatitis serologies
were negative as well. At this time his fever curve began to
trend down, and he was transferred to the surgical floor. A
transthoracic echo was done, which was negative for
endocarditis.
During his hospital stay the Plastic surgery service was
consulted as well for management of his open wounds. They
determined that revision of the sacral ulcer would not be
necessary at this time, but that the wounds to the lower
extremities and right elbow were suitable for skin grafting.
Unfortunately he was not able to be scheduled for grafting
during this hospital stay, and will have plastic surgery
followup as an outpatient. As his fever had resolved and all
workup was negative, the decision was made to discharge him back
to his rehabilitation facility on [**2148-11-15**].
During his hospital stay he was also evaluated by Physical and
Occupational therapy; he will continue to require ongoing
intensive rehabilitation because of his multiple injuries.
Medications on Admission:
1. Keppra [**2141**] QHS, 1500 QAM
2. Folate 1g daily
3. Colace 100 [**Hospital1 **]
4. Metoprolol 50mg TID
5. Diflucan 400mg daily
6. Vancomycin 1.25g Q12h
7. Amikacin 1175mg daily
8. Dilantin 100mg QID
9. Topamax 100mg 5x daily
10. Dilaudid 4mg IV Q4hPRN
11. Sodium bicarbonate 2 tabs TID
12. Magnesium oxide 400 mg daily
13. Senna 2 tabs [**Hospital1 **]
14. Lansoprazole 30 mg [**Hospital1 **]
15. Potassium chloride
16. MVI daily
Discharge Medications:
1. Acetaminophen 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q6H (every
6 hours) as needed for fever.
2. Therapeutic Multivitamin Liquid [**Hospital1 **]: One (1) Cap PO DAILY
(Daily).
3. Senna 8.6 mg Tablet [**Hospital1 **]: Two (2) Tablet PO BID (2 times a
day) as needed.
4. Ferrous Sulfate 325 (65) mg Tablet [**Hospital1 **]: One (1) Tablet PO
DAILY (Daily).
5. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Topiramate 100 mg Tablet [**Hospital1 **]: One (1) Tablet PO 5X/DAY (5
Times a Day).
7. Levetiracetam 100 mg/mL Solution [**Hospital1 **]: 1500 (1500) mg PO QAM
(once a day (in the morning)).
8. Levetiracetam 100 mg/mL Solution [**Hospital1 **]: [**2141**] ([**2141**]) mg PO QHS
(once a day (at bedtime)).
9. Folic Acid 1 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO DAILY (Daily).
10. Docusate Sodium 50 mg/5 mL Liquid [**Year (4 digits) **]: One Hundred (100) mg
PO BID (2 times a day).
11. Metoprolol Tartrate 25 mg Tablet [**Year (4 digits) **]: Three (3) Tablet PO
TID (3 times a day). Tablet(s)
12. HYDROmorphone (Dilaudid) 1-4 mg IV Q4H:PRN pain
pt stabilized on regimen
13. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
14. Heparin (Porcine) 5,000 unit/mL Solution [**Year (4 digits) **]: One (1) ML
Injection TID (3 times a day).
15. Insulin Regular Human 100 unit/mL Solution [**Year (4 digits) **]: One (1) Dose
Injection four times a day as needed for per sliding scale.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 38**]
Discharge Diagnosis:
Fever of unknown origin
Grade IV Decubitus Ulcer
Discharge Condition:
Stable
Discharge Instructions:
You were admitted to the hospital with fever of unknown origin.
Your PICC line was thought to be a potential source of infection
and was removed. Your fever resolved without antibiotic
treament. You were seen by the plastic surgeons who will
perform skin grafting to your legs and try to repair your elbow
at a future date. Plastic surgery also evaluated your sacral
ulcer and did not think any intervention was needed at this
time. You will be called by the plastic surgery service with a
date and time for your surgery. If you are not contact[**Name (NI) **]
regarding a time for your surgery, you should call plastic
surgery clinic.
.
Please call your doctor or return to the hospital for:
* Return of fevers (T > 101)or chills
* Abdominal pain
* Nausea or vomiting
.
Diet: You may resume tube feeds as before.
.
Medication:
Please continue medications as listed:
1. Acetaminophen 500 mg Tablet [**Name (NI) **]: One (1) Tablet PO Q6H (every
6 hours) as needed for fever.
2. Therapeutic Multivitamin Liquid [**Name (NI) **]: One (1) Cap PO DAILY
(Daily).
3. Senna 8.6 mg Tablet [**Name (NI) **]: Two (2) Tablet PO BID (2 times a
day) as needed.
4. Ferrous Sulfate 325 (65) mg Tablet [**Name (NI) **]: One (1) Tablet PO
DAILY (Daily).
5. Aspirin 81 mg Tablet, Chewable [**Name (NI) **]: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Topiramate 100 mg Tablet [**Name (NI) **]: One (1) Tablet PO 5X/DAY (5
Times a Day).
7. Levetiracetam 100 mg/mL Solution [**Name (NI) **]: 1500 (1500) mg PO QAM
(once a day (in the morning)).
8. Levetiracetam 100 mg/mL Solution [**Name (NI) **]: [**2141**] ([**2141**]) mg PO QHS
(once a day (at bedtime)).
9. Folic Acid 1 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO DAILY (Daily).
10. Docusate Sodium 50 mg/5 mL Liquid [**Year (4 digits) **]: One Hundred (100) mg
PO BID (2 times a day).
11. Metoprolol 75mg PO TID
12. HYDROmorphone (Dilaudid) 1-4 mg IV Q4H:PRN pain
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) 1005**] ([**Hospital **] Clinic [**Telephone/Fax (1) 1228**]) in
4 weeks.
Please call Plastic Surgery Clinic ([**Telephone/Fax (1) 57665**] if you are not
contact[**Name (NI) **] regarding a date and time for your surgery within the
next week.
Follow up with Dr. [**Last Name (STitle) 519**], Trauma Surgery in 4 weeks or sooner if
necessary, call [**Telephone/Fax (1) 6554**] for an appointment.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
Completed by:[**2148-11-19**]
|
[
"041.85",
"V44.0",
"427.31",
"041.7",
"707.03",
"V49.60",
"V54.16",
"041.04",
"V58.66",
"348.1",
"730.18",
"908.9",
"E929.0",
"780.6",
"780.39",
"V44.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
11447, 11528
|
7270, 9343
|
340, 347
|
11621, 11630
|
1532, 3150
|
13598, 14198
|
1098, 1115
|
9829, 11424
|
11549, 11600
|
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|
11654, 13575
|
1130, 1513
|
277, 302
|
375, 869
|
3159, 7247
|
891, 1030
|
1046, 1082
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,441
| 143,476
|
26537
|
Discharge summary
|
report
|
Admission Date: [**2179-2-5**] Discharge Date: [**2179-2-16**]
Date of Birth: [**2121-8-21**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
s/p Ascending Aorta and Hemi-Arch Replacement
History of Present Illness:
57 y/o male with h/o HTN who presented to OSH with chest pain
and approx. 1 week of dizziness. Patient had a CT Scan which
revealed a Type A Aortic Dissection. Emergently transported to
[**Hospital1 18**] for surgical repair.
Past Medical History:
Hypertension
Diabetes Mellitus
Social History:
Tobacco x 20yrs (1 ppd), Quit 20 yrs ago
Denies ETOH, Drugs
Family History:
Sister had Aortic Aneurysm at 58
Physical Exam:
VS: 98.3 62 LBP 148/79 RBP 145/79 18 100% 5L
General: Awake and Alert
Lungs: CTAB
COR: RRR, +S1S2, -Bruits
Abd: Soft NT/ND
Pulses: 2+ throughout
Pertinent Results:
Chest CT [**2-5**]: The original impression was typed incorrectly in
the draft report. This is a type A aortic dissection involving
the ascending aorta, not the descending.
Echo [**2-5**]: PRE-BYPASS: The ascending aorta is moderately
dilated. The descending thoracic aorta is mildly dilated. There
are simple atheroma in the descending thoracic aorta. A mobile
density is seen in the ascending aorta consistent with an
intimal flap/aortic dissection. There is flow in the false
lumen. There are three aortic valve leaflets. The aortic valve
leaflets are mildly thickened. Trace aortic regurgitation is
seen. Mild (1+) mitral regurgitation is seen. There is a
moderate sized pericardial effusion. Dissection flap visualized
in the ascending aorta originationg from the sinotubular
junction, to the ascending aorta. No dissection flap visualized
in the descending thoracic aorta POSR CPB: Preserved
biventricular systolic function. Tube graft visualized in the
ascending aortic position, without evidence of
compression/abnormal flow pattern on the CFD.
CXR [**2-15**]:
[**2179-2-5**] 02:50AM BLOOD WBC-9.2 RBC-4.08* Hgb-13.6* Hct-35.9*
MCV-88 MCH-33.2* MCHC-37.8* RDW-14.6 Plt Ct-118*
[**2179-2-14**] 05:33AM BLOOD WBC-9.1 RBC-3.76* Hgb-11.7* Hct-33.6*
MCV-89 MCH-31.0 MCHC-34.7 RDW-14.4 Plt Ct-207
[**2179-2-12**] 02:42AM BLOOD PT-14.5* PTT-22.3 INR(PT)-1.3*
[**2179-2-5**] 02:50AM BLOOD UreaN-21* Creat-1.1
[**2179-2-13**] 05:27AM BLOOD Glucose-105 UreaN-37* Creat-1.1 Na-144
K-3.9 Cl-113* HCO3-20* AnGap-15
[**2179-2-15**] 06:45AM BLOOD Mg-2.0
[**2179-2-5**] 04:20AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-50 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
Brief Hospital Course:
Mr. [**Known lastname 65534**] had an emergent CT scan which confirmed a Type A
Aortic Dissection. He was emergently brought to the operating
room where he underwent an Ascending Aorta and Hemi-Arch
Replacement. Please see operative note for surgical details. Mr.
[**Known lastname 65534**] tolerated the procedure well and was transferred to the
CSRU in stable condition. Patient remained sedated/paralyzed
until post-operative day four d/t being unable to wean from
ventilator because of poor respiration and agitation. He was
finally weaned from sedation, awoke neurologically intact and
weaned from mechanical ventilation and extubated. Chest tubes
were removed on post-op day two. Aspirin and diuretics were
initiated on post-op day one. He was initially aggressively
diuresed w/ pulmonary toilet followed by gentle diuresing during
his entire post-operative period towards his pre-op weight.
Lopressor was initiated and eventually Captopril and Norvasc
were added. All three were adjusted for optimal blood pressure
control. His epicardial pacing wires and Foley catheter were
removed on post-op day six. He was transfused 1 unit of PRBC's
on post-op day six with adequate response in his HCT. As
mentioned earlier he had episodes of agitation and several
episodes of confusion which were believed to be related to
post-cardiopulmonary bypass. He eventually was improving and
with stable vital signs and was transferred to the cardiac
surgery step-down unit on post-op day seven. On post-op day
eight he had drainage from his right groin with mild erythema
and small seperation. Very mild increase in his WBC without a
fever. Vancomycin was started alond with dressing changes TID.
Physical therapy began working with patient for post-op strength
and mobilty. His groin wound drainage decreased but had
persistent erythema around the margins. There was no frank
purulence. On POD 11 Mr. [**Known lastname 65534**] was afebrile, his WBC count
was normal, he was 3kg below his preop weight with good exercise
tolerance, no SOB, or Chest pain. His blood pressure was
stable. His sternotomy was clean, dry, and intact without
evidence of infection. He was discharged home on POD 11 in good
condition, cardiac diet, sternal precautions, and instructed to
follow up with his PCP/cardiologist in [**12-28**] weeks. He was
instructed to conduct twice daily wet to dry dressing changes to
his groin, paint the wound margins with betadine and take Cipro
500mg po bid x 7 days. He will come to [**Hospital Ward Name 121**] 2 for a groin wound
check in 3 days. He will follow up with Dr. [**Last Name (STitle) **] in four
weeks.
Medications on Admission:
Norvasc, Toprol, Hyzaar, MVI
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. 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. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
Disp:*270 Tablet(s)* Refills:*2*
7. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO twice a
day for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
8. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
9. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day for 5
days.
Disp:*10 Tablet(s)* Refills:*0*
10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO twice a day for 5
days.
Disp:*10 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Aortic Dissection, Type A, s/p Ascending Aorta and Hemi-Arch
Replacement
Hypertension
Diabetes Mellitus
Discharge Condition:
Good
Discharge Instructions:
[**Month (only) 116**] take shower. Wash incisions with warm water and gentle soap.
Gently pat dry. Do not take bath. Do not apply lotions, creams,
ointments or powders to incisions.
Do not drive for 1 month.
Do not lift more than 10 pounds for 2 months.
Please contact office immediately if you notice chest/sternal
drainage or experience fever more than 101.5.
Please call to make all follow-up appointments.
Followup Instructions:
Dr. [**Last Name (STitle) **] in 4 weeks.
Dr. [**Last Name (STitle) 41442**] in [**12-28**] weeks.
Cardiologist in [**1-29**] weeks.
Completed by:[**2179-2-16**]
|
[
"250.00",
"401.9",
"998.59",
"427.69",
"293.9",
"441.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"99.07",
"88.72",
"96.6",
"99.04",
"38.45"
] |
icd9pcs
|
[
[
[]
]
] |
6690, 6696
|
2691, 5325
|
331, 378
|
6843, 6849
|
994, 2668
|
7308, 7471
|
780, 814
|
5404, 6667
|
6717, 6822
|
5351, 5381
|
6873, 7285
|
829, 975
|
281, 293
|
406, 633
|
655, 687
|
703, 764
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,552
| 169,155
|
52629
|
Discharge summary
|
report
|
Admission Date: [**2162-12-29**] Discharge Date: [**2163-1-1**]
Service: MEDICINE
Allergies:
Ceftriaxone
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
85 yo female with history of HTN, hyperlipidemia, and recurrent
UTIs who presents from an assited living facility with cough
productive of green sputum and shortness of breath. She had a
UTI about 2 wks ago that was was treated with a macrolide. She
was placed on maintenace dose antibiotics 3x/wk. Six-seven days
prior to admission, she developed a cough. She felt weak and
subjectively febrile the next day an dher PCP started her on
Azithromycin. She took this for 3-4 days wihtout improvement in
symptoms, and was then started on moxifloxacin. On Monday, she
started to feel better, but today had worsening SOB, wheezing,
and increase work of breathing. She called EMS who found her
with a Sat 88-89 on RA, 91% on [**4-25**] L and 95-96 on NRB.
In the ED, initial VS: 100.8 125 124/96 30s Sats 91 on 4L, which
came up to 96 % on a non-rebreather with RR 25-30s. Her CXR
showed multi-focal pneumonia. Her lungs were somewhat wheezy.
She was treated with albuterol, ipratropium, CeftriaXONE 1gm,
Oseltamivir 75 mg, and levofloxacin 750mg, Vancomycin 1gm. She
did not get IVF. Blood cultures were sent. Prior to transfer,
VS 99.6 HR 96 BP 139/60 RR 24 Sat 99/NRB. While awaiting a bed
in the ICU and after receiving all her antibiotics, she noticed
a new rash on her legs. This was warm but not itchy.
.
In the ICU, she was breathing comfortably on a NRB.
.
ROS: Denies chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, chest pain, abdominal pain,
nausea, vomiting, diarrhea, constipation, BRBPR, melena,
hematochezia, dysuria.
Past Medical History:
HTN
hyperlipidemia
recurrent UTI
Social History:
She lives in [**Hospital3 **], but is generally independent in
her ADLs. Husband was a trustee for [**Hospital1 18**], past away recently.
Husband smoked 3 packs per day, she never smoked. Drinks rarely.
She did not get an H1N1 vaccine.
Family History:
Brother with asthma
Physical Exam:
GENERAL: A&Ox3 NAD Speaking in complete sentences
HEENT: NCAT. Dry mouth
CARDIAC: RRR, 2/6 systolic murmur at base
LUNG: Diminished at bases. No rhonchi or wheezes.
ABDOMEN: S NT ND
EXT: WWP, no edema
DERM: L>R 1-2 cm erythematous macules.
Physical Exam on transfer from ICU to floor [**2162-12-30**]:
T 97.4 BP 126/41 HR 81 RR 21 95% 4L NC
GENERAL: A&Ox3, NAD, sitting in chair, pleasant, conversational,
speaking in complete sentences
HEENT: NCAT. EOMI, Dry MMM, OP clear
CARDIAC: RRR, 2/6 systolic murmur at base
LUNG: Coarse breath sounds at bases bilaterally, no wheezes or
rales. No supraclavicular or subcostal retractions.
ABDOMEN: +BS, soft, nontender, nondistended. No rebound or
guarding.
EXT: warm, well perfused, no edema, 2+ DP/PT pulses b/l
DERM: Faint maculopapular rash just above knees bilaterally on
inner thighs.
Physical exam on discharge [**2163-1-1**]:
VSS SaO2 94-96% RA
GENERAL: A&Ox3, NAD, pleasant, conversational, speaking in
complete sentences
HEENT: NCAT. EOMI, MMM, OP clear
CARDIAC: RRR, 2/6 systolic murmur at base
LUNG: Coarse breath sounds at bases bilaterally, no wheezes or
rales. No supraclavicular or subcostal retractions.
ABDOMEN: +BS, soft, nontender, nondistended. No rebound or
guarding.
EXT: warm, well perfused, no edema, 2+ DP/PT pulses b/l
Pertinent Results:
MICRO:
[**2162-12-29**] BCx: no growth
[**2162-12-29**] UCx: contaminated
[**2162-12-30**] Influenza A&B negative; culture negative
[**2162-12-30**] MRSA screen: negative
EKG on Admission: Sinus tach @ 100, LAD, tall r-waves, Q in I,
avL, V2-4, no ST-T wave changes.
EKG [**2163-1-1**] Normal sinus rhythm. Leftward axis at minus 22
degrees. Q waves in leads I, aVL and lead V1 with tall R wave in
lead V1. The tall R wave in lead V1 may be related to altered
lead placement. Consider left atrial abnormality. The Q waves in
leads I, aVL and V6 are narrow and non-diagnostic but deep.
Consider possible lateral wall myocardial infarction. Compared
to the previous tracing of [**2162-12-29**] the current changes in the
precordial leads may be related to altered lead placement. No
other diagnostic interval change.
[**2162-12-30**] CXR (portable):
As compared to the previous radiograph, the lung volumes are
increased, as a consequence, the pre-existing opacities have
decreased in extent. No newly appeared focal parenchymal
opacities, no evidence of pleural effusions. Tortuosity of the
thoracic aorta, borderline size of the cardiac silhouette
without signs of pulmonary edema.
ECHO [**2162-12-31**]: The left atrium is mildly dilated. There is mild
symmetric left ventricular hypertrophy with normal cavity size
and regional/global systolic function (LVEF>55%). Tissue Doppler
imaging suggests an increased left ventricular filling pressure
(PCWP>18mmHg). Doppler parameters are most consistent with Grade
I (mild) left ventricular diastolic dysfunction. Right
ventricular chamber size and free wall motion are normal. The
ascending aorta is mildly dilated. There are three aortic valve
leaflets. The aortic valve leaflets are moderately thickened.
There is mild aortic valve stenosis (valve area 1.2-1.9cm2).
Mild (1+) 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. There is an anterior space which most likely
represents a fat pad. IMPRESSION: Mild symmetric left
ventricular hypertrophy with normal global and regional
biventricular systolic function. Mild diastolic LV dysfunction.
Mild calcific aortic stenosis. Elevated left ventricular filling
pressures and mild pulmonary hypertension.
CT CHEST [**2162-12-30**]: Pulmonary nodules, the largest is 8.8 mm in
the left upper lobe with lower lobe predominant bronchial wall
thickening and bronchial mucus plugging with atelectasis most
likely due to recent infection or inflammation, followup CT
thorax is recommended in three months following antimicrobial
treatment to assess for resolution and interval change in the
left upper lobe nodule. Diffuse coronary artery, aortic valve
and mitral annulus calcification. Moderately large hiatal
hernia. Air in the gallbladder may be due to previous
sphincterotomy, clinical correlation is advised.
Brief Hospital Course:
MICU Course [**Date range (3) 108618**]:
In the ICU, she was easily weaned from non-rebreather face mask
and was put on 4L NC with good oxygen saturation. Vancomycin and
levofloxacin were continued, but given rash, ceftriaxone was
stopped and she was started on tobramycin. Influenza A&B were
negative and tamiflu stopped. Given concern for macrobid or
hypersensitivity pneumonitis, a CT was ordered. ECHO ordered to
evaluate for cardiac pathology given pt has some orthopnea out
of proportion to whats explained by CXR.
.
Floor course [**Date range (1) 108619**]:
#. Dypsnea/cough: Vancomycin and tobramycin stopped as pt was
afebrile. Influenza negative as above. [**Month (only) 116**] have also been due to
bronchospasm/bronchitis or hypersensitivity pneumonitis (new
surroundings with carpet/rugs/curtains) given imaging findings
and nebulizers greatly helped symptoms. She was treated with
levofloxacin course for pneumonia and given nebulizers at
discharge.
.
# Rash: Unclear which antibiotic was culprit, but Ceftriaxone is
most likely cause given tolerating quinolone recently and
rareness of Vanc allergy. Per pt, rash significantly improved
during hospitalization.
.
# Hypertension: Thiazide initially held, restarted at discharge.
.
# Hyperlipidemia: Continued Aspirin/statin
.
# Urinary sx/stress incontinence: continued home oxybutynin
.
# Insomnia/anxiety: Pt has some anxiety, increasing since death
of her husband, which contributes to her subjective dyspnea. She
was given low dose lorazepam during hospitalization given that
benzos, infection and hospital setting can precipitate delirium
in the elderly. She was discharged with lorazepam per home
regimen.
.
# Pulmonary nodules- seen on CT chest. Pt will follow up as
outpatient with repeat imaging.
.
#Code: Full Code - confirmed with pt and Son [**Name (NI) **] (HCP)
.
#Communication: Patient, Son [**Name (NI) **] [**Name (NI) 100345**]: [**Telephone/Fax (1) 108620**] (H),
[**Telephone/Fax (1) 108621**] (C), [**Telephone/Fax (1) 108622**] (W); #2 wife [**Name (NI) 1328**]
[**Telephone/Fax (1) 108623**] (C)
Medications on Admission:
Methyclothiazide 5 mg Daily
Cranberry
Centrum silver
Miralax 2 teaspoons
Caltrate 600+D Plus Minerals 600 mg-400 unit Tab Daily
Aspirin 81 mg Tab Daily
Vitamin B-6 50 mg Daily
Vitamin D Daily
Omeprazole 20 mg Twice Daily
Pravastatin 40 mg Daily
Oxybutynin 2.5 mg TIW
Lorazepam 1.0-1.5 mg PO QHS
Sucralfate 2 tabs
Recently:
- Macrobid mon, wed, Fri for past week with improved urinary sx.
- Avelox Daily
- Simbacort 2 puffs [**Hospital1 **] x 5 days
Discharge Medications:
1. methylclothiazide Sig: Five (5) mg once a day.
2. Centrum Silver Tablet Sig: One (1) Tablet PO once a day.
3. Miralax 17 gram Powder in Packet Sig: Two (2) teaspoons PO
once a day as needed for constipation.
4. Caltrate 600+D Plus Minerals 600 mg (1,500 mg)-400 unit
Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day.
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Vitamin B-6 50 mg Tablet Sig: One (1) Tablet PO once a day.
7. Vitamin D 1,000 unit Tablet Sig: One (1) Tablet PO once a
day.
8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
9. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. Lorazepam 0.5 mg Tablet Sig: Two (2) Tablet PO at bedtime as
needed for insomnia.
11. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO BID (2 times
a day).
12. Oxybutynin Chloride 5 mg Tablet Sig: 0.5 Tablet PO QHS (once
a day (at bedtime)).
13. Macrobid 100 mg Capsule Sig: One (1) Capsule PO qMWF.
14. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q48H
(every 48 hours) for 1 days.
Disp:*3 Tablet(s)* Refills:*0*
15. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation four times a day as needed
for cough.
Disp:*30 * Refills:*0*
16. Nebulizer
Nebulizer for home use
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary:
Pneumonia
Secondary:
Recurrent UTI
HTN
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
You were admitted to the hospital with Pneumonia. You were
treated with breathing treatments and antibiotics. Your
breathing improved. You had a CT scan of your lungs which showed
no infiltrate. You also had an Echocardiogram that showed
diastolic dysfunction for which you do not currently need new
medications. You also had a small pulmonary nodule which needs
to be followed up in 3 months via your PCP.
The following changes were made to your medication regimen.
Please contiune to take all other medications as prescribled.
1. Please continue to take Levofloxacin for your pnuemonia for 1
more day
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] early next week. His phone number
is [**Telephone/Fax (1) 10011**].
You will need a CT in 3 months to follow up nodule in your
lungs. Dr. [**Last Name (STitle) **] will arrange this.
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
|
[
"272.4",
"599.0",
"300.00",
"518.81",
"E930.9",
"693.0",
"625.6",
"401.9",
"780.52",
"486"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10514, 10571
|
6552, 8637
|
226, 232
|
10664, 10664
|
3527, 3703
|
11439, 11772
|
2168, 2189
|
9136, 10491
|
10592, 10643
|
8663, 9113
|
10809, 11416
|
2204, 3508
|
179, 188
|
260, 1840
|
3717, 6529
|
10678, 10785
|
1862, 1896
|
1912, 2152
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,780
| 182,800
|
54470
|
Discharge summary
|
report
|
Admission Date: [**2159-8-27**] Discharge Date: [**2159-9-4**]
Date of Birth: [**2105-11-10**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
urinary urgency, dysuria
Major Surgical or Invasive Procedure:
PICC placement
History of Present Illness:
53 yo with h/o renal and pancreas transplant in [**2142**], repeated
renal transplant in [**2158-9-9**] who presents with dysuria,
fever and urgency x2 days. THe pt states that 2 days ago she
started to experience dysuria and urgency. THen the day prior to
admission she started to experience fever up to 103, chills and
LH. SHe went to see her PCP who sent her into the ED.
ROS: positive for diarrhea, longstanding, s/p w/u for Cdiff in
the past, denies CP, SOB, cough, abdominal, recent antibiotic
therapy other then Bactrim for chronic suppressive therapy.
Denies N, V.
In the Ed the pt received 1g Vancomycin, 1g Cefrtiaxone,
Decadron 10mg and Cefepime 1gm iv. She was started on Levophed
for pressure support after a RIJ was placed. Pt received a total
of 5L NS in the ED before being transfered to the MICU.
Past Medical History:
1.Gastroparesis
2.h/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 15532**]??????s Esophagus
3.h/o gastric adenoma
4.Pancreatic Insufficiency
5.Esophageal Ulcer
6.Left Upper Extermity Chronic Edema
7.h/o renal transplant in [**2142**]
8.h/o pancreatic transplant in [**2142**]
9.s/p CCY
10.Mild neuropathy
11.Moderate retinopathy s/p multiple laser treatments
12.h/o HD and PD
13.Lactose intolerance
14.Frequent UTIs since transplant every 6-8 months
15.s/p L subclavian stent due to chronically swollen left arm
16.Right foot osteomyletis
Social History:
No tobacco. Occassional EtOH. No drugs or herbal meds. Lives
with her husband.
Family History:
Father died from alcoholism
Mother 81 no med problems
Sister with anal cancer
Physical Exam:
VS: 98.4 103/74 84 NB100% SVO2 70
GEN: NAD, comfortable, talking in full sentences
HEENT: anicteric sclera, MMM, good dentition
Neck: neck supple, no LAD, no thryomegaly
Pulm: coarse, bronchial breath sounds on the R, + egophony
Cardio: nl rate, regular rhythm, nl S1 S2, no murmurs
Abd: soft, NT, ND, palpable kidney in LLQ that is slightly
tender,
positive bowel sounds
Ext: 2+ edema left upper extremity, trace edema in extremity;
5th digit amputated
Neuro: A&O x3, Cn 2-12 intact, PERRL, EOMI, moving all
extremities
Pertinent Results:
LAB DATA:
WBC:
[**2159-8-27**] 03:40PM WBC-16.1*# RBC-3.51* HGB-10.2* HCT-31.3*
MCV-89 MCH-29.1 MCHC-32.6 RDW-15.0
[**2159-8-27**] 03:40PM NEUTS-53 BANDS-38* LYMPHS-3* MONOS-6 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2159-8-27**] 03:40PM PLT COUNT-205
COAGS:
[**2159-8-27**] 03:40PM PT-14.8* PTT-34.2 INR(PT)-1.3*
CHEMISTRIES:
[**2159-8-27**] 03:40PM GLUCOSE-88 UREA N-43* CREAT-3.1*# SODIUM-139
POTASSIUM-4.0 CHLORIDE-101 TOTAL CO2-23 ANION GAP-19
LFTS:
[**2159-8-27**] 03:40PM ALT(SGPT)-44* AST(SGOT)-82* ALK PHOS-135*
AMYLASE-66 TOT BILI-0.6
[**2159-8-27**] 03:40PM LIPASE-20
[**2159-8-27**] 03:40PM ALBUMIN-3.2*
LACTATE:
[**2159-8-27**] 03:47PM LACTATE-3.3*
[**2159-8-27**] 05:29PM LACTATE-2.7*
URINE:
[**2159-8-27**] 05:30PM URINE RBC-[**2-11**]* WBC->1000 BACTERIA-MANY
YEAST-NONE EPI-0
[**2159-8-27**] 05:30PM URINE BLOOD-LG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2159-8-27**] 05:30PM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.016
MISC:
[**2159-8-27**] 09:44PM FIBRINOGE-380
CT Abd:
1. Marked [**Month/Day/Year 1106**] calcifications.
2. Similar pancreatic calcifications, which can be seen in
chronic pancreatitis.
3. Ascites and diffuse edema in the intra-abdominal fat, as well
as bibasilar pleural effusions.
4. Calcific density in the left lower lobe which may represent a
granuloma but is of unclear etiology.
5. Areas of increased density in the right lung base. As some of
these are over 100 Hounsfield units, these are probably either
calcifications or representative of contrast which may have been
aspirated, which is felt more likely. This finding was discussed
with Dr. [**Last Name (STitle) **] on the same evening.
6. Atrophic native kidneys.
7. Left lower quadrant renal transplant not well evaluated here
and better evaluated on a renal ultrasound of the same day.
CXR:
1. Interval development of retrocardiac opacity, new since the
previous examination of three hours prior. Differential
possibilities would include left lower lobe collapse or
aspiration.
2. Right internal jugular central venous catheter terminates in
the right atrium. More optimal positioning would be achieved if
this line were pulled back 3.5 cm.
EKG:
NS, normal interval, R axis, delayed RW progression. ST
depressions in lateral leads.
US Abd:
1. Status post cholecystectomy.
2. Mildly dilated 5 mm pancreatic duct. This appearance can be
seen in chronic pancreatitis.
3. Right pleural effusion.
4. Ring down artifacts consistent with pneumobilia centrally.
This area is not well evaluated on the CT of the same day given
streak artifacts from cholecystectomy clips. This appearance
could be due to the presence of clips and central pneumobilia,
which could be associated with a prior ERCP with sphincterotomy.
Correlation regarding history of ERCP is recommended.
RENAL US:
1. Normal vasculature within transplanted kidney.
2. Thickening of the transplant renal pelvis which could
represent chronic inflammatory change, or intrapelvic debris
(blood, pus).
Brief Hospital Course:
1. Sepsis:
This likely represented urosepsis given pos UA. The patient had
a history of resistant e.coli which was sensitive to Cefepime.
Initially, the patient was also covered for PNA given new
retrocardiac opacity, concerning for respiratory infection; of
note, the there was no cough reported on presentation. Given a
history of diarrhea, cdiff was considered - stool toxin was
negative x2.
She was started on vancomycin, azithromycin and cefepime.
Required large fluid volumes for resuscitation initially. SvO2
was > 70 (did not require transfusion or inotropes) and CVPs
were maintained above >[**7-19**]. Patient required norepinephrine
to maintain MAPs >65 from admission until [**8-29**]. She was
empirically started on stress dose steroids, which were tapered
back to her home dose on [**9-1**].
On [**8-28**] 2/4 bottles grew GNR, which speciated e.coli, sensitive
to ceftaz (presumably cefepime). Eventually 3/4 bottles grew
E. coli, however Ucx did not. Sensitivities were checked and
she was changed to PO Augmentin. Plan was for continued
antibiotics for five additional days.
Patient improved remarkably and on transfer to the floor she was
afebrile with SBPs in the 150s. Her WBC continued to trend down
and was 9.4 on discharge. She continued to diurese on the floor
and plan was for continued diuresis upon discharge.
2. ARF on CRF:
Likely due to hypotension. SCr was 3.1 on admission. With fluid
repletion trended down to 1.9 on transfer and continued to trend
down to 1.0 upon discharge. An US did not show evidence of
obstruction.
3. Elevated liver enzymes:
Likely due to hypotension. No RUQ pain. Trended down following
volume repletion.
4. Renal/Pancreas transplant:
Was continued on cellcept for immunosuppression. Tacrolimus was
dosed by level per renal recs.
5. Access:
RIJ placed on admission and pulled on the floor.
6. PPX:
Maintained on PPI, heparin sc, pneumoboots
7. Code:
Full while in house.
Medications on Admission:
Lasix 80 mg in the morning, 40 mg in the pm
CellCept [**Pager number **] mg b.i.d.
Prograf one milligram in the morning and two milligrams in the
evening
prednisone five milligrams a day
Creon with meals
Nexium 20 mg b.i.d.
Zofran four milligrams t.i.d.
fluconazole 100 mg three days per month
Levsin
potassium 20 meq daily
1 single strength tab Bactrim a day
Levoxyl 50 mcg once a day
collagenase
nystatin
pamidronate 30 mg every three months
MVI
Vit E, Vit B, Vit D complex
Ecotrin
Iron
Calcium Citrate
Glucosamine
Flaxseed
Cranberry
Discharge Medications:
1. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day: Please
take 80mg in the morning and 40mg in the evening.
Disp:*60 Tablet(s)* Refills:*2*
2. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
Disp:*120 Tablet(s)* Refills:*2*
3. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO QAM (once a
day (in the morning)): Please take 1mg in the morning and 2mg in
the evening.
Disp:*60 Capsule(s)* Refills:*2*
4. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Amylase-Lipase-Protease 33,200-10,000- 37,500 unit Capsule,
Delayed Release(E.C.) Sig: One (1) Cap PO QIDWMHS (4 times a day
(with meals and at bedtime)).
Disp:*90 Cap(s)* Refills:*2*
6. Nexium 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
7. Ondansetron HCl 2 mg/mL Solution Sig: One (1) Intravenous
tid prn ().
Disp:*60 * Refills:*2*
8. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) Injection
QMOWEFR (Monday -Wednesday-Friday).
Disp:*1 1* Refills:*2*
10. Bactrim DS 160-800 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
11. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 5 days.
Disp:*20 Capsule(s)* Refills:*0*
12. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO Q12H (every 12 hours) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
13. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
14. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
15. Potassium Chloride 20 mEq Packet Sig: One (1) PO once a
day.
Disp:*30 1* Refills:*2*
16. Outpatient Lab Work
Please check a chem-7 and a tacrolimus level in 3 days.
Discharge Disposition:
Home
Discharge Diagnosis:
Urosepsis
Acute on chronic renal failure
-----
s/p kidney transplant
s/p pancreatic transplant
esophageal ulcer
Discharge Condition:
Good; improved
Discharge Instructions:
You were admitted for a severe urinary and blood infection. It
will be very important for you to continue taking your
antibiotics for a full two-week course.
If you experience any fevers, chills or have any other concerns,
please be sure to call your PCP or go to the emergency room.
Followup Instructions:
Please be sure to follow-up with the following appointments:
1. Provider [**Name9 (PRE) 1111**],[**First Name7 (NamePattern1) 1112**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] SURGERY (NHB)
Date/Time:[**2159-9-10**] 11:45
2. Provider [**First Name11 (Name Pattern1) 3210**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2159-9-11**] 8:50
3. Provider [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 33176**], M.D. Phone:[**Telephone/Fax (1) 96976**]
Date/Time:[**2159-9-19**] 9:00
In addition, you should plan on seeing your PCP within one week.
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
|
[
"625.8",
"794.8",
"996.81",
"584.5",
"038.42",
"457.1",
"507.0",
"785.52",
"V42.83",
"V58.65",
"585.9",
"403.91",
"410.71",
"285.21",
"276.2",
"286.9",
"428.0",
"244.9",
"590.10",
"357.2",
"787.91",
"250.61"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"00.17"
] |
icd9pcs
|
[
[
[]
]
] |
10124, 10130
|
5621, 7577
|
339, 355
|
10286, 10303
|
2528, 5598
|
10637, 11423
|
1890, 1970
|
8164, 10101
|
10151, 10265
|
7603, 8141
|
10327, 10614
|
1985, 2509
|
275, 301
|
383, 1201
|
1223, 1777
|
1793, 1874
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,059
| 131,570
|
35321
|
Discharge summary
|
report
|
Admission Date: [**2158-2-1**] Discharge Date: [**2158-2-21**]
Date of Birth: [**2075-9-11**] Sex: F
Service: MEDICINE
Allergies:
Iodine; Iodine Containing
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Transfer from [**Hospital3 **] for Interventional Pulmonary, ONC
eval, respiratory distress
Major Surgical or Invasive Procedure:
Bronchoscopy [**2-2**], [**2-12**]
Tracheostomy, PEG placement [**2-16**]
History of Present Illness:
Ms [**Known lastname 53382**] is an 82 year old woman with history of breast cancer,
s/p mastectomy, on tamoxifen, compression fractures and a newly
diagnosed lung mass, presenting from [**Hospital3 4107**] for further
oncologic evaluation.
Ms [**Known lastname 53382**] presented to OSH with respiratory distress and fever.
Admission vitals T 101.4, HR 146, BP 112-140/50-80. Patient was
admitted to ICU and required non rebreather mask for oxygen
desaturation. Ceftriaxone and Azithromycin started for suspected
post obstructive pneumonia. Patients shortness of breath
continued with tachycardia and anxiety, placed on BiPAP with
resolution of dyspnea. Pulmonologist, Dr [**Last Name (STitle) 60991**], requested
evaluation for potential intervention to relieve bronchial
obstruction.
.
Patient was transferred for further evaluation.
Past Medical History:
- Breast cancer [**2150**], s/p modified radical mastectomy, 5 years
of tamoxifen (Dr [**First Name4 (NamePattern1) 636**] [**Last Name (NamePattern1) 116**])
- Lung mass, squamous cell carcinoma?
- COPD, on 3L NC at rest
- T8 compression fracture s/p kyphoplasty
- CAD s/p MI, h/o pericardial effusion
- Dyslipidemia
- PVD
- Cervical OA
- Atrial arryhtmia?
- GERD
- Osteoporosis
Social History:
Retired secretary, occasional alcohol, past smoker, quit 17
years ago, live at [**Hospital1 **] Village alone.
Family History:
CAD, Factor V Laiden, diabetes, pancreatic cancer, breast
cancer, lng cancer, PVD
Physical Exam:
GENERAL: Pleasant, well appearing woman in moderate distress
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No
LAD, No thyromegaly.
CARDIAC: Regular rhythm, tachycardic. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**].
LUNGS: Loud left lower lobe rhonchi and expiratory wheezes
throughout.
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: No edema or calf pain, 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. [**11-18**]+ reflexes,
equal BL. Normal coordination. Gait assessment deferred
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
[**2-2**] Chest CT
IMPRESSION:
1. There is evidence of increase in size in the left infrahilar
mass which
occludes the lingular bronchus, though it is difficult to tell
the precise
borders of the lesion and size of the lesion given the
non-contrast technique.
There is also new collapse of the left lower lobe, though the
airway remains
narrowed but patent, as evidenced by air bronchograms throughout
the left
lower lobe. Patchy nodular opacities elsewhere within the left
upper lobe and
within the right lung are also new, possibly infectious or
disease related.
2. Slight increase in left pleural effusion, new trace right
pleural effusion
and mild increase in pericardial effusion. Trace free pelvic
fluid.
3. Bulkiness of the left adrenal, unchanged, without a focal
lesion noted.
4. Hypodense area within the anterior liver as described, not
fully
characterized using non-contrast CT technique. If indicated,
this could be
further evaluated with ultrasound for the presence of a focal
lesion.
5. Calcified lesion of the interpolar left kidney, not fully
characterized.
6. Sigmoid diverticulosis, without evidence of diverticulitis.
7. Compression fractures of T8 (treated with vertebroplasty) and
T12.
8. Mild interval increase in size of subcentimeter mediastinal
lymph nodes, nonspecific.
[**2-6**] MR [**Name13 (STitle) 430**]
IMPRESSION: 1. Abnormal focus of enhancement is identified in
the left frontal lobe subcortical white matter as described in
detail above.
2. Punctate areas of restricted diffusion are also noted in both
cerebral
hemispheres in the convexity, possibly consistent with
metastatic foci, versus thromboembolic ischemic changes versus
septic emboli.
3. Chronic microvascular ischemic changes identified in the
subcortical white matter. Obliteration of the paranasal sinuses
with fluid levels within the maxillary sinuses bilaterally and
significant mucosal thickening involving the frontal, ethmoidal
and sphenoid sinus, bilateral opacities in the mastoid air
cells.
[**2158-2-21**] 03:59AM BLOOD WBC-12.0* RBC-3.14* Hgb-10.0* Hct-30.4*
MCV-97 MCH-31.8 MCHC-32.8 RDW-14.6 Plt Ct-190
[**2158-2-21**] 03:59AM BLOOD Glucose-108* UreaN-13 Creat-0.2* Na-143
K-4.0 Cl-102 HCO3-33* AnGap-12
[**2158-2-1**] 03:55PM BLOOD CK-MB-12* MB Indx-8.3* cTropnT-0.13*
[**2158-2-2**] 10:13AM BLOOD CK-MB-6 cTropnT-0.11*
[**2158-2-8**] 04:28AM BLOOD CK-MB-3 cTropnT-0.16*
[**2158-2-1**] 03:55PM BLOOD ALT-53* AST-62* LD(LDH)-260* CK(CPK)-145*
AlkPhos-166* TotBili-0.3
[**2158-2-2**] 10:13AM BLOOD CK(CPK)-102
[**2158-2-8**] 04:28AM BLOOD CK(CPK)-14*
[**2158-2-11**] 03:13AM BLOOD LD(LDH)-210 TotBili-0.2
[**2158-2-21**] 03:59AM BLOOD Calcium-8.6 Phos-3.6 Mg-1.8
[**2158-2-20**] 03:22AM BLOOD Calcium-8.7 Phos-3.2 Mg-2.0
[**2158-2-19**] 05:13AM BLOOD Calcium-8.5 Phos-2.9 Mg-2.2
Brief Hospital Course:
82 year old woman with newly diagnosed sqamous cell lung cancer,
presenting with respiratory distress in setting of post
obstructive pneumonia.
.
#. Acute Hypoxic Respiratory Distress: Patient is s/p trach
placement as she was ventilator dependent. Patient's condition
was multifactorial given lung cancer, prior emphysema requiring
oxygen and development of post obstructive pneumonia. Patient
had bronchoscopy on [**2-2**] that showed lots of pus (consistent
with pneumonia) and external compression of airways. Patient
was intubated and was tough to completely wean off the
ventilator. Patient had tracheostomy placed on [**2-16**] and has been
intermittantly ventilator dependent. Patient has been able to
tolerate trach mask for increasing duration during end of
hospitalization, however has not been able to be off for full 24
hours and has been intermittantly pressure support dependent.
Patient has also been treated with course of methylprednisonlone
and has been completely weaned off.
- Continue trach mask as tolerated, goal > 24 hours
- Continue Atrovent / Albuterol nebs as needed
- Continue mouth rinse
# Post Obstructive Pneumonia: In the setting of new diagnosed
lung mass, patient developed LLL pneumonia and was treated with
Ceftriaxone, Levofloxacin, Flagyl for a total 14 day course.
Patient has remained afebrile and has been maintaining
saturations on trach mask. Ultimately, patient will need her
lung mass addressed as she is prone to obstructive process in
the future.
- Monitor patient for signs and symptoms of infection
.
# Left squamous cell lung cancer: Per CT report, it has
increased in size comapared to [**12-6**] comparison and it
completely obstructs the lingular bronchus. Patient was
evaluated by Radiation oncology and recieved a short course of
radiation. Patient was also followed by the Heme/Onc service
and recommended possible chemotherapy as an outpatient once
patient continues to be stable.
- Patient to follow up as an outpatient with
Hematology/Oncology. Patient/family should be contact[**Name (NI) **] by
Heme/Onc -- if not contact[**Name (NI) **] in 1 week, please call ([**Telephone/Fax (1) 11624**].
.
# Nurtrition: Patient had PEG placed on [**2-16**] and was receiving
tube feeds during her hospitalization.
- Continue Nutren tube feeds
Medications on Admission:
Transfer Medications
- Solumedrol 80mg q8H
- Atrovent
- Xopenex
- Mucinex
- Spiriva
- Advair 250/50
- Aspirin 81
- Prinivil (Lisinopril) 2.5
- Cardizem CD 120mg
- Pravachol 40mg
- Nitroglycerin
- Azithromax 500mg
- Zosyn 3.375mg Q6H
- Trazodone 25mg QHS PRN
- Caltrate
- Protonix
- MVI
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution [**Month/Day (2) **]: One (1)
Injection TID (3 times a day).
2. Chlorhexidine Gluconate 0.12 % Mouthwash [**Month/Day (2) **]: One (1) ML
Mucous membrane [**Hospital1 **] (2 times a day): Please use if patient
mechanically ventilated.
3. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Hospital1 **]:
Four (4) Puff Inhalation Q6H (every 6 hours).
4. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Hospital1 **]: Two (2)
Puff Inhalation Q6H (every 6 hours).
5. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Diltiazem HCl 60 mg Tablet [**Hospital1 **]: One (1) Tablet PO QID (4
times a day).
7. Lisinopril 5 mg Tablet [**Hospital1 **]: 0.5 Tablet PO DAILY (Daily).
8. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
9. Heparin, Porcine (PF) 10 unit/mL Syringe [**Last Name (STitle) **]: One (1) ML
Intravenous PRN (as needed) as needed for line flush: For PICC.
10. Lorazepam 0.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q8H (every 8
hours) as needed.
11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
12. Senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day) as needed.
13. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: One (1) PO BID (2
times a day).
14. Oxycodone-Acetaminophen 5-325 mg Tablet [**Last Name (STitle) **]: One (1) Tablet
PO Q6H (every 6 hours) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Primary
- Left infrahilar lung cancer
- Post Obstructive Pneumonia
- Acute Hypoxic Respiratory failure
- Chronic obstructive lung disease
- Hypertension
Discharge Condition:
Afebrile, vitals stable, on Trach
Discharge Instructions:
You were hospitalized because you had respiratory failure. This
was secondary to several other conditions you have and your lung
cancer. As a result, you developed a Pneumonia that was treated
and is now resolved. We we unable to wean you from the
ventilator and thus had to place a tracheostomy as a bridge
until you are able to be off the ventilator completely.
Additionally, you had a PEG tube placed that will allow for tube
feedings.
If you have worsening shortness of breath, fevers, chills,
please let one of the physicians at the facility know. If these
symptoms continue, please return to the ER.
Followup Instructions:
Please follow up with the physican at your rehab
Hematology/Oncology
Please call ([**Telephone/Fax (1) 14703**] to set up an appointment in [**11-18**] weeks
for evaluation for chemotherapy.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
Completed by:[**2158-2-21**]
|
[
"366.9",
"285.9",
"733.00",
"198.3",
"564.00",
"553.3",
"491.21",
"162.5",
"V10.3",
"518.84",
"486",
"272.4",
"414.01",
"562.10",
"V02.54",
"288.60",
"287.5",
"427.89",
"721.0",
"401.9",
"443.9",
"584.9",
"530.81",
"410.71",
"276.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"31.1",
"33.23",
"38.93",
"93.90",
"33.24",
"43.11",
"96.71",
"38.91",
"96.6",
"92.29"
] |
icd9pcs
|
[
[
[]
]
] |
9894, 9966
|
5585, 7894
|
377, 452
|
10163, 10199
|
2767, 5562
|
10859, 11208
|
1868, 1951
|
8230, 9871
|
9987, 10142
|
7920, 8207
|
10223, 10836
|
1966, 2748
|
246, 339
|
480, 1320
|
1342, 1724
|
1740, 1852
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,921
| 190,946
|
9286
|
Discharge summary
|
report
|
Admission Date: [**2128-9-11**] Discharge Date: [**2128-11-9**]
Date of Birth: [**2051-9-14**] Sex: M
Service: [**Hospital Unit Name 196**]
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2880**]
Chief Complaint:
Rectal bleed, change in MS, CHF
Major Surgical or Invasive Procedure:
none
History of Present Illness:
76 y/o male w/ h/o rheumatic heart dz s/p mechanical mvr/avr,
afib (s/p VVI PPM); h.o CHF; s/p recent admit to [**Hospital1 18**] for 7 wks
(work up for valve leakage included TTE, TEE, MRI showing 2+ MR
perivalvular leakage; s/p cath x 2 with stenting of RCA and LAD;
s/p VVI pacemaker for chronic afib and prolonged attempts of
diuresis) who is being transferred from OSH today after
admission for hemorrhoidal bleed s/p surgical I and D of
thrombosed hemorrhoid on [**9-6**], followed by normal colonoscopy on
[**9-8**]. Since colonoscopy patient has had persistent increased
somnolence despite attempts to reverse sedatives with Narcan.
Patient got Fentanyl and Versed during colonoscopy, since then
all sedating meds were held but change in MS persisted. Patient
was also found to have peri-rectal abscess but not transferred
on antibiotics. During the same admission the patient was noted
to be in acute on chronic renal failure with Creat. of 2.3 from
1.8 (and K of 6) on admission therefore lisinopril and aldactone
were held. Patient was continued on Lasix and had serial rising
BNPs from 723 on [**9-8**] to 1163 on [**9-11**]. Patient transferred per
family request for further management.
On admission initial ABG 7.29/77/237 during Nebulizer treatment,
next ABG 7.28/78/163, normal Lactate.
He was intubated and admitted to the CCU and extubated on
[**2128-10-9**]. He was then placed on a heparin gtt, lasix gtt,
dopamine gtt and nesiritide for diuresis. After transferring
back to the floor service, he failed to wean off the dopamine
and nesiritide and was readmitted to the CCU on [**2128-10-20**]. He
failed to tolerate an ACE and was restarted on dopamine which
was then weaned off. He is now on natrecor, bumex [**Hospital1 **].
Past Medical History:
1. CAD - s/p cath [**2128-7-30**]:stenting of the RCA with 3
overlapping cypher [**Name Prefix (Prefixes) **] -[**Last Name (Prefixes) **] [**2128-8-11**]: rotational atherectomy,
PTCA and stenting of the LAD/LCX.
2. MVR/AVR
3. CHF - EF >55% 2+MR perivalvular, RV dysfunction, moderate
pulmonary HTN
4. PAF s/p VVI pacemaker
5. CRI
6. MDS
7. Chronic mechanical hemolysis
8. Hx. of perirectal abscess s/p surgery
Social History:
no hx of etoh or tobacco, lives at home alone, widower.
Children are very involved in his care.
Family History:
non-contributory
Physical Exam:
Temp 98.8
BP 112/60
Pulse 60
Resp 34
O2 sat 98% on 4LNC
Gen - Elderly male in moderate respiratory distress.
HEENT - PERRL, extraocular motions intact, anicteric, mucous
membranes moist
Neck - JVD to jaw, no cervical lymphadenopathy
Chest - diffuse wheezing, decreased breath sounds at the right
base more than the left
CV - Mechanical S1/S2, RRR, [**2-28**] holosystolic murmer
Abd - Distended, hypertympanic, +BS, NT, no rebound or guarding.
Back - No costovertebral angle tendernes
Extr - 1+ non-pitting edema. 2+ DP pulses bilaterally
Neuro - Confused, not oriented but responsive.
Skin - No rash
Pertinent Results:
ECHO ([**2128-9-13**]):Conclusions:
1. The left atrium is moderately dilated. The right atrium is
moderately
dilated.
2. There is moderate symmetric left ventricular hypertrophy. The
left
ventricular cavity size is normal. Regional left ventricular
wall motion is
normal. Overall left ventricular systolic function is normal
(LVEF>55%).
3. The ascending aorta is moderately dilated.
4. A bileaflet aortic valve prosthesis is present. The
transaortic gradient is
higher than expected for this type of prosthesis. Trace aortic
regurgitation
is seen.
5. A bileaflet mitral valve prosthesis is present. Mitral
regurgitation is
present but cannot be quantified.
6. Moderate [2+] tricuspid regurgitation is seen. There is
moderate pulmonary
artery systolic hypertension.
7. Compared with the findings of the prior study of [**2128-7-22**],
there has been no
significant change.
PERSANTINE MIBI [**2128-10-13**]
IMPRESSION: A moderate to severe, fixed perfusion defect of the
inferior and
inferolateral myocardial walls and apex. Compared to the
previous scan, the
previously reversible perfusion defect in this region is now
fixed and the
apical perfusion defect has become more severe. The left
ventricle is enlarged.
Wall motion is normal with a calculated left ventricular
ejection fraction of
50%.
RIGHT AND LEFT HEART CATHETERIZATION:
1. Selective coronary angiography demonstrated a
right-dominant
circulation with three-vessel coronary artery disease. LMCA was
angiographically-normal. LAD had a widely patent proximal
stent, and
was subtotally occluded in the very apical portion (slightly
progressed
from prior study). LCx had a 60% origin stenosis at the site of
prior
PTCA, and a 70% lesion in a small-caliber mid-vessel. RCA had a
40%
origin stenosis, a 50% distal stenosis, and a 70% lesion in the
posterolateral branch. Prior RCA stents were widely patent.
2. Left ventriculography was deferred because of renal
insufficiency
and presence of aortic valve prosthesis.
3. Resting hemodynamics demonstrated mild pulmonary
hypertension
(39/16 mmHg), minimally elevated filling pressures (mean RA 6
mmHg, mean
PCWP 12 mmHg), and a preserved cardiac index of 2.9 L/min/m2.
These
represent marked improvement since prior hemodynamic assessment
in [**7-28**],
although current study was performed with patient receiving
intravenous
dopamine and nesiritide.
4. Right internal jugular venous sheath was sutured in place.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease, minimally changed
from prior
angiography.
2. Mild pulmonary hypertension.
3. Minimally elevated filling pressures with preserved cardiac
output.
3. Congestive heart failure.
Brief Hospital Course:
# CHF - On admission we placed a right IJ triple lumen catheter
for adequate access. He was in decompensated CHF on exam and we
started treatment with Natrecor, Lasix, and dopamine drips. He
was diuresed with these agents for several days with good output
and weight loss. He was converted to Lasix IV as a bridge to PO
and then converted to PO lasix once adequately diuresed.
Dopamine and Niseritide stopped after changeed to Po lasix. On
one occastion whie on lasix gtt pt had creatitine bump to 2.2.
This resolved when diuretics decreased. We initially held his
Digoxin, spironolactone, and ACE-I with a plan to re-start them
back gradually. Pt was doing better from CHF stand point until
he was transfused and again decompensated requiring Natrecor and
Dopamine gtt. Dopamine could not be weaned off since his BP
would drop without Dopa. Pt then underwent right and left heart
cath to determine precise fluid status which showed PCWP of 12
and left cath showing 3 vessel dz. Given his PCWP of 12 which
is much better than we expected, it was thought that he was
overdiuresed causing decline in BP. He was transferred to CCU
for brief period of time for tailored therapy where Natrecor and
Dopamine gtt were weaned off and po Bumex and spironolactone
were started for diuresis. He did not tolerate Captoril in CCU
because of drop in BP. Once he returned to the floor, he was
slowly started on very low dose lisinopril, and then Coreg was
added in low dose. These medications were slowly titrated up.
He remained net even for few days but became slightly overloaded
as he required multiple transfusion for his anemia. Bumex was
increased to 2 mg [**Hospital1 **] which he responded well with daily net
negative I's/O's. However, since spironolactone had to be
discontinued for hyperkalemia, Bumex was increased to 2mg [**Hospital1 **].
He was able to tolerate lisinopril 3.75 mg qd, Coreg 3.125 mg
[**Hospital1 **]. If his hyperkalemia resolves or if pt is hypokalemia,
would recommend adding back spironolactone. At rehab, need to
closely monitor pt's weight and consider increasing Bumex as
needed. Goal wt <60kg. Also, pt's creatinine ranged from
~1.3-2.2, most recently 1.9 at discharge. Pt's BUN also
elevated, likely due to diuresis. Pt should have electrolytes
checked periodically at rehab and, if renal function worsens,
consider decreasing lisinopril dose.
# CAD - Upon admission he had a troponin of 0.02, it was likely
due to subendocardial ischemia from increased demand. We
continued his ASA and plavix. Pt was hypotensive during diuresis
and was started on Dopa both for BP support and diuresis. BP
ranged from 90's-100's. BP meds were held for BP less than 100.
Restarted Carvedilol after dopamine stopped and BP back up to
baseline.
# Heme - He has a history of chronic anemia [**1-26**] MDS and
mechanical hemolysis. While he was in the hospital we
continued his iron and folate therapy. He received 2
transfusions during the hospital stay for HCT <28. He was
initially continued on Procrit 60,000u Qmonday. Then he
developed more brisk drop in Hct compared to before requiring
almost transfusion 1-2x/week. Hemolysis panel was again
positive with high LDH, low haptoglobin, however with normal
bilirubin. Hematology was consulted for his condition to rule
out other etiology. His anemia has three component.
1)mechanical hemolysis 2)MDS 3)anemia of chronic illness (by
Iron studies). The major part of the acute drop is from
mechanical hemolysis. The echo does not show any change in the
perivalvular leakage of the mitral valve, and it was unlcear why
his anemia has progressed. Per Hem recommendation, Epo was
increased to 60,000 units/week (20,000 units qMWF) and he was
getting IV iron for sometime. His Hct was as low as 21 and
required multiple transfusion to keep the Hct>30. The only
solution to his condition is a valve repair surgery. However,
pt refused this option and preferred to get transfusion weekly
rather than going through a major surgery. After getting the
increased EPO dose, pt 's Hct remained stable at 30-34 with
increased retic count. IV iron was held since pt was able to
hold his Hct without it.
# Rhythm - He has chronic afib s/p VVI pacer [**2128-8-12**]. At this
hospitalization there was some question of the utility of BiV
upgrade to help with CHF management. This should be adressed
further as an outpatient. The pacemaker site hematoma had
resolved by discharge.
# Mechanical valve - Coumadin was initially held and he was
maintained on a Heparin drip while he had to get central line
placed for the CHF management. Once his CHF issue had
stabilized, his coumadin was restarted and titrated. Blood
cultures were checked to rule out endocarditis and were all
negative. He needs to have his INR 2.5-3.5 for the mechanical
valve. Pt's INR was therapeutic at Coumadin 13 mg qd. Pt's INR
should be checked periodically and warfarin adjusted as
indicated. He should have INR periodically checked until INR
stable at therapeutic level.
# Change in mental status - Upon presentation from the OSH Mr.
[**Known lastname 11215**] was disoriented and changed from his baseline. He got a
stat head CT to evaluate for possible bleed or stroke which was
normal. It was felt that it was most likely toxic/metabolic in
origin. He was started on Levo/Flagyl given history of
colonoscopy and recent perirectal abscess. Blood cultures and
Urine cultures were sent with concern of a infectious etiology.
We checked LFTs, Chem10, Amylase, and Lipase. He had an
elevated LDH which was felt to be secondary to his known
mechanical hemolysis. All sedating meds were held given the
history of recent sedation for colonoscopy immediately prior to
change in MS. His ABG indicated hypercarbia which could be
causing his change in MS. His oxygen was decreased and he was
maintained at an O2 sat between 92-94%. He was treated with
nebulizers and steroids. He was also aggressively diuresed
given his CHF history. He was continued on these treatments and
two days after admission his mental status resolved to baseline.
# Hypercarbia - He was hypercarbic on his initial ABG. There
was evidence of CO2 retention as hypercarbia improved with
decreased FIO2. He was treated with q2hour nebs and solumedrol.
He remained stable and never required BIPAP. His hypercarbia
resolved.
# Perirectal abscess - There was no evidence of fluctuance or
drainage on exam. He was treated with Levo/Flagyl for a full
course of 10 days during his hospital stay.
# Ileus - Upon initial evaluation he was seen to have enlarged
bowel loops on abdominal x-ray. All narcotics were held. There
was no need for NG tube decompression since he was passing
Flatus and having bowel sounds. He was initially NPO but then
his diet was advanced when he was having bowel movements. He
tolerated solid food well and there was no need for further
evaluation.
# Prophylaxis/FEN - Throughout his stay he was maintained on
Protonix and a heparin drip. Heparin gtt was stopped when INR
therapeutic. Pt was ambulating daily. Electrolytes were followed
and repleted as needed.
Medications on Admission:
Transfer medications: Coumadin 4, Procrit 20,000 M/W/F, FeSO4
325, Folic Acid 1g po qd, Lopressor 50 [**Hospital1 **], SL NTG, Plavix 75,
Tylenol
Discharge Medications:
1. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD
().
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO QD ().
3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
[**12-26**] Disk with Devices Inhalation [**Hospital1 **] (2 times a day).
4. Menthol-Cetylpyridinium Cl 2 mg Lozenge Sig: One (1) Lozenge
Mucous membrane PRN (as needed).
5. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q3-4H () as needed.
6. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
8. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO QD
().
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO QD ().
11. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
12. Spironolactone 25 mg Tablet Sig: 0.5 Tablet PO QD ().
13. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed.
14. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
15. Epogen 20,000 unit/mL Solution Sig: One (1) Injection qMWF.
16. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
17. Lisinopril 5 mg Tablet Sig: 0.75 Tablet PO HS (at bedtime).
18. Bumetanide 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
19. Warfarin Sodium 6 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
20. Warfarin Sodium 1 mg Tablet Sig: One (1) Tablet PO once a
day.
Discharge Disposition:
Extended Care
Facility:
[**Doctor First Name 391**] Bay - [**Hospital1 392**]
Discharge Diagnosis:
Congestive Heart Failure
Coronary Artery disease
Chronic renal insufficiency
Mechanical hemolysis
MDS
Anemia of chronic illness
Discharge Condition:
Stable
Discharge Instructions:
Please return to the hospital if you experience chest pain,
shortness of breath, lightheadedness, increasing leg edema or
any other severe symptoms. Please call your doctor if you have
any questions about your symptoms.
Please follow-up with Dr. [**Last Name (STitle) 73**] in 3 weeks after discharge.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction:
Followup Instructions:
Please call Dr. [**Last Name (STitle) 73**] to make a follow-up appointment three
weeks after your discharge from the hospital.
Please call for a follow up appointment with [**Hospital 1902**] clinic
([**Telephone/Fax (1) 3512**]) at next available date except for Thursday.
Please call for a follow up appointment with his hematologist as
soon as possible.
[**First Name11 (Name Pattern1) 900**] [**Last Name (NamePattern1) 2882**] MD, [**MD Number(3) 2883**]
Completed by:[**2128-11-9**]
|
[
"285.9",
"428.0",
"427.1",
"518.82",
"427.31",
"428.30",
"238.7",
"584.9",
"276.0",
"560.1",
"414.01",
"V43.3",
"585"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"99.04",
"38.93",
"37.23",
"00.13",
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
14992, 15072
|
6084, 13219
|
367, 373
|
15244, 15252
|
3377, 5819
|
15723, 16246
|
2722, 2740
|
13416, 14969
|
15093, 15223
|
13245, 13245
|
5838, 6061
|
15276, 15700
|
2755, 3358
|
296, 329
|
13268, 13393
|
401, 2157
|
2179, 2593
|
2609, 2706
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,942
| 130,772
|
19538
|
Discharge summary
|
report
|
Admission Date: [**2131-1-8**] Discharge Date: [**2131-1-15**]
Date of Birth: [**2074-8-21**] Sex: M
Service: CARDIOTHOARCIC
CHIEF COMPLAINT: Increased dissiness with exertion.
HISTORY OF PRESENT ILLNESS: The patient is a 54-year-old
gentleman who had a back injury in [**2130-8-7**] at which
time he went to the Emergency Room. CAT scan done in the
Emergency Room revealed an abdominal aortic aneurysm. He saw
our vascular surgeon and was recommended to have a cardiac
work-up prior to repair.
An stress echocardiogram at that time was positive where he
was found to have severe left main and two-vessel disease.
He was then referred to [**Hospital6 256**]
for carotid stenting and coronary artery bypass grafting.
He underwent carotid stenting on [**12-22**] by [**First Name8 (NamePattern2) 487**]
[**Last Name (NamePattern1) **], M.D., and was discharged to home following stent
placement. He returned on [**1-8**] for coronary artery
bypass grafting as an outpatient admission, postoperative
admit.
PAST MEDICAL HISTORY: Severe peripheral vascular disease.
Bilateral carotid disease. Obesity. Hypertension.
Hypercholesterolemia. Chronic low back pain. Prior
intravenous drug use. Cardiac catheterization done on
[**2130-11-28**], showed left main at 60-70%, left anterior
descending 60%, circumflex 100%, right coronary artery 30%,
ejection fraction of 70%.
Echocardiogram on [**11-18**] showed an ejection fraction of
50-55%, left atrial enlargement, left ventricular
hypertrophy, inferior hypokinesis.
MEDICATIONS ON ADMISSION: Lipitor 20 mg q.d., Metoprolol 25
mg b.i.d., enteric coated Aspirin 81 mg q.d., Vitamin B,
Folate, B6.
ALLERGIES: NO KNOWN DRUG ALLERGIES.
SOCIAL HISTORY: He is a construction worker. He smokes a
half to one pack per day times 40 years. He denied alcohol
use. He has been sober times 11 years. No recent
intravenous drug use.
PHYSICAL EXAMINATION: Vital signs: On preadmission testing,
his heart rate was 56 and regular, blood pressure 148/90,
respirations 20, height 5 ft 6 in, weight 212 lbs. General:
He was obese but somewhat fit. Skin: No obvious lesions.
He had multiple park scarring on both arms. HEENT: Pupils
equal, round and reactive to light. Extraocular movements
intact. Pupil mucosa was normal. Neck: Supple. No jugular
venous distention. He had bilateral bruits, right greater
than left. Chest: Clear to auscultation bilaterally.
Heart: Irregular. S1 and S2. No murmur appreciated.
Abdomen: Soft, nontender, nondistended. Extremities: Warm
and well perfused with no clubbing, cyanosis, or edema. No
varicosities. Neurological: Cranial nerves II-XII grossly
intact. Nonfocal exam. Strength equal in all four
extremities. Pulses: Femoral 1+ bilaterally. Dorsalis
pedis 2+ on the right and left. Posterior tibial 1+
bilaterally. Radials 1+ bilaterally.
LABORATORY DATA: None at the time of preadmission testing.
Chest x-ray pending. Electrocardiogram showed sinus at a
rate of 55, with occasional premature ventricular
contractions, T-wave inversions in lead III and AVF, normal
intervals.
HOSPITAL COURSE: The patient was admitted on [**1-8**] for
coronary artery bypass grafting directly to the Operating
Room. Please see the operative report for full details.
In summary, the patient had coronary artery bypass grafting
times two with LIMA to the left anterior descending and
saphenous vein graft to the obtuse marginal. His bypass time
was 122 min with a cross-clamp time of 100 min. He tolerated
the operation well and was transferred from the Operating
Room to the Cardiothoracic Intensive Care Unit.
At the time of transfer, the patient was in sinus rhythm with
a mean arterial pressure of 80, PA of 25/15. He had
Neo-Synephrine at 0.5 mcg/kg/min.
He did well in the immediate postoperative period. His
anesthesia was reversed, and he was successfully extubated.
On postoperative day #1, the patient remained hemodynamically
stable, and he was transferred to ................ for
continuing postoperative care and cardiac rehabilitation.
His chest tubes remained in place on postoperative day #1, as
he had a significant amount of drainage. On postoperative
day #2, the patient was noted to have rapid atrial
fibrillation with a ventricular response of 140-160 and a
blood pressure ranging from 90-110, not associated with any
dizziness, shortness of breath, or chest pain.
At that time, the patient was started on Amiodarone, and by
on postoperative day #3, the patient had converted to normal
sinus rhythm.
Over the next several days, the patient had an uneventful
postoperative course. He did however, have an additional
episode of atrial fibrillation on postoperative day #4, and
at that time, he was started on Heparin infusion, and
Coumadin was begun.
The patient again converted to normal sinus rhythm and has
been in normal sinus rhythm since that time.
With the assistance of the nursing staff and Physical
Therapy, the patient's activity level was gradually
increased, and now on postoperative day #7, the patient is
stable and ready to be discharged to home.
DISCHARGE PHYSICAL EXAMINATION: Vital signs: Temperature
99??????, heart rate 68 in sinus rhythm, blood pressure 116/50,
respirations 20, oxygen saturation 96% on room air. Weight
preoperatively 220 lbs, on discharge 100 kg. Neurological:
The patient was alert and oriented times three. He moves all
extremities. He follows commands. Chest: Clear to
auscultation bilaterally. Sternum is stable. Incision with
Steri-Strips, open to air, clean and dry. Cardiovascular:
Regular, rate and rhythm. S1 and S2. No murmurs. Abdomen:
Soft, nontender, nondistended. Positive bowel sounds.
Extremities: Warm and well perfused. He had 1+ edema
bilaterally. Right leg saphenous vein graft site with
Steri-Strips, open to air, clean and dry.
DISCHARGE LABORATORY DATA: Sodium 140, potassium 4.1,
chloride 106, CO2 29, BUN 12, creatinine 0.9, glucose 102;
white count 8.1, hematocrit 23.5, platelet count 197; PT
13.7, PTT 68, on 1400 U Heparin, INR 1.3.
DISCHARGE MEDICATIONS: Aspirin 81 mg q.d., Atorvastatin 20
mg q.d., Plavix 75 mg q.d., Metoprolol 50 mg b.i.d.,
Amiodarone 400 mg b.i.d. x 1 week, then 400 mg q.d. x 1 week,
then 200 mg q.d., Coumadin the patient is to take as
directed, he is to receive 5 mg on the day of discharge, 3 mg
the day after discharge, and then have his INR checked with
Dr. [**Last Name (STitle) 1159**] on [**1-17**], at which time she will instruct him
on how much Coumadin to take from that point forward.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DIAGNOSIS:
1. Bilateral carotid disease status post carotid stenting.
2. Coronary artery disease status post coronary artery
bypass grafting times two with LIMA to the left anterior
descending and saphenous vein graft to the obtuse marginal.
3. Abdominal aortic aneurysm reported as 3.5 cm.
4. Hypertension.
5. Hypercholesterolemia.
6. Prior intravenous drug use.
7. Chronic low back pain.
DISCHARGE STATUS: The patient is to be discharged home.
FO[**Last Name (STitle) **]P: He is to have follow-up in the [**Hospital 409**] Clinic in
two weeks. He is to follow-up with Dr. [**Last Name (STitle) 1159**] in [**2-8**] weeks.
Follow-up with Dr. [**Last Name (Prefixes) **] in four weeks. Additionally,
the patient is to have his INR checked on [**1-17**] in Dr.[**Name (NI) 53002**] office. He is to call Dr. [**Last Name (STitle) 1159**] for an appointment
prior to Wednesday morning to schedule a time for his INR
check.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Name8 (MD) 415**]
MEDQUIST36
D: [**2131-1-15**] 13:31
T: [**2131-1-15**] 13:36
JOB#: [**Job Number 53003**]
|
[
"272.0",
"724.2",
"997.1",
"414.01",
"401.9",
"441.4",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"36.15",
"39.61",
"36.11"
] |
icd9pcs
|
[
[
[]
]
] |
6111, 6577
|
6632, 7807
|
1574, 1716
|
3140, 5136
|
5159, 6087
|
164, 200
|
229, 1034
|
1057, 1547
|
1733, 1909
|
6602, 6611
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,694
| 185,673
|
13233
|
Discharge summary
|
report
|
Admission Date: [**2167-5-19**] Discharge Date: [**2167-6-11**]
Date of Birth: [**2112-10-13**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1828**]
Chief Complaint:
squamous cell carcinoma, bacteremia, need for PEG and extraction
of teeth
Major Surgical or Invasive Procedure:
None major - had extraction of all teeth, and placment of
gastrostomy tube
History of Present Illness:
Mr. [**Known lastname 40332**] is a 54 year old man with TYPE I DM, CKD stage V
on dialysis, coronary artery disease who was diagnosed a little
over one month ago with SCC of head and neck. He is admitted
now for management of multiple issues. Since his diagnosis,
radiation oncology, medical oncology and dental have spent
extensive time and energy arranging for treatment plan.
Ultimately, decision made to pursue PEG tube, followed by teeth
extraction (very poor dentition) followed by radiation treatment
and Erbitux. He was seen in the [**Hospital **] clinic today for planned PEG
tube but GI unable to place due to concern for compromising
airway with sedation. He is admitted for ongoing management.
.
When seen, patient reports he has been fatigued of late, but has
been able to tolerate solids as long as they are followed by
liquids. The patient's HCP also reports that he had fever last
week and at dialysis 4D prior to admit ([**5-15**]) had blood cultures
drawn which subsequently returned positive. He was given
vancomycin on [**5-17**] at dialysis. No fevers, chills, abdominal
pain, chest pain, shortness of breath, diarrhea, nausea,
vomiting over this time.
=
=
=
=
=
=
=
=
================================================================
ROS: Otherwise detailed review of systems negative except as
noted.
Past Medical History:
PCP: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] [**Name (STitle) 1022**] ([**Telephone/Fax (1) 40328**])
Primary Nephrologist: Dr. [**Last Name (STitle) **] ([**0-0-**])
.
Type 1 Diabetes Mellitus
Failure to Thrive
Coronary Artery Disease s/p MI in [**2149**] and CABG in [**2165**]
Right Eye Blindness
GERD
End Stage Renal Disease on HD (qMWF at [**University/College **] Dialysis
Center)
Alcohol Abuse
Sqaumous Cell Carcinoma of head and neck
Social History:
Lives with daughter
[**Name (NI) 1139**]: 2 PPD
EtOH: previous history of alcohol use, pt denies recent use
Drugs: denies
Per patient's dialysis nurse ([**Doctor First Name **]), he has been very depressed
since his wife passed away several years ago. He is very
withdrawn and often comes to dialysis unwashed wearing clothes
he has not changed for several days.
Brother-in-law: [**Name (NI) 4468**] [**Name (NI) **] [**Telephone/Fax (1) 40329**]; [**Telephone/Fax (1) 40330**]
--Health Care Proxy
Daughter: [**Name2 (NI) **] [**Telephone/Fax (1) 40331**]
Family History:
Not contributory vis a vis current issues
Physical Exam:
VS: Temp:97.4 BP:120/70 HR:88 RR:16 96%rm airO2sat
.
General Appearance: cachectic, yellow bronze skin tone, NAD, non
toxic
Eyes: EOMI, no conjuctival injection, anicteric
ENT: MMdry, poor dentition, palpable posterior cerv lymph node
Respiratory: CTA b/l with good air movement throughout
Cardiovascular: RR, S1 and S2 wnl, +2/6 systolic murmur
Gastrointestinal: nd, +b/s, soft, nt, scaphoid
Musculoskeletal/extremities: no edema
Skin/nails: warm, no rashes/yellowish skin tone
Neurological: AAOx3. Cn II-XII intact. 5/5 strength
throughout. No asterixis, no pronator drift, fluent speech.
Psychiatric:pleasant, appropriate affect
Heme/Lymph: posterior cervical adenopathy
GU: no catheter in place
LEFT AV FISTULA with bruit.
Pertinent Results:
Admit labs:
[**2167-5-20**] 05:40AM BLOOD WBC-6.7 RBC-4.63# Hgb-13.0*# Hct-41.5#
MCV-90# MCH-28.1# MCHC-31.3 RDW-13.3 Plt Ct-294
[**2167-5-20**] 05:40AM BLOOD Plt Ct-294
[**2167-5-20**] 05:40AM BLOOD Glucose-72 UreaN-47* Creat-5.7* Na-141
K-4.7 Cl-95* HCO3-29 AnGap-22*
[**2167-5-20**] 05:40AM BLOOD Calcium-8.3* Phos-5.0*# Mg-2.4
[**2167-5-20**] 05:40AM BLOOD Vanco-8.9*
=============================================================
Transthoracic echo:
The left atrium and right atrium are normal in cavity size. The
right atrial pressure is indeterminate. A left-to-right shunt
across the interatrial septum is seen at rest c/w a small
secundum atrial septal defect. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is
moderate global left ventricular hypokinesis (LVEF = 35 %). No
masses or thrombi are seen in the left ventricle. The estimated
cardiac index is normal (>=2.5L/min/m2). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) appear minimally thickened with good leaflet
excursion and no aortic regurgitation. The mitral valve leaflets
are mildly thickened. A very small fluttering echodensity is
suggested on the posterior mitral leaflet and coaptation of the
mitral leaflets (clips 13, 14). There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
Compared with the prior study (images reviewed) of [**2166-10-21**],
left ventricular systolic function is now depressed (global),
the mitral leaflets are thickened with a possible vegetation and
mild mitral regurgitation is present. A small secundum type
atrial septal defect is also identified.
If clinically indicated a TEE is suggested to better define the
mitral valve.
==============================================
CHEST (PA & LAT) [**2167-5-20**] 12:03 PM
CHEST (PA & LAT)
Reason: ?pneumonia
[**Hospital 93**] MEDICAL CONDITION:
54 year old man with SCC of head and neck, rigors, bacteremic at
dialysis
REASON FOR THIS EXAMINATION:
?pneumonia
PROCEDURE: Chest PA and lateral on [**2167-5-20**].
COMPARISON: [**2167-4-9**] and [**2167-4-14**] PET/CT scan
examination.
HISTORY: 54-year-old man with squamous cell carcinoma of the
head and neck with vigorous bacteremia dialysis, rule out
pneumonia.
FINDINGS:
New diffuse infiltrates are seen in both right and left lung,
more severe on the right side predominantly in the right upper
and middle lobe. The patient is status post CABG procedure with
multiple well aligned sternotomy wires and surgical clips. The
heart size is top normal. There is no pleural effusion.
IMPRESSION:
1. New bilateral pulmonary infiltrates worrisome for atypical
pneumonia.
RADIOLOGY Final Report
CT CHEST W/O CONTRAST [**2167-5-23**] 2:03 PM
CT CHEST W/O CONTRAST
Reason: ? evidence septic emboli/pneumonia
[**Hospital 93**] MEDICAL CONDITION:
54 year old man with endocarditis, unclear pulm process
REASON FOR THIS EXAMINATION:
? evidence septic emboli/pneumonia
CONTRAINDICATIONS for IV CONTRAST: dialysis
HISTORY: 54-year-old male with endocarditis and unclear
pulmonary process.
COMPARISON: PET CT of [**2167-4-14**].
TECHNIQUE: MDCT axial imaging was performed through the chest
without administration of IV contrast. Multiplanar reformatted
images were essential for study interpretation.
A feeding tube terminates in the pylorus. The patient is status
post CABG and median sternotomy. Diffuse coronary
atherosclerotic calcifications are noted. Mediastinal lymph
nodes are noted, the largest measuring 12 mm in the subcarinal
region. There is no hilar adenopathy. There is no pneumothorax
or pleural effusion. Patchy densities that were seen in the left
lung base on the PET CT of [**2167-4-14**] have improved. Milder
opacities in the right lung base are unchanged. Bullous changes
are again noted particularly in the lung apices. The central
airways are patent. The non-enhanced liver, gallbladder, spleen,
pancreas, stomach, adrenal glands and kidneys, as partially
visualized, are unremarkable. Punctate calcifications are noted
in the spleen which likely represent calcified granulomas.
Extensive calcifications are noted along the abdominal aorta and
along the splenic artery.
No region of bony destruction is seen concerning for malignancy
or infection.
IMPRESSION:
1. Resolving left predominantly lower lobe infiltrate which may
be infectious or inflammatory in nature. Mild patchy opacities
in the right lower lung is unchanged.
2. Mediastinal lymph nodes unchanged.
Brief Hospital Course:
This is 54 a year-old man with Type I dm, CKD stage V and
recently diagnosed squamous cell cancer of head and neck
admitted for multiple complaints.
.
1)Bacteremia/endocarditis
2)Squamous Cell Carcinoma of pharynyx
3)Bilateral pulmonary infiltrates, consistent with aspiration
pneumonia
4)DM1 with complications and poorly controlled
5)CKD stage V on hemodialysis
6)Anemia chronic kidney disease
7)hypertension, well controlled on current medications
8)malnutrition -- at goal on tube feeds
9)hypothyroidism
During hospitalization, pt. had extraction of all teeth, and
surgical placement of gastrostomy tube.
Found to have bacteremia on blood cultures drawn on [**5-15**] at
dialysis center. Staph and strep species. Had been given dose
of vanc [**5-18**] at dialysis. Echo here with vegetation on mitral
valve. Initiated vanc [**5-20**], serial surveillance blood cultures
negative. Afebrile throughout. Planned course for six weeks,
per recommendation of infectious disease team. Dental
extractions performed as presumed source of endocarditis. This
means that course of vancomycin would be completed on [**6-26**].
Plan is 3 weeks of vancomycin prior to initiation of chemo/XRT
to allow appropriate bacteria clearance in addition to adequate
mucosal healing in mouth. Radiation evaluated him for treatment
of squamous cell carcinoma and completed mapping, with plan for
first treatment on [**6-11**]. Rad onc, med/onc, ID involved in
decision. Additionally, pt. will undergo adjuvant chemo with
Erbitux, first administered [**6-5**] at [**Hospital1 18**] with subsequent doses
to be administered after discharge to [**Hospital1 **] with coordination
with Dr. [**First Name (STitle) **] [**Name (STitle) **] ([**Hospital1 18**] oncologist). Please have oncology
staff at [**Hospital1 **] contact Dr. [**Last Name (STitle) **] to discuss. The likely
arrangement is that patient will return to outpatient [**Hospital 478**]
clinic for infusions.
For pulmonary infiltrates, received chest CT on [**5-23**] which
demonstrated interval improvement and no clear evidence of
septic emboli, and initially received azithromycin for coverage
of atypical organisms completed, along with vancomycin, as
above.
On [**5-27**] pt. aspirated after vomiting, and developed a new lll
infiltrate consistent with pneumonitis, and required high flow
oxygen to maintain oxygen sats in the 90s subsequent to this.
He was transfered to the ICU after spiking a fever and with
radiographic evidence of bilateral aspiration pneumonia. His
antibiotics were expanded to vanc/cipro/flagyl. In the ICU, he
remained non-compliant with therapies, required restraint, and
refused hemodialysis. He was sent back to the floor the
following day ([**5-29**]) as his oxygenation improved (90's on two
litres nasal cannula, which he would not keep on, thus requiring
restraint). Olanzapine was started for agitation. His mental
status improved gradually, and by discharge he was no longer
noncompliant or agitated, and per family was near baseline.
Pneumonia was felt to be aspiration, and he completed a seven
day course of cipro/flagyl with radiologic and clinical
improvement. Swallow evaluation [**6-5**] showed silent aspiration
but with counseling and observation he tolerated soft foods and
thin liquids. He was anxious to expand his diet, but was
witnessed to have problems with aspiration when he eats more
solid food.
On [**6-6**], the morning after receiving dexamethasone premedication
for erbitux, he developed severe hyperglycemia, unresponsive to
large doses of SC insulin. He was transferred to the ICU for
management by an insulin drip, and was able to be transferred
back to the general medicine unit on [**6-8**].
Since that time his sugars have remained in relatively good
control, with a bedtime dose of glargine 14 u and insulin by
sliding scale. He continued to receive dialysis which was well
tolerated. His diet was advanced to soft solids and even some
regular food items (chicken pot pie, cheeseburger), with no
observed aspiration. On [**6-11**] he received his first radiation
therapy treatment, with plans to return for daily treatments.
Medications on Admission:
Patient and HCP unsure of medications but say they are the same
as on discharge here in [**Month (only) 547**]. Also got dose of vancomycin at
last dialysis
Meds from last discharge summary:
1. Bupropion 100 mg Tablet Sustained Release [**Month (only) **]: One (1) Tablet
Sustained Release PO QAM (once a day (in the morning)).
Disp:*30 Tablet Sustained Release(s)* Refills:*0*
2. Levothyroxine 88 mcg Tablet [**Month (only) **]: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Clonidine 0.3 mg/24 hr Patch Weekly [**Month (only) **]: One (1) Patch Weekly
Transdermal QFRI (every Friday).
Disp:*4 Patch Weekly(s)* Refills:*0*
4. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
[**Month (only) **]: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0*
5. Lisinopril 20 mg Tablet [**Month (only) **]: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
6. Amlodipine 5 mg Tablet [**Month (only) **]: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
7. B Complex-Vitamin C-Folic Acid 1 mg Capsule [**Month (only) **]: One (1) Cap
PO DAILY (Daily).
Disp:*30 capsules* Refills:*0*
8. Simvastatin 10 mg Tablet [**Month (only) **]: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
9. Omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Month (only) **]: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
10. Insulin Glargine 100 unit/mL Solution [**Month (only) **]: Four (4) Units
Subcutaneous QHS.
Disp:*2 mL* Refills:*0*
11. Insulin Lispro 100 unit/mL Solution [**Month (only) **]: As per sliding
scale (included) Units, insulin Subcutaneous QACHS.
Disp:*10 mL* Refills:*0*
12. Reglan 10 mg Tablet [**Month (only) **]: One (1) Tablet PO QACHS.
Disp:*120 Tablet(s)* Refills:*0*
Discharge Medications:
1. Clonidine 0.3 mg/24 hr Patch Weekly [**Month (only) **]: One (1) Patch Weekly
Transdermal QTUES (every Tuesday).
2. Levothyroxine 88 mcg Tablet [**Month (only) **]: One (1) Tablet PO DAILY
(Daily).
3. Lisinopril 20 mg Tablet [**Month (only) **]: Two (2) Tablet PO DAILY (Daily).
4. Amlodipine 5 mg Tablet [**Month (only) **]: Two (2) Tablet PO DAILY (Daily).
5. B-Complex with Vitamin C Tablet [**Month (only) **]: One (1) Tablet PO
DAILY (Daily).
6. Simvastatin 10 mg Tablet [**Month (only) **]: One (1) Tablet PO DAILY
(Daily).
7. Metoprolol Tartrate 50 mg Tablet [**Month (only) **]: One (1) Tablet PO BID
(2 times a day).
8. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
9. Metoclopramide 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q6H (every
6 hours).
10. Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: One (1)
Injection TID (3 times a day).
11. Bupropion 100 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times
a day).
12. Acetaminophen 160 mg/5 mL Solution [**Last Name (STitle) **]: One (1) PO Q6H
(every 6 hours) as needed for fever or pain.
13. Senna 8.6 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO BID (2 times a day)
as needed.
14. Humalog 100 unit/mL Solution [**Last Name (STitle) **]: Two (2) units Subcutaneous
QAC and QHS: by sliding scale, if BG is 160-200 give 2 units, if
201-240 give 4 units, if 241-280 give 6 units, if 281-320 give 8
units, if 321-360 give 10 units, if 361-400 give 12 units, if
greater than 401 [**Name8 (MD) 138**] MD.
15. Vancomycin 1000 mg IV HD PROTOCOL
to start [**6-8**] and continuing until [**6-26**]
16. Insulin Glargine 100 unit/mL Solution [**Month/Year (2) **]: One (1) 14u
Subcutaneous at bedtime.
Disp:*1 14u* Refills:*2*
17. Insulin Lispro 100 unit/mL Solution [**Month/Year (2) **]: One (1)
Subcutaneous once a day: see sliding scale (as attached
separately).
18. B-Complex with Vitamin C Tablet [**Month/Year (2) **]: One (1) Tablet PO
DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
1. Head and neck cancer (pharyngeal squamous cell carcinoma,
non-operable)
2. Type one diabetes, poorly controlled, with complication
3. Endocarditis with MSSA and streptococcal species most likely
due to poor dentition and resultant bacteremia
4. aspiration pneumonia
5. end stage renal disease on hemodialysis
6. s/p extraction of all teeth due to severe caries and gingival
disease
7. s/p surgical placement of gastrostomy tube
Discharge Condition:
Stable, very cachectic, afebrile, edentulous, G-tube, no
permenent or semi-permanent intravenous access, left arm AV
fistula.
Discharge Instructions:
Return to the [**Hospital1 18**] Emergency Department for:
Fevers over 101 F, altered mental status, erythema or exudate
from G-tube, difficulty breathing, or any other alarming
symptoms.
[**Month (only) 116**] eat soft solids and some solid foods with discretion,
chewing completely.
Followup Instructions:
With Dr. [**Last Name (STitle) **] - call for follow up appointment at: ([**Telephone/Fax (1) 21830**]
With Dr. [**Last Name (STitle) 3929**] - for first XRT treatment on [**2167-6-11**] at [**Hospital1 18**]
([**Telephone/Fax (1) 8082**]) at 9:30 am. Please arrange transport to and
from [**Hospital1 **] for appointment.
With Dr. [**First Name (STitle) 1022**] - call for appointment at [**Telephone/Fax (1) 17794**]
|
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"V45.81",
"244.9",
"585.6",
"250.13",
"305.1",
"369.60",
"285.21"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"43.11",
"24.5",
"23.19",
"99.25",
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] |
icd9pcs
|
[
[
[]
]
] |
16501, 16580
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8305, 12471
|
347, 424
|
17055, 17183
|
3681, 5641
|
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|
2860, 2903
|
14392, 16478
|
6636, 6692
|
16601, 17034
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17207, 17494
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2918, 3662
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234, 309
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6721, 8282
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452, 1786
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1808, 2270
|
2286, 2844
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,520
| 109,130
|
6573
|
Discharge summary
|
report
|
Admission Date: [**2101-7-20**] Discharge Date: [**2101-8-16**]
Date of Birth: [**2021-8-26**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea at rest
Major Surgical or Invasive Procedure:
- [**2101-7-20**] Aortic valve replacement (23mmSt. [**Male First Name (un) 923**] Epic Supra
tissue), and Three Vessel coronary artery bypass grafts(left
internal mammary artery to left anterior descending artery with
saphenous vein grafts to diagonal and PDA)
- [**2101-7-30**] Exploratory laparotomy, Lysis of adhesions, Repair of
enterotomy, Placement of gastrojejunostomy tube
History of Present Illness:
This is a 79 year old white male with known coronary artery
disease and severe aortic stenosis who presented to [**Hospital1 25157**] with decompensated congestive heart failure, a
non STEMI and acute renal insufficiency. After undergoing
extensive evaluation he [**Hospital 25158**] transferred to [**Hospital1 18**] for high
risk cardiac surgical intervention. On admission he remained
extremely short of breath at rest with complaints of 3 pillow
orthopnea and mild pedal edema. He denied chest pain and
syncope. He admitted to a single presyncopal episode several
weeks ago but none since. He remains on a diuretic with only
mild relief in symptoms. Renal function prior to discharge did
improve to a creatinine of 1.0.
Past Medical History:
- Aortic Stenosis, Mitral Regurgitation
- Coronary Artery Disease, Ischemic Cardiomyopathy
- Bare Metal Stent [**2097-12-24**] to Circumflex(Vision Stent)
- Prior Inferior Wall MI [**2084**]
- History of Sustained Ventricular Tachycardia
- AICD/PPM in [**2098-2-22**](Guidant Model T125/Guidant Lead 0158)
- History of TIA/Stroke in [**2088**], s/p TPA therapy
- History of Abd Aortic Aneurysm, - Enodvascular Repair of Abd
Aortic Aneurysm [**2099**]
- History of Acute Renal Failure
- Diverticular Disease, s/p Colectomy
- Anemia
- Varicose Veins
Social History:
Denies smoking tobacco but does chew cigars daily. There is no
history of alcohol abuse, patient drinks one [**Location (un) **] every two
weeks. Patient is a janitor at [**Hospital6 1109**].
Family History:
Denies premature coronary artery disease. Four brothers died of
MI in their 80's.
Physical Exam:
Pulse: 70 Resp: 16 O2 sat: 100%
B/P Right: Left: 117/86
General: Elderly male in no acute distress. Mildly SOB
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade 4/6 SEM
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema [x] 1+
bilaterally
Varicosities: Right GSV varicosed. Left GSV appears OK
Neuro: Grossly intact [x]
Pulses:
Femoral Right: 1 Left: 1
DP Right: 1 Left: 1
PT [**Name (NI) 167**]: 1 Left: 1
Radial Right: 1 Left: 1
Carotid Bruit: soft transmitted murmurs noted
Pertinent Results:
[**2101-7-20**] Intra operative TEE:
PREBYPASS
A left-to-right shunt across the interatrial septum is seen at
rest. A small secundum atrial septal defect is present. The left
ventricular cavity is severely dilated. There is severe regional
left ventricular systolic dysfunction with akinesis of the
inferior and inferoseptal walls and hypokinsesis of the
remaining segments. Overall left ventricular systolic function
is severely depressed (LVEF <20 %). Right ventricular chamber
size is normal. with mild global free wall hypokinesis. The
ascending aorta is mildly dilated. The descending thoracic aorta
is mildly dilated. There are simple atheroma in the descending
thoracic aorta. The aortic valve leaflets are severely
thickened/deformed. There is critical aortic valve stenosis
(valve area <0.8cm2). Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Moderate (2+) mitral
regurgitation is seen.
POSTBYPASS
The patient is receiving epinephrine infusion at 0.05 ucg/kg/min
The LV is marginally improved in the setting of inotropes. RV
function now appears normal. There is a well seated, well
functioning bioprosthesis in the aortic postion. There is trace
perivalvular AI. The MR is now trace to mild.
.
[**2101-7-30**] Postoperative TEE:
The right ventricular cavity is mildly dilated with moderate
global free wall hypokinesis. The ascending, transverse and
descending thoracic aorta are normal in diameter .A
bioprosthetic aortic valve prosthesis is present. No aortic
regurgitation is seen. The mitral valve leaflets are moderately
thickened.Mild to moderate mitral regurgitation present. There
is a small pericardial effusion. LVEF is 20-25% with Global
hypokinesis. Inferior and inferoseptal wall is akinetic. The
septal motion is dyssynchronous.
.
[**2101-7-27**] Flouroscopy:
Uncomplicated ultrasound and fluoroscopically guided
double-lumen
PICC line placement via the right basilic venous approach. Final
internal
length is 37 cm, with the tip positioned in SVC.
.
POSTOP BLOOD WORK:
[**2101-8-15**] WBC-11.0 RBC-2.97* Hgb-8.6* Hct-26.0* RDW-14.9 Plt
Ct-456*
[**2101-8-13**] WBC-10.3 RBC-3.01* Hgb-8.9* Hct-26.1* RDW-14.8 Plt
Ct-364
[**2101-8-11**] WBC-12.9* RBC-2.83* Hgb-8.5* Hct-25.3* RDW-15.0 Plt
Ct-321
[**2101-8-10**] WBC-15.4* RBC-3.06* Hgb-9.1* Hct-27.4* RDW-15.0 Plt
Ct-293
[**2101-8-9**] WBC-17.6* RBC-3.24* Hgb-9.5* Hct-29.7* RDW-15.4 Plt
Ct-303
[**2101-8-8**] WBC-12.7* RBC-3.18* Hgb-9.2* Hct-29.2* RDW-15.3 Plt
Ct-265
[**2101-8-9**] WBC-17.6* RBC-3.24* Hgb-9.5* Hct-29.7* RDW-15.4 Plt
Ct-303
[**2101-8-6**] WBC-12.2* RBC-3.27* Hgb-9.7* Hct-29.7* RDW-15.2 Plt
Ct-207
[**2101-8-3**] WBC-17.4* RBC-3.43* Hgb-10.0* Hct-29.7* RDW-15.1 Plt
Ct-147*
[**2101-8-1**] WBC-31.6*# RBC-3.67* Hgb-10.9* Hct-32.4* RDW-15.0 Plt
Ct-144*
.
[**2101-8-16**] 05:30AM BLOOD PT-17.0* INR(PT)-1.5*
[**2101-8-15**] 10:24AM BLOOD PT-18.7* INR(PT)-1.7*
[**2101-8-14**] 05:54AM BLOOD PT-23.6* INR(PT)-2.2*
[**2101-8-13**] 05:04AM BLOOD PT-28.4* PTT-28.7 INR(PT)-2.7*
[**2101-8-12**] 02:22PM BLOOD PT-32.6* INR(PT)-3.2*
[**2101-8-11**] 05:45AM BLOOD PT-26.9* INR(PT)-2.6*
[**2101-8-10**] 08:15AM BLOOD PT-29.3* INR(PT)-2.8*
[**2101-8-9**] 09:20AM BLOOD PT-32.7* INR(PT)-3.2*
[**2101-8-8**] 06:20AM BLOOD PT-37.4* INR(PT)-3.8*
[**2101-8-7**] 05:10AM BLOOD PT-35.2* PTT-31.3 INR(PT)-3.5*
[**2101-8-6**] 01:41AM BLOOD PT-28.0* PTT-29.7 INR(PT)-2.7*
[**2101-8-5**] 02:20AM BLOOD PT-23.8* PTT-31.4 INR(PT)-2.2*
[**2101-8-4**] 06:26AM BLOOD PT-21.4* PTT-29.6 INR(PT)-2.0*
[**2101-8-3**] 02:02AM BLOOD PT-18.9* PTT-33.2 INR(PT)-1.7*
[**2101-8-1**] 01:47AM BLOOD PT-16.8* PTT-32.3 INR(PT)-1.5*
.
[**2101-8-16**] Glucose-133* UreaN-35* Creat-1.0 Na-139 K-3.9 Cl-102
HCO3-30 [**2101-8-14**] Glucose-97 UreaN-36* Creat-1.1 Na-139 K-3.4
Cl-98 HCO3-35*
[**2101-8-12**] Glucose-134* UreaN-30* Creat-1.1 Na-137 K-4.0 Cl-97
HCO3-37* [**2101-8-10**] Glucose-115* UreaN-30* Creat-1.0 Na-143 K-3.8
Cl-103 HCO3-30 [**2101-8-8**] Glucose-76 UreaN-33* Creat-1.1 Na-148*
K-4.8 Cl-112* HCO3-29 [**2101-8-7**] Glucose-114* UreaN-41* Creat-1.0
Na-147* K-3.3 Cl-109* HCO3-28 [**2101-8-8**] Glucose-76 UreaN-33*
Creat-1.1 Na-148* K-4.8 Cl-112* HCO3-29 [**2101-8-6**] Glucose-108*
UreaN-50* Creat-1.0 Na-150* K-3.5 Cl-111* HCO3-32 [**2101-8-4**]
Glucose-89 UreaN-53* Creat-1.2 Na-150* K-4.0 Cl-111* HCO3-30
[**2101-7-29**] Glucose-143* UreaN-62* Creat-1.5* Na-137 K-3.4 Cl-97
HCO3-27 [**2101-7-27**] Glucose-126* UreaN-82* Creat-1.9* Na-136 K-4.3
Cl-99 HCO3-24 [**2101-7-26**] Glucose-93 UreaN-77* Creat-2.1* Na-138
K-3.4 Cl-99 HCO3-25 [**2101-7-26**] Glucose-164* UreaN-77* Creat-2.4*
Na-135 K-3.7 Cl-96 HCO3-26 [**2101-7-24**] Glucose-119* UreaN-61*
Creat-2.3* Na-130* K-3.9 Cl-95* HCO3-21*
[**2101-7-21**] Glucose-85 UreaN-17 Creat-1.0 Na-141 K-4.3 Cl-111*
HCO3-24
.
[**2101-8-8**] ALT-13 AST-26 LD(LDH)-338* AlkPhos-69 Amylase-117*
TotBili-1.4
[**2101-7-31**] ALT-8 AST-19 AlkPhos-39* TotBili-1.9*
[**2101-7-30**] ALT-18 AST-25 LD(LDH)-305* AlkPhos-71 Amylase-186*
TotBili-1.1
[**2101-7-29**] ALT-20 AST-26 LD(LDH)-280* AlkPhos-75 Amylase-234*
TotBili-1.3
[**2101-7-26**] ALT-15 AST-39 LD(LDH)-283* AlkPhos-72 Amylase-52
TotBili-1.6*
[**2101-7-25**] ALT-10 AST-37 LD(LDH)-299* AlkPhos-55 Amylase-32
TotBili-1.7*
[**2101-7-24**] ALT-9 AST-29 AlkPhos-55 Amylase-40 TotBili-1.7*
.
[**2101-8-16**] Calcium-8.4 Phos-2.7 Mg-2.1
.
Brief Hospital Course:
Mr. [**Known lastname 25159**] was admitted and underwent extensive preoperative
workup. On [**7-20**] he was taken to the Operating Room where he
underwent aortic valve replacement (23-mm St. [**Male First Name (un) 923**] Epic
Supra)and coronary artery bypass grafting x3. See operative note
for details. Post-operatively he was admitted to the CVICU
intubated and sedated on Epinephrine, Neo Synephrine and
Propofol drips. He was weaned from sedation and awoke
neurologically intact and was extubated on POD 1. His internal
pacer was interrogated and found to be working appropriately.
He weaned from Neo Synephrine on POD 1 and then Epinephrione,
but required resumption of the Epinephrine and addition of
Milrinone soon after for sagging hemodynamics ansd cardiac
output. He was reswanned, a Lasix infusion was begun to diurese
the excess fluid. Epinephrine was discontinued on POD 4, along
with the Milrinone. He continued to have marginal cardiac
output and low SVO2. Dobutamine was started at 2.5ug/kg/min
with a prompt improvement. The PA catheter was removed and he
improved gradually and diuresed well so that the Lasix infusion
was stopped. He had a period of atrial fibrillation and was
started on heparin and Coumadin.
He had an ileus with nausea and vomiting and surgery was
consulted on POD 4. He was placed NPO and over a couple of days
had worsening pain, distention and required pressors. Central
hyperalimentation was begun. An exploratory laparotomy was
performed on POD 10. Adhesions were released and a feeding tube
placed. He was extubated on [**2101-8-1**] and covered with Vancomycin,
Cefazolin and Zosyn for his surgical procedure. Trophic tube
feeds were eventually begun and advanced, hyperalimentation was
weaned and discontinued. Pressors were weaned off over that
time, he remained stable and Physical Therapy worked with him.
On [**2101-8-6**] he was transferred to the floor where Physical
Therapy continued to work with him for strength and mobility.
He cotinued to progress slowly. His diet was advanced slowly and
tube feeds were changed to clyclical 110cc/hr 5pm-6am. He
remains on calorie counts and needs encourgement.
He also has had multiple skin issues. Transplant surgery
removed some of the upper staples from his abdominal wound due
to dehisence the area was debrided and wound VAC applied for
period. He was transitioned to wet-dry dressing changes. The
area is approximately [**12-26**] inch deep and appears to be healing
well. The remaining abd wound has intact staples with some mild
lower abd erythemia and moderated serous drainge. He has 3
unroofed blisters on right foot and one large unroofed blister
dorsum of left foot. He has small ulcerated area around old CT
site. GT sutured in place with some surrounding irritation from
sutures. Per surgery his sutures and staples are to remain in
for 4-6weeks. He also has unstageable wound from coccyx to anus.
He has been followed closely by the skin care nurse. Please see
nursing page 1 for further details of wound care.
ACE inhibitor was started but discontinued secondary to
hypotension. He has remained in normal sinus rhythm with stable
BP low at times but asyptomatic. He remains on Amiodarone and
low dose beta blockade. INR was followed closely and titrated
for a goal INR between 2.0 and 2.5. Given his chronic systolic
congestive heart failure, ACE inhibitor should be resumed as an
outpatient when his blood pressure allows.
He has continued to have considerable lower extremity edema and
has been aggressively diuresed. He developed contraction
alkalosis and has been transitioned to oral diuretics for
continued diuresis. He is presently at his preop weight. Given
his heart failure, he should remain on diuretics
He was medically cleared for discharge to [**Hospital **] [**Hospital 1110**] Rehab
on postoperative day 27 for further strengtening, conditioning
and monitoring. Prior to discharge, all follow up appointments
were made with Drs. [**Last Name (STitle) **], [**Name5 (PTitle) **] and [**Name5 (PTitle) 8051**]. Following
discharge from rehab, Dr. [**Last Name (STitle) 8051**] will manage his Warfarin
as an outpatient.
Medications on Admission:
Aspirin 81 qd, Plavix 75 qd, Simvastatin 80 qd, Metoprolol
Succinate 50mg qd, Lasix 30mg qd, Vitamin D
Discharge Medications:
1. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
0.5 Tablet Extended Release 24 hr PO DAILY (Daily): Please hold
for HR less than 60 and/or SBP less than 95mmHg.
6. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day: Take
titrate Warfarin for goal INR between 2.0 - 2.5.
9. potassium chloride 20 mEq Packet Sig: One (1) Packet PO DAILY
(Daily): Please give with Lasix. Hold if K > 4.5.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 1110**]
Discharge Diagnosis:
Chronic Systolic Congestive Heart Failure, Ischemic
Cardiomyopathy
Aortic Stenosis, Coronary Artery Disease - s/p AVR/CABG
Postop partial small bowel obstruction s/p exploratory
laparotomy, lysis of adhesions, with placement of GJ tube
Postop Atrial Fibrillation
Postop Sacral Decubitus Ulcer
Postop Abdominal Wound
History of Inferior Wall MI [**2084**]
Mitral Regurgitation
History of Sustained Ventricular Tachycardia
History of Stroke
Diverticular Disease, prior Colectomy
Anemia
Prior Enodvascular Repair of Abdominal Aortic Aneurysm [**2099**]
s/p AICD/PPM in [**2098-2-22**](Guidant Model T125/Guidant Lead 0158)
s/p Bare Metal Stent [**2097-12-24**] to Circumflex(Vision Stent)
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating with one assist
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage.
Edema: +3 lower ext edema
Abd wound: proximal wound inch open area good granulation
tissue, remaining wound with intact staples, distal abd wound
mild erythema and serous drainage. GT site
erythematous/irritated sutured to skin
Lower ext: 3 unroofed blisters right foot and left large
unroofed blister on dorsum of left foot, no sig erythema or
drainage
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**
.
Labs: PT/INR for Coumadin ?????? indication atrial fibrillaton
Goal INR: 2.0 - 2.5
First draw: [**2101-8-18**]
**Prior to discharge from rehab, please arrange coumadin
followup with Dr. [**Last Name (STitle) 8051**]**
Followup Instructions:
You are scheduled for the following appointments:
Cardiac Surgeon: Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 170**]) on [**2101-9-7**] @ 1:15 PM
PCP/Cardiologist: Dr. [**Last Name (STitle) 8051**] ([**Telephone/Fax (1) 8058**]) on [**2101-8-30**] at
3:15pm
General Surgeon: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 673**]): [**2101-9-1**] at
2:20pm ([**Last Name (NamePattern1) **], [**Location (un) 436**], [**Location (un) 86**], MA)
.
Labs: PT/INR for Coumadin ?????? indication atrial fibrillaton
Goal INR: 2.0 - 2.5
First draw: [**2101-8-18**]
**Prior to discharge from rehab, please arrange coumadin
followup with Dr. [**Last Name (STitle) 8051**]**
.
**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:[**2101-8-16**]
|
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"427.31",
"285.9",
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"412",
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"789.59",
"560.89",
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"707.03",
"263.9",
"414.01",
"428.23",
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"287.5",
"E878.2",
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"276.0",
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icd9cm
|
[
[
[]
]
] |
[
"88.72",
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"96.6",
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icd9pcs
|
[
[
[]
]
] |
13682, 13765
|
8438, 12612
|
326, 710
|
14495, 15064
|
3080, 8415
|
16124, 17032
|
2260, 2344
|
12765, 13659
|
13786, 14474
|
12638, 12742
|
15088, 16101
|
2359, 3061
|
271, 288
|
738, 1464
|
1486, 2035
|
2051, 2244
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,677
| 108,847
|
39816
|
Discharge summary
|
report
|
Admission Date: [**2134-4-5**] Discharge Date: [**2134-4-30**]
Date of Birth: [**2055-2-10**] Sex: M
Service: CARDIOTHORACIC
Allergies:
morphine
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Left heart catheterization, Coronary Catheterization [**2134-4-8**]
Aortic valve replacement (19 St.[**Male First Name (un) 923**] Tissue) [**2134-4-26**]
History of Present Illness:
This 79 year old male who is known to cardiac surgery with
critical aortic stenosis, having refused surgical intervention
in the past, s/p valuloplasy x2 [**2132-10-15**]/[**2133-12-15**],
who was transferred from an OSH for acute chest pain with
troponin bump to 4.4. He initially presented to OSH with 1 week
progressive shortness of breath, orthopnea, paroxysmal nocturnal
dyspnea which are distinct from prior shortness of breath
episodes which were attributed to COPD exacerbations and always
accomopanied by cough and wheezing.
He was transfered to [**Hospital1 18**] for further mangangment of aortic
stenosis. He now agrres to valve replacement being referred to
cardiac surgery for re-evaluation for an aortic valve
replacement.
Past Medical History:
Aortic stenosis
s/pvalvuloplasty [**10/2132**], [**12/2133**]
Coronary artery disease: Myocardial infarction [**2118**],
h/o Congestive heart failureprior estimates in the 50's),
possible diastolic component
Paroxsymal atrial fibrillation
s/p ablation for flutter
Arthritis
h/o Pulmonary embolism
Hypertension
Hyperlipidemia
s/p cervical fusion
s/p partial colectomy for ischemic colitis - Status-post
hypospadias repair
s/p fasciotomy of left lower leg for compartment
syndrome after a [**2118**]
s/p Tonsillectomy
chronic obstructive pulmonary disease
Social History:
Lives with wife, quit smoking a few months ago, 60 pack year
hx prior. No ETOH. No drugs.
Family History:
Family History: father deceased 72 from myocardial infarction,
brother had heart surgery and died of heart disease in the
hospital post-operatively
Physical Exam:
VS: temp98.2, BP152/67, HR68, RR20, O2sat 98%RA
GENERAL: WDWN in NAD. Oriented x2 and easily redirectable to
date. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, prominent arcus senilis,
EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral
mucosa. No xanthalesma.
NECK: Supple with JVP of 5cm.
CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits. left leg with large
linear bandage covering wound on lateral aspect of leg
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: radial 2+ DP 2+ PT 2+
Left: radial2+ DP 1+ PT 1+
Pertinent Results:
ADMISSION
[**2134-4-5**] 08:00PM BLOOD WBC-12.1*# RBC-3.77* Hgb-11.6* Hct-34.7*
MCV-92 MCH-30.8 MCHC-33.5 RDW-14.2 Plt Ct-286#
[**2134-4-5**] 08:00PM BLOOD PT-21.3* PTT-143.1* INR(PT)-2.0*
[**2134-4-5**] 08:00PM BLOOD Glucose-357* UreaN-35* Creat-1.2 Na-136
K-4.3 Cl-95* HCO3-27 AnGap-18
[**2134-4-6**] 10:40AM BLOOD CK(CPK)-238
[**2134-4-5**] 08:00PM BLOOD Calcium-9.6 Phos-5.2* Mg-2.3
.
PERTINENT
[**2134-4-5**] 08:00PM BLOOD CK-MB-22* cTropnT-1.16*
[**2134-4-6**] 10:40AM BLOOD CK-MB-10 MB Indx-4.2 cTropnT-0.86*
[**2134-4-8**] 06:20AM BLOOD proBNP-1376*
[**2134-4-8**] 12:45PM BLOOD %HbA1c-7.4* eAG-166*
[**2134-4-8**] 12:52PM BLOOD Type-ART pO2-90 pCO2-36 pH-7.49*
calTCO2-28 Base XS-4 Intubat-NOT INTUBA
[**2134-4-8**] 12:45PM BLOOD VitB12-732
[**2134-4-8**] 12:45PM BLOOD ALT-14 AST-19 AlkPhos-85 Amylase-29
TotBili-0.5
[**2134-4-6**] 10:40AM BLOOD CK(CPK)-238
.
ECHO [**2134-4-6**]
The left atrium is elongated. A left-to-right shunt across the
interatrial septum is seen at rest c/w a small secundum atrial
septal defect. There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (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. There are three aortic
valve leaflets. The aortic valve leaflets are moderately
thickened. There is severe aortic valve stenosis (valve area 0.8
cm2). Mild (1+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild to moderate ([**2-15**]+) mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
IMPRESSION: Severe aortic valve stenosis. Mild symmetric left
ventricular hypertrophy with preserved global and regional
biventricular systolic function. Mild-moderate mitral
regurgitation. Mild aortic regurgitation. Increased PCWP. Small
secundum type atrial septal defect.
Compared with the prior study of [**2133-12-12**], the severity of
aortic stenosis and the estimated PA systolic pressure, and
severity of mitral regurgitation are now lower. A small secundum
type ASD is now seen.
CLINICAL IMPLICATIONS:
The patient has severe aortic valve stenosis. Based on [**2128**]
ACC/AHA Valvular Heart Disease Guidelines, if the patient is
symptomatic (angina, syncope, CHF) and a surgical candidate,
surgical intervention has been shown to improve survival.
.
CARDIAC CATH [**4-8**]
1. Selective coronary angiography of this co-dominant system
demonstrated 1 vessel coronary artery disease. The LMCA had no
angiographically apparent flow-limiting disease. The LAD had
30%
stenosis . The LCx had 50% stenosis of the OM branch. The RCA
was a
small vessel that was totally occluded at mid-vessel.
2. Resting hemodynamics revealed elevated left-sided filling
pressure
with a PCWP of 18mmHg. There was pulmonary venous hypertension
with a
PA pressure of 42/17mmHg in the setting of an only mildly
elevated PVR.
Cardiac output was decreased at 4.7L/min with an index of
2.6L/min/m2.
3. Selective aortography revealed a calcified aortic root with
no
dilation, patent arch vessels, and patent renal and iliac
arteries with
only mild disease.
FINAL DIAGNOSIS:
1. One vessel coronary artery disease.
2. Elevated left-sided filling pressures with pulmonary venous
hypertension.
3. Non-dilated and calcified aortic root with patent arch
vessel,
renals, and iliac arteries.
.
[**2134-4-28**] 05:20AM BLOOD WBC-10.4 RBC-3.26* Hgb-9.9* Hct-28.7*
MCV-88 MCH-30.4 MCHC-34.5 RDW-16.2* Plt Ct-104*
[**2134-4-28**] 05:20AM BLOOD Glucose-124* UreaN-20 Creat-1.0 Na-137
K-4.2 Cl-102 HCO3-27 AnGap-12
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2134-4-5**] for further
management of his chest pain. Heparin was continued and a
cardiac catheterization was obtained which showed single,
non-occlusive coronary artery disease. An echocardiogram showed
severe aortic stenosis with a normal ejection fraction. (Please
see full report for details.) Given the severity of his disease
and the fact that he has had 2 recent failed valvuloplasty's,
the cardiac surgical service was consulted.
He was worked-up in the usual preoperative manner including a
cartotid duplex ultrasound which showed a <40% stenosis on the
right and a 40-59% stenosis on the left. Pulmonary function
testing was obtained which showed an FEV1 of 1.25L and a
diffusion capacity adjusted for hemoglobin to be 58%. As he had
urinary retention and a worsening renal function
([**2-15**]->1.7->1.2), a renal ultrasound was obtained which was
normal. A nephrology consult was obtained which suspected he
sustained an acute renal injury secondary to to Bactrim. Over
the next few days, his renal function slowly improved.
On [**2134-4-26**], he was taken to the Operating Room where he
underwent an aortic valve replacement using a 19mm St. [**Male First Name (un) 923**]
tissue prosthesis. Please see operative note for details.
Postoperatively he was taken to the intensive care unit for
monitoring. He was slowly weaned from pressors. On postoperative
day one, he awoke neurologically intact and was extubated. On
postoperative day two, he was transferred to the step down unit
for further recovery. He was gently diuresed towards his
preoperative weight.
The Physical Therapy service was consulted for assistance with
his postoperative strength and mobility. Coumadin was resumed
for paroxysmal atrial fibrillation. He continued to have
paroxysmal atrial fibrillation, Insulin was titrated for glucose
control and beta blockers adjusted when he became hypotensive to
the 80s, although he remained assymptomatic.
He remains 12kg above his preoperative weight, with significant
edema and will continue on twice daily Lasix at discharge. This
will need to be titrated at rehab as he diuresis. He was in
sinus rhythm on [**4-29**] at am rounds.
\
He was transferred to the [**Location (un) 11252**] Center for Rehab in [**Location (un) 11252**],
[**Location (un) 3844**] for further recovery on [**2134-4-30**].No Coumadin today
as INR 4.3.
Medications on Admission:
`1. Humulin N insulin 12units [**Hospital1 **] (before breakfast and before
supper)
2. Novolog insulin 8 units [**Hospital1 **] (before breakfast and before
supper)
3. aspirin 325mg QD
4. lisinopril 40mg QDAY
5. Lasix 40mg QDAY
6. Ranitidine 150mg QDAY
7. Metoprolol 25mg [**Hospital1 **]
8. Norflex 100mg [**Hospital1 **]
9. Simvastatin 40mg QDAY
10. Coumadin 2.5mg X6 days/week, 5mg wednesdays
11. Ventolin daily prn sob
12. Atrovent daily prn sob
.
transfer meds:
Albuterol + ipratropium nebs PRN
Aspirin 325mg QD
IV Furosamide 40mg [**Hospital1 **]
Insulin lispro
Discharge Medications:
1. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Atrovent HFA 17 mcg/actuation HFA Aerosol Inhaler Sig: One
(1) Inhalation every six (6) hours as needed for shortness of
breath or wheezing.
4. Ventolin HFA 90 mcg/actuation HFA Aerosol Inhaler Sig: [**2-15**]
puffs Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
5. simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
6. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain, fever.
8. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
9. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. warfarin 1 mg Tablet Sig: as directed Tablet PO once a day:
INR 2-2.5.
11. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain for 4 weeks.
Disp:*50 Tablet(s)* Refills:*0*
12. fluticasone-salmeterol 100-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
13. Lasix 80 mg Tablet Sig: One (1) Tablet PO twice a day for 2
weeks.
14. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO twice a day for 2
weeks.
15. Humulin N 100 unit/mL Suspension Sig: Twelve (12) units
Subcutaneous twice a day.
16. Novolog 100 unit/mL Solution Sig: Eight (8) units
Subcutaneous twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 11252**]
Discharge Diagnosis:
s/p aortic valve replacement
chronic obstructive pulmonary disease
s/p aortic valvuloplasty x 2
s/p atrial dysrhythmia ablation-unsuccessful
s/p laparotomy for ischemic colon with resection
h/o remote pulmonary embolism
coronary artery disease
hypertension
hyperlipidemia
benign prostatic hypertrophy
aortic stenosis
insulin dependent diabetes mellitus
paroxysmal atrial fibrillation
congestive heart failure
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: 1+
Discharge Instructions:
1) Please shower daily including washing incisions gently with
mild soap, no baths or swimming until cleared by surgeon. Look
at your incisions daily for redness or drainage.
2) Please NO lotions, cream, powder, or ointments to incisions.
3) Each morning you should weigh yourself and then in the
evening take your temperature, these should be written down on
the chart provided.
4) No driving for approximately one month and while taking
narcotics. Driving will be discussed at follow up appointment
with surgeon when you will likely be cleared to drive.
5) No lifting more than 10 pounds for 10 weeks
6) Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 170**]) on [**2134-6-2**] at1:15pm
Cardiologist: Dr. [**Last Name (STitle) 11250**] ([**Telephone/Fax (1) 11254**]) on [**2134-5-17**] at 8am
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication atrial fibrillation
Goal INR 2-2.5
First draw day after transfer
Dr. [**Last Name (STitle) 11250**] ([**Telephone/Fax (1) 11254**]) will manage Coumadin after rehab
discharge
Completed by:[**2134-4-30**]
|
[
"412",
"414.8",
"V70.7",
"428.0",
"250.00",
"E934.2",
"600.01",
"599.0",
"276.1",
"416.8",
"496",
"255.42",
"410.71",
"041.12",
"287.5",
"424.1",
"403.90",
"E931.0",
"530.81",
"285.9",
"585.3",
"V58.61",
"580.89",
"440.0",
"788.20",
"427.31",
"V58.67"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.42",
"88.56",
"88.47",
"35.21",
"37.21",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
11441, 11493
|
6737, 9171
|
294, 451
|
11947, 12123
|
2981, 5216
|
13012, 13679
|
1940, 2073
|
9789, 11418
|
11514, 11926
|
9197, 9766
|
6285, 6714
|
12147, 12989
|
2088, 2962
|
5239, 6268
|
235, 256
|
479, 1221
|
1243, 1798
|
1814, 1908
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,041
| 191,839
|
25149
|
Discharge summary
|
report
|
Admission Date: [**2166-10-10**] Discharge Date: [**2166-10-17**]
Date of Birth: [**2122-8-5**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
none this admisssion
History of Present Illness:
HPI: 44 y/o female found down in water for unknown amount of
time
after an [**9-10**] ft. Found at bottom of cliff wedged between rocks
unknown mechanism in [**Location (un) 50240**], MA. Per EMT report pt was found
with GCS of [**8-9**], cold hypotensive in 80's with occassional eye
opening, was found by a stranger. She was intubated at the
scene
Past Medical History:
ROS: Pt Intubated and sedated
PMH: Chronically low BP
PSH: None
Social History:
SH: Pt is a minister lives in [**State 3914**] with husband and children
was on retreat to [**Location (un) 50240**], MA
Family History:
not obtained
Physical Exam:
PE: Vitals: 96.4 Rectal, P 45 BP 138/56, 15 100%
Examined off sedation for was paralyed
HEENT:
Chest: clear bilaterally
CV: RRR S1 S2
ABD: soft non tender report from ER Fast -
Neuro: Examined on off Propathol for 20 minutes, pt is
intubated
PERRLA [**5-4**] brisk
Moves all extremeties very strongly spontaneously and withdraws
to pain
Opens eyes to voice does not track
Pertinent Results:
[**2166-10-10**] 05:00PM WBC-7.6 RBC-3.81* HGB-12.7 HCT-37.4 MCV-98
MCH-33.4* MCHC-34.0 RDW-12.8
[**2166-10-10**] 05:00PM PLT COUNT-162
[**2166-10-10**] 05:00PM PT-13.1 PTT-23.7 INR(PT)-1.1
[**2166-10-10**] 05:00PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.018
[**2166-10-10**] 05:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2166-10-10**] 05:16PM GLUCOSE-123* LACTATE-1.7 NA+-141 K+-4.0
CL--107 TCO2-25
[**2166-10-10**] 05:00PM UREA N-12 CREAT-0.9
[**2166-10-10**] 05:00PM AMYLASE-48: Non-contrast head CT.
FINDINGS: There has been slight interval evolution of the
previously identified scattered peripheral intraparenchymal
hemorrhages, most pronounced in the inferior temporal lobes.
There is also slight increase conspicuously of subarachnoid
hemorrhage in the left frontal lobe as well as a lesser degree
in the right frontal lobe. No other areas of hemorrhage are
identified. There remains no shift of normally midline
structures or mass effect. The appearance of the brain
parenchyma is otherwise unchanged. The osseous structures and
paranasal sinuses are unchanged in short interval.
IMPRESSION:
1. Slight interval evolution of previously identified
intraparenchymal hemorrhages and slight increase conspicuously
of bilateral frontal subarachnoid hemorrhage.
2. No new areas of hemorrhage identified.
Brief Hospital Course:
Pt was admitted to the trauma ICU for close monitoring. She was
sedated but had neuro checks q1h off meds. Repeat Head CTs were
stable. She was able to be extubated [**10-13**]. She did spike fevers
and was found to have an aspiration pneumonia and started on
antibiotics. She was transferred to the floor on [**10-14**]. She
improved neurologically but continued to have problems with
memory. She underwent swallowing study which found her able to
tolerate regular diet. Her foley was removed. Trauma service
cleared her c-spine after negative CT and her collar was
removed.
Her CBC showed a hematocrit of 32.4, a anemia panel was sent
showing a cal TIBC 215, B12 516 Folate of 6.0 and TRF of 165.
These numbers were felt to be related to her traumatic injury
and pneumonia and not any chronic process.
She was evaluated by PT and OT felt she would benefit from acute
inpatient physical and cognitive rehab.
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection every twelve (12) hours.
4. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day): Last dose 9/21.
5. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours): Last dose 9/21.
6. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**First Name8 (NamePattern2) 7635**] [**Last Name (NamePattern1) **] Rehab
Discharge Diagnosis:
Traumatice brain injury
Discharge Condition:
Neurologically stable
Discharge Instructions:
Watch for any signs of neurological change.
Remove suture in head on Monday [**10-21**]
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **] and Head CT in [**7-9**] weeks - call
[**Telephone/Fax (1) 2731**] for appt.
Completed by:[**2166-10-17**]
|
[
"E884.1",
"803.36",
"507.0",
"458.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
4544, 4646
|
2830, 3745
|
325, 348
|
4714, 4738
|
1390, 2807
|
4874, 5028
|
968, 982
|
3800, 4521
|
4667, 4693
|
3771, 3777
|
4762, 4851
|
997, 1371
|
281, 287
|
376, 727
|
749, 814
|
830, 952
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,300
| 113,852
|
4906
|
Discharge summary
|
report
|
Admission Date: [**2164-8-25**] Discharge Date: [**2164-8-28**]
Date of Birth: [**2085-5-29**] Sex: M
Service: MEDICINE
Allergies:
Lopressor / Lisinopril
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
facial swelling/laryngeal edema
Major Surgical or Invasive Procedure:
Endotrachial Intubation
History of Present Illness:
See MICU [**Location (un) **] note from [**8-26**] for full details. Briefly this is
a 79yo patient with PMH significant for HTN, CAD, s/p CABG being
transferred from the ICU for probable angioedema after taking
lisinopril.
.
Patient had been giving script for lisinopril a while back but
only started taking it on Friday [**8-24**] AM. He started to feel his
lips, tongue and face swelling and it progressivly worsened to
include his throat. He was admitted to the ICU and was intubated
and sedated. ENT saw patient and recommended keeping tube in
place. However, patient self-extubated overnight and actually
remained stable. His condition improved and he was transferred
to the floor for further care.
.
On arrival to the medical floor, patient was stable. Vital
signs- T 96.5, HR 74, BP 125/64, R 14, satting 100% on 4L. No
complaints except for some facial swelling but reduced from
admission. Denied any shortness of breath, chest pain,
headaches, dizziness. Doing well, comfortable.
Past Medical History:
-HTN
-Psoriasis
-Hypercholesterolemia
-CKD, baseline Cr 2.6
-CAD s/p MI([**2135**]) s/p Cardiac Stress Test([**5-20**]: Mild Reversible
Ischemic Changes), s/p Cath([**2-21**]: 1 vessel disease, No stenting
required), Chronic Stable Angina
-Cardiomyopathy, EF 50% 2/09
-Mild Dementia (short term memory impairment)
-Gout
-BPH
-Eczema
-s/p L hip fx s/p hemiarthroscopy [**3-/2164**]
Social History:
NA
Family History:
NA
Physical Exam:
General: Intubated, sedated
HEENT:Conjunctiva injected. Pupils symmetric, constrict equally
to light. Lip swelling. Intubated, OGT in place.
Neck: supple. No bruit.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Bradycardic rate, regular rhythm, normal S1 + S2, no
murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: No rashes, hives.
Pertinent Results:
[**2164-8-26**] 03:03AM BLOOD WBC-15.8*# RBC-3.50* Hgb-10.6* Hct-31.2*
MCV-89 MCH-30.4 MCHC-34.0 RDW-13.3 Plt Ct-336
[**2164-8-25**] 09:00AM BLOOD WBC-8.1 RBC-3.68* Hgb-11.2* Hct-33.4*
MCV-91 MCH-30.3 MCHC-33.4 RDW-13.1 Plt Ct-313
[**2164-8-25**] 09:00AM BLOOD Neuts-91.2* Lymphs-7.7* Monos-0.9*
Eos-0.2 Baso-0.1
[**2164-8-26**] 03:03AM BLOOD PT-12.0 PTT-23.5 INR(PT)-1.0
[**2164-8-26**] 03:03AM BLOOD Glucose-168* UreaN-65* Creat-2.8* Na-143
K-4.9 Cl-115* HCO3-18* AnGap-15
[**2164-8-26**] 03:03AM BLOOD Calcium-9.0 Phos-5.0* Mg-2.3
Brief Hospital Course:
79yo male admitted to ICU for probable angioedema due to
lisinopril injestion.
1. Angioedema
Pt was admitted to the ICU and was intubated and sedated. He
was also started on IV steroids, H2 blockers, and benadryl. ENT
saw patient and recommended keeping 6 mm tube in place.
However, patient self-extubated overnight and actually remained
stable. His condition improved and he was transferred to the
floor for further care on [**2164-8-26**]. He was initially on 4L NC
and satting in high 90s and this was quickly weaned. He
experienced some soreness of the throat and had a difficult time
swallowing pills at first. ENT saw him and thought this was due
to trauma from the ET tube and not lingering angioedema. As his
angioedema improved he was able to tollerate first thick
liquids, then a regular diet. He was switched to PO steroids
with a 7 day taper starting on [**8-27**].
2. Acute on chronic kidney injury - baseline 2.6. creatinine was
3.2 on admission but this trended back down to 2.4 by D/C.
Allopurinol was held in the ICU given Cr bump.
3. HTN- Antihypertensives were held in ICU but amlodipine was
restarted once stable on the medicine floor.
4. CHF. Known EF [**3-26**] 50% with mild reduced systolic function.
Appeared euvolemic on exam.
5. CAD
-held ASA as above
-continued simvastatin
Medications on Admission:
Amlodipine 2.5mg PO daily
Aspirin 325mg PO daily
Furosemide 20mg daily
Lisinopril 40mg daily
Oxybutinin 5mg daily
Simvastatin 80mg daily
Allopur. inol 100mg daily
eucerin cream
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Angioedema
Secondary Diagnosis: Hypertension
Chronic Kidney Disease
Discharge Condition:
Good. Vital Signs stable
Discharge Instructions:
You were admitted to the hospital for swelling in your face and
throat after you took lisinopril. You were taken to the ICU
because the swelling in your neck gave you difficulty breathing.
After one night in the ICU you actually pulled out your
breathing tube but did well without it. You remained stable the
next day and was transferred to the regular medicine floor on
[**8-26**], where you remained stable. You initially had trouble
swallowing pills and food but this has gotten better and you are
now able to swallow food. Your facial swelling has also
decreased.
We have scheduled follow up appointments with your primary care
doctor and the allergy Dr. [**Last Name (STitle) 357**] go to your scheduled
appointments. You were also prescribed prednisone, famotidine,
and fexofenadine to decrease residual swelling. Please take the
prednisone as follows: 6 tablets on day one, 5 tablets on day
two, 4 tablets on day three, 3 tablets on day four, 2 tablets on
day five, 1 tablet on day six, and 1 tablet on day seven.
Please return to the hospital or call your doctor if you have
worsening throat/facial swelling, hives or skin rash, or any
other symptoms that concern you.
Followup Instructions:
Please make a follow-up appointment with your primary care
doctor, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], within the next two weeks. His
office phone number is: ([**Telephone/Fax (1) 12871**]
Allergist [**Last Name (LF) **],[**Name8 (MD) **] MD ([**Telephone/Fax (1) 14583**]
Tuesday [**10-2**], 9 am
1 [**Location (un) **] pl [**Apartment Address(1) 20447**]
|
[
"E942.9",
"414.00",
"425.4",
"428.0",
"403.90",
"V45.81",
"995.1",
"V58.66",
"585.9",
"696.1",
"584.9",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
4464, 4470
|
2919, 4236
|
314, 339
|
4604, 4631
|
2361, 2896
|
5866, 6264
|
1800, 1804
|
4491, 4491
|
4262, 4441
|
4655, 5843
|
1819, 2342
|
243, 276
|
367, 1359
|
4545, 4583
|
4511, 4523
|
1381, 1763
|
1779, 1784
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,754
| 105,986
|
10136
|
Discharge summary
|
report
|
Admission Date: [**2174-2-21**] Discharge Date: [**2174-3-8**]
Date of Birth: [**2095-6-18**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6346**]
Chief Complaint:
Abdominal Distention
Nausea and vomiting for 5 days
Anorexia
Major Surgical or Invasive Procedure:
Repair Incarcerated Right Femoral Hernia with Mesh
History of Present Illness:
78F with Crohn's disease recently started on 6-MP with 5-day
history of nausea, anorexia, fatigue, and abdominal distention
Past Medical History:
Crohn's colitis (last colonoscopy 5 yrs ago)
s/p Nephrectomy
?hx of hemmoroids, anal stricture
s/p Mastectomy
HTN
Osteoporosis
Hyperlipidemia
Social History:
Lives with daughter and son; denies tobacco/alcohol/IVDA
Family History:
Family History: Non-contributory
Physical Exam:
Admission Physical Exam - [**2174-2-21**]
98.0 115 113/65 16 96%
AOx3, nontoxic. MM dry.
Tachy
CTAB
Soft, (+)distention, nontender, no peritoneal signs, guaiac (-),
right groin lump nonreduceable, mild tenderness, no erythema
No CCE
Pertinent Results:
Admission Labs
-------------------
[**2174-2-21**] 11:45AM BLOOD WBC-6.2# RBC-2.94* Hgb-11.0* Hct-30.6*
MCV-104* MCH-37.5* MCHC-36.0* RDW-22.6* Plt Ct-478*#
[**2174-2-21**] 11:45AM BLOOD Neuts-71* Bands-16* Lymphs-4* Monos-9
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2174-2-21**] 11:45AM BLOOD Hypochr-NORMAL Anisocy-2+
Poiklo-OCCASIONAL Macrocy-2+ Microcy-OCCASIONAL Polychr-1+ Tear
Dr[**Last Name (STitle) 833**]
[**2174-2-21**] 11:45AM BLOOD Plt Ct-478*#
[**2174-2-21**] 11:45AM BLOOD Glucose-116* UreaN-37* Creat-1.2* Na-131*
K-4.8 Cl-87* HCO3-25 AnGap-24*
[**2174-2-21**] 11:45AM BLOOD ALT-12 AST-29 CK(CPK)-67 AlkPhos-53
Amylase-95 TotBili-0.8
[**2174-2-22**] 06:25AM BLOOD Albumin-3.1* Calcium-9.8 Phos-3.8#
Mg-2.9*
[**2174-2-22**] 06:25AM BLOOD Triglyc-78
[**2174-3-1**] 05:45AM BLOOD TSH-2.7
[**2174-2-21**] 03:13PM BLOOD Lactate-1.1
Discharge Labs
-------------------
[**3-8**]: Hct 25.4
[**3-7**]: BUN 29; Creat 0.6
OPERATIVE REPORT
Name: [**Known lastname **], [**Known firstname **] C Unit No: [**Numeric Identifier 33862**]
Service: [**Last Name (un) **] Date: [**2174-2-21**]
Date of Birth: [**2095-6-18**] Sex: F
Surgeon: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD 2915
ASSISTANTS: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3446**], MD
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD
PREOPERATIVE DIAGNOSIS: Incarcerated right femoral hernia.
with small bowel obstruction
POSTOPERATIVE DIAGNOSIS: Incarcerated right femoral hernia
with bowel obstruction.
ANESTHESIA: General endotracheal anesthesia with 20 cc of
0.5% Marcaine.
IV FLUIDS: 400 cc.
ESTIMATED BLOOD LOSS: Minimal.
URINE OUTPUT: 600 cc.
INDICATIONS: [**Known firstname **] is a 78-year-old female, with a history of
Crohn's disease and multiple surgeries, who presented with
nausea
and vomiting for 5 days. She was evaluated by the emergency
medical staff, a CT scan was performed that showed a small bowel
obstruction. A general surgery consult was obtained. On exam,
she
had a lump in her right groin consistent with an incarcerated
hernia, and the CT scan was reviewed and this was clearly the
transition point of the bowel obstruction.
She was diagnosed with incarcerated, possibly strangulated right
femoral hernia. Risks and benefits of the procedure were
discussed with her, and she signed a surgical consent to
proceed with repair and possible bowel resection if necessary.
PREPARATION: The patient was given intravenous antibiotics,
subcutaneous heparin, and taken to the operating room and
placed in a supine position. Venodyne boots were placed and
activated. The patient was then endotracheally intubated in
normal fashion. A nasogastric tube and Foley catheter had
previously been placed.
PROCEDURE IN DETAIL: A transverse incision was made
overlying the palpable lump with a #10 blade scalpel.
Dissection through the subcutaneous tissue performed with
electrocautery. The Scarpa's layer was divided. The lump was
circumscribed with right angle dissection and electrocautery.
The
peritoneal cavity was opened at the hernia sac with
electrocautery dissection. Serous fluid came out the opening..
There was dusky bowel within the hernia sac. The
femoral hernia defect was widened with blunt dissection and then
the bowel was delivered further through the defect and it pinked
up and was clearly viable. The bowel was reduced back in the
abdominal cavity. The hernia sac was then closed with a running
2-0 Vicryl suture. The sac was reduced, and preperitoneal space
was developed with gentle blunt dissection. A preformed mesh
was
then placed into the defect and sutured in all quadrants with
2-0
Prolene sutures. The wound was irrigated with sterile saline
and small bleeders were controled with electrocautery.
The subcutaneous tissues were reapproximated with 2-0 Vicryl
suture. The skin was reapproximated with a running 4-0
Monocryl subcuticular suture. Steri-Strips and a sterile
occlusive dressing were placed over the wound. The patient
was then extubated in the operating room and transferred to
the post anesthesia care unit in stable condition.
SPECIMEN TO PATHOLOGY: None.
FINDINGS: Incarcerated right femoral hernia with small bowel
without strangulation.
COUNTS: Correct x2 prior to closure.
I, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2819**], was present for the entire procedure
per
HCFA regulations.
PORTABLE DUPLEX DOPPLER ULTRASOUND OF THE RIGHT GROIN AND RIGHT
DEEP HEMIPELVIS
CLINICAL INDICATION: 78-year-old woman with retroperitoneal
bleed and question of pseudoaneurysm on recent CT scan.
Color flow and pulse Doppler imaging of the common femoral
artery and distally show normal wall-to-wall flow and normal
pulse Doppler waveforms. No hematoma or extravasation was seen
in the thigh. Calcification was noted in the wall of the common
femoral artery. Imaging was then carried higher up to the
external iliac artery into the floor of the pelvis. Several
small tortuous branches were seen extending from the iliac
artery into the pelvic floor, but all of these appear to show
normal albeit tortuous branching patterns. There was no
definable pseudoaneurysm identified. The imaging was performed
extensively through the region of the pelvic wall hematoma.
CONCLUSION: Patent vasculature from the external iliac through
common femoral artery and branches. No pseudoaneurysm identified
around the large pelvic wall hematoma.
CT OF THE ABDOMEN WITH AND WITHOUT IV CONTRAST
There are small bilateral low-density pleural effusions,
slightly larger than before, with associated bibasilar
atelectasis. Otherwise, the visualized lung bases are clear. No
focal hepatic lesions are identified. Small calcified dependent
gallstones are noted within the gallbladder.
There is a small cystic lesion within or along the neck of the
pancreas, which measures 12 x 11 mm in axial dimensions, and is
unchanged since the earliest study available, which is a CT of
the lumbar spine from [**2173-7-22**]. On more recent scans, it is
difficult to visualize because of the presence of adjacent
ascites and edema. There is no biliary or pancreatic ductal
dilatation. Otherwise, the pancreas is unremarkable. There are
diffuse splenic arterial calcifications, as well as
calcifications in the aorta and common iliac arteries and their
major branches.
The adrenal glands and spleen are unremarkable. The patient is
status post left nephrectomy. There is new mild-to-moderate
hydronephrosis of the right kidney. Of note, small-bowel
obstruction has resolved.
The post-operative appearance of the stomach, small and large
bowel is unremarkable. There is persistent slight herniation of
non-obstructed bowel into the upper portion of the right femoral
tunnel. Residual contrast is present within the colon from a
prior recent CT.
There is no free air or lymphadenopathy. There is, however, mild
ascites and edematous change throughout the mesenteric fat, with
edema also demonstrated diffusely within the subcutaneous soft
tissues. This appearance suggests volume overload or an
edematous state.
CT OF THE PELVIS WITH IV CONTRAST: There is a new large acute
hematoma in the right lower pelvis, which measures 8.9 x 5.2 cm
in maximum axial dimensions, and extends superiorly along the
right pelvic side wall.
Extending from the posteromedial aspect of the right common
femoral artery, and coursing medially anterior to the
acetabulum, is a small arterial branch, which may represent the
right epigastric artery or another small arterial branch.
Along the anteromedial edge of the acetabulum and adjacent to
the large hematoma, there is an 8-mm diameter focus of nodular
arterial contrast, which collects and exhibits a round
configuration of 13 mm in diameter on delayed- phase imaging at
three minutes. This appearance is most consistent with a
pseudoaneurysm with associated large recent hemorrhage into the
pelvis. There is also a separate hematoma in the subcutaneous
tissues overlying the right lower anterior pelvis, measuring 5.1
x 2.3 cm in axial dimensions.
There is distal right hydroureter up to 13 mm with apparent
ureteral obstruction by the large pelvic hematoma, which also
displaces the bladder and rectum toward the left.
There are uterine calcifications, probably related fibroids.
There is also unchanged symmetric rectal thickening with a
metallic device in the pelvis that may represent a pessary. A
Foley catheter is present within the bladder.
There is atherosclerotic change but no abdominal aortic
aneurysm. The right common iliac is ectatic and measures up to
19 mm in diameter. The left common iliac shows a maximum
diameter of 17 mm immediately prior to the left iliac
bifurcation.
BONE WINDOWS: There are no suspicious lytic or blastic lesions.
IMPRESSION:
1. Hematoma in the right pelvis associated with nodular contrast
collection most consistent with a pseudoaneurysm. This is
situated immediately anteromedial to the right acetabulum. A
supplying artery to the pseudoaneurysm is noted, which emanates
from the medial right common femoral artery and courses along
anterior to the acetabulum to the pseudoaneurysm possibly
representing the inferior epigastric artery.
2. New right-sided hydronephrosis associated with obstruction by
the pelvic hematoma.
3. Unchanged cystic lesion in the neck of the pancreas, with
stability demonstrated retrospectively since 6-[**2173**]. The
differential diagnosis includes a pseudocyst or low-grade
neoplasm such as an intraductal papillary mucinous neoplasm
(IPMN). Although stable over six months, continued CT followup
could be helpful to ensure stability within one year.
4. Bilateral pleural effusions, mild ascites, and diffuse edema,
which likely relates to volume overload or an edematous state.
5. Resolution of small-bowel obstruction.
6. Similar rectal wall thickening.
The presence of acute hematoma and a pseudoaneurysm were
discussed with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 33863**] from Surgery shortly after the
study.
RENAL ULTRASOUND
------------------
The left kidney is surgically absent and bowel loops fill the
left renal fossa. The right kidney measures 12.5 cm and
demonstrates moderate hydronephrosis and distention of its
extrarenal pelvis. The proximal right ureter is dilated to 11
mm. The mid and distal ureter cannot be visualized. There is no
evidence of stones or solid mass. The cortex is preserved. A
small amount of ascites is noted around the liver and in
Morison's pouch. The urinary bladder contains a Foley catheter
and is empty.
IMPRESSION: Moderate right hydronephrosis.
Brief Hospital Course:
[**Known firstname **] [**Known lastname 7931**] was evaluated in the emergency department at [**Hospital1 18**] on
[**2174-2-21**]. An abdominal CT scan showed small bowel obstruction
and rectal thickening. Urine was positive for infection. She was
made NPO and IV fluids were started. She was evaluated and
admitted to the surgery service under the care of Dr. [**First Name (STitle) 2819**]. An
ECHO was performed which showed normal LVEF and mild TR/AI.
Cipro was started for UTI. A nasogastric tube was placed for
bowel decompression, with a one liter return of feculent
material. The CT scan was reread and showed a right femoral
hernia with right groin bulge on exam. She was taken to the
operating room where she underwent a right femoral hernia repair
with mesh. She tolerated the procedure well and was returned to
the floor after recovery in the PACU.
At POD 1 a PICC line was placed and TPN was started.
At POD 2 she remained NPO and with NGT. There was some bloody
drainage from the NGT for which was attributed to mucosal
irritation and Protonix was started with improvement. She
exhibited signs of postoperative delirium. Haldol and a sitter
were provided. No neurological deficits were noted. The urinary
catheter was discontinued in the evening.
At POD 3 she remained with confusion. Geriatrics was consulted
for recommendations. Her abdomen was distended and tender. A
catheter was inserted for 800mls of urine. She was transfused
one unit PRBCs for a Hct of 23 to prevent end organ ischemia.
Narcotics were minimized and low-dose Haldol was continued. She
continued on TPN for nutritional support.
At POD 6 she was afebrile and doing well. Her delirium/confusion
had resolved. She was (+) flatus. The NGT was removed and the
diet was advanced to sips.
At POD 7 she had a short run of asymptomatic vtach.
Electrolytes were stable and cardiac enzymes were negative x 3.
Urine was negative for infection. The foley was discontinued.
She had difficulty voiding later in the day and was I/O
catheterized for 500ml. A urine culture was sent and was
negative. A KUB was performed which showed no evidence of
obstruction. There was a lot of stool in the colon. Cathartics
were given with response.
At POD 8 Her diet was advanced and medications were
transitioned to PO. Crohn's medications were restarted. She was
afebrile and her pain was controlled. She voided spontaneously.
She was given 1 unit PRBCs for a Hct of 24.3
At POD 9 a recheck of her Hct after transfusion showed 18.8.
She was transferred to the ICU. Urinary catheter was replaced
and she was transfused with good response. There was a large
area of ecchymosis at the right flank and abdomen. CT was
completed which showed a hematoma in the right pelvis with right
hydronephrosis. There was suspect for pseudoaneurysm at the
right femoral artery. Vascular surgery was consulted. Vascular
ultrasound showed no aneurysm.
At POD 11 she was doing well. The bleeding had stopped and
serial Hcts were stable. She was tolerating a regular diet.
She was transferred back to the floor. Urology was consulted
regarding urinary retention and hydronephrosis.
At POD 15 she was discharged to rehab in good condition. She
was afebrile, tolerating a regular diet, and had full return of
bowel function. Her wound was healing nicely and without signs
of infection. She was to continue with the urinary catheter x 2
weeks. The VNA could then attempt to remove the catheter if
voiding trials are passed. She is to have weekly Hct and
Creatinine drawn. She is to have a CT scan completed to
evaluate the hydronephrosis in ~4 weeks and then follow up with
Dr. [**First Name (STitle) **]. She is to follow up with Dr. [**First Name (STitle) 2819**] in [**2-1**] weeks.
Medications on Admission:
Prednisone 15'
Sulfasalazine
6-MP 50'
Boniva
Vit C
Calcium
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
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:*2*
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours) as
needed for gastritis.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. PredniSONE 5 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily)
as needed for crohn's.
Disp:*90 Tablet(s)* Refills:*0*
5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2)
Tablet, Chewable PO TID (3 times a day).
Disp:*180 Tablet, Chewable(s)* Refills:*0*
7. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*0*
8. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
[**Hospital1 **] (2 times a day) as needed for constipation.
Disp:*20 Suppository(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
Annmark Nursing
Discharge Diagnosis:
Reduction of a strangulated right femoral hernia
Post-op delerium
Post-op urinary retention
Post-op retroperitoneal bleeding
Acute on chronic blood loss anemia requiring transfusion
Discharge Condition:
Good
Discharge Instructions:
* Increasing pain or persistent pain that is not relieved by
pain medications
*Inability to urinate
* Fever (>101.5 F)
*Nausea or Vomiting that last longer than 24 hours
* Inability to pass gas or stool
* Other symptoms concerning to you
Please take all your medications as ordered
No immersion for 2 weeks
No lifting more than 25 lbs or abdominal stretching exercises
for 4 weeks.
Follow up in one week with Dr [**First Name (STitle) 2819**]. The urinary catheter will
stay in place for ~2 weeks. At this time the home nurses may
begin voiding trials and discontinue the catheter if tolerated.
At ~4 weeks you will need a CT scan to be reviewed by Dr. [**First Name (STitle) **].
You will also have weekly blood tests to check your kidney
function.
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) 2819**] in [**2-1**] weeks. Call ([**Telephone/Fax (1) 6347**]
to make an appointment.
Please follow up with Dr. [**First Name (STitle) **]. You will need a CT scan prior
to your appointment with Dr. [**First Name (STitle) **]. Call ([**Telephone/Fax (1) 7287**] to make
an appointment with Dr. [**First Name (STitle) **]. Call ([**Telephone/Fax (1) 6713**] to schedule
your CT scan.
Your blood glucose was elevated while in the hospital. Please
follow up with Dr. [**Last Name (STitle) 2696**] in [**2-1**] weeks to make sure this does
not persist past hospitalization.
Completed by:[**2174-3-10**]
|
[
"401.9",
"997.5",
"293.0",
"555.1",
"591",
"272.0",
"788.20",
"733.00",
"427.1",
"285.1",
"552.00",
"E878.8",
"998.12",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.04",
"53.21",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
16853, 16895
|
11880, 15645
|
374, 426
|
17121, 17128
|
1145, 11857
|
17929, 18584
|
852, 871
|
15754, 16830
|
16916, 17100
|
15671, 15731
|
17152, 17906
|
886, 1126
|
274, 336
|
454, 579
|
601, 745
|
761, 820
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,774
| 179,525
|
8549
|
Discharge summary
|
report
|
Admission Date: [**2139-1-6**] Discharge Date: [**2139-1-13**]
Date of Birth: [**2068-2-28**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Melena, hypotension.
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
This is a 70 year old gentleman with ischemic cardiomyopathy EF
20%, atrial fibrillation on coumadin, history of Barrett's
esophagitis, colonic polyps, asthma, hypothyroidism, and
depression. He presents with black loose stools for one day.
Yesterday morning, the patient woke up and had diarrhea that was
black and tarry in nature. He proceeded to have a loose stool
movement every 15 minutes over the day. Over the course of the
day he became more lightheaded and this morning felt like he was
going to fall down prompting him to seek medical attention in
the ED. He did not notice frank blood in his bowel movements. He
also has had some nausea with poor appetite (has not eaten in
two days) but no vomiting or hematemesis. No abdominal pain. No
coldness in extremities.
.
The patient was bought in by his wife to the [**Name (NI) **]. There the
patient was noted to have a low blood pressure in the high 80s
systolic, P 105. Hct was 42 (baseline 31) and BUN/Cr 56/2.4
(baseline cr 1.5-1.8). NG lavage negative. Believed to be volume
depleted. He received 3 L NS, 2 units pRBC, and 1 unit FFP
(addtl' units ordered). Given IV protonix. Transferred to MICU,
on transfer pt says he feels somewhat better.
.
Of note, he is known to have Barrett's Esophagus seen on [**2133**]
EGD. In addition, he is s/p removal of adenomatous polyp (path
with dysplasia) in [**2134**], no polyps seen on [**2135**] colonoscopy.
Past Medical History:
11. CAD, s/p 1-vessel CABG and ascending aortic arch repair.
Last
cath in [**8-/2136**] with no significant CAD, patent LIMA to LAD.
P-MIBI in [**6-/2137**] with slight worsening of partially reversible,
moderate perfusion defects in the basilar anterolateral, mid
anterolateral, basilar posterolateral, mid posterolateral, and
lateral walls (entire lateral portion of the left ventricle).
2. Ischemic cardiomyopathy with EF 15-20%, NYHA class III.
3. Chronic renal insufficiency, baseline creatinine around
1.5-1.7
4. Atrial fibrillation
5. Hypothyroidism
6. Status post AICD placement, multiple firing episodes, last at
[**Hospital1 2025**] in [**9-/2137**] in setting of hypokalemia.
7. Asthma
9. Hyperlipidemia
10. Depression
11. Dementia
12. Anemia, baseline hct around 30.
13. Barrett's Esophagus seen on [**2133**] EGD
14. s/p removal of adenomatous polyp (path with dysplasia) in
[**2134**], no polyps seen on [**2135**] colonoscopy.
Social History:
Married, lives with wife, has five children. Formerly drank
alcohol but not since [**48**] years ago. No smoking or illicit drug
use. Retired painter.
Family History:
Non-contributory.
Physical Exam:
VS: T 97.6 P 77 BP 109/71 RR 22 O2 98 RA
Gen: WD/WN male Caucasian, NAD.
Eyes: Sclerae anicteric, PERRL.
Mouth: No bruising, no petechiae.
Neck: Obese, no JVD (JVP to 6 cm)
Chest: Lungs CTA b/l no wheezes, fair air movement
Abd: Obese, non tender, some nausea elicited with palpation.
Ext: No edema, faint but palpable DP pulses
Neurol: alert and oriented to time,place, and person
Pertinent Results:
[**2139-1-6**] 08:01PM HCT-35.2*
[**2139-1-6**] 02:56PM URINE HOURS-RANDOM UREA N-361 CREAT-43
SODIUM-85
[**2139-1-6**] 02:19PM HCT-34.0*
[**2139-1-6**] 12:15PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.008
[**2139-1-6**] 12:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2139-1-6**] 10:15AM GLUCOSE-112* UREA N-56* CREAT-2.4* SODIUM-137
POTASSIUM-4.3 CHLORIDE-101 TOTAL CO2-25 ANION GAP-15
[**2139-1-6**] 10:15AM estGFR-Using this
[**2139-1-6**] 10:15AM CK(CPK)-129
[**2139-1-6**] 10:15AM ALT(SGPT)-16 AST(SGOT)-26 ALK PHOS-79
AMYLASE-84 TOT BILI-0.4
[**2139-1-6**] 10:15AM CK-MB-3 cTropnT-0.03*
[**2139-1-6**] 10:15AM LIPASE-33
[**2139-1-6**] 10:15AM DIGOXIN-1.3
[**2139-1-6**] 10:15AM CK-MB-3 cTropnT-0.03*
[**2139-1-6**] 10:15AM WBC-6.3 RBC-4.66# HGB-13.8*# HCT-42.0# MCV-90
MCH-29.7 MCHC-32.9 RDW-14.1
[**2139-1-6**] 10:15AM NEUTS-77.1* LYMPHS-11.5* MONOS-9.0 EOS-1.9
BASOS-0.5
[**2139-1-6**] 10:15AM PLT COUNT-160
[**2139-1-6**] 10:15AM PT-31.0* PTT-31.9 INR(PT)-3.3*
Brief Hospital Course:
Upper GI bleed:
Pt. initially with borderline hypotension and tachycardia.
Responded well to fluid resuscitation. Admitted initially to
ICU, where an EGD was performed on AM of hospital day 2. EGD
revealed duodenitis, no active bleed, no ulcer, Barrett's
esophagus. In the ICU, was transfused 2 units pRBC, 1 unit FFP.
Given initial low BP and GIB, all antihypertensives were
initially held, as was coumadin.Throughout the rest of hospital
stay, pt. had stable vital signs, no further GIB. Hct responded
appropriately to transfusion, remained stable.
Antihypertensives and coumadin were restarted on HD 3 and were
tolerated well.
Overall, continued ASA and warfarin, but stopped plavix after
consultation with Cardiology.
.
Respiratory distress/asthma flare:
On Hospital day 3, began to have increasing respiratory
distress. Exam notable for marked wheezing. CXR with no definite
infiltrates. While initially volume overloaded after MICU stay,
no longer had evidence of CHF. Overall, he was treated with
prednisone and nebs for asthma flare. Also empirically treated
for PNA - although limited evidence for this on cxr - with
rocephin/azithro. Will be d/c with levaquin to complete 7 day
course.
.
Chest pressure:
On the night of HD 3, patient had an episode of L-sided chest
pain that was ssociated with diaphoresis and an increased 02
requirement (responded to 2L NC). Pain resolved quickly with 3
SL nitroglycerin, albuterol neb, and IV lasix.
Cardiac enzymes were trended and over the following day climbed
from 0.05 to a peak of 0.08. He had no further events, and had
stress MIBI in hospital prior to discharge, which again
demonstrated his severe ischemic dilated cardiomyopathy and
also multiple predominantly fixed perfusion defects - previous
stress in [**2137**] with progressively worse reversible perfusion
defects. Will continue medicla management.
.
ARF on CKD:
Pt. had briefly elevated Cr, which returned quickly to baseline
with fluid resuscitation. In setting of GIB, seemed c/w
prerenal picture. ACEI was initially held, but restarted
without adverse effect once Cr returned to baseline. Remained at
baseline thereafter with re-introduction of meds.
.
Abdominal pain/constipation: On HD 3, pt. developed bilateral
lower quadrant abdominal pain, which he attributed to not having
had a bowel movement since admission to hospital. Abdominal
exam was benign, KUB unremarkable. Had relief
after BM.
.
Medications on Admission:
1. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
2. Aldactone 25 mg Tablet PO once a day.
3. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
4. Digoxin 125 mcg Tablet Daily
5. Atorvastatin 20 mg PO DAILY
6. Aspirin 81 mg Tablet, PO Daily
7. Clopidogrel 75 mg PO daily.
8. Lisinopril 5 mg PO Daily
9. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS adjusted
accordingly to INR.
10. Levothyroxine 112 mcg PO Daily.
11. Citalopram 60 mg PO Daily.
12. Pantoprazole 40 mg E.C. PO Q24H (every 24 hours).
13. Mexiletine 150 mg PO Q8H.
14. Docusate Sodium 100 mg PO BID.
15. Senna 8.6 mg PO BID prn.
16. Quetiapine 50 mg Tablet PO QAM, 25 mg PO QPM, 225 mg QHS.
17. Clonazepam 0.5 mg PO TID (3 times a day).
18. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device [**Hospital1 **]
19. Trazodone 25 mg Tablet PO HS PRN.
20. Donepezil 5 mg PO HS.
Discharge Medications:
1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
4. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
5. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
6. Citalopram 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
7. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
8. Mexiletine 150 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
9. Albuterol Sulfate 0.083 % Solution Sig: [**1-13**] inh Inhalation
Q3-4H (Every 3 to 4 Hours) as needed. inh
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
12. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
15. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Nebulizer
Please dispense home nebulizer set-up.
17. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily).
Disp:*90 Tablet(s)* Refills:*2*
18. Levaquin 500 mg Tablet Sig: One (1) Tablet PO once a day for
3 days.
Disp:*3 Tablet(s)* Refills:*0*
19. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q4H (every 4 hours).
Disp:*180 neb* Refills:*2*
20. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily) for 3 days.
Disp:*9 Tablet(s)* Refills:*0*
21. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
Disp:*120 neb* Refills:*2*
22. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed).
23. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
24. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
25. Quetiapine 50 mg Tablet Sig: 4.5 Tablets PO QHS (once a day
(at bedtime)).
26. Quetiapine 25 mg Tablet Sig: Two (2) Tablet PO QAM (once a
day (in the morning)).
27. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
28. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
1. upper GI bleed secondary to gastritis, duodenitis
Secondary diagnoses:
1. CAD, s/p 1-vessel CABG
2. Ischemic cardiomyopathy with EF 15-20%, NYHA class III.
3. Chronic renal insufficiency, baseline creatinine around
1.5-1.7
4. Atrial fibrillation
5. Hypothyroidism
6. Status post AICD placement
7. Asthma
9. Hyperlipidemia
10. Depression
11. Dementia
12. Anemia, baseline hct around 30.
13. Barrett's Esophagus seen on [**2133**] EGD
14. s/p removal of adenomatous polyp
Discharge Condition:
Good
Discharge Instructions:
Continue all previously prescribed medications.
You may resume your usual diet
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight gain > 3 lbs.
Adhere to 2 gm sodium diet
Return to the hospital or call your doctor immediately for:
-Any further very dark or bloody stools
-Feeling weak or dizzy
-Fainting or feeling that you might faint
-Any trouble breathing
-Any other concerning symptoms
Followup Instructions:
Please call your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 766**] to arrange a
follow-up appointment.
You will also need a repeat endoscopy to monitor your [**Doctor Last Name 15532**]
esophagus, which is a potentially pre-cancerous condition. Your
primary care doctor can arrange the appointment with
gastroenterology for you, or you can call ([**Telephone/Fax (1) 8892**] to
schedule an appointment. You should see them within the next 4
weeks.
|
[
"285.1",
"244.9",
"493.22",
"530.85",
"427.31",
"535.61",
"486",
"428.0",
"V58.61",
"584.9",
"272.4",
"414.8",
"585.9",
"276.50",
"E934.2",
"535.51"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"99.07",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
10311, 10369
|
4484, 6910
|
334, 339
|
10887, 10894
|
3368, 4461
|
11346, 11825
|
2932, 2951
|
7819, 10288
|
10390, 10444
|
6936, 7796
|
10918, 11323
|
2966, 3349
|
10465, 10866
|
274, 296
|
367, 1781
|
1803, 2748
|
2764, 2916
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,225
| 104,405
|
8855
|
Discharge summary
|
report
|
Admission Date: [**2162-6-30**] Discharge Date: [**2162-7-8**]
Service:
HISTORY OF PRESENT ILLNESS: The patient is an 85 year old
male who was admitted on [**6-30**] for a syncopal episode while
climbing up to the stairs at his home. At that time the
patient lost consciousness. He was found by his daughter who
then called the paramedics. Upon admission the patient had a
syncopal workup which included a head computerized tomography
scan which was negative, as well as a carotid duplex which
was negative. The patient had an electrocardiogram done
which showed no ST elevation and nonspecific changes. He was
then sent for a stress test which had uninterpretable changes
because of his current regimen which included Digoxin. It
was thought that at that time the patient may have increased
vagal tone which may have lead to the syncopal episode so a
biventricular pacer was then placed. The patient at that
time was still in atrial fibrillation which he has been in
for some time. Following his pacer placement, the patient
was doing well but the following morning he was found
unresponsive and pulseless by the house staff. The patient
was immediately given oxygen and recovered quickly without
cardiopulmonary resuscitation or any other means. The
patient was then transferred to the Cardiac Care Unit. Upon
admission the patient was found to be afebrile with a
temperature of 98 degrees. His heartrate ranged between 72
and 83 with atrial fibrillation. His respirations ranged
from 17 to 26, blood pressure systolic ranged from 103 to
112/51 to 59. He was sating at 99% on 2 liters of oxygen,
nasal cannula. His ins and outs at that time for a 20 hour
period were 501 cc in, 1105 cc out for a negative total of
604 cc.
PHYSICAL EXAMINATION: On examination the patient was calm,
in no apparent distress but was found to have [**Last Name (un) 6055**]-[**Doctor Last Name **]
respirations with notable hyperventilation followed by apneic
periods. Head and neck examination, the patient was
nonicteric, mucosa were moist. No jugulovenous distension
was noted. His chest was clear to auscultation, anteriorly
and laterally. Cardiac examination, he had an irregularly
irregular rhythm with a II/VI murmur, no rubs were noted.
His abdomen had positive bowel sounds, nontender,
nondistended. His extremities showed no cyanosis, clubbing
or edema with intact 2+ pulses bilaterally. Neurological
examination, he was alert and oriented times three. Pupils
were equally round and reactive to light, extraocular
movements intact. The patient had no nystagmus. Mild
increase in tone in all four limbs symmetrically with
downgoing toes bilaterally. His strength and sensation were
grossly intact and symmetrical bilaterally.
LABORATORY DATA: Laboratory studies on admission revealed
the patient had a white count of 6.4, hemoglobin 9.5,
hematocrit of 27.1. Chem-7 with sodium 143, potassium 4.5,
chloride 108, bicarbonate 23, BUN 31, creatinine 1.7. His
AST was 24, ALT 20, lactate of 3.7. The patient had serial
cardiac enzymes with a peak CPK of 487, calcium 9.0,
phosphorus 3.2, magnesium 2.1. He had a urine culture from
[**6-30**] which was positive for enterococcus over 100,000
units. The previous head computerized tomography scan was
negative. Chest x-ray showed a possible small infiltrate.
Stress test, electrocardiogram was uninterpretable because of
Digoxin therapy. His echocardiogram done on [**7-2**] showed a
dilated left ventricle, decreased left ventricular systolic
function with an ejection fraction of 25% with 1 to 2+ aortic
regurgitation and 1 to 2+ mitral regurgitation, 2+ tricuspid
regurgitation with some mild pulmonary hypertension, all
findings which were similar to a previous echocardiogram,
[**2161-11-15**]. Carotid duplex showed no abnormalities.
HOSPITAL COURSE: During the patient's admission to Cardiac
Care Unit, serial cardiac enzymes were drawn at which time he
ruled in for a myocardial infarction with no ST segment
elevation. The patient was started on a beta blocker,
Aspirin, heparin with an Ace inhibitor which was held
temporarily because of his increase in creatinine which was
thought to be due to his hypotensive episode. The patient
was then sent the following day for a cardiac catheterization
which revealed no change in his coronary artery disease and
no intervention was done at that time. The following day,
[**7-6**], the patient was transferred to the floor and was
found to have a creatinine that improved to 1.2. At that
time an ACE inhibitor was started. The following day, [**7-7**], the patient did well but had some confusion over night
and was found to have a slight decrease in urine output with
a slight rise in creatinine to 1.4. The patient had gentle
intravenous hydration. The case manager was consulted at
that time as well as physical therapy. The patient's Foley
catheter was discontinued. The following day [**7-8**], the
patient did well over night with no confusion noted. The
patient did urinate some dark red urine which was thought to
be related to trauma from his Foley catheter. It was also
decided at that time that the patient should be cardioverted
for his atrial fibrillation so that his biventricular pacer
could function more efficiently. It was also decided at that
time that the patient should continue on anticoagulation with
Coumadin after his discharge from the hospital because of the
future risk of atrial fibrillation and history of stroke.
The following day, the patient did well. He had somewhat
decreased urine output which was red, thought to be secondary
to his Foley catheter which had since been removed. The
patient had a chest x-ray which showed no signs of congestive
heart failure so he continued with gentle intravenous
hydration. His creatinine at that time was found to be 1.5.
His blood pressure was stable with systolics to the 160s so
the patient's Lopressor was increased to 50 mg b.i.d. and his
ACE inhibitor was changed to Lisinopril 5 mg q.d. Because
the patient's INR was 1.5 on his Coumadin dose of 60 mg per
day, the patient was placed on Lovenox temporarily until his
INR became therapeutic between 2 and 3. The patient was then
discharged to a rehabilitation facility. At discharge, the
patient's status was good. The patient was found to have
good mental status, bibasilar crackles with some lower
extremity edema 1+, but the rest of the examination was
unremarkable.
DISCHARGE DIAGNOSIS:
1. Syncope with permanent pacer placement
2. Acute myocardial infarction
3. Atrial fibrillation status post cardioversion
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg once a day
2. Lipitor 10 mg once a day
3. Amiodarone 400 mg twice a day
4. Coumadin 6 mg once a day
5. Metoprolol XL 50 mg twice a day
6. Lisinopril 5 mg once a day
7. Docusate 100 mg twice a day
8. Lovenox 80 mg subcutaneously q. 12 until his INR is
therapeutic
FOLLOW UP: The patient's follow up plans are to go to a
rehabilitation facility where he will have his INR checked
and continue Coumadin. The patient will have frequent
creatinine checks with close monitoring of his ins and outs
with gentle intravenous hydration. The patient will also
continue on his Amiodarone where he will follow up with
pulmonary function tests, liver function tests and thyroid
function tests to monitor toxicities. The patient after
rehabilitation will have follow up appointments with Device
Clinic for his pacemaker, have a cardiology follow up
appointment with Dr. [**Last Name (STitle) **]. He will follow up with his
primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 30867**] for an appointment in
approximately two to three weeks. The patient will also
follow up with INR checks either at home or at [**Hospital 263**] Clinic.
DISPOSITION: The patient will be transferred to [**Hospital3 7511**] for rehabilitation.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D. [**MD Number(1) 5211**]
Dictated By:[**Last Name (NamePattern4) 30868**]
MEDQUIST36
D: [**2162-7-8**] 15:05
T: [**2162-7-8**] 16:45
JOB#: [**Job Number 30869**]
|
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icd9cm
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3841, 6454
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6926, 8176
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1775, 3823
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112, 1752
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,100
| 184,521
|
9221
|
Discharge summary
|
report
|
Admission Date: [**2134-12-22**] Discharge Date: [**2134-12-27**]
Date of Birth: [**2084-4-23**] Sex: F
Service: OMED
CHIEF COMPLAINT: Nausea, vomiting, and diarrhea.
HISTORY OF THE PRESENT ILLNESS: The patient is a 50-year-old
female with a history of metastatic breast CA to the liver
and bone who presents with several days of nausea and
vomiting, diarrhea and anorexia. The patient states that she
had similar symptoms following her first course of
gemcitabine therapy but they resolved on their own. The
patient finished her second cycle of gemcitabine six days
prior to admission. Four days prior to admission, the
patient experienced severe nausea, vomiting, diarrhea, and
poor intake. The emesis was described as dark brown with no
obvious coffee grounds, not foul smelling. She also noted
dizziness upon standing and walking. The intensity of her
vomiting increased on the day of admission. She also noted
to have several episodes of diarrhea. She also had taken
some Senna that morning. She was then admitted for further
management of these symptoms.
PAST MEDICAL HISTORY:
1. Breast cancer, metastatic to liver, bone, diagnosed in
[**2125**], status post lumpectomy and XRT with one node positive,
therapy finished in [**2126-3-24**]. In [**2131-11-24**], noticed
limping in the left hip. A new lesion was found as well as a
question of a right rib lesion. She was started on
Pamidronate at that time. In [**2132-5-24**], she was given
Tamoxifen times nine months and then changed to Arimidex due
to an increasing CA27-29. At that time, she also started
Megace briefly. She was then changed to exemestane. In
[**2133-10-24**], the patient was started on Navelbine,
received six cycles through [**2134-2-22**]. In [**2134-3-24**],
the patient started Taxol and received four cycles until
[**2134-6-24**]. In [**2134-8-24**], the patient was started
on Fasoodex. In [**2133-11-24**], the patient was started on
gemcitabine for which she is on her second cycle.
2. Hyperlipidemia.
3. Status post cesarean section.
ALLERGIES: The patient has no known drug allergies.
ADMISSION MEDICATIONS:
1. Multivitamin.
2. Lipitor.
3. Advil.
FAMILY HISTORY: Negative for cancer.
SOCIAL HISTORY: The patient is married. The patient's
husband, [**Name (NI) **], cell phone [**Telephone/Fax (1) 31680**] and pager
[**Telephone/Fax (1) 31681**], is involved in her care as is her daughter.
The patient denied any history of alcohol, smoking, or drug
use.
PHYSICAL EXAMINATION ON ADMISSION: In general, the patient
was a frail woman in no acute distress. Vital signs: 98.1,
120, 110/69, 16, 99%. HEENT: The mucous membranes were dry.
The neck veins were flat. CV: Tachycardia, regular, no
murmurs, rubs, or gallops. Chest: Clear to auscultation
bilaterally. Abdomen: Soft, nontender. The liver was
several centimeters below the costal angle. Extremities: No
clubbing, cyanosis or edema.
LABORATORY DATA: WBC 3.1, hematocrit 19.2, platelets
126,000. ALT 130, AST 604, alkaline phosphatase 508, total
bilirubin 3.1.
HOSPITAL COURSE: 1. HEMATOLOGY: The patient was admitted
for anemia and transfused 3 units of blood in the ED. She
was also noted to be in low-grade DIC with slightly elevated
D-dimer, low fibrinogen. She was transfused 2 units of FFP.
She had inadequate hematocrit increase with this and received
an additional 2 units for a total of 5 units of packed red
blood cells. The patient's blood counts remained stable
through the rest of her admission. She needs to have this
followed as an outpatient.
The cause of her DIC is likely her metastatic cancer. This
will also need to be followed as an outpatient.
She was admitted to the MICU for treatment of her anemia.
2. GASTROINTESTINAL: The patient had concern for GI bleeds,
both upper and lower, given her symptoms. The patient had NG
lavage of clot but no active bleeding in the ED. The patient
was admitted to the MICU for further evaluation. She
underwent EGD which demonstrated patchy erosions of the
mucosa in the antrum but no active bleeding. The duodenum
demonstrated a 2 cm ulcer with visible vessel. No active
bleeding in the bulb. She received seven injections of
epinephrine and electrocautery with relief. She had H.
pylori sent that was negative.
She was started on b.i.d. PPI. The patient did not have any
additional bleeding during her admission. Her GI bleed was
felt to be secondary to her NSAID use.
3. LFTs: The patient was noted to have an elevated
bilirubin upon admission which increased up to 11 during her
admission with a direct of 8.0. This declined during her
admission. She had an ultrasound which demonstrated diffuse
hepatic infiltration, edematous gallbladder with normal
ducts. I am unsure of whether or not she passed a stone
versus tumor burden are two possibilities, although
cholestasis secondary to her condition was felt to be the
most likely diagnosis.
Her LFTs slightly decreased during her admission and were
felt to be stable for discharge. Her coagulations remained
stable.
4. METASTATIC BREAST CANCER: The patient had been treated
well with her gemcitabine, on cycle two. The patient was in
the MICU and noted to have one episode of change in mental
status in which she became agitated and refused treatments.
The patient's husband felt that this was likely just
secondary to being tired of treatments.
A head CT was obtained which demonstrated a 2 cm lesion with
mass affect in the frontal lobe. Neurology was consulted and
steroids and phenytoin for seizure prophylaxis were started.
The patient then underwent an MRI of the brain which
demonstrated a 2.0 by 1.7 enhancing mass in the white matter
of the right frontal lobe with edema and mild impingement on
the frontal [**Doctor Last Name 534**] of the right lateral ventricle.
.................... foci were present in the occipital lobes
as well as 5 mm foci in the cerebellum.
Radiation/Oncology and Neurosurgery were consulted.
Neurosurgery considered stereotactic radiation of these
lesions. Radiation/Oncology also recommended radiation
therapy. The patient decided to have radiation performed at
[**Hospital6 **] where she had previous episodes of
radiation.
PLAN/DISPOSITION: The patient expresses a desire to leave
the hospital and spend some time at home and return to her
normal providers. The patient was discharged home with
follow-up with Dr. [**Last Name (STitle) 19**] for Oncology and Dr. [**Last Name (STitle) **] at
[**Hospital1 **], [**Telephone/Fax (1) 31682**].
DISCHARGE CONDITION: Stable.
DISCHARGE STATUS: The patient was discharged home with
follow-up with Dr. [**Last Name (STitle) 19**] in two days, Dr. [**Last Name (STitle) **] on the
following day for radiation, as well as the Learning Center
for diabetic teaching given her new diagnosis of diabetes on
steroids.
DISCHARGE DIAGNOSIS:
1. Metastatic breast CA to the lung, liver, and brain.
2. Duodenal ulcer, status post electrocautery and
epinephrine injection.
3. Gastrointestinal bleed from duodenal ulcer.
4. Change in mental status secondary to brain lesion.
5. Elevated liver function tests secondary to cholestasis.
6. Steroid-induced diabetes.
DISCHARGE MEDICATIONS:
1. Protonix 40 mg p.o. b.i.d.
2. Dexamethasone 4 mg p.o. q. six hours.
3. Regular insulin sliding scale while on prednisone.
4. Lactulose 30 milliliters p.o. t.i.d. for encephalopathy.
5. Zofran 2 mg p.o. p.r.n. nausea.
6. Tylenol 650 mg p.o. p.r.n.
7. Multivitamin one tablet p.o. q.d.
8. Maalox p.r.n.
9. Phenytoin 200 mg p.o. q.h.s.
10. Colace 100 mg p.o. b.i.d. p.r.n.
11. Dulcolax one tablet p.o. b.i.d. p.r.n.
[**First Name11 (Name Pattern1) 20**] [**Last Name (NamePattern1) 21**], M.D. [**MD Number(1) 31683**]
Dictated By:[**Name8 (MD) 17420**]
MEDQUIST36
D: [**2134-12-27**] 05:32
T: [**2134-12-27**] 17:41
JOB#: [**Job Number 31684**]
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icd9cm
|
[
[
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icd9pcs
|
[
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6577, 6871
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2206, 2228
|
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|
6892, 7216
|
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|
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|
157, 1095
|
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|
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|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,910
| 197,073
|
46227
|
Discharge summary
|
report
|
Admission Date: [**2119-11-2**] Discharge Date: [**2119-11-13**]
Date of Birth: [**2049-7-8**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
1. Insertion of PICC line into left arm on [**2119-11-8**].
2. EEG [**2119-11-10**].
3. Temporarily intubated for CT scan on [**2119-11-10**].
History of Present Illness:
Mrs. [**Known lastname **] is a 70 yo woman with a h/o DM, MS, HTN and frequent
UTIs [**2-8**] chronic foley who presented "not feeling well." She
states she was in her usual state of health until one week prior
to admission when she felt tired. She states that three nights
prior to admission, she experienced severe back pain which is
one of her UTI symptoms. The following day she was prescribed
Levaquin for a UTI. On day of admission, pt reports feeling
exhausted and thus came to the ED. Pt was initially sent to
[**Location (un) 620**] where she was given another dose of Levaquin and stress
dose steroids. She was then sent to [**Hospital1 18**] ED. In the ED, she was
found to have an elevated lactate and she was started on the
sepsis protocol.
.
Her recent history is significant for asymptomatic bullae on her
B LE and itch papules on her B UE for the past two months. She
saw a dermatologist who presumptively diagnosed bullous
pemphigoid and started her on a prednisone taper (started
[**10-18**]). She felt her lesions improved somewhat with the
prednisone but have not resolved completely.
On arrival to the ICU, she denied chest pain, shortness of
breath, headache, abd pain, nausea, vomiting, diarrhea, dysuria,
fevers or chills. She has some back pain and pain in her lower
legs. She states she is no longer ambulatory due to lower ext
pain.
After a night in the ICU she was felt stable for transfer to the
floor. On questioning she states she feels tired but somewhat
better. She denies any pain, dyspnea, nausea, or diarrhea.
Past Medical History:
1. Diabetes Type II.
2. MS, 3 prior episodes of transverse myelitis.
3. Hypertension.
4. Diabetic sensory motor neuropathy.
5. Depression and anxiety.
6. frequent UTIs - up to 2x/month, usually treated with
levofloxacin
7. Hypothyroidism
8. Recent diagnosis of bullous pemphigoid.
Social History:
She currently lives alone with a home health aide who visits
with her five days a week. She has two daughters who live close
by her and are involved in her care. They also serve as her
health care proxy. [**Name (NI) **] husband has passed away. She has a
motorized wheelchair. She denies any tobacco or alcohol
history.
Family History:
Positive history of diabetes in her parents and sister.
Physical Exam:
Exam: temp 97.4, BP 139/50, HR 120, R 22, O2 96%RA
Gen: Lying in bed, somewhat sleepy but easily arousable,
comfortable.
HEENT: PERRL, EOMI, MMM, OP clear
Neck: Supple, no LAD, no JVD
CV: regular, tachy, 3/6 systolic murmur at RUSB
Chest: clear, no wheezes
Abd: +BS, soft, tender to deep palpation in bilateral lower
quadrants
Ext: no edema, 2+ DP, sensation intact bilaterally
Skin: Upper extremities: multiple small round erosions with
surrounding scale. Lower extremities (primarily knees,
pre-tibial area): multiple 1-3 cm erosions, some with
hemorrhagic crusts. Plantar surfaces with few round bullae. No
target lesions, no oral lesions.
Neuro: A&O x 3, CN 2-12 grossly intact, 4/5 strength in
bilateral upper ext.
Pertinent Results:
Labs:
WBC trend:
Peak of 15.3 on admission, quickly decreased to [**6-14**].
Hct:
Stable between 32 and 35.
Platelets:
Stable around 200.
Labs at discharge:
wbc 6.7, hct 31.1, plt 206
Na 140, K 3.5, Cl 103, HCO3 29, BUN 12, Cr 1.0, glucose 93
Microbiology:
[**11-6**] Urine culture:
10-100,000 Klebsiella pneumoniae with the following sensitivity
findings:
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- =>64 R
CEFTRIAXONE----------- 8 S
CEFUROXIME------------ =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
IMIPENEM-------------- <=1 S
LEVOFLOXACIN---------- =>8 R
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 128 R
PIPERACILLIN/TAZO----- 64 I
TOBRAMYCIN------------ 8 I
TRIMETHOPRIM/SULFA---- =>16 R
[**11-8**] Urine culture: No growth.
[**11-6**] Blood culture: No growth.
[**11-9**] Blood cultures: Pending.
Reports:
[**11-10**] ABD/PELVIC CT:
1. Hypodense areas posteriorly in the upper and mid poles of
the right
kidney. It is unclear whether this is secondary to artifact or
could represent an area of focal pyelonephritis. There is no
evidence of renal abscess. There is no evidence of
intraabdominal abscess.
2. Atelectatic changes of the lungs.
[**11-6**] ABD/PELVIC CT:
1. Likely cystitis.
2. Hypodense subcentimeter cortical lesions in the left kidney
too small to be characterized. There is no hydronephrosis.
Normal excretion is seen from both kidneys.
[**11-10**] HEAD CT:
1. No evidence of acute intracranial pathology including no
evidence of acute intracranial hemorrhage or enhancing lesions.
2. Multiple extra-axial calcified nodules most likely
representing calcified meningiomas.
[**11-10**] EEG:
This EEG is consistent with a moderate encephalopathy of toxic,
metabolic, or anoxic etiology. No evidence of ongoing or
potential seizures is seen at this time.
Pathology:
LE skin biopsy:
1. Subepidermal bulla formation with associated papillary dermal
lymphohistiocytic and eosinophilic infiltrate and abundant
interstitial eosinophils, consistent with bullous pemphigoid,
see note.
Note: Direct immunofluorescence studies show linear deposition
of IgG (2+) and C3 (2+) at the dermal/epidermal junction.
Staining for fibrinogen (3+) is present within the blister
cavity (non-specific). Direct immunofluorescence studies for
IgA, IgM, and phosphate-buffered saline (negative control) are
negative. Immunostain for collagen type IV highlights the base
of the bulla.
The overall findings are consistent with a diagnosis of bullous
pemphigoid; clinical correlation is suggested to exclude a
drug-related etiology.
Brief Hospital Course:
Mrs. [**Known lastname **] is a 70 year old woman with a history of Multiple
sclerosis, DM, HTN, and frequent UTIs due to a chronic
indwelling Foley catheter who presented with a presumed
urosepsis.
.
1. Urosepsis:
She has a history of chronic UTIs, up to twice per month that
are thought to be due to her indwelling Foley catheter. She has
had a foley catheter for several years and has it changed once
per month by her home health aide. On admission she had stable
hemodynamics but had an elevated lactate and was admitted to the
ICU under the sepsis protocol. Her hemodynamics remained stable
and her lactate trended down and she was quickly transferred to
the medical floor. Her urine culture eventually grew positive
for a highly resistant strain of Klebsiella pneumonia. In
consultation with the ID service, she was treated with
ceftriaxone for six days and meropenem for four days. In
addition, abdominal CT scans were performed which did not reveal
any anatomic abnormality in the urinary tract or any evidence of
pyelonephritis (the suspicion of pyelonephritis seen on the [**11-10**]
study was thought to be due to artifact). She thus completed a
10 day course of IV antibiotics and was not discharged on any
antibiotic prophylaxis as she has a history of highly resistant
organisms. She should have her Foley catheter changed weekly
under sterile conditions to try to prevent future urinary tract
infections.
.
2. Delirium:
In the middle of her hospitalization she was noted to become
agitated and delirious alternating between becoming quite
somnolent and delirious with confusion, agitation, and
perseveration. She was so delirious that she required
intubation to perform CT scans. Evaluation of this included a
negative EEG, a negative head CT, a negative CXR, an abdominal
CT negative for an intra-abdominal infection, and normal labs
(CBC and electrolytes). In addition repeat urine and blood
cultures were negative. All of her psychotropic medications
were held including ativan and any sleeping agents such as
ambien or trazodone and she was weaned off of her paxil.
Eventually her mental status cleared and she was again alert and
oriented, conversant, and able to follow directions. Thus it
was thought that her delirium was most likely medication
induced. At discharge, she was maintained on her multiple
sclerosis meds but was not on paxil or ativan.
.
3. Diabetes mellitus:
She was maintained on her home regimen of 75/25 and glyburide.
Her metformin was held initially due to an elevated creatinine
and was not restarted during her hospitalization. Her blood
sugars ranged during her stay depending on her po intake but
over the several days preceding her discharge her blood sugars
were around 100. She was discharged on the following regimen.
75/25 18 units with breakfast and 20 units with dinner and
glyburide 5 mg twice daily. This regimen may need to be altered
depending on her po intake. She is also completing a prednisone
taper (finished [**2119-11-13**]) which may cause her blood sugars to
decrease somewhat.
4. Bullous pemphigoid:
She was seen by the dermatology service while hospitalized and a
punch biopsy was consistent with bullous pemphigoid. She was
continued on her prednisone taper (finished [**2119-11-13**]) and was
also given topical clobetasol 0.05% cream twice daily. On this
regimen her blisters and erosions over her bilateral knees
slowly began to resolve. They did not disappear completely and
if there is further concern, her outside dermatologist should be
contact[**Name (NI) **] (Dr [**Last Name (STitle) 98283**] of [**Hospital1 **] [**Name (NI) 47**] [**Telephone/Fax (1) 98284**]).
.
5. Multiple sclerosis:
She was continued on her outpatient regimen of carbamazepine,
gabapentin, and baclofen.
.
6. Hypothyroid: cont levoxyl
.
7. Ppx: SQ heparin, PPI, ASA
.
8. Code: full
.
9. Comm: daughter
.
10. Access: right IJ
.
11. Dispo: To Skilled Nursing Facility
Medications on Admission:
* Baclofen 20mg qid
* Neurontin 300mg tid
* Paroxetine 30mg [**Hospital1 **]
* Carbemazepine 200mg [**Hospital1 **]
* Metformin 1000mg [**Hospital1 **]
* Glyburide 10mg [**Hospital1 **]
* Ecotrin 325mg qd
* Levoxyl 25mcg qd
* Allopurinol 300mg qd
* Lasix 80mg qd
* KCl 10mEq qd
* Nitrofurantoin 100mg [**Hospital1 **]
* Hydroxyzine 10mg qhs
* Zyrtec 10mg qhs x 2 weeks
* Ativan 0.5mg prn
* Prednisone 60mg qd x 7days
* Aciphex 20mg qd
* Levaquin 250mg qd x 10days (start [**10-31**])
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Baclofen 10 mg Tablet Sig: Two (2) Tablet PO QID (4 times a
day).
4. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
5. Carbamazepine 200 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
6. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
8. Levothyroxine Sodium 25 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
9. Allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
10. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
12. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
once a day as needed for constipation for 1 doses.
13. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
14. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
15. Insulin Regimen
Insulin 75/25 SC 18 units with breakfast.
Insulin 75/25 SC 20 units with dinner.
16. Clobetasol 0.05 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
Discharge Disposition:
Extended Care
Facility:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Rehab & Nursing Center - [**Location (un) 47**]
Discharge Diagnosis:
Primary Diagnosis:
1. Klebsiella pneumonia urinary tract infection.
2. Delirium, thought to be medication induced, resolved.
Secondary Diagnosis:
1. Multiple sclerosis.
2. Diabetes Mellitus.
3. Hypertension.
Discharge Condition:
Stable. Stable on room air, afebrile, hemodynamically stable.
Delerium resolved.
Discharge Instructions:
1. You are being discharged to an extended care facility.
2. Please take your medications as prescribed.
3. Please come to your follow-up appointments (see below).
Followup Instructions:
1. Please call your urologist to set up a follow-up appointment
in the next few weeks to discuss appropriate Foley catheter
care. We recommend that you have your catheter changed every
week.
2. Please call your PCP to set up a follow-up appointment within
the next few weeks.
3. Please have your primary care physician set you up with
outpatient neuro-psych testing to further evaluate your frontal
lobe function.
Completed by:[**2119-11-13**]
|
[
"458.29",
"340",
"599.0",
"244.9",
"401.9",
"E947.9",
"041.3",
"694.5",
"V58.67",
"357.2",
"V58.65",
"996.64",
"250.60",
"292.81",
"276.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.11",
"38.93",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
12080, 12220
|
6190, 10132
|
291, 436
|
12472, 12555
|
3496, 3635
|
12767, 13214
|
2683, 2740
|
10666, 12057
|
12241, 12241
|
10158, 10643
|
12579, 12744
|
2755, 3477
|
242, 253
|
3654, 5006
|
464, 2019
|
12387, 12451
|
5015, 6167
|
12260, 12366
|
2041, 2323
|
2339, 2667
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,857
| 188,698
|
25390
|
Discharge summary
|
report
|
Admission Date: [**2136-8-21**] Discharge Date: [**2136-8-22**]
Date of Birth: [**2061-4-28**] Sex: M
Service: MEDICINE
Allergies:
clams / bee stings
Attending:[**Doctor First Name 1402**]
Chief Complaint:
Hypotension s/p PVI
Major Surgical or Invasive Procedure:
Pulmonary vein ablation, Direct current cardioversion
History of Present Illness:
This 75 year old patient with hx of A-fib, A-flutter s/p one
right Aflutter PVI ([**2130**]) and two left atrial PVI ([**2130**] and
[**2132**]) who presented today for elective PVI ablation after
failing medical thearpy (flecainide) and multiple
cardioversions.
.
He underwent left atrial PVI during which he received IV lasix
40 for elevated left sided pressures (LA 47/22). He also
received 200 mcg of fentanyl and 2 mg of versed during the
procedure. His in/out were 3800/2400. He was noted to be
hypotensive with SBP in 80s in the PACU (baseline SBP of 130 on
home antihypertensives) with somnolance. He was started on neo
gtt which was switched to dopa for few minutes and then switched
to neo gtt (presumably due to concern for LVOT with LV
hypertrophy and family history of hypertropic cardiomyopathy)
with good response in SBP > 1000. Emergent TTE showed unchanged
pump and valve function with no signs of cardiac tamponade. He
was subsequently transferred to CCU for monitoring overnight.
.
In the CCU, he does not report any other complaints.
Past Medical History:
1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
atrial fibrillation and atrial flutter on coumadin
hypertrophic cardiomyopathy
Myocardial bridge
dilated aorta
3. OTHER PAST MEDICAL HISTORY:
left ICA dissection c/b pseudoaneurym formation; treated with
coumadin
NSVT
? vtach on cardionet monitor
benign fatty tumors removed from scalp
knee surgery
idiopathic peripheral neuropathy bilateral feet
dermoid cyst removed
knee arthroscopy
tonsillectomy
Social History:
Married, works as a consulting engineer.
Tobacco: no
ETOH: 1 drink twice weekly
- Illicit drugs:
Family History:
brother has myocardial bridge/hypertrophic cardiomyopathy and
afib
Physical Exam:
ADMISSION EXAM
VS: 97.5 71 122/59 96%RA
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 8 cm.
CARDIAC: Irregularly irregular. No murmurs or gallops
appreciated.
LUNGS: Bibasilar crakles. No wheezing noted.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits or hematoma.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
.
DISCAHRGE EXAM
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 5cm.
CARDIAC: RRR. No murmurs or gallops appreciated.
LUNGS: CTA BL
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits or hematoma.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
ADMISSION LABS:
[**2136-8-21**] 07:00AM PT-22.1* INR(PT)-2.0*
[**2136-8-21**] 07:00AM PLT COUNT-166
[**2136-8-21**] 07:00AM WBC-6.7 RBC-4.84 HGB-15.4 HCT-42.3 MCV-87
MCH-31.8 MCHC-36.4* RDW-13.6
[**2136-8-21**] 07:00AM GLUCOSE-111* UREA N-19 CREAT-1.1 SODIUM-138
POTASSIUM-4.5 CHLORIDE-103 TOTAL CO2-25 ANION GAP-15
.
DISCHARGE LABS:
[**2136-8-22**] 05:27AM BLOOD WBC-10.2# RBC-3.92* Hgb-12.6* Hct-35.3*
MCV-90 MCH-32.2* MCHC-35.7* RDW-13.6 Plt Ct-144*
[**2136-8-22**] 05:27AM BLOOD Plt Ct-144*
[**2136-8-22**] 05:27AM BLOOD Glucose-107* UreaN-20 Creat-1.2 Na-138
K-4.1 Cl-105 HCO3-27 AnGap-10
.
PERTINENT STUDIES:
TTE ([**2136-8-21**]): The left ventricular cavity size is normal to
small. Left ventricular systolic function is hyperdynamic
(EF>75%). There is a mild resting left ventricular outflow tract
obstruction. A mid-cavitary gradient is identified. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. No mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
Brief Hospital Course:
PRIMARY REASON FOR ADMISSION: 75 year old patient with hx of
A-fib, A-flutter s/p one right Aflutter PVI ([**2130**]) and two left
atrial PVI ([**2130**] and [**2132**]) who is admitted to CCU after being
hypotensive post PVI requiring neo gtt.
.
Active Diagnoses:
# Hypotension: Likely related to versed administered during PVI.
Pt was weaned off neo gtt and BP remained stable in the 120s/60s
at the time of discahrge. His EKG was not changed from baseline
and TTE showed mild LVOT obstruction and was negative for
post-procedure pericardial effusion. FH is significant for HOCM.
.
# A-fib/flutter: Pt was in a-flutter the morning of discharge
and was successfully cardioverted to NSR. He was discharged with
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of hearts and his coumadin was continued. He was also
started on Flecanide prior to d/c. He will follow up with Dr.
[**First Name (STitle) **] and Dr. [**Last Name (STitle) 63475**].
.
Chronic Diagnoses:
# h/o PNA: Pt has a history of PNA x2 s/p PVI and was continued
on prophylactic augmentin during this hospitalization. No e/o
infection.
.
# HTN: Home BP meds were continued at discharge.
.
Transitional Issues: Pt was discharged home on flecanide with
instructions to follow up with Dr. [**First Name (STitle) **] and Dr. [**Last Name (STitle) 63475**].
Medications on Admission:
AMLODIPINE - (Prescribed by Other Provider) - 2.5 mg Tablet - 1
Tablet(s) by mouth daily in pm
AMOXICILLIN-POT CLAVULANATE - (Prescribed by Other Provider) -
250 mg-125 mg Tablet - 1 Tablet(s) by mouth twice a day
FOLIC ACID - (Prescribed by Other Provider) - 1 mg Tablet - 1
Tablet(s) by mouth daily
LOSARTAN [COZAAR] - (Prescribed by Other Provider) - 25 mg
Tablet - 1 Tablet(s) by mouth twice a day
METOPROLOL SUCCINATE - (Prescribed by Other Provider) - 25 mg
Tablet Extended Release 24 hr - 1 Tablet(s) by mouth twice a day
NIACIN [NIASPAN EXTENDED-RELEASE] - (Prescribed by Other
Provider) - 500 mg Tablet Extended Release - 1 Tablet(s) by
mouth
daily
SPIRONOLACTONE - (Prescribed by Other Provider) - 25 mg Tablet
-
1 Tablet(s) by mouth daily
WARFARIN [COUMADIN] - (Prescribed by Other Provider) - 5 mg
Tablet - 1 Tablet(s) by mouth takes in cycles of [**4-30**]/5mg
.
Medications - OTC
ASCORBIC ACID [VITAMIN C] - (Prescribed by Other Provider) -
Dosage uncertain
ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet,
Chewable - 1 Tablet(s) by mouth daily
B COMPLEX VITAMINS [B COMPLEX] - (Prescribed by Other Provider)
- Dosage uncertain
FIBER - (Prescribed by Other Provider) - Tablet - 2 Tablet(s)
by mouth daily
GLUCOS-MSM-COLLAGEN-C-MN-HRB21 [GLUCOSAMINE-MSM COMPLEX] -
(Prescribed by Other Provider) - 500 mg-333 mg-5 mg-20 mg-1.67
mg
Capsule - 1 Capsule(s) by mouth daily
MULTIVITAMIN - (Prescribed by Other Provider) - Capsule - 1
Capsule(s) by mouth daily
OMEGA-3 FATTY ACIDS-VITAMIN E [OMEGA-3 FISH OIL] - (Prescribed
by Other Provider) - 1,000 mg-5 unit Capsule - 1 Capsule(s) by
mouth daily
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. amoxicillin-pot clavulanate 250-125 mg Tablet Sig: One (1)
Tablet PO Q12H (every 12 hours) for 2 days.
4. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. losartan 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. niacin 500 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO DAILY (Daily).
7. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. warfarin 5 mg Tablet Sig: as directed Tablet PO once a day:
takes cycles of 4 mg/4mg/5mg.
9. flecainide 50 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
Disp:*60 Tablet(s)* Refills:*2*
10. metoprolol succinate 25 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Atrial fibrillation
Hypertrophic cardiomyopathy
Hypertension
Hyperlipidemia
Discharge Condition:
Hospital course: Mr. [**Known lastname 5514**] was admitted to the hospital
following an elective uncomplicated pulmonary vein ablation
(PVI) to treat atrial fibrillation. He will continue on
Coumadin, Aspirin, Toprol. He started Amoxicillin -Clavunate on
[**2136-8-18**] per primary care physician for pneumonia prevention as
he had a history of pneumonia following last 2 PVI/ablations.
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
VS:
negative carotid bruits
lungs clear
AP RRR
Abdomen is soft, nontender, nondistended (+) bowel ounds (-)
bruit
Bilateral femoral groins without hematoma, bruit (+) peripheral
pulses (+) edema, (-) varicosities
INR: [**2136-8-22**]
Discharge Instructions:
You were admitted to the hospital following a pulmonary vein
ablation to treat atrial fibrillation. Following the procedure,
your blood pressures were low, and we treated this with a
medication. You underwent a direct current cardioversion to
convert you back into sinus rhythm after the procedure.
Please continue Aspirin as ordered and take Prilosec for one
month. Continue Coumadin and please get INR's weekly for 1 month
to ensure INR is greater than >2. Please also continue the
flecainide and the toprol for rhythm and rate control of your
atrial fibrillation.
Please send daily EKG recordings to Dr. [**Last Name (STitle) 63475**] with the [**Doctor Last Name **]
of hearts monitor.
Followup Instructions:
Dr. [**First Name (STitle) **]: PT/INR [**2136-8-29**], then weekly for 1 month.
Dr. [**Last Name (STitle) 63475**] within 1 month, you can please call/ e-mail for
appointment.
|
[
"272.4",
"427.31",
"E939.4",
"458.29",
"401.9",
"V58.61",
"425.4",
"356.9",
"427.32"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.26",
"37.34",
"37.27",
"99.62"
] |
icd9pcs
|
[
[
[]
]
] |
8397, 8403
|
4398, 4645
|
300, 356
|
8523, 8523
|
3133, 3133
|
10015, 10195
|
2070, 2138
|
7416, 8374
|
8424, 8502
|
5759, 7393
|
8541, 8914
|
9299, 9992
|
3475, 4375
|
2153, 3114
|
1540, 1651
|
5588, 5733
|
241, 262
|
384, 1446
|
3149, 3459
|
8929, 9275
|
1682, 1940
|
4663, 5567
|
1468, 1520
|
1956, 2054
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,216
| 127,223
|
33493
|
Discharge summary
|
report
|
Admission Date: [**2138-7-22**] Discharge Date: [**2138-8-9**]
Date of Birth: [**2067-4-17**] Sex: M
Service: MEDICINE
Allergies:
Shellfish Derived
Attending:[**First Name3 (LF) 477**]
Chief Complaint:
Hypoxia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 71 year-old male with a history of pancreatic
adenocarcinoma and gastric outlet obstruction who presents with
hypoxic respiratory failure. Patient was noted to be hypoxic on
routine vitals with O2 saturation of 70% on 5 litres nasal
cannula. He was placed on a 100% non-rebreather with O2
saturations gradually improving to 95% over several minutes.
Rest of the vitals at the time were HR:128, RR:22, BP:125/57.
ABG on non-rebreather was 7.25/67/80. Patient received
aggressive suctioning that yielded 20cc of what appeared to be
gastric contents. On [**2138-8-3**], patient had been started on
Vancomycin and Piperacillin-Tazobactam for presumed hospital
acquired pneumonia based on increased O2 requirement,
infiltrates on chest x-ray, and low-grade fevers. Of note,
patient has failed gastric and duodenal stenting and continues
to have persistent gastric outlet obstruction with pooling of
secretions, and was felt to have intermittent aspiration of
these secretions. An NG tube was placed for persistent
obstruction. However, on the day of transfer, patient's NG tube
was found to have not been functioning, and was pulled.
.
Patient is on furosemide at home for unclear reasons, but this
had been held 4 days prior to transfer due to fluid-responsive
hypotension in setting of gastric outlet obstruction. He had not
received any fluid boluses since [**2138-8-3**]. His fluid intake
over the past 24 hours consisted of D5W for hyponatremia and
TPN.
Past Medical History:
-- Recent diagnosis of pancreatic adenocarcinoma
-- Diabetes diagnosed 25 years ago currently on Insulin.
-- Chronic kidney failure secondary to diabetes.
-- Emphysema, currently followed by a pulmonary doctor.
-- Hypertension.
-- Status post cardiac arrest, past surgery [**55**] years prior.
-- Peripheral vascular disease.
-- Stroke TIA in [**2135**].
-- Sleep apnea on CPAP at night.
-- CABG 25yrs ago
Social History:
Lives with his wife. [**Name (NI) **] stopped smoking on
[**2138-3-20**], prior to that had smoked since he was a teenager
about half a pack a day. Does not drink alcohol and works as an
accountant a few days a week
Family History:
He has a sister with cancer of unknown origin, a
father who died of heart disease, and a mother who died of old
age.
Physical Exam:
Physical Exam:
Vitals: T: BP: HR: RR: O2Sat:
GEN: Well-appearing, well-nourished, no acute distress
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, MMM, OP Clear
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Lungs CTAB, no W/R/R
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No C/C/E, no palpable cords
NEURO: alert, oriented to person, place, and time. CN II ?????? XII
grossly intact. Moves all 4 extremities. Strength 5/5 in upper
and lower extremities. Patellar DTR +1. Plantar reflex
downgoing. No gait disturbance. No cerebellar dysfunction.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
.
.
Pertinent Results:
Laboratories [**8-5**]: Notable for sodium 151, potassium 3.1,
creatinine 2.4, hct 35.1, plts 218. See below for rest
LFTs noted for elevations on [**8-6**] : ALT 51, AST 116, ALK Phos
1845 down from [**2034**] on [**7-31**] and total bili increased to 4.0 from
1.5 on [**7-31**] labs
Urine Cx and Blood Cx pending as of [**8-6**]
Urine dip: negative leuks, urobilinogen 4, negative for
nitrates, Glucose 150, negative ketones.
[**8-6**] UA: hazy, 4+ WBCs, 5 RBCS, few bacteria
[**8-6**] sediment: 12 granular casts, 5 hyaline casts
CXR [**8-5**]: Greater opacification at the right base is probably
atelectasis, though pneumonia cannot be excluded. A small right
pleural effusion and congestion of pulmonary and mediastinal
vasculature indicating improving cardiac function. Heart size is
normal. Small left pleural effusion persists. Nasogastric tube
passes into the stomach and out of view. Left jugular line ends
in the mid SVC. No pneumothorax.
[**2138-8-6**] 05:08AM BLOOD WBC-13.4* RBC-3.99* Hgb-11.8* Hct-37.1*
MCV-93 MCH-29.5 MCHC-31.7 RDW-15.7* Plt Ct-213
Brief Hospital Course:
1. Locally advanced pancreatic cancer: not surgical candidate.
Has gastric outlet obstruction related to tumor. Failed duodenal
stenting X 2. Considered G-/G-J tube placement, but was not
clinically stable enough to tolerate procedure. Given rapid
progression of disease, he was no longer considered able to
tolerate Cyberknife. Palliative external beam radiation was
considered. He ultimately required NG placement and constant
suction because of nausea and vomiting. After discussions with
the family, given his rapid decompensation, goals were changed
to symptom management and transition to hospice.
2. Hypotension/hypoxia: He developed a GI bleed related to the
stent leading to hypotension which responded to IV fluid and
blood transfusion. He later had acute desaturation from
aspiration requiring MICU transfer. He responded to tracheal
suctioning. He was treated with broad spectrum antibiotics for
health care associated pneumonia
3. Hypernatremia/Nutrition: unable to tolerate food due to
gastric outlet obstruction. Given TPN, however, this was
discontinued once his central line was removed. Hypernatremia
related to dehydration, improved with IV D5W.
4. Acute on chronic renal insufficiency: related to dehydration
and hypotensive episode. Responded to hydration.
5. Disposition: after a lengthy hospitalization and rapid
progression of his disease, goals of care were changed to
symptom management. Mr. [**Known lastname **] died with his family at bedside.
Medications on Admission:
Medications at home:
- Atorvastatin 20mg daily
- Furosemide 40mg qam
- Hydrochlorothiazide 50 qam
- Doxasosin 1mg qhs
- Lorazepam 0.5-1mg Q4-6H PRN nausea
- Metoclopramide 10mg Q6-8H PRN nausea
- Ondansetron 8mg Q8H PRN nausea
- Pantoprazole 40mg [**Hospital1 **]
- Miralax 100% powder PRN constipation
- Prochlorperazine 10mg Q6-8H PRN nausea
- Docusate
- Senna
- Insulin NPH 28 units in AM, 20 units in PM
MEDS at time transfer:
#Vancomycin 1000mg q48H
#. Piperacillin-Tazobactam 2.25mg q8H
#. Octreotide 50mcg SC q8H
#. Pantoprazol gtt
#. Albuterol
#. Ipratropium
#. Heparin SC
#. APAP
#. Atorvastatin
#. Calcium carbonate
#. Citalopram 20mg
#. Doxazosin 1mg
#. Docuasate
#. Hydromorphone 0.2-0.6mg IV q3H:PRN
#. Insulin
#. Lidocaine 5% patch q12H to low back
#. Lorazepam 0.5-1mg qHS PRN
#. Magnesium sliding scale
#. Potassium sliding scale
#. Nystatin oral QID
#. Ondansetron
#. Oxycodone 5mg q6H PRN
#. Prochlorperazine 10mg IV q6H
#. Senna
#. Simethicone
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
[**Name6 (MD) **] [**Name8 (MD) 490**] MD, [**MD Number(3) 491**]
|
[
"507.0",
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"157.8",
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"276.0",
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"537.0",
"585.3",
"707.03",
"518.81",
"584.9",
"492.8",
"530.19",
"276.51"
] |
icd9cm
|
[
[
[]
]
] |
[
"46.85",
"99.15",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
7016, 7025
|
4457, 5944
|
285, 291
|
7076, 7085
|
3359, 4434
|
7141, 7246
|
2465, 2583
|
6984, 6993
|
7046, 7055
|
5970, 5970
|
7109, 7118
|
5991, 6961
|
2613, 3340
|
238, 247
|
319, 1785
|
1807, 2215
|
2231, 2449
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,307
| 170,209
|
37775
|
Discharge summary
|
report
|
Admission Date: [**2162-11-10**] Discharge Date: [**2162-12-3**]
Date of Birth: [**2078-9-8**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Doctor First Name 2080**]
Chief Complaint:
melena and anemia
Major Surgical or Invasive Procedure:
[**11-10**]-EGD, endoclips x4 of bleeding vessel in duodenal bulb
[**11-26**]: Transesophageal echocardiogram
PICC placement and removal
History of Present Illness:
84 year old gentleman with recent hx stroke in [**2162-10-21**], hx afib
now off coumadin who presents with melena and HCT drop. He has
been at [**Hospital3 **] since his stroke. Per their records he
has had guiac positive stools for the past week, with HCT drop
on [**11-4**] from 26->21 that responded to 2 units pRBC with inc HCT
to 27. There was no overt bleeding at the time. At 2am on the
day off admission to [**Hospital1 18**], he had sudden onset dark tarry
diarrhea. He was hemodynamically stable with BP 120/56 and HR
75. He received one unit pRBC's at [**Hospital1 **] prior to transfer;
he received lasix 40mg after the unit. The patient does not
know what his bowel movements have been like, but denies abd
pain, N/V, no hematemasis, no CP, no SOB, no confusion.
Review of systems is notable for slight residual weakness on the
right side, but improvement expressive aphasia. He does still
have dysarthria. Review of systems is otherwise negative as
noted in HPI. Of note, he has failed speech and swallow in early
[**11-1**], has doboff from [**Hospital1 **]. He is also being treated for
aspiration PNA at [**Hospital1 **] with levofloxacin and flagyl to end
[**11-11**].
In the emergency department, he has had one episode of melena.
HCT 20. He received one unit pRBC's, on unit FFP, vit K 5mg IV
and protonix 40mg IV. He refused NG lavage. He was HD stable. He
was seen by GI who planned for EGD. 2 18 guage IV placed. EKG
with dig effect, trop neg x1.
vital signs 83 124//44 16 98% RA
current vitals 84 133/56 21 97% RA
Past Medical History:
- HTN
- Chronic Afib
- Bilateral Hearing loss (uses bilateral hearing aids)
- chronic bilateral inguinal hernias
- Anemia (previously refused work-up, [**Last Name (un) **], but guaiac neg)
- Polyclonal Gammopathy ([**9-/2153**])
- Adenocarcinoma of RUL, s/p lobectomy ([**2144**])
Social History:
- Lives alone in an apartment.
- Widowed, son lives in [**Name (NI) 108**]
- has several grandchildren
- Does not use a walker or cane. Manages his ADLs, including
cooking his own meals.
- Retired power plant worker.
HABITS:
- Does not drink alcohol
- Does not use recreational drugs.
- He is a former smoker, gave up over 15 years ago.
- walks every day
Family History:
- Father died of an MI in his late 60s.
- Mother had a stroke in her 70s.
- FH of colon ca (father)
Physical Exam:
GENERAL: Pleasant, well appearing elderly in NAD
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD
CARDIAC: irregular rhythm, normal rate. Normal S1, S2. No
murmurs, rubs or [**Last Name (un) 549**]. JVP= 8cm
LUNGS: no labored breathing, good air movement, diffusely
ronchrous particularly on the left side
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses. .
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Speech with
mild dysarthria Preserved sensation throughout. 5/5 strength
throughout with subtle weakness on right arm. [**12-25**]+ reflexes,
equal BL. Gait assessment deferred
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
[**2162-11-10**] 02:48PM GLUCOSE-139* UREA N-64* CREAT-1.0 SODIUM-139
POTASSIUM-4.6 CHLORIDE-104 TOTAL CO2-27 ANION GAP-13
[**2162-11-10**] 02:48PM CK(CPK)-55
[**2162-11-10**] 04:05AM cTropnT-<0.01
.
[**2162-11-10**] 04:05AM WBC-9.5 RBC-2.22* HGB-6.9* HCT-20.7* MCV-93
MCH-31.1 MCHC-33.4 RDW-16.1*
.
Admission CXR:
SINGLE FRONTAL AP CHEST RADIOGRAPH: The mildly enlarged
cardiomediastinal
silhouette is stable in appearance. The pulmonary vasculature is
within
normal limits. There is persistent opacification of the left
retrocardiac
space. No new focal airspace consolidation is noted. There is
bilateral
apical pleural thickening, right worse than left. The right
costophrenic
angle is clear. There is an enteric tube traversing the expected
course of
the esophagus with the tip ending in the stomach.
IMPRESSION: Persistent opacity in the left retrocardiac space.
Cannot
exclude a superimposed pneumonia.
If clinical concern remains high, recommend repeating with PA
and lateral
chest radiograph for better assessment.
.
EGD:
Findings: Esophagus: Normal esophagus.
Stomach:
Other Blood clot noted in the stomach body, active bleeding
from pylorus, dobhoff tube pulled out.
Duodenum:
Excavated Lesions A single spurting 5 mm visible vessel with
shallow ulcer was found in the apex of duodenal bulb. 5
cc.Epinephrine 1/[**Numeric Identifier 961**] hemostasis with success. Four endoclips
were successfully applied for the purpose of hemostasis.
Impression: Ulcer in the apex of duodenal bulb (injection,
endoclip)
Blood clot noted in the stomach body, active bleeding from
pylorus, dobhoff tube pulled out.
Otherwise normal EGD to third part of the duodenum
Recommendations: Continue iv ppi
Follow Hct closely and tranfusion as needed
Please proceed with Angio if active bleeding
.
Echo [**10-18**]: The left atrium is elongated. No left atrial
mass/thrombus seen (best excluded by transesophageal
echocardiography). The right atrium is markedly dilated. There
is mild symmetric left ventricular hypertrophy with normal
cavity size and global systolic function (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Trace aortic regurgitation is seen. The
mitral valve leaflets are structurally normal. There is no
systolic prolapse. Mild (1+) mitral regurgitation is seen. There
is mild pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Biatrial elongation. Mild symmetric left ventricular
hypertrophy with preserved global and regional biventricular
systolic function.
.
EKG: irreg in afib HR 80, downward sloping ST segent in V2-V5
wnd II, scopped ST segment in V6, no ST elevations, RRBB
patterin in V2
.
Renal Ultrasound:
CONCLUSION:
1. The kidneys are of good size, with no hydronephrosis, and
good
corticomedullary differentiation.
2. Incidental note is made of a non-obstructing 2-mm calculus in
the lower
pole of the left kidney.
.
Video Swallow:
IMPRESSION:
1. Aspiration with thin liquid consistency.
2. Penetration with nectar-thick consistency which resolve with
chin tuck
maneuver.
.
TEE [**2162-11-26**]:
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. The left atrial appendage emptying velocity is
depressed (<0.2m/s). The right atrium is dilated. No atrial
septal defect is seen by 2D or color Doppler. Overall left
ventricular systolic function is normal (LVEF>55%). There are
simple atheroma in the ascending aorta. There are simple
atheroma in the aortic arch. There are simple atheroma in the
descending thoracic aorta. The aortic valve leaflets (3) are
mildly thickened. No masses or vegetations are seen on the
aortic valve. There are filamentous strands on the aortic
leaflets consistent with Lambl's excresences (normal variant).
Trace aortic regurgitation is seen. The mitral valve leaflets
are structurally normal. There is no mitral valve prolapse. No
mass or vegetation is seen on the mitral valve. Mild to moderate
([**12-25**]+) mitral regurgitation is seen. Moderate [2+] tricuspid
regurgitation is seen. No vegetation/mass is seen on the
pulmonic valve. There is a trivial/physiologic pericardial
effusion.
IMPRESSION: No vegetation identified. Mild-to-moderate mitral
regurgitation. Minimal aortic stenosis with trace aortic
regurgitation. Moderate tricuspid regurgitation.
Brief Hospital Course:
Mr. [**Known lastname 8260**] is an 84 year old gentleman with a history of recent
hemorrhagic basal ganglia stroke in [**2162-10-21**] and atrial
fibrillation (on aspirin), who presented to the ICU with melena
and significant drop in hematocrit.
.
* ACUTE BLOOD LOSS ANEMIA/GI BLEED: On presentation, the patient
had several episodes of melena, suggesting an upper GIB. He
remained hemodynamically stable. The patient was started on PPI
drip. Aspirin, Doxazosyn, Metoprolol and bowel regimen were
held. The patient received a total of 4 units of pRBC and
underwent EGD. A bleeding vessel was identified in the duodenal
bulb, epinephrine was injected and 4 endoclips were placed.
Dobhoff tube was discontinued due to GI bleed. PICC was placed
for access and the patient was started on TPN feeds.
Post-procedure, Hct was monitored closely q6hrs. The patient
continued to have several melenic stools in the ICU, but no
fresh blood per rectum. Over the next several days, the patient
required several additional units of blood for slow decreases in
Hct, however Hct eventually stabilized and the patient required
no further transfusions.
.
He was transferred to the floor on [**2162-11-15**] where his Hct has
been generally stable but a slight drift downward. His BM on
the floor became guaiac negative. He was restarted on ASA 81mg
on [**11-26**] and tolerated it well in addition to his twice daily PPI
which should be maintained.
.
*CANDIDEMIA: After his PICC had placed and TPN initiated, the
patient spiked fever. His blood cultures subsequently grew
yeast. He was started empirically on micafungin as well as
vancomycin and cefepime (the antibacterials were soon
discontinued). His yeast returned as [**Female First Name (un) **] which was senstive
to fluconazole. His TTE and TEE were negative for vegetations
and his surveillance cultures were negative. Dilated eye exam
was also unremarkable. He required antifungal therapy for 2
weeks (completed [**12-3**]). He will need a repeat dilated eye exam
during the week of [**2162-12-6**] to ensure no persistent infection.
.
* RECENT BASAL GANGLIA STROKE: Was previously hospitalized due
to hemorrhagic CVA> His warfarin was discontinued at that time
and should not be restarted. Though he was discharged on ASA,
this was held in the setting of his bleed, cautiously restarted
on [**11-26**]. On [**11-20**], the pt was noted to have worsening R sided
weakness and the neuro team was called for further evaluation.
His repeat Head CT revealed no new process, but that his basal
ganglia lesion had evolved. His neuro exam was unchanged, but
follow up recommendations were to obtain an MRI. Unfortunately,
the pt could not tolerate the MRI and he refused repeated
attempts with Ativan for claustrophobia. With treatment of his
candidemia, his neuro exam improved and was felt to be
exacerbated deficits from acute infection.
.
* ACUTE RENAL FAILURE/ATN: On [**11-24**], his creatinine rose to 1.5,
increased to the mid 2 range. Renal was consulted and felt that
his picture was consistent with ATN in the setting of his
candidemia, despite not having had a hypotensive episode. His
urine eosinophils were negative his renal ultrasound was
negative for hydronephrosis. With supportive care his
creatinine stabilized and decreased to 2. Lasix was initiated
to aid in removal of edema. His oral lasix was increased to
40mg [**Hospital1 **], and given Lasix 20mg IV with good output of [**12-25**]
liters/day. He will be discharged on Lasix 40mg [**Hospital1 **]. For the
first week he should be run negative 1 liter per day, and even
fluid balance thereafter. Please check Chem 7 2 days post D/C
and weekly thereafter until renal function recovers. Please
have strict I/Os and daily weights to aid in diuresis. Should
follow up with nephrology after discharge.
.
*AFIB: the patient was monitored on telemetry. In the ICU he
had some asymptomatic sinus bradycardia, metoprolol and digoxin
were held. Dig level checked, was actually low. Metoprolol was
and his HR has tolerated this. It is possible he may not need
digoxin at this time for rate control, his last echo also showed
normal EF. His aspirin was restarted at 81mg daily. Warfarin
is contraindicated given his hemorrhagic CVA.
.
* ASPIRATION PNA: He finished a course of Levo/Flagyl that was
started at outside facility on [**11-11**]. However, the following
day, the patient was noted to have increased leukocytosis and
secretions, some evidence of retrocardiac opacification, with
increased concern for aspiration in the setting of recent EGD,
was started on Vanc, Cefepime and Flagyl to cover for hospital
acquired and aspiration PNA. Over the next several days, Flagyl
and Cefepime were discontinued as the patient remained afebrle
with no positive cultures and no clear evidence of PNA. Vanco
was continued as MRSA grew from sputum. He completed a 7 day
course of vanco.
.
* NUTRITION: At rehab the patient was receiving tube feeds via
Dubhoff tube due to recent failing a recent swallow evaluation
early [**11-1**], given recent CVA. He was reassessed this admission
and showed some improvement in video swallow study. He was
started on nectar thick liquids, ground solids, crushed pills,
with 1:1 observation with chin tuck for ALL po's.
.
*Hx COPD: We continued outpatient nebs. At the time of
discharge, the patient is able to ambulate without SOB or
difficulty.
.
# BPH - Resumed doxazosin which he tolerated well
.
Says his PCP is [**First Name8 (NamePattern2) 4115**] [**Last Name (NamePattern1) 36037**]. Call placed to PCP and have
updated her on his hospitalization as of [**11-19**]
.
daughter-in-law [**Name (NI) 5627**] ([**2162-11-19**]) [**Telephone/Fax (1) 84583**].
.
Code: DNR/DNI
Medications on Admission:
1. Acetaminophen 325 mg Tablet [**Telephone/Fax (1) **]: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever.
2. Docusate Sodium 50 mg/5 mL Liquid [**Telephone/Fax (1) **]: One (1) PO BID (2
times a day).
3. Multivitamin Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO DAILY (Daily).
4. Ascorbic Acid 500 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO DAILY
(Daily).
5. Calcium Carbonate 500 mg Tablet, Chewable [**Telephone/Fax (1) **]: One (1)
Tablet, Chewable PO DAILY (Daily).
6. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Telephone/Fax (1) **]: One (1)
Tablet PO DAILY (Daily).
7. Senna 8.6 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Telephone/Fax (1) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
9. Ipratropium Bromide 0.02 % Solution [**Telephone/Fax (1) **]: One (1) Inhalation
Q6H (every 6 hours) as needed for sob wheezing.
10. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Telephone/Fax (1) **]: One (1) Inhalation Q6H (every 6 hours) as
needed for sob/wheezing.
11. Digoxin 250 mcg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO DAILY (Daily).
12. Metoprolol Tartrate 25 mg Tablet [**Telephone/Fax (1) **]: 0.5 Tablet PO TID (3
times a day): hold for HR < 55.
13. Captopril 12.5 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO TID (3 times
a day).
14. Doxazosin 4 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO HS (at
bedtime).
15. HydrALAzine 10 mg IV Q6H:PRN SBP > 160
16. Levofloxacin 500 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO Q24H
(every 24 hours) for 7 days: Duration: 7 Days
Day 1 = [**10-16**]
.
17. Metronidazole 500 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO TID (3
times a day) for 7 days: 7 Days
Day 1 = [**10-16**]
Discharge Medications:
1. Doxazosin 4 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO HS (at bedtime).
Disp:*30 Tablet(s)* Refills:*2*
2. Metoprolol Tartrate 25 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Aspirin 81 mg Tablet, Chewable [**Month/Year (2) **]: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Month/Year (2) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constip.
5. Acetaminophen 325 mg Tablet [**Month/Year (2) **]: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
6. Combivent 18-103 mcg/Actuation Aerosol [**Month/Year (2) **]: 1-2 puffs
Inhalation every six (6) hours as needed for shortness of breath
or wheezing.
Disp:*1 inhaler* Refills:*2*
7. Multivitamin Tablet [**Month/Year (2) **]: One (1) Tablet PO once a day.
8. Docusate Sodium 50 mg/5 mL Liquid [**Month/Year (2) **]: One (1) dose PO BID (2
times a day).
9. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR PO BID (2 times a day).
Disp:*60 Tablet,Rapid Dissolve, DR(s)* Refills:*2*
10. Furosemide 40 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO twice a day.
11. Digoxin 125 mcg Tablet [**Last Name (STitle) **]: One (1) Tablet PO 3X/WEEK
(MO,WE,FR).
12. Menthol-Cetylpyridinium 3 mg Lozenge [**Last Name (STitle) **]: One (1) Lozenge
Mucous membrane PRN (as needed) as needed for dry mouth.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Nursing & rehab
Discharge Diagnosis:
Acute blood loss anemia/GI Bleed
Peptic Ulcer disease
Acute renal failure/acute tubular necrosis
[**Female First Name (un) 564**] albicans fungemia
h/o hemorrhagic CVA
Atrial fibrillation
Hypertension, benign
Discharge Condition:
Activity Status:Ambulatory - requires assistance or aid (walker
or cane)
Discharge Instructions:
You were admitted with a GI bleed due to an ulcer, as well as a
fungal infection in your blood stream. Your were given blood
transfusions and acid blocking medication with resolution of
your bleeding. Your fungal infection (candidemia) was treated
with 2 weeks of fluconazole, finished [**2162-12-3**]. Your aspirin
was restarted at the advice of your neurologist. Finally, you
have suffered acute kidney injury from your medical illness.
.
Please resume your home medications as before and take as
prescribed, including a baby aspirin, with the following
changes:
Aspirin 81mg daily
Metoprolol 25mg twice daily
Digoxin 0.125mg 3x/week
Protonix 40mg twice daily
Lasix 40mg twice daily. Please titrate as needed to provide a
diuresis of 1 liter negative for the first 7 days.
.
You will need a dilated eye exam during the week of [**2162-12-6**] to
ensure there is no fungal infection there.
.
Please return to the hospital if you experience any of the
symptoms mentioned below.
Followup Instructions:
Please follow up with your PCP 2 weeks after discharge:
PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 82063**]
.
Please follow up with an ophthalmologist for your dilated eye
exam during the week of [**2162-12-6**]
.
Please follow up with your gastroenterologist and neurologist as
needed
.
Patient will need to follow up with a nephrologist to monitor
his kidney function. Can call [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4883**] to schedule an
appointment in this area: ([**Telephone/Fax (1) 10135**]
|
[
"584.5",
"V10.11",
"401.9",
"428.0",
"438.82",
"285.1",
"276.1",
"707.03",
"532.40",
"599.70",
"112.89",
"707.22",
"276.7",
"427.31",
"600.00",
"787.20",
"507.0",
"V15.82",
"482.42"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"88.72",
"99.15",
"44.43"
] |
icd9pcs
|
[
[
[]
]
] |
17415, 17474
|
8223, 13982
|
334, 472
|
17727, 17802
|
3673, 8200
|
18833, 19418
|
2741, 2842
|
15922, 17392
|
17495, 17706
|
14008, 15899
|
17826, 18810
|
2857, 3654
|
277, 296
|
500, 2046
|
2068, 2352
|
2368, 2725
|
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