subject_id
int64 12
100k
| _id
int64 100k
200k
| note_id
stringlengths 1
41
| note_type
stringclasses 4
values | note_subtype
stringclasses 35
values | text
stringlengths 449
78.2k
| diagnosis_codes
listlengths 1
39
| diagnosis_code_type
stringclasses 1
value | diagnosis_code_spans
listlengths 1
21
| procedure_codes
listlengths 0
35
| procedure_code_type
stringclasses 1
value | procedure_code_spans
listlengths 1
5
| Discharge Disposition:
stringlengths 0
12
| Brief Hospital Course:
stringlengths 0
12
| Discharge Diagnosis:
stringclasses 1
value | Major Surgical or Invasive Procedure:
stringlengths 0
12
| Discharge Condition:
stringlengths 0
12
| Past Medical History:
stringclasses 1
value | History of Present Illness:
stringclasses 1
value | Social History:
stringclasses 1
value | Physical Exam:
stringclasses 1
value | Pertinent Results:
stringlengths 0
12
| Discharge Instructions:
stringclasses 1
value | Medications on Admission:
stringclasses 1
value | Followup Instructions:
stringlengths 0
12
| Family History:
stringlengths 0
12
| Discharge Medications:
stringclasses 1
value | DISCHARGE DIAGNOSES:
stringlengths 0
12
| PAST MEDICAL HISTORY:
stringclasses 1
value | DISCHARGE MEDICATIONS:
stringlengths 0
12
| [**Hospital 93**] MEDICAL CONDITION:
stringlengths 0
12
| DISCHARGE DIAGNOSIS:
stringlengths 0
12
| MEDICATIONS ON DISCHARGE:
stringclasses 983
values | MEDICATIONS ON ADMISSION:
stringlengths 0
12
| Cranial Nerves:
stringclasses 1
value | HOSPITAL COURSE:
stringlengths 0
12
| FINAL DIAGNOSIS:
stringclasses 974
values | CARE RECOMMENDATIONS:
stringclasses 32
values | DISCHARGE INSTRUCTIONS:
stringlengths 0
12
| PAST SURGICAL HISTORY:
stringclasses 1
value | DISCHARGE LABS:
stringclasses 1
value | Discharge Labs:
stringclasses 1
value | What to report to office:
stringclasses 286
values | Secondary Diagnosis:
stringclasses 1
value | ADMISSION MEDICATIONS:
stringclasses 204
values | DISCHARGE INSTRUCTIONS/FOLLOWUP:
stringclasses 212
values | Review of systems:
stringclasses 1
value | CARE AND RECOMMENDATIONS:
stringclasses 18
values | On Discharge:
stringclasses 1
value | Neurologic examination:
stringclasses 1
value | Discharge labs:
stringlengths 0
12
| Secondary Diagnoses:
stringclasses 1
value | On discharge:
stringclasses 1
value | [**Last Name (NamePattern4) 2138**]p Instructions:
stringclasses 138
values | HOSPITAL COURSE BY SYSTEM:
stringclasses 79
values | HOSPITAL COURSE BY SYSTEMS:
stringclasses 67
values | MEDICATIONS AT HOME:
stringclasses 429
values | MEDICATIONS ON TRANSFER:
stringclasses 1
value | Secondary diagnoses:
stringclasses 1
value | Secondary diagnosis:
stringclasses 1
value | TRANSITIONAL ISSUES:
stringclasses 1
value | PATIENT/TEST INFORMATION:
stringclasses 174
values | IMMUNIZATIONS RECOMMENDED:
stringclasses 1
value | -Cranial Nerves:
stringclasses 297
values | Transitional Issues:
stringclasses 1
value | Incision Care:
stringclasses 388
values | Past Surgical History:
stringlengths 0
12
| Discharge Exam:
stringclasses 1
value | DISCHARGE EXAM:
stringclasses 1
value | Labs on Discharge:
stringclasses 1
value | REGIONAL LEFT VENTRICULAR WALL MOTION:
stringclasses 171
values | PHYSICAL EXAM:
stringlengths 0
12
| Medication changes:
stringclasses 1
value | Physical Therapy:
stringclasses 313
values | Treatments Frequency:
stringclasses 226
values | SECONDARY DIAGNOSES:
stringlengths 0
12
| 2. CARDIAC HISTORY:
stringclasses 715
values | HOME MEDICATIONS:
stringclasses 441
values | Chief Complaint:
stringclasses 1
value | FINAL DIAGNOSES:
stringclasses 83
values | DISCHARGE PHYSICAL EXAM:
stringclasses 1
value | ACID FAST CULTURE (Preliminary):
stringclasses 214
values | Wound Care:
stringclasses 1
value | Blood Culture, Routine (Preliminary):
stringclasses 146
values | Discharge exam:
stringclasses 736
values | Neurologic Examination:
stringclasses 1
value | Discharge Physical Exam:
stringclasses 1
value | ACTIVE ISSUES:
stringclasses 1
value | CLINICAL IMPLICATIONS:
stringclasses 128
values | FUNGAL CULTURE (Preliminary):
stringclasses 365
values | FOLLOW UP:
stringclasses 645
values | PREOPERATIVE MEDICATIONS:
stringclasses 71
values | RESPIRATORY CULTURE (Preliminary):
stringclasses 133
values | SUMMARY OF HOSPITAL COURSE:
stringclasses 286
values | Labs on discharge:
stringclasses 1
value | MEDICATIONS PRIOR TO ADMISSION:
stringclasses 144
values | HOSPITAL COURSE BY ISSUE/SYSTEM:
stringclasses 131
values | SECONDARY DIAGNOSIS:
stringclasses 1
value | FOLLOW-UP APPOINTMENTS:
stringclasses 47
values | Cardiac Enzymes:
stringclasses 1
value | OUTPATIENT MEDICATIONS:
stringclasses 106
values | Review of Systems:
stringclasses 1
value | ADMISSION DIAGNOSES:
stringclasses 50
values | MEDICATION CHANGES:
stringclasses 1
value | Blood Culture, Routine (Pending):
stringclasses 88
values | TECHNICAL FACTORS:
stringclasses 60
values | PHYSICAL EXAMINATION:
stringlengths 0
12
| [**Last Name (NamePattern4) 4125**]ospital Course:
stringclasses 40
values | ADMISSION DIAGNOSIS:
stringclasses 115
values | Physical Exam on Discharge:
stringclasses 198
values | At discharge:
stringlengths 0
12
| RECOMMENDED IMMUNIZATIONS:
stringclasses 3
values | ON DISCHARGE:
stringlengths 0
12
| CHRONIC ISSUES:
stringclasses 1
value | Immediately after the operation:
stringclasses 71
values | Transitional issues:
stringclasses 965
values | FOLLOW-UP PLANS:
stringclasses 188
values | Changes to your medications:
stringclasses 809
values | Upon discharge:
stringclasses 1
value | REVIEW OF SYSTEMS:
stringlengths 0
12
| CARDIAC ENZYMES:
stringclasses 1
value | Cardiac enzymes:
stringclasses 361
values | Medication Changes:
stringclasses 665
values | [**Location (un) **] Diagnosis:
stringclasses 49
values | ACID FAST CULTURE (Pending):
stringclasses 59
values | Discharge PE:
stringclasses 99
values | General Discharge Instructions:
stringclasses 84
values | INDICATIONS FOR CATHETERIZATION:
stringclasses 54
values | WHEN TO CALL YOUR SURGEON:
stringclasses 31
values | Neurological Exam:
stringclasses 73
values | Exam on Discharge:
stringclasses 1
value | CHIEF COMPLAINT:
stringlengths 0
12
| REASON FOR THIS EXAMINATION:
stringlengths 0
12
| Relevant Imaging:
stringclasses 55
values | Active Issues:
stringclasses 353
values | [**Location (un) **] Condition:
stringclasses 42
values | RECOMMENDATIONS AFTER DISCHARGE:
stringclasses 2
values | [**Hospital1 **] Disposition:
stringclasses 38
values | TRANSITIONAL CARE ISSUES:
stringclasses 69
values | [**Hospital1 **] Medications:
stringclasses 41
values | [**Location (un) **] Instructions:
stringclasses 40
values | WOUND CULTURE (Preliminary):
stringclasses 63
values | DISCHARGE FOLLOWUP:
stringclasses 182
values | LABS ON DISCHARGE:
stringclasses 566
values | POST CPB:
stringclasses 1
value | URINE CULTURE (Preliminary):
stringclasses 70
values | Review of sytems:
stringclasses 249
values | Labs at discharge:
stringclasses 119
values | Immunizations recommended:
stringclasses 34
values | AEROBIC BOTTLE (Pending):
stringclasses 26
values | -Rehabilitation/ Physical Therapy:
stringclasses 39
values | FOLLOW UP APPOINTMENTS:
stringclasses 38
values | Mental Status:
stringclasses 1
value | Admission labs:
stringclasses 1
value | HOSPITAL COURSE BY PROBLEM:
stringclasses 131
values | [**Hospital 5**] MEDICAL CONDITION:
stringclasses 14
values | PHYSICAL EXAM UPON DISCHARGE:
stringclasses 47
values | WOUND CARE:
stringclasses 425
values | ANAEROBIC BOTTLE (Pending):
stringclasses 25
values | CURRENT MEDICATIONS:
stringclasses 82
values | FOLLOW-UP APPOINTMENT:
stringclasses 54
values | FINAL DISCHARGE DIAGNOSES:
stringclasses 23
values | TRANSFER MEDICATIONS:
stringclasses 76
values | Upon Discharge:
stringclasses 230
values | HISTORY OF PRESENT ILLNESS:
stringlengths 0
12
| CRANIAL NERVES:
stringlengths 0
12
| CT head:
stringclasses 1
value | Exam on discharge:
stringclasses 111
values | CT Head:
stringclasses 955
values | [**Location (un) **] PHYSICIAN:
stringclasses 130
values | Admission Labs:
stringclasses 1
value | secondary diagnosis:
stringlengths 0
12
| Head CT:
stringclasses 601
values | MRA OF THE HEAD:
stringclasses 48
values | INACTIVE ISSUES:
stringclasses 124
values | ADMISSION LABS:
stringlengths 0
12
| PROBLEM LIST:
stringclasses 49
values | PRIMARY DIAGNOSIS:
stringlengths 0
12
| OTHER PERTINENT LABS:
stringclasses 91
values | PROBLEMS DURING HOSPITAL STAY:
stringclasses 1
value | Medication Instructions:
stringclasses 48
values | IRON AND VITAMIN D SUPPLEMENTATION:
stringclasses 6
values | On admission:
stringlengths 0
12
| ANAEROBIC CULTURE (Preliminary):
stringclasses 227
values | MENTAL STATUS:
stringlengths 0
12
| ADMITTING DIAGNOSIS:
stringclasses 69
values | TRANSITIONS OF CARE:
stringclasses 92
values | Pertinent Labs:
stringclasses 205
values | 3. OTHER PAST MEDICAL HISTORY:
stringclasses 667
values | # Transitional issues:
stringclasses 71
values | [**Hospital1 **] Diagnosis:
stringclasses 24
values | Chronic Issues:
stringclasses 245
values | FOLLOW-UP INSTRUCTIONS:
stringclasses 101
values | CARE AND RECOMMENDATIONS AT DISCHARGE:
stringclasses 2
values | HOSPITAL COURSE: By systems:
stringclasses 1
value | NEUROLOGIC EXAMINATION:
stringclasses 339
values | Treatment Frequency:
stringclasses 26
values | Neurologic Exam:
stringclasses 63
values | DISCHARGE PLAN:
stringclasses 62
values | Active Diagnoses:
stringclasses 63
values | Medications on transfer:
stringclasses 568
values | Past medical history:
stringlengths 0
12
| SOCIAL HISTORY:
stringlengths 0
12
| CONDITION ON DISCHARGE:
stringlengths 0
12
| FLUID CULTURE (Preliminary):
stringclasses 112
values | Meds on transfer:
stringclasses 242
values | Exam upon discharge:
stringclasses 35
values | Other labs:
stringclasses 142
values | Discharge physical exam:
stringclasses 473
values | [**Hospital1 **] Instructions:
stringclasses 22
values | Imaging Studies:
stringclasses 111
values | Post CPB:
stringclasses 96
values |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
9,056
| 198,782
|
13164
|
Discharge summary
|
report
|
Admission Date: [**2132-10-1**] Discharge Date: [**2132-10-4**]
Service: Medicine
HISTORY OF PRESENT ILLNESS: The patient is an 85 year old
man, status post a recent admission at [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **]
[**First Name (Titles) **] [**Last Name (Titles) **] for a left basal ganglia bleed resulting in
ventricular drain. He was discharged on [**2132-9-29**] to
a rehabilitation facility, awake, alert and able to move all
The [**Hospital 228**] hospital course at [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **]
[**First Name (Titles) **] [**Last Name (Titles) **] was complicated at that time by a fluctuating
mental status and syndrome of inappropriate diuretic hormone.
At the time of admission, the patient's family visiting at
rehabilitation felt he was less responsive according to the
outside hospital Emergency Room. He was sent to [**Hospital1 **]
intubated for vague reasons and transferred to [**First Name4 (NamePattern1) 3867**]
[**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **].
In the Emergency Room at [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **]
[**Last Name (Titles) **], the patient was evaluated by neurosurgery, who felt
his ventricles were stable, and he was admitted to the
Medical Intensive Care Unit for additional evaluation of
mental status and ventricular management. There is no report
of fever, cough, nausea or vomiting.
PAST MEDICAL HISTORY: 1. Hypercholesterolemia. 2. Left
basal ganglial bleed. 3. Coronary artery disease, status
post coronary artery bypass grafting. 4. Syndrome of
inappropriate diuretic hormone.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS ON ADMISSION: Zocor, Protonix, Lopressor 25 mg
p.o.b.i.d., salt tablets 2 gm p.o.b.i.d., and 800 cc fluid
restriction.
SOCIAL HISTORY: The patient lives with his wife. [**Name (NI) **] drinks
approximately four to five alcoholic drinks per week. He is
currently staying at [**Hospital 25576**] Rehabilitation.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION: On physical examination in the
Emergency Room, the patient had a temperature of 96.6, heart
rate 107 to 128, blood pressure 116/80, respiratory rate 14
and oxygen saturation 96% on 40% FiO2. General: Arousable,
following commands, intubated, coughing with suctioning.
Head, eyes, ears, nose and throat: Dry mucous membranes,
pupils reactive. Lungs: Clear to auscultation bilaterally.
Cardiovascular: Sinus tachycardia, no murmur, rub or gallop.
Abdomen: Soft, nontender, positive bowel sounds.
Extremities: No edema. Neurologic: 1+ reflexes, moving all
extremities, with a gag, good hand grip.
LABORATORY DATA: Admission white blood cell count was 13.2
with 80 neutrophils, 12 lymphocytes, 5 monocytes and 1
eosinophil, hematocrit 39.5, platelet count 373,000,
prothrombin time 12.5, partial thromboplastin time 24.3 and
INR 1.1. Urinalysis: Large blood, 30 protein, 6 to 10 white
blood cells, few bacteria, no epithelial cells. Sodium was
137, potassium 3.5, chloride 95, bicarbonate 31, BUN 36,
creatinine 0.9 and glucose 132. Chest x-ray: Increased
heart size potentially on AP view, no infiltrate, no
effusion. Head CT: Stable ventricular size as per
neurosurgery.
HOSPITAL COURSE: The patient was admitted to the Medical
Intensive Care Unit for further management. In the Intensive
Care Unit, the patient was quickly weaned down to minimal
ventilator settings and then extubated without complications.
Due to the fact that his urinalysis returned 6 to 10 white
blood cells with few bacteria, a course of levofloxacin was
started for a urinary tract infection. Urine culture
ultimately showed no growth. Blood cultures were also drawn
but had no growth to date. The patient remained afebrile in
the Medical Intensive Care Unit.
On hospital day number two, the patient's mental status was
noted to significantly improve, with the ability to move all
of his extremities and answer questions, although he was not
aware of events leading to his hospitalization. Due to
concern about the initial presentation of delta multiple
sclerosis, a lumbar puncture was performed, which revealed 17
white blood cells, 1,500 red blood cells with a differential
of 17 polycytes, 39 lymphocytes, 20 monocytes, 3 eosinophils,
1 basophil and 20 macrophages. Cerebrospinal fluid cultures
were sent, which grew nothing during the hospitalization.
The findings on cerebrospinal fluid were deemed not particularly
worrisome given the patient's recent history of instrumentation.
On hospital day number two, the patient was transferred to
the medicine service, where he continued on levofloxacin for
his urinary tract infection. On hospital day number three,
the patient's Foley was discontinued and he was able to
spontaneously void by the end of that day.
By hospital day number three, the patient had begun to take
good oral intake and was tolerating a cardiac diet. Of note,
the patient's hyponatremia had resolved by hospital day
number two, with a sodium of 140. A physical therapy consult
was ordered and the patient began to ambulate.
CONDITION AT DISCHARGE: Stable.
DISCHARGE STATUS: Full code; discharged to [**Hospital 25576**]
Rehabilitation.
DISCHARGE DIAGNOSIS:
Urinary tract infection.
DISCHARGE MEDICATIONS:
Levaquin 500 mg p.o.q.d. times five days.
Zocor 40 mg p.o.q.h.s.
Lopressor 25 mg p.o.b.i.d.
Protonix 40 mg p.o.q.d.
FOLLOW-UP: The patient is to follow up with Dr. [**Last Name (STitle) 6910**]
in three weeks at [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **]. The
patient is to follow up with Dr. [**First Name4 (NamePattern1) 13740**] [**Last Name (NamePattern1) **], his primary
care physician, [**Name10 (NameIs) **] one to two weeks.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4446**]
Dictated By:[**Last Name (NamePattern1) 40156**]
MEDQUIST36
D: [**2132-10-3**] 03:54
T: [**2132-10-3**] 18:55
JOB#: [**Job Number **]
|
[
"427.89",
"272.0",
"276.1",
"276.8",
"599.0",
"V45.81",
"V45.2",
"788.20",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
2128, 2146
|
5411, 6168
|
5362, 5388
|
1810, 1916
|
3375, 5235
|
2169, 3301
|
5250, 5341
|
122, 1523
|
3311, 3357
|
1546, 1783
|
1933, 2111
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,227
| 188,061
|
21615
|
Discharge summary
|
report
|
Admission Date: [**2133-7-2**] Discharge Date: [**2133-7-8**]
Date of Birth: [**2063-8-21**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name8 (NamePattern2) 812**]
Chief Complaint:
CHIEF COMPLAINT: R flank pain, N/V, ARF
Major Surgical or Invasive Procedure:
Central venous catheter
Right Percutaneous Nephrostomy Tube Placement
Right and left percutaneous nephrostomy tube replacement
History of Present Illness:
Mr. [**Known lastname 12021**] is a 69 y.o. M with hypertension, prostate cancer
s/p XRT 3 years ago, s/p L percutaneous nephrostomy for
hydronephrosis secondary to retroperitoneal fibrosis, who
presents with R flank pain, nausea, vomiting, and acute renal
failure.
From [**6-9**] - [**2133-6-17**], the patient was admitted with hematuria on
the medicine service. He presented passing large clots of blood
in his urine with intermittent hematuria since Novemver [**2132**].
Hematuria was thought to be due to renal stones. He developed
worsening of his L flank pain and presented to the [**Hospital1 18**] ED.
During hospitalization, foley placed and CBI started.
Ciprofloxacin was also started for positive UA. Cr was elevated
to 3.4. CT showed B/L renal enlargement with perinephric
stranding and hydronephrosis without obstructing stone. Cr
trended downward after Foley placed, but then increased likely
due to obstruction; thus L percutaneous nephrostomy tube was
placed on [**2133-6-12**]. His hydronephrosis was thought to be
obstructive in nature, likely chronic due to RP fibrosis. For
his pyelonephritis, he was treated with cipro for pan-sensitive
e.coli x 10 days. Discharged with urology f/u for possible
permanent indwelling NU tubes will be needed.
The patient presented on day of admission due to increasing R
flank pain, nausea/vomiting, and weakness. His malaise and
weakness started 3 days ago. He has been checking for fevers at
home and his highest temperature was 98.0. Since yesterday
overnightat 10 PM, he had chills, nausea, vomiting (2-3 times)
with decreased po intake. He noted that his L nephrostomy tube
has had lower UOP. He also found it difficult to start his urine
stream yesterday. Denies dysuria or hematuria. His R sided flank
pain is [**9-17**] and sharp. Using a heating pad and taking a
percocet helped with the pain somewhat. His L sided flank pain
is a [**2134-4-12**] but has been chronic for last 3 months. These
symptoms are the same as his symptoms when he was previously
hospitalized.
In the ED, initial VS: T 98.3 HR 106 BP 115/64 RR 17 O2 96% RA.
Per [**Last Name (LF) **], [**First Name3 (LF) **] and automatic cuffs did not correlate with manual
BP rading 125/70 and automatic cuff [**Location (un) 1131**] 68/40. Labs drawn
and significant for leukocytosis 11.7 with 13% bands, anemia of
28.1, total bilirubin of 1.6, hyperkalemia of 5.4, BUN/Cr 55/3.7
and lactate 1.8. Foley placed. UA via straight cath, Urine
culture, Blood cultures sent. CT abd/pelvis performed with R
sided hydronephrosis. Received 4 L NS. UOP 320 cc.Given morphine
4 mg IV x 1, zofran 4 mg IV x 1, albuterol neb x 1,
ciprofloxacin 400 mg IV x 1, acetaminophen 1 gm x 1. RIJ placed
and confrimed with CXR. Also with 16g and 18g PIVs. CVP 13 on
transfer to MICU.
Past Medical History:
- Hypertension
- Prostate cancer
- Hyperlipidemia
- Non-insulin-dependent diabetes
- Asthma
- Chronic low back pain secondary to disc herniation
- left lung nodule on CT
Social History:
Previous cocaine/alcohol abuse; no longer smokes, uses alcohol
or drugs
Family History:
Non-contributory
Physical Exam:
MICU ADMISSION:
VITAL SIGNS: T 97.7 BP 108/63 HR 108 RR 26 CVP 13
GEN: pleasant jovial obese gentleman lying in bed shivering
HEENT: anicteric, EOMI, PERRL, OP - no exudate, no erythema,
MMM, no cervical LAD
CHEST: CTAB, no w/r/r
CV: tachy, no m/r/g
ABD: slightly distended, soft, decreased BS, NT
EXT: no c/c/e
NEURO: A&O x 3
DERM: no rashes
BACK: mild L sided CVA tenderness, moderate R sided CVA
tenderness
ARRIVAL TO MEDICAL FLOOR:
VITAL SIGNS: T 96.3 BP 109/70 HR 97 RR 20 O2 95 RA
GEN: pleasant, just showered, sitting on edge of bed, NAD
HEENT: anicteric, EOMI, PERRL, OP - no exudate, no erythema, MMM
CV: RRR, no m/r/g
CHEST: CTAB, no w/r/r
ABD: protuberant, tympanic, non-tender hypoactive bowel
EXT: no clubbing or cyanosis, 1+ pitting edema to ankles
bilaterally, DPI
NEURO: A&O x 3
DERM: no rashes
BACK: no CVA tenderness, dressings for nephrostomy tubes intact
L and R. R draining slightly pink but clear urine. L draining
clear yellow urine.
Pertinent Results:
<b><u>LABS</b></u>
<b>CBC</b>
[**2133-7-2**]
WBC-11.7* / Hgb-9.1* / Hct-28.1* / MCV-88 / Plt Ct-197
N 70 Band 13 L 9 M 4 E 1 Bas 0 Metas 3
[**2133-7-3**]
WBC-7.7 / Hgb-7.3* / Hct-22.2* / MCV-88 / Plt Ct-143*
Fibrino-641*, Ret Aut-1.7, LD(LDH)-166, Hapto-239*
[**2133-7-4**]
WBC-4.5 /Hgb-7.8* / Hct-24.5* / MCV-88 / Plt Ct-131*
[**2133-7-6**]
WBC-5.2 / Hgb-7.8* / Hct-24.0* / MCV-88 / Plt Ct-159
[**2133-7-7**]
WBC-6.3 / Hgb-7.5* / Hct-23.3* / MCV-89/ Plt Ct-175
[**2133-7-8**]
WBC-7.7 / Hgb-9.5*# / Hct-29.3*# / MCV-88 / Plt Ct-237
<b>Chemistry</b>
[**2133-7-2**]
Glucose-159* UreaN-55* <u>Creat-3.7*#</u> Na-138 K-5.4* Cl-100
HCO3-26 AnGap-17
[**2133-7-3**]
Glucose-142* UreaN-53* <u>Creat-3.4*</u> Na-136 K-4.6 Cl-106
HCO3-20* AnGap-15
[**2133-7-4**]
Glucose-165* UreaN-49* <u>Creat-2.9*</u> Na-133 K-4.4 Cl-104
HCO3-19* AnGap-14
[**2133-7-5**]
Glucose-142* UreaN-46* <u>Creat-2.7*</u> Na-135 K-4.4 Cl-104
HCO3-22 AnGap-13
[**2133-7-6**]
Glucose-135* UreaN-43* <u>Creat-2.4*</u> Na-136 K-4.1 Cl-104
HCO3-21* AnGap-15
[**2133-7-7**]
Glucose-141* UreaN-39* <u>Creat-2.3*</u> Na-137 K-4.0 Cl-106
HCO3-23 AnGap-12
[**2133-7-8**]
Glucose-135* UreaN-36* <u>Creat-2.1*</u> Na-138 K-4.3 Cl-106
HCO3-24 AnGap-12
<b>Urine</b>
UA ([**7-2**]): mod leuk, lg blood, nit positive, ketone neg, 0-2
RBC, >50 WBC, fewe bact, 0-2 epis
<b>Microbiology</b>
Urine:
[**7-2**]: E Coli (pan-sensitive)
[**7-3**]: negative
Blood:
[**7-2**]: [**2-9**] anaerobic with E Coli (pan-sensitive)
[**7-3**]: negative to date
[**7-4**]: [**1-9**] aerobic with coagulase negative staph
[**7-5**]: negative to date
<b><u>STUDIES</b></u>
CT ABD/PELVIS WO CONTRAST [**7-2**]
IMPRESSION:
1. Increased perinephric and periureteral stranding on the right
with mild
hydronephrosis and hydroureter. Stranding likely due to
progression of known retroperitoneal fibrosis but underlying
infection cannot be excluded. No renal or ureteral calculi
identified.
2. Status post nephrostomy on the left with decompression and no
residual
hydronephrosis.
3. Hiatal hernia and esophageal wall thickening raises concern
for
esophagitis.
RENAL ULTRASOUND [**7-4**]:
no evidence of abscess
Brief Hospital Course:
1. Hypotension/Sepsis due to E Coli bacteremia
Patient had hypotension, bandemia, fever 101.1, and urinalysis
suggestive of urinary tract infection. He was admitted to the
MICU and was given fluids but did not require pressors. His
blood and urine cultures grew pansensitive E. coli. He was
treated with ciprofloxacin for a planned 14 day course.
Surveillance blood cultures remain NGTD, except for one of two
aerobic cultures from [**7-4**] which grew coagulase negative staph
which is felt to have been a contaminant as cultures from [**7-5**]
have been negative and only one of the set of cultures was
positive. He will be discharged with ciprofloxacin 500 Qday
(dosed for renal insufficiency) to complete a 14-day course.
2. Hydronephrosis
Likely secondary to retroperitoneal fibrosis resulting from XRT
for prostate cancer. Per urology instruction, had right sided
nephrostomy tube placed by IR with good result. He had a Foley
which was removed on [**7-4**]. He reported seeing scant urine in his
"Depends" daily. On [**7-6**], the left nephrostomy tube was not
producing output and was not able to be flushed by IR. Both the
left and right tubes were replaced by IR on [**7-7**]. The right tube
was functioning, but was found to have an extra subcutaneous
loop which may have been causing the patient discomfort. On
discharge both nephrostomies were draining well and the urine
was not bloody.
3. Acute renal failure
Secondary to upper GU obstruction. Now with bilateral
percutaneous nephrostomies. Creatinine trended downward during
hopital stay. Medications were renally dosed and nephrotoxins
were avoided. BPH medications were continued.
4. Hypertension
Antihypertensives were held for hypotension. On [**7-5**], the
patient's blood pressure was 140s/80s and his amlodipine was
restarted. His benazepril was held until discharge.
5. Anemia
Baseline HCT is mid-high 20s and he came in dehydrated. On
[**7-4**], his hematocrit was 21% and he was transfused 1 unit of
packed red blood cells. He was also transfused on [**7-7**] for
graudally falling hematocrit (23.3% on [**7-7**]). Anemia was felt to
be secondary to chronic kidney disease. There was no evidence of
acute bleeding.Iron studies from early [**Month (only) **] were consistent with
anemia of chronic disease.
6. Non-Insulin Dependent Diabetes - Held oral hypoglycemics
while in house and patient placed on insulin sliding scale. Will
discharge on home medications.
7. Hyperlipidemia - Statin continued.
8. Asthma - Albuterol and ipratroprium continued.
9. Chronic low back pain - Secondary to disc herniation.
Percocet continued.
10. GERD - Secondary to hiatal hernia, esophageal thickening on
CT. Continued omeprazole.
11. 2 lung nodules in left base stable on repeat CT.
Medications on Admission:
Finasteride 5 mg po daily
Amlodipine 2.5 mg po daily
Oxycodone-Acetaminophen 5-325 mg po q6 hours x 10 days (last day
[**7-3**])
Prilosec 20 mg po BID
Simvastatin 20 mg po daily
Tamsulosin SR 0.4 mg po qhs
Glyburide 5 mg po BID
ProAir 90 mcg 2 puffs QID prn wheeze
Lotensin 40 mg po daily
Discharge Medications:
1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
2. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed for pain for 7 days.
Disp:*30 Tablet(s)* Refills:*0*
7. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 8 days.
Disp:*8 Tablet(s)* Refills:*0*
8. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
10. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q4H (every 4 hours) as needed for
SOB/wheezing.
11. Benazepril 40 mg Tablet Sig: One (1) Tablet PO once a day.
12. Glyburide 5 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary: Sepsis secondary to urinary tract infection,
Hydronephrosis, Acute Renal Failure
Secondary: Hypertension, Hyperlipidemia, Asthma, GERD, Low back
pain, Diabetes Mellitis Type 2
Discharge Condition:
Good
Discharge Instructions:
You were admitted to the hospital because you had an infection
in your kidney. The infection had spread to your blood and that
is why you spent several days in the intensive care unit. You
had a tube in your left kidney from your last hospitalization
and one was placed into your right kidney during this
hospitalization. You need the tubes because the urine that is
produced by your kidneys does not flow to your bladder easily.
This probably results from scar tissue from the radiation for
your prostate cancer, but the Urology procedure on [**7-21**]
will investigate this further. During your stay, your left
nephrostomy tube stopped draining. Both the left and the right
tubes were replaced by the interventional radiologists. You also
received two blood transfusions.
The following changes were made to your medications:
START Ciprofloxacin 500 mg PO Daily
Please continue all other medications. Please be sure to
complete your course of ciprofloxacin.
Please keep your outpatient appointments.
Please return to the hospital if you experience fevers, chills,
uncontrolled pain, dizziness or lightheadedness, shortness of
breath, if you see blood draining from your nephrostomy tubes or
for any other concern.
Followup Instructions:
You have a preop- appointment on [**2133-7-13**]:
Provider: [**Name10 (NameIs) **] RM 3 [**Name10 (NameIs) **]-PREADMISSION TESTING Date/Time:[**2133-7-13**]
9:30
You have an appointment in nephrology (kidney doctor) on [**7-17**]
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2133-7-17**] 9:00
Please make sure that when you are here on [**7-17**], you provide a
urine sample so that the urology team will know that the
antibiotics cleared the infection. You can do this when you
visit Dr. [**Last Name (STitle) 118**].
You have a procedure scheduled for [**7-21**].
You have an appointment with Dr. [**Last Name (STitle) 6431**] in [**Month (only) 216**]
Provider: [**Name Initial (NameIs) 6436**] ([**Month (only) **]) [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 1144**]
Date/Time:[**2133-8-17**] 11:20
[**First Name8 (NamePattern2) **] [**Name6 (MD) **] [**Name8 (MD) **] MD, DMD [**MD Number(2) 821**]
|
[
"250.00",
"591",
"276.7",
"593.4",
"V10.46",
"995.91",
"038.42",
"599.0",
"722.10",
"285.9",
"338.29",
"584.9",
"493.90",
"276.2",
"518.89",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"55.93",
"55.03",
"87.75",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
11069, 11127
|
6810, 9575
|
362, 490
|
11357, 11364
|
4623, 6787
|
12631, 13662
|
3606, 3624
|
9915, 11046
|
11148, 11336
|
9601, 9892
|
11388, 12608
|
3639, 4604
|
300, 324
|
518, 3308
|
3330, 3501
|
3517, 3590
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,396
| 111,777
|
10291
|
Discharge summary
|
report
|
Admission Date: [**2111-1-28**] Discharge Date: [**2111-2-7**]
Date of Birth: [**2028-10-29**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
Bilateral Bur Holes for Subdural Hematoma
History of Present Illness:
This is an 82 year old right handed male who presented to an
outside hospital with dizziness and headache. He was found to
have bilateral subdural hematomas. The patient reprted having
headahces for 2-3 days prior to admission. It started out as a
dull ache that was holocephalic. The morning prior to admit the
quality became for sharp. He also felt lightheaded and almost
fell.
Past Medical History:
colon cancer s/p colectomy
sick sinus syndrome s/p pacemaker
atrial fibrillation (not on Coumadin)
hypothyroidism
hernia repair
GERD
esophageal rupture s/p repair
R knee replacement
hernia repair x2
Social History:
Lives with three daughters. Non-[**Name2 (NI) 1818**]. [**2-4**]
drinks/week.
Family History:
non-contributory
Physical Exam:
On admission:
Vitals: T 98.4; BP 138/78; P 75; RR 18; O2 sat 99%
General: lying in bed NAD
Neck: supple
Extremities: no c/c/e.
Neurological Exam:
Mental status: A & O x3. Fluent speech with no
paraphasic or phonemic errors. Adequate comprehension. Follows
simple and multi-step commands.
Cranial Nerves:
I: Not tested
II: PERRL, 4-->2mm with light.
III, IV, VI: EOMI. no nystagmus.
V, VII: facial sensation intact, facial strength
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: SCM [**5-6**]
XII: Tongue midline without fasciculations.
Motor: Normal bulk. Normal tone. No pronator drift. Full
strength.
Sensation: intact light touch.
Reflexes: 1+ symmetric
Toes downgoing bilaterally.
Coordination: FNF intact.
On discharge:
Pt expired
Pertinent Results:
CTA Head [**2111-1-28**]:
1. No significant interval change in appearance of the
moderately sized
subdural collections which are isoattenuating and exert moderate
mass effect with diffuse sulcal effacement, ventricular
distortion and tight basilar cisterns.
2. Lobulated enhancing extra-axial mass overlying the left
frontal lobe most likely represents a meningioma with less
likely consideration to include dural-based metastasis. It is
unclear what roll this mass may have played in the subdural
collections. MRI can help for further assessment.
3. Chronic left maxillary sinusitis.
CT Head [**2111-1-29**]:
IMPRESSION:
1. Status post bilateral craniotomy and right frontal burr hole,
with partial drainage of bilateral subdural hematomas.
2. Postoperative pneumocephalus resulting in slightly increased
leftward
shift.
3. Known left frontal extra-axial mass is not well characterized
on this
exam.
4. Chronic left maxillary sinusitis.
IMPRESSION:
1. Increase in bilateral subdural hematomas, with moderate mass
effect.
2. Progressive edema and effacement of bilateral inferior
occipital lobes. This finding is nonspecific and may be seen
with PRES, although the patient does not have a known history of
uncontrolled hypertension, immunosuppression, or other inciting
factors. Other considerations include mass effect from SDH,
bilateral PCA infarcts, and various other
infectious/inflammatory/neoplastic etiologies. Given the
patient's pacemaker contraindication to MRI, a contrast-enhanced
CT examination could be ordered for further evaluation.
3. Chronic left maxillary sinusitis.
4. Left frontal meningioma.
Brief Hospital Course:
Mr. [**Name13 (STitle) 1549**] was admitted to [**Hospital1 **] ICU under the care of Dr.
[**Last Name (STitle) **]. He had Bilateral SDH's on imaging. There was suspicion
of an underlying lesion. MRI was not able to be performed as the
patient has a pacemake. CTA imaging showed 2.1 x 1.8 cm
irregular lobulated mass which appears to be extra-axial
overlying the left frontal lobe. The patient was lethagic and
disoriented on [**2111-1-29**]. Repeat CT imaging was performed and he
was taken to the OR. He had an evacuation of bilateral SDH with
Dr. [**Last Name (STitle) **]. He was trasnfered to the TSICU intubated. Post-op CT
showed significant pneumocephalus. It was recommended that he
remain intubated overnight.
On [**2111-1-30**] he was being weaned toward extubation. His neuro
status improved. He was following commands with all 4
extremities. He reported that his vision was impaired. He could
not see colors. He could only see moving shapes. Opthomology was
consulted.
They felt that he had an occipital lobe infarct with a right
heminoposia. Neurosurgically he was doing well and was
transfered to the floor on [**2-1**]. Neuro/Stroke service was
consulted. They recommended a follow up CT head wich showed no
change from previous scan. Their final recommendations were
obtain a TTE, HBA1C, and fasting lipid profile. They also
recommended a repeat head and neck CTA.
On [**2-4**], patient's neurologic exam began to decline, he was more
lethargic with a R pronator drift and RLE weakness. Patient's
family and health care proxy determined that the patient should
be DNI/DNR. In the morning, patient's exam continued to rapidly
decline, dilated and fixed L pupil and extensor posturing of BUE
with no movement of the LE to noxious stimuli. The family was
made aware that surgery would not be benefical at this time.
They made the decision to make the patient CMO. He then passed
at [**2040**] on [**2-7**].
Medications on Admission:
Colchicine, 0.6 mg daily
Digoxin daily
Omeprazole daily
Aspirin 81 mg daily
Colace daily
Discharge Disposition:
Expired
Discharge Diagnosis:
Bilateral Subdural Hematoma
Left Frontal Brain Mass
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
Completed by:[**2111-2-7**]
|
[
"V43.65",
"427.81",
"V10.05",
"518.81",
"530.81",
"348.4",
"579.0",
"244.9",
"285.9",
"427.31",
"369.3",
"225.2",
"V45.01",
"432.1",
"401.1",
"348.89",
"V45.72"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"01.31",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
5641, 5650
|
3574, 5501
|
328, 371
|
5746, 5755
|
1931, 3551
|
5811, 5848
|
1118, 1136
|
5671, 5725
|
5527, 5618
|
5779, 5788
|
1151, 1151
|
1900, 1912
|
1297, 1297
|
280, 290
|
399, 781
|
1458, 1886
|
1165, 1278
|
1312, 1442
|
803, 1004
|
1020, 1102
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,853
| 129,462
|
6562
|
Discharge summary
|
report
|
Admission Date: Discharge Date: [**2155-8-12**]
Date of Birth: [**2081-7-29**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: Patient is a 74-year-old male
with a recent hospitalization for ablation and pacer
placement, discharged on [**8-6**], who presents with
complaints of syncope, no dizziness, chest pain, heart
palpitations, nausea, vomiting, shortness of breath. He has
had similar episodes in [**2153-7-26**] and [**2155-5-27**] same
progression in terms of he presented to the Emergency Room
with dropped hematocrit and needed to be transfused. In [**2153-7-26**], patient was on Coumadin for atrial fibrillation.
Work up showed hemorrhoids, diverticulosis, but no specific
bleeding lesion, however, he needed eight units of packed red
blood cells. In [**2155-5-27**] he had syncope with subsequent
low hematocrit and he needed two units of packed red blood
cells as no specific source was found with colonoscopy,
esophagogastroduodenoscopy or small bowel follow through. He
did have a hyperplastic polyp removed in [**2155-5-27**]. He
also has a history of recurrent epistaxis.
PAST MEDICAL HISTORY: Upper gastrointestinal bleed and
gastroesophageal reflux disease, atrial flutter, status post
ablation and pacemaker in [**2155-7-27**]. Porcelain
gallbladder shown on CT in [**2155-5-27**], iron deficiency
anemia, insulin dependent diabetes mellitus with peripheral
neuropathy, status post many foot infections, peripheral
vascular disease with bilateral claudication, hypertension,
coronary artery disease, status post coronary artery bypass
graft, recurrent epistaxis, degenerative joint disease of the
right hip and bilateral cataracts.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: Widowed and lives alone.
MEDICATIONS UPON ADMISSION: Aspirin 81 mg, cimetidine,
hydrochlorothiazide, humulin, Lipitor, Reglan, iron sulfate
and amiodarone.
ON TRANSFER FROM THE MEDICAL INTENSIVE CARE UNIT: He was on
Isordil, amiodarone, Univasc, Protonix, Ambien and Tylenol.
PHYSICAL EXAMINATION UPON TRANSFER: Vital signs:
Temperature 96.9. Heart rate 80. Respiratory rate 22.
Blood pressure 108/60, 02 saturation 98% on room air.
General: Well comfortable. Cardiovascular: S1, S2, regular
rate and rhythm with 3/6 pansystolic murmur with radiation to
the axilla. Respiratory: Clear to auscultation bilaterally,
no wheezes, crackles or rhonchi. Abdomen: Soft, nontender,
nontender, normal active bowel sounds, no hepatosplenomegaly.
Extremities: No cyanosis, clubbing or edema.
LABORATORIES UPON TRANSFER: White blood cell count 8.5,
hemoglobin 10.9, hematocrit 32.4, glucose 139. Sodium 136,
potassium 4.3, chloride 103, bicarbonate 21, BUN 20,
creatinine 0.8, glucose 207, PT 13.1, PTT 28.3, INR 1.1,
bleeding time 6, reticulocyte count 5.4, haptoglobin 244.
PFTs were normal. CT was negative for retroperitoneal bleed
or aortic dissection. Electrocardiogram was AV paced with no
acute changes. B12, folate and iron were within normal
limits.
HOSPITAL COURSE:
1. Hematology: In the Medical Intensive Care Unit, he had a
facial laceration that bled, however, his full anemia work-up
and coag laboratories have been negative. Also, he had an
abdomen and chest CT which were negative throughout. Also,
his hematocrit during his stay was 24.2, 19.8 on the 12th and
32.4 on the 16th. He received a total four units of packed
red blood cells throughout his stay and it stabilized at this
point. An angiography was not necessary. It was decided
that the patient could be discharged finally to follow-up
with Dr. [**Last Name (STitle) 469**] for further work-up.
2. Cardiovascular: His Isordil was held as his blood
pressure was low and stable and he had an EPS appointment on
[**8-19**].
DISPOSITION: Patient was to be sent home with VNA and
follow-up with Dr. [**Last Name (STitle) 469**] in the [**Hospital **] clinic.
DISCHARGE DIAGNOSIS: Anemia.
DISCHARGE MEDICATIONS:
1. Aspirin.
2. Amiodarone.
3. Univasc.
4. Cimetidine.
5. Lipitor.
6. Reglan.
7. Humulin.
8. Hydrochlorothiazide to be started under primary care
physician advisement only.
DISCHARGE INSTRUCTIONS: Monitor blood pressure closely by
VNA as it has been in the low range during the hospital stay.
Follow-up with Dr. [**Last Name (STitle) 469**] within the week and [**Hospital **]
Clinic on [**2155-8-19**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3090**], M.D.
[**MD Number(1) 3091**]
Dictated By:[**Name8 (MD) 4385**]
MEDQUIST36
D: [**2155-12-9**] 15:02
T: [**2155-12-9**] 15:02
JOB#: [**Job Number 25129**]
|
[
"398.91",
"285.1",
"998.11",
"443.9",
"V45.81",
"401.9",
"427.31",
"250.01",
"396.2"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
1735, 1753
|
3979, 4160
|
3947, 3956
|
3058, 3925
|
4185, 4657
|
145, 1114
|
1825, 3040
|
1137, 1718
|
1770, 1810
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,574
| 177,706
|
3706
|
Discharge summary
|
report
|
Admission Date: [**2181-2-23**] Discharge Date: [**2181-2-27**]
Date of Birth: [**2106-4-8**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1234**]
Chief Complaint:
Ischemic left foot
Major Surgical or Invasive Procedure:
OPERATION PERFORMED:
1. Cutdown of left femoral to anterior tibial artery vein
graft.
2. Arteriogram of the left lower extremity.
3. Angioplasty of left dorsalis pedis artery.
4. Angioplasty of left distal anterior tibial artery.
5. Vein graft angioplasty.
6. Closure of left vein graft arteriotomy.
History of Present Illness:
Mr. [**Known lastname **] presented for followup of his lower extremity
ischemia sooner than scheduled visit. Over the last two days,
his left foot and calf has been hurting. This is the site of an
old left fem-DP bypass that acutely occluded post CABG in
[**Month (only) **] and treated with angioplasty and cutting balloon and
partial thrombectomy.
Past Medical History:
coronary artery disease
aortic stenosis
peripheral [**Month (only) 1106**] disease
gastroesophageal reflux disease
hypertension
hyperlipidemia
h/o prostate disease
s/p coronary artery stenting
Social History:
Spanish speaking. He is married and lives with his wife. [**Name (NI) **]
continues to smoke [**4-30**] cigs/day, h/o 1ppd since age 15. Denies
EtOH for years, but history of heavy drinking. Denies drug use.
Family History:
Brother died of colon CA at age 70. No sudden cardiac death.
Physical Exam:
Physical Exam: AFB VITAL SIGN STABLE
PE: AOX3 NAD
PERRL / EOMI
Neur: CN grossly intact
Lungs: no respiratory distress, CTAB antior
CARDIAC: RRR
ABDOMEN: Soft, ND, NT
EXT:
rle - pt, doppler dp doppler foot warm no erythema
lle - DP palpable graft palpable, otherwise dopplerable
Pertinent Results:
[**2181-2-27**] 06:05AM BLOOD
WBC-6.9 RBC-4.55* Hgb-11.5* Hct-37.4* MCV-82 MCH-25.2*
MCHC-30.7* RDW-17.1* Plt Ct-316
[**2181-2-27**] 06:05AM BLOOD
PT-27.1* PTT-39.3* INR(PT)-2.6*
[**2181-2-26**] 02:11AM BLOOD
Glucose-99 UreaN-14 Creat-1.2 Na-138 K-4.0 Cl-102 HCO3-27
AnGap-13
[**2181-2-23**] 7:25 pm MRSA SCREEN NASAL SWAB.
MRSA SCREEN (Final [**2181-2-26**]): No MRSA isolated.
Brief Hospital Course:
The patient had a 4 day history of left leg, Pt seen in office:
Taken emergently to the OR:
1. Cutdown of left femoral to anterior tibial artery vein
graft.
2. Arteriogram of the left lower extremity.
3. Angioplasty of left dorsalis pedis artery.
4. Angioplasty of left distal anterior tibial artery.
5. Vein graft angioplasty.
6. Closure of left vein graft arteriotomy.
Prior to the procedure, it was noted that there was a small
amount of bright red blood exiting the patient's rectum. The
patient's hematocrit was checked and
found to be 23.6, previously his baseline was noted to be ~30.
He was also found to be supra therapeutic on his Coumadin, INR
was 6.1. Of note, his INR was 1.4 on [**2181-2-8**].
Given emergent nature of procedure, decision was made to proceed
while giving blood products during the procedure. The patient
was given heparin for the procedure, and then intra op re-check
of hematocrit was found to be 16.2, with INR of 9.0. The
patient received 5 units of PRBCs, 3 units of FFP and 1 unit of
cryo, with improvement of the patient's hematocrit to 21.1.
The procedure was completed, and the patient received
resuscitation for a total of 3.8 liters of blood products and
lactated ringers. He was then brought to the PACU still
intubated and under sedation. Vital signs were stable on
transfer to PACU.
Post-operatively, then was extubated and transferred to the VICU
for further stabilization and monitoring.
While in the VICU he received monitored care. When stable he was
delined. His diet was advanced. A PT consult was obtained. When
he was stabilized from the acute setting of post operative care,
he was transferred to floor status
On the floor, remained hemodynamically stable with his pain
controlled. He progressed with physical therapy to improve her
strength and mobility. He continues to make steady progress
without any incidents. He was discharged home in stable
condition.
To note his Coumadin has been DC'ed, PCP is [**Name Initial (PRE) 12309**]. No need for
Coumadin from cardiac surgery standpoint.
Medications on Admission:
Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO
DAILY (Daily).
Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
ProAir HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: One (1)
Inhalation twice a day.
Hydrochlorothiazide 12.5 mg Tablet Sig: 0.5 Tablet PO once a
day.
Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day: Start after your
plavix is completed.
Coumadin
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
7. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
8. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): stop prilosec and take zantac when on plavix. After
plavix is complete. can take prilosec.
Disp:*30 Tablet(s)* Refills:*0*
9. ProAir HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: One (1)
Inhalation twice a day.
10. Zantac 150 mg Tablet Sig: One (1) Tablet PO once a day: can
stop and take prilosec after plavix is discontinued.
Disp:*30 Tablet(s)* Refills:*0*
11. Hydrochlorothiazide 12.5 mg Tablet Sig: 0.5 Tablet PO once a
day.
12. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
13. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day: Start after your
plavix is completed.
14. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO four times a
day for 30 days: pen.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Failing graft left lower extremity.
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
Lower Extremity Surgery Discharge Instructions
What to expect when you go home:
1. It is normal to feel tired, this will last for 4-6 weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? Unless you were told not to bear any weight on operative foot:
you may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have swelling of the leg you were operated
on:
?????? Elevate your leg above the level of your heart (use [**2-28**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? Unless you were told not to bear any weight on operative foot:
?????? You should get up every day, get dressed and walk
?????? You should gradually increase your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (unless you have stitches or foot incisions) no
direct spray on incision, let the soapy water run over incision,
rinse and pat dry
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
?????? Redness that extends away from your incision
?????? A sudden increase in pain that is not controlled with pain
medication
?????? A sudden change in the ability to move or use your leg or the
ability to feel your leg
?????? Temperature greater than 100.5F for 24 hours
?????? Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions
YOUR COUMADIN HAS BEEN STOPPED. NO NEED TO HAVE YOUR INR
FOLLOWED.
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Apartment Address(1) 871**] ([**Doctor First Name **]) [**Doctor First Name **] LMOB (NHB)
Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2181-3-6**] 3:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2181-3-6**] 3:45
Completed by:[**2181-2-27**]
|
[
"745.5",
"V10.46",
"569.3",
"569.49",
"530.81",
"401.9",
"440.31",
"424.1",
"V42.2",
"414.01",
"790.92",
"V45.82",
"790.01",
"440.20",
"305.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.50",
"88.48",
"38.94",
"00.41"
] |
icd9pcs
|
[
[
[]
]
] |
6642, 6699
|
2281, 4344
|
333, 639
|
6778, 6778
|
1863, 2258
|
9816, 10190
|
1480, 1542
|
5265, 6619
|
6720, 6757
|
4370, 5242
|
6922, 9315
|
9341, 9793
|
1572, 1844
|
274, 295
|
667, 1022
|
6792, 6898
|
1044, 1238
|
1254, 1464
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,389
| 193,179
|
9206
|
Discharge summary
|
report
|
Admission Date: [**2134-7-21**] Discharge Date: [**2134-7-27**]
Date of Birth: [**2052-11-16**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4111**]
Chief Complaint:
abdominal pain, free air on KUB
Major Surgical or Invasive Procedure:
1. Closure of a perforated duodenal ulcer, omental patch,
draining gastrostomy.
2. #20 feeding tube and feeding jejunostomy #14 whistle-
tip.
History of Present Illness:
81M recently d/c'd from [**Hospital1 18**] following an IPH of the right
parietooccipital region presented to ED with severe abdominal
pain in the epigastrium. The history is somewhat unclear, but
it seems that the pain had been present over the past few days
and had worsened acutely on the day of presentation. No
reported nausea or vomiting. Last BM had been a few days prior.
He was found in new onset Afib in the ED. His hematocrit was
18.2, a drop from 42 on his prior admission. Free air was found
on X-ray. An NGT placed in the ED returned grossly bloody
fluid.
Past Medical History:
PMH: aortic stenosis s/p porcine AVR ([**3-20**]), pneumonia (04), CAD
s/p stenting ([**3-20**]), IPH of R parieto-occipital region ([**6-22**])
PSH: b/l inguinal hernia repair, deviated septum repair,
tonsillectomy, porcine AVR, R coronary stents, b/l saphenous
vein stripping
Social History:
No tobacco, very rare and limited alcohol, no drug use. Widowed.
Retired research physicist at [**University/College **]. HCP: [**Name (NI) **] and [**Name (NI) 31626**]
[**Name (NI) 31627**] (sister-in-law and brother-in-law) in [**Name (NI) 31628**], CT
(does not know phone or street #).
Family History:
No coagulopathy, aneurysms, stroke. No known cardiopulmonary
disease. His parents lived until they reached ages greater than
90.
Physical Exam:
On admission:
T 98.5 HR 110 (A fib) BP 95/60 RR 22 O2sat 93%RA
Gen: [**Name (NI) 3584**], mostly oriented, uncomfortable, pale
CVS: tachycardic, irregular rhythm
Pulm: CTA b/l
Abd: distended, diffusely tender, + rebound, + guarding, guiaic
positive
On discharge:
T 98.9 P 76 BP 132/75 RR 18 O2sat 95%RA
Gen: NAD, A&O x 3
CVS: RRR, nl S1S2, no MRG
Pulm: CTA b/l
Abd: soft, NT, ND, +BS,
Inc: dressings c/d/i, G tube c/d/i, J tube c/d/i
Ext: no c/c/e
Pertinent Results:
On admission:
[**2134-7-21**] 04:00AM BLOOD WBC-16.6*# RBC-1.96*# Hgb-6.5*#
Hct-18.9*# MCV-97 MCH-33.1* MCHC-34.3 RDW-17.2* Plt Ct-344#
[**2134-7-21**] 04:00AM BLOOD Neuts-73.8* Lymphs-24.3 Monos-1.6*
Eos-0.1 Baso-0.2
[**2134-7-21**] 09:10AM BLOOD PT-15.0* PTT-33.1 INR(PT)-1.4*
[**2134-7-21**] 09:10AM BLOOD Fibrino-253
[**2134-7-21**] 04:00AM BLOOD Glucose-197* UreaN-40* Creat-1.5* Na-134
K-4.1 Cl-100 HCO3-18* AnGap-20
[**2134-7-21**] 04:00AM BLOOD ALT-20 AST-24 LD(LDH)-234 CK(CPK)-39
AlkPhos-51 Amylase-136* TotBili-0.3
[**2134-7-21**] 04:00AM BLOOD Lipase-90*
[**2134-7-21**] 04:00AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2134-7-21**] 04:00AM BLOOD Albumin-3.5 Calcium-9.1 Phos-3.2 Mg-2.4
[**2134-7-21**] 04:00AM BLOOD Acetone-SMALL
[**2134-7-21**] 04:40AM BLOOD Lactate-3.8*
[**2134-7-21**] 06:39AM BLOOD Hgb-5.0* calcHCT-15
[**2134-7-21**] 09:10AM BLOOD calTIBC-178* Ferritn-131 TRF-137*
[**2134-7-21**] 09:10AM BLOOD Triglyc-48
AXR ([**2134-7-21**], 03:11): No evidence of bowel obstruction.
Intraperitoneal free air.
Multiple puctate lucenct foci overlying the bowel loops, raising
the
possibility of pneumatosis intestinalis.
CXR ([**2134-7-21**], 03:11): Unchanged appearance of the chest with
tortuous aorta. Free air below the diaphragm and mid-upper
abdomen.
EKG ([**2134-7-21**], 02:48): Sinus rhythm. Left atrial abnormality. A-V
conduction delay. Frequent atrial ectopy and wandering atrial
pacemaker, new compared to the previous tracing of [**2134-6-17**]. The
effective rate has increased. Clinical correlation is suggested.
Read by: [**Last Name (LF) 578**],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 579**]
Postoperative troponin elevation:
[**2134-7-21**] 09:10AM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2134-7-21**] 03:55PM BLOOD CK-MB-7 cTropnT-0.04*
[**2134-7-21**] 10:10PM BLOOD CK-MB-7 cTropnT-0.05*
[**2134-7-22**] 05:00AM BLOOD CK-MB-6 cTropnT-0.04*
[**2134-7-23**] 11:58AM BLOOD CK-MB-4 cTropnT-0.01
CT head ([**2134-7-23**], 14:12): There is continued evolution of the
previously identified intraparenchymal hemorrhage. The
subarachnoid hemorrhage is less apparent on the current study.
There is resolution of the intraventricular hemorrhage. No
evidence of new hemorrhage, mass effect, hydrocephalus, or acute
infarction.
U/S upper ext ([**2134-7-23**], 14:22): Thrombus in the right cephalic
and basilic veins in the region of the antecubital fossa. No
DVT identified in the right arm.
EKG ([**2134-7-23**], 14:01): Sinus rhythm with frequent supraventricular
premature depolarizations and a ventricular premature
depolarizations. Non-diagnostic repolarization abnormalities.
Compared to the previous tracing of [**2134-7-21**] frequent
supraventricular ectopic activity now evident.
On discharge:
[**2134-7-27**] 07:50AM BLOOD WBC-5.8 RBC-3.43* Hgb-10.4* Hct-29.7*
MCV-87 MCH-30.3 MCHC-35.0 RDW-16.9* Plt Ct-245
[**2134-7-27**] 07:50AM BLOOD Glucose-133* UreaN-15 Creat-1.1 Na-137
K-3.5 Cl-104 HCO3-24 AnGap-13
[**2134-7-27**] 07:50AM BLOOD Calcium-8.1* Phos-2.8 Mg-1.7
Brief Hospital Course:
Surgery was consulted in the ED for free air. He was taken
emergently to the operating room for closure of his perforated
duodenal ulcer with omental patch, draining gastrostomy tube,
and feeding J tube. Amp, gent, and Flagyl were started.
On POD 1, Cardiology was consulted for his rising troponins. In
the setting of low hematocrit, Cardiology believed that his
enzyme leak was secondary to demand ischemia as opposed to
primary MI. The NGT was d/c'd on POD 1 and J tube feeds (Impact
1/2 strength) were started at 20 cc/hr.
On POD 2, Neurology was consulted for intermittent
disorientation; his mental status was confirmed to be baseline.
A repeat CT demonstrated improved IPH since his previous
imaging. Tube feeds were increased to 30 cc/hr. His right arm
was found to be swollen. An ultrasound demonstrated thrombus in
the right cephalic and basilic veins in the region of the
antecubital fossa, but no DVT.
On POD 3, patient was transferred to the floor. His tube feeds
were increased to 40 cc/hr (goal). Adequate bowel sounds were
noted, and patient was started on sips, which he tolerated.
On POD 4, patient was advanced to clears. A G-tube clamp trial
was successful. He received 1 U PRBCs overnight. He had bowel
movements overnight.
On POD 5, patient was advanced to soft diet.
On POD 6, patient was stable for discharge to [**Location (un) **]. He was
afebrile, with stable vital signs. His WBC, Hct, and troponins
had normalized. He was to complete his course of
amp/gent/Flagyl on [**2134-7-29**], to continue tube feeds of [**11-17**]
strength Impact at 40 cc/hr with regular diet ad lib, and to
clamp his G-tube continuously. PT was ordered to continue
working with him in rehab.
Medications on Admission:
Zocor 40 mg qday, Lopressor 12.5 mg [**Hospital1 **], Colace
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
Disp:*270 Tablet(s)* Refills:*2*
2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig:
One (1) Intravenous Q8H (every 8 hours).
Disp:*10 units* Refills:*2*
4. Ampicillin Sodium 1 g Recon Soln Sig: One (1) Recon Soln
Injection Q6H (every 6 hours).
Disp:*10 Recon Soln(s)* Refills:*2*
5. Gentamicin 40 mg/mL Solution Sig: One (1) Injection Q24H
(every 24 hours).
Disp:*10 units* 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*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
perforated duodenal ulcer
Discharge Condition:
stable
Discharge Instructions:
If you develop fever >101.5, abdominal pain or distention,
nausea or vomiting, chest pain, shortness of breath, redness of
your incisions or any other symptom or sign concerning to you
please call [**Hospital1 18**]. Take all medications as prescribed. You can
shower immediately, but no swimming or bathing until you have
followed up with Dr. [**Last Name (STitle) 957**] in clinic.
Followup Instructions:
Arrange to see your PCP as soon as possible following discharge.
Call Dr.[**Name (NI) 6275**] office to arrange an appointment 10-14 days
after discharge from the hospital. At this appointment he will
decide whether to remove your tubes.
Completed by:[**2134-8-27**]
|
[
"414.01",
"V12.59",
"532.60",
"427.31",
"V42.2",
"585.9",
"272.0",
"403.90",
"V45.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"46.39",
"44.42",
"43.19",
"99.04",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
7997, 8076
|
5414, 7134
|
347, 498
|
8146, 8155
|
2355, 2355
|
8589, 8859
|
1733, 1863
|
7245, 7974
|
8097, 8125
|
7160, 7222
|
8179, 8566
|
1878, 1878
|
5117, 5391
|
276, 309
|
526, 1105
|
2369, 5103
|
1127, 1407
|
1423, 1717
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,534
| 143,092
|
5472
|
Discharge summary
|
report
|
Admission Date: [**2186-1-30**] Discharge Date: [**2186-2-9**]
Date of Birth: [**2104-4-27**] Sex: M
Service: MEDICINE
Allergies:
Percocet / Ciprofloxacin
Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
Delirium
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Patient is a 81 yo man with PMHx sig. for CAD, ischemic CM
(systolic and diastolic, last EF 40% 2/10), Parkinsons disease,
DM2, HTN, Renal cell carcinoma (s/p L nephrectomy), and TIA who
presents with delirium, concern for UTI. He has a history of
enterococcal UTI and MRSA UTI. Per wife, after [**Name (NI) **], he
seemed to have episodes of confusion which progressed. His wife
was concerned that he had a UTI. In addition, he has been
getting generally weaker. It got to point that he couldn't get
out of the chair. He had also slipped out of his wheelchair
while trying to get back into bed. He has not been eating or
drinking well. On the way in, he was incontinent of stool,
loose. Patient states that he feels lousy but couldn't futher
elaborate. He reports some dysuria. Per wife, no orthopnea or
worsening pedal edema.
In the ED, initial VS were: 96.3 58 121/58 20 97%. Labs were
notable for Na 150, Cl 114. CXR showed bilateral lower lobe
opacity and bilateral pleural effusions. Hip x-ray showed
severe [**Last Name (un) **] change, L hip arthroplasty, limited stude due to
osteopenia, no fracture. The patient received azithromycin,
vanc, and CTX.
Review of Systems:
(+) Per HPI plus: nasal congestion, episode of chest pain last
week, dry cough, concerns of aspiration, L hip pain.
(-) Denies fever, chills, night sweats. Denies headache,
rhinorrhea. Denies palpitations. Denies shortness of breath.
Denies nausea, vomiting, diarrhea, constipation, or abdominal
pain. No urinary frequency. Denies rashes. All other review of
systems negative.
Past Medical History:
1. Parkinson's Disease
2. Type 2 diabetes
3. Hypertension
4. CAD - PCI with DES to RCA and LAD in [**2179**], NSTEMI [**2185-3-9**]
that was medicallly managed. Most recent Cath in [**12/2183**]: showed
3VD. PTCA (POBA) of the mid-RCA was performed. Stent placement
was unsuccessful. Has ischemic cardiomyopathy with LVEF 25%. Has
class II NYHA symptoms.
5. h/o Renal Cell Carcinoma - [**2170**], s/p partial left
nephrectomy. Now with chronic kidney disease
6. h/o prostate cancer s/p radiation therapy
7. spinal stenosis
8. Cerebrovascular disease with TIA [**12/2183**]
9. Osteoporosis
10. h/o left hip fracture, s/p left hemiarthroplasty
11. h/o left foot TMA, by Dr. [**Last Name (STitle) 1391**]
12. Polyneuropathy and amyotrophy
13. Ischemic CM (systolic and diastolic, last EF 40% 2/10)
Social History:
Patient was a concert pianist. He is married to a retired ER
nurse ([**Doctor First Name **]). He has been working with PT, has been ambulating
with a Spryet. No VNA services. Quit smoking cigarettes in
[**2160**], previously smoked for 27 years.
Family History:
Father - MI at 55.
Physical Exam:
Vitals: 98.1, 121/58, 83, 20, 96 on 2L, BS 230
Gen: NAD, alert, answers questions slowly with 1-2 words
HEENT: R pupil post-surgical, larger than L and reactive, L
pupil reactive, MMM dry, sclera anicteric, not injected
Neck: no LAD, no JVD
Cardiovascular: RRR normal s1, s2, no murmurs appreciated
Respiratory: Clear to auscultation bilaterally, decreased breath
sounds at the bases
Abd: normoactive bowel sounds, soft, non-tender, non distended
Extremities: 1+ edema, 2+ DP pulses
NEURO: PERRL, face symmetric, no tongue deviation
Integument: Warm, moist, no rash or ulceration
Psychiatric: appropriate, pleasant, not anxious
Pertinent Results:
Admission labs: [**2186-1-30**] 06:00PM
WBC-4.9 RBC-3.68* HGB-9.8* HCT-30.6* MCV-83 PLT COUNT-125*
GLUCOSE-134* UREA N-33* CREAT-1.0 SODIUM-150* POTASSIUM-3.7
CL-114* CO2-30
LACTATE-1.1
URINE BLOOD-SM NITRITE-NEG PROTEIN-75 GLUCOSE-NEG KETONE-TR
BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-SM
URINE RBC-[**4-1**]* WBC-[**4-1**] BACTERIA-FEW YEAST-FEW EPI-0-2
CHEST (PA & LAT) Study Date of [**2186-1-30**]
The previously seen right PICC has been removed. There are low
lung volumes. Moderate bilateral pleural effusions are seen,
with overlying atelectasis, underlying consolidation not
excluded. The cardiac silhouette can not be adequately assessed
due to adjacent effusions.
HIP (UNILAT 2 VIEW) W/PELVIS (1 VIEW) RIGHT Study Date of
[**2186-1-30**]--prelim:
severe [**Last Name (un) **] change, L hip arthroplasty, limited stude due to
osteopenia, no fracture
Micro:
[**2186-2-8**] URINE CULTURE-PENDING
[**2186-2-7**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL
Positive
[**2186-2-5**] URINE CULTURE-FINAL {YEAST}
[**2186-2-3**] URINE CULTURE-FINAL
[**2186-2-2**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
Negative
[**2186-2-1**] URINE CULTURE-FINAL {YEAST}
[**2186-1-31**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL
Negative
[**2186-1-30**] URINE CULTURE-FINAL {YEAST}
[**2186-1-30**] Blood Culture, Routine-FINAL No growth
[**2186-1-30**] BLOOD CULTURE Blood Culture, No growth
Other Labs:
[**2186-2-7**] 06:14AM WBC-2.9* RBC-3.41* Hgb-9.2* Hct-28.7* MCV-84
Plt Ct-125*
[**2186-2-8**] 08:40AM Glc-182* UreaN-21* Cr-1.0 Na-144 K-4.1 Cl-104
HCO3-36*
[**2186-2-1**] 06:40AM BLOOD CK-MB-8 cTropnT-0.20*
[**2186-2-2**] 06:10AM BLOOD CK-MB-4 cTropnT-0.21*
[**2186-2-8**] 01:50PM BLOOD CK-MB-4 cTropnT-0.13*
[**2186-2-8**] 09:30PM BLOOD cTropnT-0.13*
Brief Hospital Course:
81 year old man with a history of Parkinson's Disease, CAD,
ischemic cardiomyophathy with an EF of 40%, DM2, RCC s/p left
partial nephrectomy, and prostate CA s/p radiation admitted to
the ICU with hypercarbic and hypoxemic respiratory distress and
AMS. Previously admitted with delirium with concern for UTI.
Required BiPAP in the ICU given hypercarbia. UCx grew yeast with
positive UA briefly treated with ceftriaxone and we did not
treat for this. Transferred to floor from ICU on [**2186-2-4**].
.
# Hypercarbic resp. distress: This resolved. Likely due to CHF
exacerbation in setting of poor reserve and large L pleural
effusion and kyphosis. Impoved with NPPV, VBG 7.53/40/40 did
not require NPPV on [**2-4**]. This was monitored and he did not
necessitate NIV. We optimised his CHF management and diuresed
with IV furosemide to goal of -1L to 500cc on [**2-4**]. Subseqently
he developed hypernatremia and was felt to be dehydrated.
Further diuresis was held until [**2186-2-7**], when his home
Spironolactone was re-started. He was on room air for >48 hours
prior to discharge.
.
# Delirium: Likely multifactorial with a large contribution from
hypercarbia and hypoxemia. His UCx were negative (of note he
had previous VRE senstitive to ampicillin on past culture data)
and he had two UCx which grew yeast. On previous admissions he
had been treated wuth courses of fluconazole for yeast UTI but
we felt this was not indicated at this time. Given poor swallow
and aspiration on speech and swallow review on [**1-31**] it was felt
likely that he had been sub-clinically aspirating. We coninued
lorazepam (per home regimen/per pt's wife) prn
anxiety/agitation. He required frequent reorientation.
.
# Pyuria. This was felt likely [**3-1**] fungal infection. Urine
cultures were negative but grew yeast. We elected not to treat
with fluconazole. Final urine culture is pending at the time of
discharge.
.
# Hypernatremia. Likely secondary to aggressive diuresis. He was
encouraged to take further po and his Na improved with free
water. His diet should be liberalized to thin liquids when
observed so as to prevent further dehydration and for his own
comfort and enjoyment. Patient and wife understand this will
place him at greater risk for aspiration.
.
#Parkinson's disease: Given poor swallow, he was unable to take
his oral PD medications and was treated with S/L Parcopa. There
was no evidence of significant rigidity or cogwheeling and
bradykinesia seemed better by [**2-4**]. We continued Parcopa and the
dose was uptitrated on [**2-4**] to four times daily.
.
# Chronic systolic and diastolic heart failure: HF EF 40%. We
continued home metoprolol and [**Last Name (un) **] along with Spironolactone for
gentle diuresis per him home regimen.
.
# Acute on chronic renal impairment: Likely due to diuresis; now
back at baseline.
.
#CAD: nonactive issue currently. We continued aspirin, beta
blocker and [**Last Name (un) **].
.
#DM2: Pt. is controlled with lantus at home, however his wife
has been holding this medication during the time that he has had
poor PO intake. Lantus has continued to be held during the
hospitalization and his sugars have been well controlled on SS.
He was treated with an Insulin Sliding scale while in house.
Medications on Admission:
Pls see attached.
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day): Can be discontinued
when patient ambulating >3x per day.
2. ipratropium bromide 0.02 % Solution Sig: One (1) Neb
Inhalation Q6H (every 6 hours).
3. insulin lispro 100 unit/mL Solution Sig: One (1) injection
Subcutaneous ASDIR (AS DIRECTED): Per facility's usual sliding
scale.
4. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
5. carbidopa-levodopa 25-100 mg Tablet, Rapid Dissolve Sig: One
(1) Tablet, Rapid Dissolve PO QID (4 times a day).
6. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) inhalation Inhalation Q6H (every 6
hours) as needed for shortness of breath or wheezing.
7. spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
8. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
9. losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) for 8 days: Through [**2186-2-17**].
12. Outpatient Lab Work
Please check a CBC and Chem 10 on [**2186-2-10**]
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] Senior Healthcare of [**Location (un) 55**]
Discharge Diagnosis:
toxic metabolic encephalopathy
acute systolic heart failure
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted with confusion and shortness of breath. This
was likely due to heart failure. You had an evaluation by the
speech and swallow therapist and it was determined that the
safest diet for you is honey thickened liquids and pureed
solids. In discussions with you and your wife, though, it was
decided that you were willing to take on a higher risk of
aspiration by drinking the fluids you enjoy, such as water and
ginger ale, provided someone is observing you.
For your heart failure you received IV diuretics with good
effect; you were then started back on your home Spironolactone.
.
.
Please take all of your medications as prescribed and follow up
with the appointments below.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Please call your PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 719**] to
schedule a follow up appointment with 1-2 weeks of discharge
from Rehab.
|
[
"356.9",
"276.0",
"412",
"332.0",
"V45.73",
"428.43",
"585.3",
"414.01",
"349.82",
"250.00",
"V58.67",
"733.90",
"V43.64",
"V10.46",
"112.2",
"733.00",
"403.90",
"008.45",
"V12.54",
"799.02",
"V10.52",
"V49.86",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10070, 10160
|
5495, 8752
|
293, 299
|
10264, 10264
|
3693, 3693
|
11249, 11478
|
3008, 3028
|
8820, 10047
|
10181, 10243
|
8778, 8797
|
10441, 11226
|
3043, 3674
|
1522, 1903
|
245, 255
|
327, 1503
|
3709, 5104
|
10279, 10417
|
1925, 2723
|
2739, 2992
|
5116, 5472
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,924
| 151,622
|
30071
|
Discharge summary
|
report
|
Admission Date: [**2165-1-5**] Discharge Date: [**2165-1-26**]
Date of Birth: [**2139-10-18**] Sex: F
Service: MEDICINE
Allergies:
Zosyn
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
endstage liver failure
Major Surgical or Invasive Procedure:
trach tube placement
multiple line placements
History of Present Illness:
25 F w/ etoh cirrhosis and bulimia who presents from an OSH w/
endstage liver disease (encephalopathy, ascites/SBP, portal htn,
ARF). Pt was admitted to OSH on [**2164-12-18**] w/ fever, abdominal
distention, elevated WBCs, b/l LE edema. SBP was diagnosed by
paracentesis (Group B beta hemolytic Streptococcus), Pt was
placed on Vancomycin and Zosyn. Pt had alcohol withdrawal.
Transferred to OSH ICU w/ encephalopathy on [**2164-12-26**]. Intubated
on [**2164-12-29**] for respiratory distress (ARDS) thought secondary to
aspiration and shock (reported as septic). Hypotension managed
with dopamine (renal dose) and vasopressin (both off at
tansfer). Sepsis managed untimately managed w/ imipenem.
Past Medical History:
--etoh abuse (since age 12)
--cirrhosis
--bulimia
--erosive esophagitis
Social History:
Etoh abuse. Tobacco use (unclear amount). Parents are her
legal guardians. [**Name (NI) 1403**] as a waitress. Father is an attorney.
Mother is a secretary. Younger sibling. Was taking are of ADLs
before hospitalization.
Family History:
Father is a recovering alcoholic. No known hx of congenital
liver dz.
Physical Exam:
FiO2=50%, Vt=400, RR=18, PEEP=5
T=101.4
BP=112/75
HR=88
RR=18
O2sat=97%
WT=75.6 kg
HT=68 in
GEN: young female intubated, lying in bed in nad
HEENT: scleral icterus, eomi, perrl, no lad
CV: rrr, 2/6 systolic murmur @ LUSB
PULMO: ctab anteriorly
ABD: soft, bs+, nt, distended
EXT: warm, no c/c, 2+ pitting edema b/l up to knees, 2+DP
SKIN: jaundiced, caput medusa, spider angioma
Brief Hospital Course:
[**Known firstname **] [**Known lastname 71716**] was transferred to the ICU on [**2165-1-5**] for liver
failure and respiratory failure. Over the next few weeks, her
liver failure worsened and she had persistent fevers of unclear
source despite intensive workup. She developed kidney failure
and was deemed to not be a liver transplant candidate. She
remained dependent on the ventilator. CVVH was begun but her
overall status continued to decline. Her situation was felt to
be futile by the MICU team and the liver team. Her family agreed
with withdrawl of care and she died at 9 pm on [**2165-1-27**].
Discharge Disposition:
Expired
Discharge Diagnosis:
alcoholic liver failure
kidney failure
fever of unknown origin
respiratory failure
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
|
[
"572.3",
"789.5",
"E932.0",
"995.92",
"251.8",
"452",
"695.89",
"572.2",
"998.11",
"518.81",
"307.51",
"V66.7",
"507.0",
"567.23",
"038.9",
"E947.8",
"519.09",
"571.1",
"276.52",
"584.5",
"303.91",
"285.29",
"780.6",
"276.0",
"571.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"38.91",
"99.07",
"99.04",
"31.1",
"33.24",
"96.6",
"54.91",
"96.05",
"38.95",
"39.95",
"94.62"
] |
icd9pcs
|
[
[
[]
]
] |
2545, 2554
|
1916, 2522
|
289, 337
|
2680, 2689
|
2745, 2755
|
1420, 1492
|
2575, 2659
|
2713, 2722
|
1507, 1893
|
227, 251
|
365, 1065
|
1087, 1160
|
1176, 1404
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,570
| 107,567
|
41129
|
Discharge summary
|
report
|
Admission Date: [**2154-6-11**] Discharge Date: [**2154-6-18**]
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2154-6-13**] - Colonoscopy
[**2154-6-13**] - Esophagogastroduodonoscopy
[**2154-6-14**] - Capsule Study
History of Present Illness:
86 year old male with history of atrial fibrillation and aortic
stenosis ([**Location (un) 109**] 1 on Cardiac catheterization). Over the past 24
hours he presented to outside
hospital with complaint of chest pain, fatique, weakness and
mild upper back pain. EKG with chronic ST segment
changes,inferior infarct, anterior ST changes, troponin 0.4.
His hematocrit was found to be 17 and he was transfused with 2
units PRBC. Additionally INR was elevated 5.7 related to
coumadin for atrial fibrillation and was treated 2 units FFP and
Vitamin K 10mg po. Due to recurrent chest pain he was
transferred for further evaluation due to known coronary artery
disease and aortic stenosis. He was seen by cardiac surgery in
[**Month (only) **] in evaluation for cardiac surgery however declined
surgery.
Past Medical History:
Hard of hearing
Atrial fibrillation- on Coumadin
Aortic valve disorder ([**Location (un) 109**] 1)
Arthritis
Anemia recieves IV Iron
Gastroesophageal reflux disease
Colon cancer s/p colon resection
Prostate cancer s/p radioactive seed implant
Social History:
Last Dental Exam: edentulous
Lives with: widowed, lives with [**First Name9 (NamePattern2) 89616**] [**Doctor First Name 5627**]
Occupation:Retired
Tobacco: none quit [**2113**]
ETOH: [**2-10**]+ beers/day
Family History:
None
Physical Exam:
Pulse:80's irreg, Resp: 14 O2 sat: 2l 98%
B/P Right: 108/52 Left: 109/54
Height: 5'[**52**]" Weight: 80.4kg
General: Hard of hearing, sitting up in chair no acute distress
denies any pain
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [] Irregular [x] Murmur [**2-10**] syst.
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x] well healed mid-line scar s/p partial colectomy
Extremities: Warm [x], well-perfused [x]
Edema- none
Varicosities- minimal
Neuro: alert and oriented x3 nonfocal
Pulses:
Femoral Right: 2+ Left:2+
DP Right: 1+ Left:1+
PT [**Name (NI) 167**]: Doppler Left:doppler
Radial Right: 2+ Left:2+
Carotid Bruit Right: None Left:None
Pertinent Results:
ECHO [**2154-6-13**]
The left atrium is dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. There is moderate global left ventricular hypokinesis
(LVEF = 35 %). Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). The right
ventricular free wall thickness is normal. Right ventricular
chamber size is normal. with borderline normal free wall
function. The ascending aorta is mildly dilated. There are focal
calcifications in the aortic arch. The aortic valve leaflets are
severely thickened/deformed. There is severe aortic valve
stenosis (valve area 0.9 cm2). Mild (1+) aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. There is
no mitral valve prolapse. Moderate (2+) mitral regurgitation is
seen. [Due to acoustic shadowing, the severity of mitral
regurgitation may be significantly UNDERestimated.] The
tricuspid valve leaflets are mildly thickened. Moderate [2+]
tricuspid regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
Colonoscopy [**2154-6-13**]
Normal terminal ileum
Grade 1 internal hemorrhoids
Diverticulosis of the sigmoid colon
No avms seen
Otherwise normal colonoscopy to cecum and ileum
EGD [**2154-6-13**]
Angioectasia in the second part of the duodenum
Otherwise normal EGD to second part of the duodenum
Capsule study [**2154-6-14**]
Nonbleeding angioectasia
CT scan [**2154-6-17**]
1. Multifocal patchy ground-glass opacities predominantly in the
upper lobes, but also involve the RLL, concerning for multifocal
PNA. DDx also includes NSIP.
2. Moderate bilateral pleural effusions, without evidence of
loculation.
3. Sub-5mm solid nodules in the RML and RLL. Punctate calcified
granuloma in the right base. Calcified perihepatic nodule.
4. Significant 3-vessel coronary artery disease.
5. Small amount of scattered calcified atherosclerotic plaques
in the
ascending aorta, with a 2.8-cm relatively calcification-free
segment starting approximately 1.2 cm superior to the origin of
the right coronary artery.
Carotid ultrasound [**2154-6-18**]
Results pending
Brief Hospital Course:
Mr. [**Known lastname 5239**] was admitted to the [**Hospital1 18**] on [**2154-6-11**] for further
management of his cardiac disease and gastrointestinal bleed. He
was placed in the intensive care unit and a gastroenterology
consult was obtained. Anticoagulation was held and he was
transfused to maintain a hematocrit of 30. A proton pump
inhibitor was started. A cardiology consult was obtained who
recommended a low dose beta blocker and a high dose statin given
his presentation of demand ischemia in the setting of anemia.
His troponin peaked at 1.39. An EGD was performed which showed
angioectasia that were not bleeding in the duodenum with an
otherwise normal study. A colonoscopy was also performed which
showed diverticulum and internal hemorrhoid but was otherwise
normal. He was transferred to the step down unit on [**2154-6-14**] for
further management and surgical planning. As there was no
further evidence of GI bleeding, aspirin was restarted. A
capsule study/virtual colonoscopy was started on [**2154-6-14**] which
showed non bleeding angioectasia. He remained in rate controlled
atrial fibrillation. Coumadin remained on hold and will be
addressed after he has had his surgery. Surgery was scheduled
for [**2154-7-1**]. As he remained stable, he was discharged home on
[**2154-6-18**]. He will have biweekly hematocrits sent to both our
office and Dr.[**Name (NI) 5318**] office drawn by the visiting
nurse.. Surgical consent was obtained with the understanding
that there was a higher risk of further gastrointestinal
bleeding with heparinization with his surgery.
Medications on Admission:
Doxazosin 8 mg daily
Lasix 80 mg daily
Hydroxyurea 1000 mg wednesday and saturday
Prilosec 20 mg daily
Coumadin 5 mg mon-wed-fri-sun, 2.5 mg tues-thrus-sat - last dose
Vitamin C 500mg daily
Leutin 1 tab in am and 1 tab in PM
Tylenol 650 mg twice a day
Ascorbic acid
Aspirin 81 mg daily
Ferrous sulfate 325 mg TID
Multivitamin
Discharge Medications:
1. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
Disp:*30 Tablet, Sublingual(s)* Refills:*0*
2. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*90 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
6. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
7. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO once a day.
Disp:*30 Tablet, ER Particles/Crystals(s)* Refills:*0*
8. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. PreserVision 226-200-5 mg-unit-mg Capsule Sig: One (1)
Capsule PO BID (2 times a day).
Disp:*60 Capsule(s)* Refills:*0*
10. hydroxyurea 500 mg Capsule Sig: Two (2) Capsule PO 2X/WEEK
(WE,SA).
Disp:*20 Capsule(s)* Refills:*0*
11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*0*
12. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Gastrointestinal bleed - source unidentified in setting of
supratherapeutic INR.
Hard of hearing
Atrial fibrillation - Coumadin currently on hold
Aortic valve stenosis
Coronary artery disease
Arthritis
Anemia recieves IV Iron
Gastroesophageal reflux disease
Colon cancer s/p colon resection
Prostate cancer s/p radioactive seed implant
Discharge Condition:
Alert and oriented x3 nonfocal
Discharge Instructions:
1) You will need twice weekly hematocrit blood draws drawn by
visiting nurse.
2) Surgery scheduled for [**2154-7-1**]. You will be contact[**Name (NI) **] by our
office with a surgical time so you know when to arrive at the
hospital on [**2154-7-1**].
3) Visiting nurse to monitor you for signs of heart failure.
4) Call with any blood in stools, dark/tarry stools or abdominal
pain.
5) Call with any questions or concerns.
Followup Instructions:
You are scheduled for surgery on Monday [**2154-7-1**]. You will
be called with the timing by our office prior to your surgery.
Surgeon: Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 1504**]
Cardiologist: Dr. [**Last Name (STitle) 5310**] ([**Telephone/Fax (1) 5319**]
Primary care physician: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 18998**] ([**Telephone/Fax (1) 18999**]
**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:[**2154-6-18**]
|
[
"V70.7",
"537.82",
"V10.05",
"530.81",
"455.0",
"562.10",
"578.9",
"790.92",
"427.31",
"414.01",
"V10.46",
"280.9",
"424.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.23",
"45.19",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
8304, 8355
|
4763, 6352
|
277, 386
|
8735, 8768
|
2563, 4740
|
9240, 9828
|
1716, 1722
|
6730, 8281
|
8376, 8714
|
6378, 6707
|
8792, 9217
|
1737, 2544
|
218, 239
|
414, 1210
|
1232, 1476
|
1492, 1700
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,696
| 192,616
|
11472
|
Discharge summary
|
report
|
Admission Date: [**2170-5-5**] Discharge Date: [**2170-5-21**]
Date of Birth: [**2118-2-1**] Sex: M
Service: MEDICINE
Allergies:
Ciprofloxacin
Attending:[**First Name3 (LF) 6565**]
Chief Complaint:
right lower extremity swelling
Major Surgical or Invasive Procedure:
none
History of Present Illness:
52 year old man with a PMH of metatstatic prostate cancer, PE,
DVT on lovenox, hx of IVC filter in [**2168-4-9**] presents with
increased leg swelling. Patient reports right leg pain that
acutely started on the day prior to admission. He likens the
sensation to feeling as though something were crawling up his
leg and pain was reproduced with standing. These symptoms are
similar to symptoms he's experienced with previous DVTs. He
denies any injury to his leg and also denies prolonged travel or
immobility. He also noticed shortness of breath without chest
pain. Given these symptoms, he presented to the [**Hospital1 18**] ED for
further evaluation.
.
In the [**Hospital1 18**] ED, vitals were as follows T - 98.8, HR - 117, BP -
128/80, RR - 12, O2 - 99%RA. CXR was unremarkable. LENIs showed
non-occlusive DVT on the right. CTA chest was ordered, but was
pending at the time of admission. Given concern for DVT/PE, IV
Heparin was started, though because of the GIB, patient was
admitted to the ICU for concern of GIB in the setting of
anticoagulation
Past Medical History:
PAST MEDICAL HISTORY:
1. Metastatic prostate cancer to bone refractory to hormone
therapy
2. Bilateral LE DVTs complicated by bilateral PE [**4-/2168**],
treated with enoxoparin then warfarin, and status post IVC
filter placement 04/[**2168**]. Last with DVT on [**2169-1-7**], now on
enoxoparin 120 mg daily.
3. Psoriasis
4. Hypercholesterolemia
5. Seasonal allergies
6. Obstructive sleep apnea on CPAP
.
PAST ONCOLOGIC HISTORY (per prior discharge summary):
Metastatic prostate cancer to bone refractory to hormone therapy
s/p cycle 1 of Carboplatin and Taxotere [**2168-12-15**]. Dx in [**2163**] as
[**Doctor Last Name **] 8 s/p surgical prostatectomy with XRT to T9 spinal
metastasis in [**11-12**] followed by hormonal therapy, Taxotere (2
cycles), ketoconazole, hydrocortisone, mitoxantrone, and DES. He
was recently noted to have a rise in his PSA to the 400 range,
and a L-spine MRI on [**11-15**] showed multiple spine metastatic foci
(no prior MRI L-spine for comparison, bone scan in [**6-/2168**]
without clear spine metastases). He received his
first cycle of Carboplatin and Taxotere on [**2168-12-15**].
Social History:
He lives at home with his wife and his 12 year-old son. [**Name (NI) **] does
not smoke. He denies tobacco, alcohol or illicit drug use. He
formerly worked as heavy machine operator at [**Location (un) 86**] Water and
Sewage.
Family History:
No family history of thrombophilic disorders.
Physical Exam:
PHYSICAL EXAM:
Vitals: T - 99.5, BP - 131/79, HR - 119, RR - 16, O2 - 99% 3 L
NC
Gen: Awake, alert, NAD
HEENT: NC/AT; PERRLA, EOMI; OP clear, nonerythematous
CV: Distant heart sounds, [**2-10**] body habitus, but otherwise, no
m/r/g
Pulm: Small inspiratory crackles at the bases bilaterally
Abd: Soft, NT, ND + BS
Rectal: Guaiac negative
Ext: No c/c/e; RLE markedly bigger than LLE with mild erythema
and keratoses on shins
Pertinent Results:
CTA (prelim read):
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Innumerable diffuse osseous metastatic sclerotic lesions.
3. Stable T9 compression fracture.
4. Fatty liver.
LENIS:
IMPRESSION: Partially occlusive thrombus within the mid right
superficial femoral vein consistent with chronic recanalized
DVT.
CXR:
FINDINGS: Single bedside AP examination labeled "upright" with
excessive lordotic positioning, as compared with studies dated
[**2170-4-11**] and [**2169-2-21**]; the overall appearance has not much changed.
The lung volumes remain low with bibasilar vascular crowding,
but no focal airspace process. Allowing for these factors, the
heart is top normal in size with only equivocal upper zone
pulmonary vascular redistribution, but no overt CHF or pleural
effusion.
Brief Hospital Course:
52-year-old man with metastatic prostate cancer, not on active
chemo with recurrent DVTs/PEs despite anticoagulation, also with
recent GIB, presented with LE swelling, found to have RLE DVT.
.
# DVT: The patient presented with worse clot burden. He was on
enoxaparin at home. Anti-Xa activity not checked on admission.
He underwent an IVC venogram and mechanical thrombolysis with
local TPA on [**2170-5-7**]. Heparin was then discontinued, and he was
started on enoxaparin 120 mg [**Hospital1 **] on [**2170-5-8**]. (The patient had
been on enoxaparin 80 mg [**Hospital1 **] before this admission.) His anti-Xa
activity was therapeutic. He was sent home with enoxaparin 120
mg SC bid.
.
# Chronic pain: the patient experienced significant pain from
bone metastases during this admission, requiring hydromorphone
PCA. Palliative care was consulted on pain management. His pain
gradually improved and he was discharged with methadone 20 mg PO
qid and hydromorphone 12-24 mg PO q2h prn as well as gabapentin.
.
# Intermittent delirium: most likely from high-dose pain meds.
His delirium resolved as his pain medications were weaned down.
.
# Fever: The patient spiked a fever of 101.1 on [**2170-5-15**]. He was
empirically started on vancomycin because of concerning for a
PICC line infection. However, when his blood cultures came back
negative, and he defervesced promtly, the vancomycin was
discontinued after 3 days.
.
# Metastatic prostate cancer: with bone mets. Spine CT showed
extensive spine mets. Not able to tolerated spine MRI. PSA > 900
from the 126 in [**Month (only) 547**]. After a discussion with his outpatient
oncologist, he was discharged with a plan for possible samarium
as outpatient.
.
# UTI: pan-sensitive Klebsiella. He was initially started on
ceftriaxone, which was switched to TMP/SMX when sensitivities
were available. He finished a 7 days of TMP/SMX.
.
# Anemia: During his last admission, AVM seen on EGD was
cauterized on [**2170-4-24**] during last admission. During this
admission he received 2 units of pRBCs in MICU, and his
hematocrit was stable after that. He was continued on PPI and
sucralfate.
.
# Psoriasis: continued on outpatient creams.
.
# Obstructive Sleep Apnea: continued on CPAP.
.
# Communication: [**First Name8 (NamePattern2) **] [**Known lastname **](wife/HCP)-([**Telephone/Fax (1) 36628**]
(h)/([**Telephone/Fax (1) 36629**] (c)
.
# Code: FULL
Medications on Admission:
1. Lorazepam 1 mg PO Q6H
2. Docusate Sodium 100 mg PO BID
3. Senna 8.6 mg PO BID
4. Pantoprazole 40 mg PO BID
5. Sucralfate 1 gram PO QID
6. Lidocaine 5 % TD
7. Bisacodyl 10 mg PO QD
8. Nortriptyline 50 mg PO QD
9. Celecoxib 200 mg PO BID
10. Gabapentin 300 mg PO TID
11. Tylenol PRN
12. Enoxaparin 80 mg SC BID
13. OxyContin 80 mg PO TID
14. Hydromorphone 4-8 mg PO Q3-4 hours
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
Disp:*120 Tablet(s)* Refills:*2*
3. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*2*
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Enoxaparin 120 mg/0.8 mL Syringe Sig: One [**Age over 90 **]y
(120) mg Subcutaneous Q12H (every 12 hours).
Disp:*qs 1 month's supply* Refills:*2*
7. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
Disp:*120 Capsule(s)* Refills:*2*
8. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*120 Tablet(s)* Refills:*0*
9. Clobetasol 0.05 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
10. Hydromorphone 4 mg Tablet Sig: Three (3) Tablet PO Q2H
(every 2 hours) as needed for pain.
Disp:*qs 1 month's supply* Refills:*0*
11. Methadone 10 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6
hours).
Disp:*240 Tablet(s)* Refills:*2*
12. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
13. Dulcolax 10 mg Suppository Sig: Ten (10) mg Rectal once a
day as needed for constipation.
Disp:*qs 1 month's supply* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: deep venous thrombosis
Secondary diagnoses: metastatic prostate cancer, obstructive
sleep apnea, psoriasis
Discharge Condition:
stable
Discharge Instructions:
You presented to the [**Hospital1 18**] with leg pain and were found to have
a blood clot in your leg. You underwent a procedure to break up
the clot and received blood thinner. Please continue to take all
your medications, especially the enoxaparin (Lovenox), as
instructed. Please follow up with your physicians.
If you develop worsening pain, difficulty breathing, fevers,
chills, chest pain, or any other concerning symptom, please go
to the nearest Emergency Room immediately.
Followup Instructions:
* Oncology: Dr. [**Last Name (STitle) **], please call ([**Telephone/Fax (1) 31457**] to make a
follow-up appointment within 2 weeks.
* Primary care: Dr. [**Last Name (STitle) **], please call [**Telephone/Fax (1) 7477**] to maek a
follow-up appointment within 2 weeks.
[**First Name4 (NamePattern1) 2946**] [**Last Name (NamePattern1) **] MD [**MD Number(1) 3218**]
|
[
"285.9",
"198.5",
"041.3",
"272.0",
"338.3",
"293.0",
"696.1",
"327.23",
"V10.46",
"453.41",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.10",
"88.51",
"39.79",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
8629, 8635
|
4120, 6523
|
303, 309
|
8805, 8813
|
3308, 4097
|
9344, 9743
|
2801, 2848
|
6952, 8606
|
8656, 8656
|
6549, 6929
|
8837, 9321
|
2878, 3289
|
8720, 8784
|
233, 265
|
337, 1396
|
8675, 8699
|
1440, 2540
|
2556, 2785
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,973
| 122,900
|
945
|
Discharge summary
|
report
|
Admission Date: [**2181-10-18**] Discharge Date: [**2181-10-26**]
Date of Birth: [**2098-1-31**] Sex: F
Service: MEDICINE
Allergies:
Ampicillin
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
PCP: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4844**], MD
.
REASON FOR MICU ADMISSION: Sepsis.
CHIEF COMPLAINT: Fever.
Major Surgical or Invasive Procedure:
Central Line Placement
History of Present Illness:
History from daughter in law and granddaughter.
Ms. [**Known lastname 6302**] is an 82yo Polish-speaking woman with CAD s/p
anterior apical MI, chronic systolic and diastolic CHF ([**2181-5-23**]
EF 50%), s/p PPM and ICD, asthma, and HTN, who presents after
recent hospitalizatiion for anemia with [**Last Name (un) **]/EGD and capsule
study showing small intestinal ulcers, discharged yesterday, who
presents with fever to 38.8. The son called the patient's house
around noon but the line was busy. He went to her house and
found the patient lying on the floor in the bathroom next to the
toilet in her own brown stool. The patient stated that she had
slipped off the toilet. She denied LOC, head trauma. The
patient's daughter in law also arrived at the patient's house
and she noted that the patient felt dizzy, short of breath and
wheezy after the fall. Daughter in law gave her Tylenol #3 and
albuterol. Noted to have 38.4 fever at home. Family called Dr.
[**Last Name (STitle) 4844**], the PCP, [**Name10 (NameIs) **] he told them to go to the ED for
evaluation. Pt did not want to come to the hospital after most
recent hospitalization.
.
Of note, recent admission to [**Hospital1 18**] from [**2181-10-10**] - [**2181-10-17**] for GI
bleeding. Transfused pRBC and Hct stable. GI pefromed EGD and
[**Last Name (un) **] which did not show active source of her bleed. Also had
capsule endoscopy, results pending. ASA and coumadin held given
bleeding. Her outpt cardiologist wanted to restart ASA after
capsule study results obtained. Capsule study showed: Non
bleeding ulcer in the small bowel, there is a possible second
ulcer in the small bowel, thought to be likely source of
bleeding.
.
In the ED, initial VS: T 101.5 (tmax 103.6 rectal) HR 65 BP
140/60 RR 22 100% on 6 L NC. Labs drawn, notable for elevated
lactate of 3.0, leukocytosis 12.4, anemia 28.2. UA, Urine
culture, blood cultures pending. EKG, CXR, CT abd/pelvis
completed. Given acetaminophen 650 mg x 1, levofloxacin 750 mg
IV x 1, flagyl 500 mg IV x 1, albuterol and ipratropium nebs.
BP trended down from 100s to mid-upper 80s (lowest 86/38). 1.5 L
NS given. RIJ placed. GI consulted for gross blood in rectal
vault. Surgery consulted. VS on transfer: 60 102/44 20 100% 2 L
NC
.
ROS: unable to obtain.
Past Medical History:
CAD s/p anterior apical MI and s/p stent in past
Chronic systolic and diastolic CHF, EF 50%
afib
s/p PPM and ICD
DMII- diet controlled
Hypertension
Hyperlipidemia
Asthma
Left Trochanteric Bursitis
Cataract left eye- s/p extraction [**2178-6-11**]
Chronic renal insufficiency, baseline creatinine 1.7 - 2.0
Venous stasis
Recurrent LE cellulitis
Social History:
The patient is Polish and does not speak English.
She lives alone in [**Hospital3 **], but is very close with her
son and daughter-in-law [**Doctor First Name 6303**] is a [**Hospital1 18**] employee at
[**Hospital3 **]. Denies alcohol, drugs, or smoking. Walks
with cane.
Family History:
Noncontributory
Physical Exam:
Vitals - T: 99.3 BP: 100/38 HR: 64 RR:16 02 sat: 98% 3 L NC
GENERAL: elderly, malaised appearing female lying in bed
HEENT: anicteric, PERRL, OP - no exudate, no erythema, MM dry,
no cervical LAD
CARDIAC: RRR, no m/r/g
LUNG: no w/r/r, decreased BS at right lung base
ABDOMEN: NDNT, soft, NABS
EXT: 1+ pitting edema to lower calves bilaterally, no c/c
DERM: ecchymose on L thigh
RECTAL: per ED notes, gross blood in rectum
Pertinent Results:
[**10-18**] Blood cultures x 2: pending
[**10-18**] Urine culture: pending
.
STUDIES:
.
LUE US [**10-26**]: Negative for DVT.
.
Xray Ankle [**10-25**]:
No previous images. Generalized osteopenia of the visualized
bony
elements. No evidence of fracture or dislocation. The extensive
vascular
calcification suggests underlying diabetes.
.
Video Oropharyngeal Swallow Study [**10-24**]:
Penetration into the vestibule with nectar and thin
consistencies. Please refer to the complete report and dietary
recommendations from speech Pathology.
.
Chest US [**10-22**]:
The pacemaker is identified over the left anterior chest wall
and no fluid collection is identified.
.
TTE [**10-22**]:
IMPRESSION: Regional left ventricular systolic dysfunction c/w
multivessel CAD. Moderate tricuspid regurgitation. Pulmonary
artery systolic hypertension. Mild mitral regurgitation. No
discrete vegetation identified (does not exclude). Compared with
the prior study (images reviewed) of [**2181-5-23**], the distal
inferior wall is now hypokinetic (may be related to image
quality). The severity of mitral regurgitation and tricuspid
regurgitation are now increased.
.
CT ABD/PELVIS [**10-19**]:
1. No evidence of free air. Oral contrast has reached the
transverse colon, with no evidence of extraluminal contrast up
to this level. Fat stranding at the duodenum of uncertain
clinical significance. Free fluid in the pelvis and tracking in
the right lower abdominal quadrant. Anasarca.
2. Bilateral pleural effusion, more on the right with associated
atelectasis at the lung bases; cannot rule out superinfection.
.
EKG: [**10-18**] NSR @ 60 bpm, paced, prolonged PR interval, nl axis,
no acute ST changes, TWI, Qwaves (no change compared to prior on
[**2181-10-12**].
.
CXR [**2181-10-18**] (FINAL): Radiograph is limited due to rotation and
motion. There are bibasilar plate-like atelectasis. There is
opacty at the right lung base, which could be consolidation, and
correlation with clinical symptoms is recommended. There is no
pleural effusion or pneumothorax. Cardiomediastinal silhouette
is stable. Dual-lead pacer device is seen with leads in the
expected locations in the right atrium and right ventricle.
Bones are diffusely osteopenic. Atherosclerotic calcification
along the thoracic aorta is seen. Old right lower posterolateral
rib fracture is less conspicuous on the current radiograph.
IMPRESSION: Limited radiograph due to rotation and motion.
Possible airspace opacity at the right lung base, could be
consolidation, and correlation with clinical exam is
recommended.
.
TTE [**2181-5-23**]:
The left atrium is mildly dilated. The estimated right atrial
pressure is 0-5 mmHg. There is mild regional left ventricular
systolic dysfunction with severe hypokinesis of the distal
septum and anterior walls. The apex is akinetic. The remaining
segments contract normally (LVEF = 50 %). 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 mildly thickened. Mild (1+) mitral regurgitation is
seen. There is moderate pulmonary artery systolic hypertension.
There is an anterior space which most likely represents a fat
pad.
.
Compared with the prior study (images reviewed) of [**2180-6-28**] the
estimated pulmonary artery systolic pressure is now lower.
Regional left ventricular systolic function is similar.
.
Colonoscopy [**10-15**]
Normal mucosa in the whole colon
Polyp at a distance between 80 cm and 65 cm in the colon
Polyp at 20cm in the sigmoid colon (polypectomy)
Grade 1 internal hemorrhoids
Otherwise normal colonoscopy to cecum
.
Endoscopy [**10-11**]
Normal mucosa in the stomach (biopsy, biopsy)
Otherwise normal EGD to third part of the duodenum
Brief Hospital Course:
82 y.o. F with CAD s/p anterior apical MI, chronic systolic and
diastolic CHF ([**2181-5-23**] EF 50%), s/p PPM and ICD, asthma, recent
GI bleed, who presents with fever, leukocytosis, and grossly
bloody stool in rectal vault.
MICU COURSE:
=============
1. Sepsis: Met [**3-7**] SIRS criteria with possible sources of
infection, including pneumonia given findings on CXR and CT and
phsyical exam findings as well as + UA. Broadly treated with
vancomycin, cefepime, and ciprofloxacin to treat hospital
acquired pneumonia as well as UTI. Pt initially was hypotensive
and was bolused with IVFs. CVP at goal and still with
borderline BPs, so levophed was initiated. This was weaned in
24 hours. Urine culture with > 100,000 e.coli sensitive to
cefepime. [**5-5**] Blood culture returned with MRSA bacteremia. ID
was consulted for MRSA bacteremia. Vancomycin and cefepime were
continued. Cipro stopped due to no evidence of pseudomonas.
Echo without vegatations or masses.
ID was consulted, and recommended TEE to determine course of
antibiotics plus need for ongoing suppressive antibiotics. This
was not performed in the ICU based on her improving status and
was not done on the floor per family wishes. This required a 6
week course of Vancomycin, due to worry of pacemaker infection.
Though this was likely a MRSA pneumonia exclusively, she was
continued on cefepime for an 8 day course given lack of
sufficient sputum culture data.
2. Anemia from GI bleeding: Hct 28 and stable from recent
hospitalization. However, grossly bloody stool in rectal vault.
GI consulted and recommended serial Hcts and active T&S. Pt did
not need transfusions while in the ICU or on CC7 and did not
have any more evidence of GI bleed. Surgery also initially
consulted in ED, but no surgical issues.
3. UTI: + UA with e. coli > 100K. Treated with cefepime.
4. ARF: Elevated to 2.7 on [**2181-10-19**], from baseline around 1.5.
Returned to baseline on [**2181-10-24**]. Likely prerenal, patient has
tenuous volume status with total body overload and intravascular
depletion. I/O total net through hospital stay was negative
4.5-5l. Cr. at baseline on discharge.
5. CAD: Continued atorvastatin, held carvedilol in setting of
hypotension
6. CHF: systolic and diastlic dysfunction in recent echo.
Initially held lasix, carvedilol and isosorbid mononitrate given
hypotension. As pt improved, IV lasix boluses given as pt
appeared volume overloaded with symptomatic SOB. Continued
diuresis.
7. Afib: continued amiodarone, monitored on telemetry and had
many EKGs that showed different levels of atrial and ventricular
pacing.
8. HTN: Held antihypertensives initially given
hypotension/sepsis. Restarted carvedilol on CC7 but held
isosorbide mononitrate until discharge.
General medicine floor course:
1. MRSA sepsis: Her IJ line culture was negative. Family
continued to refuse TEE and so patient was kept on 6 week course
of vancomycin for a possible occult pacemaker pocket infection.
She completed an 8 day course of cefepime on [**2181-10-26**]. after
blood cultures were negative x4 no further cultures were drawn.
She was discharged on Vancomycin 100mg IV Q24 with PICC line in
place, to rehab facility in [**Location (un) **], MA. Vancomycin should be
continued through [**2181-11-30**].
2. Anemia: Hct remained stable on floor and no signs of GI
bleeding were seen. Coumadin and ASA were held throughout
hospital stay despite this, as bleeding risk was greater than
risk of staying off anticoagulation with paroxysmal atrial
fibrillation. The ASA and Coumadin can be considered for
restarting during her rehab stay, pending no further signs of GI
bleeding.
3. UTI: Clear on subsequent culture on [**2181-10-22**]. Cefepime was
continued for 8 day course and stopped on [**2181-10-26**]. Foley was
removed on [**2181-10-25**] and patient had few epsiodes of incontinence
afterwards.
4. ARF: Cr. returned to baseline level, at 1.4, on day of
discharge. Her urine output was adequate during active diuresis
and her initial spike in Cr. did appear to be prerenal related.
5. CAD: Carvedilol and Atorvastatin were restarted before she
came to medicine floor and were continued on discharge. She was
normotensive throughout and had her isosorbide mononitrate
restarted on [**2181-10-26**]. ASA conitnued to be held due to bleeding
risk and the fact that her MI was in the distant past ([**2172**]).
6. CHF: Both systolic and diastolic. EF on this admission was
40%. Patient was diuresed a total of 4.5-5l throughout this
hospitalization after initial volume support during
sepsis-related hypotension. She came to teh medicine floor on
her home dose of furosemide 40mg and was discharged on this.
7. A Fib: She was placed on telemetry intially, which showed her
to be in AF but without any symptoms. She was AV paced and
removed from telemetry on [**2181-10-25**]. Her amiodarone was continued
throughout, Coumadin was held as described above. Can consider
re-starting Coumadin and ASA following discharge if no further
GI bleed.
8. HTN: She came to the floor normotensive and on her home dose
of carvedilol. Isosorbide mononitrate was held initially but
restarted on [**2181-10-26**] at her home dose.
9. Lt. UE edema: Most likely venous insufficiency and without
pain but a UE US was obtained to look for possible DVT. This
showed no signs of a clot.
CODE: DNR/DNI (confirmed with HCP)
CONTACT: Daughter in law [**Name (NI) 6303**] [**Telephone/Fax (1) 6312**]
Medications on Admission:
Amiodarone 100 mg po daily
Atorvastatin 10 mg po daily
Calcitriol 0.25 mcg po every other day
Pepcid 40 mg po daily
Carvedilol 25 mg po BID
Lasix 40 mg po daily
Isosorbide Mononitrate SR 30 mg po qhs
Vitamin D 50,000 units po qweekly
Albuterol 90 mcg INH 2 puffs INH q4 hours prn sob/wheeze
Aranesp injection
Iron-B Cplx-B12-Liver Extract Intramuscular
Discharge Medications:
1. Pepcid 40 mg Tablet Sig: One (1) Tablet PO once a day.
2. Amiodarone 200 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO EVERY
OTHER DAY (Every Other Day).
5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
hold for SBP <95 .
6. Imdur 30 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
7. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a
week: Saturdays.
8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q2H (every 2 hours) as
needed for shortness of breath or wheezing.
9. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
gram Intravenous Q 24H (Every 24 Hours): through [**2181-11-30**] unless
otherwise instructed by infectious diseases.
10. Carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day.
11. Aranesp (Polysorbate) 100 mcg/0.5 mL Syringe Sig: One (1)
Injection once a month: To receive on or after [**2181-10-27**] if
available at rehab.
12. Heparin (Porcine) 5,000 unit/mL Syringe Sig: One (1)
Injection three times a day: To be administered until patient
ambulating.
13. Insulin Lispro 100 unit/mL Solution Sig: as directed
Subcutaneous ASDIR (AS DIRECTED): As directed per sliding scale.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Healthcare
Discharge Diagnosis:
Primary diagnosis:
1. MRSA sepsis
2. hospital-acquired pneumonia
3. E.coli UTI
Secondary Diagnoses:
1. acute on chronic systolic and diastolic CHF
2. acute on chronic renal failure
Discharge Condition:
Stable, back to baseline mental status, baseline renal function,
and baseline breathing status.
Discharge Instructions:
You were seen at [**Hospital1 18**] for fever. Initially your blood pressure
was low and you were sent to the intensive care unit and were
given medications to keep your blood pressure at an acceptable
level. you also were found to have an infection in your blood
stream, your lungs, and your urine. After starting antibiotics
these infections cleared but you were kept on 6 weeks of
vancomycin because we wanted to lower the chances of your
pacemaker getting infected.
.
Your kidney function also became worse intially during your stay
but returned to your normal level of function by the time you
got to the general medicine floor. It was thought that this
worsening kideny function was related to your infection and
fluid status.
.
Medication Changes:
1. Vancomycin 1000 mg IV Q24H through [**2181-11-30**]
.
Due to your congestive heart failure please weigh yourself every
morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 2L/day
.
If you develop fevers, chest pain, shortness of breath, or other
concerning symptoms, please return to the hospital.
Followup Instructions:
Please follow up with the following doctors below listed below:
.
Infectious disease followup appointments:
- Dr. [**Last Name (STitle) **] afternoon of [**2181-11-8**] - patient/rehab will need
to call the [**Hospital **] clinic at [**Telephone/Fax (1) 1419**] on the day of the
appointment for the exact appointment time.
- Dr. [**First Name (STitle) **] in [**Hospital **] clinic on [**2181-11-30**] at 9:30am.
- Cardiac surface echocardiogram [**2181-11-27**] at 1:00pm in [**Hospital Ward Name 23**]
Building [**Location (un) 436**]
.
Other appointments at [**Hospital1 18**]:
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 1803**] Date/Time:[**2181-11-6**]
1:00
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 721**]
Date/Time:[**2181-11-7**] 11:00
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], M.D. Date/Time:[**2181-11-15**] 1:40
.
You will need to have your labs checked on a weekly basis
(CBC/diff, BUN/Cr, Vancomycin trough) with results faxed to [**Hospital **]
clinic at ([**Telephone/Fax (1) 6313**], first draw to be faxed Monday [**10-29**].
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
|
[
"493.90",
"428.42",
"578.9",
"785.52",
"518.81",
"272.4",
"428.0",
"412",
"427.31",
"584.9",
"V45.02",
"403.90",
"250.00",
"414.01",
"038.12",
"459.81",
"599.0",
"482.41",
"585.9",
"V45.01",
"995.92",
"280.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
15022, 15075
|
7760, 13232
|
412, 436
|
15301, 15399
|
3915, 7737
|
16549, 17847
|
3436, 3453
|
13636, 14999
|
15096, 15096
|
13258, 13613
|
15423, 16158
|
3468, 3896
|
15197, 15280
|
16178, 16526
|
366, 374
|
464, 2761
|
15115, 15176
|
2783, 3128
|
3144, 3420
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,036
| 147,406
|
5634
|
Discharge summary
|
report
|
Admission Date: [**2138-2-20**] Discharge Date: [**2138-2-26**]
Date of Birth: [**2092-2-18**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Imitrex / Iodine; Iodine Containing
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Post tracheostomy tracheal stenosis.
Major Surgical or Invasive Procedure:
[**2138-2-20**]: Cervical tracheal resection and reconstruction
and bronchoscopy with aspiration.
History of Present Illness:
Ms. [**Known lastname 22571**] is a 46-year-old woman who had suffered a motor
vehicle accident and required tracheostomy placement. Subsequent
to decannulation she noted
dyspnea and a choking sensation. On bronchoscopy, she was noted
to have a dynamic stenosis at approximately the second and third
tracheal rings. She therefore was admitted for resection.
Past Medical History:
IDDM
Osteoperosis
Fibromyalgia
Anxiety
Depression
Bipolar Disorder
s/p MVA [**4-2**] w/ multiple face/pelvic/spine fx -intubated x1
month, s/p trach
Hypothyroidism
Hyperlipidemia
Social History:
The patient reports that she quit smoking since
[**2137-3-26**]. 20 pack year smoking history. She does not drink
any alcohol.
Family History:
Father had lung cancer
with a history of smoking, as well a coronary artery disease. No
known family exposure to TB.
Physical Exam:
VS: T: 98.2 HR: 78 SR BP: 116/76 Sats: 94% RA
General: 46 year-old well appearing female
HEENT: mucus membranes moist
Neck: supple no lymphadenopathy
Card: RRR, normal S1,S2 No Murmur/gallop or rub
Resp: clear breath sounds throughout
GI: bowel sounds positive, abdomen soft non-tender/non-distended
Extr: warm no edema
Incsision: cervical clean dry intact, no erythema
Neuro: non-focal
Pertinent Results:
[**2138-2-22**] WBC-9.0 RBC-3.88* Hgb-11.7* Hct-34.3* Plt Ct-211
[**2138-2-22**] WBC-12.1* RBC-4.02* Hgb-12.0 Hct-35.0* Plt Ct-207
[**2138-2-21**] WBC-14.1* RBC-4.13* Hgb-12.2 Hct-35.6* Plt Ct-241
[**2138-2-20**] WBC-13.1*# RBC-4.46 Hgb-13.3 Hct-38.8 Plt Ct-233
[**2138-2-24**] Glucose-281* UreaN-4* Creat-0.6 Na-140 K-4.5 Cl-106
HCO3-29
[**2138-2-23**] Glucose-245* UreaN-3* Creat-0.5 Na-140 K-4.2 Cl-108
HCO3-26
[**2138-2-22**] Glucose-203* UreaN-4* Creat-0.5 Na-139 K-3.6 Cl-104
HCO3-30
[**2138-2-20**] Glucose-239* UreaN-9 Creat-0.7 Na-139 K-4.4 Cl-107
HCO3-23
[**2138-2-24**] Calcium-8.9 Phos-2.9 Mg-1.5*
Culuture
[**2138-2-20**] MRSA SCREEN (Final [**2138-2-23**]): No MRSA isolated.
CXR:
[**2138-2-23**] the right basal lung is better ventilated, the
pre-existing basal opacities have completely resolved. There
are no newly occurred focal parenchymal opacities. There is no
evidence of pneumothorax or pneumomediastinum. The size and
shape of the cardiac silhouette is unremarkable. The vertebral
fixation devices are unchanged.
[**2138-2-22**]: IMPRESSION: Interval worsening of opacity at the
bases, most likely representing discoid atelectasis. See above.
[**2138-2-21**]: Opacification at the right lung base accompanied by
elevation of the hemidiaphragm is presumably atelectasis.
Another region of atelectasis at the left lung base medially has
worsened. Upper lungs clear. No pneumothorax or appreciable
pleural effusion. Normal cardiomediastinal silhouette.
Brief Hospital Course:
Ms. [**Known lastname 22571**] was admitted on [**2138-2-20**] for Cervical tracheal
resection and reconstruction and bronchoscopy with aspiration
with a guardian stitch of from the chin to the chest. She was
extubated in the operating room and monitored in the SICU with a
JP at incision site. Her saturations were 95% 4L NC, her pain
was well controlled with a Morphine PCA. Her blood sugars were
well controlled on insulin. On POD1 she had an episode of
vomiting with a good response to antiemetics. The PCA was
changed from MSO4 to Dilaudid with resolution of her nausea. She
was maintained on IV fluids. On POD2 she transferred to the
floor. The JP was removed. She was started on a sips. POD3 the
neck suture remained intact. The foley was removed. She
converted to PO pain meds. On POD4 she tolerated a regular
diet. Was continued on her home medications. On POD6 she had a
flexible bronchoscopy. She was followed with serial chest films
with improvement of the right lower lobe opacity, atelectasis.
The guardian stitch was removed and she was discharged to home.
Medications on Admission:
Fosamax 70 qweek, abilify 5 qHS, cymbalta 60 qAM, novalog,
lantus 26 u qam, 14 u qPM, synthroid 100 daily, meloxicam 7.5
daily, omeprazole 20 daily, lyrica 100 q8, seroquel 25 qAm and
75 qPM, crestor 40 daily, ASA 81 daily
Discharge Medications:
1. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. Pregabalin 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
4. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
5. Quetiapine 25 mg Tablet Sig: Three (3) Tablet PO QPM (once a
day (in the evening)).
6. Rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Aripiprazole 10 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Duloxetine 60 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO QAM.
10. Zetia 10 mg Tablet Sig: One (1) Tablet PO once a day.
11. Insulin Glargine 100 unit/mL Solution Sig: 26 Units Qam, 14
units Qhs Units Subcutaneous as directed.
12. Meloxicam 7.5 mg Tablet Sig: One (1) Tablet PO once a day.
13. Rosuvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
14. Bisacodyl 10 mg Suppository Sig: One (1) Rectal once a day
as needed.
15. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Post tracheostomy tracheal stenosis.
MVC [**4-2**] sp multiple facial/thoracic spine/ pelvic fractures,
Pulmonary Contusion, s/p trach
IDDM,
Fibromyalgia,
Osteoporosis,
Anxiety/bipolar disorder
+PPD 30
years ago, hypothyroidism, hypercholesterolemia.
Discharge Condition:
stable
Discharge Instructions:
Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 2348**] if experience:
-Fever > 101 or chills
-Increased shortness of breath, cough or sputum production
-Difficulty or painful swallowing, hoarseness.
-Nausea, vomiting
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] [**3-11**] at 9:30am in the [**Hospital Ward Name 121**]
Building, [**Hospital1 **] I Chest Disease Center, [**Location (un) **].
Report to the [**Hospital Ward Name 517**] Clinical Center, [**Location (un) **] Radiology
Department for a Chest X-Ray 45 minutes before your appointment.
Follow-up with your PCP [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 250**]
Completed by:[**2138-2-28**]
|
[
"530.81",
"729.1",
"346.90",
"E879.8",
"272.0",
"E929.0",
"296.80",
"519.19",
"244.9",
"733.00",
"V15.51",
"787.01",
"V15.82",
"V58.67",
"519.02",
"250.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.79",
"33.22"
] |
icd9pcs
|
[
[
[]
]
] |
5876, 5882
|
3244, 4327
|
340, 440
|
6177, 6186
|
1737, 3221
|
6462, 6975
|
1193, 1312
|
4600, 5853
|
5903, 6156
|
4353, 4577
|
6210, 6439
|
1327, 1718
|
263, 302
|
468, 828
|
850, 1031
|
1047, 1177
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,023
| 169,667
|
40369
|
Discharge summary
|
report
|
Admission Date: [**2101-9-15**] Discharge Date: [**2101-10-14**]
Date of Birth: [**2054-2-20**] Sex: F
Service: MEDICINE
Allergies:
Iodine / seafood / Penicillins / Sulfa (Sulfonamide Antibiotics)
/ Tegaderm
Attending:[**First Name3 (LF) 2006**]
Chief Complaint:
Bloody diarrhea
Major Surgical or Invasive Procedure:
exploratory laparoscopy
intubation
hemodialysis
History of Present Illness:
(Initial presentation to hospital per Transplant [**Doctor First Name **]):
47F with ESRD on HD s/p right arm AV Graft on [**2101-8-31**] now
presenting with a one day history of profuse diarrhea, nausea,
vomiting and crampy abdominal pain. Patient reports feeling well
until yesterday when she started having large volume diarrhea
which was watery and bloody in consistency. She states she has
also had several episodes of nausea and vomiting. This has also
been associated with lower abdominal pain. Pain is crampy and
intermittent in nature. She also notes increasing erythema and
pain in her lower right arm which has been progressing over the
last 2-3 days.
.
Upon transfer to medicine service:
47 yo F w/ h/o End Stage Renal Disease (ESRD) on Hemodialysis
(HD), Diabetes Mellitus (DM), Hypertension (HTN), Schizophrenia,
Hypothyroid dz p/w abdominal pain, watery/bloody diarrhea [**9-15**]
from rehab, CT scan w/ evidence of colitis and portal venous air
and wbc 20s on labs. Pt admitted to surgical survice, and taken
to OR [**9-16**] for exploratory lap, notable for colitis but no
ischemic bowel. She was started on broad spec abx (vanc, cipro,
flagyl). Post op she was transferred to the floor. During
admission, psych meds (clozaril/lamictal) had been held and then
restarted post-operatively. After restarting these medications
patient had a witnessed seizure and was intubated for airway
protection. Neuro was consulted. MRI was wnl. EEG showed
moderate diffuse encephalopathy still with focal features and
occasional interictal epileptiform activity. Chest CT showed
opacification of LL atalectasis vs consolidation (intubation c/b
right main stem intubation), and abx switched to vanc/cefepime
for Hospital-acquired pneumonia treatment. At this time, patient
denies all pains or shortness of breath.
Past Medical History:
PMH: Diabetes since age 12, ESRD on HD, hypertension,
hypothyroidism, GERD, COPD/Asthma, h/o pancreatitis from
hypertriglyceridemia
PSH: appendectomy, multiple dialysis access procedures including
right upper arm basilic transposition, left forearm fistulas as
well as right forearm fistulas
Social History:
SH: Lives in [**Hospital 21317**] nursing home in [**Location 21318**]. Has a
sister who is her [**Name (NI) 7474**] guardian. 70 pack year hx of tobacco
use. No etoh or other drugs.
Family History:
H/o diabetes mellitus and heart disease in the family.
Physical Exam:
ADMISSION EXAM (per transplant surgery):
VS: 98 90 153/65 18 100RA
PE: Gen - A&Ox3
CV - RRR
Pulm - CTAB
Abd - Soft, tenderness to deep palpation in bilateral lower
abdomen, no rebound/guarding
Ext - Edema
.
EXAM on transfer from SICU:
Vitals: T: 97.7 P: 84 BP: 101/52 RR: 16 O2 99%RA
General: awake, answers questions slowly but appropriately
HEENT: EEG electrodes in place, MMM
Pulmonary: Difficult to assess as patient has minimally
cooperative with moving forward, rhonchorous anteriorly, no
wheezes noted, decreased breath sound on L midaxillary line.
Cardiac: RRR, S1S2, 2/6 systolic murmur
Abdomen: abd soft and nontender
Extremities: warm, well perfused
Neuro: Left pupil irregular, both pupils large and sluggishly
reactive (4mm->3mm). EOMI with endgaze nystagmus bilaterally
(2-3 beats). Good finger grip, moves all extremities
spontaneously.
Psych: flat affect, psychomotor retardation
.
DISCHARGE EXAM:
97.3 (99.7) 114/51 111 20 100%RA
General-Lying in bed and sleeping comfortably, NAD
Cardiac: RRR, S1/S2 appreciated, 2/6 systolic murmur best heart
in right sternal border, unchaged exam
Pulmonary: CTAB, no wheezes/crackles
Abdomen: Soft, NT/ND, BSx4
Extremities: Rash on right forearm is unchanged. Swelling of the
right forearm is improved from prior exams.
Neuro: A&Ox3, moving all extremeties, gait is normal
Psych: Mood cotinues to be depressed although improved now that
she's off the 1:1. Still c/o hearing voices that are telling
her to harm self.
Pertinent Results:
ADMISSION LAB:
[**2101-9-15**] 12:15PM BLOOD WBC-20.9*# RBC-4.06* Hgb-12.5 Hct-37.8
MCV-93 MCH-30.7 MCHC-33.1 RDW-15.8* Plt Ct-274
[**2101-9-15**] 12:15PM BLOOD Neuts-94.1* Lymphs-3.5* Monos-2.2 Eos-0
Baso-0.1
[**2101-9-15**] 12:15PM BLOOD Glucose-350* UreaN-83* Creat-5.8*#
Na-125* K-5.9* Cl-92* HCO3-15* AnGap-24*
[**2101-9-15**] 12:15PM BLOOD ALT-23 AST-31 AlkPhos-189* TotBili-0.3
[**2101-9-15**] 12:15PM BLOOD Calcium-8.7 Phos-7.6*# Mg-3.0*
[**2101-9-16**] 01:53AM BLOOD Type-ART pO2-71* pCO2-39 pH-7.46*
calTCO2-29 Base XS-3 Intubat-NOT INTUBA
[**2101-9-15**] 12:26PM BLOOD Lactate-1.4 K-6.1*
.
[**2101-9-16**] 04:22PM BLOOD WBC-27.3* RBC-3.78* Hgb-11.7* Hct-34.5*
MCV-91 MCH-30.9 MCHC-33.9 RDW-15.7* Plt Ct-297
[**2101-9-16**] 04:22PM BLOOD Glucose-200* UreaN-20 Creat-3.0*# Na-136
K-3.3 Cl-92* HCO3-28 AnGap-19
[**2101-9-16**] 04:22PM BLOOD Calcium-8.5 Phos-4.6* Mg-2.1
[**2101-9-16**] 01:53AM BLOOD Glucose-179* Lactate-2.4* Na-133* K-3.2*
Cl-92*
.
DISCHARGE LAB:
===========================================
IMAGING:
ECG - [**2101-9-15**]: Sinus rhythm at upper limits of normal rate. Mild
J point and ST segment elevation in the inferior leads. P-R
interval prolongation. No previous tracing available for
comparison. Clinical correlation is suggested.
[**2101-9-19**]: Sinus rhythm. Intra-atrial conduction delay. Cannot
exclude inferior myocardial infarction of indeterminate age.
Compared to the previous tracing of [**2101-9-15**] the rate is slower.
[**2101-9-25**]: Sinus rhythm. Poor R wave progression. Compared to the
previous tracing of [**2101-9-19**] there is loss of precordial R wave
which could be due to lead placement.
.
CXR [**2101-9-15**]: Mild bibasilar atelectasis.
.
CT abdomen/pelvis [**2101-9-15**]: 1. Circumferential wall thickening
involving a long segment of colon spanning from the hepatic
flexure to the proximal descending colon with mild surrounding
fat stranding thought most likely to be infectious/inflammatory
in etiology given the long distribution involved rather than
ischemic.
2. Small amount of portal venous in segment IV of the liver.
Etiology is uncertain, but unlikely to be from ischemic bowel
given the lack of pneumatosis or main portal or superior
mesenteric venous air, as well as the fact that the colonic
abnormalities span two vascular territories. Portal venous air
may be seen with infectious/inflammatory causes.
3. Left femoral dialysis catheter ends in the upper IVC.
4. Trace left pleural effusion versus small amount of
atelectasis.
.
CT head [**2101-9-18**]: No evidence of acute intracranial hemorrhage or
mass effect. A few hypodense foci in the right frontal lobe are
indetemriante. Correlate clinically and with neuroexamn. to
decide on further workup. In addition, CT can be less sensitive
in the detection of early cerebral edema- correlate clinically.
.
CXR [**2101-9-19**]: Poorly placed ET tube. These findings were
discussed with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7741**] at 10:01 by telephone on
[**2101-9-19**].
.
CT torso [**2101-9-19**]: 1. Intubation of the right mainstem bronchus
with near complete atelectasis of the left lung. These findings
were discussed with Dr. [**First Name (STitle) **] at 9:00 a.m. via telephone.
2. Mild colon dilatation ( mainly the transverse and the
ascending colon )No signs of thickening of the colon or
intra-abdominal abscesses are identified. Still, non contrast CT
is not sensitive for detection of acute
bowel ischemia and this cannot be excluded.
3. Small portal venous gas is seen that has not enlarged in
comparison to
previous examination.
4. Small amount of free air is entrapped between the liver
capsule and the
diaphragm representing residual air post laparoscopy
.
EEG [**2101-9-20**]: This continuous recording revealed a moderately
severe to severe diffuse encephalopathy initially with some
focal features in the
right central area admixed with multifocal interictal
epileptiform activity and short duration bursts of semi-rhythmic
epileptiform activity, the latter in the right frontal central
region. As the tracing evovled temporally, the background seemed
to gradually improve such that, at the end of the record, it was
still compatible with a moderate diffuse encephalopathy still
with focal features and occasional interictal epileptiform
activity.
.
MRI head [**2101-9-20**]: 1. Limited evaluation for a seizure focus
secondary to lack of IV contrast. No seizure focus identified.
2. No cortical abnormality in right frontal lobe, suggesting
that the
suspected finding on the previous CT was secondary to volume
averaging
artifact.
3. Mild chronic small vessel ischemic disease.
.
EEG [**2101-9-21**]: This EEG continues to give evidence for a
moderately severe to severe diffuse encephalopathy with
background slowing into the theta bandwidth with considerable
admixed delta activity and some increased laterality to the
slowing over the right central temporal region, the latter
suggesting there may be a structural component in addition to
the encephalopathic changes. There continue to be multifocal
interictal epileptiform transients but no sustained seizure
discharges.
.
CXR [**2101-9-21**]: 1. No evidence of pneumothorax.
2. Endotracheal tube in a slightly high position with tip
terminating 6.0 cm above the carina and can be advanced by [**2-6**]
cm for more optimal positioning.
.
EEG [**2101-9-22**]: This EEG gives evidence for what appears to be a
moderate to moderately severe diffuse encephalopathy. There are
occasions where it appears to have some focal features in the
right central area. Superimposed are multifocal
independent-appearing interictal discharges
but there were no sustained discharges or events suggestive of
electrographic seizure activity. Overall, it appeared like the
EEG had improved slightly during the course of the record.
.
CXR [**2101-9-23**]: In comparison with the study of [**9-21**], there is no
evidence of acute pneumonia at this time. No vascular congestion
or pleural effusion.
.
Arm US ([**2101-10-7**]): IMPRESSION: Widely patent right arm AV
graft. No obvious evidence of either stenosis or clot. No
definite suggestion of a more central occlusion.
==================================
MICROBIOLOGY
BCx multiple blood cultures all negative
[**2101-9-16**] fecal culture negative for salmonella, shigella, EHEC,
ova/parasite, campylobacter, yersinia and c diff toxin
[**2101-9-19**] MRSA screen positive, one negative MRSA screen
afterwards
[**2101-9-19**] UCx negative
[**2101-9-26**] c diff toxin negative
[**2101-10-10**] c diff (-)
Brief Hospital Course:
Ms. [**Known lastname 63242**] is a 47 y/o F with ESRD on HD, schizoaffective d/o
who initially presented on [**2101-9-15**] with bloody diarrhea. Now
s/p extended hospital stay as described below:
BRIEF SUMMARY OF HOSPITAL COURSE (SEE BELOW FOR PROBLEM BASED
REVIEW)
Ms. [**Known lastname 63242**] was initially sent to the ED from her nursing
facility (Radius) with diffuse watery/bloody diarrhea. CT scan
performed on day of admission showed evidence of colitis and
portal venous air. Wbc in the 20s. Given concern for ischemic
bowel, taken to surgery where an exploratory laparoscopy was
performed. Edemetous bowel found but no e/o bowel ischemia. No
intervention during the surgery. Short SICU stay after surgery
and started on cipro, vanc and flagyl for broad spectrum
coverage. The patient was stabilized in the SICU post-op and
sent to the floor. She was initially stable and her
lamictal/clozaril (held on admission) were restarted. Following
the administration of these medications the patient suffered a
witnessed seizure ([**2101-9-19**]) and was intubated for airway
protection. Sent back to the SICU where neurology was
consulted. CT head and MRI without focal findings. EEG with
moderate to severe encephalopathy and interictal/epileptiform
spikes, but no seizure activities. The patient was stable in the
SICU and was extubated ([**2101-9-22**]). Post-extubation she was
noted to have a flat affect and AMS. Transferred back to the
medicine floor. Per psych recs, the patient's psychiatric
medications were again taken off to clarify the MS picture. At
this time began to have command auditory hallucinations and SI.
Began to re-titrate up her psych meds. On the medicine floor
the patient did generally well. Had intermittent diarrhea that
was non-bloody and treated symptomatically. Received HD
initially though femoral catheter and subsequently through newly
matured graft. Did have cellulitis around femoral cath site,
treated with vanc. Also had some right arm swelling, although
graft remained patent. Noted to have sinus tachycardia of
unknwon etiology. Patient declined a CTA to rule out pulmonary
embolism, though the index of suspicion was quite low given that
the patient had no shortness of breath, hypoxia and had been on
propylactic heparin. At time of discharge to extended care
facility, the patient's Clozaril is being uptitatrated back to
home dose. Auditory hallucinations remain present but improved.
She is without new complaint.
.
PROBLEM BASED REVIEW
#. Colitis-The patient was initially admitted with colitis as
above. Underwent ex-lap due to concern regarding ischemic bowel
although no ischemia was found and no intervention was made.
Treated post-op with broad spectrum abx and Sx improved.
Continued on cipro/flaygl to complete a 10-day course. Over the
remainder of her hospital stay, the patient had intermittent
bouts of watery diarrhea although remained afebrile and without
elevated WBC. Treated with immodium with good relief of
symptoms. Multiple C. Diff toxin assays sent and were negative.
All culture data negative. Unknwon etiology of initial bloody
diarrhea although appears to have resolved at this time.
.
# Schizophrenia/schizoaffective disorder: The patient carries a
diagnosis of schizophrenia and has been on clozaril for 20
years (100mg AM and 400mg PM). Her clozril was stopped on
admission given possible sedative affect. Following surgery,
the patient was restarted on clozaril/lamictal and subsequently
had a possible seizure. The psych medications were held while
the patient was in the SICU. On return to the floor, the
patient reported command auditory hallucinations telling her to
kill herself. Her psychiatric medications were restarted and
have been titrated up slowly. The patient's auditory
hallucinations have been improved recently and she is no longer
having any SI. Will be discharged to her long term care
facility.
.
# ESRD on HD: The patient underwent a right arm graft procedure
in 7/[**2101**]. While that graft matured, the patient received HD
through a femoral line. She is also presently being evaluated by
transplant team as an outpatient. Right arm graft matured during
her hospital stay and it was first used on [**9-29**] without problem.
The L femoral hemodialysis catheter was removed on [**2101-10-6**].
there was some question regarding cellulitis around the site of
the femoral line and the patient received a 7 day course of
vancomycin. The catheter tip and blood cultures, however
remained negative. On [**10-7**], the patient was noted to have right
arm swelling and an overlying rash although HD was tolerated and
there was a palpable thrill. RUE US was obtained that showed a
patent graft and dermatology believed the rash was simply
contact dermatitis. The rash has since begun to resolve with low
dose steroid cream. Her arm swelling has continued to improve
and dialysis is being tolerated through the graft without
difficulty.
.
# Sinus Tachycardia: On the medicine floor, the patient has been
persistently tachycardic. Unknown etiology. Possibilities
include pain from arm, discomfort from vulvar lesion (see below)
or dehydration from diarrhea. Less likely the latter as patient
is taking good PO and gets corrected at dialysis. No CP or
palp. Unlikely PE as no hypoxia and patient w/o significnat risk
factors. Patient was offered pre-treatment (iodine allergy)/CTA
but declined. Will continue to follow as an outpatient.
.
Right arm swelling - On [**10-7**], the patient was noted to have
right arm swelling and an overlying rash although HD was
tolerated and there was a palpable thrill. RUE US was obtained
that showed a patent graft and dermatology believed the rash was
simply contact dermatitis. The rash has since begun to resolve
with low dose steroid cream. The patient was also seen by
transplant surgery who did not feel that clot was involved. Her
arm swelling has continued to improve and dialysis is being
tolerated through the graft without difficulty. In discussion
with her PCP on day of discharge, it is reported that the
swelling may actually be chronic.
.
Hyponatremia - Likely [**3-9**] psychogenic polydipsia. Patient was
fluid restricted to 1200 mL daily, however, pt was not always
adherent to this restriction and sodium levels fluctuated.
.
#. Vulvar lesion: The patient has a chronic vulvar abscess that
has been "cored" by OB/Gyn in the past. On [**2101-10-12**], the
patient began to complain of pain/discomfort in the groin area.
Examination revealed a 2x3cm lesion. OB/Gyn was consulted who
diagnosed a labial abscess and recommended cosnervative
management with [**Last Name (un) **] baths and an ultrasound to assess abscess
size. The US was performed showing a septated cyst extending
1cm deep but not invading soft tisses. The following day the
abscess began draining spontaneously and OB/Gyn recommended no
further intervention. Patient instructed to make OB/Gyn
appointment as an outpatient for further evaluation of this
abscess.
.
# IDDM: Difficult to control DM in house. Has been followed by
[**Last Name (un) **] here. Will leave on following regimen:
**15 units of Glargine in AM **17 units of Glargine in PM **On
mornings/breakfast of dialysis please use [**2-6**] of recommended
humalog sliding scale dose.
.
# Hospital-acquired Pneumonia: While in the SICU, the patient
had right mainstem bronchus intubation with collapse of left
lung. Given the consolidation of left lung, she was empirically
treated for HAP with 5 days of cefepime/vancomycin. After she
was transferred to the medicine floor, repeat CXR was done
without evidence of any pneumonia, so cefepime/vancomycin were
stopped.
.
# Hypothyroidism: She was continued on home levothyroxine. No
active issues.
.
# HTN: She was continued on home diltiazem.
.
# GERD: Omeprazole changed to ranitidine.
Medications on Admission:
nephrocaps
CLOZAPINE 100 am, 400 qhs
DILTIAZEM 360
EPOGEN [**Numeric Identifier 890**] units tiw
Lantus 20am 12pm
Humalog sliding scale
LAMOTRIGINE 200 qhs
LEVOTHYROXINE 125
LORAZEPAM 1 mg 2PM, 0.5 qhs
NITROGLYCERIN 0.4 prn
PAROXETINE 40mg PO
LYRICA 50mg [**Hospital1 **]
SEVELAMER 800mg PO QAC
TIOTROPIUM BROMIDE 18mcg 1 puff INH QDay
albuterol prn
Discharge Medications:
1. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
2. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
3. diltiazem HCl 180 mg Capsule, Extended Release Sig: Two (2)
Capsule, Extended Release PO DAILY (Daily).
4. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. sevelamer carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
6. pregabalin 50 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily) as needed for no BM in 2 days.
10. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for shortness of breath or wheezing.
11. hydrocodone-acetaminophen 5-500 mg Tablet Sig: One (1)
Tablet PO Q6H (every 6 hours) as needed for pain.
12. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
13. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
14. haloperidol 5 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
15. haloperidol 5 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
16. lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO DAILY AT 2PM ().
17. benztropine 1 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
18. lamotrigine 50 mg Tablet, Rapid Dissolve Sig: One (1)
Tablet, Rapid Dissolve PO once a day for 2 weeks: Please
continue on the 50mg dosage for 2 weeks (until [**2101-10-28**]) then
resume your home dosage of 200mg.
Disp:*14 Tablet, Rapid Dissolve(s)* Refills:*0*
19. clobetasol 0.05 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
Disp:*1 tube* Refills:*1*
20. Insulin Dosing
Please see attached sheet with insulin sliding scale for
reccomendations. Specifically:
**15 units of Glargine in AM
**17 units of Glargine in PM
**On mornings/breakfast of dialysis please use [**2-6**] of
recommended humalog sliding scale dose.
21. Clozaril Dosing
Please dose PO clozaril as follows:
Saturday [**10-15**] - 150 mg qAM, 175 mg QHS;
Sunday [**10-16**] - 150 mg qAM, 200 mg QHS;
Monday [**10-17**] - 175 mg qAM, 200 mg QHS;
Tuesday [**10-18**] - 200 mg qAM, 200 mg QHS;
Wednesday [**10-19**] and onwards - 200mg qAM, 200mg qHS
23. loperamide 2 mg Tablet Sig: 1-2 Tablets PO twice a day as
needed for diarrhea.
24. Epogen 4,000 unit/mL Solution Sig: As dosed at dialysis
Units Injection 3 times weekly.
25. Outpatient Lab Work
Please draw weekly CBC with diff starting on [**2101-10-17**] and call in
results to Dr. [**First Name (STitle) 5514**] at [**Telephone/Fax (1) 88518**]
26. clozapine 100 mg Tablet Sig: as directed Tablet PO twice a
day: please dose according to attached instructions.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary diagnosis: colitis
Secondary diagnosis: seizure, altered mental status,
schizoaffective disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure to take care of you at [**Hospital1 827**]!
You were admitted to the hospital with bloody diarrhea and
required surgery to ensure you had good blood flow to your
bowel. Following surgery you were treated with a 10-day course
of antibiotics which helped resolve the diarrhea. When your
clozaril and lamictal were restarted after the surgery, you had
seizures and had to be intubated for airway protection.
Neurology and psychiatry teams were consulted to help manage
your case. You were extubated and your psychiatric medications
were restarted at very low dose without further seizures or
other problems. [**Name (NI) **] had auditory hallucinations, which improved
with clozaril and haldol. [**Last Name (un) **] was consulted to help manage
your blood glucose level. While you were in the hospital, you
received dialysis and your right arm graft was used. You had
cellulitis of your L femoral hemodialysis catheter site and were
treated with vancomycin. There was also some rash/redness on
your R arm graft site which resolved with low dose topical
steroids.
.
These changes were made to your medications:
1) Please CONTINUE to titrate your Clozaril back to your home
dose as follows:
--Saturday [**10-15**] 150 mg in the morning, and 175 mg at bedtime
--Sunday [**10-16**] 150 mg in the morning, and 200 mg at bedtime
--Monday [**10-17**] 175 mg in the morning, and 200 mg at bedtime
--Tuesday [**10-18**] 200 mg in the morning, and 200 mg at bedtime
2) Please CONTINUE to take Lamictal 50mg daily for another 2
weeks. Then return to your home dose of 100mg.
3) Please STOP the Paroxetine
4) Please see attached sheet for CHANGES to your insulin
regimen.
5) Please CONTINUE the clobetasol cream for your arm rash until
it completely resolves.
6) Please CONTINUE Haldol 5mg in the morning and 10mg at night.
You can STOP these medications once you are taking 400mg of
Clozaril daily.
7) You may CONTINUE Percocet every 6 hours as needed for your
arm pain
8) You may CONTINUE Loperamide twice daily as needed for
diarrhea
Followup Instructions:
Primary Care Visit with Dr. [**Last Name (STitle) **] at 2:15pm on Friday,
[**10-21**].
Dr. [**First Name (STitle) 5514**], your outpatient psychiatrist, has been kept updated
on your care and will follow you at [**Hospital 88519**] Rehab Center.
You may call ([**Telephone/Fax (1) 22754**] to make an OB/Gyn appointment for
further evaluation and management of your labial abscess.
Completed by:[**2101-10-15**]
|
[
"250.63",
"536.3",
"616.4",
"250.43",
"493.90",
"682.6",
"348.31",
"244.9",
"785.0",
"453.86",
"V45.11",
"692.9",
"E849.7",
"493.20",
"295.44",
"276.1",
"276.7",
"999.31",
"V62.84",
"319",
"403.91",
"V58.67",
"276.2",
"E939.3",
"585.6",
"009.1",
"997.39",
"486",
"780.39",
"E879.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.21",
"96.04",
"39.95",
"96.71",
"33.22"
] |
icd9pcs
|
[
[
[]
]
] |
22178, 22193
|
10949, 18806
|
353, 402
|
22342, 22342
|
4363, 10926
|
24563, 24980
|
2779, 2835
|
19206, 22155
|
22214, 22214
|
18832, 19183
|
22493, 24540
|
2850, 3769
|
3785, 4344
|
298, 315
|
430, 2246
|
22262, 22321
|
22233, 22241
|
22357, 22469
|
2268, 2562
|
2578, 2763
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,501
| 187,239
|
9382
|
Discharge summary
|
report
|
Admission Date: [**2155-11-19**] Discharge Date: [**2155-11-21**]
Date of Birth: [**2074-9-4**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 10682**]
Chief Complaint:
Hypoglycemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This patient is an 81-year-old Russian-speaking man with history
of insulin-dependent diabetes mellitus, recently diagnosed
pancreatic cancer (on CT scan, per report patient is not aware
of diagnosis), coronary artery disease and ischemic
cardiomyopathy who presents from home after being found confused
and leaning against a tree by EMS with a fingerstick blood sugar
of 22. Per report, he was given juice and a soda and was
transported to the [**Hospital1 18**] ED.
In the emergency [**Hospital1 **] his initial vital signs were T 100.4, HR
56, BP 97/50, RR 18, and satting 93% on RA. His blood sugar at
triage was 32. Per report from the ED, he has not been eating
well, and he vomited several times overnight. It is not clear
whether he took his insulin yesterday. In the emergency room he
was without focal complaints. He denied chest pain. An EKG
showed LBBB that was old with no ischemic changes. A chest x-ray
showed a retrocardiac opacity. UA showed occasional bacteria and
was otherwise negative. Labs were notable for INR of 1.4,
hematocrit of 31.6 (near recent baseline), with white count of
9.9 (at baseline) and 4% bands. Platelets were 198. Other labs
notable for normal electrolytes, creatinine of 1.1 (up from
recent 0.6) and BUN of 21 (up from recent [**11-12**]). Tbili was
normal, with ALT of 18 and AST of 40. Albumin was 2.9. Lactate
was 2.2. The patient was treated with hydrochlorthiazide (for
reasons not clear), levofloxacin (for presumptive pneumonia),
and given potassium, Tylenol, and Zofran. In addition he
received 3.5 liters of intravenous fluids for drop in systolic
blood pressure to 80s, per report. He was started on a D5 drip.
Additionally given 40 meq IV KCl for K of 2.9. At time of
admission lactate was down to 1.5. His current vitals are T
98.0, HR 75, BP 96/64, RR 20, satting 94% on 4L. Most recent
fingerstick blood glucose is 126. For access he has 3
peripherals - 2 18-g and 1 20-g.
Pt able to give a cursory explanation of why he is here, knowing
that he felt lightheaded and was agiasnt a tree. he could not
offer much more.
ROS: Currently, the patient endorses bowel movement ealreir
today. No abdomonial pain, no chest pain, no urinary
complaints, denied shortness of breath, although on NRB. No
diarrhea.
Past Medical History:
# Anterior wall MI s/p cath [**9-30**] with 3VD and LAD stent
# Ischemic cardiomyopathy with an ejection fraction of 20-30%
# Hypercholesterolemia
# Anxiety disorder.
# Degenerative joint disease
# Gout
# Status post inguinal hernia repair
# Advanced metastatic pancreatic cancer
# Diabetes Mellitus on insulin
Social History:
Married, lives with his wife. The patient is a retired
mechanical engineer and emigrant from [**Country 532**]. The patient has a
30 pack year tobacco history, continues to smoke 4 cigarettes
per day, with reported occasional vodka consumption.
Family History:
No significant coronary artery disease or diabetes reported.
Physical Exam:
General: No evidence of respiratory distress while on
nonrebreather.
Vitals: HR 77, BP 100/63, RR 20 100% NRB.
HEENT: NCAT. Anicteric sclera. MMM.
Neck: Supple. No LAD.
Heart: RR with occassional PAC's.
Lungs: Coarse expiratory breath sounds throughout.
Abdomen: Tympanic to percussion, nontender, active bowel sounds.
Extremities: Warm/well perfused. No edema
Neurological: Orineted to month, year, and "hospital". Did not
know day or what hospital he is in.
Pertinent Results:
Admission labs:
[**2155-11-19**] 10:20AM WBC-9.9 RBC-3.31* HGB-10.5* HCT-31.6* MCV-95
MCH-31.7 MCHC-33.2 RDW-17.1*
[**2155-11-19**] 10:20AM NEUTS-83* BANDS-4 LYMPHS-5* MONOS-4 EOS-4
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2155-11-19**] 10:20AM PLT SMR-NORMAL PLT COUNT-198
[**2155-11-19**] 10:20AM GLUCOSE-160* UREA N-21* CREAT-1.1 SODIUM-140
POTASSIUM-4.1 CHLORIDE-102 TOTAL CO2-28 ANION GAP-14
[**2155-11-19**] 10:20AM ALBUMIN-2.9* CALCIUM-8.3* PHOSPHATE-3.1
MAGNESIUM-2.2
[**2155-11-19**] 10:20AM ALT(SGPT)-18 AST(SGOT)-50* ALK PHOS-146* TOT
BILI-1.5
[**2155-11-19**] 10:20AM LIPASE-9
[**2155-11-19**] 10:20AM cTropnT-0.23*
[**2155-11-19**] 10:20AM PT-16.0* PTT-26.6 INR(PT)-1.4*
Discharge labs:
[**2155-11-21**] 05:12AM BLOOD WBC-12.9* RBC-3.59* Hgb-11.4* Hct-34.3*
MCV-96 MCH-31.7 MCHC-33.1 RDW-16.4* Plt Ct-189
[**2155-11-21**] 05:12AM BLOOD Glucose-158* UreaN-15 Creat-0.7 Na-143
K-3.6 Cl-107 HCO3-23 AnGap-17
[**2155-11-21**] 05:12AM BLOOD CK(CPK)-25*
[**2155-11-21**] 05:12AM BLOOD CK-MB-3 cTropnT-0.11*
CHEST (PORTABLE AP) Study Date of [**2155-11-19**]
FINDINGS/IMPRESSION: Overall, this examination appears
unchanged. There is
cardiomegaly with prominent interstitial markings which appear
improved.
Relative increased left basilar opacity could represent
atelectasis, however infection cannot be entirely excluded. No
pleural effusion or pneumothorax is identified. There is
tortuosity of the aorta.
BILAT LOWER EXT VEINS Study Date of [**2155-11-20**]
IMPRESSION: No evidence of DVT in the right or left lower
extremity.
CHEST (PA & LAT) Study Date of [**2155-11-21**]
FINDINGS: As compared to the previous examination, there is a
marked
improvement with regression of the pre-existing signs indicating
overhydration. Unchanged enlargement of the cardiac silhouette.
No pleural
effusions, no interval appearance of focal parenchymal opacity
suggesting
pneumonia.
Brief Hospital Course:
Patient is a 81-year-old man with history of insulin dependent
diabetes, coronary artery disease and ischemic cardiomyopathy,
likely metastatic pancreatic cancer by CT scan presented with
confusion, found with FSBG of 22, and admitted to the MICU on D5
drip.
In the MICU, patient's mental status quickly cleared once blood
sugars normalized. Hypokalemia also quickly resolved as
insulin/blood sugar was corrected.
Patient was noted to be hyoxic on transfer to the floor. His
CXR was initially concerning for pneumonia and he received a
dose of levofloxacin. Repeat CXR was more consistent with
pulmonary edema; he had received 3 L of IVFs in the ED. His
hypoxia resolved with Lasix. CXR PA and lateral on the floor
showed resolution of pulmonary edema and no infiltrate. His
levofloxacin was discontinued. Upon discharge, he was satting
in the mid 90s on RA, even with ambulation.
He was discharged to home with hospice on his home medications
EXCEPT his Lantus was discontinued. In 24 hours, he had only
required 2 units of Humalog. For discharge, he was started on
metformin extended release 500 mg daily, to be increased to 1000
mg daily if his blood sugars remain >200 after 1 week.
Medications on Admission:
Insulin Lantus 22U recently increased to 27 U qday
Creon for digestive supplmentation
ASA 81 mg qday
Metoprolol 100 mg daily
Flomax daily
Discharge Medications:
1. lipase-protease-amylase 12,000-38,000 -60,000 unit Capsule,
Delayed Release(E.C.) Sig: [**11-30**] Caps PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
2. metformin 500 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO once a day: Please take 1 pill
every morning for 7 days, then increase to 2 pills every morning
if your blood sugars are above 200.
Disp:*60 Tablet Extended Rel 24 hr(s)* Refills:*2*
3. metoprolol succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
4. aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
5. Flomax 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO once a day.
6. bisacodyl 5 mg Tablet Sig: One (1) Tablet PO once a day as
needed for constipation.
Discharge Disposition:
Home With Service
Facility:
Hospice of the Good [**Doctor Last Name 9995**]
Discharge Diagnosis:
Primary:
Acute systolic congestive heart failure
Secondary:
Hypoglycemia/Diabetes mellitus type 2
Coronary artery disease
Metastatic pancreatic cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. [**Known lastname 29467**],
It was a pleasure taking care of you. You were admitted for low
blood sugar. We have STOPPED your Lantus and started you on
metformin. Please take 1 pill every morning for 7 days, then
increase to 2 pills every morning if your blood sugars are above
200.
None of your other medications were changed.
You were also found to have fluid in your lungs. You were
treated with Lasix, which helped.
Followup Instructions:
Home with with hospice will be following you starting on Monday.
Please follow up with Dr. [**Last Name (STitle) **] as needed. His clinic
number is [**Telephone/Fax (1) 2634**].
|
[
"428.21",
"276.8",
"250.80",
"414.01",
"414.8",
"428.0",
"V49.86",
"274.9",
"197.7",
"799.02",
"157.8",
"550.90"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7917, 7995
|
5711, 6912
|
319, 326
|
8191, 8191
|
3791, 3791
|
8834, 9018
|
3232, 3294
|
7101, 7894
|
8016, 8170
|
6938, 7078
|
8374, 8811
|
4505, 5688
|
3309, 3772
|
267, 281
|
354, 2619
|
3807, 4489
|
8206, 8350
|
2641, 2954
|
2970, 3216
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,572
| 163,120
|
33473
|
Discharge summary
|
report
|
Admission Date: [**2125-5-25**] Discharge Date: [**2125-7-6**]
Date of Birth: [**2076-2-22**] Sex: M
Service: SURGERY
Allergies:
Latex
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
Bleeding gastric varices, total mesenteric venous occlusion,
cirrhosis secondary to schistosomiasis. Here for Sugiura
procedure
Major Surgical or Invasive Procedure:
[**2125-5-25**] Sugiura (esophageal skeletonization, splenectomy)
History of Present Illness:
Per Dr [**Last Name (STitle) **]; this is a 49 y/o male born in [**Country 4194**] who has a
history of
schistosomiasis, cirrhosis and portal hypertension. While in
[**Country 4194**] he
had an open gastrotomy with gastric vein ligation in [**2111**] and
splenic artery ligation in [**2116**].
In [**2124**], he had 2 episodes of hematemesis and was hospitalized
at [**Hospital3 **] Hospital on 2 occasions. He underwent endoscopy by
Dr. [**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) 23**] and had variceal ligation, neither of which
required transfusion.
He was recently hospitalized at [**Hospital **] [**Hospital **] Hospital with
melena and coffee-ground emesis. He was found to have large
gastric varices and bleeding esophageal varices that were
banded. He was transfused for a total of 7 units of packed RBC's
during that admission. He was re-admitted after repeat endoscopy
showed actively bleeding esophageal varices that were banded x4.
He was started on Protonix and Octreotide drip.
He was evaluated at [**Hospital1 18**] and was found to have large gastric
varices as well. A CT scan demonstrated total mesenteric
occlusion and prior splenic artery ligation. Angiography
demonstrated multiple arterial collaterals. He
was considered for sphenopneumopexy or gastroesophageal
devascularization splenectomy (Sugiura procedure).
Because of the markedly enlarged spleen, prior history of
gastroesophageal devascularization and the multiple arterial
collaterals to the spleen, sphenopneumopexy was not the
preferred option. He is admitted to undergo operating room for
gastroesophageal devascularization and splenectomy.
Past Medical History:
1. Schistosomiasis, diagnosed in [**Country 4194**] in [**2111**]
2. Cirrhosis per OSH imaging; last biopsy in [**Country 4194**] [**2116**] showed
fibrosis of unknown stage
3. Large gastric varices, three cords grade 2 esophageal varices
per EGD [**2125-3-22**]
4. Status post oversew of esophageal varices via open gastrotomy
and ligation of gastric vessels along the lesser and greater
curvature of the stomach; splenic artery ligation in [**Country 4194**] in
[**2116**] for history of esophageal varices
5. Pseudomonas hepatic abscess status post pigtail catheter
drainage
6. Status post cholecystectomy
7. Status post incarcerated umbilical hernia repair
Social History:
Originally from [**Country 4194**]. Married with two daughters. [**Name (NI) 1403**] as a
chef. Drinks a 6-pack on the weekends - no EtOH in 30 days. No
smoking or other drug use.
Family History:
No history of liver disease.
Physical Exam:
Post Op:
VS: 98.3, 73, 133/81, 13, 100% (intubated)
Gen: NAD, intubated and sedated
Card: RRR
Resp: Lungs clear AC .50 600/10 PEEP 5
Abd: Dressings intact, no drainage noted, soft. NGT with dark
coffee colred drainage, JP with sanguinous drainage
Pertinent Results:
[**2125-5-25**] WBC-5.0# RBC-4.46* Hgb-10.4* Hct-31.1* MCV-70*
MCH-23.4* MCHC-33.6 RDW-15.8* Plt Ct-55*
PT-18.6* PTT-38.3* INR(PT)-1.7*
Glucose-139* UreaN-14 Creat-0.8 Na-142 K-4.4 Cl-111* HCO3-23
AnGap-12
ALT-103* AST-200* AlkPhos-69 TotBili-4.2*
Calcium-9.4 Phos-4.7* Mg-1.7
Brief Hospital Course:
49 y/o male admitted postop on [**2125-5-25**] s/p splenectomy and
gastroesophageal
devascularization for h/o bleeding gastric varices, total
mesenteric venous occlusion related to cirrhosis secondary to
schistosomiasis. Surgeon was Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].
In summary from operative report, he was noted to have a
markedly enlarged spleen, extensive intra-abdominal adhesions
and large venous collaterals. He had dense adhesions overlying
the anterior surface of the liver as well as laterally,
superiorly and to the stomch. There was significant blood loss
during removal of the spleen because of the extensive
collaterals and adhesions. Crystalloid, fresh frozen plasma, 10
units of packed red cells, platelets and cryoprecipitate were
given for an EBL of 6000cc.
A dissection and devascularization of the lesser curvature was
performed. This extended gradually up the fundus and onto the
esophagus. There were extensive collaterals in the fundus of the
stomach. There was extensive devascularization up beyond the
level of the hiatus toward the inferior pulmonary ligament. The
stomach was completely devascularized and following the
devascularization no areas of ischemia were noted and the
stomach appeared viable.Please refer to operative note for full
surgical detail.
Postop, he went to the PACU intubated, and then to the SICU.
Extubation occurred on POD 1. He was transferred to the regular
surgical floor on POD 2. The NGT remained until an UGI
gastrografin study showed no leak, and was then pulled on POD 4.
Clear liquids were started and were well tolerated. Bowel
function was slow to return.
He developed a fever of 101 on POD 9. Blood cultures were
negative and the central line was removed with the tip culture
negative. An ABD CT of the abdomen was positive for colonic
ileus, mildly thickened cecum with slightly distended right
colon consistent with colonic ileus, small amount of ascites,
but no evidence of intra-abdominal collection or abscess. He
complained of increased abdominal pain and was medicated with IV
dilaudied. He was made NPO and an NG was replaced.
WBC was elevated to 17. JP drain fluid cell count/differential
revealed 35,000 WBC present. IV Vanco and Zosyn were started on
[**6-4**] while awaiting fluid culture results. This grew Strep
Viridans, Lactobacillus,staph coag negative and rare growth of
Neiserria. A total of 2 weeks of Vanco and Zosyn were given. A
Picc line was placed for antibiotics and fluids..
On [**6-6**], a repeat gastric emptying study showed no leak. NPO
status continued. There was no evidence of free air on kub. The
JP fluid color and consistency changed resembling baricat. An NG
tube was replaced with only scant amount of clear fluid. On [**6-12**]
an Abd CT demonstrated a large rent within the posterior aspect
of the stomach wall with extraluminal extravasation of orally
administered contrast and of air within extraluminal location
beneath the left hemidiaphragm. NPO status was maintained. TPN
was initiated.
Postop, JP output initially increased up to 3 liters requiring
IV fluid replacements and IV albumin. JP output decreased, but
there was persistent drainage at the insertion site, sometimes
draining large amounts of ascites. The insertion site was
sutured multiple times with brief relief of drainage. On [**6-14**]
the JP fluid was sent for culture and grew sparse growth [**Female First Name (un) 564**]
Parapsilosis. Fluconazole sensitivity was requested and sent to
[**State 77629**] for fluc and caspo sensitivities. IV fluc was
started on [**6-15**] and given for 6 days when this was switched to
IV Caspofungin. Caspofungin continued for 2 weeks until [**7-3**].
Fluconazole was resumed on day of discharge.
On [**6-21**], a repeat Abd CT was done for fever (101.6)and increased
abdominal pain. The large rent in the posterior aspect of the
stomach wall was demonstrated with extraluminal extravasation of
oral contrast, although less liquid contrast was noted compared
to the prior study. A new hypodense and air containing
collection along the posterior aspect of the stomach was seen
abutting column of oral contrast. It was unclear whether this
collection was intra- or extraluminal due to suboptimal
enhancement of the gastric wall. Reglan IV was given qid. There
was slight increase in ascites and possibly slightly increased
left pleural effusion and related atelectasis.
IV Vanco and Zosyn were re-started on [**6-21**] and continued until
[**7-3**]. Repeat blood and urine cultures were finalized negative
from [**6-21**] and [**6-22**].
Gradually, the JP drainage decreased to a scant amount, but the
insertion site leakage persisted. A two piece urostomy pouch was
applied around the JP insertion site to collect the leakage.
This was applied [**7-1**]. Drainage gradually declined to nothing
over the following days. He was also given lasix 40mg iv bid in
addition to aldactone 100mg qd. Lasix was decreased to 10mg po
qd for a home dose. Weight decreased from 79 kg to 71 by [**7-5**].
Given prolonged fasting state, TPN was started and continued
until [**7-3**] when he was tolerating continuous tube feedings at
goal rate. Nutren Pulmonary was not well tolerated due to
cramping/nausea and frequent stools. Stools were negative for
c.diff. Nutren pulmonary was switched to Replete full strength
and was well tolerated. Continuous feedings were changed to
cycled on [**7-3**].
On [**7-4**], a repeat gastrograffin emptying study was done showing
free passage through the esophagus into the stomach.
Extraluminal contrast was noted, lateral and posterior to the
stomach, consistent with known gastric fistula. There was no
gastric outlet obstruction.
Given need for prolonged NPO status, TPN was switched to a tube
feeding. A post pyloric feeding tube was placed and Nutren
pulmonary was started. He did not tolerated this well. He
experienced nausea, abdominal bloating and frequent stools.
Stools were negative for c.diff. Nutren pulmonary was switched
to Replete full strength. He tolerated this well and eventually
this was cycled. On [**7-6**], the feeding tube was re-positioned by
radiology as it pulled out a few inches and was in the stomach.
This was successfully repositioned.
PT evaluated and felt that he had no home PT needs. He was
ambulating independently.
On [**7-6**], he was discharged home with VNA services. He was
ambulatory and vital signs were stable.
Medications on Admission:
Pantoprazole 40', nadolol 40', sucralfate 1""
Discharge Medications:
1. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
3. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours).
Disp:*30 Tablet(s)* Refills:*2*
4. Furosemide 20 mg Tablet Sig: 0.5 Tablet PO once a day.
Disp:*60 Tablet(s)* Refills:*2*
5. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
Disp:*90 Tablet(s)* Refills:*2*
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Diphenhydramine HCl 25 mg Tablet Sig: One (1) Tablet PO at
bedtime as needed for sleep.
8. Outpatient Lab Work
Monday [**7-9**] for cbc, chem 10, ast, alt, alk phos, t.bili,
albumin
Fax to [**Telephone/Fax (1) 697**] attn: [**First Name4 (NamePattern1) 698**] [**Last Name (NamePattern1) 699**], RN coordinator
9. Tube Feedings
Post pyloric:
cycled qd 18 hours Replete full strength 1t 120cc
Supply: 1 month
Refill: 1
10. Tube feedings
pump, tubing, syringes for flushes
supply: 1 month
refill: 1
11. Fluconazole 400mg po qd. Supply 1month
Discharge Disposition:
Home With Service
Facility:
VNA Assoc. of [**Hospital3 **]
Discharge Diagnosis:
esophageal varices
cirrhosis
gastric fistula
Discharge Condition:
good
Discharge Instructions:
Please call Dr.[**Name (NI) 1369**] office [**Telephone/Fax (1) 673**] if fever > 101,
chills, nausea, vomiting, increased abdominal pain, dizziness,
incision redness/bleeding/drainage, jaundice or increased JP
drainage.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **] [**7-13**] 2:40pm ([**Telephone/Fax (1) 673**])
Please call [**Telephone/Fax (1) 17195**]([**First Name4 (NamePattern1) 698**] [**Last Name (NamePattern1) 699**], RN Dr.[**Name (NI) 1369**]
coordinator)
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2125-7-6**]
|
[
"459.81",
"997.4",
"537.4",
"V12.09",
"112.5",
"289.51",
"557.1",
"456.8",
"285.1",
"456.21",
"572.3",
"789.59",
"571.5",
"459.89",
"511.9",
"578.0",
"568.0",
"560.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"41.5",
"44.91",
"99.15",
"44.99",
"54.59",
"38.93",
"96.6",
"42.91"
] |
icd9pcs
|
[
[
[]
]
] |
11466, 11527
|
3657, 10104
|
392, 460
|
11616, 11623
|
3355, 3634
|
11893, 12298
|
3040, 3070
|
10200, 11443
|
11548, 11595
|
10130, 10177
|
11647, 11870
|
3085, 3336
|
224, 354
|
488, 2141
|
2163, 2826
|
2842, 3024
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,625
| 163,123
|
26660
|
Discharge summary
|
report
|
Admission Date: [**2101-3-5**] Discharge Date: [**2101-3-8**]
Date of Birth: [**2019-7-24**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / clavulanic acid / Oxycodone
Attending:[**First Name3 (LF) 896**]
Chief Complaint:
Bleeding, hypotension
Major Surgical or Invasive Procedure:
Endoscopy [**2101-3-6**]
History of Present Illness:
This is an 81yo F PMHx ESRD not on HD (LUE fistula in place),
COPD, CHF (EF unknown), CAD on ASA and plavix, recent rehab
discharge who then presented to [**Hospital3 26615**] with lethargy,
coffee ground emesis and dark stools. Per family report, 3wks
prior to admission, patient was admitted to [**Hospital 8641**] Hospital for
LUE fistula placement, and subsequently discharged to Country
Manor at [**Hospital 5028**] Rehab facility. Pt was discharged from
rehab 1d prior to admission. Since discharge, patient reported
feeling progressively "very weak". On day of admission, she had
3-4 episodes of large coffee ground emesis, as well as multiple
tarry black stools. As patient was becoming increasingly
lethargic, she her family called 911.
.
Per EMS report, patient was found hypotensive in the field to
60/40. She was fluid resuscitated and stabilized with normal
saline, brought to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], where her labs were significant
for WBC 5.8, Hct 17.9, plt 150, Cr 3.1. She was immediately
transfused with 2 units pRBCs, given a bolus of IV protonix, and
trasferred to [**Hospital1 18**] for further management.
.
In [**Hospital1 18**] ED, initial vital signs were 97.7 55 135/42 15 97%RA.
Patient was alert and oriented, comfortable, able to give
history. Exam notable for nontender abdomen, rectal exam w
melena. EKG demonstrated NSR at 53bpm w/o ST/Twave changes.
Labs were notable for Hct 26.3, plt 144, lactate 1.3, CXR with
prominent vascular markings, small L pleural effusion. NGL
demonstrated coffee grounds that did not clear w 500cc fluid.
Case discussed with GI, who recommended platelet transfusion
(not done given concern for fluid overload). Patient was type
and crossed x2 units and admitted to MICU for further
management. Vitals prior to transfer were 145/47 61 16 100%RA.
Access was 18g x2, 20g x1.
.
On arrival to the MICU, patient comfortable, sleepy, without
complaint. Vital signs were 97.8 60 128/34 16 98%RA.
Past Medical History:
Past Medical History:
- ESRD not on HD (RUE fistula in place)
- COPD
- CHF (EF unknown)
- HTN
- CAD on ASA and plavix
- HLD
- OA
- Osteoporosis
- Back Pain
- Gout
- s/p CCY
Social History:
Lives by herself in [**Location 17448**],MA; widowed, her son lives next
door and takes care of her; she is able to walk around
unassisted; 40pkyr history, denies EtOH.
.
Family History:
No family history of GI bleeds
Physical Exam:
VS 97.8 60 128/34 16 98%RA
General: Elderly female, NAD
HEENT: +pallor, sclera anicteric, dry MM, PERRL
Neck: supple, no JVD
CV: RRR, II/VI systolic murmur @ RUSB
Lungs: Sparse crackles, mild wheezing, no rales/ronchi
Abdomen: soft, obese, non-tender, naBS
GU: + foley
Ext: WWP, 2+ DP/PT/radial pulses, no cyanosis or edema
Neuro: AOx3, moving all extremities
Pertinent Results:
[**2101-3-5**] 02:05AM BLOOD WBC-5.9 RBC-2.60* Hgb-8.1* Hct-26.3*
MCV-101* MCH-31.3 MCHC-30.9* RDW-18.0* Plt Ct-144*
[**2101-3-5**] 10:40AM BLOOD WBC-6.2 RBC-2.75* Hgb-8.6* Hct-27.4*
MCV-99* MCH-31.4 MCHC-31.6 RDW-18.8* Plt Ct-157
[**2101-3-5**] 04:47PM BLOOD Hct-27.9*
[**2101-3-5**] 07:48PM BLOOD Hct-26.3*
[**2101-3-6**] 02:17AM BLOOD WBC-6.1 RBC-2.58* Hgb-8.4* Hct-25.8*
MCV-100* MCH-32.8* MCHC-32.8 RDW-19.2* Plt Ct-131*
[**2101-3-6**] 07:45AM BLOOD Hct-23.3*
[**2101-3-6**] 05:58PM BLOOD Hct-31.0*#
[**2101-3-6**] 10:03PM BLOOD Hct-29.4*
[**2101-3-7**] 06:32AM BLOOD WBC-5.1 RBC-3.19* Hgb-10.2* Hct-32.6*
MCV-98 MCH-32.0 MCHC-32.6 RDW-19.1* Plt Ct-162#
[**2101-3-7**] 10:54AM BLOOD Hct-31.7*
[**2101-3-5**] 02:05AM BLOOD Neuts-75.3* Lymphs-22.2 Monos-2.0 Eos-0.1
Baso-0.4
[**2101-3-7**] 02:07AM BLOOD Neuts-67.5 Lymphs-27.3 Monos-3.5 Eos-1.0
Baso-0.7
[**2101-3-7**] 06:32AM BLOOD Neuts-71.3* Lymphs-22.7 Monos-4.7 Eos-1.1
Baso-0.2
[**2101-3-5**] 02:05AM BLOOD Plt Ct-144*
[**2101-3-5**] 10:40AM BLOOD PT-11.9 PTT-25.9 INR(PT)-1.1
[**2101-3-5**] 10:40AM BLOOD Plt Ct-157
[**2101-3-6**] 02:17AM BLOOD Plt Ct-131*
[**2101-3-7**] 02:07AM BLOOD Plt Ct-100*
[**2101-3-7**] 06:32AM BLOOD Plt Ct-162#
[**2101-3-5**] 02:05AM BLOOD Glucose-148* UreaN-152* Creat-3.1* Na-139
K-4.7 Cl-102 HCO3-24 AnGap-18
[**2101-3-5**] 10:40AM BLOOD Glucose-104* UreaN-140* Creat-2.7* Na-143
K-3.9 Cl-105 HCO3-25 AnGap-17
[**2101-3-7**] 02:07AM BLOOD Glucose-92 UreaN-82* Creat-2.1* Na-145
K-4.1 Cl-107 HCO3-29 AnGap-13
[**2101-3-5**] 02:05AM BLOOD CK(CPK)-80
[**2101-3-5**] 02:05AM BLOOD CK-MB-3 cTropnT-0.02*
[**2101-3-6**] 02:17AM BLOOD Calcium-9.2 Phos-4.6* Mg-2.1
[**2101-3-7**] 02:07AM BLOOD Calcium-9.4 Phos-3.3 Mg-2.2
[**2101-3-5**] 08:17PM BLOOD Type-[**Last Name (un) **] Temp-37.1 pH-7.27* Comment-GREEN
TOP
[**2101-3-7**] 02:34AM BLOOD Type-[**Last Name (un) **] pH-7.35 Comment-GREEN TOP
[**2101-3-5**] 08:17PM BLOOD K-4.5
[**2101-3-5**] 08:17PM BLOOD freeCa-1.16
[**2101-3-7**] 02:34AM BLOOD freeCa-1.18
[**2101-3-7**] 12:09AM URINE
[**2101-3-7**] 12:09AM URINE Mucous-RARE
[**2101-3-7**] 12:09AM URINE RBC-9* WBC-31* Bacteri-NONE Yeast-NONE
Epi-0
.
Urine
Hematology
GENERAL URINE INFORMATION Type Color Appear Sp [**Last Name (un) **]
[**2101-3-7**] 00:09 Straw Clear 1.010
Source: Catheter
DIPSTICK URINALYSIS Blood Nitrite Protein Glucose Ketone Bilirub
Urobiln pH Leuks
[**2101-3-7**] 00:09 MOD NEG 30 NEG NEG NEG NEG 5.0 MOD
Source: Catheter
MICROSCOPIC URINE EXAMINATION RBC WBC Bacteri Yeast Epi TransE
RenalEp
[**2101-3-7**] 00:09 9* 31* NONE NONE 0
Source: Catheter
OTHER URINE FINDINGS Mucous
[**2101-3-7**] 00:09 RARE
Source: Catheter
.
MICRObiology
[**2101-3-7**] URINE URINE CULTURE-PENDING INPATIENT
.
[**2101-3-5**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
No MRSA isolated
.
[**2101-3-5**] BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY [**Hospital1 **]
.
[**2101-3-5**] BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY [**Hospital1 **]
.
Imaging
.
CHEST (PORTABLE AP) Study Date of [**2101-3-5**] 1:37 AM
IMPRESSION: Mild vascular congestion and small left pleural
effusion.
The study and the report were reviewed by the staff radiologist.
.
EGD. Saturday, [**2101-3-5**]
Old blood which was easily cleared without any evidence of
active or or former bleeding Fresh blood was seen in the
duodenal sweep which was cleared. A small area of active
bleeding was visualized, compatible with either a bleeding AVM
v. dieulafoy lesion (endoclip). Otherwise normal EGD to third
part of the duodenum
Brief Hospital Course:
1. Acute GI bleed - En endoscopy performed by GI on [**2101-3-5**] which
showed a small area of active bleeding consistent with bleeding
AVM v. dieulafoy lesion. This was clipped. She was treated with
IV pantoprazole which was transitioned to oral upon discharge.
Plan going forward:
Continue ASA 325 as below
Hold Plavix as discussed with cardiologist and PCP
Continue pantoprazole
2. Acute blood loss anemia - Related to #1. Received a total of
3 units of pRBC and 1 bag of platelets. At the time of
discharge, hematocrit was 32.6
3. Acute renal failure - Cr was noted to be 3.1 on admission.
Unclear baseline. Likely due to volume depletion/anemia. Patient
Cr was trended while in MICU and improved to 2.1 before transfer
to floor in the setting of receiving blood. Upon discharge the
patient's Cr was 1.7.
4. CHF (unknown EF) / CAD / Hypertension - Patient's
cardiovascular status was monitored closely. She had one
troponin of 0.02 in the setting of a Cr of 3.1. Her CKMB was not
elevated. She had no chest pain or concerning EKG changes. The
likelihood of a significant coronary event were felt to be very
low. In the MICU the patient's lopressor, isosorbide
mononitrate, pravachol, niaspan, fenofibrate, ASA, plavix,
hydralazine, and isosorbide were initially held in setting of
large GI bleed. After she was stabilized from a hemodynamic
standpoint and could take oral medications she was restarted on
metoprolol while in the MICU. After she was transferred to the
floor she remained on room air and was restarted on her home
meds save for clopidogrel as above.
5. Back Pain. The patient's neurontin, tramadol, tylenol were
initialyl held in the MICU due to her GI bleed and NPO status.
On the floor they were restarted with good effect
6. COPD. Patient was placed on standing fluticasone and
albuterol/ipratropium nebs. She was then transitioned to
tiotropium and advair with as needed combivent nebs before
transfer to the floor. She was dischareged on her home regimen
7. Gout. The patient's allopurinol was initially held in the
MICU. On the floor it was restarted without issue
Transitional issues
Medication Reconciliation-patient was unsure of all her
medications, these were consolidated with her pharmacy
Medications on Admission:
- VitD2 [**2088**] units daily
- MVI
- Lopressor 50mg [**Hospital1 **]
- Isosorbide mononitrate 15mg daily
- Neurontin 100mg TID
- Lasix 60mg qAM
- Lasix 20mg qPM
- Tramadol 50mg [**Hospital1 **]
- Tylenol prn
- Symbicort [**Hospital1 **]
- Spiriva 18mcg daily
- Pravachol 40mg daily
- Plavix 75mg daily
- Niaspan 750mg daily
- Ferrous Sulfate 325mg daily
- Fenofibrate 145mg daily
- Colace 200mg daily
- ASA 325mg daily
- Allopurinol 100mg daily
- Trazadone 25mg qhs
- Hydralazine 10mg TID
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. Niaspan Extended-Release 750 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
4. gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
5. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: 0.5 Tablet Extended Release 24 hr PO DAILY (Daily).
6. fenofibrate nanocrystallized 145 mg Tablet Sig: One (1)
Tablet PO Daily ().
7. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours)
as needed for pain.
9. 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*
10. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
11. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
13. Symbicort 160-4.5 mcg/actuation HFA Aerosol Inhaler Sig: Two
(2) inhalation Inhalation twice a day.
14. multivitamin Capsule Sig: One (1) Capsule PO once a day.
15. Lasix 20 mg Tablet Sig: Three (3) Tablet PO once a day.
16. Lasix 20 mg Tablet Sig: One (1) Tablet PO at bedtime.
17. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1) daily Inhalation once a day.
18. iron 325 mg (65 mg iron) Tablet Sig: One (1) Tablet PO once
a day.
19. Colace 100 mg Capsule Sig: Two (2) Capsule PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
Bleeding AVM
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 65731**],
It was a pleasure taking care of you at [**Hospital1 18**], you were
admitted to the hospital with a bleeding blood vessel in your
stomach. Our GI experts were able to visualize it with a camera
and clip the bleeding vessel. You stopped bleeding and were
deemed safe for discharge home.
.
The follwing changes were made to your medication list:
- STOP taking Plavix until Dr. [**Last Name (STitle) 65732**] tells you otherwise
- START taking Protonix 40mg twice per day until Dr. [**First Name (STitle) **]
tells you otherwise
Followup Instructions:
Name: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 32458**], PA
Location: CLIPPER CARDIOVASCULAR ASSOCIATES
Address: 112A [**Location (un) **] ST, [**Location (un) **],[**Numeric Identifier 12023**]
Phone: [**Telephone/Fax (1) 65733**]
Appt: [**3-14**] at 1pm
Name: [**Last Name (LF) 11937**],[**First Name3 (LF) **] J.
Location: [**Hospital **] MEDICAL ASSOCIATES
Address: [**Street Address(2) 65734**], [**Location (un) **],[**Numeric Identifier 32948**]
Phone: [**Telephone/Fax (1) 65735**]
Appt: [**3-17**] at 2:45pm
Completed by:[**2101-3-8**]
|
[
"327.23",
"428.32",
"403.90",
"584.9",
"496",
"285.1",
"276.50",
"585.4",
"537.83",
"733.00",
"414.01",
"272.4",
"274.9",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"44.43"
] |
icd9pcs
|
[
[
[]
]
] |
11210, 11293
|
6767, 9000
|
321, 348
|
11350, 11350
|
3213, 6744
|
12095, 12664
|
2784, 2817
|
9544, 11187
|
11314, 11329
|
9026, 9519
|
11501, 12072
|
2832, 3194
|
260, 283
|
376, 2382
|
11365, 11477
|
2426, 2579
|
2595, 2768
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,242
| 126,035
|
8239
|
Discharge summary
|
report
|
Admission Date: [**2127-2-24**] Discharge Date: [**2127-3-2**]
Date of Birth: [**2040-3-29**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3376**]
Chief Complaint:
right colonic mass
Major Surgical or Invasive Procedure:
1. Open right colectomy.
2. Excision of tumor in sidewall.
3. Repair of umbilical hernia.
History of Present Illness:
86F initially presentig with fatigue and anemia, and found to
have right-sided colon mass concerning for colonic
adenocarcinoma. She presented this admission for resection.
Past Medical History:
HTN, hypercholesterolemia, diverticulits, atrial fibrillation
Social History:
Noncontributory
Family History:
Noncontributory
Physical Exam:
97.7 97.3 65 119/70 20 97RA
GEN: NAD, A&Ox3
CV: irregular rate, no mumurs appreciated
PULM: CTAB
ABD: soft, mild peri-incisional tenderness to palpation,
non-distended
Incision: clean, dry, intact, no evidence of infection
EXT: WWP, no edema
Neuro: grossly intact
Pertinent Results:
[**2127-2-27**] 06:30AM BLOOD WBC-14.1* RBC-3.99* Hgb-9.2* Hct-29.8*
MCV-75* MCH-23.0* MCHC-30.7* RDW-18.4* Plt Ct-524*
[**2127-2-28**] 11:40AM BLOOD WBC-11.6*
[**2127-3-1**] 05:30AM BLOOD Glucose-112* UreaN-11 Creat-0.7 Na-134
K-4.4 Cl-100 HCO3-26 AnGap-12
[**2127-3-1**] 05:30AM BLOOD Calcium-8.5 Phos-2.5* Mg-2.1
Pathology, surgical specimen:
Colonic adenocarcinoma, pT3N0Mx. See synoptic report in OMR.
CHEST (PORTABLE AP) Study Date of [**2127-2-25**] 5:28 PM
FINDINGS: As compared to the previous radiograph, there is newly
occurred
mild-to-moderate interstitial edema. No large effusions are
visualized.
Borderline size of the cardiac silhouette. Moderate perihilar
haze.
CHEST (PORTABLE AP) Study Date of [**2127-2-26**] 4:36 AM
FINDINGS: As compared to the previous radiograph, there is a
decrease in
extent of the pre-existing parenchymal opacity. Otherwise, the
radiograph is unchanged. Other monitoring and support devices
are in constant position.
Brief Hospital Course:
The patient had an open right colectomy for her colon mass. For
details, see the separately-dictated operative note.
RESPIRATORY DISTRESS: By POD#1, the patient continued to have
marginal UOP since the OR. The patient was baseline anemic from
her colon cancer, and she had an expected drop in her Hct with
the addition of IVF resuscitation. She received 2uPRBC. Several
hours later, she developed acute shortness of breath with
desaturation. Her O2 saturation failed to improve with
supplemental O2, and a trigger was called. She was found on CXR
to have pulmonary edema. She received nebulized ipratropium and
xopenex, with little improvement. Diuresis was initiated with
lasix, and she put out about 450cc in about the first hour.
Nonetheless, she began to tire from her tachypnea, and it was
decided to transfer her to the ICU for intubation. She was
continued on diuresis, and by the next morning, she was able to
extubate and actually looked and felt much better. She was
transferred back to the floor the afternoon of POD#2, breathing
comforably.
NEURO/PAIN: Immediately post-operatively, the patient had an
auto-infusing bupivicaine pump at her incision. She was also was
maintained on IV pain medication until she was able to tolerate
PO pain medication. By discharge, she was well-controlled on
just PO tylenol. While intubated during her overnight stay in
the ICU, she received appropriate sedation. She was otheriwise
A&Ox3.
CARDIOVASCULAR: At the time when she developed pulmonary edema,
the patient was noted to have an elevated troponin (0.1). She
was given aspirin. Troponins were drawn serially, and during her
stay in the ICU they trended downward to 0.03. It was thought
that she was not having an MI, and that this was likely demand
ischemia. For a short period of time after intubation on POD#1,
the patient required phenylephrine for blood pressure support,
but this was discontinued the same night. An echocardiogram in
the ICU showed normal ventricular function and normal ejection
fraction. On POD#2, as she was being transferred back to the
floor, she developed atrial fibrillation with RVR. She was
rate-controlled with metoprolol. Medicine consulted, and she was
eventually well-rate-controlled (HR 70s-90s, with only
occasional few-second periods of tachycardia) on PO metoprolol
and diltiazem. Medicine continued to follow the patient and
assist through the day of discharge. The decision was made not
to anticoagulate her, with a CHADS score of 2, for now. The
patient should follow up with her PCP regarding future
management of her metoprolol and diltiazem, as well as for
further consideration of anticoagulation.
RESPIRATORY: The patient was extubated in the immediate post-op
period successfully. She was re-intubated as above. Following
her second extubation, she had no further respiratory issues and
saturated adequately on room air.
GASTROINTESTINAL/FEN: The patient was NPO following her
procedure, and advanced to sips on POD#1. After being NPO during
her ICU stay, she was gradually advanced as her bowel function
returned. By POD#4, she was tolerating a regular diet with PO
medications. At the time of her flash pulmonary edema, her IVF
were held. She received electrolyte repletion as needed.
GENITOURINARY: The patient's urine output was monitored. She had
low urine output immediately post-operatively, and actually
triggered for it; this was initially treated with albumin. A
Foley catheter had been placed intra-operatively and removed on
POD#4, and she voided well.
HEME: The patient had baseline anemia (Hct about 27) associated
with her colon cancer. The patient received 2uPRBC on POD#1, as
above, for a Hct of 21. Her Hct increased appropriately, and she
required no further transfusions.
ID: Intraoperativley, the patient was found to have had a
perforated colon cancer. She was started on cefazolin and
flagyl. As her cultures were found to grow back group B
beta-hemolytic streptococcus, her antibiotics were changed to
unasyn on POD#3, and then to augmentin on POD#4 when she was
taking PO medications. She will complete a 7-day course of
augmentin (5 more days). She was not febrile, and her WBC
trended downward from 24.4 on POD#1 to 11.6 on POD#4. Her wound
remained without signs of infection.
ENDOCRINE: The patient's blood glucose was monitored, and she
had no active endocrine issues.
PROPHYLAXIS: This was maintained with subcutaneous heparin,
aspirin when she developed elevated troponin, pneumatic boots,
and ambulation when safe and cleared by PT. She was given
omeprazole. She was encouraged to use incentive spirometry.
On the day of discharge, the patient was discharged to a rehab
facility, as recommended by PT. She needs follow-up by her PCP
for management of her atrial fibrillation and potential
anticoagulation. She should also call to make a follow-up
appointment with colorectal surgery. She was ambulating well
with assistance, her bowel function had returned, her heart rate
was controlled, and her pain was controlled by tylenol.
______________________________________________________________
Post-Surgical Complications During Inpatient Admission:
[ ] Post-Operative Ileus resolving w/o NGT
[ ] Post-Operative Ileus requiring management with NGT
[ ] UTI
[ ] Wound Infection
[ ] Anastomotic Leak
[ ] Staple Line Bleed
[ ] Congestive Heart failure
[ ] ARF
[ ] Acute Urinary retention, failure to void after Foley D/C'd
[ ] Acute Urinary Retention requiring discharge with Foley
Catheter
[ ] DVT
[ ] Pneumonia
[ ] Abscess
[x] atrial fibrillation with RVR
[x] flash pulmonary edema requiring intubation and ICU stay
[ ] None
Social Issues Causing a Delay in Discharge:
[ ] Delay in organization of VNA services
[ ] Difficulty finding appropriate rehabilitation hospital
disposition.
[ ] Lack of insurance coverage for VNA/ Rehab services
[ ] Lack of insurance coverage for prescribed medications.
[ ] Family not agreeable to discharge plan.
[ ] Patient knowledge deficit related to ileostomy delaying
discharge.
[x] No social factors contributing in delay of discharge.
Medications on Admission:
Atenolol 50', MVI
Discharge Medications:
1. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day) as needed for pain: No more than 4000mg in a day.
Each tab has 325mg.
Disp:*90 Tablet(s)* Refills:*2*
3. mupirocin calcium 2 % Ointment Sig: One (1) Appl Nasal [**Hospital1 **] (2
times a day) for 2 days: Apply NU [**Hospital1 **] for 2 days.
Disp:*QS * Refills:*0*
4. amoxicillin-pot clavulanate 875-125 mg Tablet Sig: One (1)
Tablet PO Q12H (every 12 hours) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
7. diltiazem HCl 30 mg Tablet Sig: 1.5 Tablets PO Q6H (every 6
hours).
Disp:*180 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Health Care Center - [**Location (un) **]
Discharge Diagnosis:
colonic adenocarcinoma, umbilical hernia, atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - with assistance as needed.
Discharge Instructions:
You were admitted to the hospital after an open Right-Sided
Colectomy for surgical management of your colon lesion. You have
recovered from this procedure well and you are now ready to
return home. Samples from your colon were taken and this tissue
has been sent to the pathology department for analysis. You will
receive these pathology results at your follow-up appointment.
If there is an urgent need for the surgeon to contact you
regarding these results they will contact you before this time.
You have tolerated a regular diet, passing gas and your pain is
controlled with pain medications by mouth. You may return home
to finish your recovery.
Please monitor your bowel function closely. It is important that
you have a bowel movement in the next 3-4 days. After
anesthesia it is not uncommon for patients to have some decrease
in bowel function but you should not have prolonged
constipation. Some loose stool and passing of small amounts of
dark, old-appearing blood are expected; however, if you notice
that you are passing bright red blood with bowel movments or
having loose stool without improvement please call the office or
go to the emergency room. If you are taking narcotic pain
medications there is a risk that you will have some
constipation. Please take an over the counter stool softener
such as Colace, and if the symptoms does not improve call the
office. If you have any of the following symptoms please call
the office for advice or go to the emergency room if severe:
increasing abdominal distension, increasing abdominal pain,
nausea, vomiting, inability to tolerate food or liquids,
prolonged loose stool, or constipation.
You have a long vertical incision on your abdomen. This incision
can be left open to air or covered with a dry sterile gauze
dressing if that is more comfortable for you. Please monitor the
incision for signs and symptoms of infection including:
increasing redness at the incision, opening of the incision,
increased pain at the incision line, draining of
white/green/yellow/foul smelling drainage, or if you develop a
fever. Please call the office if you develop these symptoms or
go to the emergency room if the symptoms are severe. You may
shower, let the warm water run over the incision line and pat
the area dry with a towel; do not rub.
No heavy lifting for at least 6 weeks after surgery. You may
gradually increase your activity as tolerated. You should
continue to walk as tolerated.
You may take Tylenol as recommended for pain. Please do not take
more than 4000mg of Tylenol daily. Do not drink alcohol while
taking Tylenol.
Stop taking your atenolol, and instead take the medications as
prescribed from this hospital stay. Your PCP will give you
firther instructions about your medications.
You developed a heart condition called atrial fibrillation. This
makes your heart beat too quickly and irregularly. We started
you on two new medications called diltiazem and metoprolol. You
should follow up with your primary doctor about your atrial
fibrillation, and they may make adjustments in your medications.
Followup Instructions:
Call the colorectal surgery office to make a follow-up
appointment. Please call [**Telephone/Fax (1) 160**] to make this appointment.
Call your PCP for [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 702**] appointment for about 1 week.
Please discuss your atrial fibrillation, and ask if there should
be any adjustments to your medications
Completed by:[**2127-3-2**]
|
[
"276.61",
"E878.6",
"198.2",
"458.29",
"427.31",
"285.1",
"553.1",
"401.9",
"272.0",
"041.02",
"276.52",
"153.6",
"411.89",
"250.00",
"518.52",
"285.22"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.3",
"96.71",
"45.73",
"53.49"
] |
icd9pcs
|
[
[
[]
]
] |
9204, 9288
|
2061, 8125
|
321, 413
|
9394, 9394
|
1072, 2038
|
12663, 13046
|
750, 767
|
8193, 9181
|
9309, 9373
|
8151, 8170
|
9559, 12640
|
782, 1053
|
263, 283
|
441, 615
|
9409, 9535
|
637, 700
|
716, 734
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,404
| 112,399
|
30173
|
Discharge summary
|
report
|
Admission Date: [**2189-10-16**] Discharge Date: [**2189-10-26**]
Date of Birth: [**2115-9-22**] Sex: M
Service: MEDICINE
Allergies:
Lactose
Attending:[**Doctor First Name 3290**]
Chief Complaint:
Low back pain, shortness of breath
Major Surgical or Invasive Procedure:
Thoracentesis
Pigtail pleural catheter placement
History of Present Illness:
The patient is a 74M who presented to the ED with back pain. He
has had three mechanical falls in the past two weeks. He has had
difficulty ambulating secondary to pain. He denied fevers,
chills, chest pain, cough or cold symptoms, nausea, vomiting,
abdominal pain, and dysuria though does endorse worsened
dyspnea.
On arrival to the ED, he triggered for hypoxia to 88% which
improved with supplemental oxygen. A head CT was negative, CXR
showed PNA in RLL and CT torso showed a loculated effusion and
compression fractures. He was started on vanc and zosyn and 1L
NS. He was also given morpinge 4mg IV and percocet. Spine was
consulted for the compression fractures and recommended a TLSO
brace and an MRI on a non-urgent basis.
Past Medical History:
BPH
Anemia
Dyspepsia
Weight Loss
Atrial flutter diagnosed in [**2187**], s/p ablation in [**2188-4-26**]
Vitamin D Deficiency
DMII
MDS
Colonic adenomas
h/o Sigmoid diverticulitis.
h/o Basal cell carcinoma.
h/o Left hip fracture, status post ORIF in [**2183**].
Social History:
Retired, lives with wife. [**Name (NI) **] denies any alcohol. Is
currently smoking tobacco pipes, 50y history. Denies any other
illicit drug use.
Family History:
Maternal aunt with diabetes. There is no family history of
premature coronary artery disease, arrhythmias, or sudden death.
Physical Exam:
Physical Exam on admission:
GENERAL - cachectic male appearing older than stated age
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, dry mucous
membranes with poor dentition
NECK - supple, no thyromegaly, no JVD, no lymphadenopathy
LUNGS - bronchial on right
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact
Physical Exam on discharge - Unchanged from above except for:
HEENT - moist MM
LUNGS - Mild crackles and bronchial breath sounds in the right
lung base.
Pertinent Results:
Labs on admission:
[**2189-10-15**] 08:21PM BLOOD WBC-27.6*# RBC-3.48* Hgb-9.2* Hct-30.7*
MCV-88 MCH-26.3* MCHC-29.8* RDW-17.3* Plt Ct-179
[**2189-10-15**] 08:21PM BLOOD Neuts-85* Bands-1 Lymphs-3* Monos-6 Eos-0
Baso-0 Atyps-0 Metas-2* Myelos-2* NRBC-1* Other-1*
[**2189-10-15**] 08:21PM BLOOD PT-13.3 PTT-27.4 INR(PT)-1.1
[**2189-10-15**] 08:21PM BLOOD Glucose-140* UreaN-36* Creat-1.1 Na-139
K-4.2 Cl-101 HCO3-29 AnGap-13
[**2189-10-15**] 08:21PM BLOOD ALT-35 AST-71* AlkPhos-373* Amylase-51
TotBili-0.3
[**2189-10-16**] 03:43AM BLOOD TotProt-6.1* Albumin-2.3* Globuln-3.8
Calcium-10.6* Phos-3.7 Mg-2.0
[**2189-10-16**] 03:43AM BLOOD PTH-6*
[**2189-10-15**] 08:26PM BLOOD Lactate-3.8* K-4.4
[**2189-10-16**] 02:53AM BLOOD Lactate-2.3*
[**2189-10-16**] 04:42AM PLEURAL WBC-[**Numeric Identifier 38617**]* RBC-1625* Polys-97*
Lymphs-3* Monos-0
[**2189-10-16**] 04:42AM PLEURAL TotProt-4.2 Glucose-15 LD(LDH)-2507
[**2189-10-17**] 05:44PM PLEURAL WBC-[**Numeric Identifier 43204**]* RBC-2500* Polys-94*
Lymphs-2* Monos-4*
[**2189-10-17**] 05:44PM PLEURAL TotProt-3.1 Glucose-2 LD(LDH)-2393
Cholest-44
Blood culture [**10-15**] and [**10-16**]: Pending
[**2189-10-16**] 2:40 am SPUTUM Source: Expectorated.
**FINAL REPORT [**2189-10-18**]**
GRAM STAIN (Final [**2189-10-16**]):
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2189-10-18**]):
SPARSE GROWTH Commensal Respiratory Flora.
[**2189-10-16**] 4:42 am PLEURAL FLUID
GRAM STAIN (Final [**2189-10-16**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
Legionella antigen: negative
[**2189-10-17**] 5:44 pm PLEURAL FLUID PLEURAL FLUID.
GRAM STAIN (Final [**2189-10-17**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary):
Images:
-CXR [**2189-10-18**]:
Small residual of right pleural effusion has remained stable
since insertion of the pigtail pleural drain at the base of the
lung. Consolidation primarily in the right lower lobe, to a
lesser degree anterior segment of the right upper and middle
lobes is improving. Infrahilar atelectasis in the left lower
lobe, however, is worsening. Heart size normal. Normal pulmonary
vasculature. No edema. No pneumothorax.
-CT head [**2189-10-15**]: no acute intracranial process
-CXR ([**2189-10-23**]): 1. No evidence of pneumothorax following right
pigtail pleural catheter removal.
2. Improving mass-like consolidation in right lower lobe
consistent with
pneumonia.
3. Small pleural effusions, right greater than left.
-Abd US ([**2189-10-23**]): No evidence of gallstones or biliary
dilatation. Splenomegaly. Ascites.
EKG at admission: sinus tachy, LAD, q waves v1-2
Discharge labs:
[**2189-10-16**] 03:07PM BLOOD PTH-7*
[**2189-10-20**] 04:55AM BLOOD VITAMIN D [**1-20**] DIHYDROXY-24 (nl)
[**2189-10-17**] 06:56AM BLOOD PARATHYROID HORMONE RELATED
PROTEIN-negative
[**2189-10-16**] 03:43AM BLOOD VITAMIN D 25 HYDROXY- 27
[**2189-10-26**] 06:25AM BLOOD WBC-5.6 RBC-3.04* Hgb-7.8* Hct-26.1*
MCV-86 MCH-25.8* MCHC-30.0* RDW-18.1* Plt Ct-221
[**2189-10-26**] 06:25AM BLOOD Glucose-76 UreaN-16 Creat-1.0 Na-140
K-3.8 Cl-103 HCO3-32 AnGap-9
[**2189-10-26**] 06:25AM BLOOD Calcium-8.7 Phos-2.7 Mg-2.4
Brief Hospital Course:
74 year old male with history of MDS, weight loss of 70-80
pounds, multiple falls, diabetes mellitus, who presented for low
back pain, found to have multifocal pneumonia and complicated
parapneumonic effusion.
#) Pneumonia with complicated parapneumonic effusion/loculation:
On admission to the MICU he had a thoracentesis and 1L of cloudy
non-purulent fluid was drained. He was initially covered broadly
with Vanc/Zosyn/Levofloxacin. On [**10-17**], he had an additional
throacentesis with chest tube placement by IP. There was concern
for aspiration versus community acquired PNA. Once legionella
antigen was negative levofloxacin was discontinued. Early in the
hospitalization, he had occasional desaturations overnight which
required oxygen via facemask. This was not occurring for the
5-6 days prior to discharge. At time of discharge, he had
completed a 9 day course of antibiotics and will not need
further antibiotics. Clinically, his breathing was improved at
discharge, he was maintaining good oxygen saturation on room air
and there was no reaccumulation of the pleural effuion on repeat
CXR.
#) Leukocytosis: Persistent in the in the high 20's on
admission, but decreased to normal range at the time of
discharge. Increased WBC likely secondary to his pneumonia. C.
diff was negative x3.
#) Hypercalcemia: Given unintentional weight loss of 70-80 lbs
and smoking history, there is concern for malignancy. PTH was
appropriately low at 7. 1,25-OH-VitD was normal and PTHrP was
also negative. Skeletal survey did not show evidence of lytic
lesions, only suggestive of osteoporotic changes. He was given
a dose of pamidronate 60mg on [**2189-10-20**] and his calcium level
decreased to the normal range. A urine N-telopeptide was sent
and was elevated, suggesting some process leading to increased
bone turnover. Paget's is another possible explaiantion given
elevated alk phos and calcium, no evidence of Paget's on
skeletal survery per radiology. Had a bone scan in [**2-/2188**] which
also did not show evidence of Paget's.
#) Weight loss: PSA was 0.5 in [**2188**]. Per pt he had a normal
colonoscopy last year. As mentioned above, no obvious cause
despite negative PET/CT as well as negative bone marrow biopsy
prior to admission. Has follow-up with hematology/oncology
arranged.
#) Pain control: He was treated with acetaminophen 1g q8h,
toradol 15 mg IV q8h for three days, lidocaine patch, morphine
sulphate prn, oxycodone prn. A TLSO brace was placed. MRI showed
compression fracture in L1 and L2, recommended follow-up in 4
weeks. At discharge, pain well controlled only on PRN tylenol
and lidocaine patch, not requiring narcotics.
#) DM: Metformin was held and he was covered with insulin
sliding scale. Blood sugars remained well controlled during
admission and he will be restarted on metformin at discharge.
#) Diarrhea: Had diarrhea during this admission with 4-5 BMs per
day. C. diff was negative x3. It is thought that he had
antibiotic-associated diarrhea which should improve at discharge
now that he is off antibiotics. Also encouraged yogurt to
improve the diarrhea.
#) Code status during this admission: FULL CODE
Trnasitional Issues:
-Follow-up MRI in 4 weeks from [**2189-10-18**] to follow-up on lumbar
compression fractures
-Ongoing work-up for weight loss and hypercalcemia, as described
above
-Emailed pt's Hemotologist who is aware of weight loss and has
talked with PCP regarding concern for malignancy
-Received Pamidronate 60mg IV on [**2189-10-20**], would be due for this
every month if ongoing therapy with bisphosphonates is desired
Medications on Admission:
LISINOPRIL - (Prescribed by Other Provider) - 5 mg Tablet - one
Tablet(s) by mouth daily
METFORMIN - (Prescribed by Other Provider) - 500 mg Tablet - one
Tablet(s) by mouth twice a day
PRAVASTATIN - (Prescribed by Other Provider) - 20 mg Tablet -
one Tablet(s) by mouth daily
Medications - OTC
ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet, Delayed
Release (E.C.) - 1 Tablet(s) by mouth once a day
CALCIUM CARBONATE [TUMS] - (Prescribed by Other Provider) -
Dosage uncertain
CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D-3] - (Prescribed by
Other Provider) - 1,000 unit Tablet, Chewable - one Tablet(s) by
mouth daily
Discharge Medications:
1. miconazole nitrate 2 % Powder Sig: One (1) application
Topical three times a day: Apply to buttocks.
2. lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
3. metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
4. pravastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
6. cholecalciferol (vitamin D3) 1,000 unit Capsule Sig: One (1)
Capsule PO once a day.
7. dextromethorphan-guaifenesin 10-100 mg/5 mL Syrup Sig: Five
(5) ml PO every six (6) hours as needed for cough or chest
congestion.
8. Fleet Enema 19-7 gram/118 mL Enema Sig: One (1) enema Rectal
once a day as needed for constipation.
9. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection three times a day.
10. DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for
Nebulization Sig: One (1) neb Inhalation every four (4) hours as
needed for shortness of breath or wheezing.
11. Lidoderm 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) patch Topical once a day: Apply to L1-L2 area. 12 hours
on, 12 hours off.
12. pamidronate 60 mg/10 mL (6 mg/mL) Solution Sig: Sixty (60)
mg Intravenous once a month: Last given [**2189-10-20**].
13. aluminum-magnesium hydroxide 200-200 mg/5 mL Suspension Sig:
Five (5) mL PO four times a day as needed for indigestion.
14. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every
four (4) hours as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 4316**] Rehabilitation & [**Hospital **] Care Center - [**Location (un) **]
Discharge Diagnosis:
Primary:
Aspiration pneumonia
Lumbar Compression fracture
Rib fractures
Hypercalcemia
Secondary:
Diabetes Mellitus
Myelodysplastic Syndrome
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. [**Known lastname 5749**],
It was a pleasure taking care of you during your
hospitalization at [**Hospital1 69**]. You
were admitted with low back pain, for which we found that you
had a new compression fracture. Orthapedics did not recommend
surgery and instead placed you in a special type of brace.
You also presented with shortness of breath and oxygen
saturation. We discovered that you had a pneumonia, for which
we treated you with two different intravenous antibiotics. We
also placed a tube to drain some of the fluid that had
accumalated in the pneumonia. At discharge, you were breathing
more comfortably and do not need any more antibiotics after
discharge.
Your calcium level was found to be elevated. We did not
find a cause for this, although you have had an extensive
work-up priot to this admission which also did not find a cause.
You were given Pamidronate and your calcium level improved,
this medication should be given every month.
You also had significant diarrhea, which was negative for
the infection C. diff 3 times. It is likely related to the
antibiotics, which we have stopped now. Eating foods like
yogurt can help improve your symptoms, and you should feel
better now that the antibiotics are stopped.
MEDICATION CHANGES:
START guaifenesin-dextromethorphan 5mL by mouth as needed for
cough
START Pamidronate 60mg IV every month (last given [**2189-10-20**])
START lidoderm patch 1 patch apply to L1-L2 area, on for 12
hours and off for 12 hours.
START Duonebs 1 nebulizer every 4 hours as needed for shortness
of breath of chest tightness
START miconazole powder 1 application to buttocks and groin
three times daily
Followup Instructions:
PCP appointment to be arranged by rehab
Department: HEMATOLOGY/ONCOLOGY
When: FRIDAY [**2189-11-6**] at 11:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9052**], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"805.4",
"238.75",
"783.21",
"276.3",
"807.01",
"272.4",
"507.0",
"V15.88",
"275.42",
"600.00",
"E888.9",
"511.9",
"787.91",
"799.4",
"305.1",
"287.5",
"E930.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.91",
"34.04"
] |
icd9pcs
|
[
[
[]
]
] |
11885, 11999
|
6135, 9744
|
306, 357
|
12184, 12184
|
2463, 2468
|
14072, 14441
|
1584, 1710
|
10422, 11862
|
12020, 12163
|
9770, 10399
|
12360, 13633
|
5598, 6112
|
1725, 1739
|
13653, 14049
|
232, 268
|
385, 1118
|
2482, 4141
|
4685, 5582
|
12199, 12336
|
1140, 1403
|
1419, 1568
|
4635, 4650
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,643
| 119,503
|
47870
|
Discharge summary
|
report
|
Admission Date: [**2170-9-27**] Discharge Date: [**2170-10-1**]
Date of Birth: [**2096-12-4**] Sex: M
Service: MEDICINE
Allergies:
Aminoglycosides
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
Epistaxis, BRBPR, STEMI
Major Surgical or Invasive Procedure:
none.
History of Present Illness:
73 year old male with history of with HTN, CAD s/p MI'[**63**], ILD
who presented from his NH with 1 wk h/o of confusion and
epistaxis. The patient is a poor historian given his dementia,
and most of his history was obtained from his records and his
son, [**Name (NI) **] [**Name (NI) 1968**], the HCP. The patient denies CP, SOB,
abdominal pain, back pain, lightheadedness or dizziness. The
patient somewhat remembers having the episodes of epistaxis. He
states that he recently hallucinated because the nurses at the
NH were "not paying attention to him". Further characterization
of the hallucinations were difficult to obtain. The patient's
son and daughter stated that within the last few days, he has
had epistaxis on and off. The daughter states that yesterday,
she went to see him in the NH and he had a minimal amount of
blood from his left nostril, but that it seemed to have stop
after that episode. Both children stated that he does not have
a history of epistaxis, GIB, or bleeding/clotting disorders.
.
In the ED, he had BRBPR and EKG showed STEMI. He was not a
candidate for anticoagulation given his GIB and he only received
ASA. He was admitted to the CCU for monitoring.
.
On review of symptoms, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
.
Speaking to the children and his HCP, they stated that the
patient had a stroke around [**2150**], but they are not sure of all
the details. Also, they are not sure if the patient has ever
had a heart attack, and the patient denies MI in the past as
well. They are otherwise unsure of his medical history but
state that he received his medical care at [**Hospital1 112**] prior to
transferring his care to [**Hospital1 18**].
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
HTN
PVD - SFA and a peroneal angioplasty in [**2170-4-27**], as
well as a common iliac artery and external iliac stent.
CAD, MI [**4-27**], \
CRI - baseline 2.4-3.0
CVA [**2149**]
Fat embolism to lung following hip fx in [**2154**], tx at [**Hospital1 112**]
interstitial fibrosis
DM2
depression
osteoporosis.
[**Last Name 1093**] problem (syringomyelia?) unable to ambulate
Social History:
divorced, smoked 1 pck a day for 50 years. gave up 5 years ago.
alcohol ocassionally. Currently lives in nursing home
Family History:
Father died of heart attack in his 50s; Mother died in her 70s
of cancer. Three children in their 40s.
Physical Exam:
VS: T 97.2 , BP 125/82 , HR 89 , RR 19 , O2 100% on 3LNC
Gen: elderly, chronically ill appearing male, NAD, bed bound.
Oriented x3.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor; moderately dry MM.
Neck: Supple; could not determine JVP due to neck skin folds;
didn't appear to have elevated JVP.
CV: RR, normal S1, S2. No S4, no S3.
Chest: Resp were unlabored, no accessory muscle use. bilateral
posterior crackles halfway up lungs, no wheeze, no rhonchi.
Abd: thin, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: No c/c/e. well healed surgical scar of right 5 toes
amputation and left 3rd toe amputation.
Skin: senile purpura present on all extremities.
Pulses:
Right: Carotid 2+ without bruit; Femoral 1+ without bruit; could
not palpate DP pulse
Left: Carotid 2+ without bruit; Femoral 1+ without bruit; could
not palpate DP pulse
Pertinent Results:
[**2170-10-1**] 05:30AM BLOOD WBC-9.7 RBC-3.66* Hgb-10.3* Hct-32.5*
MCV-89 MCH-28.1 MCHC-31.6 RDW-19.3* Plt Ct-189
[**2170-9-27**] 11:20AM BLOOD WBC-8.1 RBC-2.75* Hgb-7.2* Hct-23.7*
MCV-86 MCH-26.2* MCHC-30.4* RDW-19.2* Plt Ct-236
[**2170-9-27**] 11:20AM BLOOD Neuts-65.8 Lymphs-27.9 Monos-4.3 Eos-1.9
Baso-0.2
[**2170-9-29**] 06:40AM BLOOD PT-16.0* PTT-33.8 INR(PT)-1.5*
[**2170-10-1**] 05:30AM BLOOD Glucose-108* UreaN-46* Creat-2.6* Na-146*
K-4.6 Cl-112* HCO3-23 AnGap-16
[**2170-9-30**] 06:51AM BLOOD CK(CPK)-52
[**2170-9-27**] 11:20AM BLOOD ALT-16 AST-37 CK(CPK)-116 AlkPhos-76
Amylase-46
[**2170-9-30**] 06:51AM BLOOD CK-MB-NotDone cTropnT-1.54*
[**2170-9-27**] 11:20AM BLOOD CK-MB-16* MB Indx-13.8* cTropnT-0.42*
[**2170-10-1**] 05:30AM BLOOD Calcium-8.4 Phos-3.0 Mg-1.9
[**2170-9-27**] 11:28AM BLOOD Glucose-141* Lactate-3.0* Na-142 K-4.8
Cl-111
ECHO [**2170-9-27**]
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. There is severe regional left ventricular systolic
dysfunction with mid to distal septal akinesis, apical akinesis
and mid angerior hypokinesis with mild to moderate hypokinesis
elsewhere. No definite apical thrombus seen (cannot definitively
exclude). Overall left ventricular systolic function is severely
depressed (LVEF= 20 %). Right ventricular systolic function
appears depressed. The ascending aorta is mildly dilated. The
aortic valve leaflets are mildly thickened. There is no aortic
valve stenosis. 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 no pericardial effusion.
Compared with the prior study (images reviewed) of [**2170-9-10**],
left ventricular systolic function now appears worse with more
anteroseptal and anterolateral segments now appear more
hypokinetic.
CXR [**2170-9-27**]
FINDINGS: There are bilateral interstitial opacities consistent
with
the patient's history of interstitial fibrosis, unchanged.
There are
persistent low lung volumes. There is no pneumothorax. There
are no focal
consolidations or large pleural effusions identified. The
pulmonary
vasculature is unremarkable.
IMPRESSION: Unchanged appearance of bilateral diffuse
interstitial opacities
consistent with known history of interstitial fibrosis.
ECG [**2170-9-27**]
Sinus rhythm with ventricular premature beats. Borderline first
degree
A-V block. ST segment elevations in leads V1-V3 suggest acute
anterior
injury. Q waves in leads II, III and aVF suggest prior inferior
myocardial
infarction. Compared to prior tracing of [**2170-9-8**] new ST segment
elevations
are present in the anteroseptal leads. Clinical correlation is
advised.
ECG [**2170-9-29**]
Baseline artifact. Sinus rhythm. Left atrial abnormality.
Inferior wall
myocardial infarction of indeterminate age. Mild Q-T interval
prolongation
with ST-T wave abnormalities. Since previous tracing of [**2170-9-28**]
the rate is
slower. The Q-T interval is longer.
Brief Hospital Course:
73 yo Male with h/o CAD s/p ? MI in '[**63**], peripheral arterial
disease, interstitial lung disease, HTN, CKD, and DM now
presents with GIB and STEMI with mild elevation in troponin.
.
# STEMI: The patient's initial ECG showed small (~1mm) ST
elevations in V1-V3. Although these could be due to tachycardia
and possibly a rate dependent LBBB, it was felt that these
represented real ST elevations. The CK did not elevate that
high, and there was a mild increase in his troponins. The
patient could not undergo cardiac catherization at the time of
admission due to his active GI bleed. He was evaluated by GI
consult service and they felt that he was not a candidate for
colonoscopy at that time due to active cardiac ischemia. They
recommended cardiac workup be done, and after discharge, they
would see him and schedule outpatient GI bleed workup. The
[**Hospital 228**] hospital course was uncomplicated otherwise. He did
not have any chest pain or other symptoms. His dyspnea also
improved throughout his hospitalization. He will need followup
with cardiology to further assess his cardiac function and
determine other testing for his cardiac issues. His old records
from [**Hospital1 112**] were obtained, but there were no prior catheterization
results or stress testing which showed any defects. His
echocardiogram revealed significant hypokinesis and akinetic
segments of the LV with severe systolic dysfunction. He will
continue on aspirin, atenolol and a statin at this time, but we
will hold his clopidogrel in the setting of GI bleed. Once his
GI issues are resolved, it would be beneficial for him to
restart clopidogrel given his prior stent placement for his
peripheral arterial disease of his lower extremities.
.
# GI bleed: The GI service evaluated the patient as noted above.
At admission, the patient had gross blood in his stool with a
decreased Hct of 23.7. His baseline is near 26-28. In the
setting of acute cardiac ischemia, he was transfused with 3
units of pRBCs for a goal HCT of greater than 30. He maintained
his Hct throughout his hospitalization after his transfusion
despite his guaiac positive stools. He will continue high dose
PPI therapy as an outpatient and will follow up in [**Hospital **] clinic for
further consultation and upper/lower endoscopy. At discharge,
the patient's HCT was stable without any acute volume issues.
.
# CKD: The patient's baseline cr is 2.4-3.0; At discharge, he
was 2.6. He will need to continue to followup with his PCP
regarding his kidney function. On admission, he appeared to
have volume overload and was diuresed given his increased volume
and the blood products he received. At discharged, he appeared
euvolemic and he will be discharged home on furosemide 40 mg
daily. He will need to followup with his PCP regarding future
furosemide dosing and potassium levels. Also, an ACE-I was not
started during this admission due to his elevated creatinine.
This will need to be readressed in the outpatient setting and a
plan regarding the institution of an ACE-I will need to be
discussed with the patient's PCP and cardiologist.
.
# DM: At admission, the patient was not on any meds for
diabetes. He was covered with an insulin sliding scale which he
did not receive much insulin. He will be discharged without
medications for his diabetes, but this will need to be
readdressed with his PCP and possibly [**Name Initial (PRE) **] HbA1c will need to be
drawn by his PCP.
[**Name Initial (NameIs) **] will check fingersticks QACHS for couple of days; if
elevated will cover with HISS, otherwise, if normal will stop
fingersticks
.
# HTN: The patient was started on metoprolol in the acute STEMI
period. His atenolol was held. He maintained good blood
pressures throughout his hospitalization and did not appear to
have difficulty with his volume after completing his
transfusions. The patient was then switched back to atenolol as
he had been on that prior to admission but with an increased
dose in the setting of STEMI. This dosing may need to be
further adjusted by his PCP or cardiologist in the outpatient
setting.
.
# Interstitial Lung Disease: On admission, the patient was
requiring >3L O2 on nasal cannula. At discharge he was between
room air and 2L O2 to maintain O2 saturations greater than 92%.
The patient may need occasional supplemental O2 as an outpatient
given his interstitial lung disease. His CXR revealed stable
disease. Also, the patient has pulmonary followup for PFTs
scheduled. He will need to followup with his PCP and
pulmonologist for further therapy. He will be discharged on his
home respiratory medications.
.
# DNR/DNI- d/w family regarding use of pressors
.
# Comm: son [**Name (NI) **] [**Name (NI) 1968**] [**Telephone/Fax (1) 101007**]
# That patient will be discharged to his nursing
home/rehabilitation facility.
Medications on Admission:
- Aspirin 325 daily
- Atorvastatin 10 daily
- Clopidogrel 75 daily
- Baclofen 10 daily
- Citalopram 40 mg daily
- Docusate Sodium
- Calcium Carbonate 500 mg daily
- Cholecalciferol (Vitamin D3) 400 daily
- Prilosec 20 mg daily
- Atenolol 37.5 mg PO once a day.
- Fluticasone 110 mcg/Actuation Aerosol 2 puff [**Hospital1 **]
- Dextromethorphan-Guaifenesin PRN
- Albuterol Sulfate Q6H
- Ipratropium Bromide Q6H
- Epoetin Alfa 10,000 unit/mL QWK
- Ferric Gluconate 125mg IV once weekly X 7 weeks.
Discharge Medications:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: Two (2)
Inhalation Q6H (every 6 hours) as needed for wheezing.
5. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO DAILY (Daily).
7. Baclofen 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
9. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge
Mucous membrane PRN (as needed) as needed for sore throat.
10. Procrit 10,000 unit/mL Solution Sig: [**Numeric Identifier 961**] ([**Numeric Identifier 961**]) units
Injection once a week.
11. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
12. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Liquid Sig: Five
(5) ML PO Q6H (every 6 hours) as needed for cough.
13. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain or fever.
14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
15. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO twice a
day as needed for constipation.
16. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day.
17. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
18. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Doctor First Name 391**] Bay - [**Hospital1 392**]
Discharge Diagnosis:
Primary Diagnosis: Myocardial Infarction
Secondary Diagnosis: GI Bleeding NOS, likely diverticulosis,
Interstitial Lung Disease, Peripheral Vascular Disease
Discharge Condition:
Stable, on 2L NC, wheelchair dependent.
Discharge Instructions:
You have were admitted to the hospital for evaluation of
bleeding from your rectum and chest pain. On admission, it was
found that you had a small heart attack due to a decrease in
blood supply to heart. It is recommended that after leaving the
hospital you follow-up with a Cardiologist as directed below for
a stress test of your heart. Your cardiologist will decide on
the basis of this test whether you would benefit from further
therapy for your heart. In the mean time, please continue to
take all medications as directed.
For your bleeding, it is recommended that you have a colonoscopy
and an endoscopy for evaluation. This should be scheduled in
the near future. Please follow-up as directed with
gastroenterology for this procedure.
Please return to the ER or call your PCP if you develop any
chest pain, shortness of breath, new GI bleeding, or any other
complaint concerning to you.
|
[
"412",
"294.8",
"562.12",
"414.01",
"410.11",
"443.9",
"585.9",
"784.7",
"250.00",
"403.90",
"V12.54",
"276.6",
"515"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
14363, 14443
|
7154, 12014
|
299, 307
|
14644, 14686
|
4063, 7131
|
3044, 3148
|
12559, 14340
|
14464, 14464
|
12040, 12536
|
14710, 15615
|
3163, 4044
|
236, 261
|
335, 2492
|
14526, 14623
|
14483, 14505
|
2514, 2891
|
2907, 3028
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,961
| 108,588
|
6580
|
Discharge summary
|
report
|
Admission Date: [**2115-7-13**] Discharge Date: [**2115-7-26**]
Date of Birth: [**2043-2-28**] Sex: M
Service: MEDICINE
Allergies:
Demerol / Actos
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
Intubation
Tracheostomy/[**First Name3 (LF) 282**] placement [**2115-7-24**]
History of Present Illness:
Mr. [**Known lastname **] is a 72-year-old gentleman with a past medical
history significant for VF arrest s/p AICD placement in [**2102**],
CHF with EF of 15%, afib, DM, COPD, HTN, and recent admission
([**6-20**] to [**7-10**]) syncope complicated by hemodynamically unstable
afib with RVR, CCU transfer, aspiration pneumonia, intubation,
and subsequent inability to take POs due to deconditioning with
D/C to rehab and readmission ([**7-11**] to [**7-12**]) after he pulled out
his PICC and was unable to receive IV medications who presents
from rehab due to unresponsiveness.
.
Notably, during his extended admission, he was found to have
severe aspirations and a subsequent aspiration pneumonia. Speech
and swallow reevalutated him multiple times with subsequent
recommendation of strict NPO. The patient refused Dobbhoff tube
placement, and requested that a [**Month/Year (2) 282**] be placed. A [**Month/Year (2) 282**] was placed
on [**2115-7-5**]. He pulled out this [**Date Range 282**] on [**2115-7-6**]. He was placed on
TPN as a bridge to another g-tube (which has not been placed yet
pending reevaluation scheduled for [**7-15**]). As stated above, he
pulled out his PICC and returned to the hospital [**7-11**]. In the
ED, he had a PICC placed, but then pulled this out so he was
given a peripheral IV and discharged to [**Hospital **] rehab MACU on
PPN.
.
Normally pt is not oriented, but he is usually able to
communicate. However, today at [**Hospital 100**] rehab MACU he was noted to
be somnolent, tachypneic, and pale. He was on tele and noted to
have several runs of NSVT. He reportedly had been up the whole
night and complained of abdominal discomfort. He otherwise
denied feeling short of breath, chest pain, palpitations. His
mental status deteriorated and he became much less responsive.
.
In the ED, patient was unable to give a history. On exam the
patient was dry with course rhonchi bilaterally. He was
intubated for airway protection and started on fentanyl/versed.
EKG: showed native left bundle with intermittent pacing and he
was noted to have 8 beats of NSVT. He would [**Last Name (un) 25177**] have
bradycardia to the 30s before his pacer would start pacing.
Cardiology was consulted for ST elevations? and they felt his
EKG was at baseline and not concerning. The patient was given
lidocaine bolus for non sustained vtach. He had a head CT which
showed "No evidence of acute intracranial abnormalities, but air
in the masticator spaces." CXR showed R PNA so he was given vanc
and levofloxacin. UA was negative. Abd CT showed distended
gallbladder and bilateral pleural effusions. RUQ U/S showed
distended gallbladder with thickened wall and sludge, concerning
for acute cholecystitis. Surgery was consulted but had not yet
seen pt in ED. He was ordered for zosyn.
.
On the floor, pt is sedated and intubated. Hemodynamically
stable.
Past Medical History:
Diabetes
Dyslipidemia
Hypertension
sCHF- TTE 20-25%, dry weight 198 lbs.
Paroxysmal atrial fibrillation- on Coumadin
CAD -Cath showed [**2-22**] showed single vessel LCx disease
ACID after VF arrest in [**2102**], [**Company 1543**] [**Last Name (un) 24119**] VR 7232Cx
COPD
Barrett's esophagus with high grade dysplasia.
Post-cryotherapy x 3, BARRx [**2-23**]
S/p GI bleed- UGIB from a gastric ulcer [**12/2102**]
S/p Appendectomy [**2063**]
S/p Bone tumor excision from shoulder [**2057**]
Portal vein thrombosis
Social History:
Occupation: Retired from [**Location (un) 86**] police force and security
service at [**Location (un) 745**] [**Hospital 3678**] Hospital
Housing: Lives independently at Blakes Estate senior center (a
retirement community), but found to be in squalor in [**6-27**].
Family: Closest family is cousin [**First Name5 (NamePattern1) **] [**Name (NI) 23636**]), lives down the
street from him. HCP is [**Name (NI) **] [**Name (NI) 25176**]. Adopted. Never married,
no children.
Tobacco: 45 year 1-2ppd history, quit 11 years ago.
Alcohol: None
Drugs: None
Family History:
Adopted. Does not know his family history.
Physical Exam:
Vitals: T:96.1 BP: 110/68 P: 82 R: 19 O2: 100%
General: sedated, intubated
HEENT: Sclera anicteric, pipoint reactive pupils, ET tube in
place
Neck: JVP not elevated
Lungs: bilateral rhonchi
CV: Regular rate and rhythm, no murmurs
Abdomen: soft, non-distended, bowel sounds present
GU: + foley
Ext: venous stasis changes, warm, well perfused, 2+ pulses,
trace pretibial edema
At discharge:
37.1, 71-98, 92-131/52-83, 100%, TBB -2500 (-300)
PS 5/5, 0.4, RSBI 84
Trach, awake, following commands, moving all extremities. Lungs
clear anteriorly. Heart regular. Abdomen soft, NT, ND, with
normal bowel sounds. Extremities without peripheral edema.
Pertinent Results:
Labs at admission:
[**2115-7-12**] 06:55AM BLOOD WBC-7.2 RBC-3.86* Hgb-9.1* Hct-29.7*
MCV-77* MCH-23.5* MCHC-30.6* RDW-20.1* Plt Ct-321
[**2115-7-13**] 11:40AM BLOOD Neuts-76.9* Lymphs-15.6* Monos-7.1
Eos-0.3 Baso-0.1
[**2115-7-13**] 11:40AM BLOOD PT-20.3* PTT-41.6* INR(PT)-1.9*
[**2115-7-12**] 06:55AM BLOOD Glucose-148* UreaN-71* Creat-1.3* Na-139
K-4.2 Cl-102 HCO3-27 AnGap-14
[**2115-7-13**] 11:40AM BLOOD ALT-33 AST-47* AlkPhos-155* TotBili-1.5
[**2115-7-13**] 11:40AM BLOOD cTropnT-0.02*
[**2115-7-13**] 11:40AM BLOOD Lipase-14
[**2115-7-12**] 06:55AM BLOOD Calcium-8.3* Phos-3.6 Mg-2.3
[**2115-7-14**] 04:11PM BLOOD Triglyc-87
[**2115-7-16**] 07:35AM BLOOD Vanco-18.6
[**2115-7-13**] 11:40AM BLOOD Digoxin-1.3
[**2115-7-13**] 12:36PM BLOOD Type-ART Temp-38.1 Rates-16/ Tidal V-500
PEEP-5 FiO2-100 pO2-394* pCO2-43 pH-7.41 calTCO2-28 Base XS-2
AADO2-277 REQ O2-53 -ASSIST/CON Intubat-INTUBATED
Imaging:
HIDA [**7-15**]
RADIOPHARMACEUTICAL DATA:
3.8 mCi Tc-[**Age over 90 **]m DISIDA ([**2115-7-15**]);
1.9 mCi Tc-99m DISIDA ([**2115-7-15**]);
HISTORY: 82 year old male with abdominal pain.
INTERPRETATION: Serial images over the abdomen show uptake of
tracer into the
hepatic parenchyma. Tracer activity is noted in the small bowel
at 23 minutes.
The gallbladder is not visualized at 60 minutes. 60 minutes
following morphine
administration, there is faint uptake lateral to the common bile
duct, which is
atypical for but could represent evidence of partial delayed
gallbladder
uptake.
IMPRESSION: Abnormal study, without definite visualization of
gallbladder.
Although this cpuld be due to the prolonged fasting status,
acute or chronic
cholecystitis cannot be excluded.
Unilateral Upper Ext Vein
FINDINGS: Occlusive thrombus is present within the right
axillary vein,
extending to the mid and proximal portions of one of the
brachial veins. A
venous catheter traverses this region, eventually exiting that
brachial vein
into a superficial branch. The right IJ, second brachial vein,
cephalic vein,
basilic vein, and subclavian vein are patent. No fluid
collections are
present.
IMPRESSION: Occlusive thrombus within the right axillary vein
and one of two
brachial veins (the one containing a venous catheter). These
findings were
discussed by Dr. [**Last Name (STitle) **] with Dr. [**Last Name (STitle) 12933**] at 1:20 p.m. on [**2115-7-14**].
The study and the report were reviewed by the staff radiologist.
Abd U/S
INDICATION: 72-year-old man with abdominal pain, NPO. Assess for
acute
cholecystitis.
COMPARISON: Abdominal CT performed earlier in the day and CTA
abdomen of
[**2115-7-7**] and a portable abdominal ultrasound of [**7-6**], [**2114**].
FINDINGS: The gallbladder is markedly distended containing a
large amount of
echogenic sludge. Areas of the sludge appear mass-like and may
be consistent
with tumefactive sludge. The gallbladder wall is thickened,
though this may
be due to known heart failure. There is no intra- or
extra-hepatic biliary
dilation. The common bile duct is normal measuring up to 6 mm in
diameter.
The pancreas is not well seen. There is a large pleural
effusion, better
evaluated on the recent CT. A small amount of perihepatic
ascites is present.
The main portal vein is patent with appropriate direction of
flow.
IMPRESSION: Markedly distended gallbladder containing sludge.
Nonspecific GB
wall thickening which could reflect heart failure. Nondiagnostic
son[**Name (NI) 493**]
[**Name2 (NI) 515**] sign. Given these findings, the possibility of acute
acalculous
cholecystitis cannot be excluded. If further evaluation is
required, HIDA
scan is recommended.
Findings were discussed with Dr. [**Last Name (STitle) **] at approximately 6 pm on
[**2115-7-13**], in person.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **]
DR. [**First Name8 (NamePattern2) 814**] [**Name (STitle) 815**]
Approved: SUN [**2115-7-14**] 6:33 PM
CT abd
INDICATION: 72-year-old man with abdominal pain, intubated and
septic.
Please evaluate for acute process.
COMPARISON: [**2115-7-7**].
TECHNIQUE: MDCT-acquired images were obtained from the lung
bases to the
pubic symphysis after the administration of 130 cc of Optiray
intravenous
contrast and oral contrast. Coronal and sagittal reformatted
images were also
displayed.
FINDINGS:
CT ABDOMEN: There are at least moderate bilateral pleural
effusions, which
are unchanged in size since the prior study. There is adjacent
bibasilar
compressive atelectasis. The visualized portion of the right
lower lobe is
completely collapsed. An NG tube is noted within the stomach.
However, the
side port is at the GE junction and could be advanced a few
centimeters.
Heart size is enlarged without pericardial effusion. Leads are
noted going to
the right atrium, right ventricle, and left ventricle.
The spleen, adrenal glands, pancreas, abdominal loops of bowel
are within
normal limits. The gallbladder remains distended. Overall
unchanged
appearance since the [**2115-7-7**] study. Small amount of
stranding around
the gallbladder may also be due to patient's fluid overload
state, as there is
a small amount of perihepatic ascites and perisplenic ascites.
An IVC filter is noted in place with infrarenal position.
Accessory right
upper renal artery supplies the lower right kidney.
There is no free air. There is no retroperitoneal or mesenteric
lymphadenopathy. There is diffuse calcified plaque
atherosclerotic disease.
CT PELVIS: The prostate is grossly unremarkable. There is
diverticulosis
without evidence of diverticulitis. The rectal wall appears
somewhat
edematous and featureless, though unable to determine if this
might be
resulting from acute or chronic colitis, vs underdistention.
Foley catheter
is noted within the bladder. Air within the bladder is likely
due to recent
instrumentation.
There is no inguinal or pelvic lymphadenopathy. There is no free
fluid within
the pelvis.
BONE WINDOWS: No concerning osseous lesions are identified.
IMPRESSION:
1. The gallbladder remains distended, which is unchanged in
appearance since
the [**2115-7-7**] study. This again may represent the
patient's fasting
state (please correlate clinically). However, if there is a
concern for acute
cholecystitis, ultrasound is recommended for further evaluation.
2. Large bilateral pleural effusions, which appear stable since
the [**7-7**], [**2114**] study. There is adjacent compressive atelectasis with
collapse of
the visualized aspect of the right lower lobe.
3. Trace amount of perihepatic and perisplenic ascites and
diffuse anasarca,
unchanged.
4. Somewhat featureless and minimally thickened appearance of
the rectum,
similar to the prior study from [**2115-7-7**], may be related to
chronic or acute
colitis, though underdistention and third-spacing is a
possibility.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Approved: SAT [**2115-7-13**] 7:59 PM
CT head
FINDINGS: There is no acute intracranial hemorrhage, edema, or
mass effect.
There is preservation of [**Doctor Last Name 352**]-white matter differentiation. The
ventricles
and sulci are normal in size and configuration.
There is no fracture. There is air in the soft tissues of the
masticator
spaces, left greater than right. There is mild mucosal
thickening of the
maxillary sinuses bilaterally.
IMPRESSION:
1. No evidence of acute intracranial abnormalities.
2. No fracture seen. Air in the masticator spaces, left greater
than right,
of uncertain etiology.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **]
DR. [**First Name11 (Name Pattern1) 95**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 96**]
Approved: SAT [**2115-7-13**] 7:56 PM
[**7-13**]
FINDINGS: The ET tube ends 5.4 cm above the level of the carina.
The NG tube
passes below the level of the diaphragm, although the inferior
extent cannot
be assessed. A right pacemaker/ICD with associated right atrial
and right
ventricular leads is again noted. Abandoned left pacemaker leads
are seen.
There are moderate right and small left pleural effusions, not
significantly
changed in size compared to [**2115-6-30**]. Associated
compressive
atelectasis at the right base as well as minimal left basilar
atelectasis are
also unchanged. The is possibly mild interstitial pulmonary
edema. Moderate
cardiomegaly is unchanged. The mediastinal contours are
unchanged. Old right
rib fractures.
IMPRESSION:
1. ETT appropriately positioned. NG tube tip not assessed,
correlate with
subsequent CT.
2. Moderate cardiomegaly, moderate bilateral pleural effusions,
and possible
mild intersitial pulmonary edema.
The study and the report were reviewed by the staff radiologist.
EKG [**7-13**]
Probable atrial fibrillation with ventricular demand pacing.
Compared to the
previous tracing of [**2115-7-3**] no diagnostic change.
Micro:
[**2115-7-13**] 8:52 pm SPUTUM Source: Endotracheal.
GRAM STAIN (Final [**2115-7-14**]):
[**9-10**] PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final [**2115-7-16**]):
Commensal Respiratory Flora Absent.
YEAST. SPARSE GROWTH.
ESCHERICHIA COLI. RARE GROWTH.
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 8 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.
FUNGAL CULTURE (Preliminary):
YEAST.
Blood 8/27 pending
Urine [**7-13**] negative
Labs prior to discharge:
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2115-7-24**] 01:19 7.2 3.74* 8.6* 27.6* 74* 23.0* 31.2 19.3*
202
Source: Line-aline
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2115-7-24**] 01:19 202
Source: Line-aline
[**2115-7-24**] 01:19 15.0* 75.4* 1.3*
Source: Line-aline
[**Year (4 digits) **] USE ONLY
[**2115-7-24**] 01:19
Source: Line-aline
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2115-7-24**] 16:16 114*1 17 0.7 136 4.1 96 31 13
[**2115-7-24**] 01:19 165*1 18 0.6 137 3.9 97 36* 8
Source: Line-aline
IF FASTING, 70-100 NORMAL, >125 PROVISIONAL DIABETES
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2115-7-24**] 16:16 8.0* 3.2 1.9
[**2115-7-24**] 01:19 7.9* 2.8 2.0
Source: Line-aline
Brief Hospital Course:
Mr. [**Known lastname **] is a 72 YOM with CHF with EF of 15%, AICD, afib, DM,
COPD, HTN, and recent admission complicated by aspiration and
malnourishment, on PPN who presented from rehab with increased
somnolence.
.
MICU COURSE:
# Somnolence/AMS: The patient reportedly was more lethargic and
tachypneic at rehab and was intubated in the ED for airway
protection. He had a Head CT that was negative for acute
process. His somnolence was thought to be from systemic
infection given the patient was not on sedating medications, EKG
appeared baseline, and there were no gross electrolyte
abnormalities. Sources of infection were presumed initially to
be pneumonia within stable right pleural effusion and/or
cholecystitis given CT abdomen that showed distended gall
bladder and RUQ U/S that confrimed distended gallbladder
containing sludge. UA and blood cultures were negative. The
patient was started on Vanc/zosyn to cover for HAP and
cholecystitis. Surgery was consulted and did not think the
patient had cholecystitis given his CT abdomen looked similar to
CT from [**7-7**] and thought the findings could be due to lack of PO
intake on TPN. They recommended HIDA scan which was
inconclusive. The patient's abdominal exam remained stable and
he was not felt to have had cholecystitis. The patient did not
exhibit septic physiology and did not require IV fluids or
pressors to maintain urine output and blood pressure. He did
not have elevated WBC or fevers. Sputum was sent for culture
and grew sensation gram negative rods, and he was switched to
Ceftriaxone on [**7-17**] and finished an 8 day course. Due to RUE
DVT, he was taken down to IR for replacement L sided PICC but
b/l UE dvts were discovered and piccs were exchanged for b/l
midline IVs. The right midline (older midline) was removed on
[**7-25**]. His mental status improved on minimal sedation.
.
Intubation: The patient was intubated for airway protection in
the setting of altered mental status. He was noted to have some
mild white secretions. He has a history of aspiration and had
previously been NPO. His vent settings were weaned to minimal
support. He was sedated initially with fent/midax but this was
changed to propofol as he was expected to be extubated soon. He
was extubated on [**7-19**] for approx 8 hours after aggressive
diuresis with lasix gtt. He was reintubated later that day for
poor oxygenation, difficulty clearing secretions and increased
work of breathing.
IP evaluated the patient for trach/[**Month/Day (2) **] according to goals of
care discussion with HCP and patient. They placed trach/[**Month/Day (2) **] on
[**7-24**]. His vent settings were weaned and he was started on
pressure support. Trache collar was attempted on [**7-25**] and
continued through the day until discharge on [**7-26**]. Sutures
should be removed at 2 weeks from [**7-24**] on [**2115-8-7**]. Trache was
placed for airway protection for secretions so plan would be to
keep it in for that reason and if anything decrease size. Valve
can be attempted for speech upon discharge.
# DVT in upper extremities: Both line associated however still
has left midline in place. Lovenox was started as above.
Discharge with plan to transition to coumadin given atrial
fibrillation.
# Pleural Effusions: The patient was noted to have a right sided
pleural effusion which had been present on chest x rays seince
[**2114-9-17**]. He was not noted to be hypoxic, but thought to
be in respiratory distress at rehab. His ABG did not indicate he
had a large A-a gradient. His effusions were thought to be a
combination of CHF with recent aspiration pneumonia, but a
superimposed pneumonia could not be ruled out. He was started
on vanc/zosyn as above to empirically cover for pneumonia. He
was on a lasix drop on [**7-17**]- [**7-25**]. He was changed to the
equivalent home dose of his lasix on [**7-26**] at 40mg daily. His
electrolytes should be checked on [**7-27**] to ensure stability and
assess need for replacement.
.
# Malnutrition: Patient wanted [**Month/Year (2) 282**] tube last admission in
setting of severe aspiration. However, he subsequently pulled
out G tube. He has also pulled multiple PICCs placed for TPN.
Plan was for repeat swallow eval on Monday with reconsideration
of goals of care pending the results. The patient was intubated
for airway protection and extubated on [**7-19**] briefly before being
reintubated for airway protection [**12-19**] work of breathing and
increased secretions. He was given PPN. NGT was attempted but
was unable to be placed [**12-19**] turbinate swelling. Discussion with
HCP regarding [**Name2 (NI) **] tube resulted in IP consult for trach/[**Name2 (NI) **]
placement.
.
# Atrial fibrilation: Patient currently intermittantly V paced.
He received lidocaine in the ED for concern of Vtach though he
did not show evidence of this in the ICU. He was continued on
his home dose digoxin 0.1 mg IV every 2 days, Lopressor 2.5 mg Q
6 hr. His lovenox was held in the setting of possible procedure
and he was on a Heparin drip. Lovenox was restarted on [**7-25**].
.
# sCHF: The patient appeared euvolemic and was not hypotensive.
He was on a lasix gtt for several days and changed to lasix
through the [**Month/Day (4) 282**] tube on [**7-25**]. He was restarted on aspirin at 81
mg daily given the addition of lovenox to his regimen. He was
restarted on beta blocker with metoprolol tartrate on [**7-25**]. [**Month/Day (4) **]
inhibitor should be added as possible after discharge.
.
# CAD: The patient's lopressor was initially held and then
restarted. He was continued on home digoxin. His aspirin was
initially held in the setting of being NPO then restarted at 81
mg daily.
.
# DM: The patient was continued on fingersticks with insulin
sliding scale
.
# goals of care: Patient is full code. HCP is [**Name (NI) **] [**Name (NI) 25176**].
Goals of care discussion was held with patient and HCP while
extubated and it was determined that he would proceed with
trache/[**Name (NI) 282**].
Medications on Admission:
digoxin 0.1 mg IV every 2 days
Lopressor 2.5 mg Q 6 hr
Lasix 20 mg IV Q day
Albuterol neb 2.5 mg Q6 PRN
Aspirin 325 mg Q day
Atrovent neb 0.5 mg Q6 PRN
Insulin SS
Lovenox 70 mg SQ Q12
Discharge Medications:
1. insulin lispro 100 unit/mL Solution Sig: insulin sliding
scale Subcutaneous ASDIR (AS DIRECTED).
2. chlorhexidine gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML
Mucous membrane [**Hospital1 **] (2 times a day).
3. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
4. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
4-6 Puffs Inhalation Q4H (every 4 hours).
5. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig:
Six (6) Puff Inhalation QID (4 times a day).
6. ranitidine HCl 15 mg/mL Syrup Sig: Ten (10) mL PO BID (2
times a day).
7. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
8. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
10. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
11. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
12. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily) as needed for constipation.
13. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for pain.
14. enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) syringe
Subcutaneous Q12H (every 12 hours).
15. docusate sodium 50 mg/5 mL Liquid Sig: Five (5) mL PO BID (2
times a day).
16. digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day): started on [**7-26**].
17. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
Mid-line, heparin dependent: Flush with 10 mL Normal Saline
followed by Heparin as above, daily and PRN per lumen.
18. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
Mid-line, heparin dependent: Flush with 10 mL Normal Saline
followed by Heparin as above, daily and PRN per lumen.
19. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Mid-line, non-heparin dependent: Flush with 10 mL Normal
Saline daily and PRN per lumen.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
pneumonia
acute on chronic CHF
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
You were admitted to [**Hospital1 69**] with
decreased mental status. While you were here you were treated
for a course of pneumonia. You also had fluid on your lungs
which improved with lasix infusion. You were initially
intubated with a breathing tube and when we tried to remove it
on [**7-19**], you were not able to breathe well on your own because of
increased sputum, so it was replaced. Before it was replaced, we
discussed if you would like to proceed with a more permanent
breathing tube, or tracheostomy, and feeding tube ([**Month/Day (2) 282**]) which
you decided with your health care proxy you wanted.
While you were here, some of your medications were changed.
Please see the attached medication list for your list of
medications.
CHANGE digoxin from IV to [**Month/Day (2) 282**] tube
CHANGE lopressor from IV to Metoprolol 12.5 mg by [**Month/Day (2) 282**] twice a
day
CHANGE lasix from IV to 40mg by [**Month/Day (2) 282**] tube daily
CHANGE aspirin from 325mg to 81mg daily
INCREASE lovenox to 80mcg every 12 hours
START Ranitidine twice a day while on the ventilator and for 24
hours after
START chlorhexadine twice a day while on the ventilator and for
24 hours after
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
You should follow-up with your doctors as your nursing facility
|
[
"507.0",
"V58.61",
"482.82",
"427.31",
"V58.67",
"799.4",
"427.1",
"357.2",
"585.9",
"428.0",
"362.01",
"272.0",
"496",
"V12.51",
"518.84",
"428.23",
"403.90",
"996.74",
"250.60",
"250.50",
"453.82",
"110.3",
"263.9",
"V12.71",
"112.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"99.15",
"43.11",
"38.97",
"96.72",
"31.29"
] |
icd9pcs
|
[
[
[]
]
] |
24748, 24814
|
16419, 22456
|
298, 376
|
24889, 24889
|
5127, 15447
|
26334, 26401
|
4399, 4444
|
22690, 24725
|
24835, 24868
|
22482, 22667
|
25026, 26311
|
4459, 4835
|
15483, 16396
|
4849, 5108
|
237, 260
|
404, 3277
|
24904, 25002
|
3299, 3815
|
3831, 4383
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,055
| 177,938
|
9145
|
Discharge summary
|
report
|
Admission Date: [**2106-8-3**] Discharge Date: [**2106-8-12**]
Date of Birth: [**2041-4-4**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
Abdominal aortic aneurysm
Major Surgical or Invasive Procedure:
[**2106-8-3**] Resection and repair of abdominal aortic aneurysm with
18-mm Dacron tube graft.
History of Present Illness:
This 65-year-old gentleman with obesity and COPD has an
enlarging abdominal aortic aneurysm, now about 5.5 cm in maximum
transverse diameter. The aneurysm starts at the level of the
renal arteries and is not a candidate for endovascular repair.
Past Medical History:
COPD
hypertension
CAD (s/p PTCA and stenting of the left circumflex)
AAA
nephrolithiasis
chronic back pain
alcohol abuse
Anxiety
Social History:
divorced - wife still very involved in care
unemployed (used to work as a painter and handyman).
Smokes 0.5 pk/day. History of alcohol abuse.
Family History:
unknown
Physical Exam:
VSS, Afebrile
Gen: Obese male in NAD, alert and oriented
Cardiac: RRR
Lungs: CTA bilaterally
Abd: soft,no m/t/o; incision - clean, dry, intact, without
drainage or erythema
Extremities: warm, well perfused. mild edema bilat. Palpable
pedal pulses bilat
Pertinent Results:
[**2106-8-10**] 07:30AM BLOOD WBC-9.2 RBC-3.70* Hgb-11.4* Hct-33.0*
MCV-89 MCH-30.8 MCHC-34.6 RDW-14.9 Plt Ct-224
[**2106-8-9**] 04:52AM BLOOD WBC-8.2 RBC-3.59* Hgb-11.1* Hct-31.8*
MCV-89 MCH-30.8 MCHC-34.7 RDW-14.8 Plt Ct-187
[**2106-8-3**] 01:52PM BLOOD Neuts-87.9* Lymphs-8.5* Monos-2.8 Eos-0.5
Baso-0.2
[**2106-8-10**] 07:30AM BLOOD Plt Ct-224
[**2106-8-9**] 02:49PM BLOOD Glucose-123* UreaN-12 Creat-0.4* Na-138
K-3.5 Cl-96 HCO3-35* AnGap-11
[**2106-8-9**] 04:52AM BLOOD Glucose-140* UreaN-11 Creat-0.4* Na-138
K-3.4 Cl-96 HCO3-35* AnGap-10
[**2106-8-4**] 04:10AM BLOOD ALT-10 AST-17 AlkPhos-27* Amylase-22
TotBili-0.3
[**2106-8-3**] 05:50PM BLOOD CK-MB-6 cTropnT-0.02*
[**2106-8-9**] 02:49PM BLOOD Calcium-8.0* Phos-3.2 Mg-1.9
[**2106-8-7**] 07:55AM BLOOD Glucose-94 K-3.3*
[**2106-8-7**] 01:35AM BLOOD Glucose-94 Lactate-0.6 K-3.8
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 27740**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 31495**]Portable TEE
(Complete) Done [**2106-8-5**] at 10:10:23 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) 1111**], [**First Name3 (LF) 1112**] B.
[**Hospital Unit Name 19046**]
[**Location (un) 86**], [**Numeric Identifier 31496**] Status: Inpatient DOB: [**2041-4-4**]
Age (years): 65 M Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Hypertension. Left ventricular function.
ICD-9 Codes: 396.9
Test Information
Date/Time: [**2106-8-5**] at 10:10 Interpret MD: [**Name6 (MD) 19047**] [**Name8 (MD) 19048**], MD
Test Type: Portable TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 19048**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR non-cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2010AW538-: Machine: IE33
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *4.8 cm <= 4.0 cm
Left Atrium - Four Chamber Length: 4.7 cm <= 5.2 cm
Left Ventricle - Septal Wall Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.9 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 4.0 cm
Left Ventricle - Fractional Shortening: *0.18 >= 0.29
Aorta - Sinus Level: 2.9 cm <= 3.6 cm
Aortic Valve - Valve Area: 3.4 cm2 >= 3.0 cm2
Findings
65 years old male for AAA with suprarenal clamp. Hasa multiple
DES in the RCA, LAD and CRX distribution. There is mild MR and
E/E' ratio is 9 suggesting normal LVEDP. The patient developed
anterior and inferior wall hypokinesis with suptrarenal clamp
that recovered after the clamp came off. There is right coronary
cusp calcification without any regugitation or stenosis.
LEFT ATRIUM: Mild LA enlargement. All four pulmonary veins
identified and enter the left atrium.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or
color Doppler.
LEFT VENTRICLE: Moderately depressed LVEF. TDI E/e' < 8,
suggesting normal PCWP (<12mmHg). Doppler parameters are most
consistent with Grade I (mild) LV diastolic dysfunction.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending aorta diameter. Normal descending aorta
diameter.
AORTIC VALVE: Three aortic valve leaflets.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+)
MR.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. No TEE related
complications.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. Overall left ventricular systolic
function is moderately depressed (LVEF= 40 %). Tissue Doppler
imaging suggests a normal left ventricular filling pressure
(PCWP<12mmHg). Doppler parameters are most consistent with Grade
I (mild) left ventricular diastolic dysfunction. Right
ventricular chamber size and free wall motion are normal. There
are three aortic valve leaflets. The mitral valve leaflets are
mildly thickened. Mild (1+) mitral regurgitation is seen.
Electronically signed by [**Name6 (MD) 19047**] [**Name8 (MD) 19048**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2106-8-5**] 10:21
Brief Hospital Course:
[**2106-8-3**]
The patient was scheduled for an open AAA repair. He had
cardiology clearance preop by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. Intra-op the
patient required multiple blood transfusion for blood loss of
4500cc and hypotension. He was transferred to the CVICU for
immediate post op care.
[**2106-8-4**]
POD #1, Continued to be intubated and sedated. No overnight
issues. Aggressive pulmonary toilet. Plavix held (patient has
bare metal cardiac stents) for bleeding- this was cleared with
Dr. [**Last Name (STitle) **]. Neo gtt for pressure support. ICU monitoring.
[**Date range (1) 5287**]
Continued intubation and diuresis. CMV vent setting. Received 2
units of PRBC for Hct of 26. No active bleeding presently. Neo
weaned off. Good pain management. CPAP trials [**8-6**].
[**2106-8-7**]
Extubated, stable. Continued pulmonary toilet. OOB to chair.
Transferred to VICU.
[**2106-8-8**]
Some deliruim overnight. Received 2units PRBC for Ht of 26.
Continues to diuresis with IV lasix TID. Started on clear,
liquid diet and bowel regimen.
[**2106-8-9**]
Stable. Physical therapy working with patient and recommending
Rehab. Mentally intact. Rehab screening. Foley and central line
removed. Tolerating regular diet. Plavix 75mg po QD restarted.
[**2106-8-10**]
Rehab screening. 1-2 L NC of 02 (which is patient's baseline).
[**2106-8-11**]
Pt remains stable on 1-2L of O2. Diuresing well, change to oral
lasix today. Ambulating with PT. [**Hospital 25403**] rehab bed offer
[**2106-8-12**]
Pt has done well overnight with no acute issues. He is
discharged to rehab facility today.
Medications on Admission:
albuterol 90mcg prn, plavix 75', diazepam 5'', fluoxetine 60mg',
advair 500/50 1 puff'', vicodin 5/500 prn, motrin 800mg prn,
toprol xl 25', singulair 10', penicillamine 500mg 6x/day,
Kcitrate 20meq''', ranitidine 150'', simvastatin 40', spiriva
18mcg', trazodone 100mg', vit c 1000', asa 81mg', mvi', omega 3
FA 1000mg'
Discharge Medications:
1. Advair Diskus 500-50 mcg/Dose Disk with Device Sig: One (1)
Inhalation twice a day.
2. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for wheezing.
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Fluoxetine 20 mg Capsule Sig: Three (3) Capsule PO DAILY
(Daily).
5. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
6. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
7. Multiple Vitamins Tablet Sig: One (1) Tablet PO once a
day.
8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day.
9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day): may d/c when pt fully ambulatory
and at low risk for dvt.
10. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
DAILY (Daily) as needed for itching.
11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for mild pain.
12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
13. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
14. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for wheezing.
15. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Zantac 150 mg Tablet Sig: One (1) Tablet PO twice a day.
18. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day.
19. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
20. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): take 20 [**Hospital1 **] x 2 weeks then 20 qd x 1 week, then
discontinue if pcp feels appropriate .
21. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
22. Beclomethasone Dipropionate 80 mcg/Actuation Aerosol Sig:
One (1) Inhalation [**Hospital1 **] ().
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] LivingCenter - Heathwood - [**Location (un) 55**]
Discharge Diagnosis:
Primary: Abdominal aortic aneurysm
Secondary:
COPD
HTN
CAD (s/p PTCA and stenting of the left circumflex)
Nephrolithiasis Cystinuria
Chronic back pain
Alcohol abuse
Anxiety
Discharge Condition:
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Abdominal Aortic Aneurysm (AAA) Surgery Discharge Instructions
What to expect when you go home:
1. It is normal to feel weak and tired, this will last for [**7-13**]
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 (use [**3-10**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? 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 that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
?????? Redness that extends away from your incision
?????? A sudden increase in pain that is not controlled with pain
medication
?????? A sudden change in the ability to move or use your leg or the
ability to feel your leg
?????? Temperature greater than 101.5F for 24 hours
?????? Bleeding from incision
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
We have made you a follow up appointment with a new PCP who is
in the [**Hospital1 18**] system. Please keep this apppointment - this new
physician will be able to manage all of your long term medical
issues and medications and write prescriptions for your
medications.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 815**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2106-8-25**] 3:00
Location: [**Hospital Ward Name 23**] Building ([**Hospital1 18**] [**Hospital Ward Name 516**])
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2106-8-30**] 10:00
Location: [**Hospital Unit Name **] clinic 5b ([**Hospital Ward Name 517**])
Completed by:[**2106-8-12**]
|
[
"V45.82",
"278.00",
"E878.2",
"414.01",
"300.00",
"998.11",
"401.9",
"458.29",
"305.1",
"293.0",
"441.4",
"496"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"38.44"
] |
icd9pcs
|
[
[
[]
]
] |
9970, 10062
|
5832, 7463
|
339, 436
|
10280, 10355
|
1339, 4981
|
13451, 13953
|
1041, 1050
|
7834, 9947
|
10083, 10259
|
7489, 7811
|
10463, 12726
|
12752, 13428
|
5030, 5809
|
1065, 1320
|
273, 301
|
464, 712
|
10370, 10439
|
734, 865
|
881, 1025
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,314
| 125,246
|
54220
|
Discharge summary
|
report
|
Admission Date: [**2132-9-24**] Discharge Date: [**2132-10-6**]
Date of Birth: [**2073-9-13**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
nausea, vomiting, increased creatinine
Major Surgical or Invasive Procedure:
R frontal/temporal crani for clot evacuation
Thoracentesis
History of Present Illness:
Patient is a 59 yo female with a PMH of metastatic breast cancer
on gemzar recently admitted for fevers, cough, malaise and
discharged 2 days ago on levofloxacin for a 7 day total
antibiotic course for presumed pneumonia. She is now referred to
[**Hospital1 18**] from clinic for nausea, vomiting, perioribal swelling and
creatinine increase from 1.7 to 3.1 in 48 hours. She has had
generalized nausea since discharge. She has decreased appetite
and poor po intake. She was wretching this afternoon and had
associated episode of vomiting. She is still with a dry cough.
She complains malaise and lethargy. She denies rashes, myalgias.
She denies diarrhea or constipation. Her last bowel movement was
this morning and was only associated with a small amount of
stool. She denies bloody or black stools.
Review of Systems:
(+) Per HPI, headache currently
(-) Denies chills, night sweats, recent weight loss or gain.
Denies sinus tenderness, rhinorrhea or congestion. Denies chest
pain or tightness, palpitations. Denies shortness of breath or
wheezes. No dysuria. Denies arthralgias or myalgias. No
numbness/tingling in extremities. All other review of systems
negative.
Past Medical History:
-[**2-22**]: Left ICDm T2NO poorly differentiated, ER+, PR+, HER2neu
neg, lumpectectomy then treated with cytoxan and adriamycin x 4
cycles, then 4 cycles of taxol. SRT at [**Company 2860**] and Tam started
[**9-23**].
-[**10-26**]: routine breast MRI-left breast multifocal mass- poorly
differentiated invasive ductal carcinoma with minimal lobular
fearures: ER+, PR+, HER2neu neg.
-[**2129-11-30**]: left mastectomy and prophylactic right mastectomy
-[**12-28**]: Liver met found on PET, started on letrozole, herceptin
-[**5-27**]: xeloda
-[**12-29**]: tumor progesssion in liver, started weekly taxol; avastin
added 2nd cycle
-[**1-29**]: avastatin 10 mg/kg day 1 and day 15 added cycle 2
-[**12-30**]: avastatin on hold for epistaxis
-[**2-27**]: resumed avastin but further nose bleeds
-[**2132-7-22**]: changed therapy to weekly gemzar
.
Other Past Medical History:
GERD
Hypothyroidism
CAD: Cardiac Catheterization, Percutaneous transluminal coronary
angioplasty of OM1
Social History:
Worked in health care quality IT. Retired two years ago when
diagnosed with recurrent breast cancer. No hx of smoking; drinks
1 glass of wine with dinner each night; no recreational drug
use.
Family History:
Father: prostate cancer, CHF, MI, died at age 89
Mother: multiple TIAs
Physical Exam:
Expired on [**2132-10-6**]
Brief Hospital Course:
[**Hospital 2035**] HOSPITAL COURSE:
#Thrombotic microangiopathy: Patient was admitted with elevated
creatinine to 3.7 and signs of volume overload. Labs were
consistent with thrombotic microangiopathy- renal failure,
hemolysis, thromobocytopenia, likely gemcitibine induced. She
was treated with solumedrol 125 mg iv q12h then changed to a
prednisone taper on [**2132-9-30**]. Creatinine, thrombocytopenia,
anemia and hemolysis labs improved. Patient was duiresed 1-2L
per day with furosemide 120 mg iv. - follow volume status (goal
for -1-2 L negative). She has elevated phosphate levels and
given sevelamer 800 mg po tid.
.
#Hypertension: Blood pressure was felt to be elevated in the
setting of ARF and volume overload. Her blood pressure ranged
from 140-160 in the beginning of her hospitalization. Her
metoprolol was increased from 12.5 mg po bid to metoprolol 37.5
mg po BID. She was also given furosemide 120 mg iv daily. Her BP
was as high as 220/110 on the morning of of [**2132-10-1**]. It came
down to a systolic blood pressure of 150 with hydralazine 10 mg
iv x 1. She then had elevated pressures to 180 and was given
hydral 10 mg iv prn q6h for BP >180.
.
#Headaches: patient complained of intermittent headaches
throughout her hospitalization. Patient said she had similar
headaches in the past when she was not eating well. She was
treated with fiorinal/ fioricet prn headache with moderate
relief.
.
#Fall: Around 02:00 am on [**2132-10-1**], patient had an unwitnesses
wall. She had a stat CT which showed intracranial hemorrhage.
She was evaluted by neurosurgery and was transferred to their
service.
.
#Metastatic Breast Cancer: on gemcitibine chemotherapy, last
dose was approximately 3 weeks prior to admission.
.
#Depression: mood, affect were stable. She was continued on
amitriptyline.
The patient was transferred to the NSurg service in the TSICU on
[**2132-10-1**]. She was maintained on Dexamethasone and placed on
Dilantin for seizure control. Consent was obatined and she was
taken to the operating room in the afternoon for a craniotomy
and evacuation of the blood. A large hematoma/clot was
discovered. She tolerated the procedure well and was
transported back to the TSICU for Q1 neuro checks. Her post op
head CT demonstrated good evacuation and no post op hemorrhage.
On the morning of [**10-2**] she was weaned to extubation. When off
sedation she moved all of her extremities pusposefully and
symmetrically. Because she received gadolineum for her MRI,
Renal was consulted and because she was uremic, dialysis was
done.
On [**10-3**] pt was seen on morning rounds and was following simple
commands in her upper extremities and moving all extremities
purposefully. She had a stable repeat head ct and was improving.
During the evening pt found to be tachypneic with decreased O2
sats and labored breathing. Chest x ray showed bilateral pleural
effusions and she was reintubated.
On [**10-4**] pt remained intubated and her exam was worse on morning
rounds. She was not following commands off sedation but was
moving all extremites. A stat head CT showed no change and
patient was made CMO on [**2132-10-5**] after a family discussion.
She expired on [**2132-10-6**]
Medications on Admission:
Levothyroxine Sodium 112 mcg PO/NG 3X/WEEK (TU,TH,SA)
Levothyroxine Sodium 175 mcg PO/NG 4X/WEEK ([**Doctor First Name **],MO,WE,FR) 4.
Rosuvastatin Calcium 10 mg PO DAILY
Amitriptyline 100 mg PO/NG HS
Acetaminophen 650 mg PO/NG Q6H:PRN pain
Prochlorperazine 10 mg IV Q6H:PRN nausea
Senna 1 TAB PO/NG [**Hospital1 **]:PRN constipation
Docusate Sodium 100 mg PO BID
Lorazepam 0.5 mg PO/NG Q6H:PRN nausea,
Ranitidine 75 mg PO/NG DAILY
Omeprazole 40 mg PO Q 12H
sevelamer HYDROCHLORIDE 800 mg PO TID W/MEALS
Lorazepam 2 mg PO/NG HS sleep
Metoprolol Tartrate 37.5 mg PO/NG [**Hospital1 **]
PredniSONE 60 mg PO/NG
HydrALAzine 10 mg IV ONCE Duration: 1 Doses [**9-30**] @ 0752
Aspirin-Caffeine-Butalbital [**12-22**] CAP PO/NG ONCE
HydrALAzine 10 mg IV Q6H:PRN BP>180
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Acute renal failure secondary to Thrombotic Microangiopathy
Right Temporal IPH and SAH
Discharge Condition:
Expired
Discharge Instructions:
N/A
Followup Instructions:
Expired
Completed by:[**2132-10-7**]
|
[
"518.81",
"853.00",
"530.81",
"287.49",
"199.1",
"584.9",
"244.9",
"511.81",
"E933.1",
"V10.3",
"784.0",
"V45.82",
"276.69",
"401.9",
"283.11",
"311",
"V87.41",
"E888.9",
"446.6",
"V49.87"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.95",
"34.91",
"01.59",
"96.04",
"96.71",
"38.91",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
7043, 7052
|
2984, 3004
|
358, 419
|
7183, 7193
|
7245, 7283
|
2846, 2918
|
7015, 7020
|
7073, 7162
|
6226, 6992
|
3021, 6200
|
7217, 7222
|
2933, 2961
|
1269, 1619
|
280, 320
|
447, 1250
|
2514, 2621
|
2637, 2830
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,407
| 133,240
|
39078
|
Discharge summary
|
report
|
Admission Date: [**2179-3-24**] Discharge Date: [**2179-3-29**]
Date of Birth: [**2124-3-17**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
decreased vision
Major Surgical or Invasive Procedure:
[**2179-3-26**] s/p Mitral Valve Replacement (#[**Street Address(2) 44058**]. [**Male First Name (un) 923**] Mechanical
Valve)
History of Present Illness:
54 year old male who has a history of mitral valve streptococcal
endocarditis in [**2176-12-17**] with severe mitral regurgitation.
He has been having worsening
dilatation of his left-sided cardiac [**Doctor Last Name 1754**]. A cardiac
echocardiogram from [**2177-2-15**] showed myxomatous-appearing
mitral valve and severe mitral regurgitation. A cardiac MRI
in [**2177-6-17**] showed bileaflet mitral valve prolapse of the flail
posterior leaflet and mild left atrial enlargement
with a forward ejection fraction of about 41%.
Past Medical History:
Myxomatous mitral valve s/p streptococcal endocarditis [**12-25**] with
severe MR. (EF 65% with regurgitant fraction 36% in [**2-22**].
Forward Ef 41%)
MVProlapse
Dyslipidemia
Mastoid removal age 7
Hernia repair-10yrs old
Undescended testicle removal 10yrs ago
Social History:
Lives with: Single 2 children
Occupation:part time police office([**Location (un) **]).
Also owns concrete cutting company
Tobacco:+tob- **quit today** 1pk/day x45 years
ETOH: none
Family History:
Father MI [**51**]. Mother MI [**45**]
Physical Exam:
Temp: Pulse: 84 Resp: 16 O2 sat: 96%-RA
B/P Right: 134/90 Left:
Height: 5'[**79**]" Weight: 220 lbs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x] no JVD
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur: 4/6 SEM
Abdomen:Soft[x] non-distended[x] non-tender[x] bowel sounds +
[x]
Extremities: Warm [x], well-perfused [x] Edema: none
Varicosities: None [x]
Neuro: Grossly intact
Pulses:
Femoral Right: 2+ Left: 2+ -no sign of infection
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit no Right: Left:
Pertinent Results:
[**2179-3-29**] 04:50AM BLOOD WBC-9.3 RBC-3.85* Hgb-10.7* Hct-30.9*
MCV-80* MCH-27.7 MCHC-34.5 RDW-14.4 Plt Ct-275#
[**2179-3-24**] 01:31PM BLOOD WBC-28.3*# RBC-4.21* Hgb-12.4* Hct-35.9*
MCV-85 MCH-29.5 MCHC-34.6 RDW-13.7 Plt Ct-202
[**2179-3-29**] 03:18PM BLOOD PT-27.3* PTT-58.9* INR(PT)-2.7*
[**2179-3-29**] 08:40AM BLOOD PT-24.5* PTT-46.6* INR(PT)-2.3*
[**2179-3-24**] 01:31PM BLOOD PT-13.0 PTT-30.6 INR(PT)-1.1
[**2179-3-24**] 01:31PM BLOOD Plt Ct-202
[**2179-3-29**] 04:50AM BLOOD Glucose-104* UreaN-15 Creat-0.7 Na-138
K-4.7 Cl-103 HCO3-26 AnGap-14
[**2179-3-24**] 01:31PM BLOOD UreaN-16 Creat-0.8 Cl-110* HCO3-23
[**2179-3-24**] 08:52PM BLOOD K-4.3
[**2179-3-29**] 04:50AM BLOOD Mg-2.3
[**2179-3-25**] 02:22AM BLOOD Calcium-8.5 Phos-4.0 Mg-2.1
Cardiology Report ECG Study Date of [**2179-3-24**] 2:21:24 PM
Sinus rhythm. Tracing is without diagnostic abnormality.
Compared to the
previous tracing of [**2179-3-16**] there is no diagnostic change.
Read by: [**Last Name (LF) **],[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 975**]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
69 108 90 [**Telephone/Fax (2) 86619**] 48
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Ejection Fraction: 45% to 50% >= 55%
Findings
LEFT ATRIUM: Moderate LA enlargement. No spontaneous echo
contrast or thrombus in the body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal
interatrial septum. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Moderately dilated LV cavity. Mildly 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: Normal ascending, transverse and descending thoracic
aorta with no atherosclerotic plaque.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Myxomatous mitral valve leaflets. Partial mitral
leaflet flail. No MS. Eccentric MR jet. Severe (4+) MR. [**Name13 (STitle) 15110**] to
the eccentric MR jet, its severity may be underestimated (Coanda
effect).
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. The TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. No TEE related
complications.
Conclusions
Pre-bypass:
The left atrium is moderately dilated. No spontaneous echo
contrast or thrombus is seen in the body of the left atrium or
left atrial appendage. No atrial septal defect is seen by 2D or
color Doppler. The left ventricular cavity is moderately
dilated. Overall left ventricular systolic function is mildly
depressed (LVEF= 45 %). [Intrinsic left ventricular systolic
function is likely more depressed given the severity of valvular
regurgitation.] Right ventricular chamber size and free wall
motion are normal. The ascending, transverse and descending
thoracic aorta are normal in diameter. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic regurgitation. The mitral valve leaflets are
myxomatous. There is partial mitral leaflet flail of the
anterior and posterior leaflets. There are torn chordae
tendinae. An eccentric, posteriorly directed jet of Severe (4+)
mitral regurgitation is seen. Due to the eccentric nature of the
regurgitant jet, its severity may be significantly
underestimated (Coanda effect). There is no pericardial
effusion.
Post-bypass:
The patient is receiving 0.03 mcg/kg/min of epinephrine for
inotropic support post-CPB. There is a well-seated bileaflet
mechanical valve in the mitral position with good leaflet
excursion. There is no paravalvular regurgitation. There are
small transvalvular regurgitation jets consistent with "washing
jets." The mean gradient is 5 mm Hg with a cardiac output of 6.2
L/min. Biventricular systolic function is preserved and all
other findings are consistent with prebypass finding. The aorta
is intact post-decannulation. All findings were communicated to
the surgeon intraoperatively.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) 6506**] [**Name8 (MD) 6507**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2179-3-25**] 09:16
Brief Hospital Course:
Admitted same day admission and underwent mitral valve
replacement surgery. Please see operative report for further
details. He received cefazolin for perioperative antibiotics.
Post operatively he was transferred to the intensive care unit
for management. In the first twenty four hours he was weaned
from sedation, awoke neurologically intact and was extubated
without complications. He was started on coumadin for
mechanical mitral valve on night of surgery. He remained
hemodynamically stable and was weaned off all drips. All lines
and tubes were discontinued in a timely fashion. Physical
therapy was consulted for strength and mobility. He continued to
progress and was ready for discharge home with services on post
operative day five.
Medications on Admission:
ASA 81'
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*0*
3. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
4. Bupropion HCl 150 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO BID (2 times a day).
Disp:*60 Tablet Sustained Release(s)* Refills:*0*
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
6. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*0*
7. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO q3hours as
needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
9. Warfarin 5 mg Tablet Sig: INR goal 3.0-3.5 Tablets PO once a
day: dose to vary based on INR please take 10 mg on [**3-30**] with
lab draw [**3-31**] - MWHC to dose coumadin after lab draw .
Disp:*60 Tablet(s)* Refills:*2*
10. Warfarin 2 mg Tablet Sig: goal INR 3.0-3.5 Tablets PO once
a day: dose to vary .
Disp:*60 Tablet(s)* Refills:*2*
11. coumadin
You have received two prescriptions for coumadin
5 mg tablets and 2 mg tablets so that your dose can be adjusted
The coumadin clinic at [**Hospital1 **] will continue to monitor your
INR and dose your coumadin
Please take 10 mg on [**3-30**] - VNA to draw lab [**3-31**] and further
dosing will be based on results
12. Outpatient Lab Work
Labs: PT/INR for coumadin dosing with goal INR 3.0-3.5 for
mechanical mitral valve - results to coumadin clinic at
[**Hospital1 **] heart center # [**Telephone/Fax (2) 6256**] with first draw Wednesday
[**3-31**]
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
s/p Mitral Valve Replacement (#[**Street Address(2) 44058**]. [**Male First Name (un) 923**] Mechanical Valve)
s/p Myxomatous mitral valve s/p streptococcal endocarditis [**12-25**]
with
severe mitral regurgitation and mitral valve prolapse
Dyslipidemia
Discharge Condition:
Alert and oriented
Ambulating, gait steady
Sternal pain managed with dilaudid prn
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Dr [**Last Name (STitle) **] at [**Hospital1 **] Heart Center [**Telephone/Fax (2) 6256**] on Thursday
[**2179-4-15**] at 9am
Please call to schedule appointments
Primary Care Dr [**First Name4 (NamePattern1) 1193**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 84156**] in [**12-19**] weeks
Cardiologist Dr. [**First Name8 (NamePattern2) 3924**] [**Last Name (NamePattern1) 20222**] in [**12-19**] weeks
Labs: PT/INR for coumadin dosing with goal INR 3.0-3.5 for
mechanical mitral valve - results to coumadin clinic at
[**Hospital1 **] heart center # [**Telephone/Fax (2) 6256**] with first draw Wednesday
[**3-31**]
Completed by:[**2179-3-29**]
|
[
"285.9",
"305.1",
"272.4",
"511.9",
"429.5",
"424.0",
"428.0",
"V12.09"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"35.24"
] |
icd9pcs
|
[
[
[]
]
] |
9619, 9678
|
6931, 7680
|
295, 424
|
9976, 10060
|
2244, 6908
|
10600, 11259
|
1488, 1528
|
7739, 9596
|
9699, 9955
|
7706, 7716
|
10084, 10577
|
1543, 2225
|
239, 257
|
452, 987
|
1009, 1272
|
1288, 1472
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,526
| 116,228
|
47777
|
Discharge summary
|
report
|
Admission Date: [**2145-12-11**] Discharge Date: [**2145-12-15**]
Date of Birth: [**2066-12-10**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 11892**]
Chief Complaint:
found down
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is a 79 yo F with history of hypertension,
hyperlipidemia, NIDDM and pituitary mass that presents having
been found down. It is unclear how long the patient was down.
She states she think that she fell after veterans day. She
thinks she fell trying to sit on her kitchen chair. She states
she has felt lightheaded for up to several months and had a cold
for the past week but otherwise she reports no specific
symptoms. She denies vertigo, chest pain, palpitations, nausea,
vomiting. Her closest contact is her [**First Name9 (NamePattern2) **] [**Name (NI) 44286**] who was the
one who called the police. [**First Name8 (NamePattern2) **] [**Last Name (un) 44286**], she has been "this
close" to her needing to be in an asissted living facility. He
hasn't been feeling well for the past year. He picks up her
medications. He last saw her a week ago and las talked to her
today when she said she was on the floor. He talked to her prior
to then several days before. Today, she seemed "groggy" to him.
He confirmed that she did not drunk. In the ED, she was
hypothermic to 94. BP was 88/45, HR 97, oxygen 98 on room air.
She was given 2L NS. She had one episode of hypotension to the
70/40 which responded to an additional 1L of NS. She was also
started on [**1-24**] NS for hypernatremia. Vitals on transfer were P
79 Bp 125/35 14 100% 2L
Past Medical History:
Hypertension
Hyperlipidemia
Diabetes
Memory Loss
Unsteady gait
pituitary macroadenoma
Social History:
lives at home. reports that her son beats her if she doesnt give
him money. prior h/o etoh but quit in [**2125**] and quit smoking in
[**2125**]
Family History:
nc
Physical Exam:
ADMISSION EXAM:
General Appearance: No acute distress, Thin
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic, Poor dentition
Lymphatic: Cervical WNL
Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t)
Systolic, No(t) Diastolic)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Clear : , No(t) Crackles : , No(t) Bronchial: , No(t) Wheezes :
)
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right lower extremity edema: Absent, Left lower
extremity edema: Absent, No(t) Cyanosis, No(t) Clubbing
Skin: Warm, No(t) Rash:
Neurologic: Attentive, Responds to: Not assessed, Oriented (to):
place, year, month, Movement: Purposeful, Tone: Not assessed,
neuro non focal
On discharge: Exam stable, with ability to walk to bathroom with
assistance and mild ear congestion. Vital signs stable, with
normal blood pressure.
Pertinent Results:
ADMISSION LABS:
[**2145-12-11**] 12:30PM BLOOD WBC-12.2* RBC-4.64 Hgb-13.7 Hct-41.9
MCV-90 MCH-29.6 MCHC-32.7 RDW-12.9 Plt Ct-286
[**2145-12-11**] 12:30PM BLOOD Neuts-68.6 Lymphs-26.2 Monos-2.6 Eos-2.2
Baso-0.3
[**2145-12-11**] 03:05PM BLOOD PT-15.9* PTT-33.7 INR(PT)-1.4*
[**2145-12-11**] 09:20PM BLOOD Glucose-142* UreaN-124* Creat-3.0*
Na-146* K-3.8 Cl-111* HCO3-20* AnGap-19
[**2145-12-11**] 09:20PM BLOOD ALT-19 AST-26 LD(LDH)-264* CK(CPK)-107
AlkPhos-50 TotBili-0.3
[**2145-12-11**] 03:05PM BLOOD cTropnT-0.04*
[**2145-12-11**] 09:20PM BLOOD Albumin-3.4* Calcium-8.5 Phos-4.8* Mg-2.4
[**2145-12-11**] 04:18PM BLOOD Type-ART Temp-36.4 Rates-/14 pO2-157*
pCO2-28* pH-7.40 calTCO2-18* Base XS--5 Intubat-NOT INTUBA
Comment-GREEN TOP
[**2145-12-11**] 12:43PM BLOOD Glucose-151* Lactate-3.3* Na-155* K-4.2
Cl-114* calHCO3-16*
On discharge:
[**2145-12-15**] 06:15AM BLOOD Glucose-87 UreaN-27* Creat-1.1 Na-143
K-3.8 Cl-111* HCO3-24 AnGap-12
URINE:
[**2145-12-11**] 12:30PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.014
[**2145-12-11**] 12:30PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
MICRO:
[**2145-12-11**] BCx: pending on discharge
[**2145-12-11**] UCx: negative
[**2145-12-11**] MRSA screen: negative
[**2145-12-11**] Legionella: negative
STUDIES:
[**2145-12-11**] CT head:
1. No evidence of acute intracranial process.
2. Small left basal ganglia lacune.
3. Age-related involution and small vessel ischemic disease.
4. Findings suspicious for pituitary adenoma with erosion of
sellar floor. Correlation with clinical history recommended. MRI
can help for further assessment as clinically indicated.
5. Complete opacification of the sphenoid sinus with extension
of disease into posterior ethmoidal air cells.
[**2145-12-11**] CT Cspine:
No acute cervical spine injury. Erosive changes are seen in
clivus. Please see head CT for further details.
[**2145-12-11**] CXR:
Possible aspiration in the bases. Large gallstone.
[**2145-12-12**] MR Pituitary:
MR EXAMINATION OF THE BRAIN AND PITUITARY GLAND WITHOUT
CONTRAST, [**2145-12-12**].
HISTORY: 79-year-old female with history of "pituitary mass"
presents with
fall; "stroke protocol" for subacute stroke and evaluate
pituitary lesion.
TECHNIQUE: Routine [**Hospital1 18**] non-enhanced MR examination of the
brain and sella
turcica was performed. N.B. Given the patient's severe renal
insufficiency
(BUN 124, creatinine 3.0 with eGFR 13 mL/min), no intravenous
gadolinium
contrast material was administered.
FINDINGS: The study is compared with the recent NECT of the head
dated
[**2145-12-11**]. As on that study, there is a markedly abnormal
appearance to the
sella turcica, which is markedly expanded with much of the
cortex of its
floor, completely eroded. The normal pituitary tissue is
replaced by an
ill-defined and somewhat heterogeneous mass, roughly
isointense-to-normal [**Doctor Last Name 352**] matter. Though its precise borders are
difficult to delineate, this process measures at least 17 (AP) x
22 (TRV) x 18 mm (CC) and likely represents a large
macroadenoma, occupying much of the sella and transgressing its
floor and possibly anterior wall. Of note, no definite posterior
pituitary "bright spot" is identified. The process within the
sella blends into the contents of the largely opacified sphenoid
sinus, which is nearly completely filled with abnormal soft
tissue material, with only its most superior-anterior portion
apparently aerated, as on the CT. The sphenoid air cells contain
foci of relative [**Name (NI) **] and more marked T2-hypointensity, with
"blooming" susceptibility artifact, which likely represent
secretions with various degrees of inspissation. The extent of
intrasphenoidal extension of the sellar mass is very difficult
to assess.
Allowing for the lack of intravenous contrast, a normal-caliber
infundibular stalk is identified, and slightly deviated to the
right with a grossly normal appearance. Though there is
effacement of the suprasellar cistern, there is no contact with
or mass effect upon the optic chiasm or the hypothalamus. Based
on the coronal T2-weighted sequence, there is no evidence of
cavernous sinus invasion, and the normal cavernous carotid
arterial flow voids are preserved.
The limited whole brain imaging is notable for moderate global
atrophy. There is relatively mild [**Name (NI) **]/FLAIR-hyperintensity,
largely limited to bifrontal periventricular white matter,
likely the sequelae of chronic small vessel ischemic disease.
There is no focus of slow diffusion to suggest an acute ischemic
event and the principal intracranial vascular flow voids,
including those of the dural venous sinuses, are preserved.
There is no evidence of intra- or extra-axial hemorrhage,
including in the sella, itself. Incidentally noted is a likely
Tornwaldt cyst in the midline nasopharynx, as well as relatively
mild chronic-appearing inflammatory changes in the maxillary
sinuses and anterior ethmoidal air cells, bilaterally, as on the
recent CT.
IMPRESSION:
1. Limited study, in the absence of intravenous contrast (which
could not be given, due to the patient's profound renal
insufficiency), redemonstrates a markedly abnormal appearance to
the sella turcica. In conjunction with the recent NECT, this
suggests an aggressive pituitary macroadenoma with marked
erosion and frank dehiscence of the sellar floor, as well as the
anterior aspect of the clivus.
2. Markedly abnormal appearance to the sphenoid air cell, which,
as on the
CT, is virtually-completely opacified with heterogeneous-signal
contents, most suggestive of differing degrees of inspissation.
However, the full extent of transgression of sphenoid by the
sellar mass is impossible to assess without contrast
enhancement. Additionally, fungal colonization cannot be
excluded, with this appearance.
3. Though there is effacement of the suprasellar cistern, there
is no
definite mass effect upon the optic chiasm or invasion of the
cavernous
sinuses.
4. No finding to suggest an acute ischemic event, with no
evidence of
previous territorial infarction.
5. Global atrophy.
.
ECHO:
The left atrium and right atrium are normal in cavity size.
There is mild symmetric left ventricular hypertrophy with normal
cavity size. Regional left ventricular wall motion is normal.
Left ventricular systolic function is hyperdynamic (EF>75%). The
estimated cardiac index is high (>4.0L/min/m2). Right
ventricular cavity size and free wall motion are normal. The
ascending aorta and aortic arch are mildly dilated. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis. Mild (1+) aortic regurgitation
is seen. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is borderline pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
normal regional/hyperdynamic global systolic function. Mild
aortic regurgitation.Borderline pulmonary artery hypertension.
Dilated thoracic aorta.
CLINICAL IMPLICATIONS:
Based on [**2141**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
Brief Hospital Course:
Ms. [**Known lastname 39602**] is a 79 yo F with h/o hypertension, hyperlipidemia,
diabetes mellitus and pituitary macroadenoma presenting found
down.
# Found down: Differential includes acute illness (h/o cold
symptopms and ?infiltrate on cxr), vs stroke, vs encephalopathy
[**2-24**] renal failure vs cardiogenic syncope. Treated for CAP with
Azithromycin. MR head did reveal a clear reason for fall. ECHO
was equally unremarkable.. Cardiac enzymes were negative. Given
constellation of bradycardia, hypothermia, and known pituitary
mass, possible endocrinopathy as well. TSH and cortisol were
both normal. Physical therapy evaluated the patient who was very
deconditioned--a simple mechanical fall may have been the
culprit as no other etiology was identified.
# PNA: No risk factors for resistant organisms, treated for CAP
with Azithromycin. Urinary Legionella was negative.
# Acute kidney injury: improved with hydration, creatinine 1.1
upon discharge. HCTZ, lisinopril, and metformin held during
stay, with metformin started on discharge. Creatinine should be
checked after discharge at which time, if blood pressure can
support and creatinine remains stable, lisinopril 20mg and then
HCTZ 25mg can be reinitiated daily.
# Diabetes: on insulin sliding scale
# Elevated inr: INR 1.4 on admission, possibly [**2-24**] poor
nutrition. Should be rechecked as outpatient.
# Pituitary mass: No evidence of endocrine abnormality on labs,
but imaging demonstrated possibility of slightly larger mass
versus prior images. Will need primary care followup.
Transitional issues
# Please follow creatinine/electrolytes to ensure safe
reinitiation of lisinopril and HCTZ.
# Please follow INR as well and encourage good nutrition.
# Follow-up imaging on pituitary macroadenoma.
Medications on Admission:
LISINOPRIL 20 MG TABS 1 tab po every day
METFORMIN HCL 500 MG TABS 1 tab po daily in the morning
SIMVASTATIN 40 MG TABS 1 tab by mouth QHS
HYDROCHLOROTHIAZIDE TAB 25MG 1 tab po every day
Discharge Medications:
1. azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 1 days.
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. metformin 500 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] Senior Healthcare of [**Location (un) 55**]
Discharge Diagnosis:
Primary diagnoses:
Renal failure
Mechanical fall
Domestic violence
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. [**Known lastname 39602**],
It was a pleasure caring for you at the [**Hospital1 827**]. You came to the hospital after a fall. You
were found to be weak and to have failure of your kidneys.
You improved with IV fluids.
Medication changes:
START azithromycin for your infection, for only 1 more day.
STOP lisinopril and hydrochlorothiazide for now. The doctors at
your facility will restart these slowly to control your blood
pressure.
You should continue taking the rest of your medications as
prescribed
Followup Instructions:
Please follow up with your primary care physician [**Last Name (LF) **],[**Name9 (PRE) **]
[**Telephone/Fax (1) 798**] after leaving your rehab. Your [**Hospital1 778**] social
worker will help coordinate your living situation.
You also have the following appointments already scheduled:
Department: [**Hospital3 1935**] CENTER
When: WEDNESDAY [**2146-1-5**] at 9:00 AM
With: EYE IMAGING [**Telephone/Fax (1) 253**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital3 1935**] CENTER
When: WEDNESDAY [**2146-1-5**] at 9:20 AM
With: [**First Name11 (Name Pattern1) 354**] [**Last Name (NamePattern4) 3013**], M.D. [**Telephone/Fax (1) 253**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] DO 12-BDU
|
[
"E888.9",
"276.0",
"250.00",
"707.21",
"401.9",
"227.3",
"486",
"276.2",
"272.4",
"707.03",
"584.9",
"991.6"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
12782, 12872
|
10413, 12195
|
319, 325
|
12983, 12983
|
3030, 3030
|
13712, 14723
|
1992, 1996
|
12432, 12759
|
12893, 12962
|
12221, 12409
|
13166, 13400
|
2011, 2860
|
10154, 10390
|
3872, 4382
|
13420, 13689
|
269, 281
|
353, 1705
|
4391, 10131
|
3046, 3858
|
12998, 13142
|
1727, 1814
|
1830, 1976
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,437
| 180,570
|
4224
|
Discharge summary
|
report
|
Admission Date: [**2109-1-8**] Discharge Date: [**2109-1-11**]
Date of Birth: [**2065-5-28**] Sex: F
Service: OTOLARYNGOLOGY
Allergies:
Penicillins / Cabbage / Strawberry / Lactose
Attending:[**First Name3 (LF) 8480**]
Chief Complaint:
hypoxia s/p tonsillectomy
Major Surgical or Invasive Procedure:
tonsillectomy
History of Present Illness:
43F with history of sleep apnea admitted POD #0 s/p elective
tonsillectomy for continuous O2 monitoring. Tonsillectomy was
performed wtihout complication. Patient was extubated, and
developed some post op bleeding. She was reintubated for airway
protection, and cautery was performed to stop the bleeding. She
was then extubated again. She was then noted have labored
breathing, thought to be due to laryngospasm. She was
reintubated briefly, and then extubated. After extubation, she
was started on CPAP, initially at 8L O2; this was titrated down
to 3L in the PACU. She is admitted to the [**Hospital Unit Name 153**] for continuous
O2 sat monitoring.
.
In the PACU she complained of b/l frontal HA ([**7-8**]); sore
throat. Denies abd pain, n/v. States she was well prior to
admission without recent fever, URI, urinary sx, N/V/D/C. She
does have frequent headaches at home.
Past Medical History:
Sleep apnea.
Seasonal Allergies
H/o anaphylaxis Food allergies (strawberry, cabbage, tomatoes)
Social History:
No smoking, occasional alcohol, no drug use
Family History:
NC
Physical Exam:
VS: Temp:99.7 BP:152/93 HR:84 RR:18 O2sat 99% RA
GEN: awake, oriented, appropriate, raspy/quiet voice, pleasant,
comfortable, NAD, nasal CPAP in place
HEENT: PERRL (4->2mm), EOMI, anicteric, MMM, some dried blood in
OP
NECK: thick neck, no supraclavicular or cervical
lymphadenopathy, no jvd, no carotid bruits, no thyromegaly or
thyroid nodules
RESP: CTA b/l with good air movement throughout
CV: distant heart sounds, RR, S1 and S2 wnl, no m/r/g
ABD: obese, nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e, cool, good pulses
SKIN: no rashes/no jaundice
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch appreciated. 2+DTR's-patellar
and biceps
Pertinent Results:
[**2109-1-8**] 09:19PM BLOOD WBC-18.0*# RBC-4.27 Hgb-11.2* Hct-36.1
MCV-85 MCH-26.2* MCHC-30.9* RDW-14.5 Plt Ct-274
[**2109-1-8**] 09:19PM BLOOD PT-12.7 PTT-21.5* INR(PT)-1.1
[**2109-1-8**] 09:19PM BLOOD Glucose-280* UreaN-11 Creat-0.8 Na-138
K-4.1 Cl-101 HCO3-28 AnGap-13
[**2109-1-8**] 09:19PM BLOOD Calcium-8.4 Phos-2.2* Mg-1.8
.
CXR: Large areas of consolidation in the right upper and lower
lobe most likely pneumonia. Left lung clear.
Brief Hospital Course:
A/P: 43F with history of sleep apnea, POD#0 s/p tonsillectomy
admitted to [**Hospital Unit Name 153**] for continuous O2 monitoring. Transferred to
floor on POD #1 for inability to tolerate PO. Tolerated good
PO, pain controlled with Chloraseptic spray, and pt was
discharged to home on POD#2.
.
1. Hypoxia: Hypoxia was thought likely due to sedation/ upper
airway edema. There was no upper airway bleed per ENT. Received
two doses of decadron per ENT. Post-Op CXR with RUL, RLL
consolidation, consistent with aspiration. CPAP discontinued at
patient request on admission to [**Hospital Unit Name 153**]. Spent the night on CPAP RA
and satting 98%. Remained comfortable POD #1 off CPAP with O2
saturations of 99% room air. She did not develop fever or
further signs of respiratory distress since admission to [**Hospital Unit Name 153**].
When transferred to floor, she continued to do well - O2
saturations remained 97-100% on room air. Levoquin and Flagyl
for possible aspiration pneumonia radiographically (no clinical
signs of pneumonia - afebrile, WBC 11, no cough, chest pain,
SOB. f/u with PCP.
2. s/p tonsillectomy - pain controlled with chloraseptic spray
and Tylenol. Oropharynx clear, no bleed, uvula swelling
decreased daily, no signs of obstruction.
She will continue soft diet, f/u with Dr. [**First Name (STitle) **] in [**3-3**] weeks.
3. Leukocytosis/Hyperglycemia: Detected on labs after surgery
and decadron administration.Was thought to be secondary to
effects of decadron. The patient had fingersticks measured QID
and placed on ISS. Repeat WBC was 11, and repeat BS were WNL.
4. Headache - resolved once CPAP was taken off.
Medications on Admission:
Tylenol prn
Benadryl p.r.n
Discharge Medications:
1. Acetaminophen 160 mg/5 mL Solution Sig: Six [**Age over 90 1230**]y
(650) cc PO Q6H (every 6 hours) as needed for pain, fever.
2. Phenol-Phenolate Sodium Mouthwash Sig: One (1) Spray
Mucous membrane Q6H (every 6 hours) as needed.
Disp:*1 bottle (large if multiple sizes)* Refills:*1*
3. Levaquin 500 mg Tablet Sig: One (1) Tablet PO once a day for
10 days.
Disp:*10 Tablet(s)* Refills:*0*
4. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a day
for 10 days.
Disp:*30 Tablet(s)* Refills:*0*
5. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
Disp:*600 ML(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
1) s/p tonsillectomy
2) possible (nonclinical) pneumonia
Discharge Condition:
stable
Discharge Instructions:
Resume all home medications except blood thinning medications
unless cleared by your surgeon.
Seek immediate medical attention for fever >101.5, chills,
increased redness, swelling, bleeding or discharge from nose or
mouth, chest pain, shortness of breath, difficulty breathing,
severe headache, any neurological deficit, or anything else that
is troubling you. No strenuous exercise or heavy lifting until
follow up appointment, at least. Do not drive or drink alcohol
while taking narcotic pain medications. Call your surgeon to
make follow up appointment.
Followup Instructions:
1) Please call Dr.[**Name (NI) 18353**] office at [**Telephone/Fax (1) 2349**] (ask for
[**Doctor First Name 717**]) to schedule a follow-up appointment for 2-3 weeks or
earlier as needed.
2) Please call your Primary Care Physician to schedule an
appointment in 1 week for follow-up of pneumonia.
|
[
"507.0",
"998.11",
"478.6",
"518.82",
"327.23",
"474.11",
"E878.6",
"274.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"28.7",
"28.2"
] |
icd9pcs
|
[
[
[]
]
] |
5053, 5059
|
2678, 4336
|
336, 351
|
5160, 5169
|
2212, 2655
|
5777, 6078
|
1466, 1470
|
4413, 5030
|
5080, 5139
|
4362, 4390
|
5193, 5754
|
1485, 2193
|
271, 298
|
379, 1270
|
1292, 1389
|
1405, 1450
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,702
| 114,254
|
37372
|
Discharge summary
|
report
|
Admission Date: [**2189-1-13**] Discharge Date: [**2189-1-15**]
Date of Birth: [**2105-10-18**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7333**]
Chief Complaint:
Pericardial effusion in setting of ablation
Major Surgical or Invasive Procedure:
Ablation
History of Present Illness:
83 yoF with h/o CAD, afib and recently new AVNRT, admitted for
pericardial effusion in setting of ablation.
Pt recently admitted for Afib with CP with follow up
catheterization to look for ischemia and discharged on [**2188-12-27**].
She underwent cardiac catheterization without intervention on
[**2188-12-25**] with pressure wire to the LAD, complicated by AVNRT with
rate 150 and hypotension, systolic drop from 140 to 90. She was
give IV diltiazem during the procedure and was back in NSR by
the time she left the Cath Lab. Per report, patient developed
ligtheadedness/presyncope the morning post procedure after daily
atenolol dose; she became bradycardic to the 30s and initially
not responding but was easily [**Last Name (LF) 18248**], [**First Name3 (LF) **] report, and HR
returned to 60s when aroused. She was switched from atenolol to
metoprolol, had no further episodes of bradycardia but did have
an episode of AVNRT which resolved on its own. She was brought
back for elective ablation.
Pt underwent ablative procedure successfully on [**2189-1-13**], but in
setting of chest pain was noted to have SBP in 100s, and HR in
100s. Lowest BP noted to be 79/70 during procedure. ECHO
revealed circumferencial effusion (1-1.5cm width). Given HD
stability effusion was not drained and pt transferred to CVICU
on CCU service for closer monitoring and repeat echo. She was
given 3L IVFs during procedure.
On arrival to CVICU, patient was mentating well and
hemodynamically stable. Repeat transthoracic echo preliminarily
appeared to show mild increase in size of pericardial effusion.
.
Cardiac review of systems is notable for pleuritic chest pain,
nausea. Negative for shortness of breath.
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes (diet controlled),
Dyslipidemia,
2. CARDIAC HISTORY:
-PERCUTANEOUS CORONARY INTERVENTIONS:
CAD: cath [**2188-12-25**], no intervention at that time
Social History:
Lives with daughter, denies ETOH or tobacco, retired
housekeeper.
Family History:
Parents expired in 80's - one with CAD. 1 brother with
leukemia.
Physical Exam:
Admission exam:
VS: T=96.8 BP=125/81 HR=96 RR=23 O2 sat= 97% 2L NC
Pulsus = 8mmHg
GENERAL: elderly female, WDWN, in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK: JVP not elevated
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis, ulcers, or xanthomas.
PULSES:
Right: Femoral 2+ DP 2+
Left: Femoral 2+ DP 2+
Pertinent Results:
[**2189-1-15**] 06:35AM BLOOD WBC-6.1 RBC-3.29* Hgb-9.3* Hct-28.0*
MCV-85 MCH-28.4 MCHC-33.3 RDW-13.1 Plt Ct-229
[**2189-1-15**] 06:35AM BLOOD Glucose-130* UreaN-32* Creat-0.8 Na-144
K-4.1 Cl-115* HCO3-21* AnGap-12
[**2189-1-14**] 01:54AM BLOOD Glucose-168* UreaN-22* Creat-0.8 Na-141
K-4.0 Cl-112* HCO3-21* AnGap-12
Brief Hospital Course:
83 year old woman with h/o afib, SVNRT, now with pericardial
effusion in setting of SVNRT ablation.
# Pericardial Effusion: The patient developed pericardial
effusion post EP procedure after her ablation. An echo showed
mild increase in the size of the effusion post procedure, with
some evidence of impaired filling consistent with tamponade.
The patient was volume repleted and she remained hemodynamically
stable. Repeat echo the following day on [**2189-1-14**] showed some
resolution of the pericardial effusion and less evidence of
tamponade.
# Chest pain: The patient had pleuritic chest pain, which was
thought most likely to be post procedural and pericarditis
related pain. This resolved spontaneously. The patient was
discharged on indomethacin for 1 week as needed for pain.
# Hx Afib, AVNRT s/p ablation [**2189-1-13**]: Ablation appeared to have
been successful because of inability to reproduce AVNRT. Patient
has been taking metoprolol as outpatient. She was continued on
this.
# Diabetes Mellitus: The patient was noted to have high blood
sugars while admitted, states she has never been told she is
diabetic. She will require close follow-up with a check of her
hemoglobin A1c as an outpatient.
.
# Coronary Artery Disease: The patient's plavix discontinued
secondary to the effusion. Her aspirin dose was decreased to
81mg.
Medications on Admission:
1. Aspirin 325 mg PO DAILY
2. Isosorbide Mononitrate 30 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. Nitroglycerin 0.4 mg prn
5. Metoprolol Tartrate 25 mg PO BID
6. Calcium Carbonate-Vitamin D3
7. Multivitamin
8. Nitroglycerin 0.4mg SL prn chest pain
Discharge Medications:
1. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual every 5 minutes for total 3 doses as needed for chest
pain: If you still have chest pain after 3 doses, call 911.
2. Indomethacin 25 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) for 1 weeks.
Disp:*21 Capsule(s)* Refills:*0*
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. Outpatient Lab Work
please check chem 7 and Hct on Monday [**1-19**]. Call results to
[**Last Name (LF) 84032**], [**First Name3 (LF) **] G. Phone: [**Telephone/Fax (1) 28612**]
ICD-9 585.3
7. Calcium 600 + D(3) 600 mg(1,500mg) -200 unit Tablet Sig: One
(1) Tablet PO once a day.
8. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Pericardial Effusion
Coronary Artery Disease
Hyperglycermia
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
Dear Ms. [**Known lastname 84033**],
You were admitted to the hospital after your ablation procedure
because you were having some bleeding into the sac around your
heart, and we were concerned about the bleeding getting worse
and affecting your heart function. We watched you for a few
days and saw that the bleeding was not worsening and this should
slowly resolve over the next few weeks. Please call Dr. [**Last Name (STitle) **]
[**Name (STitle) **] if you notice that your chest pressure and shortness of
breath returns.
...
The following changes were made to your medications:
1. Start taking Indomethecin to treat the chest pressure. This
should be for one week only.
2. Stop taking Plavix
3. Decrease aspirin to 81 mg daily (baby dose)
4. decrease Metoprolol to 25 mg (1 pill only) twice daily
Please be sure to keep all of your follow up appointments. Pleae
talk to Dr.[**Last Name (STitle) 84034**] about your high blood sugars in the hospital.
He will want to do more testing to see if you are diabetic.
Followup Instructions:
Primary care:
[**Last Name (LF) 84032**], [**First Name3 (LF) **] G. Phone: [**Telephone/Fax (1) 28612**] Date/time: Monday
[**1-26**] at 10:00am.
[**Street Address(2) **]
Suite # 2
[**Location (un) 5028**], [**Numeric Identifier 84035**]
.
Cardiology:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone: [**Telephone/Fax (1) 62**] Date/time: Office will
call with an appt.
Completed by:[**2189-1-16**]
|
[
"423.3",
"420.99",
"427.89",
"998.2",
"250.00",
"427.31",
"414.01",
"E878.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.26",
"37.34"
] |
icd9pcs
|
[
[
[]
]
] |
6161, 6167
|
3543, 4895
|
360, 370
|
6271, 6271
|
3202, 3520
|
7458, 7888
|
2412, 2480
|
5196, 6138
|
6188, 6250
|
4921, 5173
|
6416, 7435
|
2495, 3183
|
2216, 2312
|
277, 322
|
398, 2107
|
6285, 6392
|
2129, 2196
|
2328, 2396
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,646
| 119,381
|
25983
|
Discharge summary
|
report
|
Admission Date: [**2125-2-17**] Discharge Date: [**2125-2-27**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
84 yo male w/hx of cad, copd, afib, NSCLcancer, RCC who
presented with 1 day history of chest pain. Patient reports
sudden, rest onset right-sided chest pain over 4-7th ribs,
pleuritic, non-exertional. Started [**2-16**] afternoon and was so
unbearable he couldn't walk so presented to the emergency [****] early AM. No associated shortness of breath, nausea,
diaphoresis. Says he has been afebrile but reports a shaking
episode about 2 days ago. 1 episode of vomiting 2 days ago, and
had one episode of diarrhea last night.
No steroids recently, no sick contacts. [**Name (NI) **] not started
chemotherapy.
.
In the emergency department, patient was initially hypertensive
(sbp's 190's), tachypneic and afebrile, thought to be volume
overloaded and given 80 iv lasix and started on nitro drip.
Blood pressure then to 80's, spiked fever to 101.2m central line
placed, lactate to 4.9 and levophed started. Ceftriaxone and
azithromycin for cap. Has not been significantly hypoxic in ED.
In ED on presentation also in afib with RVR. Received 1.25
liters in ED.
.
Transferred to the [**Hospital Unit Name 153**] on levophed.
.
Had VATS in early [**Month (only) 958**], chest tube and then to rehab for 4 days
and has been at home over the past few weeks at baseline.
Past Medical History:
1. Coronary artery disease. The patient notes that he had a
positive stress test in [**2113**] and he underwent a cardiac
catheterization at [**Hospital6 1708**] in [**2113**]. The
patient is followed by Dr. [**Last Name (STitle) 41632**] at [**Hospital 1562**] Hospital.
2. COPD unknown FEV1 all at [**Hospital 1562**] hospital
3. Afib--not currently taking coumadin since being at rehab,
unclear why
4. Hypertension.
5. Gout.
6. Anxiety disorder.
7. NSCLCA-new dx presented as hemoptysis [**9-23**], LUL and L hilar
mass with VATS on [**2125-1-17**] revealed poorly differentiated Lg cell
8. RCC dx on CT bx-[**12-25**] papillary type
Social History:
Lives with wife and daughter, performs his own [**Name (NI) 5669**]. Former 60
pack-year histroy smoker, now stopped a few years ago. No
alcohol or drugs.
.
Family History:
Non contributory
Physical Exam:
Temp: 101.2 tmax in ed, now 98 BP: 104/60 on levophed
HR:70 RR:16 98%3lO2sat
CVP: 13
general: pleasant, comfortable, NAD
HEENT: PERLLA, EOMI, no scleral icterus, no sinus tenderness,
MMdry, op without lesions, , no jvd
lungs: diffuse exp wheezes
heart: irreg irreg, S1 and S2 wnl, no murmurs, rubs or gallops
appreciated
abdomen: nd, +b/s, soft, nt
extremities: trace edema
skin/nails: no rashes
neuro: AAOx3. Cn II-XII intact.
Pertinent Results:
EKG:Initial: afib, rvr to 126, rbbb, left ant fasc block
Repeat at 8AM afib with rate 70, rbb, left ant fasc block--no
signifcant changes from prior ekg's
.
Radiologic:
CXR on admit:
IMPRESSION: Decreased opacity in left middle lung field,
representing
resolving postsurgical change. Tortuous aorta.
Multiple nodules seen on prior CT are not confidently
identified. Please also
refer to the official report of PET CT for detailed evaluation
of the lung
Brief Hospital Course:
Mr. [**Known lastname 17226**] was admitted to the I CU with respiratory distress
and chest pain. The pain was pleuritic in nature, and did not
sound cardiac. The pt was noted to have an elevated white count
and fever, likely secondary to pneumonia/pneumonitis. The pt's
repeat chest x-ray also showed a blossoming right-sided
infiltrate. The ICU team did consider the possibility of a
pulmonary embolism, and less likely aortic dissection, but no
there was no clear evidence for either. The pt was treated with
vancomycin and ceftriaxone for community acquired pneumonia. He
has a history of likely MAC colonization (TB already ruled out),
and azithromycin and Levaquin were not used so that they could
be saved to treat symptomatic MAC in the future, if needed. The
pt responded well to this treatment, and was quickly weaned of
pressors on his first ICU day. The next morning he began
wheezing, suggestive of a COPD flare. Therefore he was started
on IV steroids, and his inhalers were changed to Q4hr nebulizer
treatments. He stabilized on this regimen and was called out to
the floor. On the floor the pt remained afebrile. He was noted
to have penicillin sensitive S. pneumoniae growing in his
sputum. The pt's antibiotic regimen was changed to Amoxicillin.
He was also noted to have an elevated WBC count, in the setting
of being on steroids and diarrhea. A stool Cdiff toxin was
positive and the pt was
started on oral Flagyl. The pt was discharged with instructions
to follow-up with his PCP.
.
Pneumonia:
The pt was noted to have a right lower lobe pneumonia on CXR.
His sputum culture showed S. pneumoniae sensitive to
penicillins. The pt was started on a 10 day course of
Amoxicillin.
.
COPD Flare:
The pt was started on IV steroids in the ICU. These steroids
were tapered to PO prednisone. While on steroids he was noted to
have a rising WBC count. His WBC counts will need to be followed
as an out-patient.
.
Hypotension: It was unclear the hypotension was secondary to
sepsis vs. over-diuresis (pt was hypertensive on presentation to
ED, placed on a Nitro drip and 80 iv Lasix after which he became
hypotensive). He was placed on Levophed in the ICU, which was
gradually weaned off. The pt's hypotension did not appear to be
cardiac in etiology as his cardiac enzymes were negative.
.
Acute on chronic renal failure: (baseline Creatinine: 1.5)
The pt was noted to have acute on chronic renal failure for
which he was hydrated with IVF. His creatinine trended down from
1.9 to 1.3 on the day of discharge.
.
Elevated WBC count:
The pt was noted to have a rise in WBC count in the setting of
steroids and diarrhea. His stool for Cdiff toxin was positive.
The pt was initiated on oral Flagyl therapy which will be
continued to complete a 14 day course.
.
Anemia:
The pt was noted to have a hematocrit drop from 37.6 to 26.7.
This drop was attributed to hydration, but there was some
concern given guaiac positive status. The pt was noted to have a
gradual improvement in his HCT to 35.2 on discharge.
.
CV:
The pt has a history of CAD and atrial fibrillation. The pt was
not on Coumadin on admission. Per the pt's PCP the Coumadin was
held for a lung biopsy 2-3 weeks ago. The pt's home Coumadin
dose was restarted and he was continued on digoxin (dose
decreased to 0.0625 mg). No events were noted on telemetry. His
Coumdin became supratherapeutic on the day of discharge (to 4.0)
thus the dose of Coumadin will be held on [**2125-2-27**], with
instructions for the pt to have his INR checked on [**2125-3-1**] for
titration of Coumadin dose by the pt's PCP.
.
Oncology:
Mr. [**Known lastname 17226**] has NSCLC and RCC for which has had no treatment to
date. The pt was noted to have clinical stage II non small cell
lung cancer and was thought to not be a good candidate for
surgical resection, as it would require a pneumonectomy. He has
been evaluated by Dr. [**First Name (STitle) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3274**] and was offered
chemo-radiation. He is contemplating this option currently and
has been scheduled for follow-up in the [**Hospital **] clinic.
.
Gout:
The pt was continued on allopurinol for gout. He has no active
symptoms of gout.
.
Anxiety:
The pt was maintained on Celexa for anxiety.
.
Prophylaxis:
The pt was maintained on prophylaxis with SC Heparin and
Protonix. He had a RIJ placed [**2-17**] in the ED which was removed
prior to transfer to the floor.
.
FEN:
The pt was initially NPO, and then restarted on a cardiac diet
with no complications. Electrolytes were monitored and repleted.
.
He is DNR/DNI per his stated wishes
Medications on Admission:
Ramipril 5 mg qd
senna/colace prn
lipitor 20
Coumadin--currrently not taking
Lasix 40 mg qd
Lexapro 20 mg qd
allopurinol 300 mg qd
digoxin 0.125 mg qd
albuterol--taking about [**Hospital1 **]
Atrovent --taking [**Hospital1 **]
Discharge Medications:
1. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
2. Escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**11-20**]
Puffs Inhalation Q4H (every 4 hours) as needed.
5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Pramipexole 0.125 mg Tablet Sig: One (1) Tablet PO QHS (once
a day (at bedtime)) as needed for Restless leg syndrome.
7. Amoxicillin 500 mg Capsule Sig: One (1) Capsule PO Q12H
(every 12 hours) for 5 days: last dose [**2125-3-3**].
Disp:*10 Capsule(s)* Refills:*0*
8. Ramipril 5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily).
9. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*60 Tablet, Chewable(s)* Refills:*2*
10. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
12. Outpatient Lab Work
You will need have your INR level checked while on Coumadin.
Please have INR checked on [**2125-3-1**] and have teh result faxed to
Dr. [**Last Name (STitle) 64557**] at fax# [**Telephone/Fax (1) 62724**].
13. Prednisone 10 mg Tablet Sig: One (1) Tablet PO QD () for 1
doses: [**2125-1-28**].
Disp:*1 Tablet(s)* Refills:*0*
14. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 9 days.
Disp:*27 Tablet(s)* Refills:*0*
15. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
16. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours).
Disp:*100 ML(s)* Refills:*2*
17. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day) for 14 days.
Disp:*1 inhaler* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Primary: Pneumonia
.
Secondary:
1. Coronary artery disease.
2. COPD unknown FEV1 all at [**Hospital 1562**] hospital
3. Afib--not on coumadin on admission
4. Hypertension.
5. Gout.
6. Anxiety disorder.
7. NSCLCA-new dx presented as hemoptysis [**9-23**], LUL and L hilar
mass with VATS on [**2125-1-17**] revealed poorly differentiated Lg cell
8. RCC dx on CT bx-[**12-25**] papillary type
9. Restless leg syndrome? (per pt)
Discharge Condition:
Stable
Followup Instructions:
Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) **]. Phone: [**Telephone/Fax (1) 36175**].
Date/Time: [**2125-3-2**] at 1:00 pm.
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 4340**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2125-3-6**] at 2:00pm
.
ONCOLOGY:
Provider: [**First Name8 (NamePattern2) 251**] [**Name11 (NameIs) **], MD Phone:[**0-0-**]
Date/Time:[**2125-3-14**] 2:30
Completed by:[**2125-2-27**]
|
[
"374.9",
"285.9",
"491.21",
"008.45",
"481",
"585.9",
"274.9",
"414.01",
"300.00",
"427.31",
"V10.11",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
10256, 10305
|
3405, 8011
|
272, 279
|
10774, 10783
|
2923, 3382
|
10806, 11351
|
2432, 2450
|
8288, 10233
|
10326, 10753
|
8037, 8265
|
2465, 2904
|
222, 234
|
307, 1578
|
1600, 2239
|
2255, 2416
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,171
| 194,849
|
20053
|
Discharge summary
|
report
|
Admission Date: [**2158-12-12**] Discharge Date: [**2158-12-20**]
Date of Birth: [**2089-12-1**] Sex: M
Service: Medicine
HISTORY OF PRESENT ILLNESS: Sixty-eight year old male with
history of lumbar degenerative joint disease and stenosis
with chronic low back pain, which has been treated with
steroid injections, last one on 10/089/03 presented to an
outside hospital on [**2158-12-8**] with severe right lumbar back
pain radiating to the right leg, similar to his usual pain,
but more intense. He was also noted to have a low grade
temperature to 100 and white blood cell count of 23.7 with a
left shift.
Initial lumbar spine MRI was read as degenerative joint
disease and multiple disk herniations without nerve
compressions. No signs of infection, however, patient's
blood cultures there grew out 4/4 bottles of Strep mitis
initially treated with Unasyn and gentamicin, and then
changed to penicillin and gentamicin on [**2158-12-10**]. Patient's
low back pain and right leg pain were being treated with
narcotics and Toradol. Patient's course there was
complicated by a colonic ileus which was decompresses a
rectal tube and a colonoscopy on [**2158-12-11**]. Given the
bacteremia, endocarditis workup was pursued with a
transthoracic echocardiogram which was limited, but had no
valvular abnormalities.
A transesophageal echocardiogram was not done. On comparison
of the MRI of the lumbar spine, two MRIs, it was read as
increased density in the L1-L2 disk, which is potentially
consistent with diskitis. Patient continued to have
increasing back pain requiring increased doses of narcotics,
and patient was transferred to [**Hospital1 188**] on [**2158-12-12**].
PAST MEDICAL HISTORY:
1. Hypertension.
2. NASH.
3. Degenerative joint disease with lumbar stenosis.
4. Migraine.
5. Status post arthroscopy.
HOME MEDICATIONS:
1. Flexeril.
2. Vioxx.
3. Accupril.
4. Aspirin.
5. Atenolol.
TRANSFER MEDICATIONS:
1. Protonix 40 mg IV q.d.
2. Penicillin 4 mIU q.4. IV.
3. Gentamicin 120 mg IV q.12.
4. Dilaudid PCA.
5. Vioxx 25 mg q.d.
SOCIAL HISTORY: No alcohol, tobacco, or drug use. Works as
a Reverend, lives with his wife, very supportive family.
PHYSICAL EXAMINATION: Temperature 99.8, blood pressure
150/80, heart rate 74, respirations 20, and O2 saturation 96%
on 2 liters. In general: Appears in severe discomfort and
pain. HEENT: Anicteric. Oropharynx is clear. Positive
pain to palpation of left lower teeth. Pupils are equal,
round, and reactive to light. Extraocular movements are
intact. No evidence of intraoral fluctuance. Neck is
supple. Cardiovascular: Regular, rate, and rhythm, 1/6
systolic ejection murmur at left lower sternal border. Lungs
are clear to auscultation bilaterally. Back: Positive pain
to palpation of right lumbar area. Abdomen is soft,
moderately distended, normoactive bowel sounds, diffuse
tenderness to palpation, no rebound or guarding.
Extremities: No edema. Skin: No rashes. Neurologic:
Cranial nerves II through XII intact. Alert and oriented
times one. Is able to follow commands, bilateral upper
extremity strength 5/5. Dorsiflexion and plantar flexion [**5-22**]
bilaterally. Knee flexion and hip flexion/extension were [**3-22**]
bilaterally, and limited by pain. Bilateral lower extremity
sensation intact, 2+ patellar and ankle reflexes bilaterally.
Toes are downgoing bilaterally. Straight leg test positive
on left at 45 degrees.
LABORATORIES: White count 17.3, hematocrit 37.5, platelets
219, neutrophils 65, bands 17. Coags within normal limits.
INR 1.2. Chem-7: Sodium 137, potassium 4.2, chloride 102,
bicarb 32, BUN 17, creatinine 0.8, glucose 137.
IMAGES: Lumbar spine film from outside hospital. Extensive
degenerative disk disease.
MRI of lumbar spine without contrast on [**2158-12-8**] compared to
[**2158-9-12**]: Diffuse hyperintensity of L1-L2 disks consistent
with diskitis, no bony destruction, no evidence of soft
tissue mass or abscess.
Chest x-ray within normal limits.
Transthoracic echocardiogram: Technically limited, ejection
fraction 50%, no valvular abnormalities noted.
EKG: Normal sinus rhythm, diffuse T-wave flattening, no ST
changes.
Right upper quadrant ultrasound within normal limits. Left
renal cyst.
HOSPITAL COURSE: Patient was admitted on the night of
[**2158-12-12**] and was noted to be in severe pain and his
neurologic examination was limited by this. He had not
received any narcotic pain medications for five period of
time during the transfer process, though he was started on
his Dilaudid PCA. On [**2158-12-13**], MRIs from the outside
hospital were shown to the neuroradiologist here, who
recommended a contrast MRI to better evaluate the soft tissue
and Neurosurgery consult was also obtained.
The MRI showed a large epidural abscess at T10-L1, and
patient was taking emergently to the operating room on night
of [**2158-12-13**], and started on steroids as there was evidence of
spinal cord compression. Postoperatively, the patient was
difficult to extubate, and was transferred to the MICU.
While there, he had a transesophageal echocardiogram done,
which was complicated by methemoglobinemia secondary to the
Hurricaine spray local anesthetic. Patient was given
methylene blue and recovered well from this episode, and was
transferred to the floor on [**2158-12-17**].
1. Epidural abscess: The patient was noted to have a large
epidural abscess on contrast MRI on [**2158-12-13**] and was taken
emergently to the OR that night. He underwent a
decompression of the abscess and a T10-L1 laminectomy.
Postoperatively, Hemovac drain was placed and was removed on
[**2158-12-18**]. After the surgery, the patient began slow
neurologic improvement of his weakness.
By the time of discharge, he had 4+/5 strength in his right
dorsiflexors and plantar flexors, and 3+/5 strength
proximally in his right lower extremity. His left lower
extremity remained 3/5 strength throughout. Continued to
have some paresthesias in his leg, however, these were slowly
improving during hospital course. Patient was continued on
his regimen of penicillin and gentamicin. The cultures from
the epidural abscess grew out alpha Strep and the
identification and sensitivities were pending at the time of
discharge. The plan at the time of discharge was for the
patient to continue on the penicillin to complete a total
course of six weeks, and to continue on gentamicin to
complete a course of two weeks.
MRI of the lumbar spine was obtained on [**2158-12-19**] and the read
was pending at the time of discharge. This was to serve as a
baseline for future followup MRI. The patient's back pain
was well controlled at the time of discharge on p.o. regimen.
2. Colonic ileus: The colonic ileus was thought to be
narcotics induced. Was decompressed with rectal tube and
colonoscopy at the outside hospital prior to transfer,
however, the patient continued to have constipation. He was
placed on an aggressive bowel regimen and began having bowel
movements on [**2158-12-17**]. His diet was advanced and he was
tolerating a regular diet at the time of discharge without
nausea, vomiting, having regular bowel movements and flatus.
3. Strep mitis bacteremia: The source of the Strep mitis
bacteremia was thought to be from a loose/infected dental
implant. An OMFS consult was obtained and there was no
evidence of abscess requiring drainage around the implant,
however, the implant should be removed on an outpatient basis
within the next couple of weeks.
The transesophageal echocardiogram was obtained while the
patient was in the Medical ICU, which showed no evidence of
any vegetations or significant valvular lesions, however, it
was believed that the patient did at one time have
endocarditis, and the antibiotic therapy was tailored with
this assumption. Patient was to continue on high dosed
penicillin for a total of six weeks and gentamicin for a
total of two weeks. Patient was initially on clindamycin for
approximately one week, which was discontinued prior to
discharge.
The patient's ESR on presentation was 85, which had decreased
to 59 by the time of transfer. His white count was slowly
decreasing from a peak of 24 to 18 at discharge. Patient
remained afebrile x5 days at the time of discharge. His
surveillance blood cultures after the operation were negative
for growth.
4. Urinary retention: On [**2158-12-18**], the patient's Foley was
removed, however, patient was unable to void x12 hours, and
the Foley was replaced with 750 cc of urine return. It was
determined that the patient will need to have a Foley for the
short term as patient has continued urinary retention
secondary to spinal cord compression/narcotic induce.
5. Hyponatremia: Patient's sodium drifted down during the
hospital course, and was 129 at the time of discharge. He
was fluid restricted to 1500 cc per day. His sodium should
be followed at the rehab facility.
6. Pain: The patient was able to be switched over to a p.o.
regimen of OxyContin with prn oxycodone. His OxyContin dose
was increased with the amount of prn oxycodone as needed. At
the time of discharge, he was requiring 40 mg b.i.d. of
OxyContin. His OxyContin dose should be adjusted depending
on how much oxycodone he is requiring. Patient is also
placed on scheduled Tylenol and Valium prn for muscle spasm.
7. Hypertension: Patient's blood pressure remained under
good control on his usual regimen. His beta blocker was held
for several doses due to bradycardia, and should be continued
to be held if the heart rate is less than 55.
8. Prophylaxis: Patient should be continued on his Pepcid,
subQ Heparin, and pneumoboots, and incentive spirometry
should continue to be encouraged.
DISCHARGE DIAGNOSES:
1. Epidural abscess.
2. Spinal cord compression.
3. Streptococcus mitis bacteremia.
4. Narcotic induced ileus.
5. Infected dental implant.
6. Hypertension.
7. Nonalcoholic steatohepatitis.
8. History of lumbar stenosis/degenerative joint disease.
PROCEDURES: T10-L1 laminectomy with decompression of
epidural abscess.
DISCHARGE MEDICATIONS:
1. Heparin 5,000 units subQ q.8h.
2. Colace 100 mg p.o. b.i.d.
3. Quinapril 20 mg p.o. q.d.
4. Atenolol 25 mg p.o. q.d., hold for heart rate less than
55.
5. Dulcolax 10 mg p.o. q.d.
6. Lactulose 30 mL p.o. t.i.d. prn.
7. Oxycodone 5 mg p.o. q.4h. prn.
8. Pepcid 20 mg p.o. b.i.d.
9. Insulin Lantus 12 units subQ q.h.s. with regular
insulin-sliding scale.
10. Dexamethasone 4 mg p.o. q.8h. should be tapered to 5 mg
b.i.d. on [**12-22**] mg b.i.d. on [**12-24**] mg b.i.d. on [**12-26**] mg b.i.d. on [**12-28**] mg b.i.d. on [**12-30**], and steroid
should be stopped on [**2159-1-1**].
11. Tylenol 500 mg p.o. q.6h.
12. Oxycodone sustained release 40 mg p.o. b.i.d.
13. Gentamicin 100 mg IV q.8h. should be discontinued on
[**2158-12-23**].
14. Penicillin-G 3 mIU q.4h., should be discontinued on
[**2159-1-22**] or as directed by Infectious Disease consult team.
15. Valium 5 mg p.o. q.8h. prn for muscle spasm.
FOLLOWUP:
1. Neurosurgery with Dr. [**Last Name (STitle) 1338**] on [**2159-1-4**].
2. Infectious Disease with Dr. [**Last Name (STitle) 53990**] on [**2159-1-5**].
3. Patient should be arranged as an outpatient to have his
dental implant removed within 2-3 weeks.
DIET: Cardiac healthy.
ACTIVITY: Patient should have aggressive Physical Therapy
with active range of motion exercises and continue to
progress towards normal functioning.
DISPOSITION: Patient was transferred to rehab on [**2158-12-20**].
[**Doctor Last Name **] [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 5712**]
Dictated By:[**Name8 (MD) 17848**]
MEDQUIST36
D: [**2158-12-20**] 11:22
T: [**2158-12-20**] 11:42
JOB#: [**Job Number 53991**]
|
[
"573.3",
"041.09",
"324.1",
"518.81",
"560.1",
"788.20",
"276.1",
"336.9",
"996.69"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"88.72",
"96.07",
"03.4"
] |
icd9pcs
|
[
[
[]
]
] |
9772, 10093
|
10116, 11798
|
4287, 9751
|
1863, 1925
|
2212, 4269
|
1947, 2070
|
172, 1703
|
1725, 1845
|
2087, 2189
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,244
| 101,553
|
39341
|
Discharge summary
|
report
|
Admission Date: [**2198-9-23**] Discharge Date: [**2198-9-24**]
Date of Birth: [**2128-12-3**] Sex: F
Service: MEDICINE
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 3556**]
Chief Complaint:
abdominal pain, diarrhea, hypotension
Major Surgical or Invasive Procedure:
Arterial line placement
History of Present Illness:
69F with DM, CAD, PVD, HTN, multiple MIs (most recently [**8-/2198**]),
and AF recently hospitalized for treatment of bilateral heel
ulcers, now transferred to [**Hospital1 18**] for abdominal pain, guaaic
positive stool and hypotension SBP 80s. Per notes, pt was in
USOH at [**Hospital 5503**] Rehab when noted to have decreased UOP last
3 days (<120ml last 24 hours). She had episode of CP 4-5 days
ago for which CXR was obtained which revealed mild pulmonary
edema. This was being treated with lasix IV with uptrending Cr
2.3->2.7. NGT also placed for TFs approx 4 days ago for
decreased PO intake (albumin 1.7) and she was subsequently noted
to have N/V/D x 3 days. She was also transfused 2 units [**9-21**] for
HCT 25 and started on fluconazole for funguria. Today, she was
noted to have guaiac positive stool so was sent to OSH for
possible GIB. Of note, she has been on Primaxin and Xyvox for
MRSA and VRE in bilateral heel ulcers and was noted to have
downtrending PLT ?->70K->40K.
.
At [**Hospital3 **], she was guaiac positive with troponin 0.4 and a
positive UA. CT abdomen revealed a distended gallbladder with
layering gallstones but no other signs of cholecystitis. SBP 80s
so LIJ was placed and she was started on dopamine and
transferred to [**Hospital1 18**] for management of possible sepsis. She was
given 2L NS, CTX 1G, Flagyl 500MG, Zosyn 3.375GIV, VANCO 1G.
.
In the ED, initial vs were: 96.7 100 81/56 20 99%2LNC. She was
started on levophed with improvement in SBP to 100s and improved
mentation to AAOx3. BP 86/47 2 hours after arrival on
0.3mcg/kg/min levophed so neo was added at 2200. She received
Vancomycin 1g, Zofran and 3L NS. Surgery was consulted for
abdominal pain and recommended serial exams and cx. Labs
remarkable for pancytopenia with PLT 30K, WBC 12K, lactate 4.7,
Cr 2.6, Na 129, HCT 30, Trop 0.39, INR 1.7 and positive UA. VS
prior to transfer:95 99/69 13 94% 2L NC
.
On the floor, she feels "unwell" but unable to be more specific.
Reports left sided abd pain, difficulty breathing and endorses
recent nausea and dry heaves as well as diarrhea but unable to
state how long. Denies cough, increased LE pain, fever, or
chills.
Past Medical History:
Afib not on coumadin for unclear reasons
[**Name (NI) 2091**] Stage 3
PVD
HTN
Morbid obesity
IDDM
CAD s/p CABG [**2189**], cath [**5-/2198**] and NSTEMI [**8-/2198**]
Chronic VRE and MRSA heel ulcers tx with primaxin and zyvox
VRE UTI
Peripheral neuropathy
Hyperlipidemia
.
Past Surgical History: hysterectomy, iridectomy bilaterally,
laminectomy, CABG [**2198**], RCA stent ? [**2198**]
Social History:
Lives in MA with her husband prior to stays at rehab. Has one
daughter (a nurse) who is her proxy. Denies E/T/D.
Family History:
unable to obtain
Physical Exam:
Vitals: T:96.5 BP:80s/60s P:90s R:26 O2:94% 4L
General: Awake, somnolent but arousable, oriented to self, city,
state, month, year, not date or hospital
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP 10cm, LIJ, PICC R arm, no LAD
Lungs: Anterior wheezes with bibasilar crackles
CV: Irreg irreg. Distant. Normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, obese, hypoactive BS, Mildly TTP RUQ, LLQ, LUQ.
No rebound tenderness or guarding, No CVAT, no organomegaly
GU: no foley
Ext: Cool, dopplerable pulses, +anasarca, R and L heel ulcer
with necrotic debris and exposed bone. No purulent exudate, mild
erythema.
Pertinent Results:
[**2198-9-23**] Initial Labs
Glucose-154* UreaN-60* Creat-2.6* Na-129* K-4.3 Cl-95* HCO3-19*
AnGap-19
PT-18.7* PTT-36.9* INR(PT)-1.7*
WBC-12.7* RBC-3.44* Hgb-9.9* Hct-30.2* MCV-88 MCH-28.8 MCHC-32.8
RDW-17.9*
Neuts-79* Bands-1 Lymphs-13* Monos-7 Eos-0 Baso-0 Atyps-0
Metas-0 Myelos-0
Plt Ct-59*
Ret Aut-1.1*
Lactate-4.7*
Cortsol-50.3*
Albumin-2.4* Calcium-7.2* Phos-4.8* Mg-2.2 Iron-147
proBNP-[**Numeric Identifier 86991**]*
cTropnT-0.39*
ALT-4 AST-14 LD(LDH)-222 AlkPhos-227* TotBili-0.4 DirBili-0.2
IndBili-0.2
[**2198-9-24**] 4am Labs
Lactate-10.4*
ART Temp-35.8 O2 Flow-4 pO2-135* pCO2-27* pH-7.19* calTCO2-11*
Glucose-89 UreaN-61* Creat-2.7* Na-130* K-4.6 Cl-98 HCO3-10*
AnGap-27*
WBC-12.2* RBC-3.53* Hgb-10.2* Hct-31.7* MCV-90 MCH-28.8
MCHC-32.1 RDW-17.7* Plt Ct-42*
Imaging
CXR:PICC, left IJ catheters in appropriate position. NGT tip not
clearly seen. Bibasilar effusions and atelectasis. Limited
study.
RUQ U/S:IMPRESSION:
1. Limited examination. Cholelithiasis, but no evidence for
cholecystitis.
ECG:Atrial fibrillation. Intraventricular conduction delay. No
previous tracing available for comparison.
Micro data:
Urine cx: URINE CULTURE (Preliminary):
YEAST. >100,000 ORGANISMS/ML..
GRAM NEGATIVE ROD(S). 10,000-100,000 ORGANISMS/ML..
Blood cx NGTD
..........
OSH Imaging
[**9-19**] OSh CXR: No intestinal obstruction. Some gaseous distension
of stomach. Mild CHF with vascular congestion.
CT abd/pelvis: moderate bilateral effusions, distension of GB,
layering stones, no wall thickening, no free air or fluid,
diffuse SC edema in chest wall and abdominal wall
CXR: loculated R pleural effusion/pleural thickening at R base
KUB: No intestinal obtruction.
Brief Hospital Course:
69F with CAD s/p CABG [**2189**] and MI x [**5-6**] and [**2198-8-5**], HTN,
PVD, bilateral heel ulcers on impinem and linezolid, and [**Hospital **]
transferred from OSH with vasopressor dependent shock, likely
multifactorial.
#. Shock/Hypotension: Differential diagnosis included septic,
hypovolemic, cardiogenic shock. Cool extremities and recent CP
with pulm edema on CXR and CVP 20-24 most consistent with
cardiogenic shock. Patient also developed worsening hypoxia and
increased O2 requirement which was exacerbated with laying flat.
It is possible she had recent MI when c/o CP several days prior
or worsening CHF related to transfusions received several days
prior. Dobutamine was attempted for inotropy but hypotension
worsened on max levophed and uptitrated neo. She was also
treated with Dapto/PO Vanco/Zosyn/Fluconazole for possible
infectious sources such as skin/osteo given heel ulcers which
probe to bone, C difficile/colitis with recent diarrhea, UTI
with positive UA, and line infection with PICC in place. Lack of
leukocytosis and fever argued against infectious cause. Guaiac
positive stool in the setting of thrombocytopenia make slow GIB
a possible source of hypotension as well although HCT remained
stable. UOP remained low and pt maxed out on 4 pressors as above
with progressive hypotension MAPs in 40s-50s in addition to
altered mental status and hypoxia requiring nonrebreather. Her
daughter and HCP was called to discuss prognosis and pt was made
DNR/DNI with focus on comfort care and she expired several hours
later.
#. Hypoxia: Likely secondary to pulmonary edema and cardiogenic
shock. Started on bipap with no improvement.
.
#. Thrombocytopenia: Likely related to myelosuppressive effects
of linezolid and imipenem +/- sepsis +/- GIB/consumptive
process.
.
#. Anemia/Guaiac positive stool: Likely secondary to GIB +/-
myelosuppression as above. HCT stable.
#. Abdominal pain: Most likely secondary to ischemia in setting
of poor florward flow but covered for infectoius sources with
zosyn as well. CT A/P without contrast did not demonstrate
acute pathology.
.
#. Hyponatremia: Likely related to volume overload and anasarca
as appears total body hypervolemic.
.
#. [**Last Name (un) **] on [**Last Name (un) 2091**]: Unclear baseline. Likely prerenal secondary to
CHF and decreased forward flow vs ATN from sepsis. Urine Na<10.
.
#. Heel ulcers: On chronic abx and probe to bone so likely has
undergoing osteo. Covered with abx as above.
# Code: Full then changed to DNR/DNI
Medications on Admission:
Carvedilol 3.125mg [**Hospital1 **]
Crestor 40mg daily
Colace 100mg [**Hospital1 **]
Fluconazole 100mg PO daily x 1 more day (total 5 days)
Isosorbide mononitrate Cr 30mg daily
Levemir 100U/mL 10 U q bedtime
Lisinopril 2.5mg daily
Meclizine 12.5mg TID
Novolog 10U q lunchtime and 8U qAM
Reglan 10mg PO QID
Rocephin 1gm IV x 10 days (started empirically [**9-21**])
Ranexa 500mg PO BID started [**9-21**]
Primaxin 500-500mg IV TID (imipenem-cilastin)
Zyvox 600mg [**Hospital1 **]
Nystatin powder
Triple pink cream
Furosemide 20mg IV x 1 [**9-22**], 40mg IV daily
SL nitro prn [**9-21**], vicodin prn
Zofran prn
Solumedrol 20mg IV x 1 [**9-22**]
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Cardiogenic Shock
Discharge Condition:
Expired
Discharge Instructions:
None
Followup Instructions:
None
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]
|
[
"V09.80",
"403.90",
"585.3",
"272.4",
"410.92",
"785.51",
"995.92",
"038.9",
"443.9",
"286.9",
"V45.81",
"787.91",
"789.00",
"428.22",
"V58.61",
"278.01",
"787.01",
"785.52",
"574.20",
"427.31",
"578.9",
"584.9",
"287.5",
"428.0",
"041.12",
"414.00",
"356.9",
"707.14"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
8772, 8781
|
5529, 8048
|
334, 359
|
8842, 8851
|
3809, 4953
|
8904, 9040
|
3119, 3137
|
8743, 8749
|
8802, 8821
|
8074, 8720
|
8875, 8881
|
2880, 2973
|
3152, 3790
|
257, 296
|
4988, 5506
|
387, 2561
|
2583, 2857
|
2989, 3103
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,061
| 149,922
|
32924
|
Discharge summary
|
report
|
Admission Date: [**2189-3-29**] Discharge Date: [**2189-4-7**]
Date of Birth: [**2107-3-30**] Sex: M
Service: NEUROLOGY
Allergies:
Tetanus
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
left-hemispheric syndrome
Major Surgical or Invasive Procedure:
none
History of Present Illness:
81 LHM with a history of hypertension,ischemic cardiomyopathy
with an LVEF ranging 25-35%, CAD s/p Cx stenting and PAD s/p
lower extremity PTA/stenting, and AF on dabigatran presenting
with a severe left-hemispheric syndrome and Code Stroke called.
Patient was last seen well seen well on [**2189-3-29**] at 3AM after
going to sleep well at 8pm the preceding day. At that time he
complained of
"itching" in his right arm and put some wlcohol on it and went
back to sleep (patient sleeps in another room given sporadic
"gasping" during sleep which likely represents undiagnosed OSA).
He denied any weakness or sensory disturbance at that time and
wife spoke to himm and speech was normal. He then went back to
bed. At 0500 AM (wife very sure of the time as she remembers
clearly looking at the clock) she heard a loud bang and found
her husband had fallen on teh stairs on a landing at the bottom
of 6 steps. There was blood on the stairs noted after EMS left.
At that point, his eyes were open and he was not responding but
appeared uncomfortable. Wife tried to help him up but his right
side was rigid and he was not moving his right side. She also
noticed that he was profusely sweating an dhe was not pale or
cold and was not grasping at his cchest. He was not following
commands and he seemed to have roving eye movements going from
side to side and was not able to fix on a point ot at his wife's
face.
He has a history of TIA and is on dabbigatran for his AF. His
last
dose was on [**2189-3-28**] at around 5 PM. He has not missed any doses.
Per report (I arrivved to relieve a colleague at 07:15) on
presentation he was globally aphasic with a dense right
hemiparesis.
At baseline he is fully functional and very active
per family members. Of note, patient had been well yesterday
although wife [**Name (NI) 76616**] patient felt transiently light-headed 2
days ago while in a store after shopping for 8 hours which did
not recur denied CP and drove himself home.
Wife denies any symptoms prior to this am other than teh
light-headedness 2 days prior. Unable to acquire ROS from
patient as intubated and ventilated.
Past Medical History:
- PVD s/p bilateral lower extremity angioplasties for
claudication (at [**Hospital3 **]??????s) s/p stent to right leg only.
S/p gene therapy to left leg for PVD
- Hypertension
- Hypercholesterolemia
- TIA approximately 12 years ago-loss of speech x 1 day
Social History:
Married. + Tobacco use. Denies EtOH.
Family History:
Non-contributory.
Physical Exam:
Physical Exam:
Vitals: T:93F P:47-73 AF R:16 BP:116/70 but dropped to SBP 80s
SaO2: 97% on 3L then 100% on 40% O2
General: Ventilated and sedated on fentanyl and midazolam.
Thready pulse throughout, Diaphoretic, cold + peripheries. At
times bradycardic to 40s-50s generally 60s to 70s
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity.
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: AF nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds. Foley in situ.
Extremities: No edema. Peripherally shut down and cold all 4
extremities. Weak thready pulses. Absent Right foot pulses
absent and weak left DP. Cap refill 4s bilaterally.
Skin: No head lacs. Grazes bith lower ant shins.
Neurological examination:
Initial NIHSS per resident
NIH Stroke Scale score was 15:
1a. Level of Consciousness: 2
1b. LOC Question: 2
1c. LOC Commands: 2
2. Best gaze: 1
3. Visual fields: 1
4. Facial palsy: 0
5a. Motor arm, left: 0
5b. Motor arm, right: 2
6a. Motor leg, left: 0
6b. Motor leg, right: 2
7. Limb Ataxia: 0
8. Sensory: 1
9. Language: 3
10. Dysarthria: 0
11. Extinction and Neglect: 0
My exam
- Mental Status:
GCS E1-2 VT M4-5
Intubated and sedated with fentanyl and midazolam and partially
opening eyes but no grimmacing. Weak flexion on right and weak
withdrwal on left. Per report before intubartion was staring
into space and only responding to pain.
- Cranial Nerves:
I: Olfaction not tested.
II: PERRL 1.5 to 1mm and brisk. No blink to threat blaterally.
Funduscopic exam not possible due to small pupils +++ and poor
compliance.
III, IV, VI: No Doll's eye no nystagmus.
V: Unable to assess motor - corneals presnet bilaterally.
VII: Right facial droop.
VIII: Unable to assess.
IX, X: Present gag and cough.
[**Doctor First Name 81**]: Unable to assess.
XII: Unable to assess.
- Motor: Normal bulk, tone reduced on right.
No asterixis noted.
Withdraws left arm and leg better than right side. Some
withdrawal right leg less than on left and arm more
significantly effected with minimmal flexion.
- Sensory: Does not grimace to pain all 4 limbs.
- DTRs:
Generally hyporeflexic.
There was no evidence of clonus.
[**Last Name (un) 1842**] negative.
Plantar response was extensor bilaterally.
- Coordination: Unnable to assess.
- Gait: Not possible to assess.
On discharge:
Patient died
Pertinent Results:
On admission:
[**2189-3-29**] 05:25AM THROMBN-17.3*
[**2189-3-29**] 05:25AM PLT COUNT-212
[**2189-3-29**] 05:25AM PT-11.2 PTT-27.4 INR(PT)-1.0
[**2189-3-29**] 05:25AM WBC-5.8 RBC-4.00* HGB-13.6* HCT-41.1 MCV-103*
MCH-34.0* MCHC-33.1 RDW-13.1
[**2189-3-29**] 05:25AM cTropnT-<0.01
[**2189-3-29**] 05:25AM LIPASE-54
[**2189-3-29**] 05:25AM estGFR-Using this
[**2189-3-29**] 05:25AM GLUCOSE-118* UREA N-29* CREAT-1.6* SODIUM-142
POTASSIUM-5.0 CHLORIDE-108 TOTAL CO2-22 ANION GAP-17
[**2189-3-29**] 11:33AM WBC-10.1# RBC-3.69* HGB-12.4* HCT-38.8*
MCV-105* MCH-33.6* MCHC-31.9 RDW-13.4
[**2189-3-29**] 07:56PM TYPE-ART PO2-150* PCO2-26* PH-7.42 TOTAL
CO2-17* BASE XS--5
Imaging studies:
MRI brain
[**2189-3-30**]:
IMPRESSION: Subacute infarction involving predominantly the
left frontal
lobe, with extension into the left putamen, globus pallidus,
caudate, as well as the parietal and occipital lobes.
Hemorrhage within the left globus pallidus.
ECHO:
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. Left atrial appendage ejection
velocity is good (>20 cm/s). No atrial septal defect or PFO is
seen by 2D or color Doppler and after saline bubble injection.
Overall left ventricular systolic function is moderately
depressed (LVE~35-40%). There are complex (>4mm) atheroma in the
descending thoracic aorta. The aortic valve leaflets (3) are
mildly thickened with no aortic regurgitation. No masses or
vegetations are seen on the aortic valve. The mitral valve
leaflets are mildly thickened. No mass or vegetation is seen on
the mitral valve. Mild (1+) mitral regurgitation is seen. There
is no pericardial effusion.
IMPRESSION: No cardiac source of embolus (other than atrial
fibrillation) identified.
Brief Hospital Course:
Admission:
81yoM,hx of HTN, CHF, CAD, PAD, AF on dabigatran presented with
acute R sided plegia and aphasia, hypotension and possible UTI.
Patient was last seen well seen well on [**2189-3-29**] at 3AM after
going to sleep well at 8pm the preceding day. At that time he
complained of "itching" in his right arm and put some alcohol
on it and went back to sleep. He denied any weakness or sensory
disturbance at that time and wife spoke to him and speech was
normal. He then went back to bed.
At 0500 AM wife heard a loud bang and found her husband had
fallen down the stairs to a landing at the bottom of 6 steps.
There was blood on the stairs noted after EMS left. At that
point, his eyes were open and he was not responding but appeared
uncomfortable. Wife tried to help him up but his right side was
rigid and he was not moving his right side. She also noticed
that he was profusely sweating and he was not pale or cold and
was not grasping at his chest. He was not following commands and
he seemed to have roving eye movements going from side to side
and was not able to fix on a point ot at his wife's face.
On arrival to the ED, code stroke was called. NIHSS on
presentation was 23. On assessment patient was markedly
hypothermic at 93F and was profusely diaphoretic and was
peripherally shut down with weak thready pulses and no head lac
or bruises but grazed shins. Pre-intubation neurological
examination revealed dense right hemiparesis, global aphasia
with likely visual field defect and a left gaze preference.
Reflexes are generally hyporeflexic and plantars were extensor
bilaterally post intubation but only extensor on the right on
pre-intubation exam with otherwise globally hyporeflexic.
CT head showed extensive small vessel disease and old lacunar
infarcts and no clear early infarct signs. CTA showed very high
grade stenosis/occlusion in the L ICA siphon region (calcified)
with ophthalmic artery supplying the distal end of the ICA and
the MCA stem. CTP showed decreased perfusion in the left MCA
distribution ? more so superior division. CTA chest showed no PE
and possible tracheomalacia and mediastinal and hilar
lymphhadenopathy. CT C spine showed no fracture. Labs show
thrombin time 17.3 Cr 1.6 and CEs were negative.
Dabigatran as a relative contra-indication was discussed and
consent was obtained from the family for IV-tPA which was
started shortly thereafter. Due to hypothermia, BCs were sent
and patient became hypotensive dropping his BP to 80s and was
started on IV norepinephrine prior to transfer to ICU.
The likely aetiology of his left MCA stroke was thought to be
likely cardioembolic despite being on dabigatran. He was
admitted to the neuro ICU for post-tPA
management.
ICU course: ([**2189-3-29**] - [**2189-4-7**])
# Neuro:
Neurologically, he demonstrated dense R hemiparesis and global
aphasia that essentially did not improved during the 8 days
following IV tPA. He was restarted on aspirin 325mg but
anticoagulation was defered given the extent of his MCA infarct
and the risk for hemorrhagic conversion.
On [**2189-4-5**], despite an improving level of arousal, he remained
unable to follow even simple commands "close your eyes, stick
out your tongue". His RUE did not demonstrate spontaneous
movement and only extensor posturing with noxious stimuli.
A family meeting was held on [**2189-4-6**]. Given his lack of
improvement over the preceeding week, his global aphasia and
likely inability to participate in rehab, his poor prognosis
overall, multiple comorbidities including heart failure,
protracted rehab course with limited projected overall benefit
and the high likelihood of never achieving independence, a
decision was made to proceed to DNR/DNI, extubation and then CMO
status. His medications were changed to comfort measures only
with Morphine IV gtt. He passed away on [**2189-4-7**].
# CV:
TTE showing worsening EF (down to 25-30%) which clinical signs
of peripheral edema and hypotension requiring intermittent
pressors. Diuresis with lasix was attempted several times but
limited by his hypotension. He was not restarted on his
dabigatran despite afib/low EF given the concern for hemorrhagic
conversion of his infarct.
# Pulm :
Mr. [**Known lastname 10595**] remained intubated, intermittently on sedation given
agitation. He self extubated on day 2 but was reintubated
shortly thereafter given concern for airway protection and
inability to clear secretions. He was extubated on [**2189-4-6**] with
the understanding that he would not be reintubated. His coded
status was changed to DNR/DNI then CMO on [**2189-4-6**].
# ID:
febrile over several days in the ICU, broad spectrum ABx
(Vanc/Cipro/Cefepime) were started for empiric 8 day course for
VAP PNA/ UTI. These were stopped when patient was made CMO.
# Heme:
downtrending HCT during first several days was attributed to
traumatic foley. This stabilized
Medications on Admission:
ATENOLOL - (Prescribed by Other Provider) - 25 mg Tablet - 1
Tablet(s) by mouth daily
DABIGATRAN ETEXILATE [PRADAXA] - (Prescribed by Other Provider)
- 150 mg Capsule - 1 Capsule(s) by mouth twice a day
IBUPROFEN - (Prescribed by Other Provider) - 400 mg Tablet - 1
Tablet(s) by mouth daily
LISINOPRIL - (Prescribed by Other Provider) - 5 mg Tablet - 1
Tablet(s) by mouth daily
SIMVASTATIN - (Prescribed by Other Provider) - 40 mg Tablet - 1
Tablet(s) by mouth daily
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
|
[
"518.81",
"433.10",
"E879.8",
"V15.82",
"414.8",
"351.0",
"403.90",
"041.49",
"272.4",
"V49.86",
"285.9",
"784.51",
"V66.7",
"V45.82",
"997.31",
"434.11",
"427.31",
"V43.65",
"327.23",
"443.9",
"368.40",
"585.9",
"599.0",
"784.3",
"428.0",
"342.02"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"88.72",
"33.24",
"96.6",
"99.10"
] |
icd9pcs
|
[
[
[]
]
] |
12582, 12591
|
7130, 12030
|
302, 308
|
12642, 12651
|
5273, 5273
|
12704, 12711
|
2814, 2834
|
12553, 12559
|
12612, 12621
|
12056, 12530
|
12675, 12681
|
2864, 4051
|
5240, 5254
|
237, 264
|
336, 2463
|
4330, 5225
|
5288, 5959
|
4066, 4314
|
2485, 2743
|
2759, 2798
|
5977, 7107
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,901
| 103,908
|
46461
|
Discharge summary
|
report
|
Admission Date: [**2107-8-20**] Discharge Date: [**2107-8-26**]
Date of Birth: [**2033-4-27**] Sex: F
Service: MED
HISTORY OF PRESENT ILLNESS: The patient is a 74-year-old
female, with past medical history significant for
schizophrenia, a recent T12 burst fracture complicated by
bilateral lower extremity paresis, diabetes mellitus and
COPD, who presented from her rehab with fever, change in
mental status and hypotension. In rehab, there was concern
for pneumonia, so she was given empiric Flagyl and
levofloxacin. In the emergency department, temperature was
104, heart rate 130, BP 168/63, respiratory rate 36-42, 100%
on nonrebreather, unable to answer questions. She
subsequently developed respiratory distress and was
intubated. Her orogastric tube put out small amounts of
reddish fluid. Her stool was guaiac positive. She developed
supraventricular tachycardia at a rate of approximately 150,
subsequently read out as sinus tachycardia, and she was
admitted to the ICU.
REVIEW OF SYSTEMS: Unable to be obtained at the time of
admission.
MEDS AT TRANSFER FROM OUTSIDE FACILITY: Levaquin 500 mg p.o.
x1, insulin - Lispro per sliding scale, Ativan 0.5 mg p.o.
p.r.n. anxiety, metoprolol 50 mg p.o. b.i.d., albuterol nebs,
Atrovent nebs, calcitonin 200 units inhaled q. day, Haldol 50
mg IM q. month, fluticasone 110 mcg b.i.d., Zyprexa 7.5 mg
p.o. once daily, mirtazapine 30 mg p.o. at bedtime, senna
daily, aspirin daily, Colace daily, nicotine patch q. 24 h.
11 mg, lactulose 30 mL p.o. b.i.d. p.r.n., heparin subcu
b.i.d., multivitamin, Cogentin 1 mg p.o. b.i.d.
ALLERGIES: Include Risperdal and an ACE inhibitor for which
she developed angiolaryngeal edema requiring intubation.
PAST MEDICAL HISTORY: Dementia, schizophrenia, history of GI
bleed for which she declined work-up, gastroesophageal reflux
disease, COPD, hypertension, diabetes mellitus,
osteoarthritis, neuropathy, urinary incontinence, recent T12
burst fracture complicated by bilateral lower extremity
paresis, status post T12 vertebrectomy and T11-L1 fusion by
Dr. [**Last Name (STitle) 363**]. Her OR course at that time was complicated by a
lung collapse requiring a chest tube placement, spinal,
status post PEG placement in [**2107-7-9**].
FAMILY HISTORY: Has siblings with schizophrenia, otherwise
noncontributory.
SOCIAL HISTORY: Longstanding mental illness, presently
living in nursing home.
PHYSICAL EXAM ON ADMISSION: She was intubated, sedated.
Pupils equal, round and reactive to light. Oropharynx could
not be assessed. Neck: Right IJ in place with dressing.
Chest: A few crackles at base, decreased breath sounds, no
wheezes. Cardiac: Normal S1, S2, II/VI systolic ejection
murmur heard across the chest. Abdomen soft, nontender. PEG
tube without erythema or draining. Extremities warm, no
cyanosis, clubbing or edema, 2+ DPs bilaterally. Neuro:
Unable to assess. Skin: No rash.
PERTINENT LABS TIME OF ADMISSION: White count 12.9,
hematocrit 28.8, platelets 447, 84% neutrophils, 10%
lymphocytes, INR 1.2. Chem-7 was notable for hypernatremia,
sodium 150, mild hyperglycemia--161, and a BUN and creatinine
of 51 and 0.8. There were low-grade troponin elevations of
0.17 and 0.18, but there was no significant change throughout
the hospitalization. Iron studies revealed a ferritin of 160,
an iron of 58, TIBC of 191, TSH was 1.8. Initial lactate was
2.7.
HOSPITAL COURSE: The patient was admitted to the ICU,
treated with broad-spectrum antibiotics and intubated for
respiratory failure. There was initial concern that she might
have a source of infection in her low back from recent
instrumentation. Full imaging with MRI was precluded by the
placement of hardware; however, she did have a CT and an
evaluation by orthopedics who now feel that this was the
source. Despite broad cultures, no specific organism was
identified; however, during the hospital stay she was noted
to have a left lower lobe consolidation which may be the
primary etiology of her sepsis syndrome. She was successfully
extubated and transferred to the medical floor where she
continued on vancomycin and ceftazidime. Remainder of course
by problems.
1. SCHIZOPHRENIA: Patient was restarted on olanzapine and
Cogentin and remained stable through her hospitalization.
1. SINUS TACHYCARDIA: Patient had intermittent bursts of a
sinus tachycardia at a rate of approximately 140-150;
however, despite the cardiology read this could be an
atrial tachycardia, although flutter seemed unlikely. In
order to treat this, her beta blockers were titrated up
with good effect.
1. DIABETES MELLITUS: She was continued on sliding scale
insulin with good glucose control.
1. She was noted to have several small bullous lesions on
her lower extremities which remained stable.
RELEVANT IMAGING STUDIES:
CT of the chest,INDICATION: Fever, altered mental status.
Recent spine surgery. Evaluate for abdominal source of
infection.
TECHNIQUE: MDCT-acquired axial images from the thoracic inlet to
the pubic symphysis were acquired with the use of intravenous and
oral contrast material and displayed with 5-mm slice thickness.
COMPARISONS: No prior studies are available on PACS for
comparison.
CT OF THE CHEST WITH INTRAVENOUS CONTRAST: There is bilateral
lower lobe atelectasis, left larger than right and small left
pleural effusion. No consolidations are seen. The heart appears
normal and there is no pericardial effusion. There are coronary
artery calcifications and calcifications of the
aortic arch and left subclavian origin. There are stable
mediastinal lymph nodes, [**Location (un) **] of which meet size criteria for
pathologic enlargement. No hilar or axillary lymphadenopathy is
seen. There are pedicle screws\t the level of
L2. There are fusion rods extending up to the level of T6. A
metallic cage is seen in the space that appears to be resected
T12 vertebral body. There are transverse fixations screws in the
vertebral bodies of L1 and T11. No paravertebral fluid
collection is seen to suggest the presence of an abscess.
CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: The gallbladder
contains several gallstones but no signs of cholecystitis are
seen. The liver, spleen, pancreas, stomach and small and large
bowel loops appear unremarkable. A G- tube is seen in
appropriate position. No free air is seen. There is no
ascites. No localized fluid collections are seen to suggest the
presence of an abscess. The kidneys contain multiple
hypoattenuating lesions, sub-centimeter in size, too small to
characterize. The right adrenal gland appears normal, the left
adrenal gland contains a 19 x 16 mm nodule which may represent an
adenoma but cannot be fully characterized on this single phase
study.
CT OF THE PELVIS WITH INTRAVENOUS AND ORAL CONTRAST: There is
sigmoid diverticulosis without evidence of diverticulitis. The
rectum appears unremarkable. The bladder contains a Foley
catheter and appears unremarkable. The uterus is not well seen,
and may be atrophic or surgically absent. No
free fluid is seen in the pelvis. No abscess is seen. No pelvic
lymphadenopathy is seen.
BONE WINDOWS: Extensive post-surgical changes as described in
the chest section. There is a bony defect in the right iliac
[**Doctor First Name 362**] consistent with a bone graft harvest site. No suspicious
lytic or sclerotic lesions are seen.
IMPRESSION:
1. Status post extensive spine surgery without evidence of
paraspinal abscess.
2. Bilateral dependent atelectasis and small left pleural
effusion.
3. Cholelithiasis without evidence of cholecystitis.
4. Multiple hypoattenuating lesions in both kidneys, too small
to characterize. Statistically, these most likely represent
cysts.
5. Sigmoid diverticulosis without evidence of diverticulitis.
6. Possible left adrenal adenoma. A dedicated CT may be
performed for further evaluation if clinically inicated.
ECHOCARDIOGRAM:
The left atrium is normal in size. Left ventricular wall
thickness, cavity size, and systolic function are normal
(LVEF>55%). Regional left ventricular wall motion is normal.
Right ventricular chamber size and free wall motion are
normal. The aortic valve leaflets (3) are mildly thickened. There
is no aortic valve stenosis. Mild to moderate ([**1-10**]+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse.
Trivial mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion.
PORTABLE CHEST X-RAY: Compared to portable film from [**107-8-21**], there is placement of a left PICC terminating in the mid
SVC. A new patchy infiltrate is seen retrocardiac in the left
lower lobe representing either atelectasis or consolidation. The
endotracheal tube has been removed. The remainder of the
examination appears unchanged since prior film.
IMPRESSION: Placement of left PICC terminating in the distal
SVC. Interval removal of endotracheal tube. Atelectasis versus
consolidation in left lower lobe.
MAJOR INTERVENTIONS: Include endotracheal intubation, right
internal jugular subclavian vein triple-lumen catheter, and
left antecubital PICC line placement.
-Lopressor 50 mg Tablet Sig: 75 mg Tablets PO twice a day.
-Combivent 103-18 mcg/Actuation Aerosol Sig: [**1-10**] Inhalation
four times a day.
-Ceftazidime 1 g Recon Soln Sig: One (1) Intravenous every
eight (8) hours for 3 days: Stop on [**8-28**].
-Vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous every
twelve (12) hours for 3 days: stop on [**8-28**].
-Nicotine 11 mg/24 hr Patch 24HR Sig: One (1) Transdermal once
a day.
-Lovenox 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous once a
-Olanzapine 7.5 mg Tablet Sig: One (1) Tablet PO once a day.
-Cogentin Sig: 1 mg PO once a day.
-Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Inhalation
twice a day.
-Insulin Lispro (Human) 100 unit/mL Cartridge Sig: One (1)
Subcutaneous four times a day: As per Sliding Scale.
-Calcium 500 500 mg Tablet Sig: One (1) Tablet PO three times
a day.
-Senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
-Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
-Lactulose 10 g/15 mL Solution Sig: Three (3) PO twice a day
as needed for constipation.
-Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
-Remeron 15 mg Tablet Sig: One (1) Tablet PO at bedtime.
-Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
-Nystatin 100,000 unit/mL Suspension Sig: One (1) PO three
times a day as needed: swish&swallow.
-Calcitonin (Salmon) 200 unit/Actuation Aerosol, Spray Sig:
One (1) Nasal once a day.
-Haldol Decanoate 100 mg/mL Solution Sig: 80mg Intramuscular
once a month.
-Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
-Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO 2x/week
for 3 months.
-Bactroban 2 % Ointment Sig: One (1) Topical twice a day: To
open bullae on right lower extremity
DISCHARGE DIAGNOSES -
PRIMARY:
1. Sepsis.
2. Respiratory failure.
3. Left lower lobe pneumonia.
4. Delirium.
5. 19 x 16 mm nodule left adrenal adenoma, outpatient follow-up
recommended.
DISCHARGE DIAGNOSES - SECONDARY:
1. Dementia.
2. Schizophrenia.
3. Chronic gastrointestinal bleed for which she declined
gastrointestinal work-up.
4. Gastroesophageal reflux disease.
5. Chronic obstructive pulmonary disease.
6. Vitamin D deficiency.
7. Hypertension.
8. Diabetes mellitus.
9. Osteoarthritis.
10. Neuropathy.
11. Urinary incontinence.
12. Status post T12 burst fracture complicated by paraplegia
status post T11 through L1 fusion.
13. Chest tube placement for lung collapse.
14. Laryngeal edema requiring intubation secondary to ACE
inhibitor.
15. Methicillin resistant Staphylococcus aureus.
16. Percutaneous endoscopic gastrostomy tube placement.
CONDITION ON DISCHARGE: Patient stable for transfer to
[**Hospital **] Healthcare which is the facility from which she
came.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 5704**], [**MD Number(1) 5705**]
Dictated By:[**Last Name (NamePattern1) 28140**]
MEDQUIST36
D: [**2107-8-26**] 11:57:10
T: [**2107-8-26**] 13:04:31
Job#: [**Job Number 98706**]
|
[
"272.0",
"276.0",
"038.9",
"401.9",
"995.92",
"518.81",
"496",
"530.81",
"715.90",
"486",
"250.00",
"294.8",
"285.9",
"332.0",
"268.9",
"427.89",
"578.9",
"355.9",
"295.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"38.91",
"03.31",
"96.04",
"96.6",
"99.04",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
2269, 2330
|
3402, 4814
|
1023, 1719
|
165, 1003
|
2440, 3384
|
1742, 2252
|
2347, 2425
|
12071, 12445
|
4832, 12046
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,594
| 128,941
|
29921
|
Discharge summary
|
report
|
Admission Date: [**2156-11-25**] Discharge Date: [**2156-12-2**]
Date of Birth: [**2133-3-17**] Sex: F
Service: NEUROLOGY
Allergies:
Penicillins / Sulfa (Sulfonamides) / Cephalosporins
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
numbness and weakness
Major Surgical or Invasive Procedure:
EMG
History of Present Illness:
progressive numbness, ataxia
HPI: This HPI is per Dr. [**Last Name (STitle) 71497**] admission note, details were
reviewed with the patient
"Ms [**Known lastname 71498**] is a RH 23-year-old woman who is studying technical
writing. She is also a marathon runner, and was due to
participate in the [**Location (un) **] marathon on [**11-14**]. Initially her
symptoms started with an upper respiratory tract infection, with
yellow nasal discharge and a cough. She then developed a severe
headache on [**2156-11-15**], at which time she was evaluated in the
emergency room. The headache was associated with meningismus,
photophobia, and it was a sudden onset frontal headache that had
a pain score of [**11-12**], and was associated with nausea.
She underwent lab testing for CBC and Monospot,
which were normal. She did not have an LP at that time. Her
headache persisted and the following day she presented to
[**Hospital3 **] for evaluation, where she was prescribed
Midrin and Tylenol for headache and was presumed to have a
migraine. She followed up with the [**Company 191**] four times in total, and
they also advised her to follow up with neurology. Since
that time, she says that she has developed a new onset fatigue,
numbness, and tingling in her feet and hands, nausea, diarrhea
six bowel movements in six hours last night as well as
persistent
frontal headache.
Prior to these symptoms, she was running up to 20 miles a week
and says that her weakness is debilitating, and she cannot do
any
of her daily chores such as carrying her groceries without
feeling fatigued. She tries to go out for about 3-4 hours
during
the day and then is exhausted. The numbness and tingling
occurred in her toes travelled up her legs, and is now in her
finger tips, she also cannot close her eyes properly. She
currently has a much milder headache that is predominantly
frontal. She denies any current fevers, chills, cough, sore
throat. She denies any history of bug bites or rashes. She
denies history of trauma, no shooting electrical pain, no blurry
vision, no chest pain, palpitations, shortness of breath,
abdominal pain, and no lower extremity swelling."
Past Medical History:
Per Dr. [**Last Name (STitle) 71497**] note, reviewed with pt
1. Notable for a history of right-sided hemiparesis at age 19
after a visit to [**Country 149**], she will try to get the records from
[**Location (un) 55444**]. Interestingly, her right hand has since been weaker, and
she has difficulty playing the drums!
2. PCOS
3. TMJ surgery [**2148**]
Social History:
Per Dr. [**Last Name (STitle) 71497**] note, reviewed with pt
"No history of tobacco, occasional alcohol, no
illicits. Marathon runner. Has already got a degree in music,
wishes to become a lawyer."
Family History:
Per Dr. [**Last Name (STitle) 71497**] note, reviewed with pt
"Mother with rheumatoid arthritis and PCOS.
Brother with rheumatoid arthritis. Grandmother with breast
cancer at age 28."
Physical Exam:
Physical Exam:
Vitals: T:98.7 P: 76 R: 16 BP: 112/64 SaO2: NIF -58 CV 1.1 L
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity.
slight weakness of neck flexion and extension
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Nl rectal tone
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive. Language is fluent with intact
repetition and comprehension. Normal prosody. There were no
paraphasic errors. Pt. was able to name both high and low
frequency objects. Able to read without difficulty. Speech was
not dysarthric. Able to follow both midline and appendicular
commands. There was no evidence of apraxia or neglect.
CN
I: not tested
II,III: VFF to confrontation, pupils 4mm->2mm bilaterally, fundi
normal
III,IV,V: EOMI, no ptosis. No nystagmus
V: sensation intact V1-V3 to LT
VII: Facial strength symmetrical, decreased ability to hold air
in mouth
VIII: hears to voice bilaterally
IX,X: palate elevates symmetrically, uvula midline
[**Doctor First Name 81**]: SCM/trapezeii [**6-7**] bilaterally
XII: tongue protrudes midline
Motor: Normal bulk and tone; no asterixis or myoclonus. No
pronator drift.
Delt [**Hospital1 **] Tri WE FE Grip
C5 C6 C7 C6 C7 C8/T1
L 4----------------
R 4----------------
IP Quad Hamst DF [**Last Name (un) 938**] PF
L2 L3 L4-S1 L4 L5 S1/S2
L 4-------------------
R 4-------------------
Reflex: No clonus
[**Hospital1 **] Tri Bra Pat An Plantar
C5 C7 C6 L4 S1 CST
L 0-----1 0 mute
R 0-----1 0 mute
-Sensory: No deficits to light touch, pinprick, no clear spinal
sensory level. No extinction to DSS.
-Coordination: No intention tremor, dysdiadochokinesia noted. No
dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem without difficulty. Romberg
absent.
Pertinent Results:
[**2156-11-25**] 10:43PM PT-12.4 PTT-29.0 INR(PT)-1.1
[**2156-11-25**] 09:44PM CEREBROSPINAL FLUID (CSF) PROTEIN-22
GLUCOSE-64
[**2156-11-25**] 09:44PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-0 POLYS-0
LYMPHS-90 MONOS-10
[**2156-11-25**] 08:05PM GLUCOSE-92 UREA N-11 CREAT-0.7 SODIUM-140
POTASSIUM-4.1 CHLORIDE-102 TOTAL CO2-27 ANION GAP-15
[**2156-11-25**] 08:05PM ALT(SGPT)-22 AST(SGOT)-18 LD(LDH)-139 ALK
PHOS-55 TOT BILI-0.2
[**2156-11-25**] 08:05PM ALBUMIN-4.7 CALCIUM-9.8 PHOSPHATE-3.0
MAGNESIUM-2.2
[**2156-11-25**] 08:05PM IgA-171
[**2156-11-25**] 08:05PM WBC-8.3 RBC-4.39 HGB-12.7 HCT-37.7 MCV-86
MCH-28.8 MCHC-33.6 RDW-13.1
[**2156-11-25**] 08:05PM NEUTS-60.9 LYMPHS-31.9 MONOS-4.8 EOS-2.0
BASOS-0.3
[**2156-11-25**] 08:05PM PLT COUNT-355
EMG: IMPRESSION:
Normal study. There is no electrophysiologic evidence for acute
inflammatory demyelinating polyradiculoneuropathy or for a
polyneuropathy affecting large diameter fibers.
Brief Hospital Course:
23-year-old RH woman with a PMH of a prior episode of ascending
weakness and hemiparesis presents an ascending weakness and
paresthesias 4 years ago. She presented now with a gradually
progressive weakness and numbness/tingling ascending
from her toes and now reaching her arms. These occur in the
context of a recent URI and Diarrhea.
Her exam is remarkable for a low VC for a young athlete. She
also
has marked weakness now in all extremities with strength of [**5-8**]
in all groups. She also has weakness
of neck flexors and extensors. She is areflexic except at the
patellars. Her labs are
unremarkable.
Given this presentation, her symptoms were concerning for
GBS
Patient was admitted to ICU where her respiratory condition
remained normal and stable.
Her CSF was normal:
WBC RBC Polys Lymphs Monos ([**2156-11-25**])
1 0 0 90 10
An EMG was performed on [**2156-11-26**], which was normal.
The likelihood of a GBS diagnosis was very low given the normal
CSF and EMG.
MRI total spine with contrast showed no evidence of mass,
infarct, or demyelinating disease. MRI brain with contrast
showed no evidence of mass, infarct, or demyelinating disease.
Patient will be re-evaluated in clinic.
Differential diagnosis remains conversion disorder or
reactivation of a viral process she had years ago.
Medications on Admission:
ACETAMINOPHN-ISOMETH-DICHLORAL
OCP (Generic [**Female First Name (un) **])
Flixonase
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain, fever.
2. [**Female First Name (un) **] 28 Oral
3. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
still unclear; we could during this admission affirm that the
diagnosis of Guillain-[**Location (un) **] Syndrome is unlikely
Discharge Condition:
Good
Discharge Instructions:
You were admitted with weakness concerning for the diagnosis of
Guillain-[**Location (un) **]. Howerever, your exams, such as cerebral spinal
fluid analysis and electromyography exam were normal, making
this diagnosis unlikely. You should have a follow-up with Dr.
[**Last Name (STitle) **] in the clinic.
Followup Instructions:
Neurology: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 640**] [**Last Name (NamePattern4) 3445**], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2156-12-15**] 3:00
Completed by:[**2156-12-2**]
|
[
"300.11",
"728.87",
"781.3",
"V13.02"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
8258, 8328
|
6521, 7842
|
344, 350
|
8498, 8505
|
5544, 6498
|
8860, 9076
|
3155, 3342
|
7977, 8235
|
8349, 8477
|
7868, 7954
|
8529, 8837
|
3372, 3955
|
283, 306
|
378, 2544
|
3970, 5525
|
2566, 2921
|
2937, 3139
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,770
| 142,184
|
27526
|
Discharge summary
|
report
|
Admission Date: [**2140-8-5**] Discharge Date: [**2140-9-1**]
Date of Birth: [**2115-5-25**] Sex: F
Service: MEDICINE
Allergies:
Vicodin
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Acute pancreatitis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Reason for Transfer: severe post-ERCP pancreatitis.
.
The patient is a 25 yo F with post-ERCP pancreatitis transferred
from an OSH for further management. Pt describes sharp,
stabbing, RUQ pain beginning ~[**1-10**] a/w N/V/fever. Pt underwent
a lap chole in [**3-14**] for her 2 months of abdominal pain
associated with nausea and vomiting. The pain persisted after
the lap chole and her LFTs increased. One week PTA, the patient
saw Dr. [**Last Name (STitle) 48587**] for a GI consult, and underwent an outpatient
ERCP on [**2140-8-2**] which showed an 8mm dilated CBD and CBD stone. A
sphincterotomy was performed and the stone was removed. Later
that day, the pt complained of severe abdominal pain and
presented to the [**Hospital1 189**] Emergency Room. Amylase returned at
3,818 and lipase at 12,148. She was given pain meds and fluids
at 200cc/hr, however, pt continued to complain of pain and she
began to third space all fluids. (hemoconcentration Hct 41->
48%, intravascular depletion with Cr up to 1.4, borderline urine
output at 30 cc/h, somewhat tachycardic, low grade-temps to
100). CT abdomen confirmed 3rd spacing, but showed pancreas
still perfused. A PICC was placed for TPN and pt was on a
dilaudid PCA. The patient was transferred to MICU for further
management.
.
On arrival to the ICU, pt was complaining of severe pain and her
HR was in the 140s. Over the next two days, she received a total
of 12L and her pain was controlled with 1mg of dilaudid every
3hrs. She was alert and requesting liquids. She was transferred
to the floor on HD#3. On the floor, pt was somnolent but
arousable with HR into the 110s (up to 140s with pain), RR in
the 20s but up to 30s with pain. O2 sats remained stable >92%
with 2L. On night prior to txf back to MICU, pt triggered with
acute SOB and HR up to 140s, 92% on 2L. She was given dilaudid,
nebs and ativan and she improved both symptomatically and
clinically. During her stay on the floor, her fluids were
decreased from 200 cc/hr to 75 cc/hr due to increasing concern
for third spacing and worsening pleural effusions. On day of
transfer, pt's HR again increased to 140 with worsening abd
pain, located in RUQ associated with more SOB. Again, the team
tried nebs, ativan and dilaudid, this time with no improvement.
Bld gas showed 7.4/33/55 on 2L with a lactate of 2.5. Temp
spiked to 101.7 and bld cx were drawn. A CXR showed a large
gastric bubble, low lung volumes and bilateral pleural effusions
(but unchaged from prior CXR). The ICU was called to evaluate
pt.
.
On txf back to the ICU, pt was somnolent, answering questions
with one-word answers. She was very tachypneic with a RR in the
40s and diaphoretic. She complained of not being able to pull
enough air in. She pointed to her RUQ when asked where she had
pain. She denied nausea, vomiting or constipation. Last bowel
movement yesterday. On ambulation to the bathroom, HR increased
to 178.
.
Referring MD: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] via Dr. [**Last Name (STitle) 48587**] ([**Telephone/Fax (1) 67304**] cell
phone number, [**Telephone/Fax (1) 67305**] endoscopy suite, [**0-0-**] direct
pager)
.
[**Hospital3 36606**] [**Telephone/Fax (1) 67306**]
PCP: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Hospital1 189**])
Past Medical History:
none.
Social History:
Denies tobacco or IVDU use. Occasional ETOH consumption ([**4-9**]
times per year). Lives with Fiance. Works for Boys and Girls
club of America.
Family History:
Father with "gallbladder problem."
Physical Exam:
Upon admission to MICU:
VS: HR 129 BP 90/60 O2 93%2L
General - well nourished female lying in bed, mildly sedated
from pain medication, but easily arousable and answers questions
appropriately.
HEENT - PERRL, no scleral icterus, mucous membranes dry.
Neck - supple, no LAD, no JVD.
CV - tachycardic, no murmurs, rubs or [**Last Name (un) 549**] appreciated.
Chest - mildly decreased breath sounds at the bases (poor
inspiratory effort [**3-10**] pain), otherwise clear, no rales.
Abdomen - tender to palpation diffusely (worse on right and
epigastric area).
Ext - no c/c. Some puffiness around sight of right peripheral
IV.
Readmission to MICU:
Physical Exam:
temp 101.7 --> 99.7 (with tylenol), BP 127/84, HR 178 --> 132, R
27, O2 91% on 2L
Gen: somnolent but opens eyes to voice, answering some questions
HEENT: MM somewhat dry; pupils dilated
CV: tachy but regular, no murmurs
Chest: decreased breath sounds throughout, occ exp wheezes
Abd: +BS, tense edematous skin; TTP in RUQ, no rebound or
peritoneal signs
Skin: total body anasarca
Ext: 2+ tense edema in all ext, cool lower ext, 2+ DP
Neuro: AO x 3
Pertinent Results:
[**2140-8-6**] 07:08AM BLOOD WBC-11.3* RBC-5.11 Hgb-14.4 Hct-43.9
MCV-86 MCH-28.3 MCHC-32.9 RDW-13.2 Plt Ct-265
[**2140-8-6**] 07:08AM BLOOD Plt Ct-265
[**2140-8-6**] 07:08AM BLOOD Glucose-135* UreaN-27* Creat-0.9 Na-140
K-5.1 Cl-115* HCO3-20* AnGap-10
[**2140-8-6**] 07:08AM BLOOD ALT-39 AST-40 AlkPhos-60 Amylase-3885*
TotBili-0.4
[**2140-8-6**] 07:08AM BLOOD Lipase-1423*
[**2140-8-6**] 07:08AM BLOOD Calcium-7.0* Phos-2.4* Mg-1.8
OSH labs:
Hepatitis C VL - negative
Hepatitis B surface antigen - negative
Hepatitis B surface antibody - positive
Alpha 1 antitrypsin - negative
ceruloplasmin - normal
Hepatitis A - negative
[**2140-8-2**] OSH ERCP - 8mm gallstone in the distal common bile duct,
status post successful sphincterotomy and balloon extraction.
.
[**2140-8-3**] OSH CT Abdomen - prominent head of the pancreas with
free fluid in the right anterior perirenal space and free fluid
within the pelvis consistent with pancreatitis
.
[**2140-8-5**] OSH CT Abdomen - Dramatic interval increase in the amout
of free fluid within the abdomen. New small bilateral pleural
effusions and compressive atelectasis of the lower lobes
bilaterally. The pancreas is relatively unremarkable in
appearance.
[**2140-8-10**] CT Abd/pelvis - Complex collection in the anterior
mediastinum measuring 4.7 x 4.0 cm which most likely represents
a moderate-sized hematoma. There is no evidence of compression
on the adjacent trachea or vascular structures. Clinical
correlation recommended. Bibasilar consolidation with air
bronchograms which may represent atelectasis versus pneumonia.
Large right and smaller left pleural effusions and small
pericardial effusion. Diffuse fatty infiltration of the liver.
Normal appearance of the pancreas without evidence of
pancreatitis or
pseudocyst. Diffuse anasarca and mild ascites.
[**2140-8-11**] TTE - The LA is normal in size. No atrial septal defect
or patent foramen ovale. Mild symmetric LV hypertrophy. The LV
cavity is unusually small. LV systolic function is hyperdynamic
(EF 80%). RV size is normal. Right ventricular systolic
function is normal. Trivial mitral regurgitation. There is no
mitral valve prolapse. There is moderate pulmonary artery
systolic hypertension. There is a small to moderate sized
pericardial effusion. The effusion appears circumferential. No
tamponade.
[**2140-8-14**] CT abd/pelvis - Stable appearing complex collection
within the anterior mediastinum which could represent a
hematoma. An alternate consideration is lymphadenopathy (query
history of lymphoma), or thymoma. Clinical correlation is
recommended. No evidence of necrotizing pancreatitis, pancreatic
pseudocyst, or calcifications. Slight increase in mesenteric and
intra-abdominal and pelvic ascites. Diffuse anasarca.
Slight decrease in the right pleural effusion. Right basilar
atelectasis
versus pneumonia. Small pericardial effusion. Fatty infiltration
of the liver.
[**2140-8-24**] TEE - No spontaneous echo contrast or thrombus is seen
in the body of the left atrium or left atrial appendage. No
atrial septal defect. LV wall thickness, cavity size, and
systolic function are normal (LVEF>55%). RV chamber size and
free wall motion are normal. No valvular vegetations or
paravalvular abscess seen. There is a small pericardial effusion
without tamponade.
[**2140-8-24**] CTA - No evidence of pulmonary embolism. Unchanged
anterior mediastinal mass. Small bilateral pleural effusions
with associated atelectasis.
Brief Hospital Course:
Brief hospital course/MICU course:
# Resp failure
Pt developed respiratory failure likely due to volume overload
with ? component of ARDS. Pt was intubated on [**8-10**] after failing
a trial of BiPAP. Pt continued to require elevated levels of
PEEP given her significant volume overload as well as ? ARDS and
significant chest wall soft tissue swelling. Pt was continued
on the ventilator for 14+ days. Slowly with extensive diuresis
and recovery from her initial insult, pt's ventilator
requirements decreased, and pt was transitioned to PS. On [**8-27**],
pt had a SBT that she tolerated fairly well but required more
diuresis prior to her successful extubation on [**8-28**]. After
extubation patient remained stable with good O2 sats on 4L NC.
She had an episode of tachycardia and anxiety and due to concern
for PE a CTA was done that was negative. The patient was weaned
down to 2L NC without desaturation.
.
# Fever:
Pt had developed fevers initially to 103 in the setting of
hypotension and septic shock. Pt was placed on double pressor
therapy with levophed/vasopressin along with broad spectrum Abx
coverage. Cultures eventually returned positive for E.Coli
bacteremia and Enterococcus urinary infxn. Antibiotics were
tailored to Levo/Amp and her pressors were discontinued after 48
hours but patient continued to spike on a daily basis despite
negative cultures and therapy was broadened to
Vanc/Cefepime/Amp/Flagyl. Re-imaging of CT sinuses and
Abd/Chest/Pelvis showed no progression of Pancreatitis or acute
processes, and no evidence of abscess or pseudocyst with
necrosis. She was noted to have an anterior mediastinal process
c/w a hematoma/teratoma which was stable and deemed clinically
non-relevant at the time. Eventually, her Abx were again
narrowed to Levaquin/Ampicillin given a lack of source for her
fevers and she completed a 2 week course of [**Last Name (un) **] for her e.coli
bacteremia and a 10 day course of Ampicillin for her
Enterococcal UTI.
.
On [**8-20**], blood cultures (from [**8-18**]) grew [**2-10**] coag (-) Staph; she
was started on vancomycin until speciation. Blooc cx from [**8-20**]
also grew [**2-10**] coag (-) Staph and she was continued on a 14 day
course. Pt continued to have persistant fevers despite (-)
re-imaging of CT sinuses/chest/abd/pelvis. A TEE was performed
on [**8-24**] that was negative for any endocarditis or vegetations.
A CT guided biopsy of her mediastinal mass/hematoma was negative
for any growth. A pelvic w/u for GC/chlamydia was negative as
well. Her central lines were re-sited numerous times (x3)
during her MICU stay without any evidence of a central line
infection. On [**8-23**] the patient developed redness of her upper R
thigh that was concerning for cellulitis vs drug reaction.
Vancomycin was discontinued (on day 9) as a possible cause for
the possible drug rash and zosyn was started for ? cellulitis.
Once extubated and taking PO she was switched to PO
dicloxacillin for 10 day course. Currently day [**5-16**]. She
remained afebrile and recent blood/urine cultures show no growth
to date.
.
# Post-ERCP pancreatitis:
Pt initially admitted with a post-ERCP pancreatitis with enzymes
in the thousands. These eventually decreased, and pt would
develop intermittant bouts of pancreatitis with flares of her
enzymes to the hundreds. She had a post-pyloric feeding tube
placed to help with pancreatic rest, and TFs were initiaed.
Repeat CT abd/pelvis did not show any development of any
pancreatic pseudocysts or necrosis of the pancreas. Once
extubated, pt was eventually transitioned to PO diet and
tolerated it well. On day of discharge, pancreatic enzymes and
LFTs were normal.
*
# Tachycardia:
Pt with a persistant tachycardia that despite adequate fluid
resuscitation did not reverse. An extensive w/u was undertaken
to r/o PE, pericardial effusion, and CVPs remained in the
euvolemic range. It remained unclear the etiology of pt's
tachycardia.
*
# Pneumothorax
Pt had a CT-guided mediastinal bx that entered into the pleural
cavity and created a pneumothorax on [**8-24**]. Initially a pleurex
catheter was placed that decompressed the PTX but this had to be
slightly readjusted on [**8-26**] as the PTX had reaccumulated.
Post-catheter readjustment, her lung remained re-expanded. The
catheter was removed sucessfully on [**8-29**] without complication.
*
# Volume overload
Due to persistant episodes of bacteremia and sepsis along with
hypotension, pt was aggressively fluid resuscitated and due to
her low albumin, developed an excessive amount of third spacing.
Aggressive diuresis was instituted once her BP had stabilized
post-intubation and patient remained on Lasix 20mg IV tid to
remove the 20+ liters that she had accumulated during her length
of stay. Goal I/O have been >1L/day which has been achieved so
far. She is now transitioned to lasix 60mg PO tid with good
effect. Her lasix shoudl be titrated for goal I/O - 1
liter/daily and adjusted depending on clinical status.
*
# Rash
On [**8-26**], pt began to develop a erythematous rash over her lower
back and down her right thigh. ID was initially concerned for
infectious cellulitis despite being on Vancomycin therapy and
Zosyn was added for broader coverage. She was switched to PO
dicloxacillin prior to discharge. The cellulitis was resolving
on antibiotics.
*
# FEN:
Due to her being intubated in the setting of post-ERCP
pancreatitis, pt was initally placed on TPN. Once her
pancreatitis had resolved, pt was transitioned to TFs by NG
tube. However, due to episodic flares of pancreatitis, her NG
was advanced to a post-pyloric position and TFs were continued
until she was extubated. Post extubation the patient was
evaluated by speech and swallow and cleared for a regular diet.
.
# PPx: Hep SC, PPI, pneumoboots,bowel reg prn
.
# Code: full
Medications on Admission:
TPN via PICC
dilaudid pca
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Acute post-ERCP pancreatitis
E.coli bacteremia and septic shock
Enterococcal UTI
Respiratory failure due to CHF/ARDS
Coag (-) Staph bacteremia
Mediastinal hematoma s/p biopsy c/b Pneumothorax
R thigh cellulitis
Discharge Condition:
Afebrile, vital signs stable, abdominal pain improved
Discharge Instructions:
Please contact a physician if you feel abdominal pain, nausea,
vomiting, diarrhea, stools that are dark or bloody, or any other
concerning symptoms that do not improve.
.
Please take medications as prescribed.
Followup Instructions:
Please repeat CT abdomen 4-6 weeks after discharge to evaluate
for pancreatic pseudocyst.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2140-9-1**]
|
[
"512.1",
"560.1",
"038.42",
"997.4",
"599.0",
"577.0",
"682.6",
"287.5",
"518.5",
"785.52",
"273.8",
"518.0",
"995.92",
"785.0",
"041.04",
"782.1",
"275.41",
"428.0",
"998.12",
"584.9",
"511.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90",
"00.17",
"88.72",
"96.6",
"96.04",
"99.15",
"34.09",
"34.25",
"38.93",
"00.14",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
14449, 14528
|
8520, 14372
|
292, 299
|
14783, 14839
|
5028, 8497
|
15097, 15352
|
3845, 3881
|
14549, 14762
|
14398, 14426
|
14863, 15074
|
4559, 5009
|
234, 254
|
327, 3635
|
3657, 3664
|
3680, 3829
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,031
| 161,027
|
10823
|
Discharge summary
|
report
|
Admission Date: [**2122-8-6**] Discharge Date: [**2122-8-7**]
Date of Birth: [**2061-9-28**] Sex: M
Service: Medicine
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 1193**] is a 60-year-old male
with a significant alcohol past history who was transferred
to the [**Hospital6 256**] from [**Hospital3 35296**] Hospital on [**2122-7-24**] after an episode of hematemesis.
Upon admission to [**Hospital3 934**] Hospital Mr. [**Known lastname 35297**]
hematocrit was 35 and systolic blood pressure was 102, which
was intravenous fluid resuscitated to 118 with a pulse of 64.
Emergent esophagogastroduodenoscopy revealed blood in the
stomach and three units of red blood cells were transfused,
and he was placed on octreotide with no further bleeding.
A repeat esophagogastroduodenoscopy during that
hospitalization revealed several grade III esophageal varices
on [**2122-7-28**]. He underwent band ligation and was discharged
home with an hematocrit of 34.
On [**2122-7-31**] the patient woke up with chills and diaphoresis,
and had another episode of hematemesis. His wife and son
brought him back to the [**Name (NI) **] Emergency Room. Blood
pressure was 90. Fluid was resuscitating. Hematocrit was
18.5 and he was transfused a total of 10 red blood cell units
and two units of fresh frozen plasma. During this second
hospital course he continued to have melena, which began
after first discharge. Colonoscopy was performed, which
offered a limited view due to large amount of bright red
blood in the colon. He was continued on octreotide and
intravenous pantoprazole. The patient underwent a second
colonoscopy, which was negative.
The patient was then transferred on [**2122-8-4**] to the Medical
Intensive Care Unit at the [**Hospital6 2018**] for further evaluation with angiography.
On admission to the Medical Intensive Care Unit his
hematocrit was 24.5. A colonoscopy was performed, which
revealed a polyp in the ascending colon, grade II internal
hemorrhoids, with an otherwise normal colonoscopy to the
cecum.
The patient was continued on octreotide and vitamin K and he
remained stable in the Medical Intensive Care Unit, at which
point octreotide was discontinued.
Mr. [**Known lastname 1193**] was transferred to the medicine unit at the [**Hospital6 1760**] on [**2122-8-6**] due to his stable
condition in the Medical Intensive Care Unit with no evidence
of active bleeding. The patient [**Date Range 15797**] bright red blood per
rectum. On admission to the medicine unit the patient said
that he felt "well". He [**Date Range 15797**] any epigastric pain or
nausea.
PAST MEDICAL HISTORY: His past medical history is
significant for thrombocytopenia documented in [**2120-8-7**] (possible alcohol induced), status post video endoscopic
right inguinal hernia repair, status post neck surgery in
[**2110**], status post bone spur surgery on ankles bilaterally in
the [**2100**], tuberculosis exposure with positive PPD, and
hemorrhoids.
ALLERGIES: The patient has no known drug allergies.
FAMILY HISTORY: The patient has a family history of stomach
cancer and myocardial infarction. His father had a
myocardial infarction at the age of 48. Mr. [**Known lastname 1193**] has two
living children who are in good health. The patient denies a
family history of GI-related disorders and alcohol abuse.
SOCIAL HISTORY: Mr. [**Known lastname 1193**] has a strong history of alcohol
use. He drinks three full glasses of wine and three shots of
bourbon, equivalent to nine shots per week. He [**Known lastname 15797**] ever
trying to cut down, feeling annoyed about others' comments
about his drinking, ever feeling guilty about his drinking,
or ever feeling a need to drink in the morning. He says that
his drinking has never disrupted his life in any way, up
until now. Due to his current condition, Mr. [**Known lastname 1193**] said
that he will try to never drink again. He says that he has a
lot of strong emotional support to help him quit. He denies
any tobacco use. In addition, he says he is very active
during the day and that he tries to keep a healthy diet. He
worked as the director of engineering for a corporation, and
has been retired for several years. He lives in [**Location **],
[**State 350**], and lives on a houseboat for six to seven
months out of the year.
REVIEW OF SYSTEMS: His review of systems is notable for a
20-pound weight loss over the past two years, which the
patient feels is due to increased exercise and diet. The
patient denies loss of appetite, vomiting, or diarrhea during
this time period. Mr. [**Known lastname 1193**] [**Last Name (Titles) 15797**] any cardiac, pulmonary,
musculoskeletal, or neurological problems.
PHYSICAL EXAMINATION: On admission his general appearance
was that of a well-nourished man in no apparent distress. He
appeared his stated age, and seemed well informed of his
condition. He was a good historian.
VITAL SIGNS: On admission to the medicine unit his
temperature was 99.8, pulse 62, respiratory rate 20, blood
pressure 132/80, O2 saturation 89% on room air.
HEAD, EYES, EARS, NOSE AND THROAT: His head was atraumatic
with a 6 mm nodule, slightly erythematous, on top of his
head, which the patient said was evaluated by his primary
care physician and determined to be benign. His eyes showed
pupils equal, round and reactive to light and accommodation
with concentric reaction; extraocular movements intact; full
to confrontation. Conjunctivae were normal, sclerae were
white. There was no icterus noted. Funduscopic examination
was normal with clear vessels and optic discs. There was no
nystagmus observed, no lid lag. Ear examination showed clear
tympanic membranes, finger rubbing and finger clicking heard
bilaterally. Throat examination revealed clear posterior
pharynx with no exudate; poor dentition.
NECK: Supple, trachea midline, no carotid bruits, 2+ carotid
pulses bilaterally, no cervical lymphadenopathy, no jugular
venous distension appreciated.
LYMPH NODES: There was no adenopathy.
RESPIRATORY/THORAX: There were no scars observed; multiple
spider angiomas on the trunk. He had normal respiratory
expansion and no accessory muscle use. He was hyporesonant
at the bases bilaterally. Crackles were heard at the based
bilaterally, louder on the left, no wheezing or rubs.
CARDIAC: There was a regular rate and rhythm, normal S1 and
S2, no S3, S4, murmurs, clicks, or rubs. Point of maximal
impulse was not appreciated.
ABDOMEN: His abdomen was distended diffusely, nontender, no
visible veins, no hernias observed, hyperactive bowel sounds,
hyperresonant on percussion, no renal bruits. The liver
percussed at 9 cm. There was no splenomegaly appreciated and
no masses.
RECTAL: Tone was normal. External hemorrhoids were noted.
No masses were palpated in the rectum; guaiac positive.
There was positive shifting dullness approximately 7 cm up.
There was a negative fluid wave test.
VASCULAR: Radial, femoral, dorsalis pedis, and posterior
tibialis were 2+ bilaterally; no femoral bruits.
EXTREMITIES/SKIN: The extremities were slightly edematous,
nonpitting, no erythema. Clubbing was present. There was no
cyanosis. Normal hair appearance. Skin was warm and dry to
touch. Spider angiomas were noted on the trunk.
NEUROLOGIC: The patient was alert and oriented x 3. Cranial
nerves two through 12 were intact. Motor examination was [**4-11**]
throughout; normal bulk and tone. Biceps, radial, and
patellar deep tendon reflexes were 3+ bilaterally. He had
decreased vibratory, temperature, and soft sense on the right
lower extremity.
LABORATORY STUDIES: On admission to the medicine unit his
white blood cell count was 5.3, red blood cells 3.18,
hemoglobin 9.7, hematocrit 30.9, MCV 89, MCH 30.6, MCHC 34.5,
RDW 15.5. Prothrombin time was 13.7, PTT 29.9, platelet
count 99. Glucose 122, BUN 8, creatinine 0.8, sodium 136,
potassium 3.6, chloride 105, total bicarbonate 23, anion gap
of 12, calcium 7.1, magnesium 1.8, protein 4.2. Hepatitis C
antibody negative.
STUDIES: Electrocardiogram done on [**2122-8-5**] revealed normal
sinus rhythm, limb lead voltage criteria for left ventricular
hypertrophy, early R wave progression with prominent R waves
in leads V2 through V3; cannot rule out posterior myocardial
infarction, however no previous tracing available for
comparison.
Abdominal ultrasound on [**2122-8-6**] revealed a slightly nodular
course in liver with associated ascites, splenomegaly, and
dampening of the portal venous waveform, suggestive of
cirrhosis with portal hypertension.
Colonoscopy and esophagogastroduodenoscopy studies are as per
history of present illness notes.
HOSPITAL COURSE: 1. Gastrointestinal bleed: Mr. [**Known lastname 35297**]
gastrointestinal bleed remained stable in the medicine unit,
with hematocrit rise from 24.5 on admission to the Medical
Intensive Care Unit to an hematocrit of 29.8 on the day of
discharge. The blood pressure remained stable at 150/90 on
the day of discharge with a range of 132-150/70-90 throughout
the medicine unit admission. Colonoscopy done during his
stay in the Medical Intensive Care Unit at the [**Hospital6 1760**] revealed a polyp in the
ascending colon and grade II internal hemorrhoids, with an
otherwise normal colonoscopy to the cecum, thereby ruling out
lower gastrointestinal bleed. Melena was most likely due to
his upper gastrointestinal bleed. Hepatitis serology was
negative.
The patient was discharged on [**2122-8-7**] to home due to stable
condition, with Cipro 500 x 4 days, Protonix b.i.d., and
M.V.I. He was advised to restrict activity to a moderate
level with no heavy lifting. In regards to diet,
gastroenterology advised no heavy solids for the first two
days post discharge. In addition, he was advised to chew his
food well. It was explained to Mr. [**Known lastname 1193**] that it is
possible that his second episode of hematemesis was caused by
a dislodging of one of the bands due to heavy solid
ingestion. In addition, he will follow up in the liver
clinic as an outpatient in two weeks.
2. Cirrhosis/portal hypertension/ascites/varices: Abdominal
ultrasound on [**2122-8-6**] revealed a slightly nodular course in
liver with associated ascites, splenomegaly, and dampening of
the portal venous waveform suggestive of cirrhosis with
portal hypertension. In the medicine unit, resting
bradycardia precluded the use of beta blockers at this time
to reduce risk of recurrent bleed. Cipro for SBP prophylaxis
per gastrointestinal recommendations was given. No liver
biopsy was done due to the high suspicion of alcohol
cirrhosis. Mr. [**Known lastname 1193**] will follow up in the liver clinic as
an outpatient two weeks from the discharge date. Hepatoma
screening protocol is advised.
3. Alcohol: The patient has a significant alcohol past
history. The patient understands the risks of future abuse,
and clearly states that he will quit alcohol drinking status
post discharge. He feels that he has strong emotional
support from family and friends, along with his priest, to
help him quit and does not feel the need at this time for a
support group.
4. Lungs: Crackles were heard at the bases bilaterally,
which resolved throughout his stay in the medicine unit. A
chest x-ray was performed on [**2122-8-6**], which revealed a left
lower lobe consolidation with possible left lower lobe
effusion that could not be ruled out. There was no evidence
of cerebrospinal fluid as per radiologist's report. In
addition, no pneumothorax was noted, and x-ray was unchanged
from the x-ray of [**2122-8-5**]. Due to Mr. [**Known lastname 35297**] absence of
symptoms for pneumonia, consolidation is likely not due to an
infectious [**Doctor Last Name 360**]. Another possible cause of lung symptoms
includes atelectasis. The patient's lung symptoms were much
improved on the day of discharge with very few crackles heard
at the bases bilaterally.
CONDITION ON DISCHARGE: Stable.
DISPOSITION: The patient was discharged on [**2122-8-7**] to home.
DR.[**First Name (STitle) **],[**First Name3 (LF) 734**] J. 12-944
Dictated By:[**Last Name (NamePattern1) 35298**]
MEDQUIST36
D: [**2122-8-15**] 15:44
T: [**2122-8-19**] 06:26
JOB#: [**Job Number 35299**]
|
[
"578.9",
"571.5",
"572.3",
"285.1",
"789.5",
"287.5",
"211.3",
"303.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.23"
] |
icd9pcs
|
[
[
[]
]
] |
3064, 3360
|
8722, 11981
|
4754, 8704
|
4368, 4731
|
164, 2623
|
2646, 3047
|
3377, 4348
|
12006, 12329
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,371
| 103,241
|
38501
|
Discharge summary
|
report
|
Admission Date: [**2182-7-22**] Discharge Date: [**2182-7-26**]
Service: MEDICINE
Allergies:
Aspirin
Attending:[**First Name3 (LF) 7651**]
Chief Complaint:
NSTEMI
Major Surgical or Invasive Procedure:
Gastric endoscopy
colonoscopy
History of Present Illness:
This is an 85 year old female presenting from OSH with bright
red blood per rectum with troponin I elevation to 8 with TWI in
inferior leads in the absence of anginal symptoms. Her past
medical history is remarkable for history of colon cancer s/p
right hemicolectomy in [**2170**], with repeat colonoscopy in [**2180**]
showing no recurrences but diverticulosis and benign polyps.
Her symptoms started two days prior to admission, when she
noticed loose stools in the absence of abdominal symptoms with
bright red blood and dark colored stool. She denied, nausea,
vomiting or hematemesis. No abdominal cramping, no prior
history of GI bleeds. She has been taking aleve twice a day for
the past three months for back pain secondary to recent fall,
but no other NSAIDs other than baby aspirin. In OSH, she was
started on a protonix drip and no further episodes of lower GI
bleed were noted. HCT on admission was 27; she was transfused 3
units pRBCs with improvement to 35. Hemodynamically stable.
Her cardiac enzymes at first set were noted to be elevated to 8
(troponin I) with T-wave inversions in inferior leads; there
were no anginal symptoms at this time. Given her troponin
elevations in the setting of GI bleed, she was transferred to
[**Hospital1 18**] for treatment of NSTEMI and possible catheterization.
.
Upon transfer to the CCU, she continued to be hemodynamically
stable. HCT was 35. There were no active signs of GI bleeding,
with no dizziness, lightheadedness. EKG showed persistent TWI
in inferior leads and sinus rhythm with frequent APCs. She has
a history of both tachy and brady arrythmias in the past. She
denied chest pain, pressure, shortness of breath, orthopnea,
PND, lower extremity edema, abdominal pain, nausea/vomiting,
diarrhea. Her last PO intake was on [**7-22**] and her last bowel
movement was loose stools on [**7-21**]. Review of systems otherwise
negative.
Past Medical History:
-History of acute inferolateral myocardial infarction
-lower GI bleed (not on coumadin)
-paroxysmal atrial fibrillation
-hypertension
-hyperlipidemia
-colon carcinoma s/p right hemicolectomy in [**2170**]
-colonoscopy in [**2180**] showing benign polyps and diverticulosis
Social History:
NC
Family History:
NC
Physical Exam:
GEN: NAD
CV: RRR, no m/r/g
RESP: CTAB, no w/r/r
Abd: soft, nt, nd, +bs
Ext: no edema
Pertinent Results:
Admission labs:
[**2182-7-22**] 02:31PM BLOOD WBC-15.8* RBC-3.95* Hgb-12.0 Hct-35.4*
MCV-90 MCH-30.4 MCHC-34.0 RDW-16.6* Plt Ct-248
[**2182-7-22**] 02:31PM BLOOD Neuts-83.4* Lymphs-11.6* Monos-4.7
Eos-0.1 Baso-0.2
[**2182-7-22**] 02:31PM BLOOD PT-11.8 PTT-21.0* INR(PT)-1.0
[**2182-7-22**] 02:31PM BLOOD Glucose-102* UreaN-22* Creat-0.8 Na-137
K-3.7 Cl-100 HCO3-25 AnGap-16
[**2182-7-22**] 02:31PM BLOOD ALT-22 AST-82* LD(LDH)-305* CK(CPK)-187
AlkPhos-48 TotBili-1.0
[**2182-7-22**] 02:31PM BLOOD CK-MB-38* MB Indx-20.3* cTropnT-0.95*
[**2182-7-22**] 02:31PM BLOOD Calcium-7.9* Phos-2.5* Mg-1.6
.
Cardiac Enzymes:
[**2182-7-22**] 02:31PM BLOOD CK-MB-38* MB Indx-20.3* cTropnT-0.95*
[**2182-7-22**] 02:31PM BLOOD CK(CPK)-187
[**2182-7-23**] 04:07AM BLOOD CK-MB-21* MB Indx-17.4* cTropnT-0.97*
[**2182-7-23**] 04:07AM BLOOD CK(CPK)-121
[**2182-7-23**] 10:01AM BLOOD CK-MB-15* MB Indx-17.0* cTropnT-0.88*
[**2182-7-23**] 10:01AM BLOOD CK(CPK)-88
[**2182-7-24**] 03:29AM BLOOD CK-MB-6 cTropnT-0.62*
[**2182-7-24**] 03:29AM BLOOD CK(CPK)-39
.
Discharge labs:
[**2182-7-26**] 05:50AM BLOOD WBC-11.7* RBC-3.52* Hgb-11.3* Hct-31.8*
MCV-90 MCH-32.0 MCHC-35.4* RDW-16.2* Plt Ct-248
[**2182-7-26**] 05:50AM BLOOD Glucose-105* UreaN-33* Creat-0.8 Na-133
K-3.9 Cl-99 HCO3-26 AnGap-12
[**2182-7-25**] 05:58AM BLOOD Triglyc-103 HDL-39 CHOL/HD-3.5 LDLcalc-76
.
[**2182-7-24**] H.Pylori IgG negative
.
[**2182-7-24**] Echo:
The left atrium is mildly dilated. The estimated right atrial
pressure is 0-5 mmHg. Left ventricular wall thicknesses and
cavity size are normal. There is mild regional left ventricular
systolic dysfunction with near akinesis of the inferior and
inferolateral walls. The remaining segments contract normally
(LVEF = 40 %). The estimated cardiac index is normal
(>=2.5L/min/m2). Right ventricular chamber size and free wall
motion are normal. The ascending aorta is mildly dilated. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. 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
pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
IMPRESSION: Regional left ventricular systolic dysfunction c/w
CAD (PDA distribution). Mild mitral regurgitation.
.
[**2182-7-22**] CXR:
IMPRESSION: AP chest reviewed in the absence of prior chest
radiographs:
Heart is mildly to moderately enlarged. Thoracic aorta is
generally large,
tortuous and heavily calcified. Pulmonary vascularity is normal
and pleural effusion is minimal if any. Therefore the thickened
septal lines seen in both lungs are likely to be chronic rather
than due to acute pulmonary edema. No radiographic evidence of
pneumonia.
.
[**2182-7-23**] Colonoscopy
Diverticulosis of the descending colon and sigmoid colon
Ulcer at the site of anastomosis
Polyps in the rectum
Otherwise normal colonoscopy to site of anastomosis and
neoterminal ileum
Recommendations: No site of bleeding was noted although it could
be a diverticular bleed as well.
Patient is going to need a repeat colonoscopy as an outpatient
to remove the rectal polyps given history of colon cancer.
Brief Hospital Course:
This is a 85 year old female with history of paroxysmal atrial
fibrillation, hypertension, history of colon carcinoma s/p right
hemicolectomy in [**2170**] with repeat colonoscopy in [**2180**] showing no
recurrence now presenting from OSH with lower GI bleed and
NSTEMI
.
# NSTEMI: Since patient has history of GI bleed the decision was
made not to perform a cardiac catherization instead. The patient
was started on medical managment that included lisinopril,
metoprolol, aspirin, and atorvastatin.
.
# GI Bleed - Patient had colonoscopy. Most likely a diverticular
bleed. Patient needs to have colonoscopy as outpatient to remove
rectal polyps.
.
# Paroxysmal atrial fibrillation - Currently in sinus with heart
rates in the 70s, with frequent PACs. Not anticoagulated in
setting of GI bleed. Patient will continue on aspirin.
.
-low dose metoprolol as above for ACS
-Holding anticoagulation in setting of GI bleed; CHADS2 score is
2 (hypertension and age)
.
# Leukocytosis - Likely [**3-12**] ACS. No source of infection
identified.
.
# Hypertension - continue metoprolol, lisinopril, and
hydrochlorothiazide
.
# Hyperlipidemia - Switched to atorvastatin.
.
# Colon Carcinoma - Patient needs to have repeat colonoscopy as
outpatient to remove rectal polyps
Medications on Admission:
HCTZ 25 mg daily
nifedipine 60 mg daily
digitek .125 mg daily
simva 20 daily
asp 81 mg daily
tylenol
MVA
Discharge Medications:
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as
needed for constipation.
4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day): do not give within 1 hour of any ohter medicines.
10. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
11. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
14. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours).
15. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO once a
day: give in am.
16. Tramadol 50 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for pain.
Discharge Disposition:
Extended Care
Facility:
Life Care Center - [**Location (un) 3320**]
Discharge Diagnosis:
Gastrointestinal bleed
Paroxysmal Atrial Fibrillation
Non ST Elevation Myocardial Infarction.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You had a bleed in your intestine that has resolved. We started
you on some medicines to help prevent the bleeding from coming
back. You will probably have another colonoscopy in the next few
months. You also had a heart attack from the low blood counts.
We have adjusted your medicines to help your heart recover. You
will need to see a cardiologist at the end of this month.
Medication changes:
1. Stop digoxin and nifedipine
2. Change simvastatin to Atorvastatin
3. Start Lidoderm patch, tylenol, and Tramadol
4. Start colace and senna to prevent constipation
5. Start Ferrous sulfate, folic acid and vitamin C to help your
body make red blood cells
6. Start pantoprazole twice daily to prevent bleeding
7. Start Metoprolol to help control your heart rate.
Followup Instructions:
Department: Cardiology
Name: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5310**]
When: Wednesday [**2182-8-7**] at 11:30AM
Address: [**Doctor Last Name 37166**],LOWER LEVEL, [**Location (un) **],[**Numeric Identifier **]
Phone: [**Telephone/Fax (1) 5315**]
Fax: [**Telephone/Fax (1) 66988**]
Department: Gastroenterology
Name: Dr. [**First Name8 (NamePattern2) 333**] [**Last Name (NamePattern1) 2520**]
When:
Address: [**Apartment Address(1) 85659**], [**Location (un) **],[**Numeric Identifier **]
Phone: [**Telephone/Fax (1) 85660**]
Fax: [**Telephone/Fax (1) 85661**]
Completed by:[**2182-7-26**]
|
[
"401.9",
"569.0",
"272.4",
"534.90",
"562.12",
"414.01",
"V10.05",
"410.71",
"427.31",
"V12.71",
"V45.89",
"288.60",
"285.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.23"
] |
icd9pcs
|
[
[
[]
]
] |
8630, 8700
|
5895, 7160
|
222, 254
|
8838, 8838
|
2651, 2651
|
9805, 10431
|
2527, 2531
|
7315, 8607
|
8721, 8817
|
7186, 7292
|
9021, 9398
|
3705, 5872
|
2546, 2632
|
3265, 3689
|
9418, 9782
|
176, 184
|
282, 2195
|
2667, 3248
|
8853, 8997
|
2217, 2491
|
2507, 2511
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,972
| 101,005
|
20928
|
Discharge summary
|
report
|
Admission Date: [**2128-7-2**] Discharge Date: [**2128-7-17**]
Date of Birth: [**2062-12-18**] Sex: M
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
SOB and productive cough. Inability to wean from ventilator at
[**Hospital 55664**] Hospital.
Major Surgical or Invasive Procedure:
Post-pyloric nasogastric tube.
Extubation.
Removal of chest tube #1.
Right Internal Jugular Central Line Placement.
History of Present Illness:
Pt is a 65 yo Vietnamese male w/ a PMH sig for Non-small cell
endobronchial lung CA s/p RMSB stent ([**5-21**]), COPD, and CRI
recently admitted to OSH on [**6-27**] w/ increased SOB and O2 sat in
the 70??????s. He denied CP/N/V/HA/change in UO/recent travel/sick
contacts/pedal edema at that time. He was found to have a MSSA
pna and COPD exacerbation. He was started on steroids, Nebs,
BiPAP, and gatafloxacin. On [**6-28**] he was intubated secondary to
resp failure, w/ resultant PTX. 2 Chest tubes were placed at
that time. Pt was not able to be weaned off the vent and he was
transferred to [**Hospital1 18**] MICUA on [**7-2**]. Pt was extubated on [**7-7**] and
one of his CT??????s was removed on [**7-8**]. Pt was initially noted to
be confused and agitated, which has subsequently improved once
he left the MICU. A post-pyloric NGT was successfully placed and
pt was at goal tube feeds of 40 cc/hr. He noted a non-radiating
pain in his L chest over the CT and pain at his peripheral IV
site. He continued to have a cough.
He denies substernal CP/SOB/Abd pain/N/V/D/HA.
Current Hx obtained via translator.
Past Medical History:
1. Non-Small Cell Lung CA s/p RMSB stent [**5-21**]
2. HTN
3. COPD
4. TB 10 yrs ago tx??????ed in [**Country 3992**]
5. ? h/o DVT
6. CRI (baseline Cr 1.7)
7. Chronic b/l LE pain and paraesthesia
8. hyperlipidemia
9. asymmetric pupils
10. Asthma FEV1 0.7 L
11. EF 64%, Mild MR, mild diastolic dysfxn
12. h/o MSSA pna in[**5-21**]
Social History:
Pt denies tob or EtOH use.
Family History:
GM w/ Lung CA.
Physical Exam:
O: Tm: 100.4 Tc:99.2 BP: 130 /53 (119-130/43-60)
HR: 70 (63-81)
RR: 15 (15-20) O2Sat.: 98-100% 2.5 LNC I/Os:
2770/1310
Gen: Cantonese speaking gentlemen, appears comfortable, sitting
up in bed.
HEENT: NC/AT. asymmetric pupils, PERRL. Anicteric. MMM. No
pallor, pos
Ecchymosis on post pharynx.
Neck: Supple. No masses or LAD. No JVD. Subcutaneous crepitus
over entire neck to ears
Lungs: Pos rhonchi and expiratory wheezes, decreased BS over R
base to mid lung fields.
Cardiac: distant heart sounds, RRR. S1/S2. No M/R/G.
Abd: pos subcutaneous crypitus, Soft, NT, ND, +NABS. No rebound
or guarding.
Extrem: No C/C/E.
Pertinent Results:
[**2128-7-2**] 09:42PM TYPE-ART TEMP-37.3 RATES-20/ TIDAL VOL-400
O2-60 PO2-191* PCO2-65* PH-7.29* TOTAL CO2-33* BASE XS-3
-ASSIST/CON
[**2128-7-2**] 09:42PM LACTATE-2.3*
[**2128-7-2**] 09:42PM freeCa-1.14
[**2128-7-2**] 08:05PM GLUCOSE-153* UREA N-45* CREAT-1.9* SODIUM-142
POTASSIUM-5.1 CHLORIDE-104 TOTAL CO2-28 ANION GAP-15
[**2128-7-2**] 08:05PM ALT(SGPT)-19 AST(SGOT)-27 ALK PHOS-47 TOT
BILI-0.2
[**2128-7-2**] 08:05PM ALBUMIN-3.3* CALCIUM-8.2* PHOSPHATE-2.9
MAGNESIUM-2.3 IRON-61
[**2128-7-2**] 08:05PM calTIBC-187* VIT B12-537 FOLATE-14.1
FERRITIN-443* TRF-144*
[**2128-7-2**] 08:05PM WBC-22.2*# RBC-3.18* HGB-9.0* HCT-28.8*
MCV-91 MCH-28.4 MCHC-31.4 RDW-14.2
[**2128-7-2**] 08:05PM NEUTS-81* BANDS-6* LYMPHS-1* MONOS-3 EOS-0
BASOS-0 ATYPS-0 METAS-5* MYELOS-4*
[**2128-7-2**] 08:05PM HYPOCHROM-1+ ANISOCYT-NORMAL POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL
[**2128-7-2**] 08:05PM PLT SMR-NORMAL PLT COUNT-410
[**2128-7-2**] 08:05PM PT-12.3 PTT-26.6 INR(PT)-1.0
Brief Hospital Course:
Pt is a 65 yo Vietnamese male with a PMH sig for Non-small cell
endobronchial lung CA s/p RMSB stent ([**5-21**]), COPD, and CRI
admitted to [**Hospital1 18**] MICU on [**2128-7-2**] for inability to wean from a
ventilator. Pt was inititally admitted to an OSH with resp
failure secondary to pneumonia, which required intubation. He
susequently developed a Left PTX and received 2 Left sided chest
tubes. Pt was extubated on [**7-7**] and one of his CT??????s was removed
on [**7-8**]. Pt was initially noted to be confused and agitated,
which has subsequently improved once he left the MICU. A
post-pyloric NGT was successfully placed and pt was at goal tube
feeds of 40 cc/hr. Throughout his stay he noted a non-radiating
pain in his L chest over the CT. He continued to have a cough.
Pt also received a post-pyloric nasogastric tube after he failed
a swallow evaluation post extubation. He was maintained at goal
tube feeds of 40 cc/hr until he pulled out the tube. A repeat
swallow evaluation was normal and the patient's diet was
advanced as tolerated.
1. Respiratory Failure. Etiology thought to be multifactorial.
Pt was successfully extubated on [**2128-7-7**] and transferred out of
the intensive care unit on [**2128-7-10**]. His O2 sats were initially
maintained on 2.5 L NC and on RA prior to discharge. Oncology
was consulted while the pt was in the intensive care unit for
his NSCLC. It was determined that he was not a surgical
candidate and radiation oncology was consulted to talk to the pt
about radiation therapy for palliation. A CT w/ contast was done
to evaluate his tumor burden. He was given IVF and mucomyst for
his CRI. Pt will follow-up with radiation oncology and oncology
as an out-patient.
2. COPD. Likely contributing to his respitory symptoms. He was
started on prednisone in the unit, which was subsequently
tapered prior to his discharge. He was continued on nebulizer
and inhaler treatments. He was also given Guaifenesin q 6 hrs
for cough.
3. PTX, thought to be secondary to barotrauma. One chest tube
was removed in the unit. Subcutaneous emphysema developed. It
sebsequently improved and the chest tube was changed from wall
suction to water seal and then to air. It continued to drain pus
and was left in place at the time of discharge as per thoracic
surgery's recommendation. The patient and his daugher were
instructed on how to care for the tube and a follow-up
appointment was made with thoracic surgery. They plan to remove
the tube 2 inches per week.
4. HTN. Well controlled throughout his hospital stay on ACEI and
B-B.
5. Hyponatremia. Etiology thought to be secondary to large
amounts of free water boluses added to his tube feeds.
Hyponatremia resolved once the fluid boluses were decreased.
6. CRI. Baseline Cr reported as 1.7. Cr decreased to 1.2,
however bumped to 1.5 post contrast. He was aggressively
hydrated and his Cr improved to 1.3 on day of discharge.
7. ID. staph bacteremia- initially started on iv oxacillin which
was then changed to dicloxacillin. Pt continued to spike temps
during his stay. Bld, Sputum, Pleural fluid, and Urine cultures
were obtained. Blood and pleural fluid with MSSA. Urine grew
GPC in pairs and clusters. Pt started on IV Vanco while on the
floor.
8. GI. Pt had 1 episode of melena. Etiology thought to be
gastritis or small ulcer. pt has 2 PIV's. he was consented and
crossmatched, however remained hemodynamically stable. He was on
po protonix. No EGD performed given clinical stability &
comorbities.
9. Agitation. Noted while pt was in the unit, however appeared
to resolve once the patient was on the floor. He was initially
controlled on Haldol prn with a sitter.
10. Social. SW consulted to help pt and family cope w/ new dx
of CA.
Medications on Admission:
1. Neurontin 100 tid
2. Atrovent
3. Alb IH
4. Lipitor 20 qd
5. Nifedipin 60 qd
6. Atenolol 75 qd
7. Colace
8. Tylenol
9. Senna
Discharge Medications:
1. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q1-2H () as needed.
Disp:*1 * Refills:*0*
2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q1-2H () as needed.
Disp:*1 * Refills:*0*
3. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
4. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO every six (6)
hours as needed for cough.
Disp:*90 ML(s)* Refills:*0*
5. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO QD (once a
day).
Disp:*60 Tablet(s)* Refills:*2*
6. 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*
7. Dicloxacillin Sodium 250 mg Capsule Sig: One (1) Capsule PO
Q6H (every 6 hours) for 8 days.
Disp:*32 Capsule(s)* Refills:*0*
8. Percocet 2.5-325 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Non-small Cell Lung Cancer status-post Right Main Stem Bronchus
Stent.
MSSA pneumonia
Probable Gastritis.
Discharge Condition:
Stable. Ambulating with walker, tolerating regular diet,
breathing comfortably on RA.
Discharge Instructions:
Please call return to the hospital if you have difficulty
breathing or any other problems arise.
Followup Instructions:
1. Provider: [**Name10 (NameIs) **],[**Doctor Last Name **] THORACIC LMOB 2A Where: THORACIC LMOB 2A
Date/Time:[**2128-7-20**] 10:30
2. Radiation Oncology. [**Hospital Ward Name 23**] Clinical Center, [**Location (un) 442**].
[**2128-7-20**] at 2:00 PM.[**Telephone/Fax (1) 55665**].
3. Pt is to follow up at [**Hospital3 55666**],
located at [**State **]. [**Location (un) 86**], [**Numeric Identifier 4809**]. The phone
number is ([**Telephone/Fax (1) 26420**]. He has an appointment for Thursday,
[**7-22**] at 1000. The patient must bring his medication list,
discharge worksheet, and identification. He should have his
renal function checked at this appointment.
4. Please call [**Hospital **] clinic to set up appointment with Dr.
[**Last Name (STitle) **]. [**0-0-**]
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
|
[
"584.9",
"276.0",
"401.9",
"593.9",
"511.1",
"958.7",
"162.2",
"493.20",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"42.81",
"33.23",
"96.6",
"34.04",
"96.05",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
8771, 8777
|
3825, 7576
|
403, 521
|
8927, 9014
|
2786, 3802
|
9159, 10062
|
2087, 2103
|
7754, 8748
|
8798, 8906
|
7602, 7731
|
9038, 9136
|
2118, 2767
|
270, 365
|
549, 1674
|
1696, 2027
|
2043, 2071
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,276
| 175,595
|
35300
|
Discharge summary
|
report
|
Admission Date: [**2166-9-25**] Discharge Date: [**2166-10-14**]
Date of Birth: [**2084-6-24**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Male First Name (un) 4578**]
Chief Complaint:
Dense R hemiparesis with aphasia
Major Surgical or Invasive Procedure:
IA tPA and MERCI extraction R MCA clot
History of Present Illness:
Patient is a 82 yo RHM with hx of Afib on coumadin,
hyperlipidemia and HTN here from OSH with sudden dense R
hemiparesis with aphasia. Per admission note and OSH physician,
[**Name10 (NameIs) **] was attending a meeting or a show when he suddenly slumped to
his R with dense R hemiparesis around 1:30 pm yesterday. He was
nonverbal but awake. There is no hx of trauma or fall. EMS was
called who found him to be severely bradycardic as well with HR
down to 30's hence he received 2 doses of atropine en route to
OSH. At the OSH, he had stat CT of head and was intubated for
airway protection after much sedation including Versed. He was
then transferred to [**Hospital1 18**].
Here at [**Hospital1 18**] he was minimally responsive given sedation and
continued to be R hemiplegic - repeat imaging including CTA and
CTP showed distal R ICA and MCA occlusion with increased MTT and
decreased CBV over R hemisphere. He was urgently taked to the
cerebral angio suite where he received IA tPA plus MERCI
procedue which successfully removed the clot over superior
division of R
MCA but due to the tortuosity of the inferior division, only IA
tPA was give for the inferior division. He was taken admitted
to SICU where he remained hemodynamically stable overnight.
He is more alert this morning but remains intubated although
requiring minimal support.
Per son, patient lives alone and independently. He drives,
walks without assistance and pays own bills. No hx of recent
infection or illness per family but they do not live with him.
Past Medical History:
1. Afib on coumadin
2. Hyperlipidemia
3. RBBB
4. HTN
5. Urticaria
6. hx of hernia repair in [**2148**]
7. s/p lap cholecystectomy in [**2161**]
8. perforated appendicitis with abscess in [**2164**]
9. CKD (baseline ~1.4)
Social History:
Separated, has 4 grown children who live locally. No EtOH,
cigarettes or illicit drug hx. Was a draftsman (architect) then
worked for [**Location (un) **] until 12 yrs ago.
Family History:
NC
Physical Exam:
T 97.8 BP 114~148/56~72 HR 58~77 RR 20 O2Sat 95% on CPAP 5/5
Gen: Lying in bed, intubated but arousable.
CV: Irregularly irregular but no murmurs/gallops/rubs
appreciated lots of transmitted upper airway sounds
Lung: +breath sounds bilateally but frequent coughing with thick
secretions.
Abd: +BS, soft, nontender
Ext: 1+ symmetric dorsalis pedis; trace edema bilaterally.
Neurologic examination on admission:
MSE: Awake and oriented to self. Follows simple commands ("open
your eyes," "stick out your tongue") but not with motor
movements. Remains nonverbal.
Neuro exam at d/c: expressive aphasia, EOMI, CN II-XII intact,
UE & LE reflexes +2, motor strength intact as far as can be
assesed UE & LE [**5-5**], follow 95% commands.
Cranial Nerves:
Pupils are round and equally reactive to light (4->2mm) but no
blink to visual threat on R and L gaze preference although eyes
pass midline with oculocephalic maneuver. Face symmetric and
+cough.
Motor:
Normal to slight hypotonia. Little voluntary movement even in L
but >[**3-5**] in both UE and LE. R biceps [**3-5**] but rest difficult to
assess. No purposeful withdrawal movements either.
Sensation: Grimaces to noxious stimuli and more pin prick
sensation on L than R.
Reflexes:
2 and symmetric throughout. Toes upgoing bilaterally
Unable to test coordination or gait.
Pertinent Results:
TELEMETRY demonstrated: A fib with HR today ranging up to 170.
Currently in 130s.
.
2D-ECHOCARDIOGRAM
[**2166-10-2**]
The left atrium is normal in size. The right atrium is
moderately dilated. Left ventricular wall thickness, cavity size
and regional/global systolic function are normal (LVEF 60-70%).
Right ventricular chamber size and free wall motion are normal.
The aortic root is moderately dilated at the sinus level. The
ascending aorta is mildly dilated. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Trivial mitral regurgitation is seen.
Compared with the findings of the prior study (images reviewed)
of [**2166-9-26**], no major change.
.
Echo [**2166-9-26**]
Extremely poor image quality. Cardiac chamber dimensions and
contractile function grossly preserved.
.
If clinically indicated, a transesophageal echocardiogram is
recommended for adequate imaging of cardiac structure and
function.
.
OTHER TESTING:
CXR [**2166-10-3**]:
CHEST RADIOGRAPH
FINDINGS: As compared to the previous radiograph, the
nasogastric tube has been removed and replaced by Dobbhoff
catheter. The catheter could be advanced by 5 cm. The left-sided
central venous access line is in unchanged position. The size of
the heart is also unchanged, however a subtle left-sided partly
retrocardiac area of hypoventilation has newly appeared.
There is no evidence of other focal parenchymal opacities
suggestive of pneumonia, no evidence of pleural effusions.
.
CT brain perfusion [**2166-9-25**]:
IMPRESSION:
1. CT of the head demonstrating hyperdense left middle cerebral
and internal carotid arteries, consistent with thrombosis. No
evidence for hemorrhage, edema, or mass effect.
2. CT perfusion study demonstrating increased mean transit time
for preserved blood volume and flow in the entire left MCA
territory, consistent with reversible ischemia.
3. CTA demonstrating occlusion of the left internal carotid
artery distal to the carotid bifurcation. There is no flow in
the entire cervical and intracranial internal carotid artery on
the left or the left middle cerebral artery. The anterior
cerebral artery is reconstituted the flow from the anterior
communicating artery. The remainder of the CTA is unremarkable.
.
CTA head and neck [**2166-9-25**]:
IMPRESSION:
1. CT of the head demonstrating hyperdense left middle cerebral
and internal carotid arteries, consistent with thrombosis. No
evidence for hemorrhage, edema, or mass effect.
2. CT perfusion study demonstrating increased mean transit time
for preserved blood volume and flow in the entire left MCA
territory, consistent with reversible ischemia.
3. CTA demonstrating occlusion of the left internal carotid
artery distal to the carotid bifurcation. There is no flow in
the entire cervical and intracranial internal carotid artery on
the left or the left middle cerebral artery. The anterior
cerebral artery is reconstituted the flow from the anterior
communicating artery. The remainder of the CTA is unremarkable
.
[**2166-9-27**] CT head without contrast
IMPRESSION: Evidence for left middle cerebral artery territory
infarction is reidentified with patchy foci of hyperdense
attenuation suggestive of petechial hemorrhage. No significant
change compared to the study from a day prior.
.
[**2166-9-25**] 04:30PM BLOOD WBC-5.2 RBC-4.83 Hgb-15.6 Hct-46.6 MCV-97
MCH-32.3* MCHC-33.4 RDW-14.7 Plt Ct-127*
[**2166-10-8**] 06:40AM BLOOD WBC-4.7 RBC-3.32* Hgb-10.6* Hct-31.0*
MCV-93 MCH-31.8 MCHC-34.1 RDW-14.6 Plt Ct-240
[**2166-10-8**] 11:13PM BLOOD WBC-11.9*# RBC-3.47* Hgb-11.2* Hct-32.5*
MCV-94 MCH-32.2* MCHC-34.4 RDW-14.7 Plt Ct-253
[**2166-10-9**] 03:52AM BLOOD WBC-14.2* RBC-3.42* Hgb-11.0* Hct-32.0*
MCV-93 MCH-32.2* MCHC-34.5 RDW-14.6 Plt Ct-245
[**2166-10-9**] 03:52AM BLOOD Neuts-79* Bands-7* Lymphs-6* Monos-6
Eos-0 Baso-0 Atyps-1* Metas-1* Myelos-0
[**2166-9-25**] 04:30PM BLOOD PT-23.1* PTT-35.2* INR(PT)-2.2*
[**2166-10-9**] 09:20AM BLOOD PT-47.1* INR(PT)-5.2*
[**2166-9-25**] 04:30PM BLOOD Glucose-94 UreaN-20 Creat-1.2 Na-137
K-4.6 Cl-106 HCO3-23 AnGap-13
[**2166-10-9**] 03:52AM BLOOD Glucose-121* UreaN-24* Creat-1.4* Na-135
K-4.0 Cl-104 HCO3-23 AnGap-12
[**2166-9-26**] 03:14AM BLOOD CK(CPK)-65
[**2166-9-26**] 01:24PM BLOOD CK(CPK)-603*
[**2166-9-27**] 02:28AM BLOOD CK(CPK)-799*
[**2166-10-4**] 07:20AM BLOOD CK(CPK)-187*
[**2166-10-5**] 05:14AM BLOOD ALT-43* AST-45* CK(CPK)-184* AlkPhos-63
Amylase-54 TotBili-0.8
[**2166-10-5**] 10:00AM BLOOD CK(CPK)-204*
[**2166-10-6**] 06:10AM BLOOD ALT-56* AST-58* AlkPhos-75 TotBili-1.0
[**2166-10-7**] 06:40AM BLOOD ALT-67* AST-64* AlkPhos-67
[**2166-10-8**] 06:40AM BLOOD ALT-71* AST-64* AlkPhos-66 TotBili-0.9
[**2166-10-13**] AST46 ALT33 LD251 Alk ph61 Tbili 0.7
[**2166-9-26**] 03:14AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2166-9-26**] 01:24PM BLOOD cTropnT-<0.01
[**2166-9-27**] 02:28AM BLOOD cTropnT-<0.01
[**2166-10-5**] 05:14AM BLOOD CK-MB-5 cTropnT-<0.01
[**2166-10-5**] 10:00AM BLOOD CK-MB-5 cTropnT-<0.01
[**2166-10-5**] 05:14AM BLOOD Lipase-40
[**2166-9-26**] 03:14AM BLOOD Calcium-7.8* Phos-2.4* Mg-1.7 Cholest-104
[**2166-10-9**] 03:52AM BLOOD Calcium-8.8 Phos-2.3* Mg-1.7
[**2166-9-26**] 01:24PM BLOOD %HbA1c-5.8
[**2166-9-26**] 01:24PM BLOOD Triglyc-80 HDL-32 CHOL/HD-2.8 LDLcalc-42
[**2166-9-26**] 01:12PM BLOOD Digoxin-0.6*
.
Labs on day of d/c
N134 Cl101 BUN25 glc91 AGap=9
K5.0 HCO329 Creat1.3
Ca: 9.1 Mg: 2.0 P: 3.2
WBC94 H/H 4.9/33.8 plt312
Brief Hospital Course:
Patient is a 82 yo RHM with hx of paroxysmal Afib, HTN and
hyperlipidemia who had a witnessed dense R hemiparesis with
aphasia found to have clot in his R MCA who underwent IT tPA and
MERCI procedure which successfully removed his superior division
clot but not the inferior divison (supplying the R temporal
lobe) - only IA tPA.
.
Possibly emoblic stroke given the sudden nature of onset -
possible sources include cardiac or carotid. Patient does have
risk factors including age, HTN, hyperlipidemia and PAF although
he was anticoagulated and was therapeutic on admission.
.
He was admitted to Neuro ICU and was successfully extubated on
HD#2 - he continued to make improvements especially in motor
movements and although due to impaired comprehension, its
difficult to do formal strength testing, he appears to be full
strength throughout. His main deficits remain speech/language
given extensive L temporal lobe infarct. He has an expressive
aphasia but follows 90% of commands. He was initially started on
ASA only then on HD#5, restarted on Coumadin with ASA bridging
only given the extensive infarct to minimize risk of hemorrhagic
transformation. His coumadin was held during the second half of
his hospitalization as his INR was supratherapeutic. He was
instructed to restart his coumadin the day after discharge. Echo
was done twice - initial study was subpar but the 2nd study was
adequate to show preserved systolic functions and no thrombus.
.
He has known PAF but his rate was poorly controlled during this
admission. Cardiology was consulted and they recommended
streamlining his regimen including discontinuation of digoxin,
disopyramide, and metoprolol and changing to long acting
diltiazem. He was later continued on diltiazem and started on
amiodarone 200mg PO TID but he continued to have PAF at which
point he was started on an amiodarone drip. He converted to NSR
while on the amiodarone drip. After finishing 5hrs on drip of
1mg/min and then 18hrs at 0.5mg/min he was switched to
amiodarone 200mg TID. He went back into Afib on the Amiodarone
PO which was likely secondary to the stress of his UTI (see
below). On [**2166-10-13**] he converted back to NSR. He is being
discharged on amiodarone 200mg PO TID and after he has been
loaded for a total of 10g he will be switched to a maintenance
dose of 200mg daily (loading will be done on [**2166-10-22**]). His
LFTs (AST & ALT) increased from the 40s to the 70s likely due to
the amiodarone but trended back down. His statin was stopped in
the setting of his increased LFTs and he was restarted on the
statin when his LFTs fell. The patient's goal INR is 2.5-3 but
he was supratherapeutic for much of his hospitalization. The
patient's previous coumadin home regimen was 4mg (TTSS) and 2mg
(MWF) as he should be restarted on that the day after discharge.
.
Late in his admission he developed rigors and decreased UOP.
His foley was changed and his urine analysis showed evidence of
a UTI. His UTI was being treated with cipro but his culture came
back resistent to cipro and he was changed to nitrofurantoin. He
needs to finish his course of nitrofurantion and his last day of
a seven day course will be [**2166-10-17**]. He is being discharged
with a foley due to problems with urinary retention. He is set
up with urology follow up for urinary retention.
.
The patient was seen by speech and swallow and has the following
food restrictions.
-Dysphagia with following recs from swallowing exam: Diet:
ground consistency solids w/ thin liquids, Meds: whole in puree,
Seated upright during meals, and Needs full supervision for
feeding.
.
The patient is full code which was confirmed by the patient and
his son.
.
The patient will get Speech, PT, and OT at [**Hospital 38**] Rehab.
Medications on Admission:
1. Coumadin (4mg TTSS and 2mg MWF)
2. Digoxin 125mcg daily
3. Metoprolol 50 am /25 night
4. Lipitor 10 daily
5. Verapamil 40 TID
6. MVI
7. Disopyramide 150 [**Hospital1 **]
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day as needed for constipation.
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
4. coumadin Resume when INR < 3 in order to maintain goal INR of
2.5-3. (previous regimen TTSS 4mg and MWF 2mg)
5. MVI daily
6. lab work [**2166-10-13**] AST, ALT, CBC, Chem 7 fax results to PCP
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 29247**]
7. Outpatient Lab Work INR checks daily (goal 2.5-3)
8. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO three times a
day for 13 days: last dose evening of [**2166-10-22**].
9. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day:
START ON [**2166-10-23**] after finishing TID dosing.
10. Nitrofurantoin (Macrocryst25%) 100 mg Capsule Sig: One (1)
Capsule PO BID (2 times a day): Until [**10-17**].
11. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
12. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Primary
Stroke of LMCA
Paroxysmal Atrial Fibrillation
Urinary tract infection
Urinary retention
Difficulty swallowing
Hyperlipidemia
Increased LFTs
.
Secondary
RBBB
HTN
Urticaria
hx of hernia repair in [**2148**]
s/p lap cholecystectomy in [**2161**]
perforated appendicitis with abscess in [**2164**]
CKD
Discharge Condition:
Stable. Expressive aphasia. Understands 80% of commands.
Treating UTI. NSR.
Discharge Instructions:
You were admitted with a R hemiparesis and aphasia and found to
have clot in your L MCA vessel. You underwent IT tPA and MERCI
procedure which was successfully removing his superior division
clot but not the inferior divison (supplying the R temporal
lobe). You understand about 80% of commands but have expressive
aphasia and a slight pronator drift. You were in paroxysmal
atrial fib and treated with oral and IV amiodarone. You will be
discharged on oral amiodarone. You also developed urinary
retention and will be discharged with a foley with urology
follow up. You had a urinary tract infection which was treated
with nitrofurantoin and will need to finish a 7 day course of
antibiotics. Once you finish this antibiotic course, you should
have your foley catheter removed, if possible. If the foley
catheter cannot be removed, your urinary retention should be
addressed at your urology appointment. You also had some
difficulty swallowing and should take the following precautions
when eating:
1. Diet: ground consistency solids w/ thin liquids
2. Meds: whole in puree
3. Seated upright during meals
4. Needs full supervision for feeding
5. Continue to monitor for aspiration
.
New medication:
Amiodarone 200mg PO TID until [**2166-10-22**] and then amiodarone 200mg
PO daily
Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day as needed for constipation.
Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
Nitrofurantoin 100 [**Hospital1 **] until [**10-17**]
.
Stopped medications:
Digoxin
Verapamil
Disopyramide
Coumadin is being held due to supratherapeutic INR, should be
resumed when INR < 3 for goal INR of 2.5-3.
.
Continue the following old medications:
MVI
.
Please return to the ED if you experience any palpitations,
chest pain, new weakness, numbness, difficulty seeing, or any
other new medical problem.
Followup Instructions:
Urology: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Hospital1 **] [**Hospital Ward Name 23**] center on [**2166-10-22**]
at 10 am.
Neurology: Dr. [**Last Name (STitle) 6938**] on Friday [**10-24**] 3:30 [**Hospital Ward Name 23**]
building.
Primary Care: Please Call Dr. [**Last Name (STitle) 29247**] for an appointment within 2
weeks. [**Telephone/Fax (1) 29248**]
.
Provider: [**Last Name (NamePattern4) **]. [**First Name11 (Name Pattern1) 275**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2166-10-31**] 10:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2166-11-21**] 1:20
Completed by:[**2166-10-22**]
|
[
"V58.61",
"876.0",
"427.31",
"272.4",
"999.2",
"585.9",
"788.20",
"426.4",
"431",
"342.81",
"458.29",
"403.90",
"451.84",
"E884.2",
"787.20",
"784.3",
"599.0",
"E879.8",
"434.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.41",
"39.74",
"00.41",
"96.71",
"38.91",
"38.93",
"96.6",
"99.10"
] |
icd9pcs
|
[
[
[]
]
] |
14447, 14544
|
9324, 13094
|
353, 393
|
14894, 14974
|
3793, 9301
|
17013, 17812
|
2418, 2422
|
13318, 14424
|
14565, 14873
|
13120, 13295
|
14998, 16990
|
2437, 2834
|
281, 315
|
421, 1964
|
3189, 3774
|
2848, 3173
|
1986, 2209
|
2225, 2402
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,219
| 162,986
|
27591
|
Discharge summary
|
report
|
Admission Date: [**2175-7-11**] Discharge Date: [**2175-7-19**]
Date of Birth: [**2110-5-31**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
65M with dyspnea.
Major Surgical or Invasive Procedure:
[**2175-7-12**] - Pericardiocentesis with placement of a pericardial
drain.
[**2175-7-15**] - Right VATS, pericardial window
History of Present Illness:
This 65M is s/p CABGx3 on [**6-6**] and was discharged to home on
POD#7. He had an uneventful postop course but developed
increased DOE/SOB over the past week. He had a negative ETT
yesterday and an echo revealed pericardialwith loculations which
was suggestive for tamponade. He was transferred from MWMC for
further treatment.
Past Medical History:
s/p CABGx3(LIMA->LAD< SVG->Ramus, Diag) [**2175-6-6**]
[**Month/Day/Year **]
^chol.
[**Month/Day/Year 5550**]
Depression
s/p spinal fusion
Social History:
Lives with wife, works as a carpenter.
Cigs: quit in [**2138**]
ETOH: 1-2 drinks/day
Family History:
Unremarkable.
Physical Exam:
Gen: WDWN [**Male First Name (un) 4746**] in NAD
VS: Afeb HR: 77 BP: 160/68 RR:10 97% sat on RA
HEENT: NC/AT, PERLA, EOMI, oropharynx benign
Neck: supple, FROM, no lymphadenopathy or thyromegaly, carotids
2+= bilat. without bruits, + JVD
Lungs: bibasilar crackles
CV: RRR without R/G/M, nl. S1, S2,
Abd: +BS, soft, nontender, without masses or hepatosplenomegaly
Incisions: Healing well, no errythema or drainage
Ext: cool, no C/C/E, pulses 2+=bilat.
Neuro: nonfocal
Pertinent Results:
[**2175-7-16**] 07:55PM BLOOD WBC-13.1* RBC-3.97* Hgb-11.8* Hct-34.0*
MCV-86 MCH-29.8 MCHC-34.8 RDW-14.2 Plt Ct-273
[**2175-7-16**] 04:00AM BLOOD PT-13.2* PTT-24.3 INR(PT)-1.1
[**2175-7-17**] 09:10AM BLOOD Glucose-124* UreaN-19 Creat-1.1 Na-134
K-4.9 Cl-100 HCO3-25 AnGap-14
PATIENT/TEST INFORMATION:
Indication: Pericardial effusion. Pericarditis. S/p pericardial
window.
Height: (in) 68
Weight (lb): 211
BSA (m2): 2.09 m2
BP (mm Hg): 120/70
HR (bpm): 60
Status: Inpatient
Date/Time: [**2175-7-17**] at 12:00
Test: TTE (Focused views)
Doppler: Limited Doppler and no color Doppler
Contrast: None
Tape Number: 2006W035-0:50
Test Location: West Echo Lab
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name (STitle) 412**] [**Last Name (Prefixes) 413**]
MEASUREMENTS:
Mitral Valve - E Wave: 0.8 m/sec
Mitral Valve - A Wave: 0.9 m/sec
Mitral Valve - E/A Ratio: 0.89
Mitral Valve - E Wave Deceleration Time: 226 msec
TR Gradient (+ RA = PASP): 20 mm Hg (nl <= 25 mm Hg)
INTERPRETATION:
Findings:
This study was compared to the prior study of [**2175-7-14**].
RIGHT ATRIUM/INTERATRIAL SEPTUM: The IVC is normal in diameter
with
appropriate phasic respirator variation.
LEFT VENTRICLE: Normal LV wall thickness, cavity size, and
systolic function
(LVEF>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTIC VALVE: Normal aortic valve leaflets.
MITRAL VALVE: Normal mitral valve leaflets.
TRICUSPID VALVE: Normal PA systolic pressure.
PERICARDIUM: Small to moderate pericardial effusion. No RV
diastolic collapse.
No significant respiratory variation in mitral/tricuspid valve
flows.
Conclusions:
Left ventricular wall thickness, cavity size, and systolic
function are normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal.
The aortic valve leaflets appear structurally normal with good
leaflet
excursion. The mitral valve leaflets are structurally normal.
The estimated
pulmonary artery systolic pressure is normal. There is a small
to moderate
sized partially echo filled predominantly anterior pericardial
effusion (1.3cm
around he basal right ventricle, 2.0cm anterior to the right
atrium and distal
right ventricle) without evidence for hemodynamic compromise.
Compared with the prior study (images reviewed) of [**2175-7-15**],
the size of the
effusion is reduced, the IVC now demonstrates normal respiratory
variation,
and tamponade physiology is no longer suggested.
Electronically signed by [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4083**], MD on [**2175-7-17**]
12:51.
[**Location (un) **] PHYSICIAN: [**Name10 (NameIs) **],[**First Name3 (LF) **] J.
CHEST (PA & LAT) [**2175-7-18**] 1:43 PM
CHEST (PA & LAT)
Reason: s/p drain removal, eval ptx
[**Hospital 93**] MEDICAL CONDITION:
65 year old M s/p R. VATS, pericardial window, drainage of
loculated pericardial effusion.
REASON FOR THIS EXAMINATION:
s/p drain removal, eval ptx
PA AND LATERAL VIEWS OF THE CHEST
REASON FOR EXAM: S/P drain removal, evaluate pneumothorax.
65-year-old man S/P right VATS with pericardial window.
Comparison is made with prior study performed a day before.
FINDINGS: The right chest tubes have been removed. There is no
pneumothorax. The right hemidiaphragm remains elevated with
atelectasis in the adjacent right lower lobe. A small right
pleural effusion. Unchanged small retrocardiac atelectasis.
Persistent marked enlargement of the cardiac silhouette likely
secondary to the patient's known pericardial effusion.
IMPRESSION: No pneumothorax.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) 3901**] [**Name (STitle) 3902**]
DR. [**First Name (STitle) **] [**Initials (NamePattern5) 3250**] [**Last Name (NamePattern5) 3251**]
Approved: WED [**2175-7-19**] 11:46 AM
Brief Hospital Course:
The patient was admitted on [**2175-7-11**] to the CSRU for close
monitoring. Echo here revealed tamponade physiology and on HD#1
he underwent pericardiocentesis by Dr. [**Last Name (STitle) 911**] and 500 cc of fluid
was drained. The patient tolerated the procedure well and his
symptoms resolved. An echo the following morning revealed
reaccumulation of the fluid and Dr. [**Last Name (STitle) **] of thoracic
surgery was consulted. On [**7-15**] he had a R VATS for a loculated
pericardial effusion and tolerated the procedure well. On POD#2
the [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 406**] drain was d/c'd and on POD#3, the other drain was
d/c'd. He grew out gm + rods from the pericardial fluid and he
was evaluated by ID. He had a negative Lyme titer and stool
samples sent. They felt no furhter treatment was needed. He was
discharged to home in stable condition on POD#4.
Medications on Admission:
Colace 100 mg PO BID
ASA 81 mg PO daily
Lisinopril 40 mg PO daily
Lipitor 40 mg PO daily
Prilosec 20 mg PO daily
Fluoxetine 40 mg PO daily
Lopressor 25 mg PO BID
Norvasc 10 mg PO daily
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 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. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
5. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
8. Fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*0*
9. Prilosec 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:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Pericardial effusion/tamponade
s/p CABG x 3 [**6-6**]
[**Month/Year (2) **]
[**Month/Year (2) 5550**]
hyperlipidemia
depression
s/p spinal fusion
Discharge Condition:
Good.
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pound sin one day or five in one week,
No lifting more than 10 pounds.
Shower, no lotions, creams powders to incision.
Followup Instructions:
Dr. [**First Name (STitle) **] 1-2 weeks
Dr. [**Last Name (STitle) **] 2 weeks Call [**Telephone/Fax (1) 170**] for appointment
Completed by:[**2175-7-20**]
|
[
"530.81",
"401.9",
"423.9",
"311",
"272.0",
"V45.81",
"414.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.12",
"37.0",
"37.21"
] |
icd9pcs
|
[
[
[]
]
] |
7733, 7739
|
5482, 6392
|
339, 465
|
7929, 7937
|
1628, 1903
|
8182, 8341
|
1107, 1122
|
6627, 7710
|
4421, 4512
|
7760, 7908
|
6418, 6604
|
7961, 8159
|
1929, 4203
|
1137, 1609
|
282, 301
|
4541, 5459
|
493, 826
|
4235, 4384
|
848, 988
|
1004, 1091
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,013
| 109,243
|
8636
|
Discharge summary
|
report
|
Admission Date: [**2150-11-30**] Discharge Date: [**2150-12-22**]
Date of Birth: [**2073-10-4**] Sex: M
Service: VSU
The patient was admitted for a evaluation of a right lower
extremity free flap by the plastic CV service. The lower
extremity warranted a vascular evaluation. A right anterior
tibial artery angiogram was obtained for evaluation. There
was noted necrosis at the site of a prior saphenous vein
harvest for a coronary artery bypass graft. Vascular surgery
was consulted with Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **] who determined
that a right below the knee amputation was needed and the
right below the knee amputation was performed on [**2150-12-7**].
The postoperative course was complicated by respiratory
failure requiring reintubation and transfer to Intensive Care
Unit and also some renal failure for which both the
cardiology service and the renal service were consulted. The
patient's renal failure continued to improve. The
electrophysiology service was consulted regarding an episode
of arrhythmia, the patient with a known automatic implantable
cardiac defibrillator. The patient was evaluated and was
noted to have right ventricle sensing abnormality and
outpatient follow-up was deemed appropriate. The patient
also had a large pleural effusion while he was intubated.
This effusion was drained on [**2150-12-14**], and the patient then
proceeded to self extubate which he was able to tolerate. He
was begun on Coumadin on [**2150-12-16**], and continued on such.
The patient was doing well off the ventilator, had an episode
of emesis on [**2150-12-17**]. The chest x-ray done repeated
showed a new right apical patchy alveolar opacity that was
likely consistent with aspiration. The patient continued to
do relatively well with no need for frequent suctioning for
increased secretions. The patient was transferred to the
Vascular Intensive Care Unit on [**2150-12-17**], and was doing
well. A rehabilitation facility screen was instituted and
the patient continued to do well. On the morning of
[**2150-12-22**], the patient was seen and evaluated and was verbal
about his desire to go to rehabilitation facility. At around
0700 in the a.m. of [**2150-12-22**], the patient was noted to have
no respiratory rate on telemetry and was then evaluated and
found to be unresponsive at the bedside. A code was called
and the patient was noted to have a systolic blood pressure
[**Location (un) 1131**] in the 70s on telemetry but no pulse was noted on
examination. PEA progressing to ventricular fibrillation was
noted, and intermittent direct cardioversion per the
patient's own automatic implantable cardiac defibrillator was
noted. The patient was intubated, no compressions or shocks
were performed as per the patient and family's wishes. ACLS
protocol was instituted and the team was unable to obtain a
pulse throughout despite all the efforts. The patient
expired at 0730 in the morning [**2150-12-22**]. Series of events
were discussed with Dr. [**Last Name (STitle) **], who then proceeded to
contact the family. The medical examiner declined the
postmortem examination. The family agreed to a voluntary
postmortem examination which was to take place as soon as
possible.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 17755**], [**MD Number(1) 17756**]
Dictated By:[**Last Name (NamePattern1) 30263**]
MEDQUIST36
D: [**2150-12-22**] 18:44:30
T: [**2150-12-22**] 19:09:07
Job#: [**Job Number 30264**]
cc:[**Last Name (NamePattern4) 30265**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 30266**], MD
|
[
"428.0",
"599.0",
"682.6",
"995.92",
"427.5",
"707.13",
"730.17",
"038.8",
"584.5",
"518.5",
"998.59",
"427.31",
"730.07",
"998.83",
"V53.32",
"V45.81",
"507.0",
"440.23"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"86.27",
"88.42",
"88.48",
"89.49",
"99.04",
"38.93",
"96.04",
"34.91",
"96.72",
"39.50",
"84.15"
] |
icd9pcs
|
[
[
[]
]
] | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,057
| 140,838
|
27987
|
Discharge summary
|
report
|
Admission Date: [**2156-7-24**] Discharge Date: [**2156-8-10**]
Date of Birth: [**2088-8-9**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Erythromycin Base / Heparin Agents
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Tracheomalacia
Major Surgical or Invasive Procedure:
[**2156-7-30**]: had rigid bronch, electrocautery and balloon dilatation
of trachea, and upsizing of her trach to a #7
[**2156-8-9**]: rigid bronch, T-tube placement
L-PICC placement
History of Present Illness:
Txfer from [**Hospital3 3583**]
In [**1-30**], patient was difficult to extubate s/p CABG and required
a tracheostomy. She was subsequently sent to pulmonary rehab.
.
She was referred to Dr. [**Last Name (STitle) **] in [**6-25**] who performed a rigid
bronchoscopy here followed by replacement of her tracheostomy
tube. She was found to have a circumferential area of stenosis
below the cricoid cartilage extending 6cm; it was not felt to be
granulation tissue. DEbridement was minimally successful. A CT
scan was done which showed that she had:
-Focal tracheal stenosis at the inferior extent of the
tracheostomy tube.
-There was also: proximal narrowing which may relate to
granulation tissue versus secretions.
-Polypoid soft tissue density just above the insertion of the
tracheostomy tube may relate to granulation tissue.
.
- she was discharged back to rehab
.
On [**2156-7-4**], she was then admitted to [**Hospital3 **] with SOB
and desatted to the low 90s. She was given O2, suctioning and
nebulizers without significant improvement. Initially, she was
started on Levoquin and finished a 14 day course for suspected
bronchitis. Her respiratatory status improved and hence she did
not require ventilation.
.
She was found on HOD #2 to have Enterococcus bacteremia - via Cx
x 2 on [**7-4**] and Cx x 2 on [**7-5**]. (A TTE was negative for
vegetations. A TEE was not performed). As such, She was started
on Vancomycin with subsequent negative surveillance cultures.
.
[**7-8**]: ID was consulted. They added on Gent once her urine
culture came back positive for Klebsiella UTI. This particular
Klebsiella UTI was only sensitive to Gentamicin, Imipenem, Zosyn
and Cefotetan.
- Started on Imipenem on [**2156-7-24**] for this.
.
On [**7-19**], she was obtunded and had significant mucous secretions
and mucus plugging requiring suctioning; ENT changed her
cuffless trach from a #6 to a #4 and transitioned to a trach
collar after transient ventilation.
.
On [**7-19**], she has a IJ TLC placed in OR at [**Hospital1 46**].
On [**7-22**], noticed to have "mild stridor" and mild tachypnea and
was replaced on a ventilator.
.
Of note:
- was found to be C Diff + and was started on flagyl
.
Today, she is transferred to [**Hospital1 18**] for further options regarding
placement of a new tracheostomy tube.
Past Medical History:
1. CAD - s/p PTCA [**2153**], NSTEMI [**1-30**], s/p CABGx4 (LIMA->LAD, vein
grafts to OM and Distal Cflx, reverse saphenous to post
descending artery) [**1-30**]
- s/p sternal wound debridement [**2156-2-22**] (Proteus and Staph) ->
ID recommended 6 wks of Ceftriaxone and Vancomycin -> ? if
finished
- brief episode of Afib/aflutter -> Amiodarone -> 2nd degree
heart block -> converted back to sinus
- complicated by: Proteus Mirabilis sepsis
2. L Subdural hematoma ([**4-29**] - s/p fall)with R aneurysm; With R
homonymous hemianopsia
3. SIADH
4. diabetes mellitus II
5. Aortic valve replacement (bovine) [**1-30**]
6. Pituitary tumor
7. GERD
8. Urinary tract infection;
9. Sternal wound infection.
10. s/p tracheostomy for respiratory failure.
10. Tracheomalacia -> s/p laser removal of granulation tissue x
2 ([**5-28**])
11. C Diff colitis
12. Renal insufficiency (baseline Cr: ? - Last Cr was 1.5 at
[**Hospital3 **])
13. s/p hysterectomy
Social History:
She presently resides in Rehab facility on [**Hospital3 **]. Son and
daughter involved w/ care. Does not drink ETOH. SMoked in past
but not at this time.
Family History:
Significant for CAD in her mother at age of 62. [**4-28**] siblings
died from heart disease.
Physical Exam:
T: 97.9 BP: 114/42 P: 63
REsp: CPAP + PS : [**10-28**] 20 x 425 @ FiO2 of 0.3
Gen: Obese female in NAD
HEENT: PERRLA EOMI. OP without upper dentition. Multiple
fillings in lower dentition.
Neck: Large with trach in place and attached to ventilator.
CV: +s1+s2 SEM [**3-29**] heard in multiple fields
Resp: Coarse sounds c/w ventilator. No crackles or wheezing
heard
Abd: Midline scar. Multiple ecchymoses and bruises from
injections. Soft NT ND.
Ext: 2+ pretibial edema. Patient with 2 healing ulcers on L leg
in region of scars from vein removal for CABG. No splinter
hemorrhages seen in finger nails.
Neuro: AAO x 3
Pertinent Results:
REPORTS:
.
CHEST (PORTABLE AP) [**2156-7-24**] 8:17 PM
A tracheostomy tube terminates within the trachea just above the
level of the clavicles. Left internal jugular vascular catheter
terminates in the superior vena cava, and a nasogastric tube
courses below the diaphragm. Cardiac silhouette is enlarged.
There are patchy and linear areas of atelectasis at the lung
bases. There is a questionable small left pleural effusion.
.
TEE [**2156-7-26**]
Conclusions:
No spontaneous echo contrast or thrombus is seen in the body of
the left
atrium/left atrial appendage or the body of the right
atrium/right atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler. Overall left ventricular systolic function is normal
(LVEF>55%). The ascending,
transverse and descending thoracic aorta are normal in diameter
and free of atherosclerotic plaque. A bioprosthetic aortic valve
prosthesis is present. The aortic prosthesis appears well
seated, with thin leaflets that display normal motion. There is
no aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. There is no pericardial effusion.
IMPRESSION: Normal aortic bioprosthesis. Mild mitral
regurgitation with mildly thickened leaflets. No vegetation
seen.
.
WRIST(3 + VIEWS) RIGHT PORT [**2156-7-28**] 11:52 AM
IMPRESSION:
1. No definite evidence for fractures.
2. Degenerative changes as described above.
.
CHEST PORT. LINE PLACEMENT [**2156-7-29**] 8:57 AM
IMPRESSION:
1. Left-sided PICC with tip in SVC. Findings discussed with
[**Doctor First Name **] of IV therapy at 10:30 a.m.
2. Improving opacity in the left perihilar region could
represent improving aspiration or asymmetric edema. Stable
bibasilar atelectasis.
.
IMAGING:
[**8-4**] KUB
IMPRESSION:
1) Distention of small bowel suggestive of functional colonic
abnormality causing small-bowel obstruction.
2) Interval decrease in size of transverse colon now measuring 4
cm in widest diameter.
.
.
ADMISSION LABS:
.
[**2156-7-24**] 10:02PM URINE COLOR-Straw APPEAR-Cloudy SP [**Last Name (un) 155**]-1.012
[**2156-7-24**] 10:02PM URINE BLOOD-LG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2156-7-24**] 10:02PM URINE RBC->50 WBC->50 BACTERIA-MANY YEAST-MANY
EPI-0-2
[**2156-7-24**] 08:24PM GLUCOSE-137* UREA N-45* CREAT-1.5* SODIUM-145
POTASSIUM-3.9 CHLORIDE-111* TOTAL CO2-26 ANION GAP-12
[**2156-7-24**] 08:24PM CALCIUM-8.6 PHOSPHATE-2.8 MAGNESIUM-1.9
[**2156-7-24**] 08:24PM VANCO-10.7*
[**2156-7-24**] 08:24PM PHENYTOIN-6.7*
[**2156-7-24**] 08:24PM WBC-19.7*# RBC-3.33* HGB-9.7* HCT-29.2*
MCV-88 MCH-29.1 MCHC-33.1 RDW-17.9*
[**2156-7-24**] 08:24PM NEUTS-90.6* LYMPHS-5.8* MONOS-2.2 EOS-1.0
BASOS-0.2
[**2156-7-24**] 08:24PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-1+
MICROCYT-1+
[**2156-7-24**] 08:24PM PLT COUNT-186
[**2156-7-24**] 08:24PM PT-13.1 PTT-29.3 INR(PT)-1.1
.
DISCHARGE LABS:
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2156-8-10**] 04:57AM 14.6* 3.79* 11.0* 33.1* 87 29.0 33.2
17.9* 264
Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2156-8-10**] 04:57AM 126* 53* 1.6* 134 4.1 106 19* 13
.
LFTs:
ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili
[**2156-8-3**] 05:00PM 15 14 20* 127* 21 0.2
[**2156-7-25**] 06:03AM 6 7 140 97 0.2
Lipase
[**2156-8-3**] 05:00PM 9
.
Albumin Globuln Calcium Phos Mg
[**2156-8-7**] 10:13AM 1.6* 7.2* 3.6 2.2
.
HEME:
calTIBC Ferritn TRF
[**2156-8-1**] 05:54AM 74* 872* 57
.
PITUITARY:
Prolact TSH
[**2156-8-1**] 05:54AM 107* 2.1
Free T4
[**2156-8-1**] 05:54AM 0.6
Phenyto
[**2156-8-6**] 04:00AM 3.0
freeCa
[**2156-8-3**] 11:09AM 1.19
.
.
MICRO:
.
[**7-24**] blood cx: negative
[**2156-8-1**] 5:30 pm BLOOD CULTURE 2 OF 2 NEGATIVE
.
[**2156-7-26**] 4:10 pm CATHETER TIP-IV Source: LIJ triple lumen.
-NO GROWTH
.
.
[**2156-7-24**] 9:57 pm SPUTUM Site: ENDOTRACHEAL
Source: Endotracheal.
**FINAL REPORT [**2156-7-30**]**
GRAM STAIN (Final [**2156-7-25**]):
[**11-17**] PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE DIPLOCOCCI.
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final [**2156-7-30**]):
OROPHARYNGEAL FLORA ABSENT.
ACINETOBACTER BAUMANNII. MODERATE GROWTH.
"Note, for Amp/sulbactam, higher-than-standard dosing
needs to be
used, since therapeutic efficacy relies on intrinsic
activity of
the sulbactam component".
KLEBSIELLA PNEUMONIAE. SPARSE 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.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ACINETOBACTER BAUMANNII
| KLEBSIELLA PNEUMONIAE
| |
AMPICILLIN/SULBACTAM-- =>32 R =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- 16 I R
CEFTAZIDIME----------- =>64 R =>64 R
CEFTRIAXONE----------- R
CEFUROXIME------------ =>64 R
CIPROFLOXACIN--------- =>4 R =>4 R
GENTAMICIN------------ <=1 S 4 S
IMIPENEM-------------- =>16 R <=1 S
LEVOFLOXACIN---------- 4 I =>8 R
MEROPENEM------------- <=0.25 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ <=1 S =>16 R
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
.
[**7-25**] C.diff: positive
.
[**7-25**] urine cx: yeast
.
[**2156-7-29**] 12:17 am SPUTUM Site: ENDOTRACHEAL
Source: Endotracheal.
**FINAL REPORT [**2156-7-31**]**
GRAM STAIN (Final [**2156-7-29**]):
<10 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Final [**2156-7-31**]):
SPARSE GROWTH OROPHARYNGEAL FLORA.
ACINETOBACTER BAUMANNII. MODERATE GROWTH.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
[**Numeric Identifier 68150**]
[**2156-7-24**].
KLEBSIELLA PNEUMONIAE. SPARSE GROWTH.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
[**Numeric Identifier 68150**]
[**2156-7-24**].
.
[**2156-8-4**] URINE
URINE Site: CLEAN CATCH
**FINAL REPORT [**2156-8-6**]**
URINE CULTURE (Final [**2156-8-6**]):
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML..
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.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- R
CEFTAZIDIME----------- =>64 R
CEFTRIAXONE----------- R
CEFUROXIME------------ =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ 4 S
IMIPENEM-------------- <=1 S
LEVOFLOXACIN---------- =>8 R
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 256 R
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- =>16 R
Brief Hospital Course:
67 yo female with history of tracheobronchomalacia transferred
from OSH for further management.
MICU Course: Pt followed by IP, tracheomalacia c/w subglottic
granulation tissue and Mid trach stenosis. S/P rigid bronch +
excision, debridement, dilatation and trach change. She was
managed for Acinobacter/Klebsiella VAP, +C-diff and followed by
ID. TEE negative for vegetations. Pt back to MICU on [**8-3**] for
aggressive fluid resuscitation given C-Diff colitis and poor PO
intake with metabolic acidosis. Was given IVF w/bicarb, [**Doctor First Name **]
following but not surgical candidate given comorbidities,
started IVflagyl/PO vanco with slowly improving diarrhea. On
[**8-3**] went into RAF, s/p CV now in NSR remains stable.
Transferred to floor [**8-6**].
.
# Respiratory:
**Tracheomalacia: This was noted on previous admission to [**Hospital1 18**].
- s/p laser removal of tissue x 2 in the past
- on [**7-28**]: was switched from vent to trach mask and tolerated
this well
- on [**7-30**]: had rigid [**Last Name (un) 1066**], electrocautery and balloon dilatation
of trachea and upsizing of her trach to a #7 -> Will need a
special long trach which was ordered and will be available on
[**8-9**]. Per IP underwent a trach change with T-tube placement on
[**8-9**] without complications. Her trach was capped with stable
O2sats and voice audible. Per IP her trach is to be capped
during the day and with humidified O2 at night for her OSA. If
pt needs oxygenation she can be oxygenated with nasal cannula O2
with capped trach.
.
**Acinobacter/Klebsiella VAP: Started Bactrim on [**7-28**], completed
14 day course on [**8-10**]
-- Continue mucinex PRN mucus buildup
-- D/Cd atrovent, albuterol standing nebs
-- pt was on solumedrol 60 IV BID prior to admission (unclear
reason why, ? COPD flare), and pt was started on taper on [**2156-7-25**]
and completed taper without any difficulties
.
# ID: Pt had hx of enteroccus bacteremia, which was believed to
be treated adequately with 23 day course of vanc at OSH. She
had a TEE here, which was negative for vegetation, per ID
recommendations the vanc was d/c'd. Surveillance cx's were NGTD.
Pt grew acinetobacter from her sputum, and was started on
bactrim on [**7-28**] for 14 day course for Vent Associated PNA. Pt
also had hx of klebsiella UTI, and had been treated with
imipenem at OSH. Per ID recommendations, pt was likely colonized
from frequent foley catheterizations, and imipenem was d/c'd. Pt
had dirty UA on admission here, but urine cx only grew yeast.
Attempted to contact [**Name (NI) 336**] to obtain records of antimicrobial
succeptibilities of sternal infections and bacteremias in past.
Sternal wound infection was Staph and Proteus per surgical
summary. However, they did not send the micro data, so will need
to call the micro lab at some point in the future for further
information. Pt had hx of C.dif, and was continued on flagyl
for additional 14 day course. Pt had low grade temps during her
MICU stay (with a Tmax of 100.5), but did not have a significant
temp spike. She then had explosive diarrhea with +C-diff in
stools. She had persistent diarrhea, resistent to PO flagyl
treatment, she was started on PO Vanco as well as IV flagyl on
[**8-2**] for C-diff colitis. ID again reconsulted for persistent
diarrhea and elevated WBC. Her diarrhea improved with PO Vanco
and IVflagyl, her WBC peaked at 29 and came down to 14.4 at time
of discharge. She was also started on Meropenem on [**8-3**] for
Klebsiella UTI. Per ID she was to continue PO Vanco/flagyl until
all other Antibiotics d/c'd and diarrhea improved. She remained
afebrile with improving WBC and no new culture data. She will
complete a recommended 10day course of meropenem on [**2156-8-12**]. She
remained afebrile with improving WBC and no new culture data at
time of discharge.
.
#. C-DIFF Colitis: pt with explosive diarrhea treated for C-diff
as noted above. She was followed closely by surgery, however
given her other comorbidities she was not a surgical candidate.
She was followed with daily KUBs, her last KUB notable for
improvement in loops of bowel size. However, notable for small
bowel obstruction on [**2156-8-4**]. Pt was kept on a clear liquid diet
with plan to advance when improved colities. Her stool output
improved at time of discharge. Continued c-diff precuations.
.
# Neuro:
Seizure Prophylaxis
- on phenytoin (likely since she had subdural sustained in [**4-29**])
- continued phenytoin during this admission, increased dose
given low albumin and subtherapeutic with corrected dose.
Changed dose from 200mgqAM to 300mg qAM and increased 300mg qPM
to 400mgqPM. She did not have any siezure activity while
hospitalized.
- CT from OSH revealed mass in supracisternal region on R and
patient notes that she has had changes in vision in her R eye -
specificially she notes seeing random objects since her fall. Pt
had R homonymous hemianopsia and was to follow up with
neuroopthamology.
- [**7-29**]: contact[**Name (NI) **] Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 21721**] (Endocrine at [**Hospital1 112**]) regarding
her pituitary tumor. restarted her on carbergoline for her
prolactinoma. Per Dr. [**Last Name (STitle) 21721**] should reckeck prolactin levels in
6 weeks since prolactin levels elevated during this admission.
Plan to continue Cabergoline at current dose 0.5mg 2x/week. If
her Prolactin levels are persistently elevated may increase dose
0.75mg 2x/week.
- pituitary tumor is a prolactinoma and measures approx 5cm x
2.5cm x 3cm
.
# Renal:
- Cr 1.5 on admission; this is similar to level when she left
[**Hospital1 46**]
- Renally dose medications -> increaed Cr on [**7-31**] with peak to
2.4 due to poor PO intake and explosive diarrhea. Renal followed
pt, found no muddy brown casts, ARF c/w prerenal etiology also
ATN in setting of poor forward flow. She was agressively
hydrated in the MICU with addition of 50mEq NaHCO3. Her ARF
improved with Cr. decreased to 1.6 at time of discharge. Her IVF
were discontinued on [**8-9**] as she was significantly volume
overloaded and making urine, although poorly ~700cc per day.
.
#. Metabolic Acidosis: Pt with explosive diarrhea with low
bicarb. She was started on 50mEQ NaHCO3w/1000ml 1/2NS to manage
metabolic acidosis. Her HCO3 improved, her hypernatremia
corrected. However, she also developed hyponatremia with IVF
resuscitation. Her IVF were d/c'd on [**8-9**], her HCO3 at time of
discharge was 19.
.
# Cardio: Pt s/p CABG in the past, she also went into AFlutter
for which she was cardioverted on [**8-3**]. She remained in NSR. She
did not tolerate a BB throughout her hospital course due to
hypotension. she was continued on an ASA and statin. No other
antihypertensive medication was added to her medical regimen.
Her SBP was stable at time of discharge SBP 115. d/c'd HCTZ
during this admission, due to borderline low BP and likely need
for BB in the future
.
# DM2: Her BS was persistently elevated while she was on
steroids. She was maintained on an ISS which was titrated for
better BS control. Check FS QID
.
# GERD: continued PPI
.
# [**Month/Year (2) **]: PPI, fondaparinaux for DVT [**Name (NI) **] (pt has hx of HIT).
However fondaparinaux was held prior to IP procedure, but was
restarted s/p procedure. head of bed at 30 degress
.
# FEN: Pt grossly volume overloaded. Allow pt to autodierese
and holding further IVF. Currenlty receiving TPN since poor PO
intake; clear liquid diet until colitis improved. Note on [**7-29**]:
had FEES study by speech/swallow team -> OK to have nectar thick
liquids and ground solids, however changed diet to clear liq due
to colitis. Will need a new nutrition evaluation at [**Hospital1 3325**] to advance diet.
.
# Access: L subclavian - placed in OR on [**7-19**] at [**Hospital3 **]
- removed on [**7-26**] with no growth on culture data
- switched PICC on [**7-29**] because patient has HIT. Hence switched
to [**Last Name (un) 68151**] PICC which does not require heparin.
.
# Code status: DNR/DNI. Evolving discussions with HCP [**Name (NI) 4049**]
[**Name (NI) 696**] cell [**Telephone/Fax (1) 68152**]
home [**Telephone/Fax (1) 68153**]
Medications on Admission:
# Flagyl 250mg PO QID
# Pantoprazole 40 mg IV daily
# Clonzepam: 0.5mg [**Hospital1 **]
# Albuterol Sulfate (1) neb Q6H:PRN
# Ipratropium Bromide (1) neb Q6H: PRN
# MVI daily
# Fondaparinux 2.5mg SC daily
# solumedrol 60mg IV BID
# Guaifenasin 600mg NG QID
# Ranitidine 150mg PO BID
# Phenytoin Sodium : 200mg qAM, 300mg qPM
# ativan: 0.5mg -1mg Q6 PRN
# Hydrochlorothiazide 75 mg DAILY
# Fe SO4 325mg PO DAILY (Daily).
# colace 100mg QAM and [**Hospital1 **]:PRN
# Tylenol PRN
# Insulin SS
# Acetylcysteine: 200mg Q4:PRN
# Vancomycin: 1g IV Q48
# Nystatin powder to groin
# Epoetin Alfa [**Numeric Identifier 961**] units QMOWEFR (Monday -Wednesday-Friday).
# Imipenem: 250mg Q6hr
# Was on carbergoline 0.5mg QTue, QFri
Discharge Medications:
1. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
2. Acetaminophen 160 mg/5 mL Solution Sig: One (1) PO Q4-6H
(every 4 to 6 hours) as needed.
3. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One
(1) PO DAILY (Daily).
4. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
5. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection
QMOWEFR (Monday -Wednesday-Friday).
6. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Phenol-Phenolate Sodium 1.4 % Mouthwash Sig: One (1) Spray
Mucous membrane Q6H (every 6 hours) as needed.
8. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: 2-6 Puffs
Inhalation Q4-6H (every 4 to 6 hours) as needed.
9. Cabergoline 0.5 mg Tablet Sig: One (1) Tablet PO QTues,
QFriday ().
10. Fondaparinux 2.5 mg/0.5 mL Syringe Sig: One (1)
Subcutaneous DAILY (Daily).
11. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours).
13. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
14. Phenytoin Sodium Extended 100 mg Capsule Sig: Four (4)
Capsule PO QPM (once a day (in the evening)).
15. Phenytoin Sodium Extended 100 mg Capsule Sig: Three (3)
Capsule PO QAM (once a day (in the morning)).
16. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
17. Lidocaine HCl 0.5 % Solution Sig: One (1) ML Injection Q1H
(every hour) as needed for cough.
18. Lidocaine HCl 1 % Solution Sig: One (1) ML Injection Q1-2H
() as needed.
19. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
20. Lorazepam 0.5-1 mg IV Q6H:PRN
21. Meropenem 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q12H (every 12 hours): will complete 10 day course
on [**8-12**].
22. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **]
Discharge Diagnosis:
Primary:
Tracheomalacia and Stenosis
MDR Klebsiella UTI
C. Difficile Colitis
Toxic Megacolon
High output diarrhea
Acute Tubular Necrosis secondary to hypovolemia
Acinetobacter/Klebsiella VAP
Enterococcal/Klebsiella Bactermia (prior to admission)
Anasarca
Malnutrition-severe
AF w/RVR s/p Cardioversion
.
Secondary:
Coronary Artery Disease s/p CABG x 4 [**1-30**]
Bioprosthetic Aortic Valve Replacement [**1-30**]
Sternal Wound Infection
Perioperative Paroxsmal Atrial Fibrillation
Left Subdural Hematoma s/p Fall - R Homonymous Hemianopsia
SIADH
Diabetes Mellitus Type II
Pituitary Tumor - Prolactinoma, on seizure prophylaxis
Morbid Obesity
Chronic Kidney Disease Cr~1.5
Heparin Induced Thrombocytopenia (HIT)
Discharge Condition:
Stable
Discharge Instructions:
Please take all your medications as directed.
.
Always cap trach during the day and humidified oxygen at night
for OSA, please see instruction for Trach care noted below to
prevent mucous plugging
.
Site: Anterior LLE
Type: Leg ulcer
Cleansing [**Doctor Last Name 360**]: Saline
Change dressing: [**Hospital1 **]
Comment: Aquacel dressing
.
Continue Pressure relief measures
-[**Doctor First Name **] Air bed-low air loss bed
-Turn and reposition every 1-2hours off back
-Heels off bed surface at all times
.
Cleanse trach site with NS, pat dry
--Apply No Sting barrier wipe to irritated skin, air dry
--apply allevyn foam trach sponges around trach, change every
2-3days prn
.
T-tube care:
-Keep cap at all times, use nasal canula for oxygenation
-Apply 204ml of NS q12hours to prevent mucous plugging
-If need to uncap use humidified O2 at all times
Followup Instructions:
Follow up with Dr. [**First Name (STitle) **] [**Name (STitle) **] in 4 weeks at Bronch Unit at
[**Hospital1 18**], please call if you have further questions at ([**Telephone/Fax (1) 27079**].
Completed by:[**2156-8-10**]
|
[
"584.5",
"556.9",
"995.92",
"518.83",
"585.9",
"227.3",
"519.02",
"478.74",
"482.83",
"V42.2",
"008.45",
"287.4",
"482.0",
"E934.2",
"V45.81",
"276.2",
"253.6",
"427.31",
"998.83",
"599.0",
"261",
"038.9",
"276.52",
"519.1",
"V09.81",
"368.46"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"99.15",
"88.72",
"97.23",
"99.62",
"31.99",
"31.41",
"31.5",
"96.6",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
23857, 23900
|
12958, 21136
|
321, 505
|
24655, 24664
|
4751, 6764
|
25564, 25788
|
4003, 4097
|
21908, 23834
|
23921, 24634
|
21162, 21885
|
24688, 25541
|
7746, 12935
|
4112, 4732
|
267, 283
|
533, 2845
|
6780, 7707
|
2867, 3815
|
3831, 3987
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,883
| 149,002
|
160
|
Discharge summary
|
report
|
Admission Date: [**2189-2-5**] Discharge Date: [**2189-2-15**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
s/p collapse
Major Surgical or Invasive Procedure:
Intubation
Central venous line placement
History of Present Illness:
[**Age over 90 **] yo F hx IDDM, HTN who presented after she collapsed in the
lobby of her building while awaiting her son to pick her up for
appointment to see her PCP. [**Name10 (NameIs) **] was reportedly feeling well
recently according to son, no infectious symptoms. She came
down to the lobby and sat in a chair while waiting and then
collapsed. Pt had CPR initiated from bystanders (RN and aide in
lobby), per report EMS on presentation noted VFib, was
defibrillated 200J x1. Review of provided strip appears to
demonsrate a NSR with artifact followed by shock and resumption
of NSR. FS was 188, unresponsive, intubated in the field. Pt
hypotensive to 60's on arrival to ED, rec'd 1.5 L NS, started on
levophed transiently. Pt had head, chest/abd CTs performed
which were unrevealing.
Past Medical History:
IDDM c/b retinopathy, neuropathy
HTN
H/O FRONTAL LOBE MENINGIOMA - RESECTED IN [**2124**]
S/P HEMORROIDECTOMY
S/P T AND A
Social History:
lives by herself, independently, no prior hx of tobacco.
Family History:
NC
Physical Exam:
VS: T 93.4, BP 156/60, HR 58 , RR 16, O2 % on
Gen: elderly female, sedated, intubated, unresponsive.
HEENT: Pupils 2mm, nonreactive.
CV: RRR nl S1, S2, no m/r/g
Chest: breath sound b/l
Abd: soft, ND, no HSM
Ext: 2+ R pedal edema, palpable DP and PT pulses b/l
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
[**2189-2-5**] 02:46PM BLOOD WBC-7.4 RBC-3.00* Hgb-9.6* Hct-28.7*
MCV-96 MCH-32.2* MCHC-33.6 RDW-15.1 Plt Ct-265
[**2189-2-5**] 02:46PM BLOOD PT-12.2 PTT-25.8 INR(PT)-1.0
[**2189-2-5**] 07:15PM BLOOD Glucose-216* UreaN-27* Creat-0.9 Na-141
K-4.1 Cl-108 HCO3-22 AnGap-15
[**2189-2-5**] 07:15PM BLOOD CK-MB-10 MB Indx-5.2 cTropnT-<0.01
[**2189-2-6**] 06:00AM BLOOD CK-MB-9 cTropnT-0.02*
[**2189-2-5**] 07:15PM BLOOD CK(CPK)-192*
[**2189-2-6**] 06:00AM BLOOD CK(CPK)-131
[**2189-2-6**] 04:10PM BLOOD ALT-12 AST-13 AlkPhos-41 TotBili-0.5
[**2189-2-7**] 02:34AM BLOOD Calcium-8.8 Phos-4.1 Mg-2.6
[**2189-2-5**] 09:55PM BLOOD calTIBC-226* VitB12-325 Ferritn-158*
TRF-174*
[**2189-2-6**] 04:10PM BLOOD TSH-0.80
[**2189-2-6**] 04:10PM BLOOD Free T4-1.0
[**2189-2-6**] 04:10PM BLOOD Cortsol-42.3*
[**2189-2-5**] 02:46PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-14.5
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2189-2-7**] 02:48AM BLOOD Type-ART pO2-88 pCO2-35 pH-7.34*
calTCO2-20* Base XS--5
CXR:
No priors available for comparison. Today's examination is
markedly limited by low lung volumes causing crowding of the
bronchovascular structures. The right hemidiaphragm is
asymmetrically elevated in comparison to the left hemidiaphragm.
There is marked distention of the stomach and abdominal bowel
likely related to resuscitative effort. Slightly increased
spacing between the gastric bubble and the left hemidiaphragm
may suggest a component of subpulmonic effusion. There is an
ill-defined retrocardiac opacity which may reflect atelectasis
and/or sequelae of aspiration. Endotracheal tube terminates 4.7
cm from the carina. The aorta is slightly ectatic and calcified
and there is multilevel degenerative changes of the spine. No
pneumothorax or large effusions are identified.
IMPRESSION:
1) Appropriately positioned endotracheal tube. Gaseous
distention of stomach and bowel likely related to resuscitative
efforts. NGT may be of benefit.
2) Ill-defined retrocardiac opacity may represent atelectasis
and/or sequelae from aspiration.
CTA Torso:
1. No etiology for acute arrest identified. No PE or aortic
dissection. Mild dilatation of the right main pulmonary artery
may suggest underlying pulmonary arterial hypertension.
2. Moderate amount of secretions distal to the endotracheal tube
within the trachea proximal to the carina may place the patient
at risk for aspiration.
3. Non-obstructive left renal calculi and simple left renal
cyst.
4. Incompletely characterized right adrenal lesion, likely
benign on patient of this age. Hypoattenuating right thyroid
lesion also likely benign in a patient's age.
5. Cholelithiasis without evidence of acute cholecystitis.
6. Extensive vasculopathy. Is there a history of diabetes?
TTE:
The left atrium is elongated. The interatrial septum is
aneurysmal. Left ventricular wall thicknesses are normal. The
left ventricular cavity is small. Left ventricular systolic
function is hyperdynamic (EF 70-80%). 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. Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Trivial mitral regurgitation is seen. [Due to
acoustic shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] The left ventricular inflow
pattern suggests impaired relaxation. The tricuspid valve
leaflets are mildly thickened. The supporting structures of the
tricuspid valve are thickened/fibrotic. The pulmonary artery
systolic pressure could not be determined. There is no
pericardial effusion.
EEG:
This is an abnormal EEG due to the existence of an active
area of epileptogenesis in the left posterior frontal to
anterior
temporal region. Though this activity did not meet criteria for
focal
status epilepticus, there were periods of apparent
electrographic
seizures without evident clinical correlate. The presence of a
slow and
disorganized background is consistent with a moderate
encephalopathy of
toxic, metabolic, or anoxic etiology.
CT C-SPINE W/O CONTRAST [**2189-2-9**] 9:17 PM
1. No fracture or malalignment is detected.
2. Diffuse calcification of the transverse ligament adjacent to
the dens causes severe canal narrowing and cord impingement. The
thecal sac measures approximately 5 mm at this area.
3. Hyperdense focus within the lower pole of pons and upper
medulla, might represent intraparenchymal hemorrhage or
cavernoma.
4. Bilateral thyroid nodules which can be further evaluated on
nonemergent basis.
CT HEAD W/O CONTRAST [**2189-2-9**] 9:15 PM
SMALL INTRAVENTRICULAR HEMOORHAGE IN THE OCCIPITAL HORNS AND
SMALL FOCUS OF HEMORRHAGE IN THE UPPER MEDULLA. HOWEVER, THE
CAUSE OF THIS IS UNCERTAIN FROM THE PRESENT STUDY. A CLOSE
FOLLOW-UP EXAMINATION OR MR HEAD WITHOUT AND WITH IV CONTRAST,
WOULD BE HELPFUL.
MRI HEAD/CSPINE [**2189-2-11**]
1-cm hemorrhagic non-enhancing lesion of the caudal medulla with
expansion and edema. This finding may represent a hemorrhagic
infarct versus a cavernoma. Given the findings on the concurrent
MR cervical spine, a hemorrhagic infarct is favored. Hemorrhagic
neoplasm is thought to be less likely given the lack of contrast
enhancement and no prior history of cancer.
Multiple extra-axial partially calcified enhancing masses as
described above consistent with meningiomas.
Intraventricular blood as before.
Brief Hospital Course:
The patient presented with syncope of unknown etiology, but
likely secondary to ischemia/hemorrhage in her caudal medulla
and also found to have cervical lesion and edema causing canal
stenosis and compression. She was initially treated with cooling
protocol due to possible cardiac arrest, but found to be in
sinus rhythm. Patient was intubated and not breathing
spontaneously. Initially, patient evaluated by CT head on [**2-5**]
that showed no intracranial hemorrhage or mass. Unable to do MRI
as patient with staples from prior meningioma surgery from
[**2120**]. We did daily neurologic assessments to follow recovery
s/p cooling protocol, showing patient was awake, sometimes
tracking with her eyes, with some facial movements, but not
moving any extremities. Repeat CT head/spine on [**2-9**] showing
multiple hemorrhages including a lesion in her caudal medulla
and edema/mass around her cervical spine. Neurology was
following and after speaking to neuroradiology, patient was
deemed safe to have MRI evaluation. On [**2-10**], patient evaluated
by MRI which showed same findings. Read of MRI showing two
hemorrhagic/ischemic lesions of the caudal medulla and cervical
cord with severe cord compression. No indication for any
surgical intervention per neurosurg and neurology.Patient
trialed twice on PSV with no spontaneous respirations. One week
after insult, family meeting arranged to discuss poor prognosis
given lack of recovery and goals of care. Family made decision
not to remove care but to place patient on spontaneous breathing
trial without reinstating intubation. The patient failed the
the SBT and expired 8 minutes afterwards.
Medications on Admission:
Klonopin
Insulin
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
Completed by:[**2189-2-17**]
|
[
"427.41",
"458.9",
"362.01",
"250.50",
"438.53",
"431",
"250.60",
"357.2",
"336.1",
"401.9",
"518.81",
"344.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
9074, 9083
|
7319, 8974
|
274, 316
|
9134, 9143
|
1738, 7296
|
9199, 9237
|
1382, 1386
|
9042, 9051
|
9104, 9113
|
9000, 9019
|
9167, 9176
|
1401, 1719
|
222, 236
|
344, 1145
|
1167, 1291
|
1307, 1366
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,036
| 135,083
|
14144
|
Discharge summary
|
report
|
Admission Date: [**2109-4-21**] Discharge Date: [**2109-5-3**]
Date of Birth: [**2046-6-13**] Sex: F
Service: ACOVE
HISTORY OF PRESENT ILLNESS: The patient is a 62 year-old
female admitted to the Acove Service on [**2109-4-21**] after transfer
from the Medical Intensive Care Unit. The patient was initially
admitted to an outside hospital on [**4-16**] for a right total hip
replacement. Postoperatively, the patient was anticoagulated
with Lovenox and Coumadin secondary to thromboembolic concerns
given her history of deep venous thrombosis, pulmonary embolus
and known anticardiolipin antibody positive. On postop day
number two several adverse events occurred including the patient
spiking a temperature to greater then 101, having an elevated
white blood cell and an INR, which was noted to be
supratherapeutic. Her creatinine also increased from a baseline
of 1.4 to 3.8 and the patient had become anuric and acidotic. On
postoperative day number three the patient became transiently
hypotensive and an infection workup was instituted. At that time
she was given stress dose steroids. Further anticoagulation was
held and the renal team was consulted. Subsequently the patient
was transferred to the [**Hospital1 69**] on
postoperative day number four for further management. Prior
to transfer she was given bicarbonate and transfused 3 units
of packed red blood cells.
On the 30th the patient was directly admitted to the Intensive
Care Unit. At that time she was evaluated by the Renal Service
who felt that her physiology, urine and phena represented acute
ATN and as such hemodialysis was not indicated. The patient also
had antibiotics tapered to Levaquin for treatment of an E-coli
urinary tract infection. On the 27th the patient was noted to
have a hematocrit drop from 28 to 22 and abdominal pelvic CT
demonstrated a right hip thigh hematoma. As such the patient was
taken to the Operating Room by orthopedics Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 1022**] for
exploration and evacuation of the expanding hematoma. The
patient was transfused 5 units of packed red cells at that time.
She was also noted to hve neurological deficits in the right leg.
It is not clear as to the timing of these deficits.
PAST MEDICAL HISTORY: 1. Right hip avascular necrosis
diagnosed by MRI with subsequent total hip replacement as
described in the history of present illness. 2. History of
prior deep venous thrombosis and pulmonary embolism last
approximately five years prior to admission. 3. Systemic
lupus erythematosus. 4. Sjogren. 5. Chronic renal
insufficiency. 6. Peripheral vascular disease. 7.
Coronary artery disease status post myocardial infarction,
status post percutaneous transluminal coronary angioplasty.
8. Known anticardiolipin antibody positive. 9. Anemia
thought secondary to chronic renal insufficiency. 10. Total
abdominal hysterectomy. 11. History of benign prostatic
biopsy.
MEDICATIONS ON TRANSFER: 1. Synthroid .125. 2. Protonix
40 mg po q day. 3. Prednisone 60 mg po q day. 4. Sodium
bicarb [**2056**] mg t.i.d. 5. Amphojel 30 cc q.d. 6. Zocor 5
mg po q day. 7. Epogen 3000 units one time per week. 8.
Colace 100 mg po b.i.d. 9. Percocet prn. 10. Iron sulfate
325 mg po b.i.d. 11. Levaquin 250 mg po q.o.d. 12. Lovenox
30 mg subQ b.i.d. 13. Regular insulin sliding scale. 14.
Lactulose prn.
ALLERGIES: The patient has reported allergies to Penicillin,
sulfa, Codeine and Imuran.
SOCIAL HISTORY: The patient lives with her husband. She has
a remote history of both tobacco and ethanol use
unquantitative.
HOSPITAL COURSE ON THE ACOVE SERVICE: Given the patient's renal
failure the decision was made in consultation with the Renal
Service to hold her Lovenox and change over to heparin as there
is little data as to the clearance of Lovenox in acute renal
failure and as such could not be appropriately dosed. During the
transition period to heparin, which was done without a bolus the
patient was again noted to have increasing girth of her right
thigh and an 8 point hematocrit drop. As such repeat CT scan of
the thigh was done, which showed reaccumulation of the hematoma.
The patient was again evaluated by orthopedics in this setting,
however, since there was no progression of her neurologic
deficits and there was no neurovascular compromise of the leg the
decision was made not to intervene at this time. Instead
anticoagulation was held until the patient was stabilized and the
patient was transfused a total of 3 units of packed red blood
cells. During this time the patient was also evaluated by the
Neurology Service for her right sided deficits. On further
evaluation it was determined that the patient that the patient
has a history of spondylolithiasis. However, this could not
account for all of her symptoms.
Consultation with both orthopedics and neurology suggests the
possibility of damage of the nerve at time of initial surgery, as
her nerve was noted to be very superficial in the operative
report during the second operation at the [**Hospital1 190**] for evacuation. It also possible that some
compression of the nerve occurred with her initial hematoma.
After the patient was hemodynamically stable her renal function
was noted to return to baseline and her creatinine fell to 1.1.
As such it was felt that it was safe to reinstitute Lovenox in
this patient and to slowly load Coumadin. It was verified with
her primary care physician that indeed the patient is
anticardiolipin antibody positive and as such will require
long term anticoagulation with a goal INR of approximately 3.5.
In this setting Coumadin was again started. On both Lovenox and
Coumadin the patient was hemodynamically stable with no further
evidence of bleeding for greater then 48 hours. Given the
patient's neurologic deficits evaluation by physical therapy
revealed that the patient would benefit from a rehab facility and
the patient was discharged on hip precautions for three months to
rehab.
DISCHARGE MEDICATIONS: 1. Synthroid 0.125 mg po q day. 2.
Zocor 5 mg po q.d. 3. Iron sulfate 325 mg po b.i.d. 4.
Colace 100 mg po b.i.d. 5. Tylenol 500 mg po q 6. 6.
Oxycontin 10 mg po q 12. 7. Aspirin 81 mg po q day. 8.
Prednisone 5 mg po q day, which is her baseline dose. 9.
Metoprolol 75 mg po t.i.d. 10. Captopril 25 mg po t.i.d.
11. Oxycodone 5 mg po q 6 prn. 12. Lovenox 30 mg subQ q 12
until therapeutic INR is met. 13. Coumadin 5 mg po q.h.s.
with goal INR of approximately 3.5. 14. Multivitamin one
tab po q day.
The patient is to be on hip precautions for three months
including no hip flexion with internal rotation. The patient
is to follow up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 1022**] of [**Location (un) 86**] Orthopedics,
[**Telephone/Fax (1) 36310**]. At this time EMG will be deferred as the patient
is to be anticoagulated and as such the risk of the procedure
would out weigh the benefits of the information gained. The
patient was discharged to rehab in stable condition.
DISCHARGE DIAGNOSES:
1. Status post right total hip replacement with subsequent
hematoma and evacuation with reaccumulation.
2. Anticardiolipin antibody positive.
3. ATN now resolved.
SECONDARY DIAGNOSES:
1. Hypothyroidism.
2. Sjogren.
3. Systemic lupus erythematosus.
4. Right AVN.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4446**]
Dictated By:[**Last Name (NamePattern1) 9348**]
MEDQUIST36
D: [**2109-5-3**] 07:28
T: [**2109-5-3**] 08:25
JOB#: [**Job Number 42109**]
|
[
"998.12",
"244.9",
"710.0",
"041.4",
"584.5",
"443.9",
"V45.82",
"599.0",
"412"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.04",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
7108, 7275
|
6065, 7087
|
7296, 7622
|
165, 2271
|
3000, 3509
|
2294, 2974
|
3526, 6041
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,363
| 102,827
|
52326
|
Discharge summary
|
report
|
Admission Date: [**2155-10-20**] Discharge Date: [**2155-10-24**]
Date of Birth: Sex: F
Service: Medicine
HISTORY OF PRESENT ILLNESS: The patient is a 63-year-old
female with a past medical history of end-stage renal disease
(on hemodialysis) secondary to lithium toxicity, papillary
thyroid cancer (status post tracheostomy complicated by vocal
cord paralysis), and methicillin-resistant Staphylococcus
aureus pneumonia with positive surveillance cultures, with a
recent admission last week for fevers, hypertension,
shortness of breath, and leukocytosis.
The patient was treated with gentamicin, Flagyl, and
vancomycin. However, on hemodialysis day three, after the
original admission, all cultures were negative, and her
temperature had resolved. Therefore, the antibiotics were
discontinued. However, she was to continue receiving
vancomycin for one week after discharge. However, it appears
that she had not been receiving the vancomycin.
Today, the patient was admitted with a fever of 103.1 degrees
Fahrenheit, and her usual arm and hand pain after
hemodialysis. Review of systems was otherwise negative.
However, the patient does have diffuse abdominal pain which
is not getting any better but is unchanged from before.
In the Emergency Department, the patient received
intravenously gentamicin, 500 mg of Flagyl, and vancomycin
times one. She received a 500-cc normal saline bolus and her
blood pressure medications, and her blood pressure remained
stable after that.
PAST MEDICAL HISTORY:
1. Methicillin-resistant Staphylococcus aureus pneumonia.
2. End-stage renal disease.
3. Papillary thyroid cancer; status post tracheostomy.
4. Intention tremor secondary to lithium.
5. Osteoporosis.
6. Crohn's disease; status post ileostomy.
7. Recurrent right upper extremity arteriovenous graft
thrombosis and pseudoaneurysm malformation.
8. History of upper gastrointestinal bleed secondary to
nonsteroidal antiinflammatory drugs.
9. Hypoparathyroidism.
10. An echocardiogram in [**2152**] showed an ejection fraction of
60%.
SOCIAL HISTORY: The patient is a resident at [**Hospital3 2558**].
FAMILY HISTORY: Family history was noncontributory.
MEDICATIONS ON ADMISSION:
1. Oxycodone 10 mg on Monday, Wednesday, and [**Hospital3 2974**] with
hemodialysis.
2. Renagel 800 mg by mouth three times per day.
3. Atrovent meter-dosed inhaler.
4. Salmeterol meter-dosed inhaler.
5. Phos-Lo 617 mg by mouth twice per day (on Tuesday,
Thursday, Saturday, and [**Hospital3 1017**]).
6. Subcutaneous heparin twice per day.
7. Mucinex 600 mg by mouth twice per day.
8. Lithium 700 mg three times per week after hemodialysis.
9. [**Last Name (un) **] at hour of sleep.
10. Ambien at hour of sleep.
11. Duragesic patch 125-mcg q.72h.
12. Elavil 75 mg by mouth at hour of sleep.
13. Nephrocaps on Tuesday, Thursday, Saturday, and [**Last Name (un) 1017**].
14. Tylenol as needed.
15. Premarin 0.625 mg by mouth once per day.
16. Synthroid 0.125 mg by mouth every day.
17. Midodrine 5 mg once per day (with hemodialysis).
18. Maprotiline 125 mg on Tuesday, Thursday, Saturday, and
[**Last Name (un) 1017**].
ALLERGIES:
1. PENICILLIN (causes lip swelling).
2. CEPHALOSPORINS (cause lip swelling).
3. CLINDAMYCIN (causes an unknown reaction).
4. MOTRIN (causes an unknown reaction).
5. CIPROFLOXACIN (leads to lip swelling).
6. PERCOCET (causes nausea and vomiting).
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
on admission revealed the patient's temperature was 101.6
degrees Fahrenheit, her heart rate was 70s to 80s, her blood
pressure was 80 to 110/40 to 60, and her oxygen saturation
was 97% on room air. In general, the patient was irritated.
She was alert and oriented times three. Head, eyes, ears,
nose, and throat examination revealed the pupils were equal,
round, and reactive to light and accommodation. The
extraocular movements were intact. Cardiovascular
examination revealed a regular rate and rhythm. No murmurs,
rubs, or gallops. Pulmonary examination revealed coarse
breath sounds throughout; anterior and laterally. The
abdominal examination revealed well-healed scars present.
The abdomen was diffusely tenderness to palpation. Extremity
examination revealed she had no cyanosis, clubbing, or edema.
No palpable cords. [**Last Name (un) 13623**] examination was nonfocal.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories on
admission were significant for a potassium of 6, a
bicarbonate of 30, and a creatinine of 4. Her white blood
cell count was 31.4. Her lactate level was 5.4.
PERTINENT RADIOLOGY/IMAGING: A chest x-ray was read as
normal.
CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM: The
patient was admitted to the Intensive Care Unit for blood
pressure monitoring. Her blood pressure responded to fluid
resuscitation.
1. INFECTIOUS DISEASE ISSUES: The patient was started on
broad spectrum antibiotics. Imaging of her abdomen was
unremarkable. An echocardiogram showed no valvular
vegetations. Several days into her admission, her blood
cultures from her hemodialysis line grew Xanthomonas
maltophilia which were felt to be the organism causing her
likely line sepsis.
The patient responded to antibiotics appropriately and was
continued on vancomycin and gentamicin which were to be dosed
and given during her hemodialysis for the next two weeks.
2. CARDIOVASCULAR ISSUES: Her blood pressure remained
stable during her hospitalization.
3. PULMONARY ISSUES: The patient was continued on
tracheostomy care medications and pulmonary toilet.
4. END-STAGE RENAL DISEASE: The patient was continued on
her regular dialysis schedule.
5. PSYCHIATRIC/BIPOLAR ISSUES: The patient was continued on
her lithium.
6. ENDOCRINE/HYPOTHYROIDISM ISSUES: The patient was
continued on her Synthroid.
7. MUSCULOSKELETAL ISSUES: For her cervical radiculopathy,
she was continued on her pain medications.
DISCHARGE STATUS: The patient was to be discharged to the
[**Hospital3 2558**] (which is an extended care facility).
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was instructed to take all medications as
prescribed.
2. The patient was instructed to be on two weeks of
antibiotics for her line infection.
3. The patient was instructed to follow up in the Pain
Management Center on [**2155-11-4**].
4. The patient was instructed to follow up with Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 217**] on [**2155-11-18**].
5. The patient was instructed to follow up with her primary
care physician and was to call to schedule an appointment.
FINAL DISCHARGE DIAGNOSES:
1. Bacteremia.
2. Hypothyroidism.
3. Peripheral neuropathy.
4. Chronic renal failure.
MEDICATIONS ON DISCHARGE:
1. Oxycodone 10 mg on Monday, Wednesday, and [**Year (4 digits) 2974**] with
hemodialysis.
2. Renagel 800 mg by mouth three times per day.
3. Atrovent meter-dosed inhaler.
4. Salmeterol meter-dosed inhaler.
5. Phos-Lo 617 mg by mouth twice per day (on Tuesday,
Thursday, Saturday, and [**Year (4 digits) 1017**]).
6. Subcutaneous heparin twice per day.
7. Mucinex 600 mg by mouth twice per day.
8. Lithium 700 mg three times per week after hemodialysis.
9. [**Last Name (un) **] at hour of sleep.
10. Ambien at hour of sleep.
11. Duragesic patch 125-mcg q.72h.
12. Elavil 75 mg by mouth at hour of sleep.
13. Nephrocaps on Tuesday, Thursday, Saturday, and [**Last Name (un) 1017**].
14. Tylenol as needed.
15. Premarin 0.625 mg by mouth once per day.
16. Synthroid 0.125 mg by mouth every day.
17. Midodrine 5 mg once per day (with hemodialysis).
18. Maprotiline 125 mg on Tuesday, Thursday, Saturday, and
[**Last Name (un) 1017**].
19. Vancomycin and gentamicin (to be dosed at hemodialysis).
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D.
Dictated By:[**Name8 (MD) 8736**]
MEDQUIST36
D: [**2155-12-2**] 18:09
T: [**2155-12-6**] 14:51
JOB#: [**Job Number 59878**]
|
[
"296.7",
"996.62",
"V44.2",
"V44.0",
"038.49",
"585"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
2175, 2212
|
6845, 8103
|
2239, 4709
|
6183, 6700
|
4743, 6099
|
6114, 6150
|
6727, 6818
|
163, 1516
|
1539, 2088
|
2105, 2157
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,254
| 198,648
|
33291
|
Discharge summary
|
report
|
Admission Date: [**2189-9-6**] Discharge Date: [**2189-9-11**]
Date of Birth: [**2135-1-22**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
sepsis
Major Surgical or Invasive Procedure:
removal of tunneled HD line. Insertion of new tunneled HD line.
History of Present Illness:
54 y/o M with PMH of IDDM, ESRD on HD, PVD s/p R AKA and L 2nd
and 3rd finger amputation, transferred from [**Doctor First Name 8125**] ER for fever
and pus from HD catheter. His symptoms began the day of
admission when he developed altered mental status while at home.
Family reports he was doing pretty well at home, able to attend
a wedding two days prior to admission. They then noted he became
more confused, fell at home and hit his head on the television.
Denied LOC. He was unable to recognize family members and the
brought him to an OSH ED. He was also noted to have purulence
draining from his tunneled RIJ HD line two days prior to
admission at HD. At OSH ED, his T 103.2 BP stable at
105-176/50-89. He was given 1g Vancomycin and 1gm Ceftriaxone
X1. CT Head negative for bleed. Old R cerebellar infarct noted.
Blood cultures were sent from HD line and he was transferred to
[**Hospital1 18**] for further management.
.
In the ED, initial vs were: T 102.8 P 104 BP 106/53 O2 sat 100%
2L NC. Exam significant for obtundation. Labs revealed elevated
WBC count to 25 (93%PMN, no bands) and a normal lactate of 1.4.
CXR showed cardiomegaly with HD line in place and right hilar
fullness without obvious infiltrate. EKG showed 1 AVB, TWI
inferiorly, unchanged from prior. A CT abdomen/pelvis was
performed to evaluate for etiology of leukocytosis and showed a
question of spigelian hernia with small bowel, portion of
appendix and cecal tip
within it. No obstruction or signs of surrounding inflammation.
Surgery consult was obtained and felt hernia not likely cause of
infection. Repeat blood cultures were drawn, and he was given
zosyn in addition to his previous antibiotics. Transplant team
was made aware of catheter. Pt also evaluaed by nephrology team,
felt urgent HD not needed and recommended pulling HD line. Pt
received 1L NS and was admitted to the MICU for further care.
.
In the ICU, the patient continues to be arousable but sedated.
He is not answering questions but moves all extremities
spontaneously.
Past Medical History:
# IDDM
# ESRD on HD M/W/F
# R AKA
# CAD (MI, BMS/PCI [**11-30**])
# CHF (EF 50% 10/06) chronic diastolic
# dyslipidemia
# HTN
# CVA without residual effects
# DMII w/ retinopathy, nephropathy, neuropathy
# GERD
# h/o pancreatitis
# fungal peritonitis s/p PD cath removal
# CRF on HD (T, Th, Sa), AOD, depression,
# PVD/ aortoocclusive disease
-- PTA & stenting BLE
-- R BKA [**7-2**]
-- R 4th finger amp
-- L 2nd and 3rd finger amputation
-- L heel ulcer
Social History:
Hx of tobacco use - 2 PPD x min 40yrs. Lives with mother and son
Family History:
Noncontributory
Physical Exam:
Gen ?????? lethargic, arousable
Peripheral Vascular: (Right radial pulse: present), (Left radial
pulse: present), (Right BKA, L foot cold, nonpalp pulse
L hand ?????? 1st and 2nd finger amputation, 2nd finger bone exposed,
4th finger with dry gangrene ?????? TTP, R hand 2nd and 3rd finger
amputation, well healed
Neurologic: Responds to: voice and pain in all ext
HEENT ?????? Pupil 3mm and equal, oropharynx clear
Neck L SC, R IJ tunneled line +induration, no drainage
CV: II/VI SM LLSB
Resp: CTAB
Abd: R hernia, NT/ND, NABS
Brief Hospital Course:
54y/o M with PMH of ESRD on HD and PVD admitted with line
sepsis, now s/p removal of tunneled HD catheter.
# Line Sepsis: Tunneled line was removed [**9-6**] and had frank
pus. Blood Cx from [**Hospital 8125**] hospital growing MRSA. Initial blood
cx grew MRSA. He remained hemodynamically stable. Other source
of fever could potentially be gangrene in left hand although per
vascular does not appear infected. On Vancomycin, dosing by
levels and with HD although no HD yet while in MICU. He did not
have sepsis physiology and did not require pressors. He had 48
hour line holiday from [**9-7**] at 11am until [**9-9**]. TTE was
negative but since he had positive cultures on [**2191-9-4**] we
performed a TEE, which showed mitral valve endocarditis.
Vancomycin course will be 6 week course on these grownds. Start
date [**2189-9-9**]. Cultures were NGTD on [**11-16**], and [**9-9**]. he
will need to have vanc levels checked and dosing at HD (M, W, F)
# Altered mental status: AMS most likley multifactorial. CT head
neg for bleed at OSH. MS improved with abx and holding sedating
meds. Oriented x 3 at time of transfer. on the floor he
continued to do well on this regard.
# PVD/CAD: Continued on plavix, statin and ASA. Vascular surgery
consulted and did not believe amputated digits were infected or
were cause of bacteremia. Plain films of hand were c/w possible
osteo L 4th digit. Vascular did not think that this was osteo as
pt did not have any symptoms. L 4th digit was noticeable for
dry gangrene on physical exam pt pt did not want another
amputation.
# ESRD on HD: Renal following. After the line [**Last Name (un) **] (48 hrs)
pt had a new tunneled line placed controlateral to the infected
site. HD was started subsequently with decrease in Cre.
Medications on Admission:
Prilosec 20mg daily
Gabapentin 200mg [**Hospital1 **] and 100mg at lunchtime
Plavix 75mg daily
Metoprolol XL 100mg MWF
ASA 325mg daily
Simvastatin 80mg QHS
Neprho Vit 1tab QHS
Colace 100mg [**Hospital1 **]
Tylenol 1000mg Q8 PRN
MS Contin 60mg [**Hospital1 **] PRN
Renagel 2400mg TID
Nortriptyline 25mg QHS
Dilaudid 8mg Q4PRN
Insulin Reg SS
Lantus 6 Units daily
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
6. Sevelamer HCl 800 mg Tablet Sig: Three (3) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous Q
hemodialysis protocol for 5 weeks weeks: date of last dose =
[**10-19**].
9. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
10. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
11. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
12. Insulin Glargine 300 unit/3 mL Insulin Pen Sig: Four (4) U
Subcutaneous once a day: please note this is a lower dose than
you were on before.
13. Insulin Lispro 100 unit/mL Insulin Pen Sig: One (1) U
Subcutaneous four times a day: please administer per attached
sliding scale.
14. Dilaudid 4 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain.
15. MS Contin 60 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO twice a day.
16. Nortriptyline 25 mg Capsule Sig: One (1) Capsule PO at
bedtime.
Discharge Disposition:
Home With Service
Facility:
VNA Assoc. of [**Hospital3 **]
Discharge Diagnosis:
mitral valve endocarditis
Discharge Condition:
good, AF, VSS, blood cultures negative.
Discharge Instructions:
You were admitted to the hospital with a serious infection of
your dialysis catheter. This catheter was removed and a new one
was placed. You were also found to have an infection of a heart
valve, called endocarditis. You should be treated with
vancomycin for this problem for a total of 6 weeks; your
dialysis facility should coordinate this.
If you have any fevers, chills, redness or pain around your
line, nausea, vomiting, chest pain, or any other concerns, then
please see your doctor or go to the ED.
Other than the vancomycin (antibiotic) we have changed your
Lantus dose from 6U to 4U daily. We have not changed any of
your other medications.
Followup Instructions:
Please go to dialysis on Monday, Wednesday, Friday. You will
get your antibiotics there, it is crucial that you make it to
dialysis.
Please call [**Telephone/Fax (1) 19657**] to schedule an appointment with a new
primary care doctor: Dr [**Last Name (STitle) **]
Completed by:[**2189-9-14**]
|
[
"311",
"428.0",
"790.7",
"362.01",
"041.12",
"996.62",
"357.2",
"426.11",
"285.9",
"250.60",
"443.9",
"553.29",
"E879.1",
"421.0",
"250.50",
"530.81",
"428.32",
"785.4",
"V45.82",
"585.6",
"403.91",
"414.01",
"V12.54",
"V49.76",
"272.4",
"V49.62",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.07",
"88.72",
"39.95",
"86.05"
] |
icd9pcs
|
[
[
[]
]
] |
7324, 7385
|
3606, 4576
|
320, 387
|
7455, 7497
|
8203, 8499
|
3022, 3039
|
5790, 7301
|
7406, 7434
|
5404, 5767
|
7521, 8180
|
3054, 3583
|
274, 282
|
415, 2444
|
4591, 5378
|
2466, 2923
|
2939, 3006
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,638
| 122,879
|
15382
|
Discharge summary
|
report
|
Admission Date: [**2179-11-21**] Discharge Date: [**2179-12-3**]
Date of Birth: [**2108-5-29**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
shoulder pain
Major Surgical or Invasive Procedure:
1. Irrigation and debridement left shoulder via anterolateral
deltopectoral miniarthrotomy with cultures.
2. Aspiration left hip joint under fluoroscopy.
3. Irrigation and debridement 3rd metacarpophalangeal joint,
superficial abscess.
4. Endotracheal Intubation
History of Present Illness:
71 yo F w/ CAD, ischemic CMY (EF 10%) s/p [**Hospital1 **]-V ICD, atrial
fibrillation, CKD, with past history of DVT and PE on Coumadin
who was recently discharged from the CCU ([**11-6**]) for CHF
exacerbation c/b C.diff infection, who is now being transferred
from [**Hospital **] hospital for ?Septic shoulder joint and hypoxia,
requiring intubation. Patient is intubated and sedated so
history obtained from HCP (niece) and transfer records. She
presented to [**Location (un) **] on [**11-18**] with left shoulder pain.
Orthopedics was consulted and joint aspiration was done which
showed +hemarthrosis. Joint culture now growing staph aureus.
She was given oxacillin initially and then per discharge note,
received Vancomycin althouth transfer medication list does not
have Vancomycin listed as being given. Today, the patient
developed hypoxia and required increasing O2 requirement and was
placed on a NRB with O2 sat in 90-92% range per HCP. O2 sat
then declined to 70% on NRB and patient was then electively
intubated prior to transfer.
Past Medical History:
1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS: BM stent to the LAD in
[**2164**], Occluded RCA/no intervention
-PACING/ICD: Ischemic cardiomyopathy (EF 10-25%) s/p BiV ICD and
atrial fibrillation
3. H/o PE secondary to DVT s/p IVC filter on Coumadin
4. PVD
5. Small VSD
6. Hypothyroidism
7. CKD
8. Osteoarthritis
Social History:
-Tobacco history: 20 pack year history, however she quit 30 yrs
ago
-ETOH: Denies
-Illicit drugs: Denies
Pt lives alone but currently resides at [**Hospital 599**] rehab. She is not
married.
Family History:
Mother had MI at age 50, maternal uncle died of MI in his 50's.
No family history of arrhythmia, cardiomyopathies, or sudden
cardiac death; otherwise non-contributory.
Physical Exam:
VS: Temp BP 99/58 HR 70 RR 14 on AC TV 450, PEEP 5, 100%
FiO2
GENERAL: Elderly female, intuabed, sedated
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
NECK: Supple with JVP to angle of jaw
CARDIAC: normal S1, S2. II/VI SEM, RRR
LUNGS: CTAB, no wheezes, crackles or ronchi
ABDOMEN: Soft, NT, +ascites, +fluid wave
EXTREMITIES: No c/c/e, dopplerable pedal pulses, Right shoulder
with +effusion no erythema, right MCP joint with +blanching
erythema and edema, +TTP
SKIN: +dry skin
Pertinent Results:
ADMISSION LABS [**2179-11-21**]:
[**2179-11-21**] 03:48AM WBC-10.9# Hgb-12.3 Hct-39.3 Plt Ct-207
[**2179-11-21**] 03:48AM PT-80.1* PTT-48.4* INR(PT)-9.6*
[**2179-11-21**] 03:48AM Glucose-141* UreaN-70* Creat-2.7* Na-129*
K-5.5* Cl-93* HCO3-22 AnGap-20
[**2179-11-21**] 03:48AM ALT-9 AST-17 LD(LDH)-213 CK(CPK)-15*
AlkPhos-130* TotBili-1.7*
[**2179-11-21**] 03:48AM CK-MB-NotDone cTropnT-0.07*
[**2179-11-21**] 03:48AM Albumin-3.5 Calcium-8.9 Phos-4.6*# Mg-2.4
[**2179-11-21**] 03:48AM ESR-30*
[**2179-11-21**] 03:48AM CRP-291.3*
[**2179-11-21**] 03:48AM Vanco-10.1
[**2179-11-21**] 03:48AM Digoxin-3.8*
[**2179-11-21**] 04:13AM Type-ART pO2-81* pCO2-46* pH-7.32* calTCO2-25
Base XS--2
[**2179-11-21**] 04:13AM Lactate-1.4
URINE:
[**2179-11-21**] 05:45AM Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.007
[**2179-11-21**] 05:45AM Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG
Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR
[**2179-11-21**] 05:45AM RBC-[**2-18**]* WBC-[**5-26**]* Bacteri-RARE Yeast-NONE
Epi-0-2 RenalEp-[**2-18**]
[**2179-11-21**] 05:45AM Hours-RANDOM UreaN-190 Creat-20 Na-69
JOINT FLUID:
[**2179-11-21**] 10:19AM WBC-[**Numeric Identifier **]* RBC-[**Numeric Identifier 44665**]* Polys-84* Lymphs-3
Monos-5 Macro-8
[**2179-11-21**] 10:19AM Crystal-FEW Shape-RHOMBOID Locatio-INTRAC
Birefri-POS Comment-c/w calcium phosphate deposits
[**2179-11-25**] 08:30AM WBC-[**Numeric Identifier 42138**]* RBC-[**Numeric Identifier 44666**]* Polys-91* Lymphs-1
Monos-8
OTHER PERTINENT LABS:
[**2179-11-21**] 03:48AM INR(PT)-9.6*
[**2179-11-21**] 10:24AM INR(PT)-11.2*
[**2179-11-21**] 08:04PM INR(PT)-3.3*
[**2179-11-22**] 04:04AM INR(PT)-3.4*
[**2179-11-23**] 02:30AM INR(PT)-2.7*
[**2179-11-24**] 06:29AM INR(PT)-2.8*
[**2179-11-24**] 03:32PM INR(PT)-2.8*
[**2179-11-25**] 03:28AM INR(PT)-2.7*
[**2179-11-25**] 11:27AM INR(PT)-2.0*
[**2179-11-26**] 05:25AM INR(PT)-2.4*
[**2179-11-27**] 03:10AM INR(PT)-2.5*
[**2179-11-28**] 03:56AM INR(PT)-2.2*
[**2179-11-29**] 02:56AM INR(PT)-2.0*
[**2179-11-29**] 10:56AM INR(PT)-2.0*
[**2179-11-30**] 05:44AM INR(PT)-1.8*
MICRO:
[**Date range (1) 44667**] BCx: MRSA
[**2179-11-21**] MRSA Screen: positive
[**2179-11-21**] Joint fluid (shoulder): MRSA
[**2179-11-21**] UCx: negative
[**2179-11-21**] Sputum Cx: respiratory flora
[**2179-11-23**] Catheter tip: negative
[**2179-11-25**] Joint fluid (L hip): MRSA
[**2179-11-25**] R 3rd MCP: MRSA
[**2179-11-25**] Shoulder: MRSA
[**Date range (1) 44668**] BCx: NGTD
IMAGING:
[**2179-11-21**] CXR:
There is opacification in the right upper zone. This could
represent volume loss in the right upper lobe or possible
supervening consolidation.
[**2179-11-21**] Repeat CXR:
In comparison with the earlier study of this date, there has
been
substantial clearing of the right upper lung opacification. This
suggests
expectoration of a mucous plug with relief of volume loss.
[**2179-11-21**] Shoulder XR:
No previous films are available for comparison. There is
sclerosis, with narrowing and some irregularity involving the
glenohumeral
joint. This may merely reflect degenerative changes, though the
possibility of an indolent infection cannot be excluded. MRI
might be helpful for further evaluation.
[**2179-11-21**] Hand XR:
The third MCP joint is quite well maintained without convincing
erosions. Degenerative change is seen involving the first CMC as
well as the second DIP joint. Some narrowing is also seen
involving several other DIP and PIP joints.
[**2179-11-22**] CXR:
No significant change from prior exam, allowing for significant
leftward rotation of the patient
[**2179-11-23**] ECHO:
The left atrial appendage emptying velocity is depressed
(<0.2m/s). A probable thrombus is seen in the left 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
severely depressed. The right ventricular cavity is dilated with
moderate global free wall hypokinesis. 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 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 structurally normal, though restricted
motion of the posterior leaflet is seen. There is no mitral
valve prolapse. No mass or vegetation is seen on the mitral
valve. Mild (1+) mitral regurgitation is seen. Moderate [2+]
tricuspid regurgitation is seen. [Due to acoustic shadowing, the
severity of tricuspid regurgitation may be significantly
UNDERestimated.] No vegetation/mass is seen on the pulmonic
valve. There is a trivial/physiologic pericardial effusion.
IMPRESSION: No valvular vegetation or wire-associated
vegetation. Probable left atrial appendage thrombus with
spontaneous echo contrast also identified within the body of the
left atrial appendage. Mild mitral regurgitation, at least
moderate tricuspid regurgitation. Severe biventricular systolic
dysfunction.
[**2179-11-29**] ECHO:
The left atrium is elongated. The right atrium is markedly
dilated. The interatrial septum is aneurysmal. The estimated
right atrial pressure is 10-20mmHg. Left ventricular wall
thicknesses are normal. The left ventricular cavity is
moderately dilated with severe global hypokinesis. The basal
inferolateral wall contracts best (LVEF = 20 %). The estimated
cardiac index is borderline low (2.0-2.5L/min/m2). No masses or
thrombi are seen in the left ventricle. The right ventricular
cavity is moderately dilated with severe global free wall
hypokinesis. [Intrinsic right ventricular systolic function is
likely more depressed given the severity of tricuspid
regurgitation.] 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 to moderate ([**12-18**]+) mitral regurgitation is
seen. Moderate to severe [3+] tricuspid regurgitation is seen.
There is moderate pulmonary artery systolic hypertension.
Significant pulmonic regurgitation is seen. There is a very
small circumferential pericardial effusion without
echocardiographic signs of tamponade.
Compared with the prior study (images reviewed) of [**2179-10-26**],
estimated pulmonary artery systolic pressure is now higher
DISCHARGE LABS:
Brief Hospital Course:
71 yo F w/ CAD, ischemic CMY (EF 10%) s/p [**Hospital1 **]-V ICD, atrial
fibrillation, CKD, with past history of DVT and PE on Coumadin
who was recently discharged from the CCU ([**11-6**]) for CHF
exacerbation complicated by C.diff infection who was transferred
from an outside hospital with a septic shoulder joint and acute
respiratory failure requiring intubation.
1. Respiratory Failure: Patient has history of CHF with EF 10%
which is the likely cause of her respiratory failure. She was
diuresed agressivly with lasix drip, weaned from vent. She was
also maintained on dopamine to maintain high cardiac output,
eventually weaned off and restarted on digoxin. Her respiratory
status continued to improve with diuresis. At time of discharge
she was saturating well on room air.
Of note, the patient changed her code status to DNR/DNI
following extubation although she briefly reversed this status
to be taken to the operating room (see below). However, on day
of discharge, she reversed herself and decided she did want CPR,
intubation and pressors for short term therapy only. She stated
she would not want to be intubated long term.
2. Septic Joint: Patient with + staph aureus in left shoulder
and later, blood cultures from the outside hospital also grew
MRSA. Presented with low BP, requiring pressor support likely a
combination of sepsis and cardiogenic shock (see below). Per
report, patient also had +hemearthrosis of left shoulder in the
setting of supratherapeutic INR. Patient's picc line was felt
to be the likely source of infection and this line was
discontinued at the time of admission. Initially, it was
unclear if Staph aureus in culture at OSH was a contaminant,
given that physical exam was not entirely consistent with a
spetic joint. Vancomycin was continued and ortho reaspirated
the left shoulder on day of admission; fluid analysis confirmed
bacterial infection. On [**11-25**], the patient was taken to the
operating room for washout of shoulder and right 3rd MCP joint,
both of which contained pus. Left hip was also aspirated, which
eventually grew MRSA also. Patient was continued on Vancomycin
with routine trough levels monitored. Blood cultures were
followed daily and remained positive until [**2179-11-25**]. Echo on
[**11-23**] showed no evidence of endocarditis although an intraatrial
thrombus was visualized which may be infected. The patient will
need prolonged therapy with vancomycin. She will follow up with
in the infectious disease clinic.
3. CORONARIES: Patient with history of extensive CAD with right
dominant system, mild instent re-stenois of the LAD BM stent and
occluded RCA. Throughout hospitalization, patient had no
subjective or objective symptoms of ischemia, and serial cardiac
enzymes were stable. Initially, b-blocker was held secondary to
severe hypotension requiring pressor support although aspirin
continued. By time of discharge, patient was also tolerating
low dose b-blocker and ACEI.
4. PUMP: Patient with history of ischemic cardiomyopathy, EF
10%, s/p BiV ICD ([**Company 1543**] Concerto C154DWK) on [**12-24**].
Presented with symptoms of acute on chronic congestive heart
failure with symptoms of both volume overload (high RV pressure,
pulmonary edema, ascites, peripheral edema) and poor cardiac
output (acute on chronic kidney failure, hypotension). With
initial hypotension, a CVL was inserted with attempt to float a
swan-ganz catheter to better assess fluid status.
Unfortunately, due to technical difficulties, PA catheter was
not able to be placed and the patient was treated with dopamine
to improve cardiac output. Once blood pressure had stabilized
and systemic infection improved, patient was started on lasix
drip for aggressive diuresis. Prior to discharge, patient was
restarted on her home medication regimen of torsemide,
lisinopril and metoprolol. Of note, patient was also restarted
on digoxin after discontinuation of dopamine. These levels will
need to be monitored carefully given patient's fluctuating
creatinine clearance.
5. RHYTHM: Patient with h/o atrial fibrillation, s/p BiV ICD
([**Company 1543**] Concerto C154DWK) [**12-24**], on coumadin and amiodarone as
antiarrhythmic. Presented with supratherapeutic INR and
hemarthosis of left shoulder. Coagulopathy was reversed with
FFP prior to shoulder and MCP washout. Found to have
intra-atrial thrombus on TEE during hospitalization. Needs to
be maintained on heparin gtt following surgical procedure until
coumadin reached theraputic goal of INR [**1-19**]. Heparin can be held
while vancomycin is infusing.
6. Acute on CRF: Patient w/ baseline Cr 1.3-1.8, 2.4 on
presentation, likely related to poor forward flow from CHF.
Medications were renal dosed and renal function followed
carefully throughout hospital course. Kidney function improved
to baseline by time of discharge.
7. H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and
has [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 260**] filter in place. As noted above, patient
presented with supratherapeutic INR which was reversed prior to
surgical intervention. For the duration of the hospital stay,
the patient was maintained on heparin gtt, which should be
continued until coumadin reachs therapeutic levels again,
2.0-3.0.
8. Hypothyroidism: stable, continue Levothyroxine.
9. Access: The patient had a new single lumen PICC line placed
in her right arm on [**2179-11-30**] by interventional radiology. The
PICC line would not pass beyond the mid-clavicular area due to a
stenosis in the subclavian vein. It was cut to this length and
is slightly longer than a traditional midline. A PICC cannot be
placed in the other arm because of her pacemaker. The patient
should get her vancomycin infusion over an hour. Her vancomycin
should be diluted into 250ml to decrease the chance of fibrosis
or irration to this artery. Please monitor the patient's arm
for swelling or pain because she is at an increased risk of
clot, however, she is on anticoagulation.
10. CODE STATUS: Full code on [**2179-12-3**]
Medications on Admission:
Allopurinol 100mg daily
Amiodarone 200mg daily
Aspirin 81mg daily
Vit C 500mg daily
Cholestyramine 4gm [**Hospital1 **]
Digoxin 0.0625mg daily
Levothyroxine 0.125mg daily
Metolazone 2.5mg daily
Metoprolol Tartrate 12.5mg [**Hospital1 **]
MVI
Omeprazole 20mg daily
Simvastatin 20mg qHS
Torsemide 40mg daily
Zinc Sulfate 220mg daily
Warfarin
Oxacillin 1gm q6h
Propofol bolus for intubation, changed to Fentanyl/Versed
Dilaudid 0.4mg q4h PRN pain
Vicodin 1-2 tabs q4h PRN pain
Discharge Medications:
1. Outpatient Lab Work
Please get weekly CBC with differential, BUN/ Creatinine and
vancomycin trough. Start date: [**2179-12-8**]
Fax results to [**Hospital **] clinic: [**Telephone/Fax (1) 1419**]
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
9. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours): Please d/c once pain well controlled.
10. Tramadol 50 mg Tablet Sig: One (1) Tablet PO QID (4 times a
day).
11. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
12. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily):
HOLD SBP < 85.
13. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
14. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
16. Torsemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
17. Digoxin 125 mcg Tablet Sig: 0.5 Tablet PO EVERY OTHER DAY
(Every Other Day).
18. Vancomycin 500 mg IV Q 24H
19. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
20. Heparin (Porcine)-0.45% NaCl 25,000 unit/250 mL Parenteral
Solution Sig: sliding scale units Intravenous continuous.
21. Heparin Lock 10 unit/mL Solution Sig: Two (2) ml Intravenous
after NS flush.
22. Saline Flush 0.9 % Syringe Sig: Ten (10) cc Injection before
and after vancomycin dose.
23. Outpatient Lab Work
Please get chem-7 every 3 days to follow K, Na and renal status.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Primary Diagnosis:
Septic Joint
acute on chronic congestive heart failure
intra-atrial thrombus
Secondary Diagnosis:
atrial fibrillation
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Out of Bed with assistance to chair or
wheelchair
Discharge Instructions:
You were admitted to the hospital with left shoulder pain. You
were found to have an infection in your shoulder that had spread
to your blood, left hip and right hand. In the operating room,
the orthopedic doctors [**Name5 (PTitle) 44669**] out your infected joints which
should help cure your infection. You were also started on
vancomycin, an antibiotic that you will need to continue after
you leave the hospital. You should follow up with the
infectious disease specialists who will determine how long you
need to continue the vancomycin.
.
You also had difficulty breathing when you first came to the
hospital, requiring a breathing tube. Your trouble breathing
was likely caused by an exacerbation of your heart failure which
caused fluid to accumulate on your lungs. We treated you with
medications to help remove this excess fluid and the breathing
tube was able to be removed.
Medication changes:
1. Start Vancomycin to treat the joint and blood infections.
2. Decrease the Torsemide to 20 mg twice daily
3. Decrease the Digoxin to every other day
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs in 1 day or 6 pounds in 3 days.
Followup Instructions:
Please follow up in infectious disease clinic with Dr. [**First Name (STitle) **]
on [**2179-12-24**] at 9:30. Phone:[**Telephone/Fax (1) 457**] [**Hospital Unit Name **]
[**Location (un) 448**], [**Doctor First Name **], [**Location (un) 86**].
.
Cardiology:
Dr. [**First Name8 (NamePattern2) 401**] [**Last Name (NamePattern1) 437**] Phone [**Telephone/Fax (1) 62**] Date/Time: Monday [**12-13**] at
9:00am. [**Hospital Ward Name 23**] clinical center, [**Location (un) 436**], [**Hospital Ward Name 516**] [**Hospital1 18**].
.
Ortho:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] NP. Date/Time: [**12-21**] at 11:00am. [**Hospital Ward Name 23**]
Clinical Center, [**Location (un) **], [**Location (un) **], [**Hospital Ward Name 516**],
[**Hospital1 18**].
|
[
"244.9",
"038.12",
"414.8",
"414.01",
"428.0",
"518.81",
"429.89",
"584.9",
"V45.82",
"414.2",
"745.4",
"V12.51",
"428.23",
"V58.61",
"785.52",
"585.9",
"427.31",
"V45.02",
"995.92",
"719.11",
"711.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"80.14",
"96.71",
"81.91",
"80.11",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
18292, 18364
|
9598, 15686
|
338, 602
|
18546, 18546
|
3006, 4495
|
19925, 20711
|
2320, 2490
|
16210, 18269
|
18385, 18385
|
15712, 16187
|
18716, 19608
|
9575, 9575
|
2505, 2987
|
1777, 2095
|
19628, 19902
|
285, 300
|
630, 1683
|
18503, 18525
|
18404, 18482
|
4517, 9558
|
18560, 18692
|
1705, 1757
|
2111, 2304
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,898
| 107,275
|
15921
|
Discharge summary
|
report
|
Admission Date: [**2171-12-17**] Discharge Date: [**2171-12-19**]
Date of Birth: [**2128-7-6**] Sex: M
Service: MICU/[**Location (un) **] MEDICINE
CHIEF COMPLAINT: Status post V fibrillation arrest.
HISTORY OF PRESENT ILLNESS: The patient is a 43 year-old
male with a history of metastatic melanoma with course
complicated by duodenal and pancreatic metastases causing
biliary and small bowel obstruction requiring total
parenteral nutrition who presented with worsening abdominal
pain on the day prior to admission. He complained of diffuse
diarrhea, nausea and vomiting. Approximately ten days ago
total parenteral nutrition was discontinued and the patient
was started on po.
On arrival to the Emergency Department the patient appeared
pale and blue and then promptly when into ventricular
tachycardia and V fibrillation arrest. The patient was
shocked at 200 jewels, given Cefepime, Flagyl, Zofran,
morphine, Fentanyl and Propofol. During the code the patient
was given calcium, magnesium, bicarb, insulin and glucose.
The patient was subsequently resuscitated and transferred to
the MICU for further care.
PAST MEDICAL HISTORY:
1. Metastatic melanoma status post DTIC times three, last
echocardiogram two and a half weeks prior to admission.
2. Astrocytoma grade 2 diagnosed eight months ago status
post resection.
3. Metastases to duodenum causing biliary and mechanical
small bowel obstruction on total parenteral nutrition status
post endoscopic retrograde cholangiopancreatography with
biliary stent.
4. Basal cell carcinoma.
MEDICATIONS ON ADMISSION:
1. Compazine 10 mg po q day.
2. Ativan.
3. MS Contin 60 mg po q day.
4. MSIR 15 mg prn.
5. Dulcolax.
6. Megace.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: Significant for breast cancer in the family.
SOCIAL HISTORY: Quit alcohol and tobacco use 14 years ago.
The patient is currently not working and sister is health
care proxy.
PHYSICAL EXAMINATION: Temperature 104. Heart rate 129.
Blood pressure 156/107. O2 sat 100%. In general, the
patient is intubated and sedated on mechanical ventilation
500 by 17. HEENT extraocular movements intact. Neck supple.
No JVP. Heart tachycardic. Normal S1 and S2. Lungs clear
to auscultation anteriorly and laterally. Abdomen was soft,
mildly tender. No bowel sounds were heard. Extremities no
edema. Rectal was guaiac positive.
LABORATORY DATA: Significant for a potassium of 2.5 and a
glucose of 241. White blood cell count of 1.3 with 37%
neutrophils, 21% bands and 31% lymphocytes, hematocrit 33.5,
platelets 212, ALT and AST were within normal limits.
Alkaline phosphatase elevated at 246, LDH elevated at 1164,
lipase normal, total bilirubin is .6. PT/PTT/INR were 14.1,
20.8 and 1.3 respectively. Lactate was 7.8. Arterial blood
gas status post cardiac arrest with 7.48, 36 and 530. Free
calcium 1.23 and lactate of 4.6. Electrocardiogram number
one showed a wide complex tachycardia, number two showed a
questionable sides and a wide complex tachycardia at 300
beats per minute. Number three was sinus tach at 130 beats
per minute with left axis deviation. Chest x-ray showed no
acute cardiopulmonary process. CT of the torso showed
worsening metastatic disease in liver, pancrease, small bowel
and mesentery. Pancreatic mass was compressing the IVC.
There was ill defined pulmonary nodules, increased in size
from [**2171-12-16**].
HOSPITAL COURSE: The patient is a 43 year-old male with
metastatic melanoma and abdominal pain status post V
fibrillation arrest.
1. V fibrillation arrest status post resuscitation: It was
initially thought that the V fibrillation arrest was due to
hypokalemia and may have been exacerbated by prolonged QT
from Compazine. His potassium and magnesium were
aggressively repleted and all other medications were stopped.
2. Sepsis: The patient became profoundly hypotensive with a
systolic blood pressure in the 60s and started on
neo-synephrine after initially being tachycardic and
hypotensive. Since some of the hypotension was attributed to
Propofol, but most likely it was due to septic physiology
with a fever of 104, warm extremities and neutropenia. The
patient was given Vancomycin, Cefepime and Flagyl. A PICC
line was planned to be discontinued. A chest CT also showed
new bilateral infiltrates not seen on chest x-ray and it was
thought that the patient was beginning to develop ARDS. He
was continued to be aggressively intravenous fluid hydrated
and he was started on Vasopressin, neo-synephrine and
Levophed drips. Blood cultures were sent, which eventually
grew out strep.
3. Hypoxic respiratory failure from early ARDS or aspiration
pneumonia: H was started on mechanical ventilation with a
low volume regulation strategy.
Throughout the course of the night the patient became
increasingly hemodynamically unstable. Levophed,
neo-synephrine and Vasopressin drips were maximally dosed.
Systolic blood pressures continued to drop to the 50s and 60s
despite multiple normal saline boluses throughout the night.
A cordis catheter was emergently placed and the patient was
still aggressively fluid resuscitated without resolution of
his hypotension. Dopamine was added, but also did not
improve his blood pressure. He then became bradycardic and
had a PEA arrest. After multiple discussions with the family
we decided to stop CPR secondary to medical futility. The
patient passed away at 1:57 a.m. immediately after
discontinuing CPR. The family was notified at bedside and
the health care proxy refused autopsy.
CONDITION ON DISCHARGE: Expired.
DISCHARGE DIAGNOSES:
1. Metastatic melanoma.
2. Gram positive sepsis from unclear source most likely from
PICC line.
3. Septic shock.
4. ARDS.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4561**]
Dictated By:[**Last Name (NamePattern1) 218**]
MEDQUIST36
D: [**2172-4-3**] 11:09
T: [**2172-4-6**] 10:29
JOB#: [**Job Number 45661**]
|
[
"518.81",
"197.7",
"197.4",
"427.5",
"276.2",
"038.9",
"197.8",
"427.41",
"197.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.62",
"96.04",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
1766, 1812
|
5621, 6019
|
1592, 1749
|
3436, 5565
|
1966, 3418
|
182, 218
|
247, 1137
|
1159, 1566
|
1829, 1943
|
5590, 5600
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,478
| 127,205
|
11023
|
Discharge summary
|
report
|
Admission Date: [**2160-2-21**] Discharge Date: [**2160-2-27**]
Service: [**Location (un) 259**]
CHIEF COMPLAINT: Failure to thrive and question of sepsis
episode.
HISTORY OF PRESENT ILLNESS: This is an 81-year-old female
with a complex past medical history including a Billroth II
surgery, cholecystectomy, and history of biliary sepsis and
VRE bacteremia since [**2159-7-25**]. Due to failure to thrive
and poor nutrition at her rehabilitation facility, she had AN
IR placement of a PEJ tube; however, due to the Billroth II,
this was complicated, and a PEG tube was placed instead.
During this procedure on [**2160-2-20**], she vomited
twice, and there was a concern for aspiration. She was
discharged to [**Hospital **] [**Hospital **] Hospital.
On the evening of [**2-20**], she had a temperature to
101.4?????? but no changes in her systolic blood pressure. On the
morning of [**2-21**], she complained of abdominal pain and
had abdominal distention and vomiting. On a CAT scan the
stomach appeared to be separated from the abdominal wall, but
there was no free air in the abdomen. Although the PEG tube
fastener looked "loose" on G-tube fluoroscopy, there was no
evidence of extravasation. She was admitted to [**Hospital6 1760**].
On [**2-22**], she had the PEG tube revised by IR, and a CT done
on [**2-22**] showed no leakage in good position; however, she
had a short episode of hypotension and was given
Neo-Synephrine with good resolution and was observed in the
SICU overnight with stable vitals signs off pressors. Also
there was a failed attempt to pass the NG tube past her
stomach, and it remained in her stomach during the admission.
REVIEW OF SYSTEMS: The patient was unable to give review of
systems at this time.
PAST MEDICAL HISTORY: 1. Jaundice episode in [**2159-7-25**]
leading to ERCP that was complicated by duodenal hematoma.
She needed Billroth II surgery and had a complicated course
including biliary sepsis with VRE. 2. Treatment with
Gentamicin led to APN secondary to toxicity. 3. Status post
cholecystectomy. 4. History of cholangeitis. 5.
Gastroesophageal reflux disease. 6. History of peptic ulcer
disease. 7. Hypertension. 8. Dementia status post
cerebrovascular accident. 9. Depression. 10. Polycythemia
[**Doctor First Name **]. 11. Diverticulitis. 12. Electrocardiogram evidence
of inferior Q-wave myocardial infarction occurring between
[**2159-7-25**] and [**2159-10-25**]. 13. Stage IV sacral
decubitus ulcer.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: Before [**2159-7-25**], she lived at [**Hospital1 2670**]
at [**Hospital 5871**] Nursing Home. She has had multiple admissions to
the [**Hospital6 256**] since [**2159-7-25**]
and has been at [**Hospital **] [**Hospital **] Hospital in between to
[**Hospital6 256**] admissions. She has a
daughter. She denied alcohol or tobacco use.
MEDICATIONS ON ADMISSION: Protonix 40 mg IV q.d., Heparin
5000 U subcue b.i.d., Docusate Sodium 100 mg per NG tube
q.d., Acetaminophen 650 mg per NG tube q.4 hours p.r.n. pain,
Modafinil 400 mg p.o. q.d., Compazine 25 mg p.r. q.6 hours
p.r.n. nausea, Tobradex 1 application ophthalmic O.S. O.D.
t.i.d.
ALLERGIES: NO KNOWN DRUG ALLERGIES.
PHYSICAL EXAMINATION: Vital signs: Temperature 98.6??????, blood
pressure 92-119/37-68, heart rate 88-100, 98-100% on 4 L
nasal cannula. General: There was an elderly,
frail-appearing female in no acute distress. She responded
to voice and occasionally verbalizes to questions, mostly
nodding yes or no, and is oriented to self and place but
thinks the year is [**2079**]. HEENT: Normocephalic, atraumatic.
Pupils equal and reactive to light. She did not cooperative
to extraocular movements, but they appear intact. Oropharynx
clear. Sclerae anicteric. Neck: Supple. Full range of
motion. No lymphadenopathy appreciated. Cardiovascular:
Regular, rate and rhythm at 90 beats per minute. Normal S1
and S2. No murmurs, rubs or gallops appreciated. Lungs:
Limited exam to anterior chest but clear to auscultation
bilaterally. A right subclavian line had no erythema or
edema. Abdomen: Soft, slightly obese, with moderate
distention symmetrically. Positive bowel sounds in all four
quadrants. Tender to palpation along the epigastrium but no
guarding. There was no erythema at the PEG site. She had
several well-healed scars. Back: She had a grade IV sacral
decubitus ulcer 2.7 cm diameter, 2.7 mm deep with
foul-smelling purulent discharge. Extremities: No edema.
Left foot was in padded brace. Bilaterally the feet were
warm with good pulses. Neurological: Cranial nerves II-XII
grossly intact. She moved all four extremities spontaneously
with slightly increased muscle tone in the upper extremities.
LABORATORY DATA: On admission her CBC showed a white count
of 11.7, hematocrit 32.7, platelet count 305; on [**2-22**] the
CBC showed a white count of 6.5, hematocrit 28.3, platelet
count 294; CHEM7 was normal throughout the admission; she had
normal liver function tests and amylase and lipase;
coagulation showed a PT of 13.8, with an INR of 1.3; CK was
negative, troponin I was negative; iron work-up revealed a
TIBC of 125, ferratin 289, TRF 96, vitamin B12 was normal at
475, folate normal at 16.1; hepatitis B antibody negative;
microscopic gram stain of the decubitus ulcer showed
gram-positive cocci in pairs; urine culture was contaminated.
CT scan on [**2-22**] showed no evidence of free air, no
contrast extravasation or fluid collection to suggest
perforated viscus. There was no evidence of obstruction.
Electrocardiogram on [**1-7**] showed an inferior myocardial
infarction with Q-waves in leads II, III, and AVF, with poor
R-wave progression, in normal sinus rhythm.
Electrocardiogram on [**2160-2-23**], showed no changes from
the previous electrocardiogram on [**1-7**].
HOSPITAL COURSE: This is an 81-year-old lady with a long
past medical history including complicated multi-admission
course in [**2159-7-25**] including ERCP, cholecystectomy, and
Billroth II, and VRE biliary sepsis. She was admitted on
this occasion due to complicated PEG placement and episode of
hypotension and question of sepsis. She was briefly on
Neo-Synephrine and fluids and observed with stable vitals
signs in the SICU for 24 hours before being transferred to
the floor on [**2160-2-23**].
1. Cardiovascular: Hypotensive episode, now resolved.
Differential included hypovolemia due to poor NG tube intake
plus nausea and vomiting which she was poorly responsive to a
large volume resuscitation. She responded quickly to
Neo-Synephrine. There could be a secondary infection but
unclear source, and she remained afebrile throughout the
admission.
Upon review of 12-lead electrocardiogram in [**2160-1-7**],
there was evidence of an old Q-wave inferior myocardial
infarction and a history of a normal electrocardiogram in
[**2159-7-25**] which appeared to be a silent myocardial
infarction. An electrocardiogram was done on [**2160-2-23**],
with no acute changes, and CK and troponin I were negative.
The patient was started on Aspirin for cardioprotective
therapy.
2. Gastrointestinal: History of poor p.o. intake and nausea
and vomiting and distention on admission. She was started on
NG tube feeds at only 20 cc/hr and monitored for tolerance.
Overnight on [**2-24**], she had one episode of vomiting. On
[**2-25**], the PEG was started to be used at 20 cc/hr and
slowly increased to the goal of 60 cc/hr, which was well
tolerated with residuals under 5 cc. She was continued on
Protonix and Compazine p.r.n. for nausea.
For a focal intra-abdominal infection that could not be ruled
out, she was given a course of Ampicillin, Flagyl, and
Levofloxacin for 4 days and was changed to Flagyl and
Levofloxacin for the last three days.
3. Pulmonary: She had excellent oxygen saturations of
98-100% on 4 L nasal cannula weaned to 1 L nasal cannula with
97% oxygen saturation. It was unlikely an aspiration
pneumonia because she remained afebrile with no increase in
her white count, and she was covered by the Flagyl and
Levofloxacin.
4. Skin: She has a decubitus stage IV ulcer at the sacrum.
Plastic Surgery was consulted recommending normal saline
wet-to-dry dressing changes t.i.d. and p.r.n., and she is not
considered a surgical candidate.
5. FEN: She was admitted for poor nutritional state and low
albumin. Nutrition was consulted, and goal for nutrition was
Promote with fiber at 60 cc/hr to provide 1440 kcal and 90 g
of protein. She achieved this goal tube feeds on [**2-26**]
overnight and has tolerated it well and will be discharged
with a recommendation to continue these tube feeds.
The patient asked several times to eat and had a swallowing
evaluation. She is found to be a low aspiration risk if she
is sitting upright in bed while she eats and should be
allowed to eat soft solids, as she edentulous. Often this
patient would ask for food but then refuse it when it arrived
at her bedside.
6. Renal: She has a history of ATN in the past. On this
admission, she had excellent BUN and creatinine throughout
with a good urine output.
7. Neurological: At baseline she has a history of dementia,
and her Modafinil was continued.
8. Psychiatric: History of depression. She was continued
on Modafinil 400 mg per NG tube.
9. Heme: Hematocrit on admission was 33 and fell to 28,
slowly increasing to 28.9 by discharge. Anemia labs were
sent and consistent with anemia of inflammation with a high
storage iron ferratin but low total iron TIBC and PRF.
CONDITION ON DISCHARGE: Good.
DISCHARGE DIAGNOSIS:
1. Gastroesophageal reflux disease.
2. History of peptic ulcer disease.
3. Hypertension.
4. Dementia.
5. Depression.
6. Anemia.
7. History of inferior myocardial infarction.
8. Question of focal peritonitis bacteremia.
DISCHARGE MEDICATIONS: Protonix 40 mg q.d., Heparin 5000 U
q.d. to b.i.d., Docusate 100 mg per NG tube q.d.,
Acetaminophen 650 mg per NG q.4 hours p.r.n. pain, Aspirin
325 mg per NG tube q.d., Modafinil 400 mg p.o. q.d.,
Compazine 25 mg p.r. q.6 hours p.r.n. nausea, Tobradex 1
application each eye t.i.d., Flagyl 500 mg per NG tube
t.i.d., Levofloxacin 500 mg per PEG q.d.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 11283**]
Dictated By:[**Last Name (NamePattern1) 35690**]
MEDQUIST36
D: [**2160-2-27**] 09:29
T: [**2160-2-27**] 09:36
JOB#: [**Job Number 35691**]
|
[
"285.9",
"458.2",
"707.0",
"790.7",
"412",
"294.8",
"996.59",
"783.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"97.02",
"96.6",
"97.01"
] |
icd9pcs
|
[
[
[]
]
] |
2525, 2543
|
9886, 10501
|
9634, 9862
|
2925, 3240
|
5887, 9581
|
3263, 5869
|
1698, 1762
|
127, 178
|
207, 1678
|
1785, 2508
|
2560, 2898
|
9606, 9613
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,567
| 171,132
|
39624
|
Discharge summary
|
report
|
Admission Date: [**2145-2-26**] Discharge Date: [**2145-3-5**]
Date of Birth: [**2094-8-15**] Sex: M
Service: SURGERY
Allergies:
Lisinopril
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
[**First Name3 (LF) 499**] cancer with liver metastases
Major Surgical or Invasive Procedure:
[**2145-2-26**]: 1. Right hepatic lobectomy, cholecystectomy,
intraoperative ultrasound. 2. Ileostomy takedown
[**2145-3-4**]: Fistulogram, IR guided partial thrombectomy
[**2145-3-5**]: Open AVF thrombectomy
History of Present Illness:
The patient is a 51-year-old male who underwent an uncomplicated
laparoscopic low anterior resection with diverting loop
ileostomy on [**2145-1-13**], for adenocarcinoma of the [**Year (4 digits) 499**].
The final path report demonstrated that pT3, N0 lesion. He
also is maintained on chronic hemodialysis through a left arm
fistula. He is also known to have metastatic disease to the
liver. He underwent a CT scan of the abdomen on [**2145-2-17**],
that demonstrated multiple hypodensities in the right lobe
consistent with metastatic disease. The left lobe of the liver
was clear of evidence of metastatic disease. He is now to
undergo right hepatic lobectomy, cholecystectomy, intraoperative
ultrasound and takedown his loop ileostomy.
Past Medical History:
Past Medical and Surgical History: [**Year (4 digits) **] cancer s/p laparoscopic
LAR with loop ileostomy [**2145-1-13**], HTN, DM II, ESRD, HD started
[**2143-7-30**], via an LUE AVF
Social History:
Graphic designer, single, no EtOH or illicit drugs, previous
smoker, quit 15 years ago, smoked [**11-29**] PPD x 20 years
Family History:
Mother and aunt with [**Name2 (NI) 499**] cancer
Physical Exam:
Temp 98.5 HR 92, BP 153/86 RR 16, weight 90.3 kg.
On physical exam he is an alert male in no acute distress.
HEENT: No scleral icterus. Oropharynx clear.
Neck: No lymphadenopathy.
His lungs are clear to auscultation.
Cardiac exam: Normal S1-S2. No S3, S4, murmurs, or rubs.
Regular rate and rhythm.
His abdominal exam is benign.
His incisions arewell healed. The ileostomy is in place and
functioning.
He has no hepatosplenomegaly, masses, or tenderness.
Extremities: No peripheral edema. LUE suture line intact no
drainage or swelling. Palpable uniform thrill, Audible uniform
bruit throughout. Neurologically grossly intact.
Pertinent Results:
At Admission: [**2145-2-26**]
WBC-17.7*# RBC-3.75* Hgb-11.3* Hct-32.9* MCV-88 MCH-30.3
MCHC-34.5 RDW-17.1* Plt Ct-342
PT-15.1* PTT-28.8 INR(PT)-1.3*
Glucose-97 UreaN-22* Creat-5.9*# Na-135 K-5.3* Cl-105 HCO3-22
AnGap-13
ALT-834* AST-636* AlkPhos-94 TotBili-2.3*
Albumin-2.5* Calcium-8.8 Phos-4.3 Mg-1.4*
At Discharge: [**2145-3-5**]
WBC-8.8 RBC-3.15* Hgb-9.4* Hct-28.6* MCV-91 MCH-30.0 MCHC-33.0
RDW-17.6* Plt Ct-135*
PT-14.6* PTT-27.3 INR(PT)-1.3*
Glucose-153* UreaN-53* Creat-9.8* Na-138 K-3.5 Cl-103 HCO3-27
AnGap-12
ALT-90* AST-27 AlkPhos-140* TotBili-0.7
Calcium-7.6* Phos-5.8* Mg-2.1
Brief Hospital Course:
Patient was scheduled for his operation on [**2145-2-26**]. In the
pre-operative area, he was examined and evaluated and there was
no significant changes in history and exam. He then underwent
right hepatectomy, cholecystectomy with intra-operative
ultrasound with the hepatobiliary team (Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]).
His ileostomy was then taken down by the colorectal team
(Dr.[**First Name (STitle) **] [**Name (STitle) **]). He lost 3L of blood and was given 3units
pRBC and 3500ml of crystalloid. The patient was extubated in the
OR and transferred to the PACU in stable condition. Please refer
to operative notes for further details.
In the recovery room, the patient became hypotensive with SBP in
70's. He was resuscitated with fluid and Levophed, and then
transferred to the ICU for hemodynamic monitoring. His K was
noted to be elevated to 6.3 with EKG changes and he was treated
with insulin/dextrose/calcium with good response. A femoral HD
catheter was placed on [**2145-2-27**] and patient was started on CVVH.
CVVHD was stopped on [**2-28**]. The dialysis line was removed. He was
started on clears which he tolerated. Hct was noted to have
decreased to 26.3 from 31. One unit of PRBC was transfused on
[**3-1**] with hct stabilizing at 31.
Hemodialysis was performed via AVF on [**3-2**] with removal of 2.5
liters.
Diet was advanced and tolerated. IV pain medication was switched
to oxycodone with good pain control. He was passing flatus by
[**3-3**], but did not have a BM. A dulcolax supp was given on [**3-3**]
with passage of several stools.
Incision remained intact without redness or drainage. The JP
drain averaged 600-700 nonbilious fluid. He received drain
teaching.
Of note, AST and ALT increased immediately postop then trended
down (AST up to 636 then down to 57, ALT up to 869 then down to
319. Alk phos decreased and t.bili remained in the 2.2 to 2.0
range).
He was assisted out of bed. PT was consulted and recommended PT
at home for a few visits as he was deconditioned. VNA services
were arranged for JP drain assistance and PT.
On [**3-4**], he went to hemodialysis but the AVF was not able to be
accessed proximally. Clots were removed at this site.
+thrill/bruit was present, however, thrill/bruit diminished
proximally. He was evaluated by interventional radiology who
found a tight stenosis at the cephalic arch and mid cephalic
stenosis and clot. IR attempted a percutaneous thrombectomy and
angioplasty. However, an attempt at dialysis following the
procedure yielded unsatisfactory results and the patient was
scheduled for the following day to have OR revision of the
access.
On [**3-5**], he underwent an AV Fistula revision and a right
thrombectomy. He tolerated the procedure well without
complications. He had a palpable thrill. He received
hemodialysis post-operatively with good flows through the
access, and HD was completed without complication from the
access.
Pt was discharged [**3-5**] to home with VNA with planned and
scheduled hemodialysis at his outpatient clinic [**3-6**] at 11am and
follow-up in AV Care for a fistulogram within 1-2 weeks. He had
excellent pain control and was tolerating a regular diet at the
time of discharge. Mr. [**Known lastname 58659**] [**Last Name (Titles) 87406**] understanding and
agreement with the plan.
Medications on Admission:
Triphrocaps
Carvedilol 25mg PO BID
Lantus 5 units qhs
Sevelamer 800mg POD TID
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain or Temp above 101F: no more than
2000mg per day.
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
4. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
5. sevelamer HCl 400 mg Tablet Sig: Six (6) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
6. insulin glargine 100 unit/mL Solution Sig: Five (5) units
Subcutaneous at bedtime.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
metastatic adenoma of [**Hospital 499**] to liver
Rectal cancer with diverting loop ileostomy.
clotted avf s/p thrombectomy and revision
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Please call Dr.[**Name (NI) 1369**] office [**Telephone/Fax (1) 673**] if you experience
any of the following:
fever, chills, nausea, vomiting, increased abdominal pain or
distension, jaundice, constipation/diarrhea or incision
redness/bleeding or drainage
CareGroup VNA has been arranged
You may shower with soap and water. Pat dry. Do not apply
powder/lotion or ointment to incision
No driving while taking pain medication
No heavy lifting/straining
Followup Instructions:
[**First Name4 (NamePattern1) 698**] [**Last Name (NamePattern1) 699**], RN coordinator for Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 17195**] will
call you with a follow up appointment. Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
office [**Telephone/Fax (1) 673**]
You will need to schedule follow up appointment with Dr. [**First Name (STitle) **]
[**Name (STitle) **] ([**Telephone/Fax (1) 160**]in [**11-29**] weeks.
You are scheduled for Hemodialysis at your outpatient HD center
tomorrow [**2145-3-5**] at 11:00 AM.
Please also call AV Care to ([**Telephone/Fax (1) 87407**] to schedule a
Fistulogram in [**11-29**] weeks.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2145-3-5**]
|
[
"403.91",
"E878.8",
"E849.8",
"197.7",
"575.11",
"E849.7",
"585.6",
"V10.06",
"453.87",
"458.29",
"996.73",
"285.9",
"V10.05"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.97",
"39.49",
"88.76",
"39.95",
"38.95",
"00.40",
"00.44",
"88.49",
"46.51",
"39.79",
"51.22",
"39.50",
"50.3"
] |
icd9pcs
|
[
[
[]
]
] |
7169, 7227
|
3011, 6395
|
324, 535
|
7408, 7408
|
2397, 2701
|
8070, 8894
|
1674, 1725
|
6523, 7146
|
7248, 7387
|
6421, 6500
|
7592, 8047
|
1740, 2378
|
2715, 2988
|
229, 286
|
563, 1310
|
7423, 7568
|
1332, 1518
|
1534, 1658
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,623
| 161,572
|
43844
|
Discharge summary
|
report
|
Admission Date: [**2197-1-31**] Discharge Date: [**2197-2-3**]
Date of Birth: [**2125-12-8**] Sex: M
Service:
ADMISSION DIAGNOSES:
1. Coronary artery disease.
2. Hypertension.
3. Skin cancer.
4. Osteoarthritis.
5. Gastroesophageal reflux disease.
6. Complete occlusion of right vertebral artery.
7. Left carotid stenosis to 70-80%.
8. History of transient ischemic attacks.
9. Peripheral vascular disease.
10. Hypercholesterolemia.
11. History of pancreatitis.
12. History of hepatitis.
DISCHARGE DIAGNOSES:
1. Coronary artery disease.
2. Hypertension.
3. Skin cancer.
4. Osteoarthritis.
5. Gastroesophageal reflux disease.
6. Complete occlusion of right vertebral artery.
7. Left carotid stenosis to 70-80%.
8. History of transient ischemic attacks.
9. Peripheral vascular disease.
10. Hypercholesterolemia.
11. History of pancreatitis.
12. History of hepatitis.
13. Status post re-do coronary artery bypass graft times two.
HISTORY OF PRESENT ILLNESS: The patient is a 70-year-old
male with a history of coronary artery disease status post
coronary artery bypass graft in [**2186**] and known aortic
stenosis murmur for several years. He recently developed
daily angina relieved by multiple nitroglycerin sprays. The
patient has had multiple Interventional Cardiology procedures
in the interim with stents and angioplasty since his coronary
artery bypass graft. He has a congenital bicuspid aortic
valve. Echocardiogram in [**2196-7-22**] demonstrated an
ejection fraction of 35%, mild left ventricular hypokinesis,
inferior hypokinesis, moderate aortic stenosis, 2+ aortic
insufficiency. Cardiac catheterization in [**2196-10-22**]
demonstrated an ejection fraction of approximately 50%, with
patent stents. The left anterior descending artery was
occluded to 100%. Circumflex was occluded to 100%. The
patient now presents for re-do coronary artery bypass graft
and concomitant aortic valve replacement.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Skin cancer.
3. Coronary artery disease.
4. Osteoarthritis.
5. Gastroesophageal reflux disease.
6. Left carotid stenosis to 70-80%.
7. Right vertebral artery occlusion.
8. History of transient ischemic attacks.
9. Peripheral vascular disease.
10. Hypercholesterolemia.
11. History of pancreatitis.
12. History of hepatitis.
PAST SURGICAL HISTORY:
1. Cholecystectomy.
2. Multiple skin cancer excisions.
3. Bilateral bunionectomy.
4. Bilateral cataract.
5. Coronary artery bypass graft times two in [**2186**] with left
internal mammary artery to the left anterior descending
artery, saphenous vein graft to the OM1.
6. Bilateral knee arthroscopies.
7. Umbilical herniorrhaphy.
8. Right inguinal herniorrhaphy.
9. Tonsillectomy.
ALLERGIES:
1. Zestril causes a cough.
2. Dipyridamole causes an acute anaphylactic reaction.
3. Aggrenox (contains dipyridamole).
4. Question muscle relaxant causing laryngeal spasm and
trouble swallowing postoperatively in [**2191**].
PREOPERATIVE MEDICATIONS:
1. Imdur 30 mg b.i.d.
2. Cozaar 25 mg b.i.d.
3. Aspirin 325 mg q. day.
4. Lopressor 100 mg b.i.d.
5. Diltiazem 240 mg q. day.
6. Nitroglycerin sublingual spray p.r.n.
7. Zocor 20 mg q. day.
8. Rabeprazole 20 mg q. day.
9. Vitamin E 400 units q. day.
10. Calcium with zinc supplementation.
11. Vitamin C 400 units q. day.
12. Multivitamin.
13. Salsalate 750 mg b.i.d.
SOCIAL HISTORY: The patient admits to having one alcoholic
beverage a day. Nonsmoker. No recreational drug use.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: 5'7", 175
pounds. Heart rate of 63 and in sinus, blood pressure
127/44, 98% on room air. Chest has a well-healed sternotomy
scar. The sternum is stable. Clear to auscultation
bilaterally. Cardiovascular: Regular rate and rhythm with a
holosystolic ejection murmur grade [**2-25**] radiating to both
sides of the neck. Abdomen soft, non-tender, non-distended.
There is occasional tenderness in the left lower quadrant.
Hypoactive bowel sounds. A well-healed umbilical hernia
scar. Extremities are warm, well perfused. No cyanosis
detected. There is 1+ pedal edema on the left. Well-healed
left saphenous vein excision scar from groin to ankle. Pulse
examination is as follows and are equal bilaterally: Carotid
1+, radial 2+, femoral 2+, dorsipedal 2+, posterior tibial
1+.
HOSPITAL COURSE: On [**2197-1-23**], the patient was
admitted to [**Hospital1 69**] for aortic
valve replacement as well as re-do coronary artery bypass
graft times two. For details of the operative procedure,
please see dictated operative note. Of note, when the re-do
sternotomy was performed, the left internal mammary artery
was injured and repaired with 7-0 Prolene. The valve was
replaced with a #23 mm [**Last Name (un) 3843**]-[**Doctor Last Name **] valve. The bypass
grafts were performed with saphenous vein graft to the
posterior descending artery and saphenous vein graft to the
_______________________. Postoperatively, the patient was
transferred to the ESRU for close monitoring. He was
initially placed on a dobutamine drip and also Levophed for
hypotension. The patient was immediately transfused fresh
frozen plasma and platelets for some mild postoperative
bleeding and elevated INR and PTT. On postoperative day one,
the patient was transfused one unit of packed red blood cells
and his vasopressor drips were weaned off. Lasix diuresis
was begun. The patient was also started on Plavix due to the
injury to the left internal mammary artery as well as poor
target vessels. Subsequent to this, the patient had an
essentially unremarkable postoperative course. He progressed
well with physical therapy. His chest tubes were
discontinued when outputs were less than 150 cc q. 8h., the
wires were removed on postoperative day three. The patient
was transferred to the floor on postoperative day two and did
well on the floor. He was cleared for physical therapy for
discharge to home. Ultimately, the patient was discharged on
postoperative day three tolerating a regular diet, ambulating
well and having no more anginal pain.
CONDITION AT DISCHARGE: Stable. Cleared by Physical Therapy
for discharge home.
DIET: Cardiac diet.
DISCHARGE MEDICATIONS:
1. Lopressor 50 mg b.i.d.
2. Lasix 20 mg b.i.d. times seven days.
3. KCl 20 mEq b.i.d. times seven days.
4. Colace 100 mg b.i.d.
5. Plavix 75 mg q. day times three months.
6. Percocet 5/325 one to two q. 4h. p.r.n.
7. Zocor 20 mg q. day.
DISCHARGE INSTRUCTIONS: The patient is being discharged to
home with the VNA for cardiopulmonary and wound checks. He
should follow up with Dr. [**Last Name (STitle) **] in four weeks' time. He
should follow up with his cardiologist in one to two weeks
for adjustment of medication as well as monitoring of
diuresis. No heavy lifting or strenuous activity. VNA
should remove his staples in two weeks' time.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Last Name (NamePattern1) 5745**]
MEDQUIST36
D: [**2197-2-3**] 15:27
T: [**2197-2-3**] 15:31
JOB#: [**Job Number 94171**]
|
[
"998.2",
"E878.2",
"401.9",
"414.01",
"433.30",
"530.81",
"998.11",
"424.1",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.05",
"99.04",
"39.61",
"39.31",
"35.21",
"36.11",
"36.15",
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
537, 965
|
6234, 6480
|
4362, 6116
|
6505, 7170
|
2356, 2987
|
3013, 3390
|
150, 516
|
6131, 6211
|
994, 1957
|
3542, 4344
|
1979, 2333
|
3407, 3527
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,866
| 168,134
|
51450
|
Discharge summary
|
report
|
Admission Date: [**2117-6-24**] Discharge Date: [**2117-7-2**]
Service: MEDICINE
Allergies:
Ace Inhibitors / Aspirin / Atorvastatin / Fluvastatin /
Pravastatin Sodium
Attending:[**First Name3 (LF) 14145**]
Chief Complaint:
Aspirin Desensitization
Major Surgical or Invasive Procedure:
Cardiac catheterization [**2117-6-25**]
History of Present Illness:
This [**Age over 90 **] year old patient w/ history of a CABG in [**2107**], AF,
pacemaker for heart block, thoracic aneurysm repair in [**2115**],
mobile clot on pacer wire in [**2108**], on Coumadin. Patient has been
complaining of increasing SOB on exertion, weight gain, leg
edema with normal LVEF. Dr. [**Last Name (STitle) **], his primary cardiologist is
requesting cath. for worsening CHF symptoms. He is Aspirin
allergic (angioedema) and will need to be desensitized before
his planned catherization on [**6-25**]. Patient has been off of
Coumadin since [**6-18**].
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
palpitations, syncope or presyncope.
Past Medical History:
1. Diabetes mellitus.
2. Renal insufficiency.
3. Hypertension.
4. Hypercholesteremia.
5. Atrial fibrillation.
6. Septal myocardial infarction, status post CABG and AAA
repair.
7. Mild aortic regurgitation.
8. Pleural effusion secondary to trapped lung.
9. Bilateral carotid stenosis.
10. Status post hip replacement.
11. Skin cancers.
12. Stasis dermatitis.
13. Pacemaker placed [**2102**], replaced [**2109**]
14. Replaced right hip [**2108**]
15. Replaced left hip [**2109**]
16. Cataract removed (left eye)[**2110**] + on right eye [**2112**]
17. Mohr procedure for basal cell carcinoma on right leg.
18. Gout (left foot)-last three months has had pain in second
digit on right foot.
19. Carotid artery stenosis (left) 40 %??
20. mobile clot on pacer wire in [**2108**] on coumadin
Social History:
The patient lives alone and has limited supports. His brother on
[**Location (un) **] will be coming up to drive him home from the hospital.
Family History:
Multiple members with CAD less than 60 y.o.
Dyslipidemia
type 2 diabetes mellitus
HTN
Physical Exam:
VITAL SIGNS: Blood pressure 100/60, pulse 65 beats/min, RR-16,
O2 sat 95%RA.
GENERAL: NAD, looks younger than stated age
CHEST: Normal to palpation. Decreased breath sounds, toward
lower left lung base. No wheezes few bibasilar crackles.
CARDIOVASCULAR: Heart sounds are normal with irregular rhythm
and soft systolic murmur in the 4th intercostal space,
nonradiating.
EXTREMITIES: +2 to +3 pitting edema. Bilateral ulcers on shins
with associated 2 + edema,and erythema. Left leg is warm to
touch. Both legs are nontender to touch. DS and TP pulses are
nonpalpable however picked up on doppler bilaterally. Femoral
pulse bilaterally intact 2+.
ABDOMEN: Very distended with accompanying ascites and + fluid
wave, BS +, nontender, no pulsatile massess and no abdominal
bruits.
Neuro- CN's grossly intact and power sym in UE's and LE's [**4-14**].
Pertinent Results:
Admission Labs
[**2117-6-24**] 08:26PM PT-15.5* PTT-30.1 INR(PT)-1.4*
[**2117-6-24**] 08:26PM PLT COUNT-150
[**2117-6-24**] 08:26PM WBC-6.7 RBC-4.05* HGB-11.9* HCT-36.1* MCV-89
MCH-29.3 MCHC-32.9 RDW-15.9*
[**2117-6-24**] 08:26PM CALCIUM-9.3 PHOSPHATE-4.2 MAGNESIUM-2.6
[**2117-6-24**] 08:26PM estGFR-Using this
[**2117-6-24**] 08:26PM GLUCOSE-119* UREA N-41* CREAT-1.2 SODIUM-140
POTASSIUM-4.6 CHLORIDE-104 TOTAL CO2-30 ANION GAP-11
.
Discharge Labs
[**2117-6-28**] 06:35AM BLOOD WBC-5.6 RBC-3.90* Hgb-11.1* Hct-35.8*
MCV-92 MCH-28.5 MCHC-31.1 RDW-16.4* Plt Ct-139*
[**2117-6-28**] 06:35AM BLOOD Plt Ct-139*
[**2117-6-28**] 06:35AM BLOOD Glucose-123* UreaN-38* Creat-1.2 Na-144
K-3.5 Cl-102 HCO3-34* AnGap-12
[**2117-6-27**] 06:10AM BLOOD Glucose-135* UreaN-38* Creat-1.2 Na-142
K-3.8 Cl-101 HCO3-31 AnGap-14
[**2117-6-27**] 07:40PM BLOOD Na-142 K-4.0 Cl-103
[**2117-6-25**] 05:10AM BLOOD ALT-26 AST-27 AlkPhos-171* Amylase-51
TotBili-0.8
[**2117-6-28**] 06:35AM BLOOD Calcium-9.0 Phos-3.7 Mg-2.0
.
Reports
.
BRIEF HISTORY: [**Age over 90 **] year old male with a history of a thoracic
aorta
aneurysm repair and 2 vessel CABG in [**2107**] and HF with preserved
EF
coming in with increased right and left sided heart failure
symptoms. He
was referred for diagnostic coronary angiography.
INDICATIONS FOR CATHETERIZATION: CHF, Coronary artery disease
PROCEDURE: [**2117-6-25**]
Left Heart Catheterization: was performed by percutaneous entry
of the
right femoral artery, using a 4 French JL4 catheter, advanced to
the ascending aorta through a 4 French introducing sheath.
Coronary Angiography: was performed in multiple projections
using a 4
French JL4 and a 4 French JR4 catheter, with manual contrast
injections.
Graft Angiography: of 1 saphenous vein bypass graft was
performed using
a 4 French ARII Modified catheter, with manual contrast
injections.
Arterial Conduit Angiography: of a left internal mammary artery
graft
was performed using a preformed [**Female First Name (un) 899**] catheter, with manual
contrast
injections.
Supravalvular Aortography: was performed in the 30 degrees [**Doctor Last Name **]
projection, using 40 ml of contrast injected at 20 ml/sec,
through the
angled pigtail catheter.
Conscious Sedation: was provided with appropriate monitoring
performed by
a member of the nursing staff.
HEMODYNAMICS RESULTS BODY SURFACE AREA: 1.99 m2
HEMOGLOBIN: 11.2 gms %
REST
**PRESSURES
LEFT VENTRICLE {s/ed} 142/22
AORTA {s/d/m} 137/61/88
**CARDIAC OUTPUT
HEART RATE {beats/min} 52
RHYTHM ATRIAL FIBRILLATION WITH V-PACING
**ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM
**RIGHT CORONARY
1) PROXIMAL RCA NORMAL
2) MID RCA NORMAL
2A) ACUTE MARGINAL NORMAL
3) DISTAL RCA NORMAL
4) R-PDA NORMAL
4A) R-POST-LAT NORMAL
**ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM
**LEFT CORONARY
5) LEFT MAIN NORMAL
6) PROXIMAL LAD NORMAL
6A) SEPTAL-1 NORMAL
7) MID-LAD NORMAL
8) DISTAL LAD NORMAL
9) DIAGONAL-1 NORMAL
12) PROXIMAL CX NORMAL
13) MID CX NORMAL
13A) DISTAL CX DISCRETE 50
14) OBTUSE MARGINAL-1 DISCRETE 100
15) OBTUSE MARGINAL-2 NORMAL
**ARTERIOGRAPHY RESULTS TO SEGMENTS MORPHOLOGY % STENOSIS
LOCATION
**BYPASS GRAFT
28) SVBG #1 20 NORMAL
32) LIMA 14 NORMAL
TECHNICAL FACTORS:
Total time (Lidocaine to test complete) = 1 hour 27 minutes.
Arterial time = 1 hour 23 minutes.
Fluoro time = 33 minutes.
IRP dose = 2361 mGy.
Contrast injected:
Non-ionic low osmolar (isovue, optiray...), vol 170 ml
Premedications:
Fentanyl 25 mcg IV
Anesthesia:
1% Lidocaine subq.
Anticoagulation:
Heparin 1000 units IV
Other medication:
Heparin 1000 units per hour
Cardiac Cath Supplies Used:
- ALLEGIANCE, CUSTOM STERILE PACK
- MERIT, LEFT HEART KIT
COMMENTS:
1. Coronary angiogrpahy revealed the LMCA to be free of disease.
The LAD
had mild non obstrcutive disease. The left circumflex artery had
a
discrete 50% narrowing in the distal vessel. The OM1 was totally
occluded. The RCA was normal.
2. Arterial conduit angiography revelaed a widely patent
LIMA-LAD graft.
3. Aortography was performed in an attempt to locate the SVG
graft to
the OM1. This revealed an ascending aortic tube graft from the
prior
thoracic aortic aneurysm repair.
4. Venous conduit angiography revelaed a patent SVG-OM1 graft.
6. LV filling pressures were elevated with LVEDP of 22
FINAL DIAGNOSIS:
1. One vessel native coronary artery disease.
2. Patent LIMA-LAD and SVG-OM1 grafts
3. Elevated LV filling pressures
.
EKG [**2117-6-25**]:Ventricularly paced rhythm. It is difficult to
assess the atrial rhythm. Compared to the previous tracing of
[**2115-1-3**] ventricularly paced rhythm is unchanged. However, prior
sinus rhythm is no longer present.
Brief Hospital Course:
The patient is a [**Age over 90 **] year old patient w/history of CABG in [**2107**],
AF, pacemaker for heart block, thoracic aneurysm repair in [**2115**],
mobile clot on pacer wire in [**2108**], on warfarin who was admitted
on [**2117-6-24**] for aspirin desensitization prior to elective cardiac
cath on [**2117-6-25**].
# Aspirin desensitisation: He tolerated the desensitization
well, with no evidence of reaction. He [**Date Range 1834**] cardiac
catheterization on [**2117-6-25**] and was continued on aspirin 81mg
daily.
# CAD: Mr [**Known lastname 106674**] [**Last Name (Titles) 1834**] cardiac cath on [**2117-6-25**] that
revealed one vessel native coronary artery disease, patent
LIMA-LAD and SVG-OM1 grafts, and elevated LV filling pressures.
There was no intervention, and the plan was for medical
management with aspirin and warfarin. The patient was re-started
on Coumadin at his home dose following the cath, and was started
on Lovenox as bridge until his INR was therapeutic. He was sent
home on a reduced warfarin dose given concomitant antibiotic
prescribing. He was continued on metoprolol and simvastatin, and
his metoprolol was changed to metoprolol succinate prior to
discharge.
.
# Acute on Chronic diastolic CHF: Mr [**Known lastname 106674**] was diuresed with
furosemide, and sspironolactone was added on [**2117-6-28**]. Labs
reflected some contraction alkalosis and his fluid balance was
closely monitored. He was fluid restricted to 1500cc/day and was
placed on a low Na diet. His [**Last Name (un) **] and beta blocker were
continued. He will continue on furosemide and spironolactone as
an outpatient.
.
# Desaturation on ambulation, ? due to chronic pleural
effusion/pulmonary congestion: The patient was noted to
desaturate to the low-mid 80s when ambulating on room air or
climbing the stairs, with O2 sats reverting to low-mid 90s% with
rest. He remained hypoxic on exertion during the remainder of
his hospital course, with sats in the low 80s on room air with
ambulation. Given his clinical exam findings suggestive of
pulmonary vascular congestion, the patient was started on
Spironolactone on [**2117-6-28**]. A CXR revealed a chronic loculated
large left pleural effusion, similar to multiple prior studies;
a small right pleural effusion, similar to CT abdomen/pelvis of
[**2116-10-20**]; and no evidence of pulmonary edema. His fluid balance
was negative, and he was given no further diuresis above the
spironolactone. He was minimally symptomatic despite his
desaturations and patient declined the offer of home oxygen
therapy. He was symptomatically much improved by discharge. He
will continue on spironolactone and PO furosemide as an
outpatient.
.
# A fib: on [**6-27**], the patient had >20 beats of wide complex
tachycardia most consistent with AF with aberrant conduction.
Discussed telemetry with EP fellow. Vitals were stable and he
was asymtomatic. Electrolytes were within normal limits. He had
no further episodes of the above. He was discharged home on
warfarin with decreased dose given concomitant antibiotic
pescription. He is also on metoprolol succinate.
.
# Venous stasis ulcer and possible cellulitis: The patient has
venous stasis ulcers, which appeared erythematous and somewhat
indurated on exam. Cellulitis seemed unlikely. I.D saw the
patient and advised Cefazolin IV Q8H as inpatient, which will be
switched to Cephalexin as outpatient for 10 days oral treatment
in addition to leg elevation.
.
# CKD: Stable despite diuresis.
.
#HTN: Well controlled on [**Last Name (un) **] and beta blocker. Patient will also
be discharged on diuretic regimen of furosemide and
spironolactone.
.
# DMT2: He was maintained on HISS and home Glyburide with good
glycemic control.
.
# Prophylaxis: Patient was on a heparin gtt, then later
re-started on warfarin (with Lovenox bridge) during his hospital
course.
Medications on Admission:
Potassium Chloride 10meq -take 3 pills every day with food.
ALLOPURINOL - 100 mg Tablet - 1 Tablet(s) by mouth once a day
ATENOLOL - (Prescribed by Other Provider) - 50 mg Tablet - 1
Tablet(s) by mouth daily
CLOBETASOL - 0.05 % Cream - as directed as directed
FINASTERIDE [PROSCAR] - (Prescribed by Other Provider) - 5 mg
Tablet - 1 Tablet(s) by mouth daily
FLUTICASONE [FLONASE] - 50 mcg Spray, Suspension - 2 puffs
nostril once a day as needed
FUROSEMIDE - 40 mg Tablet - 2 Tablet(s) by mouth [**Hospital1 **]
GLYBURIDE - (Prescribed by Other Provider) - 1.25 mg Tablet - 1
Tablet(s) by mouth twice a day
MUPIROCIN CALCIUM [BACTROBAN NASAL] - (Prescribed by Other
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] - Dosage uncertain
SIMVASTATIN - 10 mg Tablet - 1 Tablet(s) by mouth once a day
TERAZOSIN [HYTRIN] - (Prescribed by Other Provider) - 5 mg
Capsule - 1 Capsule(s) by mouth daily
TOBRAMYCIN-DEXAMETHASONE [TOBRADEX] - (Prescribed by Other
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] @ [**Last Name (un) **]) - Dosage uncertain
VALSARTAN [DIOVAN] - (Prescribed by Other Provider) - 160 mg
Tablet - 1 Tablet(s) by mouth daily
WARFARIN [COUMADIN] - (Prescribed by Other Provider) -5mg for 3
days a week M,TH,SA and 2.5mg on 4 days of week Teus, wed, fri,
sunday
Discharge Medications:
1. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO once a day.
2. Clobetasol 0.05 % Cream Sig: One (1) Topical once a day.
3. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Fluticasone 50 mcg/Actuation Disk with Device Sig: Two (2)
puffs Inhalation once a day.
5. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
6. Glyburide 1.25 mg Tablet Sig: One (1) Tablet PO twice a day.
7. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Terazosin 5 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
9. Warfarin 5 mg Tablet Sig: 0.5 Tablet PO once a day.
10. Mupirocin 2 % Ointment Sig: One (1) Topical once a day.
11. Outpatient Lab Work
Please check INR, Chem 7 on [**2117-7-3**] by VNA and call results to
Dr.[**Name (NI) 5765**] office.
Phone Number: [**Telephone/Fax (1) 5768**]
12. Valsartan 160 mg Tablet Sig: One (1) Tablet PO once a day.
13. Cholecalciferol (Vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO once a day.
14. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for rash .
15. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
16. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
17. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
18. Cephalexin 500 mg Tablet Sig: One (1) Tablet PO three times
a day.
Disp:*30 Tablet(s)* Refills:*0*
19. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily).
Disp:*30 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 1952**], [**Location (un) 86**]
Discharge Diagnosis:
Acute on chronic diastolic heart failure
coronary Artery disease
Atrial Fibrillation on Coumadin with Lovenox bridge
Diabetes Type 2
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 to care for you
.
You were brought to the hospital because of worsening heart
failure symtoms. As a result of these symptoms your cardiologist
felt like a cardiac catherization was appropiate to assess any
coronary arterial disease. To receive this procedure you went
through a aspirin desensitization process because of your past
history of aspirin [**Last Name (un) **]. You tolerated the aspirin
desensitization and caridac catherization well. The cardiac
catherization revealed one of your smaller heart vessels to be
occluded and your CABG grafts to be free of disease. WE found
that you were in congestive heart failure and retaining fluid in
your abdomen and legs. We increased your diuretics and you lost
about 14 pounds. Your weight this am is 177 pounds. Your ideal
weight is probably about 175 pounds.
.
We have made the following changes to your home medication list:
1. Start spironolactone to help keep fluid from accumulating
2. Decrease your Warfarin to 2.5 mg daily while you are on the
antibiotics.
3. Increase your Furosemide (lasix) to 80 mg daily
4. Decrease your Potassium to 20 meq daily. The spironolactone
will keep your potassium higher.
5. Stop taking Atenolol
6. Start taking Metoprolol succinate. This medicine is better
for the congestive heart failure.
7. Start taking Cephalexin, an antibiotic to treat the
cellulitis in your left leg, you will take this for 10 days.
Please keep your left leg elevated as much as possible.
.
Please follow up with the following outpatient directions:
You will need to get your INR checked within 2 days of
discharge. I will order a outpatient INR check, which your home
nurse will draw for you.
.
Followup Instructions:
Department: Cardiology
When: Tuesday [**7-6**] at 9:30am
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **],MD
Address: [**Street Address(2) 2687**],STE 7C, [**Location (un) **],[**Numeric Identifier 822**]
Phone: [**Telephone/Fax (1) 5768**]
Department: GERONTOLOGY
When: THURSDAY [**2117-7-15**] at 11:00 AM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 719**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: GERONTOLOGY
When: THURSDAY [**2117-8-26**] at 12:00 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 719**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Dermatology
Dr. [**Last Name (STitle) 17915**]
[**7-22**] at 2:15pm
This appt was already scheduled.
|
[
"459.81",
"427.31",
"V07.1",
"414.01",
"403.90",
"V43.64",
"V45.01",
"428.33",
"707.12",
"585.9",
"V45.81",
"428.0",
"511.9",
"276.3",
"V58.61"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.57",
"88.42",
"37.22",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
15211, 15286
|
8180, 12056
|
306, 347
|
15463, 15463
|
3358, 4664
|
17353, 18288
|
2388, 2476
|
13425, 15188
|
15307, 15442
|
12082, 13402
|
7802, 8157
|
15646, 17330
|
2491, 3339
|
6648, 7785
|
4698, 6629
|
243, 268
|
375, 1405
|
15478, 15622
|
1427, 2214
|
2230, 2372
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,735
| 175,220
|
54547
|
Discharge summary
|
report
|
Admission Date: [**2190-2-23**] Discharge Date: [**2190-2-26**]
Date of Birth: [**2108-5-28**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Bactrim / E-Mycin / Flagyl / Pepcid
Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
Stroke during cardiac catheterization
Major Surgical or Invasive Procedure:
Cardiac catheterization
History of Present Illness:
Ms. [**Known lastname 111600**] is an 81 year old female with severe AS who presents
after a catheterization. She was getting an outpatient work-up
for AS repair with a right and left heart cath. However, the
vascular access was difficult in the procedure and she has a
residual groin hematoma. Also, directly post-procedure course
was complicated by right grip strength decreased and right
finger-to-nose decreased. She also had a change in her affect
post-procedure.
.
In the post-cath recovery room, neurology service evaluated the
patient and agreed that she had focal neuro deficits. She
underwent a CT head which showed concern for aneurysm vs
tortuous vessel vs hypodensity in the the right MCA territory.
Her symptoms improved. At time of cath a HCT was drawn and was
22. Repeated it remained stable at 22. A CT abdomen was done for
concern of RP bleed and the wet read was negative for bleed.
.
On arrival to the floor, patient was having mild abdominal
discomfort, denied CP, SOB, orthopnea, though she continued to
be fatigued.
.
Cardiac review of systems is notable for absence of chest pain,
positive for recent dyspnea on exertion, ankle edema, negative
for paroxysmal nocturnal dyspnea, orthopnea, palpitations,
syncope or presyncope.
Past Medical History:
Critical aortic stenosis [**Location (un) 109**] 0.7cm2, peak/mean 128/58
1. CARDIAC RISK FACTORS: - Diabetes, - Dyslipidemia, -
Hypertension
2. CARDIAC HISTORY: AS
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: none
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
Hysterectomy [**2135**]
Dyslipidemia
GERD
Bladder CA s/p surgical removal [**2165**]
Dysphagia
Neuropathy
Anemia
CCY [**2137**]
Hernia [**2175**]
Back surgery [**2183**]
Cataract removal
Social History:
Lives at home, son lives at home with her. Retired from sewing
business. Tobacco: never. ETOH: denies. Drug
use: denies.
Family History:
Mom passed away age 59 from heart problems. [**Name (NI) **] passed away age
74 from PNA. Sister passed away age 79 had a history of valve
surgery but died from leukemia. Brother passed away age 50 from
cancer. Brother alive age 84 had a valve replacement one year
ago.
Physical Exam:
ADMISSION EXAM:
VS: T=97.5 BP=117/50 HR=70 RR=13 O2 sat= 96%
GENERAL: Elderly woman in NAD. Oriented x3. Mood, affect
appropriate. General fatigue.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
NECK: Supple with JVP of 8 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. Normal rate, regular rhythm, [**1-26**] crescendo decrescendo
murmur loudest at the upper sternal borders.
LUNGS: Scoliosis and kyphosis. Resp were unlabored, no accessory
muscle use. CTAB with basilar crackles, no wheezes or rhonchi.
ABDOMEN: Soft, NTND. Palpable pelvic kidney in right lower
quadrant. No HSM or tenderness. Ileostomy. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits. Small right groin
hematoma at cath site
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
DISCHARGE EXAM:
VS: 98.2 113/62 75 96%RA
+100cc x24hrs
GENERAL: Elderly woman in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: MMM
CARDIAC: [**1-26**] crescendo-decrescendo murmur best at USB with +S2
LUNGS: Scoliosis and kyphosis. Resp were unlabored, no accessory
muscle use. CTAB with basilar crackles, no wheezes or rhonchi.
ABDOMEN: Soft, NTND. Palpable pelvic kidney in right lower
quadrant. No HSM or tenderness. ostomy bag draining clear yellow
urine
EXTREMITIES: No c/c/e. No femoral bruits. Small right groin
hematoma at cath site
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Neuro: CN II-XII intact. No dysarthria. Str [**3-27**] b/l UE. Str
with poor effort LE b/l, but equal.
Pertinent Results:
[**2190-2-23**] 04:17PM BLOOD WBC-4.5# RBC-3.12*# Hgb-6.6*# Hct-22.9*#
MCV-73*# MCH-21.1* MCHC-28.7*# RDW-17.4* Plt Ct-357
[**2190-2-23**] 11:00AM BLOOD PT-11.4 INR(PT)-1.1
[**2190-2-24**] 06:00AM BLOOD Glucose-85 UreaN-18 Creat-0.8 Na-146*
K-3.3 Cl-111* HCO3-24 AnGap-14
[**2190-2-24**] 06:00AM BLOOD Cholest-139
[**2190-2-24**] 06:00AM BLOOD Triglyc-71 HDL-72 CHOL/HD-1.9 LDLcalc-53
LDLmeas-62
[**2190-2-23**] 03:18PM BLOOD Type-ART O2 Flow-2 pO2-134* pCO2-38
pH-7.47* calTCO2-28 Base XS-4 Comment-NC 2 LIT
[**2190-2-25**] 07:45AM BLOOD Calcium-8.5 Phos-2.9 Mg-2.1
[**2190-2-25**] 07:45AM BLOOD WBC-9.0 RBC-3.82* Hgb-8.3* Hct-27.9*
MCV-73* MCH-21.6* MCHC-29.6* RDW-17.4* Plt Ct-323
[**2190-2-25**] 07:45AM BLOOD Glucose-90 UreaN-16 Creat-0.6 Na-145
K-4.1 Cl-113* HCO3-24 AnGap-12
[**2-23**] Cath:
HEMODYNAMICS RESULTS BODY SURFACE AREA: 1.47 m2
HEMOGLOBIN: 9.5 gms %
FICK
**PRESSURES
RIGHT ATRIUM {a/v/m} 7/4/4
RIGHT VENTRICLE {s/ed} 31/9
PULMONARY ARTERY {s/d/m} 20/11/15
PULMONARY WEDGE {a/v/m} 18/19/14
LEFT VENTRICLE {s/ed} 171/14
AORTA {s/d/m} 120/56/83
**CARDIAC OUTPUT
HEART RATE {beats/min} 84
RHYTHM SINUS
O2 CONS. IND {ml/min/m2} 125
A-V O2 DIFFERENCE {ml/ltr} 49
CARD. OP/IND FICK {l/mn/m2} 3.8/2.6
**RESISTANCES
SYSTEMIC VASC. RESISTANCE 1663
PULMONARY VASC. RESISTANCE 21
Total time (Lidocaine to test complete) = 1 hour 8 minutes.
Arterial time = 59 minutes.
Fluoro time = 18.6 minutes.
Effective Equivalent Dose Index (mGy) = 1066 mGy.
Contrast injected:
Non-ionic low osmolar (isovue, optiray...), vol 106 ml
COMMENTS:
1. Selective coronary angiography in this right-dominant system
demonstrated no significant disease. The LMCA had mild disease.
The LAD
had a 40-50% lesion in its mid portion. The LCx had mild
disease. The
RAC had mild disease.
2. Resting hemodynamics revealed normal right- and left-sided
filling
pressures, with an RVEDP of 9 mm Hg and a PCWP of 14 mm Hg.
There was no
pulmonary arterial hypertension, with a PASP of 20 mm Hg. The
cardiac
index was preserved at 2.6 L/min/m2. There was a 51 mm Hg
gradient
across the aortic valve.
3. Critical aortic stenosis, with a calculated valve area of
0.47 cm2.
FINAL DIAGNOSIS:
1. No hemodynamically significant coronary artery disease.
2. Critical aortic stenosis.
[**2-23**] CTA Head:
1. CTA demonstrates no gross evidence of infarct or hemorrhage.
Note is made that the MRI performed a few hours later
demonstrates an acute infarction in the territory of the
posterior division of the right MCA which was too early to be
seen on this current CT exam.
2. Diffuse atherosclerotic disease without evidence of
significant stenosis
or occlusion.
3. Heterogeneous thyroid gland. Ultrasound is suggested if
clinically
warranted.
4. Questionable 2.8 mm infundibilum/aneurysm at the left M1-M2
junction.
5. Possible right upper lobe infiltrate and thickening of the
bilateral
interlobular septa which may represent pulmonary congestion.
Chest CT is
suggested if clinically warranted.
[**2-24**] CAROTID U/S
A mild amount of heterogeneous plaque was seen in the bilateral
internal carotid arteries.
On the right side, peak systolic velocities were 73 cm/sec for
the proximal internal carotid artery, 87 cm/sec for the mid
internal carotid artery and 97 cm/sec for the distal internal
carotid artery. Peak systolic velocities in the common carotid
artery were 50 cm/sec and 73 cm/sec in the right external
carotid artery. The right ICA/CCA ratio was 1.9.
On the left side, peak systolic velocities were 55 cm/sec for
the proximal
ICA, 69 cm/sec for the mid ICA, 58 cm/sec for the distal ICA. A
peak systolic velocity of 68 cm/sec was seen in the left CCA and
a peak systolic velocity of 53 cm/sec was seen in the left ECA.
The left ICA/CCA ratio was 1.0.
Both vertebral arteries presented antegrade flow.
COMPARISON: Findings are concordant with what was seen in the
carotid CTA
obtained on [**2190-2-23**].
IMPRESSION: Less than 40% stenosis of the bilateral internal
carotid
arteries, in their cervical portion.
[**2-24**] MR HEAD
Acute infarct in the posterior division right middle cerebral
artery with
findings indicative of slow or collateral flow through the right
middle
cerebral artery sylvian branches. Mild brain atrophy is seen. No
midline
shift or hydrocephalus.
[**2-23**] CT ABDOMEN
1. No evidence of retroperitoneal or intra-abdominal hemorrhage.
2. Small amount of soft tissue density surrounding the right
femoral access
site which may represent a small amount of hemorrhage (less than
1 cm).
3. Stable intrahepatic duct dilation from previous CTs. Cause is
not
identified on this CT.
4. Ileal conduit with bilateral moderate hydronephrosis.
5. Multiple wedge compression fractures of the lumbar spine,
stable since
[**2185**].
.
Discharge labs:
[**2190-2-26**] 07:25AM BLOOD WBC-7.4 RBC-4.07* Hgb-9.0* Hct-30.8*
MCV-76* MCH-22.2* MCHC-29.3* RDW-17.9* Plt Ct-366
[**2190-2-23**] 06:15PM BLOOD Neuts-77.8* Lymphs-16.1* Monos-4.5
Eos-1.0 Baso-0.6
[**2190-2-26**] 07:25AM BLOOD PT-11.8 PTT-29.3 INR(PT)-1.1
[**2190-2-26**] 07:25AM BLOOD Glucose-95 UreaN-21* Creat-0.8 Na-144
K-4.4 Cl-110* HCO3-25 AnGap-13
[**2190-2-26**] 07:25AM BLOOD Calcium-8.9 Phos-3.8 Mg-2.2
[**2190-2-24**] 06:00AM BLOOD Triglyc-71 HDL-72 CHOL/HD-1.9 LDLcalc-53
LDLmeas-62
Brief Hospital Course:
81 year old admitted for evaluation of critical AS, with post
cath complication of left hemianopia and left hypesthesia as
well as hematoma at cath site.
.
# Transient Ischemic Attack:
Directly post-cath course was complicated by right grip strength
decreased and right finger-to-nose decreased. She also had a
change in her affect post-procedure. She was brought to the PACU
and evaluated by neurology who noted these deficits, with quick
improvement. She underwent a CT head which showed possible
hypodensity in MCA territory. She was transferred to the CCU
where her symptoms were noted to be almost entirely resolved.
An MRI of the head was performed showing acute infarct in the
posterior division right middle cerebral artery with findings
indicative of slow or collateral flow through the right middle
cerebral artery sylvian branches. Her blood pressure was
maintained greater than 120 for perfusion. No TPA was indicated.
Aspirin was continued. No significant carotid stenosis was noted
on ultrasound. She was evaluated by PT who recommended rehab and
she was discharged.
.
# Critical AS: Patient found to have a valve area of 0.5 at cath
with symptoms of DOE progressing. She is currently being managed
as an outpatient. Lasix was held given her euvolemia.
.
Transitional issues:
-Check electrolytes and renal function Monday [**3-1**] and adjust
potassium, lasix as indicated
-Physical therapy
Medications on Admission:
Folic acid 1mg daily
Lasix 40mg [**Hospital1 **]
K-dur 40mg daily
Omeprazole 20mg daily
Simvastatin 20mg daily
Ambien 10mg QHS
Iron 650mg daily
MVI daily
Tylenol PRN
ASA 81mg daily
Lactulose 15ml PRN
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
5. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
6. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO once a day.
7. Iron (ferrous sulfate) 325 mg (65 mg iron) Tablet Sig: One
(1) Tablet PO twice a day.
8. multivitamin Tablet Sig: One (1) Tablet PO once a day.
9. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO once a
day.
10. lactulose 10 gram/15 mL (15 mL) Solution Sig: Fifteen (15)
ml PO once a day as needed for constipation.
11. Outpatient Lab Work
Please check chemistry panel including BUN/Cr on Monday [**3-1**]
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Nursing & Therapy Center - [**Location 1268**] ([**Location (un) 86**] Center
for Rehabilitation and Sub-Acute Care)
Discharge Diagnosis:
Stroke
Aortic Stenosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Ms. [**Known lastname 111600**],
You were admitted to the Cardiac ICU because you had a stroke
after your cardiac catheterization. This resolved spontaneously
and was felt to be related to clots from your cath.
.
We have made several changes to your medications, which will be
relayed to the rehab facility. You should make sure to go over
your medications with them carefully at the time of discharge.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] W.
Location: [**Hospital **] MEDICAL ASSOCIATES
Address: [**Location (un) **], [**Street Address(1) 4323**],[**Numeric Identifier 4325**]
Phone: [**Telephone/Fax (1) 5457**]
Appt: [**3-4**] at 1:30pm
Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Doctor Last Name **] BLDG, [**Apartment Address(1) 17383**]
Address: [**Last Name (NamePattern1) 8541**], [**Location (un) **],[**Numeric Identifier 8542**]
Phone: [**Telephone/Fax (1) 7960**]
Appt: [**3-10**] at 2:30pm
Department: NEUROLOGY
When: TUESDAY [**2190-3-23**] at 4:00 PM
With: DRS. [**Name5 (PTitle) **] & HAUSSEN [**Telephone/Fax (1) 1694**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SURGERY
When: WEDNESDAY [**2190-4-7**] at 2:00 PM
With: [**Name6 (MD) **] [**Name8 (MD) 6144**], MD [**Telephone/Fax (1) 170**]
Building: LM [**Hospital Unit Name **] [**Location (un) 551**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
[
"434.11",
"V13.01",
"E879.0",
"V45.79",
"414.01",
"V88.01",
"368.46",
"V10.51",
"285.29",
"424.1",
"998.12",
"V17.3",
"997.02",
"530.81",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"37.23",
"88.53"
] |
icd9pcs
|
[
[
[]
]
] |
11943, 12103
|
9368, 10637
|
348, 373
|
12170, 12170
|
4089, 6247
|
12781, 13953
|
2285, 2556
|
11024, 11920
|
12124, 12149
|
10800, 11001
|
6264, 8831
|
12353, 12758
|
8847, 9345
|
2571, 3361
|
1836, 1912
|
3377, 4070
|
10658, 10774
|
271, 310
|
401, 1652
|
12185, 12329
|
1943, 2131
|
1674, 1816
|
2147, 2269
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,141
| 136,542
|
35633
|
Discharge summary
|
report
|
Admission Date: [**2187-1-23**] Discharge Date: [**2187-3-8**]
Date of Birth: [**2119-2-25**] Sex: M
Service: MEDICINE
Allergies:
Vancomycin / Cephalosporins
Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
Found down, altered mental status, renal failure, sepsis
Major Surgical or Invasive Procedure:
-Intubation
-Removal of R subclavian artery CVL in cath lab, with stent
deployment
-Femoral CVL
-R IJ CVL
-Arterial line
History of Present Illness:
67 yo M with a history of EtOH abuse was found down in his home.
He had not been seen by his neighbors for 3 days prior to being
found, was reportedly found with many empty alcohol containers
around him. The patient was taken to [**Hospital3 **], where he
was intubated for airway protection due to GCS = 3, no sedation
was given but did have spontaneous respirations to 20. Pt was
noted to be incontinent of bloody diarrhea. Head CT and C-spine
CT negative. Labs remarkable for Ph 7.03, bicarb 6, cr 5, gluc
111, K 4.1, CK 10,000. EtOH 403, NGT placed with coffee ground
material. UTox negative. R SC CVL placed, given 1L fluid and
shipped via [**Location (un) 7622**]. Also given Narcan 1mg IV, Thiamine IV and
started on Levophed.
.
Upon arrival to [**Hospital1 18**] ED, VS T 96, 96, 65/p --> 138/66,
ventilated with 100% SaO2. Negative guaiac, soft abdomen. CVL
subclavian line from OSH noted to be in the R SC artery,
vascular consulted and recommended leaving in place until
patient was stable for removal in the controlled setting of the
cath lab. A L femoral CVl was placed in the ED. he received
Levophed, Protonix IV, IV NS x 4L, Zosyn 4.5mg IV, Levofloxacin
750mg IV and Versed 2mg x 1. VS upon transfer 99/49, 100/ PEEP
5/FIO2 100 and RR 20. Admitted with PNA, Rhabdomyolysis,
encephalopathy, AG metabolic acidosis, guaiac positive from
above, ARF, elevated liver enzymes.
Past Medical History:
Alcoholism
Seizure disorder
Hyperlipidemia
Bipolar disorder
Disasotic dysfunction, Ef = 55%
H/o AMS [**12-18**] seizure
H/o tubulous adenoma and colon polyps
? AVR malformation
Social History:
Lives independently. Tobacco: prior use for 30 years. +EtOH
Family History:
NC
Physical Exam:
On admission -
97.4, 97, 92/59, 20 and 100% on 100% FIO2
GEN: obtunded, unkempt
HEENT: PER minimally reactive but symmetric; no corneal reflex
on initial exam; face symmetric, ET in place
CV: RRR without [**1-19**] harsh systolic murmur throughout precordium
PULM: Course b/l breath sounds with intermittent wheeze
ABD: Soft, nondistended, without HSM, active bowel sounds, no
grimace to deep palpation
Ext: WWP with c/c/e, pulses distally [**12-20**]
Neuro: Initially with no corneal reflex, minimal gag, no
withdrawl to pain; then spontaneously moving all limbs
.
On Disharge -
Pertinent Results:
=====
labs
=====
[**2187-1-28**] 03:10AM BLOOD WBC-10.1 RBC-3.15* Hgb-9.3* Hct-28.6*
MCV-91 MCH-29.6 MCHC-32.6 RDW-14.1 Plt Ct-123*
[**2187-1-27**] 04:07AM BLOOD WBC-13.7* RBC-3.34* Hgb-10.1* Hct-30.2*
MCV-91 MCH-30.2 MCHC-33.4 RDW-14.1 Plt Ct-121*
[**2187-1-26**] 05:59PM BLOOD Hct-27.1*
[**2187-1-26**] 10:47AM BLOOD WBC-10.3 RBC-2.96* Hgb-9.1* Hct-26.4*
MCV-89 MCH-30.7 MCHC-34.5 RDW-13.7 Plt Ct-108*
[**2187-1-26**] 02:31AM BLOOD WBC-7.8 RBC-2.84* Hgb-8.6* Hct-25.6*
MCV-90 MCH-30.3 MCHC-33.7 RDW-14.0 Plt Ct-95*
[**2187-1-25**] 06:04PM BLOOD Hct-20.5*#
[**2187-1-25**] 10:35AM BLOOD Hct-29.1*
[**2187-1-25**] 04:04AM BLOOD WBC-6.2 RBC-3.26* Hgb-9.9* Hct-28.5*
MCV-87 MCH-30.5 MCHC-34.9 RDW-13.8 Plt Ct-148*
[**2187-1-24**] 09:20PM BLOOD WBC-7.6 RBC-3.18* Hgb-9.6* Hct-27.7*
MCV-87 MCH-30.2 MCHC-34.7 RDW-13.9 Plt Ct-183
[**2187-1-24**] 07:29PM BLOOD Hct-30.8*
[**2187-1-24**] 06:54PM BLOOD WBC-6.4# RBC-3.70* Hgb-11.4* Hct-31.8*
MCV-86 MCH-30.9 MCHC-36.0* RDW-13.8 Plt Ct-245
[**2187-1-24**] 11:14AM BLOOD Hct-36.2*
[**2187-1-24**] 09:02AM BLOOD WBC-2.5* RBC-3.22* Hgb-10.0* Hct-29.4*
MCV-92 MCH-31.2 MCHC-34.0 RDW-13.5 Plt Ct-168
[**2187-1-24**] 08:28AM BLOOD WBC-2.8*# RBC-3.13*# Hgb-10.0*#
Hct-28.6*# MCV-92 MCH-31.8 MCHC-34.8 RDW-13.5 Plt Ct-166#
[**2187-1-23**] 10:00PM BLOOD WBC-17.1* RBC-4.81 Hgb-14.6 Hct-43.8
MCV-91 MCH-30.4 MCHC-33.4 RDW-13.8 Plt Ct-446*
[**2187-1-25**] 04:04AM BLOOD Neuts-68 Bands-11* Lymphs-14* Monos-5
Eos-0 Baso-0 Atyps-2* Metas-0 Myelos-0
[**2187-1-24**] 06:54PM BLOOD Neuts-81.3* Lymphs-13.5* Monos-4.4
Eos-0.6 Baso-0.1
[**2187-1-23**] 10:00PM BLOOD Neuts-86.4* Lymphs-8.8* Monos-4.0 Eos-0.5
Baso-0.2
[**2187-1-25**] 04:04AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2187-1-28**] 03:10AM BLOOD Plt Ct-123*
[**2187-1-28**] 03:10AM BLOOD PT-14.2* PTT-29.0 INR(PT)-1.2*
[**2187-1-27**] 04:07AM BLOOD Plt Ct-121*
[**2187-1-27**] 04:07AM BLOOD PT-12.7 PTT-28.8 INR(PT)-1.1
[**2187-1-26**] 10:47AM BLOOD Plt Ct-108*
[**2187-1-26**] 10:47AM BLOOD PT-12.7 PTT-29.0 INR(PT)-1.1
[**2187-1-26**] 02:31AM BLOOD PT-13.4 PTT-30.8 INR(PT)-1.2*
[**2187-1-25**] 04:04AM BLOOD Plt Smr-VERY LOW Plt Ct-148*
[**2187-1-25**] 04:04AM BLOOD PT-15.7* PTT-30.7 INR(PT)-1.4*
[**2187-1-24**] 09:20PM BLOOD Plt Ct-183
[**2187-1-24**] 09:20PM BLOOD PT-16.6* PTT-30.8 INR(PT)-1.5*
[**2187-1-24**] 06:54PM BLOOD PT-17.3* PTT-30.2 INR(PT)-1.6*
[**2187-1-24**] 09:02AM BLOOD Plt Ct-168
[**2187-1-24**] 08:28AM BLOOD Plt Ct-166#
[**2187-1-24**] 03:02AM BLOOD PT-15.4* PTT-38.7* INR(PT)-1.4*
[**2187-1-26**] 10:47AM BLOOD Fibrino-421*
[**2187-1-25**] 04:04AM BLOOD Fibrino-433*
[**2187-1-28**] 03:10AM BLOOD Glucose-PND UreaN-PND Creat-PND Na-PND
K-PND Cl-PND HCO3-PND
[**2187-1-27**] 07:58PM BLOOD Glucose-137* UreaN-64* Creat-4.2* Na-151*
K-3.3 Cl-115* HCO3-25 AnGap-14
[**2187-1-25**] 04:04AM BLOOD Glucose-113* UreaN-74* Creat-3.8* Na-148*
K-3.6 Cl-110* HCO3-25 AnGap-17
[**2187-1-24**] 09:20PM BLOOD Glucose-226* UreaN-78* Creat-3.9* Na-143
K-3.4 Cl-105 HCO3-28 AnGap-13
[**2187-1-24**] 12:45PM BLOOD Glucose-485* UreaN-86* Creat-4.1* Na-142
K-2.6* Cl-94* HCO3-22 AnGap-29*
[**2187-1-24**] 08:07AM BLOOD Glucose-652*
[**2187-1-24**] 03:02AM BLOOD Glucose-288* UreaN-96* Creat-4.4* Na-146*
K-4.1 Cl-109* HCO3-10* AnGap-31*
[**2187-1-23**] 10:00PM BLOOD Glucose-116* UreaN-111* Creat-5.4* Na-144
K-5.1 Cl-105 HCO3-5* AnGap-39*
[**2187-1-28**] 03:10AM BLOOD ALT-PND AST-PND CK(CPK)-PND AlkPhos-PND
TotBili-PND
[**2187-1-26**] 02:31AM BLOOD CK(CPK)-5781*
[**2187-1-24**] 06:54PM BLOOD ALT-248* AST-546* CK(CPK)-[**Numeric Identifier 81081**]*
AlkPhos-67 TotBili-0.3
[**2187-1-24**] 03:02AM BLOOD ALT-291* AST-775* CK(CPK)-[**Numeric Identifier 81082**]*
AlkPhos-81 Amylase-383*
[**2187-1-23**] 10:00PM BLOOD ALT-301* AST-643* CK(CPK)-[**Numeric Identifier **]*
AlkPhos-108 TotBili-0.2
[**2187-1-23**] 10:00PM BLOOD Lipase-257*
[**2187-1-26**] 02:31AM BLOOD CK-MB-41* MB Indx-0.7 cTropnT-0.22*
[**2187-1-25**] 04:04AM BLOOD CK-MB-111* MB Indx-0.7 cTropnT-0.43*
[**2187-1-23**] 10:00PM BLOOD cTropnT-0.06*
[**2187-1-27**] 07:58PM BLOOD Calcium-7.8* Phos-4.2 Mg-1.9
[**2187-1-27**] 04:07AM BLOOD Calcium-8.1* Phos-4.8* Mg-2.1
[**2187-1-26**] 02:31AM BLOOD Calcium-7.2* Phos-5.3* Mg-1.7
[**2187-1-25**] 04:04AM BLOOD Albumin-1.7* Calcium-6.0* Phos-4.9*
Mg-2.3
[**2187-1-24**] 09:20PM BLOOD Calcium-6.1* Phos-4.4 Mg-1.5*
[**2187-1-24**] 06:54PM BLOOD Albumin-2.2* Calcium-6.8* Phos-4.4 Mg-1.7
[**2187-1-24**] 12:45PM BLOOD Calcium-6.1* Phos-4.3# Mg-1.6
[**2187-1-23**] 10:00PM BLOOD Osmolal-425*
[**2187-1-24**] 02:39PM BLOOD Cortsol-96.9*
[**2187-1-24**] 12:52PM BLOOD Cortsol-75.9*
[**2187-1-26**] 10:48AM BLOOD Genta-1.1* Vanco-17.6
[**2187-1-25**] 06:31AM BLOOD Vanco-10.2
[**2187-1-25**] 04:04AM BLOOD Genta-2.6*
[**2187-1-23**] 10:00PM BLOOD ASA-NEG Ethanol-342* Carbamz-<1.0*
Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2187-1-28**] 03:20AM BLOOD Type-[**Last Name (un) **] pH-7.42 Comment-GREEN TUBE
[**2187-1-27**] 04:21AM BLOOD Type-ART Temp-36.1 pO2-72* pCO2-33*
pH-7.48* calTCO2-25 Base XS-1 Intubat-NOT INTUBA
[**2187-1-26**] 09:17AM BLOOD Type-ART Temp-35.6 Rates-/18 Tidal V-450
PEEP-5 FiO2-40 pO2-94 pCO2-36 pH-7.47* calTCO2-27 Base XS-2
Intubat-INTUBATED
[**2187-1-26**] 02:36AM BLOOD Type-ART Temp-35.9 pO2-121* pCO2-32*
pH-7.46* calTCO2-23 Base XS-0 Intubat-INTUBATED
[**2187-1-25**] 07:49PM BLOOD Type-ART Temp-35.9 pO2-96 pCO2-36 pH-7.44
calTCO2-25 Base XS-0 Intubat-INTUBATED
[**2187-1-25**] 04:31AM BLOOD Type-ART Temp-35.9 pO2-104 pCO2-35
pH-7.46* calTCO2-26 Base XS-1
[**2187-1-24**] 09:01PM BLOOD Type-ART pO2-119* pCO2-34* pH-7.54*
calTCO2-30 Base XS-7
[**2187-1-24**] 05:45PM BLOOD pH-7.52*
[**2187-1-24**] 11:26AM BLOOD Type-[**Last Name (un) **]
[**2187-1-24**] 02:00AM BLOOD Type-ART PEEP-5 FiO2-100 pO2-419*
pCO2-29* pH-7.12* calTCO2-10* Base XS--19 AADO2-290 REQ O2-53
Intubat-INTUBATED Vent-CONTROLLED
[**2187-1-23**] 10:17PM BLOOD pO2-428* pCO2-24* pH-7.10* calTCO2-8*
Base XS--20
[**2187-1-25**] 04:31AM BLOOD Glucose-114* Lactate-1.4 K-3.3*
[**2187-1-24**] 09:01PM BLOOD Lactate-2.8* K-3.6
[**2187-1-24**] 05:45PM BLOOD Lactate-5.4* K-2.7*
[**2187-1-24**] 04:12PM BLOOD Lactate-7.8*
.
============
microbiology
============
Blood culture [**1-23**]
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
SALMONELLA ENTERITIDIS
| STAPHYLOCOCCUS,
COAGULASE NEGATIVE
| |
AMPICILLIN------------ <=2 S
CEFTRIAXONE----------- <=1 S
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ 2 S
LEVOFLOXACIN----------<=0.25 S <=0.12 S
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- =>16 R
TRIMETHOPRIM/SULFA---- <=20 S
VANCOMYCIN------------ <=1 S
.
FECAL CULTURE (Final [**2187-2-22**]): NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final [**2187-2-22**]): NO CAMPYLOBACTER
FOUND.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2187-2-21**]):
REPORTED BY PHONE TO [**Doctor First Name **] [**Doctor Last Name **] @ 0546 ON [**2187-2-21**]-
CC6C.
CLOSTRIDIUM DIFFICILE.
FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA.
.
==========
Cardiology
==========
TTE
The left atrium is dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity is
unusually small. Left ventricular systolic function is
hyperdynamic (EF>75%). There is a severe resting left
ventricular outflow tract obstruction. Right ventricular chamber
size and free wall motion are normal. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is systolic anterior motion of the
mitral valve leaflets. Mild (1+) mitral regurgitation is seen.
The estimated pulmonary artery systolic pressure is normal.
There is no pericardial effusion.
IMPRESSION: Small left ventricle with hyperdynamic systolic
function. There is systolic anterior movement of the mitral
valve with a severe LVOT gradient, due to apposition of the
valve leaflet to the septum at end systole. Mild mitral
regurgitation.
Compared with the prior study (images reviewed) of [**2187-1-24**],
the measured LVOT gradient is similar to prior study (not
reported on prior). The other findings are similar.
.
===========
Radiology
===========
CT Head
IMPRESSION:
1. Gyriform high density focus at left frontovertex, without
associated
edema, mass effect, or gyral effacement, likely a chronic
finding. This could likely represents mineralization, related to
old trauma or infarct.
2. Air-fluid levels in the left maxillary and frontal sinuses
and sphenoid
air cells, bilaterally, with mild mucosal thickening in the
ethmoid air cells,representing acute-on-chronic inflammation. No
associated fracture.
.
CT Torso
IMPRESSION:
1. Bibasilar dependent consolidation with peripheral
nodular/tree-in-[**Male First Name (un) 239**]
opacities worrisome for infection or aspiration.
2. Marked enlargement of the left chest wall musculature and
right gluteal
muscles. The muscles are overall lower in attenuation,
suggesting edema.
3. Pancolitis, most proiminent of the sigmoid colon.
4. Irregular contour of the kidneys. Exophytic right renal mass,
most c/w
heamorrhagic cyst. Recommend US evaluation..
5. Intra-arterial right chest vascular line as noted on prior
chest
radiograph.
.
Scrotal ultrasound
IMPRESSION:
1. Severe scrotal edema, with no evidence of fluid collection or
abscess.
2. Normal testes with small hydroceles bilaterally.
.
RIGHT UPPER QUADRANT ULTRASOUND:
The liver is again coarsened in echotexture. The portal vein is
patent with antegrade flow. There is no ascites. There is no
intra- or extra-hepatic bile duct dilation. The common duct
measures 3 mm. No gallstones or wall thickening.
IMPRESSION: No evidence of biliary ductal dilatation.
.
MRCP
1. Trace fluid around the pancreas compatible with acute
pancreatitis. No
evidence of fluid collection or biliary ductal dilatation.
2. Small bilateral pleural effusions and trace ascites are
increased from the [**2-4**] study.
4. Indeterminate lesion in the mid right kidney which has
evidence of
hemorrhagic components. This mass is concerning for malignancy.
Further
evaluation is recommended.
.
LENI
IMPRESSION: Normal deep veins in the right leg. Noncompressible
left common femoral vein is most likely due to edema.
Brief Hospital Course:
# s/p Sepsis secondary to Salmonella/Coag Neg Staph: Resolved.
The patient was admitted to the MICU intubated in septic shock,
rhabdo, metabolic acidosis, ARF, and aspiration PNA, and was
resuscitated with IVF and pressors. He received broad spectrum
antibiotics, initially with Vancomycin and Zosyn. A CT scan
revealed pancolitis, and Surgery was consulted and recommended
conservative management. Patient's blood cx grew out coag neg
staph and salmonella; group B strep was cultured from the
sputum. Antibiotics were tailored to CTX/Vanco/Flagyl. When he
stabilized off pressors, the CVL which was placed at [**Hospital1 **] in the R subclavian artery was removed with angio
guidance by Vascular Surgery; a stent was deployed due to
ongoing extravasation. The patient was weaned to minimal vent
settings and extubated successfully on HD 5. Patient was
transferred to the floor and treated with a 10 day course of
Vancomycin and Ceftriaxone (later switched to cefepime -
described below), which was shorter duration than the total 14
days anticipated because of patient's pancreatitis,
hepatotoxicity, and [**Hospital1 **] (acute generalized exanthematous
pustulosis). Patient had fluctuating WBC count during his stay
(likely reactive), but surveillance cultures remained negative,
and was afebrile and hemodynamically stable.
#. Transaminitis/Cholestasis/Pancreatitis: Patient was septic
on admission and required pressors. On admission, patient had a
transaminitis consistent with shock liver that improved during
the course of his admission. Patient had been improving during
hospitalization, but was noted to have an elevated WBC count
(18) on [**2-2**]. Patient had been afebrile, hemodynamically
stable, but there was concern for possible intra-abdominal
abcess vs worsening colitis (noted on admission) that raised
suspicion for occult infectious process. On [**2-3**], patient was
noted to have elevated amylase/lipase, elevated direct bilirubin
and Alk phos, and was noted to be somnolent. Given the
multiorgan system involvement, there was concern for possible
drug toxicity. Patient had a Valproate level and Carbamazepine
level checked as the doses of these medication had been
increased on [**1-30**] to his home doses. These medications were
taped off over several days. CT abdomen, MRCP, RUQ u/s were
performed and were unremarkable as to the etiology of the
patient's hepatic and pancreatic involement -- no evidence of
ductal dilation or gallstones. Patient's cholestatic markers
continued to trend upward over several days and so hepatology
was consulted. Hepatology attributed patient's cholestatic
pattern to Zosyn that he received in the MICU earlier in his
course. Patient's cholestatic markers have stabilized and
amylase,lipase were no longer trended when patient improved
clinically.
.
#. C difficile Colitis: Patient developed C diff colitis on [**2-20**]
with a fever, increased white count, and tachycardia. Patient
was transiently re-admitted to the MICU where he received
fluids, and was started on flagyl and vancomycin. Vancomycin was
stopped (see below) and patient continued on Flagyl for planned
21 day course.
.
# Acute Generalized Exanthematous Pustulosis: On [**2-3**] patient
was noted to have an erythematous [**Month/Year (2) **] involving his inguinal
region that was initially thought to be a candidal cellulitis.
On the following days, was noted to be spreading, and was noted
to be involving patient's trunk and back. Dermatology was
consulted and diagnosed this [**Month/Year (2) **] as acute generalized
exanthematous pustulosis, attributed to use of B lactam
antibiotics in the past. Patient was treated with emollient and
triamcinalone cream. Vancomycin oral was started in the setting
of C diff and patient broke out in a new [**Last Name (LF) **], [**First Name3 (LF) **] this was
stopped. [**First Name3 (LF) **] was not nearly as severe as prior AGEP and
resolved within 3 days.
.
#Acute on Chronic Renal Failure: Patient was admitted with a Cr
of 5, thought to be related to patient's septic shock.
Patient's Cr had trended downward to 1.5 during the admission,
likely secondary to ATN. Per his PCP, [**Name10 (NameIs) 5348**] Cr is around 1.4.
Additionally, patient reports known history if diabetes
insipidus due to prior Lithium use.
.
# Pancolitis: Unclear etiology. Patient was in septic shock
when he was initially admitted and was noted to have pancolitis
on CT scan on admission. It was thought that patient may have
developed this from hypotension, but unclear. Of note, patient
was noted to have salmonella in his blood cultures. Patient was
followed by general surgery who recommended conservative
management. A repeat CT Abd/Pelvis shows interval improvement
in colonic wall. Patient's PCP was [**Name (NI) 653**] and faxed
colonoscopy records dating 1-2 years ago that showed normal
colon then.
.
#History seizure disorder: Patient has a history of seizure
disorder and has been on carbamazepine and valproic acid at
home. On admission, patient's home doses of these medications
was unclear and was started on low doses of each. Patient's
pharmacy was [**Name (NI) 653**]. His home dose (as of [**Month (only) **]) was
Carbamazepine 400/600, and Valproic Acid [**Telephone/Fax (1) 81083**]. Patient
was started on this medication on [**1-30**]. Patient was noted to
have hepatotoxicity/pancreatitis on [**2-3**], but it is unclear if
these medications are related to his state. Patient had been
previously on these doses as an outpatient and had been
refilling regularly. Neurology was consulted to help taper
these medications. He was taped off over several days and was
started on Keppra for seizure prophylaxis. He had a therapeutic
Keppra level prior to discharge.
.
# Bipolar disorder: Transitioned to risperidone in house and
patient did well on this regimen. Psychiatry was involved and
felt that patient should have neuro-psych evaluation after acute
medical issues resolved, but felt that Bipolar was likely at
[**Month/Year (2) 5348**] at the time of discharge.
.
#. Hypothyroid: Thyroid studies checked in the setting of
hypothermia and diarrhea. TSH 16, but free T4 normal at 1.2
likely indicating sick euthryoid in the setting of patient's
multiple other medical problems. [**Name (NI) **] to retest TSH as
outpatient after acute issues resolve by PCP.
.
# RCC: Mass noted on MRI abdomen in house. It appears patient
has known RCC based on prior records from [**Hospital1 2025**] and is s/p RFA
[**9-23**]. Plan for patient to follow up with Dr. [**Last Name (STitle) **] [**Name (STitle) 8671**] at
[**Hospital1 2025**] with plan for Q3 month CT scans for first year.
# Contact: Brother [**Name (NI) **] [**Telephone/Fax (1) 81084**]. [**Telephone/Fax (1) **] [**Name (NI) 81085**]
[**Telephone/Fax (1) 81086**]. [**Name2 (NI) **] HCP, patient has indicated that [**Name (NI) **]
[**Name (NI) 81085**] should be his HCP, however [**Name (NI) **] has refused. [**Name (NI) **]
brother is willing to be HCP, but patient is refusing. For now,
if there are any issues, will have to use next of [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **]
[**Known lastname 81087**] for consent. Will need to readdress with patient.
Medications on Admission:
Medications confirmed from pharmacy (CVS [**Telephone/Fax (1) 81088**])
Carbamazipine 400mg qam 1200mg qhs (last filled [**2186-12-29**])
Depakote 250mg qhs (last filled [**2186-12-20**])
Simvastatin 40mg qhs
Timolol 5% opth soln to left eye prn
of note, in [**11/2186**] the patient was taking Depakote 500mg qam
500mg q afternoon and 2000mg qhs
Psych meds are being prescribed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] from [**Hospital1 2025**]
[**Telephone/Fax (1) 81089**]
Other meds rx by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (3) 81090**]
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. White Petrolatum-Mineral Oil Cream Sig: One (1) Appl
Topical DAILY (Daily).
3. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day) for 2 days: through [**3-4**].
4. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic
DAILY (Daily).
5. Risperidone 1 mg Tablet Sig: Two (2) Tablet PO QPM (once a
day (in the evening)).
6. Risperidone 1 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
7. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
8. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) Please stop [**3-13**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 1562**] Care & Rehabilitation
Discharge Diagnosis:
1. Septic shock
2. Rhabdomylosis
3. Acute Renal Failure
4. Respiratory failure
5. Salmonella septicemia
6. Clostridium difficile colitis
Discharge Condition:
stable, afebrile
Discharge Instructions:
You were initially admitted with septic shock from [**Hospital1 6591**]. You were found to have a very serious blood infection,
likely originating from your colon. You were treated with
antibiotics which caused hepatitis and pancreatitis that
resolved on their own. These antibiotics also caused a severe
skin [**Hospital1 **] that improved on its own. You subsequently developed
another infection of your colon called clostridium difficile
colitis, and were treated with different antibiotics which would
will need to continue. Finally, your depakote was thought to
have caused some of your liver problems, so it was stopped and
you were started on Risperdal and Keppra instead for your
bipolar disorder and seizures respectively.
.
You are being [**Hospital1 **] to a rehab facility to help you regain
your strength.
.
Please seek immediate medical attention if you experience chest
pain, shortness of breath, abdominal pain, nauasea, vomitting,
fevers, chills, worsening diarrhea or any change from your
[**Hospital1 5348**] health status.
Followup Instructions:
Please follow up with your team of [**Hospital1 2025**] doctors after being
[**Name5 (PTitle) **] from rehab, including Dr. [**Last Name (STitle) **] your PCP and Dr.
[**Last Name (STitle) 8671**] your kidney specialist.
Completed by:[**2187-3-9**]
|
[
"556.6",
"008.45",
"728.88",
"E930.8",
"585.9",
"348.39",
"276.2",
"585.2",
"285.1",
"428.32",
"577.0",
"E930.5",
"997.2",
"296.80",
"995.92",
"570",
"253.5",
"507.0",
"998.2",
"785.52",
"038.19",
"518.81",
"428.0",
"003.1",
"345.90",
"244.9",
"693.0",
"584.5",
"189.0",
"303.01",
"287.5",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.71",
"39.79",
"88.49",
"86.11"
] |
icd9pcs
|
[
[
[]
]
] |
22076, 22145
|
13390, 20651
|
344, 466
|
22325, 22344
|
2803, 13367
|
23435, 23686
|
2183, 2187
|
21325, 22053
|
22166, 22304
|
20677, 21302
|
22368, 23412
|
2202, 2784
|
248, 306
|
494, 1889
|
1911, 2090
|
2106, 2167
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,752
| 116,624
|
34502
|
Discharge summary
|
report
|
Admission Date: [**2114-7-21**] Discharge Date: [**2114-8-24**]
Date of Birth: [**2053-11-28**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Metoprolol
Attending:[**First Name3 (LF) 2745**]
Chief Complaint:
Pt found down after 10 hours; transfer from OSH for abnormal
LFTs, unable to wean from ventilator.
Major Surgical or Invasive Procedure:
Left IJ central line placed on [**7-22**]
Right chest tube pulled out on [**7-26**]
Lumbar puncture [**7-26**]
Left IJ central line retreived on [**7-27**]
Left PICC line palced on [**7-27**]
Tracheostomy placed on [**7-27**]
Left PICC line retreived on [**7-30**] after positive blood cultures
Thoracosentesis [**8-2**] draining 500 CC
History of Present Illness:
60 y/o F with PMHx of borderline DM and Crohns disease who was
admitted to OSH on [**7-10**] after being found non-responsive at home
for 8-10 hours. She was hypothermic, bradycardic and
hypotensive. BS was 1467 on admission with elevated anion gap
consistent with DKA. She was also noted to have elevated serum
CK, increased amylase and lipase and WBC of 30k. CT head was
negative. In the ED she was intubated for airway protection and
given Vanc/Levo. She was given one dose of hydrocortisone and
started on a levophed gtt. Her presumptive diagnosis was DKA
[**12-23**] acute pancreatitis. She was transferred to the ICU where she
was warmed, her bradycardia resolved and she was weaned from
levophed.
Brief course: 60 yo WF w PMHx of T2DM, Crohn's disease,
initially presented on [**7-10**] at OSH after being found down at
home w BS of 1400. Pt was intubated in ER for airway protection,
and req'd pressors for hypotension. Etiology of MS was thought
to be DKA [**12-23**] acute pancreatitis. Started empirically on
vanco/levoflox. OSH course
complicated by iatrogenic PTX s/p chest tube, ARF likely [**12-23**]
rhabdo (CK peak 11,000) requring HD, and failed extubation req
re-intubation. Pt also noted to have incr AlkPhos & GGT, nl
TBili, [**Month/Day (2) 5283**] u/s unrevealing. Was briefly on TPN.
Bronch performed on 8/30Transferred to [**Hospital1 18**] ICU on [**7-21**] for
further management. Was on vanco& fluco on transfer.
For workup of her altered mental status, she has had normal
MRI, LP, and unrevaling EEG. Pt continued to spike fevers
despite normalization of her pancreatic enzymes. She underwent
trachestomy on [**7-27**]. Central line removed [**7-27**], replaced by PICC.
Cefepime & cipro added empirically for persistent fevers.Line Cx
+Coag neg staph, lines removed on [**7-31**]. Thoracentesis performed
on [**8-2**] was unrevealing. Started on meropenem on [**8-3**] for ESBL
enterobacter from sputum Cx. Pt was started on Vanc and
Meropenem for hospital acquired Pneumonia. Based on sputum cx,
Vanc was discontinued after an 8 day course and meropenem was
continued. Hospital course continued to be signif for persistent
fevers (o/n 102F) and episodes of tachycardia and hypertension
thought [**12-23**] anxiety. Pt was seen by ID on [**8-7**] and underwent
C/A/P CT to look of source of infection and it showed
increasing/stable upper lobe opacities and decreasing pleural
effusions as well as diffuse LAD. Surgery was consulted to
biopsy one of the lymph nodes and they did not feel as though it
was worth the risk and thought that LAD was likely [**12-23**]
infection. On [**8-9**], pt noted to have increasing WBC again and
ID recommended starting pt on po vanc on [**8-10**] to cover for
Cdiff. No diarrhea noted, Cdiff stool pending.
Pt also followed by psych due to agitation/delirium. They
noted increased cogwheel rigidity, which they thought [**12-23**] haldol
and [**Month (only) **] dose. CPK was not elevated.
Pt is very interactive and less frustrated after having a
passy muir valve placed.
Past Medical History:
Borderline DM (presented with DKA)
Crohns Disease
Social History:
Pt takes care of mentally challenged family and has not been
taking care of herself.
Family History:
non-contributory
Physical Exam:
Vitals: T 96.7 BP 110/58 HR 66 Sats 94% on Vent
AC/40%/12/500/PEEP 5
GEN: Comfortable, intubated, sedated, does not respond to
commands
HEENT: pinpoint pupils bilaterally, minimal response to light,
sclera anicteric, no epistaxis or rhinorrhea,
NECK: RIJ with erythema around base, right subclavian temp
dialysis line with mild erythema at site, no purulent drainage
COR: RRR, no M/G/R
PULM: coarse BS bilaterally, [**Month (only) **] BS at bases
ABD: Soft, NT, ND, Active BS, no [**Month (only) 5283**] tenderness
EXT: No C/C/E +DP/PT
NEURO: minimal response to sternal rub
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
Pertinent Results:
[**2114-7-21**] 05:17PM LACTATE-0.7
[**2114-7-21**] 05:17PM TYPE-ART PO2-66* PCO2-48* PH-7.40 TOTAL
CO2-31* BASE XS-3 INTUBATED-INTUBATED
[**2114-7-21**] 05:30PM PT-14.9* PTT-27.9 INR(PT)-1.3*
[**2114-7-21**] 05:30PM PLT COUNT-125*
[**2114-7-21**] 05:30PM NEUTS-88.0* LYMPHS-8.3* MONOS-2.4 EOS-0.8
BASOS-0.5
[**2114-7-21**] 05:30PM WBC-17.2* RBC-3.12* HGB-9.7* HCT-28.4* MCV-91
MCH-31.2 MCHC-34.3 RDW-15.5
[**2114-7-21**] 05:30PM TRIGLYCER-148
[**2114-7-21**] 05:30PM ALBUMIN-3.0* CALCIUM-8.6 PHOSPHATE-4.4
MAGNESIUM-2.3
[**2114-7-21**] 05:30PM proBNP-4265*
[**2114-7-21**] 05:30PM LIPASE-57
[**2114-7-21**] 05:30PM ALT(SGPT)-23 AST(SGOT)-12 LD(LDH)-188 ALK
PHOS-752* AMYLASE-44 TOT BILI-0.5
[**2114-7-21**] 05:30PM estGFR-Using this
[**2114-7-21**] 05:30PM GLUCOSE-204* UREA N-44* CREAT-2.9* SODIUM-145
POTASSIUM-3.6 CHLORIDE-108 TOTAL CO2-29 ANION GAP-12
[**2114-7-21**] 08:46PM URINE MUCOUS-RARE
[**2114-7-21**] 08:46PM URINE RBC-8* WBC-24* BACTERIA-FEW YEAST-OCC
EPI-0 TRANS EPI-<1 RENAL EPI-<1
[**2114-7-21**] 08:46PM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-SM
[**2114-7-21**] 08:46PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.008
Brief Hospital Course:
AP: 60 yo WF w T2DM, Crohn's disease, presents w/ altered mental
status likely [**12-23**] to DKA from acute pancreatitis, w/ complicated
hospital course including line assoc pneumothorax s/p Ct
placement/removal, ventilator associate pneumonia, funguria, ARF
[**12-23**] rhabdo requiring intermittent HD, w persistent delirium,
fevers and leukocytosis, all of which are resolved.
1. Fevers/leukocytosis - Over the weekend of [**9-21**], pt noted
to have rise in wbc and low grade temp. All cx neg at that
point. Repeat Chest CT stable. Per ID,even though no diarrhea,
pt started on po vanc empirically for possible Cdiff and wbc
improved. C diff X2 neg. Per ID, po vanc discontinued after a 7
day course. The patient did not have any further leukocytosis
for 4 days prior to discharge and was without low grade fevers
for over 5 days prior to discharge.
2. Altered MS - Per notes, pt improved significantly from
admission when she was essentially unresponsive. Head CT, MRI,
LP, EEG all unrevealing. MS change likely multi-factorial
including delirium [**12-23**] recent DKA, infection, ICU course and
also ? anoxic event. Pt then had issues w delirium and was
followed by psych. Pt was initially on haldol but she developed
cogwheel rigidity, so was switched to zyprexa. Zyprexa was
weaned to off on [**8-17**]. Overall, the patient has had dramatic
improvement in her mental status, although she has some residual
deficits. She underwent some cognitive testing by OT that
revealed some deficits. She currently needs some help with
daily activities. Pt will need outpt Neuropscyh eval to further
evaluate.
3. Hypoxia - Resolved. Pt had both effusions and vent assoc pna.
Pt is sp treatment with both Vanc and Meropenem. Passy muir
valve was decannulated on [**2114-8-21**]. The patient has done well
since removal of her trach. She also has some left lower lobe
collapse which was evaluated by pulmonary and they recommended
conservative management. Over time, this should reexpand. The
patient is breathing in the mid 90s on RA with ambulation.
4. Hx of ARF - resolved and likely [**12-23**] rhabdo as CPK 11K on
admission.
5. Hx of fungal UTI - s/p tx w fluconazole, last UCX NGTD
6. Acute pancreatitis - Per records from here, on admission at
OSH, pt's lipase was in [**2105**] range. Etiology of this attack
remains unclear, pt has had [**Name (NI) 5283**] US at OSH per records which was
neg and CT A/P here which also did not show any abn. Pt was
initially seen by GI here for eval and they recommended MRCP for
further eval once ARF resolved. Anti-mitochondrial Ab negative.
MRCP ordered and revealed evidence of pancreas divisum or a
dominant dorsal duct an nondistended pancreatic duct. Pt will
need to fu w Dr. [**Last Name (STitle) 174**] as outpt. Dr. [**Last Name (STitle) 174**] did mention that
there is an association between new onset diabetes and
pancreatic adeno within 2 year frame. MRCP does not show any
mass, which is re-assuring but if repeat CT shows persistent LAD
(see below), concern will be higher.
7. Hx of Crohn's - no reports of abd pain or diarrhea here. cont
to monitor. GI consult appreciated, since asymptomatic and was
not on anything as outpt for this, no meds right now, Dr. [**Last Name (STitle) 174**]
will follow as outpt.
8. Hx of atrial fibrillation - in setting of acute illness. Pt
had TTE and CTA of chest which were neg for structural hrt dz
and neg for PE respectively. TSH wnl. Cont to monitor. was on
tele but has been in NSR but with frequent ectopy. Cont tele for
now
9. DM - Per sister she was told she had diet controlled about 5
years ago. Had BS in 1400 on admission likely stress response
from acute pancreatitis. Patient now on metformin 850 mg po bid
with lispro sliding scale.
10. Diffuse lymphadenopathy - pt's recent cT C/A/P on [**7-24**] and
[**8-7**] have shown diffuse LaD. On [**8-9**], Gen [**Doctor First Name **] was consulted for
biopsy but they declined stating that she is high risk for OR as
she was recovering from VAP and that LAD was likely [**12-23**]
infection. Dr. [**Last Name (STitle) 174**] will determine whether he wants to perform
repeat CT scan in f/u appointment. Radiologists here thought
that the LAD was not concrening for malignancy and did not
recommend reimaging.
. FEN -Patient repeatedly evaluated by nutrition, currently
tolerating po comfortably but not achieving large caloric
intake. Would continue calorie counts and if patient does not
improve her intake, consider supplemental tube feeds.
. Code status - Full
.
Comm: with sister, [**Name (NI) 3508**] [**Name (NI) 2808**] [**Name (NI) 79268**] [**Telephone/Fax (1) 79269**]/ lives in CT.
She only has one sister.
Medications on Admission:
Medications on transfer:
chlorhexidine mouthwash
Senna prn
Pantoprazole 40mg daily
Fluconazole 200mg IV daily
Heparin 5000u sc TID
Fentanyl gtt
Propofol gtt
Multivitamin IV
Levofloxacin 250mg IV q48hrs
Regular Insulin SS
Nystatin powder
Duoneb q4hrs
Epoeitin 40000units
Bisacodyl
Magnesium
Tylenol
Ativan prn
Vancomycin
Discharge Medications:
1. Insulin Regular Human 100 unit/mL Solution Sig: see sliding
scale attached units Injection ASDIR (AS DIRECTED): SEE attached
lispro sliding scale.
2. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO twice a
day.
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed.
4. Metformin 850 mg Tablet Sig: One (1) Tablet PO twice a day.
5. Diltiazem HCl 180 mg Tablet Sustained Release 24 hr Sig: One
(1) Tablet Sustained Release 24 hr PO once a day: HOLD FOR
SBP<100, HR<55.
Discharge Disposition:
Extended Care
Facility:
Eagle [**Hospital **] Rehab
Discharge Diagnosis:
Altered Mental Status
Diabetic Ketoacidosis
Acute Pancreatitis
Vent Associated Pneumonia
Rhabdomyolysis
Acute Renal Failure
Cognitive Deficits s/p acute illness
Abdominal Lymphadenopathy
Discharge Condition:
Vital Signs Stable
Discharge Instructions:
Return to emergency room if having severe abdominal pain,
confusion, high fevers, high blood sugars that do not improve at
[**Hospital1 1501**] with aggressive insulin treatment.
Followup Instructions:
1. Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 174**], GI, [**Hospital1 18**] [**Telephone/Fax (1) 68666**]. Patient to call
and arrange appointment.
2. PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 22149**], [**First Name3 (LF) **], Ph: [**Telephone/Fax (1) 79270**]. Patient to arrange
f/u
3. Outpatient Neuropsych testing at [**Hospital1 18**]. Patient to call and
schedule appointment at [**Telephone/Fax (1) 1669**].
4. Patient to arrange f/u with physician located near her that
casemanagment is helping locate for her. Patient should arrange
close f/u.
|
[
"250.13",
"707.22",
"511.9",
"728.88",
"041.85",
"570",
"512.1",
"427.31",
"427.32",
"999.31",
"555.9",
"997.31",
"112.2",
"518.81",
"707.03",
"577.0",
"041.19",
"584.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31",
"31.1",
"43.11",
"33.22",
"96.72",
"96.6",
"38.93",
"97.37",
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
11548, 11602
|
5963, 10646
|
385, 723
|
11832, 11852
|
4691, 5940
|
12079, 12682
|
3997, 4015
|
11017, 11525
|
11623, 11811
|
10672, 10672
|
11876, 12056
|
4030, 4672
|
247, 347
|
751, 3804
|
10697, 10994
|
3826, 3878
|
3894, 3981
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,443
| 110,169
|
25214
|
Discharge summary
|
report
|
Admission Date: [**2100-8-6**] Discharge Date: [**2100-8-9**]
Date of Birth: [**2043-1-24**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
occasional chest pressure and palpitations
Major Surgical or Invasive Procedure:
Minimally invasive MV repair with 30mm [**Doctor Last Name 405**] Band [**8-6**]
History of Present Illness:
57 yo male with chest discomfort for one year, not related to
exertion, and assoc. palpitations occasionally. Has known mitral
valve prolapse (MVP) for at least 10 years. Has had serial echos
and cath done [**7-27**] showed 3+MR, nl. cors., and EF 55%. Referred
to Dr. [**Last Name (STitle) **] for surgical repair of MV. Had excellent exercise
capacity on pre-op testing, and [**6-22**] TEE showed EF 60%, trace
TR, flail post MV leaflet, and 3+MR with trace AI.
Past Medical History:
?HTN
depression/anxiety
BPH
MVP
mild OA hands
Social History:
works as engineer, lives with wife, smoked remotely more than 30
years ago, 2 glasses of wine per day.
Family History:
non-contrib. for cardiac disease
Physical Exam:
HR 63, RR14, 133/77 R, 144/88 L, 6'3", 195 pounds
mild rash on abdomen, NAD
HEENT and neck exam unremarkable, without bruits,
lungs CTA bilat.
RRR, 4/6 SEM at LLSB
no masses or organomegaly in abd
extrems, warm, well-perfused, no edema without varicosities
2+ bilat fem, DP/PT pulses
Pertinent Results:
[**2100-8-9**] 10:38AM BLOOD WBC-9.1 RBC-3.77* Hgb-11.7* Hct-35.5*
MCV-94 MCH-31.1 MCHC-33.0 RDW-12.5 Plt Ct-137*
[**2100-8-9**] 10:38AM BLOOD Plt Ct-137*
[**2100-8-9**] 10:38AM BLOOD Glucose-125* UreaN-21* Creat-1.1 Na-142
K-4.8 Cl-106 HCO3-28 AnGap-13
[**2100-8-9**] 02:44AM BLOOD Calcium-8.2* Mg-1.7
[**2100-8-9**] 03:04AM BLOOD freeCa-1.21
Brief Hospital Course:
Admitted [**8-6**], underwent minimally invasive MV repair with 30 mm
[**Doctor Last Name 405**] annuloplasty band by Dr. [**Last Name (STitle) **]. Transferred to CSRU
in stable condition on a phenylephrine drip. Extubated early the
following morning in SR on indulin and neo drips. Weaned off neo
on POD #2 and remained in unit for bed issues. CTs removed,
diuresis begun, and transferred to [**Hospital Ward Name 121**] 2 to increase activity
level. Beta blockade begun with lopressor. Patient did extremely
well and was cleared for discharge late in the day [**8-9**]. Right
thoracot. incis. unremarkable , lungs CTA bilat, RRR with no
murmur, abd soft with flatus, extrems warm with 1+ edema.
Discharged to home with VNA services.
Medications on Admission:
lisinopril 20 mg qd
zoloft 75 mg qd
claritin prn
MVI qd
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
4. Zoloft 50 mg Tablet Sig: 1.5 Tablets PO once a day.
Disp:*45 Tablet(s)* Refills:*2*
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
6. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours): Take with food.
Disp:*120 Tablet(s)* Refills:*2*
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO twice a day for 7
days.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Mitral regurgitation.
Hypertension
Benign prostatic hypertrophy
s/p min. inv. mitral valve repair
Discharge Condition:
Good.
Discharge Instructions:
Follow medications on discharge instructions.
You may not drive for 4 weeks.
You may not lift more than 10 lbs. for 6 weeks.
You should shower, let water flow over wounds, pat dry with a
towel.
Call our office for wound drainage, temp>101.5
Do not use lotions, powders, or creams on wounds.
Followup Instructions:
Make an appointment with Dr. [**Last Name (STitle) 2093**] for 1-2 weeks.
Make an appointment with Dr. [**Last Name (STitle) **] for 4 weeks.
Completed by:[**2100-9-10**]
|
[
"401.9",
"311",
"424.0",
"600.00",
"300.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.60",
"39.61",
"35.12"
] |
icd9pcs
|
[
[
[]
]
] |
3746, 3801
|
1845, 2582
|
343, 426
|
3943, 3951
|
1477, 1822
|
4290, 4463
|
1124, 1158
|
2688, 3723
|
3822, 3922
|
2608, 2665
|
3975, 4267
|
1173, 1458
|
261, 305
|
454, 919
|
941, 988
|
1004, 1108
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,534
| 151,324
|
28762
|
Discharge summary
|
report
|
Admission Date: [**2126-8-23**] Discharge Date: [**2126-8-28**]
Date of Birth: [**2061-5-21**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2969**]
Chief Complaint:
median sternotomy
to resect the substernal mass.
Major Surgical or Invasive Procedure:
mediansternotomy excision
History of Present Illness:
Fall of [**2124**] when she developed
the insidious onset of hoarseness/change in voise and local neck
discomfort. Symptoms continued, so she was referred for ENT
evalution in [**2125-12-30**]. She subsequently underwant an FNA
on [**2126-4-25**] that revealed papillary thyroid carcinoma. She then
underwent a left hemithyroidectomy at [**Hospital 792**]Hospital by
Dr. [**Last Name (STitle) 69509**] [**Name (STitle) **] on [**2126-5-23**]. Surgery was complicated by
recurrent laryngeal nerve palsy. Pathology revealed multifocal
papillary thyroid carcinoma. She sought a second opinion with
Dr.
[**First Name (STitle) **] Bie who performed a completion thyroidectomy in [**2125-12-30**]. At the time of surgery, extensive local disease was
identified with residual tumor on the left thyroid bed and
mediastinum engulfing local vascular structures and the trachea.
She was then referred to Dr. [**Last Name (STitle) **] for further debulking of
mediastinal disease.
Past Medical History:
DM type 2, migraines, hypercholesterolemia
PSHx: Hysterectomy, RIH repair, total thyroidectomy, breast
lumpectomy
Social History:
non-smoker/non-drinker
Family History:
non contributory
Physical Exam:
general: pleasant spanish speaking female in NAD
VS: AVSS
-O2 sat 98%
HEENT: unremarkable, symmetrical. Previous neck wound completely
healed, no cellulitis.
Lungs: CTA w/ faint expir wheezes that do not clear completely
w/ coughing.
COR: RRR S1, S2
Abd: obese soft, NT, ND, +BS
Extrem: Lower extrem w/ +1 edema bilat.
Neuro: alert and [**Doctor Last Name **] but not a good historian.
Pertinent Results:
Swallow study [**2126-8-24**]
INDICATION: Status post sternotomy for metastatic thyroid
cancer.
STUDY: Oropharyngeal video fluoroscopic swallowing evaluation.
FINDINGS: Oral and pharyngeal swallowing video fluoroscopic
evaluation was performed in conjunction with speech and swallow
pathology. Thin liquid, nectar thick liquid, puree consistency
barium, and a cookie coated with barium were orally
administered. The patient demonstrated piecemeal behavior by
dividing up boluses into multiple swallows regardless of size of
consistency of the bolus. There was subsequent premature
spillover into the valleculae. However, consecutive sips of
fluid from the cup did not exhibit piecemeal behavior,
suggesting possible action secondary to anxiety for aspiration.
There is no evidence for esophageal leak. All consistencies
demonstrated free passage into the stomach, without gross
esophageal injury. A dedicated esophageal evaluation would be
necessary to more fully evaluate the esophagus, if there is high
clinical suspicion for injury. There is no evidence for
aspiration.
For further details, please consult the speech and swallow note.
IMPRESSION: Peacemeal swallowing but no evidence for aspiration.
STUDY: AP chest, [**2126-8-25**].
HISTORY: 65-year-old woman with desaturation.
FINDINGS: Comparison is made to previous study from [**2126-8-24**].
Median sternotomy wires are seen. There are vertical and
transverse skin staples identified. There has been improvement
of the right-sided pleural effusion and the left-sided pleural
effusion appears worse. However, these findings may be
positional in nature. The opacity in the right upper lobe on the
prior study is less well seen on today's study. There is also a
persistent left retrocardiac opacity. There is atelectasis seen
within the right suprahilar region.
BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2126-8-27**] 07:20AM 6.5 3.50* 10.2* 30.1* 86 29.2 33.9 13.5
354
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2126-8-27**] 07:20AM 182* 13 0.6 139 4.0 103 27 13
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2126-8-27**] 07:20AM 2.9* 8.2* 3.2 2.1
PITUITARY TSH
[**2126-8-25**] 04:43PM 9.8*
THYROID T4
[**2126-8-25**] 04:43PM 6.5
Brief Hospital Course:
65 yo F admitted with metastatic thyroid cancer taken to the OR
on [**2126-8-23**] for a median sternotomy, bronchoscopy, esophagoscopy
with cervical incision, resection of mediastinal mass, ligation
of the left internal jugular. Findings revealed
the mass was adherent to both carotid artery, trachea,
esophagus.
Pathology not finalized.
post op course
POD#0 Chest tube was placed to sxn with moderate output. JP
drain w/ minimal output.
POD#1 episode of desat w/ cxr revealing right upper lobe
collapse. responded to aggressive pulmonary tiolet and diuresis.
Kept NPO until video swallow on POD#3.
endocrine was consulted and followed pt closely thru-out her
post op course with regards to thyroid supplementation and
calcium level.
POD#3 chest tube removed w/o incident. Passed video swallow-diet
porgressed-see results section of summary.
POD#4continued pul tiolet, diuresis, electrolyte and endocrine
management.
POD#5 JP d/c'd. Cleared by PT for d/c home tomorrow.
POD#6. Pt d/c'd to home w/ VNA services and follow up w/ Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 69510**].
Medications on Admission:
Lasix 40", levoxyl 100', ASA 325', glipizide, tricor, percocet,
vicodin, actos, metformin
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed: NO SUBSTITUTIONS PLEASE
GIVE PERCOCET 5/325.
Disp:*80 Tablet(s)* Refills:*0*
2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Glipizide 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Pioglitazone 45 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Senna 8.6 mg Capsule Sig: One (1) Capsule PO bid prn.
10. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
VNA of [**Location (un) 511**]
Discharge Diagnosis:
metastatic thyroid cancer, diabetes
Discharge Condition:
good
Discharge Instructions:
call Dr.[**Doctor Last Name 4738**] office [**Telephone/Fax (1) 170**] if you have fever, chills,
chest pain, shortness of breath, redness or draiange from your
chest incision.
After showering, gently pat the incisions dry.
continue to wear your sugical bra to promote incisional wound
healing.
check your finger sticks as prior to admission.
Followup Instructions:
Endocrinologist: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 16051**], MD Phone:[**Telephone/Fax (1) 1803**]
Date/Time:[**2126-9-6**] 1:00 in the [**Hospital Ward Name **] clinical center [**Location (un) 436**]
medical specialties.
PET scan [**2126-9-6**] 2pm in [**Hospital Ward Name **] clinical center [**Location (un) **]
radiology.
Completed by:[**2126-8-29**]
|
[
"193",
"272.0",
"197.8",
"197.1",
"250.00",
"428.0",
"197.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.5",
"34.3",
"42.32",
"45.13",
"33.22"
] |
icd9pcs
|
[
[
[]
]
] |
6512, 6573
|
4332, 5439
|
370, 398
|
6653, 6660
|
2029, 4309
|
7052, 7439
|
1590, 1608
|
5579, 6489
|
6594, 6632
|
5465, 5556
|
6684, 7029
|
1623, 2010
|
282, 332
|
426, 1396
|
1418, 1534
|
1550, 1574
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
914
| 168,503
|
21196
|
Discharge summary
|
report
|
Admission Date: [**2178-4-1**] Discharge Date: [**2178-6-4**]
Date of Birth: [**2128-6-17**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
Fever, seizures, respiratory distress
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a 49 year-old male status post orthotopic liver
transplant on [**2177-12-23**], with biliary sepsis, seizures, resp
distress, unresponsiveness and worsening liver failure. The
patient also has hepatic artery thrombosis and a right saddle
pulmonary embolus.
Past Medical History:
OLT [**2177-12-23**], rejection rx'd with solumedrol
hep c
varices
h/o encephalitis
myoclonus/seizures s/p tx
Social History:
Lives with roommate on [**Location (un) **]. Has supportive family although
they live near [**Last Name (un) 17679**]
Family History:
Noncontributory
Brief Hospital Course:
[**2178-4-29**]: sp IR drainage of biloma of R inf lobe of the liver.
Tx'd [**5-9**]-had Bronchospasm with meripenim.
[**2178-5-14**]: BC (+) Klebsiella, [**5-13**] U Cx-P, [**5-13**] Bld Cx-klebsiella
(only s-imipenem), [**5-12**] Bl-GNR, [**5-9**]-Cath tip-neg, [**5-9**]-Bile:
GNR X 2, [**5-9**]-([**3-2**]) klebsiella (S-Meropenum, S-Imipen,
S-Ceftriaxone, S-Cefipime) [**5-9**]-Urine-neg, [**5-5**] Bld-Neg, [**5-5**]
MRSA-ngtd, [**5-4**]- Bl-ngtd, [**4-29**]-bile-klebsiella (S-Imip, R-[**Last Name (un) **]),
[**4-29**]-MRSA-neg, [**4-28**] rectal swab: + VRE, [**4-27**] U: neg, [**4-17**] Bl:
Klebsiella, [**3-2**] (R to [**Last Name (un) **], [**Last Name (un) 36**] to Imipen), [**4-26**] cath tip: neg,
[**4-25**] Sp: GNR sparse, [**4-24**] Bld: coag neg staph [**12-2**] (R ox, [**Last Name (un) 36**]
vanc), [**4-23**] Bld: coag neg staph [**1-30**] (R ox, senx vanc)[**4-13**]
Bile:Lactobacillus, Staph coag neg, yeast, gnr, [**4-11**] Bile: Staph
coag neg, yeast, GNR, [**4-11**] Sp: Yeast, [**4-2**] Bl: Klebsiella
[**4-29**] 10 Fr [**Last Name (un) 2823**] to R flank, right subhepatic biloma with
serosang fluid aspirated and sent for culture.
CX: KLEBSIELLA PNEUMONIAE-panresistant. Sensitive to Imipenem.
[**5-4**] Wbc-10.1
[**5-8**] Remains in ICU. Patient awaiting another transplant. A+OX3,
responsive to questions. Right flank pigtail remains in place,
secured with Statlock, draining bilious drainage.
[**5-14**] Remains in ICU and has been consistently febrile. Is
presently refusing all further invasive
procedures/interventions. Spoke briefly to patient who said "I
have a lot of [**Doctor Last Name 10219**] searching to do. I've been here since
[**Month (only) 404**]." Right pig cath. in place draining moderate amounts of
bilious drainage. Statlock secure. Biliary tube is presently
capped.
[**5-18**] Patient has been made CMO, placed on hydromorphone drip
with lorazepam prn for agitation.
[**Date range (1) 56153**]/05 - Pt. with CMO, deceased on [**2178-6-4**].
Plan: CMO, dilaudid drip to comfort
Medications on Admission:
sirolimus 6mg po daily
mycophenolate mofetil 1000mg po BID
prednisone 10mg po daily
valgancyclovir 900mg po daily
bactrim ss po daily
methadone 100mg po daily
clonazepam .25mg po TID
dilantin 260mg po daily
keppra 1500mg po BID
atorvastatin 10mg po daily
furosemide 20mg po daily
fluconazole 400mg po daily
percocet prn
Discharge Disposition:
Expired
Discharge Diagnosis:
End-stage liver failure
Discharge Condition:
Deceased
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2178-8-5**]
|
[
"567.8",
"576.8",
"444.89",
"512.1",
"070.54",
"995.92",
"577.0",
"576.1",
"038.49",
"576.2",
"V58.67",
"996.82",
"518.84",
"287.5",
"780.39",
"250.00",
"996.62",
"511.9",
"427.31",
"997.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.17",
"96.05",
"99.05",
"99.04",
"96.72",
"99.07",
"50.11",
"96.04",
"99.15",
"51.98",
"34.04",
"00.14",
"96.6",
"87.54"
] |
icd9pcs
|
[
[
[]
]
] |
3385, 3394
|
978, 3014
|
349, 355
|
3461, 3626
|
938, 955
|
3415, 3440
|
3040, 3362
|
272, 311
|
383, 652
|
674, 786
|
802, 922
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,835
| 178,876
|
23031+57334
|
Discharge summary
|
report+addendum
|
Admission Date: [**2158-1-29**] Discharge Date: [**2158-2-3**]
Date of Birth: [**2083-9-9**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1055**]
Chief Complaint:
cough and congestion
Major Surgical or Invasive Procedure:
none
History of Present Illness:
73 year-old man with history of stomach/bladder cancer s/p
recent chemo at [**Hospital1 1474**] VA, DM, CAD presentes wit 2-3 days of
productive cough with green sputum and sob with exertion,
fatigue and lethargy. Per girlfriend, patient had decreased PO
intake and mild confusion during that time. Patient with
witnessed fall day prior to admission without head trauma.
Patient denied dysuria, fevers, frequency. In ER patient noted
to have bilateral pneumonia, UTI, hyperglycemia. Patient was
started on insulin drip, IVF levaquin and transferred to the ICU
for management of hyperosmolar ketoacidosis. No recent med
changes.
Past Medical History:
bladder ca
stomach ca
DM2 on insulin
CAD s/p MI
recent admit for chemo tx 6 weeks ago
impotence
MRSA
HTN
anemia
lacunar CVA
CRF
glaucoma
cognitive decline
urinary incontinence, chronic
Social History:
history of alcohol abuse in past
no drugs, no smoking
Family History:
non-contributory
Physical Exam:
VS: temp: 102.4 bp: 170/91 HR: 93 RR: 20 99% rm air
general: somnolent but AAOx3
HEENT: MMM, no JVD, no Virchow's node, no nuchal rigidity
lung: rales at bases
heart: RR, S1 and S2, no murmurs, rubs or gallops
abd: +b/s, soft, non-tender, non-distended
extr: no cyanosis, clubbing or edema, 2+pulses b/l
neuro: CNII-XII intact, [**6-1**] stregnth in upper extremities, DTR's
intact
Pertinent Results:
Admit labs:
[**2158-1-29**] 12:12AM WBC-9.5 RBC-2.85* HGB-8.5* HCT-27.3* MCV-96
MCH-29.8 MCHC-31.1 RDW-14.6
[**2158-1-29**] 12:12AM NEUTS-89.3* BANDS-0 LYMPHS-7.9* MONOS-2.5
EOS-0.2 BASOS-0.2
[**2158-1-29**] 12:12AM PLT COUNT-242
[**2158-1-29**] 12:12AM PT-15.2* PTT-27.5 INR(PT)-1.5
[**2158-1-29**] 12:12AM GLUCOSE-670* UREA N-53* CREAT-2.4* SODIUM-138
POTASSIUM-4.1 CHLORIDE-96 TOTAL CO2-22 ANION GAP-24
[**2158-1-29**] 12:12AM CALCIUM-9.6 PHOSPHATE-3.3 MAGNESIUM-1.7
[**2158-1-29**] 12:12AM ALT(SGPT)-25 AST(SGOT)-28 CK(CPK)-171 ALK
PHOS-87 TOT BILI-0.8
Cardiac enzymes:
[**2158-1-29**] 12:12AM CK-MB-3 cTropnT-0.05*
Toxicology:
[**2158-1-29**] 11:07AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2158-1-29**] 08:00AM BLOOD Acetmnp-NEG
[**2158-1-29**] 03:20AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
Urinalysis:
[**2158-1-29**] 12:55AM URINE Blood-LGE Nitrite-NEG Protein-TR
Glucose-1000 Ketone-15 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-SM
[**2158-1-29**] 12:55AM URINE RBC-1 WBC->50 CLUMPS SEEN Bacteri-FEW
Yeast-NONE Epi-0-2
[**2158-1-29**] chest x-ray:
UPRIGHT AP PORTABLE CHEST: The heart size is probably normal
given the AP
technique. Bilateral patchy opacities with some nodular features
are more
pronounced in the lower lobes. The left upper lobe is relatively
clear. No
pleural effusion or pneumothorax is detected. The visualized
osseous
structures are unremarkable.
IMPRESSION: Bilateral pulmonary opacities suggesting pneumonia.
Superimposed
pulmonary nodules cannot be excluded. Follow-up examination
after treatment
is recommended to document resolution.
[**2158-1-29**] head CT:
FINDINGS: There is concordant prominence of the ventricles and
sulci,
consistent with generalized volume loss. Hypoattenuation in the
periventricular white matter most likely represents chronic
microvascular
infarction. No intracranial hemorrhage, abnormal extraaxial
fluid collection,
mass effect or midline shift is detected. The basal cisterns are
patent.
Dense atherosclerotic calcifications are noted in the internal
carotid
arteries. The visualized paranasal sinuses and mastoid air cells
are clear.
IMPRESSION: No intracranial hemorrhage or mass effect.
Brief Hospital Course:
73 year-old man with bladder cancer, stomach cancer admitted now
with nonketotic hyperosmolar state (ketones in UA felt likely
secondary to starvation/ketosis-no anion gap on Chem 7 and no
acidosis on ABG), pneumonia, UTI. Following issues addressed on
this admission:
(Patient admitted to ICU initially on [**1-29**] and transferred to
floor on [**1-30**].)
ICU course:
Concerning nonketotic hyperosmolar state: Patient initially
given insulin drip in ER, IVF for glucose in 600's, possible
DKA. Patient was not acidotic, did not have gap, but ketones on
UA, felt secondary to starvation ketosis. ON transfer to the
MICU, sugars trended down and ISS started, insulin drip d/ced.
IVF were continued-D51/2NS. On morning of transfer to floor,
patient started on NPH dosing along with ISS. TID lytes were
followed and magnesium, potassium and phosphorus were repleted
PRN. Patient never developed gap or acidosis. Fingersticks
running high 100's to low 200's on transfer.
Concerning his pneumonia/UTI: Patient febrile with elevated
white count, infiltrates on chest x-ray and urine with
pansensitive Klebsiella. Maintained on Levaquin. [**1-31**] Blood
cultures from [**2158-1-29**] with pansensitive Klebsiella. Feel that
Levaquin adequate coverage given likely CAP and rapid clinical
improvement, although did have chemo treatment as inpatient
weeks ago.
Concerning his MS change: Patient with waxing and [**Doctor Last Name 688**] mental
status, sometimes disoriented. Alert but lethargic on transfer.
Attributed to hyperosmolar state and infection and possible
sundowning. Negative head CT, negative metabolic/toxic work-up.
LP not felt to be indicated at this time given other
explanations.
Continue treatment of hyperosmolar state and pneumonia/UTI.
Concerning UTI: Cover with Levaquin. Urine culture pending.
Concerning anemia: Patient admitted with Crit of 27 (appears to
be baseline). Etiology thought to be related to hematuria
secondary to hematoma. Then had drop to 20. Felt most likely due
to hydration/dilution, but given history of CAD decision made to
transfuse 1 unit on [**1-30**] and then additional 2 Units on [**2158-2-2**].
No evidence of acute bleeding.
Bladder ca/stomach ca: Stable. Continue outpt management as per
JP VA.
Concerning hypertension: Elevated here from 150's to 180's
initially. Metoprolol titrated up to 50 TID. Additionally,
captopril 25 TID added with better control, however d/c'ed when
outpt meds known. Discharged on outpt dose of Metop Tartrate 50
mg daily.
Concerning ARF: Patient admitted with creatinine in 2's
(baseline 1.5-1.8). Down to 1.4 with hydration. Likely
component of CRI secondary to hypertension/DM. Would encourage
adequate po hydration.
Medications on Admission:
metoprolol 50 [**Hospital1 **]
dorzolamide/timolol
NPH
MV
omeprazole 20
tamsulosin .4
travoprost .004%
Discharge Medications:
1. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 9 days: Please take until all pills are gone. .
Disp:*9 Tablet(s)* Refills:*0*
2. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*2*
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
4. Tamsulosin HCl 0.4 mg Capsule, Sust. Release 24HR Sig: One
(1) Capsule, Sust. Release 24HR PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24HR(s)* Refills:*2*
5. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
6. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
7. Insulin 70/30 70-30 unit/mL Suspension Sig: One (1)
Subcutaneous twice a day: INSULIN NPH HUMAN 100 U/ML INJ NOVOLIN
N INJECT 6 UNITS UNDER THE SKIN AT BEDTIME AND INJECT 24 UNITS
EVERY MORNING
(take as directed by your primary care physician).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 537**]- [**Location (un) 538**]
Discharge Diagnosis:
Nonketotic Hyperosmolar State
Pneumonia
Urinary Tract Infection
Anemia
Discharge Condition:
good
Discharge Instructions:
Please call your primary care physician or return to the
hospital if you experience worsening confusion, buring on
urination, or any other symptoms.
Followup Instructions:
Please follow-up with your primary care physician [**Last Name (NamePattern4) **] [**1-29**] weeks.
Name: [**Known lastname 10913**],[**Known firstname **] Unit No: [**Numeric Identifier 10914**]
Admission Date: [**2158-1-29**] Discharge Date: [**2158-2-3**]
Date of Birth: [**2083-9-9**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1852**]
Addendum:
Pt was started on Norvasc 5 mg daily for better blood pressure
control. ACEI was initially added however d/c'ed secondary to
increase in creatinine.
Given his CAD and CVA history, consider placing him on a statin.
It is unclear at this point why he had a CVA. Etiology may be
PAfib in which case he would benefit from anti-coagulation. A
neurology follow-up for workup of his recent CVA may be
beneficial. If he had a lacunar infarct he would benefit from
plavix or aggrenox.
Discharge Medications:
1. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 9 days: Please take until all pills are gone. .
Disp:*9 Tablet(s)* Refills:*0*
2. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*2*
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
4. Tamsulosin HCl 0.4 mg Capsule, Sust. Release 24HR Sig: One
(1) Capsule, Sust. Release 24HR PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24HR(s)* Refills:*2*
5. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
6. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
7. Epoetin Alfa 20,000 unit/mL Solution Sig: One (1) Injection
once a week.
8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
9. Norvasc 5 mg Tablet Sig: One (1) Tablet PO once a day.
10. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO daily ().
11. Insulin NPH Human Recomb 100 unit/mL Syringe Sig: One (1)
Subcutaneous twice a day: INSULIN NPH HUMAN 100 U/ML INJ NOVOLIN
N INJECT 6 UNITS UNDER THE SKIN AT BEDTIME AND INJECT 24 UNITS
EVERY MORNING .
12. Travoprost 0.004 % Drops Sig: One (1) drop each eye
Ophthalmic once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 474**]- [**Location (un) 164**]
[**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern4) 692**] MD [**MD Number(2) 693**]
Completed by:[**2158-2-3**]
|
[
"995.92",
"250.20",
"V10.04",
"041.3",
"038.49",
"437.0",
"V58.67",
"403.91",
"486",
"599.0",
"285.9",
"V10.51",
"290.40"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
10600, 10827
|
4009, 6736
|
334, 340
|
8071, 8077
|
1733, 2306
|
8274, 9239
|
1297, 1315
|
9262, 10577
|
7977, 8050
|
6762, 6867
|
8101, 8251
|
1330, 1714
|
2323, 3413
|
274, 296
|
368, 1002
|
3422, 3986
|
1024, 1210
|
1226, 1281
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,790
| 134,565
|
6668
|
Discharge summary
|
report
|
Admission Date: [**2195-10-17**] Discharge Date: [**2195-10-22**]
Date of Birth: [**2120-12-18**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Pericardiocentesis
History of Present Illness:
74 year-old with recently diagnosed adenocarcinoma of
undetermined primary who presented to the emergency department
today with chest pain. The patient had 3/10 chest pain and
abdominal pain for several hours prior to presentation. The
patient reports that his CP is associated with stretching and
positional changes. It is sharp and not assocaited with N, V or
SOB. His abdominal pain is gasy and periumbilical - currenlty
absent.
.
In the ED, EKG was STD in V3- V5 compared to prior. A CT was
done that showed a large pericardial effusion with signs of
tamponade. Cardiology was called and an ECHO was done which
showed a new localized pericardial effusion with RA collapse and
a small RV. A pulsus on exam was 12. The pt was hemodynamically
stable and was given Metoprolol 5mg iv, ASpirin and SLNTG. He
received 2L NS in the ED. The CT also showed worsening
metastatic disease.
.
On review of symptoms, he denies any prior history of deep
venous thrombosis, pulmonary embolism, bleeding at the time of
surgery, myalgias, black stools or red stools. He denies recent
fevers, chills or rigors. All of the other review of systems
were negative. He has been just recently starting to do physical
therapy and ambulating after his recent stroke and ambutation.
.
Cardiac review of systems is notable for absence of paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope
or presyncope.
Past Medical History:
- CVA on [**7-/2195**] of R MCA territory on Coumadin then transitioned
to Lovenox
- [**8-/2195**] presented with cold RLE, underwent angioplasty which
failed, and then underwent superficial femoral artery to
dorsalis pedis bypass graft with non reversed saphenous vein,
venous angioscopy with valve lysis, venovenostomy on [**2195-8-21**].
Which then failed and then underwent below the knee amputation.
- Mediastinal lymphadenopathy confirmed to be metastatic
adenocarcinoma by biopsy, unclear primary.
- Prostate cancer status post XRT in the [**2178**]
- Hypertension
- Hypercholesterolemia
- Cholecystitis s/p cholecystectomy
- Colon polyps
- Varicose veins
- Gallstones
- h/o kidney stones
- chronic back pain
- ? recent dc on RISS, diabetes??
- PVD
Social History:
Fifty-pack-year smoker, quit this year. Police officer for 31
years. Denies alcohol or exposure history.
Family History:
He has a sister with kidney problems. Says that his brother and
sisters had cancer but that he is not sure of what type, that
there is a lot of diabetes in his family. His father died of
prostate cancer at the age of 65 and his mother died of some
sort of abdominal cancer; however, they are not sure exactly
what type of cancer this was. Sister [**Name (NI) 1022**] involved in recent
care. Currently living in [**Hospital1 **].
Physical Exam:
BP125/65, HR 84 , RR 20, O298 % on2L, pulsus paradoxus of 12
Gen: NAD. Oriented x3. Mood, affect appropriate. Very sad and
depressed about new diagnosis
HEENT: Sclera anicteric. PERRL, Conjunctiva were pink, no pallor
or cyanosis of the oral mucosa.
Neck: Supple with JVP of 12 cm.
CV: PMI located in 5th intercostal space, midclavicular line.
Distant heart sounds.
Chest: Resp were unlabored, no accessory muscle use. No wheeze.
Mild crackles at bases. Bronchial breath sounds over RUL.
Abd: Soft, NTND, No HSM or tenderness. No abdominial bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: s/p right BKA
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Pertinent Results:
.
EKG demonstrated Sr, HR 80, normal axis, normal intervals, STD
in V3-V4, TWI in V2-V4, changed compared with prior dated
[**2195-8-31**]
.
CT chest/abdomen:
1. Large right-sided pericardial effusion with moderate
compression of the right ventricle.
2. Worsened metastatic disease including enlargement of
subclavicular, mediastinal, right hilar lymph nodes and
enlargement of multiple pulmonary nodules including spiculated
lesion within the right lung apex.
3. New small right greater than left pleural effusions.
4. Multiple low dense liver lesions, too small to characterize.
Recommend dedicated liver evaluation with either CT or MRI.
5. Multiple hypodense lesions within the kidneys bilaterally,
incompletely characterized. Recommend followup ultrasound
particularly regarding the left mid pole 2-cm cystic lesion.
.
2D-[**Year (4 digits) **] performed on [**2195-10-17**] demonstrated: Large
pericardial effusion. Effusion is loculated. Stranding is
visualized within the pericardial space c/w organization.
Sustained RA diastolic collapse, c/w low filling pressures or
early tamponade. RV diastolic collapse, c/w impaired
fillling/tamponade physiology.
CONCLUSIONS: The right ventricular cavity is unusually small.
There is a large pericardial effusion. The effusion appears
loculated and is 4.6 cm anterior to the right atrium and right
ventricle. Stranding is visualized within the pericardial space
c/w Organization. There is sustained right atrial collapse,
consistent with low filling pressures or early tamponade. There
is right ventricular diastolic collapse, consistent with
impaired fillling/tamponade physiology.
.
[**2195-10-17**] 01:10AM GLUCOSE-110* UREA N-23* CREAT-0.9 SODIUM-138
POTASSIUM-4.2 CHLORIDE-103 TOTAL CO2-26 ANION GAP-13
[**2195-10-17**] 01:10AM WBC-9.9 RBC-3.24* HGB-8.9* HCT-27.9* MCV-86
MCH-27.4 MCHC-31.7 RDW-18.0*
Brief Hospital Course:
Pericardial effusion: Pericardial effusion is most likely
secondary to malignancy given his history of adenocarcinoma and
also his subclinical presentation. He had a pericardiocentesis
with drainage of 400cc of bloody fluid. Following
pericardiocentesis, he was found to have a pulsus of <10 (20
prior to procedure) and improved cardiac output to 5 (from 3.8).
He remained hemodynamically stable and chest pain free. His
lovenox was initially held during the first day of admission,
however a repeat echo demonstrated resolution of pericardial
effusion and thus his lovenox was restarted. His repeat
[**Month/Day/Year 461**] showed the resolution of tamponade physiology and
a very small pericardial effusion. Cytology from his
pericardial fluid is pending. He is discharged with an
appointment for follow up [**Month/Day/Year 461**] in 1 week.
.
Metastatic adenocarcinoma: Patient has previously undergone
extensive work-up with FNA by Dr. [**Last Name (STitle) **] that showed a
metastatic carcinoma of unknown primary. The pathology from this
lesion was positive for cytokeratin but negative for PSA, PSAP,
and TTF1, consistent with metastatic carcinoma but not
supportive of prostatic origin. PET scan on [**2195-7-29**] showed
marked uptake within supraclavicular pretracheal and precarinal
mediastinal lymphadenopathy as well as minimal FDG uptake in the
distal esophagus. CEA and CA [**07**]-9 previously WNL in [**Month (only) **].
PSA 6.9 -> 9.2-->12 from [**Month (only) 205**] to [**Month (only) 359**]. Per consultation with
Oncology, chemotherapy deferred at this point given poor
performance status. He is being discharged with home with
hospice.
.
UTI: He was found to have a UTI during this hospitalization.
He was discharged with a 7 day course of ciprofloxacin.
Medications on Admission:
Lisinopril 10 mg PO DAILY
Pantoprazole 40 mg PO Q24H
Tamsulosin 0.4 mg Q24 hr PO HS
Ezetimibe 10 mg PO DAILY
Hydrochlorothiazide 25 mg PO DAILY
Amlodipine 5 mg PO DAILY
Aspirin 81 mg PO DAILY
Atorvastatin 10 mg PO DAILY
Metoprolol Tartrate 25 mg PO BID
Lovenox
Discharge Medications:
1. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
3. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
4. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
6. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain.
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Avodart 0.5 mg Capsule Sig: One (1) Capsule PO once a day.
9. Miralax 17 gram (100 %) Powder in Packet Sig: One (1) PO prn
constipation.
10. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO at bedtime.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
11. walker
1 walker for home ambulatory assistance
12. Commode
1 commode for ease of evacuation prn
13. Wheelchair cushion
1 wheelchair cushion for pressure ulcer prophylaxis
14. Enoxaparin 120 mg/0.8 mL Syringe Sig: One [**Age over 90 **]y
(120) mg Subcutaneous DAILY (Daily).
Disp:*90 syringes* Refills:*2*
15. Roxanol Concentrate 20 mg/mL Solution Sig: [**5-31**] mg PO q2
hours as needed for pain.
Disp:*30 cc* Refills:*0*
16. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for anxiety.
Disp:*15 Tablet(s)* Refills:*0*
17. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 6 days.
Disp:*12 Tablet(s)* Refills:*0*
18. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
19. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
20. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Pericardial effusion with tamponade
Metastatic adenocarcinoma
Discharge Condition:
Stable
Discharge Instructions:
You were admitted with a cardiac tamponade, a collection of
fluid around your heart. You were treated with a
pericardiocentesis or draining of fluid from your heart. You
had a repeat [**Company 461**] which showed that following the
pericardiocentesis that there is no longer fluid surrounding
your heart.
.
Your Lovenox dosing was changed to 120 mg with once daily
injection.
.
You were diagnosed with a urinary tract infection. You have 6
remaining days of an antibiotic called ciprofloxacin for
treatment of this infection.
.
You should call Dr.[**Name (NI) 25445**] office at [**Telephone/Fax (1) **] if you
are experiencing shortness of breath, chest pain, or worsening
pain that you are unable to manage at home.
.
You are being discharged with prescriptions for Roxanol
(morphine) and Ativan which can be used for emergency pain and
anxiety relief as needed at home.
Followup Instructions:
We have scheduled the following appointments for you:
.
1. You have an appointment scheduled with Dr. [**Last Name (STitle) 21136**]
tomorrow. [**Telephone/Fax (1) **].
.
2. Your repeat [**Telephone/Fax (1) 461**] is scheduled for next Tues at 3 pm
in the [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 23**] Center Cardiac Services [**Location (un) 436**].
Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 128**] Date/Time:[**2195-10-27**]
3:00
.
3. You should follow-up with Dr. [**Last Name (STitle) **] in the Division of
Oncology as previously scheduled on [**11-12**] at 11:30 a.m.
Please call [**0-0-**] if you need to reschedule.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
Completed by:[**2195-10-25**]
|
[
"285.22",
"423.3",
"401.9",
"V49.75",
"199.1",
"196.1",
"599.0",
"423.8",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.0",
"37.21"
] |
icd9pcs
|
[
[
[]
]
] |
9726, 9775
|
5786, 7579
|
329, 350
|
9881, 9890
|
3903, 5763
|
10816, 11642
|
2702, 3133
|
7891, 9703
|
9796, 9860
|
7605, 7868
|
9914, 10793
|
3148, 3884
|
279, 291
|
378, 1783
|
1805, 2564
|
2580, 2686
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,188
| 195,501
|
12865
|
Discharge summary
|
report
|
Admission Date: [**2142-1-31**] Discharge Date: [**2142-2-7**]
Date of Birth: [**2079-6-8**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2736**]
Chief Complaint:
Chest pain and fatigue
Major Surgical or Invasive Procedure:
right heart catheterization
pleurocentesis
History of Present Illness:
This patient is a 62 year old male w/ hx of NSTEMI, HIV (CD4 <
200) not on therapy, DMII, CKD, cardiomyopathy (EF 20%), Burkitt
Lymphoma and Hodgkin's (relapsed) who presents with failure to
thrive. Pt with a week of right sided chest pain under breast
intermittently, not associated w/ exertion. Does not radiate.
Feels like a shock in quality. Lasts for minutes at a time
(usually < 5 min). No chest pain currently and has not been
present for 48hrs. No clear pleuritic component. No hemoptysis.
No calf pain.
.
Pt went to Dr. [**Last Name (STitle) 438**] with cough at the end of [**Month (only) 956**], with
suspicion of PNA (vs. pulm edema) based upon exam and CXR. Pt
was treated w/ levofloxacin for one week. The patient brought
the prescription with him, but not sure he took it every day.
Pt states that he has had "weakness" for the past week as well,
and states he has not been able to walk to the door (although
denies that the symptoms were secondary to dyspnea). The
patient states he has had loose stools for the past five days,
and last had a loose BM in the ED. The patient explains that he
sometimes gets confused with his medications, and has not taken
his lasix or other medications every day. The patient sleeps
with 1-2 pillows at night, and has no trouble sleeping flat
without pillows. The patient denies PND. The patient still
reports a cough periodically. Pt has had a poor appetite in the
past week.
.
Hx of CHF with LVEF < 20% on last ECHO in [**2139**]. No CAD he knows
of, but hx of NSTEMI in [**2139**] per OMR. No history of blood clots.
.
In the ED, initial vs were:97.8 88 118/88 18 99%.
EKG: 90, sinus, T wave inversions in V2-5, st-t downsloping;
slightly more pronounced from prior.
CXR demonstrated moderate right pleural effusion increased
compared to prior, likely with subpulmonic component with
consolidation at right lung base, pulmonary congestion.
Labs demonstrated troponin negative x1, BNP (7300) elevated from
prior (5000 in [**8-/2140**]), hx range (3K-7K). Lactate 2.1. Cr 1.8
(b/l 1.3-1.9). Hct 33.8 (from b/l 32). INR 1.5. LFTs abnl (ALT
319 AST 258 AP 289).
Pt received 750mg IV levoquin and 1L IVF.
Vitals on transfer: 98 84 22 BP 98/70
Pt admitted for chest pain.
.
Review of sytems: Denies fever, chills, night sweats, headache,
vision changes, rhinorrhea, congestion, sore throat, cough,
abdominal pain, nausea, vomiting, constipation, BRBPR, melena,
hematochezia, dysuria, hematuria.
Past Medical History:
- NSTEMI [**9-/2140**] medically managed
- HIV (CD4 198 [**2142-1-17**] and VL 84,000 [**2140-12-14**])
- HIV cholangiopathy
- DM, type II, uncontrolled (most recent HA1c 9.0 on [**2142-1-17**])
- CKD
- Cardiomyopathy with EF 20% on [**2140-2-11**] likely secondary to
doxorubicin, although HIV and/or ischemia may have contributed
- Pleural effusions
- Burkitt's lymphoma ([**2134**])
- Hodgkins lymphoma (last cycle [**8-5**], stable disease)
Social History:
Originally from [**Country **]. Formerly worked at [**Hospital1 18**] in kitchen.
Lives with younger brother, [**Name (NI) 39575**]. [**Name2 (NI) **] 2 children, age 20 and
21. He quit smoking several years ago.
Family History:
Mother with gastric cancer. Father with Alzheimer's and ?cancer.
Physical Exam:
On admission:
Vitals: 98.1 120/80 77 16 98%RA
General: NAD, AOx3, pleasant
HEENT: Sclera anicteric, MM dry, poor dentition, dry lips w/
some lesions
Neck: supple, no LAD, JVP 10cm H20
Lungs: good air movement, decreased lung sounds at R lung base,
rare crackles
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, no CVA tenderness
Ext: warm, well perfused, 2+ pedal pulses, no clubbing, cyanosis
or edema, very dry skin bilaterally on feet and lower
extremities, with no clear diabetic foot ulcers appreciated, dry
skin
Neuro: CNs2-12 intact, 5- strength in lower extremities b/l,
mild decrement in sensation in feet, no pronator drift, no
asterixis
On discharge:
Tm/Tc: 98.2/98.2 HR: 81-89 BP: 96-102/60-83 RR: 20 (18-21) 02
sat: 100%
GENERAL: slowly answers questions in quiet voice, AAOx3, able to
answer basic questions, but confused as to why he is in the
hospital. No pain, NAD.
HEENT: mucous membranes moist, minimal cracking to edges of
lips, neck supple, JVP non elevated with pt. seated at 90
degrees, difficult to fully assess d/t neck dressing.
CHEST: Unlabored breathing, no accessory muscles or retractions,
no cough, lungs with bibasilar crackles.
CV: No lifts, heaves, or thrills. RRR, Normal S1, S2. No S3, S4,
murmurs, rubs, or gallops
ABD: Soft, distended, non-tender, BS normo to hyperactive x 4
quadrants. Mild tendernes with deep palpation.
EXT: WWP, legs with slight flaking to ankles, no edema.
SKIN: Skin warm, dry, intact, no pressure sores or rashes.
Bruising to left lateral right foot, below fifth toe,
non-tender.
Access: Portacath (not accessed) to left subclavian, PIVs to
right and left arms, all dressings CDI.
Pertinent Results:
On admission:
[**2142-1-31**] 03:33PM BLOOD WBC-6.6 RBC-3.52* Hgb-11.4* Hct-33.8*
MCV-96 MCH-32.4* MCHC-33.7 RDW-16.4* Plt Ct-197
[**2142-1-31**] 03:33PM BLOOD Neuts-41.9* Lymphs-51.5* Monos-4.4
Eos-1.0 Baso-1.1
[**2142-1-31**] 03:33PM BLOOD PT-16.3* PTT-23.7* INR(PT)-1.5*
[**2142-1-31**] 03:33PM BLOOD Glucose-109* UreaN-37* Creat-1.8* Na-133
K-4.8 Cl-102 HCO3-20* AnGap-16
[**2142-1-31**] 03:33PM BLOOD ALT-319* AST-258* AlkPhos-289*
TotBili-0.6
[**2142-1-31**] 03:33PM BLOOD CK-MB-2 proBNP-7345*
[**2142-1-31**] 03:33PM BLOOD cTropnT-<0.01
[**2142-1-31**] 03:33PM BLOOD Albumin-3.5 Calcium-9.2 Phos-4.0 Mg-2.1
[**2142-1-31**] 05:47PM BLOOD Lactate-2.1*
On discharge:
WBC 6.9
RBC 3.92*
Hgb 12.5*
Hct 36.7*
MCV 94
Plt 243
Glucose 184
Urea 57
Creatinine 2.3
Na 134
K 4.6
Cl 91*
HCO3 32
AG 16
ALT 152*
AST 121*
AP 267*
TB 0.3
[**2142-2-1**] TTE:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. There is severe global left ventricular hypokinesis.
Quantitative (3D) LVEF = 22%. The right ventricular cavity is
moderately dilated with severe global free wall hypokinesis.
There is abnormal diastolic septal motion/position consistent
with right ventricular volume overload. The aortic root is
mildly dilated at the sinus level. Mild (1+) aortic
regurgitation is seen. Mild (1+) mitral regurgitation is seen.
The tricuspid valve leaflets fail to fully coapt. Moderate to
severe [3+] tricuspid regurgitation is seen. Pulmonary pressures
are likely elevated, but cannot be estimated reliably because of
moderate to severe TR. Appearance of right ventricle suggests
that the RV stroke work index is abnormal. There is a small
pericardial effusion.
IMPRESSION: Severe global biventricular systolic dysfunction
with markedly depressed forward stroke volume. Mild aortic and
mitral regurgitation. Moderate to severe tricuspid
regurgitation.
Compared with the prior study (images reviewed) of [**2140-9-9**],
estimated cardiac output is lower. Right ventricle is larger and
RV systolic function is further depressed.
[**2142-2-1**] CATH:
COMMENTS:
1. Limited resting hemodynamics revealed severely elevated right
and
left-sided filling pressures with RVEDP 25mm Hg, mean PCWP 34mm
Hg.
Moderate pulmonary arterial hypertension with mean PA 40mmHg
secondary
to elevated left-sided pressures with a transpulmonary gradient
of
6mmHg. There was marked respiratory variability throughout
tracings.
2. Severely depressed cardiac output with cardiac index 1.21
with
arterial O2 saturation by pulse oximetry 97% on room air and PA
O2
saturation of 30%.
FINAL DIAGNOSIS:
1. Cardiogenic shock with marked elevation in right and left
heart
filling pressures and low cardiac index.
[**2142-2-1**] portable abdomen:
SINGLE FRONTAL SUPINE IMAGE OF THE ABDOMEN: The hemidiaphragms
are excluded from the field of view as well as the right lateral
aspect of the abdomen. Limited assessment of the abdomen shows
normal bowel caliber. Assessment for pneumoperitoneum is
extremely limited on this single view. There are calcified right
hemipelvic phleboliths. An electronic metallic device obscures
the proximal aspect of the left femur, possibly the patient's
mobile telephone.
[**2142-2-1**] liver/gb us:
IMPRESSION:
1. Prominent hepatic veins, right pleural effusion, ascites, and
diffuse
gallbladder thickening consistent with the patient's known
cardiomyopathy and
congestive heart failure.
2. No dilation of the biliary system is seen.
3. Tiny gallbladder polyps / adherent stones without signs of
cholecystitis.
[**2142-2-2**] pleural fluid: NEGATIVE FOR MALIGNANT CELLS. Few
macrophages.
Brief Hospital Course:
Mr. [**Known lastname **] is a 62 year old male w/ hx of NSTEMI, HIV (CD4 <
200), DMII, CKD, cardiomyopathy (EF 20%), Burkitt Lymphoma and
Hodgkin's who presents with failure to thrive and
decompensated/acute on chronic biventricular heart failure. He
underwent diuresis with lasix and metolazone and was started on
dopamine and milrinone. Pt responded and was transferred to the
floor and was dc-ed to a long-term acute rehabilitation in a
stable condition.
# Hypotension: He became hypotensive the day after admission
with repeat echocardiogram suggestive of low-output heart
failure. He was transferred to the CCU for further care after
small IVF bolus and broad spectrum antibiotics were initiated.
RHC revealed low CO and CI, and right sided failure primarily
due to elevated left sided filling pressures. He was started on
a low dose dopamine infusion and milrinone was initiated which
resulted in improvement in blood pressures, excellent urine
output 10L net negative and weight loss with improvement in
kidney function and liver enzymes c/w fluid overload as cause of
both. He was taken off dopamine and milrinone before transfer to
the floor and pressures were stable after initial hospital
course. He was started on torsemide, lisinopril and metoprolol.
Torsemide was held on discharge due to increase in creatinine
with plan to resume as an outpatient once creatinine returned to
baseline.
# Acute on chronic systolic congestive heart failure: His new
TTE showed low-output biventricular heart failure. He underwent
cardiac catheterization which demonstrated marked elevation in
right and left heart filling pressures and low cardiac index
consistent with CHF. Pt was started on dopamine, milrinone, and
diuresed with IV lasix gtt and metolazone. Was switched to
torsemide prior to discharge after pt was diuresed close to his
dry weight. He was started on metoprolol XL 25 qd and lisinopril
as well as torsemide. Pt became orthostatic day prior to
discharge with a rise in creatinine, and thus torsemide was
held. His diuretics should continue to be titrated since his
fluid balance is difficult to manage. His volume status is
difficult to assess on exam as he rarely has peripheral edema
and tends to hold extra fluid in his abdomen. His weight at
discharge is 60.2 kg.
# Chest Pain: Patient originally complained to EMS of chest pain
but on admission to floor said it resolved two days prior to
admission. He ruled out for ACS.
# Pleural Effusions/Burkitts and Hodgkin's lymphoma: Moderate
right pleural effusion with a likely subpulmonic component on
CXR from ED. DDx included parapneumonic effusion vs. CHF
effusion vs. malignancy (hx of lymphoma). He underwent
thoracentesis which showed no malignant cells and few
macrophages. However, he did have plamcytoid cells and large
atypical cells with basophilic cytoplasm and nucleoli c/w
immunoblasts. The flow cytometry was negative, however.
# Urinary tract infection: He reported dysuria and had a
positive UA. While awaiting urine culture, he was empirically
started on ciprofloxacin which was broadened given his
hypotension. Urine culture was negative and pleural effusion
showed no evidence of infection, thus abx were discontinued with
exception of flagyl.
# Diarrhea: Stool studies showed +ve c.diff so pt was started on
a 14 day course of flagyl.
# Abnormal LFTs: RUQ u/s showed congestive hepatopathy and
ascites. LFTs improved with managment of CHF as above.
# Mouth lesions: His acyclovir was continued and renally dosed.
Pt also with oral thrush; he was continued on nystatin given his
elevated liver enzymes. When his liver enzymes trend down, he
should be restarted on fluconazole.
#HIV. Pt w/ CD4 198 and VL 84K in 2/[**2141**]. Bactrim was
continued for PCP [**Name Initial (PRE) 1102**]. Flucanozole was held as above. Pt
has very limited understanding of his medical condition.
# Chronic kidney disease: Creatinine elevated to 2.5 and pt was
oliguric [**12-28**] to poor perfusion from heart failure. Improved
immensely with milrinone and low dose dopamine and lasix.
Continued to diurese on torsemide.
# Type 2 diabetes, poorly controlled, with complications: HA1c 9
most recently.
Continue glargine. Continue to hold glipizide given rising
creatinine
# Neuropathy: Gabapentin was continued but renally dosed.
# Mental status: Pt with no insight into his heart disease or
AIDS. He should have cognitive neurology follow up and
consideration of HIV dementia.
.
.
Code status: Full code
HCP: [**Name (NI) 39575**] [**Name (NI) 39576**]
Relationship: Older brother
Phone number: [**Telephone/Fax (1) 39577**]
.
Transitional
1) Continue to titrate diuretics
2) Follow up with Dr. [**Last Name (STitle) 438**]
3) Continue to treat for C diff with flagyl, course to be
determined by Dr. [**Last Name (STitle) 438**]
4) Follow up with Dr. [**Last Name (STitle) 39578**] for lymphoma
5) Follow up with Dr. [**First Name (STitle) 437**] for heart failure
6) Cognitive neurology for dementia
Medications on Admission:
ACYCLOVIR - 400 mg Tablet - 1 Tablet(s) by mouth three times a
day
FLUCONAZOLE - 200 mg Tablet - 1 Tablet(s) by mouth daily
FUROSEMIDE - 80 mg Tablet - 1 Tablet(s) by mouth twice a day
GABAPENTIN - 300 mg Capsule - 1 Capsule(s) by mouth twice a day
GLIPIZIDE - 10 mg Tablet Extended Rel 24 hr - 1 (One) Tablet(s)
by mouth daily with a 5mg tablet for total daily 15mg dose
GLIPIZIDE - 5 mg Tablet Extended Rel 24 hr - 1 (One) Tablet(s)
by
mouth once a day with a 10mg tablet for total daily 15mg dose
LEVOFLOXACIN - 500 mg Tablet - 1 Tablet(s) by mouth daily
LISINOPRIL - 2.5 mg Tablet - one Tablet(s) by mouth daily
METOPROLOL SUCCINATE [TOPROL XL] - 50 mg Tablet Extended Release
24 hr - 1 Tablet(s) by mouth daily
SULFAMETHOXAZOLE-TRIMETHOPRIM [BACTRIM] - 400 mg-80 mg Tablet -
1
Tablet(s) by mouth once a day
ASPIRIN [ENTERIC COATED ASPIRIN] - 81 mg Tablet, Delayed Release
(E.C.) - 1 Tablet(s) by mouth daily
FOOD SUPPLEMENT, LACTOSE-FREE [ENSURE] - Liquid - 1 can(s) by
mouth one to three times daily as needed for nutritional
supplement
WHITE PETROLATUM-MINERAL OIL [EUCERIN] - Cream - apply to dry
skin and feet daily
Discharge Medications:
1. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
2. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
6. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 8 days: last day [**2-15**].
7. nystatin 500,000 unit Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours).
8. insulin glargine 100 unit/mL Solution Sig: Fourteen (14)
units Subcutaneous at bedtime.
9. insulin lispro 100 unit/mL Solution Sig: 0-16 units
Subcutaneous four times a day: as per sliding scale.
10. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily):
Hold SBP < 90.
11. metoprolol succinate 25 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
12. Heparin Flush (10 units/ml) 5 mL IV PRN line flush
Indwelling Port (e.g. Portacath), heparin dependent: Flush with
10 mL Normal Saline followed by Heparin as above daily and PRN
per lumen.
13. Heparin Flush (100 units/ml) 5 mL IV PRN DE-ACCESSING port
Indwelling Port (e.g. Portacath), heparin dependent: When
de-accessing port, flush with 10 mL Normal Saline followed by
Heparin as above per lumen.
14. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN.
15. furosemide in 0.9 % NaCl 100 mg/100 mL (1 mg/mL) Solution
Sig: 40-80 mg Intravenous once a day as needed for weight gain
unresponsive to Torsemide adjustment.
16. torsemide 20 mg Tablet Sig: Two (2) Tablet PO once a day:
Please do not start until creatinine <= 1.8. .
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital for Continuing Medical care
Discharge Diagnosis:
Acute on Chronic Systolic congestive heart failure
Coronary artery disease
AIDS
Acute on Chronic Kidney injury
Diabetes mellitus, uncontrolled
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive but can be
lethargic after meals.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You had some chest pain and diarrhea and was admitted to [**Hospital1 18**]
with low blood pressure. You were put on medicines to help your
heart pump better and we changed some of your heart medicines to
remove about 16 pounds of fluid that had accumulated in your
lungs and abdomen. YOu are now slightly dehydrated so we have
stopped the diuretics briefly to help your kidneys recover. We
were in contact with all of your doctors [**Name5 (PTitle) **]. Weigh yourself
every morning, call Dr. [**First Name (STitle) 437**] if weight goes up more than 3 lbs
in 1 day or 5 pounds in 3 days.
.
We made the following changes to your medicines:
1. STOP taking furosemide, take torsemide instead to remove
extra fluid.
2. STOP taking glipizide and levofloxacin
3. Decrease metoprolol to 25 mg daily
4. START Glargine and humalog as your blood sugars have been
high.
5. START heparin SC to prevent blood clots
6. START Flagyl to treat the c-diff. You will need to take this
for a total of 14 days until [**2-15**].
Followup Instructions:
.
Department: HEMATOLOGY/ONCOLOGY
When: FRIDAY [**2142-2-9**] at 2:30 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6353**], LPN [**Telephone/Fax (1) 22**]
Building: [**Hospital6 29**] [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: FRIDAY [**2142-2-9**] at 3:00 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 22**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/BMT
When: FRIDAY [**2142-2-9**] at 3:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9574**], NP [**Telephone/Fax (1) 3241**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: INFECTIOUS DISEASE
When: TUESDAY [**2142-2-13**] at 10:15 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 456**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: CARDIAC SERVICES
When: MONDAY [**2142-2-19**] at 1 PM
With: DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"250.02",
"276.51",
"V15.81",
"511.9",
"414.01",
"428.0",
"425.4",
"403.90",
"788.1",
"584.9",
"042",
"785.51",
"416.8",
"008.45",
"585.9",
"791.9",
"200.20",
"428.23",
"412",
"355.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.91",
"37.21",
"89.64"
] |
icd9pcs
|
[
[
[]
]
] |
17166, 17245
|
9161, 13487
|
325, 370
|
17432, 17432
|
5470, 5470
|
18648, 20178
|
3567, 3635
|
15339, 17143
|
17266, 17411
|
14185, 15316
|
8116, 9138
|
17615, 18625
|
3650, 3650
|
6143, 8099
|
263, 287
|
2646, 2851
|
398, 2628
|
5485, 6129
|
17447, 17591
|
2873, 3319
|
3335, 3551
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,506
| 124,868
|
85
|
Discharge summary
|
report
|
Admission Date: [**2195-8-12**] [**Year (4 digits) **] Date: [**2195-8-15**]
Date of Birth: [**2120-5-13**] Sex: F
Service: MICU
CHIEF COMPLAINT: Sepsis.
HISTORY OF PRESENT ILLNESS: The patient is a 75 year old
female with an extremely complicated past medical history
including coronary artery bypass graft times four, atrial
ventricular valve replacement in [**1-12**], and a precipitously
difficult postoperative course. The patient has never been
weaned from her ventilator and has had multiple ventilator
associated pneumonias, particularly most recently with
pseudomonas Serratia and Klebsiella. The patient has end
stage renal disease and history of gastrointestinal bleed
secondary to gastritis and esophagitis.
Most recently, the patient was discharged from this hospital
to rehabilitation in early [**Month (only) 547**] only to come back with
fevers and ultimately grew out Methicillin resistant
Staphylococcus aureus wound infection requiring debridement
on [**2195-5-28**]. The patient returned to rehabilitation
[**2195-6-22**], where she sustained a pulmonary embolus arrest,
received Epinephrine and electrical conversion. The patient
was noted to have decreased responsiveness post code
attributed to anoxic brain injury per neurology. She was
transferred back to [**Hospital **] Rehabilitation where she
underwent vigorous physical therapy.
On [**2195-8-1**], per family she had a fever of 103 with culture
peripherally and from her dialysis catheter. Both grew out
Methicillin resistant Staphylococcus aureus. The patient was
started on a course of Vancomycin with only low grade
temperature. She became lethargic on [**2195-8-9**], and was
unable to tolerate hemodialysis due to hypotension, systolic
blood pressure in the 70s. The patient briefly improved
postdialysis on [**2195-8-10**], as did her mental status, but then
became increasingly lethargic with heart beats in the 130s,
blood pressure 80 over palpable, and was transferred over to
[**Hospital1 69**] for further management.
On arrival, the patient was noted to be extremely febrile,
hypotensive, tachypneic. The patient received an A line and
right internal jugular central line for monitoring and fluid
resuscitation. The patient's course was complicated by her
poor toleration of hemodialysis secondary to hypotension and
was started on pressors of Levophed and ultimately required
an addition of vasopressor. The patient was becoming
increasingly somnolent and had not defervesced at this time
despite the addition of multiple antibiotic therapy, Flagyl,
Ceftriaxone, Vancomycin, and Tobramycin.
CT of the abdomen and chest showed no frank abscess or fluid
collection. Flagyl was ultimately discontinued as decreased
probability of anaerobic infection. Cultures at outside
hospital showed multidrug resistant organisms including
Methicillin resistant Staphylococcus aureus. Transesophageal
echocardiogram was obtained to rule out endocarditis and it
was negative showing ejection fraction of 55%. Left Hickman
catheter with [**Hospital1 **] as probable source of infection.
Foley was placed at this time. The patient was anuric yet
10cc of purulent material was noted. The patient was now
growing gram positive cocci in pairs and clusters from two
different sites, the Hickman and/or previous PICC line. She
was increasing her pressor requirement and was hypotensive
despite two liters of fluid.
She was started on Dopamine in addition to her Levophed and
vasopressors. Throughout the day, the patient's systolic
blood pressure decreased to the 80/30. By [**2195-8-14**], she was
back on EC vent control. The patient was noted at 3:43 a.m.
on [**2195-8-15**], to have an episode of asystole. The family was
at bedside as well throughout the night. The pupils were
noted to be fixed and dilated and unresponsive. Ventilation
was discontinued and spontaneous respirations were not
observed. The patient was declared dead at 3:43 a.m. The
family declined autopsy.
DR.[**Last Name (STitle) 970**],[**First Name3 (LF) 971**] 12-888
Dictated By:[**Last Name (NamePattern1) 972**]
MEDQUIST36
D: [**2195-8-15**] 11:51
T: [**2195-8-18**] 20:47
JOB#: [**Job Number 973**]
|
[
"996.62",
"V46.1",
"038.11",
"707.0",
"V42.2",
"518.83",
"427.31",
"V45.1",
"403.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"00.14",
"33.24",
"96.6",
"39.95",
"38.93",
"38.91",
"89.68"
] |
icd9pcs
|
[
[
[]
]
] |
164, 173
|
202, 4230
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,118
| 103,211
|
38231
|
Discharge summary
|
report
|
Admission Date: [**2145-5-5**] Discharge Date: [**2145-5-10**]
Date of Birth: [**2083-8-25**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Niacin
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
asymptomatic.abnormal stress test on routine yearly physical
exam
Major Surgical or Invasive Procedure:
[**2145-5-6**]
1. Coronary artery bypass grafting x4, with left internal
mammary artery to left anterior descending coronary
artery; reversed saphenous vein single graft from the
aorta to the first diagonal coronary artery; reversed
saphenous vein single graft from the aorta to the first
obtuse marginal coronary artery; as well as reversed
saphenous vein single graft from the aorta to the distal
right coronary artery.
2. Epiaortic duplex scan.
3. Exploration of right atrial appendage to rule out or
rule in atrial septal defect.
4. Endoscopic left greater saphenous vein harvesting.
History of Present Illness:
61 yo male with HTN, dyslipidemia and diabetes recently seen
for routine physical. Referred for nuclear stress test on [**4-19**]
due to risk factors for CAD- showing medium area of moderate
stress induced ischemia in the PDA territory and diagonal
artery,
NL LV function. Pt now presents for cardiac catheterization to
further evaluate.
Past Medical History:
Hypertension
Dyslipidemia
Diabetes (type II with retinopathy)
BPH
Colon Polyps s/p polypectomy
Lung Nodule (right side- stable)
Basal cell CA
Diverticulosis
Social History:
Lives with: married with two adult children.
Occupation: Retired. Previously employed with [**Company 22957**].
Tobacco: Quit 30 years ago
ETOH: 10 beers per week
Family History:
Mother and father died of CAD in their 60's
Physical Exam:
Pulse:48 SB Resp:16 O2 sat: 99% RA
B/P Right: 117/50 Left:
Height: 5' 7" Weight: 225#'s
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x]
Neuro: Grossly intact
Pulses:
Femoral Right: cath site Left:+2
DP Right: +2 Left:+2
PT [**Name (NI) 167**]: +2 Left:+2
Radial Right: +2 Left:+2
Carotid Bruit Right: None Left:None- s/p CEA
Pertinent Results:
[**2145-5-8**] 06:02AM BLOOD WBC-14.6* RBC-3.12* Hgb-9.2* Hct-27.4*
MCV-88 MCH-29.7 MCHC-33.7 RDW-13.5 Plt Ct-205
[**2145-5-6**] 01:46PM BLOOD PT-13.5* PTT-21.9* INR(PT)-1.2*
[**2145-5-8**] 06:02AM BLOOD Glucose-121* UreaN-23* Creat-0.9 Na-137
K-4.1 Cl-102 HCO3-26 AnGap-13
Pre-CPB:
No mass/thrombus is seen in the left atrium or left atrial
appendage.
No inter-atrial flow could be demonstrated with doppler or
bubble studies.
Overall left ventricular systolic function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
There are simple atheroma in the descending thoracic aorta.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic regurgitation. The mitral
valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen.
There is no pericardial effusion.
An epi-aortic scan showed no significant disease at the aortic
cannulation site.
Post-CPB:
The patient is AV-Paced, on low dose phenlephrine.
Preserved biventricular systolic fxn. No MR, no AI.
Aorta intact.
No interatrial flow.
Brief Hospital Course:
The patient was admitted to the hospital and brought to the
operating room on [**2145-5-6**] where the patient underwent coronary
artery bypass x 4. Overall the patient tolerated the procedure
well and post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. Cefazolin was
used for surgical antibiotic prophylaxis. POD 1 found the
patient extubated, alert and oriented and breathing comfortably.
The patient was neurologically intact and hemodynamically
stable on no inotropic or vasopressor support. Beta blocker was
initiated and the patient was gently diuresed toward the
preoperative weight. [**Last Name (un) **] was consulted for assistance with
blood glucose management. The patient was transferred to the
telemetry floor for further recovery. Chest tubes and pacing
wires were discontinued without complication. The patient was
evaluated by the physical therapy service for assistance with
strength and mobility. By the time of discharge on POD 4 the
patient was ambulating freely, the wound was healing and pain
was controlled with oral analgesics. The patient was discharged
to the [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Rehab in good condition with appropriate
follow up instructions.
Medications on Admission:
atenolol 37.5mg
HCTZ 25mg
lisinopril 10mg
metformin 1000mg [**Hospital1 **]
Actos 15mg daily
Simvastatin 80mg
ASA 325mg
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
7. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for PAIN.
9. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
10. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
11. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
12. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
13. Repaglinide 2 mg Tablet Sig: One (1) Tablet PO three times a
day: with meals.
14. Insulin Regular Human 100 unit/mL (3 mL) Insulin Pen Sig:
One (1) Subcutaneous four times a day: dose prn for
BG>200mg/dL, per sliding scale.
15. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 1
weeks.
16. Furosemide 20 mg Tablet Sig: Two (2) Tablet PO once a day
for 1 weeks.
17. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
18. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Doctor Last Name **] Nursing & Rehabilitation Center - [**Location (un) **]
Discharge Diagnosis:
coronary artery disease, s/p CABG [**2145-5-6**]
PMH:
Hypertension
Dyslipidemia
Diabetes (type II with retinopathy)
BPH
Colon Polyps s/p polypectomy
Lung Nodule (right side- stable)
Basal cell CA
Diverticulosis
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
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**]
**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:
Please call to schedule appointments
Surgeon Dr. [**Last Name (STitle) 914**] in 4 weeks [**Telephone/Fax (1) 170**]
Primary Care Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] I. [**Telephone/Fax (1) 17794**] in [**12-12**] weeks
Cardiologist Dr. [**First Name (STitle) **],[**First Name3 (LF) 2922**] S. [**Telephone/Fax (2) 2258**]in 1-2 weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2145-5-10**]
|
[
"272.4",
"458.29",
"794.39",
"788.5",
"414.2",
"562.10",
"V10.83",
"362.01",
"401.9",
"V12.72",
"285.9",
"250.50",
"414.01",
"518.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"88.56",
"39.61",
"36.13",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
6671, 6776
|
3565, 4847
|
338, 960
|
7066, 7222
|
2457, 3542
|
7924, 8473
|
1740, 1786
|
5018, 6648
|
6797, 7045
|
4873, 4995
|
7246, 7901
|
1801, 2438
|
232, 300
|
988, 1328
|
1350, 1543
|
1559, 1724
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,745
| 184,515
|
16812
|
Discharge summary
|
report
|
Admission Date: [**2105-12-22**] Discharge Date: [**2106-1-12**]
Date of Birth: [**2063-4-27**] Sex: M
Service: TRAUMA
HISTORY OF PRESENT ILLNESS: Patient is a 42-year-old white
male who was struck by a car with significant front end
damage. He was reported to have been thrown approximately 20
feet and was found face down at the scene. It was unknown
whether the patient had loss of consciousness, but he states
he does not remember the accident. He was hemodynamically
stable in the field and transported to the [**Hospital1 **] Emergency Department for further evaluation.
PAST MEDICAL HISTORY: None.
PAST SURGICAL HISTORY: Closure of a left flank wound and
left femur fracture repair.
MEDICATIONS: None.
ALLERGIES: Penicillin.
PHYSICAL EXAMINATION: On admission temperature was 96.5 F.
He was hemodynamically stable with a heart rate of 66 and a
blood pressure of 130/palp. Respirations 20. Saturating at
98% on room air. He was alert in no acute distress with a
GCS of 15. He had a stellate laceration on his scalp.
Trachea is midline. Lungs were clear with equal breath
sounds bilaterally. Heart was regular. Abdomen was
distended with moderate diffuse tenderness, no guarding.
Rectal was heme positive with normal tone. Extremities
showed bilateral lower extremity tib fib deformities with
road rash on the right hip and thigh. He had palpable pulses
distally bilaterally. His pelvis was nontender and stable.
The back showed no deformities. The neck did have midline
tenderness. Neuro exam: He was alert. Pupils are equal,
round and reactive to light. Extraocular movements were
intact. He had [**5-17**] motor strength of the bilateral upper and
lower extremities. Although he was complaining of tingling
of both hands, there was no objective sensory deficits.
LABORATORY DATA ON ADMISSION: Significant for a hematocrit
of 37.8. N normal chemistries and normal coags. Negative
tox screen.
Chest x-ray and pelvis films were without abnormality.
CT Scan of the head showed intracranial bleed, shift or mass
effect.
CT Scan of the C spine showed several significant fractures.
There was an lateral occipital subluxation of approximately 3
to 4 mm. There is a hangman's site fracture of
C2 and C3. There was massive fracture distraction injury at
C6 and C7 with approximately 30 degree rotation of C6 on C7.
CT Scan of the chest showed bilateral apical contusions and
bilateral rib fractures.
CT Scan of the abdomen showed fluid in the left pericolic
gutter as well as mesenteric stranding and a small amount of
pelvis fluid.
HOSPITAL COURSE: The patient was taken from the Trauma
Resuscitation Bay to the Operating Room where he underwent an
exploratory laparotomy which revealed mesenteric hematoma and
omental bleeding. This is repaired and he is taken to the
Surgical ICU for further resuscitation. Of note, the patient
was performed on a hard backboard, although just prior to
initiation of anesthesia, the demonstrated weakness in his
lower extremities bilaterally.
Once he reached the Trauma ICU, resuscitation continued. He
went to the Operating Room on [**12-23**] the day following his
admission for repair of his bilateral tib fib fractures and a
right lateral compartment fasciotomy for elevated compartment
pressures. He also underwent on [**12-23**] an anterior discectomy
and partial corpectomy at C6-C7 with fusion and
instrumentation. He returned to the Operating room on [**12-25**]
for posterior C6-C7 laminectomy with grafting. Of note, on
[**12-23**] he also had placement of a halo for immobilization of
his C2 hangman's fracture.
The rest of the hospital course will be described by system.
1. NEURO: The patient underwent early stabilization both
anteriorly and posteriorly of his cervical spine fractures.
As noted, he had a halo placed for his C2 fracture. The halo
should remain for a two month time period. His initial CT
Scan of his head showed no intraparenchymal or intracranial
process. Four vessel carotid and vertebral angiogram on
[**12-22**] showed no abnormality. His current neurovascular
status has been stable since after his initial exploratory
laparotomy for bleeding. He has flexor strength of his upper
extremities, but no movement of his lower extremities
bilaterally. The extensor strength in the upper extremities
has improved somewhat since his initial operation.
Of note, he also had a question of L4 fracture on his initial
CT Scan of his spine. This was felt to be degenerative. He
also has spinous processes fractures of T6 and 7 which were
not felt to be significant. [**Known firstname **] has received sedation on
an as needed basis with Morphine and Ativan, however he is
alert, able to answer questions and express his needs without
difficulty at this time. He was maintained on Solu-Medrol
intermittent intravenous dosing for the first three days of
his hospital stay.
2. CARDIOVASCULAR: He has no history of cardiac disease.
Had no evidence of cardiovascular injury with his trauma and
has had no active issues with his heart throughout his ICU
stay.
3. RESPIRATORY: Has been ventilator dependent since his
arrival. He was initially intubated with an oral tracheal
tube. This is changed over to a percutaneous tracheostomy on
[**2106-1-7**] with an #8 [**Doctor Last Name 4726**]-Tex trach. This was done at the
bedside without complications. He also has developed a right
lower lobe pneumonia which has cleared on recent x-rays.
Sputum cultures were significant only for Methicillin
sensitive staphylococcus aureus, however there is a high
suspicion of gram negative co-infection and he has been on
appropriate antibiotic coverage. This will be described in
the section of ID.
He has required significant respiratory support thought to be
secondary to not having an intercostal contribution to
inspiratory phase. We have been able to wean his pressure
support and his PEEP over the last few days. His current
ventilator settings are pressure support ventilation of 10
with a PEEP of 13, 50% fio2. His tidal volumes are
approximately 650 by a rate of 18. We will continue to wean
the PEEP over the next couple of days in anticipation of his
transfer to [**Last Name (un) 40599**].
3. GASTROINTESTINAL: After undergoing the initial
exploratory laparotomy for mesenteric bleeding, we had
maintained [**Known firstname **] initially on TPN and then on tube feeds. He
has not tolerated gastric tube feeds and has had a
postpyloric placed and replaced a couple of times. He
tolerate postpyloric tube feeds without difficulty. Current
formula is Peptamen with a goal of 110 cc per hour.
For a bowel regimen related to his spinal cord injury, he is
on Reglan 10 mg IV q. six and Dulcolax 10 p.r. q.d. with good
effect. When these medications are stopped, he does have
trouble with gastric and intestinal ability.
4. GENITOURINARY: [**Known firstname **] was initially maintained with a
Foley which has been changed over to q. six to eight straight
catheter. He has had no evidence of urinary tract infection
throughout his hospital stay and has not had any spontaneous
voiding since the Foley was removed.
5. HEMATOLOGY: After his initial resuscitation, [**Known firstname **]
hematocrit has been in the upper 20 range without need for
transfusion in the last several weeks. For DVT prophylaxis,
he was initially maintained on pneumatic boots, however a
temporary IVC filter was placed on [**12-28**] and then removed on
[**1-8**]. He was initially not thought to be a candidate for
subcutaneous heparin or Lovenox due to the question of an
epidural hematoma along his cervical spinal cord, however in
consultation with the Ortho Spine Service, he was started on
subcutaneous heparin the week of [**1-4**] and then changed over
to Lovenox 30 mg subcutaneous q. 12 hours on [**1-8**]. He has
had bilateral lower extremity duplex studies on [**11-12**]
and [**1-5**] and they were all negative for deep venous
thrombosis.
6. INFECTIOUS DISEASE: Through his hospital course, [**Known firstname **]
has had sputum cultures that grew Methicillin sensitive
staphylococcus aureus most recently on [**1-5**]. He has had two
culture since that time that were negative. For this he has
received Vancomycin, several courses initially
peri-procedure. From [**12-22**] to [**12-24**] he received Vancomycin
and Gentamycin as prophylaxis. After his second operation,
he also received Vancomycin for another 48 hours. He then
received Vancomycin from [**12-31**] to [**1-4**] for Methicillin
sensitive staphylococcus aureus and then was resumed on [**1-8**]
after a fever spike.
He had a blood culture that was positive for coag negative
staphylococcus on [**1-8**] as well, two out of four bottles.
This is also being treated by the Vancomycin. He received
Levofloxacin from [**12-31**] to [**1-8**] which was then changed to
Cipro on [**1-8**] for empiric gram negative coverage for
presumed gram negative pneumonia. He was also resumed on
Gentamycin for the same empiric gram negative coverage on
[**1-8**]. The Vancomycin dosing was changed over to q. day
dosing on [**1-10**] and he will be due for a level on his dose on
the evening of [**1-12**].
Our plan is to continue Vancomycin, Gentamycin and
Ciprofloxacin until his white blood cell count normalized.
White count today was down from 17 to 14.
7. ENDOCRINE: [**Known firstname **] has been maintained on sliding scale
regular insulin. While he was on the Solu-Medrol drip, he
did require more coverage than he has recently.
8. TUBES, LINES AND DRAINS: [**Known firstname **] currently has peripheral
IVs, PICC placed in his left antecubital fossa on [**1-11**], post
pyloric feeding tube confirmed on [**1-11**], tracheostomy placed
on [**1-7**] with a #8 [**Doctor Last Name 4726**]-Tex and a condom catheter with
intermittent bladder catheterizations.
9. PROPHYLAXIS: [**Known firstname **] currently receiving tube feeds via
postpyloric tube. He has pneumo-boots on bilateral lower
extremities and Lovenox 30 mg subcutaneous q. 12.
DISPOSITION: It is anticipated that Mr. [**Known lastname 28181**] will be
discharged to [**Hospital 40599**] Rehabilitation Center on [**1-12**].
DISCHARGE MEDICATIONS:
1. Vancomycin the dose has just changed to 1.5 grams IV q.
12 hours. He should have levels checked on [**1-12**].
2. Gentamycin 600 mg IV q. 24 hours. He is due for a trough
for his dose on the evening of [**1-12**].
3. Ciprofloxacin 400 mg IV q. 12.
4. Sertraline 50 mg per NG tube q.d.
5. Epogen Alpha 40,000 units subcutaneous q. week.
6. Lovenox 30 mg subcutaneous q. 12 hours.
7. Dulcolax 10 mg p.r. q.d.
8. Reglan 10 mg IV q. six hours.
9. Folate 1 mg per NG tube q.d.
10. Iron Sulfate 325 mg per NG tube q.d.
11. Ativan 0.5 to 1 mg IV q. four hours p.r.n.
12. Morphine Sulfate 4 to 6 mg IV q. one hour p.r.n.
13. Tylenol p.r.n.
14. He also receive Albuterol and Atrovent MDI per
Respiratory Therapy.
DIET: Peptamen with a goal of 115 cc per hour via
postpyloric feeding tube.
TREATMENTS: Please see the page #2 and page #3 reports from
Occupational Therapy, Physical Therapy and Nursing for more
details.
FOLLOW UP: Dr. [**Last Name (STitle) **] is the attending trauma surgeon.
His office phone # [**Telephone/Fax (1) 1864**]. He can follow up on a
p.r.n. basis. Dr. [**Last Name (STitle) 47443**] [**Name (STitle) 1022**] his orthopedic and sign
attending, his office # [**Telephone/Fax (1) 4301**]. Please contact his
office for follow up information.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 11889**]
Dictated By:[**Last Name (NamePattern1) 22884**]
MEDQUIST36
D: [**2106-1-11**] 12:11
T: [**2106-1-11**] 13:53
JOB#: [**Job Number 47444**]
|
[
"344.03",
"868.03",
"806.05",
"823.22",
"998.83",
"863.89",
"482.41",
"806.00",
"860.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"83.14",
"83.65",
"81.02",
"31.1",
"80.51",
"79.36",
"54.64",
"54.11",
"81.03",
"99.15",
"86.22",
"38.7"
] |
icd9pcs
|
[
[
[]
]
] |
10255, 11183
|
2614, 10232
|
657, 766
|
11195, 11816
|
789, 1840
|
169, 603
|
1855, 2596
|
626, 633
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,858
| 176,250
|
14916
|
Discharge summary
|
report
|
Admission Date: [**2111-4-30**] Discharge Date: [**2111-5-5**]
Date of Birth: [**2074-6-6**] Sex: F
Service: SURGERY
Allergies:
Lisinopril / Entocort EC
Attending:[**First Name3 (LF) 1390**]
Chief Complaint:
Trauma: pedestrian struck by car
Major Surgical or Invasive Procedure:
[**2111-5-1**]: bilateral ORIF tib/fib fx
History of Present Illness:
Patient is a 36 y.o. female s/p pedestrian struck with positive
LOC at the scene and transient hypotension to the 60s. She was
transported to [**Hospital1 18**] for further management. On arrival to ED
she was neurologically intact and complained of pain to her
right shoulder, left knee, and left upper quadrant of her
abdomen. A head CT showed traumatic SAH and neurosurgery
consulted for further management. No nausea or vomiting, denies
weakness or paresthesia
Past Medical History:
PMH:
HTN, GERD, right breast cancer, Crohn's disease, endometriosis,
iron deficiency anemia, depression, chronic pain & generalized
fibromyalgia-like aching
PSH:
Exploratory laparoscopy, laparoscopic appendectomy [**2107**] Dr. [**First Name (STitle) 2819**]
Laparoscopic left salpingo-oophorectomy, left ureterolysis,
lysis of adhesions, cystoscopy and biopsy of right bladder flap
[**2109**]
Port-A-Cath placement [**2109**]
Sentinel node mapping and biopsy right axilla, partial
mastectomy with wire localization right breast cancer [**2109**] Dr.
[**Last Name (STitle) **]
Removal of Port-A-Cath [**2110**] Dr. [**Last Name (STitle) 853**]
MEDS AT HOME:
wellbutrin SR 150'', cymbalta 120', gabapentin 600' qhs, ambien
10' qhs, lorazepam 0.5' qhs, omeprazole 40'', acyclovir 800 '''
prn, tums prn, cholecalciferol (vitamin D3) 1,000', asacol
2400'', coenzyme Q10 10', flonase 50 mcg/actuation Nasal Spray
Nasal 2 Spray prn, BOSWELIA', iron ER 325 mg (65 mg iron)',
prochlorperazine maleate 5mg prn, probiotic''
Social History:
Social Work Note:
This writer makes +contact with pt's father, [**Name (NI) **], pt's
step-mother, [**Name (NI) **] and pt's cousin. [**Name (NI) **] arrive to ED and SW
connects family to pt at bedside. ED Resident, [**Name8 (MD) **] RN and Ortho
team also support pt and pt's family at bedside with
information.
Pt will be admitted to TSICU for further management and this is
explained to pt and pt's family and info is received w/o issue.
Additionally, during this brief SW contact with the pt and pt's
family, they describe pt as a strong, determined and motivated
woman who has battled cancer and is a survivor. Pt is obviously
in pain at this time and is overwhelmed by the severity of this
traumatic event but pt appears to be coping appropriately,
accepting information and is future-oriented.
Family History:
NC
Physical Exam:
PHYSICAL EXAMINATION: upon admission: [**2111-4-30**]
HR: 92 BP: 105/89 Resp: 17 O(2)Sat: 100 Normal
Constitutional: Moderate distress
HEENT: No facial tendenress to palpation. No jaw
malocclusion. Laceration over the left eye. Abrasion over
the right flank.
Blood in the right nare. No hemotypanum.
Chest: Airway clear with equal breath sounds bilaterally.
Chest with no subcutaneous air. Chest nontender to
compression. Old scar on the left shoulder
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Left upper quadrant and left lower quadrant
tendernes to palpation.
GU/Flank: Pelvis nontender to compression.
Extr/Back: Upper and lower extremities with equal length.
Skin: Right flank abrasion.
Neuro: Speech fluent. Alert and oriented x 3. Responding
appropriately to questions
Psych: Normal mood, Normal mentation
Physical examination upon discharge: [**2111-5-5**]
General: Awake, conversant
CV: Ns1, s2, -s3, -s4
LUNGS: clear
ABDOMEN: soft, non-tender, no guarding
EXT: knee immobilizers bil., dsd to bil. patellas, feet warm,
pink, + dp bil.
NEURO: alert and oriented x 3, speech clear, no tremors, EOM's
full, st. upper ext. +4/+5, lower ext. right +3/+5, left +4/+5,+
radial pulses bil
SKIN: Abrasions face, well healed laceration chin and left
brow, ecchymosis around eyes bil.
Pertinent Results:
[**2111-5-5**] 06:15AM BLOOD WBC-5.2 RBC-2.89* Hgb-7.8* Hct-25.6*
MCV-89 MCH-27.1 MCHC-30.6* RDW-15.2 Plt Ct-229#
[**2111-5-4**] 05:11AM BLOOD WBC-6.1 RBC-2.62* Hgb-7.5* Hct-23.0*
MCV-88 MCH-28.5 MCHC-32.5 RDW-15.2 Plt Ct-140*
[**2111-4-30**] 02:40PM BLOOD WBC-6.5 RBC-4.55 Hgb-12.7 Hct-39.2 MCV-86
MCH-27.8 MCHC-32.3 RDW-14.5 Plt Ct-200
[**2111-5-5**] 06:15AM BLOOD Plt Ct-229#
[**2111-5-3**] 04:30AM BLOOD PT-11.7 PTT-25.1 INR(PT)-1.1
[**2111-4-30**] 02:40PM BLOOD Fibrino-285
[**2111-5-4**] 05:11AM BLOOD Glucose-114* UreaN-5* Creat-0.4 Na-138
K-3.7 Cl-104 HCO3-30 AnGap-8
[**2111-5-3**] 04:30AM BLOOD Glucose-110* UreaN-3* Creat-0.4 Na-140
K-3.7 Cl-104 HCO3-30 AnGap-10
[**2111-4-30**] 02:40PM BLOOD Lipase-71*
[**2111-5-4**] 05:11AM BLOOD Calcium-7.8* Phos-2.3* Mg-1.7
[**2111-5-2**] 01:03AM BLOOD Phenyto-9.4*
[**2111-5-1**] 01:48AM BLOOD Phenyto-11.7
[**2111-4-30**] 02:40PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2111-4-30**] 02:47PM BLOOD Glucose-118* Na-140 K-3.6 Cl-105
calHCO3-27
[**2111-4-30**]: chest x-ray:
No acute traumatic injury identified within the chest
[**2111-4-30**]: cat scan of the head:
1. Nondepressed fracture of right sphenoid bone involving the
greater [**Doctor First Name 362**] and orbital surface, which extends into the
parietal bone. Non-displaced fracture of the right zygomatic
process. Non-displaced fracture of the lateral wall of the
right maxillary sinus with air-blood level within right
maxillary sinus.
2. Possible nondisplaced right orbital floor fracture without
entrapment of the inferior rectus muscle or orbital fat.
3. Subarachnoid blood within left frontal and temporal sulci.
[**2111-4-30**]: cat scan of abdomen and pelvis:
1. Segmental right superior pubic ramus fracture and minimally
displaced
right inferior pubic ramus fracture. Nondisplaced right sacral
fracture and nondisplaced right lateral fifth rib fracture.
2. No evidence of vascular or solid abdominal organ injury.
3. Right lower outer breast fluid collection with adjacent
coarse
calcifications and metallic clips, compatible with prior
lumpectomy. The
collection is likely related to a seroma, but correlation with
prior studies is recommended; if no such studies are available,
then a breast ultrasound can be performed for futher evaluation.
4. 9-mm hypodense hepatic lesion, too small to further
characterize. A
metastatic lesion cannot be excluded and MR should be obtained.
5. Right middle lobe anterior parenchymal opacities, compatible
with prior radiation therapy.
[**2111-4-30**]: cat scan of cervical spine:
IMPRESSION: No fracture, acute alignment abnormality, or
prevertebral soft tissue abnormality.
[**2111-4-30**]: x-ray of right shoulder:
IMPRESSION: No acute fracture or dislocation. Calcific
tendinopathy of the rotator cuff.
[**2111-4-30**]: x-ray of ankles bilateral:
IMPRESSION: Comminuted bilateral proximal tibial and fibular
fractures.
Lipohemarthrosis noted within the left knee.
[**2111-4-30**]: bilateral tib/fib. fracture:
IMPRESSION: Comminuted bilateral proximal tibial and fibular
fractures.
Lipohemarthrosis noted within the left knee.
[**2111-4-30**]: left elbow x-ray:
IMPRESSION: No evidence of fracture or dislocation
[**2111-4-30**]: cat scan of sinus, mandible, maxilla:
IMPRESSION:
1. Fractures of the right zygoma, right greater [**Doctor First Name 362**] of the
sphenoid, and the lateral wall of the right maxillary sinus.
Equivocal fracture of the right orbital floor along the
infraorbital canal as described above.
2. Blood noted within the right maxillary sinus.
3. Laceration in the left forehead.
[**2111-4-30**]: cat scan of lower ext.:
IMPRESSION:
LEFT KNEE: Comminuted intra-articular fracture of the proximal
metadiaphysis of the tibia that extends into the lateral condyle
with 4-5 mm depression of lateral condyle as described above.
Comminuted intra-articular fracture of the proximal fibula as
described above.
RIGHT KNEE: Comminuted fracture of the proximal metadiaphysis of
the tibia as described above. Possible impaction fracture of the
posterior medial tibial plateau. Comminuted extra-articular
fracture of the proximal fibula as described above.
[**2111-4-30**]: cat scan of the head:
IMPRESSION:
1. Stable amount of subarachnoid hemorrhage in the left frontal
and temporal sulci.
2 Stable right subgaleal hematoma
3. Incomplete visualization of known facial and skullbase
fractures.
[**2111-4-30**]: cat scan of the head:
IMPRESSION:
1. Diffuse subarachnoid hemorrhage, evolving on the left and
slightly
increased on the right.
2. Persistent tiny left subdural hematoma.
3. Nondisplaced right facial/calvarial fractures
[**2111-5-1**]: lower ext. fluro:
FINDINGS/IMPRESSION: Again are seen fractures through the
proximal tibial and fibular diaphyses. The tibial fracture has
been restored to near anatomic alignment after plate and screw
fixation. The intra-articular fracture and depressed fragment
are more apparent on prior study. For more details, please see
the operative note.
[**2111-5-1**]: x-ray of the right tib/fib:
FINDINGS/IMPRESSION: Again are seen fractures through the
proximal tibial diaphysis as well as through the fibular head,
now status post plate and screw fixation restoring the tibial
fracture to near-anatomical alignment. For more details, please
see the operative note.
[**2111-5-2**]: head cat scan:
In comparison to study obtained one day prior, there is no
significant change in subarachnoid hemorrhage. A small subdural
collection layering along the left tentorium cerebelli is more
conspicuous since prior. Subgaleal hematoma of the right
frontotemporal region has slightly decreased in size since
prior.
There is stable appearance of a nondisplaced fracture involving
the right
frontal, sphenoid, and the zygomatic arch.
Brief Hospital Course:
The patient was admitted to the hospital after being struck by a
car. Initially, she was reported to be alert, but was
hypotensive requiring intravenous fluids. Upon admission, she
was made NPO, maintained on intravenous fluids, and underwent
radiographic imaging. She sustained facial fractures, SAH,
pubic rami fracture, sacral fracture, right 5th rib fracture,
and bilateral tibia/fibula fractures. In addition, to the above
injuries, she sustained left sided facial lacerations and
abrasions. The laceration was sutured.
Because of her injuries, several services were consulted. She
was evaluated by Plastic surgery and after evaluation, they
determined that non-operative intervention was needed with
follow-up in the clinic for re-examination of her facial
fractures. She was placed on sinus precautions. On HD #2, she
was taken to the operating room for ORIF of bilateral
tibia/fibula fractures. During her operative course, she
required blood pressure support with neosynephrine. She was
extubated after the procedure and transported to the intensive
care unit for monitoring. Her pelvic fractures were deemed
non-operative. Her cervical spine showed no fractures and the
cervical collar was removed on HD #2. Her neurological status
was closely monitored by clinical examination and by repeat head
cat scans. The head cat scans were stable showing improving SAH.
She continued on her 10 day course of dilantin for seizure
prophalaxis.
After her vital signs stabilized, she was transferred to the
surgical floor on HD #3. She was maintained on a diluadid PCA
for pain management. After starting clear liquids, she was
transitioned to oral analgesia which provided pain control. She
quickly progressed to a regular diet. Her foley catheter was
removed on HD # 5 and she has been voiding without difficulty.
Her facial sutures were removed on HD #19.
During her hospitalization, she was evaluated by physical
therapy and because of her limitations, recommendations made for
discharge to a rehabilitative facilitly where she can further
regain her strength and mobility. They have provided her with
ROM exercises to her lower extremities. Social services have
been an active participant in her discharge care, providing her
and her family with support.
Her vital signs have been stable and she has been afebrile. Her
hematocrit has stabilized at 26. She is tolerating a regular
diet and voiding without difficulty. She is preparing for
discharge with instructions to follow-up in the acute care
clinic, orthopedic clinic, plastic clinic and with
neuro-surgery. Cognitive evaluation was recommended at
rehabilitation facility.
Of note:
cat scan of abdomen pelvis: [**4-30**] showed:
9-mm hepatic hypodense lesion (601b:20) is too small to further
characterize and if there is a history of malignancy, cannot
exclude
metastatic lesion and MR should be obtained. Will need to
follow-up with primary care provider upon discharge from rehab.
The patient was informed of the finding as well as Dr. [**Last Name (STitle) 3649**] and
Dr. [**Last Name (STitle) **].
Medications on Admission:
MEDS AT HOME:
wellbutrin SR 150'', cymbalta 120', gabapentin 600' qhs, ambien
10' qhs, lorazepam 0.5' qhs, omeprazole 40'', acyclovir 800 '''
prn, tums prn, cholecalciferol (vitamin D3) 1,000', asacol
2400'', coenzyme Q10 10', flonase 50 mcg/actuation Nasal Spray
Nasal 2 Spray prn, BOSWELIA', iron ER 325 mg (65 mg iron)',
prochlorperazine maleate 5mg prn, probiotic''
Discharge Medications:
1. Acetaminophen 1000 mg PO Q 8H
2. Bisacodyl 10 mg PO/PR DAILY
3. Docusate Sodium 100 mg PO BID
4. Duloxetine 120 mg PO DAILY
5. Gabapentin 600 mg PO HS
6. Heparin 5000 UNIT SC TID
7. BuPROPion (Sustained Release) 150 mg PO BID
8. Senna 1 TAB PO BID
9. Sarna Lotion 1 Appl TP QID:PRN itching
10. TraMADOL (Ultram) 50 mg PO QID
11. Zolpidem Tartrate 10 mg PO HS insomnia
12. Phenytoin Infatab 100 mg PO TID
stop date [**5-9**] after last dose administered.
13. Mesalamine DR 2400 mg PO BID
14. OxycoDONE (Immediate Release) 5-15 mg PO Q3H:PRN pain
15. Omeprazole 40 mg PO BID
16. Acyclovir 800 mg PO Q8H
prn
17. Lorazepam 0.5 mg PO HS:PRN insomnia
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at
[**Hospital6 1109**] - [**Location (un) 1110**]
Discharge Diagnosis:
Trauma: pedestrian struck:
Right temporal bone and sphenoid fracture
Left frontal SAH
Right zygoma fracture and lateral maxillary wall
Right 5th rib fracture
Right comminuted superior and inferior pubic rami fracture
Right non-displaced sacral fracture
Right tibia/fibula fracture
Left tibia/fibula +plateau fracture
L facial lac ([**4-30**]-) + abrasions
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to the hospital after you were struck by a
car. You underwent a cat scan of your head, neck, and abdomen.
You were found to have a small bleed in your head, facial
fractures, a pelvic fracture, rib fractures, a fractured right
arm, and fractures to your legs. You were takenn to the
operating room where you had surgical repair of your lower
extremities. You are slowly recovering from your injuries. You
have been seen by Physical therapy and recommendations made for
discharge to a rehabiliatation facililty where you can regain
your strenght and mobility.
Followup Instructions:
Department: DIV. OF PLASTIC SURGERY
When: TUESDAY [**2111-5-19**] at 9:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 16921**], MD [**Telephone/Fax (1) 4649**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: ORTHOPEDICS
When: THURSDAY [**2111-5-21**] at 1:20 PM
With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: ORTHOPEDICS
When: THURSDAY [**2111-5-21**] at 1:40 PM
With: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], NP [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
When: THURSDAY [**2111-5-28**] at 1:15 PM
With: ACUTE CARE CLINIC [**Telephone/Fax (1) 600**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Notes: You will need a chest x-ray prior to this appointment.
Please go to [**Hospital1 7768**], [**Hospital Ward Name 517**] Clinical Center, [**Location (un) 3202**] Radiology 30 minutes prior to your appointment.
Department: RADIOLOGY
When: MONDAY [**2111-6-8**] at 10:15 AM
With: CAT SCAN [**Telephone/Fax (1) 590**]
Building: CC [**Location (un) 591**] [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Notes: Nothing to eat or drink for 3 hours prior to this test.
Department: NEUROSURGERY
When: MONDAY [**2111-6-8**] at 10:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 43708**], MD [**Telephone/Fax (1) 2731**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2111-5-5**]
|
[
"807.01",
"E814.7",
"V10.3",
"401.9",
"808.2",
"280.9",
"802.4",
"823.02",
"458.9",
"873.42",
"555.9",
"873.44",
"805.6",
"427.89",
"801.22",
"V45.71",
"823.22",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"79.36"
] |
icd9pcs
|
[
[
[]
]
] |
14231, 14376
|
10045, 13136
|
316, 359
|
14779, 14779
|
4122, 10022
|
15559, 17634
|
2738, 2742
|
13557, 14208
|
14397, 14758
|
13162, 13534
|
14955, 15536
|
2758, 2758
|
2780, 2782
|
243, 278
|
3658, 4103
|
387, 856
|
2797, 3642
|
14794, 14931
|
878, 1897
|
1913, 2722
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,250
| 108,228
|
47712
|
Discharge summary
|
report
|
Admission Date: [**2185-9-2**] Discharge Date: [**2185-9-7**]
Date of Birth: [**2119-10-5**] Sex: M
Service: SURGERY
Allergies:
Penicillins / morphine
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
abdominal pain around umbilicus
Major Surgical or Invasive Procedure:
[**2185-9-2**]
Repair of ventral hernia with mesh.
History of Present Illness:
65M s/p prostatectomy in [**2185**] and most recently 7 wks of
radiation therapy ending in [**Month (only) **] for rising PSA, now presents w/
24 hrs of focal periumbilical pain and a palpable firm mass in
the same location. The pain started suddenly around 6 pm last
night after moving some heavy furniture. He had some nausea and
1 episode of vomiting this morning of stomach contents. He
denies
any fevers or chills. Last BM was yesterday and was normal. He
states that this has never happened before and he has no
knowledge of having an umbilical or ventral hernia.
Past Medical History:
PMH: prostate cancer, s/p prostatectomy in [**2185**] and 7 wks of
radiation ending in [**2185-6-1**], hypercholesterolemia, depression,
colon polyps or colon adenomas.
PSH: prostatectomy [**2185**] at [**Hospital1 112**], arthroscopic R shoulder surgery
Social History:
nonsmoker, drinks 2-3 beers/day, lives in [**State 3914**], home
lighting designer
Family History:
non contributory
Physical Exam:
Temp 98.5 HR 68 BP 153/81 RR 16 O2 sat 99%
GEN: NAD, A&Ox3
Head: NCAT, EOMI, PERLLA
CV: RRR nl S1,S2
Pulm: CTAB
Abd: Firm, tender, 2 inch diameter protrusion under the skin
inch
or so superior and to the right of the umbilicus with no
overlying skin changes. Unable to reduce mass into abdomen. Rest
of abd soft, non-tender, with normal bowel sounds. Voluntary
guarding w/ palpation of mass. No rebound.
Ext: nml strength, no edema
Pertinent Results:
[**2185-9-2**] 06:20PM WBC-13.1* RBC-5.07 HGB-15.8 HCT-44.4 MCV-88
MCH-31.0 MCHC-35.5* RDW-12.7
[**2185-9-2**] 06:20PM NEUTS-90.9* LYMPHS-4.9* MONOS-3.9 EOS-0.1
BASOS-0.2
[**2185-9-2**] 06:20PM PLT COUNT-327
[**2185-9-2**] 06:20PM PT-12.1 PTT-19.5* INR(PT)-1.0
[**2185-9-2**] 06:20PM GLUCOSE-136* UREA N-19 CREAT-1.0 SODIUM-142
POTASSIUM-4.0 CHLORIDE-103 TOTAL CO2-25 ANION GAP-18
[**2185-9-2**] 06:28PM LACTATE-2.0
[**2185-9-2**] CTA chest/abd/pelvis :
1. High-grade small-bowel obstruction with probable transition
point seen in the mid abdomen, possibly due to adhesion. No
evidence of pneumatosis.
2. No evidence of pulmonary embolism.
3. Bibasilar consolidation, likely atelectasis. The presence of
underlying
aspiration/infection cannot be entirely excluded
Brief Hospital Course:
Mr. [**Known lastname 6323**] was evaluated by the Acute Care team in the Emergency
Room and based on his symptoms and physical exam he had an
incarcerated ventral hernia which required urgent surgery. He
was taken to the Operating Room on [**2185-9-2**] and underwent a repair
of his hernia. He tolerated the procedure well and returned to
the PACU in stable condition. He maintained stable hemodynamics
and his pain was minimal.
Following transfer to the Surgical floor he was able to use his
incentive spirometer and ambulate independently. On POD #2 he
developed nausea and vomiting associated with hypoxia. His
chest Xray showed bibasilar atelectasis and he was transferred
to the SICU for close monitoring. He underwent a CTA of the
chest which revealed bibasilar atelectasis and no pulmonary
embolism. He underwent chest PT and increased use of his
incentive spirometer along with bronchodilators although he
never had wheezing on exam. His O2 requirements gradually
decreased and on 2L nasal cannula he was 95% saturated.
He was transferred back to the Surgical floor on [**2185-9-5**] and
began to make good progress. His diet was gradually advanced to
regular and he tolerated it well. His abdominal wound was
healing well without erythema or drainage and he had minimal
pain. As he quickly improved, he was ambulating without
difficulty and was discharged on [**2185-9-7**]. He will be staying
with a friend in [**Name (NI) 8**] until his follow up appointment as
his home is in [**State 3914**].
Medications on Admission:
lovastatin 40', ASA 81', mvi'
Discharge Medications:
1. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. lovastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Incarcerated ventral hernia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**5-10**] lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical 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.
Followup Instructions:
Call the Acute care Clinic at [**Telephone/Fax (1) 600**] for a follow up
appointment in 2 weeks for staple removal.
Completed by:[**2185-9-7**]
|
[
"V10.46",
"518.0",
"E878.8",
"552.21",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"53.61"
] |
icd9pcs
|
[
[
[]
]
] |
4702, 4708
|
2658, 4181
|
311, 364
|
4780, 4780
|
1856, 2635
|
6800, 6947
|
1361, 1379
|
4262, 4679
|
4729, 4759
|
4207, 4239
|
4931, 6389
|
6405, 6777
|
1394, 1837
|
240, 273
|
392, 964
|
4795, 4907
|
986, 1244
|
1260, 1345
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,611
| 138,998
|
46969
|
Discharge summary
|
report
|
Admission Date: [**2182-12-18**] Discharge Date: [**2183-1-15**]
Date of Birth: [**2125-6-15**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2836**]
Chief Complaint:
Incisional hernia with small bowel obstruction.
Major Surgical or Invasive Procedure:
1. Extensive lysis of adhesions
2. Bilateral component separation ventral hernia repair.
2. Placement of Prolene mesh.
3. Percutaneous tracheostomy
4. Rigid bronchoscopy
5. Tunneled dialysis line placement
6. [**Last Name (un) 1372**]-intestianl tube placement
7. [**Last Name (un) **]-guided percutaneous cholecystostomy tube placement
8. Chest Port Line Placement
History of Present Illness:
The patient is a 57-year-old female well known to Dr [**First Name (STitle) **] for
multiple prior admissions, last [**2182-7-20**], for small bowel
obstruction relating likely to adhesions as well as to her
multiple incisional hernias which appeared to be a swiss cheese
type of hernia. Because of her inability to properly comprehend
and give consent for herself, she had an attorney as a guardian
as well as a son and a caseworker who were involved in her care.
Therefore consent was obtained from her attorney after reviewing
the procedure with him in detail. Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] and his colleague
were asked to assist with the open hernia repair anticipating
need for component separation as well as a mesh repair.
Past Medical History:
1. DM
2. Neuropathy
3. CRI
3. HTN
4. Hyperparathyroidism
5. s/p left upper parathyroid adenoma ([**Doctor Last Name 5182**])
6. s/p c-section x2
7. abd operation (?for blockage, lower midline incision) @ [**Hospital1 112**]
8. Complex ventral hernia with recurrent admissions for bowel
obstruction
9. GERD
10. Schizophrenia
Social History:
Lives in a group home (supervised), smokes cigarettes, no
drug/alcohol use. Son is her co-guardian. [**Name (NI) **] lawyer as other
co-guardian. Reports getting a GED. Not working and not
attending a day program currently. Spends her time watching
DVDs, walking around neighborhood.
Family History:
Two sons: [**Name (NI) 81855**]; Maternal grandmother: [**Name (NI) 81855**],
Physical Exam:
Physical Exam on Discharge
T: 98.0 HR: 72 BP: 103/61 Res: 20 Sat:100% on 35% TM
Gen: Non acute distress, oriented to person and place
CV: Distant heart sounds, RRR
Pul: No respiratory distress, clear to auscutation antiorly.
Abd: Obese, soft, some reaction to abd palpation, reprorts no
tenderness, Left lower quadrant drain in place with appropriate
serous fluid, Percutaneous cholangio drain in place with
appropriate green fluid. No guarding, no rebound.
Ext: No Clubbing or Cyanosis
Pertinent Results:
Initial results:
[**2182-12-18**] 06:44PM freeCa-1.08*
[**2182-12-18**] 06:44PM HGB-11.4* calcHCT-34
[**2182-12-18**] 06:44PM GLUCOSE-127* LACTATE-1.3 NA+-139 K+-4.3
CL--105
[**2182-12-18**] 06:44PM TYPE-ART PO2-149* PCO2-40 PH-7.45 TOTAL
CO2-29 BASE XS-4 INTUBATED-INTUBATED
[**2182-12-18**] 08:41PM freeCa-1.27
[**2182-12-18**] 08:41PM HGB-10.8* calcHCT-32
[**2182-12-18**] 08:41PM GLUCOSE-154* LACTATE-2.4*
[**2182-12-18**] 08:41PM TYPE-ART PO2-214* PCO2-43 PH-7.41 TOTAL
CO2-28 BASE XS-2
[**2182-12-18**] 09:58PM freeCa-1.18
[**2182-12-18**] 09:58PM HGB-10.5* calcHCT-32
[**2182-12-18**] 09:58PM GLUCOSE-163* LACTATE-2.3* NA+-137 K+-4.5
CL--107
[**2182-12-18**] 09:58PM TYPE-ART TEMP-37.6 RATES-/10 TIDAL VOL-600
O2-70 PO2-316* PCO2-41 PH-7.40 TOTAL CO2-26 BASE XS-0
INTUBATED-INTUBATED VENT-CONTROLLED
Labs on Admission: [**2182-12-19**]
Glucose 235*
Urea Nitrogen 31* mg/dL 6 - 20
Creatinine 2.4* mg/dL 0.4 - 1.1
Sodium 140 mEq/L 133 - 145
Potassium 5.7* mEq/L 3.3 - 5.1
Chloride 108 mEq/L 96 - 108
Bicarbonate 23 mEq/L 22 - 32
Anion Gap 15
Labs Prior to discharge: [**2183-1-14**]
147 104 38
-------------< 179
4.1 33 3.9
Ca: 8.8 Mg: 2.0 P: 3.7
8.8
11.7>---<222
28.9
[**2183-1-14**]
Portable Abdomen for assessment of dobbhoff placement:
Single portable AP radiograph demonstrates a Dobbhoff tube
slightly coiled and terminating in the distal stomach. There is
no intraperitoneal free air.
[**2183-1-10**]
TUNNELED DIALYSIS LINE PLACEMENT:
Successful conversion of existing right internal jugular
hemodialysis line to a right tunneled hemodialysis line. The
catheter length is 23 cm tip to cuff. The tip is in the right
atrium. The line is ready to use.
[**2183-1-6**]
[**Month/Day/Year **]-guided percutaneous cholecystostomy tube placement:
IMPRESSION: Successful [**Month/Day/Year 950**]-guided transhepatic
cholecystostomy drain placement.
[**2183-1-5**] LIVER OR GALLBLADDER US (SINGLE ORGAN) PORTIMPRESSION:
1. Findings are suggestive of acute cholecystitis; however
son[**Name (NI) 493**] [**Name (NI) **] sign was confounded by pain medication. If
necessary this may be further evaluated with HIDA scan.
2. Cholelithiasis with gallbladder sludge, which is mobile on
real-time
scanning and not impacted within the gallbladder neck.
[**2183-1-5**]
CT ABDOMEN W/O CONTRAST
IMPRESSION:
1. Heterogeneous thyroid gland, ultrasonic evaluation may be
considered.
2. Pulmonary nodules with the largest being a 6-mm ground-glass
right upper lobe nodule, could represent hypoventilatory changes
or atelectases. However, given ground-glass appearance, a
six-month followup to exclude BAC is recommended.
3. Cardiomegaly.
4. Bilateral basilar opacities, may reflect atelectasis.
Superimposed
pneumonia cannot be excluded.
5. Distended gallbladder with cholelithiasis and pericholecystic
stranding, cannot exclude acute cholecystitis for which
[**Month/Day/Year 950**] is a better modality.
6. Postsurgical changes from recent hernia repair with
consequent stranding and mild soft tissue edema without
drainable fluid collections or abscesses.
7. Focally dilated loop of small bowel without obstruction. This
could
represent a small bowel diverticulum, may be further evaluated
by small bowel
series.
Brief Hospital Course:
[**Known firstname 99617**] [**Known lastname 805**] was admitted to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] surgical service
on [**2182-12-18**] with a history of small bowel obstructions likely
secondary to abdominal adhesions and incisional hernia. Because
of her inability to properly comprehend and give consent for
herself, she had an attorney as a guardian as well as a son and
a caseworker who were involved in her care. Therefore consent
was obtained from her attorney after reviewing the procedure
with him in detail. In anticipation of the complexity of the
required operation, plastic surgery was also consulted for
assistance. She was taken to the operating room on [**2182-12-18**] by
both teams. Intraoperative findings significant for adhesions
incarcerating the omentum and adherent bowel to the multiple
hernia defects. Please refer to their individual operative notes
for more detail. There were no technical complications to the
procedures but it was a long operative case. We elected to keep
the patient intubated expecting requirement for additional fluid
in particular. She was transferred to surgical intensive care
unit post-operatively for further management.
Her complicated and extensive hospital course can be summarized
by the following review of systems:
Neuro: Patient has underlying schizophrenia and mental status
was difficult to assess. While intubated, she was sedated with
propofol and fentanyl, which was then switched to precedex as a
temporizing wean. Her psychiatric medications were restarted as
she was able to tolerate orals.
Cardio: Baseline HTN. Immediately, post-operatively, lopressor
was used and now added to her regimen for more effective
management. Hydralazine was used for additional break through
relief with good effect. She otherwise remained hemodynamically
stable throughout her hospital course.
Pulm: Patient has underlying COPD which made ventilator
management a challenge. CXR were taken daily to monitor for
interval changes. Several days of antibiotics were initiated for
presumed pnuemonia. She was ventilator dependent and was not
able to be weaned successfully. Due to prolonged course, she was
taken for a tracheostomy on [**2183-1-3**] by the thoracic and
interventional pulmonary services. There were no complication to
that procedure (please refer to operative note for more
information). With nebulizer and inhaler treatments for her
obstructive airway disease, she was transitioned to trach mask
ventilation. She is currently still on trach mask support.
Nasotracheal suctioning is required due to excessive secretions.
Patient was seen and evaluated by speech and swallow [**2183-1-14**]
for PASSY-MUIR valve evaluation. She did not tolerate the
placement of the PMV as noted
by increased tracheal pressures, pt report of increased
difficulty exhaling and audible rush of air when the valve was
removed. While pt has secretions, she is managing relatively
well with a strong cough and requires infrequent suctioning [**Name8 (MD) **]
RN. It is likely pt will need a downsize before she can tolerate
the valve, but she is scheduled for d/c to rehab tomorrow. A
swallow evaluation was deferred but she should be followed by
speech therapy upon arrival to rehab. Speech recommendations:
1. Continued speech therapy intervention in rehab s/p d/c to
continue monitoring her for tolerance of the PMV and to advance
her to POs as able. 2. Remain NPO with continued tube feeds. 4.
Q4 oral care. 4. Pt may require a trach downsize before she can
tolerate a PMV/capping.
Gastrointestinal/Nutrition:
Patient underwent exploratory ex lap with extensive lysis of
adhesions on [**2182-12-18**]. She also had Bilateral component
separation and had ventral hernia repair with placement of
Prolene mesh. (Please see operative report for details).
Post-operatively she had an NGT. During her prolonged recovery
period TPN was provided to for nutritional support. Tube feeds
were started when deemed appropriate and Reglan and erythromycin
used to facility motility. The patient was on H2 blockers for
stress ulcer prophylaxis throughout hospital course. A RUQ
[**Date Range 950**] on [**2183-1-5**] is consistent with cholecystitis. She is
status post perc chole [**1-6**], and continues to drain draining
brown, muddy bile, cipro-S e. coli on Culture. Patient
tolerating Nutren pulmonary @ 35 mL/hour with erythromycin.
Dobbhoff was placed by IR and is in stomach. Patient was
maintained on a bowel regimen as appropriate throughout
Renal: Patient with base line CKD became anuric in operating
room. Patient has been followed by the renal service for
raising Cr and BUN and required and is still requiring
hemodialysis. Tunnelled HD Catheter per IR on [**1-10**]. On
discharge she has a Foley in place and is making good urine.
Hemodialysis three time weekly is recommended as well as routine
checking of labs.
ID: Patient on vancomycin per hemodialysis protocol. Patient
on Cipro for E.Coli organisms in bile cultures.
Endocrine: Primary hyperparathyroidism - will complete workup
after current issues resolved, not currently hypercalcemic, RISS
Wounds: dry mid line, 1 JP, perc chole
Medications on Admission:
acarbose 25', amlodipine 2.5', lasix 40'. lisinopril 2.5',
risperidal 2", simvastatin 20', NPH 30/28, colace, MVI, Vit,
omega 3
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Glucagon (Human Recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
3. Beclomethasone Dipropionate 80 mcg/Actuation Aerosol Sig: One
(1) Inhalation [**Hospital1 **] (2 times a day).
4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
5. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) mls PO BID (2
times a day).
6. Risperidone 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
8. Heparin (Porcine) 1,000 unit/mL Solution Sig: One (1)
Injection PRN (as needed) as needed for line flush.
9. Scopolamine Base 1.5 mg Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
10. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
11. Acetaminophen 160 mg/5 mL Solution Sig: Four (4) mls PO Q6H
(every 6 hours) as needed for fever.
12. Lidocaine (PF) 10 mg/mL (1 %) Solution Sig: One (1) ML
Injection Q6H (every 6 hours) as needed for VC spasm.
13. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
14. Amlodipine 2.5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
15. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as
needed for Wheezzing.
16. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
17. Heparin (Porcine) 1,000 unit/mL Solution Sig: One (1)
Injection PRN (as needed) as needed for line flush.
18. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
19. HydrALAzine 10 mg IV Q4H:PRN SBP>165
20. Heparin Flush (10 units/ml) 1 mL IV PRN line flush
Dialysis Catheter (Temporary 3-Lumen): THIN NON-DIALYSIS (VIP)
Lumen: ALL NURSES: Flush with 10 mL Normal Saline followed by
Heparin as above daily and PRN.
21. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN.
22. HYDROmorphone (Dilaudid) 0.25-0.5 mg IV Q3H:PRN pain
23. Vancomycin 1000 mg IV HD PROTOCOL Duration: 7 Days
24. 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.
25. Heparin Flush (10 units/ml) 1 mL IV PRN line flush
Dialysis Catheter (Temporary 3-Lumen): THIN NON-DIALYSIS (VIP)
Lumen: ALL NURSES: Flush with 10 mL Normal Saline followed by
Heparin as above daily and PRN.
26. Ciprofloxacin 250 mg Tablet Sig: Two (2) Tablet PO Q24H
(every 24 hours).
27. Insulin Regular Human 100 unit/mL Solution Sig: 3-30 units
Injection As directed per Regular Insulin Sliding Scale.
28. Free water
Please give free water bolus 100cc every 4 hours
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Medical Center - [**Hospital1 3597**]
Discharge Diagnosis:
This admission:
1) Acute on chronic kidney disease stage IV requiring dialysis
2) New tracheostomy
3) Repair small bowel adhesion with venteral hernia component
repair
Prior to admission:
1. DM with neuropathy and nephropathy as above
3. schizophrenia
4. HTN
5. hyperparathyroidism s/p L upper parathyroid adenoma resection
6. GERD
Discharge Condition:
Mental Status:Confused - always Patient with baseline
developmental delay and schizophrenia.
Level of Consciousness:Alert and interactive but slow
Activity Status:Out of Bed with assistance to chair or
wheelchair
Discharge Instructions:
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, Use Abdominal Binder when ambulating, and drink
adequate amounts of fluids. Avoid lifting weights greater than
[**4-28**] lbs until you follow-up with your surgeon, who will
instruct you further regarding activity restrictions.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
JP Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*Maintain suction of the bulb.
*Note color, consistency, and amount of fluid in the drain. Call
the doctor, nurse practitioner, or VNA nurse if the amount
increases significantly or changes in character.
*Be sure to empty the drain frequently. Record the output, if
instructed to do so.
*You may shower; wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
What to watch out for when you have a Dobhoff Feeding Tube:
1. Blocked tube: If the tube won't flush, try using 15 mL
carbonated cola or warm water. If it still will not flush, call
your nurse or doctor. Always be sure to flush the tube with at
least 60 mL water after giving medicine or feedings.
2.[**Month/Year (2) **]:
*Call doctor [**First Name (Titles) **] [**Last Name (Titles) **] persists. [**Last Name (Titles) **] causes the loss of
body fluids, salts and nutrients.
*Give the feeding in an upright position.
*Try smaller, more frequent feedings. Be sure the total amount
for the day is the same though.
*Infection may cause [**Last Name (Titles) **]. Clean and rinse equipment well
between feedings.
*Do not let formula in the feeding bag hang longer than 6 hours
unrefrigerated. After the formula can is opened, it should be
stored in refrigerator until used.
3. [**Last Name (Titles) **]:
*This is frequent loose, watery stools.
*Can be caused by: giving too much feeding at once or running it
too quickly, decreased fiber in diet, impacted stool or
infection. Some medicines also cause [**Last Name (Titles) **].
*Avoid hanging formula for longer than 6 hours.
*Give more water after each feeding to replace water lost in
[**Last Name (Titles) **].
*Call doctor [**First Name (Titles) **] [**Last Name (Titles) **] does not stop after 2-3 days.
4. Dehydration:
*Due to [**Last Name (Titles) **], [**Last Name (Titles) **], fever, sweating. (Loss of water and
fluids)
*Signs include: decreased or concentrated (dark) urine, crying
with no tears, dry skin, fatigue, irritability, dizziness, dry
mouth, weight loss, or headache.
*Give more water after each feeding to replace the water lost.
*Call your doctor.
5. Constipation:
*[**Month (only) 116**] be caused by too little fiber in diet, not enough water or
side effects of some medicines.
*Take extra fruit juice or water between feedings.
*If constipation becomes chronic, call the doctor.
6. Gas, bloating or cramping: Be sure there is no air in the
tubing before attaching the feeding tube.
7. Tube is out of place: If the tube is no longer in your
stomach, tape it down and call your doctor or home health nurse.
Do not use the tube. You will need to have a new tube placed.
Followup Instructions:
Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2183-1-22**]
11:00
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Name (STitle) **] Phone:[**Telephone/Fax (1) 721**] Date/Time:[**2183-1-23**]
2:30
Provider: [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern1) 6751**], MD Phone:[**Telephone/Fax (1) 6742**]
Date/Time:[**2183-1-28**] 3:45
Please followup with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], Surgeon in 4 weeks. Please
call ([**Telephone/Fax (1) 99618**] to schedule an appointment.
Completed by:[**2183-1-15**]
|
[
"560.81",
"574.00",
"530.81",
"552.21",
"584.9",
"585.4",
"486",
"357.2",
"252.00",
"295.90",
"250.60",
"403.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.02",
"53.69",
"31.1",
"33.21",
"38.95",
"54.59",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
14303, 14383
|
6075, 7375
|
364, 732
|
14762, 14762
|
2803, 3640
|
18548, 19175
|
2198, 2277
|
11459, 14280
|
14404, 14741
|
11306, 11436
|
15001, 18525
|
2292, 2784
|
7395, 11280
|
276, 326
|
760, 1532
|
3654, 6052
|
14776, 14977
|
1554, 1880
|
1896, 2182
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,109
| 162,197
|
45
|
Discharge summary
|
report
|
Admission Date: [**2189-9-7**] Discharge Date: [**2189-9-9**]
Date of Birth: [**2129-3-28**] Sex: F
Service: MEDICINE
Allergies:
Lomotil
Attending:[**Last Name (NamePattern1) 495**]
Chief Complaint:
Pyelonephritis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname 496**] is a 60 yo F with hx of chronic hepatitis C who
presents to the ED with dysuria x 4 days, chills, nausea and
vomiting. She first noted hematuria on Saturday, then developed
dysuria, urinary frequency, urgency and incontinence. +anorexia
x 3 days and N/V on the day prior to admission. Denies back pain
but did have mild abdominal discomfort. She did not take her
temperature at home. She has no recent hospitalizations except
for an ED visit for Bell's palsy which was felt to be related to
Lyme disease. She denies ever having a urinary tract infection.
.
In the ED her initial vitals were: T 99.0, HR 102, BP 103/59, RR
16, O2 98% on RA, however shortly afterwards developed a fever
to 104F and BP 80/30 (asymptomatic). She had a grossly positive
U/A, and CT Abd/Pelvis showed evidence of bilateral
pyelonephritis. She received approx 5L IVFs in the ED with 1L of
urine output.
.
ROS: +headache, no CP, SOB or dysphagia. denies weight change.
+constipation. no cough. no muscle weakness
Past Medical History:
- Hepatitis C infection (Liver biopsy in [**2185-2-17**] --> grade
1 inflammation and stage 0 fibrosis; followed Dr. [**Last Name (STitle) 497**] -
contracted from needlestick injury
- Osteopenia
- Herpes zoster in the right middle of the back and the side
when she was 14 years of age,
- Psoriasis
- Lyme disease/Bell's palsy
- Thyroid nodule
Social History:
She is a sociologist at [**Hospital1 498**]. She is single and lives alone.
She stopped alcohol use in [**2164**]. Prior to that, she used to
drink mostly socially, occasionally heavily. Denies ever smoking
or drug use.
Family History:
Mother is 85 and has arthritis but is otherwise in good health.
Father is 83 and appears to have some "mental decline" the exact
diagnosis is not certain. She has one sister who is 55 in good
health. Three brothers, one with hepatitis C. Paternal
grandfather with [**Name2 (NI) 499**] cancer. Paternal grandmother with lung
cancer. Paternal aunts with breast cancer and paternal uncle
with [**Name2 (NI) 500**] cancer.
Physical Exam:
Tmax: 37.8 ??????C (100 ??????F)
Tcurrent: 37.7 ??????C (99.8 ??????F)
HR: 89 (77 - 109) bpm
BP: 104/61(72) {76/34(50) - 106/74(80)} mmHg
RR: 11 (11 - 30) insp/min
SpO2: 98% RA
Heart rhythm: SR (Sinus Rhythm)
Height: 66 Inch
Gen: NAD, pleasant, conversive
HEENT: PERRL, MMM, no OP lesions, EOMI
Neck: Supple, no LAD, no bruit, no LVD
Heart: RRR, nl S1/2, nl S3/4, no murmurs
Lungs: CTA b/l, no w/r/r
Abd: Soft, NT/ND, +BS, no guarding or rebound tenderness,
normoactive bowel sounds, +CVA tenderness, R > L
Extrem: no edema, cyanosis, clubbing, 2+ dp pulses b/l
Skin: no rashes
Neuro: A+Ox3, nl muscle strength, nl sensation
Pertinent Results:
[**2189-9-9**] 05:32AM BLOOD WBC-7.3 RBC-3.16* Hgb-10.9* Hct-29.8*
MCV-95 MCH-34.5* MCHC-36.5* RDW-13.6 Plt Ct-161
[**2189-9-9**] 05:32AM BLOOD Glucose-108* UreaN-11 Creat-1.0 Na-140
K-3.9 Cl-113* HCO3-24 AnGap-7*
[**2189-9-8**] 04:59AM BLOOD ALT-28 AST-23 TotBili-0.8
[**2189-9-7**] 02:30PM BLOOD TSH-0.43
[**2189-9-7**] 02:30PM BLOOD Cortsol-32.2*
[**2189-9-7**] 09:25PM BLOOD Lactate-0.9
U/A: Mod LE, Lg blood, Nitr negative, trace protein, >50 WBC,
Bacteria - many, Epi [**1-21**].
.
Urine cx [**9-7**]- E.Coli, sensitivities PENDING
Blood cx [**9-8**]- pending
IMAGING:
CT SCAN [**9-7**]
CT OF THE ABDOMEN WITH IV CONTRAST: Dependent atelectases are
present within
the lung bases bilaterally. There is no pleural effusion.
Visualized heart
and pericardium are unremarkable.
There is a striated appearance of bilateral kidneys, with
peripheral wedge- shaped hypodensities bilaterally. The largest
of these hypodensities is in the upper pole of the left kidney.
There is associated marked inflammatory stranding surrounding
both kidneys. Additionally, contrast is seen to excrete normally
from both kidneys. However, there is circumferential wall
thickening involving both ureters throughout its course. These
findings are overall suggestive of bilateral pyelonephritis,
with associated ureteritis. Although no discrete abscess is
identified, the hypodensity in the upper pole of the left
kidney, is likely at risk for developing an internal abscess.
The liver and gallbladder are within normal limits, with a focal
hypodensity adjacent to the gallbladder, may reflect an area of
focal fat. Spleen, pancreas, and adrenal glands are
unremarkable.
The stomach, small bowel, and large bowel are unremarkable. The
appendix is not definitively visualized, without secondary
findings to suggest acute appendicitis.
There is no free fluid or free air. Scattered retroperitoneal
nodes are seen, not meeting CT size criteria for pathologic
enlargement.
Urinary bladder, rectum are unremarkable. There is no pelvic
lymphadenopathy or free fluid.
IMPRESSION:
Findings most compatible with bilateral pyelonephritis and
ureteritis.
Although no discrete abscess is identified, a hypodensity within
the left
upper pole is seen, which may be at risk for developing into an
abscess. Close interval followup is suggested.
Brief Hospital Course:
60 yo female with hx of chronic hepatitis C infection (without
cirrhosis) presenting to the ED with 4 day hx of dysuria, chills
and found to have a grossly positive U/A with evidence of
bilateral pyelonephritis on CT Abd/pelvis who became hypotensive
to 80/30.
.
# Pyelonephritis/Sepsis: Pt w/ signs and sx of UTI for several
days; most likely with ascending GU infection. The patient has
no recent UTIs or hx of resistent organisms. The patient
presented to the ICU in stable condition. CT scan of was
performed and consistent with pyelonephritis w/ no discrete
abscess, but showed a hypodensity that could represent possible
developing abscess in the left upper pole. She receieved cipro
in the ED prior to coming to the ICU and prior to blood
cultures. The patient's blood pressures continued to range SBP
70-90's, but the patient had good mentation, urine output,
peripheral perfusion, and no compliants indication adequate end
organ perfusion. Pt remains hypotensive (SBP 80-90) even after
receiving 7L of IVFs, but likely was dehydrated prior to
presentation and has high insensible losses due to fever. Pt
also reports a "low" blood pressure at baseline. The patient was
also given one dose of stress dose steriods, but was
discontinued in the AM after her random cortisol was 32. The
patient was continued on IV ciprofloxacin and and was
transitioned to po cipro 500mg Q12 x 14 day course. The
patient's urine grew E. Coli and sensitivities were pending.
The patient's blood pressure ranged between SBP 90-110 on
discharge. Pt was afebrile, ambulating, eating po, and feeling
back to her baseline.
.
# Acute renal failure: The patient initial creatine was 1.1 and
stablized to 1.0 today. Her baseline is around 0.7. This is
likely prerenal w/ combination of poor po intake, vomiting,
fever.
.
# Chronic hepatitis C infection: Stable, has not required
treatment. LFT's were wnl.
.
# Lyme disease/Bell's palsy - resolving
.
# FEN: Tolerating regular diet, replete lytes prn
.
# PPx: heparin sc, bowel regimen
.
# Access: PIV
.
# Code: full, confirmed w/ patient - ICU consent signed
.
# Comm: [**Name (NI) 501**] [**Name (NI) 496**] (sister) [**Telephone/Fax (1) 502**]
.
# Dispo: Pt will be discharged and will follow-up with her PCP
[**Name Initial (PRE) 503**] ([**9-10**]) for vitals and CBC.
Medications on Admission:
- ASA 81mg daily
- [**Female First Name (un) 504**]-C
- Vitamin D
- MVI
- multiple herbal supplements
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
3. Vitamin D Oral
4. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 12 days.
Disp:*24 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Pyelonephritis
Hypotension
Secondary:
Hepatitis C infection
Osteopenia
Herpes zoster
Psoriasis
Lyme disease/Bell's palsy
Thyroid nodule
Discharge Condition:
stable, normotensive, ambulating, tolerating normal diet, and
good O2 sats on room air
Discharge Instructions:
It was a pleasure [**Last Name (un) 505**] care of you while you were in the
hospital. You were admitted to [**Hospital1 18**] because of an infection in
your kidney. You had a CT scan performed of your kidney and it
was consistent with a kidney infection. You stayed in the ICU
because your blood pressure was low. You were given fluids and
treated with antibiotics for your infection. You improved with
these treatments and were able to go home on oral antibiotics.
Please follow the medications prescibed below.
Please follow up with the appoints made below.
Please call your PCP or go to the ED if you experience worsening
fevers, chills, pain with urination, nausea, vomiting, chest
pain, shortness of breath, back pain, or other worsening
symptoms.
***********
PCP:
[**Name10 (NameIs) **] patient should have a CBC and BP check tomorrow. The
patient was hypotensive in ICU (not pressor dependent), but was
back to her baseline blood pressure at discharge and afebrile.
The patient's urine culture is growing E. Coli, but
sensitivities are not back. Please call the ICU ([**Telephone/Fax (1) 506**])
to follow-up on sensitivies. Additionally, the patient's CT
scan showed a hypodensity within the left upper pole, which may
be at risk for developing into an abscess. Close interval
followup is suggested. Imaging should be repeated if symptoms
worsen or recurrs after treatment. The patient should be
continued for a 14 day course of antibiotics.
Followup Instructions:
PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) 507**] [**Name12 (NameIs) 508**] [**Telephone/Fax (1) 133**]
Appointment: [**9-10**] @ 11:15am
Completed by:[**2189-9-9**]
|
[
"038.9",
"584.9",
"590.10",
"241.0",
"995.92",
"276.51",
"070.54",
"733.90",
"571.5"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8166, 8172
|
5392, 7705
|
288, 295
|
8362, 8451
|
3053, 5369
|
9966, 10138
|
1967, 2392
|
7857, 8143
|
8193, 8341
|
7731, 7834
|
8476, 9943
|
2407, 3034
|
234, 250
|
323, 1343
|
1365, 1711
|
1727, 1951
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,660
| 163,939
|
51104
|
Discharge summary
|
report
|
Admission Date: [**2165-5-17**] Discharge Date: [**2165-5-21**]
Date of Birth: [**2110-12-14**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Codeine / Penicillin G / Ativan
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
angina
Major Surgical or Invasive Procedure:
Coronary Artery Bypass Graft x 2 [**2165-5-17**] (LIMA to LAD, SVG to
OM)
History of Present Illness:
54 yo male with known 3 vessel CAD and several prior
percutaneuous interventions. Now presents with increased recent
symptoms.Referred for cath and then surgical revascularization
with Dr. [**Last Name (STitle) **].
Past Medical History:
- HBV- Started tenofovir fall [**2163**] because of persistent viral
loads despite lamivudine, but stopped a few weeks ago [**Doctor Last Name **] to
ARF.
- AIDS/HIV: C/B by Kaposi's sarcoma- s/p chemo. [**3-12**] cd4 234,
vl 6400. Diagnosed [**2143**].
- severe 4 vessel cad- 2 stents to LAD [**10/2155**], stent to lad [**7-11**].
On BB, aspirin, zetia. Last echo [**1-12**]- ef 60%, 1+ar.
- H/O etoh abuse. MRI [**3-8**] with severe atrophy of cerebellar
vermis and b/l superior aspects of cerebellum.
- Pancytopenia- s/p bm bx [**2164-3-12**] without evidence of lymphoma.
- Bronchiectasis
- ARF- to cr 6.5 in [**1-12**] thought to be related to tenofovir.
1.4 yesterday and 1.8 today.
- CHF- [**1-12**]
- Cholelithiasis seen on ct scan [**10-7**]
- hiatal hernia seen on barium imaging [**12/2158**]
-hyperlipidemia
- anemia
anxiety
Giardia and cryptosporidium
diarrhea
anal dysplasia
Basal cell carcinoma
prior appendectomy
Social History:
No smoking
Alcoholic. Last drink- 2 weeks ago.
.
Denies illicit drug use. Denies tobacco
.
Contracted HIV and Hep B sexually. Under a great deal of
personal stress. Multiple family members have died or are very
sick.
Family History:
Father: heart attack in his 40's
Mother: metastatic lung CA
Physical Exam:
68" 150#
RR 20 HR 73 right 102/49 left 107/52
skin/HEENT unremarkable
neck supple with full ROM, no carotid bruits
CTAB
RRR
soft, NT, ND, no bowel sounds
extrems, warm, well-perfused, no edema
no varicosities
nuero grossly intact
2+ bil. fem/DP/PT/radials
Pertinent Results:
[**2165-5-21**] 07:25AM BLOOD WBC-4.5 RBC-2.51* Hgb-8.5* Hct-24.3*
MCV-97 MCH-33.8* MCHC-34.9 RDW-18.2* Plt Ct-110*
[**2165-5-20**] 06:02AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2165-5-21**] 07:25AM BLOOD Plt Ct-110*
[**2165-5-20**] 06:02AM BLOOD Glucose-104 UreaN-12 Creat-1.0 Na-140
K-3.7 Cl-106 HCO3-31 AnGap-7*
[**2165-5-20**] 06:02AM BLOOD Calcium-8.3* Phos-2.5* Mg-1.9
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2165-5-19**] 8:49 AM
CHEST (PORTABLE AP)
Reason: s/p chest tube pulled
[**Hospital 93**] MEDICAL CONDITION:
54 y/o male s/p CABG. Please page [**First Name8 (NamePattern2) **] [**Doctor Last Name **] at [**Numeric Identifier 8570**] with
abnormalities. Pt going to CSRU now.
REASON FOR THIS EXAMINATION:
s/p chest tube pulled
HISTORY: Chest tube removal.
Single portable radiograph of the chest demonstrates interval
removal of the left-sided chest tube. There has been interval
removal of the right internal jugular Swan-Ganz catheter. A
right internal jugular introducer sheath remains with its tip in
the SVC. The patient is status post CABG. There is mild
bibasilar atelectasis. There is probably a very small left-sided
pleural effusion. No pneumothorax is detected. Trachea is
midline.
IMPRESSION:
Interval removal of Swan-Ganz catheter and left-sided chest
tube.
Very mild bibasilar atelectasis.
Probable very small left-sided pleural effusion. No
pneumothorax.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 6892**]
Approved: SUN [**2165-5-19**] 10:56 PM
Brief Hospital Course:
Admitted [**5-17**] and underwent cabg x2 with Dr.[**Last Name (STitle) **]. Transferred
to the CSRU in stable condition on phenylephrine and
propofol drips. Extubated that night and chest tubes removed on
POD #2. Transferred to the floor to begin increasing his
activity level.Pacing
wires removed without incident on POD #3. Cleared for discharge
to home with VNA on POD #4. Pt. is to make all follow-up appts.
as per discharge instructions.
Medications on Admission:
ASA 325 mg daily
zetia 10 mg daily
lopressor 25 mg daily
prilosec 20 mg daily
kaletra 3 tabs [**Hospital1 **]
epzicom 600 mg/300mg one tab daily
trazadone 150 mg QHS
baraclude 1 mg daily
seroquel 12.5 mg QHS
campral 666 mg TID
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Lopinavir-Ritonavir 200-50 mg Tablet Sig: Three (3) Tablet PO
BID (2 times a day).
4. Entecavir 0.5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. Acamprosate 333 mg Tablet, Delayed Release (E.C.) Sig: Two
(2) Tablet, Delayed Release (E.C.) PO TID (3 times a day).
6. Prilosec 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*
7. Abacavir 300 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. Lamivudine 100 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
10. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
11. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
14. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Two (2) Capsule, Sustained Release PO DAILY (Daily) for 7 days.
Disp:*14 Capsule, Sustained Release(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
CAD/cabg x2
PCI withg stents
elev. chol.
HIV +
CRI ( tenovir induced renal failure [**2164**])
Hep B
pancytopenia
Kaposi's sarcoma s/p chemo
bone marrow biopsy
crytosporidium and giardia diarrhea
depression and anxiety
oral HSV
anal dysplasia
basal cell Ca
prior appendectomy
Discharge Condition:
Good
Discharge Instructions:
[**Month (only) 116**] shower, no baths or swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns
Followup Instructions:
Dr. [**Last Name (STitle) **] in 4 weeks
Dr. [**Last Name (STitle) 911**] in [**2-9**] weeks
Dr. [**First Name (STitle) 6164**] in [**1-8**] weeks
Completed by:[**2165-5-22**]
|
[
"070.32",
"272.4",
"585.9",
"042",
"494.0",
"413.9",
"428.0",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"38.93",
"36.15",
"36.11"
] |
icd9pcs
|
[
[
[]
]
] |
6155, 6213
|
3832, 4279
|
306, 382
|
6534, 6541
|
2196, 2758
|
7006, 7184
|
1839, 1900
|
4557, 6132
|
2795, 2962
|
6234, 6513
|
4305, 4534
|
6565, 6983
|
1915, 2177
|
260, 268
|
2991, 3809
|
410, 627
|
649, 1585
|
1601, 1823
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,801
| 154,855
|
5114
|
Discharge summary
|
report
|
Admission Date: [**2121-3-22**] Discharge Date: [**2121-3-27**]
Date of Birth: [**2076-12-29**] Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 21007**]
Chief Complaint:
Chief Complaint: Vaginal bleeding
Major Surgical or Invasive Procedure:
Total abdominal hysterectomy
History of Present Illness:
Mrs. [**Known lastname **] is a 44 year old G0 female with a history of a
fibroid uterus who had acute onset of heavy vaginal bleeding at
10pm on the evening of [**3-21**] with BRBPV and clots at home and in
the ED. She had been on continuous OCP (no placebo week) at
home. She was admitted to gynecology and noted to have falling
hematocrit over 24 hours (41->35->31->28) despite receiving 2
units of PRBCs. She also received IV estrogen. On the morning of
[**3-23**] she was taken to the OR emergently for hysterectomy due to
continued massive hemorrhage. In the OR she received 3L NS, 1.5L
LR, and additional blood products. Estimated blood loss was 500
cc intra-op with loss of likely 1-2L before surgery and 200 cc
urine output intra-op. She has received two doses of cefazolin
(4g total). In total she received 6 units PRBCs, 2 units FFP, 2
units of cryo, and 1 pack of platelets since admission.
.
On arrival to the ICU the patient is intubated and sedated.
.
Review of sytems:
Unable to obtain
Past Medical History:
Past Medical History:
1. Fibroid uterus with menorrhagia
2. Iron deficiency anemia
Social History:
Not sexually active. No tobacco, alcohol, or drugs.
Born in [**First Name8 (NamePattern2) 1495**] [**Doctor Last Name **] U.S. [**State 21008**]. Came to the United
States in the [**2101**]. She works as a nurses aide. Per report
patient is a Jehova's witness and although she consented to
receive blood as needed to keep her stable (in private), her
family has not been supportive.
Family History:
Significant for her mother who has hypertension and her father
recently was diagnosed with prostate cancer. No family history
of bleeding disorders.
Physical Exam:
Vitals: T: 96.5, BP: 170/85, P: 61, R: 16, O2: 100% AC 500x12
peep 5
General: Young female, intubated, sedated.
HEENT: Sclera anicteric, MMM
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation anteriorly and laterally, no
wheezes, rales, ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs
Abdomen: Midline incision with dressing that is dry and intact.
Absent bowel sounds, soft, non-tender laterally, non-distended.
GU: + foley
Ext: warm, well perfused, no clubbing, cyanosis or edema
Pertinent Results:
Labs: Hct: 41.4 -> 35.3 -> 31.0 -> 28.6
[**2121-3-22**] 04:50AM BLOOD WBC-6.3 RBC-4.71 Hgb-13.3 Hct-41.4 MCV-88
MCH-28.1 MCHC-32.0 RDW-12.6 Plt Ct-271
[**2121-3-22**] 10:05AM BLOOD Hct-35.3*
[**2121-3-22**] 08:00PM BLOOD Hct-31.0*
[**2121-3-23**] 03:17AM BLOOD WBC-8.1 RBC-3.32*# Hgb-9.9*# Hct-28.6*
MCV-86 MCH-29.8 MCHC-34.6 RDW-13.1 Plt Ct-201
[**2121-3-23**] 08:39AM BLOOD WBC-11.5* RBC-2.88* Hgb-8.6* Hct-23.9*
MCV-83 MCH-29.8 MCHC-36.0* RDW-14.1 Plt Ct-191
[**2121-3-23**] 12:33PM BLOOD Hct-29.3*
[**2121-3-23**] 03:20PM BLOOD Hct-28.1*
[**2121-3-23**] 05:57PM BLOOD Hct-28.3*
[**2121-3-23**] 09:54PM BLOOD Hct-26.5*
[**2121-3-22**] 04:50AM BLOOD Neuts-69.0 Lymphs-27.0 Monos-3.0 Eos-0.6
Baso-0.5
[**2121-3-22**] 04:50AM BLOOD PT-12.6 PTT-24.3 INR(PT)-1.1
[**2121-3-22**] 04:50AM BLOOD Glucose-87 UreaN-13 Creat-0.7 Na-141
K-4.1 Cl-106 HCO3-25 AnGap-14
[**2121-3-23**] 08:39AM BLOOD Calcium-10.1 Phos-2.7 Mg-1.3*
[**2121-3-22**] 04:50AM BLOOD HCG-<5
[**2121-3-23**] 05:05AM BLOOD Type-ART pO2-503* pCO2-42 pH-7.36
calTCO2-25 Base XS--1 Intubat-INTUBATED
[**2121-3-23**] 05:05AM BLOOD Glucose-98 Lactate-1.2 Na-138 K-3.4*
Cl-110
[**2121-3-22**] 02:47PM BLOOD Hgb-12.1 calcHCT-36
[**2121-3-23**] 05:05AM BLOOD freeCa-1.06*
MICRO: NONE
REPORTS:
PELIC U/S [**2121-3-22**]:
IMPRESSION: Markedly limited transabdominal ultrasound
demonstrating enlarged fibroid uterus.
MRI PELVIS [**2121-3-22**]:
Massively enlarged fibroid uterus. The majority of the uterine
fibroids
demonstrate minimal enhancement, likely because of their
extensive fibrotic component. Enhancing, exophytic fibroids are
seen extending from the left and right aspects of the uterine
fundus. Normal displaced ovaries.
Brief Hospital Course:
44 year old woman, Jehovah's witness with a long history of
uterine fibroids and intermittant iron deficiency anemia who
presents with large-volume uterine fibroid bleeding and is now
post-op total abdominal hysterectomy. She was initially admitted
to GYN but was having massive hemorrhage with falling hematocrit
over 24 hours (41->35->31->28) despite receiving 2 units of
PRBCs. Went to OR for emergent surgery to stop hemorrhage and
underwent TAH. Estimated blood loss was 500 cc intra-op with
loss of likely 1-2L before surgery. In total she received 6
units PRBCs, 2 units FFP, 2 units of cryo, and 1 pack of
platelets since admission. Of note, she decided to undergo
transfusions to save her life despite her family's initial
refusal of blood. The family is now aware of this per patient's
permission to disclose. She was extubated [**2121-3-23**] without
complications. She was having severe abdominal pain from her
surgery. She was started on a dilaudid PCA to good affect. HCT
slowsly drifted down post-op from 29->28->26, GYN made aware,
decided only to monitor for time being. AM HCT was 26.9. She was
called out to OB/GYN who has been following closely.
Ms. [**Known lastname **] was called out of the ICU on [**2121-3-24**] in stable
condition. On POD #1, the patient developed a fever to 101.6
without localizing signs. Fever felt to be secondary to
atelectasis. Blood cultures, urine culture and chest x-ray were
obtained and returned negative. Patient deffervesced
spontaneously. Her pain was well controlled on the Dilaudid PCA
and she was transitioned to PO pain meds once tolerating PO diet
on POD #2. Ms. [**Known lastname **] remained stable and was discharged to
home in stable condition on POD # 4. She will follow-up [**Hospital1 **]next week for an incision check.
Medications on Admission:
Home Medications:
Necon 0.5/35
.
Current Medications:
Estrogens Conjugated 25 mg IV Q6H Duration: 4 Doses
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
2. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*1*
3. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Uterine Fibroids
Menorrhagia
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
Discharge Instructions:
*) No heavy lifting for 6 weeks
*) Do not drive while taking narcotic pain medication
*) Please call your doctor for
- Fever > 100.4
- Abdominal pain not relieved with pain medication
- Inability to tolerate food
- Redness, swelling around incision site
- Discharge or bleeding from incision
- Heavy vaginal bleeding (saturating > 1 pad/day)
- Foul smelling vaginal discharge
Followup Instructions:
Provider: [**First Name8 (NamePattern2) 3130**] [**Last Name (NamePattern1) 3131**], MD Phone:[**Telephone/Fax (1) 7976**]
Date/Time:[**2121-4-1**] 10:40 for staple removal
[**First Name8 (NamePattern2) 3130**] [**Last Name (NamePattern1) 3131**] MD, [**MD Number(3) 21009**]
Completed by:[**2121-3-31**]
|
[
"218.9",
"626.2",
"285.1",
"518.0",
"E878.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"68.49"
] |
icd9pcs
|
[
[
[]
]
] |
6715, 6721
|
4365, 6158
|
364, 394
|
6794, 6794
|
2651, 4342
|
7342, 7678
|
1950, 2100
|
6315, 6692
|
6742, 6773
|
6184, 6184
|
6942, 7319
|
2115, 2632
|
6202, 6217
|
308, 326
|
1407, 1426
|
6238, 6292
|
422, 1389
|
6809, 6918
|
1470, 1533
|
1549, 1934
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
83,310
| 166,410
|
8627
|
Discharge summary
|
report
|
Admission Date: [**2186-2-13**] Discharge Date: [**2186-3-19**]
Date of Birth: [**2130-8-2**] Sex: M
Service: SURGERY
Allergies:
Ceftriaxone / Aldactone / Imuran
Attending:[**First Name3 (LF) 5569**]
Chief Complaint:
Fever, nausea, RUQ pain
Major Surgical or Invasive Procedure:
Diagnostic paracentesis x 2
Left orthotopic liver transplant, splenectomy
History of Present Illness:
55 yo male w/ h/o HCV cirrhosis s/p transplant x 2 (1st
transplant c/b primary graft failure believed to be due to
small-for size syndrome), course c/b biliary obstruction s/p
PTC/dilation at [**Hospital1 1774**], outflow obstruction s/p IVC dilation at
[**Hospital1 18**] on [**2186-2-8**] discharged home on Thursday, now presenting to
clinic with low grade temperature, nausea, abdominal cramps
since discharge.
.
He had been feeling unwell since discharge last Thursday with
fatigue, loose non bloody stools, chills, and nausea without
vomiting. He further reports bilateral lower quadrant abdominal
pain that is dull in nature. He had one low grade temperature
but he does not recall the exact value. He denies cough,
dysuria, urinary frequency, dizziness or lightheadedness.
.
Patient has had an complicated course since his first
transplantation at [**2185-9-14**] c/b primary graft nonfunction. On
[**2185-9-23**], he underwent a deceased donor liver transplantation.
At the end of [**2185-11-8**], he had a liver biopsy performed,
which showed evidence of venous outflow obstruction. He
underwent venograms x 2 the first, as above, that didn't show
venous outflow obstruction, the second with dilation of the
caval anastomosis with subsequent improvement in ascites but not
liver function tests. Bilirubin has remained elevated since
[**12-19**]. He has had 2 hepatic cholangiograms (one with a
dilatation of the hepatico-jejunostomy) with a PTC drain left in
place for 3 days and subsequently removed in [**2186-1-8**]. OSH
brushings have grown VRE in the past. He was recently treated
for acute cholangitis with a 10 day course of ertapenam and
daptomycin. Of note the patient was admitted on [**2186-2-8**] where he
underwent IVC angiogram with subsequent angioplasty.
.
ROS: + per HPI, denies fever, 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:
- HCV cirrhosis c/b SBP, esophageal varices (gr III),
nonocclusive thrombus in the portal vein within the SMV/splenic
confluence and extending into the main portal vein. Mode of
transmission unclear.
- Prostatitis
- BPH
- Left Hydrocele
- Benign lesions in segment II and segment III liver
- Cholelithiasis
- Hypertension
- Anxiety
- Myocarditis
- Inguinal hernia
- Abdominal hernia
- Streptococcus gallolyticus pasteurianus bacteremia (01/[**2185**]).
TTE/TEE on that admission negative. Tx w/ vanc/ceftriaxone ->
nafcillin/ciprofloxacin -> daptomycin/ciprofloxacin.
Social History:
Lives with wife, who works in quality imprrovement at [**Hospital1 **]. Works
in finance at Mass Eye & Ear. Denies tobacco, alcohol (h/o
social drinking), or illicit drug use.
Family History:
Denies any significant illnesses including liver disease. 82
year-old mother generally healthy.
Physical Exam:
ADMISSION EXAM
VS: 97.2 122/80 79 16 100% Ra
GENERAL: Ill appearing M. Comfortable.
HEENT: Sclera icteric. PERRL, EOMI.
NECK: Supple with low JVP
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RRR, S1 S2 clear and of good quality without murmurs, rubs
or gallops. No S3 or S4 appreciated.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use, moving air well and
symmetrically. CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Distended but Soft, + TTP over bilateral lower
quadrants, + hepatosplenomegaly
EXTREMITIES: Warm and well perfused, no clubbing or cyanosis. 2+
[**Location (un) **] bilaterally to knees.
NEURO: CN II-XII intact grossly, Strength 5/5, sensation in tact
to light touch
Discharge Exam:
VS: 98.5, 95, 134/91, 18, 100% RA, FSG 158
Gen: NAD, AOx3
Cards: RRR, no RMG, normal s1 and s2
Pulm: CTAB
Abd: Soft, minimal tenderness, minimal distension, no rebound,
no guarding, stitches and stables in place, no redness or
drainage from wound, drain sites with suture, no drainage
Extrem: Minimal edema
Pertinent Results:
ADMISSION LABS
[**2186-2-13**] 08:20AM BLOOD WBC-2.1*# RBC-3.70*# Hgb-13.1*#
Hct-39.4*# MCV-107* MCH-35.3* MCHC-33.1 RDW-19.7* Plt Ct-143*#
[**2186-2-13**] 08:20AM BLOOD PT-14.1* INR(PT)-1.3*
[**2186-2-13**] 08:20AM BLOOD UreaN-27* Creat-1.5* Na-142 K-3.4 Cl-102
HCO3-22 AnGap-21*
[**2186-2-13**] 08:20AM BLOOD ALT-198* AST-348* AlkPhos-249*
TotBili-52.5*
[**2186-2-13**] 08:20AM BLOOD Albumin-3.9 Calcium-10.5* Phos-3.6 Mg-2.4
[**2186-2-22**] 07:52AM BLOOD Cryoglb-NO CRYOGLO
[**2186-2-15**] 05:45AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE HAV Ab-POSITIVE
[**2186-2-22**] 05:00AM BLOOD C3-102 C4-24
HSV 1 IGG TYPE SPECIFIC AB <0.90 index
HSV 2 IGG TYPE SPECIFIC AB >5.00 H index
Index Interpretation
<0.90 Negative
0.90-1.10 Equivocal
>1.10 Positive
.
URINE
[**2186-2-13**] 02:52PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-LG Urobiln-2* pH-6.0 Leuks-NEG
[**2186-2-13**] 02:52PM URINE RBC-1 WBC-0 Bacteri-MOD Yeast-NONE Epi-0
.
ASCITES
[**2186-2-20**] 06:11PM URINE Eos-NEGATIVE
[**2186-2-24**] 03:17PM ASCITES WBC-400* RBC-[**Numeric Identifier 30228**]* Polys-7* Lymphs-9*
Monos-40* NRBC-2* Mesothe-3* Macroph-39*
.
MICROBIOLOGY
Blood cultures 2/6, [**2-14**], [**2-20**]- no growth
[**2186-2-23**] 10:35 am BLOOD CULTURE
Blood Culture, Routine (Preliminary):
ENTEROBACTER CLOACAE COMPLEX. FINAL SENSITIVITIES.
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROBACTER CLOACAE COMPLEX
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Anaerobic Bottle Gram Stain (Final [**2186-2-23**]):
Reported to and read back by [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 30229**] @ 2343 ON [**2-23**]
- FA10.
GRAM NEGATIVE ROD(S).
Blood cultures 2/17, [**2-25**], [**2-26**]- Negative
.
Urine culture- [**2-13**], [**2-20**], [**2-23**]- No growth
.
FECAL CULTURE (Final [**2186-2-16**]): NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final [**2186-2-16**]): NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final [**2186-2-15**]):
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2186-2-15**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2186-2-27**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
.
RPR- non reactive
.
CMV IgG ANTIBODY (Final [**2186-2-17**]):
NEGATIVE FOR CMV IgG ANTIBODY BY EIA.
<4 AU/ML.
Reference Range: Negative < 4 AU/ml, Positive >= 6 AU/ml.
CMV IgM ANTIBODY (Final [**2186-2-17**]):
NEGATIVE FOR CMV IgM ANTIBODY BY EIA.
INTERPRETATION: NO ANTIBODY DETECTED.
Greatly elevated serum protein with IgG levels >[**2174**] mg/dl
may cause
interference with CMV IgM results.
CMV Viral Load (Final [**2186-2-16**]):
CMV DNA not detected.
Performed by PCR.
Detection Range: 600 - 100,000 copies/ml.
[**2186-2-24**] 3:17 pm PERITONEAL FLUID PERITONEAL FLUID.
GRAM STAIN (Final [**2186-2-24**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
STUDIES
[**2186-2-13**]- CT Abdomen Pelvis
1. Normal post-surgical appearance of the liver. No focal
lesions to suggestabscess formation.
2. Mild intrahepatic pneumobilia, likely secondary to recent
percutaneous
biliary instrumentation.
3. Unchanged splenomegaly and extensive varices.
4. Mesenteric edema with engorged vessels and a small amount of
free ascitic fluid. No organized fluid collection to suggest
abscess.
5. Areas of bowel wall thickening in the duodenum, terminal
ileum, cecum, and ascending colon, most severe in the right
colon. These findings may be
secondary to third spacing from extensive edema, however, other
infectious and inflammatory etiologies should also be
considered.
CXR [**2186-2-19**]
Bibasilar areas of linear opacities representing atelectasis,
slightly
progressed since the prior study also might be attributed to
lower lung
volumes. Aspiration might be another possibility given the
interval placement of the Dobbhoff tube with its tip being in
the stomach. Upper lungs are clear. There is no appreciable
pleural effusion or pneumothorax.
RUS [**2186-2-21**]
IMPRESSION: Normal renal son[**Name (NI) **]. [**Name2 (NI) **] hydronephrosis.
Liver US [**2186-2-23**]
1. Patent hepatic vasculature.
2. Unremarkable appearance of the liver with no biliary
dilatation
identified.
3. Splenomegaly and small amount of ascites.
[**2186-2-28**] Peritoneal Fluid Cytology
NEGATIVE FOR MALIGNANT CELLS
[**2186-3-6**] Liver U/s
IMPRESSION:
1. Elevated velocity in the main portal vein at the presumed
area of
anastomosis seen on [**2186-3-3**] exam has normalized.
2. Small heterogeneously echogenic focus adjacent to falciform
ligament may represent small postoperative hematoma.
3. Hepatic hemangioma, as described above.
.
[**2186-3-10**] EKG:
Sinus rhythm at lower limits of normal rate. Q waves in leads I
and aVL
of uncertain significance. Borderline intraventricular
conduction delay.
Since the previous tracing of [**2186-3-9**] there is now less artifact.
.
[**2186-3-11**] Liver U/s
IMPRESSION:
1. Stable appearance of the transplant liver with a small
hematoma at the
site of falciform ligament.
2. Patent hepatic vasculature, with appropriate directional flow
and
waveforms.
[**2186-3-8**] Stool c Diff: negative
[**2185-3-12**] BCx: Negative
[**3-14**]/as UCx: Negative
Discharge (or otherwise recent) labs:
[**2186-3-19**] 06:44AM BLOOD WBC-4.1 RBC-3.09* Hgb-9.6* Hct-28.1*
MCV-91 MCH-31.0 MCHC-34.1 RDW-18.4* Plt Ct-327
[**2186-3-19**] 06:44AM BLOOD Plt Ct-327
[**2186-3-12**] 04:58AM BLOOD PT-12.2 PTT-27.3 INR(PT)-1.1
[**2186-3-19**] 06:44AM BLOOD Glucose-84 UreaN-45* Creat-1.8* Na-140
K-5.4* Cl-107 HCO3-27 AnGap-11
[**2186-3-19**] 06:44AM BLOOD ALT-68* AST-40 AlkPhos-144* TotBili-2.6*
[**2186-3-19**] 06:44AM BLOOD Calcium-8.2* Phos-2.0* Mg-1.5*
[**2186-3-18**] 05:30AM BLOOD Albumin-2.3*
[**2186-3-18**] 05:30AM BLOOD tacroFK-8.4
[**2186-3-17**] 05:05AM BLOOD tacroFK-12.7
[**2186-3-16**] 05:20AM BLOOD tacroFK-11.8
[**2186-3-14**] 01:38AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.010
[**2186-3-14**] 01:38AM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-70 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2186-3-14**] 01:38AM URINE RBC-1 WBC-1 Bacteri-FEW Yeast-NONE Epi-0
Brief Hospital Course:
Mr. [**Known lastname 30226**] is a 55 yo male w/ h/o HCV cirrhosis s/p transplant
x 2 (1st transplant c/b primary graft failure believed to be due
to small-for size syndrome), course c/b biliary obstruction s/p
PTC/dilation at [**Hospital1 1774**], outflow obstruction s/p IVC dilation at
[**Hospital1 18**] on [**2186-2-8**]. He was readmitted to [**Hospital1 18**] with low grade
temperature, nausea, abdominal cramps initiatally attributed to
cholangitis given recent decompensation with discontinuation of
antibiotics. Meropenam and daptomycin were empirically started
then discontinued after a few days when pain lessened and
cultures remained negative. C.diff were negative, CT showed
intestional thickening c/w edema, stool studies were negative
and CMV VL was negative. Abdominal distension increased and
diagnostic paracentesis was negative for SBP x 2. Ultimately,
Enterobacter was isolated from one set of blood cultures. This
was pan-sensitive and Zosyn was started.
Admission creatinine increased from 1.5 to 7.2. FeNa was c/w
pre-renal etiology, however, this did not respond to fluid
challenge or albumin. Renal US was negative. Urine eosinophils
were negative which argued against cyclosporine toxicity.
Nephrology felt he had HRS. Octreotide and midodrine were
initiated without response. A temporary hemodialysis catheter
was placed. Cyclosporine was held.
Mental status worsened and this was attributed to uremia and
hepatic encepholopathy. ID was consulted and recommended
continuation of Zosyn. Repeat blood cultures remained negative.
Hct then decreased from 32 to 23. No active source of bleeding
was ever identified. Stools were brown and blood tinged which
was attributed to hemorrhoidal bleeding. Smear was without
evidence of schistiocytes. Anemia was believed from some
hemolysis and splenic sequestration. On [**2-26**] he had 2 episodes
of coffee ground emesis. PPI and PRBC were given and he was
transferred to the SICU. Meld was elevated >40. He was re-listed
for liver transplant and was re-activated when blood cultures
cleared.
On [**2186-3-2**], an AB liver donor was offered and accepted
(patient's blood type is A). Plasmapheresis was performed preop
then he underwent orthotopic liver transplant with splenectomy
with placement of 3 [**Doctor Last Name 406**] drains, 1 behind the right lobe, 1
behind the porta hepatis and 1 in the left upper quadrant. He
required massive transfusions and Cellsaver. Surgeon was Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Please refer to operative report for details.
Postop, he went to the SICU postop intubated. Daily anti B
titers ranged between negative and 1. No further plasmapheresis
was done. A total of 7 doses of ATG were given per ABO
incompatible protocol. CVVHD was continued. He was extubated
without event. A feeding tube was place for nutrition and tube
feeds were started. LFTs decreased. Liver duplex was WNL. JP
outputs were bloody. He required blood products to mantain
hemostatis for the first few days. CVVHD was stopped on postop
day 5. He was transferred out of the SICU after 9 days. He
required no further hemodialysis and once it was determined he
no longer required plasmapheresis or hemodiaysis the catheter
was removed.
Urine output increased and creatinine decreased to a low of 2.1
then increased up to 3.4 likely due to elevated Prograf level of
19. Prograf was held for a couple doses and creatinine
decreased. 2 days prior to discharge he was restarted on his
home lasix dose of 40 mg daily which was well tolerated. UOP
has been great since that time.
He was broadly covered with Linezolid and Meropenum. Linezolid
was stopped after 5 days and Meropenum after 11 days. He
remained afebrile and other vital signs were stable. Drains were
removed. Incision remained intact without redness or drainage.
No other signs of infection.
Immunosuppression consisted of ATG (7 doses), Cellcept, steroid
taper and prograf. Prograf dose was adjusted per level. He was
sent on 0.5 mg [**Hospital1 **] of prograf. This level may be adjusted
fairly frequently. Labs should be checked every Monday and
Thursday with results fax'd to [**Hospital1 18**] Transplant Center
fax:[**Telephone/Fax (1) 697**], attention RN coordinator, [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 23170**]:
[**Telephone/Fax (1) 16242**] so she can coordinate further dose adjustments.
Please see the final med rec (below) for final immunosuppression
regimen. Please also see the final med rec for his prophylactic
antiobiotic regimen which includs fluconazole, bactrim and
valganciclovir.
The patient has been having some anxiety/insomnia at night. He
was deemed safe to receive 0.5 mg Ativan at night to alleviate
this. We do not recommend any higher levels of benzodiazpeines.
Food intake improved, however, Kcals were not sufficient and
tube feeds were continued. Glucoses were elevated to the 400s.
[**Last Name (un) **] consult was obtained. Insulin gtt was required then
switched to SQ NPH and scheduled regular with improved control
(glucoses decreased to low 200s). Please see final med rec for
final insulin regimen and sliding scale.
His pain has been well controlled with oxycodone. PT worked
with him and recommended rehab. A bed was available at [**Hospital1 **]
[**Location (un) 1110**]. He will transfered there.
He has a follow up appointment on [**2186-3-23**] with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **], his attending surgeon, at which time Dr. [**First Name (STitle) **] will
provide further guidance of his care.
Please note - The patient was sent on 0.5 mg Tacrolimus [**Hospital1 **].
When his level returned on [**2186-3-19**] (post discharge) it was 7.6.
We decided to increase his Tacrolimus to 1 mg [**Hospital1 **] and have his
labs checked again Monday. [**Hospital1 **] in [**Location (un) 1110**] was called
regarding this medication change.
Medications on Admission:
- cyclosporine 125 mg PO Q12H
- omeprazole 20 mg PO DAILY
- tamsulosin 0.4 mg PO HS
- valganciclovir 900 mg PO Q24H
- multivitamin PO DAILY
- furosemide 40 mg PO DAILY
- magnesium oxide 400 mg PO three times a day.
- calcium carbonate-vitamin D3 600mg(1,000mg)-1,000 unit PO BID
- ursodiol 300 mg PO BID
Discharge Medications:
1. fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
2. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
3. prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
5. white petrolatum-mineral oil 56.8-42.5 % Ointment Sig: One
(1) Appl Ophthalmic PRN (as needed) as needed for dry eyes.
6. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) ml
Injection TID (3 times a day).
7. mycophenolate mofetil 500 mg Tablet Sig: One (1) Tablet PO
QID (4 times a day).
8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
9. Zaditor 0.025 % Drops Sig: One (1) drop Ophthalmic Q12 PRN
() as needed for dry eyes: both eyes.
10. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
12. valganciclovir 450 mg Tablet Sig: One (1) Tablet PO EVERY
OTHER DAY (Every Other Day).
13. oxycodone 5 mg Tablet Sig: 0.5-1 Tablet PO Q4H (every 4
hours) as needed for pain.
14. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain: no more than 2000mg a day.
15. NPH insulin human recomb 100 unit/mL Suspension Sig: Thirty
Seven (37) units Subcutaneous Qam: am dose.
16. NPH insulin human recomb 100 unit/mL Suspension Sig: Twenty
(20) units Subcutaneous with dinner: Given with dinner
.
17. insulin regular human 100 unit/mL Solution Sig: Ten (10)
units Injection every six (6) hours: Sub cutaneous.
18. insulin regular human 100 unit/mL Solution Sig: follow
sliding scale Injection four times a day: in addition to
scheduled regular insulin.
19. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
20. tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO twice a
day: To be given at 6 am and 6 pm daily and adjusted regularly
according to levels by transplant clinic.
21. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for anxiety/insomnia.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 1110**]
Discharge Diagnosis:
Abdominal pain
HRS
Hyperbilirubinemia
malnutrition
hyperglycemia
Hepatitis C
Liver transplant
History of prior liver transplant
History of cholangitis
Portal Vein Thrombosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. [**Known lastname 30226**],
Please call the Transplant Office [**Telephone/Fax (1) 673**] if patient has
any of the following: temperature of 101 or greater, shaking
chills, nausea, vomiting,jaundice, inability to take
medications, increased abdominal/incision pain, incision
redness/bleeding/drainage, constipation/diarrhea, decreased
urine output, edema or weight gain of 3 pounds in a day,
malfunction of feeding tube.
-patient may shower, no tub baths or swimming
-no heavy lifting/straining
-Labs to be drawn every Monday and Thursday and faxed to [**Hospital1 18**]
Thank you for letting us participate in your care. We wish you
a speedy recovery.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2186-3-23**] 1:45
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 14254**], [**Name12 (NameIs) 1046**] Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2186-3-23**] 3:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2186-3-30**] 2:45
|
[
"787.91",
"263.9",
"790.7",
"283.9",
"287.5",
"041.85",
"572.3",
"401.9",
"276.2",
"600.00",
"455.6",
"V12.51",
"518.82",
"289.52",
"456.0",
"576.2",
"780.52",
"996.82",
"790.29",
"572.4",
"E878.0",
"571.5",
"782.4",
"789.59",
"537.89",
"300.00",
"070.44",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"54.91",
"00.14",
"38.95",
"96.6",
"96.04",
"39.95",
"99.71",
"38.91",
"38.93",
"50.59",
"41.5",
"00.93",
"96.72",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
20828, 20911
|
12296, 18246
|
315, 391
|
21129, 21129
|
4487, 5853
|
22004, 22483
|
3269, 3366
|
18602, 20805
|
20932, 21108
|
18272, 18579
|
21313, 21981
|
3381, 4144
|
5897, 8919
|
4160, 4468
|
252, 277
|
419, 2468
|
9002, 12273
|
21144, 21289
|
2490, 3059
|
3075, 3253
|
8951, 8966
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,581
| 150,577
|
5081
|
Discharge summary
|
report
|
Admission Date: [**2127-9-8**] Discharge Date: [**2127-9-14**]
Date of Birth: [**2061-6-5**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Sulfonamides / Sulfasalazine / Ace Inhibitors
Attending:[**First Name3 (LF) 2988**]
Chief Complaint:
L45 spondylolisthesis with spinal stenosis
Major Surgical or Invasive Procedure:
s/p L4-S1 lami/fusion with instrumentation [**2127-9-8**]
History of Present Illness:
66 y.o. female with significant spinal stenosis with flexion and
spinal stenosis that has worsened since [**2126**].
Past Medical History:
cardiomyopathy,
asthma,
gerd,
htn,
ocd,
oa,
uc,
c. diff infections
Social History:
Married, lives with husband. [**Name (NI) **] does not smoke; patient
does drink. Family history is non-contributory. Patient worked
as a social worker
Family History:
non-contributory
Physical Exam:
The patient sits upright flexed forward, in mild distress, in
good spirits, and is alert and oriented X3. Patient is afebrile.
Heart rate is 76 and regular in rhythm, the respiratory rate is
12 and is in good general health. The gait is halting and
antalgic. Spine/Pelvis: Spine is straight but with kyphosis.
Patient tolerated forward flexion to 50 and extension to -10.
Discomfort is improved with flexion and increased extension, and
unchangedwith palpation of the back. There is no sign of
instability and the muscle strength and tone are within normal
limits. Straight leg raises are negative; [**Doctor Last Name **] tests are
negative. Skin is intact. Lower Extremities: Palpation does not
result in any pain. ROM of hips, knees, and ankles is full and
painless. Hip impingement signs are negative bilaterally; knee
is stable to manipulation. Lower extremity motor strength is [**5-24**]
and symmetric at IP, Q, H, TA, [**Last Name (un) 938**], FHL, and GC. Patellar and
ankle jerks are 2+ and 0 symmetric. Skin is intact bilaterally.
Sensation is intact to light touch bilaterally in the upper and
lower extremities. Distal pulses are intact with good distal
capillary refill
Pertinent Results:
[**2127-9-11**] 03:44AM BLOOD WBC-10.2 RBC-3.05* Hgb-10.2* Hct-29.7*
MCV-97 MCH-33.6* MCHC-34.5 RDW-15.5 Plt Ct-157
[**2127-9-10**] 04:26PM BLOOD WBC-9.3 RBC-2.90* Hgb-9.6* Hct-28.3*
MCV-98 MCH-33.0* MCHC-33.8 RDW-15.7* Plt Ct-146*
[**2127-9-9**] 07:25AM BLOOD WBC-12.2* RBC-3.10* Hgb-10.1* Hct-31.1*
MCV-100* MCH-32.7* MCHC-32.6 RDW-15.5 Plt Ct-235
[**2127-9-8**] 05:34PM BLOOD WBC-10.6# RBC-3.46* Hgb-11.6* Hct-34.4*
MCV-99* MCH-33.5* MCHC-33.7 RDW-15.5 Plt Ct-211
Brief Hospital Course:
[**2127-9-8**] L4-S1 post fusion with instrumentation. Surgery went
without incident. See Op note for further details. Abx x 24
hours. Epidural placed. Management per APS.
POD 1- HV/Epidural d/c'd, transitioned to PO pain meds without
issue, + BS, AVSS
POD 2- Med consult requested secondary to Hypotensive episode.
Pt triggered at that time. Med team requested SICU eval. Pt
transferred to SICU for evaluation. UA/CXR negative. EKG
unremarkable. Pt started on Ceftriaxone/Vanco while studies
pending.
POD 3- Pt remained stable while in SICU with BP 130's/70's.
Transferred back to Ortho for further treatment. No obvious
source of hypotensive episode, likely due to hypovolemia. Pt
remained medically stable and ready for d/c.
Medications on Admission:
asacol, atenolol, diovan, flonase, flovent, klonopin, lipitor,
mobic, nexium, prozac, trazodone, ultram
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
L4/5 spondylolisthesis, L5/S1 HNP
Discharge Condition:
good
Discharge Instructions:
Activity as tolerated. No heavy lifting, bending, twisting.
Physical Therapy:
Activity: Activity as tolerated. No heavy lifting, bending,
twisting. Out of bed w/ assist
Treatments Frequency:
Back: DSD QD
[**Month (only) 116**] leave open to air as of [**2127-9-15**]
Followup Instructions:
f/u with Dr[**Name (NI) 2989**] office in 2 weeks. [**Telephone/Fax (1) 20921**]
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD, [**MD Number(3) 2991**]
Completed by:[**2127-10-1**]
|
[
"425.4",
"493.20",
"556.9",
"301.4",
"724.02",
"276.52",
"722.10",
"401.9",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.08",
"81.62",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
3444, 3527
|
2561, 3290
|
352, 412
|
3605, 3612
|
2070, 2538
|
3930, 4151
|
833, 851
|
3548, 3584
|
3316, 3421
|
3636, 3696
|
866, 2051
|
3714, 3808
|
3830, 3907
|
270, 314
|
440, 558
|
580, 648
|
664, 817
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,670
| 175,857
|
50094
|
Discharge summary
|
report
|
Admission Date: [**2196-1-3**] Discharge Date: [**2196-1-9**]
Date of Birth: #14 Sex: M
Service: Trauma
HISTORY OF PRESENT ILLNESS: The patient is a 41-year-old
male who presents with a stab wound to the left upper
quadrant and protruding bowel. The patient was
hemodynamically stable on transfer although slightly
tachycardic to the 120's. He was complaining of abdominal
pain and has had no loss of consciousness and also had a blow
to his head.
PAST MEDICAL HISTORY: Significant for Crohn's disease,
status post total abdominal colectomy with ileostomy at age
16, history of alcohol abuse, a left shoulder injury, history
of TB and history of depression.
MEDICATIONS: On admission include Prednisone 10 mg q d,
Neurontin, Buspar, Klonopin and Paxil.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: The patient has a heart rate of 130,
blood pressure 110/palp. His physical exam is remarkable for
a 4 cm laceration in his left upper quadrant with bowel
sticking out of the wound. The patient's hematocrit on
admission was 34. Chest x-ray showed no pneumothorax. IV
access was obtained.
HOSPITAL COURSE: The patient was typed and screened and he
was immediately transferred to the operating room for a
laparotomy. The patient underwent an exploratory laparotomy
[**1-3**] which showed that there was no injury to the underlying
bowel. The laparotomy incision was closed and the patient
was transported stable to the post anesthesia care unit.
Postoperative course was complicated by immediate
reintubation in the PACU secondary to bronchospasm.
Patient's postoperative course was also complicated by an
increasing fluid requirement with marginal urine output and
low blood pressure. After significant IV fluid resuscitation
of about 10 liters, it was decided that further investigation
should be performed and a Swan Ganz was placed which showed
adequate hemodynamics. An abdominal CT was obtained on
postoperative day #1 which showed no missed injuries. It was
essentially an unremarkable abdominal CT. TEE was performed
to make sure that the patient had no tamponade or evidence of
a cardiac dysfunction. The TEE was also unremarkable. On
postoperative day #2 the patient started to improve and he
started to make adequate amounts of urine. His extubation
was made difficult by problems with sedation. On
postoperative day #4 when the patient was doing well, he was
placed on a drip and subsequently extubated. The patient
tolerated extubation well and was placed on clear liquids
which he tolerated well. After it was deemed that the
patient was stable to exit the Intensive Care Unit, he was
then transferred to [**Hospital 1475**] Hospital after the correction
staff preferences.
DISCHARGE DIAGNOSIS:
1. Stab wound, status post exploratory laparotomy.
2. Crohn's disease.
3. Status post total abdominal colectomy with ileostomy.
4. History of alcohol abuse.
5. Depression.
The patient will be discharged on the following medications:
He should get Solu-Medrol 10 mg IV q 12 hours until [**2196-1-9**].
Afterwards he should be switched to his normal Prednisone
dosage of 10 mg po q d. The patient should be on Heparin
5000 units subcu [**Hospital1 **], ambulating adequately. He should be on
Zantac 150 mg po bid. He should be on Percocet 1-2 tabs po q
4-6 hours prn if tolerating po. He should be on Neurontin
300 mg po qid, Klonopin .5 mg po q h.s. and Paxil 60 mg po q
d.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 6066**]
Dictated By:[**Last Name (NamePattern1) 40667**]
MEDQUIST36
D: [**2196-1-8**] 16:47
T: [**2196-1-8**] 19:24
JOB#: [**Job Number 104585**]
|
[
"788.20",
"E956",
"868.13",
"518.5",
"959.01",
"997.5",
"V55.3",
"555.9",
"458.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"54.11",
"38.91",
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
2774, 3730
|
1159, 2753
|
849, 1141
|
160, 479
|
502, 826
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,466
| 146,483
|
11089
|
Discharge summary
|
report
|
Admission Date: [**2111-5-4**] Discharge Date: [**2111-5-8**]
Date of Birth: [**2068-7-21**] Sex: F
Service: [**Last Name (un) **]
ADMISSION DIAGNOSIS: A 42-year old female with right breast
cancer proven by core biopsy.
PROCEDURE: Right modified radical mastectomy with
reconstruction.
HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname **] is a 42-year-old
woman who was found to have a right breast abnormality on a
core breast biopsy on [**2111-3-17**] following an abnormal
mammogram. Pathologic review of that specimen showed it to be
infiltrating ductal carcinoma with grade III necrosis. Tumor
cells were noted to be negative for estrogen and progesterone
and were positive for Herceptin overexpression. The patient
does have a prior history of right breast cancer in [**2107**], at
which time a 1-cm mass was removed. She was node negative.
Following that, she [**Year (4 digits) 1834**] both chemo and radiation
therapy.
PAST MEDICAL/SURGICAL HISTORY: The patient has had a left
ATL repair.
PAST MEDICAL HISTORY: None other than the above.
MEDICATIONS: Ativan 0.5 mg p.r.n., Effexor 75 mg daily.
ALLERGIES: MORPHINE.
PHYSICAL EXAMINATION UPON PRESENTATION: The patient was
described as a healthy-appearing Caucasian female in no acute
distress. Her temperature was 98.8, blood pressure was
102/67, pulse was 63, height of 5 feet 5 inches, weight of
178. Pupils were equal and reactive to light. Cranial nerves
II through XII were intact. The lungs were clear to
auscultation bilaterally. Cardiac examination was
unremarkable. Right breast showed a prior incision, well
healed.
BRIEF HOSPITAL COURSE: On [**2111-5-4**] Ms. [**Known lastname **]
[**Last Name (Titles) 1834**] a right modified radical mastectomy of her right
breast. This was followed by a plastic surgery breast
reconstruction with a SIEA technique. The patient also
[**Last Name (Titles) 1834**] a left breast reduction. The patient reportedly
tolerated the procedure very well and was taken to the post
anesthesia care area. There, here temperature was 100. Pain
was well controlled with p.r.n. morphine. The first night
following the operation, postoperative day 1, was spent in
the intensive care unit for every 15-minute flap appraisals.
Throughout this period the flap appeared healthy with both
normal capillary refill and dopplerable arterial and venous
signals. On postoperative day 2, the patient was in a normal
floor room. She was tolerating a regular diet, and analgesia
was ultimately converted to oral medication. The following
day, after a final evaluation of her flap by the plastic
surgery team, it was felt that there had been a shift in the
Doppler signal from her flap pedicle. Given this change in
her exam it was felt necessary to hold her overnight for an
additional night of observation. The following morning the
flap was once again noted to be pink and healthy appearing
with good capillary refill and no signs of any venous
congestion or necrosis. After final examination by the
attending plastic surgeon and attending breast surgeon, it
was deemed that the patient was a good candidate for
discharge.
DISCHARGE FOLLOWUP: The patient will follow up with Dr.
[**Last Name (STitle) 11635**] in 1 to 2 weeks. The patient will also follow up
with Dr. [**First Name (STitle) **] in 1 to 2 weeks.
DISCHARGE DISPOSITION: The patient was discharged to home in
the care of her family.
CONDITION ON DISCHARGE: The patient is in stable condition.
She leaves with 2 drains in place. She has been trained on
how to empty those drains and record the output. These will
be assessed for possible removal at her first follow-up visit
with Dr. [**First Name (STitle) **].
MEDICATIONS ON DISCHARGE: The patient is discharged on all
of her home medications in addition to aspirin 162 mg p.o.
daily, Percocet 1 to 2 tablets q.4-6h. p.r.n., Keflex 500 mg
p.o. q.6h., and Colace 100 mg p.o. b.i.d. while taking
narcotics.
[**Name6 (MD) 17486**] [**Name8 (MD) 11635**], [**MD Number(1) 18026**]
Dictated By:[**Last Name (NamePattern1) 9178**]
MEDQUIST36
D: [**2111-5-8**] 10:23:06
T: [**2111-5-8**] 11:31:44
Job#: [**Job Number 35802**]
|
[
"174.4",
"311",
"V45.71"
] |
icd9cm
|
[
[
[]
]
] |
[
"85.7",
"85.43",
"85.31"
] |
icd9pcs
|
[
[
[]
]
] |
3358, 3421
|
1647, 3143
|
3728, 4192
|
174, 312
|
3164, 3334
|
341, 1029
|
1052, 1623
|
3446, 3701
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,871
| 165,868
|
39782
|
Discharge summary
|
report
|
Admission Date: [**2200-9-7**] Discharge Date: [**2200-9-16**]
Date of Birth: [**2138-4-22**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Doctor Last Name 1350**]
Chief Complaint:
MVC
Major Surgical or Invasive Procedure:
C3-C5 Posterior Cervical Decompression and Fusion
History of Present Illness:
The patient is a 62-year-old male who was
brought by ambulance to [**Hospital1 18**] on [**2200-9-6**]. Initially,
he exhibited normal neurological function, but had bilateral
upper extremity pain and numbness. He was intubated to
undergo MRI studies. MRI demonstrated spinal cord contusion
at C3-C4, as well as a disk rupture of C4-C5, with ongoing
stenosis C3-C4, C4-C5. Once intubated his sedation was lightened
so he could undergo a neurological examination. He demonstrated
progressive upper extremity weakness, he did move his lower
extremities without difficulty, he was unable to use his arms.
Due to the severity of history, the progressive nature of the
neurological status, the ongoing stenosis, and instability of
his clinical scenario he elected to undergo surgical treatment.
Past Medical History:
Prostate cancer
Hypertension
Pyloric stenosis
Social History:
n/a
Family History:
n/a
Physical Exam:
AVSS
Well appearing, NAD, comfortable
Inc c/d/i
BUE: SILT C5-T1 dermatomal distributions
BUE: [**3-14**] [**Doctor First Name **]. [**4-11**] Tri/Bic. [**3-14**] WE. 0/5 WF/FF/IO
BUE: slightly increased tone in BUE, negative [**Doctor Last Name 937**], 2+
symmetric DTR bic/bra/tri
All fingers WWP, brisk capillary refill, 2+ distal pulses
BLE: SILT L1-S1 dermatomal distributions
BLE: [**6-11**] IP/Qu/HS/TA/GS/[**Last Name (un) 938**]/FHL/Per
BLE: tone normal, no clonus, toes downgoing, 2+ DTR knee/ankle
All toes WWP, brisk capillary refill, 2+ distal pulses
Brief Hospital Course:
Patient was admitted to the [**Hospital1 18**] Spine Surgery Service and
taken to the Operating Room for the above procedure. Refer to
the dictated operative note for further details. The surgery
was without complication and the patient was transferred to the
ICU where he remained intubated for 2 days postop.
TEDs/pnemoboots were used for postoperative DVT prophylaxis.
Intravenous antibiotics were continued for 24hrs postop per
standard protocol. The patient was successfully extubated
without difficulty and was transferred to the floor from the
ICU. Diet was advanced as tolerated. The patient was
transitioned to oral pain medication when tolerating PO diet.
Foley was removed, and the patient was able to void. The
patient was maintained in a hard c-collar. He was evaluated by
speech and swallowing in his c-collar, and he passed the exam
beign cleared for a regular diet. Physical and occupational
therapy was consulted for mobilization OOB to ambulate and for
ADLs. On the day of discharge the patient was afebrile with
stable vital signs, comfortable on oral pain control and
tolerating a regular diet.
Medications on Admission:
Lisinopril 40 mg Daily
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
2. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain: Do not drink alcohol or drive while taking
this medication.
Disp:*120 Tablet(s)* Refills:*0*
3. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for spasm: Do not drink alcohol or drive while
taking this medication.
Disp:*60 Tablet(s)* Refills:*0*
4. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every four
(4) hours as needed for temp>100, headache, pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 25750**]
Discharge Diagnosis:
Central Cord Syndrome
Discharge Condition:
Stable, alert and oriented, working towards ambulation.
Discharge Instructions:
Activity: You should not lift anything greater than 10 lbs for 2
weeks. You will be more comfortable if you do not sit in a car
or chair for more than ~45 minutes without getting up and
walking around.
- Rehabilitation/ Physical Therapy:
o 2-3 times a day you should go for a walk for 15-30 minutes as
part of your recovery. You can walk as much as you can
tolerate.
o Isometric Extension Exercise in the collar: 2x/day x 10 times
perform extension exercises as instructed.
- Cervical Collar / Neck Brace: You need to wear the brace at
all times until your follow-up appointment which should be in 2
weeks. You may remove the collar to take a shower. Limit your
motion of your neck while the collar is off. Place the collar
back on your neck immediately after the shower.
- Wound Care: Remove the dressing in 2 days. If the incision is
draining cover it with a new sterile dressing. If it is dry
then you can leave the incision open to the air. Once the
incision is completely dry (usually 2-3 days after the
operation) you may take a shower. Do not soak the incision in a
bath or pool. If the incision starts draining at anytime after
surgery, do not get the incision wet. Call the office at that
time. If you have an incision on your hip please follow the same
instructions in terms of wound care.
- You should resume taking your normal home medications.
- You have also been given Additional Medications to control
your pain. . Please allow 72 hours for refill of narcotic
prescriptions, so please plan ahead. You can either have them
mailed to your home or pick them up at the clinic located on
[**Hospital Ward Name 23**] 2. We are not allowed to call in narcotic prescriptions
(oxycontin, oxycodone, percocet) to the pharmacy. In addition,
we are only allowed to write for pain medications for 90 days
from the date of surgery.
Physical Therapy:
No heavy lifting. Please help with mobility and adaptive
services.
Treatments Frequency:
Please help with mobility and adaptive services.
Followup Instructions:
Patient needs follow-up in [**7-19**] months with PCP for repeat chest
CT to monitor 6-mm nodule in the right upper lobe.
|
[
"E812.0",
"952.03",
"952.08",
"V10.46",
"336.1",
"401.9",
"336.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"02.94",
"81.62",
"81.03"
] |
icd9pcs
|
[
[
[]
]
] |
3765, 3813
|
1909, 3034
|
322, 374
|
3879, 3937
|
5991, 6115
|
1301, 1306
|
3107, 3742
|
3834, 3858
|
3060, 3084
|
3961, 4182
|
1321, 1886
|
5829, 5896
|
5918, 5968
|
279, 284
|
4753, 5811
|
402, 1195
|
1217, 1264
|
1280, 1285
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,719
| 161,849
|
50774
|
Discharge summary
|
report
|
Admission Date: [**2142-11-7**] Discharge Date: [**2142-11-23**]
Date of Birth: [**2090-6-14**] Sex: F
Service:
HISTORY OF THE PRESENT ILLNESS: The patient is a 52-year-old
female with short gut syndrome, status post ileal colectomy
for volvulus in [**2120**] who is chronically TPN dependent and has
TPN-induced liver failure. The patient was found by her
husband on the couch the morning of admission looking ill.
The patient stated that she was dizzy, unable to ambulate.
She denied fevers and chills but did complain of abdominal
pain as well as nausea and vomiting on the day of admission.
The patient was also confused and lethargic with much change
from her baseline. EMS was called. The patient was found to
have a blood pressure of 70/palpable, heart rate 86.
The patient was taken to an outside hospital ER where she was
placed on oxygen, given ceftriaxone, hydrocortisone, and 2
liters of intravenous fluids. She received an abdominal CT
that was unremarkable and was transferred to [**Hospital1 18**] for
further management.
PAST MEDICAL HISTORY:
1. Multiple sclerosis which has presented with recurrent
optic neuritis.
2. Ileal colectomy done in [**2120**] secondary to volvulus.
3. TPN dependent.
4. Degenerative joint disease.
5. Osteoporosis.
6. Multiple DVTs.
7. Progressive liver failure. At the time of admission, the
patient was waiting to receive liver and small bowel
transplant.
8. Anemia with a normal bone marrow biopsy.
9. Status post appendectomy, cholecystectomy, and
tonsillectomy.
10. Multiple line infections and episodes of sepsis.
ALLERGIC: The patient is allergic to paper tape, Betadine,
and also reports penicillin causes her GI upset. She has an
allergy to IV contrast, allergy to Demerol, Streptokinase,
and Flagyl which causes nausea.
ADMISSION MEDICATIONS:
1. Calderol 20 micrograms q.d.
2. Celexa 40 mg q.d.
3. Codeine 60 mg five times a day.
4. Lactase.
5. Levofloxacin 250 mg q.d. of unclear duration.
6. Prednisone 10 mg q.d.
7. Prilosec 40 mg q.i.d.
8. Propanolol 120 mg p.o. q.d.
9. Ritalin 10 mg q.d.
10. Serax 10 mg up to five times a day p.r.n.
11. TPN.
MEDICATIONS ON TRANSFER:
1. Ceftriaxone.
2. Dopamine.
3. Hydrocortisone.
PHYSICAL EXAMINATION: On transfer to the MICU, the patient
had a blood pressure of 95/40 on 15 micrograms of dopamine, a
pulse in the 90s, saturating 100% on 50% face mask,
temperature 99.5. The patient's skin was remarkable for a
very striking yellow-green color. HEENT: Remarkable for a
supple neck, marked conjunctival and scleral icterus and
blindness. The lungs had scattered bibasilar crackles but no
dullness to percussion. Cardiovascular: Normal S1, S2, no
murmurs. She did have a left ventricular lift. Abdomen:
Minimal bowel sounds, firm, moderate to severe tenderness to
palpation everywhere but worse in the lower quadrants. Given
the patient's guarding, it was difficult to assess for
hepatosplenomegaly. The patient had multiple healed surgical
scars. The patient had a Porta-Cath in her chest that was
nontender with no expressible pus. The extremities were
remarkable for bilateral pitting edema in her lower
extremities. The patient's mental status was noted to be
oriented times three but slow with responses. The patient's
rectal examination was heme-negative.
LABORATORY DATA ON ADMISSION: Sodium 136, potassium 2.9,
chloride 98, bicarbonate 24, BUN 27, creatinine 0.8. She had
a white count of 32.6 with a differential of 76 neutrophils,
9 bands, 10 lymphocytes, hematocrit 35.5, and platelets
185,000. Her AST was 832, ALT 1,178, alkaline phosphatase
28, amylase 194, lipase 1,295. Her ammonia level was 51,
albumin 1.6. Her total bilirubin was 21.9. INR 1.16. Her
U/A was unremarkable. The patient's blood gas revealed a pH
of 7.41, PC02 37, P02 87 on 50% face mask with a lactate of
2.1 and an ionized calcium of 0.97.
The patient's CT, as read here, was notable for no ductal
dilatation, no evidence of perforation, only for ascites.
HOSPITAL COURSE: The patient was aggressively fluid
resuscitated on arrival and weaned from the dopamine drip
overnight. The patient was started on broad spectrum
antibiotics including Zosyn and vancomycin. The patient was
evaluated by Surgery who declined intervention at this time
and preferred medical management.
The patient was pan cultured. None of her cultures while she
was in the Intensive Care Unit the first time were positive.
The patient was ultimately felt to have pancreatitis, the
etiology of which was unclear. The patient's pain initially
resolved and the patient was much improved with stable blood
pressures and tolerating p.o. She was transferred out to the
regular medical floor on [**2142-11-12**].
The patient had difficulty with potassium homeostasis on the
floor and a rising white blood cell count; however, minimal
abdominal pain and only low-grade temperatures. Given the
increasing white blood cell count, the patient underwent
repeat abdominal CT which showed a large pancreatic
pseudocyst. At this time, the patient was restarted on
Zosyn.
The patient remained afebrile but did have blood cultures
drawn from her Porta-Cath turn positive for
coagulase-negative Staphylococcus 48 hours after they were
drawn. Given the positive blood culture and the rising white
blood cell count, the attending wished to have the patient's
pseudocyst drained which was done in Interventional Radiology
on [**2142-11-18**]. Gram stain from the drainage of the
pseudocyst was negative for organisms.
After return from the procedure, the patient markedly became
hypotensive to the 80s and had confusion. She was bolused
with 2 liters normal saline and had some improvement;
however, the patient was febrile to 100.3 and given her
hypotension and febrile state, she was transferred back to
the Medical Intensive Care Unit.
In the Medical Intensive Care Unit, the patient was covered
with Zosyn, gentamicin, and vancomycin. The question of
removing the patient's Porta-Cath was discussed with Surgery
and it was felt that the patient had not had any positive
blood cultures since the initiation of vancomycin; therefore,
Staphylococcus epidermidis was unlikely to account for this
patient's hypotensive state. The patient was started on
stress-dose steroids and remained initially stable.
Unfortunately, the patient's white count continued to rise
and her hematocrit began to drop initially from 27.1 down to
24.1. The patient was Guaiac negative from below. It was
unclear what the source of her bleeding was. The patient's
hematocrit dropped as low as 20 and she was given multiple
units of packed red blood cells.
The patient had a diagnostic paracentesis due to concern of
bleeding into her peritoneum secondary to the pseudocyst
drainage; however, this revealed no white blood cells,
minimal red blood cells, and no organisms. The patient's
white count continued to climb and her belly became more
distended and tender. Unfortunately, the patient also
developed increasing coagulopathy and her BUN and creatinine
began to rise. The patient began to experience more
respiratory distress.
Given the increase in belly pain, Surgery was consulted and
declined to do any intervention given the high mortality
associated with taking this patient to the OR. The patient
was managed with antibiotics and packed red blood cells as
possible. However, it was decided after discussion with the
patient's family and the attending that this patient would be
DNR/DNI with no CPR indicated.
The patient continued to deteriorate and complained of
extreme pain. Her breathing became very labored. The
patient began to ask for more morphine. We agreed to give
the patient more morphine and explained that doing so may
actually decrease her drive to breathe and ultimately hasten
her death. The patient understood this and wanted to be
pain-free. We spoke to her husband about this as well and he
agreed with making her comfortable and continuing the
morphine.
The patient was at that time started on a morphine drip,
titrated to comfort. The patient passed away early in the
morning on [**2142-11-23**] and was pronounced at 1:30 a.m.
on [**2142-11-23**].
DR.[**First Name (STitle) **],[**First Name3 (LF) **] 11-518
Dictated By:[**Name8 (MD) 8330**]
MEDQUIST36
D: [**2143-1-5**] 01:04
T: [**2143-1-8**] 06:09
JOB#: [**Job Number 30970**]
|
[
"340",
"286.6",
"287.5",
"577.0",
"570",
"038.19",
"571.5",
"577.8",
"789.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"54.91",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
4030, 8418
|
1834, 2150
|
2250, 3339
|
3354, 4012
|
2175, 2227
|
1082, 1811
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,367
| 114,513
|
49191
|
Discharge summary
|
report
|
Admission Date: [**2153-1-16**] Discharge Date: [**2153-1-19**]
Date of Birth: [**2079-7-20**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 458**]
Chief Complaint:
Respiratory depression.
Major Surgical or Invasive Procedure:
[**Hospital1 **]-ventricular ICD upgrade
History of Present Illness:
73yoM retired surgeon with history of Parkinson's disease (?
diffuse [**Last Name (un) 309**] body disease), HTN, DM, systolic HF (EF 20% in
[**11-4**]), history of CVA (residual left visual field cut), AF s/p
AVN ablation and pacer, admitted initially to CMI for BiV ICD
placement [**1-15**], with post-procedure admission planned for
heparin-coumadin (indication for anticoagulation AF - CVA).
Intra-procedure, received haldol 5 mg IV, fentanyl 200 mg IV,
and versed 1.5 mg IV and noted to be poorly responsive to
commands and low RR in recovery area; [**Hospital Unit Name 196**] called to evaluate.
VBG at that time 52/46/7.37. At 1 hr post-procedure, patient
began to become more responsive to commands and increased level
of consciousness.
Patient being transfer to CCU for observation of his clinical
status.
Past Medical History:
1. Parkinsons Disease. ? LBD
2. DM II
3. HTN
4. Autonomic dysfunction-hx of orthostatic hypotension. Treated
with Florinef in the past, was d/c'd due to fluid retention.
Restarted [**5-4**].
5. CAD- s/p MI in [**2120**], s/p CABG
6. CHF- Echo [**11-4**]-: Regional LV wall motion abnormalities
include: basal anteroseptal - akinetic; mid anteroseptal -
akinetic; basal inferoseptal -akinetic; mid inferoseptal -
akinetic; basal inferior - akinetic; mid inferior- akinetic;
basal inferolateral - akinetic; mid inferolateral - akinetic;
septal apex- akinetic; inferior apex -akinetic; [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 5660**]
dilated. RA is moderately dilated.
The left ventricular cavity is moderately dilated. There is
severe global left ventricular hypokinesis. Overall left
ventricular systolic function is severely depressed (EF <20)
7. Stroke [**11-2**]- right PCA, residual left field cut
8. Sick Sinus syndrome, s/p PCM
9. A.fib/SVT, s/p ablation
[**56**]. Hypercholesterolemia
11. Cervical stenosis
12. H/o back pain and L1 compression fxr
13. Anemia
14. h/o prostate CA, s/p [**Year (2 digits) 16859**] ([**2146**]) and hormonal tx
15. h/o renal stones and s/p lithotripsy
16. s/p appy
Social History:
Lives with his wife. There is becoming an increasingly difficult
situation due to the need for live-in/24 hr care at home. There
is an
ongoing dialogue about this, but no plans have been made
definitively. He is a retired physician. [**Name10 (NameIs) **] [**Name11 (NameIs) **], occasional
EtOH.
Family History:
HTN, colon ca, Parkinson's
Physical Exam:
VS: T BP 133/76 HR 80 RR 19 Sats 97 RA
Gen: patient somnolent, slowly responds to questions.
HEENT: no JVD, no LAD
Chest: Left side pacemaker poket with compression dressing,
small hematoma,
Lungs: clear to auscultation b/l, no crackles or wheezes
Cardiovascular: RRR, s1-s2 normal, holosytolic murmur in the
apex
Abdomen: Bowel sounds +, non tender, non distended.
GU: condom catheter in place
Extremities: no LE edema, right groin site clean, no ozzing.
peripheral pulses upper and lower extremities normal.
Neuro: a&ox3, cn ii-[**Doctor First Name **] intact; resting tremor.
Pertinent Results:
[**2153-1-16**] 07:30AM BLOOD WBC-6.1 RBC-4.43* Hgb-12.3* Hct-37.1*
MCV-84 MCH-27.8 MCHC-33.2 RDW-14.8 Plt Ct-147* Neuts-76.4*
Lymphs-17.9* Monos-4.7 Eos-0.8 Baso-0.2
[**2153-1-16**] 07:25AM BLOOD INR(PT)-1.6
[**2153-1-16**] 07:30AM BLOOD Glucose-92 UreaN-19 Creat-1.2 Na-145
K-4.0 Cl-107 HCO3-27 AnGap-15
[**2153-1-16**] 09:28PM BLOOD ALT-15 AST-21 LD(LDH)-236 AlkPhos-56
TotBili-1.0
[**2153-1-16**] 07:30AM BLOOD Digoxin-0.6*
[**2153-1-16**] 09:28PM BLOOD Phos-4.6* Mg-1.8
[**2153-1-16**] 05:39PM BLOOD Lactate-1.3
.
[**2153-1-16**] 09:28PM Hct-30.3*
[**2153-1-17**] 06:07AM Hct-27.5*
[**2153-1-17**] 05:00PM Hct-24.8*
[**2153-1-18**] 10:45AM Hct-29.4*
[**2153-1-18**] 04:38PM Hct-28.0*
.
[**2153-1-17**]:
CHEST PA AND LATERAL.
Compared to the prior radiograph obtained yesterday, there is
decreased CHF. There is mild cardiomegaly. There are small
bilateral effusions, more on the left. The new biventricular
pacer device is seen in the left hemithorax. The pacer leads are
seen in the right atrium and two in the floor of the right
ventricle. The previous abandoned right pacer leads are also
seen in the right atrium and right ventricle. No pneumothorax.
Persistent left lower lobe atelectasis/consolidation.
IMPRESSION:
1. Improving CHF.
2. Small bilateral layering pleural effusions, more on the left.
3. Persistent left lower lobe atelectasis/consolidation.
4. Good position of the new biventricular pacer device.
.
[**2153-1-17**]:
TECHNIQUE: Non-contrast head CT.
FINDINGS: There is no intra- or extra-axial hemorrhage. The
appearance of
the ventricles, cisterns, and sulci is unchanged. There is no
mass effect,
hydrocephalus, or shift of the normally midline structures. The
[**Doctor Last Name 352**]-white
matter differentiation is preserved.
The visualized mastoid air cells are clear. Again noted is sinus
mucosal
thickening bilaterally in the maxillary sinuses, not fully
characterized here.
IMPRESSION:
1. Similar sinus mucosal thickening.
2. No evidence of significant interval change.
3. Similar appearance of the brain including prominent
encephalomalacic
changes in the right occipital lobe, and possibly in the left
occipital lobe as well.
.
[**2153-1-17**]:
CT OF THE ABDOMEN WITHOUT IV CONTRAST: There is a biventricular
pacemaker in place, not fully characterized here, and evidence
of prior sternotomy. There are large bilateral pleural effusions
with adjacent areas of compressive atelectasis. Otherwise, the
lung bases are clear.
Within the limitations of the non-contrast study, the liver,
gallbladder,
pancreas, spleen, and adrenal glands are within normal limits. A
7-mm
nonobstructing stone is again visualized in the left kidney, as
well as a 12 mm stone in the left renal pelvis. These are
unchanged. A small new 2- mm nonobstructing stone is now seen in
the right kidney. Left-sided
hydronephrosis has resolved. Within the limitations of the
non-contrast study, the appearance of the kidneys is otherwise
unremarkable.
There is calcification of the abdominal aorta, and of the
splenic artery. The stomach, small and large bowel are
unremarkable. There is no retroperitoneal or mesenteric
lymphadenopathy, or free air or fluid.
Along the anterior left lateral ribs at the base of the chest,
there is a soft tissue density, not fully characterized here,
which may represent a small hematoma or inflammatory stranding
from recent pacer placement. Its
extent is not delineated here. There is no evidence of a
retroperitoneal
hematoma.
CT OF THE PELVIS WITHOUT IV CONTRAST: There is considerable
amount of stool in the rectum. The prostate, seminal vesicles,
and bladder are within normal limits. There is a 5-mm calcific
density in the distal left ureter, which could represent a
nonobstructing stone. It was not seen previously.
BONE WINDOWS: There are no suspicious lytic or blastic lesions.
Degenerative changes of the lumbar spine are seen.
IMPRESSION:
1. Large bilateral pleural effusions.
2. Possible hematoma along the left basal chest wall, in the
subcutaneous
tissues, not fully evaluated here.
3. No evidence of retroperitoneal hematoma.
4. Multiple nonobstructing stones in the kidneys bilaterally, as
well as a 6- mm calcific density in the left pelvis, which may
represent a nonobstructing renal stone in the left ureter.
.
[**2153-1-18**]:
TECHNIQUE: Left upper extremity venous ultrasound and Doppler
examination,
and limited evaluation of the subcutaneous tissues of the left
upper
hemithorax.
FINDINGS: Grayscale and Doppler son[**Name (NI) 1417**] of the left internal
jugular,
axillary, basilic, and paired brachial veins show no evidence of
deep vein
thrombosis. Because of the presence of the overlying pacer, the
left
subclavian vein could not be evaluated. No intraluminal thrombus
is
identified.
In the tissues overlying the pacemaker, there is heterogeneous
appearance,
which may represent postoperative change, but the presence of
hematoma cannot be excluded. No large discrete fluid collection
is identified. Laterally, near the insertion of the pectoralis
major muscle, the appearance suggests either edematous muscle or
complex fluid, but the static images presented are
indeterminant.
IMPRESSION:
1. Heterogeneous tissue in the region of the pacer, which is
indeterminant in etiology.
2. Suggestion of edematous left pectoral muscle and/or complex
fluid,
suggested by resident review in real time scanning. However on
the static
images, it is difficult to discern the relationship between the
muscle, the adjacent heterogeneous soft tissue, and the pacer.
A followup ultrasound for evaluation and comparison, or
alternatively a CT, which may show an area of hyperdensity to
correspond to an acute hematoma if present, is suggested.
.
Day of discharge labs:
[**2153-1-19**] 07:30AM BLOOD WBC-9.9 RBC-3.26* Hgb-10.0* Hct-27.6*
MCV-85 MCH-30.5 MCHC-36.0* RDW-15.6* Plt Ct-116*
[**2153-1-19**] 07:30AM BLOOD PT-14.4* PTT-31.8 INR(PT)-1.4
Brief Hospital Course:
A 73yoM with parkinson disease, HTN, DM, systolic HF (EF 20% in
[**11-4**]), history of CVA (residual left visual field cut), AF s/p
AVN ablation and pacer, inmediate s/p BiV pacer upgrade with
slowly recover after sedation transfer to CCU for monitoring.
After the haldol wore off, mental status was felt to return to
baseline. Of note, hematocrit was noted to drop on the day of
procedure. CT abd/Pelvis was done and was negative for
retroperitoneal bleed. Left upper extremity also noted to be
more swollen on [**1-18**] and ultrasound was performed which was
negative for DVT.
# mental status change: Patient likely sensitive to sedation,
requiring , more alert, able to follow simple commands. He is
able to movilize all extremities, still somnolent. more likely
given his baseline disease, he is more sensitive to sedation.
Patient seemed to recover in the 10-12 hours post-sedation.
Head CT was performed and was negative for intracranial bleed.
Neurology was consulted and agreed that mental status changes
likely to haldol being given.
.
1. Parkinson's disease: will continue home medications sinemet,
mirapex and pramipexol.
2. CV:
Rhythm: h/o Afib - heparin bridge to coumadin. Heparin was
stopped in setting of hematocrit drop and restarted on [**2153-1-19**].
S/P BiV pacer- he was given Vancomycin Iv x 3 doses.
AV paced
Carvedilol continued for rate control
Pace maker checked on [**2153-1-19**].
Pump: EF 17% on MIBI, currently euvolemic. Will continue
Carvediolol and Furosemide home dose and digoxin. We will
recommend to discusse with your primary cardiologist regarding
Ace inhibitor medications
CAD: continue aspirin, statin, Carvedilol
3. Heme: On admission Hct noted to be 37. This was likely
hemoconcentrated as Hcts from 3 weeks prior were 31-32.
However, given Hct decrease to 25, CT scan of Abd/Pelvis and
including upper thighs done and negative for hematoma or bleed.
He was tranfused 2 units of pRBCs and Hct increased. Hematocrit
should be monitored on an outpatient basis.
4. left upper extremity swelling: noted on [**1-18**]. Concern for
DVT or bleed. Ultrasound of upper extrmity done and negative for
DVT.
5. GERD: Continue Pantoprazole
6. FENA: Cardiac healthy -diabetic diet.
7. Dispo: to rehab. Patient should have Hematocrit checked on
[**1-22**] (Hct 27.6 on [**1-19**]). Left upper extremity swelling seems to
be resolving. His left arm may be elevated to decrease
swelling, but is not to be elevated above shoulder level given
new biVentricular pacemaker placement.
Full code
Medications on Admission:
Carbidopa-Levodopa 25-100 mg qAM
Carbidopa-Levodopa 25-100 mg qHS
Acetaminophen 325 mg q4-6h
Carbidopa-Levodopa 50-200 mg Q6H
Mirapex 0.25 mg TID
Fluoxetine 20 mg QD
Fludrocortisone 0.2 mg QD
Donepezil 5 mg qHS
Pantoprazole 40 mg/ QD
Carvedilol 12.5 mg [**Hospital1 **]
Clonazepam 0.5 mg Qhs bedtime
Digoxin 125 mcg Tablet daily
Provigil 100 mg Tablet/ qd
Atorvastatin 10 mg Tablet QD
Furosemide 20 mg Tablet QD
Aspirin 81 mg Tablet, QD
Warfarin 5 mg Tablet qhs
Modafinil 200 mg ebery morning.
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
3. Digoxin 125 mcg 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 once a day.
5. Simvastatin 40 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
6. Pramipexole 0.25 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
7. Carbidopa-Levodopa 50-200 mg Tablet Sustained Release Sig:
One (1) Tablet PO QID (4 times a day).
8. Carbidopa-Levodopa 25-100 mg Tablet Sustained Release Sig:
One (1) Tablet PO 2200 ().
9. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
11. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for 4 days.
12. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime
as needed for insomnia. Tablet(s)
13. Warfarin 5 mg Tablet Sig: One (1) Tablet PO at bedtime.
14. Bupropion 100 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO once a day.
15. Modafinil 100 mg Tablet Sig: One (1) Tablet PO once a day.
16. Potassium Chloride 20 mEq Packet Sig: Two (2) PO once a
day.
17. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
18. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
s/p pacemaker placement
Parkinson's disease
Discharge Condition:
stable
Discharge Instructions:
You need to have your PT/INR level checked in 3 days for
coumadin titration and a serum creatinine checked in one week
(because of numerous renal stones that could obstruct your urine
output and harm your kidneys).
Please have your hematocrit checked on [**1-22**] (3 days after
discharge), please have these results sent to Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] office, ([**Telephone/Fax (1) 9530**].
Followup Instructions:
Please call Dr[**Name (NI) 8996**] office to make an appointment in [**2-2**]
weeks. ([**Telephone/Fax (1) 103173**]) [**Hospital Ward Name **] 4
.
Please call Dr.[**Name (NI) 10444**] office on ([**Telephone/Fax (1) 63315**] to scheduled
an appointment in the next 1-2 months or earlier if indicated.
Completed by:[**2153-1-19**]
|
[
"285.9",
"412",
"V12.59",
"428.0",
"250.00",
"998.12",
"V45.81",
"331.82",
"272.0",
"V10.46",
"723.0",
"414.00",
"V13.01",
"790.01",
"292.81",
"401.9",
"427.31",
"530.81",
"E939.2",
"294.10"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.49",
"00.51",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
13822, 13894
|
9325, 11864
|
295, 337
|
13982, 13991
|
3397, 9107
|
14473, 14806
|
2754, 2783
|
12409, 13799
|
13915, 13961
|
11890, 12386
|
14015, 14450
|
9123, 9302
|
2798, 3378
|
232, 257
|
365, 1183
|
1205, 2424
|
2440, 2738
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,305
| 176,923
|
45740
|
Discharge summary
|
report
|
Admission Date: [**2158-7-24**] Discharge Date: [**2158-8-3**]
Date of Birth: [**2094-3-2**] Sex: F
Service:
HISTORY OF THE PRESENT ILLNESS: This is a 64-year-old female
with myelodysplastic syndrome and history of cerebrovascular
accident in [**2154**], who was in her usual state of health until
approximately three days prior to admission, when her
daughter noticed that she seemed more lethargic than usual.
On the morning of admission, her mother complained to her of
being awakened by acute chest pain "like knives in her
chest". In addition, her mother described feeling nauseated,
lightheaded, dizzy, and weak. She denied experiencing
diarrhea, vomiting, or any change in appetite. At this time,
she denied experiencing coughing, dysuria.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature
99.3, pulse 123, blood pressure 90/50, respirations 24, and
oxygen saturation 94% on 2 liters nasal cannula. In general,
the patient was resting comfortably in bed in no acute
distress. Her oral examination was remarkable for very poor
dentition. She had a periodontal gum lesion on the left
upper gum, with swelling on the hard palate directly opposite
to the lesion on the other side of her teeth. She had tender
submandibular lymphadenopathy. Her lung examination revealed
crackles at the bases bilaterally. Her cardiac examination
revealed tachycardia but was otherwise a regular rhythm. Her
abdominal examination was benign and her neurologic
examination was remarkable for a left eye abduction and was
otherwise intact.
LABORATORY/RADIOLOGIC DATA: ........... showed no growth,
and an HSV-PCR analysis returned negative.
HOSPITAL COURSE: ........... or fluid overload. The patient
showed clinical improvement over two days in the Medical
Intensive Care Unit and returned to the Medicine Floor on
hospital day number ........... ........... precautions.
Received 2 units of packed red blood cells, and received four
bags of platelets prior to lumbar puncture.
[**Name6 (MD) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 1197**]
Dictated By:[**Last Name (NamePattern1) 51598**]
MEDQUIST36
D: [**2158-8-3**] 11:22
T: [**2158-8-5**] 13:16
JOB#: [**Job Number 97462**]
|
[
"293.0",
"428.0",
"780.6",
"492.8",
"284.8",
"272.0",
"238.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
1685, 2253
|
805, 1667
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,098
| 103,119
|
23398
|
Discharge summary
|
report
|
Admission Date: [**2152-12-6**] Discharge Date: [**2152-12-29**]
Date of Birth: [**2098-6-11**] Sex: F
Service: SURGERY
Allergies:
Ivp Dye, Iodine Containing / Tetracycline
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
MVA
Major Surgical or Invasive Procedure:
Ex-Fix RLE [**12-5**]
ORIF R tib-fib [**12-7**]
Ex-Fix LLE prox fib and distal fib pilon fx [**12-7**]
Intracranial pressure monitor (bolt) placed [**12-5**] and removed [**12-7**].
IVC Filter placed [**12-7**] and removed [**12-29**]
TTE, intra-operative, [**12-7**].
Gracilus flap and STSG RLE [**12-11**]
STSG LLE over ex-fix [**12-22**]
History of Present Illness:
54yo F unrestrained driver in MVA with ejection. +LOC with
subsequent GCS 15. Brought in by EMS to trauma plus. Pt could
not recall events leading to accident.
Past Medical History:
Lupus
asthma
COPD
Social History:
family very involved, daughter, sister, brother, son
Family History:
unknown
Physical Exam:
Afebrile, HR 105, BP 110/palp, RR 18, O2 sat 100%
A&Ox3, GCS 15.
PERRL
Neck: no c-spine step off, NT
CTAB
NT ND. FAST negative.
DRE: nl tone, guaiac negative
R open tib-fix fx, L superficial abrasion over shin. R forearm
abrasion.
BL palp DP. ABI: L 1.1, R 1.3
neuro grossly intact
Pertinent Results:
[**2152-12-5**] 07:09PM BLOOD WBC-14.7* RBC-3.97* Hgb-12.6 Hct-37.2
MCV-94 MCH-31.6 MCHC-33.7 RDW-12.5 Plt Ct-339
[**2152-12-6**] 12:58AM BLOOD WBC-13.7* RBC-2.58*# Hgb-7.9*# Hct-25.1*#
MCV-97 MCH-30.6 MCHC-31.5 RDW-12.8 Plt Ct-206
[**2152-12-6**] 04:17AM BLOOD Hct-36.1#
[**2152-12-5**] 07:09PM BLOOD PT-12.5 PTT-25.5 INR(PT)-1.0
[**2152-12-5**] 07:09PM BLOOD Plt Ct-339
[**2152-12-6**] 12:58AM BLOOD Glucose-117* UreaN-10 Creat-0.7 Na-134
K-3.2* Cl-105 HCO3-24 AnGap-8
[**2152-12-5**] 07:09PM BLOOD Amylase-40
[**2152-12-6**] 12:58AM BLOOD CK(CPK)-491*
[**2152-12-6**] 12:58AM BLOOD Calcium-6.6* Phos-3.3 Mg-1.3*
[**2152-12-5**] 07:09PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2152-12-7**] 04:10PM BLOOD Glucose-114* Lactate-1.2 Na-136 K-4.1
Cl-111
[**2152-12-17**] 04:36AM BLOOD Glucose-137* UreaN-16 Creat-0.3* Na-137
K-4.4 Cl-103 HCO3-26 AnGap-12
[**2152-12-25**] 10:30AM BLOOD WBC-10.1 RBC-3.47* Hgb-10.4* Hct-32.4*
MCV-93 MCH-29.9 MCHC-32.0 RDW-14.7 Plt Ct-842*
[**2152-12-25**] 10:30AM BLOOD Plt Ct-842*
[**2152-12-29**] 05:37AM BLOOD Plt Ct-612*
CT ABD/PELVIS 1/4/5
IMPRESSION:
IMPRESSION:
1. Bilateral sacral alar fractures extending into the neural
foramen. S1, and probably L5 transverse process fracture on the
right.
2. Right rib fractures with small right pulmonary contusion.
Repeat
1) Comminuted sacral fractures as previously described, with
mildly increased presacral hematoma and thickening adjacent to
the psoas muscles. Otherwise unchanged abdominal and pelvic exam
from four hours prior. The examination is somewhat limited by
the lack of IV contrast.
CT head 1/4/5
IMPRESSION: Findings suspicious for a small left subdural
hematoma.
CT Cspine 1/4/5
IMPRESSION: There are fractures of the C6 right posterior
foramen transversarium and transverse process, the right C7
transverse process, the right medial first and second ribs and
transverse processes. Degenerative change, multilevel.
There is also a fracture of the right medial clavicle.
Tib Fib B/L 1/4/5
IMPRESSION:
1). Oblique fractures of the distal right tibia and fibula, with
moderate displacement and override.
2). Ill-defined lucencies overlying the bones of the right mid
and hindfoot are inadequately evaluated due to overlying cast
material.
3). Oblique fracture of the proximal left fibula and comminuted
fracture of the distal left tibia, mildly displaced.
RUE 1/4/5
IMPRESSION:
1. No fracture of the right elbow.
2. Comminuted fracture of the left fifth metacarpal, with
extension of fracture line to the CMC joint articular surface.
3. Polygonal density adjacent to the base of the right first
metacarpal. Tiny avulsion fragment versus foreign body cannot be
entirely excluded.
CT T spine 1/8/5
IMPRESSION: Tiny fracture involving the T3 spinous process which
is associated with cortication of the donor site and is most
likely chronic. Alternatively, this could represent ligamentous
calcification as well.
Brief Hospital Course:
54yo W bib EMS to trauma bay for trauma plus where underwent
thorough evaluation by trauma and ER staff. Notable injuries
included R open tib-fib fracture with intact distal pulses,
stable vitals, and a GCS 15. Ortho consult was obtained and the
R foot was splinted. Pt was placed in C-collar and stabilized.
She was taken for emergent radiography notable for Head CT
showing small ? L SDH, nl Chest CT, Abd-Pel showed BL sacral
alar fx's but no acute abdominal pathology, and extremity plain
films showed the R tib-fix fx, a L Maissonerve fx, a L distal
tib fx, and a L 5th metacarpal fx. Later reads also revealed
multiple rib fx's, a pulmonary contusion, and a clavicular fx.
Injury also significant for C7 transverse process fx and C6
transverse process/ posterior foramen fracture.
Neurosurgery consult was obtained for the L SDH and who
recommended frequent neuro checks; it was decided therefore to
place an epidural for anesthesia for Ortho's RLE ex-fix and LLE
splint. Towards the end of the case, the patient experienced a
seizure. Apparently, she became hypertensive, was given a
b-blocker, went into bronchospasm (possibly related to her
asthma), significantly retained CO2, had a seizure with a blown
pupil, got stat intubated, given propafol and dropped her BP. A
femoral a-line was placed by anesthesia. She was urgently
returned to the CT scanner; Head CT showed mild cerebral edema
and no L SDH as previously noted. An Abd-Pel CT also obtained
for ? tense abdomen was also negative. She was brought to the
the T-SICU in intubated and critical condition. Neurosurgery
placed a bolt for intracranial monitoring at the bedside. She
was hypotensive 90s/50s, given volume fluid resuscitation, and
transfused 2 units PRBCs for a Hct 25 (down from 37 on
presentation). She required neo for BP support for 24 hours,
and a R subclavian triple-lumen was placed. Ortho splinted the
L hand. The abdomen was soft. She was placed on stress dose
steroids with taper to her home daily dose, given mannitol for
ICP control, given dilantin loading dose and then tid, and
Ancef/Gent for Abx.
On HD 2 a swan-ganz catheter was placed in the L subclavian but
resulted in a L pneumothorax. A L chest tube was placed, this
had a mild air leak. Serial Hcts were performed revealing a
slowly downtrending Hct.
On HD 3 the intracranial bolt was removed. She was taken to the
OR for an IVC filter for PE prophylaxis as the pt could not
receive heparin nor could pneumoboots be applied to her LE
because of her orthopedic injuries. Ortho performed an ORIF for
the RLE and an Ex-Fix LLE. An intraoperative TTE revealed no
aortic injury and an EF 65%. Transferred to the floor after CT
removal in stable and improving condition on HD 11.
A plastic surgery consult was obtained for the RLE degloving
injury- throughout hospital course the plastic surgery team
completed a gracilis flap and split thickness skin grafts to RLE
and LLE (HD 7, 17).
Throughout hospitalization, pt continued to improve steadily.
Tolerating POs well, maintained on PO pain meds, converted to
lovenox for anticoagulation, IVC filter removed, moving bowels,
and OOB to chair as tolerated. She was transferred to rehab on
HD# 25 for continued physical therapy within her limitations of
PWB for transfer only RLE and NWB LLE, and ROM exercises for
LUE. She was given instructions for followup with Neurosurgery
(2weeks for Cspine eval, hard collar at all times), Ortho (5
weeks for LLE exfix removal), Plastics (1 week for graft eval),
and Trauma (2 weeks for interval fup).
Medications on Admission:
Prednisone 20mg po qd
? plaquinel
Discharge Medications:
1. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q2H (every 2 hours) as needed.
Disp:*qs * Refills:*0*
2. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q2-3H (every 2-3 hours).
Disp:*qs * Refills:*0*
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Montelukast Sodium 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation [**Hospital1 **] (2 times a day).
Disp:*qs * Refills:*0*
6. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Hydromorphone HCl 2 mg Tablet Sig: 1-2 Tablets PO Q3-4H () as
needed.
Disp:*30 Tablet(s)* Refills:*0*
8. Hydroxychloroquine Sulfate 200 mg Tablet Sig: One (1) Tablet
PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed for for agitation/sleep.
Disp:*30 Tablet(s)* Refills:*0*
10. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
Disp:*120 Tablet(s)* Refills:*0*
11. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
Disp:*30 Tablet(s)* Refills:*0*
12. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
Disp:*qs * Refills:*0*
13. Phenol-Phenolate Sodium 1.4 % Mouthwash Sig: One (1) Spray
Mucous membrane Q4H (every 4 hours) as needed.
Disp:*qs * Refills:*0*
14. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours).
Disp:*20 Capsule(s)* Refills:*0*
15. Enoxaparin Sodium 40 mg/0.4mL Syringe Sig: One (1)
Subcutaneous [**Hospital1 **] (2 times a day).
Disp:*qs * Refills:*0*
16. Dolasetron Mesylate 12.5 mg IV Q4-6H:PRN nausea
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
MVA
L frontal SDH, small
BL sacral alar fx c presacral hematoma
R 7th posterior rib fx c contusion
R 3rd anterior rib fx
R 1st and 2nd rib fxs
R distal tib-fib fx
L proximal fibula and distal tibia fx.
L 5th metacarpal fx
S1/L5 transverse process fx
R medial clavicle fx
R C6 transverse process / posterior foramen fx
R C7 transverse process fx
bronchospasm
seizure
Discharge Condition:
stable
Discharge Instructions:
-Regular diet as tolerated
-Continue to wear the cervical collar at all times.
-Non-weight-bearing Left leg at all times. [**Month (only) 116**] weight-bear
Right leg for transfers only, otherwise non-weight-bearing Right
leg for ambulation.
Followup Instructions:
1. Follow-up with Orthopedics, Dr. [**Last Name (STitle) 1005**], for removal of
your external fixation device (left leg) in 5 weeks after
discharge. Call [**Telephone/Fax (1) 4845**] for an appointment.
2. Follow-up with Plastic Surgery [**Telephone/Fax (1) 23144**] for [**Hospital 2974**] clinic
next week to evaluate your skin grafts and your left hand
fracture.
3. Follow-up with Neurology, [**Telephone/Fax (1) 1690**], for further
evaluation of your closed head injury
4. Follow-up with Neurosurgery, Dr. [**Last Name (STitle) 739**], in 2 weeks
for evaluation of your cervical collar. Call [**Telephone/Fax (1) 1669**] for an
appointment.
|
[
"276.2",
"824.9",
"852.26",
"401.9",
"E879.8",
"807.02",
"710.0",
"810.02",
"815.12",
"780.39",
"E815.0",
"512.1",
"891.0",
"806.05",
"861.21",
"805.2",
"E849.5",
"805.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.7",
"79.66",
"88.72",
"86.69",
"99.04",
"79.36",
"83.82",
"38.91",
"38.93",
"96.08",
"96.04",
"01.18",
"86.22",
"78.17",
"93.59",
"34.04",
"96.72",
"89.64"
] |
icd9pcs
|
[
[
[]
]
] |
9725, 9797
|
4259, 7821
|
305, 648
|
10207, 10215
|
1292, 4236
|
10506, 11157
|
966, 975
|
7905, 9702
|
9818, 10186
|
7847, 7882
|
10239, 10483
|
990, 1273
|
262, 267
|
676, 839
|
861, 880
|
896, 950
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,259
| 113,831
|
47518
|
Discharge summary
|
report
|
Admission Date: [**2113-5-19**] Discharge Date: [**2113-5-28**]
Service: MEDICINE
Allergies:
Codeine / Morphine / Penicillin G Sodium / Cortisone
Attending:[**First Name3 (LF) 4421**]
Chief Complaint:
Fevers and rigors of unknown cause.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
87 yo woman with recent diagnosis of stage III, suboptimally
debulked ovarian cancer diagnosed in [**Month (only) 956**], presented with
respiratory distress and fever. She tolerated her first cycle of
single [**Doctor Last Name 360**] carboplatin beautifully 12 hours prior, and then
developed fever and chills at 3 AM today. In the ED, her T was
102 degrees F PO. CXR was consistent with CHF (BNP [**Numeric Identifier 100467**]
range). Patient denies cough/headahce/photophobia/chest
pain/diarrhea/sick contact. She recieved vancomycin and
levofloxacin in the ED for a possible infection, although no
site of infection was identified.
Upon admission, she was febrile to 103 degrees F PO with rigors,
and she was found to be in respiratory distress. Code status
was discussed at that time, and she did not want
intubation/resuscitation. In [**Hospital Unit Name 153**], her respiratory distress was
attributed to a combination of fever and CHF, the latter
possible precipitated by atrial fibrillation. Patient was
formerly DNR/DNI but reversed her code status to DNR/intubate.
She received nebulizer treatments prn. CT chest showed stable
thyromegaly. She had left shift, lactate 3.3 on presentation.
She did not have other obvious site of infection. Patient was
treated with vanco/levo/flagyl (patient has PCN allergy) but
continued to spike fevers. Urine culture/blood cultures showed
no growth for many days, and the final results are pending (the
patient refused further testing with subsequent fevers). For
atrial fibrillation, she was rate controlled with metoprolol as
needed. Upon admission she was noted to have a mild
tramaminitis.
Patient is now transferred back to the regular floor and
currently states that she "feels great," without chest pain,
sob, discomfort, nausea/vomiting, dysuria, diarrhea,
constipation.
Past Medical History:
Past Medical History:
- suboptimally debulked, stage IIIC papillary serous ovarian
cancer(with involvement of the omentum and upper abdomen)
s/p exploratory laparotomy performed by Dr. [**Last Name (STitle) 2406**] at [**Hospital1 18**] [**3-11**]
s/p Cytoreductive surgery for ovarian cancer including
omentectomy, radical resection of pelvic mass including
bilateralsalpingo-oophorectomy
- HTN
- osteoporosis
- hypercholesterolemia
- s/p TAH for fibroids at age 30
- s/p thyroid nodule resection
- LLL lung resection for "carcinoid tumor" in [**2104**].
- carpal tunner surgery
- bronchitis, hypertension,
- bilateral hearing loss for which she has a hearing aid
She is allergic to penicillin which causes a
rash.
Social History:
SOCIAL HISTORY: She does not smoke or drink alcohol. She works
in a
sales company, retired many years ago. She lives half the year
in [**State 108**] starting in [**Month (only) 1096**]. She lives in [**Location 2624**] during her
[**State 350**] part of the year.
Family History:
FAMILY HISTORY: She has no convincing history of breast or
ovarian cancer to suggest a genetic predisposition. Mother and
father died at older age without cancer. She has four brothers
and sisters who do not have colon cancer, breast cancer, ovarian
cancer. She is partly of Ashkenazi [**Hospital1 **] background.
Physical Exam:
exam: Temp: 101.3 Tcurrent: 97.9 HR: 89 BP: 104/50 RR: 16 99% on
RA
GEN: NAD, AEO x3
HEENT: CNII-XII intact, EOMI, PERRLA
CV: Irregular rhythym, [**3-12**] holosytolic murmur heard loudest at
LUSB
RESP: Right lower lobe cracles, CTA in all other lung fields
ABD: soft, nt, nd, nabs
EXT: no c,c,e
Pertinent Results:
Imaging:
CXR [**5-19**]: CHF picture with stable thyroid mass
cxr [**5-20**]: 1. Increased right lower lobe opacity which could
represent pneumonia in the right clinical setting.
2. Stable CHF.
cxr [**5-21**]: IMPRESSION: Improving aeration consistent with
improving fluid status, although persistent features of CHF
remain. No new consolidations
CT neck [**5-21**]: IMPRESSION: Enlarged thyroid gland is again seen,
and is stable in appearance.
Ct chest [**5-22**]: 1. Findings consistent with congestive heart
failure. The evaluation for underlying interstitial lung
disease is not possible due to superimposed CHF.
2. Focal patchy opacities seen in the right lower lobe may
represent a focus of atypical atelectasis, or early pneumonic
consolidation. Resolution of this lesion should be documented
on follow-up scans after treatment given the
patient's history of ovarian cancer.
3. Pulmonary hypertension.
4. Enlarged right lobe of the thyroid, which is stable in
appearance dating back to [**2112-6-13**].
Ultrasound [**5-22**]: 1) Normal hepatic echotexture with no focal
liver lesions or biliary ductal dilatation identified.
2) Likely parapelvic cysts within left kidney.
Blood cultures and urine cultures have shown no growth to date
Echo ([**5-23**]): The left atrium is moderately dilated. There is
mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%). The right ventricular
cavity is mildly dilated. Right ventricular systolic function is
normal. The ascending aorta is mildly dilated. The aortic valve
leaflets are moderately
thickened. There is mild aortic valve stenosis. Mild to moderate
(2+) aortic regurgitation is seen. The mitral valve leaflets
are mildly thickened. Mild (1+) mitral regurgitation is seen.
The tricuspid valve leaflets are mildly thickened. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
[**2113-5-19**] 04:03PM GLUCOSE-107* UREA N-32* CREAT-1.3* SODIUM-135
POTASSIUM-4.1 CHLORIDE-96 TOTAL CO2-26 ANION GAP-17
[**2113-5-19**] 04:03PM CK(CPK)-73
[**2113-5-19**] 04:03PM CK-MB-NotDone cTropnT-0.02* proBNP-[**Numeric Identifier **]*
[**2113-5-19**] 04:03PM WBC-5.5 RBC-3.81* HGB-11.4* HCT-34.0* MCV-89
MCH-29.8 MCHC-33.4 RDW-14.6
[**2113-5-19**] 04:03PM NEUTS-96.2* BANDS-0 LYMPHS-2.6* MONOS-0.9*
EOS-0.1 BASOS-0.2
[**2113-5-19**] 04:03PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2113-5-19**] 04:03PM PLT SMR-NORMAL PLT COUNT-135*
[**2113-5-19**] 03:46PM URINE GR HOLD-HOLD
[**2113-5-19**] 03:46PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.006
[**2113-5-19**] 03:46PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
Brief Hospital Course:
Respiratory distress due to CHF:
The patient had a BNP of 10,000, and she was diuresed with good
response. It was thought that her CHF was precipitated by fever
and atrial fibrillation. She was placed on aspirin, and there
was decision not to anticoagulate based on an isolated incident
of atrial fibrillation and the morbidity of coumadin. Patient
was formerly DNR/DNI but has reversed her code status to
DNR/intubate. She was maintained on lasix for her CHF.
Fever:
The etiology of her fevers remained unclear, but there was no
convincing source of an infection. Patients blood and urine
cultures were unrevealing. She had no evidence for pneumonia by
clinical sx or by imaging. In the unit she was originally
treated with vanco/levo/flagyl (patient has a pcn allergy) but
she continued to spike fevers. It was then felt that an
infectious etiology was unlikely, and all abx were therefore
stopped. We spoke to heme onc attending as to whether fevers
could be related to carboplatin. Dr. [**Last Name (STitle) **] felt this would
be very unusual for this drug, but still considered it a
possibility, especially in view of LFT abnormalities (below)
suggestive of possible drug-induced cholestasis (again unusual
for carboplatin). Patients fever curve trended down off of
antibiotics, and she was afebrile at the time of discharge.
Transaminitis and cholestasis:
Patient showed evidence of a transaminitis upon admission which
stabilized, although her bilirubin continued to trend upwards to
the low 6 range. A right upper quadrant ultrasound with dopplers
was obtained that did not indicate any liver lesions, biliary
duct dilatation, or hepatic [**Last Name (un) **] thrombus. After excluding more
likely causes, Dr. [**Last Name (STitle) **] considered the possibility that
carboplatin might explain the fevers and
transaminitis/cholestasis in view of the time course, although
acknowledged that this would be unusual for this medication.
Hepatology was consulted and agreed with him, and felt that this
was possibly a drug induced cholestatis. Hepatology also felt
that her hepatitis serologies were not consistent with active
viral hepatitis. Her statin was held, and the recommendation
was made to the patient that this medication not be restarted.
Patient's transaminases and bilirubin plateaued and were
trending downwards on discharge, with the patient feeling well
(total bilirubin plateaued in the low 6 range, mostly direct in
nature).
Thyroid mass:
Patient had a stable appearing enlarged thyroid on chest/neck CT
with associated lymphadenopathy from [**2113-5-22**]. The patient will
follow up with her outpatient endocrinologist.
Medications on Admission:
aspirin
albuterol
statin
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Toprol XL 25 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*1*
4. Calcium Carbonate 500 mg Tablet Sig: One (1) Tablet PO three
times a day.
Disp:*90 Tablet(s)* Refills:*2*
5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Potassium Chloride 20 mEq Packet Sig: One (1) packet PO once
a day.
Disp:*30 packets* Refills:*2*
7. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
8. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q3-4H () as needed.
9. Prochlorperazine 10 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for nausea.
Discharge Disposition:
Extended Care
Facility:
Commons Residence At Orchard - [**Location (un) 2624**] (a.k.a. [**Location (un) 5481**])
Discharge Diagnosis:
Drug-induced cholestasis/hepatitis
CHF
Ovarian cancer
Discharge Condition:
Stable
Discharge Instructions:
Please call your doctor or come to ED if you develop nausea,
vomiting, fevers/chills, chest pain, increased yellow color of
the skin, or shortness of breath.
You should NOT take Lipitor or similar medications again.
Please call Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 32192**]) on Monday to schedule
a follow up appointment (already made), along with follow-up
blood studies (already scheduled).
Followup Instructions:
Provider: [**Name10 (NameIs) 17515**] CHAIR 1B Date/Time:[**2113-6-1**] 10:30
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], RN Where: [**Hospital6 29**]
HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2113-6-1**] 10:30
Provider: [**Name Initial (NameIs) 4426**] 19 Date/Time:[**2113-6-8**] 2:00
Please make a follow up appointment with your PCP- [**Name10 (NameIs) **] [**Last Name (STitle) 14069**] -
within one week of discharge - [**Telephone/Fax (1) 37171**].
Also, please call Dr. [**Last Name (STitle) **] ([**0-0-**]) on Monday to
schedule a follow up appointment.
Completed by:[**2113-5-29**]
|
[
"183.0",
"576.8",
"428.30",
"403.91",
"E933.1",
"272.0",
"427.31",
"780.6",
"486",
"240.9",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10472, 10588
|
6755, 9408
|
296, 302
|
10686, 10694
|
3858, 6732
|
11153, 11809
|
3226, 3525
|
9483, 10449
|
10609, 10665
|
9434, 9460
|
10718, 11130
|
3540, 3839
|
221, 258
|
330, 2169
|
2213, 2911
|
2943, 3194
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,296
| 172,695
|
23007
|
Discharge summary
|
report
|
Admission Date: [**2180-11-15**] Discharge Date: [**2180-12-7**]
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
transfer from OSH for ICH for NSurg eval, history obtained
from niece [**Name (NI) 382**]
Major Surgical or Invasive Procedure:
Multiple CT scans
noninvasive ventilation
NGT placement
EEG
History of Present Illness:
[**Age over 90 **] yo man with h/o hypothyroidism who was found down in kitchen
by his neighbors when they spotted his kitchen light on at
midnight on [**2180-11-13**]. EMS arrived, helped him off the floor,
and then the patient refused any additional help or transfer to
the hospital. The next day, his niece [**First Name8 (NamePattern2) 14880**] [**Name (NI) 59359**]
health care proxy) asked police to visit him, they did and then
called EMS. EMS notes that patient was disheveled, had urinated
on himself, naked from the waste down, confused. Taken to Good
[**Hospital 53775**] hospital where he was rehydrated for rhabdomyalysis.
Found to have an ICH. Transferred to [**Hospital1 18**] for neurosurgical
evaluation the following day.
Patient is unable to tell a coherent story, but does complain of
hip pain. At baseline he is entirely self sufficient - gardens,
shovels, drives a standard.
Past Medical History:
Hypothyroidism
h/o deafness in left ear since age 5
h/o +PPD
atypical nevus
vertigo (?)
BPH
Social History:
former botanist (worked at [**Doctor Last Name 1193**] arboretum), no smoking, no
ETOH. DNR/DNI (confirmed with HCP niece [**Name (NI) 14880**] [**Name (NI) **]
[**Telephone/Fax (1) 59360**])
Family History:
son with some type of cancer
Physical Exam:
Vitals: 100.8 (rectal), 105-114/40-50's, HR 65-96, RR 20's,
satting well on RA
GEN: comfortable, NAD
HEENT: NC/AT, anicteric sclera, dry mm
NECK: supple, no carotid bruits, no thryoid nodules
CHEST: coarse breath sounds
CV: RRR without mur
ABD: firm (tense muscles, hypertonic throughout) but +BS, no HSM
EXTREM: no edema, thin extremities, radial pulses 2+
NEURO:
MENTAL STATUS: awake, alert, fluent, inconsistently follows
commands, would not repeat anything for me, oriented to self and
year but not place "i'm at a police station", unable to maintain
a coherent stream of thought or action, left neglect vs. visual
field defect, + snout, + glabellar tap
CRANIAL NERVES:
Pupil exam: 2->1mm bilat
EOM exam: right gaze preference but does past the midline upon
attempted tracking
Facial symmetry: left lower face droop
Gag reflex: intact
MOTOR: moves right side more so than the left side, unable to
perform formal testing.
SENSORY: withdrawls x 4 but less vigorously on the left
REFLEXES:
[**Hospital1 **] BR Tri Pat Ach Toe
R 2 2 2 3 2 down
L 3 3 3 3 2 down
Pertinent Results:
Head CT on [**2180-11-15**]: There has been no significant change in
the large right temporal lobe intraparenchymal hemorrhage with
surrounding edema and mass effect on the right lateral
ventricle. The quadrigeminal plate and suprasellar cisterns are
unchanged in appearance with no evidence of uncal or tentorial
herniation. A small amount of blood is again noted within the
occipital [**Doctor Last Name 534**] of the left lateral ventricle. There have been no
other changes compared to the study of 7 hours earlier.
Most recent Head CT on [**2180-11-22**]: There is a large right cerebral
intraparenchymal hemorrhage with surrounding edema. The
appearance is not significantly changed in the interval. There
is stable mass effect with narrowing of the sulci in the right
cerebral hemisphere. Stable periventricular low-attenuation
white matter changes are present in the left cerebral
hemisphere. No new areas of hemorrhage are present. The
ventricles are nondilated and are stable.
CXR on [**2180-11-26**]: 1) New infiltrate right lung base, compatible
with pneumonia. 2) Resolving left lower lobe pneumonia.
Right knee plain films: Osteopenia. Chondrocalcinosis. Joint
effusion. No fracture detected.
Hip plain films: Severe osteopenia. No obvious fracture. If
clinically indicated, repeat lateral views can be obtained at no
additional charge to the patient.
EEG [**2180-11-20**]: This is an abnormal routine EEG due to the presence
of more
prominent delta frequency slowing seen over the right
fronto-temporal
region as well as an attenuation of faster theta frequency
rhythms
present over the left hemisphere but less prominent over the
right.
There is also an assymetry in the posterior predominant
background
rhythm with the left hemisphere reaching the 7 Hz theta
frequency range
while the right hemisphere is in the 4 Hz delta frequency range.
These
findings suggest subcortical dysfunction affecting the right
hemisphere
more prominent in the fronto-temporal regions. In addition, the
background rhythm over the left hemisphere is slowed and
occasional
generalized delta frequency slowing is also seen suggesting
deep,
midline subcortical dysfunction that may reflect an underlying
encephalopathy. No epileptiform abnormalities were seen.
Brief Hospital Course:
[**Age over 90 **] yo man, DNR/DNI, found down in his kitchen, refused help when
EMS arrived. EMS returned the next day, found him disshelveled
on [**2180-11-14**], urinated on self. Brought to Good [**Hospital 53775**]
Hospital. Large right temporal lobe bleed seen on CT.
Transferred to [**Hospital1 18**] on [**2180-11-15**] for Neurosurgical evaluation.
No intervention was made. Etiology of bleed is likely amyloid
angiopathy given patient's age and location of bleed, although
underlying mass cannot be excluded. Patient had no history of
hypertension.
The lobar bleed remained stable and did not expand. He was
placed on low dose beta blocker for BP control. He was
originally placed on dilantin for seizure prophylaxis, although
it is possibly he could have had a seizure at home given that he
was found dissheveled and incontinent of urine. He remained
seizure free while in house. He was transitioned from dilantin
to keppra as he became sleepy several days into his admission.
Keppra was eventually weaned off after he had been on an
antiepileptic for 2 weeks after his bleed, and he still remained
sleepy. EEG showed no epileptiform activity.
His mental status waxed and waned. 2 days after admission he
became sleepy and confused. He underwent infectious workup for
this, as well as EEG and dilantin was changed to keppra. EEG
unrevealing. He was found to have a LLL (presumed aspiration)
pneumonia and was treated with 7 days of levofloxacin. On the
7th day of levofloxacin, he spiked a temperature and CXR
revealed a new RLL pneumonia as well as resolving LLL pneumonia.
His antibiotics were changed to zosyn and sputum culture
obtained. Sputum grew MRSA and thus zosyn was discontinued and
vancomycin was initiated on [**2180-11-29**]. He should complete a 10
day course of vancomycin. Last day of antibiotics will be
[**2180-12-8**]. PICC line can be removed after antibiotics course is
complete.
His alertness improved, but confusion remaines at time of
discharge (disoriented, thinks it is [**2169**], etc.). Repeat head
CTs have shown stable intraparenchymal bleed.
Exam at discharge: awake, alert, not oriented to place/time but
is oriented to self, when asked how old he is he usually says
"Too old!". Follows axial and midline commands. No blink to
threat on the left. Left lower face droop. Moves all
extremities and lifts to gravity but moves the right better than
the left. Diffusely hypertonic, hyperreflexic. Toes are
positioned in an upwards position.
Another major issue during hospitalization was nutrition. NGT
placed and TF initiated for approximately 2 weeks as he was
confused and failed repeated swallow evals, then patient began
pulling out his NGT repeatedly despite restraints. He underwent
multiple swallow evaluations when he began to become more alert
and never fully did well with swallowing. Multiple discussions
were held with patient's daughter ([**Name (NI) **] [**Name (NI) 805**]) who insisted
that his wishes were to NOT have a permanent feeding tube, and
since he kept pulling out his NGT, we decided it would be best
to let him eat a modified diet as NGTs and even PEG tubes do not
fully prevent aspiration. He should be fed a puree diet with
honey tickened liquids. NO SOLIDS. NO THIN LIQUIDS. Crush
meds in puree. Sitting upright with all meals and 30 min
afterwards, aspiration precautions. See page 1 for further
instructions.
Other issues:
After admission he had episodes of apnea x 20-30seconds in
duration, every few minutes. He spent the night in the ICU with
noninvasive ventilation (bipap) and did well, went to the floor
quickly.
He was found to have a right knee effusion, not warm to the
touch. Aspiration was attempted on [**2180-11-24**] but no fluid could be
withdrawn. The effusion resolved the next day. Plain films
showed no fracture. Plain films of hips showed no fracture as
well (he initially c/o hip pain in the ED).
B12 borderline low, macrocytic anemia
- PO B12 supplementation
- given banana bag upon admission, thiamine/folate/MVI PO
HYPOTHYROIDISM
- con't levothyroxine, TSH normal at 3.5
RHABDOMYALISIS:
- CK's trended down with IVF
MILD TRANSAMINITIS
- AST/ALT/amylase/lipase followed closely, etiology? -> RESOVLED
spontaneously
PPx: PPI, SC heparin, OOB, pneumoboots
CODE: DNR/DNI
COMM: contact was maintained with the family. FYI: the legal
health care proxy is [**Name (NI) 14880**] [**Name (NI) **]: [**Telephone/Fax (1) 59360**]. However,
[**Doctor First Name 14880**] talks over all decisions with and agrees with
patient's sister [**Name (NI) **] [**Name (NI) 805**] who is very involved with his
care although lives in [**State 622**]. CELL : ([**Telephone/Fax (1) 59361**] HOME:
([**Telephone/Fax (1) 59362**] . She was very clear that he would NOT want a
permanent feeding tube, nor life support. [**Doctor First Name **] is to be
contact[**Name (NI) **] for all major medical decisions. DNR/DNI.
PCP is [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 59363**] [**Telephone/Fax (1) 17465**] at the [**Location (un) 38**] [**Hospital1 2292**]
Medications on Admission:
levothyroxine 50mcg
loperamide
oxybutinin
lorazepam
meclizine
diphenoxylate
Discharge Medications:
1. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day) as needed for dvt
prophylaxis.
2. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily):
please crush in purree.
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
please crush in puree.
4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): please crush in puree.
5. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY
(Daily): please crush in puree.
6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day): hold for SBP<110, HR<55, please crush in puree.
7. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) as needed for constipation: crush with puree.
8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation: crush with puree.
9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for fever, pain: please crush with puree
or give rectally.
10. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
11. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One
(1) PO once a day: please give with honey-thick liquid.
12. Levothyroxine Sodium 50 mcg Tablet Sig: One (1) Tablet PO
once a day: please crush in puree.
13. Vancomycin HCl 10 g Recon Soln Sig: One (1) gram Intravenous
Q12H (every 12 hours) for 10 days: for MRSA pneumonia. Started
on [**2180-11-29**], to complete a 10 day course. Last day [**2180-12-8**].
14. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
15. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous DAILY (Daily) as needed: 10 cc NS followed
by 200 units (2cc)heparin each port in PICC line daily.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Health Care - [**Hospital1 **]
Discharge Diagnosis:
Right temporal-parietal lobe hemorrhage, likely secondary to
amyloid angiopathy.
MRSA pneumonia
Hypothyroidism
Discharge Condition:
Improving - still confused but fluent, resolving pneumonia
satting well on room air and afebrile, moves left side less so
than the right but still with some strength against resistence.
Discharge Instructions:
Please take all medications. Please call your doctor or return
to the emergency department if you experience worsening
weakness, headache, unresponsiveness or other worrisome
symptoms.
Followup Instructions:
When you leave rehab, please call [**Telephone/Fax (1) 1694**] for a stroke
clinic followup appointment. I am unable to make an appointment
for you at this time.
PCP is [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 59363**] [**Telephone/Fax (1) 17465**] at the [**Location (un) 38**] [**Hospital1 2292**], please followup on Fri [**2181-1-12**] at 10:30am, [**Doctor Last Name 59364**], [**Location (un) **], in [**Location (un) 38**], MA.
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
|
[
"431",
"459.9",
"733.90",
"790.5",
"V09.0",
"277.3",
"293.0",
"276.1",
"244.9",
"342.90",
"728.88",
"281.1",
"507.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.91",
"38.93",
"96.6",
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
12270, 12343
|
5146, 7259
|
354, 416
|
12498, 12686
|
2857, 5123
|
12920, 13506
|
1692, 1723
|
10415, 12247
|
12364, 12477
|
10314, 10392
|
12710, 12897
|
1738, 2108
|
7274, 10288
|
224, 316
|
444, 1349
|
2421, 2838
|
2124, 2403
|
1371, 1465
|
1481, 1676
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,790
| 126,309
|
12860
|
Discharge summary
|
report
|
Admission Date: [**2125-9-11**] Discharge Date: [**2125-10-10**]
Date of Birth: [**2058-10-30**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Plaquenil / Ibuprofen
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
NSTEMI, PNA, fevers of unclear etiology
Major Surgical or Invasive Procedure:
[**2125-9-27**] emergency CABG x5 with IABP (LIMA to LAD, SVG to DIAG,
SVG to OM, SVG to PDA with "y" graft to SVG to PLV)
[**2125-9-28**] re-exploration mediastinum
[**2125-9-3**] cardiac catheterization
[**2125-9-21**] right temporal artery biopsy
[**2125-9-28**] IVC filter placement
punch biopsy RUE plaque
bone marrow biopsy
Lumbar puncture
History of Present Illness:
66F with CAD s/p MI [**2108**], now with 3VD awaiting 5v CABG
(scheduled [**9-26**]) that presents from an OSH with +CEs in setting
of fever to 102.9, HR 113, RLL infiltrate on CXR.
.
The pt underwent an abnormal ETT-MIBI ([**2125-8-15**]). During that
test the patient exercised for 4 minutes 59 seconds to a HR 123.
No CP, however, the patient did report DOE and ECG revealed 1mm
of horizontal ST segment depression in leads II, III, AVF and
V4-V6. Imaging revealed apical hypokinesis, evidence of a
reversible anteroseptal and an anteroapical perfusion
abnormality and an EF of 65%. The pt subsequently underwent
cardiac catheterization (Dr. [**Last Name (STitle) 7047**] on [**9-3**] that revealed
diffuse 3VD (see details below.)
.
Last night the pt notes she was in her usual state of health.
She was awoken from sleep with sub-sternal chest pressure with
radiation to the arm, -N/V, + diaphoresis. The pt took 3
Sub-Lingual Nitroglycerin which resolved her symptoms. The pt's
friend subsequently called EMS and she was taken to [**Hospital 6451**] Hospital. Upon arrival to the hospital the patient was
noted to have temperature to 102.8, 111/70 HR 89 (113 at time of
EMS). RR 18-20. Exam notable for bibasilar crackles. Cardiac
exam benign. WBC 13K. Pt with infiltrate on CXR, troponin > 20.
The pt was given ASA, loaded with plavix, given Lopressor 12.5mg
and started on Heparin gtt. The pt was given 1 dose of
Solumedrol 100mg. The pt was given doses of Levaquin and
Vancomycin for RLL infiltrate. The pt was subsequently
transfered to [**Hospital1 18**] for further managament of NSTEMI.
.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, cough, hemoptysis, black stools or
red stools. Denies chills or rigors. All of the other review of
systems were negative.
.
Cardiac review of systems is notable for absence of paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope
or presyncope. The pt notes she had felt slightly confused over
the last few days.
.
Upon arrival to the patient had no complaints.
Past Medical History:
1. CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
-CABG: planned 5v CABG [**2125-9-26**]
-PERCUTANEOUS CORONARY INTERVENTIONS:
- [**1-/2108**] MI s/p cardiac catheterization: 50% LAD lesion and a
70%
diagonal lesion treated with medical management
-PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
Systemic Lupus Erythematosus - on steroids
Anxiety
Pernicious anemia
Arthritis
[**2120**] Seizure
Bite with cellulitis
Thrombocytopenia
? Syncopal event per patient CT negative for hemorrhage
Biliary Colic s/p cholecystectomy [**2123-1-19**]
Social History:
Lives with friend [**Name (NI) **] - will be available to assist at home
Tobacco: 15 pack year history quit [**2118**]
ETOH denies
Family History:
(parents/children/siblings CAD < 55 y/o)
Mother died of MI @ age 62
Physical Exam:
VS: T= 98 BP= 118/56 HR=71 NSR RR=18-20 O2 sat= 95% RA
GENERAL: NAD. Oriented x3. [**Last Name (un) **] Caucasian female. 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 6-7cm.
CARDIAC: Normal S1, S2. No m/r/g. No S3 or S4.
LUNGS: No chest wall deformities. Resp were unlabored, no
accessory muscle use. CTAB, mild bibasilar crackles R>L. No
appreciable wheezes or rhonchi. No bronchial breath sounds. No
egophany, no tactile fremmitus.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
[**9-27**]: 64" 75kg
Pertinent Results:
[**2125-9-22**]: Offical CT read:
1. Lytic lesion is consistent with a hemangioma
2. Bones do have a mottled appearance
3. Subacute DVT in R external iliac vein
4. Mild T12 compression fracture
5. Cyst in left ovary- 15mm (follow with pelvic ultrasound)
6. Retroperitoneal lymphnodes are not pathologic because they
are <1cm. Recommend CT follow-up in 3 months to monitor for
progression. Could be due to DVT.
.
MRI head [**2125-9-17**]:
IMPRESSION: No direct evidence to support lupus cerebritis.
Diffuse symmetric white matter lesions do not appear acute in
nature and most likely representing chronic microvascular
ischemic disease; however, correlation with prior imaging if
available is recommended.
.
Non-contrast head CT [**9-16**]
IMPRESSION:
1. No definite evidence of normal pressure hydrocephalus. Mild
ventricular
prominence may be explained by age-appropriate involutional
changes given
proportionate sulcal prominence.
2. Moderately severe chronic microvascular infarction.
.
CHEST (PORTABLE AP) [**9-15**]
FINDINGS: In comparison with the study of [**9-12**], there is little
change. The heart remains within normal limits and there is no
vascular congestion or pleural effusion. Specifically, no
evidence of acute focal pneumonia.
.
EKG: NSR, HR 86, Mild Left Axis shift, Normal PR, Narrow QRS,
TWI in V1-V4, PRWP.
COMMENTS:
1. Coronary angiography in this right dominant system
demonstrated three
vessel disease. The LMCA had non-obstructive CAD. The LAD was
moderately
calcified with an 80% ostial and a subtotally occluded stenosis
mid
vessel. There was a filling defect consistant with thrombus at
the
distal margin of the mid LAD lesion. The LCx had non-obstructive
CAD.
The OM1 had an 80% stenosis in the proximal vessel. The RCA was
moderately calcified and had a mid 95% stenosis.
2. Limited resting hemodynamics revealed normal central arterial
blood
pressure with a systolic of 124, diastolic of 63, and mean of
69mmHg.
3. Unsuccessful PTCA of the mid LAD with a 2.0 x 20mm Sprinter
balloon
complicated by subintimal dissection. Final angiography revealed
99%
residual stenosis, a grade IV proximal to distal LAD dissection,
and
TIMI 2 flow. (see PTCA comments for details)
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Normal ventricular function.
3. Unsuccessful PTCA of the LAD.
4. Emergent CABG.
ATTENDING PHYSICIAN: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **].
REFERRING PHYSICIAN: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **].
CARDIOLOGY FELLOW: [**Last Name (LF) 39562**],[**First Name3 (LF) **] G.
ATTENDING STAFF: [**Last Name (LF) **],[**First Name3 (LF) **] M.
([**Numeric Identifier 39563**])
Brief Hospital Course:
66 y/o female with CAD s/p MI in [**2108**], now with 3VD on cardiac
catheterization ([**2125-9-3**]), awaiting 5v CABG on [**2125-9-26**], who is
tranferred from OSH with NSTEMI and SIRS/Sepsis from presumed
PNA, with a hospital course complicated by fevers of unclear
etiology.
.
# Fevers of unclear etiology - patient developed fevers as high
as 105.2 of unclear etiology. She had negative blood cultures,
negative urine cultures, negative C. diff, was treated for
presumed pneumonia on cxr (despite significant symptoms) with a
7 day course of vencomycin and levofloxacin, underwent LP (which
was negative at the time of this report). Patient also had
remote history of SLE, has been on chronic steroids for 30+
years, and rheumatology was consulted for possible rheumatoligic
etiology. [**Doctor First Name **] returned positive at 1:40 titer and C3/C4
complement levels were wnl. ESR and CRP both elevated > 100.
Based on rheumatology recs, prednisone was increased to 10 mg
daily, due to possible "relative" adrenal insufficiency on the
days she receives 5mg. Patient also underwent temporal artery
biopsy as well as bone marrow biopsy. CT chest was performed,
as per dermatology recs, which showed a lytic lesion c/w
hemangioma, bones with mottled appearance, subacute DVT in R
external iliac vein (started on heparin gtt), mild T12
compression fracture, cyst in left ovary- 15mm (follow with
pelvic ultrasound), and retroperitoneal lymph nodes that are not
pathologic because they are <1cm. TEE was planned to assess for
culture negative endocarditis but was deferred given an episode
of hematemesis. It was felt that her presentation was not
consistent with cutaneous lupus or other vasculitis. Her punch
biopsy was c/w discoid lupus, but it was felt that this etiology
did not explain her high fevers either. Patient had a positive
galactomannan, but felt to be a false positives (b glucan was
negative).
.
# CORONARIES: Pt with known 3VD on [**2125-9-3**] cardiac
catheterization (90% mid vessel RCA stenosis, 80% ostial LAD
stenosis, 80% mid LCX stenosis). ECG with TWI V1-V4. CEs + in
setting of fever, tachycardia, ? infiltrate. Pt was scheduled
for elective CABG on [**9-26**]. At OSH, was loaded with 600 mg plavix.
Patient was continued on ASA, Beta-Blocker, Statin, Isosorbide
Dinitrate, heparin gtt. Pt underwent cardiac catheterization on
[**2125-9-27**] with failed attempt at stenting LAD, and taken to OR
emergently for CABG.
.
# PUMP: ETT-MIBI ([**2125-8-15**]) showing EF > 60%. During the test,
patient exercised for 4 minutes 59 seconds to a peak HR of 123
BPM. DOE with ECG showing 1mm of horizontal ST segment
depression in leads II, III, AVF and V4-V6. Imaging revealed
apical hypokinesis, evidence of a reversible anteroseptal and an
anteroapical perfusion abnormality. Patient continued on BB.
.
# RHYTHM: Per report was initially sinus tachycardic at OSH,
potentially [**2-26**] to fever SIRS/sepsis. Currently NSR. Telemetry
without events.
.
# h/o SLE: patient was continued on her home regimen of
alternating 5 mg/10 mg prednisone. This was increased to 10 mg
daily, as per rheum recs, as noted above.
.
# HLD: continued on home dose pravastatin.
.
# HTN: continued on BB
.
# Anxiety: continued on triazolam, diazepam. As per psych recs,
we attempted to wean diazepam, and her current regimen was 10 mg
[**Hospital1 **].
Cardiac surgery note:
After IABP insertion and unsuccessful LAD stenting in cath lab
on [**9-27**], taken emergently to OR for CABG with Dr. [**First Name (STitle) **].
Transferred to the CVICU in fair condition on titrated
phenylephrine and propofol drips. Had multiple blood products
for coagulopathy. Taken back to the OR in the AM of [**9-28**] for
tamponade by TEE. Medastinal exploration done with washout.
Transferred back to the CVICU in fair condition on epinephrine,
and propofol drips. Also on [**9-28**], had an IVC filter placed for
right iliac DVT noted on prior scan. She progressively improved
and epinephrine was weaned off and IABP weaned. On [**9-29**] IABP was
removed but she remained intubated due to volume which diuresis
was started. Her sedation was weaned and she was able to follow
commands. On [**9-30**] she was weaned and extubated without
complications. She remained in the intensive care unit for
hemodynamic monitoring. Beta blockers and Ace inhibitor were
started for blood pressure and heart rate management. On [**10-1**]
she was transfered to the floor which during the night she had
episodes of delirium. Psychiatry continued to follow and haldol
dose was increased [**10-2**]. Delrium improved slowly on haldol.
Physical therapy worked with her on strength and mobility. A
rehab stay was recommended prior to her return home. Diuresis
was increased secondary to pleural effusions. An attempt was
made to wean haldol, but Ms. [**Known lastname 39564**] began to hear
disembodied voices and her paranoia increased. Neuro was
consulted and they recommended for a question of normal pressure
hydrocephalus, which they found no evidence to support. Her
haldol was restarted and her paranoia and hearing of voices
abated. Remeron was started per the psychiatry service and then
the haldol was decreased. They recommended that she be
evaluated at rehab for further increase of her remeron as
needed. She was cleared for discharge by Dr. [**Last Name (STitle) **] on
post-operative day 13 to rehab.
Medications on Admission:
Cyanocobalamin 1,000 mcg/mL Solution one injection once a month
Diazepam 10 mg Tablet one Tablet(s) by mouth four times a day
Isosorbide Dinitrate [Dilatrate-SR] 40 mg Capsule, Sustained
Release one Capsule(s) by mouth daily
Labetalol 100 mg Tablet [**1-26**] Tablet(s) by mouth daily
Nitroglycerin 0.2 mg/hour Patch 24 hr
on in the am and off in the pm
Nitroglycerin 0.4 mg Tablet, Sublingual one-three Tablet(s)
sublingually as needed for chest pain
Phenytoin Sodium Extended 100 mg Capsule one Capsule(s) by mouth
three times a day
Pravastatin 20 mg Tablet one Tablet(s) by mouth at bedtime
Prednisone 5 mg Tablet 1 Tablet(s) by mouth alternating with 2
tablets by mouth daily
Propoxyphene N-Acetaminophen 100 mg-650 mg Tablet two Tablet(s)
by mouth three times a day as needed
Triazolam 0.25 mg Tablet one Tablet(s) by mouth daily at bedtime
Aspirin 81 mg Tablet one Tablet(s) by mouth daily
Multivitamin Tablet one Tablet(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).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
Disp:*90 Capsule(s)* Refills:*2*
4. Prednisone 5 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
Disp:*45 Tablet(s)* Refills:*2*
5. Atenolol 50 mg Tablet Sig: Two (2) Tablet PO QAM (once a day
(in the morning)).
Disp:*60 Tablet(s)* Refills:*2*
6. Atenolol 50 mg Tablet Sig: One (1) Tablet PO QPM (once a day
(in the evening)).
Disp:*30 Tablet(s)* Refills:*2*
7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Haloperidol 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
9. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO BID (2 times a
day) for 7 days: then eval for further treatment.
Disp:*28 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2*
11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 7 days: then eval for further treatment.
Disp:*14 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
Life Care Center of [**Location 15289**]
Discharge Diagnosis:
CAD s/p emergency CABG x5 with IABP
cardiac tamponade s/p re-exploration mediastinum
HTN
Hyperlipidemia
[**1-/2108**] MI s/p cardiac catheterization: 50% LAD lesion and a 70%
diagonal lesion treated with medical management
CAD
Systemic lupus erythematosus
Anxiety
Pernicious anemia
Arthritis
[**2120**] Seizure
Biliary colic
Bite with cellulitis
Thrombocytopenia
Cholelithiasis [**2123**]
? Syncopal event per patient CT negative for hemorrhage
DVT right iliac vein s/p IVC filter
Discharge Condition:
good
Discharge Instructions:
no lotions, creams,ointments or powders on any incision
shower daily and pat incisions dry
no driving for one month
no lifting greater than 10 pounds for 10 weeks
call for fever greater than 100.5, redness, drainage, or weight
gain of 2 pounds in 2 days or 5 pounds in 1 week
Call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
see Dr. [**Last Name (STitle) **] primary care doctor in [**1-26**] weeks
see Dr. [**Last Name (STitle) 7047**] cardiologist in [**2-27**] weeks
see Dr. [**First Name (STitle) **] cardiac surgeon in 4 weeks [**Telephone/Fax (1) 170**]
see Dr. [**Last Name (STitle) **] vascular surgeon in 2 weeks [**Telephone/Fax (1) 2395**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2125-10-10**]
|
[
"578.9",
"038.9",
"410.71",
"423.3",
"998.11",
"414.01",
"620.2",
"272.4",
"E879.0",
"412",
"453.41",
"293.0",
"V58.65",
"995.91",
"414.12",
"401.9",
"710.0",
"300.00",
"599.0",
"998.2",
"486",
"780.60"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"03.31",
"37.22",
"86.11",
"88.52",
"99.20",
"88.72",
"41.31",
"38.21",
"36.15",
"37.61",
"88.55",
"88.51",
"36.14",
"34.03"
] |
icd9pcs
|
[
[
[]
]
] |
15188, 15255
|
7360, 12784
|
329, 677
|
15780, 15787
|
4614, 6825
|
16175, 16624
|
3605, 3674
|
13780, 15165
|
15276, 15759
|
12810, 13757
|
6842, 7337
|
15811, 16152
|
3689, 4595
|
2954, 3165
|
250, 291
|
705, 2846
|
3196, 3440
|
2868, 2934
|
3456, 3589
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,724
| 151,887
|
52901
|
Discharge summary
|
report
|
Admission Date: [**2167-4-4**] Discharge Date: [**2167-4-15**]
Service: SURGERY
Allergies:
Penicillins / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
1. Epigastric Pain
2. Chest pain
Major Surgical or Invasive Procedure:
[**2167-4-4**]: ERCP
[**2167-4-6**]: ERCP
[**2167-4-8**]: 1. Distal gastrectomy with Billroth II reconstruction
and
partial duodenectomy.
2. Open cholecystectomy.
History of Present Illness:
87M with significant cardiac history p/w 4 days of epigastric
and chest pain radiating into the back. Patient presented to ED
Friday evening after no improvement in the pain. He reports
having subject fevers at home, though he never measured his
temperature. Otherwise he denies nausea, vomiting, shortness of
breath. He did report some constipation over the past few days
though reports having a bowel movement today.
Past Medical History:
1. Coronary artery disease status post coronary artery
bypass graft in [**2144**] and [**2142**]
2. Left ventricular aneurysm.
3. Congestive heart failure with ejection fraction less than
20% from the echocardiogram in [**2160-6-10**]. He had a
biventricular implantable cardioverter-defibrillator placed
in [**2160-6-10**].
4. s/p IMI
5. AAA - repaired in [**2147**]
6. Chronic obstructive pulmonary disease.
7. Hypertension.
8. Hyperlipidemia status post appendectomy in [**2092**].
9. BPH
10. DM2
Social History:
1 PPD x 30 years
He grew up in [**Location (un) 3146**], [**State 350**]. He is a veteran of the
Army. He was in the air corps. He is married, has a wife and
three grown children. He is a retired fireman and insurance
salesman. No tobacco use. He did smoke but quit 20 years ago. He
is an ex-smoker for 50 pack per year, he quit in [**2142**]. No
intravenous drug use. Social alcohol use. No drug use.
Family History:
Significant for father dying of lung cancer and mother dying of
myocardial infarction at age 65.
Physical Exam:
On Admission:
T100.6 HR102 BP148/80 RR24 O299 RA
NAD
PERRL, EOMI b/l, sclera anicteric
Neck supple
CV: RRR, paced
Pulm: CTA b/l
Abd: soft, min TTP in RUQ, non distended, no rebound/gaurding,
neg [**Doctor Last Name 515**] sign
Ext: no edema
On Discharge:
VS: T 97.4, HR 83, BP 115/65, RR 18, 94% RA
Gen: NAD
CV: RRR, paced
Lungs: CTAB
Abd: Midline incision with staples, clean/dry and intact. JP
site with suture c/d/i. Soft, tenderness around incision site.
Nondistended
Ext: Warm, no c/c/e
Pertinent Results:
[**2167-4-3**] 08:10PM WBC-14.8*# RBC-4.67 HGB-13.9* HCT-40.8 MCV-87
MCH-29.8 MCHC-34.2 RDW-13.4
[**2167-4-3**] 08:10PM NEUTS-95.5* LYMPHS-1.7* MONOS-2.0 EOS-0.5
BASOS-0.4
[**2167-4-3**] 08:10PM PT-21.7* PTT-29.8 INR(PT)-2.0*
[**2167-4-3**] 08:10PM GLUCOSE-207* UREA N-26* CREAT-1.4* SODIUM-137
POTASSIUM-4.2 CHLORIDE-101 TOTAL CO2-20* ANION GAP-20
[**2167-4-3**] 08:10PM ALT(SGPT)-313* AST(SGOT)-402* ALK PHOS-135*
TOT BILI-2.9*
[**2167-4-3**] 08:10PM LIPASE-23
[**2167-4-3**] 09:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-25
GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-12* PH-5.0 LEUK-NEG
[**2167-4-3**] 09:15PM URINE RBC-0 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-0 TRANS EPI-0-2
[**2167-4-8**] 06:58AM BLOOD WBC-10.4 RBC-4.41* Hgb-12.7* Hct-39.5*
MCV-90 MCH-28.9 MCHC-32.2 RDW-14.2 Plt Ct-168
[**2167-4-8**] 06:58AM BLOOD PT-14.9* PTT-29.1 INR(PT)-1.3*
[**2167-4-8**] 06:58AM BLOOD Glucose-121* UreaN-9 Creat-0.9 Na-141
K-3.8 Cl-109* HCO3-23 AnGap-13
[**2167-4-8**] 06:58AM BLOOD ALT-67* AST-62* LD(LDH)-220 AlkPhos-115
TotBili-1.0
[**2167-4-8**] 06:58AM BLOOD Calcium-8.1* Phos-2.6* Mg-2.0
[**2167-4-3**] 8:15 pm BLOOD CULTURE
**FINAL REPORT [**2167-4-6**]**
Blood Culture, Routine (Final [**2167-4-6**]):
ESCHERICHIA COLI.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
296-0154H [**2167-4-3**]. Anaerobic Bottle Gram Stain (Final [**2167-4-4**]):
GRAM NEGATIVE ROD(S).
Aerobic Bottle Gram Stain (Final [**2167-4-4**]): GRAM NEGATIVE
ROD(S).
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
[**2167-4-9**] 6:20 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2167-4-11**]**
MRSA SCREEN (Final [**2167-4-11**]): No MRSA isolated
[**2167-4-3**] EKG:
Ventricular paced rhythm. Compared to the previous tracing of
[**2164-5-6**] there is no change.
[**2167-4-3**] CHEST XRAY:
IMPRESSION: Chronic interstitial lung disease, most pronounced
at the lung
bases, similar to prior. No acute cardiopulmonary abnormality
otherwise
visualized.
[**2167-4-3**] ABD CT:
IMPRESSION: 1. Obstructive choledocholithiasis at the distal CBD
resulting in severe intrahepatic and extrahepatic biliary ductal
dilatation. Recommend ERCP to further assess.
2. No pulmonary embolism or acute aortic pathology. Mild
infrarenal aortic
ectasia.
3. Calcified pleural plaques with pulmonary fibrosis with lower
lobe
predominance, compatible with asbestosis. Multiple pulmonary
nodules, grossly similar or slightly larger in appearance, for
which a nonurgent dedicated CT chest is recommended for further
evaluation.
4. Significant aortic calcification, but major intra-abdominal
arteries are patent.
5. Large right exophytic renal cyst.
[**2167-4-4**] ERCP:
Impression: 1. A moderate amount of semi solid food residue was
noted in the stomach.
2. A stricture was seen in the pylorus. The scope did not
traverse the lesion.
3. A 12mm balloon was introduced for dilation and the diameter
was progressively increased to 15 mm successfully.
4. The duodenoscope was then successfully passed into the
duodenum.
5. A mass was found at the duodenal bulb. Due to duodenal
deformity, we were unable to position the scope in front of the
ampulla to attempt biliary cannulation. Large capacity forceps
biopsies were performed for histology at the mass in the
duodenal bulb.
6. Mass in the duodenal bulb
7. Otherwise normal ercp to third part of the duodenum
[**2167-4-5**] EKG:
Normal sinus rhythm, rate 81, with ventricular synchronous
pacing. Occasional ventricular premature beat. Compared to the
previous tracing of [**2167-4-3**] sinus tachycardia has given way to
normal sinus rhythm and ventricular ectopy is new.
[**2167-4-6**]: ERCP:
Impression: Small ulcer noted at the pylorus, which was stenotic
but improved after dilation 2 days ago.
Mass in the duodenal bulb as seen previously - biopsies pending
A single diverticulum with large opening was found at the major
papilla.
Cannulation of the biliary duct was successful and deep with a
sphincterotome after a guidewire was placed.
Contrast medium was injected resulting in complete
opacification.
A moderate diffuse dilation was seen at the biliary tree with
the CBD measuring 18 mm.
Three round stones ranging in size from 8 mm to 12 mm that were
causing partial obstruction were seen at the lower third of the
common bile duct.
There was post-obstructive dilation.
A sphincterotomy was performed in the 12 o'clock position using
a sphincterotome over an existing guidewire.
4 large stones and biliary sludge were extracted successfully
using a 15 mm balloon.
The bile duct was clear at the end of the procedure
Otherwise normal ercp to third part of the duodenum
[**2167-4-7**] CARDIAC PERFUSION PERSANTINE:
INTERPRETATION:
The image quality is adequate.
Left ventricular cavity size is normal, with EDV of 114 mL.
Rest and stress perfusion images reveal a severe fixed inferior
wall defect.
Gated images reveal mild global hypokinesis.
The calculated left ventricular ejection fraction is 47%.
IMPRESSION: Severe fixed inferior wall defect. Mild global
hypokinesis.
[**2167-4-8**] Pathology Examination
Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 109061**],[**Known firstname **] [**2079-8-8**] 87 Male [**Numeric Identifier 109062**] [**Numeric Identifier 109063**]
Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]
Gross Description by: DR. [**Last Name (STitle) **]. ROBENS/cofc
SPECIMEN SUBMITTED: gallbladder, stomach/duodenum.
Procedure date Tissue received Report Date Diagnosed
by
[**2167-4-8**] [**2167-4-8**] [**2167-4-11**] DR. [**Last Name (STitle) **]. [**Doctor Last Name **]/dsj??????
Previous biopsies: [**Numeric Identifier 109064**] G I BIOPSY (1 JAR).
[**-7/2209**] G.I. BIOPSIES (2 JARS)
[**-2/2991**] GI BIOPSY.
[**Numeric Identifier 109065**] (Not on file)
DIAGNOSIS:
I. Gallbladder (A-C):
Acute and chronic focally necrotizing cholecystitis with
ulceration and transmural inflammation.
One lymph node, no malignancy identified.
II. Stomach/Duodenum (D-Q): Adenocarcinoma arising in the
background of an adenoma, see synoptic report.
Small intestine: Polypectomy; Segmental Resection; Whipple
procedure (Pancreaticoduodenectomy, partial or complete, with or
without partial Gastrectomy Synopsis
MACROSCOPIC
Specimen Type: Segmental resection.
Tumor Site: Duodenum.
Tumor configuration: Exophytic (polypoid).
Tumor Size
Greatest dimension: 3.2 cm. Additional dimensions: 3.0 cm x
2.8 cm.
Other organs Received: Attached portion of stomach;
gallbladder
MICROSCOPIC
Histologic Type: Mucinous adenocarcinoma (greater than 50%
mucinous).
Histologic Grade: G1: Well differentiated.
EXTENT OF INVASION
Primary Tumor: pT2: Tumor invades muscularis propria.
Regional Lymph Nodes: pN0: No regional lymph node metastasis.
Lymph Nodes
Number examined: 1.
Number involved: 0.
Distant metastasis: pMX: Cannot be assessed.
Margins
Proximal margin:
Uninvolved by invasive carcinoma.
Distal margin:
Uninvolved by invasive carcinoma.
Circumferential/radial (mesenteric or retroperitoneal)
margin:
Uninvolved by invasive carcinoma.
Bile duct margin: Not applicable
Pancreatic margin: Not applicable
Distance of carcinoma from closest margin: 13 mm.
Specified margin: Circumferential/radial.
Venous (Large vessel) invasion: Present.
Perineural invasion: Absent.
Additional Pathologic Findings: Adenoma(s).
[**2167-4-14**] IRN 1.5
Brief Hospital Course:
The patient was admitted to the General Surgical Service for
evaluation and treatment of severe epigastric and chest pain.
Patient was admitted into MICU for observation. On [**2167-4-4**]
patient underwent ERCP which revealed a mass in the duodenal
bulb, biopsy was taken. On [**2167-4-6**] patient underwent repeat
ERCP with extraction of the 4 large stones and biliary sludge.
On [**2167-4-8**], the patient underwent distal gastrectomy with
Billroth II reconstruction and partial duodenectomy, and open
cholecystectomy which went well without complication (reader
referred to the Operative Note for details). After surgery
patient was transferred into SICU NPO, on IV fluids and
antibiotics, with a foley catheter, and IT Morphine for pain
control. The patient was hemodynamically stable.
Neuro: The patient received IT Morphine postoperatively with
good effect and adequate pain control. POD # 1 patient was
started on Dilaudid PCA, which was changed to IV Dilaudid. When
tolerating oral intake, the patient was transitioned to oral
pain medications. Patient's pain was well controlled during his
hospital course.
CV: On admission patient complained chest pain, and was
hypotensive with SBP in 80s. Cardiac enzymes were sent and they
were negative, hypotension was treated with IV fluid without
pressors. Cardiology was called to consult and ICD evaluation.
Patient underwent Cardiac Echo and Cardiac stress test. Stress
test revealed LVEF is 47%. Cardiac Echo compared with the prior
report of [**2159-4-19**] showed that left ventricular systolic function
is improved. Cardiology recommended continue Lasix with goal
negative 1000 ml, and start Lopressor 5 mg IV q6h. Patient's
Coumadin was hold for procedure, and was restarted on [**4-13**].
Patient was restarted on all his home cardiac medications on
[**4-14**]. Patient was monitored with telemetry during his hospital
course. The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: Post op patient developed respiratory distress and
was required CPAP. Patient's respiratory status improved
spontaneously after sedation was weaned off. The patient
remained stable from a pulmonary standpoint; vital signs were
routinely monitored. Good pulmonary toilet, early ambulation and
incentive spirrometry were encouraged throughout
hospitalization.
GI/GU/FEN: Post-operatively, the patient was made NPO with IV
fluids. Patient was started on sips of clears on [**4-12**]. Diet was
advanced when appropriate, which was well tolerated. Currently
patient tolerates regular Diabetic/Consistent Carbohydrate diet.
Patient's intake and output were closely monitored, and IV fluid
was adjusted when necessary, and finally d/cd. Electrolytes were
routinely followed, and repleted when necessary.
ID: On admission, patient's WBC was 21.2. Blood cultures grew
E-coli, patient was started on IV Flagyl and Cipro on [**4-4**].
Patient's WBC is treading down (14.0 on [**4-10**]), he is afebrile.
He will continue on PO Flagyl/Cipro x 4 days after discharge.
Endocrine: The patient's blood sugar was monitored throughout
his stay; insulin dosing was adjusted accordingly. FS was within
normal limits, patient was started on his home meds.
Hematology: The patient's complete blood count was examined
routinely; no transfusions were required. Prior surgery,
patient's Coumadin was on hold, patient received prophylactic
Enoxaparin 30 gm SC BID. Coumadin was restarted on [**4-13**]. INR on
[**4-15**] was 1.5, patient will continue to receive Lovenox until
his INR will 2.0 or higher.
Prophylaxis: The patient received subcutaneous Enoxaparin and
venodyne boots were used during this stay; was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating with assistance, voiding without assistance,
and pain was well controlled. The patient received discharge
teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan.
Medications on Admission:
DIGOXIN - 125 mcg Tablet - 1 Tablet(s) by mouth once a day
FUROSEMIDE - (Dose adjustment - no new Rx) - 20 mg Tablet - 1
Tablet(s) by mouth every other day
GLIPIZIDE - (Prescribed by Other Provider: [**Name Initial (NameIs) **]) - 5 mg
Tablet
- 1 Tablet(s) by mouth in am and 2 tabs in pm
LISINOPRIL - 5 mg Tablet - [**12-13**] Tablet(s) by mouth once a day
LOVASTATIN - 40 mg Tablet - 1 Tablet(s) by mouth once a day
METOPROLOL SUCCINATE - 25 mg Tablet Sustained Release 24 hr - 1
Tablet(s) by mouth once a day
OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s)
by mouth once a day
POTASSIUM CHLORIDE - 10 mEq Tablet Sustained Release - 1
Tablet(s) by mouth once a day
SITAGLIPTIN [JANUVIA] - (Prescribed by Other Provider: [**Name Initial (NameIs) **])
-
50 mg Tablet - 1 Tablet(s) by mouth once a day
TAMSULOSIN [FLOMAX] - (Dose adjustment - no new Rx) - 0.4 mg
Capsule, Sust. Release 24 hr - 1 Capsule(s) by mouth once a day
WARFARIN [COUMADIN] - 2 mg Tablet - take Tablet(s) by mouth as
directed
ASPIRIN - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by
mouth once a day
CYANOCOBALAMIN [VITAMIN B-12] - 1,000 mcg Tablet - 1 Tablet(s)
by
mouth once a day
Discharge Medications:
1. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO twice a
day for 4 days. Tablet(s)
2. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a day
for 4 days.
3. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
6. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
8. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous
[**Hospital1 **] (2 times a day): continue until INR 2.0 or greater.
9. Glipizide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
11. Sitagliptin 50 mg Tablet Sig: One (1) Tablet PO once a day.
12. Potassium Chloride 10 mEq Tablet Sustained Release Sig: One
(1) Tablet Sustained Release PO once a day.
13. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
14. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
15. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
16. Cyanocobalamin 1,000 mcg Tablet Sig: One (1) Tablet PO once
a day.
17. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for SOB.
18. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as
needed for SOB.
19. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain.
20. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO every
twelve (12) hours for 3 weeks.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 9475**] Care Center - [**Location (un) 3146**]
Discharge Diagnosis:
1. Duodenal tumor
2. Hypotension
3. E-coli bacteremia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**4-20**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical 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.
* Your suture will be removed on [**4-22**]
Followup Instructions:
Please call [**Telephone/Fax (1) 1144**] to arrange a follow up appointment with
Dr. [**Last Name (STitle) **] (PCP) in [**12-13**] weeks after discharge to check your INR
and Coumadin adjustment.
.
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2167-6-25**]
2:30
.
Provider: [**Name10 (NameIs) 1918**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2167-6-25**] 3:20
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2832**], MD Phone:[**Telephone/Fax (1) 1231**]
Date/Time:[**2167-5-1**] 9:30. [**Hospital Ward Name 23**] 3, [**Hospital Ward Name **]
Completed by:[**2167-4-15**]
|
[
"152.0",
"531.91",
"518.5",
"401.9",
"412",
"574.81",
"790.92",
"600.00",
"041.4",
"428.22",
"576.1",
"V45.02",
"V15.82",
"272.4",
"414.00",
"496",
"501",
"458.9",
"428.0",
"274.9",
"427.31",
"V45.81",
"790.7",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"43.7",
"51.10",
"44.22",
"51.88",
"45.14",
"03.90",
"51.22",
"51.85"
] |
icd9pcs
|
[
[
[]
]
] |
17684, 17770
|
10538, 14646
|
273, 438
|
17869, 17869
|
2479, 10515
|
19201, 19880
|
1851, 1950
|
15880, 17661
|
17791, 17848
|
14672, 15857
|
18052, 18630
|
18645, 19178
|
1965, 1965
|
2221, 2460
|
200, 235
|
466, 890
|
1979, 2207
|
17884, 18028
|
912, 1414
|
1430, 1835
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,821
| 177,402
|
28418
|
Discharge summary
|
report
|
Admission Date: [**2107-9-9**] Discharge Date: [**2107-10-4**]
Date of Birth: [**2046-7-15**] Sex: F
Service: MEDICINE
Allergies:
Adhesive Tape / Percocet
Attending:[**First Name3 (LF) 4282**]
Chief Complaint:
Altered mental status, tachycardia
Major Surgical or Invasive Procedure:
Lumbar puncture attempted [**9-11**]
History of Present Illness:
HPI obtained from patient, medical records and brother.
Ms. [**Known lastname 68938**] is a 61F with pancreatic adenocarcinoma s/p Whipple
[**2102**] now with metastatic recurrence to liver s/p placement of
biliary stents x 2 [**2-/2107**] currently undergoing chemotherapy
cycle 2 Day 17 capecitabine/oxaliplatin admitted with altered
mental status.
Per brother who lives with patient, she woke up this am around 9
and initially seemed normal but he realized within approxiamtely
one hour around 9am that she was having balance and gait
difficulty as well as difficulty speaking coherently and in
complete sentences. She was also repeating phrases. He did not
note slurred speech. This episode was similar to although less
severe than prior episode in [**Month (only) **] attributed to narcotics.
Since last admitted [**Date range (1) 68940**], he has been monitoring her
narcotic use and she has only take dilaudid 2mg PO x 2 and
morphine 15mg PO x 1 last 24 hours. She also took compazine,
zofran, and meclizine. He does not think she took any other
narcotics or had any other ingestions. She has had no new
medications other than recently being restarted on lasix.
Otherwise, he states she developed dry cough today and has had
rash/sores on lower extremitites since right after she started
2nd cycle of chemo but denies fever, chills, any recent change
in lower extremity edema.
In the ED, initial vs were: 98.2 118 183/76 18 97%RA. Exam was
significant for confusion, asterixis, and erythema bilateral R>L
LEs concerning for cellulitis. CT head was unremarkable and CXR
revealed small to mdoerate right pleural effusion. She received
Vancomycin, Azithromycin and Ceftriaxone for pulmonary vs
skin/soft tissue infection, lactulose for asterixis and elevated
ammonia and potassium for hypokalemia K 3.1. She was reportedly
persistently tachycardic sinus with HR 130s despite 1.5L IVF.
There was concern she would trigger on the floor so she was
admitted to MICU. VS prior to transfer: 98.2 157/55 121 30
98%RA.
On the floor, she states "I'm fine, thank you" repeatedly or
"I'm ok". She perseverates on words and repeats phrases. Her ROS
is completely negative.
Past Medical History:
ONCOLOGIC HISTORY:
- diagnosed with pancreatic adenocarcinoma in [**2102**], in the
context of an 80 lb. weight loss
- [**2103-10-9**] Whipple --> well differentiated T3N0 tumor.
- adjuvant chemoradiation with Xeloda and standard external beam
radiotherapy, completed in [**2104-1-17**]
- 4 cycles of adjuvant Gemcitabine chemotherapy with the final
dose on [**2104-6-25**]
- [**1-25**] adnexal mass on surveillance imaging
- [**3-27**] obstructive jaundice, dual biliary drains placed; she was
found to have recurrent adenocarcinoma
- [**2106-5-24**] TAH/BSO: adnexal mass was thought to be metastatic
pancreatic ca
- [**2106-7-14**] palliative chemotherapy with Gemzar three out of four
weeks
- dose was reduced by 25% with her third cycle, due to
thrombocytopenia, but she was still unable to get the third of
three doses
- starting with her fourth cycle she received Gemzar on two of a
three week cycle
- last dose of gemcitabine given on [**2107-6-8**]
- Started Xelox on [**2107-8-3**], currently C1D13
PAST MEDICAL HISTORY:
- 2 metal biliary stents placed on [**2107-3-11**]
- h/o asthma/rhinitis
- hypertension: currently resolved, as per pt
- L4-L5 fusion: fell 10 years ago and broke L4
- cholecystectomy 3 years ago
- duodenal ulcer (per patient): resected as part of Whipple
surgery
- recurrent pancreatitis
- hives (treated with benadryl prn)
- h/o C. difficile
Social History:
The patient lives with her brother. She was previously caring
for her elderly father but he passed away recently. Before
caring for her father, she worked as a medical technologist in
the blood bank at both [**Hospital1 1774**] and the [**Hospital1 **] hospitals. She
denies ever using IV drugs. No EtOH or tobacco. Uses walker at
baseline.
Family History:
Father with type I DM, several other family members with type 2
DM. No family history of pancreatitis or pancreatic cancer. Her
mother had endometrial cancer and her father's mother had
cervical cancer. Her maternal aunt had cancer of some type.
Physical Exam:
ADMISSION PHYSICAL EXAM
General: Appears scared, intermittently crying, agitated,
gripping siderails, only oriented to brother's name. Does not
state her own name, states she is at "[**Hospital6 **]" and
unable to state date, year or month.
HEENT: Sclera anicteric, MM dry, no thrush or mucositis,
oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Faint crackles R base and occ scant exp wheezes.
CV: Tachycardic. Regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops. + pericardial rub.
Abdomen: soft, tender periumbilically whic pateint states is
old, slightly distended, bowel sounds present, no rebound
tenderness or guarding, enlarged liver and spleen palpated just
below costal margin
Ext: 3+ pitting edema B/L ;warm, well perfused, 2+ pulses, no
clubbing, cyanosis
Skin: Erythematous papular rash anterior shin with left more
confluent with surrounding erythem and warmth
Neuro: Able to raise both arms symmetrically. No pronator drift.
+ asterixis. PERRL although dilated approx 5->4mm. Tongue
protrusion midline. Moving lower extremitites symmetrically.
Follows some commands.
DISCHARGE PHYSICAL EXAM
General: NAD, alert and oriented x 3
HEENT: Sclera anicteric,
Lungs: clear to auscultation anteriorly bilaterally, limited
posterior exam given pt's difficulty/pain with sitting up and
turning
CV: Regular rate and rhythm, no murmurs, rubs, gallops.
Abdomen: mildly distended, mild tenderness in epigastric region,
no rebound tenderness or guarding, + ascites,
Skin: no erythema, 1+ edema bilaterally
GU: erythematous groin/buttock rash
Back: no rash evident
Pertinent Results:
[**2107-9-9**] 07:11PM LACTATE-3.6*
[**2107-9-9**] 07:12PM AMMONIA-142*
[**2107-9-9**] 07:15PM PT-18.1* PTT-25.8 INR(PT)-1.6*
[**2107-9-9**] 07:15PM PLT SMR-NORMAL PLT COUNT-172
[**2107-9-9**] 07:15PM HYPOCHROM-OCCASIONAL ANISOCYT-2+ POIKILOCY-1+
MACROCYT-1+ MICROCYT-1+ POLYCHROM-1+ PENCIL-1+
[**2107-9-9**] 07:15PM NEUTS-62 BANDS-0 LYMPHS-23 MONOS-15* EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2107-9-9**] 07:15PM WBC-4.2# RBC-2.93* HGB-9.1* HCT-27.1* MCV-93
MCH-31.1 MCHC-33.6 RDW-24.5*
[**2107-9-9**] 07:15PM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
[**2107-9-9**] 07:15PM TSH-2.6
[**2107-9-9**] 07:15PM OSMOLAL-278
[**2107-9-9**] 07:15PM calTIBC-168* FERRITIN-405* TRF-129*
[**2107-9-9**] 07:15PM ALBUMIN-3.0* CALCIUM-8.3* PHOSPHATE-3.1
MAGNESIUM-1.7 IRON-79
[**2107-9-9**] 07:15PM LIPASE-14
[**2107-9-9**] 07:15PM ALT(SGPT)-19 AST(SGOT)-48* LD(LDH)-327* ALK
PHOS-129* TOT BILI-1.4
[**2107-9-9**] 07:15PM estGFR-Using this
[**2107-9-9**] 07:15PM GLUCOSE-114* UREA N-18 CREAT-1.1 SODIUM-134
POTASSIUM-3.1* CHLORIDE-101 TOTAL CO2-21* ANION GAP-15
[**2107-9-9**] 08:40PM URINE MUCOUS-FEW
[**2107-9-9**] 08:40PM URINE HYALINE-[**4-28**]*
[**2107-9-9**] 08:40PM URINE RBC-[**10-8**]* WBC-[**4-28**]* BACTERIA-FEW
YEAST-NONE EPI-[**4-28**]
[**2107-9-9**] 08:40PM URINE BLOOD-LG NITRITE-NEG PROTEIN-25
GLUCOSE-NEG KETONE-15 BILIRUBIN-SM UROBILNGN-NEG PH-6.5 LEUK-TR
[**2107-9-9**] 08:40PM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.022
[**2107-9-9**] 08:40PM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2107-9-9**] 08:40PM URINE UHOLD-HOLD
[**2107-9-9**] 08:40PM URINE HOURS-RANDOM
Brief Hospital Course:
61F with metastatic pancreatic cancer on palliative chemotherapy
admitted to ICU [**9-9**] for altered mental status and tachycardia,
found to have cellulitus, who developed GI bleed and oliguria
during hospital course, with transfer to oncology floor [**9-13**],
discharged to [**Hospital1 1501**] [**10-4**].
# Altered Mental Status: Most likely secondary to infection vs
med effect. Sources of infection include lower extremity
cellulitus vs C diff as outlined below. No fevers. Head CT on
admission negative. Patient has had recent admission for similar
complaint attributed largely to medication effect although
narcotic regimen was reduced at that time. On admission, TSH
1.1, folate 15.1, B12 1111 [**2107-8-16**]. Narcotics were withheld
initially and her mental status gradually improved. She is A&O
x 3 on discharge. Her pain regimen at discharge consists of
Morphine SR (MS Contin) 15 mg PO Q12H, tylenol prn pain, and
oxycodone 5 mg q6 prn severe pain.
.
# GIB: Pt developing maroon stools morning of [**9-10**] x1 and an
episode of bloody emesis later that day. Received 1 U and
vitamin K. Hct remained stable at 28.4. GI was consulted and
recommended conservative management with no need for
endoscopy/colonoscopy. Of note, pt with hx of diverticulosis,
and hemmorhoids on prior c-scope which could be contributing
cause of GI bleed. No further episodes of GI bleeding
throughout hospital course. Hcts stable.
.
# Oliguria: Patient developed oliguria prior to transfer from
[**Hospital Unit Name 153**] to the floor on [**9-13**]. Likely in setting of GIB and blood
loss. Pt with poor urine output despite multiple fluid boluses
and maintenance fluids. She was > 11L positive for LOS upon
transfer from [**Hospital Unit Name 153**] to floor. Cr also elevated. Renal team was
consulted and recommended aggressive diuresis. She was
initially diuresed with lasix and after an initial Cr bump, her
oliguria resolved and her Cr trended down. She had low
potassium levels and was switched from lasix to torsemide.
Spironolactone as added as well. She was placed on standing
potassium supplements. Will discharge on tosemide,
spironolactone, and potassium. Please check potassium levels in
1 week and adjust accordingly.
.
# Sinus Tachycardia: Tachycardic on admission to [**Hospital Unit Name 153**]. Likely
multifactorial secondary to anxiety/pain, hypovolemia, infection
with sources of infection including cellulitis and PNA. No
leukocytosis or fever. TSH 2.6. LENIs negative. Resolved as
infxn was treated.
.
# Rash: Patient reportedly developed sores on lower extremities
after starting 2nd cycle of chemo. RLE also appeared
superinfected as it was warm and mildly TTP c/w cellulitis.
Capecitabine also causes rash in 27-37% of patients. resolving
on right leg and slightly worsening on left. Completed course
of bactrim/dicloxacillin for cellulitis. Resolved prior to
discharge.
.
# LE edema: Bilateral lower extremity edema. Unclear baseline.
Diuresed as above. Continues to have LE edema upon discharge.
.
# Metastatic pancreatic cancer: On admission, was on cycle 2
palliative chemo capecitabine/oxaliplatin. Outpatient
oncologists Dr. [**Last Name (STitle) **] and [**First Name4 (NamePattern1) 636**] [**Last Name (NamePattern1) 11309**] were contact[**Name (NI) **] and
saw patient intermittently during hospital stay. No further
chemotherapy. Patient intermittently complains of abdominal
pain that is abated with redirection and/or tylenol.
.
#Ascites: likely secondary to metastatic pancreatic cancer as
well as volume overload. A diagnostic paracentesis was
performed and was negative for infection and malignancy.
Patient intially had blood discharge from site of paracentesis,
which resolved over several days. Further paracentesis for
therapeutic benefit was not performed given prognosis and lack
of respiratory or severe abdominal symptoms.
# Pleural effusion: Patient has new right pleural effusion and ?
pneumonia on CXR but no focal infiltrate and no fever or
leukocytosis. Lack of cough, SOB, or sputum production also
argued against PNA. Could be secondary to metastatic disease or
sympathetic effusion from abdominal processes. Pleural effusion
stable in size. Diuresed as above.
.
# Coagulopathy: Likely nutritional in additional to
capecitabine. Patient was given vitamin K with little
improvement in INR. DIC labs were trended for several days and
remained negative. Smear showed abnormal burr cells but no
schistocytes. Stool studies for E.coli were negative. No
interventions made. Stable at discharge.
.
# Asthma/rhinitis: Continued fluticasone inhaled and nasal
spray, albuterol inhaler prn
.
#Thrush: treated with nystatin swish and swallow
.
#Buttock rash: treated with miconazole powder
Medications on Admission:
1. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal DAILY.
2. Fluticasone 110 mcg/Actuation Aerosol Sig: One (1) Puff
Inhalation [**Hospital1 **] (2 times a day).
3. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours). Disp:*60 Tablet
Sustained Release(s) *Refills:*0*
4. Capecitabine 500 mg Tablet Sig: Two (2) Tablet PO twice a day
for 10 days: please take as directed by Dr. [**First Name (STitle) 11309**].
5. PLEASE NOTE WE DISCONTINUED YOUR LASIX. THIS WILL NEED TO BE
RE-ASSESSED BY YOUR DOCTOR AT YOUR NEXT APPOINTMENT.
6. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours as needed for ANXIETY OR NAUSEA: PLEASE NOTE WE
DECREASED THE FREQUENCY TO EVERY 8 HOURS INSTEAD OF 6.
7. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every four
(4) hours as needed for pain: PLEASE NOTE WE DECREASED THE DOSE
TO 2MG FROM 4MG. PLEASE READ YOUR PILL BOTTLES AT HOME
CAREFULLY. Disp:*30 Tablet(s)* Refills:*0*
8. Mirtazapine 7.5 mg Tablet Sig: One (1) Tablet PO at bedtime:
PLEASE NOTE WE DECREASED THE DOSE FROM 15mg. Disp:*30 Tablet(s)*
Refills:*0*
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
10. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) PUFFS Inhalation every 4-6 hours as needed for shortness
of breath or wheezing.
11. Recently restarted back on Lasix, unsure of dose
Discharge Medications:
1. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal [**Hospital1 **] (2 times a day).
2. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
3. morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
4. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours as needed for nausea or anxiety.
5. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every four
(4) hours as needed for pain.
6. mirtazapine 7.5 mg Tablet Sig: One (1) Tablet PO at bedtime.
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day as needed for constipation.
8. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: [**11-20**] Inhalation Q4H (every 4 hours) as needed
for SOB or wheezing.
9. torsemide 20 mg Tablet Sig: Three (3) Tablet PO BID (2 times
a day).
10. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
11. spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
12. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: Three (3) Tab Sust.Rel. Particle/Crystal PO twice a day:
Please hold for K >5.0.
13. ZOFRAN ODT 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every 4-6 hours as needed for nausea.
14. Outpatient Lab Work
Please check chem 7 in 1 week.
Discharge Disposition:
Extended Care
Facility:
[**Doctor First Name 37**] House Rehab & Nursing Center - [**Location (un) 38**]
Discharge Diagnosis:
Primary:
Altered mental status, NOS
GI Bleed, NOS
ARF, likely pre-renal
cellulitis, bilateral lower extremity
C diff infection
coagulopathy, likely nutritional
Secondary:
metastatic pancreatic carcinoma
asthma
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. [**Known lastname 68938**],
It was a pleasure participating in your health care. You were
admitted to [**Hospital1 69**] for altered
mental status. You were found to have a gastrointestinal bleed,
low urine output, lower leg cellulitis, and C. diff infection.
You were treated with antibiotics and fluids. You were
transfused 1 unit of blood. You were treated with vitamin K for
bleeding. You were given diuretics to help remove excess fluid
from your body. The fluid in your stomach was removed during a
procedure called a paracentesis and the cytology results were
negative for cancer. Your potassium level was consistently low
because of the diuretics and you were given potassium
supplements.
.
Please START the following medications:
ZOFRAN 8 mg every 4-6 hours as needed for nausea
Torsemide 60 mg twice a day
Spironolactone 50 mg daily
Pantoprazole 40 mg daily
Potassium 60 mEq twice a day
Please continue all other home medications. Please be cautious
when taking pain medications.
Followup Instructions:
Please schedule a follow-up appointment with heme/onc clinic
([**Telephone/Fax (1) 22**]). Please see your physician as needed.
|
[
"401.9",
"682.6",
"E933.1",
"276.3",
"789.59",
"693.0",
"197.7",
"785.0",
"584.9",
"276.2",
"008.45",
"286.9",
"578.9",
"493.90",
"511.9",
"780.97",
"157.9",
"285.9",
"287.5",
"276.1",
"276.8",
"112.0",
"560.1",
"198.6",
"V49.86"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31",
"54.91",
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
15617, 15724
|
7925, 8247
|
319, 358
|
15978, 15978
|
6202, 7902
|
17195, 17326
|
4333, 4581
|
14173, 15594
|
15745, 15957
|
12730, 14150
|
16162, 17172
|
4596, 6183
|
245, 281
|
386, 2558
|
15993, 16138
|
3612, 3958
|
3974, 4317
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,559
| 103,610
|
54722
|
Discharge summary
|
report
|
Admission Date: [**2151-7-2**] Discharge Date: [**2151-7-7**]
Date of Birth: [**2103-1-4**] Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname **] is a 48 year old man with a history of hypertension,
hyperlipidemia and cognitive delay presenting from [**Hospital1 5979**] with a right temporal lobe hemorrhage detected after
patient presented with four days of headache and chest pain.
.
The patient reports that four days ago he suddenly developed a
[**9-1**] frontal headache as well as central, nonradiating chest
pain. The headache has been getting progressively worse. He
denies any recent head trauma or drug use, though last cocaine
use was 2 months ago. He admits to not exercising and eating
poorly recently. He presented to OSH with a systolic blood
pressure of 220. In our ED the patient had a blood pressure of
208/128 on presentation with improved headache and chest pain.
He was started on a nitroprusside drip.
.
ROS: reports "blurry vision", no focal weakness, numbess, loss
of balance, word finding. No fevers, weightloss, nausea,
vomiting, abd pain, cough, shortness of breath.
Past Medical History:
-Hypertension
-Hyperlipidemia
-Obstructive sleep apnea
-Cognitive delay
Social History:
Single, no children, on disability. No tobacco, occasional ETOH,
Cocaine use as recent as 2 months prior. Contact is sister
[**Name (NI) 1787**] [**Name (NI) 3234**]: [**Telephone/Fax (1) 111883**].
Family History:
No strokes, seizure, bleeds.
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
O: T:97.6 BP:208 /128 -->127/60 HR:54 R18 O2Sats95% RA
Gen: sleepy but arousable and conversant, NAD
HEENT: Pupils: [**1-22**] bilaterally
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Obese, Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert but keeps eyes closed for most of
exam, cooperative with exam, normal affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3to2mm
bilaterally. Visual fields difficult to assess due to loss of
attention- possible deficit on left side.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: 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 [**3-27**] throughout though some giveway
on bilateral IPs. No pronator drift.
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Reflexes: 2+ patellar, bicep, tricep. 0 ankles
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger
.
PHYSICAL EXAM ON DISCHARGE:
-Vitals: 98.1/97.9 117/86 [117-178/86-94] 69-88 [**10-15**] 92-99% RA
-General: obese HM in NAD, AAOx3, no longer appears somnolent
-Neuro: left superior quadrantanopia, more dense in left eye.
Otherwise, nonfocal exam.
Pertinent Results:
ADMISSION LABS:
-WBC-10.2 RBC-5.04 HGB-15.2 HCT-45.3 MCV-90 MCH-30.1 MCHC-33.5
RDW-12.4
-NEUTS-55.2 LYMPHS-35.3 MONOS-5.6 EOS-3.4 BASOS-0.6
-PT-11.4 PTT-26.2 INR(PT)-1.1
-cTropnT-<0.01 x2
-GLUCOSE-127* UREA N-16 CREAT-0.8 SODIUM-139 POTASSIUM-3.8
CHLORIDE-102 TOTAL CO2-28 ANION GAP-13
.
MODIFIABLE STROKE RISK FACTOR LABS:
-%HbA1c-6.2* eAG-131*
-Triglyc-136 HDL-37 CHOL/HD-4.1 LDLcalc-87
-TSH-2.4
.
IMAGING:
CTA HEAD/NECK ([**7-2**]):
1. Interval mild-to-moderate increase in size of the large right
temporal parenchymal hemorrhage, with adjacent peri-hemorrhagic
edema, resulting in partial effacement of the adjacent sulci and
the right lateral ventricle, and 3-mm leftward shift of the
normally-midline structures, unchanged.
2. No new foci of acute intracranial hemorrhage. No
intraventricular extension.
3. No evidence of arteriovenous malformation, aneurysm or
cerebral venous thrombosis.
4. No CTA "spot sign" to portend rapid expansion of the
hematoma. Essentially normal CTA head and neck.
MRI HEAD ([**7-2**]): Slightly larger right temporal lobe hematoma,
with associated vasogenic edema and effacement of the
perimesencephalic cisterns as described above. There is no
evidence of abnormal enhancement or diffusion abnormalities.
NONCONTRAST HEAD CT ([**7-3**]): Limited study due to patient motion
demonstrates relatively stable appearance of right temporal lobe
hematoma with associated vasogenic edema, effacement of the
perimesencephalic cisterns, and 3 mm leftward shift of normally
midline structures.
LABS ON DISCHARGE:
-WBC-9.1 RBC-4.82 Hgb-14.6 Hct-44.3 MCV-92 MCH-30.3 MCHC-33.0
RDW-12.7 Plt Ct-305
-Glucose-115* UreaN-19 Creat-0.7 Na-136 K-4.2 Cl-100 HCO3-29
AnGap-11
Brief Hospital Course:
Mr. [**Known lastname **] is a 48 year old right handed man with a history of
hypertension, hyperlipidemia and cognitive delay presenting from
[**Hospital3 **] with a right temporal lobe hemorrhage after
four days of headache and chest pain.
# NEURO: Mr. [**Known lastname **] was initially admitted to the neurosurgical
intensive care unit on the neurosurgery service. He was given
platelets as he was on aspirin at home. He was placed on a
nitroprusside drip for blood pressure control for a goal
systolic blood pressure of under 150. This was then changed to a
nicardipine drip with PO lisinopril 40mg PO and his home dose of
atenolol. A CTA of the brain was performed to rule out an
underlying vascular lesion that may have caused the bleed, which
was negative. He then underwent an MRI which ruled out an
underlying tumor, though given the amount of blood in the
temporal lobe, the MRI should be repeated in a few months to
confidently rule out a mass. The patient received mannitol to
reduce intracranial pressure and dilantin for seizure
prophylaxis. On [**7-3**] the patient was observed by the SICU staff
to be more somnolent, though arousable. A stat head CT was done
which was movement degraded but did not show any significant
increased size of bleed or edema. On transfer to the neurology
service, neurologic exam was largely intact although limited by
pt's alertness. His somnolence was likely explained by over 2
days of q1hour neurocheck and the resulting tiredness, as per
nursing, he had been intermittently quite awake, especially when
his family visited. 2 days after, patient was awake, alert, with
only defect on exam being left superior quadrantanopia. The
etiology of the bleed was most likely hypertensive despite the
lobar location. Other etiologies such as amyloidosis and
vascular malformations should be considered.
.
On HD #4, patient was transferred out of the ICU to the
neurology floor once he was no longer requiring IV medications
to keep his SBP<160. His dilantin prophylaxis was discontinued
as he was deemed at low risk for seizure. His antihypertensives
were uptitrated, and on discharge his med regimen was:
lisinopril 40mg PO daily, amlodipine 40mg PO daily,
hydrochlorothiazide 25mg PO daily, and metoprolol succinate
150mg PO daily. Given patient's cognitive delay and concern that
he had not been compliant with antihypertensive meds prior to
admission, he was connected with VNA services who will help with
med administration at home.
.
# Cardiac: The patient initially presented with chest pain of 4
days in duration. There were no ischemic changes on EKG and his
cardiac enzymes were cycled and remained flat. His blood
pressure was managed as above.
.
# Pulm: CPAP was ordered for OSA.
TRANSITIONS OF CARE:
-Patient will need MRI with contrast in 4 weeks to evaluate for
underlying mass/ vascular lesion (has been ordered, will be
followed by Dr. [**First Name (STitle) **].
Medications on Admission:
All:NKDA
Lisinopril 20mg daily
simvastatin 20mg daily
atenolol 100mg daily
Aspirin 81mg daily
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Amlodipine 10 mg PO DAILY
RX *amlodipine 10 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*1
3. Hydrochlorothiazide 25 mg PO DAILY
HOLD for SBP<110
RX *hydrochlorothiazide 25 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*1
4. Lisinopril 40 mg PO DAILY
RX *lisinopril 40 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*1
5. Metoprolol Succinate XL 150 mg PO DAILY
RX *metoprolol succinate 50 mg 3 tablet(s) by mouth once a day
Disp #*90 Tablet Refills:*1
6. Simvastatin 20 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
Multicultural VNA
Discharge Diagnosis:
ACUTE ISSUES:
1. Temporal lobe hemorrhage
CHRONIC ISSUES:
1. High blood pressure
2. Obesity
3. Developmental delay
4. Obstructive sleep apnea
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with a severe headache and
chest pain. You were found to have a hemorrhage (bleeding) in
your brain. This may have been caused by your poorly-controlled
high blood pressure, which puts you at risk for brain bleeding.
You were admitted to the ICU where you received IV medications
to reduce your blood pressure and prevent brain swelling. Your
oral blood pressure medications were also increased.
.
Please attend the outpatient appointment with Neurology (Dr.
[**First Name (STitle) **] listed below to follow up on your hospitalization.
.
You will need an MRI of your head as an outpatient to follow up
on your brain hemorrhage and make sure there were no other
underlying brain problems that caused the bleed. You should make
sure to have the MRI done BEFORE your appointment with Dr. [**First Name (STitle) **]
(see below for instructions on scheduling this appointment).
.
We made the following changes to your medications:
1. STARTED amlodipine 10mg by mouth daily
2. STARTED metoprolol succinate 150mg by mouth daily
3. STARTED hydrochlorothiazide 25mg by mouth daily
4. INCREASED lisinopril from 20mg by mouth daily to 40mg by
mouth daily
5. STOPPED amlodipine 100mg by mouth daily
Followup Instructions:
You will be called by the Radiology department to schedule an
outpatient MRI before your Neurology appointment. If you do not
hear from them within ONE week, please call ([**Telephone/Fax (1) 111884**] to
schedule this appointment.
Department: NEUROLOGY
When: MONDAY [**2151-9-6**] at 3:00 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**], MD [**Telephone/Fax (1) 2574**]
Building: [**Hospital6 29**] [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
|
[
"327.23",
"401.9",
"780.09",
"368.8",
"432.9",
"784.0",
"272.4",
"315.9",
"786.59",
"790.92",
"348.5",
"V58.66",
"305.60"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.61"
] |
icd9pcs
|
[
[
[]
]
] |
8809, 8857
|
5155, 7894
|
311, 317
|
9043, 9043
|
3436, 3436
|
10440, 11061
|
1650, 1681
|
8229, 8786
|
8878, 8920
|
8110, 8206
|
9194, 10126
|
1696, 1710
|
3196, 3417
|
10155, 10417
|
263, 273
|
4979, 5132
|
345, 1321
|
2285, 3168
|
3452, 4960
|
1724, 1994
|
9058, 9170
|
7915, 8084
|
8936, 9022
|
1343, 1417
|
1433, 1634
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,689
| 183,077
|
2833
|
Discharge summary
|
report
|
Admission Date: [**2115-9-27**] Discharge Date: [**2115-10-2**]
Date of Birth: [**2052-4-18**] Sex: F
Service: MEDICINE/[**Hospital1 **]
CHIEF COMPLAINT: Seizure.
HISTORY OF PRESENT ILLNESS: The patient is a 63 year old woman
with a history of type 2 diabetes mellitus and coronary artery
disease, hypertension, who presents with a history of seizure.
Per report on [**2115-9-27**], the patient experienced an episode of
left leg shaking times two with no loss of consciousness. One
half hour later, the patient had a tonoclonic seizure lasting
three to four minutes with foaming at the mouth and loss of
consciousness. Following the home seizures, the patient was
agitated, confused, making only nonpurposeful movements and
speech per husband. She had been experiencing polydipsia,
polyuria and eating carbohydrate heavy meals. These episodes
occurred in the setting of medical noncompliance. The patient
reported not taking her hypoglycemic medication for a month prior
to admission, because she ran out.
In the ambulance, the patient was treated with Ativan and
upon arrival to the Emergency Department, the patient reportedly
had another seizure. Vital signs at that time revealed a
temperature 100.4, heart rate 130, blood pressure 153/77,
respiratory rate 21. The patient was saturating 91% in room air.
The patient's glucose level was over 1200, and her serum
osmolality was 350.
Of note, the patient had a similar admission [**2115-5-29**], which
was associated with a ventricular fibrillation arrest. The
patient responded in the Medical Intensive Care Unit to insulin,
intravenous fluids, Lopressor and repletion of potassium.
The patient was transferred on [**2115-9-29**], to the Medicine Service.
At that time, the patient reported no chest pain, no
palpitations, no shortness of breath, no fever, no abdominal
pain, normal bowel and bladder movements, and no headache or
changes in her vision.
PHYSICAL EXAMINATION: Temperature maximum was 100.0, blood
pressure 150/63, oxygen saturation 97% in room air, heart
rate 89, respiratory rate 18. In general, the patient was an
obese woman in no acute distress. Head, eyes, ears, nose and
throat examination revealed evidence of a tongue bite.
Mucosa was moist, no ulcers. The neck was supple, jugular
venous distention at approximately 10 mmHg. The pupils are
equal, round, and reactive to light and accommodation.
Extraocular movements are intact. Cardiovascular regular
rate and rhythm, no murmurs, rubs or gallops. The lungs are
bilaterally clear to auscultation, slightly decreased breath
sounds at the bases. The abdomen revealed positive bowel
sounds, nontender, nondistended. Extremities - trace edema
bilaterally. The pulses are intact bilaterally. Evidence of
peripheral vascular disease in the lower extremities
bilaterally with evidence of stasis. Neurologically, the
patient is oriented to name, place, year and month with
difficulty in word finding.
PAST MEDICAL HISTORY:
1. Three vessel disease coronary artery bypass graft times
three in [**2108**], angioplasty left internal mammary to left
anterior descending, saphenous vein graft to D1, saphenous
vein graft to posterior descending artery.
2. History of hypertension.
3. Hepatitis C history.
4. h/o HONC due to medical noncompliance ([**5-19**])
MEDICATIONS ON ADMISSION: Listed as per discharge in [**2115-5-18**]:
1. Atenolol 25 mg p.o. q.a.m.
2. Glyburide 10 mg p.o. once daily.
3. Glucophage 500 mg p.o. once daily.
4. Captopril 25 mg p.o. once daily.
5. Lipitor 10 mg p.o. q.h.s.
6. Protonix.
MEDICATIONS FROM MEDICAL INTENSIVE CARE UNIT:
[**Unit Number **]. Metformin 500 mg p.o. twice a day.
2. Heparin.
3. Senna.
4. Colace.
5. Metoprolol 75 mg p.o. three times a day.
6. Haldol p.r.n. agitation.
7. Nystatin suspension.
8. Protonix.
9. Aspirin.
10. Acetaminophen.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient lives with her family and
reports no smoking or alcohol use.
LABORATORY DATA: In the Emergency Department, [**2115-9-27**],
glucose noted 854. White blood cell count 14.8, hematocrit
52.2. Arterial blood gases revealed [**2115-9-27**], 308, pCO2 62,
pH 7.17, 24. Second arterial blood gas 218, pCO2 53, pH
7.30, pCO2 27. On [**2115-9-27**] lactate 2.6. AST 58, ALT 35 on
[**2115-9-27**]. Laboratories of [**2115-9-29**], white blood cell count
12.6, hematocrit 40.6, platelets 153,000. Sodium 135,
potassium 4.0, chloride 100, bicarbonate 25, blood urea
nitrogen 11, creatinine 0.6, glucose 266, calcium 8.3,
phosphorus 2.6, magnesium 2.0. On [**2115-9-28**], at 7:00 a.m. CK
MB 6.0, troponin I 7.6, CPK 122. On [**2115-9-28**], at 12:30 p.m.
troponin 7.6, CPK 83. INR 1.1. Urine culture negative.
Blood culture no growth to date as of [**2115-9-28**].
On [**2115-9-28**], CT of the chest - status post coronary artery
bypass graft, doubt acute pulmonary process. On [**2115-5-19**],
head CT with no hemorrhage and no mass. Mild atrophy and old
infarct. Per CT low attenuation left frontal region.
Chronic microvascular infarction, periventricular white
matter.
Electrocardiogram revealed sinus rhythm at 100 beats per
minute, normal axis, new right bundle branch block with
severe right heart strain change, large P in II, S-I, Q-I,
Q-III, T-III pattern. New deep T wave with inversion in V1
and V2. Of note with Lopressor, electrocardiogram turned to
sinus rhythm at 95 beats per minute, normal axis, with right
bundle branch block resolved.
HOSPITAL COURSE:
1. Endocrine/diabetes mellitus - The patient with a history
of diabetes mellitus who presents with HONC and seizure in
the setting of medical noncompliance. The patient's glucose
levels controlled in house eventually with oral agents. In
the history of medical noncompliance, it was elected to utilize
oral agents exclusively. We provided a great deal of diabetes
teaching and education to the patient. It is of note the patient
has fundamental lack of insight into her diabetes mellitus and
the treatment and consequences of the disease. The patient was
provided with nutrition counseling.
The patient was provided with educational materials
concerning diabetes control. We provided the patient with VNA
assistance concerning her medications and diabetes mellitus
treatment. We discharged the patient on Metformin and Glyburide
and planned for a follow-up appointment with Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] on [**2115-10-8**], at 2:00 p.m. We recommend outpatient
follow-up in Ophthalmology concerning the patient's diabetes
mellitus.
2. Cardiac - The patient has significant coronary artery
disease, status post coronary artery bypass graft, with
hypertension. In the acute setting, the patient showed
electrocardiographic changes corresponding to right heart strain
with a troponin leak with a maximum troponin I of 7.6. It was
felt that these changes are consistent with demand ischemia. We
discharged the patient on Aspirin, Toprol XL, Lisinopril to
control the patient's blood pressure. We suggest an outpatient
stress evaluation following the patient's control of her diabetes
mellitus.
3. Psychiatry - The patient has a history of agoraphobia. This
may be contributing to her nonadherence. The patient may be
considered for psychiatry consultation and follow-up.
DISPOSITION: The patient was seen by physical therapy in
house. She was discharged with a cane.
CONDITION ON DISCHARGE: Fair.
DISCHARGE DIAGNOSIS: Honk/diabetes mellitus type 2.
DISCHARGE FOLLOW-UP: The patient is to follow-up with Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**2115-10-8**], at 2:00 p.m.
MEDICATIONS ON DISCHARGE:
1. Metoprolol XL 150 mg p.o. twice a day.
2. Metformin 850 mg p.o. twice a day.
3. Glyburide 10 mg p.o. twice a day.
4. Lisinopril 10 mg p.o. twice a day.
5. Aspirin 325 mg p.o. once daily.
6. Lipitor 10 mg p.o. q.h.s.
DISCHARGE STATUS: The patient was discharged home with
services.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4446**]
Dictated By:[**Last Name (NamePattern1) 201**]
MEDQUIST36
D: [**2115-10-2**] 11:51
T: [**2115-10-5**] 08:05
JOB#: [**Job Number 13816**]
|
[
"V45.81",
"410.71",
"401.9",
"414.01",
"780.39",
"V15.81",
"250.02",
"070.54"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7501, 7690
|
7716, 8250
|
3350, 3905
|
5517, 7447
|
1962, 2966
|
171, 181
|
210, 1939
|
2988, 3323
|
3922, 5500
|
7472, 7479
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,545
| 144,393
|
54377
|
Discharge summary
|
report
|
Admission Date: [**2112-9-11**] Discharge Date: [**2112-9-13**]
Date of Birth: [**2069-1-15**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 338**]
Chief Complaint:
Acute GI bleed
Major Surgical or Invasive Procedure:
Colonoscopy
History of Present Illness:
HPI: 43 yo W with PMH of DM, hyperlipidemia and anemia of
unclear etiology presents with BRBPR. Patient is s/p colonoscopy
and polypectomy x 3 on [**9-6**]. Procedure at that time was
uncomplicated. Pt was doing well until yesterday when noted BRB
on toilet tissue and in bowl. Afterwards she had [**6-12**] bloody
bowel movements, at which time she presented to the ED. She
notes lightheadedness, but denies CP, SOB, abdominal pain,
nausea/vomiting, fever or chills.
.
In the ED, VS: T98.9 BP 148/88 HR 83 RR16 100%RA. She had 2 PIVs
placed. Pt noted to have maroon stool in ED. She had KUB with no
free air. CXR was normal. She received 1LNS. GI was called who
requested ICU transfer given high risk of brisk bleeding.
.
On arrival to the MICU, pt was stable, without complaint. VSS.
Past Medical History:
Diabetes
Hyperlipidemia
Anemia unclear etiology
Social History:
Works as unit coordinator; no tobacco, ETOH, illicits; married
lives with family
Family History:
NC
Physical Exam:
VS: 98.9 148/88 16 100%RA
GEN: Latina woman in NAD
HEENT: EOMI PERRL
NECK: Supple
CHEST: CTABL, no w/r/r
CV: RRR, S1S2, no m/r/g
ABD: Soft/NT/ND
EXT: No c/c/e
SKIN: no rashes or ecchymoses
NEURO: AAOx3, no focal deficits
Brief Hospital Course:
A/P: 43 yo W with PMH of DM, hyperlipidemia presents with
post-polypectomy bleed.
GI Bleed: Had bleeding at site of polypectomy. S/P 8 clips to
site. No further bleeding. Had normal BM after procedure. HCT
dropped to 26 but stable with repeat evaluation.
DM: continued metformin. Aspirin held given bleed. Pt will
discuss with physician when to restart.
Hyperlipidemia: continued statin
Contact: [**Name (NI) 4906**] [**Name (NI) 20204**] [**Telephone/Fax (1) 111321**]
.
Medications on Admission:
ASA
metformin
zocor
Discharge Medications:
1. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Metformin 500 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1)
Tab,Sust Rel Osmotic Push 24hr PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Lower gastrointestinal bleed
Secondary:
Diabetes mellitus
Hyperlipidemia
Discharge Condition:
Good, vital signs stable, no further signs of bleeding.
Discharge Instructions:
You were admitted to the hospital with bleeding. You were found
to have bleeding in your colon at the site of polyp removal.
Clips were placed to stop bleeding and no further bleeding
occurred.
You should not restart aspirin until speaking with your regular
doctor.
Please call your doctor or return to the emergency room if you
develop any more bleeding, lightheadedness or any concerning
symptoms such as passing out, chest pain, shortness of breath,
etc.
Followup Instructions:
Follow up with your primary care doctor in the next 2-3 weeks.
Please call about starting aspirin.
Provider: [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 15653**]
Date/Time:[**2112-9-28**] 4:15
|
[
"285.1",
"250.00",
"E878.8",
"272.4",
"998.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.43"
] |
icd9pcs
|
[
[
[]
]
] |
2365, 2371
|
1610, 2090
|
329, 343
|
2497, 2555
|
3063, 3313
|
1345, 1349
|
2161, 2342
|
2392, 2476
|
2116, 2138
|
2579, 3040
|
1364, 1587
|
275, 291
|
371, 1159
|
1181, 1231
|
1247, 1329
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,940
| 169,971
|
51490
|
Discharge summary
|
report
|
Admission Date: [**2114-5-24**] Discharge Date: [**2114-5-26**]
Date of Birth: [**2062-9-23**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Compazine / Codeine / Erythromycin Base / Iodine;
Iodine Containing
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
hypoxia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
51M with uncorrected Tetralogy of Fallot, pulmonary HTN,
seizures presented from [**Hospital 100**] Rehab with Left arm and leg
weakness. In the ED, he was noted to be satting 70-80% on NRB
which is not far from his baseline sats of 70-80% on 15L at
[**Hospital 100**] Rehab. The patient tolerated his tetralogy very well
until roughly 4 years ago when he started to require home
oxygen. Over the past year his condition has worsened to the
point that he gets dyspenic with mild activity and resides at
[**Hospital 100**] Rehab where he is connected to 15L O2 at rest. He has
been on Bosentan for pulmonary HTN although he is now on Viagra.
Of note, for the past 2-3 years he has suffered from a
neurologic syndrome of focal weakness that presents fairly
suddenly and resolves over a couple of days. The etiology for
this is unclear but has been associated with a vasogenic edema
picture on head imaging. He was recently admitted for roughly
two weeks to [**Hospital1 2025**] under the neuro service after developing R arm
and R leg weakenss. He underwent treatment initially with
phlebotomy to treat suspected hyperviscosity from polycthemia.
He also had witnessed GTC seizures (which he has a history of)
so he was put on keppra and dilantin. He was treated with
steroids as well. By hospital discharge the weakness was
improving and the pt returned to [**Hospital 100**] Rehab.
At [**Hospital 100**] Rehab on the day of admission, the pt was noted to
have L arm and L leg weakness in addition to L arm
swelling(which increased over a one week period). He was
referred to ED. In the ED, the pt was noted to be satting 70-80%
on NRB which is not far from baseline. He was evaluated in the
ED by cardiology who recommended transfer to [**Hospital1 2025**] where he gets
his care given the complicated nature of his medical story. PNA
and PE were considered as possible acute factors contributing to
the patient's hypoxia and he was admitted to MICU team.
Past Medical History:
PMH:
-Tetralogy of Fallot, unrepaired, with associated pulmonary
hypertension and polycythemia. Previous documentation notes
patient has a right aortic arch, pulmonary atresia, ventricular
septal defect, minimal AR and TR, and many systemic to venous
collaterals. Baseline O2 saturations 65-70%. Baseline Hct 55-60
per pt. Baseline O2 requirement is 12L via NC while asleep and
4L
via NC while awake. Pt gets all of his medical care at [**Hospital1 2025**].
-? complex migraine vs. TIA. Per [**Name (NI) **], pt admitted to
Neurology-Stroke service in [**2-/2110**] when he presented with
transient left-sided hemiparesis and aphasia. MRI/A/V of head
and
neck performed and was normal except for small aneurysm of left
ophthalmic artery and small but patent left vertebral artery.
TTE
showed prominent VSD was overriding aorta with absence of
definite flow across the visible ventricular septal defect. EEG
was also performed and was normal. Diagnosis was ultimately felt
to be either complex migraine vs. TIA. He was started on
topiramate prior to discharge. He presented again in [**10/2110**]
with
transient right sided-hemiparesis. Repeat MRI/A was unchanged.
Diagnosis was again ? complex migraine vs. TIA.
-Febrile generalized tonic-clonic seizures in context of
varicella infection in [**2086**]'s. Was eventually taken off of
dilantin until he had another seizure in the mid [**2096**]'s in the
context of another febrile illness. Has not had a seizure in
over
10 years, but remains on dilantin.
-asthma
-Bilateral cataracts
-Status post cholecystectomy
Social History:
Lives at [**Hospital 100**] Rehab where he remains on 15L O2 at rest. His
brother is HCP.
Family History:
Remarkable for a number of family members with diabetes
mellitus. One brother with CABG x2, another brother with
prostate cancer. Mother deceased in her 40's from brain tumor,
father died three years ago from CVA/ diabetes. Denies history
of blood clots in family
Physical Exam:
PE: vitals: t 98.0 85 171/85 31 79 on NRB
GEN: awake, alert, speaking in full sentences, coughing
HEENT: perioral cyanosis, bluish lesion on forehead
NECK: no JVD, no LAD
CV: continuous murmur heard loudest during systole
LUNGS: ctab
ABD: soft, nt, nd
EXT: warm, dry. significant LUE edema
NEURO: A/O X3, CN II-XII grossly intact. LUE [**3-7**] biceps and
tricpes. LLE [**2-6**] hams, quads, 0/5 dorsiflexion and plantar
flexion
Pertinent Results:
[**2114-5-24**] 05:04PM PT-15.1* PTT-29.9 INR(PT)-1.3*
[**2114-5-24**] 03:52PM PO2-35* PCO2-46* PH-7.39 TOTAL CO2-29 BASE
XS-1
[**2114-5-24**] 03:52PM LACTATE-1.3
[**2114-5-24**] 03:40PM GLUCOSE-103 UREA N-30* CREAT-1.6* SODIUM-145
POTASSIUM-4.4 CHLORIDE-105 TOTAL CO2-27 ANION GAP-17
[**2114-5-24**] 03:40PM estGFR-Using this
[**2114-5-24**] 03:40PM CK(CPK)-76
[**2114-5-24**] 03:40PM cTropnT-0.10*
[**2114-5-24**] 03:40PM CK-MB-NotDone
[**2114-5-24**] 03:40PM CALCIUM-9.0 PHOSPHATE-3.6 MAGNESIUM-1.8
[**2114-5-24**] 03:40PM PHENYTOIN-14.0 VALPROATE-<3.0*
[**2114-5-24**] 03:40PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2114-5-24**] 03:40PM LACTATE-1.1
[**2114-5-24**] 03:40PM WBC-12.1*# RBC-7.32*# HGB-17.1 HCT-57.7*
MCV-79*# MCH-23.4*# MCHC-29.6* RDW-17.8*
[**2114-5-24**] 03:40PM NEUTS-90.6* LYMPHS-3.8* MONOS-3.6 EOS-1.9
BASOS-0.1
[**2114-5-24**] 03:40PM PLT COUNT-168
.
RUE:IMPRESSION: Non-occlusive thrombus within the distal left
cephalic vein.
.
[**5-24**] CXR: IMPRESSION: Likely mild edema superimposed on chronic
changes from known congenital heart disease.
.
[**5-24**] head CT: IMPRESSION:
1. No evidence of acute intracranial injury.
2. New area of vasogenic edema involving the superior right
frontal lobe. An underlying lesion cannot be excluded. An MR may
be obtained for better characterization.Findings entered into
the emergency dashboard at the time of interpretation.
Brief Hospital Course:
A/P:
51M with uncorrected Tetralogy of Fallot, pulmonary HTN,
seizures presented from [**Hospital 100**] Rehab with Left arm and leg
weakness.
.
# Weakness: This appears to be a syndrome of recurrent episodes
of focal motor deficits that appear fairly suddenly and then
resolve over a few days and are associated with an imaging
finding of vasogenic edema in the brain. Pt is followed by Dr.
[**Last Name (STitle) 74788**] from [**Hospital1 2025**]. In the past, he has been considered by
physicians for the multiple diagnoses including TIA, reversible
leukoencephalophy, hyperviscosity syndrome, etc. There does not
seem to be a concern for embolic stroke on imaging. pt was
continued on dilantin and keppra. Neurology was consulted here
and pt declined the consult. Pt was accepted by Dr. [**Last Name (STitle) 74788**]
and will be transferred to [**Hospital1 2025**] today. He was accepted to the
neuro-medicine floor.
.
# Tetrology of Fallot: He is followed at [**Hospital1 2025**]. This is
uncorrected and pt has developed chronic hypoxia, requiring 15L
oxygen at rest and tolerating sats in 70s-80s. There does not
seem to be any other contributors to his hypoxia as he has
returned to baseline--There was no infiltrate on CXR, low
clinical suspicion for PE and risk/benefit likely favors not
pursuing CTA of chest given CRI. Pt was placed on supplemental
02 by NRB. He was continued on his home regimen cardiac
medications, including transitioning to po labetolol. Cardiology
was consulted.
.
# Pulmonary hypertension: Pt continued on his outpt sildenafil.
.
# LUE superficial venous thrombosis: Seen by US, present on
imaging last week at [**Hospital1 2025**]. Given sthe uperficial location it was
thought that pt was unlikely to benefit from anticoagulation.
.
# CRI: Creatinine at baseline of 1.6. creatinine monitored.
Nephrotoxins avoided, meds renally dosed.
.
# Trop of 0.1: This is possibly [**2-3**] RV strain from pulm HTN in
setting of chronic renal failure. ECG not highly concerning for
ischemia. 2nd set of enzymes have trended down. PE is
considered, though the pt would likely not tolerate this insult
so well given his known baseline condition.
.
# Hypertension. Pt continued on his outpt antihypertensives.
Labetolol, amlodipine.
.
# Communication: HCP is brother [**Name (NI) **] [**Name (NI) 7842**] [**Telephone/Fax (1) 106760**]
# Code: DNI/DNR, confirmed with patient
Medications on Admission:
abetalol 20 IV q4
tylenol
ASA 325
amio 200'
amlodipine 20'
vit b12 500'
colace
advair 100/50 1 puff [**Hospital1 **]
hep SC
Atrovent neb q4 PRN
Keppra 1500 [**Hospital1 **]
MVI
pntoxyfylline 400 TID
Dilantin 200"
rantidine 150'
Sildenafil 40 TID
Discharge Medications:
1. Aspirin, Buffered 325 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Cyanocobalamin 500 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
6. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
7. Ipratropium Bromide 0.02 % Solution Sig: One (1) inh
Inhalation Q6H (every 6 hours) as needed.
8. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
9. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
10. Pentoxifylline 400 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO TID (3 times a day).
11. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2)
Capsule PO BID (2 times a day).
12. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Sildenafil 50 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
14. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
15. Labetalol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
16. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
17. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Four (4) mg
Injection Q8H (every 8 hours) as needed.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
left cephalic vein thrombosis
tetralogy of fallot uncorrected
pulmonary hypertension
chronic renal failure
Discharge Condition:
stable, afebrile,
Discharge Instructions:
You were admitted with left arm and leg weakness as well as left
arm swelling. You had an ultrasound of your left arm that
showed a blood clot in a superficial vein (cephalic vein). You
also had a head CT that showed a new area of vasogenic edema
involving the superior right frontal lobe. The neurology
service was asked to evaluate you, which you declined. Your
neurologist is at [**Hospital1 2025**] and transfer to that hospital was
initiated.
You should continue to take all of your medications as
prescribed.
Please seek medical attention if you have worsening weakness,
dizzyness, numbness, headache, chest pain, shortness of breath,
or any other concerning symptoms.
Please follow up with your neurologist and your primary care
physician.
Followup Instructions:
You should call your PCP and make an appointment within two
weeks of discharge from the hospital.
Completed by:[**2114-6-3**]
|
[
"585.9",
"345.90",
"348.5",
"453.8",
"403.90",
"745.2",
"416.8"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10416, 10431
|
6266, 8669
|
350, 356
|
10582, 10602
|
4783, 5933
|
11401, 11529
|
4053, 4318
|
8966, 10393
|
10452, 10561
|
8695, 8943
|
10626, 11378
|
4333, 4764
|
303, 312
|
384, 2342
|
5942, 6243
|
2364, 3930
|
3946, 4037
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,607
| 102,053
|
12343+12373+12344+56355
|
Discharge summary
|
report+report+report+addendum
|
Admission Date: [**2146-1-4**] Discharge Date:
Date of Birth: [**2076-12-7**] Sex: M
Service:
HISTORY OF THE PRESENT ILLNESS: The patient is a 68-year-old
male with substernal chest pain, status post cardiac
catheterization two years prior. He has positive stress teat
and cardiac catheterization at an outside hospital revealed a
50% to 55% stenosis of his left main and 80% of the LAD. The
patient was transferred to the [**Hospital1 188**] for further management.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Coronary artery disease.
3. Status post salivary gland removal in [**2121**].
MEDICATIONS:
1. Atenolol 25 once a day.
2. Aspirin 325 once a day.
3. Lipitor 10 once a day.
ALLERGIES: The patient is allergic to SULFA DRUGS.
SOCIAL HISTORY: No cigarette smoking, no ethanol abuse.
After review of films, it was determined that the right RCA
also had 60% occlusion and his ER 60% by echocardiogram. He
had preserved EF.
HOSPITAL COURSE: He was taken to the operating room on
[**2146-1-5**] with the diagnosis of coronary artery disease. He
had a CABG times four done by Dr. [**Last Name (STitle) 70**].
Postoperatively, the patient was transferred to the
Cardiothoracic Intensive Care Unit, where he was extubated
and transferred to the floor on postoperative day #1. The
patient required some Neodrips for pressor support. He was
not transferred to the floor until the evening of [**2146-1-7**],
after being weaned.
Postoperatively, the patient was doing well. Foley catheter
was discontinued. Wires were discontinued. Chest tube was
discontinued. However, the patient pulled the wires,
suffered some atrial fibrillation. The patient was given
Lopressor and Amiodarone. A light rash was noted and the
patient's physical examination remained benign. This was
discussed and some Benadryl was started.
On [**2146-1-9**] it was noted that the patient's rash seemed
stable. He remained in atrial fibrillation. Amiodarone was
given, Magnesium, otherwise, he was at no time
hemodynamically unstable. The Gram stain of his sputum
showed 3 to 4 gram negative rods, which eventually grew out
Serratia. The patient was noted on postoperative day #5,
[**2146-1-10**] to have a white count of 29.7, remained in atrial
fibrillation with a blood pressure, which was relatively low
at 86/50 nonsymptomatic. He was transferred to the Intensive
Care Unit for pressor support, if required while being given
Lopressor.
The Department of Dermatology was called and they stated that
we should discontinue any unnecessary medications and start
topical creams and ointments as well as Zyrtec every night
and topical steroids such as Lidex, which was done.
On [**2146-1-11**] the patient remained on Ancef, Amiodarone,
Lopressor and Heparin for anticoagulation. The patient was
doing relatively well. The rest of his Intensive Care Unit
stay was uneventful. He maintained his pressure without the
requirement for Neomycin. He was started on Augmentin on
[**2146-1-12**]. He was transferred to the back to the floor
without incident.
The Department of Infectious Disease was called that same day
because the patient's white count had now gone to 32.
Infectious Disease recommended blood cultures and urine
cultures. They recommended us discontinuing Augmentin, which
was done and they felt that the reaction was allergic to a
medication he had received, which was consistent with the
eosinophilia seen on the peripheral differential. This was
done and a C.difficile culture was also sent because it was
felt that the C. difficile could also cause white counts to
be high. The C. difficile specimen returned negative.
The patient's wound, throughout all these events, remained
stable with no discharge. The patient was ambulating very
well to level 5 in the hospital mainly because of his rash.
It was noted that he had fluid on his foot and arms, which
were noninfected looking and left alone for the time being on
[**2146-1-14**].
Final discharge summary to follow. Another addendum will be
inserted regarding the final disposition and the discharge
medications.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 02-358
Dictated By:[**Name8 (MD) 16758**]
MEDQUIST36
D: [**2146-1-14**] 13:18
T: [**2146-1-14**] 13:29
JOB#: [**Job Number 38473**]
Admission Date: [**2146-1-4**] Discharge Date: [**2146-1-18**]
Date of Birth: [**2076-12-7**] Sex: M
Service:
ADDENDUM: The patient, on [**2146-1-14**], was doing well and
Physical Therapy was involved. The patient was doing a Level
IV. Infectious Disease and Immunology were following along.
Allergy felt that the pitting in the skin was most likely
related to the diuretics, and possibly other medications.
They advised continuing with Zyrtec and Benadryl ointment to
the itchy area over his skin, avoiding vancomycin, amiodarone
and Toradol and penicillin. Nothing grew out positive.
The patient was doing well and the rash was improving and the
skin desquamation was going down. The patient remained with
low-grade temperature and a white blood cell count was down
to 12 by [**2146-1-17**]. The decision was made to discharge the
patient on [**2146-11-17**] after his white count had decreased and
he was afebrile and vital signs were stable, with only a
low-grade temperature.
DISCHARGE MEDICATIONS:
1. Potassium chloride 20 mEq twice a day for 15 days supply,
but only meant to be taken when the patient is taking lasix
2. Lasix 20 mg by mouth twice a day for five days
3. Lidex ointment to the affected areas
4. Percocet one to two tablets by mouth every four to six
hours as needed for pain
5. Lopressor 50 mg by mouth twice a day
6. Zyrtec 10 mg daily at bedtime, given 30
7. Lipitor 10 mg by mouth once daily, dispensed 30
The patient is to follow up with his primary care physician
within three weeks, and is doing well upon discharge.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 02-358
Dictated By:[**Name8 (MD) 16758**]
MEDQUIST36
D: [**2146-1-17**] 23:41
T: [**2146-1-18**] 00:09
JOB#: [**Job Number 32332**]
Admission Date: [**2146-1-4**] Discharge Date: [**2146-1-19**]
Date of Birth: [**2076-12-7**] Sex: M
Service: Cardiothoracic Surgery
HISTORY OF PRESENT ILLNESS: This is a 60-year-old male with
a past medical history significant for hypertension, coronary
artery disease diagnosed in [**2142**], who had a cardiac
catheterization done at that time which showed 3-vessel
coronary artery disease. He was managed medically. He
subsequently wanted a second opinion. He later had a
positive stress and repeat cardiac catheterization which
revealed 30% to 55% left main disease and 80% left anterior
descending artery disease. The patient was then referred for
coronary artery bypass grafting.
ALLERGIES: The patient has an allergy to SULFA DRUGS.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
on admission revealed the patient was neurologically intact.
Cranial nerves II through XII were intact. The patient had
no jugular venous distention. Pupils were equal, round, and
reactive to light and accommodation. No bruits. Lungs were
clear. Heart was regular in rate and rhythm, normal first
heart sound and second heart sound. The abdomen soft and
nontender, normal active bowel sounds. Extremities revealed
the patient had good veins, 2+ distal pulses.
HOSPITAL COURSE: The patient underwent coronary artery
bypass graft on [**2146-1-5**] with left internal mammary
artery to the diagonal, saphenous vein graft to the right
coronary artery and right posterior descending artery
sequential, and saphenous vein graft to the obtuse marginal.
The patient arrived to the unit with ST elevations. An
electrocardiogram was done as well as a transesophageal
echocardiogram, and they felt that there was no wall motion
abnormalities. The patient was on intravenous nitroglycerin
which was turned off due to the patient's hypotension. The
patient had frequent premature atrial contractions and rare
premature ventricular contractions with a heart rate in the
110s, so the patient received some intravenous Lopressor
times two with good affect to bring the heart rate down to
the 90s, with a systolic blood pressure of 100 to 150s.
A red/warm rash was noted over the back, trunk and thigh, and
the patient complained of feeling claustrophobic.
On postoperative day one, the patient's temperature maximum
was 100.8, temperature current of 99.8, blood pressure 95/53,
heart rate 101, in sinus tachycardia. The patient was
satting at 99% on 4 liters nasal cannula. On physical
examination, the patient's lungs were clear to auscultation
bilaterally. Heart had a regular rate and rhythm. The
abdomen was soft, nontender, and nondistended. Extremities
were warm. Chest tube output total was 405. White blood
cell count of 10.8, hematocrit of 26.9, platelet count
of 129. Sodium 136, potassium 4.5, blood urea nitrogen 11,
creatinine 0.8, glucose of 134. Magnesium of 2, and calcium
of 1.14. The plan was to transfer the patient to the floor.
There was no progression of the patient's rash. The skin was
intact without breakdown.
On postoperative day two, the patient's temperature was 99.5,
heart rate 82, in normal sinus rhythm, blood pressure of
103/54, satting at 100% on 4 liters of nasal cannula. The
patient was awake and alert. Lungs were clear to
auscultation bilaterally. Wound incisions were clean, dry,
and intact. Heart was regular in rate and rhythm. The
abdomen was benign. Extremities were benign. Chest tube
output was 98 on the last shift. White blood cell count was
up at 13.3, hematocrit was down at 23.3, with platelets
of 139. Sodium of 137, potassium of 4.6, blood urea nitrogen
of 13, creatinine of 0.8, with a glucose of 131. Calcium
was 1.15 with a magnesium of 1.5. The plan was to wean the
Neo-Synephrine, to discontinue the chest tube, continue
Lopressor. Question of transfusing because the patient has
no transfusion history; will discuss with Dr. [**Last Name (STitle) 70**]. The
plan was to transfer to the floor if off Neo-Synephrine.
On postoperative day three, the patient's temperature maximum
was 99.6, temperature current 98.3, heart rate 64, blood
pressure 104/60, satting at 97% on 2 liters. The patient was
in sinus rhythm. A few premature atrial contractions. On
physical examination heart had a regular rate and rhythm.
Lungs were clear to auscultation bilaterally. Chest tubes
were in place. Wires were in place. Wounds were all right.
Laboratories revealed white blood cell count of 7.3,
hematocrit of 25.8, platelet count of 112. Sodium of 134,
potassium of 4.5, blood urea nitrogen of 16, creatinine
of 0.9, with a glucose of 95. The plan was to discontinue
Foley and to replete electrolytes. The Cardiothoracic
Service also noted the patient with a diffuse rash. No
respiratory distress. No wheezing. Saturations were all
right. Vital signs were stable. Chest tubes and wires were
discontinued. The plan was to administer Benadryl,
attributing the rash to the patient's antibiotics (to the
patient's Vancomycin).
On postoperative day four, temperature maximum of 101.4,
temperature current of 99.4, heart rate 100, blood pressure
102/60, satting at 95% on 2 liters. The patient was in and
out of atrial fibrillation with sinus rhythm and premature
atrial contractions. Lopressor was given yesterday. Chest
x-ray yesterday showed no consolidation, and no pneumonia.
On physical examination the lungs were clear. Heart had a
regular rhythm. The wounds had no discharge or erythema.
Laboratories were pending. The plan was to start amiodarone.
Gram stain showed 3 to 4+ gram-negative rods. They began
Levaquin. At 12:30 p.m. the patient was found to be in
atrial fibrillation. They started amiodarone. At 8:30 p.m.
on [**1-9**], Cardiothoracic Surgery was called for a
temperature of 101.4. Blood pressure was 84/50. The patient
had received Lopressor in the morning, amiodarone, and
Levaquin. The patient was transferred back to the unit alert
and oriented times three with complaints of sweats. No
shortness of breath, and no chest pain. Lungs were clear to
auscultation bilaterally. Heart was tachycardic. The
abdomen was soft. Hematocrit was 31. White blood cell count
was 12. Potassium was 4.2. Calcium was 7.8, magnesium
of 1.8. Blood pressure increased to 98/40 on its own, heart
rate 110 but irregular. The plan was to decrease the
Lopressor, and the patient was on Levaquin and to check
culture.
On postoperative day five, the patient's temperature maximum
was 101.7, temperature current was 101, heart rate in the
100s, blood pressure 86/50. White blood cell count had
increased to 20.7. Blood cultures were pending. On physical
examination heart was irregularly irregular. Lungs were
clear to auscultation bilaterally. Sternal wounds had no
discharge, no click, and no erythema. Leg wounds had no
discharge; however, there was some ecchymosis. The plan was
to follow up with the culture and check x-ray, continue him
on his amiodarone.
Dermatology was asked to evaluate the patient for the
patient's skin eruption. They recommended discontinuing any
unnecessary medications, use topical Sarna p.r.n.,
antihistamines (preferably Zyrtec 10 mg p.o. q.6h.), and
topical steroids (Lidex ointment b.i.d.).
On postoperative day six, the patient was on Ancef,
amiodarone, and heparin. The patient's temperature maximum
was 102.2, temperature current was 100.5, heart rate 111, in
sinus tachycardia, blood pressure 100/54, satting at 93% on
nasal cannula. The patient was awake and alert. Lungs were
clear to auscultation bilaterally. Heart had a regular rate
and rhythm; however, tachycardic. The abdomen was benign.
Extremities were benign. Skins was still with erythematous
rash persisting. White blood cell count was up to 25, and
hematocrit was down to 26.4. Sodium 131, potassium 4.4,
blood urea nitrogen 21, creatinine 1.1, with a glucose
of 117. Calcium of 1.06. The plan was to continue
amiodarone, check the coagulations because of the heparin,
continue Ancef.
On postoperative day seven, the patient's temperature maximum
was 100.8, temperature current 96.9, heart rate in sinus
tachycardia at 102, blood pressure 98/44, satting at 93%.
The patient was awake and alert, on heparin and Augmentin.
The lungs were clear to auscultation bilaterally. Dressings
were clean, dry, and intact. Heart had a regular rate and
rhythm; however, tachycardic. The abdomen was benign. The
lower extremities were benign. The patient's white blood
cell count was up to 27.5, hematocrit was down to 25.9,
platelets of 242. Sodium 134, potassium 4.1, blood urea
nitrogen 21, creatinine 0.9, with a glucose of 89. The plan
was to transfer the patient to the floor.
Infectious Disease came by to see the patient on [**1-12**].
The patient with increased leukocytosis without localizing
symptoms. They recommended following the complete blood
count. Blood cultures through C-line and peripherally.
Discontinue Augmentin if the patient develops diarrhea. They
would also send stool for Clostridium difficile toxin assay
and empirically start metronidazole. If there were any
changes in the chest wound, they would image with CT and
initiate empiric coverage from gram-negative rods and
gram-positive cocci with levofloxacin.
Infectious Disease came by and saw the patient again
[**1-13**]. They noted the patient to have a diffuse
erythematous rash but was thought likely secondary to drugs;
now with persistent increased white blood cell count. The
plan was as previously stated. Still concern for Clostridium
difficile. The plan was also to discontinue Augmentin. The
patient had no cough and no infiltrate on the chest x-ray,
and it may be worsening Clostridium difficile.
On postoperative day eight, the patient's temperature maximum
was 99.6, temperature current was 99.4, heart rate 100, blood
pressure of 100/43, satting at 95% on room air. The patient
was transferred out of the unit with a white blood cell count
of 32 yesterday. The patient was stable on the floor. The
patient remained red and afebrile. His sternal wound was
clean with no discharge and no click. The left leg was
slightly erythematous with no infection. The plan was to
discontinue Augmentin per Infectious Disease request and
continue the current regimen.
On postoperative day nine, the patient's temperature maximum
was 99.8, temperature current was 99.6, heart rate of 104,
blood pressure of 116/56, satting at 94% on room air. The
rash was better. The patient was in regular rhythm at this
time. Lungs were clear to auscultation bilaterally. Sternal
wound with no discharge and no erythema. Leg wounds with no
cellulitis. The plan was to increase Lopressor to 50 mg p.o.
b.i.d.
Infectious Disease came by and saw the patient again on
[**1-14**]. They recommended to continue to monitor the
patient off of antibiotics, check the Clostridium difficile
two more times, monitor the bullous lesions. They did not
think that antibiotics were needed at that point.
Allergy and Immunology came by and saw the patient on
[**1-14**]. They were asked to consult with the patient
regarding severe dermatitis. They recommended to continue
Zyrtec 10 mg p.o. q.d., plus Benadryl 25 mg to 50 mg p.o.
q.6h. p.r.n., moisturizer to the face and dry skin, Lidex
ointment b.i.d. to t.i.d. to the itchy areas, avoid
vancomycin, amiodarone and Toradol for now. Try to eliminate
as many medications as possible. Avoid penicillins unless
absolutely necessary. Continue to pursue sources of
infection, as the increased white blood cell count with
increased neutrophils and bands were concerning.
Infectious Disease came by and saw the patient on
[**1-15**]. They assessed that the leukocytosis was still
continuing to resolve without antimicrobial coverage. The
wound appeared clean. No diarrhea, just Clostridium
difficile. No active infectious process was seen. Follow
white blood cell count off the antibiotics.
On postoperative day 10, the patient was afebrile, with a
heart rate of 89, blood pressure of 102/52, satting at 96%.
The lungs were clear to auscultation bilaterally. Heart was
regular in rate and rhythm. The abdomen was benign.
Extremities were benign. The patient was doing well.
Infectious Disease came by and saw the patient on
[**1-16**]. They recommended to follow white blood cell
count if the patient's spikes again. The patient needed a
fever workup with blood cultures, urinalysis, urine culture,
and chest x-ray, and continued to state that the patient did
not need any antibiotics at this point.
On postoperative day 11, the patient with premature atrial
contractions this morning. Temperature maximum was 99.1,
heart rate of 90, blood pressure of 109/65, satting at 99%.
Heart was regular in rate and rhythm. Lungs were clear to
auscultation bilaterally. The abdomen was benign. The rash
was improving.
On postoperative day 12, temperature maximum and temperature
current were 100.9. White blood cell count of 12, hematocrit
of 24.3, platelets of 491. Sodium of 129, potassium of 4.3,
blood urea nitrogen of 13, creatinine of 1, glucose of 108.
The patient's rhythm was slightly irregular. His skin was
peeling on physical examination. The sternal wounds and leg
wounds were all right with no discharge.
Infectious Disease came by and saw the patient on
[**1-17**]. They were informed that the patient continued
to have temperatures all day yesterday. The lowest
temperature was 100.3; however, examination was nonfocal.
They agreed that the central line may be the source. They
recommended checking blood cultures times two to rule out
bacteremia and await catheter tip results. They recommended
that if there is a line infection, if the line is already
out, but depending on the organisms may need a short course
of antibiotics.
Allergy and Immunology also came by and saw the patient on
[**1-17**], and they recommended discontinuing the
antihistamine and topical steroids and use moisturizing
lotion p.r.n. The patient may follow up as an outpatient for
further advice regarding medical allergies and possible
testing to penicillin.
Infectious Disease came and saw the patient on [**1-18**].
The patient had a spike to 101.2 the night prior with no
blood cultures drawn. Still nothing focal on the
examination. Likely related to his central line. Awaiting
the cultures on the central line tip, and the plan was to
follow the cultures. If the patient re-spiked, they
recommended further fever workup.
On postoperative day 13, the patient's temperature maximum
was 101.2, temperature current 99.8, heart rate 91, blood
pressure of 117/68, satting at 100% on room air. Heart was
regular. Lungs were more clear at the bilateral bases. The
incisions were clean with no discharge. The patient's skin
was still peeling from the rash. The plan was to follow up
with the cultures and to check urinalysis.
Infectious Disease came by and saw the patient on
[**1-19**]. They stated that since the patient remained
afebrile overnight, with a white blood cell count at 5.9, and
blood cultures were negative, catheter tip was negative, the
patient was not declaring an active infection at that time,
they would sign off for now.
On physical examination the patient was alert and oriented
times three, moved all of his extremities, conversational.
Respiratory wise he was clear to auscultation bilaterally.
Heart was regular in rate and rhythm with first heart sound
and second heart sound. No murmurs. His sternum was stable.
The incision with Steri-Strips and was clean and dry. The
abdomen was soft, nontender, and nondistended, with normal
active bowel sounds. Extremities were warm and well
perfused. No clubbing, cyanosis or edema. The patient was
still with a generalized rash which was resolving; however,
he was still with skin peeling, especially in the arms and
groin. The patient's preoperative weight was 66.4 kg;
discharge weight was 68 kg. Laboratories revealed white
blood cell count of 5.9, hematocrit of 26.4, with a platelet
count of 488. Sodium of 133, potassium of 4.5, blood urea
nitrogen of 17, creatinine of 1, with a glucose of 101.
DISCHARGE STATUS: The patient was discharged home.
MEDICATIONS ON DISCHARGE:
1. Aspirin 325 mg p.o. q.d.
2. Lopressor 50 mg p.o. b.i.d.
3. Lipitor 10 mg p.o. q.d.
4. Colace 100 mg p.o. b.i.d.
5. Percocet one to two tablets p.o. q.4h. p.r.n. for pain.
CONDITION AT DISCHARGE: The patient's condition on discharge
was stable.
DISCHARGE FOLLOWUP: The patient was to follow up with [**Hospital 409**]
Clinic in two weeks. Follow up with Dr. [**Last Name (STitle) 70**] in four to
six weeks. Follow up with Dermatology and the Allergy
Service as needed.
DISCHARGE DIAGNOSES: Coronary artery disease.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Doctor Last Name 182**]
MEDQUIST36
D: [**2146-1-19**] 10:46
T: [**2146-1-20**] 15:12
JOB#: [**Job Number 38474**]
Name: [**Known lastname 6963**], [**Known firstname **] Unit No: [**Numeric Identifier 6964**]
Admission Date: [**2146-1-4**] Discharge Date: [**2146-1-16**]
Date of Birth: [**2076-12-7**] Sex: M
Service:
DISCHARGE SUMMARY ADDENDUM: Over the ensuing days the patient
continued to do well. He was afebrile, white count had
diminished. The patient was discharged home in stable
condition to follow up with Dr. [**Last Name (STitle) 71**] within two weeks of
discharge or as needed.
DISCHARGE MEDICATIONS:
1. Aspirin 325 milligrams po q day.
2. Colace 100 milligrams po q day.
3. Lipitor 10 milligrams po q HS.
4. Zyrtec 10 milligrams po q HS.
5. Lopressor 50 milligrams po bid.
6. Lasix 10 milligrams po bid.
7. Potassium Chloride 20 milligrams po bid.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 2728**]
Dictated By:[**Last Name (NamePattern1) 5280**]
MEDQUIST36
D: [**2146-1-16**] 08:34
T: [**2146-1-17**] 11:45
JOB#: [**Job Number 6965**]
|
[
"401.9",
"427.31",
"414.01",
"V70.7",
"693.0",
"458.2",
"285.9",
"E930.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"88.72",
"36.13",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
22923, 23767
|
23790, 24349
|
22415, 22605
|
7465, 22389
|
22620, 22670
|
22692, 22900
|
6331, 7446
|
512, 764
|
781, 962
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,172
| 175,211
|
45446+58819
|
Discharge summary
|
report+addendum
|
Admission Date: [**2106-2-5**] Discharge Date: [**2106-2-11**]
Date of Birth: [**2037-6-2**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Effexor
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
cough and dyspnea
Major Surgical or Invasive Procedure:
[**2106-2-5**]: Right thoracotomy and tracheoplasty with mesh,
right main stem bronchus/bronchus intermedius bronchoplasty
with mesh, left main stem bronchus bronchoplasty with mesh,
bronchoscopy with bronchoalveolar lavage.
History of Present Illness:
Ms. [**Known lastname 96986**] is a 68-year-old woman who has had significant
dyspnea. She underwent a bronchoscopy which revealed diffuse and
severe tracheobronchomalacia with the preponderance of disease
at the distal trachea and main bilateral bronchi. She underwent
a stent trial and had
significant alleviation of her dyspnea and an improved overall
quality of life and activity level. She was brought in for
tracheoplasty.
Past Medical History:
Hypertension
hypothyroid
COPD
TBM
depression
elevated cholesterol
osteoarthritis
GERD
Obstructive sleep apnea
Past surgical history:
Bilateral Knee replacements
Oophorectomy on left
tonsillectomy
rotator cuff repair
Social History:
Lives with partner. Ex [**Name2 (NI) 1818**], quit: 23 years ago; used to smoke
2.5 to 3 packs per day. Denies drugs, ETOH,
Family History:
Mother: hypothyroid and stroke
Father: [**Name (NI) 2481**]
Physical Exam:
Discharge vital signs:
T 96.6 P 79 reg HR 110/60 RR 18 O2 sats 95% on 4L NC
Discharge Physical Exam:
Gen: Pleasant in NAD
Lungs: clear t/o, at times rhonchorus t/o clearing with cough
right thoracotomy healing without redness, purulence or drainage
CV: RRR S1, S2, no MRG or JVD
Abd: soft, NT, ND
Ext: warm without edema
Pertinent Results:
[**2106-2-9**] 07:55AM BLOOD WBC-8.9 RBC-3.93* Hgb-11.6* Hct-35.1*
MCV-89 MCH-29.5 MCHC-33.0 RDW-14.4 Plt Ct-333
[**2106-2-9**] 07:55AM BLOOD Glucose-107* UreaN-13 Creat-0.8 Na-143
K-4.1 Cl-105 HCO3-29 AnGap-13
[**2106-2-9**] 07:55AM BLOOD Calcium-9.5 Phos-3.7 Mg-2.5
CXR [**2106-2-9**]:
IMPRESSION: Appearance is similar to prior study with mild basal
atelectasis on the left and small right effusion in addition to
mild increased interstitial markings peripherally in the right
lung and at the left lower zone, which may reflect underlying
interstitial disease, possibly with mild superimposed edema.
Brief Hospital Course:
Ms. [**Known lastname 96986**] was taken to the operating room by Dr. [**Last Name (STitle) **] on
[**2106-2-5**] for right thoractomy and tracheoplasty with mesh, right
main stem bronchus/bronchus intermedius bronchoplasty with mesh,
left main stem bronchus bronchoplasty with mesh, and
bronchoscopy with bronchoalveolar lavage, for her
tracheobronchomalacia. The patient was extubated in the OR, and
transfered to the PACU for recovery then to the SICU for further
management that evening. The patient had epidural with
bupivicaine and dilaudid for pain management. The patient was
transferred to the floor in stable condition on [**2106-2-7**] (POD 2).
The following is a systems review of her hospital course.
Neurologic: The patient had a bupivicaine and dilaudid PCA which
was effective in pain control. Acute pain service managed this
until it was discontinued on POD 3. The patient was transitioned
to tylenol, ibuprofen, oxycodone, and lidocaine which was
effective. She is also on home gabapentin. She remained
neurologically intact. Of note she admits to former narcotic
addiction, therefore care will be made to assist in titrating
off oxycodone after the immediate postoperative period.
Pulmonary: The patient was brought out of the OR with a right
[**Doctor Last Name **] chest tube which was removed on POD 1 without pneumothorax
on postpull film. Aggressive pulmonary toilet was instituted
with around the clock mucolytics, nebulizers, and incentive
spirometry. The patient was kept on her home inhalers, and home
bipap. She also remained on oxygen via nasal canula 4L during
the day. At night she used her home bipap. Pulmonary was
consulted and followed alongside. The patient had desaturations
during the night on bipap therefore her nightly oxygen was
increased to >92% with 6L. Two doses of lasix were given POD 3
and 4 for pulmonary congestion and to diurese after the initial
fluid given postoperatively. CXR's were followed.
CV: The patient remained hemodynamically stable throughout her
stay in NSR.
Abd: The patient was advanced to a regular diet which she
tolerated. Stool softeners were given. The patient passed gas
and was close to having a bowel movement on date of discharge.
GU: A foley was kept during the epidural and dc'd POD 3 with
good urinary response thereafter.
ID: The patient remained afebrile with CBC trends followed.
There were no infectious processes during the stay.
Prophylaxis: Heparin was given for DVT prophylaxis.
Dispo: PT evaluated the patient on POD 4 and deemed the patient
would benefit from a short stay in rehab, which the patient
would also like.
The patient was ambulating with PT, tolerating a regular diet
with pain controlled on an oral regimine. Her oxygen on 4L nasal
cannula was 95%. The patient was deemed stable for transfer to
rehab on [**2106-2-11**].
Medications on Admission:
ADVAIR DISKUS - 250-50 mcg/Dose Disk with Device - 1 (One) puff
inhaled twice a day
ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler - 2
puffs inhaled every 4-6 hours as needed for shortness of
breath/wheezing
CABERGOLINE - (Prescribed by Other Provider) - 0.5 mg Tablet -
1 Tablet(s) by mouth three times a week
FLUTICASONE - (Prescribed by Other Provider) - 50 mcg Spray,
Suspension - 2 sprays(s) nares twice a day
GABAPENTIN - (Prescribed by Other Provider) - 300 mg Capsule -
[**3-4**] Capsule(s) by mouth twice a day 600 mg in am, 900 mg in pm
LEVOTHYROXINE - (Prescribed by Other Provider) - 137 mcg Tablet
- 1 (One) Tablet(s) by mouth once a day
OMEPRAZOLE - (Prescribed by Other Provider; Dose adjustment -
no new Rx) (Not Taking as Prescribed: pending GI study) - 40 mg
Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth twice a
day
PRAVASTATIN - (Prescribed by Other Provider) - 40 mg Tablet - 1
Tablet(s) by mouth daily
RANITIDINE HCL - (Not Taking as Prescribed: pending GI study) -
300 mg Capsule - 1 Capsule(s) by mouth daily
SERTRALINE [ZOLOFT] - 100 mg Tablet - 1 (One) Tablet(s) by mouth
twice a day
TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - 18 mcg Capsule,
w/Inhalation Device - 1 tablet inhaled daily
TOLTERODINE [DETROL LA] - 4 mg Capsule, Sust. Release 24 hr - 1
(One) Capsule(s) by mouth once a day
TRIAMTERENE-HYDROCHLOROTHIAZID - 37.5-25 mg Capsule - 1 (One)
Capsule(s) by mouth once a day
ZAFIRLUKAST [ACCOLATE] - 20 mg Tablet - 1 (One) Tablet(s) by
mouth twice a day
ACETAMINOPHEN [TYLENOL] - (Prescribed by Other Provider) -
Dosage uncertain
ASCORBIC ACID [VITAMIN C] - (OTC) - 500 mg Tablet - one tablet
by mouth once a day
CALCIUM - (Prescribed by Other Provider; OTC) - Dosage
uncertain
DHA-EPA-POLICOSANOL-B6-B12-FA - (OTC) - 200 mg-300 mg-10 mg-250
mcg-250 mcg-6.25 mg Capsule - 1 (One) Capsule(s) by mouth once a
day
FERROUS SULFATE [IRON (FERROUS SULFATE)] - (OTC) - 325 mg (65
mg Elemental Iron) Tablet - 1 (One) Tablet(s) by mouth twice a
day
GUAIFENESIN [MUCINEX] - 1,200 mg Tab, Multiphasic Release 12 hr
- 1 Tab(s) by mouth twice a day To continue while stent in place
MULTIVITAMIN-MINERALS-LUTEIN [CENTRUM SILVER] - (OTC) -
Tablet - 1 (One) Tablet(s) by mouth once a day
S-ADENOSYLMETHIONINE [[**Male First Name (un) **]-E] - (OTC) - 400 mg Tablet - 1 (One)
Tablet(s) by mouth once a day
VITAMIN E - (OTC) - 400 unit Capsule - 1 (One) Capsule(s) by
mouth once a day
Discharge Medications:
1. cabergoline 0.5 mg Tablet Sig: One (1) Tablet PO MWF
(Monday-Wednesday-Friday).
2. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
spray Nasal twice a day.
4. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO QAM (once a
day (in the morning)).
5. gabapentin 300 mg Capsule Sig: Three (3) Capsule PO QPM (once
a day (in the evening)).
6. levothyroxine 137 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) puffs Inhalation every 4-6 hours as needed for shortness
of breath or wheezing.
8. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
9. sertraline 100 mg Tablet Sig: One (1) Tablet PO twice a day.
10. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
11. pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
12. ranitidine HCl 300 mg Tablet Sig: One (1) Tablet PO once a
day.
13. Detrol LA 4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO once a day.
14. triamterene-hydrochlorothiazid 37.5-25 mg Capsule Sig: One
(1) Cap PO DAILY (Daily).
15. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
16. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for thick secretions.
17. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): place x
12 hours during the day and take off at night.
18. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
19. ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
20. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H
(every 8 hours).
21. acetylcysteine 20 % (200 mg/mL) Solution Sig: Three (3) ML
Miscellaneous Q6H (every 6 hours).
22. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours):
give with mucomyst.
23. zafirlukast 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
24. Centrum Silver Tablet Sig: One (1) Tablet PO once a day.
25. ferrous sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO twice a day: may want to hold if constipated during
the first couple weeks following surgery.
26. Vitamin C 500 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 11496**]
Discharge Diagnosis:
Tracheobronchomalacia
HTN
Hypothyroid
COPDdepression
elevated cholesterol
osteoarthritis
GERD
obstructive sleep apnea
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:
Call Dr. [**Last Name (STitle) **] if you have:
-Fevers greater than 101.5
-chills
-sweats
-shakes
-shortness of breath
-worsening cough
Call if right incision opens, become increasingly red, swollen
or drains.
Call for uncontrolled surgical pain.
Take stool softeners while on narcotics. Do not drive while on
narcotics for pain.
You may shower but do not tub bath for 6 weeks.
Followup Instructions:
Provider: [**Name10 (NameIs) 1532**] [**Last Name (NamePattern4) 8786**], MD Phone:[**Telephone/Fax (1) 3020**]
Date/Time:[**2106-3-2**] 10:30 [**Hospital1 18**] [**Hospital Ward Name **] [**Location (un) 453**] [**Hospital1 **]
116.
Get a chest xray 30 minutes prior to your appointment on [**Location (un) **] clinical center radiology department.
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 3020**] Date/Time:[**2106-3-2**]
11:15
Completed by:[**2106-2-11**] Name: [**Known lastname 15443**],[**Known firstname 2868**] (JINI) Unit No: [**Numeric Identifier 15444**]
Admission Date: [**2106-2-5**] Discharge Date: [**2106-2-11**]
Date of Birth: [**2037-6-2**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Effexor
Attending:[**First Name3 (LF) 3454**]
Addendum:
The [**Hospital 1325**] rehab stay is anticipated to be less than 30 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1620**]
[**Name6 (MD) **] [**Last Name (NamePattern4) 3455**] MD [**MD Number(2) 3456**]
Completed by:[**2106-2-11**]
|
[
"272.0",
"416.8",
"530.81",
"311",
"496",
"251.2",
"327.23",
"244.9",
"401.9",
"519.19",
"514",
"V43.65"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.48",
"31.79",
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
12051, 12237
|
2430, 5264
|
290, 517
|
10496, 10496
|
1801, 2407
|
11087, 12028
|
1374, 1436
|
7756, 10263
|
10355, 10475
|
5290, 7733
|
10679, 11064
|
1131, 1216
|
1451, 1536
|
233, 252
|
545, 976
|
10511, 10655
|
998, 1108
|
1232, 1358
|
1561, 1782
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,265
| 113,858
|
37773
|
Discharge summary
|
report
|
Admission Date: [**2196-10-26**] Discharge Date: [**2196-11-30**]
Date of Birth: [**2118-7-15**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3043**]
Chief Complaint:
Cellulitis/DVT
Major Surgical or Invasive Procedure:
Thoracentesis (x2)
Placement of Chest Tube
Pleurodesis
Abdominal paracentesis (x4)
PICC line placement
History of Present Illness:
This is a 78 year old man with history notable for extensive
pulmonary asbestosis, atrial fibrillation, and RP fibrosis s/p
ureterolysis and omental wrap who presented to an outside
hospital on [**2196-10-26**] for elective hernia repair. The patient
has long been awaiting repair of a large inguinal hernia and
ventral hernia and had stopped taking his coumadin 10 days prior
to presentation (he is on this for atrial fibrillation) in order
to get these procedures completed. Over the week prior to
presentation he had also noted worsening left lower extremity
edema and increasing abdominal girth with worsening of his
preexisting vental hernia. Other review of systems notable for
some nonproductive cough as well as general fatigue and
decreased mobility for the past month, which he largely
attributed to his impressive hydrocele. He denied any
fevers,chest pain, orthopnea, or PND.
At the outside hospital initial evaluation revealed abdominal
wall erythema concerning for cellulitis as well as a swollen
left lower extremity. Ultrasound showed left common femoral
vein DVT. He was transferred to [**Hospital1 18**] for further management.
On arrival he complained of fatigue and discomfort from his
large hernias. No other issues.
Past Medical History:
-asbestosis
-atrial fibrillation
-ureterolysis
-RP fibrosis (presumed idiopathic)
-omental wrap
Social History:
The patient worked as a steam engineer for over 40 years. He
reports significant asbestos exposure over a period of several
years. He lives with his wife of 58 years. He denies TOB or
drug use and says he drinks alcohol only very occasionally.
Family History:
Father died of complications of pernicious anemia, mother died
at age 66 of ??????heart problems??????. [**Name2 (NI) **] brother died of an MI at
age 53, both younger brothers died of CVD in their 40??????s. One
sister died of complications of alcoholism at 66, another sister
died at age 68 of cerebral hemorrhage. His one remaining
sibling, a sister, is 77 and well.
Physical Exam:
On Presentation:
T=94.7 HR 60 BP 153/56 RR30 93% NRB
PHYSICAL EXAM
GENERAL: Pleasant, speaking in full sentences
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA. dry mmm. OP clear. Neck Supple, No LAD.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**]. no elevation of JVD
LUNGS: decreased breath sounds in lower [**2-9**] of right lung and
poor air movement with crackles in the rest of the lung.
ABDOMEN: large ventral hernia, multiple large other hernias. NT,
ND. +bs
EXTREMITIES: +2 edema to the sacrum. 1+ dorsalis pedis pulses
bilaterally
GU: very large scrotal hernia and scrotal edema
SKIN: macular rash on abdomen and back
NEURO: A&Ox3. Appropriate. CN 2-12 intact. UE and LE strength
[**5-10**].
PSYCH: Listens and responds to questions appropriately,
pleasant, tangential speech.
Pertinent Results:
=====================
LABORATORY RESULTS
=====================
BLOOD
------
On Presentation:
WBC-11.5* RBC-4.20* Hgb-11.4* Hct-34.5* MCV-82 RDW-15.3 Plt
Ct-452*
---Neuts-84.8* Lymphs-5.1* Monos-8.7 Eos-1.0 Baso-0.4
PT-14.2* PTT-25.5 INR(PT)-1.2*
Glucose-105 UreaN-37* Creat-2.0* Na-140 K-5.5* Cl-107 HCO3-24
Calcium-8.7 Phos-4.1 Mg-1.8
Last Full Labs:
WBC-16.1* RBC-3.82* Hgb-10.4* Hct-32.0* MCV-84 RDW-15.9* Plt
Ct-649*
---Neuts-86.8* Lymphs-3.4* Monos-8.6 Eos-0.8 Baso-0.4
PT-15.2* PTT-37.0* INR(PT)-1.3*
Glucose-121* UreaN-102* Creat-2.0* Na-136 K-4.2 Cl-104 HCO3-21*
Other Important Labs:
[**2196-11-4**] 07:50AM BLOOD ALT-10 AST-20 AlkPhos-60 TotBili-0.2
[**2196-11-5**] 07:15AM BLOOD Triglyc-135 HDL-29 CHOL/HD-4.2 LDLcalc-67
[**2196-11-18**] 03:50AM BLOOD TSH-4.1
[**2196-11-18**] 03:50AM BLOOD Cortsol-15.9
[**2196-11-8**] 12:52PM BLOOD PSA-0.8
[**2196-11-9**] 07:25AM BLOOD PEP-NO SPECIFIC PEAK ID's
Protein/Albumins:
[**2196-11-4**] 07:50AM Albumin-2.7*
[**2196-11-5**] 07:15AM TotProt-6.4 Albumin-3.5
[**2196-11-9**] 07:25AM TotProt-6.2*
[**2196-11-11**] 05:00AM TotProt-5.9* Albumin-3.2*
[**2196-11-12**] 05:37AM Albumin-3.3*
[**2196-11-18**] 03:50AM Albumin-2.5*
[**2196-11-22**] 05:56AM TotProt-4.3* Albumin-2.2*
Urine
------
[**2196-11-25**]: Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.017 Blood-TR
Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG
Urobiln-NEG pH-5.5 Leuks-NEG
RBC-2 WBC-1 Bacteri-NONE Yeast-NONE Epi-1 TransE-<1
CastGr-18*
Pleural Fluid
---------------
[**2196-11-13**] WBC-190* RBC-5875* Polys-11* Lymphs-59* Monos-18*
Eos-1* Meso-11*
TotProt-3.6 Glucose-129 LD(LDH)-116 Cholest-75 Triglyc-1120
[**2196-11-15**] WBC-1000* RBC-9333* Polys-19* Lymphs-55* Monos-15*
Eos-1* Meso-10*
TotProt-3.5 LD(LDH)-116 Amylase-28 Albumin-2.0
Peritoneal Fluid
-----------------
[**2196-11-5**] WBC-1875* RBC-[**Numeric Identifier **]* Polys-22* Bands-1* Lymphs-40*
Monos-0 Macroph-37* LD(LDH)-120 Albumin-2.0 Triglyc-1304
Adenosine Deaminase: 6.4 (Normal)
[**2196-11-10**] WBC-740* RBC-3150* Polys-8* Lymphs-57* Monos-33*
Mesothe-2*
TotPro-3.6 LD(LDH)-114 Albumin-2.1 Triglyc-815
[**2196-1-24**] WBC-570* RBC-720* Polys-58* Lymphs-27* Monos-0 Eos-1*
Plasma-2* Mesothe-1* Macroph-11*
TotPro-2.4 Glucose-133 LD(LDH)-139 Amylase-16 Albumin-1.4
===============
MICROBIOLOGY
===============
Blood Cultures *6: No growth
Urine Cultures *4: No Growth
Stool for C diff: Negative
Peritoneal Fluid Culture *4: No growth
Pleural Fluid Culture*3: No Growth
===========
PATHOLOGY
===========
Pleural Fluid Cytology from [**11-10**], [**11-13**], and [**11-15**]: Negative for
Malignant Cells
Peritoneal Fluid Cytology from [**11-5**] and [**11-13**]: Negative for
malignant cells
Pleural Fluid Immunophenotyping:
NTERPRETATION
Non-specific T cell dominant lymphoid profile; diagnostic
immunophenotypic features of involvement by lymphoma are not
seen in specimen. Correlation with clinical findings and
morphology (see C09-[**Numeric Identifier **]) is recommended. Flow cytometry
immunophenotyping may not detect all lymphomas as due to
topography, sampling or artifacts of sample preparation.
===============
OTHER STUDIES
===============
ECG [**2196-10-26**]:
Sinus bradycardia. Otherwise, tracing is within normal limits
CT Abdomen and Pelvis W/O Contrast [**2196-10-26**]:
IMPRESSION AND PLAN:
1. Abnormal soft tissue encasing the retroperitoneal structures,
surrounding the aorta and IVC, extending inferiorly along the
presacral space. These findings are incompletely characterized
without intravenous contrast. Findings could reflect
retroperitoneal fibrosis, though correlation with prior history
or any prior imaging would be helpful. The attenuation of this
material is not compatible with hemorrhage
2. Complex ventral abdominal wall hernia containing fat, fluid
and small
bowel, without evidence of obstruction.
3. Large left inguinal hernia, with herniation of fluid and
sigmoid colon to the left scrotal sac.
4. Large amount of ascites.
5. Left external iliac, common femoral, and superficial femoral
venous
thrombosis.
Chest Radiograph [**2196-11-1**]:
IMPRESSION: Marked cardiac enlargement predominantly involving
the left heart. Extensive bilateral pleural changes including
calcifications consistent with previous asbestos exposure.
Pulmonary vasculature demonstrates upper zone re-distribution
pattern but no conclusive evidence for acute infiltrates.
Bilateral Lower Extremity Ultrasounds [**2196-11-3**]:
IMPRESSION:
1. Occlusive deep venous thrombosis in the common femoral vein
extending into the greater saphenous and deep femoral veins. Of
note, the proximal extent of thrombus is not defined.
2. No right lower extremity deep venous thrombosis.
Spirometry [**2196-11-4**]:
Impression:
Marked restrictive ventilatory defect with a marked gas exchange
defect.
The reduced DLCO suggests an interstitial process. There are no
prior studies available for comparison.
TTE [**2196-11-4**]:
Conclusions
The left atrium is moderately dilated. No atrial septal defect
is seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). There is no VSD
seen. Right ventricular chamber size and free wall motion are
normal. The ascending aorta is mildly dilated. The aortic arch
is mildly dilated. The aortic valve leaflets (3) are mildly
thickened. There is a minimally increased gradient consistent
with minimal aortic valve stenosis. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is mild 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.
Abdominal Ultrasound w/Dopplers [**2196-11-4**]:
IMPRESSION:
1. Normal portal venous, hepatic venous, and hepatic arterial
flow to the
liver.
2. Large amount of ascites
CT Chest W/O Contrast [**2196-11-7**]:
IMPRESSION:
The constellation of findings including an increasing right
pleural effusion which is moderately large, massive hiatal
hernia, diffuse ground-glass opacities throughout the lungs
probably infective or inflammatory, extensive calcification in
multiple pleural plaques with extensive intra- abdominal ascites
all contribute to the worsening respiratory status.
The presence of an increasing pleural effusion with calcified
and noncalcified pleural plaques in the setting of
asbestos-related disease raises the remote possibility of
mesothelioma.
TTE [**2196-11-8**]:
IMPRESSION: Mild concentric hypertrophy with normal
biventricular regional and global systolic function. Moderate
diastolic dysfunction with elevated PCWP. Mild aortic
regurgitation. Moderate pulmonary hypertension.
Compared with the prior study (images reviewed) of [**2196-11-4**],
the findings are similar. A paramembranous VSD is not seen on
either study (mentioned in initial report). The velocity across
the aortic valve is now lower
CT Chest [**2196-11-12**]:
IMPRESSION:
1. Large right-sided pleural effusion which has increased in
size since the
study performed five days prior. Associated compressive
atelectasis of the
right lung base. Also compressive atelectasis of the left lung
base due to
large hiatal hernia which is unchanged.
2. Scattered ground-glass opacities throughout both lungs,
stable, likely
infectious or inflammatory in nature. No focal consolidations.
No other
significant changes since the prior study.
Renal Ultrasound [**2196-11-12**]:
IMPRESSION: No hydronephrosis. Non-diagnostic Doppler evaluation
due to
patient's inability to hold breath.
CT Chest w/o Contast [**2196-11-14**]:
FINDINGS: There has been a slight decrease in size of the large
right pleural effusion since the previous CT on [**11-12**] with
no pneumothorax. The right lower lobe compressive atelectasis
remains similar and the large intrathoracic hiatal hernia now
contains peripheral fluid tracking up from the extensive
ascites. Otherwise, no change since the CT torso on [**2196-11-12**], and reference to the previous CT report is recommended for
complete description of findings.
KUB [**2196-11-25**]:
FINDINGS:
In the left anterior mid abdomen in the expected location of the
patients
known ventral abdominal hernia, multiple air-filled and dilated
bowel loops
are seen, likely involving both small and large bowel. Air is
visualized in
the rectum. CT is recommended to rule out large or small bowel
obstruction.
Chest Radiograph [**2196-11-26**]:
FINDINGS: Portable AP upright chest radiograph is compared with
[**11-22**]
and [**2196-11-25**]. There is a large hiatal hernia. There is
increase in
the right mid lung opacification, which may be atelectasis or
pneumonia.
There is left basal atelectasis with increasing pleural
effusion. Within the left upper lung there is increased
opacification, which may be secondary to infection. The right
pigtail catheter is unchanged in position. There is
atherosclerotic disease of the thoracic aorta.
Brief Hospital Course:
This is a 78 year old male with history of paradoxical atrial
fibrillation, pulmonary asbestosis, and idiopathic RP fibrosis
presenting with cellulitis and increased abdominal distension
found to have DVT and with progressive chylous ascites.
1)Chylous Ascites: The patient was noted to have a distended
abdomen on presentation and imaging revealed a large amount of
ascites. As the patient had not had a previous history of
ascites this was worked up with liver ultrasound that revealed
no parenchymal or vascular dysfunction. Diagnostic paracentesis
was obtained on [**2196-11-5**] that showed chylous ascites. This
paracentesis also revealed >250 neutrophils so the patient was
empirically started on a five day course of ceftriaxone though
he remained afebrile and had no abdominal pain. After the
chylous ascites was discovered primary concern was for a
malignancy given the lack of liver disease. Multiple imaging
studies failed to show a mass, however, multiple fluid
cytologies were negative, and the patient's LDH was within
normal limits making lymphoma quite unlikely. Therefore, most
likely etiology of the development of chylous ascites was
thought to be progressive lymphatic obstruction from RP fibrosis
leading to increased hydrostatic pressure and leak into the
peritoneal cavity. The patient had three therapeutic
paracentesis on [**11-14**], and [**11-29**] respectively removing 900
cc, 3L and 1 L of chylous fluid respectively. The second of
these revealed a neutrophil count of 280 so led to a second
course of five days of antibiotics with ciprofloxacin (as the
patient was on cefepime/vanc when the paracentesis occured)
which completed on [**2196-11-29**]. All cultures remained negative.
Unfortunately, the patient developed secondary chylothorax from
fluid tracking up into the pleural space causing respiratory
distress. Attempts were made to slow accumulation of fluid with
medical therapies including octreotide and low fat diet then low
fat TPN but these were unsuccessful. General surgery was
consulted twice and both times said that surgery to attempt to
improve lymph drainage would be unsuccessful as structures are
very small and diffuse and post-surgical scarring would likely
be as damaging as initial insult. Case was discussed with
thoracic surgery who thought that without clear damage to
thoracic duct there was no indication for procedural management.
Finally, the possibility of lymphangiogram was discussed
extensively with a possible intervention and balloon dilation of
cisterna chyli. Unfortunately, planning MRI would have been
required and given patient's progressively poor respiratory
status this would have required intubation. As lymphangiogram
and balloon dilation are extremely uncommon procedures, odds of
success were not considered high and risk of intubation and
likely difficulty extubation was discussed with the family and
patient and they elected to pursue comfort focused care. The
possibility of disease modifying therapy for RP fibrosis was
discussed with rheumatology, but they said there would be no
role for the agents used (almost all of which are immune
suppressants) in this acutely sick individual and these things
would be unlikely to lead to quick turn-around.
2) Chylothorax/Hypoxic Respiratory Failure: The patient was
initially noted to be hypoxic soon after admission with desats
to the low 90's on room air. He was seen by pulmonary who
attributed this to ascites and his large abdomen causing
restrictive pathology in the setting of his underlying pulmonary
asbestosis and plaques. This was supported by his initial PFT's
that showed a restrictive pattern. The patient then became
progressively more hypoxic in the setting of an expanding right
sided pleural effusion and a large amount of compressive
atelectasis. He was desatting to the low 90's on 4L O2 by nasal
cannula when he had his first thoracentesis on [**2196-11-10**] with
considerable improvement after the procedure. By [**11-12**], however,
he had reaccumulated almost completely and by [**11-13**] was
desaturating again so that an ABG showed of O2 of around 53.
Therefore, he was transferred to the unit while he awaited a
second thoracentesis. As he reaccumulated quickly again after
that thoracentesis decision was made to place a pigtail
catheter, which was placed on [**2196-11-15**]. Over the ensuing days
the patient continued to put out greater than one liter of
chylous fluid per 24 hour period despite the various
interventions meant to reduce chylous ascites mentioned (low fat
diets, octreotide, etc...). On [**2196-11-29**] a pleurodesis was
attempted in hopes of allowing eventual removal of the chest
tube though interventional pulmonology thought this had a very
low probability of being successful. After the second
thoracentesis the patient remained dependent on at least 4L of
oxygen by nasal cannula to keep sats> 90%. On [**11-26**] he
desaturated to the 80's on 6L in the context of worsening
infiltrates bilaterally but this seemed to improve with holding
TPN and was ultimately thought most likely due to volume
overload. However, on the day of expected discharge ([**11-30**]), his
respiratory status worsened (oxygen saturation of 90-92% on
non-rebreather) and he did not wish to use the mask. Given that
comfort was the goal, he was transitioned back to nasal cannula,
and oxygen saturations were no longer followed.
3) Nutrition/Protein Loss: Initially the patient was allowed to
eat a regular diet but in attempts at medical management he was
converted to a low fat, high protein diet and then made NPO with
TPN. Despite TPN his protein and albumin continued to fall
presumably due to losses in the chest tube. After he became
quite volume overloaded on [**2196-11-27**] and given the minimal
reduction in fluid output seen even with the TPN modifications
TPN was stopped as of [**11-27**] and he was allowed to eat for
comfort. He and his family understand he will ultimately
continue to become malnourished and weaker but given poor
toleration of TPN and comfort focused care this was considered
acceptable by them.
4) Health Care Associated Pneumonia: The patient was noted to
have intermittently elevated white counts and on [**2196-11-19**] had a
right upper lobe infiltrate on chest radiograph and had purulent
sputum. Therefore, he received 9 days of cefepime/vancomycin
with some improvement in his sputum production and stable chest
radiograph findings. White count failed to trend reliably. He
was never febrile.
5) LLE DVT: He was initially on heparin gtt then transitioned to
be therapeutic on coumadin. He was transferred back to heparin
gtt once on the medical service and continued on this throughout
his course there to make procedures feasible without needing a
long warfarin wash-out. Anticoagulation with medications other
than unfractionated heparin (enoxaparin, warfarin) was not
optimal given his renal failure and poor nutritional status.
6)Cellulitis: The patient initially received a dose of
penicillin then a few days of cefazolin with minimal improvement
in his abdominal rash. He then received 10 days of vancomycin
as well as steroid cream after dermatology thought the abdominal
rash could be a contact dermatitis. This led to resolution of
his abdominal rash.
7) Likely drug rash: Later in his hospitalization (around
[**11-19**]-15th) he developed a morbilliform eruption on his
trunk in the context of receiving a dose of
piperacillin-tazobactam in the ICU. This medication was stopped
an his rash resolved.
8) Hypotension: The patient developed relative hypotension in
the hospital. Multiple blood cultures were negative and this
seemed stable without mental status changes or end organ
dysfunction (except some worsening of his CKD). This was
thought likely due to poor cardiac return due to massive third
spacing from his protein losses and perhaps external compression
of the IVC by his abdomen.
9) Acute Kidney Injury: The patient's baseline Cr is unclear.
At presentation Cr was 2 then trended down to 1.5 before
trending up again in the setting of worsening ascites and his
general deterioration. Renal was consulted twice and ultimately
concluded this was likely due to poor preload and forward flow
from the heart in the context of his third spacing and massive
abdominal distension. He never became oliguric or anuric.
10) Atrial fibrillation: The patient developed atrial
fibrillation with rapid ventricular response while his nodal
agents were being held. This broke with diltiazem and he was
restarted on this medication with good rate control.
11) Goals of Care: After extensive discussion with the family
and patient about the lack of options for reversing the
patient's chylous ascites accumulation and subsequent
respiratory compromise and progressive protein wasting they
elected to pursue comfort focused care. Reasonably benign
interventions (i.e. antibiotics, pleurodesis through a
preexisting chest tube) were pursued but other aggressive cares
were not. Similarly oral feeds were pursued even in the face of
a possible SBO for the patient's comfort and happiness. His
major goal was comfort and the family and patient understood his
poor prognosis. When his respiratory status deteriorated on
[**11-30**] (as above), further diagnostics and interventions were not
pursued, and he was given morphine. He passed away in the
evening of [**11-30**], and his family was notified. Autopsy was
requested and will be performed at [**Hospital1 18**].
Medications on Admission:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Diltiazem HCl 300 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary Diagnoses
==================
Chylous Ascites Presumed Secondary to Retroperitoneal Fibrosis
Secondary Chylothorax
Hypoxic respiratory distress due to external compression
Hospital Acquired Pneumonia
Spontaneous Bacterial Peritonitis
Acute Kidney Injury
Cellulitis
Left Lower Extremity DVT
Secondary Diagnoses
=====================
Paroxysmal Atrial Fibrillation
Pulmonary Asbestosis
Large inguinal and ventral hernias
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
|
[
"603.9",
"518.81",
"276.51",
"511.9",
"567.23",
"518.0",
"707.03",
"458.9",
"486",
"593.4",
"560.1",
"585.3",
"285.1",
"692.9",
"550.90",
"428.0",
"427.31",
"276.4",
"553.21",
"501",
"250.02",
"608.4",
"693.0",
"707.22",
"789.59",
"E930.0",
"285.29",
"682.2",
"584.9",
"428.32",
"457.8",
"453.41"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91",
"38.93",
"99.15",
"34.04",
"34.92",
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
22715, 22724
|
12511, 22042
|
332, 437
|
23195, 23204
|
3404, 12488
|
23260, 23270
|
2117, 2492
|
22683, 22692
|
22745, 23174
|
22069, 22659
|
23228, 23237
|
2507, 3385
|
278, 294
|
465, 1716
|
1738, 1836
|
1852, 2101
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,891
| 198,669
|
31293
|
Discharge summary
|
report
|
Admission Date: [**2140-6-8**] Discharge Date: [**2140-6-15**]
Date of Birth: [**2082-9-4**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Epidural Abscess
Major Surgical or Invasive Procedure:
L2/3 partial laminectomy and L5 Laminectomy for epidural abscess
washout
History of Present Illness:
Patient is a 57 year old woman with history of IVDU,
hypertension, hypothyroidism, anxiety and depression who was
transferred from OSH after being found to have an epidural
abscess. She had presented there with back pain on the R side x
2-3 days, which was not relieved by flexeril. Pt is poor
historian and unable to provide much detail other than she was
having back pain. Pt did deny fever/chills at home and
bowel/bladder incontinence. Laboratories at this OSH revealed a
creatinine of 2.1 (from baseline of 1) and elevated ESR of 105.
MRI spine was performed and revealed abscess at L2-L3 level with
phlegmon L4-L5-S1, no cord compression. Blood cultures from
[**2140-6-7**] from OSH grew gram negative rods, which were
pan-sensitive and gram positve cocci.
.
She was transferred on [**2140-6-8**] to [**Hospital1 **] and underwent laminectomy
and washout of L2, L3, and L5 with epidural drain placement.
Past Medical History:
1) Intravenous drug use: cocaine, reported last use 1-2 weeks
age
2) Hypertension
3) Hypothyroidism
4) Anxiety
5) Depression
6) h/o iron deficiency anemia 2 years ago, requiring
transfusions adn weekly iron infusions x3mo
7) Status post R knee surgery for OA, torn meniscus, [**2136**]
8) Status post L ankle surgery with pin placement for fracture,
[**2106**]
9) Status post cholecystectomy, [**2102**]
10) C-section, [**2102**]
Social History:
Pt lives with her husband and is his caretaker as he is a double
amputee. Pt has a daughter.
Pt denies tobacco and ETOH use.
Family History:
Unknown cancer in father; CHF, atherosclerosis, and neuropathy
in mother.
Physical Exam:
T99.4, BP 126/77, P84, R18, O2sat 95%, BS 163
Gen: NAD, obsese
HEENt: NC/AT, conjunctiva clear, MMM
Chest: CTAB
Cor: RRr, nl S1/S2, no murmur
Abdomen: +BS, soft, mildly tender in LLQ, nontender
Ext: trace pedal edema.
Neuro: alert and oriented x3, muscle strength 5/5 in UEs and LEs
Pertinent Results:
Admission labs:
.
[**2140-6-8**] 05:50AM WBC-8.8 RBC-3.66* HGB-9.0* HCT-26.6* MCV-73*
MCH-24.7* MCHC-34.0 RDW-15.9*
[**2140-6-8**] 05:50AM NEUTS-84.9* LYMPHS-10.0* MONOS-4.1 EOS-1.0
BASOS-0.1
[**2140-6-8**] 05:50AM GLUCOSE-114* UREA N-28* CREAT-1.4* SODIUM-135
POTASSIUM-4.8 CHLORIDE-98 TOTAL CO2-26 ANION GAP-16
.
Imaging:
.
[**2140-6-8**] 9:45 PM LUMBAR SP,SINGLE FILM IN O.R.
FINDINGS: No comparisons. A series of two intraoperative lateral
radiographs of the lumbar spine were obtained without a
radiologist present. These demonstrate radiopaque probes
posteriorly. Assuming that the lowest movable disc represents
L5-S1, the probe is located posterior to the L3 vertebral body.
Retractors are seen posteriorly. Please refer to operative
report for full details.
.
[**2140-6-8**] 8:04 AM MR [**Name13 (STitle) 6452**] W & W/O CONTRAST; MR [**Name13 (STitle) **] W &W/O
CONTRAST
IMPRESSION: Overall, examination slightly limited secondary to
patient motion.
1. Ventrally located epidural process along the L2 and L3
vertebral bodies with mild associated mass effect, likely a
combination of phelgmon and abscess.
2. Enhancing mass located intradurally along the posterior
aspect at the L4, L5 and S1 levels with appearance suggestive of
inflammatory - infectious change/phlegmon.
.
[**2140-6-10**] ECHO
Conclusions:
The left atrium is moderately dilated. The estimated right
atrial pressure is 5-10 mmHg. Left ventricular wall thickness,
cavity size, and systolic function are normal (LVEF>55%).
Regional left ventricular wall motion is normal. Transmitral and
tissue Doppler imaging suggests normal diastolic function, and 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. No masses or
vegetations are seen on the aortic valve. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. No mass or vegetation is seen
on the mitral
valve. There is mild pulmonary artery systolic hypertension.
There is a
trivial/physiologic pericardial effusion.
Brief Hospital Course:
Post-operatively the patient was persistently agitated and
required frequent doses of IV Ativan and Dilaudid. She had
pulled out several of her IV lines. She remained afebrile and
other than mild tachycardia was hemodynamically stable. Given
concern for substance abuse withdrawal and poor mental status in
setting of known bacteremia, the patient was transferred to the
MICU. In the MICU, she was on PCA and CIWA scale with standing
Valium for the first 4 days of MICU stay. The CIWA scale was
discontinued on [**2140-6-11**] when the patient become somnolent. Upon
resolution of mental status changes, pt was transferred to the
floor on [**2140-6-12**].
.
1. Epidural abscess/Bacteremia: Blood cultures from [**2140-6-10**]
showed gram (-) rods and grew S. Marcescens. Subsequent serial
blood cultures were negative. Pt was evaluated and followed by
ID. It was felt that the source of her infection was likely
related to IVDU. There was a question of endocarditis as the
source for seeding; however, there was no notable murmur on exam
and a TTE failed to show any valvular abnormalities. EKG did
not show any abnormalities. Pt was discharged on ciprofloxacin
IV for 6 weeks as recommended by ID. She will have to see the
infectious disease doctors [**First Name (Titles) **] [**Last Name (Titles) 18**] and [**Name5 (PTitle) **] appointment has been
scheduled for a follow up.
.
2. Substance Abuse, cocaine: Pt was referred to social work.
.
3. Anemia, microcytic: Pt had no sign of active bleed. Iron
studies appeared to be c/w anemia of chronic disease. HCT
remained stable after 1 unit of PRBCs on [**2140-6-8**].
.
4. Hypertension: Pt on home medications.
.
5. Hypothyroidism: Pt on home medication.
.
6. Depression: Pt on home medication.
.
7. Hyperglycemia/DM II (newly diagnosed): Pt on insulin SS.
Will need further work up as an outpatient.
Medications on Admission:
1) Amitryptaline 25 mg daily
2) Lorazepam 1 mg twice daily
3) Alprazolam 1 mg twice daily
4) Celexa 40 mg daily
5) Hydrochlorothiazide 25 mg daily
6) Levothyroxine 100 mcg daily
7) Senna
8) Colace
9) Vancomycin 1 gram day
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
9. Insulin Sliding Scale
Please see attached insulin sliding scale
10. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: Three
(3) Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
11. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed.
12. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
13. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
14. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
15. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
16. Ciprofloxacin 400 mg/40 mL Solution Sig: One (1)
Intravenous Q 8H (Every 8 Hours) for 5 weeks.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2222**] - [**Location (un) 538**]
Discharge Diagnosis:
Primary:
1. L2-L5 Serratia Epidural Abscess.
2. Serratia Bacteremia.
3. Acute Renal Failure.
4. Polysubstance Abuse - IVDU Cocaine.
.
Secondary:
1. Hypertension.
2. Iron Deficiency Anemia.
3. Hypothyroidism.
4. Anxiety - Depression.
5. Obesity.
6. S/P Cholecystectomy
7. Diabetes
Discharge Condition:
Neurologically stable
Discharge Instructions:
Please keep wound(s) clean and dry / No tub baths or pools for
two weeks from your date of surgery
.
If you have steri-strips in place ?????? keep dry x 72 hours. Do not
pull them off. They will fall off on their own or be taken off
in the office
.
No pulling up, lifting> 10 lbs., excessive bending or twisting
.
Limit your use of stairs to 2-3 times per day
.
Have a family member check your incision daily for signs of
infection
.
If you are required to wear one, wear cervical collar or back
brace as instructed
.
You may shower briefly without the collar / back brace unless
instructed otherwise
.
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
.
Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation
.
Clearance to drive and return to work will be addressed at your
post-operative office visit
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? Pain that is continually increasing or not relieved by pain
medicine
?????? Any weakness, numbness, tingling in your extremities
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, drainage
?????? Fever greater than or equal to 101?????? F
?????? Any change in your bowel or bladder habits
Remove drain when less than 30 cc per 8 hour shift
Remove staples/sutures in 10 days
.
You have a new diagnosis of Diabetes and you are on insulin.
Please follow up with your primary care physician for further
management of Diabetes.
Followup Instructions:
Infectious Diease Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2140-7-18**] 9:00
.
Neurosurgery Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 548**]
Please come to your appointment on [**2140-7-6**] at 3:15. The
[**Hospital 4695**] Clinic is located at 110 [**Doctor First Name **], [**Location (un) 470**], [**Hospital Unit Name **].
Completed by:[**2140-6-15**]
|
[
"324.1",
"041.85",
"278.01",
"401.9",
"285.9",
"305.61",
"244.9",
"250.00",
"300.4",
"292.0",
"790.7",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.09"
] |
icd9pcs
|
[
[
[]
]
] |
8077, 8150
|
4573, 6441
|
328, 403
|
8474, 8498
|
2352, 2352
|
10126, 10664
|
1958, 2033
|
6713, 8054
|
8171, 8453
|
6467, 6690
|
8522, 10103
|
2048, 2333
|
272, 290
|
431, 1345
|
2368, 4550
|
1367, 1799
|
1815, 1942
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,068
| 174,422
|
33634
|
Discharge summary
|
report
|
Admission Date: [**2154-5-14**] Discharge Date: [**2154-5-20**]
Date of Birth: [**2082-8-27**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Codeine / Morphine Sulfate
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
[**2154-5-15**] Coronary Artery Bypass Graft x 3 (LIMA to Diag, SVG to
OM, SVG to PDA)
History of Present Illness:
71 y/o female with known coronary artery disease s/p myocardial
infarction in [**2132**] with PCI to RCA in [**2140**]. Since then she has
been doing well, but since [**4-6**] after a viral illness she has
developed chest pain and dyspnea on exertion. Recent stress test
was positive and therefor underwent a cardiac cath. Cath showed
severe three vessel coronary artery disease and she was
transferred from [**Hospital1 **] to [**Hospital1 18**] for surgical intervention.
Past Medical History:
Coronary Artery Disease s/p Myocardial Infarction [**2132**], PCI of
RCA [**2140**], Hypertension, Hypercholesterolemia, Hypothyroidism,
Gastroesophageal Reflux Disease, s/p Hysterectomy, s/p Bladder
suspension, s/p Cholecystectomy, s/p Cochlear implant
Social History:
Quit smoking in [**2132**] after 1ppd x 36yrs. Rare ETOH use.
Family History:
+Multiple brothers with MI in 40-50's.
Physical Exam:
Gen: WDWN elderly female in NAD, lying supione in bed.
Skin: W/D intact
HEENT: EOMI, PERRL, NCAT
Neck: Supple, FROM -JVD, -Carotid bruit
Chest: CTAB -w/r/r
Heart: RRR -c/r/m/g
Abd: Soft, NT/ND, +BS
Ext: Warm, well-perfused, -edema, superficial varicosities
bilat.
Neuro: A&O x 3, MAE, non-focal
Pertinent Results:
CHEST (PA & LAT) [**2154-5-20**] 10:14 AM
CHEST (PA & LAT)
Reason: pna / effussions / pmneumo
[**Hospital 93**] MEDICAL CONDITION:
71 year old woman with s/p cabg
REASON FOR THIS EXAMINATION:
pna / effussions / pmneumo
HISTORY: Pneumonia.
PA and lateral radiographs of the chest demonstrate interval
removal of the right internal jugular central venous catheter
seen on [**2154-5-18**]. No pneumothorax. The appearance of the heart
and lungs is unchanged. There are persistent bilateral small
pleural effusions. Trachea is midline. Patient is again noted to
be status post CABG.
[**2154-5-20**] 08:10AM BLOOD WBC-9.7 RBC-3.08* Hgb-9.8* Hct-28.4*
MCV-92 MCH-31.9 MCHC-34.6 RDW-13.2 Plt Ct-177
[**2154-5-15**] 04:48PM BLOOD PT-13.9* PTT-30.9 INR(PT)-1.2*
[**2154-5-20**] 08:10AM BLOOD Glucose-121* UreaN-9 Creat-0.6 Na-144
K-4.4 Cl-107 HCO3-31 AnGap-10
[**2154-5-14**] 12:50PM BLOOD ALT-14 AST-20 LD(LDH)-141 CK(CPK)-44
AlkPhos-76 Amylase-44 TotBili-0.6
Brief Hospital Course:
As mentioned in the HPI, Mrs. [**Known lastname 77891**] was transferred from
[**Hospital1 **] to [**Hospital1 18**] for surgery. Upon admission she underwent
usual pre-operative work-up. On [**5-15**] she was brought to the
operating room where she underwent a coronary artery bypass
graft x 3. Please see operative report for surgical details.
Following surgery she was transferred to the CVICU for invasive
monitoring in stable condition. Within 24 hours she was weaned
from sedation, awoke neurologically intact and extubated. On
post-op day one she was restarted on pre-op medications along
with beta blockers and diuretics. She was gently diuresed
towards he pre-op weight. Later on this day she was transferred
to the telemetry floor for further care. Her chest tubes were
removed on post-op day two. Epicardial pacing wires were removed
on post-op day three. She continued to recover well while
working with physical therapy for strength and mobility. On
post-op day 5 she was discharged to rehab with the appropriate
medications and follow-up appointments.
Medications on Admission:
Aspirin 81mg qd, Synthroid .112mcg qd, Omeprazole 20mg qam,
Crestor 20mg qd, Folic acid qd, MVI qd, Nadolol 20mg qd
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 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. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 tablets* Refills:*0*
7. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
8. Prilosec 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:*0*
9. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Hospice and VNA
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 3
PMH: Myocardial Infarction [**2132**], PCI of RCA [**2140**], Hypertension,
Hypercholesterolemia, Hypothyroidism, Gastroesophageal Reflux
Disease, s/p Hysterectomy, s/p Bladder suspension, s/p
Cholecystectomy, s/p Cochlear implant
Discharge Condition:
Good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Dr. [**Last Name (STitle) **] in 4 weeks
Dr. [**Last Name (STitle) 27117**] in [**3-3**] weeks
Dr. [**Last Name (STitle) **] in [**1-30**] weeks
Completed by:[**2154-5-21**]
|
[
"412",
"530.81",
"V15.82",
"244.9",
"413.9",
"414.01",
"272.0",
"401.9",
"V45.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"38.93",
"36.13",
"39.63",
"36.15",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
4874, 4936
|
2619, 3686
|
304, 392
|
5271, 5277
|
1637, 1735
|
5788, 5963
|
1267, 1307
|
3852, 4851
|
1772, 1804
|
4957, 5250
|
3712, 3829
|
5301, 5765
|
1322, 1618
|
254, 266
|
1833, 2596
|
420, 895
|
917, 1172
|
1188, 1251
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,076
| 133,788
|
53804
|
Discharge summary
|
report
|
Admission Date: [**2148-2-18**] Discharge Date: [**2148-2-21**]
Date of Birth: [**2089-10-5**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
AMS
Major Surgical or Invasive Procedure:
intubation, extubation
History of Present Illness:
58 yo M w/ HCV cirrhosis, PUD, EtOH abuse, L frontal traumatic
hemmorhage who was brought from home by ambulance in setting of
suspected seizure, intubated in the field, now admitted to
further evaluation of his encephalopathy.
.
Pt. was in USOH until the evening PTA. While in bed in the
middle of the night, noted by his wife to sit up, staring off
into space. During this time was not responding to his wife.
She was able to lay him down, but then noted to look to the
right, move RUE up in the air and appear "stiff." When wife and
son were unable to move him, EMS was called. It is unclear from
wife's description and from EMS record how long the seizure
lasted. Of note, per wife, over the past week has been c/o
intrmittent RUQ pain, persistent daily cough productive of white
sputum. Wife notes that last drink was Thursday night.
.
EMS on arrival noted patient had a right gaze preference on on
evaluation and was not responsive to stimuli. He was noted to
be anisocoric 4mm R and 2mm L and non-reactive. Given 5mg of
ativan, 1mg lidocaine, 6mg of versed. FS was 233. Reportedly
was mottled centrally. Intubated given respiratory compromise.
.
In the ED, initial VS were: 142 22 113/72 99.2F intubated 100
% on unknown vent settings. OG lavage produced 500cc of dark
brown material. He received 4L NS, 80mg protonix IV and ppi
gtt, 1mgof folate, 500mg IV of thiamine. Head CT showed Left
frontal encephalomalacia with ex vacuo changes. Neurology was
c/s who recommended CTA neck, Keppra 1.5g load. Impression was
that pt. had sz from prior focus in setting of possible etOH
withdrawal. EtOH lvl was 0 and serum/urine tox was neg.
.
On arrival to the MICU, intubated, 100.8F, 120/86, 77 100% on
22x550x50% FiO2. Neurology evaluated pt and he was Keppra
loaded, now on 1g IV BID. Had LP which looked clean (HSV PCR
pending) so initial Abx and acyclovir were stopped. 24hrs of EEG
monitoring showed no evidence of seizures so this was
discontinued today. Pt has significant history of 18 beers/day
with reported last drink Thursday so have been monitoring for
alcohol withdrawal although difficult to tell what CIWA was
while intubated in unit. He was extubated yesterday morning
and is doing okay from a pulmonary standpoint. However, he has
been significantly delerious since extubation. He hasn't
received any benzos since extubation and received last ativan
yesterday evening for sedation. He had one elevated elevated
temperature to 100.8 on [**2-18**] but has been afebrile since
then. While in ICU, also had dark brown fluid through his OG
lavage and was started on a [**Hospital1 **] PPI. Hct dropped after IV
fluids but has been stable in the last 24 hours
.
Overnight, the patient has no complaints. He was still confused
and was not sure what exactly was going on. He reported
breathing well. Reports history of alcohol withdrawal in the
past but didn't feel like he was anxious or withdrawing
overnight.
.
This morning, T- 98.0, BP- 120/60, HR- 74, RR- 18, SaO2- 96% on
RA. The patient seemed more awake and oriented than overnight.
He reports feeling "groggy" but was oriented to person, year,
month, president. He thought he was [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 745**] [**Hospital 64552**] hospital,
not [**Hospital1 18**]. He was able to state the days of the week both
forward and backwards.
Past Medical History:
- HCV cirrhosis, VL 920K [**2-3**], no prior tx
- [**2146**] small SDH and SAH (left frontal-parietal)
- GIB [**12-28**] PUD (gastritis/esophagitis and mutliple gastric ulcers
on EGD, no report of varices, [**2145**]), baseline HCT 33-34
- HTN
- COPD
- Anxiety
Social History:
Lives at home in [**Hospital1 **] w/ wife and 40 [**Name2 (NI) **] son. [**Name (NI) **] not worked
in 3 yrs, due to difficulty concentrating.
- Tobacco: 1ppd for "longtime"
- Alcohol: 18beers/day, last drink 4days PTA
- Illicits: denies
Family History:
wife unaware.
Physical Exam:
Admission exam:
General: Intubated, off propofol x 20 mins, opens eyes to
sternal rub.
HEENT: Sclera anicteric, right scleral hemorrhage, dMM
Neck: supple, JVP not elevated, no LAD
CV: Regular rate, normal S1 + S2, no murmurs
Lungs: CTA, no wheezes, rales, ronchi anteriorly or laterally
Abdomen: distended, soft, non-tender, non-distended, bowel
sounds present, no organomegaly
GU: foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: spider angiomata, palmar erythema
Neuro:
Intubated, 20 mins off propofol. Opens eyes spont. but not to
command, does not follow any axial commands. Moving about w/
b/l UEs > LEs, no clear assymetry, appears to be reaching for
ETT. Prefers left side, though no gaze preference. does not
follow examiner or wife past midline.
CNII-XII: PERRL 3-2mm, hippus b/l, no roving or nystagmus,
intact corneal, face symmetric, intact gag and cough.
Increase tone in RUE and RLE. No clonus, but has spread
distally at biceps and patellar. Toe Up on right, down on left.
withdraws symmetrically to noxious.
Discharge exam:
O: VS- T- 97.8, BP- 120/60, HR- 69, RR- 18, SaO2- 99% on RA.
GENERAL - Alert, interactive, AAO x 2, in NAD
HEENT - PERRLA, sclerae anicteric, MMM, OP clear
NECK - Supple, no cervical LAD
HEART - RRR, nl S1-S2, no MRG
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored
ABDOMEN - NABS, soft/NT/non-distended
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses
SKIN - spiders on chest with palmar erythema
NEURO - awake, interactive, A&Ox2 (place- "[**Location (un) 745**]", "[**Hospital1 **]"),
no asterixis, attentive
Pertinent Results:
[**2148-2-18**] 07:25AM BLOOD WBC-10.0 RBC-4.03* Hgb-12.9* Hct-44.0
MCV-109* MCH-32.0 MCHC-29.3* RDW-14.1 Plt Ct-254
[**2148-2-18**] 07:25AM BLOOD PT-11.6 PTT-31.7 INR(PT)-1.1
[**2148-2-18**] 09:04PM BLOOD Glucose-100 UreaN-10 Creat-1.0 Na-138
K-4.2 Cl-110* HCO3-21* AnGap-11
[**2148-2-18**] 07:25AM BLOOD ALT-41* AST-85* AlkPhos-76 TotBili-0.5
[**2148-2-18**] 02:49PM BLOOD CK-MB-2 cTropnT-<0.01
[**2148-2-18**] 07:25AM BLOOD Lipase-36
[**2148-2-18**] 07:25AM BLOOD Albumin-4.1 Calcium-9.2 Phos-6.2* Mg-2.5
[**2148-2-18**] 09:58AM BLOOD Type-ART Temp-37.3 Tidal V-550 PEEP-5
FiO2-40 pO2-209* pCO2-40 pH-7.35 calTCO2-23 Base XS--3
Intubat-INTUBATED
[**2148-2-18**] 08:22AM BLOOD Type-ART Temp-37.3 Tidal V-500 FiO2-100
pO2-539* pCO2-48* pH-7.21* calTCO2-20* Base XS--8 AADO2-128 REQ
O2-32 Intubat-INTUBATED Vent-CONTROLLED
[**2148-2-18**] 06:00PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-0 Polys-16
Lymphs-54 Monos-30
[**2148-2-18**] 06:00PM CEREBROSPINAL FLUID (CSF) TotProt-41 Glucose-78
[**2148-2-18**] 06:00PM CEREBROSPINAL FLUID (CSF) HERPES SIMPLEX VIRUS
PCR-Negative
[**2148-2-19**] 04:35AM BLOOD WBC-8.2 RBC-3.37* Hgb-10.7* Hct-35.6*
MCV-106* MCH-31.8 MCHC-30.1* RDW-14.6 Plt Ct-184
[**2148-2-19**] 02:09PM BLOOD WBC-9.6 RBC-3.15* Hgb-10.0* Hct-33.3*
MCV-106* MCH-31.9 MCHC-30.2* RDW-14.7 Plt Ct-157
[**2148-2-21**] 06:30AM BLOOD WBC-6.3 RBC-3.19* Hgb-10.4* Hct-32.4*
MCV-102* MCH-32.4* MCHC-31.9 RDW-14.2 Plt Ct-163
[**2148-2-19**] 04:35AM BLOOD Glucose-83 UreaN-11 Creat-1.0 Na-141
K-3.9 Cl-110* HCO3-23 AnGap-12
[**2148-2-19**] 02:09PM BLOOD Glucose-89 UreaN-8 Creat-1.0 Na-139 K-4.0
Cl-109* HCO3-22 AnGap-12
[**2148-2-21**] 06:30AM BLOOD Glucose-94 UreaN-11 Creat-0.8 Na-140
K-3.2* Cl-106 HCO3-24 AnGap-13
[**2148-2-21**] 06:30AM BLOOD ALT-24 AST-36 AlkPhos-62 TotBili-1.1
[**2148-2-21**] 06:30AM BLOOD Calcium-8.7 Phos-3.2 Mg-1.8
EEG:
IMPRESSION: This telemetry captured no pushbutton activations.
It showed normal waking background throughout much of the
recording plus normal sleep patterns. There were no areas of
prominent focal slowing. There were no clearly epileptiform
features or electrographic seizures
MRI brain:
IMPRESSION:
1. No evidence of acute infarct or hemorrhage.
2. Left frontal and left parietal chronic infarction
CXR:
IMPRESSION:
1. Endotracheal tube tip approximately 3 cm above the carina.
2. Posterior right rib fractures.
Liver US:
The liver is normal in size and is mildly echogenic, suggesting
steatosis. Patent portal vein. No ascites. No dilatation of
common bile duct.
CT head ([**2148-2-18**])
IMPRESSION:
1. No acute intracranial process.
2. Left frontal encephalomalacia with ex vacuo changes.
CT c-spine ([**2148-2-18**])
IMPRESSION: No definite fracture or subluxation seen.
Degenerative changes.
CTA head/neck ([**2148-2-19**])
IMPRESSION:
1. Previous CT has shown encephalomalacia in the left frontal
region which likely reflects old infarcts, but if there is
persistent clinical concern, an MRI with diffusion imaging can
help for further assessment.
2. CT angiography of the neck demonstrates mild vascular
calcifications but no stenosis or occlusion.
3. CT angiography of the head demonstrates no occlusion or
stenosis. No evidence of an aneurysm greater than 3 mm in size.
Brief Hospital Course:
# LOC. This was thought to be due to tonic seizure and
post-ictal state at the time of initial evaluation by EMS. He
was urgently intubated in the field and admitted to the MICU.
Given low grade fever, patient was treated with acyclovir
empirically and underwent LP (normal), acyclovir was d/ced.
Imaging revealed left frontal and parietal foci from prior
traumatic ICH, which were likely the underlying predisposing
factor for seizures. In addition EtOH withdrawal was felt to be
a predisposing factor, with last drink being over 48hrs prior to
admission. Serum toxicology on [**2-18**] at 0725 was negative
(including benzos) with urine toxicology collected 1 hour later
positive for benzos (remainder of screen was negative). Other
infectious source (blood, urine, ascites and sputum) were ruled
out and he had no further evidence of fever. Neurology was
consulted and the patient was started on keppra 1gm IV BID (was
keppra loaded in the ED). Continous EEG showed no evidence of
seizure over 48 hour period. He did not score on CIWA for EtOH
withdrawal. He was extubated on [**2-19**] and did well so he was
transferred to the medicine floor on [**2-20**]. While on the floor,
he did well. He did not score on his CIWA scale on the floor
either. Mental status slowly improved (AAO x 2, thought he was
in [**Location (un) 745**] or [**Hospital1 **]) and the patient was attentive and
interactive but had notable memory problems. [**Name (NI) **] his wife, this
is his baseline. Neurology believes the patient has underlying
Korsakoff's syndrome. He will continued keppra 1000mg [**Hospital1 **] on
discharge and will follow-up with neurology as an outpatient.
Patient understands that alcohol is what lead to his seizure and
admission and he understands that he needs to stop drinking
immediately. Per his wife, she is the one that buys him [**Hospital1 5127**]
and she states that she will stop purchasing alcohol for the
patient and instead buy non-alcoholic [**Last Name (LF) 5127**], [**First Name3 (LF) **] ale and club
soda. PT/OT saw the patient and OT recommended 24 hours home
supervision given patient's memory deficits and concerns about
him alone at home. We discussed this at length with his wife
who felt that he was actually at his baseline and that he did
not need any services at home. We even offered the possibility
of rehab for a short-term but she refused that as well. She
states that, at baseline, the patient stays at home every day
and watches TV, eats food, and naps. She says that, given this
is "how he is", he would not need home services or rehab. She
stated the same thing to the case manager. The patient was
discharged home on keppra, thiamine, folic acid and
multivitamin.
# Brown emesis- The patient had an isolated episode of dark
brown emesis, concerning for GI bleed. His initial Hct 44 but
decreased to the mid-30s, which is his baseline. Admission Hct
likely hemoconcentrated. Although the patient has a diagnosis
of HCV cirrhosis, he has no prior history of varices and,
clinically, was not consistent with variceal bleed (usually
large volume in patients w/ decompensated cirrhosis, which pt.
does not have). He underwent NG lavage, which cleared by 500cc,
however there was no bile. There were no further episodes
concerning for GIB and his hematocrit remained stable throughout
the rest of the hospitalization. He had normal bowel movements
that were described as brown with no blood. He was discharged
on omeprazole 40mg daily and will need further outpatient
evaluation of this.
# EtOH abuse- Patient with extensive EtOH history with last
drink being 4 days prior to admission. He did not demonstrate
signs of active withdrawal during the admission. He did not
score on CIWA. Social work consultation was obtained. Patient
understands that alcohol is what lead to his seizure and
admission and understands that he needs to stop drinking
immediately. Per his wife, she is the one that buys him [**First Name3 (LF) 5127**]
and she states that she will stop purchasing alcohol for the
patient and instead get non-alcoholic [**Last Name (LF) 5127**], [**First Name3 (LF) **] ale and club
soda. He was started on folic acid, thiamine and multivitamin,
which he will continue on discharge. In addition, the patient
was given the phone number to a day treatment service in his
area. Patient was given contact information at [**Hospital 1191**] Hospital
if he wanted to pursue a day treatment program for EtOH abuse
# Acidosis. +AG on ABG. likely metabolic as well as some
respiratory component. Resolved w/ fluid resuscitation. Work-up
negative for infection.
# Dx HCV and/or EtOH cirrhosis- this has never been treated.
Per history from [**Hospital1 2025**], he does not seem to be decompensated as he
has normal coags, alb and platelets. Liver u/s w/o PVT and felt
to be more consistent w/ steatosis by [**Hospital1 **] radiologists. Will
need outpatient f/u with his prior providers.
Medications on Admission:
Buspar- unknown dose
Discharge Medications:
1. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. thiamine HCl 100 mg Tablet Sig: Two (2) Tablet PO once a day.
Disp:*60 Tablet(s)* Refills:*2*
4. Keppra 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
5. buspirone Oral
6. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary- Unresponsive episode secondary to seizure
Secondary- Depression
Alcohol Abuse
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital after being found
unresponsive. Most likely, you had a seizure which is thought
to be secondary to both your history of head trauma and alcohol
withdrawl. You were intubated on arrival to [**Hospital1 18**] but were
extubated shortly thereafter and did will from a breathing
standpoint. Initially, you were very confused but this improved
over the course of the hospitalization and you were at your
baseline mental status by discharge. You are now being
discharged home with plans to follow-up with your primary care
physician and the neurologist.
1. START taking keppra 1000mg by mouth twice day
2. START taking multivitamin by mouth once daily
3. START taking thiamine 100mg by mouth once daily
4. START taking folic acid 1mg by mouth once daily
5. START taking omeprazole 40mg by mouth daily
Please resume your other medications as prescribed by your
outpatient providers.
It is very important that you stop drinking alcohol. If you are
interested in pursuing outpatient treatment for alcohol use,
please contact [**Hospital 1191**] Hospital at [**Telephone/Fax (1) 100238**]
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) 177**] K.
Location: [**Hospital1 **] WEST INTERNAL MEDICINE
Address: [**Apartment Address(1) 44648**], [**Hospital1 **],[**Numeric Identifier 26419**]
Phone: [**Telephone/Fax (1) 38995**]
Appointment: Thursday [**2148-2-29**] 3:45pm
The neurologist will contact you in the near future to schedule
a follow-up appointment. If you do not hear from them by
[**2148-2-29**], please contact their clinic at [**Telephone/Fax (1) 2756**] to schedule
an appointment.
If you are interested in pursuing outpatient treatment for
alcohol use, please contact [**Hospital 1191**] Hospital at [**Telephone/Fax (1) 100238**]
Completed by:[**2148-2-22**]
|
[
"496",
"571.5",
"V12.54",
"291.1",
"780.39",
"V12.71",
"276.2",
"305.01",
"401.9",
"305.1",
"070.54",
"780.09",
"291.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
14839, 14845
|
9199, 14174
|
308, 332
|
14988, 14988
|
5944, 9176
|
16292, 16983
|
4290, 4305
|
14245, 14816
|
14866, 14967
|
14200, 14222
|
15141, 16269
|
4320, 5383
|
5399, 5925
|
265, 270
|
360, 3729
|
15003, 15117
|
3751, 4014
|
4030, 4274
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,755
| 159,586
|
31149
|
Discharge summary
|
report
|
Admission Date: [**2152-6-26**] Discharge Date: [**2152-7-11**]
Date of Birth: [**2085-9-18**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
Aortica Aneursym
Major Surgical or Invasive Procedure:
[**2152-6-26**]
Repair of infrarenal abdominal aortic aneurysm
with a 16 mm Dacron graft.
History of Present Illness:
This is a 66-year-old male with a history of asymptomatic
infrarenal abdominal aortic aneurysm which reached 5.7 cm in
diameter, which is consistent with a
rupture risk requiring surgery. He was not a candidate for an
Endo graft repair to the very short neck below the renal
arteries. He was consented for an open retroperitoneal repair of
his abdominal aortic aneurysm.
Past Medical History:
Past Medical History:
- Coronary Artery Disease
- COPD
- Hyperlipidemia
- Hypertension
- Calcified aorta
- New finding of Left lingula lung mass
- Bilateral Pleural Effusions; s/p left thoracentesis [**2151-11-8**]
- Hypothyroidism
- Trauma to lower extremities
- Emphysema
Past Surgical History:
- coronary artery bypass grafting surgery x5 in [**2137**] - [**Hospital3 **] Dr.[**Name (NI) 43096**]
- Polypectomy [**2151**]
- Right elbow seroma, s/p debridement and drainage
- Appendectomy
- Recurrent left pleural effusion s/p Left VATS pleurodiesis.
Social History:
Occupation: retired
Last Dental Exam:has only 2 native teeth; no recent dental care
Lives with wife in [**Name (NI) 1411**]
Race:Caucasian
Tobacco:[**1-15**] cigarettes daily
ETOH:[**4-17**] glasses of wine daily
Family History:
Brothers with CAD. One brother died of MI at age 57, another
brother with CABG in early 50's.
Physical Exam:
Weight: 99 kg
Tmax: 98.8 HR: 68 BP: 137/74 RR: 18 Spo2: 100% 2LNC
FSBG 132-156
Gen: NAD, alert and oriented x 3, flat affect
Cardiac: RRR
Lungs: CTA bilaterally
Abd: Soft, NT, ND
Abdominal incicison without sign/symptoms of infection. Staples
out and steri strips intact
Extremities [**5-17**], ambulates with minimal assistance
Pertinent Results:
[**2152-7-11**] 03:53AM BLOOD WBC-12.1* RBC-3.21* Hgb-9.2* Hct-29.1*
MCV-91 MCH-28.5 MCHC-31.5 RDW-15.8* Plt Ct-464*
[**2152-7-10**] 04:58AM BLOOD WBC-12.6* RBC-3.11* Hgb-9.3* Hct-28.3*
MCV-91 MCH-30.0 MCHC-33.0 RDW-15.5 Plt Ct-465*
[**2152-6-26**] 01:25PM BLOOD Neuts-85.8* Lymphs-8.6* Monos-4.5 Eos-0.7
Baso-0.4
[**2152-7-11**] 03:53AM BLOOD Plt Ct-464*
[**2152-7-11**] 03:53AM BLOOD PT-13.3 PTT-26.6 INR(PT)-1.1
[**2152-7-11**] 03:53AM BLOOD Glucose-101* UreaN-22* Creat-1.2 Na-133
K-4.7 Cl-101 HCO3-28 AnGap-9
[**2152-7-10**] 04:58AM BLOOD Glucose-102* UreaN-25* Creat-1.2 Na-136
K-3.9 Cl-101 HCO3-28 AnGap-11
[**2152-7-9**] 09:42AM BLOOD ALT-39 AST-35 AlkPhos-222* TotBili-1.2
[**2152-7-8**] 07:54AM BLOOD ALT-45* AST-36 AlkPhos-246* TotBili-1.3
[**2152-7-7**] 06:05AM BLOOD CK-MB-2 cTropnT-0.01
[**2152-7-6**] 09:23PM BLOOD CK-MB-2 cTropnT-<0.01
[**2152-7-11**] 03:53AM BLOOD Calcium-8.8 Phos-2.7 Mg-1.7
[**2152-7-3**] 07:02AM BLOOD Ferritn-1172*
[**2152-7-10**] 08:50PM BLOOD Vanco-11.8
[**2152-7-6**] 02:44AM BLOOD Type-ART Rates-/20 pO2-93 pCO2-46*
pH-7.42 calTCO2-31* Base XS-4 Intubat-NOT INTUBA
[**2152-7-3**] 8:06 pm BRONCHIAL WASHINGS
**FINAL REPORT [**2152-7-5**]**
GRAM STAIN (Final [**2152-7-3**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2152-7-5**]): NO GROWTH, <1000
CFU/ml.
[**2152-7-5**] 6:36 pm CATHETER TIP-IV Source: right sc tlc.
**FINAL REPORT [**2152-7-7**]**
WOUND CULTURE (Final [**2152-7-7**]): No significant growth.
[**2152-6-29**] 4:15 pm SPUTUM Source: Endotracheal.
**FINAL REPORT [**2152-7-1**]**
GRAM STAIN (Final [**2152-6-29**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE DIPLOCOCCI.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
RESPIRATORY CULTURE (Final [**2152-7-1**]):
Commensal Respiratory Flora Absent.
MORAXELLA CATARRHALIS. MODERATE GROWTH.
IDENTIFICATION PERFORMED ON CULTURE # [**Numeric Identifier 73522**]
([**2152-6-28**]).
ESCHERICHIA COLI. SPARSE GROWTH.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
[**Numeric Identifier 73522**]([**2152-6-28**]).
[**2152-6-28**] 6:15 pm SPUTUM Source: Endotracheal.
**FINAL REPORT [**2152-6-30**]**
GRAM STAIN (Final [**2152-6-28**]):
[**11-6**] PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM NEGATIVE DIPLOCOCCI.
RESPIRATORY CULTURE (Final [**2152-6-30**]):
Commensal Respiratory Flora Absent.
ESCHERICHIA COLI. MODERATE GROWTH.
MORAXELLA CATARRHALIS. MODERATE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- 1 S
GENTAMICIN------------ 4 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ 2 S
TRIMETHOPRIM/SULFA---- =>16 R
[**Known lastname 73523**],[**Known firstname 21376**] [**Medical Record Number 73524**] M 66 [**2085-9-18**]
Radiology Report CHEST (PA & LAT) Study Date of [**2152-7-7**] 2:46 PM
[**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 6889**] VICU [**2152-7-7**] 2:46 PM
CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 73525**]
Reason: eval for pna, pleural effusion, etc
[**Hospital 93**] MEDICAL CONDITION:
66 year old man with sob/desat/inc wbc. s/p retroperitnoeal
aaa repair
REASON FOR THIS EXAMINATION:
eval for pna, pleural effusion, etc
Final Report
HISTORY: 66-year-old man with shortness of breath and
desaturation with
increased white blood cells. The patient is status post
retroperitoneal AAA
repair.
TECHNIQUE: AP chest radiograph, single view.
COMPARISON: [**2152-7-5**] at 5:30 p.m.
FINDINGS: PICC line with tip at the mid SVC. Interval removal of
right
central venous line. No pneumothorax. There is a stent
projecting in the mid
mediastinum, corresponding to the area of the ascending aorta.
Cardiomediastinal silhouette is stable.
There is a stable opacity at the right mid lung, concerning for
consolidation.
There is interval increase in opacity at the left lung base,
concerning for
consolidation or aspiration. There are bilateral small pleural
effusions.
There is no pneumothorax.
IMPRESSION:
1. Stable consolidation in the right mid lung, concerning for
pneumonia.
2. Interval worsening in retrocardiac opacity at the left lung
concerning for
pneumonia or aspiration.
3. Small bilateral stable pleural effusions.
4. No pneumothorax.
The study and the report were reviewed by the staff radiologist.
[**Known lastname 73523**],[**Known firstname 21376**] [**Medical Record Number 73524**] M 66 [**2085-9-18**]
Radiology Report CHEST (PORTABLE AP) Study Date of [**2152-6-28**]
12:02 PM
[**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 6889**] CSRU [**2152-6-28**] 12:02 PM
CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 73526**]
Reason: assess for effusions/infiltrates
[**Hospital 93**] MEDICAL CONDITION:
66 year old man s/p AAA repair
REASON FOR THIS EXAMINATION:
assess for effusions/infiltrates
Final Report
HISTORY: Status post AAA repair.
COMPARISON: [**2152-6-26**].
CHEST PORTABLE AP:
Swan-Ganz catheter has been removed. ET tube terminates
approximately 6 cm
above the carina. Median sternotomy wires appear intact.
The lung volumes are low with increased bibasilar atelectasis.
Increase in pulmonary interstitial markings are likely due to
mild
interstitial edema. Slightly increased in bilateral pleural
effusion, small on
the left and now small to moderate on the right. There is no
pneumothorax.
The cardiomediastinal and hilar contours are stable.
IMPRESSION:
1. Slightly increased bilateral pleural effusions, small on the
left and now
small to moderate on the right.
2. Mild interstitial edema and bibasilar atelectasis are
slightly increased.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5785**]
Approved: WED [**2152-6-28**] 8:10 PM
Imaging Lab
Brief Hospital Course:
[**2152-6-26**]
Patient was taken to the OR for an open AAA repair under general
anesthesia. Epidural and foley were placed. No intra-operative
complications. Remained stable in PACU. Intubated on a
phenylephrine and Propofol drip. Acute pain service following.
Transferred to CVICU. Lisinopril and Lasix held for suprarenal
clamping during procedure.
[**2152-6-27**]
Monitored in ICU. Tmax 100.6, urine output minimal. Creatinine
elevated. Continued to be intubated and sedated. Patient is O2
dependent at home. Fluid resuscitation with IV bolus for
hypotension due to hypovolemia secondary to blood loss vs
epidural. UOP remains minimal. Received 1 unit of PRBC for a hct
of 29.2. Epidural on hold while hypotensive.
[**2152-6-28**]
Continue ICU monitoring. Continued intubation/sedation and pain
management. Nitro gtt off.
[**2152-6-29**]
Temp spoke 101.7, continues to be intubated on CMV. Epidural
removed. At 2100 patient went into spontaneous AFIB at 130.
Became hypotensive. Lopressor 10mg IV given without conversion.
Unsuccessful cardioversion x2. Diltiazem drip started at 5mg/hr,
Afib continued at 100.
[**2152-6-30**]
Sputum culture positive (see lab report). Antibiotics continues,
Cefepime and Vancomycin. Continued gentle diuresis. Intubated.
Fever work up pending. Tube feeds started. Converted to NSR on
Diltiazem drip.
[**2152-7-1**]
Vented and attempts to wean off. Continued diuerisis. Continued
on IV abx for pneumonia.
6/20/10-6/22
Failed extubation. Tube replaced. Continued pain management, IV
abx, comfort care. Incisions intact without signs of infection.
Chest PT continued. In NSR. Bowel regimen for constipation.
[**2152-7-5**] Bronch for occluded ETT. PICC placed
[**2152-7-6**] Extubated. Tolerating CPAP. Mildly confused. Afebrile
and VSS. Transferred to VICU.
[**2152-7-7**] Stable overnight. Denies pain. Continue pulmonary
toilet, Sat 95% on 4LNC.
[**2152-7-8**] Weaning O2. Ambulating with PT. Some mild confusion but
mostly oriented x3. Continued IV abx for PNA. Encouraged
pulmonary toilet
[**Date range (3) 73527**]
Rehab screening. PT/Nutrition/Social Work following. Please see
attached notes.
[**2152-7-11**] DC to Rehab. IV antibiotics stopped (received a total of
2 weeks course for PNA). PICC line removed.
Medications on Admission:
Lipitor 80mg daily, Lisinopril 10mg daily, Synthroid 137mcg
daily, Lasix 20mg daily, Atenolol 50mg daily, Aspirin 81mg
daily, Proventil inhaler prn.
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed for constipation.
4. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
5. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as
needed for wheeze.
6. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
8. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever/pain.
10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
11. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
12. Lipitor 80 mg Tablet Sig: One (1) Tablet PO once a day.
13. Zetia 10 mg Tablet Sig: One (1) Tablet PO once a day.
14. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO
twice a day: Hold for sbp<100 hr<60 .
15. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
16. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
17. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1) Inhalation once a day.
18. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-15**]
Drops Ophthalmic Q8H (every 8 hours) as needed for lubricate
eyes.
19. Doxazosin 1 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
Newbridge on the [**Doctor Last Name **] - [**Location (un) 1411**]
Discharge Diagnosis:
Pre-op (AAA)
Pneumonia
PMH:
Coronary Artery Disease
COPD
Hyperlipidemia
Hypertension
Calcified aorta
New finding of Left lingula lung mass,
Bilateral Pleural Effusions
s/p left thoracentesis [**2151-11-8**]
Hypothyroidism
Emphysema
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Abdominal Aortic Aneurysm (AAA) Surgery Discharge Instructions
What to expect when you go home:
1. It is normal to feel weak and tired, this will last for [**6-20**]
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 (use [**2-16**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? 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 that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
?????? Redness that extends away from your incision
?????? A sudden increase in pain that is not controlled with pain
medication
?????? A sudden change in the ability to move or use your leg or the
ability to feel your leg
?????? Temperature greater than 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) 3469**], MD Phone:[**Telephone/Fax (1) 2625**]
Date/Time:[**2152-7-19**] 2:45
Completed by:[**2152-7-11**]
|
[
"443.9",
"458.29",
"244.9",
"584.5",
"427.31",
"V45.81",
"401.9",
"482.83",
"285.9",
"348.30",
"518.5",
"441.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"99.61",
"96.6",
"38.44",
"33.22"
] |
icd9pcs
|
[
[
[]
]
] |
13146, 13240
|
8992, 11258
|
331, 423
|
13517, 13517
|
2118, 6041
|
16384, 16567
|
1649, 1745
|
11457, 13123
|
7803, 7834
|
13261, 13496
|
11284, 11434
|
13668, 15931
|
15957, 16361
|
1143, 1401
|
1760, 2099
|
275, 293
|
7866, 8969
|
451, 824
|
13532, 13644
|
868, 1120
|
1417, 1633
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,514
| 171,769
|
39486
|
Discharge summary
|
report
|
Admission Date: [**2101-5-17**] Discharge Date: [**2101-5-22**]
Date of Birth: [**2072-12-18**] Sex: F
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 301**]
Chief Complaint:
morbid obesity
Major Surgical or Invasive Procedure:
[**2101-5-17**]
1. Open cholecystectomy.
2. Open Roux-en-Y gastric bypass.
History of Present Illness:
[**Known firstname 87221**] has class III extreme morbid obesity with BMI of 60.7.
Previous weight loss efforts have included Weight Watchers,
Slim-Fast, prescription [**Street Address(1) 87222**]/PCP [**Name Initial (PRE) 51433**]. She has
been struggling with weight her entire life and cites as
contributors large portions, late night eating, too many
carbohydrates and saturated fats, stress and lack of exercise.
She denies history of eating disorders - no anorexia, bulimia,
diuretic or laxative abuse. Has history of depression but has
not been followed by a therapist nor has she been hospitalized
for mental health issues. She was once on psychotropic
medication (citalopram), but is no longer.
Past Medical History:
HTN, migraine, OSA(recommended CPAP), fatty liver,
cholelithiasis
Social History:
Denies tobacco or recreational drug usage, does drink about 8
alcoholic beverages weekly and has both carbonated and
caffeinated drinks. Works as a day care teacher and she is
single living with her mother age 62 and she has no children.
Family History:
Father deceased age 72 with cancer, diabetes and hyperlipidemia.
Mother living age 62 with heart disease, hyperlipidemia, DM, OA
and obesity. Sister in her 40s also with obesity and underwent
Roux-en-Y gastric bypass.
Physical Exam:
Admission Physical Exam:
BP 129/79, pulse 73, respirations 18 and O2 saturation 100% on
room air.
GEN: casually dressed, pleasant and in no distress.
SKIN: warm, dry with no rashes.
HEENT: Sclerae were anicteric, conjunctiva clear except for mild
hyperemia of the right lower conjunctiva, pupils were equal
round and reactive to light, fundi noted sharp optic disks
without hemorrhage, mucous membranes were moist,
tongue was pink and the oropharynx was without exudates or
hyperemia. Trachea was in the midline and the neck was large but
supple with no adenopathy, thyromegaly or carotid bruits.
CHEST: CTAB, symmetric, good air movement
CV: distant but present S1 and S2 heart sounds, regular rate and
rhythm, no murmurs, rubs or gallops.
ABD: very obese, soft and non-tender, non-distended with bowel
sounds activity and no appreciable masses or hernias, no
incision scars. No spinal tenderness or flank pain.
EXT: Lower extremities 1+ edema to the mid-shin of the left
lower extremity, very mild venous insufficiency, no clubbing and
perfusion was good. There was no joint swelling or inflammation
of the joints.
NEURO: There were no gross neurological deficits and gait was
normal.
Pertinent Results:
Post-operative: [**2101-5-17**] 03:27PM
HCT-45.7
Discharge Labs: [**2101-5-21**] 03:06AM
WBC-7.2 Hgb-11.4* Hct-34.1* Plt-210
Na-136 K-3.6 Cl-101 HCO3-28 UreaN-8 Creat-0.7 Glucose-109*
Calcium-8.3* Phos-3.0 Mg-2.0
[**2101-5-19**] - CTA Chest
No large central PE. Evaluation of segmental and subsegmental
branches is limited.
[**2101-5-19**] - CT Abdomen
The patient is status post recent gastric bypass surgery. No
contrast is noted in the peritoneal cavity. The liver, spleen,
both adrenals, both kidneys, pancreas are unremarkable. The
patient is status post cholecystectomy. A drain is noted in the
right upper quadrant appropriately. The small bowel loops are
mildly prominent, likely representing ileus. The large bowel is
unremarkable. No free fluid or air noted. No evidence of leak.
[**2101-5-19**] - UGI
Approximately 20 cc of Optiray contrast was administered orally
which passed freely into the gastric pouch and proximal loops of
bowel without evidence of a leak. Subsequently, thin barium was
orally administered, which demonstrated no further evidence of a
leak.
Brief Hospital Course:
Ms [**Known firstname 87221**] was evaluated by anaesthesia and taken to the
operating room for open cholecystectomy and Roux-en-Y gastric
bypass. There were no adverse events in the operating room;
please see Dr[**Name (NI) 78793**] operative note for details. She was
extubated in the OR, taken to the PACU until stable, then
transferred to the [**Hospital1 **] for observation. She remained on the
surgical [**Hospital1 **] for 2 days then was transferred to the ICU given
her persistent tachycardia and concern for anastamotic leak. She
was transferred back to the floor 2 days later and was
discharged on POD 5.
Neuro: She was alert and oriented throughout her
hospitalization. Her pain was initially managed with an epidural
which was removed on post-operative day 4. She was transitioned
to low dose oral Roxicet but this appeared to make her
somnolent, so she was provided liquid acetaminophen as
monotherapy for pain relief.
CV: She was persistently hypertensive and tachycardic beginning
immediately post-operatively. This was felt to be due primarily
to fluid deficit, given her post-op hemoconcentration (hct 45).
She was refractory to hydralazine and metoprolol IV. She
responded partially to fluid boluses, but not until starting a
labetolol drip in the ICU were we able to control her heartrate
and blood pressure. After weaning her off the drip, her
hemodynamics sustained in a normal range using only her home
dose of chlorthalidone. Serial EKGs were performed for
intermittent dull epigastric pain; these showed no changes from
prior.
Pulmonary: She was administered CPAP during some of her nights
while admitted. She did not tolerate this well, and preferred to
sleep without it. She had mild oxygen demand POD [**3-17**] and given
persisent tachycardia, she was evaluated by CTA chest to
rule-out pulmonary embolus. The study was negative albeit
limited by body habitus. Good pulmonary toilet, early ambulation
and incentive spirometry were encouraged throughout
hospitalization.
GI/GU/FEN: She was initially kept NPO until an upper GI study,
methylene blue test, and CT abdomen were performed on
post-operative day 2. All were negative for leak, therefore, her
diet was advanced to a bariatric stage I. She tolerated this for
over 24 hours before being advanced to Stage II. After a day of
Stage II, she was put on Stage III which was well tolerated. Her
intake and output were closely monitored.
The JP bulb was removed on post op day 5 immediately prior to
discharge.
ID: Her fever curves and WBC count were closely watched for
signs of infection. Perioperative antibiotics were
adminitstered; none other were warranted.
HEME: Her blood counts were closely watched for signs of
bleeding, of which there were none. Her hematocrit returned back
down to baseline following resuscitation.
Prophylaxis: She received subcutaneous heparin and venodyne
boots were used during this stay; she was encouraged to ambulate
as early as possible. She was ambulating independently by POD 4.
At the time of discharge, she was doing well, afebrile with
stable vital signs. She was tolerating a stage 3 diet,
ambulating, voiding without assistance, and pain was well
controlled. She received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan.
Medications on Admission:
chlorthalidone 25'
Discharge Medications:
1. acetaminophen 650 mg/20.3 mL Solution Sig: 20-30 mL PO Q6H
(every 6 hours) as needed for Pain / Fever: Maximum 120mL per
day.
Disp:*1000 mL* Refills:*0*
2. Colace 60 mg/15 mL Syrup Sig: Two (2) tsp PO twice a day:
hold for loose stool.
Disp:*600 mL* Refills:*0*
3. pediatric multivitamin-iron Tablet, Chewable Sig: One (1)
Tablet, Chewable PO once a day.
4. Zantac 15 mg/mL Syrup Sig: Ten (10) mL PO twice a day.
Disp:*600 mL* Refills:*0*
5. chlorthalidone 25 mg Tablet Sig: One (1) Tablet PO once a
day: Please crush and mix with liquid.
Discharge Disposition:
Home
Discharge Diagnosis:
1. Obesity, body mass index of 64, weight of 394 pounds.
2. Obstructive sleep apnea.
3. Fatty liver.
4. Gallstones.
5. Borderline type 2 diabetes.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call your surgeon or return to the emergency department
if you develop a fever greater than 101.5, chest pain, shortness
of breath, severe abdominal pain, pain unrelieved by your pain
medication, severe nausea or vomiting, severe abdominal
bloating, inability to eat or drink, foul smelling or colorful
drainage from your incisions, redness or swelling around your
incisions, or any other symptoms which are concerning to you.
Diet: Stay on Stage III diet until your follow up appointment.
Do not self advance diet, do not drink out of a straw or chew
gum.
Medication Instructions:
Resume your home medications, CRUSH ALL PILLS.
You will be starting some new medications:
1. You are being discharged on medications to treat the pain
from your operation. These medications will make you drowsy and
impair your ability to drive a motor vehicle or operate
machinery safely. You MUST refrain from such activities while
taking these medications.
2. You should begin taking a chewable complete multivitamin with
minerals. No gummy vitamins.
3. You will be taking Zantac liquid 150 mg twice daily for one
month. This medicine prevents gastric reflux.
4. You will be taking Actigall 300 mg twice daily for 6 months.
This medicine prevents you from having problems with your
gallbladder.
5. You should take a stool softener, Colace, twice daily for
constipation as needed, or until you resume a normal bowel
pattern.
6. You must not use NSAIDS (non-steroidal anti-inflammatory
drugs) Examples are Ibuprofen, Motrin, Aleve, Nuprin and
Naproxen. These agents will cause bleeding and ulcers in your
digestive system.
Activity:
No heavy lifting of items [**11-26**] pounds for 6 weeks. You may
resume moderate exercise at your discretion, no abdominal
exercises.
Wound Care:
You may shower, no tub baths or swimming.
If there is clear drainage from your incisions, cover with
clean, dry gauze.
Your steri-strips will fall off on their own. Please remove any
remaining strips 7-10 days after surgery.
Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
Followup Instructions:
[**Hospital 1560**] Clinic, Surgical Subspecialties, [**Hospital Ward Name 23**] Building
[**Hospital1 **] [**Last Name (Titles) 516**]
[**2101-6-1**] 11:00 Dr. [**Last Name (STitle) **],MD [**Telephone/Fax (1) 305**]
[**2101-6-1**] 11:30 [**First Name8 (NamePattern2) **] [**Doctor Last Name **],RD,LDN [**Telephone/Fax (1) 305**]
|
[
"997.1",
"V85.44",
"785.0",
"278.01",
"327.23",
"997.91",
"E878.2",
"574.20",
"571.8",
"790.29"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.22",
"93.90",
"38.91",
"44.39"
] |
icd9pcs
|
[
[
[]
]
] |
7972, 7978
|
4011, 7332
|
286, 363
|
8169, 8169
|
2903, 2953
|
10451, 10792
|
1460, 1680
|
7401, 7949
|
7999, 8148
|
7358, 7378
|
8320, 8886
|
2969, 3988
|
1720, 2884
|
232, 248
|
10094, 10428
|
391, 1099
|
8911, 10082
|
8184, 8296
|
1121, 1189
|
1205, 1444
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,998
| 199,312
|
26143
|
Discharge summary
|
report
|
Admission Date: [**2119-11-19**] Discharge Date: [**2119-11-23**]
Date of Birth: [**2070-9-28**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
s/p restent of RCA
Major Surgical or Invasive Procedure:
1. PCIx2 (performed at [**Hospital6 33**])
2. intra-aortic balloon pump (performed at [**Hospital6 33**])
3. r groin temp pacer wire (performed at [**Hospital6 33**])
History of Present Illness:
49 yom w/ h/o factor V leiden deficiency, >35 pack years of
smoking, fhx of cad and hemachromatosis presents throat
discomfort and found to have [**2-24**] ST elevation II, III, AVF (ST
III>II, no right sided leads) s/p cath multiple stents in RCA
and a stent in PDA one day pta.
.
This am patient had L arm pain and sscp. He was taken to cath
again and was found to have thrombus in RCA which was restented
and an intra-aortic balloon pump was placed. Pt remained
hemodynamically stable throughout.
.
Patient was subsequently transferred to [**Hospital1 18**] for observation
and for possible need for emergent CABG if the stent restenoses.
.
Patient currently denies chest pain, difficulty breathing,
orthopnea, PND, DOE, edema in LE. +occas palpitations with LOC
this past summer after being run over by a golf cart.
Past Medical History:
1. factor V leiden deficiency
2. borderline hyperlipidemia
No diabetes
Social History:
Lives with wife. [**Name (NI) 1403**] at a dry cleaner. Three kids. Likes to
golf. Smokes 1-1.5 packes for ~30 yrs, social drinking approx
5-6 beers/wine qweek, denies illicit drugs.
Family History:
father CAD MI in 40's
Physical Exam:
5'[**23**]" 188lbs
VS: T 99.8, 111/75, 69, 23, 92-95% 4L.
GEN: WD, WN male lying in bed in mild distress c/o chronic back
discomfort
Skin: flushed, erythematous face
HEENT: PERRL, EOMI, MMM, JV flat, neck supple, no carotid
bruits
Chest: CTA anteriorly and laterally.
CVR: RRR, nl S1, S2, ?S3 gallop, no murmurs/rubs
Abdomen: soft, nt, +BS, right groin with IABP + pacer in place,
no visible hematoma or ecchymosis
Ext: nonedematous, 1+ DP pulses bilaterally
Neuro: AOx3
Pertinent Results:
at outside hospital:
17.9/46.8/417
141/4.2/102/27/12/1.2/111
Ca: 10.3
INR 1.2 PT 15.0 113.7
TB 0.3 AP 76 ALT 29 AST 36 TP 7.1 Alb 4.4
CK 218 CKMB 3.7 TropT<0.01
U/A negative
.
on admission:
WBC-19.1* RBC-3.89* Hgb-13.3* Hct-37.3* Plt Ct-288
Neuts-88.1* Bands-0 Lymphs-9.2* Monos-2.6 Eos-0 Baso-0.1
PT-13.9* PTT-93.1* INR(PT)-1.3
Glucose-114* UreaN-11 Creat-1.1 Na-140 K-4.4 Cl-107 HCO3-23
AnGap-14
ALT-89* AST-342* CK(CPK)-3831* AlkPhos-62 TotBili-0.6
CK-MB-245* MB Indx-6.4* cTropnT-14.24*
Calcium-8.3* Phos-4.3 Mg-1.8
calTIBC-234* Ferritn-211 TRF-180*
Triglyc-111 HDL-38 CHOL/HD-3.8 LDLcalc-86
TSH-2.3
URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.019 Blood-NEG
Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG
Urobiln-4* pH-6.5 Leuks-NEG
Hours-RANDOM Creat-163 Na-108
.
EKG: NSR 64 ST 0.5-1mm elevation in II, III, AVF; 1-2mm
depressions in AVL, V1-4, resolved depressions in V5-6 otherwise
unchanged from priors (pre-cath).
.
On cath at OSH [**11-18**]: Right dominant
LAD (prox) 65%, (ostial) 50%, (mid) 30%
LCx nl, Diags 40%
RCA (prox) tubular 80%, thrombus 70%, RCA (mid) 100% thrombus
.
Cath at OSH [**11-19**]:
RCA (prox) 100% thrombus
RT PDA (distal) 100% discrete
.
[**11-21**] ECHO
1. The left ventricular cavity size is normal. Overall left
ventricular
systolic function is mildly depressed. Septal and inferior
hypokinesis is present. LVEF 45%.
Brief Hospital Course:
This is a 49 yom h/o Facotr V leiden deficiency and fhx
hemachromatosis p/w inferior MI s/p cath w/multiple stents to
RCA and stent to PDA which restenosed requiring repeat cath and
stenting the morning of admission. Intra-aortic balloon and temp
pacing wire was placed. Patient was transferred to [**Hospital1 18**] for
possible CABG. Now IABP and temp wire dc'd. Called out to floor.
.
##CARDIAC
# Ischemia: s/p MI tropT 14.24, RCA and PDA occlusions s/p
stents. Patient started on ASA, plavix, integrillin (completed
18hrs now dc'd), dc'd IV heparin. Ideally, would like to start
pt on both ACEi and BB however pt BP low and HR 50-60's. Since
patient already "beta blocked" (decreased BP and HR) started
ACEi for the benefits it has on remodeling and decreasing
afterload. Heparin gtt was discontinued and lovenox SQ [**Hospital1 **] was
started until therapeutic on coumadin. Patient was on coumadin
5mg qhs. Continued lisinopril 5mg PO QD and recommend starting
beta blocker as HR and BP allows. Cont lipitor 80mg QD.
# Pump: weaned off balloon pump, BP in 90-100's systolic with HR
50-60's. Asymptomatic, denies lightheadeness when getting out of
bed. ECHO [**11-21**] septal/inferior hypokinesis and EF 45%.
Continued lisinopril and autodiuresed goal of keeping even.
# Rhythm: NSR. Per records, pt had transvenous temp pacing wire
placed on [**11-18**] at OSH and went into afib. Temp wire was
discontinued with 6 beats of VT [**11-21**] no abnormal tele events
since. Again, consider starting beta blocker as tolerated.
.
## Anticoagulation: will need coumadin for long term (at least 6
months) given restenosis in the setting of factor V leiden
deficiency. Discontinued heparin gtt and started lovenox SQ [**Hospital1 **].
Continued coumadin 5mg qhs.
.
## Decreased Hct: 31.5 from 33.7. Likely dilutional as all cell
lines down. This am 33.1 from 31.5. Stable at time of discharge.
.
## Wheezing: continue duonebs, encourage quitting smoking.
.
## Urge incontinence: likely secondary to edema from foley
catheter. UA negative for UTI. Resolving at time of discharge.
.
## Chronic LBP: cont percocets PRN.
.
## FEN: encourage PO, cardiac healthy diet, consulting nutrition
.
## Prophy - on IV heparin bridge to coumadin, colace/senna and
dulcolax PRN as needed.
## Access - 2 PIVs
## Code - full code
## Dispo - PT consult, callout to [**Hospital Ward Name **] 6 today, likely d/c home
tomorrow if clinically stable, cardiac rehab in 4 weeks.
Medications on Admission:
1. baby ASA
2. MVI
Discharge Medications:
1. Albuterol Sulfate 0.083 % Solution Sig: Two (2) puffs
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
Disp:*1 inhaler* Refills:*0*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Disp:*30 Tablet(s)* Refills:*2*
4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*30 Capsule(s)* Refills:*0*
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. Enoxaparin 100 mg/mL Syringe Sig: Ninety (90) mg Subcutaneous
Q12H (every 12 hours): Continue this medication until you are
contact[**Name (NI) **] by Dr.[**Name (NI) 17410**] office to stop taking this medication.
Disp:*30 syringes* Refills:*0*
10. Outpatient Lab Work
Please check PT/INR Monday [**11-27**] @2:30pm at Dr.[**Name (NI) 17410**] office
and make sure Dr. [**First Name (STitle) **] is sent the results.
11. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual q5 minutes as needed for chest pain: Take 1 pill
every 5 minutes x 3 as needed for chest pain.
Disp:*10 tablets* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Acute MI
Secondary:
Factor V Leiden deficiency
Borderline hyperlipidemia
Discharge Condition:
Good
Discharge Instructions:
Please take medications as prescribed.
You have been started on a medication called warfarin that helps
prevents clot formation. You need to get your PT/INR lab checked
regularly and have your primary care physician follow the values
up and adjust your warfarin dose accordingly. You will likely
need to stay on coumadin for at least 6 months given your
history of factor V leiden and restenosis of stents.
You are currently taking Enoxaparin while your warfarin
medication becomes therapeutic. Once your INR/PT level is
therapeutic, your primary care physician will instruct you to
stop Enoxaparin.
Please call your primary care physician or return to the
emergency room if you have any chest pain, shortness of breath,
fevers/chills or any other worrying symptoms.
Followup Instructions:
Please get labs (PT/INR) drawn on Monday [**2119-11-27**] 2:30pm at Dr. [**Name (NI) 64861**] office.
Please follow-up with you primary care physician [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] on Thursday [**2119-11-30**] 3:30pm Phone: [**Telephone/Fax (1) 64161**].
Dr. [**First Name (STitle) **] Marks' (cardiology) office will call you at your
home ([**Telephone/Fax (1) 64862**]) tomorrow to schedule a follow-up
appointment. Their office number is ([**Telephone/Fax (1) 64863**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
Completed by:[**2119-11-24**]
|
[
"V45.82",
"414.01",
"286.3",
"427.1",
"428.9",
"410.41"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7650, 7656
|
3610, 6066
|
336, 505
|
7783, 7790
|
2203, 2380
|
8608, 9313
|
1667, 1691
|
6136, 7627
|
7677, 7762
|
6092, 6113
|
7814, 8585
|
1706, 2184
|
278, 298
|
533, 1355
|
2394, 3587
|
1377, 1450
|
1466, 1651
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,549
| 102,467
|
53812
|
Discharge summary
|
report
|
Admission Date: [**2129-5-26**] Discharge Date: [**2129-6-3**]
Date of Birth: [**2050-7-31**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
[**2129-5-27**] Aortic Valve Replacement utilizing a 25mm St. [**Male First Name (un) 923**]
Porcine Valve
History of Present Illness:
This is a 78 year old male with severe aortic stenosis and a
history significant for atrial fibrillation on coumadin,
hypertension, dyslipidemia, history of DVT/Phlebitis s/p filter
placement & removal, COPD and a history of respiratory failure.
An echo by Dr [**First Name (STitle) 7756**] on [**2129-4-22**] demonstrated progressive aortic
stenosis with [**Location (un) 109**] 0.9, peak gradient 80/mean 45, mild MR/ TR.
LVEF 65%. He reports shortness of breath on exertion only, such
as climbing one flight of stairs, carrying a bag from car, or
walking up an incline. This has been getting worse over the past
6 months. He also reports bilateral ankle edema. He was
referred for right and left heart catheterization. He is now
being referred to cardiac surgery for an aortic valve
replacement.
Past Medical History:
Severe aortic stenosis
Atrial fibrillation, on Coumadin
Hypertension
Dyslipidemia
History of DVT/Phlebitis in post -op state, s/p filter placement
& removal
COPD
History of respiratory failure
OSA, uses CPAP
History of pneumonia, remote
Obesity
Hypothyroidism
History of prostate cancer, s/p TURP
Radiation proctitis
ED
Diverticular disease
Osteoarthritis with bilateral knee pain
GERD
Renal insufficiency, per patient
Hernia
Rhematoid arthritis
s/p Cataract surgery, bilateral
s/p TURP
s/p Arthroscopic knee surgery
s/p 3 hernia repairs
Social History:
Lives with: wife
Occupation:retired
Cigarettes: quit 40 years ago, smoked for 15 years 2 packs/day
ETOH: < 1 drink/week [x] [**3-15**] drinks/week [] >8 drinks/week []
Illicit drug use: denies
Family History:
No premature coronary artery disease
Physical Exam:
PREOP EXAM
Pulse:50 Resp:16 O2 sat:100/RA
BP Right:119/57 Left:132/59
Height: 6' Weight: 238 lbs
General: WDWN elderly male in NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x] Cataract surgery x 2
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x] distant lung sounds
Heart: RRR [] Irregular [x] Murmur [x] grade _2/6 Systolic _
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel
sounds+ [x], obese, diastasis
Extremities: Warm [x], well-perfused [x] Edema [x] ___1+__
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: 2 Left: 2
DP Right: 1 Left: 1
PT [**Name (NI) 167**]: 1 Left: 1
Radial Right: 2 Left: 2
Carotid Bruit Right: no Left: no
Discharge:
Gen NAD
Neuro A&O x3, MAE, nonfocal exam
Pulm CTA diminished bases bilat
CV irreg-irreg, sternum stable, incision-CDI
Abdm soft, NT/ND/NABS
Ext warm, well perfused. 2+ edema bilat
Pertinent Results:
[**2129-5-27**] ECHO
Pre Bypass: The left atrium is mildly dilated. Mild spontaneous
echo contrast is present in the left atrial appendage. A
probable thrombus is seen in the left atrial appendage. No
atrial septal defect is seen by 2D or color Doppler. There is
mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Regional left ventricular
wall motion is normal. Overall left ventricular systolic
function is normal (LVEF>55%). The right ventricular cavity is
mildly dilated with normal free wall contractility. The right
atrium is markedly enlarged. There are complex (>4mm) atheroma
in the aortic arch. There are complex (>4mm) atheroma in the
descending thoracic aorta. There are three aortic valve
leaflets. The aortic valve leaflets are severely
thickened/deformed. There is severe aortic valve stenosis (valve
area 0.8-1.0cm2). Trace aortic regurgitation is seen. The mitral
valve leaflets are moderately thickened. There is severe mitral
annular calcification. Trivial mitral regurgitation is seen.
There is no pericardial effusion.
Post Bypass: For the post-bypass study, the patient was
receiving vasoactive infusions including phenylepherine. A
well-seated bioprosthetic valve is seen in the aortic position
with normal leaflet motion and gradients (mean gradient = 14
mmHg). No aortic regurgitation is seen. Regional and global left
ventricular systolic function are normal. Mitral valve anterior
leflet with increased mobility mva 3.24 cm2 by pressure half
time. MR remains trace. Remaining exam is unchanged. All
findings discussed with surgeons at the time of the exam.
Admission Labs:
[**2129-5-26**] 05:25PM PT-12.4 PTT-29.5 INR(PT)-1.1
[**2129-5-26**] 05:25PM PLT COUNT-153
[**2129-5-26**] 05:25PM WBC-5.7 RBC-3.90* HGB-10.7* HCT-35.6* MCV-91
MCH-27.4 MCHC-30.1* RDW-18.6*
[**2129-5-26**] 05:25PM %HbA1c-5.9 eAG-123
[**2129-5-26**] 05:25PM ALBUMIN-4.1 MAGNESIUM-2.3
[**2129-5-26**] 05:25PM LIPASE-32
[**2129-5-26**] 05:25PM ALT(SGPT)-18 AST(SGOT)-19 ALK PHOS-63
AMYLASE-72 TOT BILI-0.5
[**2129-5-26**] 05:25PM GLUCOSE-139* UREA N-27* CREAT-1.5* SODIUM-142
POTASSIUM-4.5 CHLORIDE-104 TOTAL CO2-30 ANION GAP-13
Discharge Labs:
[**2129-5-31**] 04:32AM BLOOD WBC-6.9 RBC-3.06* Hgb-8.4* Hct-27.8*
MCV-91 MCH-27.3 MCHC-30.0* RDW-18.5* Plt Ct-118*
[**2129-5-31**] 04:32AM BLOOD Plt Ct-118*
[**2129-5-31**] 04:32AM BLOOD Glucose-107* UreaN-26* Creat-1.1 Na-141
K-3.9 Cl-104 HCO3-27 AnGap-14
[**2129-5-31**] 04:32AM BLOOD Calcium-8.3* Phos-2.1* Mg-2.6
[**2129-6-2**] 04:43AM BLOOD PT-14.0* PTT-54.5* INR(PT)-1.3*
[**2129-6-1**] 04:49AM BLOOD PT-12.7* PTT-42.4* INR(PT)-1.2*
Radiology Report CHEST (PA & LAT) Study Date of [**2129-5-30**] 8:30 AM
Final Report : There is mild improvement of bilateral
interstitial markings and hilar prominence compared with prior
exam. No focal opacities are seen in the right, while the left
lung demonstrates improved aeration although with persistent
lower lobe atelectasis with concurrent small pleural effusion.
The mediastinum is widened secondary to mediastinotomy, but
unchanged compared with prior exam. There is no evidence of
pneumothorax. Old right-sided sixth rib fracture is again noted.
A right IJ line is seen ending in the mid SVC. Sternotomy wires
are intact.
IMPRESSION: Interval improvement of pulmonary vascular
congestion, left lower lobe atelectasis and left sided pleural
effusion.
Brief Hospital Course:
Mr. [**Known lastname 67619**] was admitted for intravenous Heparin and routine
preoperative evaluation prior to aortic valve replacement.
Workup was unremarkable and he was cleared to proceed with
surgery. On [**5-27**] Dr. [**Last Name (STitle) **] performed a bioprosthetic aortic
valve replacement - for surgical details, please see operative
note.
In summary he had: Aortic valve replacement with [**Street Address(2) 17009**]. [**Hospital 923**]
Medical Biocor Epic tissue valve. His bypass time was 77 minutes
with a crossclamp time of 58 minutes. He tolerated the operation
well and post-operatively was brought to the CVICU for invasive
monitoring. On the day of surgery he woke neurologically intact,
was weaned from the ventilator and extubated.
On postoperative day one, he was transferred to the stepdown
floor for continued post-operative care. Coumadin was resumed
for atrial fibrillation. Gentle diuresis was initiated. He
worked with nursing and physical therapy to increase his
postoperative strength and mobility. All tubes lines and
epicardial pacing wires were discontinued without complication.
On postoperative day three, he did have a temperature of 101.0.
Blood cultures were drawn and negative at the time of discharge,
urine culture was negative and the the triple lumen catheter was
discontinued. Heparin intravenous was started for [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 2966**]
on intra-op echo and preoperative atrial fibrillation. He failed
a voiding trial and the foley catherter was replaced. Flomax
therapy was initiated. The foley catheter was discontinued on
the evening of postoperative day number 3 without further
complication. He did have some serous midsternal drainage and
was started on Kefzol on POD3. This was resolved at the time of
discharge. He was afebrile, WBC normal and was sent home on no
antibiotics. He is to come to the wound clinic on [**2129-6-7**] for
follow up.
The remainder of his hospital course was uneventful and he was
discharged home on POD 7. He is to follow-up with Dr [**Last Name (STitle) **] in
1 month-appointment already scheduled.
Medications on Admission:
AMITRIPTYLINE 10 mg HS
ATENOLOL 50 mg Daily
CLOBETASOL 0.05 % Cream - as needed
DESONIDE 0.05 % Cream - as needed
ADVAIR DISKUS 250 mcg-50 mcg/Dose Disk with Device - one puff
inhaled twice a day
FOLIC ACID 1 mg daily
FUROSEMIDE 20 mg daily
LEVOTHYROXINE 150 mcg Daily
METHOTREXATE SODIUM 2.5 mg Tablets, Dose Pack - three Tablets
once a week on Friday
OMEPRAZOLE 20 mg Daily
PREDNISONE 5 mg Daily
VIAGRA 100 mg PRN
SIMVASTATIN 20 mg Daily
SPIRIVA WITH HANDIHALER 18 mcg Capsule, w/Inhalation Device -
two
puffs inhaled once a day
WARFARIN 2 mg Daily
CALCIUM CARBONATE-VITAMIN D3 Dosage uncertain
VITAMIN D3 400 unit Daily
VITAMIN B-12 500 mcg Daily
METHYLCELLULOSE 500 mg PRN
MULTIVITAMIN Dosage uncertain
OMEGA 3 FISH OIL Dosage uncertain
Discharge Medications:
1. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
2-4 Puffs Inhalation Q4H (every 4 hours) as needed for wheezing,
sob.
Disp:*1 * Refills:*1*
3. ipratropium bromide 17 mcg/actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation QID (4 times a day).
Disp:*1 * Refills:*2*
4. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Disp:*30 Cap(s)* Refills:*1*
5. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*1*
6. levothyroxine 50 mcg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*1*
7. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
8. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*60 Disk with Device(s)* Refills:*2*
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*30 Capsule(s)* Refills:*1*
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:*1*
11. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
12. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*1*
13. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
14. methotrexate sodium 2.5 mg Tablet Sig: Three (3) Tablet PO
QFRI (every Friday).
Disp:*12 Tablet(s)* Refills:*1*
15. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
Disp:*30 Capsule, Ext Release 24 hr(s)* Refills:*1*
16. amitriptyline 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for sleep.
Disp:*30 Tablet(s)* Refills:*0*
17. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*1*
18. potassium chloride 20 mEq Packet Sig: One (1) Packet PO once
a day.
Disp:*30 Packet(s)* Refills:*1*
19. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
20. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*1*
21. warfarin 5 mg Tablet Sig: Seven (7) mg PO once a day: Please
check INR on [**2129-6-4**].
Disp:*30 mg* Refills:*1*
22. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a
day for 7 days.
Disp:*28 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Aortic Stenosis - s/p AVR
Atrial Fibrillation with left atrial appendage thrombus
Hypertension
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with percocet
Incisions:
Sternal - healing well, no erythema or drainage
Edema 1+
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
WOUND CARE NURSE Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2129-6-7**] 10:30am
in the [**Hospital **] medical office building, [**Doctor First Name **], [**Hospital Unit Name **]
Surgeon: Dr. [**First Name (STitle) **] [**Name8 (MD) 6144**], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2129-6-29**] 1:30pm in the [**Hospital **] medical office building,
[**Doctor First Name **], [**Hospital Unit Name **]
Cardiologist: Dr. [**Last Name (STitle) 7526**] [**2129-6-13**] at 11:30a
Please call to schedule appointments with your
Primary Care Dr.[**Last Name (STitle) **],[**First Name3 (LF) **] [**Telephone/Fax (1) 71053**] in [**5-12**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication atrial fibrillation and
thrombus in the left atrial appendage
Goal INR 2-2.5
First draw [**2129-6-3**] and then [**Last Name (un) **] other day until stable
Results to phone fax Atrius coumadin clinic
Completed by:[**2129-6-3**]
|
[
"278.00",
"496",
"714.0",
"V15.3",
"429.89",
"397.0",
"327.23",
"427.31",
"V12.51",
"V12.52",
"715.36",
"V58.65",
"V58.61",
"780.62",
"396.2",
"530.81",
"272.4",
"V15.82",
"V10.46",
"274.9",
"V85.34",
"244.9",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.21",
"39.61",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
12177, 12226
|
6493, 8623
|
318, 427
|
12365, 12532
|
3063, 4686
|
13372, 14518
|
2047, 2085
|
9416, 12154
|
12247, 12344
|
8649, 9393
|
12556, 13349
|
5260, 6470
|
2100, 3044
|
270, 280
|
455, 1257
|
4702, 5244
|
1279, 1819
|
1835, 2031
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,477
| 164,686
|
43119
|
Discharge summary
|
report
|
Admission Date: [**2112-11-28**] Discharge Date: [**2112-12-5**]
Date of Birth: [**2033-5-6**] Sex: M
Service: MEDICINE
Allergies:
Ace Inhibitors
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
fever/chills, hypotension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
79M with AF (on coumadin), diastolic CHF, CRI (Cr baseline
1.4-1.6), h/o breast cancer, recently admitted for CHF
exacerbation, presents with fever/chills this afternoon. He also
suffered from a mechanical fall in bathroom, but did not hit his
head and also denies any LOC. No syncope either. He reportedly
only slipped on a film of water. However, he could not get up
and EMS was called. His heart rate was found to be the 170s. He
received 8mg of cardizem IV and HR decreased to 80s, but also
SPBs to 80s. Pt received 250cc IVF bolus with SPB coming up to
120s.
.
In the ED, his VS were T103.8, HR 105, BP 130/28, RR 37 (down to
21 on NRB), O2 sats 83% on RA, requiring a NRB to keep sats in
high 90s. His diastolic BP remained in the 20s and he received
another 300ml IVF bolus. In addition, a R IJ was placed as part
of code sepsis. Lactate was 2.7 but immediate repeat lactate was
only 1.5. UA was positive. Cr at baseline. WBC was 9.2 from
baseline of 6 (with 92% neutrophils). EKG with AF at 99. CXR
with volume overload. BNP of [**Numeric Identifier 961**]. He received on dose of
tylenol 650mg PR and vanco/levo/flagyl IV and was admitted for
suspected sepsis.
.
On arrival in the ICU, he was in NAD with BP 90s/40s, satting
well on NRB which could rapidly been weaned to NC.
.
On ROS, he denied any chest pain, SOB, palpitations, pain
anywhere, current F/C. Also no dysuria but urinary frequency. No
new cough or sputum production (but mild, chronic dry cough). No
increased salt intake or changes in his medications since his
recent discharge. 3 lbs weight gain since recent discharge. Was
advised to take extra dose of 20mg Torsemide per his cardiac RN
this afternoon. In addition, ROS positive as above.
Past Medical History:
diastolic CHF
atrial fibrillation
male breast cancer s/p R mastectomy in [**2104**]
hypertension
dyslipidemia
gout
Social History:
Drinks one drink per night. No w/d symptoms ever. No current
smoking. Last in [**2069**]. Has been teaching physics at [**University/College **]
[**Location (un) **].
Family History:
Noncontributory
Physical Exam:
VS - T98.0, BP 102/42, HR 95 in AF, 27, 94% on 4L NC, CVP 4
Gen: Elderly male in NAD. Oriented x3. Irritable.
HEENT: Sclera anicteric. PERRL, EOMI. Dry MM, clear OP.
Neck: Supple with JVP of 10 cm.
CV: Irregularly irregular, normal S1, S2. 2/6 SEM at RUSB. [**3-1**]
systolic murmur over mitral area with radiation to axilla. No
thrills, lifts. No S3 or S4.
Chest: Resp were slightly labored. No r/r/w. CTAB.
Abd: Soft, NTND. No HSM or tenderness.
Ext: 1+ ankle edema b/l. 1+ DP pulses b/l
Skin: + stasis changes bilateral LE. No ulcers, scars, or
xanthomas.
Pertinent Results:
Admission labs:
[**2112-11-28**] 05:00PM WBC-9.2# RBC-4.71 HGB-13.9* HCT-43.4 MCV-92
MCH-29.6 MCHC-32.2 RDW-17.4*
[**2112-11-28**] 05:00PM NEUTS-92* BANDS-2 LYMPHS-0 MONOS-6 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2112-11-28**] 05:00PM PLT SMR-LOW PLT COUNT-108*
[**2112-11-28**] 05:00PM PT-20.3* PTT-28.3 INR(PT)-1.9*
[**2112-11-28**] 05:00PM GLUCOSE-119* UREA N-85* CREAT-1.3* SODIUM-136
POTASSIUM-4.2 CHLORIDE-96 TOTAL CO2-25 ANION GAP-19
[**2112-11-28**] 05:00PM CALCIUM-8.7 PHOSPHATE-2.3* MAGNESIUM-2.3
[**2112-11-28**] 05:38PM LACTATE-2.7*
[**2112-11-28**] 05:00PM cTropnT-0.05*
[**2112-11-28**] 05:00PM proBNP-[**Numeric Identifier 26648**]*
.
Discharge labs:
[**2112-12-5**] 05:50AM BLOOD WBC-7.5 RBC-4.14* Hgb-12.5* Hct-39.3*
MCV-95 MCH-30.1 MCHC-31.7 RDW-17.6* Plt Ct-113*
[**2112-12-5**] 05:50AM BLOOD Glucose-127* UreaN-61* Creat-1.0 Na-141
K-3.9 Cl-104 HCO3-29 AnGap-12
[**2112-12-5**] 05:50AM BLOOD Calcium-8.5 Phos-2.8# Mg-2.4
.
Imaging:
RENAL U.S. PORT [**2112-11-30**]
IMPRESSION:
1. No stones or hydronephrosis.
2. Innumerable bilateral renal cysts.
3. Large right-sided pleural effusion and small amount of
intra-abdominal ascites.
.
PROSTATE U.S. [**2112-11-30**]
CONCLUSION: Prostatomegaly with particular enlargement of the
central gland. No evidence of prostatic abscess.
.
CT ABDOMEN W/O CONTRAST [**2112-12-1**]
IMPRESSION:
1. Bilateral pleural effusions, right greater than left and
cardiomegaly.
2. Multiple bilateral renal cysts, which are incompletely
evaluated on this non-contrast study. No evidence of renal or
ureteral calculi or hydronephrosis.
3. Extensive calcification of the descending aorta and its
branches.
4. Small-to-moderate amount of free fluid within the abdomen and
pelvis and generalized anasarca.
.
TTE (Complete) Done [**2112-12-1**]
The left atrium is markedly dilated. The right atrium is
markedly dilated. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. Overall
left ventricular systolic function is normal (LVEF 70%). There
is no ventricular septal defect. The right ventricular cavity is
dilated. Right ventricular systolic function appears depressed.
The ascending aorta is mildly dilated. The aortic valve leaflets
are moderately thickened. There is a small vegetation on the
aortic valve (right cusp). There is a minimally increased
gradient consistent with minimal aortic valve stenosis. Mild
(1+) aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened and somewhat shaggy in appearance suggestive of
mitral valve vegetations. There is no mitral valve prolapse. An
eccentric, posteriorly directed jet of Moderate (2+) mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral regurgitation may be significantly UNDERestimated.]
The tricuspid valve leaflets are mildly thickened. The
supporting structures of the tricuspid valve are
thickened/fibrotic. Moderate [2+] tricuspid regurgitation is
seen. There is moderate pulmonary artery systolic hypertension.
There is a small pericardial effusion.
Impression: aortic and mitral valve vegetations
Compared to the previous study of [**2112-4-5**], increased
valvular regurgitation and probable vegetatioons are seen.
.
CHEST PORT. LINE PLACEMENT [**2112-12-5**]
IMPRESSION:
1. Tip of left PICC in lower right atrium, at least 6 cm from
the cavoatrial junction. No pneumothorax.
2. Enlarged cardiac silhouette with a globular shape, suggestive
of pericardial effusion in addition to cardiomegaly.
3. Larger moderate right pleural effusion.
4. Fluid overload.
Brief Hospital Course:
A/P: 79M who p/w urosepsis [**1-29**] pan-sensitive E. Coli, found to
have aortic and mitral valve vegetations.
.
# Septic shock: Source is E. coli UTI [**1-29**] prostatomegaly. Pt
grew pan-sensitive E. coli in UCx and [**12-31**] BCxs upon admission.
Pelvic CT negative for prostatic/renal abcess. Surveillance
bcxs were neg. from [**2112-11-28**] on. Pt was initially started on
levofloxacin. However, vegetations were noted on ECHO that were
concerning for endocarditis although E. coli is not a common
microorganism associated with endocarditis. Infectious Diseases
service was consulted and recommended ceftriaxone x 4 weeks. He
will follow up with repeat ECHO after completion of antibiotics
and with Infectious Diseases.
.
# Urinary tract infection: as above.
.
# Acute on chronic diastolic congestive heart failure: BNP in
ED was [**Numeric Identifier 26648**], unchanged from last admission). Pt did receive
IVF boluses on the field and in the ED. The patient's home dose
of digoxin was continued, and he was placed on a low-salt diet.
His diuretics (torsemide) and anti-hypertensives were initially
held for hypotension. However, he had went into flash pulmonary
edema after his episode of RVR, and on the first full hospital
day he required gentle diuresis and initiation of his beta
blocker for rapid ventricular rates. His anti-hypertensive were
uptitrated slowly to torsemide 40 mg daily, metoprolol 50 mg
[**Hospital1 **], and Losartan 25 mg daily, per Dr. [**Last Name (STitle) 73**]. He was
titrated off O2 by discharge. He will follow up with the Heart
Failure Clinic.
.
# Prostatomegaly with urinary retention: A Foley catheter was
placed, and the Urology service recommended 2 weeks. He was
also started on finasteride and tamsulosin. He will follow up
with Urology.
.
# Atrial fibrillation: Pt had a brief episode of RVR, which
responded to cardizem in the field. HR was initially
well-controlled on digoxin alone, but HR increased in setting of
infection. He required re-starting of PO metoprolol, which was
titrated up as needed to metoprolol 50 mg [**Hospital1 **]. His coumadin was
adjusted per INR. He will follow up with Cardiology.
.
# Aortic and mitral valvular vegetations: The differential is
infectious vs. marantic. ID recommended 4 weeks of abx followed
by repeat TTE, which was scheduled. The patient will f/u with
ID and cardiology.
.
# CRI: Creatinine stayed at baseline.
.
# Renal Cysts: Ct noted large renal cysts; size appears
unchanged from abdominal u/s in [**2109**]. Pt will f/u with Urology
as outpatient.
.
# Elevated Alk phos: This has been trending up over the past
year. CT abdomen showed no GB pathology. US may be considered
for further workup as outpatient.
.
# HTN: He was initially hypotensive and all anti-hypertensives
were held. With recovery, he was re-started and titrated up to
torsemide 40 mg daily, metoprolol 50 mg [**Hospital1 **], and losartan 25 mg
daily. Pt will follow up with Cardiology.
.
# Hyperlipidemia: Pt was continued on home regimen of statin
and fibrate.
.
# Gout: Pt was continued on outpatient allopurinol.
.
# Thrombocytopenia: Plt count remained at baseline.
.
# Breast cancer: Pt was continued on outpatient regimen of
femara.
.
# FULL CODE
Medications on Admission:
1. Atorvastatin 10 mg PO DAILY (Daily).
2. Gemfibrozil 600 mg PO DAILY (Daily).
3. Losartan 100 mg PO DAILY (Daily).
4. Letrozole 2.5 mg daily
5. Acetaminophen 325 mg PO Q6H (every 6 hours) as needed.
6. Docusate Sodium 100 mg PO BID (2 times a day).
7. Senna 8.6 mg PO BID (2 times a day) as needed.
8. Warfarin 1 mg PO 3X/WEEK (MO,WE,FR)
9. Warfarin 2 mg PO 4X/WEEK ([**Doctor First Name **],TU,TH,SA).
10. Digoxin 125 mcg PO DAILY (Daily).
11. Metoprolol Tartrate 25 mg PO BID (2 times a day).
12. Chlordiazepoxide HCl 5 mg PO DAILY (Daily) as needed.
13. Torsemide 80 mg PO DAILY (Daily).
14. Hydrochlorothiazide 12.5 mg PO DAILY (Daily): Please
administer at the same time as the demodex.
15. K-Dur 20 mEq Tab Sust.Rel. PO once a day.
16. Allopurinol 300 mg daily
Discharge Medications:
1. Outpatient Lab Work
Please draw weekly CBC, BUN, Cr, and LFTs until course of
ceftriaxone complete.
Please fax results to ([**Telephone/Fax (1) 1353**], attention to Dr. [**First Name8 (NamePattern2) 4035**]
[**Last Name (NamePattern1) 976**].
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Letrozole 2.5 mg Tablet Sig: One (1) Tablet PO daily ().
6. Warfarin 1 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime):
Please take 1 mg every Mon/Wed/Fri and 2 mg every
Tues/Thurs/Sat/Sun.
7. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
9. Chlordiazepoxide HCl 5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily) as needed for anxiety.
10. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. 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*
12. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO once a day.
Disp:*90 Capsule, Sust. Release 24 hr(s)* Refills:*0*
13. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
14. Finasteride 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*90 Tablet(s)* Refills:*0*
15. Ceftriaxone-Dextrose (Iso-osm) 2 gram/50 mL Piggyback Sig:
Two (2) gram Intravenous Q24H (every 24 hours): To be completed
on [**2112-12-27**].
Disp:*qs until [**2112-12-27**]. gram* Refills:*0*
16. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for fever, pain.
17. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
18. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
19. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
20. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-29**] Sprays Nasal
QID (4 times a day) as needed.
21. Outpatient line care
Saline 5-10 cc sash prn
Heparin 100 units/mL 3-5 cc sash prn
22. Torsemide 20 mg Tablet Sig: Two (2) Tablet PO once a day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary:
Septic shock
Urinary tract infection
Hypoxia
Acute on chronic diastolic failure
Aortic and mitral valvular vegatations
.
Secondary:
Urinary retention
Atrial fibrillation
Chronic renal failure
Hypertension
Hyperlipidemia
Gout
Thrombocytopenia
Discharge Condition:
Stable
Discharge Instructions:
You were admitted for urinary tract infection leading to septic
shock. You were treated with antibiotics. You will need to
continue the antibiotic ceftriaxone for a total of 4 weeks (Last
day will be [**2112-12-27**]). You will need to follow up with Infectious
Diseases, and an appointment has been made for you. You will
need weekly lab tests when you are on the antibiotic
ceftriaxone; these will need to be faxed to the Infectious
[**Hospital 2228**] clinic. You will also need a follow-up echocardiogram
after completion of your antibiotics. This has been scheduled
for you as well.
.
You were thought to have a urinary tract infection because of
your enlarged prostate. The Urology service has seen you while
you were in the hospital. It was recommended that you keep the
Foley catheter in for 2 weeks and you were started on Flomax and
finasterid per Urology's recommendations. An outpatient
appointment with Urology has been made for you.
.
Please take your medications as prescribed. In addition to the
medications mentioned above, several other medications have been
changed. Due to low blood pressure while you were sick, your
hydrochlorothiazide has been discontinued. Your torsemide has
been decreased to 40 mg daily and losartan has been decreased to
25 mg daily. Please follow up with Dr. [**First Name (STitle) 437**] on when to restart
the hydrochlorothiazide and resume your regular doses of
torsemide and losartan.
.
Please resume your warfarin dosing prior to admission, which was
1 mg Mo/We/Fr and 2 mg [**Doctor First Name **]/Tu/Th/Sa. You will need close follow
up on your INR because of the new antibiotic.
.
If you develop fevers, lightheadedness, shortness of breath,
chest discomfort, weight gain or any concerning symptoms, please
call your primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] at [**Telephone/Fax (1) 24396**]
or go to the Emergency Department.
Followup Instructions:
You have a follow-up appointment with Dr. [**Last Name (STitle) 770**] of Urology on
[**2112-12-14**] at 10AM. The clinic number is [**Telephone/Fax (1) 164**].
.
You have an appointment with Dr. [**First Name (STitle) 437**] at the Heart Failure
Clinic on [**2113-12-13**] at 10:30AM. The clinic number is ([**Telephone/Fax (1) 29956**].
.
You also have an appointment with Dr. [**Last Name (STitle) 73**] on [**2112-1-5**] at
8AM. The clinic is in the process of getting you a sooner
appointment and will contact you at home if this can be done.
His clinic number is ([**Telephone/Fax (1) 12468**].
.
You also have a follow-up appointment with Dr. [**Last Name (STitle) 976**] of
Infectious Diseases on [**2113-1-10**] at 10:30 AM. His clinic number
is [**Telephone/Fax (1) 457**]. Prior to your follow-up appointment, you will
need an outpatient echocardiogram. This has been scheduled for
[**2112-12-28**] at 2PM. The clinic number is [**Telephone/Fax (1) 128**].
.
Please also follow-up with your primary care physician [**Last Name (NamePattern4) **].
[**Last Name (STitle) **] within 2-3 weeks. Since he has moved to [**Hospital1 **], you will need to call ([**Telephone/Fax (1) 92960**] to re-register
under their system before you can make a follow-up appointment.
|
[
"995.92",
"421.0",
"753.19",
"272.4",
"427.31",
"785.52",
"V58.61",
"600.01",
"287.5",
"V10.3",
"428.33",
"041.4",
"274.9",
"585.9",
"599.0",
"428.0",
"788.20",
"038.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
13083, 13141
|
6611, 9873
|
300, 306
|
13436, 13445
|
3004, 3004
|
15427, 16711
|
2392, 2409
|
10693, 13060
|
13162, 13415
|
9899, 10670
|
13469, 15404
|
3691, 6588
|
2424, 2985
|
235, 262
|
334, 2052
|
3020, 3675
|
2074, 2191
|
2207, 2376
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,008
| 163,415
|
14069
|
Discharge summary
|
report
|
Admission Date: [**2181-3-3**] Discharge Date: [**2181-3-10**]
Date of Birth: [**2118-5-6**] Sex: M
Service: Cardiothoracic Surgery
HISTORY OF PRESENT ILLNESS: The patient was initially
transferred to [**Hospital6 256**] for chest
pains. He is a 62 year old male with known coronary artery
disease status post stent placement in [**2173**] for chest pain,
positive stress test complicate by acute thrombosis, repeated
catheterization showing that the ejection fraction was
preserved. On outpatient management with medications the
patient had been painfree. Baseline exercise tolerance, he
was able to walk and bike ride with no shortness of breath,
no paroxysmal nocturnal dyspnea, no orthopnea, no lower leg
edema and presented to [**Hospital3 **] on the morning of
admission with acute onset of chest pain, 10 out of 10, while
showering, radiating to the jaw and left arm, associated with
nausea, vomiting and diaphoresis. Electrocardiogram was
without significant findings. The patient was started on a
heparin drip, Nitroglycerin, Aggrastat, Morphine for pain
which brought his pain level to 7 out of 10 and he was
transferred via [**Location (un) **] to [**Hospital6 2018**] for catheterization. In the Catheterization
Laboratory, the patient had a distal left main ruptured
plaque with 60% residual stenosis, 75% ostial left anterior
descending, 60% posterior descending artery with evident
distal embolization and an akinetic apex. The patient had no
intervention and was planned for coronary artery bypass
graft.
PAST MEDICAL HISTORY: Significant for catheterization status
post stenting, cervical spondylopathy status post surgery for
chronic pain, tonsillectomy, appendectomy,
hypercholesterolemia and hypertension.
OUTPATIENT MEDICATIONS: Oxycontin 10 mg q.h.s., Cardizem 180
mg q. day, Aspirin 81 mg q. AM, Multivitamin, Zocor 20 mg
p.o. q. day, Tylenol PM, Melatonin and Prilosec 20 mg p.o. q.
day.
FAMILY HISTORY: Mother with lung cancer, father with heart
disease, died of stroke in his 50s.
SOCIAL HISTORY: He lives with his wife, Department of
Corrections inspector, postal worker, retired. Denies
tobacco, two drinks per week and no illicit drugs. The
patient has no known drug allergies.
PHYSICAL EXAMINATION: On physical examination the patient
was afebrile, heart rate 76, blood pressure 117/78, pulmonary
pressure was 32/15 with breathing rate of 20, sating 97% on 2
liters by nasal cannula. The patient was in no acute
distress, was normocephalic, atraumatic. Pupils equal, round
and reactive to light. Neck was supple. There was on
jugulovenous distension. Heart sounds, normal S1 and S2, the
patient was on a balloon pump. Pulmonary, the patient had
equal breath sounds bilaterally with no rales, rhonchi or
crackles. Abdomen was soft, nontender, nondistended, the
patient had right groin stick with no hematoma. Extremities,
the patient's distal pulses were +1 and +2 bilaterally.
There was no edema. Neurologic, the patient was grossly
intact.
LABORATORY DATA: White count 9.1, hematocrit 40.3, platelet
count 161. Chemistries sodium 141, potassium 4.2, chloride
109, bicarbonate 24, BUN 27, creatinine 0.9 and glucose 134.
AST was 26, ALT 50, amylase 82, lipase was not done.
Alkaline phosphatase was 36, calcium 4.1. The patient's
electrocardiogram was normal sinus rhythm at 78, Q waves in
leads 3 and AVF. Chest x-ray showed a low lung volumes,
balloon pump and PA catheter.
HOSPITAL COURSE: This is a 62 year old man with known
coronary artery disease, preserved ejection fraction with
known four vessel disease on cardiac catheterization. The
patient was seen by Cardiothoracic Surgery and planned for
coronary artery bypass graft. On hospital day #2, the
patient was seen by Dr. [**Last Name (STitle) 70**]. The patient had no events
over night. The patient continued on the intra-aortic
balloon pump. The patient was made NPO for surgery on
hospital day #3. On [**2181-3-5**], the patient was brought
to the Operating Room for a coronary artery bypass graft
times three with intra-aortic balloon pump preoperatively.
The patient had a left internal mammary artery to left
anterior descending, saphenous vein graft to ramus and
saphenous vein graft to posterior descending artery. The
patient tolerated the procedure well, was transferred to the
Cardiac Surgery Recovery Unit on Levophed and a Propofol
drip. The patient was intubated. On postoperative day #1,
the patient was continued on intra-aortic balloon pump at a
ratio of 1 to 2. The patient on Nitroglycerin drip, Insulin
drip, and the patient was weaned and extubated. The patient
was on a shovel mask with good arterial blood gases. The
patient was sating 96% on a shovel facemask. The patient was
afebrile with a temperature maximum of 100.6, heart rate 117
and sinus tachycardiac. The patient had laboratory values
which were within normal limits. Plan for postoperative day
#1, the patient's balloon pump was discontinued. The patient
was started on Lasix. Swan was removed and the patient was
started on intravenous Lopressor. On postoperative day #2,
the patient was weaned from his drips and started on
Lopressor 50 b.i.d. The patient received intravenous
Lopressor times two over night. The patient was taken off of
the shovel mask and was started on nasal cannula and was
sating 92% on nasal cannula. The patient was out of bed on
postoperative day #2. On postoperative day #3, the patient
was tolerating a soft diet. The patient was on Lopressor,
was transferred. The patient had chest tube and wires
discontinued prior to transfer.
The patient was transferred to the floor without any
problems. The was seen by physical therapy who had him out
of bed on postoperative day #3. The patient had brief bursts
of sinus tachycardiac to 130s. The patient was on Aspirin,
Lasix and Metoprolol. The patient was afebrile with at
temperature maximum of 99.7. The patient was out of bed with
physical therapy. The patient's Metoprolol was increased to
100 b.i.d. The patient's laboratory values were all within
normal limits. The patient continued to work with physical
therapy. On postoperative day #4, the patient had some
complaints of oral irritation. On examination, the patient
had some white plaques in mouth felt to be consistent with
possible thrush. The patient was started on Fluconazole and
Nystatin Swish and Swallow. The patient had good affects
with those. The patient was afebrile to temperature maximum
of 99.7. The patient was weaned off of his oxygen and was on
room air, sating 97%. The patient was ambulating with
physical therapy and was doing well. The patient continued
with physical therapy. His Lasix was decreased from 20
b.i.d. to 20 q. day. The patient was prepared for discharge
on postoperative day #5.
On postoperative day #5, the patient was afebrile over night.
Vital signs were stable. The patient was discharged to home
in stable condition, tolerating a regular diet and ambulating
on his own.
DISCHARGE MEDICATIONS:
1. Metoprolol 100 mg tablet p.o. b.i.d.
2. Aspirin 325 mg tablet, one tablet p.o. q. day.
3. Colace 100 mg tablet, one tablet p.o. b.i.d.
4. Lipitor 10 mg tablet, two tablets p.o. q. day.
5. Fluconazole 100 mg tablet, one tablet p.o. q. 24 hours
times ten days.
6. Dilaudid 2 mg tablet, one to two tablets p.o. q. 4 hours
as needed for pain.
7. Lasix 20 mg tablet, one tablet p.o. q. day for ten days.
8. Potassium chloride 10 mEq, 2 tablets p.o. q. day for ten
days.
FOLLOW UP: The patient will follow up with Dr. [**Last Name (STitle) 41964**] in one
to two weeks. The patient will call for an appointment. The
patient will follow up with Dr. [**Last Name (STitle) 70**] in six weeks. The
patient will call for an appointment. The patient has a
visiting nurse [**First Name (Titles) **] [**Last Name (Titles) 19677**] monitoring and wound
evaluation.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 10638**]
MEDQUIST36
D: [**2181-3-10**] 09:47
T: [**2181-3-10**] 10:01
JOB#: [**Job Number 41965**]
|
[
"112.0",
"272.0",
"410.11",
"414.01",
"V45.82",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.23",
"39.61",
"37.61",
"36.12",
"88.53",
"88.56",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
1963, 2043
|
7049, 7526
|
3480, 7026
|
7538, 8221
|
1783, 1946
|
2270, 3462
|
182, 1551
|
1574, 1758
|
2060, 2247
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,667
| 129,337
|
17337+56840+56841
|
Discharge summary
|
report+addendum+addendum
|
Admission Date: [**2114-8-2**] Discharge Date: [**2114-8-8**]
Date of Birth: [**2052-6-26**] Sex: F
Service: MICU
CHIEF COMPLAINT: Hypercarbic respiratory failure.
HISTORY OF PRESENT ILLNESS: This is a 63-year-old female
with a history of restrictive lung disease of unclear
etiology and [**Doctor Last Name 48516**] syndrome status post Whipple
in [**2113-1-7**]. She presents in hypercarbic respiratory
failure status post recent admission to the medical intensive
care unit in early [**2114-7-8**] following a syncopal episode and
similar hypercarbic respiratory failure. On that admission,
arterial blood gas in the Emergency Department showed a pH of
7.14 and a PCO2 of 123. The patient was admitted to the
Neonatal Intensive Care Unit for further treatment. She was
briefly treated with noninvasive mask ventilation and her
ventilator status improved such that she was off noninvasive
mask ventilation within 24 hours. On that admission she was
noted to chronically hypoventilate. Chest x-ray at the time
showed left lower lobe atelectasis. Pulmonary function tests
done in early [**Month (only) **] showed a restrictive pattern with an FEV1
of 45% of predicted, an FVC of 34% of predicted with a ratio
of 133% of predicted. Additionally a TLC was 53% of
predicted, FRC was 70% of predicted, RV was 81% of predicted.
The RV to TLC ratio was 153% of predicted. DSB (VA) was 46%
of predicted consistent with moderate reduction of diffusion
capacity suggesting the possibility of interstitial disease,
in addition to the likely neuromuscular disease that was
suggested by her lung volumes. Electromyogram was performed
to assess for neurologic causes and showed no evidence for
disorder of neuromuscular transmission, though there was some
paraspinal denervation present acutely. Additionally, an MRI
of the brain showed no lesions that might cause central
apnea.
Over the course of that hospitalization the acidosis resolved
without specific intervention and on discharge her blood
gases showed a pH of 7.4 and PCO2 of 71. She was discharged
home on [**2114-7-14**].
The patient had been doing well at home although she had
complained of some fatigue over the last three weeks.
According to her sons she had two very active days just prior
to the day of admission. At 7 AM on the day of admission her
sons left the house to go to work and reported that their
mother was awake although still in bed. They returned home
at approximately 9 PM and found their mother still in her
pajamas, face down in the bed with decreased respirations.
They performed rescue breathing and the patient was brought
to the [**Hospital1 69**] Emergency
Department by EMS. On arrival her blood gas showed a pH of
7.09, PCO2 of 119, PO2 of 198 and a bicarbonate of 38 with
lactate of 7.4 and she was initiated on BiPAP and transferred
to the medical intensive care unit for further management.
For past medical history, allergies, medications, social
history and family history, please refer to the admission
note from [**2114-8-2**].
PHYSICAL EXAMINATION: The patient was resting on BiPAP and
did arouse to voice. Vital signs were blood pressure 84/38,
heart rate 108, respiratory rate 14, saturating 100% on BiPAP
with pressure support of 12 and 10. A repeat blood gas on
those settings showed improvement to 7.20, 91, 160 and 40.
Skin was warm and dry. HEENT examination was normocephalic,
atraumatic, sclerae anicteric. Neck was supple with no
lymphadenopathy and a jugular venous pressure of
approximately 8 cm. Lungs had poor inspiratory effort with a
few scattered inspiratory squeaks. Cardiovascularly she was
tachycardic, S1 and S2, no murmur. Abdomen was soft and
nontender. Extremities had no edema although cool hands and
feet. On neurological examination the patient nodded to
simple questions but was poorly attentive though did follow
some simple commands. Deep tendon reflexes were 3+/4 in the
bilateral upper extremities.
LABORATORY DATA: For complete admission laboratory studies
please refer to the admission note from [**2114-8-2**]. Briefly,
pertinent laboratory studies included a chest x-ray that
showed low lung volumes but no infiltrates. Electrolytes
were sodium 131, potassium 6.4, chloride 84, bicarbonate 28,
BUN 36, creatinine 1.2, glucose 352, with an anion gap of 19.
White blood cell count was 11.8. Hemoglobin 12.2, hematocrit
41.1, platelet count 296.
HOSPITAL COURSE: 1. Respiratory failure: After admission
the patient was placed on noninvasive mask ventilation and
overnight her pH normalized. Her PCO2 improved. She also
received 4?????? liters of normal saline with improvement of her
blood pressure. Currently the patient is doing well on 1??????
liters nasal cannula oxygen when she is awake and BiPAP with
pressure support of 15 and 5, FIO2 of 0.3 when she is
sleeping. Please note that the patient must be on BiPAP when
she is sleeping otherwise she hypoventilates and goes into
respiratory acidosis. Her most recent blood gas showed a pH
of 7.4 and a PCO2 of 70. The etiology of her lung disease
remains unclear at this point. High-resolution chest CT
showed bilateral pleural effusions, small to moderate in
size, right greater than left, with some nodular plaques
along the pleura near the effusion. However there was no
evidence of interstitial lung disease. Right now it is
thought that the most likely etiology of her respiratory
failure is secondary to a neuromuscular process. EMGs on the
last admission showed that it was not likely that there was a
problem with her synaptic transmission, thus putting
myasthenia [**Last Name (un) 2902**] and Lambert-Eaton syndrome as the
etiological causes low on the list. Currently, neurology
believes that it is likely that the patient has a myopathy
and a muscle biopsy is planned. Neurosurgery is aware of the
patient and two residents have been [**Name (NI) 653**], Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **], pager #39-510, and Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**First Name3 (LF) **]
#90-206. They will be speaking with Dr. [**Last Name (STitle) 1132**], the
neurosurgery attending today to see if they can arrange for a
muscle biopsy this week for this patient. We have spoken
with the neuropathologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 122**], who has
informed us that for technical reasons it is extremely
important that the pathologist be present in the operating
room when the muscle biopsy is taken in order for the muscle
to be properly preserved. So once an OR day and time is set,
they need to be [**Last Name (NamePattern1) 653**] so that they can be present.
Neurology has said that based on the results of her EMGs and
on the fact that she has muscle weakness proximal greater
than distal, the right deltoid is the best site for biopsy
and neurosurgery has been so informed.
Additionally, the neurology and neuromuscular consultation
services have requested that antibodies to [**Doctor First Name **]-1, musk, and
voltage-gated calcium channels be tested for, so we have sent
those laboratory studies out. If the muscle biopsy is
negative, neurology will consider repeating EMGs with nerve
conduction studies and possibly an MRI of the spine as well.
They will also consider doing a Tensilon test at that time.
Finally, a diaphragmatic excursion test at the bedside was
performed on [**2114-8-3**] and was grossly normal.
2. Bacteremia: On the night of [**8-4**] to [**8-5**] the patient
spiked a fever to 103 and cultures drawn at that time showed
E. coli present in [**6-11**] bottles. The patient was initially
started on empiric therapy of ceftriaxone, Flagyl, and
levofloxacin. Sensitivities of E. coli showed that it was in
fact sensitive to levofloxacin so that has been continued for
a total of a 10-day course and the ceftriaxone and Flagyl
have been discontinued. Since then the patient has been
afebrile for 72 hours now. Cultures drawn on [**2114-8-6**] and
[**2114-8-7**] have shown no growth to date. The source of the E.
coli is presently unclear. Urine cultures and urinalysis
were negative for urinary tract infection. Abdominal CT was
negative for an intrahepatic abscess. There had been concern
for this because the patient has intermittently increased her
liver function tests. The pleural effusion on the patient's
right side was tapped on [**2114-8-5**] and the results were
consistent with an exudate. Currently, cultures are pending.
The Gram stain showed PMNs but no bacteria. Cytology on the
pleural fluid is also pending.
3. Increased liver function tests: On admission the patient
had increased liver function tests that were at the time
thought to be secondary to her respiratory failure and poor
oxygenation status on admission. They initially were
trending down but bumped up on [**2114-8-5**]. They are again
trending down. Ultrasound and hepatitis serologies were all
negative. Ultrasound and abdominal CT showed no evidence of
biliary disease although ultrasound can miss the majority of
retained stones. If she bumps her liver function tests
again, we will obtain a magnetic resonance
cholangiopancreatography.
4. Anemia: Over the course of the hospitalization as we have
fluid resuscitated the patient, her blood counts have been
trending down, currently with a hemoglobin of 7.8 and an
hematocrit of 26.7. Studies revealed an iron of 18, ferritin
of 46, and a calculated TIBC of 230 consistent with iron
deficiency anemia and we have started the patient on iron.
5. Zollinger-[**Doctor Last Name 9480**] syndrome: The patient is status post
Whipple antrectomy and vagotomy in [**2113-1-7**]. Despite
that procedure the patient has continued to have high gastrin
levels and we have maintained her on Protonix 40 mg p.o.
t.i.d.
6. Diabetes mellitus: The patient was noted on her last
admission to have high sugars and we have continued her on a
sliding scale. She will likely need to be started on an oral
hypoglycemic [**Doctor Last Name 360**].
7. Access: The patient had a left subclavian line placed on
[**2114-8-5**].
8. Code status: The patient is full code.
CONDITION ON DISCHARGE: The patient's respiratory status has
improved greatly since admission, although we still do not
have an etiology for this problem. Currently she is stable
enough to go to the floor, though she needs to remain
hospitalized until a diagnostic work-up has been completed
and home health has been arranged for her to get training on
the BiPAP machine.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7585**]
Dictated By:[**Last Name (NamePattern1) 8978**]
MEDQUIST36
D: [**2114-8-8**] 11:49
T: [**2114-8-8**] 12:06
JOB#: [**Job Number 48517**]
Name: [**Known lastname 8948**], [**Known firstname 300**] Unit No: [**Numeric Identifier 8949**]
Admission Date: [**2114-8-2**] Discharge Date: [**2114-8-14**]
Date of Birth: [**2052-6-26**] Sex: F
Service:
CONTINUATION OF HOSPITAL COURSE:
1. Respiratory failure: Patient's deltoid biopsy revealed
rare degenerating-regenerating myofibrils, increased
internalized nuclei and scattered nuclear knot, but there was
no significant inflammation or vacuolization. Patient was
followed closely for Neurology throughout her admission and
had a full spinal MRI as well to rule out spondylosis. There
were degenerative changes of the spine, but no impressive
changes of cervical spondylosis on the MRI.
Neurology also performed a tensilon test at bedside with
patient which was unrevealing. A second EMG was set-up for
the day of discharge on [**8-14**] in Neurology on [**Hospital Ward Name 600**].
The patient continued to do well, and was discharged with
home BiPAP and oxygen with pulse oximetry.
2. Bacteremia: Patient's surveillance cultures remained
negative. She was continued on her po Levaquin dose
throughout her admission and was sent home to complete a 14
total day course. She remained afebrile without elevation in
her white count.
3. Elevated LFTs: Patient's transaminases continued to trend
down except for her alkaline phosphatase, which remained
elevated throughout admission. Ultrasound while in Intensive
Care was unrevealing for common bile duct dilatation or
gallstones. This will be followed up as an outpatient. The
patient never complained about abdominal pain.
4. Anemia: Patient's anemia remained stable. The etiology
of this is unclear. She will need a colonoscopy upon
outpatient.
5. Zollinger-[**Doctor Last Name 6764**] syndrome: The patient experienced
several episodes of diarrhea while in-house. She was
continued on her regimen of Viokase four tablets tid with
meals and Protonix 40 mg tid as well as Reglan 10 mg [**Hospital1 **].
This was her home regimen and worked well for the patient.
6. Diabetes mellitus: The patient was on sliding scale
throughout admission and maintained sugars from the 100's to
low 200's. It was thought that patient would need insulin
upon discharge, so she was given a trial of metformin 500 mg
[**Hospital1 **] which was increased during admission to 850 mg [**Hospital1 **] to
control her sugars. Patient was given diabetes teaching in
order to check her own fingersticks at home qid. She was
discharged on metformin.
Patient continued to do well throughout her admission, and
was discharged to home with her sons with several follow-up
appointments including pulmonary sleep studies, Neurology
EMG, and Neurosurgery, as well as following up with me, her
new primary care physician in the [**Name9 (PRE) 112**] Clinic. The patient
will be followed closely by all of these departments because
the etiology of her respiratory status remains unclear. It
is thought that this is very likely neuromuscular, however, a
specific diagnosis has not been made. The patient was setup
with VNA home services, as well as her home BiPAP, and
diabetes education, and she was discharged in stable
condition.
DISCHARGE DIAGNOSES:
1. Hypercapnia respiratory failure of unclear etiology.
2. Resolved E. coli bacteremia.
3. Transaminitis resolved.
4. Anemia.
5. Zollinger-[**Doctor Last Name 6764**] syndrome.
6. Diabetes mellitus.
DISCHARGE MEDICATIONS:
1. Metformin 850 mg [**Hospital1 **].
2. Protonix 40 mg tid.
3. Viokase four tablets with meals tid.
4. Reglan 10 mg [**Hospital1 **].
5. Levaquin 500 mg po q day for 14 days.
6. Home O2 and BiPAP.
FOLLOW-UP PLANS: She was discharged by ambulance straight to
[**Hospital Ward Name 600**] for her Neurology appointment in the [**Hospital 8950**] Clinic.
On [**8-20**], she has an appointment with Dr. [**Last Name (STitle) **] [**Name (STitle) **] in
the Sleep Unit at 1 pm. On [**9-4**], she has an appointment
with Neurology, Dr. [**Doctor Last Name 8951**] at 8:30, and she will see
me, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at 2:30 on [**9-4**] at the [**Hospital 112**]
Clinic. She will see Neurosurgery, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 24**] at 1 pm on
[**9-14**].
[**First Name11 (Name Pattern1) 520**] [**Last Name (NamePattern4) 521**], M.D. [**MD Number(1) 522**]
Dictated By:[**Last Name (NamePattern1) 1791**]
MEDQUIST36
D: [**2114-8-15**] 19:58
T: [**2114-8-16**] 05:23
JOB#: [**Job Number 8952**]
Name: [**Known lastname 8948**], [**Known firstname 300**] Unit No: [**Numeric Identifier 8949**]
Admission Date: [**2114-8-2**] Discharge Date: [**2114-8-14**]
Date of Birth: [**2052-6-26**] Sex: F
Service: MEDICINE-[**Hospital1 248**]
This is and addendum to the discharge summary per Dr.
[**Name (NI) 781**] on [**2114-8-8**].
HISTORY OF PRESENT ILLNESS: Patient is a 63-year-old lady
with Zollinger-[**Doctor Last Name 6764**] syndrome and history of hypercapnia
with respiratory failure, who is transferred out of the
Intensive Care Unit on [**2114-8-8**].
Physical examination upon arrival to the floor: Temperature
was 98.9, blood pressure 127/56, pulse 80, respirations 19.
Patient was sating 98% on 2 liters. Fingerstick was 156.
Generally, the patient was sitting in chair, comfortable with
nasal cannula. HEENT: Pupils are equal, round, and reactive
to light and accommodation. Extraocular movements are
intact. Mucous membranes were moist. Nasal cannula was in
place. Oropharynx clear, no erythema. Neck: No cervical
nodes, no jugular venous distention, no thyromegaly, supple.
Chest: Bilaterally clear to auscultation in apices.
Decreased breath sounds at bilateral bases with dullness to
percussion at bases bilaterally, no wheezing or crackles.
Cardiovascular: Regular, rate, and rhythm. Abdomen is soft,
nontender, nondistended, no masses. Extremities:
Bilaterally upper extremity edema, nonpitting, bilateral
lower extremity mild nonpitting edema, 2+ pulses, diminished
patellar reflexes bilaterally. Neurologic: Cranial nerves
II through XII intact bilaterally. Strength is [**5-12**] grossly
in bilateral lower extremities, alert and oriented times
three. Patient is a good historian.
LABORATORIES UPON TRANSFER TO FLOOR: White blood cells 8.2,
hematocrit 26.7, platelets 158. Sodium 135, potassium 3.6,
chloride 96, bicarbonate 40, BUN 7, creatinine 0.3, glucose
179, calcium 8.2, magnesium 1.8, phosphorus 2.3, ALT 192, AST
53, alkaline phosphatase 267.
CONTINUED HOSPITAL COURSE FROM INTENSIVE CARE UNIT ADMISSION:
1. Respiratory failure: Patient was stable on [**2-8**] liters
throughout entire admission. She received BiPAP therapy each
night to prevent her apneic episodes. Respiratory therapy
visited patient each night to ensure adequate oxygenation.
The patient did not have any episodes of oxygen desaturation
throughout her admission, and was off of her nasal cannula
throughout the day and her last three days of admission. To
followup with the neuromuscular workup, a deltoid biopsy was
performed on [**8-9**] without complications.
[**First Name11 (Name Pattern1) 520**] [**Last Name (NamePattern4) 521**], M.D. [**MD Number(1) 522**]
Dictated By:[**Last Name (NamePattern1) 1791**]
MEDQUIST36
D: [**2114-8-15**] 19:40
T: [**2114-8-16**] 05:13
JOB#: [**Job Number 8953**]
|
[
"724.4",
"041.4",
"271.0",
"V45.3",
"790.7",
"251.5",
"511.9",
"358.9",
"518.84"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"83.21",
"93.90",
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
14080, 14280
|
14303, 14502
|
11116, 14059
|
3081, 4427
|
14520, 15794
|
153, 187
|
15823, 18336
|
10227, 11099
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,996
| 104,941
|
8254+55925
|
Discharge summary
|
report+addendum
|
Admission Date: [**2129-1-21**] Discharge Date: [**2129-1-24**]
Date of Birth: [**2061-12-10**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 67 year old man
with a history of coronary artery disease, peripheral
vascular disease, status post bilateral above the knee
amputation, chronic renal insufficiency, diabetes mellitus,
abdominal aortic aneurysm, who presented with a two day
history of cough, and one day of nausea and vomiting without
producing any sputum. The patient also noted feeling hot and
experiencing diaphoresis. He awoke on the day of admission
and ate a normal breakfast and felt nauseated and vomited
once. He was [**Doctor Last Name 352**], he denied hematemesis, hemoptysis,
diarrhea, bright red blood per rectum, melena or abdominal
pain or dysuria.
The patient called his primary care physician and was
referred to an outside hospital where he was evaluated and
found to have increased creatinine to 2.1, baseline in the
high 1.0 range, and a potassium of 6.2. He also had
increased amylase and lipase of 188 and 368. His CPK was 88
and troponin I was 0.9. At the outside hospital, he
subsequently became hypotensive into the 70s systolic and
tachycardic into the 120s. He was placed on Dopamine and
transported to [**Hospital1 69**] for
further management. Symptoms were felt to be secondary to
pancreatitis with acute on chronic renal failure and
hyperkalemia. Chest x-ray was clear and electrocardiogram
was without changes.
PAST MEDICAL HISTORY:
1. Coronary artery disease with a myocardial infarction in
[**2104**], coronary artery bypass graft in [**2112**], most recent
ejection fraction was 15 to 20%.
2. History of Guillain-[**Location (un) **] disease.
3. History of peripheral vascular disease, status post
bilateral above the knee amputation.
4. Ischemic bowel in [**2121**].
5. Ischemic colitis [**10/2128**].
6. Chronic renal insufficiency with creatinine 1.9 to 2.4.
7. Diabetes mellitus, type II.
8. Abdominal aortic aneurysm with a right iliac aneurysm.
ALLERGIES: The patient has no known drug allergies.
ADMISSION MEDICATIONS:
1. Lopressor 50 milligrams once a day.
2. Zestril 10 milligrams once a day.
3. Lasix 20 milligrams once a day.
4. Aldactone 25 milligrams once a day.
5. Protonics 40 milligrams once a day.
6. Enteric Coated Aspirin 325 milligrams once a day.
7. Lipitor 40 milligrams once a day.
8. Iron 325 milligrams once a day.
9. Digoxin 250 once a day.
10. Allopurinol 300 milligrams once a day.
TRANSFER MEDICATIONS:
1. Subcutaneous Heparin.
2. Enteric Coated Aspirin 325 milligrams once a day.
3. Allopurinol 300 milligrams once a day.
4. Lipitor 40 milligrams once a day.
5. Digoxin 0.25 milligrams once a day.
6. Colace 100 milligrams twice a day.
7. Prilosec 20 milligrams once a day.
LABORATORY DATA: On admission to [**Hospital1 190**] were troponin 0.9, CK 88. Chem7 revealed
sodium 133, potassium 6.2, chloride 96, bicarbonate 25, blood
urea nitrogen 56, creatinine 2.9. White count 7.4,
hematocrit 43.0, amylase 188, lipase 368, total bilirubin
0.6, ALT 15, AST 19, alkaline phosphatase 132. INR was 1.1,.
Chest x-ray was without infiltrate or congestive heart
failure. KUB showed no ileus and no free air.
HOSPITAL COURSE: In the Medical Intensive Care Unit, the
patient's hypotension responded well to boluses of
intravenous fluid. The following day he was ready for
transfer to the floor. The patient did well on the floor
tolerating a regular diet by his second day on the floor.
He had an abdominal CT scan to rule out pancreatic phlegmon
and had no abdominal tenderness. His lipase and amylase
trended steadily downward. In addition, his blood urea
nitrogen and creatinine returned toward their baseline values
with a creatinine on the day of discharge being 2.1.
The patient was discharged in stable condition. He will
follow-up with Doctor [**Doctor Last Name 11679**] one week after discharge.
DISCHARGE MEDICATIONS:
1. Lopressor 50 milligrams once a day.
2. Zestril 10 milligrams once a day.
3. Lasix 20 milligrams once a day.
4. Aldactone 25 milligrams once a day.
5. Protonics 40 milligrams once a day.
6. Enteric Coated Aspirin 325 milligrams once a day.
7. Lipitor 40 milligrams once a day.
8. Iron 325 milligrams once a day.
9. Digoxin 250 once a day.
10. Allopurinol 300 milligrams once a day.
DISCHARGE DIAGNOSES:
1. Pancreatitis.
2. Hypotension.
3. Chronic renal insufficiency.
4. Acute renal failure.
5. Diabetes mellitus.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 21980**]
Dictated By:[**Name8 (MD) 19393**]
MEDQUIST36
D: [**2129-1-24**] 15:05
T: [**2129-1-24**] 19:33
JOB#: [**Job Number 29294**]
Name: [**Known lastname 5124**], [**Known firstname **] Unit No: [**Numeric Identifier 5125**]
Admission Date: [**2129-1-21**] Discharge Date: [**2129-1-24**]
Date of Birth: [**2061-12-10**] Sex: M
Service:
ADDENDUM: The patient was found to have an E coli urinary
tract infection. He is being sent out on five days of oral
ciprofloxacin 250 mg [**Hospital1 **]. Also his dose of Lopressor is
being decreased to 12.5 mg [**Hospital1 **]. He will have follow up this
week with Dr. [**Last Name (STitle) 5126**].
[**Name6 (MD) **] [**Name8 (MD) **], MD [**MD Number(1) 285**]
Dictated By:[**Name8 (MD) 5127**]
MEDQUIST36
D: [**2129-1-24**] 15:30
T: [**2129-1-25**] 08:20
JOB#: [**Job Number 5128**]
|
[
"599.0",
"585",
"428.0",
"276.7",
"041.4",
"414.01",
"584.9",
"577.0",
"276.5"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
4407, 5533
|
3992, 4386
|
3284, 3969
|
2137, 2531
|
2553, 3266
|
157, 1496
|
1518, 2114
|
Subsets and Splits
No community queries yet
The top public SQL queries from the community will appear here once available.