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|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
667
| 119,154
|
28321
|
Discharge summary
|
report
|
Admission Date: [**2123-8-25**] Discharge Date: [**2123-9-8**]
Date of Birth: [**2053-9-17**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Transferred from [**Hospital6 2561**] with with tracheal
stenosis following previous admission with intubation for
unclear DKA and coma.
Major Surgical or Invasive Procedure:
Rigid bronchoscopy for tracheal dilation
History of Present Illness:
69 year old woman with Type II DM was admitted to [**Hospital1 1012**] [**Hospital 9095**]
Hospital [**2123-6-28**] for DKA and coma c/b respiratory failure. She
was intubated x8 days, deintubated, and reintubated x3 days.
Post intubation experienced dysphonia and dysphagia. Transferred
to rehab [**7-14**] to [**8-4**]. At home she started to experience
increased bowel sounds and LE edema. She also experienced cough
and stridor. These symptoms ultimately resulted in an admission
to [**Hospital 8**] Hospital ([**8-24**]) and transfer to [**Hospital3 **]
([**8-25**]). There she had flexible bronchoscopy and CT scan,
revealing significant stricture to 50% about 3-4 cm distal to
vocal cords. She was finally transferred to [**Hospital1 18**] ([**8-25**]) for
further evaluation and management.
Past Medical History:
1) Type II DM
2) Anemia
3) Claustrophobia and anxiety
4) Pneumonitis
5) Ovarian cyst
6) Appendectomy in the remote past
Social History:
Patient lived alone in [**Location (un) 9095**]. She suffers an unclear
"short-term memory loss." Since her admission to [**Location (un) 68753**]hospital and discharge from rehab, she has lived with her son in
[**Name (NI) 8**]. He has taken responsibility for her medical
management but has had to miss work to do so. He is now feeling
the strain of this responsibility and understands that his
mother may need [**Hospital 4820**] nursing care.
History is unclear for use of alcohol, tobacco, and illicits.
Family History:
Unclear.
Physical Exam:
On admission to TSICU [**8-25**]
HEENT: PERRLA. Oral dry/pink. Neck no JVD or bruits. Thyroid
enlargement noted. Stridor noted.
CV: RRR. S1 S2. Tachy.
Pulm: Audible wheezing without stethoscope. Decreased breath
sounds with expiratory wheezes.
GI: Positive BS. Abd soft, nontender.
GU: cloudy urine via foley.
Extrem: No edema or clubbing. Paplable pulses.
Neuro: Oriented to year, season, and month. Looks at calendar to
determine day. Knows herself, her son, her BD, is poor
historian. Not sure which hospital she is in but does know she
is in hospital. Moves all limbs purposefully and to command.
Articulates needs and wishes. Wants all shades and doors open
due to claustrophobia.
Pertinent Results:
LAB DATA:
CBC:
[**2123-8-25**] BLOOD WBC-17.2* RBC-3.51* Hgb-9.4* Hct-29.4* MCV-84
MCH- 26.9* MCHC-32.1 RDW-18.2* Plt Ct-549*
COAGS
[**2123-8-25**] PT-12.4 PTT-21.6* INR(PT)-1.1
[**2123-8-25**] Plt Ct-549*
HEMOLYTIC
[**2123-8-29**] Ret Aut-1.6
CHEMISTRY
[**2123-8-25**] Glucose-212* UreaN-12 Creat-0.5 Na-145 K-3.8 Cl-105
HCO3- 28 AnGap-16
[**2123-8-25**] Calcium-9.0 Phos-3.6 Mg-1.8
URINE
[**9-4**] Blood-NEG Nitrate-NEG Protein-NEG Glucose-1000
Ketone- NEG Bilirubin-NEG Urobiln-NEG pH-6.5 Leuk-NEG
OTHER
[**2123-9-5**] TSH 3.7
RAPID PLASMA REAGIN TEST (Final [**2123-9-6**]): NONREACTIVE.
Reference Range: Non-Reactive.
EKG [**8-26**]
Normal sinus rhythm. Left atrial abnormality. RSR' pattern in
leads V1-V2 with T wave inversions in leads V1-V2 suggest
possible anteroseptal ischemia. Clinical correlation is
suggested. No previous tracing available for comparison
CT TRACHEA [**8-26**]
1. High-grade (more than 90%), focal proximal tracheal stenosis,
4 cm below the vocal cords, extending less than 1 cm in
cranicaudad length. These findings are most consistent with
post-intubation benign tracheal stenosis given history of prior
intubation.
2. Mucous plugging involving the right bronchus intermedius and
right lower lobe bronchus.
3. Small noncalcified lung nodule in the right middle lobe
measuring 6 mm. Followup CT in 3 months is recommended to assure
stability.
4. Evidence of prior granulomatous disease.
CXR [**8-26**]
Single AP view of the chest is obtained [**2123-8-26**] and is compared
with the prior radiograph performed [**2123-8-25**]. No pneumothorax is
visualized. Left basilar subsegmental atelectasis. Small small
granuloma in the left upper lobe. Otherwise no change since the
prior examination.
Brief Hospital Course:
1. Hyperglycemia.
Patient was admitted taking metformin/glipizide and getting
lantus (30 units) QHS. At [**Hospital3 **] she was on an insulin
drip for blood glucose levels in the 300s, which subsequently
fell to the 50s. In the [**Hospital1 18**] TSICU glucose levels ranged
100-270 on insulin drip.
[**Last Name (un) **] consult note [**8-27**] assessed insulin resistance and
recommended discharge on patient's regimen of metformin and
amaryl. But due to refractory glucose levels (raning 166-343) on
the floor, she was started on an HISS 70/30 [**Hospital1 **] with daily
titration for serum glucose. [**Last Name (un) **] note [**8-31**] suggested this was
a reasonable starting point for improving glycemic control. She
was maintained on a diabetic diet.
At time of discharge, the patient was taking 70/30 insulin [**Hospital1 **];
plan was for administration by her son or self-admnistration
under the direct supervision of her son.
2. Tracheal stenosis.
Patient underwent bronchoscopy [**2123-8-27**]. Report found post
intubation tracheal stenosis, status post electrocautery knife
and balloon dilatation and mitomycin C application with final
internal diameter of 15 mm. Following the procedure Sa02 was 95%
on 5L NC. Thoracic surgery progress note indicated lungs CTAB.
Sa02 [**8-28**] was 96% RA and remained normal through the rest of her
hospital course.
Plan was for follow-up with interventional pulmonology in [**3-4**]
weeks.
3. Anemia.
Patient had microcytic anemia with low iron and normal TIBC. Hct
on adsmission was 29.4. This is suggestive of iron deficiency
anemia but warrants outpatient follow-up with colonoscopy.
Medications on Admission:
(as per [**8-25**] [**Hospital3 **] discharge summary).
1) Lipitor which she says she has not been taking recently,
2) ? of Glucophage
3) ? of Metoprolol
4) ? of Vitamin E
5) Aspirin
6) Lasix
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. CT chest
Small noncalcified lung nodule in the right middle lobe
measuring 6 mm.
Followup CT in 3 months is recommended to assure stability
3. Diltiazem HCl 120 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO DAILY (Daily).
Disp:*30 Capsule, Sust. Release 24HR(s)* Refills:*2*
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*2*
5. Lansoprazole 30 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*
6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
8. Cyanocobalamin 1,000 mcg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
9. Insulin NPH-Regular Human Rec 100 unit/mL (70-30) Suspension
Sig: Fifty Five (55) units Subcutaneous once a day: just before
eating breakfast.
Disp:*QS units* Refills:*2*
10. Insulin NPH-Regular Human Rec 100 unit/mL (70-30) Suspension
Sig: Fifty (50) units Subcutaneous once a day: just before
eating dinner.
Disp:*QS units* Refills:*2*
11. Lancets Misc Sig: One (1) Miscell. three times a day.
Disp:*1 box* Refills:*2*
12. Glucometer Dex Test Sensors Strip Sig: One (1) Miscell.
three times a day.
Disp:*1 box* Refills:*2*
13. Syringe Syringe Sig: One (1) Miscell. twice a day.
Disp:*1 box* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Diabetes Mellitus type 2
anxiety
pneumonitis
ovarian cyst
appendectomy
Tracheal stricture
Discharge Condition:
Good; improved
Discharge Instructions:
Call Interventional Pulmonary [**Telephone/Fax (1) 3020**] for: fever, shortness
of breath, chest pain, coughing up blood.
Take insulin twice per day under supervision of family member.
Please be sure to eat immediately after taking insulin, as your
blood sugar can get too low.
It will be very important that you take all your medications as
prescribed - this is including your insulin. In addition,
please be sure to call and make an appointment to see your PCP
[**Name Initial (PRE) 176**] 1-2 weeks.
You need to be worked-up for your anemia deficiency anemia.
Please be sure you have a colonoscopy done through your PCP.
Followup Instructions:
1. Call Interventional Pulmonary [**Telephone/Fax (1) 3020**] for an appointment
in 4 weeks for bronchoscopy procedure and re-evaluation
consultation.
2. Call to make a follow-up appointment with your PCP [**Name Initial (PRE) 176**] 1
week.
3. Small noncalcified lung nodule in the right middle lobe
measuring 6 mm. Followup CT in 3 months is recommended to assure
stability.
4. You are anemic with possible iron deficiency. You should
speak with your primary doctor about an evaluation for this,
including a colonoscopy if this has not been done to ensure you
do not have an early colon cancer.
5. Your diabetes is difficult to manage. You can consider
making a follow-up appointment at the [**Last Name (un) **] Diabetes Center to
help control your diabetes over the long-term. You may call
them at [**Telephone/Fax (1) 2378**] and schedule an appointment.
|
[
"496",
"280.9",
"997.3",
"519.19",
"518.89",
"250.02"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.5",
"31.99"
] |
icd9pcs
|
[
[
[]
]
] |
8078, 8084
|
4561, 6211
|
450, 493
|
8218, 8235
|
2739, 4538
|
8913, 9784
|
2007, 2017
|
6453, 8055
|
8105, 8197
|
6237, 6430
|
8259, 8890
|
2032, 2720
|
274, 412
|
521, 1321
|
1343, 1464
|
1480, 1991
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,654
| 163,742
|
37900
|
Discharge summary
|
report
|
Admission Date: [**2141-10-3**] Discharge Date: [**2141-10-20**]
Date of Birth: [**2077-2-7**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Left Hand Clumsiness and Dysarthria
Major Surgical or Invasive Procedure:
None
History of Present Illness:
PER ADMITTING RESIDENT:
64 y.o. RH man with PMH remarkable for hypertension,
hyperlipidemia, DM 2 with recently diagnosed CAD and s/p drug
eluting stents 72h ago (to RCA and LAD: 70% stenosis) p/w new
onset chest heaviness and slurred speech starting abruptly at
20:06.
He was able to understand his relatives and produce speech.
However, his son and the pt feel he sounded "tired" or "drunk".
There were no mistakes when using words or word finding
difficulty.
He also refers a mild sensation of numbness (lidocaine
sensation)
initially in his first three fingers in the LEFT hand that
progressed toward all his fingers in the palmar and dorsal
aspect
of the hand (cannot explain how long it took for it to spread).
In addition, he cannot recall for how long it had been present
(now resolved per pt).
He had no nausea or vomiting. No visual deficits, weakness or
heaviness of his arms or legs. No dizziness or disequilibrium or
any other symptoms.
He has been compliant with his ASA and plavix since his cardiac
cath. He has not experienced this slurred speech before. He has
no hx of seizure disorder. He had no headache at the time this
episode happened.
At [**Hospital1 18**] ED: FSBS 132, BP 186/60.
Past Medical History:
Diabetes
Hyperlipidemia
Hypertension
Prior Tobacco Use
Cervical disc disease s/p C1-2 fusion
Lower Extremity Edema
Asthma/Bronchitis
Umbilical Hernia Repair
Arthritis
Social History:
- He is widow and lives in [**Location 3786**].
- He is a retired high school teacher.
- He has a grown son and daughter who do not live with him.
.
HABITS:
ETOH: none
Family History:
Father with MI in his 50's, and died of pneumonia.
Motherhas CHF and is presently 80 (she got married at age 14).
Physical Exam:
ON ADMISSION
BP: 97.6 60 172/44 20 100
Gen: Alert, oriented. Sclerae anicteric. MMM.
No meningismus.
No carotid bruits auscultated.
Lungs clear bilaterally.
Heart regular in rate.
Abd soft, nontender, nondistended. Bowel sounds heard
throughout.
Neuro:
>>MS??????Alert. Oriented to self, location, date. Speech fluent,
articulate. No paraphasic errors. Registration, repetition,
recall intact. Able to read w/o difficulty. Naming watch,
thumb. DOW and [**Doctor Last Name 1841**] forward and backwards. Mild dysarthria.
Abstract thinking: school bus and banana differences
>>CN??????PERRL . VFIC.
No ptosis. EOMI w/ smooth pursuit. Facial sensation and
pterygoid strength intact. Facial mm intact. Hearing intact to
finger rub. Palate elevates midline. SCMs intact. Tongue
protrudes midline.
>>Motor??????
>>Sensory??????Light touch, temp, pinprick and vibration.
>>DTRs??????2+ throughout.
>>Coord/Gait??????
Dysmetria: -
Dysdiadochokinesia:-
Intact FTN and HTS:
1a LOC =0
1b Orientation =0
1c Commands =0
2 Gaze =0
3 Visual Fields =0
4 Facial Paresis = 0
5a Motor Function R UE = 0
5b Motor Function L UE= 0
6a Motor Function R LE= 0
6b Motor Function L LE= 0
7 Limb Ataxia = 0
8 Sensory perception = 0
9 Language = 0
10 Dysarthria = 1
11 Extinction/Inattention = 0
TOTAL = 1
Examination at time of discharge was notable for:
Alert, awake, oriented to [**Hospital1 18**], Date and person. Attention
impaired to MOYB. Follows midline and axial commands.
CN: PERRL, 4->2mm, VF intact to threat could not assess fields
reproducibly, face w/ L facial droop, tongue midline, severely
dysarthric, shoulder shrug impaired on L. Right gaze
preference, no neglect.
Motor: Normal bulk, flacid LUE and LLE. RUE full strenght, RLE
4-/5 at IP, [**4-11**] H, Q, TA, G. No clonus.
Coordination: R FNF intact.
Pertinent Results:
Admission Lab Data:
.
WBC-6.2 RBC-3.86* HGB-10.8* HCT-33.7* MCV-87 MCH-27.9 MCHC-32.0
RDW-14.9
NEUTS-54.1 LYMPHS-36.7 MONOS-4.6 EOS-3.8 BASOS-0.8
cTropnT-0.01 CK(CPK)-185*
GLUCOSE-122* UREA N-38* CREAT-1.2 SODIUM-140 POTASSIUM-4.6
CHLORIDE-101 TOTAL CO2-29 ANION GAP-15
.
URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG
BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG
.
Modifiable Risk Factors for Stroke:
Cholest-109 Triglyc-91 HDL-31 LDLcalc-60
%HbA1c-6.9*
.
Discharge Lab Data:
.
IMAGING
.
CTA Head and Neck ([**2141-10-4**]):
IMPRESSION:
1. While full evaluation of the lumen of the right internal
carotid artery is limited given the extensive calcification,
there does appear to be a short segment of high- grade stenosis
at the origin.
2. Moderate grade stenosis at the origin of the left vertebral
artery.
3. Additional multifocal atherosclerotic disease as detailed,
including
moderate stenosis of the distal right vertebral artery.
4. Focal lucencies within the centrum semiovale and corona
radiata on the
right. These likely represent subacute infarcts and could be
further
evaluated with MRI. These may be downstream effects of the
high-grade stenosis at the origin of the right internal carotid
artery. Further evaluation of the right internal carotid artery
could be attempted with ultrasound, though the calcification
will likely limit this examination, at which point a contrast-
enhanced MRA could be performed.
5. Extensive degenerative and post-surgical changes within the
cervical spine with ossification of the posterior longitudinal
ligament from C3 through C5 which appears to create at least a
moderate degree of canal narrowing and could be further
evaluated with dedicated cervical spine MRI as indicated.
.
Carotid Duplex ([**2141-10-4**]):
Impression:
Right ICA stenosis <40%.
Left ICA stenosis <40%.
.
CTA Head, Neck ([**2141-10-6**]):
IMPRESSION:
1. Expected post-surgical changes following interval right
carotid
endarterectomy, with a now patulous right carotid bulb and
proximal internal carotid artery.
2. Origin of the right common carotid artery is not
well-evaluated, but
appears poorly-opacified, new since the recent CTA; interval
thrombosis/occlusion of this vessel cannot be excluded.
3. Stable moderate atherosclerotic disease and stenosis of the
distal right vertebral artery.
.
CT Head without Contrast ([**2141-10-8**]):
IMPRESSION:
1. Interval progression in the hypodense region involving the
right centrum semiovale and corona radiata, now spanning
approximately 5 cm (AP). This could represent evolution of
previously identified infarct, or could reflect new infarct. MRI
is more sensitive for detection of acute ischemia.
2. No hemorrhage, significant mass effect or shift of midline
structures.
.
NOTE ADDED IN ATTENDING REVIEW: The process, described above,
represents
further progression of relatively acute infarct involving the
right corona
radiata, with subtle mass effect on the lateral margin of the
lateral
ventricular body and minimal leftward deviation of the anterior
portion of
the septum pellucidum.
.
CT Perfusion ([**2141-10-9**]):
IMPRESSION: Diminished cerebral perfusion is present throughout
the majority of the right cerebral hemisphere with patchy areas
of diminished blood volume, compatible with infarcts as seen on
the preceding CT scan.
.
Transthoracic Echocardiogram ([**2141-10-4**]):
The left atrium is mildly dilated. No thrombus/mass is seen in
the body of the left atrium. A patent foramen ovale is present.
Left ventricular wall thicknesses are normal. The left
ventricular cavity is mildly dilated. Regional left ventricular
wall motion is normal. Overall left ventricular systolic
function is normal (LVEF>55%). No masses or thrombi are seen in
the left ventricle. There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
ascending aorta is mildly dilated. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. No
masses or vegetations are seen on the aortic valve. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. No mass or
vegetation is seen on the mitral valve. Trivial mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is mild pulmonary artery systolic hypertension.
.
US LUE [**10-17**] (obtained for edema in LUE)
CONCLUSION: There is no ultrasound evidence of deep venous
thrombosis of the left upper extremity.
Brief Hospital Course:
Mr. [**Known lastname **] is a 64 year-old right-handed man with a past medical
history including hypertension, hyperlipidemia, DM 2, and CAD
-three days s/p drug eluting stent placement to the RCA and LAD
who presented to the [**Hospital1 18**] with left hand clumsiness and
dysarthria in addition to chest discomfort. He was initially
admitted to the medicine service, dueing which time his pain was
deemed non-cardiac in origin. As his symptoms were considered
concerning for stroke, he was transferred to the Neurology
Stroke Service from [**2141-10-4**] to [**2141-10-20**].
.
NEURO/CVS
As the time of admission, a CTA of the head and neck was
performed. The imaging demonstrated right-sided focal lucencies
within the centrum semiovale and corona radiata in the setting
of an apparent high grade stenosis of the right internal carotid
artery. A heparin drip was started with a goal PTT of 50 to 70.
.
A [**Month/Day/Year 1106**] surgery consult was requested to evaluate the utility
and feasbility of a carotid endarterectomy. At their
recommendation, carotid duplex studies were performed to
evaluate the degree of carotid stenosis with an alternative
modality. While the carotid duplex studies showed less than 40%
stenosis bilaterally, it was thought to be a falsley low result.
Accordingly, the patient underwent a right carotid
endarterectomy (CEA). A CT angiogram performed thereafter
revealed a widely patent right extracranial internal carotid
artery.
.
Following the CEA, the patient developed a more pronounced
dysarthria and left hemiparesis. As the symptoms did not
resolve with the optimization of cerebral blood flow, the
neurosurgery team was consulted for a potential intervention.
The patient subsequently underwent cerebral angiography. As the
anatomy was not conducive to the procedures, no stent was placed
and no thrombectomy was performed. The patient was transferred
to the intensive care unit for close monitoring. In the setting
of persistent symptoms, a CT perfusion scan was subsequently
performed. The study revealed global hypoperfusion of the right
MCA territory. With the the thought that a more proximal,
intracranial internal carotid stenosis was responsible, a second
cerebral angiography was performed. It was not possible to
place a stent in the target area secondary to anatomical
challenges.
.
At the suggestion of the cardiology team, aspirin 325 mg and
plavix 75 mg po daily were continued. The carvedilol was also
continued to provide cardioprotection. However, the lisinopril
and bumex were temporarily held to allow for blood pressure
autoregulation in the setting of subacute stroke. In addition,
gentle hydration was provided to maximize cerebral perfusion.
Prior to discharge the anti-hypertensive agents were restarted,
his regimen included lisinopril 40mg, meotoprolol 25mg [**Hospital1 **],
Norvasc 5mg, hydralazine 10mg IV prn SBP > 180.
.
Patient will require bridge from heparin to coumadin with PTT
goal of 50-70 and INR goal of [**1-9**].5. He will require further
further evaluation with speech and swallow within one week.
Video swallow on day of discharge showed penetration with thin
liquids.
.
RESP
Following his transfer to the intensive care unit, the patient
developed respiratory distress. He was intubated for several
days. He was successfully extubated prior to his return to the
floor.
.
HEME
In the course of the hospitalization, the patient's hematocrit
dropped to approximately 24. This was felt to be due to
dilutional causes. His HCT subsequently returned to 29
(baseline 32-34).
.
GU
On [**10-18**], patient was noted to have urinary retention after
removal of foley catheter. This necessitated replacement, which
was traumatic resulting in hematuria. He was irrigated however
had persistent hematuria. His HCT remained stable. Hematuria
improved at time of discharge.
.
NUTRITION:
Patient required NGT placement due to oropharyngeal dysfunction,
likley secondary to his stroke. This improved as
hospitalizaiton progressed. A video swallow is recommended to
upgrade his diet. Calorie counts increased from 500Kcal, to
1050Kcal to 1060 on day of discharge. NGT can be discontinued
once patient takes adequate intake (see nutrition
recommendations) and will require nutrition follow up.
.
CODE
Full
Medications on Admission:
Lisinopril 40mg tablet daily
Zocor 20mg tablet daily
Glyburide/Metformin 2.5/500mg 2 tablets [**Hospital1 **]- LD [**9-27**] pre cath
per Dr [**Last Name (STitle) 5686**]
Ecotrin 81mg tablet daily
Coreg 25mg tablet [**Hospital1 **]
Bumex 0.5mg 1 tablets [**Hospital1 **]
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Heparin (Porcine) in D5W 25,000 unit/250 mL Parenteral
Solution Sig: 1300 (1300) Intravenous ASDIR (AS DIRECTED):
Please check PTT every 6 hours. Goal PTT 50-70. .
4. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
8. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Bumetanide 0.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Hydralazine 20 mg/mL Solution Sig: 10mg Injection every six
(6) hours as needed for prn SBP >180.
12. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q4H (every 4 hours) as
needed for wheezing/SOB.
13. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
14. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
16. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
17. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for fever.
19. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed for pain.
20. Ondansetron 4 mg IV Q8H:PRN nausea
21. 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.
22. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
23. Insulin NPH & Regular Human Subcutaneous
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary: Embolic stroke in corona radiata, embolic strokes in
MCA and ACA distribution
Secondary: CAD, HTN, HL, DM2
Discharge Condition:
Alert, awake, oriented to [**Hospital1 18**], Date and person. Attention
impaired to MOYB. Follows midline and axial commands.
CN: PERRL, 4->2mm, VF intact to threat could not assess fields
reproducibly, face w/ L facial droop, tongue midline, severely
dysarthric, shoulder shrug impaired on L. Right gaze
preference, no neglect.
Motor: Normal bulk, flacid LUE and LLE. RUE full strenght, RLE
4-/5 at IP, [**4-11**] H, Q, TA, G. No clonus.
Coordination: R FNF intact.
Discharge Instructions:
You were admitted to [**Hospital1 18**] with left hand clumsiness and
difficulty with speech after you had recently undergone coronary
artery stenting. You were found to have a right sided stroke.
To treat your symptoms, you underwent a carotid endarterectomy.
Unfortunately, you experienced additional strokes due to
blockages in the arteries of your head. You udnerwent two
additional procedures (angiograms) with attempts to clear these
blockages, however these were unsuccessful. At time of
discharge, you were left with significant difficulty with speech
and left sided weakness.
You were treated with multiple new medications, and you will
require taking these further. Please consult with your doctors
[**Name5 (PTitle) **] to [**Name5 (PTitle) 5002**] any of theses.
Because of you diagnosis of heart failure, please weigh yourself
every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs.
Please follow up with all of your appointments.
Should you develop any warning signs as listed below, please
call your doctor or go to the emergency room.
Followup Instructions:
[**Name8 (MD) **]: Provider: [**Name10 (NameIs) **] [**Apartment Address(1) 871**] ([**Doctor First Name **]) [**Doctor First Name **] LMOB (NHB)
Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2141-11-20**] 2:00
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2141-11-20**] 2:50
CARDIOLOGY: Please follow up with Dr. [**Last Name (STitle) **], [**First Name3 (LF) **] on [**11-23**], at 11.30am.
NEUROLOGY: Provider: [**Name10 (NameIs) 4267**] [**Last Name (NamePattern4) 4268**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 657**]
Date/Time:[**2141-11-22**] 2:00
PRIMARY CARE DOCTOR: Please call the office of Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] S.
at [**Telephone/Fax (1) 84739**] to set up a follow up appointment within two
weeks of discharge from the rehabilitation facility.
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
Completed by:[**2141-10-20**]
|
[
"V45.82",
"493.90",
"518.81",
"401.9",
"564.00",
"250.00",
"433.31",
"414.01",
"433.11",
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] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"38.12",
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"96.04",
"96.71",
"00.40",
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icd9pcs
|
[
[
[]
]
] |
15088, 15158
|
8501, 12809
|
351, 357
|
15318, 15795
|
3969, 8478
|
16919, 17944
|
1992, 2108
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13131, 15065
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15819, 16896
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385, 1599
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1621, 1790
|
1806, 1976
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,083
| 131,212
|
5641
|
Discharge summary
|
report
|
Admission Date: [**2103-6-2**] Discharge Date: [**2103-6-7**]
Date of Birth: [**2029-12-9**] Sex: M
Service: [**Doctor First Name 147**]
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
Septic shock due to necrotizing fasciitis of the left flank
Major Surgical or Invasive Procedure:
1. Sharp debridement of necrotizing wound of the left flank
([**2103-6-2**])
2. Placement of central venous catheter [**2103-6-2**]
History of Present Illness:
73 yo male with a history of diabetes, end stage renal failure,
and congestive heart failure presents to the emeergency
department with evidence of septic shock following a recent
fall. Pt has been confused, acutely hypotensive (80/50). The
patient has had diarrhea and dizziness for the last 2 days and
fell while trying to go to the bathroom. A family member noted
that he struck his head and flank on falling.
Past Medical History:
end stage renal disease on hemodialysis
diabete mellitus
congestive heart failure (EF 30% with 3+ MR)
Atrial fibrillation (on coumadin)
hypertension
gout
Social History:
Divorced living with daughter.
History of alcohol abuse
Family History:
None
Physical Exam:
VS: t98.4 bp 114/59 (levophed 0.3) 80 (on pacer) 12 100%
Confused, AOx1
pulm: clear to aucsultation bilaterally
cv: regular systolic murmur
abd: distended with left flank ecchymosis, erythema, and
tenderness. Extends from pelvis to the shoulder.
rectum: guaiac negative, no masses
ext: warm
Pertinent Results:
[**2103-6-2**] 11:56PM TYPE-ART TEMP-37.2 RATES-[**7-27**] TIDAL VOL-700
PEEP-5 O2-50 PO2-84* PCO2-54* PH-7.32* TOTAL CO2-29 BASE XS-0
INTUBATED-INTUBATED VENT-CONTROLLED
[**2103-6-2**] 11:56PM LACTATE-3.5*
[**2103-6-2**] 11:41PM GLUCOSE-153* UREA N-37* CREAT-4.9* SODIUM-134
POTASSIUM-5.6* CHLORIDE-94* TOTAL CO2-25 ANION GAP-21*
[**2103-6-2**] 11:41PM WBC-24.5* RBC-4.02* HGB-11.7* HCT-39.3*
MCV-98 MCH-29.2 MCHC-29.9* RDW-17.9*
[**2103-6-2**] 05:57PM TYPE-ART O2-40 PO2-116* PCO2-51* PH-7.37
TOTAL CO2-31* BASE XS-3 INTUBATED-NOT INTUBA
[**2103-6-2**] 05:57PM LACTATE-3.1*
[**2103-6-2**] 12:56PM LACTATE-2.6*
[**2103-6-2**] 12:27PM GLUCOSE-108* UREA N-32* CREAT-5.1*
SODIUM-131* POTASSIUM-5.4* CHLORIDE-91* TOTAL CO2-25 ANION
GAP-20
[**2103-6-2**] 12:27PM CALCIUM-8.6 PHOSPHATE-3.1 MAGNESIUM-1.4*
[**2103-6-2**] 12:27PM WBC-20.3* RBC-4.04* HGB-11.7* HCT-39.1*
MCV-97 MCH-28.9 MCHC-29.9* RDW-18.1*
[**2103-6-2**] 07:10AM LACTATE-5.6*
[**2103-6-2**] 06:56AM CK-MB-NotDone cTropnT-0.13*
[**2103-6-2**] 06:56AM WBC-18.4*# RBC-4.00* HGB-11.6* HCT-38.8*
MCV-97 MCH-28.9 MCHC-29.8* RDW-17.7*
[**2103-6-4**] 04:35AM BLOOD WBC-15.7* RBC-3.86* Hgb-11.0* Hct-35.9*
MCV-93 MCH-28.4 MCHC-30.5* RDW-17.7* Plt Ct-146*
[**2103-6-6**] 03:43AM BLOOD WBC-20.7* RBC-3.97*# Hgb-11.3* Hct-37.4*
MCV-94 MCH-28.5 MCHC-30.4* RDW-17.7* Plt Ct-187
[**2103-6-2**] 06:56AM BLOOD PT-17.3* PTT-30.9 INR(PT)-2.0
[**2103-6-4**] 04:35AM BLOOD PT-19.1* PTT-32.2 INR(PT)-2.4
[**2103-6-6**] 03:43AM BLOOD PT-17.4* PTT-31.7 INR(PT)-2.0
[**2103-6-2**] 12:27PM BLOOD Glucose-108* UreaN-32* Creat-5.1* Na-131*
K-5.4* Cl-91* HCO3-25 AnGap-20
[**2103-6-4**] 11:26PM BLOOD Glucose-148* UreaN-42* Creat-5.4* Na-129*
K-5.4* Cl-95* HCO3-18* AnGap-21*
[**2103-6-6**] 03:43AM BLOOD Glucose-177* UreaN-35* Creat-4.4* Na-134
K-4.5 Cl-97 HCO3-19* AnGap-23*
[**2103-6-3**] 03:31AM BLOOD Type-ART pO2-101 pCO2-42 pH-7.41
calHCO3-28 Base XS-1
[**2103-6-4**] 11:56PM BLOOD Type-ART O2-70 pO2-85 pCO2-40 pH-7.33*
calHCO3-22 Base XS--4
[**2103-6-6**] 04:08AM BLOOD Type-ART Temp-37.1 pO2-84* pCO2-41
pH-7.34* calHCO3-23 Base XS--3
[**2103-6-2**] 07:10AM BLOOD Lactate-5.6*
[**2103-6-3**] 03:31AM BLOOD Lactate-3.4*
[**2103-6-5**] 04:20AM BLOOD Lactate-3.0*
[**2103-6-6**] 04:08AM BLOOD Lactate-3.9*
Brief Hospital Course:
Following initiation of resuscitative efforts in the ED the
patient was taken to the operating room for debridement of his
left flank necrotizing soft tissue infection. He was
subsequently tranferred to the surgical intensive care unit for
resuscitation of his septic shock.
The remainder of his hospital course will be summarized by
system:
Neuro:
The patient was maintained on sedative and analgesic medications
throughout his course. There were no specific untoward events
during his stay.
Pulmonary:
The patient was mainained on the ventilator throughout his
hospital course due to the severity of his illness. There were
no
Cardiovascular:
Beginning in the ED and continuing thereafter the patient
required multiple pressor agents to sustain a perfusing
pressure. Agents included vasopressin, and levophed
predominantly. He stabilized with massive fluid resuscitation
and these medications but remained dependent on them throuhout
his stay.
Fluids/GI:
Initial and continued fluid resuscitation to approximately 15
liters above his baseline was required to maintain peripheral
perfusion. There were no GI problems except for ileus.
Renal:
The patient was oliguric throughout his course consistent with
his basline ESRD. Hemodialysis was started after he appeared to
stabilize late in his hospital stay.
Heme/ID:
The patient was started on broad spectrum empiric antibiotic
therapy with input from the infectious disease team as well.
Blood cultures were positive for Strep Pneumo and his antibiotic
coverage was tailored accordingly. Additional work-up to rule
out an occult process contributing to his sepsis included
cross-sectional body imaging, and cardiac echo both of which
were unfruitful.
Endocrine:
Good glycemic control was acheived with insulin therapy.
Wound:
The left flank wound was found to track extensively along the
fascial plane of the left side. Wet to dry dressing changes
were done daily with significant improvement in the overall
appearance of the wound. The progress of the wound necrosis had
been halted with sharp debridement and resuscitation.
The patient stabilized on intensive supportive therapy including
antibiotics, mechanical ventilation, IV fluids, blood products,
sharp debridement of the necrotic tissue, and pressors. However
there was little evidence that he would be able to wean from
these measures. Multiple meetings were held with members of his
family. By hospital day 5, they requested that comfort measures
only be administered and the patient subsequently expired the
same evening. The cause of death is thought to be compications
secondary to septic shock.
Medications on Admission:
allopurinol
coumadin
toprol
vitamin b12
amiodarone
aspirin
folate
Discharge Medications:
none
Discharge Disposition:
Home
Discharge Diagnosis:
Septic shock
Discharge Condition:
Deceased
Discharge Instructions:
None
Followup Instructions:
None
|
[
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icd9cm
|
[
[
[]
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[
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icd9pcs
|
[
[
[]
]
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3863, 6498
|
391, 524
|
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|
1569, 3840
|
6768, 6775
|
1235, 1241
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6614, 6620
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6670, 6684
|
6524, 6591
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6739, 6745
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1256, 1550
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292, 353
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552, 968
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990, 1146
|
1162, 1219
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,494
| 169,113
|
22717
|
Discharge summary
|
report
|
Admission Date: [**2123-9-27**] Discharge Date: [**2123-10-15**]
Date of Birth: [**2048-2-6**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamides) / Penicillins / Tetracycline /
Cephalosporins
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
[**2123-9-27**] - AVR(19mm CE Magna Pericardial Tissue Valve),
Ascending Aorta Replacement (24mm gel weave graft).
History of Present Illness:
75 year old female with MI in [**1-2**] status post mutiple
percutaneous interventions to the right coronary artery and left
anterior descending artery with known severe aortic stenosis.
Increased fatigue and chest discomfort recently. Experienced an
episode of crushing chest pain with dyspnea, emesis and
diaphoresis. Her pain resolved en route to the hospital with
aspirin and nitroglycerin. Cardiac enzymes were negative. She
presents now for surgical management of her aortic valve
disease.
Past Medical History:
Coronary Artery Disease s/p Myocardial Infarction in [**1-2**], PCI
to RCA x 3 in [**1-2**] and now to RCA x2 [**6-28**] and mLAD x 2
Severe Aortic Stenosis (valve 0.6) w/ gradient of 35 on recent
cath
Hypertension
Congestive Heart Failure w/ EF 45 on echo [**1-2**] but now 75% on
cath
Atrial Fibrillation
Colon cancer s/p resection on '[**17**]
Subclavian steel and cartoid stenosis
s/p pelvic fx in '[**21**]
Anemia
Social History:
Lives with husband who has [**Name (NI) 11964**]. Drinks [**11-29**] glasses per
night of wine. Smoked [**11-29**] ppd for about 40 years, quiting in the
mid-[**2097**]'s. Retired phone rep.
Family History:
Mother had DM. Brother has borderline DM.
Physical Exam:
GEN: pleasant, well appearing elderly female in NAD. Pt
conversing fluently in full sentences.
HEENT: PERRL, EOMI, anicteric, mmm, op clear
CV: RRR, s1, s2 with prominent early systolic murmur best heard
at RUSB. ? murmur intensity inc. with valsalva.
Chest: CTA bilaterally
Abd: soft, NT, ND, BS+ bilaterally
Groin: right groin with slight echymosis. No hematoma but
positive tenderness to palpation. No bruits appreciated on
auscultation.
Ext: wwp, no c/c/e, DP +1 bilaterally
Pertinent Results:
[**2123-9-30**] Video Swallow
Moderate impairment of swallow as described above. There was
mild penetration and aspiration as described above.
[**2123-10-2**] Head CT
There is no acute intracranial hemorrhage, mass effect, or shift
of normally midline structures. Specifically, there is no
evidence of brainstem compression. There are numerous foci of
low density in the periventricular and subcortical white matter
of both cerebral hemispheres, many of which are confluent,
consistent with chronic microvascular ischemic disease.
Bilateral thalamic lacunar infarctions are present, which are of
unknown age. Lacunar infarction is also noted in the lateral
aspect of the right lentiform nucleus, age also unknown. Chronic
infarctions are present in the right and left cerebral
hemispheres. Atherosclerotic vascular calcifications are noted.
The ventricles are normal in size. Both orbits appear
unremarkable. The visualized osseous structures also appear
unremarkable.
[**2123-10-5**] Video Swallow
Moderate residue, mild penetration, and mild aspiration to
improve with the compensatory maneuvers the patient was able to
perform. For a detailed description of the findings and
recommendations, please see the speech pathology report under
CareWeb.
[**2123-10-8**] MRI/MRA
MRI - Acute small infarcts in the right frontal, left posterior
temporal, and right cerebellar regions. Other changes as above
including chronic infarcts in thalami and white matter.
MRA - No significant abnormalities detected on the MRA of the
head.
[**2123-10-6**] CXR
Small bilateral pleural effusions, improved compared to prior
chest radiograph.
[**2123-9-27**] EKG
Sinus rhythm. Long QTc interval. Lateral ST segment changes are
non-specific. Since the previous tracing of [**2123-9-5**] no
significant change, except for faster rate.
[**2123-10-15**] 06:10AM BLOOD WBC-10.6 RBC-3.33* Hgb-10.2* Hct-29.9*
MCV-90 MCH-30.5 MCHC-34.0 RDW-15.5 Plt Ct-279
[**2123-10-15**] 06:10AM BLOOD PT-13.5* PTT-26.9 INR(PT)-1.2
[**2123-10-15**] 06:10AM BLOOD Glucose-132* UreaN-10 Creat-0.6 Na-137
K-4.2 Cl-103 HCO3-23 AnGap-15
Brief Hospital Course:
Ms. [**Known lastname 58825**] was admitted to the [**Hospital1 18**] on [**2123-9-27**] for elective
surgical management of her aortic valve disease. She was taken
directly to the operating room where she underwent an aortic
valve replacement with a 19 Magna pericardial valve and an
ascending aorta replacement with a 24mm gelweave graft.
Postoperatively she was taken to the cardiac surgical intensive
care unit for monitoring. On postoperative day one, she was
weaned off of mechanical ventilation and sedation and extubated.
She was alert, but had difficulty focusing ans appeared
confused. By POD #2 pt was having difficulty swallowing and was
coughing up all boluses and a swallow evaluation was performed
(please see results). On POD #3 pt continued to be confused and
now agitated. In addition she was noted to have hallucinations.
She was started on Halodol and Ativan and a sitter was placed in
the room (sitter remained with the pt during almost entire
post-op course). It was thought pt was having DT's and was
started on Thiamine and Folate. On this day her chest tubes and
epicardial pacing wires were removed. Her rhythm converted from
sinus to atrial fibrillation. She was already on Lopressor,
Amiodarone and Heparin was started (eventually coumadin was
started). Pt. continued to remain confused and agitated and was
noted to have a dilated left pupil on POD #5. Head CT was
performed and was negative for acute CVA. Also do to the
confusion pt was having difficulty coordinating the IS. She had
occassional wheezes with decreased breath sounds and needed
aggressive pulmonary therapy and toilet while in the CSRU. On
POD #7 she was hemodynamically stable and transferred to the
telemetry floor. But she did remain NPO and a repeat swallow
study was performed. She did improve but was only able to have
diet advanced to pureed solids and nectar thick liquids. Despite
DT prevention and ativan pt continued to remain agitated and
confused, with difficulty [**Location (un) 1131**] still on POD #9. And was noted
to have a fixed gaze with restricted EOMI laterally. Neurology
was consulted on this day and an MRI was performed on POD #11.
MRI showed several small acute strokes. Neurology noted that
these lesions didn't correlate with symptoms. Neurology thought
that confusion might have been do to Amiodarone causing
supranuclear ophthalmoplegia. Amiodarone was d/c'd and symptoms
improved. Pt. continued to have difficulty swallowing and
advancing diet therefor a PEG tube was placed under fluoro on
POD #14. She had another repeat swallow study and was started on
swallow therapy.
Pt. was followed by both physical therapy and nutrition during
post-op course and treated accordingly.
Her mental status cleared and she was advanced on her TF. She
is being anticoagulated with coumadin and will have daily INR
checks at rehab. As an outpatient she will have her INR
followed by Dr. [**Last Name (STitle) 13075**].
On POD#18 she was discharged to rehab in stable condition.
Medications on Admission:
ASA 325 mg PO daily
Plavix 75 mg PO daily
Lopressor XL 100 mg PO daily
Lipitor 80 mg PO daily
Lisinopril 15 mg PO daily
Methenamide 1 gm PO daily
Lasix 20 mg PO daily
Zetia 10 mg PO daily
FeSO4 325 mg PO daily
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. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
3. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*qs 1 inhaler* Refills:*2*
6. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One
(1) PO DAILY (Daily).
Disp:*30 * Refills:*2*
7. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 6
days.
Disp:*12 Tablet(s)* Refills:*0*
8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
9. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**11-29**]
Puffs Inhalation Q6H (every 6 hours).
Disp:*1 qs* Refills:*2*
10. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
11. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed. Tablet(s)
12. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO once a day for
1 days: Give for INR goal of [**12-30**].5.
FS Probalance TF @ 55cc/hr.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Aortic Stenosis
Aspiration
Coronary artery disease
CVA
Subclavian Steel Syndrome
CVD
Hypertension
Atrial Fibrillation
Hypercholesterolemia
Discharge Condition:
Good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include redness,
drainage or increased pain.
2) Report any fever greater then 101.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in
1 week.
4) Coumadin for atrial fibrillation. Goal INR 2.0-2.5. Monitor
PT/INR daily and adjust coumadin appropriately. Dr. [**Last Name (STitle) 13075**] will
manage coumadin as an outpatient. ([**Telephone/Fax (1) 58826**]. Please
schedule blood draw and coumadin appointment on discharge from
rehab..
5) Call our office for sternal drainage.
[**Last Name (NamePattern4) 2138**]p Instructions:
Dr. [**Last Name (Prefixes) **] in two weeks, call for appointment
Dr. [**Last Name (STitle) 13075**] in [**11-29**] weeks, call for appointment
Dr. [**First Name (STitle) **], in [**12-31**] weeks, call for appointment
Completed by:[**2123-10-15**]
|
[
"424.1",
"414.01",
"V15.82",
"V45.82",
"412",
"428.0",
"997.02",
"401.9",
"333.0",
"427.31",
"440.0",
"291.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"43.11",
"89.60",
"96.6",
"99.04",
"38.45",
"35.21"
] |
icd9pcs
|
[
[
[]
]
] |
8956, 9028
|
4333, 7329
|
344, 460
|
9211, 9218
|
2212, 4310
|
1651, 1694
|
7590, 8933
|
9049, 9190
|
7355, 7567
|
9242, 9785
|
9836, 10088
|
1709, 2193
|
294, 306
|
488, 985
|
1007, 1427
|
1443, 1635
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,164
| 187,230
|
54643
|
Discharge summary
|
report
|
Admission Date: [**2173-6-25**] Discharge Date: [**2173-6-26**]
Date of Birth: [**2116-5-25**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Tetracycline
Attending:[**First Name3 (LF) 2712**]
Chief Complaint:
recurrent PNA
Major Surgical or Invasive Procedure:
none
History of Present Illness:
57 yo F with PMH non-small cell lung cancer s/p LUL lobectomy in
[**3-/2173**] with radical LND plus intercostal flap patch and
pulmonary artery angioplasty, vocal cord paralysis [**12-24**]
intubation, HTN, depression, CREST syndrome transferred from OSH
for possible stent. She is s/p mult admissions for PNA after
lobectomy - had an ICU stay in [**Hospital1 1474**] for hypoxia and HCAP
where she was diagnosed with COP (date unknown but likely in
[**Month (only) **] vs early [**Month (only) 205**]). Discharged to rehab on steroids. Admitted
from rehab to OSH again on [**2173-6-2**] for increased somnolence and
tachypnea and gradual increase in SOB over weeks. CT showed
loculated left PTX. Had [**Date Range **] that showed necrotic tissue and
BOOP. Prescribed steroids and abx and d/ced to rehab. Admitted
again to [**Hospital1 1474**] on [**2173-6-23**]. Intubated for [**Date Range **] and started
again on broad spec abx including vanc/ceftaz and bactrim for
PCP. [**Name10 (NameIs) **] on [**6-24**] showed left main bronchus obstruction [**12-24**]
dead mucosa. cultures sent, ETT left in place. Course
complicated by SVT and pauses on lopressor so she was started on
dilt drip. on fent/midaz drip for vent sedation. On transfer was
in NSR, HR 60s, BP 100-120s/60-70s, T 100.6.
Lines and Tubes: Came in to OSH with portacath in place. Foley
placed [**2173-6-23**] at OSH.
LABS/STUDIES at OSH:
MRSA swab neg at OSH
UCx [**6-23**] No growth (final)
Sputum cx [**6-24**] Pending; [**11-30**] GPCs in singles and pairs, >25 yeast
species
AFB smear [**6-24**] pending
Labs on transfer: Hct 25.9 (33.4 on admission), WBC 7.5 (11.6 on
admission), Plat 161, INR 1.2, PTT 23.3, Na 133, K 3.7, Cl 96,
CO2 24, Ca 8.7, Mg 1.8, gluc 194, BUN 19, cr 0.7, phos 2.6.
ECHO [**2173-6-23**] EF 40-45%
CXR [**6-25**]: partial re-expansion of LLL, slight residual asymmetric
confluent opacity at that level.
CTA CHEST [**2173-6-20**]: no PE. moderate loculated left apical PTX,
decreased in size. Right lung with extensive groundglass
opacities and interstitial thickening, decreased. Left lung
small scattered groundglass infiltrates are new.
On arrival to the MICU, VS 97.7, 102/56, 61, 21, 94% ETT. Pt not
responsive.
Review of systems:
unable to obtain.
Past Medical History:
non-small cell lung cancer s/p LUL lobectomy in [**3-/2173**] with
radical LND plus intercostal flap patch and pulmonary artery
angioplasty
vocal cord paralysis [**12-24**] intubation
HTN
depression
CREST syndrome
Raynaud's
anemia
h/o VRE
Social History:
presenting from rehab, smoked until quit 10 years ago. worked as
[**Name8 (MD) **] RN at [**Hospital6 **]. divorced.
Family History:
one sister [**Name (NI) 111773**] cancer. parents deceased
Physical Exam:
Vitals: 97.7, 102/56, 61, 21, 94% ETT
General: intubated, sedated, not responding to commands or voice
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, pin point
pupils equal bilat
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: diffuse exp wheezes bilat, mildly coarse mechanical BS
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: foley in place with yellow urine in bag
Ext: cool, 2+ pulses in UE and LE bilat, 2+ pitting edema bilat
to hips
Neuro: intubated, sedated, not responsive
DISCHARGE EXAM:
deceased
Pertinent Results:
[**2173-6-26**] 12:03AM BLOOD WBC-9.6 RBC-3.20* Hgb-7.6* Hct-26.2*
MCV-82 MCH-23.8* MCHC-29.0* RDW-19.2* Plt Ct-147*
[**2173-6-26**] 12:03AM BLOOD Neuts-86* Bands-10* Lymphs-2* Monos-2
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-6*
[**2173-6-26**] 12:03AM BLOOD Hypochr-3+ Anisocy-2+ Poiklo-1+
Macrocy-NORMAL Microcy-2+ Polychr-OCCASIONAL Ovalocy-1+
Pencil-OCCASIONAL Fragmen-OCCASIONAL
[**2173-6-26**] 12:03AM BLOOD PT-13.4* PTT-26.1 INR(PT)-1.2*
[**2173-6-26**] 12:03AM BLOOD Glucose-96 UreaN-17 Creat-0.6 Na-138
K-3.7 Cl-103 HCO3-27 AnGap-12
[**2173-6-26**] 12:03AM BLOOD Calcium-8.3* Phos-2.9 Mg-2.1
[**2173-6-26**] 12:15AM BLOOD Type-ART pO2-73* pCO2-50* pH-7.35
calTCO2-29 Base XS-0
[**2173-6-26**] 12:15AM BLOOD Lactate-1.9
Brief Hospital Course:
57 yo F with PMH non-small cell lung cancer s/p LUL lobectomy in
[**3-/2173**] with radical LND plus intercostal flap patch and
pulmonary artery angioplasty, vocal cord paralysis [**12-24**]
intubation, HTN, depression, CREST syndrome transferred from OSH
for possible bronchial stent after several episodes of recurrent
PNA and hypoxia. Pt intubated at OSH. Cause of LLL bronchial
compression was uncertain but suspicion was that recurrent lung
cancer could be the cause. LUL stump had been bronched in past
and found to be necrotic. Plan was for CT scan and possible
[**Month/Day (2) **] in AM. However, several hours after admission pt began
hemorrhaging into ETT tubing (over a liter of frank blood in
minutes). She rapidly lost her blood pressure, desaturated, and
became pulseless. Code Blue was called and attempt was made to
resuscitate patient, but this was deemed futile after a short
time. At that time, she had no pulse, no respirations, pupils
were fixed and unresponsive to light, and there were no dolls
eyes. Time of death 0545. Death reported to ME who declined
autopsy. Family also declined autopsy.
Medications on Admission:
Medications HOME:
ASA 81 mg daily
ipratropium 18mcg daily
Furosemide 20 mg PO/NG DAILY
pantoprazole 40mg po daily
Senna 1 TAB PO/NG [**Hospital1 **]:PRN constipation
enoxaparin 40mg subcutaneously
BuPROPion 150 mg PO BID
Verapamil SR 240mg po BID
Docusate Sodium 100 mg PO/NG [**Hospital1 **]
mucomyst 2mL inh q4h
duoneb 1 amp q4h
prednisone 60mg po daily
Gabapentin 600 mg PO/NG TID
fluconazole 100mg po daily
CefTAZidime 100mg IV Q8H
Vancomycin 750 mg IV Q 12H
miralax daily
ferrous sulfate 325mg daily
calcium carbonate 1250mg po daily
timolol one drop each eye qHS
.
MEDS ON TRANSFER:
-Artificial Tears 1-2 DROP BOTH EYES [**Hospital1 **]
-Gabapentin 600 mg PO/NG TID
-Aspirin 81 mg PO/NG DAILY
-Heparin 5000 UNIT SC TID
-Insulin SC (per Insulin Flowsheet) SSI
-BuPROPion 150 mg PO BID
-Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL TID
-MethylPREDNISolone Sodium Succ 60 mg IV Q8H
-CefTAZidime 1 g IV Q8H
-Midazolam 5-20 mg/hr IV DRIP
-Nystatin Oral Suspension 5 mL PO QID:PRN thrush
-Docusate Sodium 100 mg PO/NG [**Hospital1 **]
-Pantoprazole 40 mg IV Q24H
-Senna 1 TAB PO/NG [**Hospital1 **]:PRN constipation
-Diltiazem 5-15 mg/hr IV INFUSION
-Sulfamethoxazole-Trimethoprim 275 mg IV Q12H
-Furosemide 20 mg PO/NG DAILY
-Vancomycin 750 mg IV Q 12H
-Fentanyl Citrate 25-100 mcg/hr IV DRIP INFUSION
-Verapamil 80 mg PO Q8H
-Combivent nebs q4h INH
-racepinephrine neb 0.5mL q4h
-fluconazole 100mg IV daily for thrush
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Lung cancer, pulmonary hemorrhage
Discharge Condition:
deceased
Discharge Instructions:
N/A
Followup Instructions:
N/A
|
[
"162.9",
"V15.82",
"486",
"513.0",
"443.0",
"401.9",
"V45.76",
"311",
"710.1",
"285.9",
"V16.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.60",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
7054, 7063
|
4430, 5549
|
297, 303
|
7140, 7150
|
3676, 4407
|
7202, 7208
|
2997, 3057
|
7026, 7031
|
7084, 7119
|
5575, 6146
|
7174, 7179
|
3072, 3631
|
3647, 3657
|
2566, 2585
|
244, 259
|
331, 2547
|
2607, 2847
|
2863, 2981
|
6164, 7003
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,391
| 102,916
|
52611
|
Discharge summary
|
report
|
Admission Date: [**2116-3-4**] Discharge Date: [**2116-3-23**]
Date of Birth: [**2054-11-6**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1115**]
Chief Complaint:
Fatigue, Chills
Major Surgical or Invasive Procedure:
Percutaneous Liver Drainage
History of Present Illness:
61 y/o M with hx of DM, hyperlipidemia and memory loss presents
today with one week of generalized fatigue, poor PO intake and
chills.
Per patient and daughter, patient noted profound fatigue and
frequent chills over last three days. He hasn't been able to
eat, and hasn't taken any of his medications. Denies dysuria,
cough, chest pain, shortness of breath, diarrhea, abdominal
pain, neck pain. Taken by his daughter to his PCPs office, there
he was noted to be sluggish, dyspneic, tachycardic in clinic and
has a FSG of 455, on repeat 525.
.
In the ED, initial vitals were T 99.8, HR 127, BP 127/58, R 50
and 100% 10L NRB. He was noted to have a glucose of 411 and an
anion gap of 20. His troponin was 0.15 and EKG demonstrated
sinus tach with < 1mm STD laterally. He received a full dose
aspirin for possible ACS and tylenol for fever. He was given 6L
NS, and started on an insulin gtt at 3 units/hr.
Past Medical History:
DM2 - on metformin/glyburide
Hyperlipidemia
Memory Loss
Social History:
Patient was born in [**Location (un) 4708**] and came to the US in [**2085**]. He has
an eigth grade education. He did construction work in [**Location (un) 4708**]
and in the US worked in parking and transportation. He smokes 5
cigarettes a day. Never been a drinker
Family History:
Mother had dementia, beginning in her fifties
Physical Exam:
ADMISSION EXAM:
VITALS:T 95.4, HR 81, BP 108/51, RR 18, 100/3L
GEN: pleasant, comfortable, NAD
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no
supraclavicular or cervical lymphadenopathy, no jvd, no carotid
bruits, no thyromegaly or thyroid nodules
RESP: CTA b/l, shallow breaths
CV: RR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e
SKIN: no rashes/no jaundice/no splinters
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch appreciated. No pass-pointing on
finger to nose. 2+DTR's-patellar and biceps. Slow mentation, but
AAO x 3
Pertinent Results:
Admission Labs: [**2116-3-4**]
CBC: WBC-13.5*# RBC-4.76 Hgb-12.8* Hct-37.7* MCV-79* MCH-26.9*
MCHC-34.1 RDW-13.9 Plt Ct-168
Diff: Neuts-86.3* Lymphs-6.4* Monos-4.6 Eos-0.0 Baso-0.2
Coags: BLOOD PT-15.1* PTT-20.2* INR(PT)-1.3*
Chemistries: Glucose-411* UreaN-24* Creat-2.1* Na-132* K-3.7
Cl-92* HCO3-20* AnGap-24*
.
Labs on Discharge:
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
10.2 3.06* 8.1* 24.1* 79* 26.6* 33.6 18.7* 393
UreaN Creat
20 2.4*
ALT:15, AST:19, Alk Phos: 214
.
Microbiology:
Blood Culture ([**3-4**]): SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
STREPTOCOCCUS ANGINOSUS (MILLERI)
GROUP
|
CLINDAMYCIN----------- S
ERYTHROMYCIN----------<=0.25 S
PENICILLIN G----------<=0.06 S
VANCOMYCIN------------ <=1 S
Anaerobic Bottle Gram Stain (Final [**2116-3-5**]):
GRAM POSITIVE COCCI IN CHAINS.
Aerobic Bottle Gram Stain (Final [**2116-3-5**]):
GRAM POSITIVE COCCI.
IN PAIRS AND CHAINS.
Liver Abscess Culture:
GRAM STAIN (Final [**2116-3-9**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CHAINS.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN CLUSTERS.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
SMEAR REVIEWED; RESULTS CONFIRMED.
FLUID CULTURE (Final [**2116-3-15**]):
STREPTOCOCCUS ANGINOSUS (MILLERI) GROUP. SPARSE GROWTH.
ANAEROBIC CULTURE (Final [**2116-3-13**]):
BACTEROIDES FRAGILIS GROUP. SPARSE GROWTH.
BETA LACTAMASE POSITIVE.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2116-3-10**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
.
Chest X-ray ([**3-4**]): Single AP view of the chest demonstrates low
lung volumes. There is no pleural effusion, focal consolidations
or pneumothorax. The hilar and mediastinal silhouettes are
unremarkable. The heart is of normal size. Pulmonary vasculature
appears prominent.
.
TTE ([**3-9**]):
The left atrium is normal in size. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). Right ventricular chamber size and free wall
motion are normal. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic regurgitation. 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.
Trivial mitral regurgitation is seen. The estimated pulmonary
artery systolic pressure is normal. There is no pericardial
effusion.
IMPRESSION: No vegetations or clinically-significant regurgitant
valvular disease seen (adequate-quality study). Normal global
and regional biventricular systolic function.
.
CT Chest ([**3-6**]):
1. Multifocal peripheral nodular opacities in the upper lobes,
could represent early multifocal pneumonia. Bibasilar
atelectasis, also suspicious for superimposed infection.
2. 1.5 cm multilobulated slightly hyperdense nodule in the
right upper lobe, while this could be part of the infectious
process, concern is raised for underlying neoplasm such as
bronchioloalveolar carcinoma (BAC) based on the morphology and
attenuation. Recommend repeating CT chest after antibiotic
treatment to ensure clearance and to rule out underlying
neoplasm.
3. 2.8-cm hypodensity in the right hepatic lobe, incompletely
assessed without IV contrast. Differential diagnosis includes
hepatic cyst versus intrahepatic abscess. Consider right upper
quadrant ultrasound for further evaluation.
.
Abdominal Ultrasound ([**3-7**]):
1. Heterogenous, predominantly hypoechoic lesion within the
right lobe of the liver with ill-defined margins and no
vascularity is identified. This lesion can't be classified as a
cyst or hemangioma (two of the more common benign lesions of the
liver) based on this study. Wide differential diagnosis remains
including neoplasm. Triple phase MRI or CT can be pursued for
further evaluation as clinically indicated.
2. Splenomegaly.
.
MR [**Name13 (STitle) **] ([**3-8**]):
1. No evidence of acute intracranial abnormality. Please note,
no contrast
could be given due to low GFR.
2. Multiple focal FLAIR hyperintensities are present within the
supratentorial brain most consistent with the sequela of chronic
small vessel ischemic disease.
3. Bilateral mastoid sinuses demonstrate fluid/mucosal
thickening. Please
clinically correlate.
.
MR spine ([**3-8**]):
1. No evidence of epidural abscess or discitis. Please note no
contrast was given due to a low GFR.
2. Minimal degenerative changes with moderate neural foraminal
narrowing at L3-L4 due to facet arthrosis bilaterally.
3. On the scout image, there is partial imaging of a
heterogeneous signal
mass within the liver. Please see recent abdominal ultrasound
for further
details.
.
TEE ([**3-9**]):
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. No atrial septal defect is seen
by 2D or color Doppler. Left ventricular wall thicknesses and
cavity size are normal. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. The ascending, transverse and
descending thoracic aorta are normal in diameter and free of
atherosclerotic plaque to 42 cm from the incisors. 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 leaflets are
structurally normal. No mass or vegetation is seen on the mitral
valve. Mild (1+) mitral regurgitation is seen. No
vegetation/mass is seen on the pulmonic valve. There is no
pericardial effusion.
IMPRESSION: Mild mitral regurgitation with structurally normal
valve. No 2D echo evidence for endocarditis identified.
.
MRI Pelvis ([**2116-3-10**]):
1. Normal hip joints. No evidence of osteomyelitis, or joint
effusion. No evidence of abscess.
2. Mild symmetric bilateral adductor muscle edema, and mild
edema about the greater trochanters, tracking along the tensor
fascia lata, and iliotibial band, and bilateral gluteal muscles.
Findings are nonspecific, but could represent myositis, possibly
associated with patient's severe illness.
3. Diverticulosis.
4. Mild degenerative change at the sacroiliac joints, and pubic
symphysis.
.
Liver Ultrasound ([**2116-3-13**]):
IMPRESSION: Residual abnormal echotexture involving an extensive
portion of the right lobe is likely related to residual
inflammation in the hepatic parenchyma. A CT of the abdomen and
pelvis is recommended to better delineate the extent of the
abnormality and may help to determine a possible cause.
.
MRI Abdomen w/o Contrast ([**2116-3-18**]):
1. Right hepatic abscess, minimally changed in size compared to
the ultrasound [**2116-3-13**], though comparison is difficult
given the difference in technique. More fluidic pockets
measuring up to 2.5 cm each may benefit from more medial
repositioning of the drain.
2. Findings highly suggestive of sigmoid diverticulitis with a 7
cm stretch of abnormally thickened sigmoid colon. MRI of the
pelvis from eight days prior demonstrated edema and possible
intramural abscess associated with the sigmoid colon. Further
evaluation with CT is recommended to evaluate the extent of
inflammation and serve as a baseline study for future exams.
.
CT Pelvis: Sigmoid diverticulosis with mild wall thickening and
fat stranding appears improved from prior MRI suggesting
resolving diverticulitis.
.
CT Abdomen:
1. Allowing for differences in technique, right hepatic abscess
is unchanged with drain located within the lateral portion of
the abscess. Assessment is limited due to absence of intravenous
contrast.
2. Small-to-moderate right pleural effusion with associated
atelectasis.
3. Left basilar nodularity and pleural thickening which could
reflect atelectasis or previously described infectious process.
Brief Hospital Course:
61 year-old male with history of non-insulin dependent DM,
hyperlipidemia and memory loss who presented with one week of
fatigue, chills and poor PO intake.
.
# Sepsis/Liver Abscess: Blood cultures on admission grew
Streptococcus anginosus. Liver ultrasound demonstrated a 6 x 9
cm lesion, which was drained at bedside by IR, and found to be
an abscess growing Strep anginosus and B. fragilis. Started on
ceftriaxone/metronidazole. MRCP demonstrated diverticulitis
which is likely etiology of bacteremia and subsequent abscess.
No endocarditis by TEE. Dental exam normal. MRCP [**3-18**]
demonstrated size of abscess unchanged compared to initial
ultrasound on admission. CT Abd did indicate drain in place. The
patient was evaluated by Hepatobiliary surgery service given the
lack of resolution of hepatic abscess. It was determined that
likely cause of abscess persistence was that his drain was not
being appropriately flushed, accounting for the slow resolution
of abscess visualized on CT. The patient will follow-up with
Infectious Disease and Hepatobiliary Surgery as an outpatient.
It is very important to continue TID drain flushes as specified
in treatments and freq. Plan is for a 4 week (starting [**2116-3-23**])
course of the ceftriaxone and flagyl. He will need weekly
monitoring labs drawn which are specified in treatments and
frequency of PAGE1. ID and Transplant Surgery appts have been
scheduled.
.
#. [**Last Name (un) **]/Likely ATN: Baseline Cr unknown. Creatinine trend up to
3.7 during ICU course. Believed to be secondary to ATN in
setting of septic shock given history and muddy brown casts in
sediment. Renal ultrasound was normal. Creatinine gradually
improved with good urine output. Creatinine at the time of
discharge was 2.4. BUN/Cr will be drawn weekly as part of aABX
monitoring. Pt scheduled for outpatient nephrology f/u at [**Hospital1 18**].
.
# Hypoxemic Respiratory Failure: On hospital day two, patient
became acutely hypoxic, likely from flash pulmonary edema and
was intubated. On [**3-12**], the patient was weaned from the
ventilator and extubated without complication. His respiratory
status continued to improve with diuresis (likely post-ATN). He
was ultimately weaned off oxygen and remained stable on RA
throughout hospital course
.
# Hypertension: Pt has no documented history of HTN and was not
on an anti-hypertensive regimen. On admission he was
hypertensive following fluid resucitation to 180s. He was slowly
started on regimen of hydralazine, amlodipine, and metoprolol
which has kept systolics in 130's. Pt will need PCP f/u and
possible medication titration.
.
# Hip pain: On admission, patient complained of hip pain. MRI
pelvis was obyained to rule out infection. This showed mild
symmetric bilateral adductor muscle edema, mild edema at greater
trochanters. Ortho was consulted and recommended pain control
for trochanteric bursitis.
.
# DM: Held home metformin and glyburide at presentation give
[**Last Name (un) **]. Patient was initiated on lantus and insulin sliding scale,
which was slowly uptitrated during the course of his hospital
stay. At the time of discharge, the patient was taking 41 U
lantus each night, with 3 U pre-prandial humalog. The patient's
insulin requirement may decrease as his infection resolves; his
blood sugars will need to be monitored closely and his insulin
downtitrated. Pt and his family will need insulin dosing and
administration teaching.
.
# Outstanding Labs: None
.
# Transitions of Care:
--DRAIN CARE: aspirate the right flank percutaneous drain,
record output, then vigorously flush drain with 10cc NS TID.
Aspirate all contents again and record the difference of NS
flush minus drain output.
--QID fingersticks on the patient in rehab, given ongoing
insulin titration. We suspect insulin requirement will decrease
--Check CBC with differential, BUN/Cr, LFTs weekly given pt on
long term antibiotics. Please fax results to [**Telephone/Fax (1) 1419**]
(Infectious Disease Clinic at [**Hospital1 18**])
--Patient will follow-up with Hepatobiliary surgery in 1 week.
At this time, determination will be made regarding further
imaging and need for drain to remain in place.
--Patient will follow up with Infectious Disease and Nephrology
in [**2-6**] weeks time.
--Pt will need PCP f/u after rehab stay for BP check and
monitoring of his diabetes treatment regimen
FULL CODE ON THIS ADMISSION
Medications on Admission:
# Glyburide 2.5 mg daily
# Metformin 850 mg [**Hospital1 **]
# ASA 81 mg daily
# Pravastatin 20 mg qHS
# Memantine 10 mg [**Hospital1 **]
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
3. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours): Last day: [**2116-4-20**].
4. ceftriaxone in dextrose,iso-os 2 gram/50 mL Piggyback Sig:
Two (2) grams Intravenous Q24H (every 24 hours): Last day:
[**2116-4-20**].
5. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
6. memantine 10 mg Tablet Sig: One (1) Tablet PO twice a day.
7. Humalog 100 unit/mL Solution Sig: Three (3) units
Subcutaneous three times a day: Please take just before meals.
8. Outpatient Lab Work
Please check CBC with differential, BUN/Cr, LFTs weekly. Please
fax results to [**Telephone/Fax (1) 1419**].
9. hydralazine 25 mg Tablet Sig: One (1) Tablet PO every six (6)
hours.
10. Lantus 100 unit/mL Solution Sig: Forty (40) units
Subcutaneous at bedtime.
11. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO
three times a day.
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 3504**] [**Last Name (NamePattern1) **] Rehabilitation & Nursing Center - [**Location (un) 538**]
Discharge Diagnosis:
Primary Diagnoses:
-Strep Anginosus Bacteremia
-Liver Abscess
-Respiratory Failure
-Acute Kidney Injury
-Diverticulitis
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 Mr. [**Known lastname **],
.
It was a pleasure taking care of you here at [**Hospital1 771**]. You were admitted to the intensive
care unit with an infection in your blood and in your liver.
You were started on antibiotics for these infections and
administered aggressive intravenous fluid. You were placed on
the ventilator for a short period of time in order to remove
fluid from your lungs. When you were able to breathe comfortably
on your own, you were transferred to the medical [**Hospital1 **]. Here,
your symptoms improved significantly over the following days
with continued antibiotics. You underwent further studies to
determine a source of your blood and liver infections. It
appears as though your infections may have originated from a
condition called diverticulitis in your bowel.
.
You will continue on antibiotics for several more weeks. You
will follow-up closely with the infectious disease specialists,
hepatobiliary surgeons, and kidney specialists in the coming
weeks. The liver drain will remain in place until you follow-up
with the surgeons. At the time of this appointment, they will
evaluate whether this drain may be removed and determine the
need for further imaging.
.
Please START the following medications:
CEFTRIAXONE (to be continued through [**2116-4-20**])
FLAGYL (to be continued through [**2116-4-20**])
AMLODIPINE
METOPROLOL
HYDRALAZINE
LANTUS
HUMALOG
.
Please STOP the following medications:
METFORMIN
GLYBURIDE
.
If you experience any symptoms that concern you after leaving
the hospital, please call your primary care doctor or return to
the emergency room as soon as possible.
.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD
Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2116-3-26**] 8:30
[**Last Name (NamePattern1) **], [**Hospital **] Medical Building [**Location (un) **]
[**Location (un) 86**], [**Numeric Identifier 718**]
.
Name: [**Last Name (un) **]-[**Hospital1 **],MYECHIA
Location: [**Hospital 3578**] COMMUNITY HEALTH CENTER
Address: [**Hospital1 3579**], [**Location (un) **],[**Numeric Identifier 3580**]
Phone: [**Telephone/Fax (1) 3581**]
Appointment: Tuesday [**2116-3-24**] 12:30pm
.
Department: WEST [**Hospital 2002**] CLINIC
When: WEDNESDAY [**2116-4-1**] at 9:00 AM
With: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 720**], M.D. [**Telephone/Fax (1) 721**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
.
Department: INFECTIOUS DISEASE
When: TUESDAY [**2116-4-7**] at 10:00 AM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
.
Department: INFECTIOUS DISEASE
When: FRIDAY [**2116-5-8**] at 9:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 27625**], 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: TRANSPLANT CENTER
When: THURSDAY [**2116-3-26**] at 8:30 AM
With: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,045
| 189,451
|
33110
|
Discharge summary
|
report
|
Admission Date: [**2194-2-16**] Discharge Date: [**2194-2-21**]
Date of Birth: [**2131-2-12**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
AICD firing
Major Surgical or Invasive Procedure:
None
History of Present Illness:
63 y/o M hx CAD s/p CABG in [**2175**] and s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (Prefixes) 28525**] in [**2190**]
(anatomy unclear at time of admission), s/p [**Company 1543**] AICD
placement and biventricular pacer in [**2189**] for Vfib arrest, Type
II DM, CHF (EF40%), and s/p AVR with St. [**Male First Name (un) 1525**] mechanical valve
on coumadin presents after ICD firing X 6 times.
.
Today, patient was sitting at home watching football game (8PM)
when he had a few seconds of pressure in chest consistent with
previous ICD firing episodes before ICD fired. He called 911,
EMS noted VT, and went to [**Hospital2 **] [**Hospital3 6783**] hospital. His ICD fired
a total of 6 times until he arrived at OSH. At OSH, received
amiodarone 150 mg X 2 and started amio gtt. Tx to [**Hospital1 18**] for
further management.
.
Upon arrival to [**Hospital1 18**], potassium 2.9, and EKG with U waves c/w
hypokalemia. No further firing since arrival to OSH. Further hx
revealed that yesterday, he did not take his K (normally takes
60 meq daily) after script ran out, and today took only 40 meq
later than usual (at 3PM). Also, this AM he did not take any of
his AM meds including amiodarone until 3PM. EP saw patient and
interrogated ICD which revealed 9 episodes of VT each lasting
for 8-12 seconds, 6 treatments. He received K 60 PO, 10 IV in
ED.
.
This is the 3rd episode of ICD firing since it was placed in
[**2189**] for Vfib arrest. Then in [**2190**], while playing golf it fired
in setting of chest pain and was subsequently found to have
?graft occlusion (hx needs to be clarified with OSH records).
Then, recently on [**2193-12-18**], ICD fired 48 times, and he went
to [**Hospital1 **]-[**Last Name (un) 17679**]. Per wife, he underwent VT ablation but no
inducible foci found. He was initially hyperkalemic and then
hypokalemic at the time. EP fellow note reports that K was 2.5
at that time. Amiodarone was increased to 400 mg [**Hospital1 **] at that
time.
.
Currently, in CCU, pt reports feeling well with no complaints.
No further firing for 6 hrs.
.
Cardiac review of systems is notable for + PND [**2-19**] X per month.
Weight up 3 pounds from dry weight (177->180 lbs), +
intermittent leg and abd edema. Otherwise no chest pain, dyspnea
on exertion (can climb 3 flights of stairs with minimal
difficulty), syncope or presyncope.
.
On review of symptoms, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, cough, hemoptysis, black stools or red stools.
He denies recent fevers, chills or rigors. He denies exertional
buttock or calf pain, but does get cramps when K low. All of the
other review of systems were negative.
Past Medical History:
- CAD: [**2175**] s/p CABG (anatomy unclear at admission) and then had
repeated occlusions and s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (Prefixes) 5303**] in [**2190**]
- [**2188**] s/p AVR with [**Hospital3 9642**] mechanical valve on coumadin
- [**2189**] s/p bilateral renal artery stents
- V. fib arrest: [**2189**] s/p ICD placement on amiodarone
- Hypothyroidism
- type 2 DM: c/b peripheral neuropathy
- hyperlipidemia
- hypertension
- s/p cholecystectomy
Social History:
Social history is significant for the absence of current tobacco
use. Quit 20 years ago and previosuly only smoked [**2-19**] pack/day.
There is no history of alcohol abuse.
Family History:
Mother: died MI age 38
Father: died ETOH abuse
Half-brother: died massive MI age 33
Brothers with hyperlipidemia, ETOH abuse
Physical Exam:
VS: T 98.4, BP 114/52 , HR 64, RR 24, O2 94% on 4LNC
Gen: WDWN middle aged male in NAD, resp or otherwise. Oriented
x3. Mood, affect appropriate. Pleasant.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP of 8 cm.
CV: regular, 2/6 systolic murmur best at LUSB, no rubs, gallops
Chest: + crackles 1/3 up bilaterally, No chest wall deformities,
scoliosis or kyphosis. Resp were unlabored, no accessory muscle
use. + tracte back and sacral edema
Abd: midline scar, Obese, soft, NTND, No HSM or tenderness. No
abdominial bruits.
Ext: No c/c/+ trace pitting edema in ankles.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; 2+ DP
Left: Carotid 2+ without bruit; 2+ DP
Pertinent Results:
CXR on admission: No acute cardiopulmonary process
.
Echocardiogram:
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is 0-10mmHg. Left ventricular wall thicknesses are normal. The
left ventricular cavity is mildly dilated. There is mild to
moderate regional left ventricular systolic dysfunction with
anterior, anterolateral, and inferolateral hypokinesis.
[Intrinsic left ventricular systolic function is likely more
depressed given the severity of valvular regurgitation.] The
estimated cardiac index is depressed (<2.0L/min/m2). Right
ventricular chamber size and free wall motion are normal. The
aortic arch is mildly dilated. A mechanical aortic valve
prosthesis is present. The transaortic gradient is normal for
this prosthesis. Trace aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Moderate to severe (3+) mitral regurgitation is seen.
The tricuspid valve leaflets are mildly thickened. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Moderate regional left ventricular systolic
dysfunction consistent with multivessel CAD. Moderate to severe
mitral regurgitation. Mechanical aortic valve is not well seen,
but the transvalvular gradient is normal for this prosthesis.
Moderate estimated pulmonary artery systolic hypertension.
Brief Hospital Course:
The following were active issues during this hospitalization:
.
1. AICD activation: The patient's ICD was interrogated and was
found to have fired 6 times for ventricular tachycardia. This
occured in the setting of hypokalemia (admission potassium of
2.9) afer missing a dose of supplemental potassium and in the
setting of a missed dose of amiodarone. His admission EKG showed
u waves. His potassium was aggressively repleted on admission,
and he was placed on an amiodarone drip. He was seen by the EP
service and converted to a po regimen of amiodarone at 200mg
qday. His potassium level normalized, as did his EKG. He
remained in normal sinus rhythm thereafter. We also initiated
an ACE inhibitor to give him some potassium sparing with his
home regimen of lasix, which he tolerated well.
.
2. Hypokalemia: He was noted to have quite stubborn hypokalemia
throughout his hospitalization. We did the following to help
control this: His lasix dose was decreased to 40mg daily as this
was thought to be the main reason for potassium wasting; we
added lisinopril for potassium sparing properties; and we
increased his daily supplemental potassium dose to 80mEQ daily.
He will have close follow up with his cardiologist for
monitoring
.
3. INR: His INR was low at 1.4, so he was discharged with a
lovenox bridge and close follow-up for INR monitoring.
.
2. History of CHF: On his admission exam, he was noted to be
slightly fluid overloaded with inspiratory crackles on lung
exam, and some pitting edema on his sacrum. We performed an
echocardiogram to establish a baseline which showed
anterior/anterolateral/inferolateral hypokinesis with EF 40%, 3+
TR, and moderate PA HTN.
Medications on Admission:
Toprol XL 150 daily
amiodarone 400 daily
Digoxin 125 mcg daily
Plavix 75 daily
Aspirin 81 every other day
Warfarin
Protonix 40 daily
Baclofen 20 TID
Lasix 80 mg [**Hospital1 **]
Crestor 40 daily
Zetia 10 daily
Glipizide??
Synthroid 100 mcg, 50 mcg alternating days
iron
MVI
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Baclofen 10 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
9. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO At your
home regimen of alternating doses of 50 and 100mcg per day.
10. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*3*
13. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) 0.8mL syringe
Subcutaneous [**Hospital1 **] (2 times a day): Please continue until your INR
is therapeutic (2.0-2.2).
Disp:*60 0.8mL syringe* Refills:*2*
14. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: 1.5 Tablet Sustained Release 24 hrs PO once a day.
15. Warfarin 5 mg Tablet Sig: At your usual home dose Tablet PO
HS (at bedtime).
16. Potassium Chloride 20 mEq Packet Sig: Four (4) Packet PO
ONCE (Once) for 1 doses.
Disp:*240 Packet(s)* Refills:*6*
17. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*3*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Hyperkalemia with ICD firing.
Secondary: CHF
Discharge Condition:
Stable
Discharge Instructions:
You were admitted because your ICD fired for an abnormal heart
rhythm called ventricular tachycardia. We think that this is
probably due to an abnormal potassium level in your blood, which
was too low. We gave you supplemental potassium and your heart
rhythm remained normal.
.
.
We made the following changes to your outpatient medication
regimen:
1. lisinopril 2.5mg po daily
2. Potassium chloride 80meq daily
3. Lasix 40mg by mouth daily instead of 80mg daily
4. Amiodarone 200mg by mouth daily instead of twice daily
.
Please return to the emergency department if your ICD fires
again, or if you experience any chest discomfort remnant of your
ICD activity.
.
Please follow up with your Cardiologist on Monday and ask them
to check your potassium and make any adjustments necessary to
your potassium dosing.
Followup Instructions:
Please follow up with your cardiologist on Monday [**2194-2-24**] to have
your potasssium checked and make any necessary changes in your
potassium dosing. In addition, your cardiologist should
interrogate your pacemeaker as well.
|
[
"V43.3",
"276.8",
"V45.02",
"357.2",
"401.9",
"V58.61",
"244.9",
"250.60",
"397.0",
"V45.81",
"272.4",
"427.1",
"428.0",
"414.8"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9867, 9873
|
6261, 7948
|
326, 332
|
9971, 9980
|
4800, 4804
|
10842, 11075
|
3842, 3969
|
8273, 9844
|
9894, 9950
|
7974, 8250
|
10004, 10819
|
3984, 4781
|
275, 288
|
360, 3111
|
4818, 6238
|
3133, 3634
|
3650, 3826
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,118
| 120,890
|
47316
|
Discharge summary
|
report
|
Admission Date: [**2196-9-15**] Discharge Date: [**2196-9-24**]
Date of Birth: [**2116-2-28**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
Colonoscopy X2 ([**9-15**]. [**9-19**])
EGD ([**9-21**])
Angiogram with embolization 4th branch of the mesenteric artery
([**9-15**])
right IJ cordis placement [**9-15**]
History of Present Illness:
80 y/o with PMH sig for CAD s/p 1 vessel CABG, EF 15%, CHF s/p
ICD, recent admit for GIB [**9-7**] for GIB requiring 1 U PRBC.
During this admission, he an EGD/colonoscopy off of coumadin but
was restarted ASA/Plavix/coumadin on [**9-9**] following procedure.
The EGD showed at that time showed mild gastritis and the
colonoscopy showed 3 sessile nonbleeding polyps in ascending
colon s/p hot snare single piece polypectomies (path showed
adenoma)
.
Pt presented to the ED on [**9-15**] after two episodes of BRBPR: one
at approximatley 12:45 am, and another one after the patient
presented to the ED. Pt denied any
n/v/diarrhea/melena/hematemesis/ cp/sob/f/c/NS or abdominal
pain.
.
In ED, found to have initial HCT of 35.4; INR 1.7, Pt was
initially HD stable but then dropped his SBP to 70s-->repeat HCT
was 28. Pt was given a 250 cc NS bolus, along with 1 U PRBC, 1
mg Glucagon, Protonix 40 mg IV. NGT lavage was normal (+bilious
return). The GI service was consulted
DDx at that time included polypectomy site bleed vs. SB bleed
vs. brisk UGIB?- most likely from polypectomy. Initially
hemodynamically stable, but became hypotensive to BP 70's at 4
am, Hct drop to 28. Improved w/ IVF bolus 500 cc to BP 130's,
then trended down again to BP 90's. He was transferred to the
ICU for further managment
Past Medical History:
Past Medical History:
1. Coronary Artery Disease s/p CABG [**2162**] (SVG-LAD known to be
occluded) s/p LCX stent in [**2186**]; D1 stent (DES) placed [**11-6**]
2. CHF (EF 20%) with ICD placed in [**2192**], on coumadin for
?apical
thrombus
3. Prostate Cancer with stable PSA, followed by heme-onc
4. Right Complex Renal Mass followed by serial US; most recent
renal US on [**2196-3-1**] showing complex cystic mass in right kidney,
unchanged; cannot exclude neoplasm.
5. Gallstones
6. CRI
7. Gout
8. HTN
9. Melena: [**9-9**], EGD showed mild gastritis, [**Last Name (un) **] showed 3
sessile nonbleeding polyps in ascending colon s/p hot snare
single piece polypectomies, path showed adenoma.
Social History:
Denies T/A/D. Lives with wife, has 3 children. Former
meatpacker, retired 22 yrs ago.
Family History:
Father died at age 42 from embolism. No history of early CAD,
sudden cardiac death. No DM
Physical Exam:
PE
VS: 97.5 55 112/58 14 96% RA
Gen laying in bed, non-toxic appearing, pleasant comfortable
eldery gentleman
HEENT NCAT, Mild dry MM
Neck: supple, JVP flat
Chest: CTAB without rales/wheezes
CVS: rrr, no mrg appreciated
Abd soft, nabs, ND, slight RLQ discomfort
Extrem: trace edema
neuro: A&oX3, grossly intact
.
Pertinent Results:
WBC RBC Hgb Hct MCV MCH MCHC RDW
Plt Ct
[**2196-9-24**] 09:11AM 8.2 3.95* 12.4* 36.1* 91 31.4 34.3 15.9*
212
[**2196-9-23**] 06:25AM 9.4 4.02* 12.7* 35.5* 88 31.7 35.9* 15.8*
165
[**2196-9-22**] 09:00PM 33.5*
[**2196-9-22**] 03:15PM 34.9*
[**2196-9-22**] 09:35AM 34.9*
[**2196-9-22**] 06:30AM 7.1 3.46* 11.1* 30.0* 87 32.0 36.9* 15.9*
136*
[**2196-9-21**] 09:00PM 32.7*
[**2196-9-21**] 04:16PM 34.9*
[**2196-9-21**] 06:33AM 8.2 3.79* 11.8* 33.2* 88 31.1 35.5* 16.0*
156
[**2196-9-20**] 07:45PM 35.0*
[**2196-9-20**] 04:02AM 9.6 3.68* 11.6* 32.3* 88 31.6 36.1* 15.8*
124*
[**2196-9-19**] 11:04PM 31.8*
[**2196-9-19**] 06:10PM 32.8*
[**2196-9-19**] 01:13PM 31.7*
[**2196-9-19**] 04:16AM 8.1 3.29* 10.2* 28.6* 87 31.0 35.8* 16.1*
115*
[**2196-9-18**] 11:49PM 30.7*
[**2196-9-18**] 07:00PM 32.8*
[**2196-9-18**] 03:05PM 33.6*
[**2196-9-18**] 11:15AM 11.9* 12.0* 33.2* 86 31.2 36.2* 15.6*
105*
[**2196-9-18**] 07:00AM 10.2* 29.9*
[**2196-9-18**] 04:16AM 9.7 3.22* 9.5* 27.0* 84 29.5 35.2* 16.5*
128*
[**2196-9-17**] 11:46PM 11.0* 29.9*
[**2196-9-17**] 07:44PM 11.2* 31.0*
[**2196-9-15**] 01:49AM HGB-11.3* calcHCT-34
[**2196-9-15**] 01:53AM WBC-8.6 RBC-3.66* HGB-11.4* HCT-35.4* MCV-97
MCH-31.1 MCHC-32.2 RDW-14.9
[**2196-9-15**] 03:46AM HGB-9.2* calcHCT-28
[**2196-9-15**] 09:00AM HCT-26.7*
[**2196-9-15**] 01:30PM HCT-26.1*
[**2196-9-15**] 05:36PM HCT-24.3*
[**2196-9-15**] 09:59PM HCT-26.5*
[**2196-9-15**] 01:53AM PT-15.8* PTT-27.7 INR(PT)-1.7
[**2196-9-15**] 01:53AM GLUCOSE-118* UREA N-39* CREAT-1.6* SODIUM-140
POTASSIUM-4.5 CHLORIDE-104 TOTAL CO2-26 ANION GAP-15
[**2196-9-15**] 09:00AM GLUCOSE-128* UREA N-39* CREAT-1.3* SODIUM-139
POTASSIUM-4.7 CHLORIDE-107 TOTAL CO2-23 ANION GAP-14
[**9-15**] colonoscopy
Findings:
Contents: Clotted blood was seen in the rectum and sigmoid
colon. Stool was found in the rectum and sigmoid colon.
Impression: Blood in the rectum and sigmoid colon
Stool in the rectum and sigmoid colon
Otherwise normal colonoscopy to distal sigmoid colon
Recommendations: Bleeding Scan, if positive angiogram by IR.
If Bleeding scan negative and unable to do IR, continue golytely
prep and will re-attempt colonoscopy.Transfusion support.
[**9-15**] Embolization
PROCEDURE/FINDINGS:
IMPRESSION: Super selective superior mesenteric arteriogram
demonstrating extravasation of the contrast at the region of the
ascending colon, which was embolized with four microcoils. No
extravasation of the contrast noted at the end of the procedure
[**9-18**] colonoscopy
Findings:
Excavated Lesions A single circular non-bleeding 8 mm ulcer was
found in the proximal ascending colon. 3 cc.Epinephrine 1/[**Numeric Identifier 961**]
hemostasis with success. [**Hospital1 **]-CAP Electrocautery was applied for
hemostasis successfully. 3 1 cc.[**Country 11150**] ink injections were
applied for tattooing with success.
Other The area of the ulcer was about 3 cm from the ileocecal
valve. The scope visualized this area for 20 minutes and there
was no bleeding. Clots of blood were seen throughout the colon
all areas were washed and there was no active bleeding
Impression: Ulcer in the proximal ascending colon
Clots of blood were seen throughout the colon all areas were
washed and there was no active bleeding
The area of the ulcer was about 3 cm from the ileocecal valve.
The scope visualized this area for 20 minutes and there was no
bleeding.
Recommendations: Patient should continue to be observed in ICU
with frequent HCTs. If rebleeds will discuss with surgeons
utility of repeat endoscopy versus surgery.
[**9-21**] EGD
Findings: Esophagus: Normal esophagus.
Stomach:
Contents: Bilious fluid was seen in the stomach body.
Duodenum:
Flat Lesions A single, non-bleeding localized 1 mm red spot was
noted in the transverse duodenum. Mono-Polar Cautery Unit was
applied for hemostasis successfully.
Protruding Lesions A single, very small benign appearing
,non-bleeding polyp was found in the duodenum.
Impression: 1 mm spot in the Transverse duodenum
Polyp in the duodenum
Fluids in stomach
Brief Hospital Course:
80 y/o with PMH sig for CAD s/p 1 vessel CABG, EF 15%, recent
admit for GIB [**9-7**] for GIB requiring 1 U PRBC. During this
admission, he an EGD/colonoscopy off of coumadin but restarted
ASA/Plavix/coumadin [**9-9**] following procedure. The EGD showed
mild gastritis and the colonoscopy showed 3 sessile nonbleeding
polyps in ascending colon s/p hot snare single piece
polypectomies (path showed adenoma)
.
Pt presented on [**9-15**] with two episodes of BRBPR: one at
approximatley 12:45 am, and another one after the patient
presented to the ED. Pt denied any
n/v/diarrhea/melena/hematemesis/ cp/sob/f/c/NS or abdominal
pain.
1) GI bleed:
In ED, found to have initial HCT of 35.4; INR 1.7, Pt was
initially HD stable but then dropped his SBP to 70s-->repeat HCT
was 28. Pt was given a 250 cc NS bolus, along with 1 U PRBC, 1
mg Glucagon, Protonix 40 mg IV. NGT lavage was normal (+bilious
return).
DDx at that time included polypectomy site bleed vs. SB bleed
vs. brisk UGIB?- most likely from polypectomy. Initially
hemodynamically stable, but became hypotensive to BP 70's at 4
am, Hct drop to 28. Improved w/ IVF bolus 500 cc to BP 130's,
then trended down again to BP 90's.
Pt was admitted to ICU at 6 am and was hemodynamically stable w/
BP 110's s/p 1u RBC and 1u FFP. He got 2nd u RBC and 2nd u FFP.
On [**9-15**], pt had a colonoscopy that was unsucessful [**1-6**] too much
bleeding. He went for tagged RBC scan which localized bleeding
to the RUQ. He then went to angiography where the 4th branch of
SMA was embolized. His hct was montired closely after this . His
hct trended downward with rebleeding occuring on [**9-18**], DDAVP
given [**9-18**]. A repeat colonoscpy was done at that time and an
8mm nonbleeding ulcer ~3cm from ileocecal valve was bicapped,
injected with epi and dye. No active bleeding was noted at the
time of scope. Surgery was consulted during his MICU stay for
possiblity of colectomy if ongoing bleeding was an issue.
Since colonoscopy, his Hct and hemodynamics remained stable. Pt
remained without any complaints except for vague RLQ discomfort.
He notes no nausea , vomiting, diarrhea, chest pain or other
symptoms. His last transfusion was at 8am on [**9-19**] . In total,
he has required 20 units of PRBC transfusion since admission on
[**9-15**].
The polypectomy site remained the most likely source of bleed.
PPt hematocrit was followed Hct closely. At least [**Hospital1 **] and then
finally to Q24 hours in the last 2 days of his hospital stay. An
EGD was done on 10/ 19 which did not reveal any additional
bleeding source. The team including the medical attending, Dr.
[**Last Name (STitle) **] his cardiologist, and the GI attending agreed on restarting
plavix without a loading dose but to continue to hold coumadin
and aspirin. Pt was continued on protonix 40 mg po bid. While on
plavix, his Hct continued to be stable and even rose slightly.
He remains HD stable. He continued to have large bore IV
access. He was discharged with a plan for follow-up in 2 days
for hematocrit check and re-evaluation by his cardiologist who
will decide on the timing of restart of aspirin and whether
coumadin should be restarted.
2. CAD s/p CABG: Restarted plavix several days prior to
discharge. Pt's aspiring and coumadin were held throughout his
hospital stay. They will continue to be held until his
cardiologist, gastroenterologist, and PCP agree that it is safe
to continue these medications given his bleeding risk. His
anti-htn agents were held since admission. Half dose of his ACE
inhibitor was restarted. His carvedilol was restarted as well at
3.125 mg [**Hospital1 **].
PUMP: Anti-htn agenets were on hold including ace, bb,
amlodipine, nitrates. Pt did not have persistent HTN or
significant signs of CHF. His carvdelilol and ace inhibitor were
restarted after he remained hemodynamically stable with stable
HCT for several days.
Rhythm: Pt continued low dose amiodiarone for hx VT, His ICD was
in place. He was monitored on telemetry for VT and GI bleed
concerns
3. Gout: Restarted allopurinol given increased risk for this
with GI bleed
.
4. Acute Renal failure: Pt presented with elevated Cr to 1.6
from baseline 1.0-1.2. This was likely due to prerenal state
given his dramatic bleeding on presentation. This improved to
baseline with IV fluids and transfusion support
.
5. PPX: PPI, pneumoboots
.
6. FEN: Pt was advance to full liquids and then to full diet in
the day prior to discharge. Magnesium and potassium were
repleted aggressively given his hx CAD and VT.
7. Code: FULL Code
8. PT consult - pt was cleared for home dischare
Medications on Admission:
Allopurinol 300 mg qd
Finasteride 5 mg qd
Amiodarone 400 mg qd
Amlodipine 5 mg qd
Quinapril 20 mg [**Hospital1 **]
Imdur 30 mg qd
Lipitor 30 mg qd
Coreg 3.125 mg [**Hospital1 **]
Aldactone 25 mg qd
Protonix 40 mg [**Hospital1 **]
ASA 325 mg qd
Plavix 75 mg qd
Coumadin
Discharge Medications:
1. Atorvastatin 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
3. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. 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*
5. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
8. Quinapril 10 mg Tablet Sig: One (1) Tablet PO twice a day:
Please see your doctor before going up to your previous dose.
9. Finasteride 5 mg Tablet Sig: One (1) Tablet PO once a day: as
previously prescribed.
Discharge Disposition:
Home
Discharge Diagnosis:
GI bleed (requiring 20unit PRBC transfusion)
blood loss anemia
renal failure
Discharge Condition:
afebrile, hemodynamically stable, tolerating full diet,
ambulating without difficulty (cleared by PT) hematocrit stable
for over 4 days
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet and fluid Restriction: 1.5 liters
******Please do not take aspirin or coumadin unless instructed
by your doctors to [**Name5 (PTitle) **] [**Name5 (PTitle) **]. Please do not take aldactone, imdur
or amlodopine until instructed to do so by your primary
physician or your cardiologist. Please note that your quinapril
is at half the regular dose currently (10mg twice each day)
Please be in contact with your primary physician and your
cardiologist in the next week and be sure to schedule
appointments with both of them.
Please return to the emergency department immediately if you
have any signs of bleeding including red blood with stools,
maroon or black stools, lightheadedness, weakness, chest pain,
shortness of breath or any other worrisome symptoms
Followup Instructions:
Please contact Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2204**] on Monday morning [**9-26**] for an
appointment early next week.
Please be sure to keep your appointment with Dr. [**Last Name (STitle) **], your
cardiologist, on Monday [**9-26**]. Please be sure to have your
blood level (hematocrit) checked at that time as well as your
chemistries. Please be sure to discuss the restart of your heart
and blood pressure medications (aldactone, amlodipine, imdur)
with Dr. [**Last Name (STitle) **].
Please discuss with your doctors when [**Name5 (PTitle) **] if your should restart
aspirin. Please discuss with your doctors when [**Name5 (PTitle) **] if you should
restart coumadin.
Please contact Dr. [**Last Name (STitle) 349**] [**Telephone/Fax (1) 7703**], your
gastroenterologist, for his next available appointment to
discuss your recent bleeding.
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2197-2-27**] 10:30
Provider: [**First Name11 (Name Pattern1) 2946**] [**Last Name (NamePattern4) 3217**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2197-3-7**] 10:30
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
Completed by:[**2196-10-24**]
|
[
"569.85",
"569.82",
"285.1",
"286.9",
"427.31",
"276.52",
"V45.82",
"274.9",
"185",
"584.9",
"401.9",
"V45.81",
"V45.02",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.04",
"88.47",
"39.79",
"45.24",
"99.07",
"45.13",
"99.05",
"45.43"
] |
icd9pcs
|
[
[
[]
]
] |
13310, 13316
|
7510, 12115
|
320, 494
|
13437, 13575
|
3144, 7487
|
14485, 15753
|
2674, 2765
|
12435, 13287
|
13337, 13416
|
12141, 12412
|
13599, 14462
|
2781, 3102
|
275, 282
|
522, 1830
|
1874, 2552
|
2568, 2658
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,307
| 194,810
|
46518
|
Discharge summary
|
report
|
Admission Date: [**2174-11-25**] Discharge Date: [**2174-11-27**]
Date of Birth: [**2100-4-30**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
hyperkalemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
74yoF with history of Wegener's Granulomatosis with tracheal
involvement with recent admission from [**11-10**] to [**11-17**] for
respiratory distress and PNA and was discharged on
vanc/zosyn/vori presents to ED with hyperkalemia. Since last
admission, patient has been at rehab during which time she has
been doing well. Endorsed diarrhea that has been persistent
since last admission. Denies any fevers, chills, nausea,
vomiting. Has had normal urine output per patient without any
dysuria or other urinary symptoms. No new respiratory symptoms.
Feels thirsty.
.
In the ED, initial VS were: 98.5 83 123/66 18 94% RA. Was stable
on arrival. EKG showed Peaked T waves with hyperkalemia to 7.3.
Received the following:
- Calcium Gluconate 1g/10mL x2
- Dextrose 50% x1
- Sodium Polystyrene Sulfonate 15g/60mL Bottle 2 [**Last Name (LF) 98802**], [**First Name3 (LF) **]
- Insulin Human Regular 10units
- 2L NS
.
On arrival to the MICU, pt was resting comforably without any
complaints.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
- Wegener's granulomatosis: recently complicated by
tracheobronchial disease in particular bilateral bronchial
stenosis status post balloon dilation with intralesional steroid
therapy by [**First Name3 (LF) **] pulmonology
- Hypothyroidism
- Osteoporosis
- History of breast cancer: in [**2151**], s/p surgery and chemo
- minimal short term memory
Social History:
Lives with her son [**Name (NI) 122**]. Quit smoking ~50 years ago. Former
social drinker, no alcohol in 2 years.
Family History:
-Brother with [**Name (NI) 98796**] Disease
-Mother passed from sudden cardiac arrest s/p "hand procedure"
at age 75
-Father passed at 89 from "old age" with Parkinson's Disease
-Hypertension in several family members
-[**Name (NI) **] history of cancer, autoimmune diseases
Physical Exam:
Vitals: see Metavision
General: chronically ill appearing, NAD, comfortable, slow to
respound
HEENT: Sclera anicteric, dry MM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: coarse breath sounds
Abdomen: soft, mildly tender over epigastric area,
non-distended, bowel sounds present, no organomegaly
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
.
Discharge exam:
Vitals: 97 143/79 75 20 98% 2L
General: Thin elderly woman in NAD
HEENT: MMM
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: coarse breath sounds b/l, better today
Abdomen: non-tender, non distended.
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Admission labs:
[**2174-11-25**] 04:50PM BLOOD WBC-4.6 RBC-4.12* Hgb-12.4 Hct-38.8
MCV-94 MCH-30.0 MCHC-31.9 RDW-14.8 Plt Ct-560*
[**2174-11-25**] 04:50PM BLOOD Neuts-88.4* Lymphs-7.8* Monos-3.4 Eos-0.1
Baso-0.3
[**2174-11-25**] 04:50PM BLOOD PT-10.6 PTT-26.6 INR(PT)-0.9
[**2174-11-25**] 04:50PM BLOOD Glucose-111* UreaN-17 Creat-1.1 Na-135
K-7.3* Cl-99 HCO3-28 AnGap-15
[**2174-11-25**] 04:50PM BLOOD ALT-72* AST-61* LD(LDH)-256* CK(CPK)-15*
AlkPhos-184* TotBili-0.2
[**2174-11-25**] 04:50PM BLOOD Albumin-3.9 Calcium-10.2 Phos-4.2 Mg-2.3
[**2174-11-25**] 05:14PM BLOOD Lactate-1.9 K-6.5*
.
CXR: 1. Left-sided PICC has migrated more proximally as compared
to the prior study, now terminating in the proximal
SVC/SVC-brachiocephalic junction. 2. Lateral and medial left
base opacities, as above, may relate to atelectasis although
underlying consolidation is not excluded.
.
u/s: Coarse liver with mild diffuse echogenic liver suggesting
the
possibility of parenchymal disease.
.
Discharge labs:
[**2174-11-27**] 05:33AM BLOOD WBC-5.3 RBC-3.77* Hgb-11.2* Hct-35.6*
MCV-94 MCH-29.7 MCHC-31.5 RDW-14.6 Plt Ct-466*
[**2174-11-27**] 05:33AM BLOOD PT-10.7 PTT-21.0* INR(PT)-0.9
[**2174-11-27**] 05:33AM BLOOD Glucose-57* UreaN-15 Creat-0.8 Na-138
K-4.4 Cl-101 HCO3-31 AnGap-10
[**2174-11-27**] 05:33AM BLOOD ALT-51* AST-32 LD(LDH)-199 AlkPhos-143*
TotBili-0.3
[**2174-11-27**] 05:33AM BLOOD Albumin-3.3* Calcium-8.9 Phos-3.5 Mg-2.0
Brief Hospital Course:
Summary: 74yoF with history of wegener's granulomatosis with
recent admission for post-obstructive pneumonia, who was
re-admitted from rehab for asymptomatic hyperkalemia and EKG
changes
.
# Hyperkalemia: Felt to be most likely related to exogenous
potassium supplementation in the setting of acute kidney failure
(baseline 0.5-0.7, 1.1 on admission). Her potassium normalized
after medications including insulin, kayexelate and Ca
gluconate. She was initially transferred to the MICU for EKG
changes (peaked T waves). These changes remained stable and
present after her potassium had normalized for 24 hours, and she
was transferred to the floor, where she was subsequently
discharged to rehab without incident.
.
# Acute renal failure: Baseline Cr 0.5-0.7, admitted with Cr
1.1, improved with IV hydration. Possibly related to decreased
PO intake in setting of chronic loose stool.
.
# Transaminitis: Improved, likely related to voriconazole
therapy. U/s did raise possibility of parenchymal disease, so
this may warrant further outpatient work-up.
.
# Recent PNA and Aspergillous infection/COPD: Diagnosed with
presumed post-obstruction pneumonia recently on [**11-17**] on
vanco/zosyn/vori. Slated to finish Vanc/zosyn on [**12-2**] and
voriconazole on [**11-29**], and this course was continued this
admission
.
# Wegener's Granulomatosis: Last ANCA in house was negative. Her
prednisone dose during last admission was 20mg per rheumatology.
She came in on 30mg daily, and this was decreased back to 20mg
daily this admission
.
# Osteoporosis: We continued calcium/vitamin D
.
# Hypothyroidism: We continued home levothyroxine
.
# Depression/Anxiety: We continued home citalopram and ativan
=====
Transitional issues:
#) hyperkalemia: if potassium needs to be repleted, would do so
very judiciously given her hyperkalemia that required MICU
transfer.
.
#) EKG: Her EKGs have persistently peaked T waves, and these T
waves were present on multiple EKGs well after potassium had
been corrected
.
#) Antibiotics: Should complete the course previously set on
the last admission. Vanc/zosyn to finish [**12-2**], and
voriconazole on [**11-29**].
.
#) Liver ultrasound: Suggested the possibility of parenchymal
disease, which may suggest the need to be investigated further
as an outpatient.
.
Medications on Admission:
1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Month/Day (4) **]: One (1) Inhalation Q4H (every 4 hours) as
needed for wheeze.
2. heparin (porcine) 5,000 unit/mL Solution [**Month/Day (4) **]: One (1)
Injection TID (3 times a day).
3. atovaquone 750 mg/5 mL Suspension [**Month/Day (4) **]: Ten (10) ml PO DAILY
(Daily).
4. prednisone 20 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO DAILY (Daily).
5. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
Disp:*30 Tablet,Rapid Dissolve, DR(s)* Refills:*2*
6. alendronate 70 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO QFRI (every
Friday).
7. levothyroxine 100 mcg Tablet [**Last Name (STitle) **]: 1.5 Tablets PO DAILY
(Daily).
8. citalopram 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
9. voriconazole 200 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q12H (every
12 hours).
Disp:*60 Tablet(s)* Refills:*0*
10. Vancomycin 1000 mg IV Q 24H
11. Piperacillin-Tazobactam 4.5 g IV Q8H
12. furosemide 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
13. cholecalciferol (vitamin D3) 400 unit Tablet [**Last Name (STitle) **]: Two (2)
Tablet PO DAILY (Daily).
14. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
[**Last Name (STitle) **]: One (1) Tablet, Chewable PO DAILY (Daily).
15. Vitamin B Complex Capsule [**Last Name (STitle) **]: One (1) Capsule PO once a
day.
16. omega-3 fatty acids-vitamin E 1,000-5 mg-unit Capsule [**Last Name (STitle) **]:
One (1) Capsule PO once a day.
17. vitamin C-vitamin E Capsule [**Last Name (STitle) **]: One (1) Capsule PO once
a day.
18. nystatin 100,000 unit/mL Suspension [**Last Name (STitle) **]: Five (5) ML PO QID
(4 times a day) as needed for thrush.
19. lorazepam 0.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q4H (every 4
hours) as needed for anxiety.
20. ipratropium bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) nebs
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
21. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
Discharge Medications:
1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Last Name (STitle) **]: One (1) Inhalation Q6H (every 6 hours) as
needed for SOB.
2. heparin (porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: One (1)
Injection [**Hospital1 **] (2 times a day).
3. atovaquone 750 mg/5 mL Suspension [**Hospital1 **]: Ten (10) mL PO DAILY
(Daily).
4. prednisone 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
5. alendronate 70 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a week:
Every friday.
6. levothyroxine 100 mcg Tablet [**Hospital1 **]: 1.5 Tablets PO DAILY
(Daily).
7. citalopram 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
8. voriconazole 200 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q12H (every
12 hours).
9. vancomycin in D5W 1 gram/200 mL Piggyback [**Hospital1 **]: One (1)
Intravenous Q 24H (Every 24 Hours).
10. piperacillin-tazobactam-dextrs 4.5 gram/100 mL Piggyback
[**Hospital1 **]: One (1) Intravenous Q8H (every 8 hours).
11. furosemide 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day.
12. cholecalciferol (vitamin D3) 400 unit Tablet [**Hospital1 **]: One (1)
Tablet PO once a day.
13. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
[**Hospital1 **]: One (1) Tablet, Chewable PO DAILY (Daily).
14. Vitamin B Complex Capsule [**Hospital1 **]: One (1) Capsule PO once a
day.
15. omega-3 fatty acids-vitamin E 1,000-5 mg-unit Capsule [**Hospital1 **]:
One (1) Capsule PO once a day.
16. vitamin C-vitamin E Capsule [**Hospital1 **]: One (1) Capsule PO once
a day.
17. ipratropium bromide 0.02 % Solution [**Hospital1 **]: One (1) Inhalation
Q6H (every 6 hours) as needed for SOB.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 14468**] Nursing & Rehabilitation Center - [**Location (un) 1456**]
Discharge Diagnosis:
Hyperkalemia
Wegener's Granulomatous
Discharge Condition:
Level of Consciousness: Alert and interactive.
Mental Status: Confused - sometimes.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital because you had a dangerously
high potassium. We gave several medications to help reduce this
level. Ultimately, your potassium fell to a normal range.
.
You were receiving potassium supplements while at rehab which
were discontinued. Additionally we reduced your prednisone dose
to 20mg from 30mg.
No other changes were made to your medications. It is important
for you to tell your doctors that [**Name5 (PTitle) **] have had a high potassium
level in the past that required treatment in the ICU.
Followup Instructions:
Please be sure to keep the following appointments:
Department: RHEUMATOLOGY
When: FRIDAY [**2174-12-9**] at 10:30 AM
With: [**First Name8 (NamePattern2) 11595**] [**Last Name (NamePattern1) 11596**], MD [**Telephone/Fax (1) 2226**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 861**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: [**Hospital Ward Name 706**]
When: TUESDAY [**2174-12-27**] at 8:30 AM
With: CAT SCAN [**Telephone/Fax (1) 327**]
Building: CC CLINICAL CENTER [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: WEST [**Hospital 2002**] CLINIC
When: TUESDAY [**2174-12-27**] at 10:00 AM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 3020**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
Completed by:[**2174-11-27**]
|
[
"276.7",
"446.4",
"E930.1",
"496",
"V10.3",
"300.00",
"790.4",
"484.6",
"584.9",
"244.9",
"733.00",
"311",
"117.3"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11265, 11376
|
4885, 6589
|
307, 314
|
11457, 11504
|
3431, 3431
|
12201, 13349
|
2316, 2593
|
9541, 11242
|
11397, 11436
|
7212, 9518
|
11642, 12178
|
4430, 4862
|
2608, 3096
|
3112, 3412
|
6610, 7186
|
1349, 1796
|
254, 269
|
342, 1330
|
3448, 4413
|
11519, 11618
|
1818, 2168
|
2184, 2300
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,463
| 132,415
|
20461+20462
|
Discharge summary
|
report+report
|
Admission Date: [**2148-4-9**] Discharge Date:
Date of Birth: [**2082-7-14**] Sex: F
Service: Neurology
REASON FOR ADMISSION: Left-sided weakness and dysarthria.
HISTORY OF PRESENT ILLNESS: This is a 65-year-old
right-handed woman with a past medical history significant
for bronchitis but does not have regular medical care who
presented as a transfer from an outside hospital on [**4-8**]
after arriving there with left-sided weakness and dysarthria.
She recalled being at home on the cough doing a crossword
puzzle. The next thing she knew, she was on the floor, and
the husband was saying that she was slurring her words. She
was last known to be well around 8:15 when she was helping
her husband in the garage. At around 8:30 he went inside and
found her on the floor and noted that she was slurring her
words and that the left side of her mouth was drooping.
Also, she was not moving her left side.
She was immediately brought to the [**Hospital3 **] where a
head computed tomography was negative for hemorrhage. The
Stroke team was called at [**Hospital1 188**], and they advised immediate t-[**MD Number(3) 54793**] on the clinical
history and the negative computerized axial tomography for
hemorrhage. She received a 7.7 mg bolus of t-PA at 10:30
p.m. and a 69 mg infusion was started as she was transported
to [**Hospital1 69**] via medical flight.
Upon arrival to [**Hospital1 69**] she was
alert and talking on arrival. She claimed that she was
having no problems whatsoever. She stated that the reason
for going to the hospital was because "they said I was having
slurred speech." Of note, she did have a recent upper
respiratory illness with cough and congestion. No fevers,
chills, nausea, vomiting, or abdominal pain. There was no
history of bloody stools.
PAST MEDICAL HISTORY:
1. Bronchitis.
2. Headaches of tension type.
MEDICATIONS ON DISCHARGE: None.
ALLERGIES: ASPIRIN causes supposed anaphylaxis.
MEDICATIONS ON TRANSFER:
1. Lipitor 10 mg by mouth once per day.
2. Plavix 75 mg by mouth once per day.
3. Famotidine 20 mg intravenously twice per day.
4. Subcutaneous heparin.
5. Regular insulin sliding-scale.
SOCIAL HISTORY: She lives at home with her husband. She has
smoked two packs every three days for about 40 years but quit
two to three years ago. There is no alcohol history.
FAMILY HISTORY: Her mother died of an aneurysm, and her
father died of a myocardial infarction.
PHYSICAL EXAMINATION ON PRESENTATION: Her temperature was
97.1 degrees Fahrenheit, her blood pressure was 144/80, her
heart rate was 83, and her respiratory rate was 20. In
general, she was a well-developed and obese woman lying in
bed in no apparent distress. Her head, eyes, ears, nose, and
throat examination revealed a supple neck without
lymphadenopathy or thyromegaly. Her cardiovascular
examination revealed a regular rate and rhythm without
murmurs, rubs, or gallops. There were no carotid bruits that
were heard. The lungs were clear to auscultation
bilaterally. The abdomen was soft, nontender, and
nondistended. There was no hepatosplenomegaly. Extremities
showed no cyanosis, clubbing, or edema. On neurologic
examination her mental status revealed she was sleepy.
Arousable to repeated vocal stimulation but kept her eyes
closed during the entire examination. She said her name but
not much else spontaneously. She did follow some one-step
commands intermittently. On cranial nerve testing, she
blinked to threat on the right but not the left. Her
extraocular movements revealed right gaze deviation, but she
was able to get her eyes opened to the left occasionally.
Her corneas were intact bilaterally. There was a left facial
droop that was present. The tongue appeared midline. On
motor examination, she moved her right arm and leg
spontaneously but was motor impersistent. She had
hypotonicity in the left arm and left leg, and these did not
move with painful stimulation. The deep tendon reflexes were
2+ reflexes in the biceps, triceps, brachioradialis
bilaterally. There were 1+ reflexes at the patella and the
ankles bilaterally. The toes were upgoing on the left.
There was no clonus in the ankles. Coordination and gait
testing were deferred. On sensory examination, she localized
to pain in the left and right arm. Her left leg withdrew
nonspecifically from pain.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories
upon admission were notable for a white blood cell count of
12.1, and a bicarbonate of 30, and a glucose of 202. Her
renal function was normal. Her hematocrit was 41.5, and the
coagulation studies were normal.
PERTINENT RADIOLOGY/IMAGING: A chest x-ray obtained on
admission also revealed a possible focal infiltrate in the
right lower lobe.
BRIEF SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM:
1. RIGHT MIDDLE CEREBRAL ARTERY CEREBRAL INFARCTION ISSUES:
The patient under intravenous t-[**MD Number(3) 54794**] the protocol meeting
the 3-hour time window. There were no clinical change in
symptoms over the course of the next 24 hours while she was
monitored in the Intensive Care Unit. There was a moderate
amount of swelling with mild depression of the lateral
ventricles, but there was no evidence of downward herniation.
After more than 24 hours observation in the Unit, she was
felt to be clinically unchanged and stable for the floor.
While on the floor, she appeared to be the same for the first
one or two days; however, she became less responsive and
another computerized axial tomography was done. This
revealed increased swelling in the area of the right frontal
hemisphere with subfalcine herniation and distortion of the
brain stem due to uncal herniation in the right hemisphere.
Due to this, an urgent Neurosurgery consultation was called,
and the patient was moved quickly to the Neurology Intensive
Care Unit for monitoring and intracranial pressure
management.
On [**2148-4-13**] the patient was taken for a right frontal
temporoparietal with decompressive craniectomy with
duraplasty and a right abdominal subcutaneous placement of
the craniectomy bone flap. The patient tolerated the
procedure well. Soon thereafter she had an increase in the
level of her consciousness and was able to regain the ability
to follow commands that she was doing prior to the clinical
deterioration leading to the decreased level of
consciousness. Therefore, she was able to follow simple
one-step commands on the right side of the body with
spontaneous movement of the arm and leg but minimal flexion
to pain on the left side of the body.
She remained intubated and continued to follow commands, and
she was alert each time she was examined. Neurologically,
she was kept on Plavix for secondary stroke prevention, and
she did exhibit any further signs of increased intracranial
pressure.
2. PULMONARY ISSUES: The patient did remain intubated after
the craniectomy until [**2148-4-19**]. She was thought to have
clinically decompensated congestive heart failure due to
volume resuscitation and a known ejection fraction, based on
this admission's echocardiogram which estimated an ejection
fraction of about 15% to 20% which was previously not known.
She continued to have high rates of rapid shallow breathing
indices which indicated a borderline ability to predict her
successful weaning from the endotracheal tube and ventilator.
However, on [**4-19**], she was extubated after receiving three
doses of acetazolamide in an effort to try to reduce her
metabolic alkalosis induced respiratory dysfunction. She
tolerated extubation well and was breathing on a shovel mask
with good oxygen saturations.
3. NUTRITIONAL ISSUES: The patient was kept on nasogastric
tube feeds. It is anticipated that she will likely need a
percutaneous endoscopic gastrostomy tube. This was discussed
with her husband who felt that he would be in agreement with
such a plan.
NOTE: An Addendum to this Discharge Summary will be dictated
at a later date. For now, the patient remains in the
Neurology Intensive Care Unit and her disposition will be
determined after she is stabilized and has received her
percutaneous endoscopic gastrostomy tube.
DR.[**Last Name (STitle) **],[**First Name3 (LF) 4224**] 13-303
Dictated By:[**Name8 (MD) 4064**]
MEDQUIST36
D: [**2148-4-19**] 20:53
T: [**2148-4-19**] 23:44
JOB#: [**Job Number 54795**]
Admission Date: [**2148-4-9**] Discharge Date: [**2148-4-30**]
Date of Birth: [**2082-7-14**] Sex: F
Service: NEUROLOGY
ADDENDUM - 1) NEUROLOGY - RIGHT MCA CARDIOVASCULAR
INFARCTION, STATUS POST CRANIECTOMY: The patient will
continue on Plavix until 2 days prior to visit with Dr. [**First Name (STitle) **],
her neurosurgeon. She will then remain off antiplatelet and
anticoagulation until 1 week after her brain surgery, or as
instructed by Dr. [**First Name (STitle) **]. She should start on Coumadin 1 week
after surgery, or as per Dr.[**Name (NI) 14510**] instructions.
2) CARDIOVASCULAR - CONGESTIVE HEART FAILURE: In addition to
the beta blocker, low-dose lasix and ACE inhibitor were
added. She has an outpatient appointment with congestive
heart failure doctor.
3) PULMONARY - TRACHEOSTOMY AND PNEUMONIA: The patient had a
difficult time with extubation because of consistent high
PCO2. The decision was made to have a tracheostomy. The
patient also has Staphylococcus aureus, susceptible to
oxacillin, in her sputum. So, she was put on a 2-week course
of Levaquin.
4) GYNECOLOGY - VAGINAL BLEEDING: The patient had vaginal
bleeding which slowed down to quarter size spotting q 4 h.
Hematocrit stayed stable. Pelvic ultrasound showed fluid
within endometrial cavity which is consistent with cervical
stenosis or possibly cancer. She will follow-up with
gynecology.
DISCHARGE DIAGNOSES:
1. Right middle cerebral artery cerebrovascular infarction, s/p
iv TPA treatment; status post craniectomy for brain edema
2. Congestive heart failure.
3. Pneumonia.
4. Vaginal bleeding.
5. Percutaneous endoscopic gastrostomy.
6. Tracheostomy.
DISCHARGE MEDICATIONS:
1. Colace 150 mg po bid.
2. Dulcolax 10 mg po PR qd prn.
3. Lipitor 10 mg po qd.
4. Plavix 75 mg po qd.
5. Tylenol 325-650 mg po q 4-6 h prn pain.
6. Nystatin suspension prn.
7. Miconazole powder prn.
8. Albuterol nebulizer q 4 h prn wheezes.
9. Prevacid 30 mg po d.
10.Lopressor 12.5 mg po bid.
11.Captopril 12.5 mg po tid.
12.Lasix 10 mg po qd.
13.Subcu heparin 5,000 U subcu [**Hospital1 **].
14.Levaquin 500 mg po qd x 10 days.
DISCHARGE CONDITION: Stable.
DISCHARGE STATUS: To rehabilitation center.
FOLLOW-UP:
1. The patient is to follow-up with Dr. [**First Name (STitle) **], her neurosurgeon,
on [**2148-5-13**] at 11:30 am at the 110 [**Doctor First Name **] Bldg, Third
Fl, [**Hospital Unit Name 12193**], phone number ([**Telephone/Fax (1) 26566**].
2. Follow-up with gynecology, Dr. [**First Name8 (NamePattern2) 402**] [**Last Name (NamePattern1) **], in the
[**Hospital Ward Name 23**] Bldg, 8th Fl, on [**2148-5-13**] at 2:00 pm, phone number
([**Telephone/Fax (1) 22754**].
3. Follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in the Congestive Heart
Failure Clinic on [**2148-5-28**] at 10:00 am, at the [**Hospital Ward Name 23**]
Center Cardiac Services, phone number ([**Telephone/Fax (1) 7179**].
4. Follow-up with primary care provider [**Last Name (NamePattern4) **] [**1-19**] weeks after
discharge from rehabilitation center.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 12114**]
Dictated By:[**Last Name (NamePattern1) 4270**]
MEDQUIST36
D: [**2148-4-30**] 11:02
T: [**2148-4-30**] 11:13
JOB#: [**Job Number 54796**]
|
[
"428.0",
"348.5",
"482.41",
"401.9",
"626.8",
"438.82",
"518.5",
"434.11",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.09",
"01.24",
"38.93",
"02.12",
"96.6",
"43.11",
"96.72",
"31.1"
] |
icd9pcs
|
[
[
[]
]
] |
10563, 11748
|
2378, 4798
|
9841, 10085
|
10108, 10541
|
1907, 1964
|
4832, 9820
|
213, 1810
|
1989, 2182
|
1832, 1880
|
2199, 2361
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,443
| 119,431
|
21592
|
Discharge summary
|
report
|
Admission Date: [**2171-10-17**] Discharge Date: [**2171-10-19**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
Dizziness, bradycardia
Major Surgical or Invasive Procedure:
1. Temporary pacemaker
2. Permanent pacemaker
History of Present Illness:
Pt is a [**Age over 90 **] yo woman with h/o HTN who presented to outside
hospital with dizziness. There she was found to be bradycardia
into the 20's with stable BP. She was externally paced in the
60's and transferred to [**Hospital1 18**].
.
Per discussion with the daughter patient had been in normally
state of health until today. The patient had awoken at 3am with
a HA, dizziness, and fatigue. She then called her daughter at
7am and told her she felt like she was going to die. Her
daughter then went to her mother's house. She noted her to be
"acting differently". In the afternoon she was noted to have
episodes of shaking, eyes were glazed over, and she would groan.
She did not eat anything throughout the day so they brought her
to the ED for fluids. At the outside hospital they noted her to
be bradycardic. External pacer placed and she was transferred
to [**Hospital1 18**]. She denied any SOB, DOE, chest pain, palpitations,
syncope. No recent fevers, chills, vomiting, abd pain,
diarrhea, constipation. Mild nause throughout the day but no
vomiting.
Past Medical History:
HTN
s/p right hip fracture and repair
Social History:
Lives with 2 sons. [**Name (NI) **] 11 children. No T/A/D use.
Family History:
Non-contributory
Physical Exam:
T 97.4 BP 110/75 HR 70(V-paced) RR 18 O2sats 100% 2L
Gen: Thin, elderly female in NAD, A&O times 3
HEENT: Anicteric, dry mm
Neck: Right IJ catheter in place
Lungs: CTAB
Heart: V-paced, irregular rhythm, no m/r/g
Abd: Soft, NT, ND + BS
Ext: No edema, 2+ right DP, 1+ left DP
Neuro: Grossly intact
Pertinent Results:
Labs on Admission:
[**2171-10-17**] 08:40PM GLUCOSE-162* UREA N-20 CREAT-1.2* SODIUM-137
POTASSIUM-3.3 CHLORIDE-102 TOTAL CO2-24 ANION GAP-14
[**2171-10-17**] 08:40PM CK(CPK)-51
[**2171-10-17**] 08:40PM cTropnT-0.02*
[**2171-10-17**] 08:40PM CK-MB-NotDone
[**2171-10-17**] 08:40PM CALCIUM-8.9 PHOSPHATE-3.9 MAGNESIUM-1.7
[**2171-10-17**] 08:40PM WBC-6.9 RBC-4.41 HGB-13.0 HCT-36.2 MCV-82
MCH-29.4 MCHC-35.8* RDW-14.0
[**2171-10-17**] 08:40PM NEUTS-87.4* LYMPHS-11.0* MONOS-1.5* EOS-0.1
BASOS-0.1
[**2171-10-17**] 08:40PM PLT COUNT-178
[**2171-10-17**] 08:40PM PT-13.6* PTT-27.6 INR(PT)-1.2*
.
CXR [**10-17**]: Right lung opacity of unclear etiology. Comparison
with prior films is recommended if they can be made available,
as a similar opacity was reported in [**2170-8-21**],but those images
are not available on pacs. Accordingly the opacity may be
chronic, and it would be important to either show long-term
stability, establish the etiology, perhaps by CT, or follow-up
to ensure resolution after treatment.
.
CXR [**10-19**]:
A left-sided pacemaker is present, the tip overlying on right
ventricle. The aorta is tortuous. No CHF, focal infiltrate or
effusion is identified. There is relatively speculated opacity
in the right infrahilar region. Further evaluation by CT scan is
recommended to exclude an underlying pulmonary nodule. The lungs
are hyperinflated, consistent with COPD.
Brief Hospital Course:
[**Age over 90 **] yo F w/ HTN p/w complete heart block. S/p VDD pacemaker
placement.
# Cardiac
Rhythm: Patient presented to outside hospital in complete heart
block with rate of 20's, BP stable. She was transported
directly to the CCU and a temporary pacing wire was placed. She
tolerated this procedure well without complications. Her heart
rate was paced in the 80s. Her BP was stable. TSH was wnl.
Lyme serologies were negative. She went for permanent pacemaker
on [**2171-10-18**]. HR was in the 50s-90s. Post-procedure CXR
demonstrated proper lead placement. She was restarted on her
B-blocker and HCTZ. He was given Keflex 500 TID x 5 days for
prophylaxis. She should f/u in the Device clinic in one week.
She was given the number of the cardiology clinic and asked to
follow up there within 4 weeks.
.
# HTN- Her BP meds were initially held. After her permanent
pacemaker was placed, she was put back on B-blocker and
thiazide. BP was controlled.
.
# Pulmonary opacity - CXR incidentally noted an infrahilar,
nodular opacity. After discussing this finding with the patient
and her daugher, I learned that this has been known since for at
least several months by both the patient and her primary care
physician. [**Name Initial (NameIs) **] was informed that the patient does not want work
up for this nodular opacity due to the fact that she would
decline treatment anyway. CT scan was recommended to the
patient as an outpatient to further evaluate this opacity.
.
# Chronic Kidney Disease: Her creatinine was baseline on
admission. Her medications were renally dosed.
.
# FEN- cardiac diet
.
# PPx- Heparin sc, bowel regimen
.
#Code: Patient was full code during this admission
Medications on Admission:
Atenolol/chlorthalidone 50mg/25mg PO qd
Discharge Medications:
1. Atenolol-Chlorthalidone 50-25 mg Tablet Sig: One (1) Tablet
PO once a day.
2. Keflex 500 mg Tablet Sig: One (1) Tablet PO three times a day
for 5 days.
Disp:*15 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Complete AV block, w/p pacemaker placement
2. HTN
Discharge Condition:
stable
Discharge Instructions:
Please take all your medications as prescribed. You were
prescribed an antibiotic that you should take for the next 5
days. This is to prevent infection. You should call your
primary doctor [**First Name (Titles) **] [**Last Name (Titles) **] an appointment within 1-2 weeks.
You also need to find a cardiologist to follow up with. You
should call the cardiology department @ [**Telephone/Fax (1) 62**] for an
appointment in approximently 4 weeks. You also have an
appointment to have your pacemaker checked in one week, which
you should keep. You should call your doctor or return to the
hospital if you have dizziness, pass out, chest pain, shortness
of breath, palpitations, or any other concerning symptoms.
.
Your your knowledge, your chest x-ray showed a nodule in the
hilar region. As per our conversation, this nodule is known by
you and your primary doctor. A CT scan is recommended to
evaluate this nodule for malignancy
Followup Instructions:
You should [**Telephone/Fax (1) **] an apointment with your primary doctor
within 2 weeks.
You should call [**Telephone/Fax (1) 56866**] to [**Telephone/Fax (1) **] an appointment with a
cardiologist in about 4 weeks.
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2171-10-28**]
1:30
Completed by:[**2171-10-21**]
|
[
"401.9",
"496",
"585.9",
"426.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.71",
"37.82"
] |
icd9pcs
|
[
[
[]
]
] |
5390, 5396
|
3382, 5088
|
287, 334
|
5493, 5502
|
1950, 1955
|
6489, 6848
|
1601, 1619
|
5178, 5367
|
5417, 5472
|
5114, 5155
|
5526, 6466
|
1634, 1931
|
225, 249
|
362, 1442
|
1969, 3359
|
1464, 1503
|
1519, 1585
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,864
| 123,656
|
737
|
Discharge summary
|
report
|
Admission Date: [**2136-10-23**] Discharge Date: [**2136-11-21**]
Date of Birth: [**2080-8-23**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS:
Patient is a 56-year-old woman previously healthy and began
developing a diffuse mild headache and discomfort in [**Month (only) **].
Complained of left arm weakness toward the end of [**Month (only) 216**]
lasting a few minutes, and since then has had four similar
episodes. Approximately a month ago she had slight change in
the character of the headache. It is now constant diffuse
pain with some nausea [**7-20**] severity at its worse. In some
days is pain free. No history of nonsteroidal
anti-inflammatory or aspirin use. Sometimes the occipital
portion of the headache improves with sleep approximately the
same time she noted unsteady gait and falls to the left. She
had an occipital steroid injection with transient
improvement.
PAST MEDICAL HISTORY:
Benign.
PAST SURGICAL HISTORY:
Bowel surgery in [**2128**] for obstructive volvulus.
REVIEW OF SYSTEMS:
General appearance: Denies fever or chills. Positive weight
loss over the last three months [**4-19**] lb with no chest pain,
shortness of breath, palpitations, abdominal pain, no change
in bowel or urinary habits.
PHYSICAL EXAMINATION:
Skin is warm and dry. Head is normocephalic, atraumatic.
Eyes: Sclerae are anicteric. Throat: Pharynx is pink,
clear without exudate or drainage. Teeth intact. Gums are
pink and moist. Tongue normal. Neck is supple without
jugular venous distention. Heart regular, rate, and rhythm
without murmurs, rubs, or gallops. Chest was clear to
auscultation. Abdomen is soft, nondistended, positive bowel
sounds. Extremities: No clubbing, cyanosis, or edema.
Neurologically visual fields are full to confrontation. Her
pupils are equal, round, and reactive to light. Her cranial
nerves are intact. Her motor strength is [**4-14**] in all muscle
groups. Her reflexes are 2+ throughout. She has got no
ankle clonus. Sensation through touch intact in the arms and
legs. Cerebellar, finger-to-nose, heel-to-shin, and rapid
alternating movements with finger-to-toe tapping were intact
with slight dysmetria on the left. Gait: Stance slightly
wide based and normal initiation. Her stride is slightly
dragging and arm swinging. Tandem walking was unsteady with
falls to the left.
The patient had a head CT scan which showed left subdural
hematoma which was drained at the bedside. Repeat head CT
scan in the morning showed residual left subdural hematoma
without midline shift.
The patient continued to have severe headaches, therefore the
patient was taken to the operating room. On [**2136-10-25**] head CT
scan was essentially unchanged. The patient's subdural
hematoma was slightly smaller in size in the left frontal
area. Midline shift was slightly improved. Ventricles were
open without evidence of obstruction or hydrocephalus.
The patient was taken to the operating room and had open
craniotomy for drainage of a subdural hematoma on [**2136-10-25**]
without intraop complications. Patient was awake, alert, and
oriented times three. Pupils were equal and reactive three
down to 2.5 mm. Motor strength is [**4-14**] in all muscle groups
and incision was clean, dry, and intact.
On [**10-26**], the patient was alert, following commands with 5/5
strength in bilateral upper extremities with no eye opening.
Pupils were 4 down to 3 on the left; and three down to two on
the right. Patient had a head CT scan on [**2136-10-26**] that
showed evidence of no cephalus in the area of operation.
On [**2136-10-26**] the patient was taken to the angio suite and
had a diagnostic angiogram which was negative for any
aneurysms.
On [**2136-10-27**] the patient was difficult to arouse, opened eyes
briefly, follow two-step commands inconsistently. Was
oriented to the hospital year. Withdrawal extremities to
pain and localized. The patient had MRI with diffusion
weighted images which was negative for infarct. The patient
also had repeat head CT scan on [**2136-10-28**] which showed no
increase in subdural hematoma and no increase in mass effect.
Although patient continued to be sleepy, but arousable.
The patient had two electroencephalograms which showed no
evidence of seizure activity, just evidence of diffuse
slowing. Patient was treated with Vancomycin for Staph
pneumonia.
On [**2136-11-7**], the patient was re-admitted to the Surgical
Intensive Care Unit, where she was intubated electively. On
[**2136-11-7**], the patient underwent re-evacuation of the right
subdural hematoma. There were no intraoperative
complications, and the patient was monitored in the Surgical
Intensive Care Unit postop. She was continued on Mannitol 50
grams IV q six hours. Neurologically she opened her eyes
spontaneously. Stated her name and year. Pupils were three
down to 2.8 mm bilaterally reactive. EOMs are full. Follows
commands. Moving all extremities. Her dressing was clean,
dry, and intact.
The patient was seen by the Neurology service who recommended
starting the patient on Glycerol in an attempt to reduce
brain edema and continue on Mannitol.
On [**2136-11-12**] the patient was transferred to the regular
floor and continued to have her Mannitol weaned. Seen by
Speech and Swallow Service, who found that she was aspirating
and recommended more permanent form of feeding. The patient
had a PEG tube placed on [**2136-11-16**] without complications.
The patient's mental status deteriorated. The patient became
unarousable with periods of waxing and [**Doctor Last Name 688**]. Mental status
appeared periods of being awake, and following commands, and
then being obtunded.
She was restarted on Mannitol 50 grams IV q eight hours and
continued on Glycerol and decadron. Mental status improved.
She is currently discontinued off Mannitol, continues on
Glycerol, and weaning off Decadron. She was seen by physical
therapy and occupational therapy, and found to acquire rehab
prior to discharge to home.
DISCHARGE MEDICATIONS:
Levofloxacin 500 mg nasogastric q day, Glycerol 25 grams po q
six hours, Zantac 150 mg po bid, Tylenol 650 mg po q four
hours prn.
The patient had G tube placed and now is tolerating soft
solids and puree diet with head of bed at 90 degrees and
supervision. Vital signs remain stable and patient is
afebrile. She is off all antibiotics at this point and is
stable neurologically, and ready for transfer to Rehab. The
patient will follow up with Dr. [**Last Name (STitle) 1327**] in [**2-12**] weeks time with
repeat head CT scan at that time.
[**Name6 (MD) 1339**] [**Last Name (NamePattern4) 1340**], M.D. [**MD Number(1) 1341**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2136-11-21**] 11:22
T: [**2136-11-21**] 11:54
JOB#: [**Job Number 5405**]
|
[
"432.1",
"482.41"
] |
icd9cm
|
[
[
[]
]
] |
[
"43.11",
"99.15",
"01.31",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
6058, 6873
|
961, 1016
|
1275, 6035
|
1035, 1253
|
161, 907
|
929, 938
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,968
| 175,282
|
48934
|
Discharge summary
|
report
|
Admission Date: [**2161-3-26**] Discharge Date: [**2161-4-1**]
Service: MEDICINE
Allergies:
Nsaids / Bupivacaine / Sulfa (Sulfonamides) / Penicillins
Attending:[**First Name3 (LF) 69838**]
Chief Complaint:
Syncope, altered mental status
Major Surgical or Invasive Procedure:
Endotracheal intubation.
History of Present Illness:
84yo woman with past medical history notable for hypertension,
hypothyroidsim, rheumatoid arthritis, CHF was brought into ED
after syncopal episode. By EMS reports, she was walking outside
on sidewalk when she told a bystander that she was not feeling
well. She subsequently fell (no trauma, caught by bystander) and
lost consciousness. When EMS arrived, they found her minimally
responsive and s/p nausea/vomiting.
.
On evaluation in our ED, initial vitals were 98.9, 75, 146/70,
16, and 100% on RA; she was suspected to have had an aspiration
event, and she was intubated for airway protection. Otherwise,
her evaluation in ED was notable for the following: UA with
negative LE, Nit, WBC, trace ketones. Normal CBC. Normal Coags.
Negative serum and urine tox screen. Mild elevation in amylase
at 208, but otherwise normal LFT's and lipase. Chemistry with
mild elevation of BUN at 23, normal anion gap of 11, and
elevated lactate at 3.3. Initial set of cardiac enzymes was CK
35, MB nd, trop < 0.01. Abdominal CT was done to evaluate
abdominal pain and nausea/vomiting, which was negative for any
acute abdominal pathology. Chest film had no acute infiltrates
or other findings. CT and CTA of the head demonstrated no new
pathology and patent cerebral and vertebral vasculature.
.
In ED, she received empiric levaquin/flagyl for possible
abdominal infection. She also received fentanyl and versed for
intubation/sedation.
Past Medical History:
Hypothyroidism
Osteopenia
h/o Congestive heart failure, though EF nl by TTE on this
admission
Rheumatoid arthritis
Hypertension
Bilateral L5/S1 lumbar radiculopathy by EMG
Endometrial thickening s/p D&C
h/o DVT when she delivered her son by [**Name (NI) 32007**]
Social History:
Denies tobacco, alcohol.
Family History:
Non-contributory
Physical Exam:
on admission to floor:
VS - T 98.0, BP 143/71, HR 112, O2 sat 100% RA
Gen - comfortable, NAD, speaking full sentences
HEENT - NCAT, PERRL, EOMI, OP clr, MMM, no LAD
Chest - clear anteriorly
CV - tachy, but regular; no m/r/g
Abd - NABS, soft, NT/ND, no g/r
Ext - no edema, WWP
Pertinent Results:
labs on admission:
GLUCOSE-186* UREA N-23* CREAT-1.0 SODIUM-141 POTASSIUM-4.5
CHLORIDE-104 TOTAL CO2-26
ALT(SGPT)-14 AST(SGOT)-19 LD(LDH)-153 CK(CPK)-35 ALK PHOS-49
AMYLASE-208* TOT BILI-0.7 LIPASE-55
WBC-8.2 RBC-3.95* HGB-12.4 HCT-36.2 MCV-92 MCH-31.3 MCHC-34.2
RDW-13.2 PLT COUNT-291
- NEUTS-68.6 LYMPHS-25.7 MONOS-3.4 EOS-1.5 BASOS-0.8
BLOOD-TR NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-TR
BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG
- RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0-2
SED RATE-12, CRP-0.5
PT-11.9 PTT-24.5 INR(PT)-1.0
ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG
tricyclic-NEG
VitB12-260 Folate-10.6
TSH-5.8*
SPEP pending.
Ucx no growth
Bcx no growth
CXR [**3-28**]: Minimal patchy density at the right base, new compared
with
[**2161-3-26**]. Most likely etiology is some subsegmental atelectasis,
but given the history of fevers, the possibility of an early
pneumonic infiltrate cannot be entirely excluded.
B LE u/s: Postsurgical changes of the left leg, with patent left
common
femoral and popliteal veins. The left superficial femoral vein
can only be followed for a few centimeters proximally, where it
is patent.
Ct abd: 1. No acute intra-abdominal pathology.
2. 5 x 3 cm left adnexal cyst is smaller than on prior study.
Slightly
enlarged uterine cavity could be further evaluated with pelvic
ultrasound when the patient's clinical status improves.
CTA head and neck: No evidence of infarction. No evidence of
hemorrhage. No vascular stenosis or occlusions detected.
Echo: The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Overall left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic regurgitation. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is a trivial/physiologic pericardial effusion.
Compared with the report of the prior study (images unavailable
for review) of [**2154-6-6**], there is no definite change.
Brief Hospital Course:
Ms. [**Known lastname 102770**] is an 84yo woman with hypertension, untreated
hypothyroidism, rheumatoid arthritis on prednisone and congetive
heart failure. She reports symptoms lasting over months
including lethargy, feeling presyncopal about once per week,
pins and needles in her feet and hands with poor sleep at night,
and recurrent chest pain. During her admission, her PCP [**Last Name (NamePattern4) **].
[**Last Name (STitle) 2903**] was out of his office so we could not speak with him
direcly, however notes faxed form his office to [**Hospital1 18**] reported
all of the above symptoms (except for presyncope/syncope) over
the course of months. She presented to the hospital after a
syncopal episode with nausea and vomiting.
# Syncope: On arrival she was quite lethargic. She was seen by
the stroke team, who found her exam to be nonfocal and not
consistent with stroke. She was intubated in the ER for airway
protection given her somnolence and nausea. There was fear of
aspiration, however this was not noted on her intial CXR. She
was transferred to the MICU for further care where she remained
intubated until HD#2 when she was successfully extubated without
evidence of respiratory distress. Subsequent work up of syncope,
including CT of the head, abdomen, and pelvis were all
unremarkable. Telemetry showed no arhythmia. A TTE was
unremarkable, with no valvular disease, normal EF, and no wall
motion abnormalities. She had no further episodes of syncope or
presyncope throughout her stay. Cause of her syncope remains
unknown but is likely multifactorial, including hypothyroidism,
dehydration (the patient drinks a maximum of 2 glass water per
day at home, orthostatics could not be checked given early
intubation), and possible vasovagal component.
# aspiration pneumonia: On hospital day 2, after extubation, she
became febrile to 101.1, her CXR revealed evidence of likely
aspiration PNA and she was started on levofloxacin and flagyl
without difficulty. She was quickly weaned to room air and
remained on this throughout her hospital stay without
respiratory difficulty. On the day of discharge flagyl was
discontinued as the patient complained of nausea. She is
discharged to complete a 10 day course of levofloxacin.
# Hypothyroid: On pasat records, the pateint has a history of
hypothyroidism. Per discussion with Dr.[**Name (NI) **] office as well
as his faxed notes, she was previously treated with 125mcg
synthroid which resulted in hyperthyroidism. She was
subsequently treated with 100mcg synthroid which resulted in
hyperthyroidism. She has not taken any synthroid since [**Month (only) 216**]
[**2160**], however her TSH has been elevated during this time. She
does seem symptomatic, noting months of lethargy, constipation,
feeling sleepy, sleeping late in the morning. Her TSH was
elevated at 5.8 during this hospitalization and she was started
on 50mcg synthroid po qday. Her TSH should be checkedto monitor
this dose in one month as an outpatient.
.
# Rheumatoid Arthritis: The patient came in on prednisone for
her rheumatoid arthritis. After receiving dexamethasone poast
extubation as above for facial swelling, she was tapered down to
her homedose of prednisone and is discharged on this dose. She
complained of continued leg and knee pain during her stay, which
has been an ongoing problem for her as an outpatient.
.
# Bilateral lower extremity ?neuropathy: She notes tingling
bilaterally in her feet, legs and hands. Her PCP believes that
she has restless leg syndrome and did recommend that she see a
neurologist, Dr. [**Last Name (STitle) 31464**], for this, however the patient has not
seen him. The patient has no history of diabetes. Since her pain
sounds neuropathic in origin, B12 and folate were checked and
were normal. At the time of discharge SPEP for neuropathy
workup is pending and should be followed up as an outpatient.
We have made her a follow up outpatient appointment with Dr.
[**Last Name (STitle) 31464**].
# Hypertension: Her blood pressure was well controlled on
hydrochlorothiazide and lisinopril, as at home.
.
# ?CHF: The patient's echo on this admission shows improvement
in her cardiac function and a normal EF of 55%. She was
asymptomatic from this standpoint and it is unclear whether she
does have CHF. Her leg swelling may be in the setting of fluid
retention with prednisone use.
.
# Nausea: The patient had no complaint of nausea after
extubation, until the day prior to discharge. Her abdominal exam
remained benign and vitals were stable. She was tolerating POs.
Nausea was felt likely secondary to PO flagyl and this was
discontinued on the day of discharge.
.
# S/p extubation: The patient complained of facial swelling and
feeling that her tongue was swollen. Family members corroborated
this story though no definite clinical evidence of swelling was
noted. Pt's family states they noticed it after being given
antibiotics in the ED (levo/flagyl). Ms. [**Known lastname 102770**] was started on a
3 dose course of dexamethasone after complaining of facial
swelling after extubation. She remained stable from a
respiratory standpoint and she was changed to a prednisone
taper. She was seen by swallow therapy who cleared her for a
regular diet. She tolerates her pills, but I believe prefers
them in apple sauce.
.
During her stay she was FULL CODE confirmed with her son who is
HCP (cell [**Telephone/Fax (1) 102771**]).
Medications on Admission:
HCTZ 25 QD
Zestril 20 QD
Prednisone 5 QAM, 2.5 QPM
Timolol 0.5% OU QD
Discharge Medications:
1. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic
DAILY (Daily).
4. Prednisone 5 mg Tablet Sig: One (1) Tablet PO QAM (once a day
(in the morning)).
5. Prednisone 2.5 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
6. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 4 days.
Disp:*4 Tablet(s)* Refills:*0*
8. Anzemet 50 mg Tablet Sig: One (1) Tablet PO q8hr PRN for 30
doses.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] Of [**Location (un) 620**]
Discharge Diagnosis:
Primary:
-Hypothyroidism
-Syncope
.
Secondary:
-Osteopenia
-History of Congestive heart failure, though EF (>55%) on TTE in
[**2161-3-12**]
-Rheumatoid arthritis
-Hypertension
-Bilateral L5/S1 lumbar radiculopathy by EMG
-Endometrial thickening s/p D&C
-History of DVT when she delivered her son by [**Name (NI) 32007**]
Discharge Condition:
-Stable. Tolerating PO liquids and solids.
Discharge Instructions:
-You were admitted to the hospital for an episode of syncope.
You were initially intubated for protection of your airway, but
extubated within 24 hours. Cardiac and neurological evaluations
were performed to help explain a cause for your symptoms.
Testing was negative. Most likely, decreased PO intake and
hypothyroidism caused your symptoms.
-In addition, you were started on several antibiotics for
aspiration pneumonia. Speech and swallow evaluation was normal.
You will continue on the medications prescribed on discharge.
Several are new--levothyroixine and levofloxacin. Continue the
levofloxacin until a ten day course is completed.
-You need to keep all scheduled appointments (see below). You
will need thyroid testing performed in one month.
-If you experience any more syncope, weakness, lightheadedness,
loss of consciousness, or any other concerning symptoms,
Followup Instructions:
-You have an appointment with your PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2903**]
([**Telephone/Fax (1) **]) on Monday, [**2161-4-20**] at 12:00PM. His office
is located on [**Location **]in [**Location (un) **], MA.
-Please follow-up with Dr. [**Last Name (STitle) 31464**], a neurologist, on Tuesday
[**2161-4-14**] at 10:20am. His address is [**Location (un) 102772**].
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 69841**]
Completed by:[**2161-4-1**]
|
[
"507.0",
"355.8",
"428.0",
"276.51",
"V58.65",
"714.0",
"780.2",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
11012, 11089
|
4740, 10168
|
296, 322
|
11454, 11500
|
2450, 2455
|
12428, 13016
|
2120, 2138
|
10289, 10989
|
11110, 11433
|
10194, 10266
|
11524, 12405
|
2153, 2431
|
226, 258
|
350, 1775
|
2469, 4717
|
1797, 2061
|
2077, 2104
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75
| 112,086
|
26356
|
Discharge summary
|
report
|
Admission Date: [**2147-4-5**] Discharge Date: [**2147-4-11**]
Date of Birth: [**2070-6-27**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Codeine / Morphine / Pentothal / Percodan / Talwin
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
DOE/ presyncopal events
Major Surgical or Invasive Procedure:
[**2147-4-5**] - AVR with 21 mm CE pericardial valve
History of Present Illness:
76 yo female with several episodes of pre-syncope while dancing
. Has DOE and ETT was positive. Echo revealed AS with normal EF.
Cath showed severe AS with [**Location (un) 109**] 0.6 cm2, minimal CAD, AV gradient
56 mm mean. Referred to Dr. [**Last Name (STitle) 1290**] for AVR
Past Medical History:
AS
HTN
elev. chol.
NIDDM
diverticulosis
hiatal hernia
obesity
PNA X 3
PSH: C-sections x3, right TKR, chole, bladder suspension with
urethral sling,appy,coccygectomy,
Social History:
lives with husband
quit smoking 30 years ago
rare ETOH
Family History:
brother had CABG at age 66
mother/brother/sister with CHF
Physical Exam:
HR 88 RR 16 BP 106/60
5'3" 195#
NAD
no jaundice
EOMI, carotid bruits versus transmitted AS murmur
CTAB
3/6 SEM radiates throughout precordium
abdomen midline scar
2+ radial/DP/PT pulses RKR scar
no varicosities
neuro nonfocal
Pertinent Results:
[**2147-4-7**] 05:40AM BLOOD WBC-15.3* RBC-2.66* Hgb-7.9* Hct-23.5*
MCV-88 MCH-29.7 MCHC-33.6 RDW-15.6* Plt Ct-126*
[**2147-4-9**] 09:25AM BLOOD Hct-30.9*#
[**2147-4-7**] 05:40AM BLOOD Plt Ct-126*
[**2147-4-11**] 05:49AM BLOOD UreaN-11 Creat-0.6 K-4.0
[**2147-4-9**] 09:25AM BLOOD Mg-2.0
[**2147-4-9**] CXR
Small left-sided effusion. Status post aortic valve replacement.
No consolidation demonstrated.
[**2147-4-5**] ECHO
PRE-CPB: No spontaneous echo contrast is seen in the left atrial
appendage. Left ventricular wall thickness, cavity size, and
systolic function are normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. There are simple
atheroma in the descending thoracic aorta. There are three
aortic valve leaflets. The aortic valve leaflets are severely
thickened/deformed. Mild to moderate ([**1-30**]+) aortic regurgitation
is seen. The mitral valve appears structurally normal with
trivial mitral regurgitation. Moderate [2+] tricuspid
regurgitation is seen. There is no pericardial effusion.
Insufficient time to measure MV or AO valve gradient/area before
beginning CPB. LVOT = 1.8. Annulus = 2.2.
Post-CPB: Well seated and functioning aortic valve prosthesis.
No leak, no AI. Other parameters remain as pre-bypass. Intact
aorta. Good biventricular
systolic function.
[**Last Name (NamePattern4) 4125**]ospital Course:
Mrs. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2147-4-5**] for surgical
management of her aortic valve disease. She was taken to the
operating room where she underwent an aortic valve replacement
utilizing a 21mm pericardial valve. Postoperatively she was
taken to the cardiac surgical intensive care unit. On
postoperative day one, she awoke neurologically intact and was
extubated. She was then transferred to the cardiac surgical step
down unit for further recovery. Mrs. [**Known lastname **] was gently diuresed
towards her preoperative weight. The physical therapy service
was consulted for assistance with her postoperative strength and
mobility. Her pacing wires and drains were removed per protocol
without incident. On postoperative day five, Mrs. [**Known lastname **] had a
fever spike. She was pan cultured and empirically started on
ciprofloxacin.Her urine culture was positive for E.Coli and
ciprofloxacin was continued. She complained of numbness of her
right lateral thigh which improved slowly. It was presumed that
this was related to a right lateral femoral cutaneous nerve
neuropathy likely from positioning. Mrs [**Known lastname **] continued to make
steady progress and was discharged home on postoperative day
six. She will follow-up with Dr. [**Last Name (Prefixes) **], her cardiologist
and her primary care physician as an outpatient.
Medications on Admission:
zocor 40 mg daily
glucotrol 5 mg daily
zestril 10 mg daily
ASA daily
fish oil daily
folic acid daily
Vit. C daily
Discharge Medications:
1. Glipizide 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day).
Disp:*30 Tablet(s)* Refills:*2*
2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(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:*2*
5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 1 months.
Disp:*60 Tablet(s)* Refills:*0*
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
7. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
8. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
9. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 1 months.
Disp:*60 Tablet(s)* Refills:*0*
10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
14. Potassium Chloride 20 mEq Packet Sig: One (1) PO BID (2
times a day) for 5 days.
Disp:*10 * Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 6138**] VNA
Discharge Diagnosis:
s/p AVR
AS
elev. chol. HTN
UTI
NIDDM
diverticulosis
GERD
hiatal hernia
obesity
s/p bladder suspension
Discharge Condition:
stable
Discharge Instructions:
1) You may shower and pat wound dry
2) No lotions, creams or powders on incisions
3) No driving for one month
4) No lifting greater than 10 pounds for 10 weeks
5) Call for fever, redness, or drainage
6) Take lasix with potassium for five days then stop.
7) Take ciprofloxacin for five days then stop.
8) Take vitamin C and iron for 1 month and stop.
9) Call with any questions or concerns.
Followup Instructions:
see Dr. [**Last Name (STitle) 1290**] in the office in 4 weeks [**Telephone/Fax (1) 170**]
see Dr. [**Last Name (STitle) 58201**] in [**1-30**] weeks
see Dr. [**Last Name (STitle) 5310**] in [**3-3**] weeks
Completed by:[**2147-4-28**]
|
[
"250.00",
"997.3",
"518.0",
"599.0",
"997.09",
"V15.82",
"553.3",
"530.81",
"424.1",
"401.9",
"272.0",
"355.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"89.64",
"99.04",
"39.61",
"35.21",
"34.04",
"39.64"
] |
icd9pcs
|
[
[
[]
]
] |
5859, 5918
|
340, 395
|
6064, 6073
|
1308, 2623
|
6512, 6751
|
983, 1043
|
4228, 5836
|
5939, 6043
|
4090, 4205
|
6098, 6489
|
1058, 1289
|
2674, 4064
|
277, 302
|
423, 704
|
726, 894
|
910, 967
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,691
| 186,176
|
46886
|
Discharge summary
|
report
|
Admission Date: [**2199-11-8**] Discharge Date: [**2199-11-24**]
Date of Birth: [**2133-1-19**] Sex: M
Service: MEDICINE
Allergies:
Simvastatin / Nitrofurantoin
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is a 66 yo M with DM, HTN, HCV, PVD with chronic
heel ulcers, h/o prostate cancer in [**2194**] s/p XRT and Lupron,
chronic foley presents with altered mental status. The patient
lives at a rehab and per report is AAOx3, ambulates and performs
ADL's at baseline. He was found at his nursing home to be
altered and minimally responsive. he was also noted to have a
fever to 101. They drew labs and they were significant for
leukocytosis of 14.2, Cr 1.6, Calcium 12.1 and glucose 270. He
was sent to the ED for further evaluation. He has recently
stopped his Linezolid/Zosyn after 13 weeks of treatment of
.
In the ED, initial vs were: T99.7 P144 BP153/77 26R 100%O2 sat
NRB. He spiked to 104.8 in the ED and was weaned to NC 4L
sating 100%. He was minimally responsive on arrival. A right
fem line was placed for access. He was given a total of 4L NS
IVF. He was started on Vancomycin/Zosyn. UA was grossly
positive. Labs were significant for WBC 15.1, Ca: 12.9, Cr. 1.9.
The patient underwent CT-head that showed 2x2cm hypodensity
that showed hemorrhage with surrounding edema vs. focal ischemia
vs infection. The patient VS on transfer 122 158/76 15 99% 3L
98.2
.
On the floor, the patient was minimally responsive. ABG was
obtained and showed 7.43/31/89/21. Neuro was consulted and
evaluated the patient. He was continued on IVF x 2L
Past Medical History:
Past Oncologic History:
Diagnosed with prostate cancer in [**2194**]. He had a biopsy at that
time with 12 out of 12 cores, positive for 4 +4 with no other
evidence of metastatic disease other than some right pelvic
iliac lymph nodes. He received neoadjuvant hormonal therapy and
radiation. The external beam started on [**2195-10-27**] and lasted
[**2196-2-4**] to a total of 7200 [**Doctor Last Name 352**]. He initiated therapy with
Lupron in the setting of a PSA rise and he was recently admitted
to the [**Hospital1 18**] on [**2199-7-15**] and discharged on [**2199-7-22**]. On [**2199-8-1**],
he received a 3 month Lupron depot shot and the plan was to see
his oncologist again in 3 months.
.
Other Past Medical History:
DMII
HTN
HCV genotype Ib acquired via IV drug use in the 70s
Rhabdomyolysis [**1-22**] statins in [**2195**] and immobility in [**2196**]
PVD s/p chronic heel ulcerations
hx of osteomyelitis
hx of cocaine abuse
PVD
anxiety
R tibioperoneal trunk angioplasty (04)
R AKpop-PT bypass ([**8-24**], failed 06)non-reversed greater
saphenous vein
R PT angioplasty (06)
Bilateral hallux arthroplasty
Right fifth digit debridement (06)
Exlap for auto accident
Hx of tracheostomy
TURP [**2197**]
Incision and drainage left hallux
Bilateral total knee replacements
Social History:
Smokes half pack per day; does not drink any alcohol. Currently
living in a nursing home, previous history of cocaine abuse.
Family History:
Diabetes in both mother and father
Physical Exam:
VS: afebrile, 156/80
GEN: Alert, oriented to place, disoriented to time, mildly
agitated
HEENT: PERRLA. MMM. no LAD. no JVD. neck supple.
Cards: RRR S1/S2 normal. no murmurs/gallops/rubs.
Pulm: inspiratory wheeze on right, mild expiratory wheeze, no
crackles
Abd: soft, distended, NT, +BS. no rebound/guarding. neg HSM. neg
[**Doctor Last Name 515**] sign.
Extremities: wwp, no edema
Skin: no rashes or bruising
Neuro/Psych: CNs II-XII grossly intact, able to move all
extremities, followed simple commands.
Pertinent Results:
ADMISSION LABS
[**2199-11-8**] 12:10AM BLOOD WBC-15.1*# RBC-3.09* Hgb-10.7* Hct-32.2*
MCV-104*# MCH-34.8*# MCHC-33.4 RDW-17.2* Plt Ct-208
[**2199-11-8**] 06:28AM BLOOD WBC-11.5* RBC-2.61* Hgb-9.1* Hct-27.6*
MCV-106* MCH-34.9* MCHC-33.0 RDW-16.9* Plt Ct-160
[**2199-11-8**] 12:10AM BLOOD Neuts-80* Bands-4 Lymphs-11* Monos-2
Eos-0 Baso-0 Atyps-2* Metas-1* Myelos-0
[**2199-11-8**] 06:28AM BLOOD Neuts-81* Bands-13* Lymphs-4* Monos-2
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2199-11-8**] 12:10AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL
Macrocy-3+ Microcy-NORMAL Polychr-NORMAL
[**2199-11-8**] 12:10AM BLOOD PT-18.9* PTT-30.6 INR(PT)-1.7*
[**2199-11-8**] 12:10AM BLOOD Glucose-224* UreaN-45* Creat-1.9* Na-135
K-4.2 Cl-102 HCO3-23 AnGap-14
[**2199-11-8**] 12:10AM BLOOD Albumin-3.8 Calcium-12.9* Phos-3.4 Mg-1.6
[**2199-11-8**] 06:28AM BLOOD PSA-23.5*
[**2199-11-8**] 07:08AM BLOOD PTH-15
[**2199-11-8**] 12:10AM BLOOD Ammonia-35
[**2199-11-8**] 06:28AM BLOOD PEP-POLYCLONAL IgG-2813* IgA-306 IgM-82
[**2199-11-8**] 06:28AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2199-11-8**] 12:10AM BLOOD Type-ART Temp-37.6 Rates-/26 O2 Flow-15
pO2-136* pCO2-28* pH-7.53* calTCO2-24 Base XS-2 Intubat-NOT
INTUBA Comment-NON-REBREA
[**2199-11-8**] 12:10AM BLOOD Glucose-215* Lactate-1.9 Na-140 K-4.4
Cl-103
[**2199-11-8**] 12:10AM BLOOD Hgb-11.6* calcHCT-35
[**2199-11-8**] 12:10AM BLOOD freeCa-1.49*
EKG [**2199-11-7**]
Sinus tachycardia. Compared to the previous tracing of [**2199-7-17**]
no change
ECHOCARDIOGRAM [**2199-11-8**]
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity is unusually
small. Left ventricular systolic function is hyperdynamic (EF
80%). 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 no
mitral valve prolapse. Trivial mitral regurgitation is seen.
Resting bubble study with no obvious shunt detected. However,
this study is inadequate to exclude intracardiac shunt.
CHEST XRAY [**2199-11-8**]
IMPRESSION:
1. No pneumonia.
2. Prominent right hilum which could be a small lung lesion or
enlarged
hilus.
PA and Lateral view is recommended to clarify when patient
stable.
FOOT XRAYS [**2199-11-8**]
IMPRESSION: No radiographic evidence of osteomyelitis.
CT TORSO [**2199-11-8**]
IMPRESSION:
1. Right hilar lymphadenopathy with a centrally located lung
nodule is
concerning for primary carcinoma of the lung.
2. Multiple lytic osseous metastases as described above. An MR
of the spine may be obtained for further evaluation if central
canal encroachment or involvement is a clinical concern.
3. Left-sided pyelonephritis with delayed excretion and a
dilated ureter with significant stranding around it. An
ureteroscopy may be obtained following resolution of the
infectious symptoms to evaluate the ureter in this location if
clinically [**Year (4 digits) 9304**].
C-SPINE [**2199-11-9**]
IMPRESSION:
1. Small linear metallic densities in anterior neck and
overlying angle of
mandible. Recommend clinical correlation prior to MRI.
2. NGT looped in hypopharynx. Recommend repositioning.
EEG [**2199-11-11**]
IMPRESSION: Abnormal EEG due to diffuse mild to moderate slowing
with
superimposed occasional bifrontal triphasic waves. The record is
most
consistent with a diffuse mild to moderate encephalopathy with
superimposed elements suggestive of a metabolic encephalopathy.
No
frank epileptiform discharges were seen.
CT HEAD [**2199-11-11**]
IMPRESSION: Stable round hypodensity in the left frontoparietal
white matter with a central focus of hyperdensity is relatively
unchanged in size since the prior scan. Central area of
hyperdensity appears more prominent on the study. Differential
diagnosis includes isolated brain metastases, (in a patient with
known prostate cancer and recent lung lesion on CT torso,
primary tumor, focus of hemorrhage with edema, focal ischemia
with central blood products, although the location is unusual
for this; or very early focal septic embolism). MRI is
recommended for further characterization.
NOTE ADDED AT ATTENDING REVIEW: I agree with the above, although
hemorrhagic infarction or metastatics prostate carcinoma appear
unlikely. There is also effacement of the occipital and parietal
sulci bilaterally, new since the study of [**2199-11-8**]. As noted
above, MR [**First Name (Titles) **] [**Last Name (Titles) 9304**] for further evaluation.
BONE BIOPSY [**2199-11-13**]
PENDING
VENOUS DUPLEX [**2199-11-15**]
IMPRESSION: No deep venous thrombosis in right or left lower
extremity.
Limited visualization of left calf veins.
Brief Hospital Course:
#Altered Mental Status: Patient was brought to MICU for altered
mental status, initially thought to be multifactorial d/t
combination of new met vs. infection in frontal lobe,
hypercalcemia, urosepsis. Patient's M.S. continued to fluctuate
during ICU stay, though overall trend was improvent mainly upon
correction of electrolyte abnormalities (patient defervesced
earlier than any substantial mental status improvement).
.
#Metastatic disease: Patient with newfound bony mets to spine,
probable met to brain, and new lung mass. Prostate mets thought
unlikely d/t location of new lesions and PSA not high enough for
diffuse disease. Upon consultation with onc team and famuily,
decision was made to biopsy bony mets first to see if mets are
indeed from new cancer type. Bone biopsy from hip mass revealed
a non-small cell malignancy that was like metastatic from the
lung. Pt was transfered to OMED for further evaluation of NSCLC,
but was transfered to [**Hospital Unit Name 153**] for worsening respiratory distress.
#hypercalcemia: thought to be related to patient's neoplasm
(diffuse new spinal/pelvic mets on CT, lung mass, brain mass),
whether PTHrp or just bone mets. Patient was treated with
diruetics and fluid, calcitonin x4 doses, and palindronate,
after which calcium slowly started to decrease.
.
#hypernatremia: patient became hypernatremic during ICU course
and was given hypotonic IV fluid therapy and free water flushes
which resolved the hypernatremia.
.
#UTI: culture showed CTX sensitive klebsiella without, so
patient was treated with ceftriaxone without recurrence of
fever.
.
# Heel Ulcers: chronic problem, did not appear infected, was
followed by podiatry with frequent dressing changes.
.
#tachypnea: was tachypneic during much of ICU stay without
hypoxia and with reassuring ABGs. Was thought to be a central
cause.
.
# Hypertension: intermittently with systolics up to 180s.
Once tolerating PO, patient was replaced on most of his home
regimen.
[**Hospital Unit Name 13533**]:
Patient presented to [**Hospital Unit Name 153**] with respiratory distress of unknown
etiology. Was subsequently intubated. His course on the
ventilator continued to be tenuous, with episodes of sporadic
tachypnea not associated with desaturations. Could not wean
from the ventilator. Developed suspected VAP, and was placed on
vancomycin and cefepime. Sputum cultures came back positive fo
acinebacter resistant to cefepime, so he was switched to unasyn.
Vancomycin was continued. On [**2199-11-24**], Mr [**Last Name (Titles) **] family
decided to make him comfrot measures only and the patietn was
extubated that afternoon. He passed away at 8:50pm.
Medications on Admission:
Lantus 25U qhs
Oxycodone 100mg q12
Lopid 600mg [**Hospital1 **]
Klonopin 1mg qhs
colace 100mg [**Hospital1 **]
[**Hospital1 10687**] [**Hospital1 **]
Ferrous Sulfate 325mg [**Hospital1 **]
Lisinopril 20mg daily
Venlafaxine 150mg [**Hospital1 **]
Neurontin 300mg qhs
Doxazosin 8mg qhs
ASA 81mg daily
MV
Thiamine 100mg daily
HCTZ 25mg daily
Folic Acid 1mg daily
Famotidine 20mg daily
Percocet 2 tabs q6:prn
Combivent QID
Colace [**Hospital1 **]
Tylenol 325mg q6
MOM
Lactulose 30ml prn
Discharge Medications:
Pt deceased
Discharge Disposition:
Expired
Discharge Diagnosis:
hypoxic respiratory failure
metastatic NSCLC
Pneumonia
Discharge Condition:
Pt deceased
Discharge Instructions:
Pt deceased
Followup Instructions:
Pt deceased
|
[
"590.10",
"038.49",
"V49.86",
"348.5",
"707.14",
"V43.65",
"584.9",
"286.9",
"997.31",
"401.9",
"348.30",
"995.92",
"276.3",
"198.3",
"305.1",
"250.60",
"276.0",
"162.9",
"357.2",
"198.5",
"070.70",
"518.81",
"E879.6",
"996.64",
"185",
"008.45",
"275.42"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"77.49",
"38.93",
"86.28",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
11812, 11821
|
8568, 8577
|
312, 318
|
11920, 11934
|
3757, 8545
|
11994, 12009
|
3177, 3213
|
11776, 11789
|
11842, 11899
|
11268, 11753
|
11958, 11971
|
3228, 3738
|
251, 274
|
346, 1714
|
8592, 11242
|
2464, 3019
|
3035, 3161
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,641
| 197,552
|
44007+44008
|
Discharge summary
|
report+report
|
Unit No: [**Numeric Identifier 94511**]
Admission Date: [**2142-4-28**]
Discharge Date: [**2142-6-6**]
Date of Birth: [**2063-9-1**]
Sex: M
Service: [**Last Name (un) 7081**]
HISTORY OF PRESENT ILLNESS: This 78-year-old white male is
status post transurethral resection of the prostate in [**2142-4-24**] at [**Hospital 1474**] Hospital and began having chest pain [**4-27**]
which was associated with diaphoresis and shortness of
breath. He had increased systolic blood pressure and ST
depressions in V2 to V5 and was treated with nitroglycerin,
aspirin and morphine with complete resolution of symptoms.
He experienced 10/10 chest pain again on [**4-28**] and was
started on heparin drip and Aggrastat and transferred to [**Hospital1 1444**] for cardiac catheterization.
PAST MEDICAL HISTORY: Significant for history of
hypertension, history of insulin-dependent diabetes mellitus,
history of peripheral vascular disease status post left below-
the-knee amputation, history of chronic renal insufficiency
with a creatinine of 1.7 to 2.2, history of dementia, history
of coronary artery disease, status post NSTE myocardial
infarction on [**2142-4-27**], status post transurethral
resection of the prostate [**2142-4-24**], history of adrenal
insufficiency and a history of Clostridium difficile.
ALLERGIES: Quinolone.
MEDICATIONS ON ADMISSION: Prednisone 10 mg p.o. q. day,
Aricept 10 mg p.o. q. day, Zocor 10 mg p.o. q. day,
lisinopril 10 mg p.o. q. day, insulin, Celexa 20 mg p.o. q.
day, Flagyl 500 mg p.o. t.i.d., vancomycin 250 mg p.o. q.
4h., nitro drip, Plavix 75 mg p.o. q. day, Coreg 6.25 mg p.o.
b.i.d. and he came in on a heparin drip.
FAMILY HISTORY: Unremarkable.
SOCIAL HISTORY: He lives with his wife and smokes a pipe.
REVIEW OF SYMPTOMS: Unremarkable.
PHYSICAL EXAMINATION: He is an elderly white male in no
apparent distress. Vital signs stable, afebrile. HEENT
examination: Normocephalic, atraumatic. Extraocular
movements intact. Pupils equal, round and reactive to light
and accommodation. Oropharynx benign. Poor dentition. Neck
was supple. Full range of motion. No lymphadenopathy or
thyromegaly. Carotids 2 plus and equal bilaterally without
bruits. Lungs were clear to auscultation and percussion.
Cardiovascular examination: Regular rate and rhythm. Normal
S1, S2. No murmurs, rubs or gallops. Abdomen was soft, non-
tender with positive bowel sounds. No masses or
hepatosplenomegaly. Extremities: The left hand index finger
was amputated. A left below-the-knee amputation. Well-
healed stump. One plus pedal edema on the right and pulses
were 2 plus bilaterally throughout. Neurological: Alert and
oriented times two and nonfocal.
HOSPITAL COURSE: He was admitted and underwent cardiac
catheterization on [**4-30**] which revealed a 100 percent right
coronary artery stenosis, 80 percent proximal left anterior
descending artery lesion, 80 percent obtuse marginal 1
lesion, 90 percent obtuse marginal 2 lesion, and a diffusely
diseased left circumflex lesion. Dr. [**Last Name (STitle) 70**] was consulted
for coronary artery bypass graft and this was discussed with
Dr. [**Last Name (STitle) 94512**] and the family and the patient and they chose a
high risk intervention rather than coronary artery bypass
graft. So he, on [**2142-5-1**], underwent high risk
intervention and there was extensive local dissection of the
left anterior descending artery with an inability to deliver
the stent and Dr. [**Last Name (STitle) 70**] was consulted for an emergency
coronary artery bypass graft. The family consented and the
patient underwent emergency coronary artery bypass grafting
times one with left internal mammary artery to the left
anterior descending artery. Crossclamp time was 17 minutes,
total bypass time 32 minutes. He was transferred to the CSRU
on insulin drip and propofol in stable condition. He also
had a balloon from the Catheterization Laboratory and on
postoperative day one his balloon was discontinued and
Endocrinology was consulted to follow him for his steroid
taper. He was on CPAP at that point. He was extubated on
postoperative day one. He had his chest tubes discontinued
on postoperative day three and he remained in CSRU for
respiratory therapy. He was also followed by Renal as his
creatinine had bumped up to 2.5. He was requiring high doses
of Lasix. He then went into atrial fibrillation and he was
started on Coumadin for atrial fibrillation. He was seen by
the Speech and Swallowing people on [**5-7**] and they felt
he did not have any dysphagia _______________ with his diet.
He had a PICC line placed on postoperative day seven and had
some lethargy and hypothermia and was cultured. He remained
on vancomycin, Fluconazole and Flagyl at that point. He was
awaiting transfer to [**Hospital Ward Name 121**] Two. On postoperative day nine he
was transferred to the floor to be screened for
rehabilitation. All his narcotics were being held. He
continued to progress and his INR had gone up to 3.8 on
postoperative day 11 so his Coumadin was held. His
creatinine was always around 2 and stable at that. He
continued to improve but on postoperative day 12 he became
agitated and thrashing and was in respiratory distress and
required re-intubation and was transferred back to the CSRU.
He had a transthoracic echocardiogram performed at that time
which revealed no tamponade and an ejection fraction of 30-40
percent with global hypokinesis. He was transfused on
postoperative day 13 to over 30. Zosyn was added to his
antibiotic regimen. He was being weaned from the vent after
that and was followed by Infectious Disease. He was
extubated on postoperative day 14 and continued to improve.
He continued to do better and was again being screened for
rehabilitation. On [**5-20**] he again had respiratory distress
and acute hypercapnia and was intubated again. He was then
slowly improving but on postoperative day 20 he had an
effusion on the right and he had a Cook catheter placed which
following that he had acute hemoptysis requiring a
bronchoscopy. Thoracic Surgery was consulted. He required
blood transfusions. He continued to remain intubated and
required some frequent bronchs. He was reversed with fresh
frozen plasma because he was anticoagulated from his
Coumadin. On postoperative day 24 he had a percutaneous
tracheostomy with no complications. He continued to require
aggressive respiratory therapy and treatment with
antibiotics. He did continue to grow Pseudomonas from his
sputum. Infectious Disease was not sure if it was colonized
but he had his Zosyn discontinued and when this would happen
he would become confused and as soon as he was back on
antibiotics he would have fewer secretions and tolerated the
vent. He also continued to stay on high PEEP of ten to keep
his airways open. Otherwise, they would collapse down and he
would have secretions. He continued to progress and on
postoperative day 34 he again had some thin secretions and
was bronchoscoped and was found to just have tracheal
bronchitis but no thick secretions. On postoperative day 36
he was discharged to rehabilitation in stable condition. We
did have a TP trial two days prior to discharge and he
tolerated it for about two hours but did have a drop in his
sats so at this point his vent settings are CPAP with
pressure support of 10 and PEEP of ten and tolerating that
well. He is awake and alert and sitting up and responsive.
LABORATORY ON DISCHARGE: Hematocrit 32.5, white count 15.2,
platelet count 344,000. Sodium 144, potassium 4.1, chloride
106, CO2 30, BUN 73, creatinine 2.0, blood sugar 141.
DISCHARGE MEDICATIONS:
1. Prednisone 10 mg p.o. q. day.
2. Calcium carbonate 1000 mg p.o. t.i.d.
3. Vitamin D 800 units p.o. q. day.
4. Epogen 10,000 units subcu q. Friday.
5. Pepcid 30 mg p.o. q. day.
6. Combivent two puffs q. 4h.
7. Aspirin 325 mg p.o. q. day.
8. Norvasc 7.5 mg p.o. q. day.
9. Nystatin Swish 'n Swallow 5 mL p.o. q.i.d.
10. Colace 100 mg p.o. b.i.d.
11. Haldol 1 mg p.o. q. hs.
12. Percocet one to two p.o. q. 4-6h. p.r.n. pain.
13. Tylenol p.r.n.
14. Flagyl 500 mg p.o. q. day. He should stay on this
for at least a week after his Zosyn is discontinued for
his recurrent Clostridium difficile.
15. Zosyn 2.25 grams IV q. 6h.
16. Lasix 20 mg p.o. b.i.d.
17. Potassium 20 mEq p.o. b.i.d.
18. Simvastatin 10 mg p.o. q. day.
19. Donepezil hydrochloride 5 mg p.o. q. hs.
20. Citalopram hydrobromide 30 mg p.o. q. day.
FOLLOW UP: He will be followed by Dr. [**Last Name (STitle) 94513**] following
discharge from rehabilitation, by Dr. [**Last Name (STitle) 70**] following
discharge from rehabilitation.
DISCHARGE DIAGNOSES: Coronary artery disease.
Peripheral vascular disease.
Prolonged ventilation.
Hypertension.
Insulin-dependent diabetes mellitus.
Chronic renal insufficiency.
Dementia.
Adrenal insufficiency.
Clostridium difficile.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5662**], [**MD Number(1) 5663**]
Dictated By:[**Last Name (NamePattern1) 18588**]
MEDQUIST36
D: [**2142-6-5**] 17:50:49
T: [**2142-6-5**] 18:29:05
Job#: [**Job Number **]
Unit No: [**Numeric Identifier 94511**]
Admission Date: [**2142-4-28**]
Discharge Date: [**2142-6-6**]
Date of Birth: [**2063-9-1**]
Sex: M
Service: [**Last Name (un) 7081**]
ADDENDUM:
The patient had a white blood cell count of 21.2 on the day
of discharge and had his Foley changed and had a new PICC
line placed on the left. His antibiotic coverage was
broadened with Ciprofloxacin 500 mg p.o. twice a day. Also,
his Norvasc was increased to 10 mg p.o. once daily. The
patient was transferred to rehabilitation in stable
condition.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5662**], [**MD Number(1) 5663**]
Dictated By:[**Last Name (NamePattern1) 18588**]
MEDQUIST36
D: [**2142-6-6**] 19:07:11
T: [**2142-6-6**] 20:12:47
Job#: [**Job Number 45805**]
|
[
"250.01",
"997.3",
"786.3",
"410.71",
"518.5",
"518.0",
"008.45",
"255.4",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.20",
"31.1",
"37.22",
"33.22",
"37.61",
"88.56",
"36.01",
"36.15",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
1681, 1696
|
8763, 10075
|
7678, 8553
|
1360, 1664
|
2725, 7489
|
8565, 8741
|
1815, 2707
|
7504, 7655
|
210, 782
|
805, 1333
|
1713, 1792
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,377
| 119,723
|
24673
|
Discharge summary
|
report
|
Admission Date: [**2188-9-10**] Discharge Date: [**2188-9-19**]
Date of Birth: [**2108-12-7**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
Arm pain
Major Surgical or Invasive Procedure:
Tracheostomy
History of Present Illness:
79 yo male with parkinson's disease presented to ED s/p fall
down stairs with unknown loss of consciousness.
Past Medical History:
Parkinson's
Multiple bilateral finger amputations
Prostate (?BPH)
Bilateral TKA
Social History:
Lives with family?
Family History:
n/a
Physical Exam:
See admission note
Pertinent Results:
[**2188-9-10**] 12:05AM BLOOD WBC-13.1* RBC-3.40* Hgb-11.5* Hct-31.3*
MCV-92 MCH-33.7* MCHC-36.6* RDW-13.7 Plt Ct-159
[**2188-9-10**] 07:30PM BLOOD Hct-26.1*
[**2188-9-11**] 01:02AM BLOOD Hct-23.9*
[**2188-9-12**] 02:08AM BLOOD WBC-8.4 RBC-3.04* Hgb-10.0* Hct-28.4*
MCV-94 MCH-32.8* MCHC-35.1* RDW-14.0 Plt Ct-134*
[**2188-9-12**] 09:23PM BLOOD Hct-29.2*
[**2188-9-13**] 09:52PM BLOOD Hct-29.1*
[**2188-9-14**] 06:15AM BLOOD WBC-6.2 RBC-3.47* Hgb-11.1* Hct-31.6*
MCV-91 MCH-32.0 MCHC-35.2* RDW-14.2 Plt Ct-175
[**2188-9-16**] 04:52AM BLOOD WBC-9.2 RBC-3.13* Hgb-10.1* Hct-28.4*
MCV-91 MCH-32.4* MCHC-35.6* RDW-14.1 Plt Ct-214
[**2188-9-17**] 04:30AM BLOOD WBC-6.9 RBC-2.98* Hgb-9.6* Hct-28.5*
MCV-96 MCH-32.1* MCHC-33.6 RDW-14.1 Plt Ct-238
[**2188-9-18**] 07:25AM BLOOD WBC-7.3 RBC-3.01* Hgb-9.7* Hct-28.9*
MCV-96 MCH-32.2* MCHC-33.5 RDW-14.0 Plt Ct-266
[**2188-9-10**] 12:05AM BLOOD PT-14.3* PTT-28.0 INR(PT)-1.4
[**2188-9-10**] 12:05AM BLOOD Plt Ct-159
[**2188-9-10**] 03:55AM BLOOD Plt Ct-160
[**2188-9-10**] 03:55AM BLOOD PT-14.6* PTT-30.6 INR(PT)-1.5
[**2188-9-11**] 04:03AM BLOOD Plt Ct-130*
[**2188-9-13**] 03:26PM BLOOD PT-13.9* PTT-31.1 INR(PT)-1.3
[**2188-9-17**] 04:30AM BLOOD Plt Ct-238
[**2188-9-18**] 07:25AM BLOOD Plt Ct-266
[**2188-9-10**] 12:05AM BLOOD Fibrino-220
[**2188-9-10**] 12:05AM BLOOD UreaN-27* Creat-1.1
[**2188-9-10**] 03:55AM BLOOD Glucose-152* UreaN-26* Creat-1.1 Na-142
K-4.1 Cl-110* HCO3-21* AnGap-15
[**2188-9-11**] 04:03AM BLOOD Glucose-97 UreaN-26* Creat-1.3* Na-146*
K-3.9 Cl-112* HCO3-23 AnGap-15
[**2188-9-12**] 02:08AM BLOOD Glucose-86 UreaN-27* Creat-1.4* Na-142
K-3.9 Cl-110* HCO3-24 AnGap-12
[**2188-9-13**] 03:26PM BLOOD Glucose-118* UreaN-24* Creat-1.1 Na-144
K-4.2 Cl-113* HCO3-21* AnGap-14
[**2188-9-15**] 03:31PM BLOOD Glucose-122* UreaN-29* Creat-1.0 Na-146*
K-4.1 Cl-115* HCO3-22 AnGap-13
[**2188-9-16**] 04:52AM BLOOD Glucose-120* UreaN-26* Creat-1.0 Na-145
K-4.0 Cl-114* HCO3-20* AnGap-15
[**2188-9-18**] 07:25AM BLOOD ALT-57* AST-43* AlkPhos-94 Amylase-19
TotBili-0.9
[**2188-9-18**] 07:25AM BLOOD Albumin-2.9* Calcium-7.7* Phos-2.3*#
Mg-2.1
[**2188-9-10**] 03:55AM BLOOD Calcium-8.3* Phos-3.2 Mg-1.8
[**2188-9-16**] 04:52AM BLOOD Vanco-20.7*
[**2188-9-16**] 12:30PM BLOOD Vanco-12.4*
[**2188-9-10**] 12:05AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2188-9-10**] 12:18AM BLOOD freeCa-1.12
[**2188-9-13**] 03:37PM BLOOD freeCa-1.17
Brief Hospital Course:
Admitted to Trauma SICU for retroperitoneal bleed seen on CT.
Patient remained hemodynamically stable. Orthopedic surgery was
consulted and provided a splint for the left humerus fracture.
While in the SICU, the patient remained hemodynamically stable,
but required PRBC transfusion and FFP administration. In the
SICU, experienced acute delerium worsening his baseline mental
status. HD [**6-25**] his deleriem resolved and he was considered by
the family to beat baseline.
He was started on vancomycin and levaquin after chest xray c/w
pneumonia and given high aspiration risk. The antibiotic plan
was for 2 weeks of coverage. A dobhoff tube was placed to
provide nutrition. DHT malfunctioned on [**9-18**] and was replaced
under flouroscopy on [**2188-9-19**].
Geriatrics followed while in house.
MRSA swab positive on day of discharge.
Afebrile and hemodynamically stable for >48 hours.
Medications on Admission:
Carbidopa
Requip
Doxaosin
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
Disp:*12 * Refills:*2*
2. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet, Rapid
Dissolve PO BID (2 times a day) as needed.
Disp:*30 Tablet, Rapid Dissolve(s)* Refills:*0*
3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
Disp:*20 Tablet(s)* Refills:*2*
4. Doxazosin 4 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
Disp:*20 Tablet(s)* Refills:*2*
5. Ropinirole 0.25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
Disp:*22 Tablet(s)* Refills:*2*
6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
Disp:*90 Tablet, Chewable(s)* Refills:*2*
7. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Ropinirole 0.25 mg Tablet Sig: One (1) Tablet PO QAM AND NOON
().
Disp:*22 Tablet(s)* Refills:*2*
9. Oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours)
as needed.
Disp:*22 Tablet(s)* Refills:*0*
10. Levofloxacin 750 mg IV Q24H
11. Vancomycin HCl 1000 mg IV Q 12H
please check trough with 3rd dose
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
1. Left humerus fx
2. Multi-rib fx
3. Left renal lac with hematoma
4. Left iliac [**Doctor First Name 362**] fx with hematoma,
5. Aspiration pneumonia
6. Sm left acetabulum fx.
7. Poor swallow/ pharyngeal weakness
Discharge Condition:
Stable
Discharge Instructions:
1. Humidified oxygen as required
2. Keep left arm in splint
3. MRSA precautions (+ Nares swab)
4. Continue antibiotics for total of 14 days
Followup Instructions:
Trauma clinic in [**12-20**] weeks. Call to schedule an appointment at
[**Telephone/Fax (1) 24689**].
Primary care physician [**Last Name (NamePattern4) **] [**11-18**] weeks
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
|
[
"808.41",
"293.0",
"808.0",
"507.0",
"E880.9",
"V49.62",
"807.00",
"866.02",
"372.00",
"868.03",
"V43.65",
"812.21",
"781.2",
"332.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.07",
"79.01",
"96.6",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
5300, 5379
|
3134, 4036
|
323, 338
|
5637, 5646
|
690, 3111
|
5834, 6142
|
631, 636
|
4112, 5277
|
5400, 5616
|
4062, 4089
|
5670, 5811
|
651, 671
|
275, 285
|
366, 476
|
498, 579
|
595, 615
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,941
| 112,360
|
41305
|
Discharge summary
|
report
|
Admission Date: [**2195-4-9**] Discharge Date: [**2195-4-19**]
Date of Birth: [**2127-2-15**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain s/p hip replacement
Major Surgical or Invasive Procedure:
Coronary artery bypass grafting x4
urgent with a left internal mammary artery graft to left
anterior descending and reverse saphenous vein graft to the
marginal branch, diagonal branch and posterior descending
artery.
History of Present Illness:
68 yo male underwent a R total hip
replacement [**4-7**] for osteoarthritis. The procedure was
uncomplicated, but the night of POD 0 and early morning on POD 1
he develpoed indigestion, nausea, vomiting with chest pain
radiating to both hands with a tingling sensation. He develpoed
EKG changes with ST depression in inferior and lateral leads
which have resolved. His peak troponin was 22 at 6am on [**4-9**].
He underwent cardiac cath on [**4-9**] which showed elevated LVEDP
and
severe 3vd. He is transfered to [**Hospital1 18**] for surgical evaluation.
Past Medical History:
hypertension
hyperlipidemia
Past Surgical History:
s/p R hip replacement [**2195-4-7**]
Social History:
Lives with:wife
Occupation:truck driver for Shaws
Tobacco: Nonsmoker
ETOH: about 1 beer/day
Family History:
Positive for father with arthritis and
hypertensiion. mother s/p valve replacement x3
Physical Exam:
Pulse:84 Resp: 18 O2 sat:96% on 3L NC
B/P Right: 144/66 Left:
Height:5'[**95**]" Weight:208#
General:
Skin: Dry [x] intact [x] L leg w/dry skin and mild chronic
venous
stasis discoloration
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] No Murmur
Abdomen: Softly distended [x] non-tender [x] bowel sounds + [x]
Extremities: Warm [x], well-perfused [x] Edema none[x]
Varicosities: None [x]
Neuro: Grossly intact[x]
Pulses:
Femoral Right: 2+ Left:2+
DP Right: 2+ Left:2+
PT [**Name (NI) 167**]: 2+ Left:2+
Radial Right:post cath TR band in place Left:2+
Carotid Bruit Right:? soft bruit Left:none
R hip incision no erythema or obvious bleeding, transparent
dressing with small amount of blood. Area edematous, slightly
tender, no bruising noted
Discharge Physical
VS: T: 98.1 HR: 80-90 SR BP: 120-130's/ 60-70 RR 18 Sats: 98
2L
Wt: 94.6 ([**2195-4-19**])
General: 68 year-old male in no apparent distress
HEENT: normocephalic, mucus membranes moist
Neck: supple no lymphadenopathy
Card: RRR
Resp: decreased breath sounds with crackles 1/4 up bilateral
GI: bowel sounds positive, abdomen soft non-tender/on-distended
Extr: warm R 3+ edema, L 2+
Incision: sternal clean/dry/intact, stable, Right hip site
ecchymotic with 3+ edema
Neuro: awake, alert oriented
Pertinent Results:
[**2195-4-18**] WBC-13.7* RBC-3.75* Hgb-11.6* Hct-32.1* MCV-86 MCH-31.0
MCHC-36.2* RDW-13.9 Plt Ct-301
[**2195-4-9**] WBC-12.4* RBC-3.57* Hgb-11.0* Hct-30.7* MCV-86 MCH-30.8
MCHC-35.8* RDW-13.3 Plt Ct-156
[**2195-4-18**] PT-36.1* INR(PT)-3.6* [**2195-4-17**] PT-17.4* INR(PT)-1.6*
[**2195-4-16**] PT-14.5* INR(PT)-1.3*
[**2195-4-18**] UreaN-26* Creat-0.9 Na-137 K-4.0 Cl-96
[**2195-4-9**] Glucose-122* UreaN-18 Creat-0.9 Na-140 K-3.9 Cl-104
HCO3-31
[**2195-4-18**] ALT-21 AST-22 LD(LDH)-364* AlkPhos-118 Amylase-126*
TotBili-1.9*
[**2195-4-16**] ALT-21 AST-21 AlkPhos-74 Amylase-73 TotBili-1.9*
[**2195-4-18**] Lipase-249
[**2195-4-16**] Lipase-93*
[**2195-4-17**] Abdomen: Persistent bowel dilatation, consistent with
ileus.
CXR: [**2195-4-15**]: FINDINGS: The patient has been extubated. The
left chest tube has been removed without evidence for
pneumothorax. The right internal jugular line and intestinal
tube have been removed. The stomach is distended. Persistent
small left pleural effusion and basilar atelectasis are
unchanged. Mild pulmonary vascular congestion persists.
Brief Hospital Course:
The patient was brought emergently to the operating room on
[**2195-4-13**] with a NSTEMI post-operatively from a right total hip
replacement on [**2195-4-7**]. The patient underwent a coronary
artery bypass grafting x4 with a left internal mammary artery
graft to left anterior descending and reverse saphenous vein
graft to the
marginal branch, diagonal branch and posterior descending
artery. Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. On POD #1 the
patient was extubated, alert and oriented and breathing
comfortably. The patient was neurologically intact and
hemodynamically stable, weaned from inotropic and vasopressor
support. Beta blocker was initiated and the patient was gently
diuresed toward the preoperative weight. On POD#1 the patient
was transferred to the telemetry floor for further recovery.
Chest tubes and pacing wires were discontinued without
complication on POD #2.
Respiratory: Sucessfully extubated POD1. Aggressive pulmonary
toilet, nebs, incentive spirometer his oxygen requirements
improved to 98% 2L via nasal cannula
Cardiac: pacing wires removed [**2195-4-16**]. Beta-blockers were
initiated he weaned off NTG. On [**2195-4-15**] he developed atrial
fibrillation rate 130-160's converted to sinus rhythm with
amiodarone IV load, Dilt drip he converted to sinus rhythm. He
continued to have intermittent RAF 130-160's. His was
transitioned to PO 30 qid, Beta-block 37.5 mg [**Hospital1 **] and amiodarone
PO 400 mg [**Hospital1 **]. Heart rate 80-90's SR. ACE and statins were
restarted. He was hypertensive his home meds clonidine,
doxazosin were restarted with SBP 120-130's.
GI: aggressive bowel regime and PPI were continued. His diet
was slowly advanced but was found to an ileus on [**2195-4-17**]. He
was kept NPO, KUB showed stool in colon/air in small bowel.
Aggressive bowel regime continued with good results on [**2195-4-18**].
His diet was slowly increased which he tolerated.
Renal: gently diuresed. Renal function remained within normal
limits with good urine output. His electrolytes were repleted
as needed.
Heme: [**2195-4-14**] he was transfused 2 units PRBC for HCT 23 to Hct
of 27. Heparin SQ DVT prophylaxis was transitioned to Lovenox
40 mg [**Hospital1 **] was started [**4-17**], Warfarin 3 mg was given [**4-16**] & [**4-17**],
INR [**4-18**] 3.2 warfarin was held. INR [**4-19**] 2.9 0.5 mg ordered. He
will follow-up with his PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 21448**] for warfarin managment as
an outpatient.
Endocrine: insulin sliding scale and lantus were given. His
blood sugars were less than < 200. Please adjust and titrate
off.
Pain: IV Dilaudid transitioned to PO Dilaudid which was stopped
when his ileus developed. He was given acetaminophen with good
pain control.
Disposition: he was seen by physical therapy recommended rehab.
He was discharged to [**Hospital3 **] TCu on [**2195-4-19**]. He will
follow-up as an outpatient with Dr. [**Last Name (STitle) **], his orthopedic
surgeon, and PCP for outpatient warfarin follow-up.
Medications on Admission:
Bisoprolol-HCTZ [**11-24**] daily, Doxazosin 4mg daily, dilt ER 240
daily, lisinopril 40 daily, simvastatin 40 daily, clonidine 0.3
daily, ASA 81, MVI, Vit E
Discharge Medications:
1. doxazosin 4 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
2. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. clonidine 0.1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
9. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
10. diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4
times a day): hold for HR < 60 SBP < 100.
11. tramadol 50 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for pain.
12. potassium chloride 10 mEq Tablet Extended Release Sig: One
(1) Tablet Extended Release PO DAILY (Daily).
13. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) PO once a day.
14. Senna-S 8.6-50 mg Tablet Sig: One (1) Tablet PO twice a day.
15. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
once a day as needed for constipation.
16. warfarin 1 mg Tablet Sig: One (1) Tablet PO as directed to
maintain INR 2.0-3.0: dose to maintain INR 2.0-3.0.
17. Insulin sliding scale
71-109 mg/dL 0 Units 0 Units 0 Units 0 Units
110-140 mg/dL 3 Units 3 Units 3 Units 0 Units
141-180 mg/dL 5 Units 5 Units 5 Units 1 Units
181-210 mg/dL 7 Units 7 Units 7 Units 3 Units
211-240 mg/dL 9 Units 9 Units 9 Units 5 Units
241-280 mg/dL 11 Units 11 Units 11 Units 7 Units
18. insulin glargine 100 unit/mL Solution Sig: Ten (10) units
Subcutaneous with breakfast.
19. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety .
20. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 5016**] [**Doctor Last Name 1495**] Raphaels TCU - [**Location (un) 7661**]
Discharge Diagnosis:
Coronary artery disease with a NSTEMI, and post-operative atrial
fibrillation.
hypertension
hyperlipidemia
Past Surgical History:
s/p R hip replacement [**2195-4-7**]
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 and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Surgeon Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] [**5-7**] 1:15 in the [**Last Name (un) 2577**]
Building [**Last Name (NamePattern1) **], [**Location (un) 551**].
Cardiologist Dr. [**Last Name (STitle) 5017**], [**First Name3 (LF) 4597**]: follow-up on [**2194-5-14**]:45
Primary Care Dr. [**Last Name (STitle) 21448**] [**Telephone/Fax (1) 69547**] for warfarin follow-up once
discharged from rehab
Warfarin for atrial fibrillation. INR Goal 2.0-3.0
Last dose of Warfarin [**2195-4-19**], 0.5 mg. INR [**2195-4-19**] 2.9
Follow-up with your orthopedic surgeon Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 89929**] for
your right hip surgery.
**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:[**2195-4-19**]
|
[
"410.71",
"560.1",
"V43.64",
"414.01",
"E878.2",
"E878.1",
"427.31",
"997.1",
"272.4",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.13",
"39.61",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
9373, 9488
|
4022, 7186
|
341, 561
|
9701, 9857
|
2911, 3999
|
10645, 11577
|
1395, 1483
|
7394, 9350
|
9509, 9617
|
7212, 7371
|
9881, 10622
|
9640, 9680
|
1498, 2892
|
270, 303
|
589, 1154
|
1176, 1205
|
1285, 1379
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,996
| 129,938
|
40174
|
Discharge summary
|
report
|
Admission Date: [**2198-2-8**] Discharge Date: [**2198-2-10**]
Date of Birth: [**2148-9-25**] Sex: F
Service: NEUROSURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics) / Moxifloxacin / Minocycline /
Penicillins / Bactrim
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
R frontoparietal meningioma
Major Surgical or Invasive Procedure:
Right F/P craniotomy for tumor resection
History of Present Illness:
Elective admit for resection of R frontoparietal lesion
Past Medical History:
occassional oral herpes, GERD, seizures
Social History:
married, has daughter and 2 step-daughters. smokes 1/2ppd x 30
yrs and social EtOH.
Family History:
paternal grandfather died of lung ca father had MI, still
living; brother IDDM
Physical Exam:
On Discharge:
Left UE [**Hospital1 **]/Tri 4+/5, otherwise full strengths and non-focal
Pertinent Results:
MR HEAD W/ CONTRAST [**2198-2-8**]
1.5 x 2.6 x 2.7-cm enhancing extra-axial superior right frontal
mass without significant change in size or enhancement pattern
compared to
[**2198-1-25**], and again with associated edema in the underlying
right frontal lobe.
CT HEAD W/O CONTRAST [**2198-2-8**]
Expected post-operative change without intracranial hemorrhage
or
mass effect. There is pneumocephalus, and vasogenic edema in the
region of
the tumor resection.
MR HEAD W & W/O CONTRAST [**2198-2-9**]
1. Small amount of blood products at the right frontal
craniotomy and
extra-axial mass resection bed, without residual mass seen.
2. Small area of restricted diffusion in the resection bed is
consistent with cytotoxic edema
Brief Hospital Course:
49 y/o F presented for elective procedure. She was taken to the
OR on [**2198-2-8**] for R frontoparietal craniotomy for tumor
resection. OR was uncomplicated and patient was transported to
the PACU. Post op head CT showed post op pneumocephalus with no
hemorrhage. On examination, patient had L side weakness of 4+/5.
On [**2-9**], MRI was performed and showed no residual mass. She
remained stable, weakness improved in the left UE and on [**2-10**] she
was cleared for discharge home. Her dilantin level continued to
remain subtherapeutic therefore she was changed to Keppra and
decadron was tapered to off over 7 days.
Medications on Admission:
asa, dilantin, colace, percocet, prilosec, tylenol
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Keppra 500 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
3. acetaminophen-codeine 300-30 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
4. dexamethasone 1 mg Tablet Sig: taper Tablet PO taper for 7
days: 4mg Q8 hrs on [**2-10**] & [**2-11**] then 2mg Q8hrs x2 days, 1 mg Q8hrs
x 1 day, 1 mg Q12hrs x1 day, 1mg daily x1 day then stop.
Disp:*qs Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
R frontoparietal meningioma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures and/or staples have
been removed. If your wound closure uses dissolvable sutures,
you must keep that area dry for 10 days.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? You haven been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
?????? Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in 4 weeks.
?????? You will need a CT scan of the brain without contrast prior to
this appointment.
Completed by:[**2198-2-10**]
|
[
"780.39",
"305.1",
"599.0",
"V14.2",
"530.81",
"V14.0",
"225.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"02.12",
"38.91",
"01.51"
] |
icd9pcs
|
[
[
[]
]
] |
2925, 2931
|
1640, 2264
|
376, 418
|
3002, 3002
|
889, 1617
|
4793, 5081
|
685, 766
|
2365, 2902
|
2952, 2981
|
2290, 2342
|
3152, 4770
|
781, 781
|
795, 870
|
309, 338
|
446, 503
|
3017, 3128
|
525, 567
|
583, 669
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,099
| 180,397
|
51614
|
Discharge summary
|
report
|
Admission Date: [**2134-10-7**] Discharge Date: [**2134-10-9**]
Date of Birth: [**2083-12-8**] Sex: M
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
alcohol withdrawal, hematemesis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
50 yo male with long hx of etoh abuse, hx of DT and seizure
during withdrawl, was at [**Hospital1 **] for detox and discharged to a
sober house. Recently left the sober house and began drinking,
last drink [**10-5**]. Had left the sober house where had been living
and was drinking large amounts of vodka "enough to pass out".
Sent to [**Hospital1 18**] when developed n/v hematemesis. Denies melena,
hematochezia. Reports multiple episodes of emesis that had
spots of blood. Denies cough, sore throat, chest pain, SOB,
abdominal pain, dysuria, arthralgias, myalgias.
In ED noted to have continued emesis in ED which was
gastroccult positive.
Past Medical History:
1. EtOH withdrawl with DT and seizure
2. Asthma
3. Gout
4. GERD
5. UBIG "from the esophagus"-unclear if varix but required 4u
PRBC transfusion (history per patient and studies performed at
[**Hospital1 65180**])
6. ?Hepatitis C
Social History:
Has been staying at a "sober house" in [**Location (un) 1157**], MA. Recently
has come to [**Location (un) 86**] and is currently homeless. Currently on
military disability. Former printer. 40+ pk/yr history, current
smoker. +IVDU in past including cocaine, crystal meth.
Physical Exam:
T 98.8 BP 188/97 HR 92 RR 17 96%@RA
Gen- Lying in bed, tremulous, in mild distress
HEENT- Anicteric, PERRL, EOMI, MMM, OP clear
Neck- no JVD
Lungs- +mild expiratory wheeze
CV- S1S2, reg rate and rhythm, no m/r/g
Abd- Soft, NT/ND, BS present. No HSM, negative [**Doctor Last Name 515**] sign, no
caput medusae, no spider angiomata, no asterixis.
Ext- No calf tenderness, no edema.
Skin- no rash
Neuro- AOx3, CN II-XII intact, 5/5 strength all extremities
without deficit.
Pertinent Results:
[**2134-10-7**] 02:09AM BLOOD WBC-10.1 RBC-4.64 Hgb-11.9* Hct-36.0*
MCV-78* MCH-25.6* MCHC-33.0 RDW-15.0 Plt Ct-381
[**2134-10-7**] 02:09AM BLOOD Neuts-81.5* Lymphs-13.4* Monos-3.8
Eos-0.5 Baso-0.8
[**2134-10-7**] 02:09AM BLOOD PT-12.9 PTT-24.2 INR(PT)-1.1
[**2134-10-7**] 02:09AM BLOOD Glucose-116* UreaN-15 Creat-0.9 Na-140
K-4.0 Cl-103 HCO3-25 AnGap-16
[**2134-10-7**] 02:09AM BLOOD ALT-18 AST-24 AlkPhos-84 Amylase-57
TotBili-0.6
[**2134-10-7**] 02:09AM BLOOD Lipase-33
[**2134-10-8**] 03:30AM BLOOD calTIBC-384 VitB12-537 Ferritn-26*
TRF-295
Brief Hospital Course:
1. EtOH withdrawal: Pt was initiated on CIWA scale and was
loaded with IV Valium, requiring 50mg IV in the ED. He was
requiring hourly checks for withdrawal and was sent to the
[**Hospital Ward Name 332**] ICU for closer monitoring. His CIWA score subsequently
decreased and was sent to the floor on [**2134-10-8**]. There were no
episodes of seizure. On day of discharge the patient was >
72hours from his last drink and had an unremarkable CIWA score.
He was discharged with four tablets of 5mg Valium for anxiety.
2. Hematemesis: NG lavage was performed in the ED which was
negative. Rectal guiaic for occult blood was negative. A GI
consult was obtained for further evaluation of his UGI tract
given his history of HCV and past UGIB requiring transfusions.
Serial HCT checks have been stable with no evidence of blood
loss. GI recommended further outpatient workup to be performed
either at the [**Hospital1 65180**] or at [**Hospital1 18**]. The patient reports that he has
a planned upper and lower endoscopy at the [**Hospital1 65180**] later this month
and is already taking Protonix.
3. Anemia: Notable anemia on laboratory data, likely
iron-deficiency. He was started on FeSO4 and instructed to
continue these tablets.
Medications on Admission:
Prozac 40mg PO QD
Albuterol Inh
Atrovent Inh
Aciphex
Indocin PRN
Viagra PRN
Discharge Medications:
1. Multivitamin Capsule Sig: One (1) Cap PO QD (once a day).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
6. Fluoxetine HCl 20 mg Capsule Sig: Two (2) Capsule PO QD (once
a day).
7. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO QD
(once a day).
8. Quetiapine Fumarate 25 mg Tablet Sig: Two (2) Tablet PO QHS
(once a day (at bedtime)).
Discharge Disposition:
Home
Discharge Diagnosis:
alcohol withdrawal/ detoxification
hematemesis
Discharge Condition:
stable
Discharge Instructions:
please use the taxi voucher to proceed to south station in
transit to your [**Location (un) 1157**] facility/ sober house.
please take [**1-8**] tablet of Valium tonight and tomorrow night for
anxiety.
follow up at the [**Hospital **] Hospital for your scheduled endoscopy
procedures.
Followup Instructions:
follow up at the [**Hospital **] Hospital for your scheduled endoscopy
procedures.
|
[
"274.9",
"291.81",
"070.70",
"530.81",
"578.0",
"305.01",
"280.9",
"493.90"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
4661, 4667
|
2648, 3890
|
341, 348
|
4758, 4766
|
2077, 2625
|
5101, 5187
|
4016, 4638
|
4688, 4737
|
3916, 3993
|
4790, 5078
|
1585, 2058
|
270, 303
|
376, 1025
|
1047, 1277
|
1293, 1570
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,195
| 154,834
|
14668
|
Discharge summary
|
report
|
Admission Date: [**2176-8-12**] Discharge Date: [**2176-9-9**]
Service: Medical Intensive Care Unit
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is an 84-year-old
gentleman with medical history significant for atrial
fibrillation treated with Coumadin and glaucoma. He
presented to the [**Hospital1 69**]
Emergency Room on [**8-12**] from [**Hospital3 4527**] Hospital for
treatment of a subdural hematoma following a fall.
PHYSICAL EXAMINATION: Vital signs, temperature 98.8, heart
rate 92 and regular. His blood pressure is 123/67,
respiratory rate 29 and he is saturating at 98% on 40% trach
collar. General appearance, Mr. [**Known lastname **] is a well developed,
well nourished elderly gentleman with tracheostomy. He is
mildly agitated but in no acute distress. He has a well
healed craniotomy scar on the right side. His pupils are
equal, round and reactive to light. His oral pharynx is
clear and dry. His sclera are anicteric. Neck, supple with
no jugulovenous distension or lymphadenopathy.
Cardiovascular, Mr. [**Known lastname **] is tachycardic with occasional
premature beats. There are no murmurs, rubs or gallops
appreciated. Chest, coarse breath sounds throughout
consistent with tracheostomy. He has mildly decreased breath
sounds in his left lower lobe and occasional faint expiratory
wheezes on his right side. Abdomen, soft, mildly distended,
nontender, tympanitic with normal bowel sounds. PEG site is
clean, dry and intact. Extremities, Mr. [**Known lastname **] has 1+
pitting edema bilateral and symmetrical in his upper
extremities, no edema in his lower extremities. He has a
PICC line in his left antecubital fossa which is clean, dry
and intact at the insertion site. Skin, clear, no rashes or
erythema.
LABORATORY DATA: Mr. [**Known lastname **] has a non contrast CT of the
head on [**8-14**] which [**Month/Year (2) 3780**] a drainage catheter within
the right subdural fluid collection, probably representing a
chronic subdural hematoma. There was persistent subdural
collection associated with mass effect and shift of the
midline structures. Mr. [**Known lastname **] also had a follow-up CT of
the head, non contrast on [**8-17**] which showed decrease in size
of the subdural hematoma and decrease in the midline shift.
He also had another CT of the head, also non contrast on [**8-19**]
which showed no significant change in the size of the
subdural collection overlying the right cerebral hemisphere
with increased interval size in air fluid levels of the
paranasal sinuses. On [**8-27**] Mr. [**Known lastname **] [**Last Name (Titles) 1834**] another CT
of the head, non contrast, which [**Last Name (Titles) 3780**] slight increase
in anterior portion of the right subdural collection as well
as a more prominent right posterior subdural collection.
There was interval improvement of the sinuses. Other studies
of note: On [**8-26**] Mr. [**Known lastname **] [**Last Name (Titles) 1834**] a right upper quadrant
ultrasound which [**Last Name (Titles) 3780**] a 1.6 cm stone in the
gallbladder, adenomyomatosis, slightly thickened gallbladder
wall and edema suggesting cholecystitis. On [**9-7**] Mr. [**Known lastname **]
[**Last Name (Titles) 1834**] a portable chest x-ray which [**Last Name (Titles) 3780**] an
enlarged heart with pulmonary venous engorgement and early
perihilar pulmonary edema and a possible opacification at the
left base, either consolidation or pleural effusion. On [**9-9**]
Mr. [**Known lastname **] had laboratory studies drawn which included the
following: A complete blood count showing a white blood cell
count of 10,200, hematocrit 32.5 and platelet count 257,000.
He had a PT of 13.5, PTT 25.2 and INR 1.3. His chemistry 7
was as follows: Sodium 143, potassium 3.6, chloride 107, CO2
30, BUN 12 and creatinine 1.4. His glucose was 161. His
calcium was 8.8, magnesium 1.7 and phosphorus 1.9. His total
bilirubin on this date was 0.9, AST 29, ALT 17 and alkaline
phosphatase 114.
Microbiology studies: During the course of his stay, Mr.
[**Known lastname **] grew Enterobacter, enterococcus and Methicillin
resistant staphylococcus aureus from his sputum cultures.
Urinalysis: Mr. [**Known lastname **] [**Last Name (Titles) 3780**] the presence of
eosinophils on his urinalysis from [**9-7**]. Mr. [**Known lastname **] had an
EKG which showed sinus rhythm with occasional atrial
premature beats and left axis deviation.
HOSPITAL COURSE: On [**8-12**] to [**8-13**] the patient was admitted to
the neurosurgical ICU for evacuation of his subdural
hematoma. He subsequently had a subdural drain placed
followed by craniotomy membrane excision for evacuation of
the subdural hematoma. For the craniotomy procedure Mr.
[**Known lastname **] was intubated and following this procedure, there was
difficulty extubating Mr. [**Known lastname **]. Each extubation attempt
initially in the neurosurgical ICU was associated with
agitation and episodic hypertension and tachycardia by Mr.
[**Known lastname **]. These episodic periods of agitation prevented his
extubation. During that time he also developed fevers and
grew Enterobacter, enterococcus from his sputum. In
addition, Mr. [**Known lastname **] on x-ray was noted to have pulmonary
edema and echocardiogram [**Known lastname 3780**] normal ejection
fraction. In addition, Mr. [**Known lastname **] complained of right upper
quadrant pain during his time in the neurosurgical ICU.
Right upper quadrant ultrasound [**Known lastname 3780**] cholelithiasis
and cholecystitis, however, he was determined not to be a
surgical candidate and instead was treated with antibiotics
and pain medications. Serial CT scans of Mr. [**Known lastname 9149**] head
read by the neurosurgical team [**Known lastname 3780**] stability of the
subdural hematoma and on [**8-29**] he was transferred to the
medical ICU for failure to wean from the ventilator and
episodic agitation and hypertension in addition to management
for his presumed Enterobacter and enterococcus pneumonia.
Following his transfer to the medical Intensive Care Unit,
Mr. [**Known lastname **] grew Methicillin resistant staphylococcus aureus
from his sputum. He was treated with Levofloxacin followed
by Zosyn and Flagyl and Ampicillin for 7 days respectively
for presumed GI infection related to his cholecystitis.
During the subsequent days, Mr. [**Known lastname **] was successfully
weaned from his ventilator and tolerated his trach collar
without requiring ventilatory support. His pneumonia
improved with decrease in number of secretions and he was
diuresed with improvement in his pulmonary edema by x-ray.
Cardiovascular: Mr. [**Known lastname **] [**Last Name (Titles) 3780**] episodes of
hypertension and tachycardia with occasional premature atrial
beats related primarily to his agitation. He was placed on a
standing dose of Lisinopril 10 mg once a day and Metoprolol
12.5 mg [**Hospital1 **] with fairly good control of his blood pressure
except during periods of agitation. He was not treated for
his intermittent atrial fibrillation as his blood pressure
remained stable throughout his stay in the medical Intensive
Care Unit.
Infectious Disease: As mentioned above, Mr. [**Known lastname **] has been
treated with Levofloxacin for roughly a total of 20 days for
his pneumonia. He is also being treated with Zosyn for a
total of 10 day course for the pneumonia. In addition, he
received 7 days of Flagyl and 7 days of Ampicillin for
empiric coverage related to his cholecystitis.
GI: For his MRSA, Mr. [**Known lastname **] received a percutaneous
enterojejunostomy tube on the [**7-8**] and has
tolerated tube feeds well without residual. His
cholecystitis has been treated with antibiotics and pain
medications from which he has been weaned by the [**7-9**].
Neurologic: As mentioned before, Mr. [**Known lastname 9149**] subdural
hematoma has been deemed stable by the neurosurgical team.
He continues to be delirious with episodic agitation,
gradually decreasing in duration, although he continues to be
agitated up to 3-4 times per day for up to an hour at a time
associated with hypertension and tachycardia. Mr. [**Known lastname 9149**]
agitation was deemed likely secondary to polypharmacy with
multiple sedatives, analgesics and anti-psychotic agents
being gradually weaned with little improvement in mental
status, although by the end of his stay, Mr. [**Known lastname **] was able
to communicate intermittently with the nursing staff.
Renal: Mr. [**Known lastname 9149**] renal function had been normal until
roughly [**9-7**] when his creatinine gradually increased over the
next several days from .9 to 1.4. Urinalysis revealed the
presence of eosinophils, likely related to acute interstitial
nephritis. The interstitial nephritis may be related to one
of a number of agents including Vancomycin for which he is
being treated for the Methicillin resistant staphylococcus
aureus, Ampicillin or Lasix which has been given for his
pulmonary edema. The creatinine levels will continue to be
followed.
Lines: Mr. [**Known lastname **] has a left PICC line placed on [**9-5**].
Prophylaxis: Mr. [**Known lastname **] is receiving Protonix and is wearing
pneumoboots.
DISPOSITION: Mr. [**Known lastname **] will be discharged to rehabilitation
facility of family's choosing.
CODE: Mr. [**Known lastname **] is full code.
CONDITION ON DISCHARGE: Mr. [**Known lastname **] is in stable condition at
discharge.
DISCHARGE DIAGNOSIS:
1. Subdural hematoma.
2. MRSA pneumonia.
3. Atrial fibrillation.
4. Delirium.
DISCHARGE MEDICATIONS: Include Cosopt eyedrops, one drop OU
[**Hospital1 **], Combivent meter dose inhaler 4 puffs qid, Artificial
tears one drop OU prn, Colace 100 mg po bid, Lacrilube
ointment one application OU prn, Lisinopril 10 mg po q d,
Metoprolol 12.5 mg po bid, Multivitamin liquid 5 ml po q d,
Protonix 40 mg IV q day, Zosyn 2.25 gm IV q 6 hours,
Vancomycin 1 gm q 24 hours. Mr. [**Known lastname **] will likely have to
have his Protonix converted to po and will need to complete a
10 day course of Zosyn and 10 day course of Vancomycin prior
to discharge or at the rehabilitation facility.
FOLLOW-UP PLANS:
1. Mr. [**Known lastname **] is to follow-up with his primary physician,
[**Last Name (NamePattern4) **]. [**Last Name (STitle) 5292**], one week following discharge. His family is to
call for appointment. They are aware of their need to do so.
2. Mr. [**Known lastname **] is to follow-up with Dr. [**Last Name (STitle) 1327**], his
neurosurgeon. Appointment is scheduled for [**10-8**] at 3 p.m.
He is to be seen prior to that in the morning for a CT scan.
At this point it is unclear to which rehabilitation facility
Mr. [**Known lastname **] will be sent to. Please check the medical records
to find out which facility needs to receive a copy of this
report.
[**Name6 (MD) 1339**] [**Last Name (NamePattern4) 1340**], M.D. [**MD Number(1) 1341**]
Dictated By:[**Last Name (NamePattern1) 17270**]
MEDQUIST36
D: [**2176-9-9**] 14:50
T: [**2176-9-9**] 14:57
JOB#: [**Job Number 43185**]
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44,724
| 189,442
|
48214
|
Discharge summary
|
report
|
Admission Date: [**2197-9-11**] Discharge Date: [**2197-9-16**]
Date of Birth: [**2131-1-28**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Hypoxia, Altered Mental Status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
66 y/o male with schizophrenia, COPD, previous episodes of
aspiration pneumonia and chronic rhabdomyolysis who was admitted
for altered mental status with recurrent falls and an increasing
oxygen requirement. At admission he had been on Azithromycin for
three days for a bronchial infection but no improvement had been
noted and his oxygen requirement was gradually increasing. His
oxygen saturations were 83% on room air on admission and
required 4-5 liters to maintain saturations of 95-96%. There
was high concern for another aspiration event and he was started
on Levofloxacin and Flagyl. He had been febrile to the low 100s
prior to admission but was afebrile on presentation to [**Hospital1 18**]. He
was initially admitted to medicine but on the morning after
admission, the patient was found to be hypoxic to 82% on 5L NC.
A CXR from the prior night was concerning for volume overload.
Lasix were given and the patient was placed on a NRB with
subsequent improvement in O2 saturation to 100%. He was
transferred to the MICU for presumed impending respiratory
failure. The patient improved on Levofloxacin and Flagyl and was
able to be weaned down to low flow oxygen by nasal canula. He
was then transferred back out to the medicine floor.
Past Medical History:
Paranoid schizophrenia
COPD
History of psychogenic polydipsia
Anemia
Aspiration pneumonias
Rhabdomyolysis (? Chronic)
Social History:
Ordained as a rabbi, no longer engaged in rabbi[**Name (NI) **] work.
Lived in his current [**Hospital3 **] apartment for approximately
10 years.
Smokes 1.25-2 ppd but no other substance.
Brother [**Name (NI) 5045**] is his guardian.
[**Name (NI) **] immediate family in the [**Location (un) 86**] area.
Family History:
Deferred. Not addressed during this admission.
Physical Exam:
Vitals: T: 96.3, BP: 152/78, P: 85, R: 18 O2: 98% RA
General: restless at times, NAD
HEENT: NCAT, sclera non-icteric, no TM, no cervical LAD
Lungs: frequent coughing, minimal diffuse wheezing, +/-
decreased breath sounds at right lung base
CV: no JVD, regular rate and rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Psych: patient actively hallucinating, frequently delivering
lectures religious in nature, patient able to be redirected
Neuro: CN II-XII grossly intact, sensation grossly intact,
requires assistance to ambulate
Pertinent Results:
[**9-11**] CT head: Study limited by motion artifact, but no gross
intracranial
abnormality.
[**9-12**] Pelvis xray: No evidence of fracture or dislocation.
[**9-12**] CXR: No acute cardiopulmonary process.
[**9-13**] CT Spine:
1. No acute cervical spine fracture or malalignment is detected.
2. Multilevel degenerative changes of the cervical spine, worse
at C5-C6
level causing mild narrowing of the spinal canal and right
neural foramina at
this level.
[**9-14**] CT Abdomen and Pelvis:
1. No evidence of retroperitoneal bleed or bleed into the
thighs.
2. There is an opacity in the right lower lobe of the lung that
is most
consistent with aspiration versus infection.
[**9-14**] pCXR: Right lower lobe consolidation significantly improved
since
[**2197-8-25**]. However, persistent since recent priors.
Six-week follow-up
radiograph to document resolution is recommended.
[**2197-9-11**] 12:20PM BLOOD cTropnT-0.10*
[**2197-9-12**] 05:30AM BLOOD CK-MB-4 cTropnT-0.05* proBNP-988*
[**2197-9-12**] 03:45PM BLOOD CK-MB-6 cTropnT-0.06*
[**2197-9-13**] 04:58AM BLOOD CK-MB-6 cTropnT-0.02*
[**2197-9-14**] 02:38AM BLOOD calTIBC-131* Hapto-465* Ferritn-722*
TRF-101*
[**2197-9-11**] 12:20PM BLOOD CK(CPK)-[**2155**]*
[**2197-9-12**] 05:30AM BLOOD CK(CPK)-1742*
[**2197-9-12**] 03:45PM BLOOD CK(CPK)-1590*
[**2197-9-13**] 04:58AM BLOOD CK(CPK)-1154*
[**2197-9-14**] 02:38AM BLOOD CK(CPK)-561*
[**2197-9-15**] 06:14AM BLOOD CK(CPK)-246
[**2197-9-11**] 12:20PM BLOOD Glucose-99 UreaN-30* Creat-1.4* Na-145
K-4.9 Cl-103 HCO3-34* AnGap-13
[**2197-9-12**] 03:45PM BLOOD Glucose-124* UreaN-29* Creat-1.1 Na-150*
K-4.5 Cl-107 HCO3-34* AnGap-14
[**2197-9-13**] 04:58AM BLOOD Glucose-223* UreaN-34* Creat-1.0 Na-144
K-4.1 Cl-105 HCO3-33* AnGap-10
[**2197-9-15**] 06:14AM BLOOD Glucose-112* UreaN-37* Creat-0.9 Na-145
K-4.1 Cl-108 HCO3-30 AnGap-11
[**2197-9-11**] 12:20PM BLOOD WBC-7.2 RBC-3.32* Hgb-10.0* Hct-30.8*
MCV-93 MCH-30.1 MCHC-32.3 RDW-15.9* Plt Ct-291
[**2197-9-11**] 12:20PM BLOOD Neuts-73.7* Lymphs-17.1* Monos-8.1
Eos-0.1 Baso-1.0
[**2197-9-13**] 04:58AM BLOOD WBC-7.9 RBC-2.72* Hgb-8.2* Hct-25.3*
MCV-93 MCH-30.1 MCHC-32.4 RDW-15.5 Plt Ct-254
[**2197-9-13**] 04:58AM BLOOD Neuts-88.0* Lymphs-9.3* Monos-2.3 Eos-0.1
Baso-0.2
[**2197-9-14**] 02:38AM BLOOD WBC-14.4*# RBC-2.29* Hgb-6.8* Hct-20.7*
MCV-91 MCH-29.9 MCHC-33.0 RDW-15.8* Plt Ct-240
[**2197-9-14**] 02:38AM BLOOD Neuts-90.7* Lymphs-7.2* Monos-1.9*
Eos-0.2 Baso-0.1
[**2197-9-16**] 06:50AM BLOOD WBC-13.5* RBC-3.53* Hgb-10.7* Hct-30.6*
MCV-87 MCH-30.2 MCHC-34.9 RDW-16.1* Plt Ct-256
Brief Hospital Course:
Mr. [**Known lastname 101623**] is a 66 year old male with COPD, paranoid
schizophrenia and recurrent aspiration events who presented with
altered mental status and hypoxia concerning for an aspiration
pneumonia and COPD exacerbation.
.
1. Hypoxic Respiratory Distress: Patient has history of
recurrent aspiration events and presented with hypoxia
refractory to high-flow O2 by nasal canula. Preliminary CXR was
concerning for possible volume overload and patient received
Lasix. High O2 requirements persisted, he as placed on a
non-rebreather and transferred to the MICU. Treatment was
initiated with Levofloxacin Metronidazole for a presumed
aspiration pneumonia given RLL infiltrate on CXR. A sputum gram
stain was consistent with oral flora, revealing 1+ GPC and GPRs,
> 25 PMNs, < 10 epithelial cells but no growth was found.
Albuterol and Ipratropium nebulizations and Solumedrol were also
given for a concomitant COPD exacerbation. A TTE revealed a
grossly normal ejection fraction. Oxygen saturations improved
and the patient was transferred back to the medicine floor with
low O2 requirements. CBCs revealed a normal white count
initially but subsequently increased and this was attributed to
steroids. Patient remained afebrile. Speech and swallow
evaluations were performed daily on the floor and his diet was
adjusted accordingly to thin liquid and ground solids. No
further aspiration events were witnessed. At discharge, patient
had oxygen saturations near 100% on room air. He was discharged
with instructions to complete a full 10-day course of
Levofloxacin and Metronidazole. ** Radiology recommended a
follow-up repeat CXR in [**4-25**] weeks to evaluate for resolution of
the RLL infiltrate. **
.
2. acute blood loss anemia: Patient has anemia of chronic
inflammation at baseline with hematocrit of 30.8 on admission.
On day two of hospitalization, the patient removed his own foley
with the balloon inflated. Hematuria was initially noted.
Urology was consulted and recommended foley replacement with
continuous bladder irrigation until the bleeding cleared.
Initial hematuria was followed by clotting but clearance was
achieved over the course of several hours. Patient was
concomitantly received IVF. The following day a 10 point
hematocrit drop was noticed. A CT of the abdomen and pelvis
revealed no bleed into the retroperitoneum or thighs. The
patient was transfused two units of packed red blood cells. The
drop in hematocrit was attributed to hematuria with subsequent
CBI and IVF, as the patient was net positive approximately 4
liters of fluid in a 24 hour period. Hematocrit remained stable
post-transfusion.
.
3. Altered mental status - Patient presented with altered
sensorium in the setting of hypoxia. Given inability to assess
if further recent falls had occurred, a non-contrast head CT and
CT spine were performed and revealed no bleed and no fractures,
respectively. His mental status was likely worsened by the fact
that he was initially maintained in a C-collar due to inability
to clear his spine, the presence of a foley and restraints after
he removed his own foley. Patient also received large doses of
Haldol in the MICU for extreme agitation. Psychiatry was
consulted and recommended Ativan for agitation as well as the
addition of Cogentin given the high-doses of Haldol. Once back
on the medicine floor, the C-collar was removed as patient was
able to be assessed for midline pain. Restraints and foley were
also removed. The patient continued to have hallucinations due
to his underlying schizophrenia but his mental status greatly
improved.
.
4. Troponin Leak: Troponin-T elevated to 0.10 on admission but
trended down to 0.02 during hospitalization. CK-MB decreased
from an initial 6 to 4. Troponin leak was eventually attributed
to right heart strain in the setting of hypoxic vasoconstriction
of pulmonary arteries, especially given that the enzymes trended
down with treatment of the underlying pulmonary process and
restoration of oxygen saturation.
.
5. Schizophrenia with acute psychosis: The patient was actively
hallucinating throughout his hospitalization. Clozapine and
Divaloprex were continued throughout the hospital stay.
.
6. Chronic Rhabdomyolysis: Patient had reported chronic
rhabdomyolysis on transfer to the medicine floor. CKs had been
as high as 20,000-30,000 in the past. CKs were initially [**2155**]
but trended down to 246 throughout the hospital stay. The
rhabdomyolysis has previously been attributed to recurrent
falls. ** No work-up was performed during this hospitalization
but is recommended if does not resolve. **
.
7. INR: INR was elevated to 1.4 on admission and trended down
to 1.2 during hospitalization. This was attributed to a possible
Vitamin K deficiency. Patient was treated with oral Vitamin K
during hospitalization with initial INR drop. Patient was
discharged on two weeks of Vitamin K supplementation. ** If INR
does not normalize with Vitamin K therapy, appropriate
evaluation as an outpatient is likely warranted. **
Medications on Admission:
1. Clozapine 100 mg daily
2. Clozapine 500 mg QHS
3. Divaloprex 500 mg [**Hospital1 **]
4. Ferrous sulfate 325 mg daily
5. Multivitamin daily
6. Thiamine HCl 100 mg daily
Discharge Medications:
1. Clozapine 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Clozapine 100 mg Tablet Sig: Five (5) Tablet PO HS (at
bedtime).
3. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 6 days: Take all of this medication. Do not skip a
dose. .
Disp:*16 Tablet(s)* Refills:*0*
4. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily) for 5 days: Take all of this medication. Do not skip a
dose. .
Disp:*5 Tablet(s)* Refills:*0*
5. Divalproex 500 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO BID (2 times a day).
6. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) for 5 days.
Disp:*200 ML(s)* Refills:*0*
7. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
for 5 days: Take 2 tablets per day on [**9-17**]. Take 1 tablet per
day on [**9-18**] and [**9-19**]. Take 0.5 tablets per day on [**9-20**] and [**9-21**].
Stop taking on [**9-22**]. .
Disp:*5 Tablet(s)* Refills:*0*
8. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Phytonadione 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 2 weeks: Take this medication until you see your primary
care doctor. .
Disp:*15 Tablet(s)* Refills:*0*
10. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Nebulization Inhalation every six (6)
hours as needed for dyspnea for 5 days.
Disp:*20 Nebulizations* Refills:*0*
11. Ipratropium Bromide 0.02 % Solution Sig: One (1)
Nebulization Inhalation every six (6) hours as needed for
wheezing for 5 days.
Disp:*20 Nebulization* Refills:*0*
12. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1643**]
Discharge Diagnosis:
Primary Diagnosis:
Aspiration Pneumonia
Altered Mental Status (Delirium)
COPD Exacerbation
Seconday Diagnoses:
Rhabdomyolysis (Chronic)
Schizophrenia with acute psychosis
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Mr. [**Known lastname 101623**]:
You were admitted to the hospital because of a severe lung
infection that was likely caused by an aspiration event, where
some of the bacteria from your mouth ended up in your lungs. You
were treated with antibiotics and the infection improved. You
will need to continue these antibiotics at home for several more
days to ensure that the infection is completely cleared.
THESE ARE NEW MEDICATIONS THAT WERE STARTED IN THE HOSPITAL:
1. Metronidazole 500 mg by mouth every eight hours: you will
need to take this medication for five more days (stop on [**9-21**]).
2. Levaquin 750 mg by mouth once a day: you will need to take
this medication for five more days (stop on [**9-21**]).
3. Guaifenesin [**5-29**] mL by mouth every six hours as needed for
cough: this medication helps to clear some of the fluid from
your airways and can be stopped when you feel your cough has
improved.
4. Prednisone 20 mg tablets to be taken as directed: Take 2
tablets per day on [**9-17**]. Take 1 tablet per day on [**9-18**] and [**9-19**].
Take 0.5 tablets per day on [**9-20**] and [**9-21**]. Stop taking on [**9-22**].
This medication helps to decrease the inflammation in your
lungs.
5. Albuterol Sulfate 0.083 % solution to be taken as
nebulization every six hours as needed for dyspnea.
6. Ipratropium Bromide 0.02 % solution to be taken as
nebulization every six hours as needed for wheezing.
7. Phytonadione 5 mg tablet by mouth daily for two weeks.
YOU SHOULD NOT TAKE THESE MEDICATIONS UNTIL YOU SEE YOUR PRIMARY
CARE DOCTOR:
1. Ferrous sulfate 325 mg by mouth daily: This medication can
interfere with the antibiotic Levaquin that you are taking for
your lung infection.
No changes were made to your other medications and you should
continue your regular medications as directed.
Followup Instructions:
Department: [**Hospital3 249**]
When: MONDAY [**2197-10-2**] at 2:10 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
Completed by:[**2197-9-16**]
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[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
12347, 12394
|
5430, 10454
|
345, 352
|
12610, 12610
|
2854, 2865
|
14632, 15071
|
2109, 2157
|
10675, 12324
|
12415, 12415
|
10480, 10652
|
12795, 14609
|
2172, 2835
|
275, 307
|
380, 1629
|
2874, 5407
|
12434, 12589
|
12625, 12771
|
1651, 1771
|
1787, 2093
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,989
| 131,611
|
7047
|
Discharge summary
|
report
|
Admission Date: [**2144-5-20**] Discharge Date: [**2144-5-23**]
Date of Birth: [**2104-8-20**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7223**]
Chief Complaint:
transferred from OSH for ICD firing for VT
Major Surgical or Invasive Procedure:
none
History of Present Illness:
39 yo M with PMH of premature CAD s/p CABG in [**2142**] (LIMA to LAD,
SVG to diag, SVG to posterolateral branch of RCA) s/p multiple
RCA stents, s/p ICD for cardiomyopathy and VT, chronic pain and
anxiety who presents from OSH with his ICD firing. He reports
that around noon today, he woke up out of sleep and knew that
his ICD was firing. He does not describe chest pain,
palpitations, or shortness of breath. He called 911 and went to
the OSH. He notes his ICD fired 4 times at home and 2 x in the
ambulance and at least 3 times in the ED at the OSH. He was
given a bolus of lidocaine and started on a lidocaine drip.
Since then, he did not have further episodes of VT.
.
Of note, he describes not having taken his lasix in months. He
was recently discharged in early [**2144-4-11**] with a CHF
exacerbation from not taking his lasix. He says he has not taken
it since he left the hospital either. He denies SOB and says he
can walk several flights of stairs without SOB. He reports that
he does take the rest of his medications including the sotolol
(changed from procainamide during his last admission). He also
describes 3 days of loose stools [**4-14**] x per day. Denies fevers,
chills, abdominal pain. Denies dysuria, hematuria, nausea or
vomiting. He endorses cough with brown sputum for a couple of
weeks; no hemoptysis.
.
Currently, he feels "fine." Denies currently CP, palpitations,
SOB, n/v/f/c. No abdominal pain. +chronic back pain all over.
+claudication symptoms in his lower calves bilaterally.
.
.
*** 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:
-Premature CAD s/p CABG, [**2142-3-7**], anatomy as follows:
LIMA->LAD, SVG->Diagonal, SVG->Posterolateral branch of RCA
s/p multiple RCA stents c/b restenoses, brachytherapy
-Pacemaker/ICD, in [**11-12**], for cardiomyopathy and VT
-systolic CHF EF 30-35% [**2-16**]
-dyslipidemia
-GERD
-h/o drug seeking behavior
-chronic back pain
-Anxiety disorder
-attention deficit disorder
.
Cardiac Risk Factors: No Diabetes, +Dyslipidemia, Hypertension
Social History:
Lives alone but his mother is around. He used to smoke 2-4 packs
per day for over 20 years. Currently smokes a couple cigarettes
per day. Denies alcohol or drug use.
Family History:
Father with CAD: MI age 40, s/p CABG x3v
Mother with CAD: MI age 57, s/p stent, also with metastatic
breast ca and DM2
Brother: cancer (unknown type)
No history of sudden death in the family.
Physical Exam:
VS: T 102.3, BP 127/73, HR 120, RR 17, O2 95% on RA.
Gen: obese male in NAD, but mildly diaphoretic. Oriented x3.
Mood, affect depressed.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Difficult to assess JVP given body habitus.
CV: tachycardic RR, normal S1, S2. No S4, no S3. No murmur
appreciated
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Mild bibasilar
crackles. Decreased BS on left base.
Abd: Obese, soft, NTND. No abdominial bruits.
Ext: No c/c. No to trace peripheral edema.
Pulses:
Right: Carotid 2+ without bruit; 2+ DP
Left: Carotid 2+ without bruit; 2+ DP
Pertinent Results:
[**2144-5-20**] 08:37PM WBC-13.8*# RBC-4.49* HGB-13.7* HCT-40.4
MCV-90 MCH-30.5 MCHC-33.9 RDW-17.3*
[**2144-5-20**] 08:37PM PLT COUNT-235
[**2144-5-20**] 08:37PM PT-13.1 PTT-27.1 INR(PT)-1.1
[**2144-5-20**] 08:37PM GLUCOSE-198* UREA N-19 CREAT-0.9 SODIUM-137
POTASSIUM-4.0 CHLORIDE-100 TOTAL CO2-24 ANION GAP-17
[**2144-5-20**] 08:37PM CALCIUM-8.9 PHOSPHATE-1.7*# MAGNESIUM-1.9
[**2144-5-20**] 08:37PM ALT(SGPT)-44* AST(SGOT)-50* LD(LDH)-281* ALK
PHOS-64 TOT BILI-0.4
[**2144-5-20**] 10:14PM URINE bnzodzpn-POS barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2144-5-20**] 10:14PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-1 PH-6.5 LEUK-NEG
[**2144-5-21**] 06:26AM BLOOD Neuts-71* Bands-8* Lymphs-9* Monos-11
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-1*
[**2144-5-23**] 06:04AM BLOOD WBC-15.5* RBC-4.31* Hgb-12.9* Hct-38.3*
MCV-89 MCH-30.0 MCHC-33.8 RDW-16.6* Plt Ct-339
[**2144-5-23**] 06:04AM BLOOD PT-13.1 PTT-26.3 INR(PT)-1.1
[**2144-5-23**] 06:04AM BLOOD Glucose-141* UreaN-14 Creat-0.8 Na-139
K-4.1 Cl-101 HCO3-23 AnGap-19
[**2144-5-23**] 06:04AM BLOOD Calcium-8.8 Phos-3.5 Mg-1.5*
.
Micro:
UCx negative
BCx [**2144-5-20**] NTD x 2
.
Reports:
CHEST (PORTABLE AP) [**2144-5-20**] 8:20 PM
The heart size is top normal, stable. The post-sternotomy wires
are in unchanged position allowing the technical differences
given the current apical projection of the study. Although the
lungs are clear except for minimal bibasilar opacities
consistent with atelectasis. Note is made that right
costophrenic angle is not included in the field of view. No
appreciable pleural effusion is demonstrated. Left-sided
pacemaker is noted with one of its leads terminating in the
right ventricle. Another lead most likely external or
subcutaneous is noted, changing its position compared to the
prior films.
.
ECG Study Date of [**2144-5-20**] 8:48:24 PM
Supraventricular tachycardia, probably sinus tachycardia. Left
atrial
abnormality. Consider inferior myocardial infarction, age
indeterminate.
Intraventricular conduction delay. Other ST-T wave
abnormalities.
Since the previous tracing of [**2144-4-15**] the rate has increased.
.
CHEST (PA & LAT) [**2144-5-21**] 1:52 PM
FINDINGS: In comparison with the study of [**11-19**], there is again
some enlargement of the cardiac silhouette. There is slight
fullness of the pulmonary markings, raising the possibility of
elevated pulmonary venous pressure. No evidence of pleural
effusion or definite acute infiltrate.
.
ECHO [**2144-5-21**]:
Conclusions
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity is
moderately dilated. Due to suboptimal technical quality, a focal
wall motion abnormality cannot be fully excluded. There is
moderate to severe global left ventricular hypokinesis. Overall
left ventricular systolic function is severely depressed (LVEF=
30 %). The number of aortic valve leaflets cannot be determined.
There is no aortic valve stenosis. No aortic regurgitation is
seen. The mitral valve leaflets are not well seen. Trivial
mitral regurgitation is seen. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion.
Compared with the prior study (images reviewed) of [**2143-9-25**],
the left ventricular severe systolic dysfunction appears more
global.
.
ECG Study Date of [**2144-5-22**] 8:15:30 AM
Sinus rhythm. Intraventricular conduction defect. Possible prior
inferior
myocardial infarction. Non-specific inferior and lateral ST-T
wave changes. Compared to the previous tracing of [**2144-5-20**] the
rate is slower.
Brief Hospital Course:
39 yo M with premature CAD s/p CABG, systolic CHF with EF 35%,
s/p PM/ICD for VT who presents with VT and his ICD firing. In
addition, he is febrile with fatigue and diarrhea.
.
# VT: ICD was firing and he was found to be in VT. He was given
lidocaine bolus and then started on a lidocaine drip at the OSH.
Here, his sotalol was titrated up to 120mg PO BID, mexilitine
was started, and lidocaine drip was discontinued. He was
continued on Toprol 300mg qday. He had no further episoded of VT
when on this regimen. His QTc was 451 upon discharge. He was
given instructions to follow-up with Dr. [**Last Name (STitle) **] and Dr. [**First Name (STitle) 437**].
The importance of taking his medications and following up was
stressed in his discharge paperwork.
.
# fever: His fever to 102 [**Last Name (un) **] concerning for infection, there
there was no objective source for his infection. He did not
have diarrhea while here. His PA/LAT CXR showed no signs of
infiltrate. His UA and UCx were clear. His blood cultures from
[**5-20**] were NTD upon discharge. He was initially given ceftriaxone
as empiric treatment for pneumonia, but this was discontinued
upon discharge (received 4 days) given the information above.
Suspect fevers were from viral infection, possibly pneumonia.
We were unable to obtain flu DFA or stool cultures during his
stay. He was afebrile x 24 hours upon discharge.
.
# CAD/Ischemia: known premature CAD s/p CABG. He was continued
on asa, plavix, atorvastatin, bblocker, imdur at his home
dosages (imdur and ace-i initially held because of his fever and
concern for possible onset of sepsis). His ACE-I was decreased
to 20mg qday because of SBP in the 90s intermittently with the
new regimen.
.
# Chronic Systolic heart failure: known systolic dysfunction
with LVEF 35% on ECHO [**9-17**]. He was euvolemic during his stay.
His lasix was initially held because of his febrile
presentation, but it was restarted at his home dose upon
discharge.
.
# dyslipidemia: TG were over 1200 on last admission. Currently
taking atorvastatin and although he was not discharged on
gemfibrozil, he says he takes it twice daily. He was continued
on gemfibrozil and atorvastatin.
.
# HTN: antihypertensive regimen as above.
.
# DM: no known diabetes. A1C in [**4-18**] was 5.4%.
.
# chronic pain: discharged on home dose of percocet and
oxycontin.
.
# anxiety: discharged on home dose of diazepam.
.
# ADD: ritalin was held given tachycardia. He was discharged
with instructions not to take ritalin until he discusses it with
his PCP and cardiologist.
.
# Prophylaxis: heparin SQ for DVT ppx, PPI per home regimen
.
# Code: full
.
# Communication: Contact: Mother, [**Name (NI) **] [**Name (NI) 7635**] ([**Telephone/Fax (1) 26309**]
cell; ([**Telephone/Fax (1) 26313**] home.
Medications on Admission:
Per last d/c summary in [**4-17**] and confirmed with the patient:
-Aspirin 325 mg Tablet PO DAILY
-Clopidogrel 75 mg Tablet PO DAILY
-Isosorbide Mononitrate 60 mg Tablet Sustained Release DAILY
-Lisinopril 40 mg Tablet PO DAILY
-Diazepam 10 mg Tablet PO BID for 1 week- but he says he is
still taking this.
-Methylphenidate 10 mg Tablet PO TID
-Sotalol 80 mg Tablet PO BID
-Metoprolol Succinate 300 mg Tablet Sustained Release PO DAILY
-Pantoprazole 40 mg Tablet, Delayed Release (E.C.) PO Q24H
-Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H as needed.
-Oxycodone 40 mg Tablet Sustained Release 12 hr PO Q12H for 1
week- but says he still takes this
-Furosemide 40 mg Tablet PO DAILY ---says he is not taking this
-gemfibrozil 600mg [**Hospital1 **] --- not discharged on this, but he says
he takes it
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO once a day.
6. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Sotalol 80 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day).
Disp:*90 Tablet(s)* Refills:*2*
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO every four
(4) hours as needed for pain.
10. OxyContin 40 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO twice a day.
11. Diazepam 10 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for anxiety.
12. Mexiletine 200 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
Disp:*90 Capsule(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
ventricular tachycardia
.
Secondary:
-chronic systolic CHF
-Premature CAD s/p CABG, [**2142-3-7**], anatomy as follows:
LIMA->LAD, SVG->Diagonal, SVG->Posterolateral branch of RCA
s/p multiple RCA stents c/b restenoses, brachytherapy
-Pacemaker/ICD, in [**11-12**], for cardiomyopathy and VT
-dyslipidemia
-GERD
-h/o drug seeking behavior
-chronic back pain
-Anxiety disorder
-attention deficit disorder
Discharge Condition:
good, stable
Discharge Instructions:
You were seen at [**Hospital1 18**] for ICD firing for ventricular
tachycardia. Your medication regimen was changed to improve
control of your heart rate and rhythm. It is very important to
take your medications as prescribed. If you do not take your
medications, you risk needing to return to the hospital,
worsening your heart function, or even death.
.
You were also treated for possible pneumonia because of your
fever when you were admitted. There was no pneumonia by repeat
chest xray, so the antibiotic was stopped. Your urine was
negative for infection and blood cultures have been negative
thus far. The fever could have been from a viral infection,
possibly influenza. You should call your primary care provider
or report to the emergency department if you feel worsening
shortness of breath, fever, cough, or body/joint aches.
.
Please also follow-up as below. It is very important to make
appointments with Dr. [**Last Name (STitle) **] and Dr. [**First Name (STitle) 437**] as below.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
.
You should call your cardiologist or your primary care provider
or return to the emergency department if you experience chest
pain, shortness of breath, lightheadedness, palpitations,
shocking from your ICD, loss of consciousness, cough, body
aches, fever/chills greater than 100.5 degrees F, or any other
symptoms that concern you.
Followup Instructions:
Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in the next 7-10 days.
Please call [**Telephone/Fax (1) 2934**] for an appointment.
.
Please follow-up with Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**] in the next 2-3 weeks.
Please call [**Telephone/Fax (1) 4451**] for an appointment.
.
Please follow-up with your primary care provider, [**Name10 (NameIs) **],[**Name11 (NameIs) **]
[**Name Initial (NameIs) **]. [**Telephone/Fax (1) 26303**], in the next week.
|
[
"V45.02",
"401.9",
"300.00",
"428.0",
"272.4",
"425.4",
"428.22",
"427.1",
"414.01",
"V45.81",
"079.99",
"314.00",
"530.81",
"724.5"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
12162, 12168
|
7362, 10158
|
358, 365
|
12625, 12640
|
3690, 7339
|
14130, 14670
|
2763, 2957
|
11034, 12139
|
12189, 12604
|
10184, 11011
|
12664, 14107
|
2972, 3671
|
276, 320
|
393, 2095
|
2117, 2564
|
2580, 2747
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,958
| 148,427
|
54627
|
Discharge summary
|
report
|
Admission Date: [**2155-5-23**] Discharge Date: [**2155-6-10**]
Date of Birth: [**2079-3-1**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 594**]
Chief Complaint:
Acute Cord Compression, Probable Epidural Abscess
Major Surgical or Invasive Procedure:
T7-T12 Post Spinal Decompression and Fusion, with debridement of
a pre-sacral decubitis ulcer
History of Present Illness:
Patient seen and examined, agree with house officer admission
note by Dr. [**Last Name (STitle) 111743**] with additions below
76 year old Male emergently transferred from [**Hospital3 26615**]
Hospital after being initially admitted after being found down
at his [**Hospital1 1501**] with a severe COPD exacerbation that by report
devolved into bradycardic with idioventricular rhythm he was
given atropine x1, he was not hypotensive and did not receive
chest compression, and he was started on amiodarone. The patient
was ultimately intubated for his COPD flare as he developed
hypoxic respiratory failure and admitted to the MICU. While in
the micu, he was treated with prednisone for COPD flare and
extubated the day before admission at which time severe lower
extremity weakness was noted. He underwent urgent spine imaging
with both CT and MRI, which were concerning for epidural
abscess, diskitis, osteomyelitis and collapse of T9 with cord
compression with edema from T8-T11. Patient started on
vancomycin/Zosyn prior to transfer.
As [**Hospital3 26615**] has no spine surgery, he is emergently
transferred from spine evaluation. He is admitted to the medical
service as there are no critical care beds or neurosurgery beds
at this time.
Past Medical History:
CABG [**2147**] (4 vessle)
Systolic CHF EF - 35%
COPD on Home O2
Obstructive Sleep Apnea
Chronic Kidney Diease Stage 3 baseline Cr 1.7
Type 2 Diabetes (IDDM)
Hypothyroidism
Atrial Fibrillation
Heel Ulcers
BPH
Social History:
Lives in [**Hospital1 1501**]. 50 pack year hx of smoking, quit in [**2147**]. no EtOH
or drug use
Family History:
Family history unknown by patient
Physical Exam:
ROS:
GEN: - fevers, - Chills, - Weight Loss
EYES: - Photophobia, - Visual Changes
HEENT: - Oral/Gum bleeding
CARDIAC: - Chest Pain, - Palpitations, - Edema
GI: - Nausea, - Vomitting, - Diarhea, - Abdominal Pain, -
Constipation, - Hematochezia
PULM: - Dyspnea, - Cough, - Hemoptysis
HEME: - Bleeding, - Lymphadenopathy
GU: - Dysuria, - hematuria, - Incontinence
SKIN: - Rash
ENDO: - Heat/Cold Intolerance
MSK: - Myalgia, - Arthralgia, - Back Pain
NEURO: Paralyzed below waist, - Vertigo, - Headache
PHYSICAL EXAM:
VSS: 98.1, 108/66, 72, 20, 94%3.5L
GEN: Mobridly Obese
Pain: 0/10
HEENT: Edentulous, EOMI, MMM, - OP Lesions, Class 4 airway
PUL: CTA B/L
COR: RRR, S1/S2, - MRG, Midline sternotomy scar
ABD: NT/ND, +BS, - CVAT
EXT: - CCE
NEURO: CAOx3, Motor: UE/Finger spread [**3-29**] Flex/Ext, LE: 0/5
Flex/Ext, Sensory: on Left sensory level at T9, Right to mid
shin (different exam sometime after arrival), slightly slurred
speech
Pertinent Results:
OSH MRI T-Spine: marked destruction of the T9 vertebra involving
adjascent discs and vertebra. Also with discitis, osteomyelitis.
Severe cord compression with edema extending from T8-T11
Brief Hospital Course:
Mr. [**Known lastname **] is a 76 y.o. man with Stage IV COPD CAD s/p CABG, CHF
admitted to OSH with COPD flare, his course was complicated by
hypercarbic respiratory failure and lower extremity paralysis
with cord compression and paraspinal abscess now POD12 s/p
surgical debridement and fusion, course complicated by transient
episodes of complete AV block, poor systolic function,
respiratory failure x 2 requiring intubation, and hypotension
requiring pressors. His respiratory failure has resolved, his
hypotension is resolved on midodrine, but he has persistent LE
paralysis secondary to paraspinal abscess/cord compression.
Active Issues
#)Respiratory failure:
Per OSH, pt had COPD exacerbation leading to hypercarbic
respiratory failure and intubation and uneventful extubation.
He did experience dyspnea [**12-26**] excess secretions and atelectasis.
Required ipratopium and saline nebs. He was extubated and did
well enough to transfer from the MICU to the floor. However, he
began having respiratory distress and poor blood gases
necessitating transfer back to the MICU, where he was intubated
and put on pressure support. He became hypotensive and
tachycardic in this setting, likely b/c he was put on pressure
support b/c of concern for an ARDS picture. He was switched to
CMV, and his hypotension became less profound, and his
respiratory status improved. He was able to have sedation
reduced the 3rd day of his intubation ([**6-2**]). On [**6-3**], he was
able to have a successful spontaneous breathing trial, a RSBI
45, had O2 sats in the 90s, and was arousable but not able to
clear secretions. He did well on CPAP, but extubation was held
off due to his inability to clear secretions. On [**6-6**] he became
more alert, again passed an SBT, and had a RSBI<100. He was
given a trial of extubation since he was felt to be about as
good as he will be re: mental status. He passed this trial and
was able to be weaned down to 4L NC over the next few days w/o
having acute respiratory distress. Oxygen should be weaned as
tolerated for goal sat >90%.
# Hypotension:
This is the result of multifactorial processes: poor systolic
function + neurogenic hypotension + sepsis + sedation. Also has
baseline orthostatic hypotension for which he was on
fludrocortisone prior to admission. During his initial MICU
stay, he required IVF and pressor support and was successfully
weaned off after he was restarted on fludrocortisone at an
increased dose of daily instead of every other day. However, he
again became hypotensive in the setting of pressure-support
ventilation and an [**Month/Year (2) 7792**]. He maxed out on levophed and was
placed on phenylephrine as well. When his ventilator settings
were changed to CMV, he was able to be weaned off levophed
althoug he remained on phenylephrine even after his MAP
titration floor was changed to <55. He also had elevated
troponins and was diagnosed w/ an [**Month/Year (2) 7792**] in this repeat setting
of hypotension, so the [**Month/Year (2) 7792**] may have contributed to his
hypotension by worsening his systolic function, although his
LVEF remained at 35% on f/u Echo. He was able to be weaned off
phenylephrine after extubation and was transitioned to PO
midodrine for blood pressure support. He has follow-up with his
cardiologist [**7-7**].
# Epidural abscess and T9 osteomyelitis s/p debridement and
fusion:
Pt presented with cord compression and lower extremity flaccid
paralysis [**12-26**] epidural abscess and osteomyelitis. After
surgical debridement [**5-23**], he was empirically covered with
vancomycin and ceftriaxone and flagyl. Epidural abscess cultures
revealed Gram+ cocci. Likely source was sacral decubitus ulcer.
ID on board and advised to continue vancomycin for 6 weeks since
the tissue grew Strep viridans but after sensitivities returned
changed the antibiotic to ceftriaxone. Antibiotics should
continue until [**2155-7-10**]. He will follow-up with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 1352**] of orthopedics in ~4weeks and will follow up at [**Hospital **]
clinic as well. Weekly labs should be faxed to infectious
disease RNs with ESR, CRP and CBC/diff checked weekly.
#[**Hospital 7792**]:
In the setting of his hypotension upon his second transfer to
the MICU on [**5-31**], he was found to have elevated troponins for
which he was started on heparin gtt, atorvastatin 80 mg, and ASA
325 for [**Month/Day (4) 7792**]. His troponins trended down [**6-1**], so heparin gtt
was discontinued. A TTE, which was poor quality, was performed
[**6-1**] which revealed LVEF 35%, moderate LV dilated systolic
dysfunction hypokinesis w/ distal 3rd of ventricle having
hypokinesis, nl R chamber, no AR/MR, and no effusions. A
subsequent TEE was similar to the TTE. He was started on
clopidogrel 75 mg PO daily as well in this setting after being
cleared by ortho to do so. He has follow-up with his
cardiologist Dr. [**Last Name (STitle) 13310**] on [**7-7**], at this appointment
anticoagulation for LV aneurysm should be considered but was
deferred during hospitalization given comorbidities and recent
surgery.
#Complete AV Block / Tachycardia-Bradycardia syndrome:
Pt had 2 episodes of bradycardia with complete AV block which
required atropine and pressors to break during initial MICU
stay. Per cardiology and EP, a pacemaker is likely to be
required after his acute osteomyelitis has resolved and
antibiotics course completed. AV nodal blocking drugs have been
held. Given continued concern for possible cardiac vegetations
or complication such as abscess, a TEE was performed [**6-13**], which
revealed no cardiac vegetations or clinically significant
valvular disease. He has follow-up with his cardiologist Dr.
[**Last Name (STitle) 13310**] on [**7-7**] at which time a pacemaker should be considered.
#Renal Failure:
His baseline Cr 1.0. He developed renal failure where his Cr
doubled to 2.2 from [**5-31**] to [**6-4**] following his episode of
hypotension and [**Last Name (LF) 7792**], [**First Name3 (LF) **] this was likely pre-renal in nature.
His Cr stayed around 2.0 a week after this event, so this may be
his new baseline. Cr on discharge 1.9
#Paroxysmal Atrial Fibrillation: Patient was not on
anticoagulation prior to admission and given setting of recent
surgery was not started while in MICU. Should follow up on this
issue at his cardiology visit.
#Delirium:
On the 1st MICU admission, he exhibited waxing and [**Doctor Last Name 688**] mental
status with some agitation before transfer to the general floor.
Seroquel 25 mg x 2 was given without benefit. He received
Haldol 1mg IM, which improved without significant increase in
QTC. On the 2nd MICU admission, he was started on seroquel 25
mg TID to help address his agitation. He did require haldol 6 mg
IV during his second MICU stay due to acute agitation. On
discharge he was confused but not agitated and continued on
seroquel 25 mg TID. The need for continued antipsychotics should
be reassessed after discharge to extended care.
# Sacral Decubitus Ulcer:
This was an issue which the ACS service was monitoring. This
ulcer has not been improving per nursing, wound care, and ACS.
Santyl (collagenase) enzymatic debridement was started to help
address this.
Chronic Issues
#Pulmonary HTN: Stable, not on medications for this and was
continued on supplmental O2.
# Chronic systolic heart failure:
EF 35% per report from [**2155-6-1**]. Lasix was originally held in
the setting of hypotension, but this was restarted since Mr.
[**Known lastname **] was several liters positive during the hospitalization. His
metoprolol was held throughout his hospitalization given his
complete heart block. He was discharged on lasix 80 mg in AM and
40 mg in PM which was his home regimen, but volume status should
be reassessed and dose may be increased if patient gains more
than 3 lbs in one day or concern for hypervolemia.
# CAD:
4-Vessel CABG in [**2147**] at [**Hospital1 2025**]. His ASA and simvastatin were
increased to ASA 325 and atorvastatin 80 mg for [**Hospital1 7792**].
# Hypothyroidism:
Stable, continued outpt meds.
# Diabetes Mellitus:
His blood glucose levels remained below 240 on SSI and below 150
the last few days of his hospitalization. He was continued on an
ISS as an outpatient.
Transitional Issues
- reassess need for antipsychotics, mental status may be
improving and may not have long-term need
- assess volume status daily and daily weights, consider
increasing lasix dose if weight increasing or appears
hypervolemic
- consider pacemaker placement for heart block and
anticoagulation for both paroxysmal atrial fibrillation and LV
aneurysm at cardiology followup visit
- Continue ceftriaxone 2 gm daily until [**2155-7-10**] and weekly
CBC/diff and ESR/CRP to be faxed to infectious disease nurses at
[**Hospital1 69**]
#Full code as per HCP, nephew, [**Name (NI) 449**] [**Name (NI) **] [**Name (NI) 976**] ([**Telephone/Fax (1) 111744**].
Medications on Admission:
Preadmissions medications listed are incomplete and require
futher investigation. Information was obtained from Records.
1. Aspirin 325 mg PO DAILY
2. Simvastatin 20 mg PO DAILY
3. Calcitriol 0.25 mcg PO DAILY
4. Metoprolol Succinate XL 12.5 mg PO BID
5. Vitamin D 1000 UNIT PO DAILY
6. Levothyroxine Sodium 175 mcg PO DAILY
7. Fluoxetine 20 mg PO DAILY
8. Furosemide 80 mg PO QAM
9. Furosemide 40 mg PO QPM
10. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze, shortness
of breath, cough
11. Calcium Carbonate 1000 mg PO DAILY
12. Glargine 27 Units Bedtime
13. K-DUR *NF* 40 meq Oral DAILY *AST Approval Required*
14. Fludrocortisone Acetate 0.1 mg PO DAILY
15. Morphine SR (MS Contin) 30 mg PO Q12H
16. Carbamazepine (Extended-Release) 200 mg PO DAILY
17. Tiotropium Bromide 1 CAP IH DAILY
18. Amiodarone 200 mg PO DAILY
19. Lorazepam 0.5 mg PO TID
20. Omeprazole 40 mg PO DAILY
21. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing, cough,
shortness of breath
2. Aspirin 325 mg PO DAILY
3. Calcitriol 0.25 mcg PO DAILY
4. Atorvastatin 80 mg PO DAILY
5. CeftriaXONE 2 gm IV Q24H
6. Clopidogrel 75 mg PO DAILY
7. Collagenase Ointment 1 Appl TP DAILY
8. Docusate Sodium (Liquid) 100 mg PO BID
9. Fludrocortisone Acetate 0.1 mg PO DAILY
10. Quetiapine Fumarate 25 mg PO TID
11. Midodrine 7.5 mg PO TID *AST Approval Required*
12. Vitamin D 1000 UNIT PO DAILY
13. Levothyroxine Sodium 175 mcg PO DAILY
14. Heparin 5000 UNIT SC TID
15. Furosemide 80 mg PO QAM
16. Furosemide 40 mg PO QHS
17. Insulin SC
Sliding Scale
Fingerstick QID
Insulin SC Sliding Scale using REG Insulin
18. Senna 1 TAB PO BID:PRN constipation
19. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
20. Fluoxetine 20 mg PO DAILY
21. K-DUR *NF* 40 meq ORAL DAILY
22. Calcium Carbonate 1000 mg PO DAILY
23. Tiotropium Bromide 1 CAP IH DAILY
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**]
Discharge Diagnosis:
Hypercarbic Respiratory Failure
Hypotension
Acute Renal Failure
Delirium
Congestive Heart Failure
Epidural Abscess/Osteomyelitis
Sacral Decubitus Ulcer
Non-ST elevation MI
Bradycardia / Complete AV Heart Block
Anemia
COPD
Coronary Artery Disease
Hypothyroidism
Diabetes Mellitus
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:
Dear Mr. [**Known lastname **],
You were originally admitted to the hospital because you had
difficulty breathing and an infection near your spine. Your
breathing became bad enough that we needed to give you a tube to
help you breath. You also developed low blood pressure, kidney
dysfunction, and weakness in your legs from the infection near
your spine. You remain on antibiotics for the weakness in your
legs. You will follow up with the Infectious Disease Clinic
about this.
You also had some heart dysfunction, including a mild heart
attack which did not seem to significantly impact your heart
function, and trouble with the electrical conduction system of
your heart which may require further intervention. You will
follow-up with Cardiology to further investigate this.
It was our pleasure to care for you at [**Hospital1 18**].
more than 3 lbs.
Changes to your medications:
STOPPED amiodarone
STOPPED carbamazepine
STOPPED MS Contin
STOPPED lorazepam
STOPPED metoprolol
STOPPED omeprazole
STOPPED simvastatin
STARTED atorvastatin 80 mg daily
STARTED ceftriaxone 2gm daily until [**2155-7-10**]
STARTED clopidogrel 75 mg daily
STARTED collagenase ointment
STARTED docusate
STARTED fluticasone inhaler twice a day
STARTED heparin shots three times a day
STARTED midodrine 7.5 mg three times a day
STARTED quetiapine 25 mg three times a day
CHANGED fludrocortisone to 0.1 mg daily from every other day
Followup Instructions:
Department: INFECTIOUS DISEASE
When: TUESDAY [**2155-7-1**] at 10:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4593**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Name: [**Last Name (LF) **],[**Name8 (MD) **] MD
Location: [**Hospital 46644**] MEDICAL ASSOCIATES
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 12023**]
Phone: [**Telephone/Fax (1) 25076**]
Appointment: Monday [**2155-7-7**] 11:20am
Department: [**Location (un) **] ORTHO ASSOCIATES
When: THURSDAY [**2155-7-10**] at 2:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 89824**], MD [**Telephone/Fax (1) 3736**]
Building: [**Apartment Address(1) 111745**]
Campus: OFF CAMPUS Best Parking: None
Name: [**Last Name (LF) 64403**],[**First Name3 (LF) **] L.
Location: [**Hospital 46644**] MEDICAL ASSOCIATES
Address: [**Location (un) 32946**], [**Location (un) **],[**Numeric Identifier 32948**]
Phone: [**Telephone/Fax (1) 32949**]
Please discuss with the staff at the facility a follow up
appointment with your PCP when you are ready for discharge.
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46,497
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54478
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Discharge summary
|
report
|
Admission Date: [**2145-7-15**] Discharge Date: [**2145-7-22**]
Date of Birth: [**2061-6-13**] Sex: M
Service: MEDICINE
Allergies:
Aspirin / Ace Inhibitors
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
Endoscopic retrograde cholangiopancreatography
Sphincterotomy
Percutaneous cholecystostomy [**2145-7-17**]
PICC placement [**2145-7-21**]
History of Present Illness:
[**Known firstname **] [**Known lastname **] is an 84-yo man with history of a-fib and
hypercholesterolemia who presents with right sided abdominal
pain that started on the night prior to admission. The patient
reports some associated nausea but no emesis and has had some
chills. He initially presented to [**Hospital3 **], where he
was found to have a temperature of 101, and abdominal pain.
Ultrasound of the RUQ showed a distended gallbladder with mild
pericholecystic fluid and moderately positive [**Doctor Last Name 515**] sign. Pt
was given Zosyn and 500cc NS. The pt was transfered to [**Hospital1 18**] for
further evaluation.
.
In the ED, initial vs were: 98.9 120 133/96 18 96% 2L Nasal
Cannula. Patient was given metoprolol succinate 50mg po (home
dose) for atrial fibrillation with RVR. General surgery and ERCP
services were consulted. The pt was admitted to the ICU for
further monitoring and was transferred to the surgery service.
He appeared comfortable on floor transfer.
Past Medical History:
ATRIAL FIBRILLATION
HYPERTENSION
HYPERCHOLESTEROLEMIA
PREMATURE VENTRICULAR CONTRACTIONS
PERIPHERAL VASCULAR DISEASE
RESTLESS LEG SYNDROME
H/O DUODENAL ULCER
DIVERTICULOSIS, COLON W/HEM-RECTAL BLEED
PROSTATE CANCER
SQUAMOUS CELL CA- L SHIN
Social History:
Widower. Lives alone, performing most ADL and IADLs
independently. No current or past tobacco use. No use of alcohol
or other substances. Son is Health [**Name (NI) **] Proxy.
Family History:
Brother died suddenly at 33
Physical Exam:
VITALS: T 98.0F; BP 126/76; HR 76; RR 20; O2 96% RA
TELEMETRY: HR ranges 70s and 80s consistently
GEN: Resting comfortably in bed, no apparent distress.
HEENT: Normocephalic. Mucous membranes moist. No pharyngeal
erythema or exudate.
SKIN: Ecchymosis over left femoral distribution, purple in
color. Non-tender to palpation. Keratinic lesion c/w cutaneous
[**Doctor Last Name 534**] over mid-sternum.
PULM: Mild end-expiratory wheezes throughout. Moderate
air-movement, improving. No clear crackles.
CARDS: JVP 9-10 cm. Irregularly irregular rhythm. Distant heart
sounds. Normal S1, S2. No murmurs.
ABD: BS quiet but present. Mild distension. NT. Plethoric soft
tissue. No clear organomegaly.
EXT: Radial pulses 2+. Excision site dressed on left shin.
Healing well with good granulation tissue, fibrinous exudate, no
erythema or purulence. Hyperpigmentation over shins bilaterally.
1+ pitting edema of the left foot. Capillary refill WNR.
NEURO: Grossly in-tact without focality. Able stand
independently.
.
DRAINS/TUBES:
PICC SITE: No significant hematoma, tenderness, or fresh
bleeding.
FOLEY: Draining yellow urine, non-cloudy.
CHOLECYSTOSTOMY: Draining bilious brown fluid.
Pertinent Results:
1. Labs on admission:
[**2145-7-15**] 02:00PM BLOOD WBC-28.2*# RBC-4.23* Hgb-14.3 Hct-41.0
MCV-97 MCH-33.8* MCHC-34.8 RDW-13.2 Plt Ct-302
[**2145-7-15**] 02:00PM BLOOD PT-14.2* PTT-24.7 INR(PT)-1.2*
[**2145-7-16**] 03:04AM BLOOD Glucose-122* UreaN-26* Creat-1.4* Na-138
K-4.8 Cl-105 HCO3-21* AnGap-17
[**2145-7-15**] 02:00PM BLOOD ALT-24 AST-27 AlkPhos-142* TotBili-2.1*
[**2145-7-15**] 02:00PM BLOOD Lipase-35
[**2145-7-16**] 03:04AM BLOOD Albumin-3.3* Calcium-8.3* Phos-3.0 Mg-1.9
[**2145-7-15**] 02:20PM BLOOD Lactate-1.9
.
2. Labs on discharge:
[**2145-7-22**] 09:05AM BLOOD WBC-13.9* RBC-3.79* Hgb-12.9* Hct-37.6*
MCV-99* MCH-34.1* MCHC-34.4 RDW-13.5 Plt Ct-373
[**2145-7-22**] 09:05AM BLOOD Neuts-84.9* Lymphs-10.5* Monos-2.7
Eos-1.3 Baso-0.5
[**2145-7-22**] 09:05AM BLOOD Glucose-137* UreaN-35* Creat-1.3* Na-138
K-4.1 Cl-104 HCO3-24 AnGap-14
[**2145-7-22**] 09:05AM BLOOD ALT-62* AST-60* AlkPhos-238* TotBili-0.8
[**2145-7-22**] 09:05AM BLOOD Calcium-8.3* Phos-2.4*# Mg-2.0
.
Time Taken Not Noted Log-In Date/Time: [**2145-7-17**] 4:57 pm
ABSCESS (chole tube)
**FINAL REPORT [**2145-7-21**]**
GRAM STAIN (Final [**2145-7-17**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).
SMEAR REVIEWED; RESULTS CONFIRMED.
WOUND CULTURE (Final [**2145-7-21**]):
STREPTOCOCCUS ANGINOSUS (MILLERI) GROUP. SPARSE GROWTH.
ANAEROBIC CULTURE (Final [**2145-7-21**]):
CLOSTRIDIUM PERFRINGENS. RARE GROWTH.
3. Imaging/diagnostics:
ERCP ([**2145-7-15**]): Impression: Normal major papilla
Cannulation of the biliary duct was performed with a
sphincterotome using a free-hand technique The common bile duct,
common hepatic duct, right and left hepatic ducts and biliary
radicles were filled with contrast and well visualized. The CBD
was approximately 5mm in diameter.
The course and caliber of the structures are normal with no
evidence of extrinsic compression, no ductal abnormalities, and
no filling defects.
The cystic duct and gallbladder did not fill with contrast.
Given high clinical suspicion of cholangitis, a sphincterotomy
was performed in the 12 o'clock position using a sphincterotome
over an existing guidewire.
Balloon catheter sweep of the duct did not reveal any stone or
sludge.
Excellent drainage of bile and contrast was noted
Echocardiogram ([**2145-7-20**]):
The left atrium is moderately dilated. The right atrium is
markedly dilated. There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>55%). The right ventricular cavity is mildly
dilated with normal free wall contractility. The diameters of
aorta at the sinus, ascending and arch levels are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Mild (1+) mitral regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion. IMPRESSION: Mild symmetric left
ventricular hypertrophy with normal global and regional systolic
function. Moderate pulmonary hypertension with dilated right
ventricle and mild to moderate functional tricuspid
regurgitation. Compared with the report of the prior study
(images unavailable for review) of [**2139-12-3**], RV dilation is
new. The other comparable findings appear similar.
Brief Hospital Course:
84-year-old man with history of atrial fibrillation presenting
with abdominal pain, found to have acute cholecystitis at
outside hospital, transferred for management of possible
cholangitis.
.
# Cholecystitis:
The patient was transfered from [**Hospital1 2436**] Hopsital with acute
cholecystitis; imaging showed no stones and CBD of 4 mm. Given
his WBC elevation to high 20s and fever, there was concern for
cholangitis. The patient transfered to the MICU and had an ERCP
on [**2145-7-15**], that showed no obstruction or stones. A
sphincterotomy was performed. After this, his bilirubin has
trended down from 2.1, and the patient had no signs of post-ERCP
pancreatitis. He was started first on zosyn 4.5 g IV and was
transferred to the surgery service. The patient had a US-guided
transhepatic percutaneous cholecystostomy drain placed on
[**2145-7-17**]. Antibiotic coverage was changed from zosyn to unasyn.
LFTs were monitored, with continued decline in total bilirubin.
Alkaline phosphatase remained elevated to 170s with increase to
238 on day of discharge, while AST and ALT have peaked in the
60s and 70s. We have suggested continued twice-weekly LFT
monitoring. Interventional radiology has recommended repeating a
RUQ US to assess drain location if LFTs become abnormal. The
patient continued to have drainage from his cholecystostomy
drain, and his pain resolved. Cultures of his drainage have
grown Streptococcus anginosus and Clostridium perfringens. He
will need to complete a 14-day course of unasyn, starting on
[**2145-7-17**], and follow-up with surgery to discuss cholecystectomy.
.
# Atrial fibrillation/Acute right sided CHF:
The patient was newly diagnosed with atrial fibrillation on
[**2145-7-12**] by his PCP, [**Name10 (NameIs) **] he reports possibly being told that
he had an irregular heart beat prior.
After the [**Hospital 228**] transfer to the surgery service, he was
shown to have a-fib with rapid ventricular response to the 170s.
The oral metoprolol was increased, and he was given IV
metoprolol. Then he was transferred to the medical service. He
was given diltiazem 10 mg IV x1 and started on diltiazem 30 mg
IV q6h in addition to metoprolol 100 mg IV tid with heart rate
improving to 60s-80s. He was titrated down to metoprolol
succinate 200mg and no dilt on discharge.
He was noted to be very hypervolemic from his admission, with a
roughly 6 kg increase from baseline (92.7 kg, pt. reported and
91.9 kg on [**2145-7-16**]; 98.6 kg at discharge). He was diuresed with
good response to doses of furosemide 20 mg IV with goal of
0.5-1.0L per day. His heart rate and renal function continued to
improve with diuresis. An echocardiogram on [**2145-7-20**] showed a
dilated left atrium and right ventricle, with evidence of
moderate pulmonary hypertension and mild-moderate tricuspid
regurgitation. Continuous telmetry monitoring showed no
recurrent rapid ventricular rate on exertion.
Notably, the patient was reluctant to begin aspirin therapy due
to a remote history of duodenal ulcer. Anticoagulation was
initially held due to recent sphincterotomy until [**2145-7-20**]. On
[**2145-7-21**], the patient was started on aspirin 325 mg qday after
confirmation of negative H. pylori testing after treatment
roughly 1 year prior per the patient. He was also continued on
omeprazole 20 mg po qday for GI protection. The patient's PCP
was [**Name (NI) 653**], with plan made to defer discussion of warfarin or
digibatran after hospital discharge per request of the PCP.
.
# Dyspnea:
The patient reported chronic SOB on exertion but worsening SOB
after hospitalization in the setting of hypervolemia per above.
In setting of afib with RVR, he needed 4L NC, but was weaned to
RA with diuresis. Chronic dyspnea could be attributed at least
partially to the pulmonary hypertension seen on echocardiogram.
At discharge O2 sat with ambulation was 93-94% on RA. The
possibility of pulmonary embolism was raised, but since he was
doing well clinically and anticoagulation is not an option at
this time, it was not pursued further.
.
# Hyperlipidemia:
The patient's home statin was held due to elevations in LFTs and
transhepatic cholecystostomy placement, with plan to restart
once his LFTs improve.
.
# Hypertension:
The patient's home nifedipine was stopped in the setting a-fib
and rate control. He is now on metoprolol succinate with BP well
controlled. He will need continued BP monitoring.
.
# Leg Wound:
The patient has a history of squamous cell carcinoma with recent
excision by his dermatological surgeon over the right shin. The
wound appeared well-healing with granulation tissue. He will
need to follow up with his derm. surgeon after rehabilitation.
.
# Urinary retention:
The patient has a history of prostate cancer with radical
prostatectomy. Urology was consulted on admission and placed a
Foley catheter, with recommendation to keep Foley in place until
[**2145-7-27**] due to bladder neck constriciton. The patient will need
to have a voiding trial during rehabilitation per his outpatient
urologist.
.
# Left Iliacus Hematoma:
Hematoma was discovered clincially by patient's PCP and
confirmed on inpatient imaging. On exam, area showed fading
violaceous ecchymosis without significant induration or
tenderness. Physical therapy evaluation showed no focal
deficits.
.
# Hyperlipidemia:
The patient's home statin was continued during hospitalization.
.
# GERD / History of Peptic Ulcer Disease:
The patient's home omeprazole was continued and also serves as
gastric protectant while on aspirin.
.........
OUTSTANDING ISSUES:
1. Rate control: Telemetry monitoring during diuresis. Can
restart diltiazem if needed.
2. Cholecysititis/drain: Monitor percutaneous drain output
daily; order LFTs biweekly, and follow-up with surgery. If LFTs
abnormal, IR has suggested repeat RUQ US to assess drain
location.
3. Diuresis: Plan for giving furosemide 20 mg IV qam on [**2145-7-23**]
and [**2145-7-24**], with strict I&IOs, goal of negative 0.5-1L daily
until clinically euvolemic, monitoring Chem7 for renal
dysfunction. After [**2145-7-24**], please assess the patient clinically
and continue diuresis as needed. Admission weight per report:
204 lbs, or 92.7 kg.
4. Voiding Trial: Foley will need to be removed on [**7-27**] per out
pt urology.
5. Antibiotics: PICC placed. Complete course of
ampicillin/sulbactam (Unasyn), last day [**2145-7-30**].
6. Wound monitoring: Patient has wound s/p excision of squamous
cell carcinoma on his shin. Please monitor daily.
Medications on Admission:
Metoprolol succinate 50 mg once a day
Nifedipine 30 mg Tablet Extended Release once a day
Omeprazole 20 mg once a day
Simvastatin 40 mg once a day
Discharge Medications:
1. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
2. 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.
3. ampicillin-sulbactam 3 gram Recon Soln Sig: Three (3) grams
Injection Q6H (every 6 hours) for 10 days: last day is [**2145-7-30**],
to complete a 14 day course.
4. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: Two (2) Tablet Extended Release 24 hr PO at bedtime: hold
for sbp<90, hr<60.
8. cholecalciferol (vitamin D3) 1,000 unit Capsule Sig: One (1)
Capsule PO once a day.
9. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for Pain: do not exceed more than 2000mg per
day.
10. furosemide 10 mg/mL Solution Sig: Twenty (20) mg Injection
once a day for 2 days: Start on [**2145-7-23**]. Please give through IV
on [**2145-7-23**] and [**2145-7-24**] once daily in the morning.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital for Continuing Medical Care
Discharge Diagnosis:
Primary
-Acute cholecystitis
Secondary
-Atrial fibrillation with rapid ventricular response
-Right sided heart failure, with normal left ventricular
ejection fraction
-pulmonary hypertension
-prostate ca s/p resection with bladder neck stricture
Discharge Condition:
Mental Status: Clear and coherent. Hard of Hearing.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. [**Known lastname **],
It was a pleasure to care for you. You were transferred to our
hospital with abdominal pain and diagnosis of an infected
gallbladder. You required a procedure (ERCP) to look for
blockage of your gall bladder and placement of a gall bladder
drain (cholecystostomy tube). You were started on intravenous
antibiotics. Your liver and gallbladder are now improving, but
you will need surgery at a future date.
You also developed an irregular heart rythm called atrial
fibriliation at a high heart rate. You were started on
medications to control the heart rate and aspirin to prevent
clots from forming in the heart. Due to the risk of stroke
associated with this condition, you will need to discuss being
on blood thinners with your doctor. You will have continued
heart monitoring during rehabilitation. During your
hospitalization, you had an echocardiogram that showed
enlargement of the right side of your heart during the last 5
years. Please discuss this finding with your primary doctor or
new cardiologist.
You initially required a large volume of intravenous fluids, and
we have begun removing this extra volume with medications
(diuretics). Your breathing has improved as a result, and you
will continue this process during rehabilitation. You also were
seen by urologists, with concern that you had asymptomatic
urinary retention due a constriction in your urinary bladder. A
catheter was placed, with plans for removal in 1 week in
rehabilitation.
THERE HAVE BEEN CHANGES TO YOUR MEDICATIONS, documented below.
Please review your medication list before leaving
rehabilitation, as further changes may be made.
- Simvastatin was stopped for now due to your liver test
abnromalities. It can likely be restarted once these laboratory
tests improve.
- Aspirin was started to prevent stroke from your atrial
fibrillation.
- Metoprolol was increased to control your heart rate.
- Nifedipine was stopped as your blood pressure remained normal
after treatment for your heart rate.
- Ampicillin-sulbactam was started to treat your infection
Followup Instructions:
Please make an appointment with your primary doctor for
follow-up care before leaving rehabilitation. Other appointments
are detailed below:
Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
When: TUESDAY [**2145-8-10**] at 1:30 PM
With: ACUTE CARE CLINIC [**Telephone/Fax (1) 2359**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
You have an appointment for Dr.[**Doctor Last Name **] office scheduled as
below. Please call him and report the results of your voiding
trial after your Foley catheter is removed.
Department: SURGICAL SPECIALTIES
When: TUESDAY [**2145-8-3**] at 10:00 AM
With: [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 276**], M.D. [**Telephone/Fax (1) 164**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Please make an appointment with your dermatologist (Daihung Do)
for follow-up on your skin biopsy.
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
Completed by:[**2145-7-22**]
|
[
"427.31",
"V12.71",
"276.69",
"428.31",
"575.0",
"562.10",
"416.8",
"403.90",
"V10.46",
"788.29",
"596.0",
"V10.83",
"272.4",
"585.3",
"440.20",
"530.81",
"428.0",
"459.0",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.85",
"51.01",
"57.94",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
14722, 14801
|
6711, 13219
|
299, 439
|
15092, 15092
|
3176, 3184
|
17391, 18586
|
1934, 1963
|
13416, 14699
|
14822, 15071
|
13245, 13393
|
15292, 17368
|
1978, 3157
|
245, 261
|
3725, 6688
|
467, 1460
|
3198, 3706
|
15107, 15268
|
1482, 1724
|
1740, 1918
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,876
| 182,597
|
26223
|
Discharge summary
|
report
|
Admission Date: [**2197-3-16**] Discharge Date: [**2197-3-23**]
Date of Birth: [**2137-7-27**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
pancreatic cancer
Major Surgical or Invasive Procedure:
pancreaticoduodenectomy
laproscopic staging lymph node biopsy
History of Present Illness:
59 year old male who had been having symptoms of obstrcutive
jaundice - 3-4 weeks of jaundice and some nausea, evaluated with
ERCP showing a malignant stricture with stent placement. Denies
any symptoms of pain, SOB, CP, fever chills, sweats. head of
pancreas mass was found and seemed resectable, so taken to the
OR.
Past Medical History:
CAD, HTN, h/o pancreatitis, h/o polyps
Social History:
lives with wife and [**Name2 (NI) 64981**] son
Physical Exam:
NAD AOx3
CTA b/l
RRR
soft, NT ND
no c/c/e
Pertinent Results:
[**2197-3-16**] 05:43PM BLOOD WBC-15.2*# RBC-3.46* Hgb-11.4* Hct-32.9*
MCV-95 MCH-32.8* MCHC-34.5 RDW-17.6* Plt Ct-355
[**2197-3-20**] 04:19AM BLOOD WBC-9.1 RBC-3.54* Hgb-11.5* Hct-34.1*
MCV-96 MCH-32.5* MCHC-33.8 RDW-16.0* Plt Ct-405
[**2197-3-16**] 05:43PM BLOOD PT-12.4 INR(PT)-1.1
[**2197-3-16**] 05:43PM BLOOD Glucose-124* UreaN-20 Creat-1.0 Na-142
K-3.2* Cl-112* HCO3-20* AnGap-13
[**2197-3-20**] 04:19AM BLOOD Glucose-102 UreaN-15 Creat-1.0 Na-140
K-3.5 Cl-110* HCO3-21* AnGap-13
[**2197-3-17**] 05:15AM BLOOD ALT-90* AST-89* AlkPhos-211* Amylase-32
TotBili-7.5*
[**2197-3-18**] 03:46AM BLOOD ALT-60* AST-63* LD(LDH)-235 AlkPhos-195*
Amylase-56 TotBili-7.4*
[**2197-3-17**] 05:15AM BLOOD Lipase-17
[**2197-3-22**] 07:55AM ASCITES Amylase-4
PATIENT/TEST INFORMATION:
Indication: Intraoperative TEE for hypotension
BP (mm Hg): 90/50
HR (bpm): 78
Status: Inpatient
Date/Time: [**2197-3-16**] at 14:09
Test: TEE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2006AW584-:
Test Location: Anesthesia West OR cardiac
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
MEASUREMENTS:
Left Ventricle - Inferolateral Thickness: 0.8 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 3.5 cm (nl <= 5.6 cm)
Left Ventricle - Ejection Fraction: 65% (nl >=55%)
Aorta - Ascending: 3.4 cm (nl <= 3.4 cm)
Aortic Valve - Peak Gradient: 15 mm Hg
Aortic Valve - LVOT Diam: 2.3 cm
INTERPRETATION:
Findings:
RIGHT ATRIUM/INTERATRIAL SEPTUM: Dynamic interatrial septum. No
ASD by 2D or
color Doppler.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D
images. Normal LV wall thickness, cavity size, and systolic
function
(LVEF>55%). [**Known lastname 4460**] LV cavity. No resting LVOT gradient.
LV WALL MOTION: basal anterior - normal; mid anterior - normal;
basal
anteroseptal - normal; mid anteroseptal - normal; basal
inferoseptal - normal;
mid inferoseptal - normal; basal inferior - normal; mid inferior
- normal;
basal inferolateral - normal; mid inferolateral - normal; basal
anterolateral
- normal; mid anterolateral - normal; anterior apex - normal;
septal apex -
normal; inferior apex - normal; lateral apex - normal; apex -
normal;
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic root diameter. Simple atheroma in
descending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No AS. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Systolic
motion of the
mitral chordae (normal variant). No resting LVOT gradient. No
[**Male First Name (un) **] of mitral
valve leaflets. Mild (1+) MR.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild
[1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
PERICARDIUM: Trivial/physiologic pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify
I was present in compliance with HCFA regulations. No TEE
related
complications. The patient was under general anesthesia
throughout the
procedure.
Conclusions:
No atrial septal defect is seen by 2D or color Doppler. Left
ventricular wall
thickness, cavity size, and systolic function are normal
(LVEF>55%). The left
ventricular cavity is somewhat [**Known lastname **] consistent with a decreased
preload.
Right ventricular chamber size and free wall motion are normal.
There are
simple atheroma in the descending thoracic aorta. The aortic
valve leaflets
(3) are mildly thickened but aortic stenosis is not present. No
aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There
is chordal [**Male First Name (un) **] without LVOT obstruction. There is no systolic
anterior motion
of the mitral valve leaflets. Mild (1+) mitral regurgitation is
seen. The
tricuspid valve leaflets are mildly thickened. There is a
trivial/physiologic
pericardial effusion.
Brief Hospital Course:
Patient underwent staging laparoscopy, open cholecystecetomy and
pylorus preserving whipple resection [**3-16**] for pancreatic cancer.
Patient was kept intubated overnight for pressor requirement,
but was successfully extubated on POD1 and off pressors. Patient
then recovered on an accelerated course. He was transferred to
the floor on POD2 and then followed the whipple pathway. Had a
PCa for pain, was on IVF with an NGT and ambulating. Patient
ambulated early and well. Had NGT dc'd on POD4 and started on
clears. Was advanced to fulls on POD5, started on reglan,
colace, and his pre-op beta-blocker. PCA was dc'd and he was
switched to po pain meds. IVF were stopped. JP amylase was
checked and foudn to be four, so the JP was dc'd upon discahrge
on POD7. Patient was eating regular diet and doign very well.
Was given instruciton to follow- up in two weeks with dr
[**Last Name (STitle) **].
Medications on Admission:
atenolol 50', accupril 5', ASA, zocor
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. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
Disp:*120 Tablet(s)* Refills:*2*
3. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3-4H (Every
3 to 4 Hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
head of pancreas mass
Discharge Condition:
good
Discharge Instructions:
please seek medical attention if you experience fever > 101.5,
severe nausea, vomitting, or pain
no driving while on narcotic pain meds
may shower
Followup Instructions:
please follow up with Dr [**Last Name (STitle) **] in 2 weeks. Call [**Telephone/Fax (1) 2363**]
for an appointment
Completed by:[**2197-3-24**]
|
[
"401.9",
"157.0",
"414.00",
"577.1",
"V45.81",
"458.29",
"305.1",
"575.11",
"496",
"196.2",
"576.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.22",
"52.7",
"88.72",
"40.3",
"00.17",
"54.21"
] |
icd9pcs
|
[
[
[]
]
] |
6611, 6617
|
4947, 5848
|
331, 396
|
6683, 6690
|
947, 1695
|
6887, 7034
|
5936, 6588
|
6638, 6662
|
5874, 5913
|
6714, 6864
|
1721, 4924
|
885, 928
|
274, 293
|
424, 743
|
765, 805
|
821, 870
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,926
| 176,330
|
26661
|
Discharge summary
|
report
|
Admission Date: [**2129-2-10**] Discharge Date: [**2129-3-1**]
Date of Birth: [**2055-7-14**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Bradycardia, increasing lower extremity swelling and pain
Major Surgical or Invasive Procedure:
DC cardioversion
History of Present Illness:
73 yo f w/ h/o pulm embolism ([**8-9**]), presumed diastolic CHF
(last echo normal), gout X 3 years, who presented to OSH on
[**2129-2-10**] with gradual increasing lower extremity edema, bilateral
foot pain, and increasing doses of colchicine at home. At OSH,
she had decreased UOP and HR noted to be 30-40 w/ response w/
atropine 0.5mg to 70s (unclear if symptomatic). At that time,
the pt also had Hct 24 with guiaic positive stool, transfused 1
unit PRBCs, 1 unit FFP, and noted to be in renal failure with
BUN/Cr 134/6.1. At this point she was transferred to [**Hospital1 18**].
.
Here, the pt was noted to be afebrile, with abd pain, and
received IVF with bicarb, and underwent abd CT, showing an
abdominal aortic aneurysm, and right kidney hyperdense lesion,
small effusion and atelectasis. Also, she was given vanco, levo,
and flagyl for presumed ?intraabd source in the ED. Cards was
consulted and felt that patient likely had sick sinus syndrome
given sinus brady w/ junctional escape rhythm on her EKG. She
was admitted to the ICU. In ICU, remained bradycardic and
asymptomatic, normotensive. On am [**2-12**], immediately tachycardic
to 130s, with EKG showing an irregular tachycardia, afib? w/ ST
depressions in lateral leads and in leads I and aVL. Renal was
consulted as well regarding her ARF, thought [**1-6**] to a
combination of increasing doses of colchicine and indocin in the
setting of her increasing lower extremity pain/edema. She was
dialyzed [**2-11**] and [**2-12**], started on phosphate binders, epo on
[**2-14**], and on [**2-15**], renal felt that her renal HD catheter could
be pulled (had to be off heparin gtt for this). On [**2-16**], renal
felt HD no longer needed. Spoke w/ cards consult, originally
felt that patient should not receive nodal [**Doctor Last Name 360**] for rate
control but subsequently started PO Dilt 90mg QID. As of today
(day of transfer, she is hemodynamically stable with an intact
BP and so immediate plan will be to d/c her lopressor/norvasc
and have atropine at bedside, keep [**Hospital1 **] pads in place. She was
evaluated by EP for possible pacer placement for tachy/brady
syndrome, however, EP would like pt to undergo DC cardioversion
tomorrow in holding area prior to pacer plans. Pt is to be
continued on heparin gtt in anticipation of cardioversion.
.
The pt states she feels well. She c/o chronic bilateral lower
extremity pain with swelling (several weeks). No
CP/SOB/palpitations. No N/V. Tolerating po well. No abd pain.
Urinating ok. Not able to walk [**1-6**] "pins and needles" sensation
in lower extremities when bearing weight. She states the pain
is at the bottoms of the feet bilaterally, like "knives." No
other complaints.
Past Medical History:
1. Gout: has had for past three years - mostly in left foot,
recently in bilateral feet, knees.
2. CHF - first diagnosed fall [**2127**] - echos reportedly "normal"
3. PE - diagnosed [**8-/2128**] has been on coumadin since.
4. Left carotid endarterectomy in [**2122**].
5. H/O rheumatic heart disease as a child.
Social History:
Lives in [**Location **] with granddaughter, has five children. Spent
[**Month (only) 956**] in [**State 108**]. 4ppd for 30 years, quit 20 years ago. No
EtOH, no illicit drugs.
Family History:
Positive for strokes in mother, father, brother, CAD in brother,
son,
Physical Exam:
T 97.5 P 40s SR BP 111/69 RR 16 O2 sat 96% RA
Genl: Sitting up in bed, speaking comfortably, mild distress.
HEENT: Anicteric, MMM, OP clear.
Neck: Supple, elevated JVD, no appreciable carotid bruits.
Heart: Bradycardic, 2/6 SEM at LUSB.
Lungs: Slight bibasilar crackles.
Abd: Soft, hypoactive bowel sounds, non-distended, non-tender.
Guaic positive in ED.
Ext: [**12-6**]+ B LE edema extending [**2-5**] of the way up shins.
Tenderness to palpation diffusely on her bilateral feet. No
erythema or warmth of her bilateral feet or knees.
Neuro: A&O x 3, CN 2-12 grossly intact
.
Pertinent Results:
Imaging:
CXR [**2129-2-10**]: Mild Cardiomegaly. Bibasilar atelectasis. No chf.
.
[**2129-2-11**]: Abd CT: 1. Small right-sided pleural effusion and right
lower lobe atelectasis. 2. Small ascites. 3. Nonspecific
stranding in the anterior and posterior right pararenal spaces.
Correlation with patient's amylase and lipase is recommended.
**4. 3.2 cm Abdominal Aortic Aneurysm. Follow-up recommended. 5.
Right kidney small hyperdense lesion. Evaluation with US
recommended.
.
RENAL US [**2129-2-11**]
RENAL ULTRASOUND: The right kidney measures 8.3 cm. The left
kidney measures 8.4 cm. There is no evidence of hydronephrosis,
nephrolithiasis, or renal masses. There is bilateral cortical
thinning. The urinary bladder is not visualized and the patient
has a Foley catheter in place.
IMPRESSION: No evidence of hydronephrosis, nephrolithiasis, or
renal mass.
.
TTE: [**2129-2-11**]: EF >55%
1. The left atrium is moderately dilated. The right atrium is
moderately dilated.
2. The left ventricular cavity size is normal. Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Overall left ventricular systolic function is
difficult to assess but is probably normal (LVEF>55%).
3. The right ventricular cavity is mildly dilated.
4. The aortic valve leaflets are mildly thickened.
5. The mitral valve leaflets are mildly thickened. Moderate (2+)
mitral regurgitation is seen.
6. There is mild pulmonary artery systolic hypertension.
.
ECG:
[**2-10**] 51, sinus brady w/ junctional escape in the 40s. No ST-T
wave changes.
.
[**2-12**] 136, nl axis, afib, std in V4-V6, I/L
Brief Hospital Course:
ASSESSMENT: 73 yo f w/ diastolic CHF, gout, PE p/w bradycardia
thought to be due to sick sinus syndrome, acute renal failure,
gout flare, GI bleed.
.
1. CV:
Pump: The patient has known diastolic dysfxn with last TTE on
[**2129-2-11**] demonstrating EF>55%. Although there was no comment on
E/A ratio, clinically this would indicate impaired relaxation as
pt was clinically in flash pulmonary edema in the setting of
hypertension. The clinical finding of flash pulmonary edema was
confirmed with a CXR. The pt received one episode of HD to
remove fluid but has since been able to diurese successfully.
She was started on afterload reducing agents including
hydralazine and nitrates. As her creatinine was elevated, she
was not able to be started on ACEI or [**Last Name (un) **] at the time of this
admission. Her Hydralazine was increased to 75mg Q6hours, and
isorsorbide dinitrate was increased to 60mg TID. These
medications were chosen over her previous outpt regimen which
consisted of amlodipine (as this can cause side effect of fluid
retention and LE edema) and metoprolol (discontinued due to
episodes of bradycardia and concern for sick sinus syndrome).
She was aggressively diuresed on lasix 80mg IV BID and achieved
neg 1L per day. She was subsequently converted to a PO regimen
which included lasix 80mg in AM and lasix 40mg in PM. The pt
was followed by the renal service for her renal failure and
fluid overload who oversaw our management.
At acute rehab, the pt should be continued on diuresis with
PO regimens consisting of lasix 80mg PO QAM and 40mg PO QPM.
She should have daily weights and ins and outs monitored to
document appropriate diuresis (goal of neg 500cc/day). In
addition, her renal function should be followed closely
(electrolytes three times a week) to observe for worsening renal
failure. She should follow up with the [**Hospital 18**] [**Hospital 10701**] clinic
in one to two weeks time to assess her renal function.
.
Rhythm: The pt was initially admitted with bradycardia. This
may have been secondary to a sick sinus syndrome vs. beta
blocker overdose in setting of acute on chronic renal failure.
The EP service was contact and believe the latter to be the
case. Therefore no plans were made for PM placement. Since
cessation of BB, the pt was without episodes of bradycardia and
her metoprolol was discontinued all together.
In addition to her bradycardia, the pt also had an episode of
Afib with RVR. The pt had episode of HR in the 150s on [**2-12**]
with isolated elevated BP (up to 180s systolic) and some
ischemic changes on EKG, the etiology of which was unclear. [**Name2 (NI) **]
TSH was wnl. She was started on esmolol and dilt drip on [**2-12**]
for sx control and was transitioned to dilt drip alone on [**2-13**].
She was subsequently transitioned to po dilt [**2-16**] 90 mg QID then
lopressor 37.5mg po bid and HR has been stable. Pt was
cardioverted on [**2-18**], which was initially successful in keeping
pt in NSR. However, pt reverted to AFib with RVR on [**2129-2-22**].
Patient responded well to dilt 10mg IV x 1 then 60mg PO QID with
excellent rate control. EP was notified, and per EP recs,
patient also started on amiodarone 400mg QD. As on amiodarone,
pt's metoprolol was d/c'ed and the diltiazem was titrated back
to 30mg QID. At time of discharge, the pt was on amiodarone
400mg once daily which should be reduced to a maintenance dose
of 200mg once daily upon evaluation by EP. She was also on
diltiazem 150mg QID. In addition, the pt was anticoagulated
with coumadin 5mg QHS with goal INR of [**1-7**]. She should have
routine INR checked and dose of her coumadin should be adjusted
as necessary. She should follow up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] of
the [**Hospital1 18**] cardiology division for further management of her
atrial fibrillation.
.
3. Acute renal failure: The pt initially presented with ARF.
This was thought to be secondary to NSAID overuse and
hypovolemia/hypoperfusion. Cr peaked at 6.8 at [**Hospital1 18**], then
decreased to 2.9. However this subsequently increased again to
mid 4s. The secondary elevation in creatinine was thought to be
due to poor forward flow in decompensated CHF. She was
initially requiring HD on [**4-17**], but has been off since.
She was diuresed as above with good success without significant
change in her creatinine. She should received close monitoring
of her electrolytes with three times a week chem7. She should
follow up with the [**Hospital 18**] [**Hospital 10701**] clinic to assess for further
progression of her renal disease and necessity for possible HD
in the future.
.
4. ID: Pt spiked fever to 100.9 on [**2-21**]. Cultures from [**2-21**]
(earlier) grew GPC in pairs and clusters, however, pt did not
appear bacteremic clinically. U/A from [**2-21**] was however
positive for a UTI. Therefore the pt was started on
levofloxacin for tx of UTI. The pt was continued on levoflox
250mg Q48hours due to renal function. She should receive her
last dose of levoflox on [**2129-3-2**]. The pt was clinically
stable throughout the admission from an infectious standpoint.
.
5. GIB: The pt was noted at OSH to have a Hct of 24 with guiaic
positive stool, and was also noted to have G+ stools on
admission here. This was thought to be secondary to NSAID
gastritis. She received 1 unit pRBC at OSH and 3 units pRBC
here on [**2129-2-12**] and [**2129-2-13**]. Hct has been stable since that
time. Pt also on epo for renal failure briefly and may require
epo again at the discretion of the renal staff. We recommend
further work up this as an outpatient.
.
6. Hx of PE: The pt had a PE dx'd in fall, [**2127**]. She was
anticoagulated as an outpt. LENI were neg, for DVT. The pt was
started on anticoagulation with heparin followed by coumadin for
afib as above which would also ppx again further DVT/PE events.
.
7. Gout: Patient had been taking increasing doses of colchicine
prior to initial presentation, this was thought likely to be the
cause of her acute on chronic renal failure and her GIB.
Therefore her colchicine and NSAIDS were stopped on admission to
hospital.
.
8. AAA: The pt was noted to have a 3.2cm AAA on CT abd during
hospital course. She will follow up as an outpt to monitor
development of the AAA.
.
9. FEN: Cardiac low salt diet, moniter and replete lytes
carefully PRN.
.
10. Ppx: The pt was continued on DVT ppx during this admission
with either heparin sub Q, hep gtt or coumadin. In addition,
the pt was continued on GI ppx with PPI and a bowel regimen.
.
11. Communication: with pt, family, PCP is [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 38329**] [**Last Name (NamePattern1) 65736**] in
[**Location (un) **] [**Telephone/Fax (1) 10070**].
.
12. Code status: FULL CODE
Medications on Admission:
Meds - does not know her meds exactly:
1. Norvasc 10 mg qd.
2. Lopressor 100 [**Hospital1 **].
3. HCTZ 25 qd.
4. Coumadin 5 during week, 2.5 on weekend.
5. Zocor 80 qd.
6. Lopid 600 [**Hospital1 **].
7. Colchicine.
8. Vicodin.
(Augmentin several weeks ago for "cold/pharyngitis").
Discharge Medications:
1. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
4. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
5. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
6. Albuterol Sulfate 0.083 % Solution Sig: [**12-6**] Inhalation Q4H
(every 4 hours) as needed.
7. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Chewable PO DAILY (Daily).
8. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
9. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
11. Isosorbide Dinitrate 20 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day).
12. Hydralazine 25 mg Tablet Sig: Three (3) Tablet PO Q6H (every
6 hours).
13. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
14. Diltiazem HCl 60 mg Tablet Sig: 2.5 Tablets PO QID (4 times
a day).
15. Epoetin Alfa 10,000 unit/mL Solution Sig: as per renal.
Injection ASDIR (AS DIRECTED).
16. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q48H
(every 48 hours) for 1 days.
17. Lorazepam 2 mg/mL Syringe Sig: 0.5 mg Injection Q4H (every 4
hours) as needed.
18. Lasix 80 mg Tablet Sig: One (1) Tablet PO qam.
19. Lasix 40 mg Tablet Sig: One (1) Tablet PO qpm.
20. Coumadin 5 mg Tablet Sig: One (1) Tablet PO at bedtime.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
1. CHF
2. Atrial fibrillation with rapid ventricular response
3. Flash pulmonary edema
4. Acute on chronic renal failure
5. UTI
Discharge Condition:
Good
Discharge Instructions:
Please take all of your medications as prescribed. Several
changes have been made in your medication regimen.
Please follow up with all of your doctors.
Please weigh yourself daily. If your weight is increased by
more than 3lbs, please call your PCP to have your Furosemide
(lasix) dose increased.
In addition, you should have your labs checked three times a
week to evaluate your kidney function (chem7) and your coumadin
dose (INR).
If you experience any chest pain, palpitations, shortness of
breath, dyspnea on exertion, worsening swelling in your legs,
fevers, chills, abdominal pain, nausea, vomiting, diarrhea,
please call your PCP or come directly to the ED.
Followup Instructions:
Please follow up with your PCP within two weeks of discharge.
Please follow up with Dr. [**Last Name (STitle) **] of the Cardiology department
within one month of discharge. His office can be reached by
calling [**Telephone/Fax (1) 2934**].
Please follow up with the nephrology clinic within one to two
weeks of discharge. An appointment can be scheduled by calling
[**Telephone/Fax (1) 60**].
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
|
[
"276.2",
"584.9",
"427.31",
"E935.9",
"276.7",
"280.0",
"V12.51",
"518.82",
"578.9",
"427.81",
"428.0",
"599.0",
"585.4",
"274.9",
"428.30",
"276.50",
"403.91",
"441.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"96.71",
"99.04",
"96.04",
"38.95"
] |
icd9pcs
|
[
[
[]
]
] |
14872, 14944
|
6014, 12852
|
371, 389
|
15121, 15128
|
4380, 5991
|
15849, 16344
|
3695, 3766
|
13183, 14849
|
14965, 15100
|
12878, 13160
|
15152, 15826
|
3781, 4361
|
274, 333
|
417, 3143
|
3165, 3480
|
3496, 3679
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,299
| 185,750
|
29146
|
Discharge summary
|
report
|
Admission Date: [**2101-6-8**] Discharge Date: [**2101-6-19**]
Date of Birth: [**2038-3-23**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
ESRD now s/p kidney transplant
Major Surgical or Invasive Procedure:
[**2101-6-9**]: Cadaveric kidney transplant
History of Present Illness:
63M w ESRD [**1-24**] diabetic nephropathy who presents for a kidney
transplant. Patient has been on peritoneal dialysis for approx
3 years now. His last dialysis was today. He currently only
makes a small amount of urine going a few teaspoons full a day.
He was recently seen at [**Hospital6 2561**] for ? of a L great
toe infection, he finished a course of Keflex approx 2 weeks
ago. He was scheduled to have an arteriogram there next week.
He otherwise denies fevers/chills, n/v, diarrhea, SOB, CP, rash,
cough, or other complaint. Patient denies recent blood
transfusion.
Past Medical History:
ESRD, diabetes, HTN, gout, increased cholesterol
PSH: PD catheter placement
Social History:
Married with children.
Family History:
Non-contributory
Physical Exam:
PE: 96.9 56 141/68 18 98%RA
Gen: A+Ox3, NAD
Chest: CTAB
CV: RRR, -MRG
Abd: soft/obese/ND/NT, PD cath in place in LLQ
Ext: no edema. Left great toe with area of ?dry gangrene/scab.
Does not appear infected
Pertinent Results:
On Admission: [**2101-6-8**]
WBC-11.2* RBC-3.10* Hgb-10.4* Hct-31.8* MCV-103*# MCH-33.7*
MCHC-32.8 RDW-17.5* Plt Ct-273
PT-12.6 PTT-24.5 INR(PT)-1.1
Glucose-102 UreaN-48* Creat-10.8*# Na-134 K-4.4 Cl-94* HCO3-26
AnGap-18
ALT-14 AST-17 AlkPhos-64 TotBili-0.2
Albumin-3.9 Calcium-8.3* Phos-4.2 Mg-2.1
At Discharge: [**2101-6-19**]
WBC-9.6 RBC-2.64* Hgb-8.6* Hct-26.8* MCV-102* MCH-32.5*
MCHC-32.0 RDW-16.6* Plt Ct-296
PT-12.0 PTT-25.4 INR(PT)-1.0
Glucose-146* UreaN-88* Creat-3.3* Na-143 K-3.8 Cl-103 HCO3-25
AnGap-19
Calcium-9.1 Phos-4.7* Mg-2.3
tacroFK-15.1
Brief Hospital Course:
63 y/o male with ESRD currently on PD who is taken to the OR for
a cadaveric kidney transplant with Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. He received
a deceased donor (brain dead) kidney
transplant left kidney into right iliac fossa. Single renal
artery on an aortic cuff to the external iliac artery
end-to-side, single renal vein end-to-side to the external iliac
vein and extravesical ureteroneocystostomy.
He received routine induction immunosuppression to include
Cellcept, solumedrol with taper and ATG 125 mg x 4 doses.
There were no immediate complications, the kidney made urine on
the table.
In the PACU, he had an apneic episode and was not taking
spontaneous breaths and he required reintubation. He receieved a
unit of RBCs in the PACU and was placed on phenylephrine for a
short time. He had a respiratory and metabolic acidosis.
After correction of some of these issues, he was extubated
again, this time with success and maintaining respiratory
status. He was given lasix and was placed on a lasix drip for a
short while, this was d/c'd and he was transferred to the
regular surgical floor in stable condition.
Initially his urine output was about one liter, but over the
next 2 days it fell off to less than 700 mls x 2 days, with UOP
15-20 mls hourly.
Urine output again increased and he was given lasix on POD 4
with over a liter daily after the lasix started.
His creatinine was trending down slowly, and electrolytes
started to normalize with abbition of PO bicarbonate and lasix.
He did not require dialysis
Ultrasound done on POD2 showed Abnormal high-resistance
waveforms in the transplanted kidney, with absent diastolic flow
which was felt to represent ATN. There was also mild
hydronephrosis and trace perinephric fluid, likely within normal
limits post- surgical. Renal vein is reported as patent.
Vascular consult was called for h/o left foot pain and area of
dry gangrene on left great toe. He was currently in the process
of having workup done when he was called for the transplant.
On POD 4, he was noted to have increased abdominal distention
and was not passing flatus/ BMs. KUB demonstrated markedly
distended colon. NGT and rec6tal tube were placed and after 24
hours, repeat KUB again showed marked dilation, and he was
transferred to the ICU for neostigmine/glycopyralate. After 4
rounds of neostigmine, he was transferred back to [**Hospital Ward Name 121**] 10.
On POD 10, he passed stool, and was otherwise afebrile, having >
1 liter urine output daily. Creatinine was down to 3.3 by day of
discharge.
Medications on Admission:
omeprazole 20mg QD, renal caps 1 QD, metoprolol 25mg QAM and
50mg QPM, calcium acetate 667mg 2 tabs TID, renagel 800mg [**Hospital1 **],
allopurinol 100mg [**Hospital1 **], calcitriol 0.25mcg QD, lantus 25U QHS,
simvastatin 40mg QD, senispar 30mg QD, novalog 8U before
breakfast/ 8 U before lunch/ 12U before dinner, colchicine 0.6mg
[**Hospital1 **] PRN, colace 100mg [**Hospital1 **] PRN
Discharge Medications:
1. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
Disp:*600 mL* Refills:*2*
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for Pain.
4. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO 2X/WEEK
(TU,FR).
Disp:*8 Tablet(s)* Refills:*2*
5. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Tacrolimus 1 mg Capsule Sig: [**12-27**] Capsules PO twice a day: As
directed by kidney transplant team.
Disp:*120 Capsule(s)* Refills:*2*
9. Tacrolimus 5 mg Capsule Sig: 0-2 Capsules PO twice a day: As
directed by kidney transplant team.
Disp:*60 Capsule(s)* Refills:*2*
10. Lantus 100 unit/mL Solution Sig: Twenty Five (25) Units
Subcutaneous at bedtime.
11. Insulin Regular Human 100 unit/mL Solution Sig: 0-12 Units
Injection three times a day: Sliding scale, as directed by
primary care provider.
12. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO twice a
day.
13. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO qAM.
14. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO qPM.
15. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
ESRD now s/p cadaveric renal transplant
Vascular insufficiency
Discharge Condition:
Stable/Good
Discharge Instructions:
Please call the transplant clinic at [**Telephone/Fax (1) 673**] or return to
the emergency room for fever > 101, chills, nausea, vomiting,
diarrhea, constipation, pain over the kidney graft site,
inability to take or keep down food, fluids or medications.
Monitor the incision for redness, drainage or bleeding
Drink enough fluids to keep your urine light yellow in color
No heavy lifting
Labs every Monday and Thursday with results faxed to the
[**Hospital 1326**] clinic (do not need labs [**2101-6-20**] - transplant
coordinator will call you for future lab draws).
Take all medications exactly as directed.
You may shower. PD catheter will be removed at a later date.
Change dressing per routine protocol.
No driving if taking narcotic pain medication.
Follow up with vascular department and let them know you have
received a transplant kidney.
Followup Instructions:
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**] Date/Time:[**2101-6-22**]
11:40
[**Name6 (MD) 2105**] [**Name8 (MD) 2106**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2101-6-28**] 1:10
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2101-6-20**]
|
[
"E878.0",
"403.91",
"996.81",
"585.6",
"276.2",
"560.89",
"272.0",
"440.24",
"250.40",
"997.4",
"518.81",
"584.5",
"274.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"00.93",
"96.71",
"55.69"
] |
icd9pcs
|
[
[
[]
]
] |
6483, 6541
|
1997, 4574
|
343, 388
|
6648, 6662
|
1414, 1414
|
7560, 7993
|
1155, 1173
|
5016, 6460
|
6562, 6627
|
4600, 4993
|
6686, 7537
|
1188, 1395
|
1727, 1974
|
273, 305
|
416, 999
|
1428, 1713
|
1021, 1099
|
1115, 1139
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,568
| 169,789
|
31018
|
Discharge summary
|
report
|
Admission Date: [**2115-3-3**] Discharge Date: [**2115-3-7**]
Date of Birth: [**2052-7-14**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 458**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This 62 year old diabetic male with a prior history of CAD, s/p
MI and CABG x3 at [**Hospital1 2177**] in [**2112**] (graft anatomy not available), s/p
primary prevention ICD in [**4-/2114**] which was revised in [**1-/2115**]
when he became pace maker dependent [**2-2**] atrial fibrillation and
tachy-brady syndrome, presented yesterday to [**Hospital3 29691**] with dyspnea. He reports air hunger on laying flat last
night before bed, which was new, although he does endorse DOE
over the past 2 weeks.
.
He denies dietary indiscretion, although his family says
"sometimes" he eats some salty foods." He has not had any chest
pains. He does not report any PND or orthopnea prior to last
night. He does not have ankle swelling. Further denies
palpitations, syncope, or presyncope.
.
At the OSH, he was tachycardic to 120s, atrial tachycardia
alternating with sinus rhythm, with pacing spikes before each
QRS. He was placed on bipap and diuresed with lasix IV, but
could not be weaned off bipap. He was then transferred to [**Hospital1 18**].
.
.
On review of symptoms, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. He does report
productive cough for the past month, which had actually been
improving. All of the other review of systems were negative.
Past Medical History:
Coronary artery disease, s/p MI in ??????04
s/p CABG x 3 ??????05 at [**Hospital1 2177**]
Diabetes
Hypertension
Hyperlipidemia
Atrial tachycardia/Atrial fibrillation with tachy-brady syndrome
(symptomatic 2 second pauses when afib was treated with beta
blockers)
cardiomyopathy, EF 25%
s/p ICD placement and revision in [**1-/2115**] (see below)
.
Cardiac Risk Factors: Diabetes, Dyslipidemia, Hypertension
.
Cardiac History: CABG x3 in [**2112**], anatomy unavailable
.
Pacemaker/ICD: primary prevention ICD placed in [**4-8**], revised in
[**1-8**] when he became PPM dependent and the initial [**Company 1543**] lead
was recalled
Social History:
Divorced, no ETOH, quit tobacco 3 years ago.
Family History:
father died of MI at age 47, mother died of MI at age 52.
Physical Exam:
VS: T 98.1, BP 120/78, HR 104, RR 25, O2 100 % on bipap 10/6
with 100% FiO2
Gen: WDWN middle aged male lying in bed on bipap, becomes too
dyspneic to speak in full sentences without bipap, appears older
than stated age. Oriented x3. Mood, affect appropriate.
Pleasant.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple; unable to assess JVP 2/2 body habitus
CV: PMI diffuse, midclavicular line. RR, normal S1, S2. No S4,
no S3.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Crackles [**1-3**] way up
thorax bilaterally
Abd: Obese, soft, mild ttp epigastrium, No HSM. No abdominial
bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ DP
Pertinent Results:
[**2115-3-3**] 06:00AM BLOOD WBC-13.0*# RBC-5.35 Hgb-14.8 Hct-43.9
MCV-82 MCH-27.6 MCHC-33.6 RDW-15.1 Plt Ct-186
[**2115-3-4**] 05:18AM BLOOD WBC-9.3 RBC-4.52* Hgb-12.6* Hct-35.6*
MCV-79* MCH-27.8 MCHC-35.4* RDW-15.6* Plt Ct-173
[**2115-3-5**] 06:15AM BLOOD WBC-14.1*# RBC-4.59* Hgb-12.5* Hct-35.9*
MCV-78* MCH-27.3 MCHC-34.8 RDW-15.7* Plt Ct-183
[**2115-3-7**] 09:00AM BLOOD WBC-10.2 RBC-4.24* Hgb-11.8* Hct-35.0*
MCV-83 MCH-27.8 MCHC-33.7 RDW-15.0 Plt Ct-185
[**2115-3-7**] 09:00AM BLOOD PT-19.6* PTT-46.3* INR(PT)-1.8*
[**2115-3-3**] 06:00AM BLOOD Glucose-270* UreaN-21* Creat-1.2 Na-136
K-4.3 Cl-99 HCO3-22 AnGap-19
[**2115-3-3**] 06:00AM BLOOD ALT-23 AST-22 LD(LDH)-221 CK(CPK)-98
AlkPhos-68 TotBili-0.4
[**2115-3-3**] 06:00AM BLOOD cTropnT-0.02*
[**2115-3-6**] 06:25AM BLOOD CK-MB-2 cTropnT-<0.01
[**2115-3-7**] 09:00AM BLOOD Calcium-8.3* Phos-2.6* Mg-2.5
[**2115-3-3**] 03:45PM BLOOD %HbA1c-7.7*
[**2115-3-3**] 06:00AM BLOOD TSH-4.8*
[**2115-3-3**] 06:00AM BLOOD Free T4-1.2
TTE:
The left atrium is moderately dilated. The estimated right
atrial pressure is 0-5 mmHg. Left ventricular wall thicknesses
are normal. The left ventricular cavity is mildly dilated with
moderate to severe regional left ventricular systolic
dysfunction including near akinesis of the distal half of the
ventricle. The basal inferior and inferolaterl walls contract
best. No masses or thrombi are seen in the left ventricle,
though apical views area suboptimal. The estimated cardiac index
is depressed (<2.0L/min/m2). Right ventricular chamber size and
free wall motion are normal. The ascending aorta is mildly
dilated. The aortic valve leaflets are mildly thickened.
Significant aortic stenosis is not present. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild to moderate ([**1-2**]+) mitral regurgitation is seen.
The pulmonary artery systolic pressure could not be estimated.
There is a small pericardial effusion.
IMPRESSION: Left ventricular cavity dilation with extensive
regional systolic dysfunction c/w multivessel CAD. Diastolic
dysfunction. Mild-moderate mitral regurgitation.
Persantine-MIBI:
1. Severe, fixed apical and apical-inferior wall, and moderate,
fixed inferior wall perfusion defects. 2. Diffuse LV
hypokinesis, cavity
dilation and depressed EF of 28%.
CXR: The patient is status post median sternotomy. Multiple
surgical clips are reflective of underlying surgical history of
CABG. An implantable cardiac defibrillator device project of the
left upper chest with leads unchanged in position. An adjacent
radiopaque object obscures detailed evaluation of the left upper
and mid lung field. The cardiac size is overall top-to-mildly
enlarged. There is prominence of the pulmonary vasculature and
evidence of peribronchial cuffing. There is no evidence of
alveolar edema, particularly at the lung bases. No definite
pleural effusions are seen.
IMPRESSION: Findings consistent with mild to moderate congestive
heart failure
Brief Hospital Course:
# CAD/Ischemia: The patient had slightly elevated troponins
likely secondary to demand ischemia from CHF with elevated
LVEDP and tachycardia. Repeat cardiac enzymes were negative,
making ACS much less likely. He was evaluated with a
persantine-MIBI prior to discharge which showed no fixed
defects. His was continued on a beta blocker but it was changed
to Toprol for easier dosing. He was also begun and an aspirin
daily and continued on his home dose of a statin. He was also
begun on a low dose ACE for better afterload reduction. His dose
of Imdur was also increased. He will follow up with his
outpatient cardiologist, Dr. [**Last Name (STitle) **], in [**7-11**] days.
.
# Pump: The patient presented volume overloaded with dyspnea,
hypoxia requiring positive pressure ventilation, and pulmonary
edema on CXR. In discussion with the patient, he had apparently
been eating salted bologna recently. This dietary indiscretion
was likely the cause of his fluid retention. An echocardiogram
confirmed an unchanged EF of ~25% no new wall motion
abnormalities. The patient was aggressively diuresed with IV
Lasix initially with good response. He became 5-6 L negative
over the course of his admission. He was rapidly removed from
positive pressure ventilation and his oxygen requirement
decreased to room air by HD 2. His Imdur was increased for
preload reduction and he was begun on an ACE inhibitor for
better afterload reduction. He was transitioned to his home dose
of Lasix and maintained a negative fluid balance. An aldosterone
antagonist, such as spironolactone, should be considered in the
future. At the time of discharge, he was able to sleep lying
flat and was comfortable and ambulatory on room air. Again, he
will follow up with his primary cardiologist.
.
# Rhythm: The patient presented in atrial tachycardia with
appropriate ventricular pacing. The EP service was consulted and
evice interrogation revealed episodes of atrial fibrillation and
atrial tachycardia almost daily since [**2115-2-16**] and also increased
transthoracic impedance c/w volume overload over the same time
frame. It appears his volume overload began before his episodes
of atrial tachycardia, making atrial stretch the likely culprit.
His rate was initially controlled with IV metoprolol with good
effect. His atrial tachycardia resolved and he was initially
started on PO amiodarone to rhythm control. However, this was
later stopped as it was felt that his volume overload was
causing the atrial arrythmia. The arrythmia did not recur once
diuresis had begun and he remained in well controlled NSR for
the rest of his admission. He was continued on his home dose of
metoprolol and discharged on his home dose of coumadin.
.
# leukocytosis: The patient initially presented with a
leukocytosis which resolved on HD 2. This was likely a stress
response. However, it recurred on HD 3. Blood cultures were
negative but a urine culture revealed e.coli. He was begun on
ciprofloxacin, to finish a 7 day course
.
# ARF: With aggressive diuresis, the patient had a mild increase
in his creatinine to 1.6 from a baseline of approximately 1.
However, this was decreasing on the day of discharge. He will
follow up with his cardiologist and PCP to monitor his
creatinine and ensure it returns to normal now that his Lasix
has been reduced to his previous dose.
.
# DM: HbA1c was checked and found to be 7.7 indicating good
control. His metformin was held while he was in house and he was
continued on his home dose of Lantus and covered with an RISS.
His metformin was restarted on discharge. He will follow up with
his PCP for further management of his diabetes
.
# FEN:
-low salt diet
- check and replete lytes to goal K >4, Mg >2
.
# Prophylaxis:
- anticoagulated, ranitidine, bowel regimen
.
# Code: full
.
# Communication: wife and daughter
Medications on Admission:
Lantus 22 units at bedtime
Coumadin 10mg daily
Lipitor 40mg once daily in the pm
Lasix 40mg once daily
Metformin 1000mg twice a day
Imdur 30mg once daily
KCL 20meq once daily
Metoprolol 100mg tid
Discharge Medications:
1. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Coumadin 10 mg Tablet Sig: One (1) Tablet PO once a day.
3. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*60 Tablet Sustained Release 24 hr(s)* Refills:*2*
4. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: Three
(3) Tablet Sustained Release 24 hr PO once a day.
Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*2*
5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 4 days.
Disp:*8 Tablet(s)* Refills:*0*
7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
Tablet(s)
10. Potassium Chloride 20 mEq Packet Sig: One (1) PO once a
day.
11. Lantus 100 unit/mL Cartridge Sig: Twenty Two (22) units
Subcutaneous at bedtime.
Discharge Disposition:
Home
Discharge Diagnosis:
Acute on chronic congestive heart failue
Diabetes type 2
Coronary artery disease
Hypertension
Hyperlipidemia
Discharge Condition:
All vital signs stable, chest pain free, ambulatory off oxygen.
Discharge Instructions:
You were admitted with an exacerbation of your congestive heart
failure. You had increased fluid build up in your lungs that
your heart couldn't pump forward fast enough. This probably
occured from eating foods high in salt such as bologna. We gave
you extra doses of Lasix to pull this fluid off of you. Your
heart scan showed no current blockages. You should avoid foods
high in salt such as processed meats and cheeses, soups, and
chips. Keep your sodium intake to less than 2 grams (2000mg) per
day. Please weigh yourself daily and report a gain of more than
4 lbs to your physician.
Your kidney function worsened slightly with pulling the extra
fluid off but it was improving when you were discharged. Your
doctor will need to check your labs to ensure that it continued
to improve.
You were also diagnosed with a minor urinary tract infection.
This was treated well with antibiotics, which you will continue
to several days after discharge.
Please take all your medications as prescribed. Please attend
all your follow up appointments.
Please have your INR checked on Monday [**2115-3-11**] to adjust your
coumadin dosing.
Please call your doctor or return to the emergency room if you
experience shortness of breath, chest pain, fevers, chills, or
any other symptoms that concern you.
Followup Instructions:
Please call Dr.[**Name (NI) 73283**] office to arrange for a follow up
appointment in [**7-11**] days. You will need to have a Chem 7 checked
at this time.
Please call Dr. [**Last Name (STitle) 73284**] office at [**Telephone/Fax (1) 53977**] to set up a
follow up appointment in the next 2-4 weeks.
|
[
"412",
"272.4",
"250.00",
"V45.81",
"599.0",
"401.9",
"041.4",
"427.31",
"427.81",
"584.9",
"V45.02",
"428.0",
"425.4",
"428.43"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11826, 11832
|
6633, 10462
|
332, 339
|
11985, 12051
|
3634, 6610
|
13397, 13701
|
2590, 2650
|
10708, 11803
|
11853, 11964
|
10488, 10685
|
12075, 13374
|
2665, 3615
|
273, 294
|
367, 1855
|
1877, 2512
|
2528, 2574
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,139
| 171,730
|
35673
|
Discharge summary
|
report
|
Admission Date: [**2181-3-15**] Discharge Date: [**2181-3-18**]
Date of Birth: [**2138-9-9**] Sex: M
Service: MEDICINE
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
AMS
Major Surgical or Invasive Procedure:
none
History of Present Illness:
42 yo M with an unknown past medical history presents to the ED
with presumed drug overdose. Per report, patient was found in a
parking lot with altered mental status by EMS and saying that he
took a "handful of pills", that were mostly dilantin but unknown
if anything else was mixed in. He was exhibiting altered gait at
that time (around 10:30 am). He was only oriented x1 at this
time. Additional history is not available at this time. Patient
did report that he was intentionally trying to hurt himself.
.
On arrival to the ED, triage VS were 98, 93, 148/105, 18, 97%
RA, and patient was lethargic but arousable an answering
questions. At arrival, he was about 50 minutes post-ingestion.
He did confirm a past medical history of seizures, but no other
known medical history was obtained. He was given activated
charcoal, and then started to refuse this intervention and
became progressively more somnolent. He received narcan with no
improvement. He was intbated for poor mental status, but was not
reportedly hypoxic or in respiratory distress. Intubation was
uncomplicated but was noted to have aspiration of charcoal. ET
tube was noted to be high and was advanced 3 cm. QRS was narrom
on EKG, dilantin level was 9.7, and tox screen was positive for
TCAs. AG was mildly elevated at 14. On transfer, VS were HR 77,
99/63, AC 550 x 17, 50%, PEEP 5 and sat 99%.
.
A toxicology consult was requested and advised serial dilantin
levels Q4H (with administration of extra charcoal dose if
greater than 20), EKG q4H, and CT head without contrast.
.
In the ICU, patient is unarousable. He appears comfortable.
Past Medical History:
Depression
Epilepsy
Past MVA w/ left shoulder injury
Social History:
Lives in [**Location 669**] with wife, 4yo daughter and [**Name2 (NI) **], not
working on disability. Reports drinking up to 1 bottle of
whisky plus beer per day in the past but has not drunk anything
for a month. Denies smoking or doing illicit drugs.
Family History:
Non-contributory
Physical Exam:
Vitals: T: 97.7 BP: 125/78 P: 99 R: 18 O2: 92% - AC 550 cc x 18
40% FiO2
General: Intubated, Somnolent, Does not arouse to sternal rub
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: negative babinski bilaterally, 2+ patellar and biceps
reflex, tone mildly increased, no asterxis and no clonus
Discharge exam:
Vitals: T: 100.0 BP: 144/73 P: 112 R: 16 O2:97% on RA
General: Sitting comfortably, nervous and very fixated on past
automobile accident, very anxious to [**Doctor Last Name **] approval of doctors
medical team.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, no rebound tenderness
or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, otherwise non-focal
Pertinent Results:
LABS ON ADMISSION:
[**2181-3-15**] 12:45PM BLOOD WBC-8.2 RBC-4.95 Hgb-14.7 Hct-44.5 MCV-90
MCH-29.7 MCHC-33.0 RDW-12.9 Plt Ct-264
[**2181-3-15**] 12:45PM BLOOD Neuts-55.7 Lymphs-37.3 Monos-3.8 Eos-2.0
Baso-1.2
[**2181-3-15**] 12:45PM BLOOD Neuts-55.7 Lymphs-37.3 Monos-3.8 Eos-2.0
Baso-1.2
[**2181-3-15**] 12:45PM BLOOD Plt Ct-264
[**2181-3-15**] 07:20PM BLOOD PT-13.9* PTT-29.1 INR(PT)-1.2*
[**2181-3-15**] 12:45PM BLOOD Glucose-150* UreaN-12 Creat-0.9 Na-137
K-4.1 Cl-107 HCO3-17* AnGap-17
[**2181-3-15**] 12:45PM BLOOD ALT-30 AST-32 AlkPhos-107 TotBili-0.2
[**2181-3-15**] 07:20PM BLOOD Calcium-8.7 Phos-3.7 Mg-1.8
[**2181-3-15**] 12:45PM BLOOD Phenyto-9.7*
[**2181-3-15**] 12:45PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-POS
[**2181-3-15**] 01:39PM BLOOD Type-ART pO2-365* pCO2-42 pH-7.35
calTCO2-24 Base XS--2 -ASSIST/CON
[**2181-3-15**] 08:57PM BLOOD Type-ART Temp-37.3 FiO2-40 pO2-140*
pCO2-37 pH-7.40 calTCO2-24 Base XS-0 -ASSIST/CON
Intubat-INTUBATED
Admission EKG: Bassline artifact. Sinus rhythm. Inferior T waves
cannot be interpreted. Clinical correlation is suggested. No
previous tracing available for comparison.
[**2181-3-15**] chest AP x-ray: Low lung volumes are noted, with mild
crowding of bronchovascular markings. The lungs are clear
without consolidation or edema. There are no pleural effusions
or pneumothorax. An endotracheal tube is seen with tip below the
thoracic inlet, 7 cm from the carina. A nasogastric tube is
present in the stomach.
[**2181-3-17**] chest AP: FINDINGS: In the interval, the patient has
been extubated and the nasogastric tube has been removed.
Today's image represents a normal chest radiograph without
evidence of pulmonary edema, pulmonary infection or pleural
effusions. The size of the cardiac silhouette and the appearance
of the mediastinum is unremarkable.
[**2181-3-15**] N/C head CT: IMPRESSION: No acute intracranial
abnormality.
Brief Hospital Course:
42 yo M with unknown past medical history presents with apparent
intentional drug overdose, with likely phenytoin and TCAs, now
s/p intubation for airwary protection.
# Altered mental status: Appears to be related to drug overdose.
Dilantin level peaked at 10.7 and then trended down. TCA
positive on Serum tox, but no EKG changes so less likely to be
toxic from TCA. No clear toxic prodrome fits this clinical
picture as patient without tachycardia, hypertension and
diaphoresis (sympathomimetics); agitation, tachycardia, flushing
(anticholinergics); miosis, lack of response to narcan (opiods);
or autonomic instability, clonus, tremors (serotonin syndrome).
No dramatic anion gap, so less likely ethylene glycol or
methanol toxicity. CT head without acute ICH. The patient was
intubated in the ED for somnolence and maintained with
mechanical ventilation. He received activated charcoal.
Toxicology followed the patient and recommended serial EKGs,
which remained unchanged, and serial dilantin levels which were
never toxic. The day after admission, the patient's mental
status improved and he was extubated without any complications.
His neurologic exam was normal and he had no other symptoms.He
had one low-grade temperature to 100.5 without any accompanying
symptoms. CXR and UA were negative.
# Suicideal ideation: Per report patient was attempted to hurt
himself by taking a "handful of pills". He describes the
decision as impulsive and contact[**Name (NI) **] his psychotherapist
afterwards. He was seen by psychiatry who felt that he was
suicide risk and required inpatient psychiatric evaluation. He
was kept with a section 12 but made no attempts to leave AMA.
His home anti-depressants were held per psychiatry
recommendation.
# Epilepsy: most recent seizure 3 weeks ago per patient report.
Dilantin level went down to 7.8, so he was given a 300mg,
one-time loading dose and restarting on his home regimen of
100mg [**Hospital1 **].
# Sinus tachycardia: stably tachycardic. Benzo and alcohol tox
screen negative on admission, not recently using per patient.
Not responsive to fluid boluses. Patient unsure of baseline
heart rate.
Medications on Admission:
Amitriptyline 25mg QHS
Effexor SR 150mg [**Hospital1 **]
Prozac 20mg QAM
Dilantin 100mg [**Hospital1 **]
Lorazepam 0.5mg [**Hospital1 **]
Remeron 30mg QHS
Viagra
Vit D
Discharge Medications:
1. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO BID (2 times a day).
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Final diagnosis: overdose
Secondary diagnoses: depression, epilepsy
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
Discharge Instructions:
You were admitted after taking a handfull of your medicines.
You were confused and sleepy, so you were intubated and went to
the intensive care unit. You are doing better now, but we are
worried about your depression and think that you should go to
our inpatient psychiatric floor.
.
We stopped all of your medications except your Dilantin
(phenytoin). Your psychiatrists will decide if your other
medications should be restarted
Followup Instructions:
When you are ready to leave the hospital, please call your
primary care doctor, [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], and make an appointment
within the next 1-2 weeks. He should check your Dilantin level
to make sure you are protected from having a seizure.
Completed by:[**2181-3-18**]
|
[
"966.1",
"311",
"345.90",
"E950.5",
"427.89",
"780.09",
"977.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
8148, 8163
|
5657, 5835
|
299, 305
|
8275, 8275
|
3706, 3711
|
8878, 9198
|
2307, 2325
|
8034, 8125
|
8184, 8184
|
7842, 8011
|
8201, 8211
|
8422, 8855
|
2340, 3015
|
8232, 8254
|
3031, 3687
|
256, 261
|
333, 1943
|
5586, 5634
|
3726, 5577
|
8290, 8398
|
1965, 2019
|
2035, 2291
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,517
| 181,055
|
9348
|
Discharge summary
|
report
|
Admission Date: [**2179-5-28**] Discharge Date: [**2179-6-3**]
Date of Birth: [**2128-11-24**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This 50 year old male, who was
an attending nephrologist presented to the Emergency Room
short of breath and with cough. He had acute onset while
dining that evening. He denied chest pain, fever or
productive cough. He was found in the Emergency Room to have
increased oxygen requirement, initially with a 93% room air
saturation down to 75% room air saturation which increased to
81% on 100% non rebreather. He had a chest x-ray which
revealed congestive heart failure. He was noted to have a
murmur on examination and an echo revealed 4+ mitral
regurgitation. He was given Lasix and nitroglycerin and then
Nipride in the Emergency Room. His blood pressure did not
tolerate this and he was intubated in the Emergency Room. He
was given nebulizer treatments, Solu-Medrol without success.
He proceeded to the catheterization laboratory where a
catheterization revealed clean coronaries and 4+ mitral
regurgitation. His left ventricular ejection fraction was
75%. He had a balloon pump placed and was transferred to the
CCU.
PAST MEDICAL HISTORY: Unremarkable.
MEDICATIONS ON ADMISSION: [**Doctor First Name **] prn.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: He is an attending at [**Hospital1 190**]. He drinks alcohol rarely. He does not smoke
cigarettes. He is a marathon runner.
FAMILY HISTORY: Unremarkable.
REVIEW OF SYSTEMS: As above.
PHYSICAL EXAMINATION: He is a well-developed, well-nourished
white male, intubated and on a balloon. Blood pressure was
101/50; pulse 80. HEAD, EYES, EARS, NOSE AND THROAT
examination was normal cephalic, atraumatic, extraocular
movements intact. Oropharynx benign. Neck is supple. Full
range of motion, no lymphadenopathy, thyromegaly. Carotids 2+
and qual bilaterally without bruits. Lungs had rales a third
of the way up bilaterally. Cardiovascular examination:
Regular rate and rhythm, no S1 and S2, with a 3/6 systolic
ejection holosystolic murmur which went to the axilla.
Abdomen was soft, nontender, with positive bowel sounds, no
hepatosplenomegaly. Extremities were without cyanosis,
clubbing or edema. Neurologic examination was nonfocal.
HOSPITAL COURSE: Cardiac surgery was consulted and the
patient underwent mitral valve repair with a 30 mm [**Doctor Last Name 405**]
annuloplasty band and partial resection of the posterior
leaflet that afternoon. The cross clamp time was 52 minutes.
Total bypass time was 81 minutes. He was transferred to the
CSRU on Propofol and Neo-Synephrine in stable condition. He
had a stable postoperative night. He was extubated on
postoperative day number one. His balloon pump was
discontinued. He was in stable condition. He did have an air
leak in his chest tube. He was transferred to the floor and
continued to progress well. He had his epicardial pacing
wires discontinued. He continued to have a small air leak on
water seal. He had a small right pneumothorax. His chest
tube was eventually discontinued on postoperative day number
five and, on postoperative day number six, he was discharged
home in stable condition.
MEDICATIONS ON DISCHARGE:
Colace 100 mg p.o. twice a day.
Ecotrin 325 mg p.o. q. day.
Percocet one to two p.o. every four to six hours prn for
pain.
Vasotec 5 mg p.o. q. day.
LABORATORY DATA: Hematocrit 27.6; white count of 6,700;
platelets 170; sodium 139; potassium 4; chloride 101; C02 31;
BUN 8; creatinine 0.8; blood sugar 127.
He will be followed by Dr. [**Last Name (STitle) **] in one to two weeks and by
Dr. [**Last Name (STitle) 70**] in six weeks.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 31946**]
MEDQUIST36
D: [**2179-6-3**] 11:35
T: [**2179-6-3**] 10:43
JOB#: [**Job Number 31947**]
|
[
"458.9",
"424.0",
"512.1",
"428.0",
"429.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"37.22",
"88.53",
"96.04",
"39.61",
"37.61",
"88.56",
"35.12"
] |
icd9pcs
|
[
[
[]
]
] |
1487, 1502
|
3249, 3992
|
1257, 1326
|
2310, 3223
|
1556, 2292
|
1522, 1533
|
160, 1192
|
1215, 1230
|
1343, 1470
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,327
| 111,988
|
30880
|
Discharge summary
|
report
|
Admission Date: [**2134-10-14**] Discharge Date: [**2134-11-8**]
Date of Birth: [**2066-11-25**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3913**]
Chief Complaint:
fever and hypotension
Major Surgical or Invasive Procedure:
diagnositic and therapeutic paracentesis
PICC line placement
Skin biopsy
Bronchoscopy
Bone Marrow Biopsy
Wound Care
History of Present Illness:
67 yo male w/ MDS with recent admission from [**Date range (1) 73061**] to
surgical service for R. hemicolectomy with end ileostomoy and
mucous fistula admitted on [**2134-10-14**] with SIRS/early sepsis with
unknown source of infection.
.
Admission [**Date range (1) 73061**] was for evaluation for bilateral
erythema/blisters on arms after injections/ treatment with IM
vidaza for his MDS on [**9-20**]. His hospital course was
complicated by necrotic bowel and an exp lap was performed with
hemicolectomy and end ileostomy and mucous fistula ([**2134-9-28**]).
He required intubation for respiratory distress and
cardioversion for atrial fibrillation. Also developed VRE
(sensitive to daptomycin) in peritoneal fluid, discharged on
daptomycin.
.
ER visits [**10-12**] and [**10-13**]: Presented with concern of infected
wound dehisence, evalutated by surgery, discharged with bactrim
and keflex for presumed wound infection and concomittant UTI.
Represented the following day with hypotension, fever, Hct of 21
and INR of 8. Received total 6 Units PRBC, 1 unit FFP and IVF,
vitK. Rt IJ placed, started on Dapto/Zosyn.
.
SICU admission [**10-14**]: Presentation notable for skin lesion,
fever, hypotension, HCT drop, and elevated INR. He was continued
on daptomycin and pip-tazo. The patient has had volume
responsive hypotension with no current pressor requirement. He
underwent U/S-guided paracentesis w/ removal of 2700cc. He was
found to have erythema surrounding his abd incision with an
additional erythematous nodule on the R thigh. The etiology of
the patient's presentation has been unclear, however possible
infectious sources include a secondary wound infection vs.
hematogenous spread of an alternate underlying infection. The
patient's skin findings are felt to be more consistent with
inflammatory etiology (as opposed to infectious etiology).
Prelim biopsy for hip and peri-incisional biopsies read as
neutrophilic dermatosis (pyoderma gangrenosum), though cannout
rule out infectious process.
.
Upon admission to [**Hospital Unit Name 153**] patient reports intermittent abdominal
pain mid-abdomen fluctuating in intensity [**2134-4-24**], no radiation.
Occasional nausea, no vomitting. Ostomy output loose and brown.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache. Denies cough, shortness of breath, or
wheezing. Denies chest pain, chest pressure, palpitations. He
feels generalized weakness. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias.
Past Medical History:
Myelodysplastic syndrome, Carpal tunnel syndrome, COPD.
Past Surgical History:
L knee surgery, back surgery.
Social History:
Retired, used to work for a chemical company. History of
asbestos and other chemical exposure. He has a history of
significant alcohol use, which he stopped approximately seven
years ago. 60 pack year history of tobacco use. Has a daughter.
Lives alone. Was going to the gym every other day and walking
4 miles before his necrotic bowel surgery.
Family History:
Per med record: Sister - died of scleroderma; Another sister -
died of unclear etiology; Brother - died of EtOH abuse; Daughter
with Marfan's; Two brothers are alive and well; Mother - died of
lung cancer; Father - died in an MVC.
Physical Exam:
GEN: no acute distress, lying in bed
HEENT: Dry mucous membranes with white plaque on tongue. No LAD.
Lungs: coarse breath sounds, expiratory wheezing on right,
rhonchi anteriorly, with bibasilar crackles bilaterally
CV: tachycardic, regular rhythm, normal S1 S2, no M/G/R. R IJ
site c/d/i
BACK: no focal tenderness, no CVAT
GI: abdomen with large midline open incision extended from pubic
symphisis to subxiphoid with serosanguinous drainage. Ostomy
with dark necrotic appearing mucosa.
GU: foley in place draining yellow urine.
MSK: no joint swelling or erythema
EXT: trace pitting edema bilaterally
SKIN: mucocutaneous fistula site with necrotic center. 2cm
nodular lesion on lateral aspect of R thigh with surrounding
erythema, warm, and tender to touch.
NEURO: CN2-12 grossly intact, UE 5/5 strength, LE RLE [**1-22**]
strength and LLE able to lift against gravity.
Pertinent Results:
Labs upon admission:
[**2134-10-13**] 06:35PM BLOOD WBC-8.0 RBC-2.38* Hgb-7.7* Hct-21.9*
MCV-92 MCH-32.2* MCHC-34.9 RDW-18.4* Plt Ct-70*
[**2134-10-13**] 06:35PM BLOOD Neuts-79.2* Bands-0 Lymphs-13.0*
Monos-3.9 Eos-3.6 Baso-0.2
[**2134-10-16**] 05:37AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+
Macrocy-1+ Microcy-NORMAL Polychr-NORMAL Ovalocy-1+
Schisto-OCCASIONAL
[**2134-10-13**] 06:35PM BLOOD PT-51.0* PTT-45.9* INR(PT)-5.6*
[**2134-10-14**] 04:51AM BLOOD Fibrino-625*
[**2134-10-18**] 03:33AM BLOOD Gran Ct-1794*
[**2134-10-14**] 04:51AM BLOOD Ret Aut-3.1
[**2134-10-18**] 03:33AM BLOOD ACA IgG-PND ACA IgM-PND
[**2134-10-13**] 06:35PM BLOOD Glucose-108* UreaN-19 Creat-1.1 Na-129*
K-4.0 Cl-96 HCO3-26 AnGap-11
[**2134-10-14**] 04:51AM BLOOD ALT-24 AST-29 LD(LDH)-132 AlkPhos-78
TotBili-2.0*
[**2134-10-13**] 06:35PM BLOOD proBNP-1421*
[**2134-10-14**] 04:51AM BLOOD Albumin-2.4* Calcium-7.2* Phos-4.2 Mg-1.7
[**2134-10-14**] 04:51AM BLOOD Hapto-268*
[**2134-10-17**] 10:40PM BLOOD Ferritn-3219*
[**2134-10-17**] 10:40PM BLOOD Triglyc-79
[**2134-10-17**] 04:02AM BLOOD Osmolal-283
[**2134-10-17**] 04:02AM BLOOD TSH-2.4
[**2134-10-17**] 04:02AM BLOOD Cortsol-33.7*
[**2134-10-18**] 03:33AM BLOOD ANCA-NEGATIVE B
[**2134-10-18**] 03:33AM BLOOD [**Doctor First Name **]-NEGATIVE
[**2134-10-14**] 04:44AM BLOOD Type-CENTRAL VE pO2-85 pCO2-38 pH-7.46*
calTCO2-28 Base XS-2 Comment-GREEN TOP
[**2134-10-13**] 06:46PM BLOOD Glucose-107* Lactate-1.3 Na-130* K-4.1
Cl-94* calHCO3-27
[**2134-10-13**] 06:46PM BLOOD Hgb-8.1* calcHCT-24
[**2134-10-14**] 04:44AM BLOOD freeCa-1.00*
Labs upon discharge:
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2134-11-8**] 00:10 1.8* 2.80* 8.1* 24.3* 87 28.9 33.4 13.8 26*
Platelets post transfusion: 54*
Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2134-11-8**] 00:10 103*1 35* 0.6 136 4.3 98 33* 9
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili IndBili
[**2134-11-8**] 00:10 30 15 161 60 0.5
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2134-11-8**] 00:10 3.5 8.7 3.0 2.1
AUTOANTIBODIES ANCA
[**2134-10-18**] 03:33 NEGATIVE B1
OLD S# [**Serial Number **]C
NEGATIVE BY INDIRECT IMMUNOFLUORESCENCE
IMMUNOLOGY [**Doctor First Name **]
[**2134-10-18**] 03:33 NEGATIVE
B-Glucan, Galactomannan: negative
.
CXR [**2134-10-13**]: Small bilateral pleural effusions. Equivocal signs
for mild
pulmonary vascular congestion. Otherwise, unremarkable.
.
CT Abdomen [**2134-10-13**]: 1. Large volume ascites with mild
peritoneal enhancement in the right paracolic gutter. Overall
appearance appears simple though given history of recent
surgery, peritonitis cannot be excluded. Consider paracentesis
with culture.
2. Post operative changes rel;ated to recent bowel resection
without evidence of bower obstruction or perforation.
3. Small bilateral pleural effusions with bilateral lower lobe
compressive
atelectasis.
.
Right hip skin biopsy [**2134-10-14**]: The findings in both specimens
are similar, with intense neutrophilic infiltration of the
dermis. The overlying epidermis exhibits neutrophilic
spongiosis with foci of spongiform pustulation; in specimen 2,
frank cleavage is noted through the spinous layer. No
micro-organisms are identified within the inflamed tissue in
PAS, GMS, and Gram stained sections
.
Paracentesis: Technically successful diagnostic and therapeutic
paracentesis yielding 2.7 liters of amber clear ascitic fluid,
which was sent for microbiology and cell count.
.
Liver/RUQ Ultrasound [**2134-10-18**]: Ascites. Sludge within the
gallbladder. No gallstones. No dilated bile ducts. No focal
lesions seen in the liver. Assessment was limited to the liver,
gallbladder and related structures.
.
CXR [**2134-10-19**]: In comparison with the study of [**10-17**], there are
continued low lung volumes. Persistent enlargement of the
cardiac silhouette with some indistinctness of pulmonary vessels
consistent with some elevation of
pulmonary venous pressure. Probable mild bilateral effusions
with compressive atelectasis. Silhouetting of the left
hemidiaphragm is consistent with substantial volume loss in the
left lower lobe.
.
Pertinent Imaging after ICU:
.
Paracentesis:
IMPRESSION:
Successful uncomplicated therapeutic and diagnostic
ultrasound-guided
paracentesis of 1.2 liters of clear ascites. Fluid was sent for
Gram stain, culture, cell count, protein, LDH and albumin.
.
CT Torso:
1. Multifocal ground-glass pulmonary opacities, most compatible
with
multifocal infectious process. New left lower lobe collapse.
2. Small-to-moderate bilateral pleural effusions, left greater
than right,
appear simple.
3. Unchanged moderate volume ascites, with mild peritoneal
enhancement again seen in the right paracolic gutter. This may
again be post-surgical, though clinical correlation is advised
to exclude peritonitis.
4. Unremarkable appearance of the large and small bowel, status
post right
hemicolectomy, with end ileostomy and mucous fistula in the
right abdomen. No evidence of abscess formation.
5. Splenomegaly
6. Anasarca.
.
CT Chest:
1. Markedly improved multifocal lung opacities. The largest area
that remains is in the left upper lobe.
2. Mild increase in size in moderate left pleural effusion.
Resolved left lower lobe collapse.
3. Splenomegaly
.
MRI Pelvis:
1. No interval change in the free fluid within the abdomen and
pelvis but no abscess seen.
2. Bilateral AVN, more significant on the right side.
3. Extensive subcutaneous edema.
.
Pathology: R buttock skin biopsy:
Superficial and deep perivascular, periappendageal and
interstitial dermatitis with prominent neutrophils and overlying
papillary dermal edema, epidermal hyperplasia, and spongiosis.
See note.
Note: The depth of the infiltrate is suggestive of an infection
such as bacterial cellulitis. The histologic pattern is not
typical of those observed with deep fungal or atypical
mycobacterial infections (unless inflammation is more prominent
deep to the tissue sampled in this biopsy). The depth of the
infiltrate and lack of a more florid neutrophilic infiltrate are
unusual for Sweet's syndrome, however, a variety of neutrophilic
inflammatory patterns may be observed in patients with
myelodysplastic syndrome (MDS) and in association with G-CSF (if
clinically applicable). The inflammation is peri-eccrine in
areas and focally there are neutrophils involving eccrine units.
This finding raises consideration of a neutrophilic eccrine
hidradenitis (NEH) in the differential diagnosis. NEH may be
observed in association with chemotherapeutic agents and G-CSF.
It was recently reported to occur with decitabine, a derivative
of azacytidine (Vidaza).
.
Special stains (Gram, [**Last Name (un) 18566**], PAS, and GMS) are negative for
organisms. Culture may be a more sensitive method to detect
organisms than histologic special stains. In summary, if
infection is excluded, the differential diagnosis includes a
neutrophilic infiltrate associated with MDS or a drug associated
NEH. Preliminary results of this case were discussed with Dr.
[**Last Name (STitle) 73062**] on [**2134-10-28**].
.
Microbiology Cultures:
Peritoneal:
[**2134-10-14**] 2:14 pm PERITONEAL FLUID
GRAM STAIN (Final [**2134-10-14**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2134-10-17**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2134-10-20**]): NO GROWTH.
FUNGAL CULTURE (Final [**2134-10-29**]): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2134-10-15**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
.
Time Taken Not Noted Log-In Date/Time: [**2134-10-22**] 3:58 pm
PERITONEAL FLUID SOURCE IS PERITONEAL FLUID.
**FINAL REPORT [**2134-10-28**]**
GRAM STAIN (Final [**2134-10-22**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2134-10-25**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2134-10-28**]): NO GROWTH.
.
Tissue Cultures:
Time Taken Not Noted Log-In Date/Time: [**2134-10-27**] 4:01 pm
TISSUE Source: Skin biopsy.
GRAM STAIN (Final [**2134-10-27**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
TISSUE (Final [**2134-10-30**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2134-11-4**]): NO GROWTH.
POTASSIUM HYDROXIDE PREPARATION (Final [**2134-10-28**]):
NO FUNGAL ELEMENTS SEEN.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2134-10-28**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
.
Time Taken Not Noted Log-In Date/Time: [**2134-10-27**] 4:01 pm
TISSUE Source: Skin biopsy.
GRAM STAIN (Final [**2134-10-27**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
TISSUE (Final [**2134-10-30**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2134-11-4**]): NO GROWTH.
POTASSIUM HYDROXIDE PREPARATION (Final [**2134-10-28**]):
NO FUNGAL ELEMENTS SEEN.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2134-10-28**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
.
[**2134-10-26**] 12:10 pm Rapid Respiratory Viral Screen & Culture
**FINAL REPORT [**2134-10-29**]**
Respiratory Viral Culture (Final [**2134-10-29**]):
No respiratory viruses isolated.
Culture screened for Adenovirus, Influenza A & B,
Parainfluenza type
1,2 & 3, and Respiratory Syncytial Virus..
Detection of viruses other than those listed above will
only be
performed on specific request. Please call Virology at
[**Telephone/Fax (1) 6182**]
within 1 week if additional testing is needed.
Respiratory Viral Antigen Screen (Final [**2134-10-27**]):
Respiratory viral antigen test is uninterpretable due to
the lack of
cells.
Refer to respiratory viral culture for further
information.
REPORTED BY PHONE TO DR [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] 11:05AM [**2134-10-27**].
.
[**2134-10-26**] 12:10 pm BRONCHOALVEOLAR LAVAGE
GRAM STAIN (Final [**2134-10-26**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2134-10-28**]):
RARE GROWTH Commensal Respiratory Flora.
POTASSIUM HYDROXIDE PREPARATION (Final [**2134-10-28**]):
KOH REQUESTED PER DR. [**Last Name (STitle) 6401**] PG #[**Numeric Identifier 73063**].
NO FUNGAL ELEMENTS SEEN.
This is a low yield procedure based on our in-house
studies.
.
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
[**2134-10-27**]): NEGATIVE for Pneumocystis jirovecii
(carinii)..
FUNGAL CULTURE (Preliminary):
YEAST.
ACID FAST SMEAR (Final [**2134-10-27**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
.
Please see OMR for BC/UC results. All negative with UC <
100,000 CFU.
.
Bone Marrow Biopsy: Completed Follow up.
Brief Hospital Course:
67 y/o male with MDS s/p R. hemicolectomy with end
ileostomy/mucous fistula on [**2134-9-28**], who presented with fluid
responsive hypotension and fever.
.
SIRS/Sepsis/Fever: Upon admission he was intermittently febrile,
and his hyoptension was fluid responsive. He did not require
vasoactive medication. Possible etiologies included
uperinfection of right thigh lesion with neutrophilic
dermatosis, post-operative wound infection with wound
dehiscence. CT torso was completed without evidence of
intraabdominal abscess. He was started on daptomycin and zosyn,
later stopped zosyn due to low platelets, switched to
ciprofloxacin and flagyl, then finally broadened to meropenum.
Discharged from MICU on daptomycin (6 total days given in MICU)
and meropenum (2 days given in MICU). He was also empricially
covered with meropenem. An infectious cuase for the hypotension
was never identified by culture or by serology. ID followed the
patient throughout his hospital course, and eventually
recommended d/c his antibiotics after his new diagnosis of
Sweet's syndrome. Additionally, A workup was also completed
including [**Doctor First Name **], ANCA, and anti-cardiolipin out of concern for
underlying autoimmune process that could explain the etiology of
his fevers. Rheumatology was also consulted, and did not did
not recommend any additional work up for his fevers. The most
likely etiology for the hypotension was secondary to a wound
infection and sepsis.
.
#MDS/Pancytopenia: Upon admission to the hospital his counts
steadily dropped throughout his stay in the MICU. There was
initial concern for leukemia in his bone marrow. Hemolysis labs
were negative. Reticulocyte count was low. HIT antibody was
negative. The differential diagnosis included worsening MDS,
AML progression, or other hematopeoieic malignancy. Hemolysis
and Smear analysis did not suggest DIC. His counts remained low
throughout the hospital course and his WBC count continued to
flucuated. He was supported with pRBC's and platelets. He had
a BM biopsy prior to discharge and his last ANC was 790.
- Please transfuse pRBC's for HCT < 25.
- Please transfuse platelets for count < 10 or active signs of
bleeding when < 30.
- He will need Bactrim, and Acyclovir for PPX due to his low
WBC.
.
#Sweet's Syndrome/Neutrophilic dermatosis: He was found to have
an erythematous nodule on his right leg and pain. A skin biopsy
was sent which was consistent with neutrophilic dermatosis.
Based upon the biopsy in addition to his clinical findings, a
diagnosis of Sweet's syndrome was proposed to explain his high
grade fevers in addition to his skin lesions. Corticosteroid
treatment was not initiated until multiple imaging studies
confirmed that there was no infectious process or abscess in his
abdomen after his recent surgery. Multiple cultures, both urine
and blood, were negative. A bronchoscopy was also preformed
after a CT revealed multiple opacities. Subsequently, the BAL
was only positive for yeast which was thought to be a
non-pathological. The Pulmonology Consult team felt that the
infiltrates and skin findings were consistent with Sweet's
syndrome. He also developed another sight of pain adjacent to
his R sacrum that also had a neutrophilic infiltrate, but not to
the degree of the R thigh skin biopsy. The differential
diagnosis was neutrophilic dermatosis vs. neutrophilic eccrine
hidradenitis. Based upon his clinical symptomology, he was
treated empirically for Sweet's syndrome with methylprednisone 1
mg/kg with a slow week taper to 0.5 mg/kg. He was then started
on oral prednisone 50 mg/day. He was also started on GI
prophylaxis with famotidine, Vit D, and calcium. A non-contrast
CT of the lungs demonstrated improvement of his multi-focal
opacities, his skin lesions continue to heal, and he has been
afebrile since the initiation of steroids.
- Please continue prednisone 50 mg/day. Do not taper dose. His
steroid course will be determined by Dr. [**Last Name (STitle) **] as an
outpatient.
- Please continue Ca/Vit D and Famotidine for steroid
prophylaxis
- Please continue PO dilaudid for Pain, may wean as patient
tolerates
.
# End ileostomy/mucous fistula s/p hemicolectomy: He presented
with wound dehisence. His intial presentation may have been
secondary to infection of his wound. He was initially started
on broad spectrum antibiotics with minimal improvement in his
wound healing. After the initiation of corticosteroids for
Sweet's syndrome the erythema along the margins of his wound
improved. He subsequently developed granulation tissue, and his
wound continues to demonstrate healing.
- Please continue daily wound care as outlined in attached notes
- Scheduled for follow up as outlined above
.
Hyponatremia: The patient had persistent hypnatremia that was
secondary to Hypervolemia due to fluid resuscitation, and
Sweet's syndrome with SIADH due to infilatrates in the lung.
Urine osms were consistenly elevated relative to [**Name2 (NI) **] osms.
His [**Name2 (NI) **] sodium remained > 128 while on the floor. He was
placed on fluid restriction and subsequently allowed to
autodiuresis. His sodium level stabilized and he was no longer
fluid restricted.
- No fluid restriction
.
# Hyperglycemia: His sugars have been monitor QID, and he has
been placed on an ISS with lantus to help regulate his blood
glucose levels. His sugars have flucuated between 150's -200's.
- Please keep blood glucose less than 180's.
.
# Decreased hearing: Patient had large cerumen plug in left
ear. Patient received ear drops which were ineffective. His
ear canals were clear by examination, and ENT was consulted for
hearing loss. It was believed to be sensorineural, and an
audiology test confirmed the hearing loss in his R ear. He will
be followed up by ENT for a hearing aide.
.
# Ascites: He had a paracentesis on [**2134-10-14**] with removal of
2.7L of fluid which did not demonstrate any infection. He had
an additional paracentesis which did not reveal SBP. He
continues to have ascites without any evidence of infection.
although the volume decreased throughout his hospital stay. It
was thought that his ascites may have been secondary to his poor
nutritional status upon presentation when his albumen was < 3.0.
.
# Stage II decubitus ulcer: Currently has a stage II decubitus
ulcer.
- Continue wound managment
.
# Incidential AVN (bilateral based upon MRI). He had an MRI of
the pelvis and legs which demonstrated AVN.
- Will need follow up as an outpatient
.
# History of AFIB w/RVR: Patient had atrial fibrillation during
his last hospital admission. He was in sinus rhythm during this
admission, and prior to discharge. His amiodarone was
discontinued.
.
# COPD: Hed did not have any evidence of an acute exacerbation
of COPD
- Continue albuterol inhalers PRN
Medications on Admission:
1. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for to groin.
2. silver sulfadiazine 1 % Cream Sig: One (1) Appl Topical WITH
EACH DRESSING CHANGE ().
3. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
4. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed for Wheeze.
5. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
6. amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
.
Medications (on transfer to MICU):
Ondansetron 4 mg IV Q8H:PRN nausea
Micafungin 100 mg IV Q24H
Ciprofloxacin 400 mg IV Q12H
Fentanyl Citrate 25-100 mcg IV Q2H:PRN pain
Acetaminophen 1000 mg PO/NG Q6H:PRN fever
Albuterol Inhaler 2 PUFF IH Q4H
Famotidine 20 mg IV Q12H
Insulin SC (per Insulin Flowsheet)
Daptomycin 600 mg IV Q24H
Piperacillin-Tazobactam 4.5 g IV Q8H
Discharge Medications:
1. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
2. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough/sputum.
3. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as
needed for sob/wheeze.
4. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever, pain.
6. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
7. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
8. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
10. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO 1X/WEEK (WE).
11. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO DAILY (Daily).
12. insulin glargine 100 unit/mL Solution Sig: One (1) 23 units
Subcutaneous at bedtime.
13. Humalog 100 unit/mL Solution Sig: One (1) variable
Subcutaneous four times a day: ISS, Please see attached.
14. prednisone 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. hydromorphone 4 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
16. sodium chloride 0.9 % 0.9 % Syringe Sig: Three (3) ML
Injection Q8H (every 8 hours) as needed for line flush.
17. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
18. Ondansetron 4 mg IV Q8H:PRN nausea
19. heparin, porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush.
20. sodium chloride 0.9 % 0.9 % Syringe Sig: Ten (10) ML
Injection PRN (as needed) as needed for line flush.
21. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**12-19**]
Drops Ophthalmic PRN (as needed) as needed for dryness.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
Primary Diagnosis
MDS
Secondary Diagnosis
Sweet's Syndrome
Ascities
Hyponatremia
AVN bilaterally
Hyperglycemia
Poor wound healing
Discharge Condition:
Mental Status: Clear and coherent.
Activity Status: Ambulatory - Independent.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear [**Known firstname **],
Thank you for receiving your care at [**Hospital3 **] Hospital. You
were admitted for low blood pressure neccessitating and ICU stay
and a new diagnosis of Sweet's syndrome. You were initially
given antimicrobial therapy for high fevers, however, no
infectious source was cultured. You also had numerous imaging
studies which did not reveal an infectious collection of fluid.
Several lesions on your skin were biopsied which showed an
inflammatory infiltrate. After the biopsy results returned, you
were started on steroids. You will need a slow taper of
steroids. You will need to go to a rehab facility to help
improve your physical strength.
.
The following medications were ADDED to your regiment:
Lantus
Humalog
Prednisone
Hydromorphone
Vitamin D (weekly)
Calcium Carbonate
Acyclovir
Bactrim
Famotidine
Trazadone
Guaifenesin
Zofran
Artificial Tears
.
The following medications were STOPPED:
Amiodarone
Oxycodone-Tylenol
heparin
silver sulfadiazine
.
The following medications were CHANGED:
None
Followup Instructions:
Please come to the [**Hospital 18**] medical complex for the following
Appointments:
[**2134-11-26**] 10:30a [**Doctor Last Name **],[**Last Name (un) 6410**] T
LM [**Hospital Unit Name **], [**Location (un) **]
OTOLARYNGOLOGY/AUDIOLOGY (NHB)
[**2134-11-25**] 02:00p ACUTE [**Hospital 23692**]
LM [**Hospital Ward Name **] BLDG ([**Doctor First Name **]), [**Location (un) **]
SURGICAL ASSOC LMOB-3A (SB)
[**2134-11-19**] 01:45p [**Doctor Last Name **],TEACHING
SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **]
[**Hospital **] CLINIC-CC2 (SB)
[**2134-11-15**] 12:30p [**Last Name (LF) **],[**First Name3 (LF) **] E.
SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **]
HEMATOLOGY/ONCOLOGY-SC
[**2134-11-15**] 12:30p [**Last Name (LF) **],[**First Name3 (LF) **] H.
SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **]
HEMATOLOGY/ONCOLOGY-SC
Completed by:[**2134-12-26**]
|
[
"707.03",
"427.31",
"682.2",
"695.89",
"427.89",
"496",
"038.9",
"599.0",
"238.75",
"E878.3",
"995.91",
"998.59",
"276.1",
"998.32",
"707.8",
"998.83",
"E878.8",
"707.22",
"E849.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.11",
"41.31",
"33.24",
"38.93",
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
25837, 25884
|
15967, 22795
|
328, 445
|
26059, 26059
|
4687, 4694
|
27298, 28244
|
3547, 3780
|
23819, 25814
|
25905, 26038
|
22821, 23796
|
26238, 27275
|
3134, 3165
|
3795, 4668
|
15796, 15944
|
15650, 15760
|
2733, 3032
|
267, 290
|
6284, 12269
|
473, 2714
|
4708, 6268
|
26074, 26214
|
3054, 3111
|
3181, 3531
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,333
| 160,726
|
28513
|
Discharge summary
|
report
|
Admission Date: [**2159-11-19**] Discharge Date: [**2159-11-23**]
Date of Birth: [**2080-5-21**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Codeine / Oxycodone
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
worsening fatigue
Major Surgical or Invasive Procedure:
[**2159-11-19**] Aortic Valve Replacement (21mm St. [**Male First Name (un) 923**] Epic Porcine)
History of Present Illness:
79yo woman with aortic stenosis followed by echocardiogram now
with worsening fatigue and DOE. She denies any chest pain.
Presents for cardiac surgery evaluation.
Past Medical History:
Aortic Stenosis
Parkinson's disease (dx: [**2158-4-28**])
Paroxysmal atrial fibrillation (documented, however pt is
unaware
of this)
Diabetes
Hypertension
Chronic low back pain
Ovarian cyst
Brachial cleft
Hypothyroidism
Neuropathy from prior zoster
Past Surgical History: Laminectomy, Cataract removal
bilaterally,
Cholecystectomy, Removal of ovarian cyst c/b peritonitis
Social History:
Race: Caucasian
Last Dental Exam: dental extraction [**2159-9-28**], has 3 remaining
teeth
Lives with: alone
Occupation: no
Tobacco: none (quit 45yrs. ago)
ETOH: Occaisional
Family History:
non contributory
Physical Exam:
Pulse: 64 Resp: 16 O2 sat:
B/P Right: Left: 132/64
Height: 5'5" Weight: 170lb
General: NAD, WGWN, appears stated age
Skin: Dry [x] intact [x] no rash
HEENT: PERRLA [] EOMI [] (pupils slowly reactive [**1-30**] cataracts)
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur 3/6 SEM
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+ [X] mid-line scar well healed
Extremities: Warm [X], well-perfused [X] Edema- TRACE
Varicosities: spider veins on thighs
Neuro: Grossly intact
Pulses:
Femoral Right: 2+ Left:2+
DP Right: 2+ Left:2+
PT [**Name (NI) 167**]: 2+ Left:2+
Radial Right: 2+ Left:2+
Carotid Bruit Right: Left:
radiation of cardiac murmur
Pertinent Results:
[**2159-11-22**] CXR: In comparison with the study of [**11-20**], there
appears to be some decrease in the left pleural effusion with
underlying compressive atelectasis. Smaller effusion and
atelectasis seen on the right. Continued elevation of pulmonary
venous pressure in a patient with intact midline sternal wires.
[**2159-11-19**] 11:00AM BLOOD WBC-11.4* RBC-2.74*# Hgb-8.3*# Hct-24.6*#
MCV-90 MCH-30.3 MCHC-33.8 RDW-15.0 Plt Ct-136*#
[**2159-11-22**] 04:35AM BLOOD WBC-8.9 RBC-3.22* Hgb-9.8* Hct-28.7*
MCV-89 MCH-30.4 MCHC-34.1 RDW-15.0 Plt Ct-155
[**2159-11-19**] 11:00AM BLOOD PT-14.6* PTT-31.2 INR(PT)-1.3*
[**2159-11-19**] 11:58AM BLOOD PT-13.6* PTT-27.3 INR(PT)-1.2*
[**2159-11-19**] 11:58AM BLOOD UreaN-14 Creat-0.6 Na-140 K-3.9 Cl-114*
HCO3-22 AnGap-8
[**2159-11-21**] 04:50AM BLOOD Glucose-170* UreaN-13 Creat-0.7 Na-137
K-4.4 Cl-104 HCO3-23 AnGap-14
[**2159-11-22**] 04:35AM BLOOD UreaN-14 Creat-0.7 Na-137 K-4.0 Cl-103
[**2159-11-22**] 04:35AM BLOOD Mg-1.8
Brief Hospital Course:
Mrs. [**Known lastname 33976**] was a same day admit after undergoing all
pre-operative work-up as an outpatient. On [**11-19**] she was brought
directly to the operating room where she underwent an aortic
valve replacement. Please see operative note for surgical
details. Following surgery she was transferred to the CVICU for
invasive monitoring in stable condition. Within 24 hours she was
weaned from sedation, awoke neurologically intact and extubated.
On post-op day one she was started on beta blockers and
diuretics and diuresed towards her pre-op weight. Later on this
day she was transferred to the telemetry floor for further care.
Chest tubes and epicardial pacing wires were removed per
protocol. Physical therapy worked with patient for post-op
strength and mobility. On post-op day four she appeared to be
doing well and was discharged to rehab (Oak-Knoll [**Hospital1 **]).
Medications on Admission:
Losartan 50 daily
Lipitor 5mg daily
HCTZ 12.5 daily
Oxazepam 15mg daily-[**Hospital1 **]
glyburide 10mg [**Hospital1 **]
neurontin prn
Vit D daily
Advil
MVI daily
ASA 81 daily
Calcium daily
Metformin 1000 [**Hospital1 **]
Celexa 10 daily
Levothyroxine 50mcg daily
Sinemet 25/100 QID
Actos 15 daily
Zantac
Prilosec
ibuprofen prn
Vitamin D daily
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
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. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO 1X/WEEK ([**Doctor First Name **]).
6. carbidopa-levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
QID (4 times a day).
7. citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
10. glyburide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
11. losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
13. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 2 days.
14. regular insulin
per sliding scale protocol fingerstick QID
15. Insulin Glargine
15 units at bedtime
16. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day
for 2 weeks.
17. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO BID (2 times a
day) for 2 weeks.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 15644**] Long Term Care - [**Location (un) 47**]
Discharge Diagnosis:
Aortic Stenosis s/p Aortic Valve Replacement
Past medical history:
Parkinson's disease (dx: [**2158-4-28**])
Paroxysmal atrial fibrillation (documented, however pt is
unaware
of this)
Diabetes
Hypertension
Chronic low back pain
Ovarian cyst
Brachial cleft
Hypothyroidism
Neuropathy from prior zoster
Past Surgical History: Laminectomy, Cataract removal
bilaterally,
Cholecystectomy, Removal of ovarian cyst c/b peritonitis
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Edema trace
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] [**12-13**] at 1:15PM
Cardiologist: Dr. [**First Name (STitle) 1075**] [**12-19**] at 3:30PM
Please call to schedule appointments with your
Primary Care Dr. [**First Name (STitle) 9959**] [**Name (STitle) 9960**] in [**4-2**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2159-11-23**]
|
[
"250.00",
"355.9",
"332.0",
"E915",
"934.1",
"244.9",
"401.9",
"424.1",
"338.29",
"724.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.05",
"39.61",
"35.21"
] |
icd9pcs
|
[
[
[]
]
] |
5729, 5817
|
3018, 3909
|
306, 404
|
6283, 6499
|
2019, 2995
|
7422, 7937
|
1198, 1216
|
4303, 5706
|
5838, 5883
|
3935, 4280
|
6523, 7399
|
6161, 6262
|
1231, 2000
|
249, 268
|
432, 596
|
5905, 6138
|
1007, 1182
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,123
| 168,580
|
33830
|
Discharge summary
|
report
|
Admission Date: [**2172-10-20**] Discharge Date: [**2172-10-30**]
Date of Birth: [**2107-9-15**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Demerol / Corn
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2172-10-26**] Two Vessel Coronary Artery Bypass Grafting utilizing
the left internal mammary artery to left anterior descending and
vein graft to diagonal artery.
[**2172-10-21**] Cardiac Catheterization
History of Present Illness:
Mrs. [**Known lastname 4223**] is a 65 year old female who underwent bare metal
stenting to her diagonal artery in [**2172-4-9**], presented to [**Hospital1 9191**] with complaints of chest pain and shortness of breath.
She ruled out for myocardial infarction. Subsequent stress
testing revealed 2mm ST depressions. She was stabilized on
medical therapy and transferred to the [**Hospital1 18**] for further
evaluation and treatment.
Past Medical History:
Coronary artery disease s/p bare metal stent to diagonal [**4-16**],
Hypertension, Dyslipidemia, Thoracic outlet syndrome s/p
bilateral removal of 1st rib, s/p Hysterectomy and bladder
resuspension, s/p left knee surgery, s/p Tonsillectomy, s/p TMJ
surgery, s/p Appendectomy
Social History:
Denies tobacco history. Admits to occasional ETOH. She is [**Name Initial (MD) **]
retired RN.
Family History:
Two brothers with coronary disease, s/p PCI in their 50s
Physical Exam:
PHYSICAL EXAMINATION:
VS: 97.6, 107/65, 77, 18, 98% RA
GENERAL: WDWN female in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP low sitting upright.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ DP 2+ PT 2+
Pertinent Results:
[**2172-10-21**] Cardiac Cath: Selective coronary angiography of this
right dominant system revealed single vessel disease. The LMCA
was a small vessel but free of significant stenoses. The LAD had
a complex 90% in-stent restenosis of the diagonal branch and a
90% long LAD stenosis after D1. The LCx and RCA had mild luminal
irregularities but no angiographically significant stenoses.
[**2172-10-21**] Carotid Ultrasound: Normal carotid study
[**2172-10-26**] Intraop TEE: PRE BYPASS: No spontaneous echo contrast
is seen in the body of the left atrium or left atrial appendage.
No atrial septal defect is seen by 2D or color Doppler. Left
ventricular wall thicknesses and cavity size are normal. There
is mild regional left ventricular systolic dysfunction with mild
septal and apical hypokinesis. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. There are complex (>4mm)
atheroma in the aortic arch. There are simple atheroma in the
descending thoracic aorta. The aortic valve leaflets (3) are
mildly thickened. Trace 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 mild to moderate tricuspid regurgitation.
There is no pericardial effusion. Dr. [**Last Name (STitle) **] was notified in
person of the results in the operating room at the time of the
study.
POST BYPASS:Normal right ventricular systolic function. The left
ventricle now displays moderate to severe hypokinesis of the mid
and distal septal, inferoseptal, anteroseptal and apical walls.
The overall EF is about 50%. The mitral regurgitation is
slightly worse, now bordering on mild to moderate. The tricuspid
regurgitation is also worsened, now at least moderate. The
thoracic aorta appears intact.
[**10-30**] CXR: Right pleural effusion is small, left pleural
effusion is small to moderate. There is mild fluid overload.
There are bibasilar atelectasis.
[**2172-10-21**] 05:55AM BLOOD WBC-5.1 RBC-4.49 Hgb-12.4 Hct-35.2*
MCV-79* MCH-27.6 MCHC-35.2* RDW-13.4 Plt Ct-230
[**2172-10-29**] 05:15AM BLOOD WBC-7.2 RBC-3.32* Hgb-10.0* Hct-27.2*
MCV-82 MCH-30.0 MCHC-36.6* RDW-15.2 Plt Ct-133*
[**2172-10-21**] 05:55AM BLOOD PT-13.0 PTT-27.2 INR(PT)-1.1
[**2172-10-26**] 05:09PM BLOOD PT-14.1* PTT-35.2* INR(PT)-1.2*
[**2172-10-21**] 05:55AM BLOOD Glucose-98 UreaN-19 Creat-0.8 Na-140
K-4.4 Cl-105 HCO3-27 AnGap-12
[**2172-10-29**] 05:15AM BLOOD Glucose-97 UreaN-13 Creat-0.9 Na-141
K-3.6 Cl-106 HCO3-29 AnGap-10
[**2172-10-21**] 05:55AM BLOOD Calcium-9.2 Phos-4.2 Mg-2.2 Cholest-152
[**2172-10-26**] 06:25AM BLOOD Calcium-9.4 Phos-4.2 Mg-2.3
[**2172-10-21**] 05:55AM BLOOD Triglyc-215* HDL-36 CHOL/HD-4.2
LDLcalc-73
Brief Hospital Course:
Mrs. [**Known lastname 4223**] was admitted under cardiology. The following day
she underwent cardiac catheterization which revealed severe
single vessel coronary artery disease. Given the complex
in-stent restenosis involving the left anterior descending
artery and diagonal branch, cardiac surgery was consulted for
revascularization surgery. She remained stable on medical
therapy. Plavix was stopped and she was maintained on a heparin
drip given history of bare metal stent in [**2172-4-9**]. Workup was
essentially unremarkable and she was eventually cleared for
surgery.
On [**10-26**], Dr. [**Last Name (STitle) **] performed coronary artery bypass
grafting surgery. For surgical details, please see separate
dictated operative note. Following the operation, she was
brought to the CVICU for invasive monitoring. Within 24 hours,
she awoke neurologically intact and was extubated without
incident. Her postop hematocrit was noted to be 21% for which
she received two units of packed red blood cells. Her CVICU
course was otherwise uneventful and she transferred to the SDU
on postoperative day two. Chest tubes and epicardial pacing
wires were removed per protocol. She continued to recover
without any post-op complication and worked with physical
therapy for strength and mobility. On post-op day four she was
discharged home with VNA services and the appropriate follow-up
appointments.
Medications on Admission:
Transfer meds: Aspirin 81 qd, Plavix 75 qd, Lipitor 20 qd,
Lopressor 25 tid, Protonix 40 qd, Advair, Ativan prn
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
2. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*1*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*1*
4. Meclizine 12.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*1*
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours) for
1 months.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
7. 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*
8. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
9. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
tba
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass x 2
Postop Anemia
PMH: s/p Bare metal stent to Diagonal [**4-16**], Hypertension,
Dyslipidemia, Thoracic outlet syndrome s/p bilateral removal of
1st rib, s/p Hysterectomy and bladder resuspension, s/p left
knee surgery, s/p Tonsillectomy, s/p TMJ surgery, s/p
Appendectomy
Discharge Condition:
Good
Discharge Instructions:
Please shower daily , no baths or swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 100.5
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 one month and off [**Doctor Last Name **] narcotics
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 [**3-14**] weeks, call for appt
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8098**] in [**1-12**] weeks, call for appt
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2093**] in [**12-12**] weeks, call for appt
Please follow-up with neurologist regarding vertigo
Completed by:[**2172-10-30**]
|
[
"411.1",
"285.9",
"V70.7",
"V45.82",
"414.01",
"401.9",
"996.72",
"272.4",
"E878.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"36.15",
"37.22",
"39.61",
"36.11",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
7808, 7842
|
5151, 6550
|
294, 502
|
8210, 8216
|
2336, 5128
|
8731, 9098
|
1391, 1449
|
6712, 7785
|
7863, 8189
|
6576, 6689
|
8240, 8708
|
1464, 1464
|
1486, 2317
|
244, 256
|
530, 965
|
987, 1263
|
1279, 1375
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,608
| 140,695
|
1730
|
Discharge summary
|
report
|
Admission Date: [**2181-11-9**] Discharge Date: [**2181-11-16**]
Service: MEDICINE
Allergies:
Penicillins / Aspirin
Attending:[**First Name3 (LF) 9871**]
Chief Complaint:
Status post fall.
Major Surgical or Invasive Procedure:
IVC filter placement
DC cardioversion
History of Present Illness:
83 year-old female with history of breast cancer,
bronchoalveolar lung cancer with known brain metastesis. She
presents from home after an unwitnessed fall. The patient was
taking a nap sitting up in a chair at home leaning forward on
her table. She fell off of her chair towards the right. Her
husband immediately helped her off of the floor and called EMS.
At that time, she does not report any loss of consciousness.
She may have hit her head against the wall. She did not complain
of any chest pain, shortness of breath, palpitations, or
abdominal pain. Her family did not notice any seizure activity.
She denies any recent fevers, chills, nausea, vomiting. Her
appetite has been very poor and she weighs 102 lbs down from her
baseline of 118lbs. She has functionally declined over the past
month where she is dependent on her family for help transferring
to her wheelchair. She is on a decadron taper for her brain
metastases, and has had severe muscle atrophy. She does not c/o
of any changes in her bowel movements or urination. She does
have a feeling of a "tickle" in her throat with a cough, but no
hemoptysis.
Past Medical History:
Past oncology history: Right and left breast cancer status post
recent left lumpectomy for infiltrating breast cancer. Her
cancer was estrogen receptor postive. She is also status post
right lumpectomy and radiation 10 years ago. She had left
bronchoalveolar carcinoma status post resection in [**9-20**]. She
was treated with Iressa. She also had a right lung nodule of
unknown origin on needle biopsy. She has known brain metastesis
and is status post cyber knife therapy one month ago.
.
Past medical history:
1. Hypertension.
2. History of palpitations. She had SVT in the past that was
treated "with a medication that made her heart stop."
Social History:
She is married and lives with her husband. She has 2 children
and her daughter is alive. She smoked for 15 years one pack per
day. She has occasional alcohol use.
Family History:
Her father died of lung cancer in his 80s, her mother died of
stomach cancer in her 50s, and she had several siblings who have
died.
Physical Exam:
Vitals: Temperature:98.9 Pulse:94 Blood Pressure:92/70
Respiratory rate:18 Oxygen saturation:91% on room air and 94%
on 3L nasal cannula.
General: Well appearing lady in no acute distress, alert and
oriented.
HEENT: Her pupils are equal and reactive, extraoccular movements
are intact, moist mucous membranes.
Cardiac: Regular rate and rhythm without murmurs, rubs, or
gallops.
Lungs: Bibasilar crackles, otherwise clear to auscultation
bilaterally.
Abdomen: Normoactive bowel sounds, soft, nontender,
nondistended.
Extremities: Warm and well perfused, no edema, negative [**Last Name (un) **]
signs
Neuro: 4/5 strength in lower extremeties throughout, [**5-24**]
strength in upper extremeties throughout, normal sensation, CN
II-XII grossly intact.
Pertinent Results:
8.5>36<82
N:73 Band:11 L:4 M:8 E:0 Bas:0 Metas:1
.
[**Age over 90 **]|105|27/120
3.9|25|0.5\
Ca:9.0 Mg:2.1 P:2.6
.
PT:13.0 PTT:21.0 INR:1.1
Fibrinogen:444
.
ALT:39 AST:28 AP:65 Tbili:1.6
[**Doctor First Name **]:41 Lip:28
.
CK:40 MB:notdone TropT:0.02
.
Lactate:2.2
.
UA:Trace blood, positive nitrates, trace protein, 50 ketones,
0-2 RBC, [**3-24**] WBC, many bacteria, 0-2 epis.
.
EKG: 77 bpm, NSR, nl axis, nl intervals, new TWI V1 and biphasic
V2, no Q waves, No ST elevations or depressions
.
CTA Chest: multiple bilateral pulmonary emboli, right main
pulmonary artery and left main pulmonary artery extending into
lower pulmonary arteries bilaterally, patchy upper lobe air
space opacities, lung nodules
.
CT Head : 1. No acute intracranial hemorrhage.
2. Stable CT appearance of three calcified metastatic lesions
within the right frontal and parietal lobes and left frontal
lobe. No definite evidence of new metastatic foci identified. MR
of the brain is more sensitive test for evaluation for
metastatic disease.
.
CXR: 1. No evidence of pleural effusion, pneumothorax, or
pneumonia.
2. Patchy opacity at the left costophrenic angle on the frontal
view only, a finding of uncertain significance 3. Postoperative
changes within the right hemithorax and faint visualization
Brief Hospital Course:
83 year old female with breast and lung cancer admitted status
post unwitnessed fall who was found to have bilateral pulmonary
emboli.
.
1. Bilateral Pulmonary Emboli: When she was in the emergency
room, she was hypoxic and required supplemental oxygen. Given
her history of malignancy, a CT scan was done which showed
bilateral Pulmonary Emboli. Initially, she was not started on
heparin for anticoagulation given that she had known brain
metastasis. However, on hospital day 3, she developed a
supraventricular tachycardia (see below) to the 170s. It was
felt that the SVT may be secondary to right heart strain.
Therefore, she was started on heparin as a bridge to Coumadin.
She was started on 5mg of Coumadin daily. Since she became
therapeutic after 2 doses, her coumadin dose was decreased to
2.5mg daily. On discharge, her INR was 2.7.
.
2. Deep venous thrombosis: She was found to have a partially
occlusive thrombus in her left popliteal vein. Since she was
initially not anticoagulated, an IVC filter was placed to
decreased her risk of future pulmonary emboli.
.
3. Supraventricular tachycardia: On hospital day 3, she
developed SVT with a rate in the 170s. Carotid massage
converted her to normal sinus rhythm transiently for about 15
minutes. Given her low blood pressure 70s systolic and
increased oxygen requirement, she was transferred to the
intensive care unit for DC cardioversion. She received fentanyl
and midazolam for sedation. She received a total of one shock
at 100J with immediate conversion to sinus rhythm. An EKG post
cardioversion did not show any ischemic changes. She was loaded
with 150 mg IV amiodarone and maintained on a infusion of 0.5
mg/min for 24 hours. She was then transitioned to a oral
amiodarone load of 400 mg twice a day. Within 48 hours of
cardioversion, she went into SVT again, but she was converted to
sinus rhythm with carotid massage. She remained in normal sinus
rhythm for the remainder of her hospital stay. After 7 days of
the oral amiodarone load at 400 mg [**Hospital1 **], she should be tapered to
200 [**Hospital1 **] for 2 weeks and then maintained at 200 mg daily. Her
atenolol, which was started for SVT, was held since she was
started on amiodarone.
.
4. Brain metastasis: Her Decadron was maintained at 2 mg orally
twice a day given.
.
5. Hypertension: Her blood pressure remained low between 90-110s
systolic during her hospital stay. Her atenolol was held given
that she was not hypertensive.
.
6. Urinary tract infection: She was found to have a
pan-sensitive e.coli in her urine. She completed a 3-day course
of levofloxacin.
.
7. She was maintained on a regular diet. Initially, she had a
decreased appetite. She was given maintenance IV fluids while
she had a low oral intake. Her electrolytes were repleted.
.
8. Access: She had peripheral IVs.
.
9. Prophylaxis: She had heparin and Coumadin, a PPI, and a bowel
regimen.
.
10. Code: Initially, she was full code. However, she expressed
her desire to be made comfortable. After discussion with her
family and herself, she was made DNR/DNI.
.
11. Dispo: She was discharged to rehab once she was therapeutic
on her Coumadin.
Medications on Admission:
Decadron 2 mg twice daily
Zantac
Atenolol daily
Fosamax qTuesday
Ambien prn
Tylenol prn
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QTUES (every
Tuesday).
4. Dexamethasone 4 mg Tablet Sig: 0.5 Tablet PO Q12H (every 12
hours).
5. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
6. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 2 days. Tablet(s)
7. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO twice a day
for 2 weeks: Please start on [**11-18**] after 2 days of 400 mg [**Hospital1 **].
8. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day:
Please start on [**12-3**] after 2 weeks of 200 mg [**Hospital1 **].
9. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed.
10. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] Senior Healthcare of [**Location (un) 1439**]
Discharge Diagnosis:
Bilateral pulmonary emboli.
Deep venous thrombosis.
Supraventricular tachycardia.
Lung cancer with brain metastesis.
Breast cancer.
Discharge Condition:
Stable. Her oxygen requirement is now 2L by nasal cannula. She
is in normal sinus rhythm.
Discharge Instructions:
Continue taking all medications as prescribed. You are now on a
blood thinning medication for the clots in your lung. You are
also on a medication for the fast heart rhythm that you had.
You will need to follow up with Dr. [**Last Name (STitle) 9872**] in 1 week after
discharge from the rehab to have your INR (the measure of how
thin your blood is) checked and to be evaluated.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) 9872**] in 1 week after discharge from
rehab. Provider: [**Name10 (NameIs) **],[**First Name3 (LF) 870**] J. [**Telephone/Fax (1) 9873**]
Completed by:[**2181-11-16**]
|
[
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"287.5",
"401.9",
"427.89",
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] |
icd9cm
|
[
[
[]
]
] |
[
"38.7",
"99.62"
] |
icd9pcs
|
[
[
[]
]
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8817, 8909
|
4545, 7720
|
248, 287
|
9085, 9179
|
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|
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|
7859, 8794
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|
191, 210
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315, 1442
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|
2135, 2302
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,309
| 115,111
|
21314
|
Discharge summary
|
report
|
Admission Date: [**2133-5-27**] Discharge Date: [**2133-6-15**]
Date of Birth: [**2070-2-22**] Sex: M
Service: SURGERY
Allergies:
Tetracycline / Dicloxacillin
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
HBV cirrhosis/hepatomas
Major Surgical or Invasive Procedure:
[**2133-5-30**] liver [**Month/Day/Year **]
History of Present Illness:
63 M with HIV, chronic Hep B, cirrhosis on [**Month/Day/Year **] list
recently treated for SBP. On coumadin for PV thrombosis and PE
-PV thrombosis not seen on recent U/S. Listed for [**Month/Day/Year **]
this admission, listed yesterday, accepted today.
Past Medical History:
Chronic cirrhosis from hepatitis B infection with likely HCC
HIV diagnosed in [**2111**] with undetectable viral load ([**2133-2-7**] CD4
101,HIV VL <48 copies/ml)
Hepatitis B diagnosed in [**2093**] with undetectable viral load
([**2133-2-7**] HBVL <40)
Herpes simplex
HPV
Peripheral neuropathy (feet) secondary to Stavudine
Nephrolithiasis
Left sided kidney stones surgical removal in the early [**2103**]'s
and had lithotrypsy 3 times in the [**2103**]'s.
Pancytopenia
Depression
Benign prostatic hypertrophy
Basal cell carcinoma with Moh??????s surgery
Gonorrhea
Hypogonadism
[**2133-5-30**] Liver [**Month/Day/Year 1326**]
Social History:
Patient is retired restaurant/bar manager (on disability since
[**2126**] due to neuropathy). Homosexual male. He is the primary
caregiver for his mother who has dementia. Patient is not
married. Never smoked and no current alcohol. No illicit drug
use.
Family History:
Mother with [**Name2 (NI) 499**] cancer. Father had brain tumor.
Physical Exam:
98.8 57 130/60 20 98% RA
AAOx3 NAD + icterus or jaundice
no signs of skin infections
RRR
CTAB
soft, moderate distension, tympanitic, non-tender, no obvious
scars, no hernias,
no edema, extrem warm
rectal deferred
Labs:
135 108 40 89 AGap=13
4.5 19 1.6
Ca: 9.7 Mg: 2.0 P: 2.0
ALT: 39 AP: 58 Tbili: 5.8 Alb:
AST: 47 LDH: Dbili: TProt:
[**Doctor First Name **]: Lip:
Other Blood Chemistry:
AFP: Pnd
1.6>24.1<52
PT: 23.8 PTT: 33.8 INR: 2.3
Rads:
[**5-27**] Liver U/S: 1. Cirrhotic liver with grossly normal portal
hepatic venous as well as
hepatic arterial vasculature and no evidence of portal venous
thrombus.
2. Splenomegaly.
[**5-27**] CXR - neg
[**2133-5-2**] CT
1. Nonocclusive right lower lobe pulmonary embolism in the
distal
and
subsegmental branches. This study was not optimized for
evaluation of
pulmonary embolism, however there is no apparent thrombus in the
main
pulmonary arteries.
2. Nonocclusive thrombus in the main portal vein which is new.
Clot
previously described in the splenic vein is less apparent on
today's study.
The hepatic arterial vasculature remains patent.
3. Large volume ascites in the abdomen and pelvis, which appears
to have
increased since the prior examination. Splenomegaly with splenic
varices from
portal hypertension.
4. Hypodense lesions in the liver corresponding to site of prior
RF ablation.
5. Multiple hyperenhancing foci subcentimeter in size throughout
the liver
which appear stable concerning for hepatocellular carcinoma in
this cirrhotic
liver. No clear new areas of disease.
6. Nonobstructive 9 mm left lower pole renal calculi.
7. Stable pancreatic cysts.
8. Possible bladder stone, recommend correlation with patient's
symptoms.
Pertinent Results:
[**2133-6-15**] 05:30AM BLOOD WBC-5.2 RBC-3.32* Hgb-10.1* Hct-30.8*
MCV-93 MCH-30.6 MCHC-32.9 RDW-17.7* Plt Ct-122*
[**2133-6-15**] 05:30AM BLOOD PT-14.7* PTT-21.9* INR(PT)-1.3*
[**2133-6-14**] 06:10AM BLOOD PT-13.0 INR(PT)-1.1
[**2133-6-15**] 05:30AM BLOOD Glucose-210* UreaN-43* Creat-1.3* Na-134
K-4.5 Cl-103 HCO3-23 AnGap-13
[**2133-6-15**] 05:30AM BLOOD ALT-102* AST-46* AlkPhos-166*
TotBili-2.6*
[**2133-6-15**] 05:30AM BLOOD Albumin-3.1* Calcium-7.6* Phos-3.1 Mg-2.3
[**2133-6-15**] 05:30AM BLOOD tacroFK-8.8
Brief Hospital Course:
On [**2133-5-30**], he underwent piggyback orthotopic liver [**Date Range **]
for end-stage liver disease secondary to hepatitis B. He also
has HIV. Surgeon was Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**]. Please refer to operative
note for details. He received induction immunosuppression
(solumedrol,simulect,and cellcept) as well as HBIG 10,000 units
during the anhepatic phase of surgery to protect against HBV
recurrence. Of note, there was a significant size mismatch, with
the recipient artery being much smaller than the donor artery.
There was a good anastomosis with good thrill present. The liver
was quite large for the patients size. Closure was successfully
obtained and two drains were placed. He was transferred to the
SICU intubated immediately postop for management where he
received blood products to maintain hemostasis.
LFTs trended up initially then started to trend down. An u/s of
the liver was obtained on postop day 1 revealing patency and
normal flow in all vessels. There was mildly increased liver
echogenicity, with no intra- or extra-hepatic biliary duct
dilatation. No focal liver lesions were identified.
He was extubated. LFTS continued to slowly trend down. HBIG
(10,000units each dose)was given daily for 7 days with HBsAb
levels greater than 450 and negative HBsAg. Diet was started and
advanced. PO meds were started with ARVs resumed on [**6-3**]. Prograf
was started on [**5-30**]. He received intermittent doses based on
trough levels that varied between 5.5 and 16.7 due to the
interaction between ARVs. Prograf 1mg was given on [**6-1**],
[**6-2**]. Prograf 0.5mg was given on [**7-9**] and [**6-9**]. Based on
trough levels and doses given the plan was to give 0.5mg every
Monday pm with trough levels every Monday, Thursday and Friday.
Given preop condition of malnutrition and insufficient dietary
intake postop to meet his caloric needs, a postopyloric feeding
tube was placed. He was started on Nutren 2.0. This was changed
to Fibersource due to diarrhea, but he continued to have
diarrhea. Stools were negative for c.diff. Fibersource was
switched to Peptamen 1.5 at 40cc/hr continuous with improved
tolerance. Imodium was started on [**6-10**] and given x3. Stooling
decreased to once a day, but he then developed hyperkalemial.
He experienced hyperkalemia on [**6-10**] with potassium of 5.9.
Kayexalate 30grams was administered with potassium decreasing to
4.9 and diet was changed to low potassium. On [**6-13**], he again
required treatment for hyperkalemia. This was treated with
decreased repeat potassium. Lasix 10mg daily was started for the
hyperkalemia. The tube feeding was switched back to a renal
formulation, but loose stools continued, therefore, Novasource
Renal was diluted on [**6-15**] to 3/4 strength with goal of
55cc/hour.
Physical therapy worked with him extensively recommending rehab.
He was screened and accepted at [**Hospital1 **]. Of note, PT noted left
foot drop, a problem that he had experienced preop as a result
of prior ARVs. He wore a multipodis splint and an AFO was
ordered. On [**6-13**], it was noted that he had some asymmetrical
leg/foot swelling. LENIS were done showing bilateral DVTs.
There was extensive occlusive thrombus within the left
mid-to-distal superficial femoral vein extending to the left
calf veins. In addition, there was occlusive thrombus within the
right popliteal vein extending to the calf veins. There was
normal color flow within the more proximal bilateral common
femoral veins and superficial femoral veins. There was some
swelling of the dorsum of the left foot. An xray demonstrated a
substantial soft tissue prominence about the dorsum of the foot.
No evidence of acute bone or joint space abnormality was noted.
Of incidental note there was a small posterior calcaneal spur.
He was started on coumadin 3mg daily on [**6-13**] for the bilateral
DVTs and h/o segmental PE known preop. INR was 1.3 on [**6-15**].
Daily INRs were to be drawn at [**Hospital1 **] until INR stable between
2-2.5.
He developed a small stage 2 decubitus on his sacrum (1cmx0.5cm
x 3mm). Critic Aide barrier cream was applied and he was
encouraged to turn frequently.
Medications on Admission:
1. Dapsone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Emtricitabine-Tenofovir 200-300 mg Tablet Sig: One (1) Tablet
PO DAILY (Daily).
3. Acyclovir 400 mg Tablet Sig: One (1) Tablet PO twice a day.
4. Darunavir 400 mg Tablet Sig: One (1) Tablet PO twice a day.
5. Entecavir 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Escitalopram 20 mg Tablet Sig: One (1) Tablet PO once a day.
7. Folic Acid 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. Megestrol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Pregabalin 50 mg Capsule Sig: One (1) Capsule PO three times
a day.
10. Raltegravir 400 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
11. Ritonavir 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
12. Spironolactone 50 mg Tablet Sig: One (1) Tablet PO once a
day.
13. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
14. Terazosin 5 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
15. Temazepam 15 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime) as needed for insomnia.
16. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
17. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at
4 PM.
Disp:*90 Tablet(s)* Refills:*2*
19. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO once a
day: Please start [**2133-5-14**].
Disp:*30 Tablet(s)* Refills:*2*
20. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO twice a
day for 8 days: To complete [**2133-5-13**].
Disp:*16 Tablet(s)* Refills:*0*
21. Outpatient Lab Work
Please have INR checked twice weekly unless otherwise specified
by your primary care doctor.
Discharge Medications:
1. Prednisone 5 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily):
follow taper per [**Month/Day/Year **] protocol
.
2. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day) as needed for
hypocalcemia.
5. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
7. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. Ritonavir 100 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
9. Emtricitabine-Tenofovir 200-300 mg Tablet Sig: One (1) Tablet
PO Q48H (every 48 hours): last [**6-10**].
10. Raltegravir 400 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
11. Darunavir 600 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
12. Loperamide 2 mg Capsule Sig: One (1) Capsule PO TID (3 times
a day) as needed for diarrhea.
13. Insulin Glargine 100 unit/mL Solution Sig: Forty (40) units
Subcutaneous at bedtime.
14. Insulin Lispro 100 unit/mL Solution Sig: follow sliding
scale Subcutaneous four times a day: see printed scale.
15. HBIG Sig: 10,000 units once a month: 1 month from liver
[**Month/Year (2) **] ([**5-30**])-due [**6-29**]
GIVE IV form.
16. Outpatient Lab Work
Every Monday, Thursday and Friday trough prograf levels
Call Result to [**Hospital1 18**] [**Hospital1 1326**] Center [**Telephone/Fax (1) 673**]
17. Outpatient Lab Work
Labs every Monday and Thursday;
cbc, chem 10, ast, alt, alk phos, t.bili, albumin
Call results to [**Hospital1 18**] [**Hospital1 1326**] Center
18. Outpatient Lab Work
Labs:
Monthly: HBsAntibody titer and Hepatitis Surface Antigen prior
to monthly infusion of Hepatitis B Immune globulin (HBIG)
19. Left AFO
for left foot drop
20. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
21. Tacrolimus 0.5 mg Capsule Sig: 0.5 Capsule PO once a week:
Give every Monday 6pm.
Trough level every Monday, Thursday and Saturday am
[**Hospital1 1326**] Center to adjust dose ONLY
Tacrolimus interacts with Ritonivar and Darunavir therefore only
need once a week dose
.
22. Outpatient Lab Work
Daily INR
Call results to [**Hospital1 18**] [**Telephone/Fax (1) 673**]
23. Outpatient Lab Work
Every Monday and Thursday
CBC ,chem 10, ast, alt, alk phos, t.bili and albumin
Fax results to [**Hospital1 18**] [**Hospital1 1326**] Office
[**Telephone/Fax (1) 697**]
24. Furosemide 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily):
for hyperkalemia.
25. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
HIV
HBV
malnutrition
depression
peripheral neuropathy
Hyperglycemia related to steroids
Discharge Condition:
stable
Discharge Instructions:
Please call the [**Hospital1 1326**] Office [**Telephone/Fax (1) 673**] if fever, chills,
nausea, vomiting, increased abdominal pain/distension, increased
JP drainage or if drain output stops, incision
redness/bleeding/drainage or jaundice.
Daily prograf levels
Labs every Monday and Thursday
Record JP output and send record of drain outputs to next
appointment at [**Hospital 1326**] Clinic
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2133-6-18**]
8:30
Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2133-6-25**]
9:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2133-7-2**] 2:20
Completed by:[**2133-6-15**]
|
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|
1315, 1572
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,036
| 146,697
|
52974
|
Discharge summary
|
report
|
Admission Date: [**2142-11-5**] Discharge Date: [**2142-11-8**]
Date of Birth: [**2087-5-18**] Sex: F
Service: MEDICINE
Allergies:
Neurontin / Sudafed / Benadryl Decongestant / Seroquel /
Nicotine Transdermal / Haldol / Geodon / Zyprexa
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Hallucinations, tremulousness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
55 y/o w/ PTSD, anxiety and ETOH abuse presents with report of
unwitnessed seizure following ETOH use. She originally presented
to [**Hospital 8**] hospital earlier today and was discharged shortly
after. She then went back to her group home where she endorsed
auditory hallucinations. She stated voices were telling her to
commit suicide. She then was transported to [**Hospital1 18**] ED. Of note,
she has a remote history of DTs in the setting of ETOH
withdrawl.
.
In the ED, initial vitals were 98.2 138 151/107 20 98% RA. She
triggered on arrival for HR 140 bpm. Serum ETOH 295, otherwise
tox screen negative. CXR showed no acute cardiopulmonary
process. ECG showed sinus tachycardia. CBC and chem 7 within
normal limits.
ETOH level was elevated. She was given 3L NS, but despite this
was still tachycardic 100-130s and endorsed sensation of her
skin crawling. She received 2mg ativan x2, followed by 10mg
diazepam x2. She also received PO thiamine, folate and MVI.
There was no observed seizures in the ED. Vitals prior to
transfer were 107 14 97% on RA, 133/86. No evidence of seizure
activity in the ED.
.
On arrival to the MICU, she complained of feeling anxious,
tremulous, and diaphoretic. Feels like bugs are crawling on her
skin. Denies hallucinations (although had auditory
hallucinations earlier today). Also has mild sternal "squeezing"
sensation, no radiation, no associated SOB, no known
exacerbating factors, happens at rest and with exertion, started
several weeks ago. Cannot recall this mornings events, but seems
to think she had a seizure. States she has a remote history of
seizures, details unknown. Last drink was approximately 24H
prior to admission. Normally drinks 2-3 pints of vodka daily.
Past Medical History:
- anxiety/post-traumatic stress disorder
- HTN
- leukemia as a child (per patient)
- Chronic hepatitis C - confirmed on serology [**Month (only) **]/[**2136**]
- H/o atypical chest pain
- H/o cocaine use - has not used in several years
- H/o EtOH use
- personality disorder
- [**Hospital1 18**] hospitalization [**2141-8-18**], [**7-20**], [**8-18**]
x2,12/08,7/08,121/04,3/00,1/99,1/98,[**4-/2127**]
x2,[**7-/2126**] all for ETOH and risk for self harm
- eczema
Social History:
[**3-15**] pints of Vodka daily. Smoker. Last used cocaine several
years ago, denies other illicits. Currently residing in
shelters in [**Hospital1 8**]. Has a brother nearby and a women's
sponsor for support systems.
Family History:
Her father passed away from MI at age 64. Mother and sister with
depression.
Physical Exam:
ON ADMISSION
------------
General: Alert, oriented, anxious, at times tearful, tremulous
HEENT: Sclera anicteric, dry mucus membranes, oropharynx clear
Neck: supple, JVP flat, no LAD
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Lungs: CTAB, no wheezes, rales, rhonchi
Abdomen: NABS, NT/ND, no HSM GU:
Ext: warm, well perfused, 2+ pulses, no edema
Neuro: PERRL, EOMI, CN2-12 intact, 5/5 strength throughout, no
focal sensory deficits
.
Labs: 141 105 6 97 CBC 5.7, 36, 183
3.5 26 0.6 ETOH: 295
.
Images: CXR: no acute cardiopulmonary process
.
EKG: sinus tachycardia
Pertinent Results:
ADMISSION LABS:
[**2142-11-5**] 03:20PM BLOOD WBC-5.7 RBC-3.75* Hgb-12.5 Hct-36.0
MCV-96 MCH-33.4* MCHC-34.9 RDW-13.0 Plt Ct-183
[**2142-11-5**] 03:20PM BLOOD Neuts-58.0 Lymphs-35.0 Monos-3.9 Eos-2.8
Baso-0.2
[**2142-11-5**] 03:20PM BLOOD Glucose-97 UreaN-6 Creat-0.6 Na-141
K-6.1* Cl-105 HCO3-26 AnGap-16
[**2142-11-5**] 03:20PM BLOOD ALT-219* AST-174* LD(LDH)-737* AlkPhos-64
Amylase-43 TotBili-0.3
[**2142-11-5**] 03:20PM BLOOD Lipase-30
[**2142-11-5**] 03:20PM BLOOD Albumin-4.5 Calcium-9.2 Phos-5.1* Mg-1.9
[**2142-11-5**] 03:20PM BLOOD ASA-NEG Ethanol-295* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
.
DISCHARGE LABS:
[**2142-11-8**] 06:10AM BLOOD WBC-4.1 RBC-3.65* Hgb-12.3 Hct-35.4*
MCV-97 MCH-33.6* MCHC-34.8 RDW-13.5 Plt Ct-153
[**2142-11-8**] 06:10AM BLOOD Glucose-91 UreaN-19 Creat-0.8 Na-139
K-4.3 Cl-102 HCO3-26 AnGap-15
[**2142-11-8**] 06:10AM BLOOD ALT-142* AST-76* LD(LDH)-200 AlkPhos-65
TotBili-0.2
[**2142-11-8**] 06:10AM BLOOD HCV Ab-PND
[**2142-11-8**] 06:10AM BLOOD HBsAg-PND HBsAb-PND
.
CXR [**11-5**]:
1. No acute chest pathology.
2. New ovoid lucent lesion within the posterior 5th rib, further
evaluation is recommended with dedicated chest radiograph with
oblique views if necessary.
Repeat CXR [**11-5**]: In comparison with the earlier study of this
date, there is no evidence of acute cardiopulmonary disease. The
suspected lucency within the posterior fifth left rib is no
longer present and most likely represented superimposed
structure.
Brief Hospital Course:
55 y/o w/ PTSD, anxiety and ETOH abuse presents with tachycardia
and hypertension in the setting of likely ETOH withdrawl.
.
ACTIVE ISSUES
-------------
# Alcohol withdrawl: Pt received a total of 80mg diazepam in the
ICU (20mg IV, 40mg PO), with [**Month/Year (2) 60563**] scores mostly acounted for by
subjective complaints, minimally tremulousness, and had no
hemodynamic instability while in the ICU. She did not have any
evidence of seizure activity. She was eventually spaced to q3
[**Month/Year (2) 60563**] scores, and then was called out to the floor. The pt was
started on a multivitamin regimin with folate and thiamine. Her
[**Month/Year (2) 60563**] regimen was spanned out, and eventually patient was placed
on Librium 50 mg TID per psychiatry recommendation. Her
symptoms of withdrawal abated by the time of discharge.
.
# Scabies infection: patient was treated adequately with
Permetherin one week prior to admission for scabies. She began
feeling pruritic and had lesions that looked active on her skin
during her admission. Dermatology was consulted and recommended
retreatment with Permetherin, as well as one dose of ivermectin.
She was off contact precautions at the time of discharge, and
is considered to be treated and non-infectious. Patient should
be retreated once more with Permetherin from neck to toes on
[**11-15**], one week after the last treatment.
.
# Psychiatric concerns: Psychiatry was consulted to evaluate for
dual diagnosis including PTSD, anxiety, possible personality
disorder with her poly substance abuse. The psychiatry team
ultimately recommended Section 12, eventually removed, and that
patient might benefit from an inpatient psychiatric admission
once medically stable. The patient was amenable to the
suggestion. She is being discharged to [**Hospital1 **] 4 at [**Hospital1 18**] on
her own [**Location (un) **].
.
# Transaminitis: patient was noted to have LFT abnormalities
during admission. Hepatitis B and C testing was ordered and
should be followed up. Possible component of alcoholic
hepatitis. Acetaminophen level was normal.
.
# Tachycardia: Patient initially presented with tachycardia,
likely secondary to ETOH withdrawl. The pt's vital signs
stabilized with diazepam therapy.
.
INACTIVE ISSUES
---------------
# Chronic hepatitis C virus: Uncertain of current severity of
disease. Does not have stigmata of cirrhosis. LFTs elevated
compared to baseline, though in setting of alcohol use.
.
TRANSITION OF CARE
------------------
# Follow-up: patient will be discharged to inpatient Psychiatry
voluntarily. She has pending hepatitis B and C testing at the
time of discharge. She should be arranged for PCP [**Name9 (PRE) 702**] at
the time of discharge.
.
# Code status: confirmed full code
Medications on Admission:
None
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary diagnosis:
Alcohol withdrawal
Scabies infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 109075**],
It was a pleasure taking care of you at [**Hospital1 18**]. You came for
further evaluation of tremors. Further testing showed that you
were withdrawing from alcohol. You got better with treatment.
You are now being sent for inpatient psychiatry treatment. It
is important that you continue to take your medications.
The following changes have been made to your medications:
We ADDED hydrocortisone cream for your itchiness.
We ADDED folate, thiamine and a multivitamin for nutrition.
We ADDED permetherin for one additional treatment on [**11-15**] for
your scabies infection.
Followup Instructions:
None scheduled
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
|
[
"780.39",
"401.9",
"785.0",
"070.54",
"287.5",
"291.81",
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"303.01",
"300.00",
"780.97"
] |
icd9cm
|
[
[
[]
]
] |
[
"94.62"
] |
icd9pcs
|
[
[
[]
]
] |
7955, 7970
|
5125, 7900
|
395, 401
|
8071, 8071
|
3623, 3623
|
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|
2914, 2993
|
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|
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|
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|
4252, 5102
|
3008, 3604
|
326, 357
|
429, 2171
|
3639, 4236
|
8011, 8050
|
8086, 8198
|
2193, 2658
|
2674, 2898
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,078
| 168,187
|
50559
|
Discharge summary
|
report
|
Admission Date: [**2191-8-5**] Discharge Date: [**2191-8-18**]
Date of Birth: [**2127-5-5**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Codeine / Dilaudid / Keflex / citalopram /
Erythromycin Base
Attending:[**First Name3 (LF) 594**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Intubation
Extubation
History of Present Illness:
64F with past medical history of nodular regenerative
hyperplasia resulting in non-cirrhotic portal hypertension
complicated by ascites/volume overload in addition to grade II
esophageal varices, depressed EF (50-55%), ITP,
hypogammaglobulinemia on monthly IVIG, Colon cancer s/p
resection [**4-/2190**] and 6 cycles of FOLFOX, hypertension, DM1 with
retinopathy, recurrent bronchitis with bronchiectasis,
splenectomy [**5-17**] complicated by shock liver and acute renal
failure that developed shortness of breath and cough several
days ago.
She was seen at [**Location (un) 2274**] on [**8-1**] with low grade fevers and
complained of shortness of breath. A CXR showed ? CHF. Her home
lasix dosage was increased (lasix 40 mg PO BID to TID) with
addition of metazoline but today she had increased productive
cough with shortness of breath and labored brathing. She was
advised to go to ER. Patient feels that her legs are more
swollen than usual.
In the ED, initial VS were: Triage 10:53 0 68 30 58% ra
Patient was triggered on arrival for O2 sats in 50-70s at
triage.
Patient had hypertension to 180s and was given nitroglycerin and
started on nitroglycerin infusion in addition to biPAP. Foley
was placed with 150 cc urine output.
Patient received nitroglycerin 0.14 mcg/kg/min infusion in
addition to furosemide 80 mg IV, vancomycin 1000 mg IV, and
cefepime 2 gm IV.
On arrival to the MICU, the patient was taken off biPAP. Patient
was in mild-moderate respiratory distress but able to say [**4-12**]
word sentences although pOX 84-90 on face tent on 15L.
Past Medical History:
PMH:
- ITP ([**2176**], requiring IVIG and steroids)
- Hypogammaglobulinemia - managed with monthly IVIG
- Pancytopenia of unclear etiology (with bone marrow biopsies
reporting hypercellular marrow)
- Splenomegaly of unclear etiology
- Colonic mucinous adenoCA, s/p right hemicolectomy ([**4-/2190**]) and
chemotherapy (FOLFOX x6 cycles, last dose [**1-/2191**])
- Hyperbilirubinemia initially suspected secondary to hemolytic
anemia, however, etiology less clear currently
- Recurrent bronchitis with bronchiectasis
- Hypertension; Hypercholesterolemia
- Type 1 DM c/b retinopathy
- Hx parapsoriasis
- Hx of pericardial effusion
- Hx left transudative pleural effusion s/p thoracentesis
([**2191-4-2**], path: mesothelial cells, macrophages, and lymphocytes)
PSH:
- Right hemicolectomy for colon cancer ([**4-/2190**])
- Right chest port-a-cath placement ([**5-/2190**])
- Colonoscopy ([**2191-3-9**])
- Left thoracentesis ([**2191-4-2**])
Social History:
Lives with husband in [**Name (NI) 5110**], no smoking, EtOh, IVDU, Husband
[**Name (NI) **] is HCP
Family History:
Mother - thyroid dz - still living, father - prostate cancer and
"lung dz"
Physical Exam:
Admission Physical Exam:
Last weight on [**2191-7-4**]: 162 lb (73.483 kg) Admit weight 80.5 kg
General: Alert, oriented, mild respiratory distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP difficult to assess
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: crackles up 1/3 of lung base
GU: foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis.
Pedal edema
Neuro: CNII-XII intact, motor exam grossly intact
Discharge Physical Exam:
Gen: A&Ox3. Answering questions appropriately. NAD.
HEENT: sclerae anicteric, MMM, OP clear, EOMI, PERRL, NG tube in
place
Neck: supple, no JVD
Lungs: CTAB
Heart: RRR, no m/r/g
GU: Foley in place
Abd: soft, NT/ND, +BS, no hepatomegaly
Ext: moderate edema in
Pertinent Results:
[**2191-8-5**] 11:15AM WBC-16.4* RBC-3.93*# HGB-12.6# HCT-38.4#
MCV-98 MCH-32.0 MCHC-32.8 RDW-14.5
[**2191-8-5**] 11:15AM NEUTS-88* BANDS-2 LYMPHS-3* MONOS-6 EOS-1
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2191-8-5**] 11:15AM ALBUMIN-2.5*
[**2191-8-5**] 11:15AM CK-MB-2 cTropnT-<0.01 proBNP-[**Numeric Identifier 19494**]*
[**2191-8-5**] 11:15AM ALT(SGPT)-20 AST(SGOT)-43* CK(CPK)-38 ALK
PHOS-631* TOT BILI-1.6*
[**2191-8-5**] 11:15AM GLUCOSE-101* UREA N-31* CREAT-1.0# SODIUM-136
POTASSIUM-2.9* CHLORIDE-94* TOTAL CO2-31 ANION GAP-14
[**2191-8-5**] 11:20AM LACTATE-1.8
[**2191-8-5**] 08:34PM cTropnT-<0.01
[**2191-8-5**]
echocardiogram
The left atrium is elongated. The right atrium is moderately
dilated. There is a bidirectional shunt across the interatrial
septum at rest (minimal color left to right, saline contrast
right to left). Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%). There
is no ventricular septal defect. The right ventricular cavity is
mildly dilated with normal free wall contractility. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild to moderate ([**12-6**]+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is moderate pulmonary artery systolic
hypertension. There is a small pericardial effusion. There are
no echocardiographic signs of tamponade.
Compared with the prior study (images reviewed) of [**2191-4-15**],
the degree of pulmonary hypertension detected has probably
increased. A small ASD with mild bidirectional shunting is now
appreciated. Cardiac systolic function and the pericardial
effusion are similar
CT Chest [**2191-8-6**]
1. Progression of intrathoracic lymphadenopathy and significant
worsening of diffuse bilateral airspace disease consisting of
ground-glass opacities and patchy and confluent consolidations
on a background of diffuse interlobular septal thickening.
Findings are nonspecific and can be seen with pulmonary edema,
hemorrhage and/or infectious process.
2. Increased size of bilateral pleural effusions and abdominal
ascites.
3. Stable cardiomegaly and coronary artery disease. Stable
small pericardial effusion.
4. Redemonstration of bilateral lower lobe interstitial
opacities and
bronchiectasis suggestive of chronic underlying interstitial
pneumonia versus scarring.
5. Enlarged pulmonary trunk, likely related to pulmonary
arterial
hypertension.
6. Interval splenectomy.
[**2191-8-7**] cytology bronchial washings NEGATIVE FOR MALIGNANT CELLS.
[**2191-8-7**] US No evidence of deep venous thrombosis in the right
upper extremity.
[**2191-8-12**] CT Head No evidence of hemorrhage, mass effect, or acute
infarction.
[**2191-8-15**] EEG
This is an abnormal waking EEG because of slow background mostly
in the theta but some intermixed delta activity. There are
frequent bursts of frontally predominant but generalized
polymorphic delta activity. These
findings are indicative of mild to moderate diffuse
encephalopathy with
possible accentuation of midline structures and may be
representing a
metabolic dysfunction related to the respiratory condition.
[**2191-8-18**] CXR
Compared to the previous radiograph, the Dobbhoff catheter has
been
advanced. Tip of the catheter now projects over the distal
parts of the
stomach. No evidence of complications, notably no pneumothorax.
The other monitoring and support devices are in unchanged
position. Unchanged appearance of the lung parenchyma, with
bilateral diffuse parenchymal
opacities, right slightly more than left. Unchanged appearance
of the
moderately enlarged cardiac silhouette. No larger pleural
effusions.
__________________________________________________________
[**2191-8-15**] 4:47 pm SPUTUM Source: Endotracheal.
**FINAL REPORT [**2191-8-17**]**
GRAM STAIN (Final [**2191-8-15**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
1+ (<1 per 1000X FIELD): BUDDING YEAST WITH
PSEUDOHYPHAE.
RESPIRATORY CULTURE (Final [**2191-8-17**]):
SPARSE GROWTH Commensal Respiratory Flora.
YEAST. SPARSE GROWTH.
__________________________________________________________
[**2191-8-10**] 4:00 pm SPUTUM Source: Endotracheal.
**FINAL REPORT [**2191-8-12**]**
GRAM STAIN (Final [**2191-8-10**]):
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2191-8-12**]):
Commensal Respiratory Flora Absent.
YEAST. SPARSE GROWTH.
__________________________________________________________
[**2191-8-9**] 10:00 pm BLOOD CULTURE Source: Line-a-line.
**FINAL REPORT [**2191-8-15**]**
Blood Culture, Routine (Final [**2191-8-15**]): NO GROWTH.
__________________________________________________________
[**2191-8-8**] 2:10 am BLOOD CULTURE FROM LT PICC.
**FINAL REPORT [**2191-8-14**]**
Blood Culture, Routine (Final [**2191-8-14**]): NO GROWTH.
__________________________________________________________
[**2191-8-7**] 1:19 pm Rapid Respiratory Viral Screen & Culture
BRONCHIAL LAVAGE.
**FINAL REPORT [**2191-8-11**]**
Respiratory Viral Culture (Final [**2191-8-11**]):
No respiratory viruses isolated.
Culture screened for Adenovirus, Influenza A & B,
Parainfluenza type
1,2 & 3, and Respiratory Syncytial Virus..
Detection of viruses other than those listed above will
only be
performed on specific request. Please call Virology at
[**Telephone/Fax (1) 6182**]
within 1 week if additional testing is needed.
Respiratory Viral Antigen Screen (Final [**2191-8-9**]):
Less than 60 columnar epithelial cells;.
Specimen inadequate for detecting respiratory viral
infection by DFA
testing.
Interpret all negative results from this specimen with
caution.
Negative results should not be used to discontinue
precautions.
Refer to respiratory viral culture results.
Recommend new sample be submitted for confirmation.
Reported to and read back by [**Doctor First Name 105257**] NINABLA [**2191-8-9**]
11:52AM.
__________________________________________________________
[**2191-8-7**] 1:19 pm BRONCHOALVEOLAR LAVAGE BRONCHIAL LAVAGE.
GRAM STAIN (Final [**2191-8-7**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2191-8-9**]): NO GROWTH, <1000
CFU/ml.
POTASSIUM HYDROXIDE PREPARATION (Final [**2191-8-7**]):
Test cancelled by laboratory.
PATIENT CREDITED.
This is a low yield procedure based on our in-house
studies.
if pulmonary Histoplasmosis, Coccidioidomycosis,
Blastomycosis,
Aspergillosis or Mucormycosis is strongly suspected,
contact the
Microbiology Laboratory (7-2306).
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
[**2191-8-8**]): NEGATIVE for Pneumocystis jirovecii
(carinii)..
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2191-8-9**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
__________________________________________________________
Time Taken Not Noted Log-In Date/Time: [**2191-8-5**] 2:19 pm
BLOOD CULTURE SET#2.
**FINAL REPORT [**2191-8-11**]**
Blood Culture, Routine (Final [**2191-8-11**]): NO GROWTH.
__________________________________________________________
[**2191-8-5**] 11:15 am BLOOD CULTURE
**FINAL REPORT [**2191-8-11**]**
Blood Culture, Routine (Final [**2191-8-11**]): NO GROWTH.
DISCHARGE LABS
[**2191-8-18**] 04:11AM BLOOD WBC-10.4 RBC-3.05* Hgb-9.8* Hct-31.5*
MCV-103* MCH-32.2* MCHC-31.2 RDW-15.5 Plt Ct-81*
[**2191-8-18**] 04:11AM BLOOD PT-12.0 PTT-34.6 INR(PT)-1.1
[**2191-8-18**] 04:11AM BLOOD Glucose-251* UreaN-42* Creat-0.7 Na-147*
K-3.8 Cl-110* HCO3-32 AnGap-9
[**2191-8-18**] 04:11AM BLOOD ALT-41* AST-72* LD(LDH)-474* AlkPhos-627*
TotBili-1.5
[**2191-8-18**] 04:11AM BLOOD Calcium-8.1* Phos-1.7* Mg-1.9
[**2191-8-17**] 04:53AM BLOOD Type-[**Last Name (un) **] Temp-37.1 Rates-/26 FiO2-40
pO2-52* pCO2-51* pH-7.41 calTCO2-33* Base XS-5 Intubat-NOT
INTUBA
PERTINENT LABS AND STUDIES
[**2191-8-17**] 04:53AM BLOOD Lactate-1.5
[**2191-8-14**] 03:50AM BLOOD CK-MB-3 cTropnT-<0.01
[**2191-8-12**] 03:45AM BLOOD Triglyc-184*
[**2191-8-15**] 11:07AM BLOOD Ammonia-45
[**2191-8-9**] 03:26AM BLOOD TSH-3.0
[**2191-8-8**] 10:23AM BLOOD ANCA-NEGATIVE B
[**2191-8-8**] 10:23AM BLOOD [**Doctor First Name **]-NEGATIVE
[**2191-8-7**] 08:23PM BLOOD IgG-264* IgA-LESS THAN IgM-LESS THAN
[**2191-8-8**] 11:44AM BLOOD O2 Sat-94
[**2191-8-17**] 04:53AM BLOOD freeCa-1.15
[**2191-8-6**] 02:49PM BLOOD B-GLUCAN-POSITIVE (128)
[**2191-8-9**] 03:20AM URINE Blood-TR Nitrite-NEG Protein-30
Glucose-TR Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2191-8-16**] 11:32PM URINE Hours-RANDOM UreaN-1027 Creat-86 Na-LESS
THAN K-31 Cl-13 Calcium-0.4
[**2191-8-16**] 11:32PM URINE Osmolal-558
[**2191-8-7**] 01:19PM OTHER BODY FLUID Polys-92* Bands-2* Lymphs-2*
Monos-3* Atyps-1*
[**2191-8-14**] HEPARIN DEPENDENT ANTIBODIES NEGATIVE
[**2191-8-6**] ASPERGILLUS NEGATIVE
[**2191-8-8**] ANTI GBM NEGATIVE
Brief Hospital Course:
MICU Course:
Patient admitted to the MICU for respiratory distress. Was taken
off of BiPAP overnight and maintain saturation on non-rebreather
mask. On morning of hospital day 2 patient was noted to become
hypoxic during turning to 70s and required intubation. Following
intubation patient initially saturating in mid to high 80s.
Patient was noted to be asynchronous with vent and her sedation
was uptitrated followed by initiation of cisatracurium.
# Respiratory Failure
Patient intubated on morning of hospital day 2 due to hypoxia.
Initial difficulty with oxygenation improved after neuromuscular
blockade. Patient underwent bronchoscopy with specimens sent for
micro and cytology. While no microbiologic cause of respiratory
failure was identified the patient was maintained on an empiric
7 day course of broad spectrum antibiotics. The patient's
respiratory mechanics were noted to progressively improve and
FiO2 and PEEP were steadily weaned. The patient was successfully
extubated on hospital day 12 ([**2191-8-16**]). Following extubation
patient did not complain of dyspnea and was noted to be
saturating well on supplemental O2 by nasal canula.
# ARDS
Patient with bilateral pulmonary infiltrates and low PaO2/FiO2
consistant with ARDS. Was maintained on ARDS net ventilation
protocol until successful extubation.
# [**Last Name (un) **]
Experienced oliguria and progressive Cr increase after a
hypotensive episode with intubation and initiation of mechanical
ventilation. Patient subsequently became polyuric and her Cr
began to trend down, consistant with a diagnosis of ATN. At time
of discharge from ICU patient's Cr and urine output were
normalized.
# Electrolytes
Patient intermittently required free water repletion for
hypernatremia and various electrolyte repletions during her
critical illness.
# Encephalopathy
Following improvement of patient's ventilatory status major
barrier to extubation became altered mental status. Patient
would wax and wane throughout the day and had minimal purposeful
movement. Initially felt to be secondary to continued
benzodiazapine activity as she spent multiple days on a Versed
drip for sedation. Her mental status worsened in spite of being
off of Versed and an empiric course of lactulose was started for
hepatic encephalopathy. On the day after initiation of lactulose
the patient's mental status was noted to markedly improve and
she began responding to commands and purposefully moving all
four extremities. She was then successfully extubated and
maintained on PO lactulose titrated to 3 bowel movements per
day. Patient's mental status was noted to progressively improve
and she became capable of interacting and asking complex
questions.
# ? Sepsis
Patient reported ? URI symptoms with labs showing leukocytosis.
Initial presentation concerning for sepsis vs pulmonary edema.
Blood cultures and BAL sent. Started on broad spectrum
antibiotics, but no microbiologic etiology was ever identified.
# QTc prolongation
Followed with daily ECG in setting of QT prolonging medications.
Was treated with Levofloxacin in spite of prolonged QTc as
atypical causes of pneumonia could not be ruled out and
patient's respiratory status represented a major life threat.
Electrolytes closely followed and repleted PRN.
Transitional Issues:
-check electrolytes on [**2191-8-19**] to assess for hypernatremia
-adjust amount of free water intake based on sodium levels
-please check speech and swallow eval so that patient can take
POs.
- please decrease Lasix dose as appropriate so that her goal I/O
is even.
- please taper off steroids with Prendisone 20mg [**8-18**], then 10mg
[**Date range (1) 15491**], then STOP.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Furosemide 40 mg PO BID
40 mg in the AM, 80 mg in the PM
2. BuPROPion (Sustained Release) 300 mg PO QAM
3. Nadolol 20 mg PO DAILY
4. Metolazone 2.5 mg PO DAILY
5. Lorazepam 0.5 mg PO BID:PRN anxiety
6. Glargine 14 Units Bedtime
Insulin SC Sliding Scale using Lispro Insulin
7. Simvastatin 20 mg PO DAILY
Discharge Medications:
1. BuPROPion 100 mg PO TID
2. Glargine 14 Units Bedtime
Insulin SC Sliding Scale using REG Insulin
3. Nadolol 20 mg PO DAILY
4. Simvastatin 20 mg PO DAILY
5. Furosemide 20 mg PO BID
6. Docusate Sodium (Liquid) 100 mg PO BID
7. PredniSONE 20 mg PO DAILY Duration: 6 Days
20mg x3 days [**Date range (1) **]
10mg x3 days [**Date range (1) 17940**]
STOP
Tapered dose - DOWN
8. Senna 1 TAB PO BID
9. Heparin 5000 UNIT SC TID
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Primary: ARDS
Acute kidney injury
Thrombocytopenia
Secondary:
Diabetes mellitus
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
It was a pleasure taking care of you in the hospital. You were
admitted with acute lung injury requiring intubation. You were
placed on antibiotics and steroids to treat possible causes of
this lung injury. You also had kidney injury during this time.
Followup Instructions:
Please follow up with your oncologist at [**Hospital1 19860**] on Friday, [**8-26**], at 12:30pm
Department: LIVER CENTER
When: FRIDAY [**2191-9-30**] at 10:40 AM
With: [**First Name11 (Name Pattern1) 640**] [**Known lastname **], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
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"311",
"272.4",
"518.81",
"276.0",
"V45.72",
"572.2",
"300.00",
"785.50",
"287.31",
"279.00",
"571.5",
"572.3",
"272.0",
"584.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.97",
"38.91",
"96.72",
"96.04",
"33.24",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
18266, 18338
|
13687, 16966
|
340, 363
|
18476, 18476
|
3947, 11266
|
18933, 19366
|
3062, 3140
|
17821, 18243
|
18359, 18455
|
17392, 17798
|
18654, 18910
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3181, 3643
|
11507, 13664
|
11299, 11471
|
16987, 17366
|
293, 302
|
391, 1962
|
18491, 18630
|
1984, 2929
|
2945, 3046
|
3669, 3928
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,878
| 159,395
|
2971
|
Discharge summary
|
report
|
Admission Date: [**2110-1-8**] Discharge Date: [**2110-2-7**]
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
pedestrian vs. car
Major Surgical or Invasive Procedure:
[**2110-1-8**]:
Coil embolization of branches of L+R internal iliacs.
[**2110-1-9**]:
1. Placement of external fixator to right hemipelvis in order to
manipulate pelvic injury for reduction.
2. Sacroiliac fixation with two 7.3 mm cannulated screws.
3. Fixation of anterior pelvic ring to contralateral side.
4. Bilateral lateral knee arthrocentesis to remove hematomas.
[**2110-1-11**]:
Inferior vena cava venogram. Aborted IVC filter placement.
[**2110-1-15**]:
Removal of external fixator under anesthesia.
[**2110-1-16**]:
Thrombin injection L groin pseudoaneurysm.
[**2110-1-30**]:
1. Bilateral laminectomy, facetectomy, foraminotomy T5.
2. Bilateral laminectomy, medial facetectomy, foraminotomy T6.
3. Open treatment fracture dislocation T6.
4. Posterior lateral instrumentation T4-T8.
5. Arthrodesis posterolaterally T4-T8.
6. Application of local allograft.
7. Application of local autograft.
[**2110-2-5**]:
Percutaneous endoscopic gastrostomy.
History of Present Illness:
88-y.o. female pedestrian was struck by car, hypotensive on
arrival with positive FAST and gross hematuria
Past Medical History:
PMH: Dementia, Glaucoma
PSH: unknown
Social History:
Unknown.
Family History:
Non-contributory to trauma.
Physical Exam:
T 96.7 P 85 BP 82/51 O2sat 100% 4L NC
General: disoriented, GCS 14 (E4 M6 V4)
HEENT: PERRL, L occipital laceration
Heart: RRR
Lungs: CTAB
Abdomen: FAST+
Pelvis: loose rectal tone, no gross blood PR, gross hematuria
per foley
Extremities: R knee ecchymosis, moving all extremities
Pertinent Results:
[**2110-1-8**] 05:00PM WBC-8.2 RBC-4.04* HGB-11.4* HCT-33.3* MCV-83
MCH-28.3 MCHC-34.3 RDW-14.9
[**2110-1-8**] 05:00PM PLT COUNT-130*
[**2110-1-8**] 05:00PM PT-13.9* PTT-29.7 INR(PT)-1.2*
[**2110-1-8**] 05:00PM FIBRINOGE-194
CT head [**2110-1-8**]: Scalp laceration, without intracranial injury.
CT C-spine [**2110-1-8**]: 1. Mildly displaced fracture of the
anterior inferior corner of C6 vertebra. 2. Multilevel
degenerative disease. 3. Small pneumothorax of the left lung
apex. 4. Thyroid goiter.
CT torso [**2110-1-8**]: 1. Extensive pelvic fractures including
involvement of the right superior and inferior pubic rami, right
sacral ala, and right iliac [**Doctor First Name 362**] with surrounding hematoma with
areas of active extravasation. Additionally, lateral to the
right femoral greater trochanter is an area of active
extravasation within a hematoma. 2. Mildly distracted and
displaced T6 fracture with widening of the facet joints and
retropulsion of bony fragments which markedly narrows the spinal
canal at this level and is concerning for spinal cord injury.
Recommend MRI for further evaluation. 3. Splenic hypodense
lesion, which has a morphology unusual for traumatic hematoma.
Hemorrhagic within a pre-existing lesion, however, is not
excluded. If further characterization of this lesion is desired,
an MRI can be obtained. 4. Septated cyst within the right kidney
with adjacent stranding may be related to traumatic cyst
rupture. 5. Tiny left apical pneumothorax. 6. Multiple acute rib
fractures on the left of the second through tenth ribs.
CT cystogram [**2110-1-8**]: No evidence of intraperitoneal or
extraperitoneal bladder injury.
R humerus XR [**2110-1-9**]: Right proximal humerus surgical neck
comminuted fracture, as above.
L knee/ankle XR [**2110-1-9**]: No definite fracture of the left
knee or ankle.
BLE US [**2110-1-10**]: 1. Left groin pseudoaneurysm measuring 2.1
cm. 2. No evidence of deep vein thrombosis in either leg.
MRI C/T/L-spine [**2110-1-11**]: Prevertebral soft tissue swelling
anterior to the majority of the cervical spine, likely
traumatic. T6 fracture, with mild spinal cord compression.
Multilevel degenerative changes. Thoracolumbar scoliotic
deformity.
CT RLE [**2110-1-12**]: Nondisplaced fracture of the right fibular
head. A small hemarthosis is also noted within the knee joint.
L femoral US [**2110-1-14**]: Persistent pseudoaneurysm which appears
to be immediately adjacent to a hematoma.
MRI head [**2110-1-22**]: 1. Bilateral subdural fluid collections
which are larger compared to the [**1-8**] study, and were
not apparent on the [**2098**] study. The signal characteristics are
suggestive of hygromas or subacute-to-chronic hematomas rather
than acute blood products. Much smaller posterior subdural fluid
collections more suggestive of acute subdural hematomas. 2. No
acute infarct. 3. T1 bright 1 cm sellar lesion, incompletely
assessed, but not present in [**2098**]. This may represent a
hemorrhagic pituitary adenoma versus a Rathke cleft cyst.
Consider dedicated sellar imaging if desired.
EEG [**2110-1-23**]: This is an abnormal EEG due to the presence of
an attenuated, disorganized [**6-13**] Hz theta frequency background
rhythm with frequent bursts of diffuse delta slowing. This
pattern is suggestive of a moderate diffuse encephalopathy
commonly seen with medication effect, metabolic disturbance,
infection or, given the patient's history, diffuse axonal
injury. In addition, the greater attenuation seen over the right
parietal region is suggestive of a focal region of cerebral
dysfunction or possibly an underlying structural defect.
However, after 3 p.m., the background intermittently improves to
an [**9-16**] Hz alpha posterior dominant background. There were no
electrographic seizures seen.
EEG [**2110-1-24**]: This is an abnormal EEG due to a mixed [**6-13**] Hz
theta frequency and [**9-16**] Hz alpha frequency background rhythm
with frequent bursts of diffuse delta slowing. This pattern is
suggestive of a mild to moderate diffuse encephalopathy commonly
seen with medication effect, metabolic disturbance, infection
or, given the patient's history, diffuse axonal injury. In
addition, the greater attenuation seen over the right parietal
region is suggestive of a focal region of cerebral dysfunction
or possibly an underlying structural defect. There were no
electrographic seizures seen. Compared to the later part of the
previous recording, there was no significant change.
L femoral US [**2110-1-27**]: Resolution of the prior left groin
pseudoaneurysm after thrombin therapy.
R humerus XR [**2110-1-28**]: Limited evaluation of the right
humerus, however, no definite change in right proximal humerus
surgical neck comminuted fracture.
R knee/ankle XR [**2110-1-28**]: 1. No significant healing of right
fibular head fracture. 2. New fracture of the anterior tibial
plafond.
Brief Hospital Course:
On [**2110-1-8**], the patient was transferred from the trauma bay to
IR for coil embolization of her pelvic hemorrhage. She was
intubated for hemodynamic instability. Thereafter, she was
admitted to the TSICU. She was found to have a L femoral
pseudoaneurysm from a CVL placed in the trauma bay, and this was
injected with thrombin. Her pelvis was stabilized with external
fixation. Her RLE was stabilized in a knee immobilizer.
Multiple family meetings were held with TSICU staff, ACS staff,
and her son to discuss goals of care. In the time periods
between these meetings, in spite of her severe injuries, the
patient had a relatively uncomplicated hospital course.
Ultimately, her son wished to keep her full code with all
measures pursued. Thus, she underwent ORIF of her spine. On
[**2110-1-31**], she developed new-onset atrial fibrillation
requiring DC cardioversion with 100 joules followed by
metoprolol 10 mg IV push and metoprolol 25 mg PO for rate
control.
On [**2110-2-1**], she was extubated, and on [**2110-2-2**], she was
transferred to the floor.
In summary,
Neuro: For the first three weeks of her admission, mental status
was poor, with no response to verbal stimuli while off sedation.
CV: No major issues over the course of her hospital stay.
Pulm: She was intubated on [**2110-1-8**] for hemodynamic
instability. She developed ventilatory associated pneumonia
with enterobacter and serratia, which was treated with
vancomycin and ciprofloxacin [**1-14**]--[**1-21**]. On [**2110-2-1**], she
was weaned to minimal ventilator settings and was successfully
extubated.
GI: Starting [**2110-1-12**], she was given tube feeds through
OGT/NGT/dobhoff in order to maintain nutrition.
FEN: No major issues.
Endo: Blood sugars were monitored per ICU protocol and treated
prn. Pt had no other endocrinologic problems during her stay.
Heme: On admission, her pelvic hemorrhage was coil embolized
with good effect. In the context of this coil embolization, she
required 22 units of packed RBCs, 10 units of FFP, 5 platelets
and 2 units of cryoprecipitate. She also intermittently required
transfusions for slowly downtrending hematocrits. In the context
of her T4-T8 fusion she also required blood products including 7
units RBCs, 6 FFP, and 1 unit of platelets.
ID: She was treated for ventilator associated pneumonia with
vancomycin and ciprofloxacin [**1-14**]--[**1-21**].
MSK: She sustained a right pelvic fracture which was treated
with SI screws and is now TDWB RLE. She also sustained a right
knee MCL avulsion fracture for which she can be range of motion
as tolerated. She also sustained a right ankle fracture which
was non-operative and she was placed in an aircast boot. She
also sustained a right proximal humerus fracture which was also
non-operative and she was placed in a sling and was made
non-weight-bearing RUE. She will follow-up with orthopaedic
trauma surgery for managment of these injuries. Additionally,
she sustained a T6 fracture/dislocation with complete spinal
cord injury at that level, for which she underwent a
decompression and fusion at levels T4-T8. She will follow-up
with orthopaedic spine surgery for surgical follow-up.
Medications on Admission:
Unknown.
Discharge Medications:
1. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
2. docusate sodium 50 mg/5 mL Liquid Sig: Two (2) PO BID (2
times a day).
3. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q12H (every 12 hours) as needed for constipation.
4. polyethylene glycol 3350 17 gram/dose Powder Sig: Seventeen
(17) g PO DAILY (Daily) as needed for constipation.
5. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day): Hold for SBP<100 or HR<60.
6. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
Units Injection TID (3 times a day).
7. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
8. famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
via PEG.
9. acetaminophen 650 mg/20.3 mL Solution Sig: Six [**Age over 90 1230**]y
(650) mg PO Q6H (every 6 hours) as needed for pain.
10. cephalexin 250 mg/5 mL Suspension for Reconstitution Sig:
Ten (10) mL PO Q8H (every 8 hours) for 10 days: Last dose 1/8.
11. 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.
12. Morphine Sulfate 1-2 mg IV Q4H:PRN pain
13. Insulin Sliding Scale
Finger Sticks Q6H
Glucose Insulin Dose
0-70mg/dL Proceed with hypoglycemia protocol
71-150mg/dL 0 Units
151-200mg/dL 2 Units
201-250mg/dL 4 Units
251-300mg/dL 6 Units
301-350mg/dL 8 Units
351-400mg/dL 10 Units
> 400mg/dL 12 Units
14. Glucagon Emergency 1 mg Kit Sig: One (1) mg Injection q15
min as needed for hypoglycemia protocol.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Right superior and inferior pubic rami, right sacral ala, and
right iliac [**Doctor First Name 362**] fractures.
Pelvic hemorrhage.
Multiple L rib fractures with small L pneumothorax.
T6 fracture.
R fibular head fx.
R knee hemarthrosis.
R humeral head fx
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to the acute care surgery service for trauma.
Please call your doctor or go to the emergency department if:
*You experience new chest pain, pressure, squeezing or
tightness.
*You develop new or worsening cough, shortness of breath, or
wheeze.
*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 an unusual discharge.
*Your pain is not improving within 12 hours or is not under
control within 24 hours.
*Your pain worsens or changes location.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*You develop any concerning symptoms.
General Discharge Instructions:
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Please take any
new medications as prescribed.
Please take the prescribed analgesic medications as needed. You
may not drive or heavy machinery while taking narcotic analgesic
medications. You may also take acetaminophen (Tylenol) as
directed, but do not exceed 4000 mg in one day.
Please get plenty of rest, continue to walk several times per
day, and drink adequate amounts of fluids. Avoid strenuous
physical activity and refrain from heavy lifting greater than 10
lbs., until you follow-up with your surgeon, who will instruct
you further regarding activity restrictions. Please also
follow-up with your primary care physician.
Followup Instructions:
1. Please call ([**Telephone/Fax (1) 2537**] to schedule a follow-up
appointment with Acute Care Surgery Clinic in 4 weeks.
2. Please call ([**Telephone/Fax (1) 2007**] to schedule a follow-up
appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1352**] in Orthopedic Spine Clinic in
4 weeks.
3. Please call [**Telephone/Fax (1) 1228**] to schedule a follow-up appointment
in Orthopedic Trauma Clinic.
|
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icd9cm
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[
[]
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[
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icd9pcs
|
[
[
[]
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11697, 11763
|
6741, 9941
|
267, 1228
|
12062, 12062
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1814, 6718
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13995, 14432
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1467, 1496
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10000, 11674
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11784, 12041
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,977
| 105,655
|
41902
|
Discharge summary
|
report
|
Admission Date: [**2124-10-13**] Discharge Date: [**2124-10-19**]
Date of Birth: [**2039-1-25**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
[**2124-10-13**] EXPLORATORY LAPAROTOMY, abdominal washout and [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] for perforated ulcer [**Location (un) **]
History of Present Illness:
85F w/ h/o of chronic naproxen use for arthritis, presented
to [**Hospital6 19155**] earlier today for worsening abd
pain
that started on Tuesday. Pain was sharp and located on L abd.
Denied ever having this pain before. Pain worsened over next
few
days and became more diffuse but patient was tolerating PO's and
passing flatus until earlier today where she had nausea and
minimal emesis and has not passed flatus. At OSH, she had CT
abd
w/ PO contrast that caused more abd pain. She was transferred
to
[**Hospital1 18**] for possible gastric perforation. She denies F, C, CP,
SOB, hematemesis, BRBPR, recent weight loss, prior EGDs. Last
c-scope 3 yrs ago w/ only diverticulosis.
Past Medical History:
diverticulosis, HTN, hypercholesterolemia, hypothyroidism
Social History:
Lives alone, no tobacco, no ETOH
Family History:
Noncontributory
Physical Exam:
Temp 97.9 HR 68 BP 139/79 RR 20 O2 sat 98% RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: diminished bowel sounds, mildly firm, nondistended, +TTP
diffusely, more localized at epigastrium, +guarding, no palpable
masses
Ext: No LE edema, LE warm and well perfused
Pertinent Results:
ADMISSION LABS:
[**2124-10-13**] 11:59PM GLUCOSE-119* UREA N-25* CREAT-1.7* SODIUM-137
POTASSIUM-4.7 CHLORIDE-107 TOTAL CO2-20* ANION GAP-15
[**2124-10-13**] 11:59PM WBC-19.6* RBC-4.21 HGB-12.1 HCT-37.1 MCV-88
MCH-28.8 MCHC-32.7 RDW-13.8
[**2124-10-13**] 11:59PM PLT COUNT-191
[**2124-10-13**] 11:59PM PT-13.2 PTT-28.2 INR(PT)-1.1
LABS DURING HOSPITAL STAY:
[**2124-10-19**] 04:55AM BLOOD WBC-10.0 RBC-4.00* Hgb-11.3* Hct-33.8*
MCV-85 MCH-28.2 MCHC-33.4 RDW-14.0 Plt Ct-229
[**2124-10-13**] 11:59PM BLOOD Neuts-82* Bands-4 Lymphs-7* Monos-7 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2124-10-13**] 11:59PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2124-10-19**] 04:55AM BLOOD Plt Ct-229
[**2124-10-19**] 04:55AM BLOOD Glucose-93 UreaN-17 Creat-1.0 Na-136
K-2.8* (POTASSIUM REPLETED ON MORNING OF THISRESULT) Cl-101
HCO3-28 AnGap-10
Brief Hospital Course:
She was admitted to the Acute Care Surgery team and taken to the
operating room for exploratory laparotomy, abdominal washout,
[**Location (un) **] patch-omental patch repair of anterior duodenal ulcer,
and placement of drain. IV Zosyn was started. Postoperatively
she was taken to the ICU for close hemodynamic monitoring due to
postoperative hypotension where she required Neo gtt. She
received fluid resuscitation as well. Once stable the Neo was
weaned off and she was extubated and transferred to the floor
the following day.
Upon transfer to the floor she progressed as expected. Her diet
was re-introduced slowly for which she has been able to tolerate
and home medications restarted with exception of Naprosyn. Her
JP drain output has been followed very closely as well and on
day of discharge had put out approx 200 cc's in the previous 24
hours. The decision was made to keep the JP in place and to
follow up in [**Hospital 2536**] clinic in a week to assess removal. A record of
her daily outputs should accompany her to her follow up
appointment.
The IV antibiotics were stopped after she developed a macular
pruritic rash on her extremities; this improved immediately
following stopping the Zosyn.
Her fluid volume status was noted to be positive for several
liters requiring diuresis with Lasix IV based on her exam and
chest radiographs. She also required intermittent repletion of
her potassium with this diuresis. [**Male First Name (un) 14261**] for her LE edema were
applied.
She was evaluated by Physical therapy and is being recommended
for short term rehab after her acute hospital stay. She was
discharged to rehab on [**2124-10-19**] and will follow up in the [**Hospital 2536**]
Clinic in 1 week.
Medications on Admission:
atenolol 12.5', amlodipine 2.5', Benicar 20', naproxen 500'',
levothyroxine 75', statin qhs (?name/dose)
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) ML
Injection TID (3 times a day).
2. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. atenolol 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
4. amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. olmesartan 20 mg Tablet Sig: One (1) Tablet PO daily ().
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
8. tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours)
as needed for pain.
9. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours)
as needed for pain.
10. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] House Nursing Home - [**Location 9583**]
Discharge Diagnosis:
Perforated duodenal ulcer
Postoperative hypotension secondary to hypovolemia
Pleural effusion
Hypokalemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital with a perforated ulcer
requiring an operation to repair this. Following your surgery
your dietary intake was placed on hold for a few days and then
slowly restarted. Now that you are able to tolerate a diet we
are preparing for your discharge.
During your hospital stay you were found to have some excess
fluid in your body requring that you be given a diuretic to get
rid of the excess fluid. Once your body weight returns to normal
it is likely you will no longer need this medication.
You may resume your home medications with the exception of any
NSAID's (non steroidal anit-inflammatory agents) and/or aspiring
containing products.
Followup Instructions:
Follow up in next Thursday in Acute Care Surgery Clinic to
evlaute your wounds and to possibly remove your JP drain. Upon
discharge from the hospital please call [**Telephone/Fax (1) 600**] for an
appointment.
Please also follow up with your primary care providers following
discharge from the hospital or rehabilitation facility. You or
your family will needto call for an appointment.
Completed by:[**2124-10-24**]
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49,520
| 165,037
|
41898
|
Discharge summary
|
report
|
Admission Date: [**2199-9-19**] Discharge Date: [**2199-9-27**]
Date of Birth: [**2155-2-22**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2736**]
Chief Complaint:
s/p VF arrest
Major Surgical or Invasive Procedure:
[**2199-9-19**]: Arterial line placement
[**2199-9-25**]: Electrophysiology study
[**2199-9-26**]: AICD placement: Single chamber [**Company 2267**]
Teligen 100
History of Present Illness:
Ms. [**Known lastname **] is a 44 year-old lady, with a past medical history of
hypothyroidism and depression, who was admitted after a VF
arrest. History was obtained from family members, Med [**Name2 (NI) **]
and records, as the patient was already intubated and sedated.
She was in her usual state of health until this morning when she
was at work. At around 11:30 this morning, she began to have
nausea, indigestion and burping, accompanied by tingling in her
arms. She went to the bathroom, whereshe looked the door and
lost consciousness. Her co-workers called EMS when they heard a
thump. When EMS arrived at 11:45 am, she was found to be in VF
arrest. CPR was performed for 8 minutes. The patient was
defibrillated twice and given epinephrine three times. There
was return of rhythm and spontaneous circulation, with heart
rate in the 150 bpm. Cooling protocol was initiated
immediately. She was loaded with amiodarone 300 mg, intubated,
given an intraosseus line and taken to the [**Hospital **] Hospital
Emergency Department. She arrive at [**Location (un) **] at 12:07 and was
found to be in a junctional rhythm. Labs were significant for
bicarb 15; cardiac enzymes were CK 71, CK-MB 1.3, index 1.8 and
trp I 0.02. She was started on dopamine gtt for hypotension.
Head CT there was negative for any acute intracranial processes.
The patient was taken to the Cath Lab, where she demonstrated
clean coronary arteries, EF 35% on ventriculogram and mild
hypokinesis of the anterior wall and apex. In the Cath Lab,
dopamine was switched to norephinephrine 5 mcg/min, and she was
started on heparin. An intraaortic balloon pump was placed via
the right femoral artery. She was given furosemide 40 mg IV in
the Cath Lab for pulmonary edema demonstrated on chest x-ray.
.
The patient was transported to [**Hospital1 18**] by Med Flight. During
transport at 13:30, ABG was 7.14/43/120/14. She was noted to be
shivering, gagging and clenching her jaw during transport, and
was give pancuronium 6 mg, fentanyl 200 mg and midazolam 4 mg.
Cooling protocol was continued. Norepinephrine was weaned off
at 16:45. Her vent settings were AC 450/5/16/100%.
.
On arrival to the [**Hospital1 18**] CCU, the patient was intubated and
sedated with balloon pump and PA catheter in place by right
femoral sheath. Vital signs on admission were T 34.6 HR 98 BP
135/87 SaO2 99% on AC 500/8/20/100%. She had a large amount of
stool soon after presentation. A left radial arterial line was
placed and peripheral IVs inserted. Her temperature reached 33
degrees at 17:00.
.
Unable to perform review of symptoms, as the patient was
intubated and sedated.
Past Medical History:
1. CARDIAC RISK FACTORS: none
2. CARDIAC HISTORY: none
3. OTHER PAST MEDICAL HISTORY:
- Hypothyroidism
- Depression
- Dysfunctional uterine bleeding, s/p 7-day trial of
norethidrone 2 tabs daily in [**5-/2199**]
Social History:
Works at a church. Has a 14 year-old daughter.
- Tobacco history: none
- ETOH: very rare wine
- Illicit drugs: none
Family History:
Father with silent MI at 57 years old with subsequent 4-vessel
CABG and PPM/ICD placement. No family history of arrhythmia,
cardiomyopathies, or sudden cardiac death; otherwise
non-contributory.
Physical Exam:
Admission physical exam:
T 34.6 HR 98 BP 135/87 SaO2 99% on AC 500/8/20/100%
GENERAL: Intubated and sedated.
HEENT: NCAT. Sclera anicteric. Left pupil about 1mm larger than
right, but both are briskly reactive. Weak corneal reflex. EOMI.
Conjunctiva were pink, no pallor or cyanosis of the oral mucosa.
No xanthalesma.
NECK: No JVD appreciated.
CARDIAC: Heart sounds difficult to hear, but bradycardic and,
normal S1, S2. No m/r/g appreciated. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB as assessed
anteriorly but dfficult to hear, no crackles, wheezes or
rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP and PT dopplerable
Left: DP and PT dopplerable
.
Discharge physical exam:
Tm: 98.7; Tc: 98.6; HR: 82-85; BP: 128-139/78-89; RR: 14-18 ;
O2sat 95% on RA
GENERAL: Awake, moving eyes and extremities, speaking
coherently, following all commands, some short term memory
HEENT: NCAT. Sclera anicteric. Pupils equal, react and
accommodate with brisk response. Moist mucous membranes
NECK: No JVP appreciated
CARDIAC: Regular rate and rhythm, normal S1 and S2. No MRG. No
S3 or S4.
Chest: CTAB. no wheezes
ABDOMEN: Normoactive bowel sounds, soft; non-tender,
non-distended
EXTREMITIES: No edema; warm extremities bilaterally
PULSES: 2+ radial pulses bilaterally, DP 2+ bilaterally, PT dop
bilaterally
Right groin with no ecchymosis or bruit. Left groin with
moderate ecchymosis, no bruit, mild tenderness. No sig hematoma
palpated.
NEURO: CN2-12 intact, 4/5 strength in all extremities.
Pertinent Results:
ADMISSION LABS
[**2199-9-19**] 10:50PM BLOOD WBC-39.8* RBC-6.61* Hgb-15.2 Hct-50.6*
MCV-77* MCH-22.9* MCHC-30.0* RDW-16.3* Plt Ct-311
[**2199-9-19**] 10:50PM BLOOD Neuts-90* Bands-5 Lymphs-1* Monos-3 Eos-0
Baso-0 Atyps-0 Metas-1* Myelos-0
[**2199-9-19**] 06:10PM BLOOD PT-16.1* PTT-52.7* INR(PT)-1.4*
[**2199-9-20**] 05:25AM BLOOD Fibrino-273
[**2199-9-20**] 05:25AM BLOOD FDP-10-40*
[**2199-9-19**] 06:10PM BLOOD Glucose-160* UreaN-15 Creat-1.1 Na-143
K-2.8* Cl-106 HCO3-21* AnGap-19
[**2199-9-19**] 06:10PM BLOOD ALT-62* AST-124* CK(CPK)-[**2099**]*
AlkPhos-126* TotBili-0.9
[**2199-9-20**] 02:31AM BLOOD CK(CPK)-5413*
[**2199-9-20**] 08:16PM BLOOD CK(CPK)-3706*
[**2199-9-22**] 12:24AM BLOOD ALT-59* AST-134* AlkPhos-64 TotBili-0.6
[**2199-9-22**] 04:29AM BLOOD Ret Aut-1.4
[**2199-9-20**] 05:25AM BLOOD Hapto-51
[**2199-9-19**] 06:10PM BLOOD CK-MB-68* MB Indx-3.6 cTropnT-1.05*
[**2199-9-20**] 02:31AM BLOOD CK-MB-100* MB Indx-1.8 cTropnT-0.53*
[**2199-9-20**] 08:16PM BLOOD CK-MB-100* MB Indx-2.7 cTropnT-0.33*
[**2199-9-19**] 06:10PM BLOOD Calcium-6.7* Phos-2.1* Mg-1.5*
[**2199-9-22**] 12:24AM BLOOD Albumin-3.0* Calcium-7.7* Phos-2.1*#
Mg-1.6 Iron-17*
[**2199-9-22**] 04:29AM BLOOD calTIBC-244* Hapto-141 Ferritn-30
TRF-188*
[**2199-9-20**] 05:25AM BLOOD TSH-2.9
[**2199-9-20**] 05:25AM BLOOD HCG-<5
[**2199-9-19**] 07:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2199-9-19**] 06:13PM BLOOD Lactate-3.9*
[**2199-9-19**] 11:13PM BLOOD Lactate-5.4*
[**2199-9-19**] 06:13PM BLOOD freeCa-0.94*
[**2199-9-19**] 06:20PM URINE bnzodzp-POS barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
.
DISCHARGE LABS
[**2199-9-27**] 06:30AM BLOOD WBC-13.6 Hgb-11.7 Hct-35.1 MCV-74* Plt
Ct-167
[**2199-9-27**] 06:30AM BLOOD Glucose-105 UreaN-8 Creat-0.6 Na-139
K-4.0 Cl-105 HCO3-25 Anion Gap-13
.
MICROBIOLOGY
[**2199-9-19**] Blood cx (final): No growth
[**2199-9-20**] Urine Cx (final): No growth
[**2199-9-20**] Mini-BAL: GRAM STAIN (Final [**2199-9-20**]): 2+ PMNs, no
microorganisms
RESPIRATORY Cx (Final [**2199-9-22**]):NO GROWTH,
<1000 CFU/ml.
[**2199-9-20**] Rapid Respiratory Viral Screen & Culture
Respiratory Viral Culture (Pending):
Respiratory Viral Antigen Screen (Final [**2199-9-20**]): < 60
columnar epithelial cells; Specimen inadequate for detecting
respiratory viral infection by DFA testing.
[**2199-9-22**] Urine Cx (final): No growth
[**2199-9-22**] Blood Cx: NGTD
.
IMAGING
[**2199-9-24**] Cardiac MRI: 1. Normal left ventricular cavity size
with severe hypokinesis of the distal third of the left
ventricle and akinesis of the apex. The LVEF was mildly
decreased at 46%. The effective forward LVEF was mildy decreased
at 52%. Possible CMR evidence of focal subendocardial myocardial
scarring/infarction in the mid-anteroseptal wall. There was no
obvious evidence of corresponding myocardial edema.
2. Normal right ventricular cavity size and systolic function.
The RVEF was mildy decreased at 44%.
3. No significant aortic regurgitation, mitral regurgitation,
pulmonic
regurgitation or tricuspid regurgitation.
4. The indexed diameters of the ascending and descending
thoracic aorta were normal. The main pulmonary artery diameter
index was normal.
5. Normal biatrial size.
6. Normal coronary artery origins with no evidence of anomalous
coronary
arteries.
7. Bilateral small pleural effusions, right greater than left.
Diffuse
pulmonary opacifications throughout both lungs, with areas of
more focal
opacification displaying enhancement, particularly in the left
upper lung.
These represent non-specific findings with differential
including atelectasis, aspiration, or developing pneumonia.
Recommend follow-up chest radiographs to resolution or further
characterization with chest CT.
[**2199-9-19**] ECG: Sinus tachycardia. There is a late transition with
ST-T wave changes suggestive of ischemia or infarction.
Additional non-specific ST-T wave changes.
.
[**2199-9-19**] EEG: This is an abnormal continuous ICU monitoring study
because
of severe diffuse background slowing and attenuation but some
reactivity throughout the recording. These findings are
indicative of
severe diffuse cerebral dysfunction, likely secondary to
cerebral
anoxia, but also possibly affected by hypothermia and sedating
medications. No electrographic seizures are present. Although
the
timing of this EEG is too early for absolute prognostic value,
the
presence of reactivity to external stimuli has been reported to
be
associated with better outcomes following anoxic brain injury.
.
[**2199-9-19**] CHEST (PORTABLE AP): Single frontal view of the chest
was obtained. The heart is of normal size with a normal
cardiomediastinal silhouette. Severe bilateral widespread
heterogeneous opacification of the lungs, compatible with
bilateral pulmonary edema, is seen predominantly posteriorly. No
pneumothorax is seen. A femoral approach Swan-Ganz catheter
terminates distally, likely within a lobar pulmonary arterial
branch to the left lower lobe. NG tube terminates below the left
hemidiaphragm. Intra-aortic balloon pump is 2 cm from apex of
the aortic notch. Endotracheal tube is no less than 3.5 cm from
the carina.
.
[**2199-9-20**] EEG: This is an abnormal continuous ICU monitoring
study because
of moderate diffuse background slowing and disorganization with
only
fragments of a slow posterior dominant rhythm towards the end of
the
study. Background activity progressively improved over the
course of
the recording. These findings are indicative of moderate diffuse
cerebral dysfunction which is etiologically non-specific but in
this
patient likely secondary to cerebral anoxia. There are no
electrographic seizures. Compared to the prior day's recording,
there
is marked improvement in the background activity coinciding with
resolution of hypothermia.
.
[**2199-9-20**] ECHO (TTE): Poor image quality. The left atrium is
normal in size. No atrial septal defect is seen by 2D or color
Doppler. The left ventricular cavity size is normal. The LV apex
is not well seen and may be hypertrophied (versus
trabeculations) Overall left ventricular systolic function is
probably mildly and globally depressed (LVEF= 40 %) but due to
poor image quality the accuracy of this number is questionable.
There is no ventricular septal defect. Right ventricular chamber
size and free wall motion are normal. The diameters of aorta at
the sinus, ascending and arch levels are normal. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation.
Trivial mitral regurgitation is seen. The pulmonary artery
systolic pressure could not be determined. There is a very small
pericardial effusion. There are no echocardiographic signs of
tamponade.
.
[**2199-9-20**] ECG: Sinus bradycardia. The Q-T interval is prolonged.
There is a late transtion consistent with probable anterior
myocardial infarction. Non-specific ST-T wave changes. Low
voltage in the precordial leads. Compared to the previous
tracing of [**2199-9-19**] the rate is slower and ST-T wave changes are
less.
.
[**2199-9-20**] CHEST PORT. LINE PLACEMENT: Single frontal view of the
chest was obtained. The heart is of normal size with a normal
cardiomediastinal silhouette. Severe widespread heterogeneous
opacification of the lung, predominantly in the posterior lungs,
is unchanged from the [**2199-9-19**] study. No pneumothorax or
definite pleural effusion is seen. A new right IJ line
terminates in the mid to low SVC. NG tube is unchanged in
position below the diaphragm. IABP is seen 2 cm from the apex of
the aortic knob. Endotracheal tube is no less than 3.5 cm from
the carina. Femoral approach Swan-Ganz catheter has been
removed.
.
[**2199-9-20**] CT C-SPINE W/O CONTRAST: Spinal alignment, vertebral
body height, and disc height are maintained. There is no
fracture. The prevertebral soft tissues are normal in
appearance. The patient is intubated, and an orogastric tube is
in place. Coarse calcifications are noted within the left lobe
of the thyroid gland. There is airspace opacification within the
visualized dependent lung apices.
.
[**2199-9-20**] CT HEAD W/O CONTRAST: There is no acute intracranial
hemorrhage, extra-axial collection, or mass effect. The
ventricles and sulci are normal in size and configuration. [**Doctor Last Name **]
matter/white matter differentiation remains preserved. The
orbits appear normal. Visualized soft tissues are normal
appearing. The mastoid air cells are clear bilaterally. The
visualized portions of the paranasal sinuses are clear. No
acute intracranial abnormality.
.
[**2199-9-21**] EEG: This is an abnormal continuous ICU monitoring study
because
of mild diffuse background slowing with a slow posterior
dominant
rhythm. These findings are indicative of mild diffuse cerebral
dysfunction which is etiologically non-specific but, in this
patient,
likely secondary to cerebral anoxia. There are no electrographic
seizures. Compared to the prior day's recording, there is
further
improvement in the background activity as well as the appearance
of some
normal sleep architecture.
.
[**2199-9-21**] ECHO (TTE): 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%). There is a
trivial/physiologic pericardial effusion. Compared with the
prior study (images reviewed) of [**2199-9-20**], left ventricular
systolic function is more clearly visualized in the current
study. Left ventricular function may be similar in the two
studies but the prior study was technically suboptimal for
comparison.
.
[**2199-9-22**] EEG: This is an abnormal continuous ICU monitoring study
because
of mild diffuse background slowing. These findings are
indicative of
mild diffuse cerebral dysfunction which is etiologically
non-specific
but, in this patient, likely secondary to cerebral anoxia. There
are no
electrographic seizures. Compared to the prior day's recording,
there
is further improvement in the background activity with return of
a
normal frequency posterior dominant rhythm.
.
[**2199-9-22**] CHEST (PORTABLE AP): Right internal jugular venous
catheter is at the cavoatrial junction. Heart size is normal.
Lungs are significantly improved with some residual opacity,
particularly in the lung bases. No evidence of pneumothorax or
pleural effusion. Interval improvement with residual bibasilar
pulmonary opacities.
.
[**2199-9-24**] cMRI:
1. Normal left ventricular cavity size with severe hypokinesis
of the distal third of the left ventricle and akinesis of the
apex. The LVEF was mildly decreased at 46%. The effective
forward LVEF was mildy decreased at 52%. Possible CMR evidence
of focal subendocardial myocardial scarring/infarction in the
mid-anteroseptal wall. There was no obvious evidence of
corresponding myocardial edema.
2. Normal right ventricular cavity size and systolic function.
The RVEF was mildy decreased at 44%.
3. No significant aortic regurgitation, mitral regurgitation,
pulmonic
regurgitation or tricuspid regurgitation.
4. The indexed diameters of the ascending and descending
thoracic aorta were normal. The main pulmonary artery diameter
index was normal.
5. Normal biatrial size.
6. Normal coronary artery origins with no evidence of anomalous
coronary
arteries.
7. Bilateral small pleural effusions, right greater than left.
Diffuse
pulmonary opacifications throughout both lungs, with areas of
more focal
opacification displaying enhancement, particularly in the left
upper lung.
These represent non-specific findings with differential
including atelectasis, aspiration, or developing pneumonia.
Recommend follow-up chest radiographs to resolution or further
characterization with chest CT.
.
[**2199-9-27**] Chest x-ray:
PA AND LATERAL VIEWS OF THE CHEST
REASON FOR EXAM: Assess ICD placement.
Comparison is made with prior study [**9-22**].
Cardiac size is normal. Left transvenous pacemaker/ICD tip is in
a standard position in the right ventricle. There is no
pneumothorax or pleural effusion. The lungs are clear.
Brief Hospital Course:
Ms. [**Known lastname **] is a 44 year-old woman, with a past medical history of
hypothyroidism and depression, who was admitted after a VF
arrest, on IABP, arctic sun cooling protocol and
intubated/sedated.
.
.
ACUTE ISSUES:
# VF arrest: Etiology is unclear and event was unwitnessed, but
based on borderline long QTc on EKG, patient may have had a long
QT at baseline. This could have been exacerbated by paroxetine.
Additionally, it is possible that she had an acute electrolyte
disturbance, from possible vomiting and diarrhea prior to
admission, that triggered her ventricular arrhythmia. Acute MI
was possible, with autolysis of clot, given her clean coronary
arteries on OSH catheterization report and possible scar in the
anteroseptal wall on CMR. Differential also included
intoxication, suicide attempt, systemic infection and poisoning,
but all of these were less likely possibilities. The patient
underwent the arctic sun cooling protocol and subsequent
re-warming. The sedation was turned off and she was extubated
successfully. IABP was removed during the cooling-stage. The
48-hour EEG monitoring showed mild diffuse background slowing
with a slow posterior dominant rhythm, indicative of mild
diffuse cerebral dysfunction which is etiologically non-specific
but, in this patient, likely secondary to cerebral anoxia. There
were no electrographic seizures. TTE initially showed a mildly
and globally depressed left ventricular systolic function with
an EF of 35% on [**9-20**], but then showed normal left ventricular
systolic function with an EF of > 55% on [**9-21**]. She was initially
started on vancomycin, cefepime, and flagyl due to the high
white blood cell count, but was discontinued shortly after as pt
remained afebrile and there was no clear source. Lactate trended
down and lab values normalized. She had a cardiac MRI that
showed focal subendocardial myocardial scarring/infarction in
the mid-anteroseptal wall. There was extensive hypokinesis in
the distal [**12-17**] of the ventricle, as well. There was no obvious
evidence of corresponding myocardial edema, but image quality on
these images was limited due to patient motion. She was taken
for single chamber ICD placement the following day, which
occurred without incident.
.
# Leukocytosis: Patient's WBC on admission elevated to 37.7 with
a significant left shift. She was initially treated empirically
on vancomycin, cefepime, and flagyl for the possibility of
infection, though this leukocytosis may be secondary to arrest,
defibrillation and hemoconcentration. There was no evidence of
pneumonia on CXR and no other clear source of infection.
Cultures returned negative, and so the antibiotics were stopped
on HD#2.
.
# Pulmonary congestion: Patient was noted to have pulmonary
congestion on OSH CXR. It is likely that pulmonary congestion
was secondary to poor forward flow with stunned myocardium and
EF 34% s/p defibrillation. She appeared euvolemic on admission
and was not diuresed further. Repeat TTE showed recovery of EF
to >55%, and she continued her hospital stay without further
pulmonary issues.
.
.
CHRONIC ISSUES:
# Hypothyroidism: Documented history of this problem. The
patient was continued on levothyroxine at home dose
.
# Depression: Documented history of this problem. The patient's
home paroxetine was discontinued, as it may prolong QT.
.
TRANSITIONAL ISSUES:
# Please have your PCP refer you to a psychiatrist to evaluate
appropriate anti-depression medications that will not prolong
the QTc interval. You should have a follow up EKG prior to
starting any new medications.
# Recommended follow up Echocardiogram in one month.
Medications on Admission:
- levothyroxine 0.1 mg daily
- paroxetine 20 mg daily
Discharge Medications:
1. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO three times a
day as needed for pain, fever.
3. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
5. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
6. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a
day for 2 days.
7. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary diagnosis:
Ventricular fibrillation arrest
Acute Systolic dysfunction
.
Secondary diagnoses:
Short-term memory impairment
Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname **],
It was a pleasure to participate in your care here at [**Hospital1 1535**]. You were admitted after you
heart arrested. You improved slowly, after initially being on a
breathing machine and on a machine to help your heart beat. A
cardiac magnetic resonance imaging study (cMRI) showed a small
area of scarred tissue, but an electrophysiology (EP) study
showed no discrete focus of cardiac arrhythmia. On [**2199-9-26**],
you had an automatic implantable cardiac defibrillator (ICD)
placed, which will provide a shock if your heart stops again.
This will feel like a very strong kick in the chest and you may
pass out before this happens. If the ICD does fire, please call
Dr.[**Name (NI) 90966**] office right away.
Please note, the following changes have been made to your
medications:
1.) STOP Paxil
2.) START Keflex for 2 days to prevent an infection at the ICD
site
3.) START lisinopril 5 mg by mouth daily
4.) START metoprolol succinate 25 mg by mouth daily
5.) START ferrous sulfate (iron) for your anemia
6.) START docusate (colace) to prevent constipation
7.) START tylenol and oxycodone as needed for pain
It is important for you to follow up with your primary care
physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 5435**], after you get out of rehabilitation.
.
Please also keep the appointments that have been made for you
with your new cardiologist, Dr. [**Last Name (STitle) **], and the cognitive
neurologist, Dr. [**First Name (STitle) **], as listed below.
Before restarting a medication for depression, you will need to
have another EKG to make sure that the intervals look okay.
Also, you will need to have an outpatient Echocardiogram as
follow up.
Wishing you all the best!
Followup Instructions:
Department: CARDIAC SERVICES
When: THURSDAY [**2199-10-3**] at 10:30 AM
With: DEVICE CLINIC [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: COGNITIVE NEUROLOGY UNIT
When: THURSDAY [**2199-10-24**] at 1 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6403**], MD [**Telephone/Fax (1) 1690**]
Building: Ks [**Hospital Ward Name 860**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
Department: CARDIAC SERVICES
When: THURSDAY [**2199-11-14**] at 2:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 11899**], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
* This is the earliest available appointment for Dr. [**Last Name (STitle) **], but
you are on the cancellation list for the next available
appointment.*
|
[
"780.93",
"280.9",
"785.51",
"287.5",
"427.41",
"288.60",
"626.8",
"429.9",
"276.8",
"244.9",
"285.29",
"311"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.71",
"37.82",
"97.44",
"37.26",
"38.97",
"38.91",
"33.24",
"99.81",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
22296, 22366
|
17720, 20829
|
318, 481
|
22551, 22551
|
5528, 17697
|
24478, 25588
|
3554, 3751
|
21476, 22273
|
22387, 22387
|
21397, 21453
|
22702, 24455
|
3791, 4676
|
22488, 22530
|
3242, 3247
|
21102, 21371
|
265, 280
|
509, 3170
|
22406, 22467
|
22566, 22678
|
3278, 3405
|
20845, 21081
|
3192, 3222
|
3421, 3538
|
4701, 5509
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,254
| 127,443
|
7073
|
Discharge summary
|
report
|
Admission Date: [**2134-8-8**] Discharge Date: [**2134-8-11**]
Date of Birth: [**2109-12-10**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Overdose Tylenol, Somnolence
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
24M presents intoxicated, combative, hx ingestion Klonepin,
EtOH, cocaine, tylenol. Fell down flight of 5 steps.
.
In the ED he was found to have an etoh level of 177, an
acetaminophen level of 78, and a urine tox positive for cocaine.
He was intubated for airway protection. He received Propofol,
Fentanyl and Versed, Pantoprazole, Charcoal & Sorbitol. CT head
negative for acute bleed, CT abdomen/pelvis and c-spine
atraumatic. He was seen by trauma who signed off after scans
were negative. Toxicology was consulted and he was started on
N-acetylcysteine secondary to unknown time of ingestion.
.
Prior to intubation he had complained of chest pain. His EKG
demonstrated J-point elevations only, and 2 sets of cardiac
enzymes were negative.
Past Medical History:
1. Intraventricular Conduction Delay noted on EKG from [**2127**]; QRS
not prolonged
Social History:
SOC HX: lives with girlfriend and Uncle. hx of cocaine,
marijuana use intermittently. works as bartender; concern re:
obtaining benzos in this context. 1 ppd smoking hx. uncertain
EtOH use; intermittent heavy use though girlfriend cannot
provide further history.
Physical Exam:
In ED
VS: 96.7 / 126 / 141/76 / 18 / 92% RA
GEN: young man intubated, NAD
HEENT: charcoal stains, ETT in place, PERRL though minimally
reactive
Lungs: CTA
Heart: RRR, S1, S2, no r/m/g
Abd: soft, ND, no involuntary guarding
Ext: 2+ rad/DP pulses
Neuro: sedated
Pertinent Results:
CT HEAD: IMPRESSION:
No acute intracranial hemorrhage
.
CT C-SPINE: IMPRESSION:
No acute fracture identified.
.
CT ABDOMEN/PELVIS: IMPRESSION:
Unremarkable CT of the abdomen and pelvis with no evidence of
traumatic injury.
Brief Hospital Course:
24 year old male without medical history, here s/p etoh,
cocaine, tylenol, and klonopin use, s/p fall down stairs with
negative trauma workup, was originally admitted to MICU s/p
intubation for airway protection and treatment of potential
tylenol toxicity.
.
In the MICU:
1) Airway: Patient intubated purely for airway protection in the
setting of multiple intoxications and question of trauma which
has now been ruled out. Effects of etoh/cocaine/klonopin were
likely resolved by night, however nursing reporting that patient
very agitated when sedation weaned. Remained intubated
overnight. He was extubated in the morning after a successful
spontaneous breathing trial.
.
2) Potential tylenol toxicity: Patient's level 78 at 10 a.m.,
which per report from girlfriend would have been 5 hours
post-ingestion - NOT in the toxic range. However, given that
girlfriend unreliable, the team erred on the cautious side and
continued NAC overnight. His transaminases had trended down by
the morning, and the NAC was discontinued.
.
3) Chest pain: The pain was worrisome in the setting of cocaine
use, however EKG was without ST changes (J point elevation,
old), and 3 sets of enzymes were negative. He was without
further symptoms during his stay.
.
4) Drug abuse: Girlfriend denies chronic problem, though patient
seen in [**Name (NI) **] a few months ago for alcohol intoxication. Given
severity of this episode, will consult social work for substance
abuse after extubation. He was seen by Addictions Consult and
declined substance abuse treatment. He stated repeatedly that
his intoxication and acetaminophen overdose was not a suicide
attempt.
.
After his overnight MICU stay, he was transitioned to the floor:
- patient self extubated, and did not have further O2
requirements on the floor
- patient was already ruled out for MI in setting of cocaine
use; he did not have chest pain on the floor
-In regards to his Drug abuse: While his Girlfriend denied this
being a chronic problem, the patient has been seen in [**Name (NI) **] a few
months ago for alcohol intoxication. Overdose does not seem to
be a suicide attempt in this instance.
- addiction consult provided patient with outlets. However, at
this time , patient feels he does not need addiction counseling.
- asked CAGE questionaire, but patient answered no to all
questions.
- Patient did have an instance of delirium 2 days prior to
discahrge - potentially brought on by continued substance use
while in the hospital - patient had visitors o/n. Also MS change
was acute in light of clear sensorium on prior afternoon.
Recheck UTox and EtOH level were negative.
.
- Patient was cleared by PT and was discharged on HOD #4 with
follow up in [**Company 191**].
Medications on Admission:
None
Discharge Medications:
none
Discharge Disposition:
Home
Discharge Diagnosis:
etoh intoxication
cocaine intoxication
Discharge Condition:
stable
Discharge Instructions:
Please come to the ED if you have chest pain or shortness of
breath. Please stop using any drugs, and cut down on using
alcohol.
Followup Instructions:
Please see Dr. [**First Name (STitle) **] [**Name (STitle) **] in [**Hospital 191**] Medical clinic
Provider: [**Name10 (NameIs) 8741**] [**Name8 (MD) 9529**], MD Where: [**Hospital6 29**] [**Hospital **] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2134-9-8**] 2:00
Completed by:[**2135-3-1**]
|
[
"305.00",
"E880.9",
"305.60",
"518.81",
"728.88",
"959.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
4839, 4845
|
2029, 4755
|
300, 312
|
4928, 4937
|
1779, 1779
|
5115, 5415
|
4810, 4816
|
4866, 4907
|
4781, 4787
|
4961, 5092
|
1498, 1760
|
232, 262
|
340, 1091
|
1789, 2006
|
1113, 1199
|
1215, 1483
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,033
| 170,185
|
43039
|
Discharge summary
|
report
|
Admission Date: [**2187-2-12**] Discharge Date: [**2187-2-15**]
Date of Birth: [**2148-4-23**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
nausea/vomiting, hypertension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a 38 year with DM1 with complications of ESRD on
HD, gastroparesis, CAD s/p MI, sys CHF, recent GPC bacteremia
presenting with nausea/vomiting, and usual abdominal pain found
to be markedly hypertensive on arrival to the ED.
Of note he was just discharge on [**2187-2-9**] after presenting with
similar symptoms.
This morning he developed his usual abd pain, nausea and
vomiting. He presented to the ED. His initial vital signs were
96.9 100 209/141 94%RA. He received ativan and dilaudid (2mg/2mg
IV of each). He received labetalol 2.5 mg IV x2 then his home
dose of clonidine. He eventually was started on a nitroglycern
drip. He received regular insulin 4 units x1. The patient states
the symptoms are the same as all the priors without any changes.
.
ROS: no headache. no chest pain. breathing is normal. no dysuria
Past Medical History:
DMI complicated by gastroparesis
CAD s/p STEMI on [**2186-12-17**] in setting of cocaine use with bare
metal stent placement to the LAD
ESRD on HD since [**2-/2184**]
Line sepsis, coag negative staph most recently [**2187-1-10**], prior
klebsiella/enterobacteremia
Autonomic dysfunction wtih hypertensive emergency and
orthostatic hypotension
History of substance abuse (cocaine and marijuana)
History of esophageal erosion, [**Doctor First Name **]-[**Doctor Last Name **] tear
History of AV fistula clot
CVA?
Social History:
Denies EtOH, tobacco or marijuana use. although with positive
tox screens. lives with mother of his child
Family History:
Father deceased of ESRD and DM. Mother aged 50's with
hypertension. 2 sisters, one with diabetes. 6 brother, one with
diabetes
Physical Exam:
Upon arrival to the MICU:
Vitals: 97F 94 187/127 28 100%3L
Gen: ill appearing. sleepy but arousable. writhing abd muscles
HEENT: MMM. bilat small pupils 2->1mm
Neck: supple
Chest: clear anteriorly. soft bibasilar crackles. HD cath in
right chest
CV: regular tachy. S1/S2 no m/r/g
Abd: flat, soft, mild diffuse tenderness. active bowel sounds
Ext: old fistulas bilat upper arms. no leg edema
Neuro:
-MS: sleepy but arousable to voice. coherent response to
interview
-CN: II-XII grossly intact
-Motor: moving all 4 ext
Pertinent Results:
[**2187-2-12**] 08:30AM GLUCOSE-217* UREA N-62* CREAT-10.5*
SODIUM-137 POTASSIUM-5.6* CHLORIDE-97 TOTAL CO2-25 ANION GAP-21*
[**2187-2-12**] 08:30AM CALCIUM-10.7* PHOSPHATE-5.4*# MAGNESIUM-2.3
[**2187-2-12**] 08:30AM WBC-11.0 RBC-4.11* HGB-10.7* HCT-34.9* MCV-85
MCH-26.0* MCHC-30.7* RDW-18.5*
[**2187-2-12**] 08:30AM PLT COUNT-331
EKG: sinus @96. normal axis. normal intervals. Q (V1-4).
persistant ST elevations V1-5. no significant change from
[**2187-2-5**]
Studies:
[**2187-2-12**]: CXR - Diffuse interstitial more than alveolar edema,
likely related to the given history; overall, the lungs are
significantly better aerated than on the [**2-2**] studies, and
there is no pleural effusion
Brief Hospital Course:
In brief, the patient is a 38 year old man with DM1 complicated
by autonomic instability, gastroparesis, ESRD on HD, CAD s/p MI,
and multiple line infections pw/ recurrent n/v abd pain and
hypertensive urgency.
# Nausea/Vomiting - related to known gastroparesis. Resolved
with ativan/reglan/compazine/dilaudid.
# Hypertension - likely combination of autonomic instability in
setting of needing dialysis and poor medication tolerance
secondary to nausea. He had no evidence of acute end-organ
damage. He was started on a nitro gtt that was weaned off
within 24 hours. His home clonidine patch, PO clonidine, and
lisinopril were restarted. his labetolol was held at the time
of discharge because his blood pressures were well controlled.
# ESRD - has access via HD line. At the time of admission he had
mild pulm edema with hypoxia. He had HD x 2 during this
admission.
# CAD s/p MI - no acute changes on EKG and no clear chest pain.
He was continued on aspirin/statin/[**Month/Year (2) 4532**]
# Diabetes Mellitus type 1 - He was continued on his home dose
insulin.
Medications on Admission:
Lantus 12 units daily.
Aspirin 325 mg Tablet DAILY
Clopidogrel 75 mg DAILY
Atorvastatin 80 mg DAILY
Lanthanum 500 mg TID W/MEALS
Pantoprazole 40 mg PO Q24H
Labetalol 500 mg Tablet PO BID
Lidocaine Patch QD
Clonidine 0.2 mg/24 hr Patch Weekly
Metoclopramide 10 mg TID:PRN
Lisinopril 40 mg PO DAILY
Lorazepam 2 mg PO Q6H
Clonidine 0.1 mg PO BID
Prochlorperazine 10 mg PO q6h:prn
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Reglan 10 mg Tablet Sig: One (1) Tablet PO three times a day.
4. Compazine 10 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for nausea.
5. Lanthanum 500 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
6. Clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QTUES (every Tuesday).
7. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Insulin Glargine 100 unit/mL Solution Sig: Twelve (12) units
Subcutaneous once a day.
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) patch Topical once a day.
11. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
12. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
13. Ativan 2 mg Tablet Sig: One (1) Tablet PO three times a day
as needed for pain.
Discharge Disposition:
Home
Discharge Diagnosis:
Hypertensive Urgency
Diabetes Mellitus Type I
CAD
Discharge Condition:
Stable; BP well controlled on oral medications. Tolerating PO
diet.
Discharge Instructions:
You were admitted to the hospital with hypertension, nausea, and
vomiting. You were treated with IV medications and your
symptoms improved. You were dialyzed on the day of discharge.
Please continue your home medications as you were prior to this
hospitalization. Please hold your labetolol until you see Dr.
[**Last Name (STitle) **] as your blood pressures have been low.
Please return to the hospital for any chest pain, shortness of
breath, abdominal pain, fevers, or chills.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern4) 2761**], MD Phone:[**Telephone/Fax (1) 5003**]
Date/Time:[**2187-2-19**] 3:20
Provider: [**First Name11 (Name Pattern1) 31804**] [**Last Name (NamePattern1) 31805**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2187-2-22**] 3:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9546**], MD Phone:[**Telephone/Fax (1) 1047**]
Date/Time:[**2187-3-13**] 10:00
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"428.0",
"250.63",
"585.6",
"536.3",
"V45.82",
"403.01",
"414.01",
"337.1",
"428.22",
"410.92",
"276.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
5931, 5937
|
3313, 4389
|
352, 359
|
6031, 6102
|
2584, 3290
|
6635, 7240
|
1901, 2031
|
4817, 5908
|
5958, 6010
|
4415, 4794
|
6126, 6612
|
2046, 2565
|
283, 314
|
387, 1226
|
1248, 1761
|
1777, 1885
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,298
| 126,532
|
7804
|
Discharge summary
|
report
|
Admission Date: [**2118-5-16**] Discharge Date: [**2118-5-24**]
Date of Birth: [**2047-9-27**] Sex: F
Service: SURGERY
Allergies:
Tape / Morphine
Attending:[**First Name3 (LF) 1781**]
Chief Complaint:
Bilateral foot ulcers and rest pain
Major Surgical or Invasive Procedure:
[**2118-5-17**] Diagnostic abdominal aortogram, pelvic arteriogram,
bilateral lower extremity runoffs, brachial arterial puncture
with third order catheterization.
[**2118-5-19**] Revision femoral-femoral bypass graft, right common
femoral endarterectomy and patch angioplasty.
History of Present Illness:
70 year-old female with a history of LLE claudication who
presented in [**11-17**] with ischemic and gangrenous 1st left toe.
She underwent a right femoral patch angioplasty with Dacron,
right to left femoral bypass with 8-mm PTFE graft and left
superficial femoral artery profunda endarterectomies. She
presented in [**12-19**] with a wound dehiscence for which she was
treated with ciprofloxacin. She returns today for pre-operative
workup for bilateral lower extremity angio tomorrow. Currently
she feels well, but continues to have claudication in her left
calf while walking with numbness and burning in her left foot.
The ulcers on the tips of her left toes have continued to heal
daily.
Past Medical History:
- CAD s/p stent to 70% RCA lesion in [**2116**]; no CP, cath was done
in preparation of LE revascularization.
- Hypertension
- h/o syncope since childhood -> +syncope "hundreds of times"
- Seizure disorder (dx [**2112**]) (usual sxs are syncope w/ vomiting,
incontinence). Last episode in summer [**2116**]. Followed by Dr.
[**First Name (STitle) **] at [**Hospital 1474**] hospital ([**Telephone/Fax (1) 28219**]). Seizure free since
starting Keppra.
- PVD/claudication --> s/p R femoral patch angioplasty with
Dacron, R -> L femoral bypass with 8-mm PTFE graft, and L
superficial femoral artery profunda endarterectomies ([**11-17**]).
- Carotid artery disease (40-59% of the right ICA, 60-69% of the
left ICA by carotid duplex on [**2117-8-23**])
- H/o head trauma: Fractured skull (age 14 mos) after falling
out of a
second story window; hit on the head with an axe @ age 9.
- Rheumatoid arthritis
- Osteopenia
- Glaucoma
- Macular degeneration
- Cataract surgery, left eye
- Raynaud's phenomenon
- COPD/Emphysema
- s/p cholecystectomy
- s/p appendectomy
- Pernicious anemia
Social History:
Lives with her daughter. H/o tobacco use (quit [**2109**]) - 30 pack
year hx. Denies EtOH or drug use.
Family History:
Mother w/ "angina" and h/o melanoma
Physical Exam:
ON ADMISSION:
Vitals: 97.7 86 146/68 18 94% ROOM AIR
Gen: NAD
CV: RRR
Lung: CTAB
Abd: soft, obese, ND, NT, NABS
Ext: Palpable DP bilaterally, non-palpable PT, bilateral toes
hyperemic, left toe with healing ulcers.
.
ON DISCHARGE:
Vitals: 97.0 76 140/66 18 97% ROOM AIR
Gen: NAD
CV: RRR
Lung: CTAB
Abd: soft, obese, ND, NT, NABS
Ext: Palpable DP bilaterally, non-palpable PT, left toe with
healing ulcers improving, both feet warm.
Pertinent Results:
ON ADMISSION:
[**2118-5-16**] 07:00PM BLOOD WBC-7.9 RBC-3.57* Hgb-10.9* Hct-32.6*
MCV-91 MCH-30.5 MCHC-33.4 RDW-14.6 Plt Ct-316
[**2118-5-16**] 07:00PM BLOOD PT-11.7 PTT-22.5 INR(PT)-1.0
[**2118-5-16**] 07:00PM BLOOD Glucose-80 UreaN-20 Creat-0.9 Na-140
K-3.7 Cl-104 HCO3-27 AnGap-13
[**2118-5-16**] 07:00PM BLOOD Calcium-9.1 Phos-3.4 Mg-2.4
.
ON DISCHARGE
[**2118-5-21**] 09:45AM BLOOD WBC-10.2 RBC-3.63* Hgb-11.3* Hct-32.5*
MCV-90 MCH-31.2 MCHC-34.9 RDW-15.5 Plt Ct-211
[**2118-5-21**] 09:45AM BLOOD Glucose-139* UreaN-20 Creat-1.0 Na-144
K-3.9 Cl-106 HCO3-23 AnGap-19
[**2118-5-21**] 09:45AM BLOOD Calcium-9.0 Phos-3.7 Mg-2.3
.
RADIOLOGY Final Report
CHEST (PRE-OP PA & LAT) [**2118-5-18**] 12:06 PM
CHEST (PRE-OP PA & LAT)
Reason: ISCHEMIA BILATERAL LEGS
[**Hospital 93**] MEDICAL CONDITION:
70 year old woman with PVD
REASON FOR THIS EXAMINATION:
preop RT leg bypass
EXAMINATION: Peripheral vascular disease. Preop right leg
bypass.
IMPRESSION: PA and lateral chest compared to [**2117-11-25**]:
Lungs are mildly hyperinflated. Reticulation seen best in the
central right lung probably bronchiectasis. More pronounced
oligemia in the right upper lobe could be due to emphysema.
Irregular opacities at the apices of both lungs, particularly
the left, most likely scars, but a prior radiograph should be
obtained to confirm that this is not a new finding and therefore
requiring additional evaluation.
Heart is normal size. A very small pericardial effusion is
probably present. Pulmonary vascularity and hilar and
mediastinal vessels are normal. No pleural effusion.
.
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2118-5-19**] 12:11 PM
CHEST (PORTABLE AP)
Reason: SOB
[**Hospital 93**] MEDICAL CONDITION:
70 year old woman with
REASON FOR THIS EXAMINATION:
SOB
INDICATION: Shortness of breath.
CHEST, ONE VIEW: Comparison with [**2118-5-18**]. Cardiac,
mediastinal, and hilar contours are unchanged. Diffuse reticular
interstitial opacities are unchanged. Scarring at both lung
apices is unchanged. No pleural effusion or pneumothorax. No
focal consolidations. Osseous structures are also probably
unchanged on this poorly penetrated film.
IMPRESSION:
1. No acute cardiopulmonary abnormality.
2. Diffuse reticular interstitial opacities suggest interstitial
disease. HRCT may be useful for further characterization.
Brief Hospital Course:
The patient was admitted to Dr.[**Name (NI) 7257**] Vascular Surgery
Service on [**2118-5-16**]. She underwent a diagnostic abdominal
aortogram, pelvic arteriogram, bilateral lower extremity
runoffs, brachial arterial puncture with third order
catheterization on [**2118-5-17**]. For details of the operation, please
refer to the operative report. She did well post-angiogram and
was raken to the operating room on [**2118-5-19**], where she underwent a
revision femoral-femoral bypass graft, right common femoral
endarterectomy and patch angioplasty. For details of the
operation, please refer to the operative report. Her
postoperative course was relatively uncomplicated. She had a
temperature to 101.3 on POD 1 attributed to atelectasis. She
was placed on a steroid taper immediately post-operatively and
was transitioned to PO medications. She was deemed stable for
discharge on POD 4. Her foley catheter was removed without
complications. She was evaluated by physical therapy and
cleared for home. She continued to tolerate a regular diet and
remained afebrile. She will follow-up with Dr. [**Last Name (STitle) **].
Medications on Admission:
metoprolol 25'', plavix 75', keppra 500'', celebrex 100',
prednisone 5', crestor 10', ASA 325', xalatan 1 drop left eye
QHS
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 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. RESUME ALL PREVIOUS HOME MEDICATIONS
5. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
6. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
7. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
8. Rosuvastatin 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
9. Celecoxib 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
10. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Inhalation Q6H (every 6 hours).
11. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
12. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
13. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] VNA- [**Location (un) 5087**]
Discharge Diagnosis:
Bilateral foot ulcers and rest pain.
Discharge Condition:
Stable
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 [**1-15**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? Unless you were told not to bear any weight on operative foot:
?????? You should get up every day, get dressed and walk
?????? You should gradually increase your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (unless you have stitches or foot incisions) no
direct spray on incision, let the soapy water run over incision,
rinse and pat dry
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
?????? Redness that extends away from your incision
?????? A sudden increase in pain that is not controlled with pain
medication
?????? A sudden change in the ability to move or use your leg or the
ability to feel your leg
?????? Temperature greater than 100.5F for 24 hours
?????? Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions
Followup Instructions:
Scheduled Appointments :
Provider [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3310**], MD Phone:[**Telephone/Fax (1) 2226**]
Date/Time:[**2118-9-28**] 11:00
.
Appointments to be made:
Please call Dr. [**Last Name (STitle) **] at ([**Telephone/Fax (1) 1798**] to schedule a
follow-up appointment in [**12-14**] weeks.
Completed by:[**2118-5-24**]
|
[
"414.01",
"362.50",
"780.39",
"V45.82",
"440.31",
"714.0",
"440.23",
"496",
"401.9",
"365.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.48",
"88.47",
"38.18",
"00.40",
"39.49"
] |
icd9pcs
|
[
[
[]
]
] |
7872, 7949
|
5425, 6561
|
311, 591
|
8030, 8039
|
3075, 3075
|
10781, 11147
|
2562, 2599
|
6735, 7849
|
4789, 4812
|
7970, 8009
|
6587, 6712
|
8063, 10349
|
10375, 10758
|
2614, 2614
|
2849, 3056
|
236, 273
|
4841, 5402
|
619, 1317
|
3089, 3836
|
1339, 2423
|
2439, 2546
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,688
| 129,259
|
15483+15484+15485+15486+56660
|
Discharge summary
|
report+report+report+report+addendum
|
Admission Date: [**2173-9-23**] Discharge Date: [**2146-1-31**]
Date of Birth: [**2115-2-13**] Sex: M
Service: CCU
HISTORY OF PRESENT ILLNESS: The following hospital course
covers the [**Hospital 228**] hospital admission from [**2173-9-23**], and
[**2173-10-4**]. The remainder of the [**Hospital 228**] hospital course
will be dictated at a later time.
The patient is a 58 year old morbidly obese male with
diabetes mellitus and coronary artery disease, status post
multiple myocardial infarctions, lytics, ventricular
fibrillation arrest, sent with a recent protracted hospital
course between [**2173-8-12**], and [**2173-9-20**], which was complicated
by a ventricular fibrillation arrest, Clostridium difficile
colitis, Methicillin resistant Staphylococcus aureus
bacteremia, VRE bacteremia, aspiration pneumonia, who was
readmitted on [**2173-9-23**], with acute shortness of breath, due
to acute pulmonary edema. The patient was intubated due to
respiratory distress and taken to the Cardiac Catheterization
Laboratory. The patient was found to have a mid left
anterior descending in-stent thrombosis, which was restented.
PAST MEDICAL HISTORY:
1. Coronary artery disease, status post myocardial
infarction in [**2160**], [**2167**], [**2168**], [**2171**], and [**2172**]. The patient
has had multiple stents placed in the past including in
[**2172-9-1**] (proximal left circumflex), [**2173-8-26**]
(distal left anterior descending in-stent thrombosis treated
with angioplasty), [**2173-8-18**] (proximal left anterior
descending, mid left anterior descending, distal left
anterior descending).
2. Ventricular fibrillation arrest times two with the last
ventricular fibrillation arrest in [**2173-8-2**], status
post pacemaker placement but no AICD.
3. Diabetes mellitus type 2, now insulin dependent.
4. Gastroesophageal reflux disease.
5. Obstructive sleep apnea, unable to tolerated BiPAP or
CPAP.
6. Hypercholesterolemia.
7. Morbid obesity weighing over 400 pounds.
8. Congestive heart failure due to systolic dysfunction.
9. History of Clostridium difficile colitis.
10. History of Methicillin resistant Staphylococcus aureus
bacteremia.
11. Sacral decubitus ulcer, Stage II.
12. Acute tubular necrosis causing acute renal failure.
13. Anxiety.
MEDICATIONS ON ADMISSION:
1. Metoprolol.
2. Epogen.
3. Plavix.
4. Aspirin.
5. Amiodarone.
6. Zoloft.
7. Lipitor.
8. Protonix.
9. Zinc.
10. Vitamin C.
11. Flovent.
SOCIAL HISTORY: The patient does not drink, smoke or use
drugs.
PHYSICAL EXAMINATION: On admission, physical examination is
notable for a blood pressure of 92/64 with a heart rate of
97. The patient is extremely obese, with a most recent
weight of 364.5 pounds. The patient is on CPAP mask with
crackles heard throughout both lungs. His heart is regular
rate and rhythm, with distant heart sounds. He has trace
lower extremity edema bilaterally and dorsalis pedis and
posterior tibialis pulses are present although faint.
LABORATORY DATA: On admission, laboratories are notable for
a creatinine of 2.9 which is elevated from his baseline
creatinine of 1.0 approximately six months prior to
admission. His white blood cell count is also elevated at
15.3.
Electrocardiogram showed A sensed V paced rhythm at a heart
rate of 97 with a left bundle morphology similar to a
previous electrocardiogram performed on prior
hospitalization.
HOSPITAL COURSE:
1. Coronary artery disease - The patient was admitted in
acute pulmonary edema which was believed to be due to
in-stent thrombosis. The patient was taken to Cardiac
Catheterization Laboratory and was found to have an in-stent
thrombosis of the mid left anterior descending which was
restented. The patient was briefly on intra-aortic balloon
pump following cardiac catheterization but was eventually
able to be weaned off it IABP. The patient had no further
episodes of acute shortness of breath or chest pain. He
intermittently required pressor support for presumed septic
shock during the hospitalization.
2. Congestive heart failure - The patient was found to have
elevated filling pressures on cardiac catheterization on the
day of admission [**2173-9-23**]. The patient was initially
diuresed but eventually his acute renal failure worsened and
the patient became anuric. The patient required hemodialysis
to remove excess fluid which he tolerated well. The patient
was unable to tolerate continuing Carvedilol for his
congestive heart failure due to hypotension.
3. Sacral decubitus ulcer - The patient has a Stage II
bilateral gluteal pressure sores which had developed prior to
this hospitalization. Plastic surgery was consulted and they
recommended medical management with optimization of nutrition
as well as wound care. Plastic surgery was reconsulted
several times throughout the hospitalization, but continued
to believe that there was no indication for wound
debridement. The patient was also seen by the wound care
nurses who recommended a wound care regimen. At the time of
this dictation, the sacral decubitus ulcer appeared to be
improved from admission although was still Stage II ulcer.
Plain films of the sacrum were obtained to determine if the
infection had spread into the bone causing osteomyelitis.
The films were suboptimal due to the patient's large body
habitus but there was no indication of osteomyelitis.
4. Pulmonary - The patient was intubated in the Emergency
Department on admission due to respiratory distress from
acute pulmonary edema. There was difficulty weaning the
patient off mechanical ventilation due to fluid overload. The
patient was also unable to tolerate BiPAP or CPAP previously
when it was used for his obstructive sleep apnea. A
pulmonary consultation was obtained to assist with weaning
off the mechanical ventilation. The patient was unable to
tolerate spontaneous breathing trials despite ongoing
diuresis and with a RSBI less than 100. Due to concern for
his obstructive sleep apnea, severe coronary artery disease,
his history of ventricular fibrillation arrest and the risks
of repeated intubation/extubation, it was finally decided to
place a tracheostomy. The family consented to the procedure.
A tracheostomy was placed in the operating room on [**2173-10-13**],
by Cardiothoracic Surgery. Several days later, the patient
needed to have the trach changed at the baseline due to a
large air leak. Following trach change, he was finally able
to be ventilated adequately. The patient was eventually
started on CVVH to remove excess fluid. Following the start
of CVVH, the patient was finally able to be taken off
mechanical ventilation after he successfully passed a
spontaneous breathing trial. He was initially on trach mask
but eventually was able to tolerate nasal cannula.
5. Infectious disease - The patient was admitted on
Vancomycin due to a recent bout of Methicillin resistant
Staphylococcus aureus bacteremia discovered on prior
hospitalization. He had been finishing a six week course of
Vancomycin for Methicillin resistant Staphylococcus aureus
bacteremia from either his pacer wires versus his Swan-Ganz
catheter on prior hospitalization. A transthoracic
echocardiogram was obtained which showed no endocarditis
although studies were suboptimal due to the patient's body
habitus.
During the current hospitalization, the patient
became septic and hypotensive. He developed citrobacter and
VRE bacteremia and sepsis. He developed pseudomonas and
citrobacter, ventilator associated pneumonias. An infectious
disease consultation was obtained to assist with antibiotic
management. The patient was treated with Zosyn times two
weeks following desensitization for Citrobacter
and pseudomonal infections. The patient was also treated
with Linezolid times two weeks for VRE infection.
Approximately one week after completing antibiotics, the
patient developed another hypotensive episode. It was
believed to be sepsis presumed from pseudomonas growing in
the urine and in the sputum, although no organisms grew from
blood cultures. The patient was treated with Meropenem times
two weeks following desensitization. During this time, the
patient never developed a fever although his white blood cell
count did elevate to a maximum of 39.0. While on Meropenem,
the patient's white blood cell count briefly increased but
then declined with a differential showing an eosinophilia due
to most likely his Meropenem allergy.
6. Renal - The patient was admitted in acute renal failure
with an increased creatinine from his baseline. His acute
renal failure was most consistent with acute tubular necrosis
as well as prerenal failure from overdiuresis. A renal
consultation was obtained. Due to the patient's rising
creatinine, excessive volume overload and anuria, the patient
was started on renal replacement therapy. The patient was
initially on CVVH due to sepsis that required pressure
support but then he was switched to hemodialysis when he was
taken off pressors. The patient tolerated hemodialysis well
throughout the remainder of the hospitalization.
7. Nutrition - The patient has a history of morbid obesity.
Due to the patient's debilitated state, he was unable to take
p.o. while mechanically ventilated. General surgery was
consulted concerning percutaneous endoscopic gastrostomy
placement. Due to the patient's size, surgery felt that it
would not be possible to transilluminate the abdomen for
percutaneous endoscopic gastrostomy placement. The patient
would also not be a good candidate for open gastrostomy tube
due to his multiple medical problems. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 40056**] was placed
by interventional radiology under fluoroscopy. The patient
was placed on tube feedings to optimize healing of his sacral
decubitus ulcers. He was also calorie restricted to assist
with weight loss. Prior to discharge from the hospital, the
patient was able to successfully pass a swallow study by
Speech and Swallow. The patient was slowly transitioned off
tube feedings and his p.o. intake was increased during the
day.
8. Hematology - The patient required multiple blood
transfusions for blood loss anemia as well as anemia of
chronic disease due to renal insufficiency. The patient was
initially on Epogen standing three times a week and was
eventually switched to Epogen during hemodialysis sessions.
[**Doctor Last Name **] was a theoretical concern that possibly the Epogen
promoted the formation of thromboses which is concerning
especially in a patient who has had two episodes of in-stent
thrombosis. The patient was nonetheless continued on Epogen
during hemodialysis sessions.
The remainder of the [**Hospital 228**] hospital course as well as
discharge diagnoses and discharge medications will be
dictated at a later time.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-932
Dictated By:[**Name8 (MD) 44899**]
MEDQUIST36
D: [**2173-11-3**] 16:28
T: [**2173-11-3**] 16:55
JOB#: [**Job Number 44900**]
Admission Date: [**2173-9-23**] Discharge Date: [**2173-10-9**]
Date of Birth: [**2115-2-13**] Sex: M
Service:
ADDENDUM: The following addendum covers the patient's
hospitalization from [**2173-10-4**] to [**2173-10-9**].
The initial portion of the [**Hospital 228**] hospital course was
previously dictated. Please see that other dictation for
details concerning the patient's hospitalization up through
[**2173-10-4**].
HOSPITAL COURSE: 1.) Infectious disease: The patient
completed a two week course of Meropenem. He continued to
have an elevated white count although the differential
continued to show persistent eosinophilia. It was believed
that this eosinophilia was most likely due to his Meropenem
allergy. According to allergy and dermatology, it is
possible to have a delayed allergic reaction to medications
including antibiotics. The patient showed no evidence of
infection. The patient remained afebrile and hemodynamically
stable.
2.) Renal. The patient was continued on hemodialysis
throughout the remainder of the hospitalization. Prior to
discharge, his right sided Quinton catheter was changed by
transplant surgery service to a tunnel catheter. Immediately
following the placement of the tunnel catheter, it was noted
that the arterial line had poor flow. The ports had to be
reversed so the line could be used for hemodialysis. The
renal service noted that it is possible to have poor flow due
to swelling postoperatively. They felt that the patient could
be discharged and continued on hemodialysis as an outpatient.
The renal consult service will be contacting the nephrologist
at the rehabilitation facility the patient is being
discharged to.
3.) Cardiovascular: The patient remained hemodynamically
stable throughout the remainder of the hospitalization.
Prior to discharge, the patient was started on very low dose
Carvedilol 3.125 mg p.o. twice a day which he tolerated well.
There was an attempt to start the patient on Captopril but
the patient was unable to tolerate this due to low blood
pressure.
CONDITION ON DISCHARGE: Hemodynamically stable although bed
bound. The patient is on hemodialysis due to acute renal
failure. He is trached with a trach mask and FI02 of 40%.
He has a large sacral decubitus ulcer which appears to be
healing.
DISCHARGE STATUS: The patient is discharged to acute
rehabilitation.
DISCHARGE DIAGNOSES:
Coronary artery disease.
Coronary stent thrombosis.
Flash pulmonary edema.
Congestive heart failure.
Systolic dysfunction/ischemic cardiomyopathy.
Diabetes mellitus, type II, now insulin dependent.
Gastroesophageal reflux disease.
Obstructive sleep apnea.
Hypercholesterolemia.
Morbid obesity.
Clostridium difficile colitis.
Sacral decubitus ulcer.
Acute tubular necrosis.
Acute renal failure, requiring hemodialysis.
Anxiety.
Anemia.
Tracheostomy.
Septic shock with hypotension due to Pseudomonas, VRE and
Citrobacter.
VRE bacteremia.
Pseudomonas infection of the bladder.
Pseudomonas bacteremia.
Pseudomonas tracheitis.
Citrobacter bacteremia.
Urticaria from an allergic reaction Zosyn.
Ventricular fibrillation arrest.
Pseudomonas ventilatory assisted pneumonia.
Meropenem desensitization.
Zosyn desensitization.
DISCHARGE MEDICATIONS:
Plavix 150 mg p.o. q. day.
Amiodarone 200 mg p.o. twice a day.
Atorvastatin 80 mg p.o. q. day.
Collagenase 250 units per gram ointment, apply topically to
decubitus ulcer q. day.
Fluticasone 110 mcg four puffs inhaled twice a day.
Albuterol Ipratropium 103/18 mcg one to two puffs inhaled q.
six hours.
Aspirin 325 mg p.o. q. day.
Zinc sulfate 220 mg p.o. q. day.
Vitamin C 500 mg p.o. twice a day.
Papain urea ointment, apply topically prn to pressure sore as
needed.
Surchilene 100 mg p.o. q. day.
Miconazole powder twice a day.
Camphor menthol lotion apply topically twice a day prn.
Acetaminophen with codeine 120/12 mg per 5 ml; 12.5 to 25 ml
p.o. q. six hours prn.
Effexophenadine 60 mg p.o. twice a day.
Mineral oil/Hydrophil Petrolat ointment apply topically three
times a day prn to the skin.
Calcium carbonate 1000 mg p.o. three times a day with meals.
Metoclopramide 5 mg p.o. four times a day as needed.
Famotidine 20 mg p.o. twice a day.
Heparin flush to line.
Renagel 800 mg p.o. three times a day.
Regular insulin sliding scale.
Carvedilol 3.125 mg p.o. twice a day.
Fentanyl 100 to 200 mcg intravenous prn pain for changing of
the sacral decubitus dressing.
FOLLOW-UP PLANS: The patient should follow-up with his
primary care physician in one to two weeks following
discharge from rehabilitation. The patient's primary care
physician is [**Last Name (NamePattern4) **]. [**Last Name (STitle) 44844**] [**Name (STitle) 4922**]. The patient is asked to
follow-up with cardiology when he is discharged from
rehabilitation. The patient will be scheduled for outpatient
hemodialysis at acute rehabilitation.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D.
Dictated By:[**Name8 (MD) 4993**]
MEDQUIST36
D: [**2173-11-8**] 02:58
T: [**2173-11-8**] 16:38
JOB#: [**Job Number 44901**]
Admission Date: [**2173-9-23**] Discharge Date: [**2173-11-9**]
Date of Birth: [**2115-2-13**] Sex: M
Service: CCU
Please note that the dates previously dictated in the two
prior dictations were erroneous. The dictation dated
[**2173-10-4**] actually covers the [**Hospital 228**] hospital
course from [**2173-9-23**] through [**2173-11-3**].
The second dictation dated [**2173-10-9**] actually covers
the [**Hospital 228**] hospital course from [**2173-11-3**] through
[**2173-11-9**]. The patient will be discharged to rehab
today.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D.
Dictated By:[**Name8 (MD) 4993**]
MEDQUIST36
D: [**2173-11-9**] 08:05
T: [**2173-11-9**] 08:06
JOB#: [**Job Number 44902**]
Admission Date: [**2173-9-23**] Discharge Date: [**2173-11-13**]
Date of Birth: [**2115-2-13**] Sex: M
Service: CCU
ADDENDUM: There was difficulty placing the patient in an
acute rehabilitation setting due to his multiple medical
problems. However, the patient was to be discharged to
rehabilitation today (on [**2173-11-13**]).
The patient had been started carvedilol 3.125 mg by mouth
twice per day for his heart failure; however, the patient was
unable to tolerate carvedilol due to hypotension. The right
peripherally inserted central catheter line was also changed
over a wire due to leakage from the old peripherally inserted
central catheter line. The patient's sacral decubitus
ulceration continued to heal well with the current wound care
management.
MEDICATIONS ON DISCHARGE: The patient's discharge
medications remained unchanged from the dictation dated
[**2173-10-9**] except for carvedilol 3.125 mg by mouth
twice per day which was stopped prior to discharge.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D.
Dictated By:[**MD Number(1) 44903**]
MEDQUIST36
D: [**2173-11-13**] 06:21
T: [**2173-11-13**] 06:22
JOB#: [**Job Number 44904**]
Name: [**Known lastname **], [**Known firstname 7090**] L Unit No:[**Unit Number 8226**]
Admission Date: [**2173-9-23**] Discharge Date:
[**2173-9-27**]
Date of Birth: Sex:
Service:
The patient continued to do well throughout the rest of his
hospital course. Continued to have improving renal function.
He had stable pulmonary status with good O2 saturations and
he continued to be asymptomatic with improved short of
breath, no episodes of chest pain. He remained afebrile.
Stable white count. The patient appeared clinically stable.
It was decided that the [**Hospital 1325**] medical problems were
stable and he could receive further treatment in a
rehabilitation facility with close outpatient follow-up. The
patient was discharged [**2173-9-10**].
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: Extended care facility. [**Hospital6 1766**] Facility.
DISCHARGE DIAGNOSIS:
PRIMARY DIAGNOSIS:
1. Acute myocardial infarction, anterior.
SECONDARY DIAGNOSIS:
1. Coronary artery disease.
2. Ventricular fibrillation.
3. Endocarditis.
4. Acute renal failure secondary to ATN.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg one tablet once a day.
2. Nystatin ointment applied four times a day as needed.
3. Plavix 75 mg one tablet once a day.
4. Lipitor 40 mg two tablets once a day.
5. Protonix 40 mg one tablet once a day.
6. Tylenol as needed.
7. Percocet q 4 to 6 hours as needed.
8. Zinc Sulfate 220 mg capsules once a day.
9. Vitamin C 500 mg one tablet twice a day.
10. Menthol/Camphor lotion applied up to three times a day as
needed.
11. Benadryl 250 mg q 8 hours as needed.
12. Albuterol/Hypertropian inhalers q 6 hours as needed.
13. Diphenoxylate/Atropine sulfate one tablet q 6 hours as
needed.
14. Sublingual Nitroglycerin .3 mg as directed.
15. Hypertropian inhalers q 6 hours.
16. Fluticasone inhalers twice a day.
17. Ambien p.r.n. insomnia.
18. Bacitracin/polymixin ointment q 6 hours as needed.
19. Albuterol inhaler q 6 hours.
20. Collagenase ointment applied twice a day.
21. Amiodarone 2 grams one tablet twice a day.
22. Sertuline 50 mg one tablet once a day.
23. Subcutaneously Heparin 5000 units q 8 hours.
24. Vancomycin one gram q o.d. for a total of four weeks
Please dose 11/1 according to Vancomycin level less than 15.
25. Ativan q 6 to 8 hours p.r.n. anxiety.
26. Metoclopramide 5 mg one tablet q 6 hours as needed for
nausea.
27. Insulin 8 units NPH, 16 units with breakfast, 8 units
with dinner. Regular insulin sliding scale.
28. Epogen 10,000 units three times a week.
29. Hypertropian inhalers q 6 hours p.r.n. short of breath
or wheezing.
30. Albuterol inhaler q 6 hours as needed for short of
breath or wheezing.
31. Metoprolol 12.5 mg b.i.d.
FOLLOW-UP: The patient was told to follow-up with his
primary care physician in one to two weeks time. The patient
was told to follow-up with cardiologist, Dr. [**Last Name (STitle) 8249**]
[**2173-10-1**] at 2:20 PM in [**Hospital 2946**] Hospital. The patient was
also told to follow-up with Infectious Disease with Dr.
[**First Name (STitle) **] on [**2173-10-25**] at 9:30 AM. He was told to be sure to
have himself weighed every morning, adhere to a strict low
sodium diet with fluid restriction and complete a six week
course of Vancomycin with the last dose [**2173-10-2**]. He was told
to be sure to have the Vancomycin dosing adjusted according
to his blood levels for trough less than 15 particularly as
his renal function improves. He was told that he was
restarted on Lopressor o12.5 mg twice a day and that this may
be increased as he tolerates it with his blood pressure. He
will need to be restarted on ace inhibitor if his renal
function improves.
Instructions were given to the rehabilitation facility about
proper wound care for his sacral ulcers. Told to continue
his BYPAP as tolerated. Regular insulin regimen.
Intravenous antibiotics. He was also told to continue with
oxygen via face mask and to continue with
inhalers/nebulizers. He was told to have blood draws at
least every other day to check creatinine as well as Vanc and
Trough to properly adjust Vancomycin levels. Told to
continue intravenous Vancomycin for four weeks time. He has
suspected an infected pacer wire. He was told that if he
develops any fever, chills, becomes febrile or has other
worsening symptoms that he should receive two sets of blood
cultures as he may need a follow-up Transesophageal
echocardiogram to evaluate pacer wires/endocarditis. He was
also told to continue with physical therapy at rehabilitation
facility. He was also told that if he had any future
episodes of chest pain, worsening short of breath, fevers,
chills or have any other concerning symptoms that he should
immediately contact his primary care physician or come to the
emergency department where he can receive medical treatment
immediately. .
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-661
Dictated By:[**First Name3 (LF) 8250**]
MEDQUIST36
D: [**2173-9-27**] 17:17
T: [**2173-9-27**] 19:16
JOB#: [**Job Number 8251**]
|
[
"280.0",
"707.0",
"482.83",
"482.1",
"428.0",
"584.5",
"996.72",
"519.02",
"785.52"
] |
icd9cm
|
[
[
[]
]
] |
[
"97.44",
"36.06",
"99.20",
"37.61",
"33.21",
"97.23",
"39.95",
"96.04",
"88.56",
"96.72",
"88.72",
"31.1",
"37.23",
"36.01"
] |
icd9pcs
|
[
[
[]
]
] |
13461, 14278
|
19363, 23333
|
19136, 19136
|
17771, 19006
|
2323, 2470
|
11517, 13123
|
2559, 3413
|
15494, 17744
|
165, 1157
|
19220, 19340
|
19155, 19199
|
1179, 2297
|
2487, 2536
|
19031, 19115
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,427
| 114,968
|
34372
|
Discharge summary
|
report
|
Admission Date: [**2107-9-11**] Discharge Date: [**2107-9-21**]
Date of Birth: [**2042-10-19**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
S/P Cardiac arrest
Major Surgical or Invasive Procedure:
[**2107-9-14**] - CABGx3 (left internal mammary-> Left anterior
descending artery, Saphenous vein graft (SVG)-> Acute marginal
artery, SVG->Posterior descending artery.)
[**2107-9-12**] - Cardiac Catheterization
History of Present Illness:
Mr. [**Known lastname 79067**] [**Last Name (Titles) **] a 64 yo male with a h/o morbid obesity, OSA, and
HTN who presents following a witnessed cardiac arrest. Patient
does not recall the events preceding his admission to [**Hospital1 18**], and
history was obtained from OSH record and from wife. [**Name (NI) **] report,
patient was at a wedding ceremony He was in a seated position
when his wife heard a gurgling [**Last Name (un) **] and noted him to collapse
onto the ground. There were medical personnel present and CPR
reported him to have a carotid pulse. EMS arrived and reported
him to be in ventricular fibrillation. He was shocked x 1 at
200J and was returned to a perfusing rhythm. No rhythm strips
are available. Per report, a piece of chewing gum was suctioned
from the oropharynx during resuscitation. There was no report
of urinary or fecal incontinence.
.
He was subsequently brought to the ED at [**Hospital 7188**] Hospital where
he was intubated. Per report, this was a "difficult intubation."
He was reported to be hemodynamically stable at time of arrival.
CT head was reported as normal. He was admitted to the CCU and
supported overnight on a ventilator. He was started on a
heparin gtt and amiodarone gtt at 0.5 mg/min. he received ASA
325 mg and Lidocaine 100 mg IV.
.
On review of symptoms, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope. His family did endorse
episodes of dyspnea with exertion and diaphoresis.
.
Past Medical History:
Hypertension
OSA
Morbid obesity
Tobacco abuse
Social History:
Social history is significant for the presence of current
tobacco use. Patient states that he currently smokes [**1-19**] PPD.
There is no history of alcohol abuse. He reports that he
consumes an average of 1 gin & tonic every night.
Family History:
His father died in his 50's of an MI.
Physical Exam:
PHYSICAL EXAMINATION:
VS: T 98, BP 156/75, HR 63, RR 18, O2 97% on 4 liters
Gen: obese middle aged male in NAD, resp or otherwise. Mood,
affect appropriate. Pleasant.
NEURO: Oriented to person only. Moving all extremities. CN
[**3-1**] intact. Continues to perseverate and repeat the same
questions regarding where he is, what happened.
HEENT: NCAT. Ecchymoses over left side of tongue. Sclera
anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or
cyanosis of the oral mucosa.
Neck: Thick, unable to assess JVP.
CV: Very distant heart sounds. PMI located in 5th intercostal
space, midclavicular line. RR, normal S1, S2. No S4, no S3.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheeze,
rhonchi.
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: Scar over left ankle, left knee. Trace lower extremity
edema L>R. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Pertinent Results:
ADMISSION LABS:
[**2107-9-11**] 01:46PM BLOOD WBC-8.8 RBC-3.57* Hgb-12.0* Hct-34.0*
MCV-95 MCH-33.7* MCHC-35.3* RDW-19.1* Plt Ct-159
[**2107-9-11**] 01:46PM BLOOD Neuts-83.4* Lymphs-11.7* Monos-3.9
Eos-0.7 Baso-0.4
[**2107-9-11**] 01:46PM BLOOD PT-14.2* PTT-58.9* INR(PT)-1.2*
[**2107-9-11**] 01:46PM BLOOD Plt Ct-159
[**2107-9-11**] 01:46PM BLOOD Glucose-125* UreaN-11 Creat-0.9 Na-136
K-5.0 Cl-100 HCO3-27 AnGap-14
[**2107-9-11**] 01:46PM BLOOD CK(CPK)-185*
[**2107-9-11**] 01:46PM BLOOD CK-MB-10 MB Indx-5.4 cTropnT-0.07*
[**2107-9-11**] 01:46PM BLOOD Calcium-9.1 Phos-3.5 Mg-2.2 Cholest-159
[**2107-9-11**] 03:09PM BLOOD %HbA1c-5.1
[**2107-9-11**] 01:46PM BLOOD Triglyc-240* HDL-41 CHOL/HD-3.9
LDLcalc-70
[**2107-9-11**] 01:46PM BLOOD TSH-1.1
[**2107-9-11**] 01:46PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2107-9-14**] 09:41AM BLOOD Type-ART pO2-341* pCO2-44 pH-7.41
calTCO2-29 Base XS-3 Intubat-INTUBATED
[**2107-9-14**] 09:41AM BLOOD Glucose-119* Lactate-1.3 Na-135 K-4.7
Cl-99*
[**2107-9-14**] 09:41AM BLOOD Hgb-11.3* calcHCT-34
EKG demonstrated NSR, HR 60 with normal axis, normal intervals,
1mm ST depression in I. No ST elevations. Q waves present in
inferior leads. No prior available for comparison.
.
TELEMETRY demonstrated: NSR, HR 60's
.
2D-ECHOCARDIOGRAM performed on [**2107-9-10**] at [**Hospital **] Hospital
demonstrated: depressed left ventricular EF at 35-40% (no
official report available)
.
LABORATORY DATA (from OSH):
#1 CK 69, Trop 0.03
#2 CK 176, Trop 0.89
#3 CK 122, Trop 0.85
.
RADIOLOGY:
CXR ([**2107-9-11**]): cardiomegaly; left pleural effusion; mild
pulmonary vascular congestion without overt pulmonary edema;
tortuosity and narrowing of trachea noted
[**2107-9-13**] Carotid Ultrasound
Less than 40% stenosis of the internal carotid arteries
bilaterally. This is a baseline examination at the [**Hospital1 18**].
[**2107-9-13**] Thyroid ultrasound
1. Normal thyroid ultrasound.
2. Mass seen on recent CT not identified due to its retrosternal
location.
This could be further evaluated with non-contrast enhanced CT or
MRI.
[**2107-9-14**] ECHO
Pre Bypass: There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal for the
patient's body size. There is mild regional left ventricular
systolic dysfunction with mild septal and mid inferior
hypokinesis..The ascending aorta is mildly dilated. There are
complex (>4mm) atheroma in the aortic arch. The descending
thoracic aorta is mildly dilated. There are complex (>4mm)
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 appears
structurally normal with trivial mitral regurgitation. There is
a trivial/physiologic pericardial effusion.
Post Bypass: Preserved biventricular function. LVEF 50-55%.
Inferior wall motion slightly improved. Aortic contours intact.
Remaining exam unchanged. All findings discussed with surgeons
at the time of the exam.
[**2107-9-11**] CTA Chest
1. Superior mediastinal 3 cm mass, immediately contiguous with
the inferior aspect of the thyroid gland. Further evaluation
with thyroid son[**Name (NI) 867**] is recommended as clinically indicated.
The nodule is substernal and may be difficult to visualize
[**Name (NI) 79068**], however.
2. Intermediate attenuation 4.6 cm bulging along the contour of
the right
subscapularis muscle. Differential diagnosis would include a
mass such as a myxoma or elastofibroma or a cystic structure
such as a paralabral cyst or bursitis. As clinically indicated,
further evaluation with shoulder MRI is recommended.
3. Extensive coronary artery calcifications.
4. Tiny pulmonary nodules measuring 4 mm at the right lower lobe
adjacent to the major fissure and 3 mm in subpleural location
overlying the left lower lobe.
[**2107-9-12**] Cardiac Catheterization
1. Selective coronary angiography of this right-dominant system
revealed two-vessel coronary disease. The LMCA has no
angiographically-apparent stenoses. The LAD has a proximal,
hazy,
ulcerated 80% stenosis and a calcified 50% mid-vessel stenosis.
The LCX
has mild diffuse luminal irregularities with no flow-limiting
stenoses.
The RCA has a proximal chronic total occlusion with brisk
collateralization from the LCA.
2. Limited resting hemodynamics demonstrate moderate systemic
systolic
hypertension.
Brief Hospital Course:
Mr. [**Known lastname 79067**] was admitted to the [**Hospital1 18**] on [**2107-9-11**] via transfer
from [**Hospital 7188**] Hospital for further management of his cardiac
arrest. Cardiac catheterization showed multivessel coronary
disease. He was taken to the operating room on [**2107-9-14**] where
he underwent CABG x3. Please refer to Dr[**Doctor Last Name **] operative
report for further details. He was transferred to CVICU
intubated, hemodynamically stable. All lines and drains were
discontinued in a timely fashion. He was transferred to the SDU
for further tele monitoring and incresaed activity/ambulation.
Postoperative anemia was corrected with 1 unit of PRBCs and
diuresis. EP study on POD#6 showed VTach was not inducible. EP
reccommends to continue further beta-blocker, monitor
electrolytes until discharge, and repeat an echocardiogram at 3
months following discharge. During this admission Mr.[**Known lastname 79067**]
had hyperbilirubinemia. Right upper quadrant ultrasound was
performed and showed normal gallbladder, fatty liver, and
splenomegaly. The patient made excellent progress with physical
therapy, showing good strength and balance before discharge. By
the time of discharge on POD 7, the patient was ambulating
freely, the wound was healing and pain was controlled with oral
analgesics. He was discharged to home on POD#7.
Medications on Admission:
HCTZ 25 mg daily
Lexapro 10 mg daily
Amoxicillin PRN dental work
Ibuprofen 800 mg TID
Verapamil 240 XR daily (has not been filled since [**Month (only) 116**], per CVS)
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. 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*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
8. Zantac 150 mg Capsule Sig: One (1) Capsule PO once a day for
1 months.
Disp:*30 Capsule(s)* Refills:*0*
9. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
tba
Discharge Diagnosis:
CAD s/p CABGx3
HTN
OSA
Morbid obesity
Tobacco use
Cardiac arrest
Discharge Condition:
good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Gently pat the wound
dry. Please shower daily. No bathing or swimming for 1 month.
Use sunscreen on incision if exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks.
6) No driving for 1 month.
7) Call with any questions or concerns.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 1504**]
Please follow-up with Dr. [**Last Name (STitle) **] in 2 weeks.
Completed by:[**2107-9-21**]
|
[
"278.01",
"496",
"715.90",
"414.2",
"410.91",
"424.0",
"401.9",
"571.8",
"285.9",
"241.0",
"V43.65",
"414.01",
"305.1",
"427.41",
"327.23",
"518.89",
"782.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"88.56",
"39.61",
"88.53",
"37.22",
"37.26",
"36.15",
"99.04",
"36.12"
] |
icd9pcs
|
[
[
[]
]
] |
11199, 11233
|
8479, 9842
|
341, 555
|
11342, 11349
|
4029, 4029
|
12091, 12280
|
2818, 2857
|
10062, 11176
|
11254, 11321
|
9868, 10039
|
11373, 12068
|
2872, 2872
|
2894, 4010
|
283, 303
|
583, 2477
|
4046, 8456
|
2499, 2547
|
2563, 2802
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,427
| 176,586
|
49243
|
Discharge summary
|
report
|
Admission Date: [**2145-11-1**] Discharge Date: [**2145-11-9**]
Date of Birth: [**2079-7-26**] Sex: M
Service: #58
HISTORY OF PRESENT ILLNESS: The patient is a 66 year-old
male with history of hypertension and hyperlipidemia and a
remote history of angina who was free of symptoms on medical
management until early [**2145-8-15**] when the patient
developed an episode of chest pressure. The symptoms lasted
five to ten minutes and resolved. Since that time the
patient reports he has had frequent symtpoms of chest
discomfort. The patient was evaluated by a Persantine ETT,
which revealed moderate to severe fixed defects of the
lateral wall and the lateral portion of the inferior wall.
This was performed on [**2145-10-8**] with an ejection fraction of
33%.
PAST MEDICAL HISTORY: Silent myocardial infarction,
hypertension, hyperlipidemia, MRSA, rheumatic fever as a
child, orthostatic hypotension (status post surgery for
bladder cancer).
PAST SURGICAL HISTORY: Bladder cancer status post cystectomy
and prostatectomy approximately four years ago.
Postoperative course complicated by infection and
hospitalization requiring urostomy with dramatic improvement
in infection. The patient also has had basal cell cancer
excision.
ALLERGIES: No known drug allergies.
MEDICATIONS: Aspirin 325 mg po q day, Lipitor 10 mg po q
day, Atenolol 25 mg po q day, K-Dur 40 milliequivalents po q
day, Norvasc 2.5 mg po q day, Celexa 20 mg po q day, Ritalin
10 mg q.a.m. and 12 p.m., Colace 100 mg po b.i.d., ProAmatine
20 mg t.i.d. (recently cut back), Florinef recently stopped.
SOCIAL HISTORY: The patient is married, but on disability.
He has a supportive wife.
HOSPITAL COURSE: The patient was admitted to [**Hospital1 346**] on [**2145-11-1**] and had a cardiac
catheterization performed on [**2145-11-2**]. Findings included
LMCA stenosis of 70% distally, left anterior descending
coronary artery stenosis of 80% of the D2, left circumflex
occlusion 100% proximally with left to left collaterals the
two large bifurcating obtuse marginals, right coronary artery
stenosis of 95% complex proximally and 90% complex mid. The
patient was thereafter evaluated by cardiothoracic surgery
for a coronary artery bypass graft. After routine
preoperative preparation the patient was taken for coronary
artery bypass graft on [**2145-11-4**] where he had a four vessel
bypass with a left internal mammary grafted to the left
anterior descending coronary artery and the saphenous vein
graft to the diagonal, the right coronary artery and to the
obtuse marginal two. The patient was thereafter transferred
to the CSRU for continued monitoring and management. The
patient had an uneventful recovery in the CSRU and was
transferred to the Cardiothoracic Surgery Floor on postop day
number three. The patient similarly had an uncomplicated
recovery on the Cardiothoracic Surgery floor where physical
therapy was continued and discharge planning initiated. The
patient's pain was well controlled on Percocet by mouth and
the patient's blood glucose level was also well controlled on
a sliding scale insulin. The patient remained in normal
sinus rhythm throughout.
DISCHARGE CONDITION: Stable.
DISCHARGE MEDICATIONS: ______________ 20 mg po q day,
Atorvastatin 10 mg po q day, Percocet 5 one to two tablets po
q 4 to 6 hours prn, Motrin 400 mg po q 6 hours prn, Tylenol
325 to 650 mg po q 4 prn, enteric coated aspirin 325 mg po q
day, Ranitidine 150 mg po b.i.d., Colace 100 mg po b.i.d.,
potassium chloride 20 milliequivalents po b.i.d., Lasix 20 mg
po b.i.d.
FOLLOW UP: The patient is to follow up with Dr. [**Last Name (STitle) 70**]
six weeks following discharge. The patient is also to follow
up with his primary care physician in two to four weeks
following discharge.
DISCHARGE DIAGNOSIS:
Coronary artery disease requiring coronary artery bypass
graft.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Name8 (MD) 997**]
MEDQUIST36
D: [**2145-11-9**] 10:54
T: [**2145-11-9**] 11:21
JOB#: [**Job Number 103220**]
|
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"V02.59",
"401.9",
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icd9cm
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[
[
[]
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[
"88.56",
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"37.23",
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icd9pcs
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[
[
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3209, 3218
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3242, 3588
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3826, 4183
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1708, 3187
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995, 1603
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3600, 3805
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165, 787
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810, 971
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1620, 1690
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,376
| 166,341
|
48931
|
Discharge summary
|
report
|
Admission Date: [**2171-1-6**] Discharge Date: [**2171-2-7**]
Date of Birth: [**2095-9-28**] Sex: F
Service: MEDICINE
Allergies:
Bactrim / Tetracyclines / Vasotec / Isordil / Procardia / Hytrin
/ Catapres-Tts 1 / Coreg / Neurontin / Morphine Sulfate
Attending:[**First Name3 (LF) 2972**]
Chief Complaint:
Bilateral lower extremity ischemia with ulceration.
Major Surgical or Invasive Procedure:
-Right Common Iliac Artery / Right External Iliac Artery Stent
[**2171-1-7**]
-Left Carotid Endartarectomy [**2171-1-10**]
-Left Femoral to Popliteal Bypass [**2171-1-18**]
-Left IJ line placed [**2171-1-18**], resited to Right internal jugular
on [**2171-1-29**]. Right IJ catheter removed [**2171-2-6**].
History of Present Illness:
Admitted to vascular service for scheduled right common and
external iliac stent placement for LLE rest pain since [**Month (only) 1096**].
Past Medical History:
LM and three vessel CAD with DES to prox RCA in [**2164**]
Coronary artery bypass graft times four and mitral valve repair
on [**2169-7-26**]
Severe hypertension with Left Renal Artery Stenosis
TIA [**11-20**]
Dyslipidemia
Hypothyroidism
Chronic Kidney Disease (Baseline Cr 1.2-1.3)
Intermittent claudication
Obesity
Gout
Hiatal hernia
Uterine fibroids
Spine scoliosis and arthritis
Benign cartilage tumor, most probably an enchondroma
Severe spinal stenosis, diagnosed 4-5 years ago
Bilateral cataract surgery
R knee benign tumor resection
Social History:
Smoke: quit [**2124**]
EtOH: social
Drugs: never
Lives/works: with husband at home, no services currently. Used
to work in real estate. At baseline, prior to admission, she was
able to walk short distances without assistance and required a
wheelchair for prolonged activity.
Family History:
Mother had TIAs and a stroke at age 70, father died of "heart
disease" at age 56
Physical Exam:
Exam on admission [**2171-1-6**]:
PE: 98 65 170/55 20 100 RA
AAOX3 NAD
RRR
CTAB
soft NT/ND no edema
b/l mildly cool extrem, no tissue loss
RLE Fem MP PT MP DP MP
LLE Fem 2+ PT MP DP MP
no focal neuro deficits
Exam on discharge [**2171-2-7**]:
T99.4 HR 78 (64-79) BP 168/46 (155-170)/46-58
General: Alert, oriented x3, knows president, day of week, can
spell WORLD backwards, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple
Lungs: Diffuse ronchi bilaterally, bibasilar crackles, decreased
breath sounds L base, no wheezes. Occassional barking cough, no
supraclavicular or subcostal retractions
CV: Regular rate and rhythm, normal S1 + S2, 2/6 systolic murmur
at RUSB and LSB, no rubs or gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley in place
Ext: warm, well perfused, 1+ DP pulses bilaterally, trace foot
edema b/l
Neuro: CN II-XII intact, 5/5 strength in UE and LE bilaterally,
sensation to light touch intact and symmetric, slow speech and
mild word finding difficulty
Skin: well healing incision on L thigh and L groin, with some
mild erythema; groin incision with small area of dehiscence
(spoke to vascular surgery who feels wound is well healing and
staples were safely removed [**2171-2-7**] and steri strips placed).
Pertinent Results:
Labs on admission [**2171-1-6**]:
WBC-6.5 RBC-3.51* Hgb-10.6* Hct-32.2* MCV-92 MCH-30.3 MCHC-33.0
RDW-13.9 Plt Ct-179
PT-12.1 PTT-30.9 INR(PT)-1.0
Glucose-77 UreaN-35* Creat-1.4* Na-134 K-4.2 Cl-97 HCO3-26
AnGap-15
.
Labs on discharge [**2171-2-7**]:
142 101 21
-------------<97
3.2 31 1.5
Ca: 8.6 Mg: 1.9 P: 3.1
8.2 (MCV 90)
9.3>------<461
25.4
Iron studies:
[**2171-1-23**] Ret Aut-2.0
[**2171-1-26**] calTIBC-170* Hapto-304* Ferritn-826* TRF-131*
Most recent LFTs [**2171-1-26**]: ALT-26 AST-36 AlkPhos-116* TotBili-0.3
[**2171-2-3**] %HbA1c-5.7
MICRO:
[**2171-1-7**], [**2171-1-26**] MRSA screen negative
[**Date range (3) 102761**] BCx all negative
[**Date range (3) 102761**] UCx all negative
[**2171-1-26**] Sputum cx: no growth
[**2171-1-29**] Left IJ catheter tip: no growth
[**2171-1-31**] C diff negative
[**2171-2-5**] UCx: no growth
[**2171-2-5**] BCx (from R IJ): no growth to date
[**2171-2-6**] BCx (peripherally): no growth to date
[**2171-2-6**] Right IJ catheter tip: PRELIM: no significant growth
IMAGING:
[**2171-1-7**] Venous Duplex bilateral lower extremities/vein mapping:
Patent right greater saphenous vein from the ankle to the
saphenofemoral junction. Patent left greater saphenous vein from
the low thigh to the saphenofemoral junction. Patent left lesser
saphenous vein.
[**2171-1-7**] Carotid ultrasound:
1. 60-69% stenosis of the right internal carotid artery.
2. 70-79% stenosis of the left internal carotid artery.
[**2171-1-7**] CTA Head/Neck:
1. No acute intracranial findings with a stable head CT.
2. Approximately 70% stenosis of the proximal left internal
carotid artery, with approximately 60% stenosis of the proximal
right internal carotid artery. The extensive calcification
limits full evaluation of the luminal diameter.
3. Pulmonary findings as detailed which should be correlated
with clinical
findings and could be further evaluated with dedicated chest CT.
2D-ECHOCARDIOGRAM [**2171-1-23**]:
The left atrium is moderately dilated. The right atrium is
moderately dilated. No atrial septal defect is seen by 2D or
color Doppler. There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>55%). There is no ventricular septal defect. The
right ventricular free wall is hypertrophied. The right
ventricular cavity is moderately dilated with borderline normal
free wall function. There is abnormal septal motion/position.
The diameters of aorta at the sinus, ascending and arch levels
are normal. The aortic valve leaflets (3) are mildly thickened
but aortic stenosis is not present. No aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. There is
no mitral valve prolapse. Mild (1+) mitral regurgitation is
seen. [Due to acoustic shadowing, the severity of mitral
regurgitation may be significantly UNDERestimated.] The
tricuspid valve leaflets are mildly thickened. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion. IMPRESSION: Compared with the prior study (images
reviewed) of [**2169-11-20**], the RV size has probably increased.
[**2171-1-24**] Renal US:
1. No hydronephrosis.
2. The left kidney is smaller on today's exam than on prior
imaging. Bilateral cortical thinning is again noted. No renal
stones are identified.
3. Parvus tardus waveform in the main renal artery of the left
kidney and
only limited intraparenchymal arterial flow identified could be
consistent
with what the patient states is known left renal artery
stenosis. No renal
artery stenosis is seen in the right kidney.
Brief Hospital Course:
VASCULAR SURGERY and CARDIOVASCULAR ICU COURSE [**Date range (3) 102762**]:
75 yo F with PMHx of CAD s/p CABG in [**2168**], PVD, diastolic CHF,
CKD, past TIA, and HTN, who was admitted to the vascular service
[**2171-1-6**] for a previously scheduled right common and external
illiac stent placement due to LLE rest pain. The surgery was
uneventful but it was determined that pt would require left
fem-[**Doctor Last Name **] bypass as well. On afternoon after surgery [**2171-1-7**], code
stroke was called due to transient dysarthria and word finding
difficulties lasting approximately 45 minutes with severely
elevated BP. CT head negative for hemorrhage. This was felt to
be due to a Left ICA embolic event (similar to previous episode
where she was admitted for TIAs in [**2168**]). Patient was
transferred to the ICU for BP control, started on Heparin drip.
She was neurologically stable and symptoms gradually improved
with BP control. Patient had carotid dupplex in which there had
been some progression of stenosis, 60-69% stenosis of the right
internal carotid artery and 70-79% stenosis of the left internal
carotid artery since [**2170-6-13**]. It was noted at this time that
her creatinine was rising. Cardiology cleared pt for surgery and
left CEA was performed [**2171-1-10**]. She tolerated the procedure well
and was started in nitro drip for BP control. She remained
neurologically intact post-operatively. After surgery, she
remained hypertensive, on nitro drip and hydralazine IV PRN to
keep SBP<160.
.
On POD4, she began to work with physical therapy for possible
discharge. However, it was decided she would have left
femoral-popliteal bypass, which was performed [**2171-1-18**] for left
limb ischemia. She tolerated procedure well. She was given
post-op fluids and blood products and on [**2171-1-19**], developed
pulmonary edema and was transferred to the CVICU for BIPAP and a
lasix gtt. She had a good initial response on lasix drip which
was changed to IV lasix boluses. On [**2171-1-23**], pt developed fever
with T101.5 and CXR demonstrated pneumonia. She developed acute
renal failure on her CRI and renal was consulted for further
management. They felt acute renal failure was secondary to
hemodynamic changes and was of pre-renal etiology with tubular
damage. Predisposing factors included pt's diastolic
dysfunction, acutely wosening kidney function in setting of left
renal artery stenosis combined with uptitration of her ACE-I in
setting of hypertension. Her diuresis regimen was adjusted per
their recommendations. Her respiratory status has improved, but
she was still requiring oxygen 5L NC. Pt continued to have
fevers and antibiotics broadened to vancomycin/cefepime on
[**2171-1-24**] for presumed hospital acquired pneumonia.
.
On [**2171-1-25**], the patient was called out to the cardiology service
for further management. However, that night, she developed
hypoxia and SOB. Respiratory therapy suctioned thick secretions
and she was emergently intubated. The patient never lost
conciousness or pulses. Her blood pressures remained stable SBP
140-160's. She was then transferred to the MICU.
.
.
MICU COURSE [**Date range (1) 102763**]:
In the MICU hypoxic respiratory failure was atributed to HAP and
acute CHF. She received a total 8 days of vancomycin and zosyn
(changed from cefepime). Central line was resited given fevers.
She was initially on a lasix drip. Renal function improved and
she began auto-diuresing from ATN. She was easily extubated.
Lasix was stopped, and she was clinically improving. and ready
to go to the general medicine wards. Her blood pressure ranged
150-170. In that setting she went into flash pulmonary edema
requiring CPAP. After diuresis with lasix IV boluses (no drip),
she was able to be weaned to nasal cannula. Her
anti-hypertensive regimen was uptitrated to prevent
hypertension-induced flash pulmonary edema, which happened
multiple times when SBP reached ~175. She was called out to the
general medicine service for BP management with SBPs 160s and 4L
O2 requirement by NC.
.
.
FLOOR COURSE [**2171-2-2**] - Discharge [**2171-2-7**]:
# HTN - Pt's BP ranged from 140s-190s on transfer to medicine
service. Vascular surgery goal SBP 150s-160s to ensure perfusion
of lower extremities with stents. Her BP meds were uptitrated
and BP regimen on transfer to rehab was: Labetolol 600mg TID,
Amlodipine 10mg daily, Hydralazine 75mg PO q6H, Benazepril 20mg
[**Hospital1 **]. We also started Spironolactone 12.5mg daily. She still
occassionally required hydralazine 10mg IV for SBP>170 at time
of discharge. Consider increasing spironolactone to 25mg daily
if SBP>160 persists. SBP at time of discharge was 150s-170s.
.
# Pulmonary edema/diastolic CHF - Pt was diuresed with lasix IV
boluses (has good UOP to lasix 60mg IV) until she was felt to be
euvolemic. CXR demonstrated improvement in hilar congestion and
respiratory status remained stable. She was started on lasix
100mg PO BID at time of transfer to [**Hospital1 **]. Foley left in place to
monitor UOP. She was also given albuterol and ipratropium
nebulizers with good effect.
.
# Low grade fever - Pt was afebrile after HAP treatment.
However, on day prior to transfer to [**Name (NI) **], pt had low grade
fever 99.5-100.1 most likely due to atelectasis. She had no
localizing symptoms and no leukocytosis. Central line did not
appear infected but it was removed [**2171-2-6**] and tip cultured
without significant growth. Her stage 1 sacral ulcer did not
appear infected. Her groin and leg wounds were without evidence
of infection (confirmed by vascular surgery). UA negative for
UTI. CXR without new focal consolidation. No diarrhea to suggest
GI infection. BCx NGTD. No antibiotics were given. She was given
incentive spirometry and will benefit from rehab. If concern for
infection at [**Month/Day/Year **]/rehab, please call [**Hospital1 18**] Microbiology lab at
[**Telephone/Fax (1) 4645**] to obtain final culture data. We will continue to
follow cultures and will contact [**Name (NI) **]/rehab if any become
positive.
.
# Diarrhea - on transfer to floor, pt had small amts of
diarrhea. C. diff negative x1 and diarrhea resolved prior to
further samples being sent. [**Month (only) 116**] have been inflammatory reaction
to pneumonia/hospital course. Other bacterial or viral illnesses
were deemed less likely given that it developed while in the
hospital with limited exposures. Her diarrhea resolved and she
was mildly constipated on discharge. She was restarted on
docusate and senna.
.
# CAD - Pt had no chest pain on the floor. Her aspirin, beta
blocker, statin and plavix were continued.
.
# PVD - stable. Pt with warm extremities and good DP pulses.
Incision from fem-[**Doctor Last Name **] healing well. Vascular surgery followed
patient and deemed wounds were well healing at time of discharge
without evidence of infection. Staples were removed [**2171-2-7**] and
steri strips placed prior to discharge. She was continued on
aspirin, statin, plavix. She will follow up with Dr. [**Last Name (STitle) 1391**] as
below.
.
# CKD - Likely due to vascular disease. Acute renal failure
(peak creatinine 3.2 on [**2171-1-27**]) had resolved and creatinine
remained at baseline. Cr on discharge was 1.5 (baseline
1.2-1.5).
.
# s/p Stroke this admission - Remaining deficit is
slower/slightly slurred speech, word finding difficulty (Broca's
aphasia). No facial weakness on my exam but pt was noted to have
L sided facial weakness after stroke. Neuro exam upon discharge
is as above. Continue aspirin and statin and BP control. Pt will
f/u with Dr. [**Last Name (STitle) **] as below.
.
# Anemia- Hct remained stable 23-27 throughout hospitalization.
She did require occassional blood transfusions (9 total,
predominantly in perioperative periods). No evidence of
hemolysis on labs. Iron studies suggested anemia of chronic
disease. Guaiac negative. Pt should have full anemia workup as
outpatient upon discharge from rehab.
.
# Hypothyroidism - continue levothyroxine 200mcg daily.
.
# Deconditioning due to prolonged hospital course. PT
recommended rehab.
.
# Nutrition - pt had period of poor PO intake. On discharge, her
PO intake had improved. She will require continued monitoring of
nutritonal status through her recovery period.
.
# Code: FULL - confirmed with patient. Multiple code discussion
were initiated with patient and family given complications this
hospitalization. Pt chose to remain full code. Family supported
this decision.
.
# Emergency Contact: [**Name (NI) 4906**] [**Name (NI) 401**] [**Name (NI) 1968**] HCP [**Telephone/Fax (1) 102764**] (cell),
[**Telephone/Fax (1) 102765**] (home); Daughter ([**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7363**]) [**Telephone/Fax (1) 102766**]
Medications on Admission:
Medications on admission to hospital [**2171-1-6**]:
ALLOPURINOL 150 mg at bedtime
AMLODIPINE 5 mg [**Month/Day/Year **]
ATENOLOL 100 mg once a day
ATORVASTATIN 40 mg q pm
BENAZEPRIL [LOTENSIN] 20 mg twice a day
CLONIDINE 0.2 mg twice a day
CLOPIDOGREL 75 mg once a day
FUROSEMIDE 40 mg q Monday, Wednesday, Friday
LABETALOL 200 mg Tablet 2 in am, 2 in pm
LEVOTHYROXINE 200 mcg one Tablet once a day
VERAPAMIL 300 mg SR 1 qd
ASPIRIN 325 mg [**Month/Day/Year **]
DOCUSATE SODIUM 100 mg Capsule three times a day
MAGNESIUM 250 mg Tablet once a day
MULTIVITAMIN Tablet 1 [**Month/Day/Year 4962**]
Discharge Medications:
**Avoid ativan - makes patient delirious**
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
2. Furosemide 40 mg Tablet Sig: 2.5 Tablets PO BID (2 times a
day): Hold for SBP<120
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily):
Hold for SBP<120 or K>5.0
6. Benazepril 10 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day): Hold for SBP<120
7. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily):
Hold for SBP < 120
8. Hydralazine 25 mg Tablet Sig: Three (3) Tablet PO Q6H (every
6 hours): Hold for SBP<120
9. Ipratropium Bromide 0.02 % Solution Sig: One (1) inhalation
Inhalation Q6H (every 6 hours).
10. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) inhalation Inhalation Q4H (every 4
hours).
11. Guaifenesin 100 mg/5 mL Syrup Sig: Five (5) ML PO Q6H (every
6 hours) as needed for cough: Hold for confusion or sedation.
12. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day): Hold for RR<12 or sedation or confusion or MS
changes. .
13. HydrALAzine 10 mg IV Q6H:PRN SBP>170
14. Sodium Chloride 0.9% Flush 10 mL IV Q8H:PRN line flush
15. Labetalol 200 mg Tablet Sig: Three (3) Tablet PO TID (3
times a day): Hold for SBP<120 or HR<55.
16. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
19. Levothyroxine 200 mcg Tablet Sig: One (1) Tablet PO once a
day.
20. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
21. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for pain, fever.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Medical Center - [**Hospital1 3597**]
Discharge Diagnosis:
Primary diagnosis:
Hypertension
Bilateral lower extremity ischemia with ulceration
Pulmonary edema
Hospital acquired pneumonia
Acute kidney injury on chronic renal insufficiency
Anemia
Symptomatic left carotid artery stenosis
Diastolic CHF
Transient ischemic attack [**2171-1-7**]
Secondary diagnoses:
Coronary artery disease
Peripheral vascular disease
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Out of Bed with assistance to chair or
wheelchair
Stable, T99.4, SBP 150-170, HR 64-79, 94% 2L NC
Discharge Instructions:
Ms. [**Known lastname 1968**], you were admitted to [**Hospital1 18**] for stenting of your right
iliac arteries. You suffered a transient ischemic attack and
underwent a left carotid endarterectomy. You also had a left
femoral to popliteal bypass surgery. Your blood pressure was
elevated and you had fluid in your lungs requiring medications
to lower your blood pressure and make you urinate.
On discharge, there were MANY changes to your medications.
Please see your discharge medication list for your new
medications. STOP all home medications that are not on your new
medication list.
Division of Vascular and Endovascular Surgery
Carotid Endarterectomy Surgery Discharge Instructions
ACTIVITIES:
- [**Month (only) 116**] shower, pat dry your incision, no tub baths
- No driving till seen by Dr. [**Last Name (STitle) 1391**]
- No lifting heavy objects, suddent neck turns or excessive neck
bending and rotating
- Resume activities as tolerated, slowly incraese activiy as
tolerated
- Expect your activity level to return to normal slowly
DIET:
- Diet as tolerated, eat a well balanced meal
- Your appetite will take time to normalize
- Prevent constipation by drinking adequate fluid and eat foods
[**Doctor First Name **] in fiber, take stool softener while on pain medications
WOUND:
- You may have some swelling and feel a firm ridge along the
incision, slightly red and raised
- Keep your incision open to air
- Keep wound dry and clean, call if noted to have redness,
draining, or swelling, or if temp is greater than 101.5
WHEN TO CALL:
- Call the office or go to ED if you experience severe headache
that is not relieved by Tylenol, signs of TIA or stroke
(weakness/paralysis of any or all extremities, difficulty of
speech, facial drooping), difficulty of speaking, or swallowing.
OTHERS:
- You may have a sore throat and/or mild hoarseness
- Try warm tea, throat lozenges or cool/cold beverages
Division of Vascular and Endovascular Surgery
Lower Extremity Bypass Discharge Instructions
ACTIVITIES:
- ambulate essential distances until with Dr. [**Last Name (STitle) 1391**]
- Ace wrap leg from foot-knee when ambulating, to prevent
swelling
- Your operated leg is expected to have some swelling and will
resolve over time
- Elevate leg when sitting
- no driving till follow up
- may shower but do not scrub your incision (let water run over
it), pat dry your incisions, no tub baths
WOUND:
- Keep wound dry and clean, call if noted to have redness,
draining, swelling, or if temp is greater than 101.5
Followup Instructions:
MD: Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1391**]
Specialty: Vascular Surgery for f/u of multiple vascular
procedures
Date/ Time: [**2-27**] at 9:45am
Location: [**Hospital Ward Name 517**], [**Hospital Ward Name **] bldg, [**Location (un) 102767**]
Phone number: :([**Telephone/Fax (1) 4852**]
MD: Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Specialty: Neurology for f/u of stroke
Date/ Time: [**3-8**] at 2pm
Location: [**Hospital Ward Name **], [**Location (un) 8661**] 8
Phone number: [**Telephone/Fax (1) 2574**]
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8157**] M.D. (Dermatology)
Phone:[**Telephone/Fax (1) 1971**]
Date/Time:[**2171-8-6**] 11:00
Provider: [**First Name8 (NamePattern2) **] [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 3445**] MD (Neurology)
Phone:[**Telephone/Fax (1) 44**]
Date/Time: [**2171-8-21**] 1:00
|
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icd9cm
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[
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icd9pcs
|
[
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18198, 18278
|
6866, 15647
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432, 740
|
18676, 18676
|
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|
21451, 22393
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1781, 1864
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18897, 21428
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1879, 3224
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18602, 18655
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340, 394
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768, 909
|
18318, 18581
|
18691, 18873
|
931, 1473
|
1489, 1765
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,003
| 133,350
|
47628
|
Discharge summary
|
report
|
Admission Date: [**2188-3-3**] Discharge Date: [**2188-3-7**]
Date of Birth: [**2128-6-25**] Sex: F
Service: SURGERY
Allergies:
Bactrim / Iodine; Iodine Containing
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
Patient admitted for incisional hernia repair.
Major Surgical or Invasive Procedure:
Status Post Laparoscopic Incisional Hernia repair.
History of Present Illness:
59 year old female status post several abdominal surgeries who
now has discomfort related to hernias and wishes to have this
repaired.
Past Medical History:
1. History of hiatal hernia.
2. Heart murmur.
3. Coronary artery disease.
4. Colonic polyps.
5. Dyslipidemia.
6. Insulin-dependent diabetes [**First Name3 (LF) **] for which she is
followed at the [**Hospital **] Clinic.
7. Hypertension.
8. History of a car accident with rib fracture, "lung
puncture," and neck injury.
9. History of carotid stenosis.
10. Obstructive sleep apnea.
11. Recent respiratory infection, on antibiotics.
12. DJD/arthritis
Social History:
Socially, she does not smoke, drink, or use drugs. She is not
presently working, but she has been employed as a social worker
and corrections officer. She does have a history of tobacco
use.
She lives with her brother-in-law here in town.
Family History:
Family history is significant for "throat" cancer in four
relatives, diabetes [**Name2 (NI) **], hypertension, cervical cancer,
prostate cancer, breast cancer.
Physical Exam:
On examination, her temperature is 97.1, room air saturation is
98%, respirations 16, pulse 85, blood pressure 131/69. She is
alert, oriented, in no acute distress. Pupils are equal.
Sclerae are anicteric. Oropharynx is clear. Neck is supple
without lymphadenopathy, jugular venous distention, bruits,
thyromegaly, or nodules. Trachea is midline. Lungs are clear
to
auscultation bilaterally. Heart is regular. I hear no murmurs.
Abdomen is obese, soft, nontender, and nondistended. No
organomegaly or masses. She has a subcostal incision, a midline
incision as well as a lower transverse incision. I am not sure
that I am able to palpate any hernias. There is no
costovertebral angle or spinal tenderness. Extremities are
without clubbing or cyanosis. There is trace edema from foot to
mid shin. Her neurologic exam is nonfocal.
Pertinent Results:
[**2188-3-4**] 08:55AM BLOOD WBC-11.8*# RBC-4.31 Hgb-12.4 Hct-36.7
MCV-85 MCH-28.9 MCHC-33.9 RDW-15.1 Plt Ct-347
[**2188-3-6**] 05:55AM BLOOD WBC-13.7* RBC-4.17* Hgb-11.5* Hct-36.3
MCV-87 MCH-27.6 MCHC-31.7 RDW-14.5 Plt Ct-166
[**2188-3-4**] 10:04PM BLOOD Neuts-83.1* Lymphs-13.6* Monos-2.3
Eos-0.9 Baso-0.1
[**2188-3-4**] 08:55AM BLOOD Glucose-176* UreaN-15 Creat-2.0* Na-136
K-5.1 Cl-101 HCO3-26 AnGap-14
[**2188-3-6**] 05:55AM BLOOD Glucose-104 UreaN-8 Creat-0.6 Na-135
K-3.8 Cl-98 HCO3-32 AnGap-9
[**2188-3-4**] 10:04PM BLOOD CK(CPK)-463*
[**2188-3-4**] 08:55AM BLOOD Calcium-8.4 Phos-4.9* Mg-1.5*
[**2188-3-6**] 05:55AM BLOOD Calcium-8.4 Phos-3.0 Mg-1.6
Brief Hospital Course:
Patient admitted and underwent laparoscopic incisional hernia
repair with mesh. She tolerated the procedure very well. On
postoperative day one her urine output decreased and her
creatinine rose to 2.2. She was bolused with intravenous fluids,
renal service was consulted and she was monitored closely in the
intensive care unit. With fluids her urine output picked up and
her creatinine dropped back to baseline. On postoperative day
two she was started on clear liquids and resumed her lasix.
Currently she is tolerating a regular diet, passing gas and has
good pain control with oral narcotics. We will discharge her to
home with follow up with Dr. [**Last Name (STitle) **] and have instructed her
to follow up with her primary care and endocrinologist.
Medications on Admission:
asa 325mg daily
lasix 20mg daily
tums as needed
famotidine 20mg daily
lisinopril 20mg daily
hctz 25mg daily
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q6H (every 6 hours) as needed.
Disp:*400 ML(s)* Refills:*0*
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed.
5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
Disp:*60 Capsule(s)* Refills:*0*
8. Diabetic Regimen
Please continue your glargine insulin as previously prescribed.
Check your fingerstick bloodsugars 4x a day and log. Please
follow up with your endocrinologist in one week.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Incisional Hernia
Discharge Condition:
Stable
Discharge Instructions:
You are being discharged on medications to treat the pain from
your operation. These medications will make you drowsy and
impair your ability to drive a motor vehicle or operate
machinery safely. You MUST refrain from such activities while
taking these medications.
Please call your doctor or return to the emergency room if you
have any of the following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
Activity:
No heavy lifting of items [**10-16**] 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:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9325**], MD Phone:[**Telephone/Fax (1) 274**]
Date/Time:[**2188-3-21**] 2:30
Please follow up with your endocrinologist and primary care
physician.
Completed by:[**2188-3-7**]
|
[
"568.0",
"E878.8",
"584.9",
"V58.67",
"250.00",
"401.9",
"553.21",
"428.33",
"428.0",
"327.23",
"272.4",
"V45.86"
] |
icd9cm
|
[
[
[]
]
] |
[
"53.62",
"54.51"
] |
icd9pcs
|
[
[
[]
]
] |
4787, 4793
|
3031, 3792
|
340, 393
|
4874, 4883
|
2348, 3008
|
6476, 6728
|
1306, 1467
|
3950, 4764
|
4814, 4814
|
3818, 3927
|
4907, 6107
|
1482, 2329
|
254, 302
|
6119, 6453
|
421, 557
|
4833, 4853
|
579, 1030
|
1046, 1290
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,816
| 160,315
|
10593+56165
|
Discharge summary
|
report+addendum
|
Admission Date: [**2182-4-9**] Discharge Date: [**2182-4-27**]
Date of Birth: [**2126-10-24**] Sex: M
Service: MEDICINE
Allergies:
Cefepime / Demerol
Attending:[**First Name3 (LF) 6169**]
Chief Complaint:
fever, chills
Major Surgical or Invasive Procedure:
PICC placement
Induced Sputum
History of Present Illness:
55yoWM with h/o hypocellular MDS presenting with fevers. MDS was
diagnosed in [**6-/2180**] and initially treated with danazol and
aranesp. In [**6-/2181**] patient was hospitalized for bilateral lung
aspergillus infection and enterobacter bacteremia. Port-o-cath
placed [**8-/2181**] with three subsequent hospitalizations for line
infection, including discharge [**2181-12-14**] with Staph epi
infection. Most recent admission was [**Date range (1) 34838**]/05 with pneumonia
and bacteremia with Stenotrophomonus treated with a course of
bactrim and port-o-cath removal. During this course, pulmonary
nodules were visualized and the patient was treated empirically
with voriconazole
.
The patient has had fevers since Sunday evening. He complains
of myalgias and has had a slight headache at the top of his head
since onset of fevers. He denies photophobia or irritability,
and has only positional neck stiffness. He has some DOE w/stairs
(this is chronic). He admits slight burning with urination and
increased frequency of urination until today. His ROS is
otherwise negative.
.
On laboratory examination, he was found to have + Cx w/coag
negative staph in both urine and blood. He spiked to 103 in
clinic and was treated with vancomycin 1 gram at 12:20pm,
meropenem 1 gram at
4:00pm and bactrim ds 1 tab po at 4:00pm. he was given tylenol
at
2:00pm and hydrocortisone 100mg ivp at 3:45pm. He was given
1.25L IVF.
Past Medical History:
- Myelodysplastic syndrome first diagnosed [**2180-6-13**], treated
with danazol and aranesp. S/P four courses of 5-azacytidine
- Prior hospitalization complicated by Afib
- Hypertension
- Remote history of kidney stones
-Hx Sweet's syndrome
Social History:
Lives at home with wife. Employed as consultant in the
broadcast industry. tob: previous hxEtOH: none since [**2159**]
Family History:
father had prostate cancer in 80's, died of other causes
grandmother had breast cancer
Physical Exam:
101.9 81 20 90/62 95RA
NAD
Neck Supple, no LAD, PERRLA, M&O moist and clear
CTAB
Nl S1/S2
Soft, NT, ND, NABS; no CVAT
Warm x 4 w/pulses X 4
Petichae noted R ankle, no rashes
CNII-XII intact, nl ambulation, nl speech
Pertinent Results:
Admission Labs:
--------------
CBC: WBC-0.3 Hct-28.8* MCV-91 MCH-31.9 MCHC-35.0 RDW-18.6* Plt
Ct-41
*
Diff: Neuts-4* Bands-0 Lymphs-92* Monos-0 Eos-0 Baso-0 Atyps-4*
Metas-0 Myelos-0
*
CHEM: Glucose-110* UreaN-18 Creat-1.0 Na-137 K-4.9 Cl-99 HCO3-31
Albumin-3.5 Calcium-9.9 Mg-1.6
*
LFT's: ALT-25 AST-16 LD(LDH)-129 AlkPhos-131* TotBili-0.7
DirBili-0.2 IndBili-0.5
*
U/A: BLOOD-SM NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG
BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG URINE RBC-0 WBC-2
BACTERIA-NONE YEAST-NONE EPI-<1
*
Radiologic Studies-
-----------------
[**4-9**] CXR: Interval development of new left lower lobe
consolidation. Resolution of previously seen left upper lobe
consolidation and near complete resolution of the previously
seen right lower lobe pneumonia
*
[**4-13**] Chest CT:
1) No pulmonary embolism.
2) Multifocal pneumonia, mostly in the upper lobes of both
lungs. Bilateral small pleural effusions
*
[**4-15**] CXR: Worsening multifocal pulmonary opacities within the
upper and mid lung zones.
*
[**4-12**] ECHO: [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 5660**] dilated. LV wall thicknesses and cavity
size are normal. There is mild global LV hypokinesis. RV chamber
size and free wall motion are normal. Normal AV. Trace AR.
Normal MV, w/ trivial MR. Moderate pulmonary artery systolic
hypertension. There is no pericardial effusion.
Compared with the prior study (tape reviewed) of [**2181-12-20**], mild
global
hypokinesis is now suggested (without regionality) and increased
pulmonary artery systolic hypertension.
*
Microbiolic Data:
----------------
Blood Culture [**4-11**]- [**4-21**]: No growth to date
Blood Culture [**4-10**]: 1 out of 2 bottles + for Coag Neg Staph
Blood Culture [**4-9**]: 2 out of 4 bottles + for Coag Neg Staph
Blood Culture [**4-8**]: 2 our of 2 bottles + for Coag Neg Staph
*
Urine Culture [**4-8**]: >100,000 Coag Neg Staph
*
Induced Sputum [**4-13**]: GRAM STAIN-
[**10-8**] PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI IN PAIRS.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
*
RESPIRATORY CULTURE (Final [**2182-4-15**]): SPARSE OP FLORA.
*
LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.
*
IMMUNOFLUORESCENT TEST FOR PNEUMOCYSTIS CARINII (Final
[**2182-4-15**]): PNEUMOCYSTIS CARINII NOT SEEN.
*
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
*
ACID FAST SMEAR (Final [**2182-4-15**]): NO AFB SEEN ON DIRECT SMEAR.
*
[**4-13**] Nasal Wash Aspirate: Negative
*
[**4-14**] Induced Sputum: Negative for AFB, Fungus
Brief Hospital Course:
55 year old man with MDS who was initially admitted with febrile
neutropenia and coag + staph blood cultures (micrococcus sp.),
who was subsequently transferred to the ICU for increasing
respiratory distress and multi-focal pneumonia. A brief
[**Hospital 11822**] hospital course is outlined below.
1. Respiratory Distress/Multi-focal pneumoina- Mr. [**Known lastname 34834**] was
found to have a multi-focal pneumonia by chest x-ray. His
respiratory distress was felt secondary to this underlying
process and he was treated with broad antibiotics given his
neutropenic status. Of note, chest CT had also been performed
and was negative for PE. Ultimately he was placed on vancomycin
(gram positive coverage), meripenem (gram negatives/anaerobes),
azithromycin (atypicals) and caspofungin/voriconazole (fungal)
empiric coverage. He was also initially placed on treatment dose
bactrim empirically for PCP. (He also had a history of
stenotrophomonas VAP for which bactrim would be the treatment of
choice). Induced sputum cultures returned negative for PCP, [**Name10 (NameIs) **]
continuation of bactrim was not felt indicated per ID
recommendations. Initial thought had been given to intubation to
help with oxygenation and for diagnostic bronchoscopy, however
the patient adamantly requested not to be intubated if at all
possible (although he was maintained as Full Code as he would
want intubation if needed emergently). He was maintained on
aggressive oxygen support with NRB face mask with maintainence
of O2 sats >93%. Throughout this initial stage, he appeared
fairly well clinically, without persistent fever, chills or
shortness of breath. His breathing remained unlabored despite
his high O2 requirement. Serial ABG's showed persistent PaO2's
>50% (after initial PaO2 of 44%) with stable CO2 ranging from
42-48 and pH ranging from 7.40-7.47. Subsequently, he did begin
to have more subjective dyspnea with desaturations requiring
non-invasive positive pressure ventilation. Repeat CXR at this
time showed worsening multi-focal pneumonia. However, his CXR
still seemed out of proportion to his clinical status.
Unfortunately all sputum cultures had returned negative, so we
were unable to tailor therapy appropriately. It was felt that
broad antibiotic coverage should continue since the differential
remained broad, however fungal etiology was highly suspected, as
was possible gram positive pneumonia (especially given positive
blood and urine cultures for MRSE). Therefore he was placed on
double anti-fungal coverage as outlined above. Vanco dose was
tapered up for goal trough levels of 20 for greater pulmonary
penetration. His respiratory status did slowly begun to improve.
He was weaned back off of positive pressure support, and then
off of NRB face mask, with maintenance of oxygenation on nasal
cannulation upon transfer back to the bone marrow transplant
service on [**4-21**]. He continued to improve on the [**Month/Day (4) 3242**] floor, with
diuresis progressing successfully with lasix prn, and with O2
requirement improving despite a lack of radiologic improvement
on repeat CT scan. Given his clinical improvement, and given
the volume that his many IV abx presented, and given his lack of
positive cultures after [**4-10**], it was decided to change him to
the following, emperic, abx. regimen, on which he was sent home:
Vancomycin IV, Clindamycin PO, Bactrim PO, Acyclovir PO, and
Flagyl PO (which was added given loose stools on the day of D/C
over concerns for C. Diff Colitis development on Clindamycin).
Stools were sent for C. Diff toxin before D/C and will be
followed as outpatient.
# Coag Negative Staph UTI/Bacteremia - Mr. [**Known lastname 34834**] [**Last Name (Titles) 1801**]
presented with fever and neutropenia, with positive urine and
blood cultures for coagulase negative staph. He was started on
empiric antibiotic therapy with Vancomycin and final
sensitivites returned methicillin resistant. His last positive
blood culture was from [**4-10**] and all subsequent blood cultures
remained negative. Trans-thoracic ECHO was performed and showed
no vegitations. Of note, he had no line in place at time of
initial positive blood culture. PICC line was subsequently
placed for access once blood cultures were negative for greater
than 48 hours. He was sent home on an empiric course of 7 days
of Vancomycin given at 1.5 grams q 12 hours.
# Altered Mental Status: The patient developed transient
confusion and disorientation, which was felt likely secondary to
medications and ICU delerium. His ambien was discontinued and he
was treated with olanzapine prn for agitation. His mental status
subsquently improved.
# Tachycardia- He developed transient episodes of sinus
tachycardia to the 110's in the ICU. This was felt likely
secondary to volume depletion in the setting of low blood
pressures in the 90-100 systolics and recent auto-diuresis of 2
liters over the previous day. The tachycardia improved somewhat
with IVF hydration. In addition, he was given 2 units of pRBCs
for his anemia, which also could have been precipitating his
tachycardia. Of note, he remained asymptomatic without chest
pain, shortness of breath or palpiations. His tachycardia
subsequently resolved.
#MDS- Noted hypoplastic MDS. He has been treated with 5-AZA
chemotherapy, which is currently on hold. He is also on standing
prednisone at 40mg daily. He remained neutropenic and
transfusion dependent for red blood cells and platelets. His
counts were monitored daily.
# CHF- EF 40% (from [**4-12**] TTE). Continued on ACE-I, Lasix prn.
Medications on Admission:
Neulasta and aranesp QOW last [**4-5**]
Desferal QW last [**4-2**]
Vidaza on hold
Prednisone 5mg QD
Lasix 20mg PO QD
Levoflox 500 QD
Fluconazol 200mg PO QD
Acyclovir 400mg [**Hospital1 **]
Atenolol 12.5-25 PRN per pt
nexium 40mg PRN
Oxacepam 10mg PRN
MVI
Lactulose PRN
Zofran PRN
Compazine PRN
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **]
Discharge Diagnosis:
MDS
Discharge Condition:
Stable
Discharge Instructions:
Take all medications as prescribed
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 6175**], MD Where: [**Hospital6 29**]
HEMATOLOGY/[**Hospital6 3242**] Phone:[**Telephone/Fax (1) 3237**] Date/Time:[**2182-4-29**] 12:00
Provider: [**Name10 (NameIs) 3242**] CHAIR 6 Date/Time:[**2182-4-29**] 9:00
Provider: [**First Name8 (NamePattern2) 539**] [**Last Name (NamePattern1) 9816**], RN Where: [**Hospital6 29**]
HEMATOLOGY/[**Hospital6 3242**] Phone:[**Telephone/Fax (1) 3241**] Date/Time:[**2182-4-29**] 9:00
****[**Doctor Last Name **] [**Doctor Last Name 15378**], Infectious Disease Clinic. Tuesday, [**5-7**].
9:30 AM.
Call [**Telephone/Fax (1) 457**] for directions
Name: [**Known lastname 6197**],[**Known firstname **] Unit No: [**Numeric Identifier 6198**]
Admission Date: [**2182-4-9**] Discharge Date: [**2182-4-27**]
Date of Birth: [**2126-10-24**] Sex: M
Service: MEDICINE
Allergies:
Cefepime / Demerol
Attending:[**First Name3 (LF) 6199**]
Addendum:
Discharge medications as follows, and 500 mg po Flagyl q 8 hours
for 10 days.
Discharge Medications:
1. Vancomycin HCl 1,000 mg Recon Soln Sig: 1500 (1500) mg
Intravenous Q12H (every 12 hours) for 7 days.
Disp:*[**Numeric Identifier 6200**] mg* Refills:*0*
2. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
3. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*0*
5. Clindamycin HCl 150 mg Capsule Sig: Three (3) Capsule PO Q6H
(every 6 hours).
Disp:*360 Capsule(s)* Refills:*2*
6. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO HS:PRN.
Disp:*20 Tablet(s)* Refills:*0*
7. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours).
Disp:*120 Capsule(s)* Refills:*2*
8. 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*
9. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
10. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q 8 hour
prn as needed for constipation.
Disp:*24 ML(s)* Refills:*1*
11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for fever.
Disp:*60 Tablet(s)* Refills:*0*
12. Voriconazole 200 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours).
Disp:*60 Tablet(s)* Refills:*2*
13. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*15 Tablet(s)* Refills:*2*
14. Lorazepam 1 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours.
Disp:*30 Tablet(s)* Refills:*2*
15. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours.
Disp:*20 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6201**] MD [**MD Number(2) 6202**]
Completed by:[**2182-4-27**]
|
[
"518.81",
"428.0",
"427.31",
"695.89",
"293.0",
"238.7",
"482.89",
"276.5",
"790.7",
"427.89",
"401.9",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.05",
"99.15",
"99.04",
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] |
icd9pcs
|
[
[
[]
]
] |
14193, 14397
|
5132, 9534
|
293, 324
|
11146, 11154
|
2542, 2542
|
11237, 12335
|
2199, 2287
|
12358, 14170
|
11119, 11125
|
10732, 11028
|
11178, 11214
|
2302, 2523
|
4915, 5109
|
240, 255
|
352, 1778
|
2558, 4885
|
9549, 10706
|
1800, 2043
|
2059, 2183
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,352
| 104,747
|
38707
|
Discharge summary
|
report
|
Admission Date: [**2201-3-7**] Discharge Date: [**2201-3-8**]
Date of Birth: [**2150-2-18**] Sex: M
Service: MEDICINE
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
STEMI, CARDIOGENIC SHOCK
Major Surgical or Invasive Procedure:
PCI
Thrombectomy
Impella Placement
Central [**Doctor First Name **] Line Placement x 2
History of Present Illness:
51 yo M with 3V CAD, previously stented to LAD at OSH in setting
of MI, presents from [**Location (un) **] with CP, nausea and SOB similar
(but worse) to prior MI. Initially EKG within normal limits, but
was having ectopy, eventually EKG showed anterior ST elevations
and he was given aspirin, heparin, plavix and IIb/IIIA, his BP
dropped to the 100s he was given neosynpephrine.
.
He was transfered to [**Hospital1 **] for catheterization. He was taken
immediately to the cath lab, initially not intubated. Pt vomited
early but no clear aspiration noted. An IABP pump was placed. He
was found to have an acute in stent thrombosis, successfully
cleared. Pt developed VF arrest, CPR was initiated, he was
shocked to brady rhythm for which he was given 3mg of atropine.
Nadir ABG revealed 6.96/52/236, HCO3 13, Lactate 10. He was
intubated and
initially there was some small amounts of red frothy return from
the ETT. IABP was replaced by Impella and required high doses of
levophed and dopamine. Oxygenation worsened down to 70s and PEEP
increased to 18 with improvement of O2 to 80s. Did not respond
to increased tidal volumes to 750 and RR to 28, so pt paralyzed.
Received total of 400mg IV lasix and began improving oxygenation
with urine output. Pt started on amio with reduction of ectopy.
.
ROS unable to be obtained due to intubation/sedation.
.
Past Medical History:
1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension, Diabetes
2. CARDIAC HISTORY:
-PERCUTANEOUS CORONARY INTERVENTIONS: LAD stenting in
[**Location (un) 5622**]
3. OTHER PAST MEDICAL HISTORY: DM
HTN
HL
Morbid obesity
CAD s/p stenting in [**Location (un) **]
no known lung disease
Social History:
married with children and adoptive children. Unknown t/e/d
Family History:
unknown
Physical Exam:
GENERAL: WDWN, intubated.
HEENT: NCAT. Sclera anicteric. Dilated Pupils.
NECK: Supple with JVP of *** cm.
CARDIAC: Distant, uncharacterizable heart sounds
LUNGS: vetned + BS bilaterally, anterior exam only and
clear.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: Cool, blue extremities with 7 second cap refill in
feet, [**3-11**] in hand
Pertinent Results:
CBC
[**2201-3-7**] 08:10AM BLOOD WBC-18.5* RBC-5.19 Hgb-15.2 Hct-46.1
MCV-89 MCH-29.2 MCHC-32.9 RDW-14.2 Plt Ct-340
[**2201-3-7**] 03:00PM BLOOD WBC-40.3*# RBC-5.12 Hgb-14.9 Hct-46.7
MCV-91 MCH-29.0 MCHC-31.8 RDW-14.5 Plt Ct-496*
[**2201-3-7**] 10:01PM BLOOD Hgb-14.2 Hct-43.0 Plt Ct-403
INR
[**2201-3-7**] 08:10AM BLOOD PT-13.8* PTT-150* INR(PT)-1.2*
[**2201-3-8**] 03:54AM BLOOD PT-24.1* PTT-74.4* INR(PT)-2.3*
CHEM
[**2201-3-7**] 08:10AM BLOOD Glucose-198* UreaN-16 Creat-1.4* Na-138
K-4.9 Cl-104 HCO3-21* AnGap-18
[**2201-3-8**] 03:54AM BLOOD Glucose-479* UreaN-31* Creat-3.7*# Na-135
K-6.0* Cl-102 HCO3-12* AnGap-27*
CARDIAC
[**2201-3-7**] 08:10AM BLOOD CK-MB-17* MB Indx-6.6* cTropnT-0.07*
[**2201-3-7**] 03:00PM BLOOD CK-MB-GREATER TH cTropnT-22.9*
[**2201-3-7**] 10:01PM BLOOD CK-MB->500
[**2201-3-7**] 03:00PM BLOOD ALT-255* AST-864* CK(CPK)-[**Numeric Identifier 85991**]*
AlkPhos-78 TotBili-1.1
[**2201-3-7**] 10:01PM BLOOD CK(CPK)-[**Numeric Identifier **]*
[**2201-3-8**] 03:54AM BLOOD CK(CPK)-[**Numeric Identifier 85992**]*
ABG
[**2201-3-7**] 08:28AM BLOOD Type-ART pO2-68* pCO2-38 pH-7.29*
calTCO2-19* Base XS--7 Intubat-NOT INTUBA
[**2201-3-7**] 09:28AM BLOOD Type-ART pO2-236* pCO2-52* pH-6.96*
calTCO2-13* Base XS--21 Intubat-INTUBATED Vent-CONTROLLED
[**2201-3-8**] 04:07AM BLOOD Type-ART pO2-117* pCO2-34* pH-7.19*
calTCO2-14* Base XS--14
Brief Hospital Course:
Pt arrived in cardiogenic shock requiring escalating doses of
pressors (dopa, levo and vasopressin). He had an impella placed.
His wife flew in from PA.
A family meeting was held where goals were outlined. The wife
was clear that the patient would not want to live on a
ventillator; she and her children agreed that we would try to
support him and see if he could turn around.
Mr. [**Known lastname **] was anuric, profoundly acidemic, febrile to 104; he
had ischemic digits and his backside was entirely unperfused. He
was in lactic adisosis and diabetic ketoacidosis. His rhythm was
a sinus tachycardia to 150, later in RBBB and when most
acidotic, a ventricular/junctional rhythm. He was dependent on
122 units/hour insulin and a bicarb drip with regular boluses.
He had three seperate blood draws with MB fractions greater than
500.
As his rhythm deteriorated, with his wife in the room, a
decision was reached to withdraw care. His children gave their
farewells and his pressors were stopped. He passed immediately
thereafter.
Medications on Admission:
unknown
Discharge Medications:
deceased
Discharge Disposition:
Expired
Discharge Diagnosis:
deceased
Discharge Condition:
deceased
Discharge Instructions:
deceased
Followup Instructions:
deceased
Completed by:[**2201-3-8**]
|
[
"414.01",
"250.12",
"278.01",
"593.9",
"288.60",
"272.4",
"427.41",
"788.5",
"414.2",
"518.81",
"996.72",
"518.4",
"426.4",
"401.9",
"V45.82",
"427.1",
"785.51",
"410.11",
"E878.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.95",
"99.60",
"97.44",
"37.61",
"96.71",
"96.04",
"88.72",
"37.23",
"00.66",
"37.68",
"00.40",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
5154, 5163
|
4027, 5063
|
318, 406
|
5215, 5225
|
2639, 4004
|
5282, 5320
|
2186, 2195
|
5121, 5131
|
5184, 5194
|
5089, 5098
|
5249, 5259
|
2210, 2620
|
1893, 1973
|
254, 280
|
434, 1789
|
2004, 2094
|
1811, 1873
|
2110, 2170
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,982
| 108,019
|
15235
|
Discharge summary
|
report
|
Admission Date: [**2127-8-16**] Discharge Date: [**2127-8-27**]
Date of Birth: [**2067-5-30**] Sex: M
Service: GENERAL SURGERY
HISTORY OF PRESENT ILLNESS: The patient is a 60-year-old
male who was transferred from [**Hospital6 33**] with an
incarcerated umbilical hernia. The patient reports that his
abdominal pain began at 10 A.M. on the day prior to
admission, was constant, and was unable to be reduced. The
patient experienced vomiting prior to admission. There were
no fevers or chills. The patient presented to the outside
hospital, was evaluated, and was subsequently transferred to
[**Hospital1 69**] for operative
management.
PAST MEDICAL HISTORY: Significant for alcohol use and
ascites.
MEDICATIONS: None.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: No family history of hernia.
SOCIAL HISTORY: The patient reports a past history of
tobacco use. Past and current history of alcohol use, up to
two pints per day.
PHYSICAL EXAMINATION: On examination, the temperature was
99.6, heart rate was 100, blood pressure was 130/60. In
general, the patient was a morbidly obese male. Examination
of the head revealed pupils that were equal, round and
reactive to light, extraocular movements were intact. The
oral mucosa was dry. The neck was supple. Pulmonary
examination revealed lungs clear to auscultation bilaterally.
Cardiac examination revealed a regular rate and rhythm. On
examination of the abdomen, the abdomen was found to be
obese, tender, and firm at the umbilicus, with the hernia
unable to be reduced. There was no costovertebral angle
tenderness. Extremities were unremarkable for cyanosis,
clubbing or edema. There was no rash on the skin.
LABORATORY DATA: On admission, white blood cell count was
8.3, hematocrit was 42.9, platelet count was 216. PT was
12.4, PTT was 22.3, INR was 1.1. Glucose was 164, BUN was
21, creatinine 0.6, sodium 139, potassium 3.6, chloride 95,
bicarbonate 29.
HOSPITAL COURSE: The patient was admitted and taken to the
operating room, where a reduction of the incarcerated ventral
hernia and a segmental small bowel resection were performed,
along with a partial omentectomy and primary repair of the
ventral hernia. Please see the operative note for details.
Following the procedure, the patient was transferred to the
recovery room with subsequent transfer to the Surgical
Intensive Care Unit. On postoperative day one, the patient
was on CPAP ventilation and was kept sedated. He was placed
on an insulin drip for glycemic control. Perioperative
antibiotics included Zosyn, levofloxacin and Flagyl.
On postoperative day four, the patient continued on CPAP
ventilation. The patient was febrile to 101.1. On
postoperative day four, antibiotics were switched to
Cephazolin. The patient continued to be on mechanical
ventilation, still with elevated temperature.
On postoperative day six, the patient was found to be still
febrile the night before, but was found to be more awake and
following commands. The patient was continued on Kefzol.
Total parenteral nutrition was started in the unit for
nutrition. On postoperative day six, antibiotics were
changed, and ceftriaxone and oxacillin were started. The
patient was extubated and was found to be doing well. The
patient was still febrile, with a white count of 12.5.
By postoperative day eight, the nasogastric tube had been
discontinued. A sitter was assigned to the patient for
safety. The patient had been found sitting on the floor, out
of bed. The patient was subsequently transferred to the
floor.
On postoperative day nine, the patient continued on
ceftriaxone and oxacillin. The patient was found to be doing
well, running a low-grade temperature of 100.0, but
tolerating a regular diet. Ceftriaxone was discontinued.
The patient was screened for rehabilitation, and discharge
planning was arranged for transfer to a rehabilitation
facility on [**8-27**].
DISCHARGE MEDICATIONS:
1. Pantoprazole 40 mg by mouth once daily
2. Nicotine patch 21 mg transdermally once daily
3. Metoprolol 12.5 mg by mouth twice a day
4. Oxacillin 2 grams intravenously every six hours
5. Silver sulfadiazine one application to skin on back three
times a day
6. Dilaudid 2 to 6 mg intravenously every one to two hours
as needed for pain
7. Heparin 5000 units subcutaneously every eight hours
CONDITION AT DISCHARGE: Good.
DISCHARGE STATUS: Discharged to rehabilitation facility.
DISCHARGE DIAGNOSIS:
1. Incarcerated ventral hernia
2. Infarcted omentum and small bowel
3. Status post reduction of incarcerated ventral hernia with
segmental small bowel resection, partial omentectomy, and
primary repair of ventral hernia
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2213**], M.D. [**MD Number(1) 2214**]
Dictated By:[**Last Name (NamePattern1) 44338**]
MEDQUIST36
D: [**2127-8-27**] 03:18
T: [**2127-8-27**] 03:55
JOB#: [**Job Number 24702**]
|
[
"557.0",
"552.20",
"518.0",
"276.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.4",
"38.93",
"99.15",
"53.59",
"45.62"
] |
icd9pcs
|
[
[
[]
]
] |
804, 834
|
3972, 4381
|
4483, 4987
|
1988, 3949
|
993, 1970
|
4396, 4462
|
177, 663
|
686, 787
|
851, 970
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,638
| 136,238
|
15381
|
Discharge summary
|
report
|
Admission Date: [**2179-10-26**] Discharge Date: [**2179-11-6**]
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:
Increasing Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
71-year-old woman with advanced end-stage ischemic
cardiomyopathy with severe left ventricular contractile function
with LVEF of 10%, atrial fibrillation, [**Hospital1 **]-V ICD, CKD, with past
history of DVT, PE on Coumadin who presents with increasing
dyspnea. The patient was recently discharged from [**Hospital1 18**] CCU on
[**9-22**] for CHF exacerbation and was discharged to rehab facility.
Since that time, patient was hospitalized at [**Location (un) **] two weeks
ago for pneumonia.
The patient reports that over the past week, the patient has had
increasing dyspnea with exertion. At baseline, patient is unable
to perform ADLs without the assistance of physical therapy. Over
the past week, there has been a noticible worsening in her
physical limitations. The patient recently saw Dr. [**First Name (STitle) 437**] as an
outpatient and had her dose of Torsemide increased from 20mg to
40mg and Carvedilol was discontinued and switched to Metoprolol
tartrate 12.5mg [**Hospital1 **].
Patient was taken to [**Hospital **] hospital for initial evaluation and
was given another dose of torsemide 40mg x 1 and then
transferred to [**Hospital1 18**] as her cardiac care is here. Patient's
initial VS in the ED were 98.3 76 105/70 16 96 on 4LNC. Pt was
initially dyspneic, RR in 20s, wheezes bilaterally. Ascities
worse than in past few weeks. 2+ pedal edema.
Cardiac review of systems is notable for presence of chest pain
at rehab, dyspnea on exertion, paroxysmal nocturnal dyspnea,
orthopnea, ankle edema. No palpitations, syncope or presyncope.
Past Medical History:
. ischemic cardiomyopathy (EF 10-25%) s/p BiV ICD
2. Coronary artery disease status post PTCA and stenting of the
LAD in [**2164**].
3. h/o PE secondary to DVT s/p IVC filter
4. Atrial fibrillation status post cardioversion and
biventricular pacemaker implantation.
5. HTN
6. Obesity
7. PVD
8. small VSD
9. hypothyroidism
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS: + Dyslipidemia
2. CARDIAC HISTORY:
-Ischemic cardiomyopathy EF %15-20 s/p biv ICD
-CAD s/p post PTCA and stenting of the LAD in [**2164**].
-CABG: None
-PACING/ICD: atrial fibrillation on anticoagulation and ICD
biventricular pacemaker
3. OTHER PAST MEDICAL HISTORY:
chronic kidney disease
bilateral DVT s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] filter
pulmonary embolism
osteoarthritis
hyperkalemia
Social History:
Pt lives alone but currently resides at [**Hospital 599**] rehab. She is not
married. She reports a 20 pack year history, however she quit 30
yrs ago. Denies EtOH or illicit drug use.
Family History:
Mother had MI at age 50. Father in good health. Maternal uncle
died of MI in his 50's.
Physical Exam:
VS: 99.5, 95/60, 80, 22, 94% 3L NC
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 15 cm.
CARDIAC: PMI inferolaterally displaced, RR, normal S1, S2.
Holosystolic murmur at apex.
LUNGS: Bilateral rales to mid-lung fields.
ABDOMEN: Soft, distended. + Fluid wave. Mild Hepatomegaly.
Unable to palpate spleen.
EXTREMITIES: +2 BLE edema. RLE > LLE. Warm
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP 1+ PT 1+
Left: DP 1+ PT 1+
Pertinent Results:
Admission Labs:
[**2179-10-26**] 12:30AM WBC-6.2# RBC-3.60* HGB-11.3* HCT-34.7* MCV-96
MCH-31.3 MCHC-32.5 RDW-18.6*
[**2179-10-26**] 12:30AM PLT SMR-NORMAL PLT COUNT-182#
[**2179-10-26**] 12:30AM PT-28.4* PTT-36.3* INR(PT)-2.8*
[**2179-10-26**] 12:30AM CK-MB-NotDone proBNP-[**Numeric Identifier 44663**]*
[**2179-10-26**] 12:30AM cTropnT-0.04*
[**2179-10-26**] 12:30AM ALT(SGPT)-51* AST(SGOT)-56* CK(CPK)-62 ALK
PHOS-194* TOT BILI-1.7*
[**2179-10-26**] 12:30AM GLUCOSE-112* UREA N-48* CREAT-1.6* SODIUM-136
POTASSIUM-4.6 CHLORIDE-97 TOTAL CO2-27 ANION GAP-17
.
EKG: [**2179-10-26**] 0003: V Paced at 69, w/ RAD, bifascicular block.
.
TTE [**10-26**]:
The left atrium is moderately dilated. The right atrium is
markedly dilated. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity is moderately dilated.
There is severe regional left ventricular systolic dysfunction
with anterior, septal and apical akinesis, as well as akinesis
of the distal inferior wall (proximal LAD distribution). There
is mild hypokinesis of the remaining segments (LVEF = 15-20%).
No masses or thrombi are seen in the left ventricle. The right
ventricular cavity is moderately dilated with severe global free
wall hypokinesis. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Mild to moderate
([**12-18**]+) mitral regurgitation is seen. Severe [4+] tricuspid
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is a trivial/physiologic pericardial
effusion.
.
IMPRESSION: Dilated left ventricle with severe regional systolic
dysfunction, c/w an extensive prior LAD infarction. Dilated
right ventricle with severe systolic dysfunction. Mild to
moderate mitral regurgitation. Severe tricuspid regurgitation.
At least mild pulmonary hypertension.
.
Compared with the prior study (images reviewed) of [**2177-5-26**],
severity of tricuspid regurgitation has increased. The other
findings are similar.
.
RLE US [**10-26**]: No right lower extremity DVT.
ABD DOPPLER [**10-26**]:
1. Distended hepatic veins and ascites, the constellation of
findings can be seen in the setting of congestive heart failure.
Otherwise, normal Doppler examination of the liver.
.
2. No evidence of biliary pathology.
.
MYOCARDIAL VIABILITY STUDY [**10-27**]:
Within limitation of current study, fixed defects in distal
anterior
and apical walls are consistent with scarring. Improvement of
inferior wall defect with correction is suggestive of myocardial
viability.
.
LHC/RHC [**11-2**]:
COMMENTS:
1. Selective coronary angiography of this right dominant system
revealed
one vessel coronary artery disease. The LMCA had no
angiographically
apparent disease. The LAD had mild instent restenosis of the
prior
stent. The LCx had no angiographically apparent disease. The RCA
was
occluded and similar to prior.
2. Resting hemodynamics on milrinone therapy revealed moderately
elevated right and left sided filling pressures with an RVEDP of
15 mmHg
and PCWP of 20 mmHg. There was moderate pulmonary hypertension
with a
PASP of 42/20 mmHg. There was normal systemic blood pressure
with
central pressure of 108/63 mmHg. There was a low-normal cardiac
index of
2.1 L/min/m2. There was no transaortic valve gradient on careful
pullback from LV to aorta.
3. Peripheral angiography revealed patent renal arteries
bilaterally.
.
FINAL DIAGNOSIS:
1. One vessel coronary artery disease.
2. Moderate biventricular diastolic dysfunction.
3. Moderate pulmonary hypertension.
4. Normal systemic pressure.
5. Low-normal cardiac index.
6. Patent renal arteries.
.
KUB [**11-2**]:
1. There is no ileus or small bowel obstruction.
2. Tubular radiopaque left paraspinal structure of unknown
etiology warrants repeat AP and lateral radiograph.
.
Brief Hospital Course:
71-year-old woman with advanced end-stage ischemic
cardiomyopathy with severe left ventricular contractile function
with LVEF of 10%-15%, atrial fibrillation, [**Hospital1 **]-V ICD, low cardiac
output state, chronic kidney disease with past history of DVT,
PE on Coumadin.
#. NYHA Class 4 Systolic congestive Heart Failure, EF 15%. with
severe volume overloaded on examination on admission. She had a
low output state with known low EF and dilated ischemic
cardiomyopathy. It was felt that she would likely need
inotropic support and she was sent to the CCU for diuresis with
milrinone gtt + lasix gtt + metolazone. The patient had
significant diuresis on this regimen. It was felt that if there
was viable myocardium currently hibernating [**1-18**] low perfusion
state, intervention may improve cardiac function. A myocardial
viability study was performed and demonstrated inferior wall
myocardial viability. LHC/RHC were performed but no
intervenable targets were appreciated; additionally, the patient
was thought to be a poor candidate for CABG/TR [**1-18**] poor targets
for grafts. It was therefore felt that the patient could only
be maximized on medical therapy. Diuresis was changed to PO on
[**11-5**] to her precious dose of Torsemide and metolazone was added
daily to regimen. Weight on discharge________. Would follow
lytes every other day until stable and weekly thereafter.
# C-diff colitis - Positive C. difficile toxin assay. Patient
was started on PO metronidazole and cholesyramine with clinical
improvement as gauged by frequency of diarrhea, fever, and WBC
count. Peak WBC 11.4. Flagyl to be continued x 7 more days.
Once 2 week flagyl course is finished, can consider restarting
immodium for symptomatic relief.
# UTI - Patient was found to have UTI [**1-18**] Klebsiella pneumoniae,
pansensitive except for intermediate sensitivity to
nitrofurantoin. She was started on ciprofloxacin for 7 day
course, finished on [**11-4**].
#. Rhythm: She has a BiV ICD in place and was V-paced on ECG.
She was monitored on telemetry. No events.
#. Coronaries: Patient with mid-LAD BMS '[**64**]. Trop 0.04, CK-MB
negative that was likely related to CHF exacerbation. She was
continued on a statin and aspirin.
#. URI: She had been diagnosed with a URI prior to admission and
had been started on Zithromax. This was held in the hospital
and sputum cultures were sent, found to be negative. Pt is
currently asymptomatic.
#. Asicites: She had significant ascities on exam and she was
s/p 6L tap two weeks ago. It was felt her ascites was likely
related to right-sided heart failure and would be difficult to
resolve with diuretics. She was restarted on her home regimen of
torsemide plus Metolazone as noted above.
#. LFT abnormalities: She had a mild transaminities with an AP
190, TBili 1.7. It appeared to be obstructive pattern, likely
related to congestive hepatopathy. Resolved prior to discharge.
#. H/o DVT/PE: She was anticoagulated with Coumadin and has a
[**Location (un) 260**] filter in place. She had a RLE U/S that showed no
DVT. Her INR today is _______. INR should be followed every
other day until stable and weekly thereafter.
# Hypothyroidism: Continued Levothyroxine.
# CODE: She was full code during this hospitalization. It is
thought that she is end stage in regard to her CHF with medical
treatment her only option at this time. Palliative care was not
persued during this hospital stay but may be introduced by Dr.
[**First Name (STitle) 437**]/[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**MD Number(3) 44664**] continues to have frequent
hospitalizations.
Medications on Admission:
Allopurinol 100mg daily
Amiodarone 200mg daily
Levothyroxine 125mcg daily
ASA 81mg daily
Zocor 20mg daily
Zithromax 250mg daily (until [**10-26**]) for URI
Torsemide 40mg po BID
Metoprolol Succinate 12.5mg po BID
Digoxin 0.0625 mcg daily
Prilosec 20mg daily
Zinc 220mg po daily
Vit C 500mg po daily
Coumadin 2.5mg daily
Biscacodyl 10mg suppository daily prn for constipation
Milk of Mag 30ml po daily prn for constipation
Melatonin 1mg po qhs prn for insomnia
MVI
Immodium 2mg po 4x daily prn for loose stool
Discharge Medications:
1. Metolazone 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Digoxin 125 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
7. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO at bedtime.
8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: 0.5 Tablet Sustained Release 24 hr PO twice a day.
10. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) vial Inhalation Q6H (every 6 hours) as
needed for cough/sob.
11. Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO
Q6H (every 6 hours) as needed for cough: Hold for sedation or RR
< 10.
12. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 14 days: last day [**11-20**].
13. Cholestyramine-Sucrose 4 gram Packet Sig: One (1) PO BID (2
times a day): Do not give at the same time as Levothyroxine,
metolazone and Digoxin. .
14. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: check INR every other day.
15. Torsemide 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
16. Metolazone 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
17. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-18**] Sprays Nasal
QID (4 times a day) as needed for dry nose.
18. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] Senior Care Center - [**Location (un) 1439**]
Discharge Diagnosis:
Acute on chronic systolic heart failure
Clostridium difficile colitis
Klebsiella Urinary Tract Infection.
Discharge Condition:
Dry weight 100 kg.
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 seen at [**Hospital1 18**] with heart failure. You were admitted to
the cardiac care unit for diuresis with Milrinone and lasix.
We are discharging you home on the same heart failure regimen as
you were admitted with and adding metolazone 2.5mg po daily in
the am.
You were found to have clostridium difficile colitis and were
started on flagyl. You were also found to have a urinary tract
infection and were treated with a seven day course of
ciprofloxacin.
Weigh yourself every morning, call [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] NP if weight
goes up more than 3 lbs in 1 day or 6 pounds in 3 days.
Followup Instructions:
Cardiology:
Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2179-11-22**]
10:00
|
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icd9cm
|
[
[
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[
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icd9pcs
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[
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|
7518, 11162
|
343, 349
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13740, 13759
|
3705, 3705
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|
3721, 7088
|
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|
2598, 2756
|
2306, 2346
|
2772, 2959
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,718
| 192,729
|
45153
|
Discharge summary
|
report
|
Admission Date: [**2106-1-6**] Discharge Date: [**2106-1-11**]
Date of Birth: [**2043-3-27**] Sex: F
Service: NEUROSURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
headache and near-syncopal episodes
Major Surgical or Invasive Procedure:
Right craniotomy with excision of tumor
History of Present Illness:
62yoF with recent h/o headache and near-syncopal episodes.
Workup reveal right temporal tumor. She returns for elective
resection.
Past Medical History:
1. HTN
2. high chol
3. kidney stones s/p lithotripsy
4. GERD
5. s/p CCY
6. umbilical hernia repair
7. right knee meniscal tear s/p repair
8. has had CT abdomen for kidneys with incidental adrenal
adenoma, diverticulosis, and 4mm pulm nodule at base of LLL,
subsequent CT [**3-14**] showed mult sub-cm non-calcified nodules
including one seen initially, recommended f/u CT 1 yr.
Social History:
smoked in teens to twenties, quit 40 yrs ago; smoked socially
(<2 pp/year) until sister died of lung ca last year. Very rare
etoh, no other drugs.
Lives alone; retired; formerly worked in finance dept for Nynex
(now [**Company 22957**]).
Family History:
mother d. 66 [**Name2 (NI) **] [**Name2 (NI) 499**] ca; father d. 70 [**Name2 (NI) 499**] ca. Sister d. 1 yr
ago lung ca with mets to brain. Brother d. hit by drunk driver.
Has one living brother. GM died of stroke.
Pertinent Results:
[**2106-1-6**] 10:50PM GLUCOSE-166* UREA N-16 CREAT-0.7 SODIUM-141
POTASSIUM-4.4 CHLORIDE-108 TOTAL CO2-24 ANION GAP-13
[**2106-1-6**] 10:50PM CALCIUM-8.3* PHOSPHATE-4.7* MAGNESIUM-1.7
[**2106-1-6**] 10:50PM PT-12.5 PTT-20.0* INR(PT)-1.0
[**2106-1-6**] 09:08PM WBC-10.5 RBC-3.49* HGB-11.1* HCT-31.0* MCV-89
MCH-31.8 MCHC-35.7* RDW-12.9
Brief Hospital Course:
Pt was admitted and brought to the OR where under general
anesthesia she underwent right temporal craniotomy with excsion
of tumor. She tolerated this procedure and was brought to PACU
for close monitoring. Her vital signs were stable and she
remained neurologically stable. On the first post op morning
she was transferred to the floor. Her diet and activity were
advanced. Her incision was clean dry and intact. Foley was
removed and she was able to void. PT/OT assisted with
mobilization.
Frozen pathology showed high grade glioma, formal pathology
result is pending.Dr [**Last Name (STitle) 724**] from neurooncology and Dr [**Last Name (STitle) 96505**]
from radiotion oncology following will be seen in brain tumor
clinic on [**2106-1-25**]. Decadron to wean 2mg [**Hospital1 **] until seen
at the brain tumor clinic, and will continue with dilantin.
Postoperative MRI revealed status post right-sided craniotomy
and resection of the previously seen large right temporal mass.
Fluid and hemorrhagic products in the right anterior middle
cranial fossa, representing postoperative changes. There is mild
surrounding edema. The degree of leftward shift of the midline
structures is unchanged from the pre- operative MR study, and
there is no evidence of uncal herniation.
Patient was deemed ready for discharge home on post op day 5.
Medications on Admission:
atenolol
lisinopril
protonix
zetia
MVI
Discharge Disposition:
Home
Discharge Diagnosis:
Brain tumor
Discharge Condition:
Neurologically stable
Discharge Instructions:
Please resume your prior home medications. Call for fever >101.4
or any signs of infection - redness, swelling or drainage from
the wound. Call for severe headache or any other neurologic
problems. [**Name (NI) **] incision dry.
Take decadron prescription until seen in Brain tumor clinic.
Followup Instructions:
Follow up in Brain [**Hospital 341**] Clinic ([**Hospital Ward Name 516**], [**Location (un) **]) on
[**2106-1-25**] at 1400. Brain [**Hospital 341**] Clinic phone number is
[**Telephone/Fax (1) 1844**] for any questions or concerns.
Suture removal on [**2106-1-15**]. Call Dr[**Name (NI) 9034**] office for
the time at [**Telephone/Fax (1) 2731**].
Completed by:[**2106-1-11**]
|
[
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icd9cm
|
[
[
[]
]
] |
[
"01.59"
] |
icd9pcs
|
[
[
[]
]
] |
3229, 3235
|
1793, 3140
|
311, 353
|
3291, 3315
|
1425, 1770
|
3655, 4036
|
1188, 1406
|
3256, 3270
|
3166, 3206
|
3339, 3632
|
236, 273
|
381, 514
|
536, 916
|
932, 1172
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,812
| 191,916
|
48202
|
Discharge summary
|
report
|
Admission Date: [**2180-6-20**] Discharge Date: [**2180-6-28**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 22401**]
Chief Complaint:
Altered Mental Status, Hyperkalemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: 81 yo F with h/o Seizure disorder, HTN, ESRD on HD,
meningioma s/p resection [**2154**] and DM who initially presented on
[**2180-6-20**] from [**Hospital3 2558**] were she was found to be nonverbal
and unresponsive. In the ED she was hypertensive to the 200's
requiring a labatolol gtt and had a K of 7.1 (improved with
bicarb and insulin). One day PTA she developed nausea and
vomiting. Per report her initial neurologic exam was remarkable
for profound encephalopathy with increased RUE tone.
.
She was loaded with IV phenytoin for a subtherapeutic level; she
transiently developed complete heart block during the infusion.
CT head revealed a lobulated mass in the left ventricular
atrium. She was given empiric ceftriaxone 2g, ampicillin,
vanco, and acyclovir for possible meningitis. She was
transferred to the [**Hospital Unit Name 153**] for further managment. In the [**Hospital Unit Name 153**] her
BP was controlled. She was dialyzed and an LP was performed.
.
Of note she was recently admitted to [**Hospital1 2177**] (discharged 2 wks ago)
after a tonic clonic Sz at dialysis. Her Phenytoin level was
subtherapeutic at that time. She was reloaded. She had been on
phenobarb, which was stopped.
.
Currently she is alert and following verbal commands. She is
able to answer some questions with one word response.
.
Social Hx: Denies etoh or tobacco use. Pt was ambulatory and
conversant living at home prior to recent [**Hospital1 2177**] admission.
Currently living at [**Hospital3 2558**]. Nurse [**First Name (Titles) **] [**Hospital3 2558**]
reports that she was ambulatory with a walker and was alert and
oriented prior to decompensation.
.
Family Hx: Denies h/o sz disorder. Reports FH of DM and HTN.
.
Past Medical History:
PMH:
- seizure disorder. Per report she was Sz free on phenobarb and
dilantin until 2 weeks ago.
- h/o right frontal meningioma in [**2144**]'s s/p resection in [**2154**]
- encephalomalacia per her epileptologist (Dr. [**Last Name (STitle) 101604**] [**Name (STitle) **]
at [**Hospital1 2177**] 2988)
- ESRD on HD 3x/wk - suboptimal given reversed intake and
outflow ports
- ?clot in L UE AV fistula
- DM2
- HTN
- hyperlipidemia
- ?hyperthyroidism
Social History:
Social Hx: Denies etoh or tobacco use. Pt was ambulatory and
conversant living at home prior to recent [**Hospital1 2177**] admission.
Currently living at [**Hospital3 2558**]. Nurse [**First Name (Titles) **] [**Hospital3 2558**]
reports that she was ambulatory with a walker and was alert and
oriented prior to decompensation.
Family History:
Family Hx: Denies h/o sz disorder. Reports FH of DM and HTN.
Physical Exam:
Physical Exam:
Tc 98.1, 148/62, 70, 18, 98% 2L NC, FS 128
General: appears comfortable lying in bed, NAD
HEENT: no scleral icterus, MMM, OP clear, R pupil 4mm, L pupil
3mm, minimally reactive, able to squeeze eyes shut and open
mouth on command
Neck: Supple, no JVD, right EJ in place
Pulmonary: CTAB
Cardiac: RRR, nl S1S2, no M/R/G noted
Abdomen: soft, NT/ND, nl BS, No HSM.
Extremities: weak DP/PT pulses, no edema
Neuro: Following verbal commands, Moving all extremities.
Cogwheel rigidity of upper extremities. Patellar and biceps
reflexes brisk and symmetric, Toes upgoing. Garbled speech,
occasionally able to answer question with one word response.
Occasionaly myoclonic jerking movements of upper and lower
extremities. Right leg externally rotated.
.
Pertinent Results:
[**2180-6-20**] 05:00AM BLOOD WBC-12.3* RBC-3.74* Hgb-12.9 Hct-39.2
MCV-105* MCH-34.4* MCHC-32.8 RDW-16.0* Plt Ct-253
[**2180-6-20**] 05:00AM BLOOD Neuts-80.7* Lymphs-12.0* Monos-6.3
Eos-0.5 Baso-0.4
[**2180-6-20**] 07:00AM BLOOD PT-11.8 PTT-22.7 INR(PT)-1.0
[**2180-6-20**] 04:50AM BLOOD Glucose-148* UreaN-82* Creat-9.2* Na-131*
K-7.5* Cl-94* HCO3-15* AnGap-30*
[**2180-6-20**] 07:00AM BLOOD ALT-81* AST-77* AlkPhos-108 Amylase-117*
TotBili-0.1
[**2180-6-20**] 04:50AM BLOOD CK(CPK)-57
[**2180-6-20**] 04:39PM BLOOD CK(CPK)-44
[**2180-6-20**] 07:00AM BLOOD Lipase-29
[**2180-6-23**] 04:40AM BLOOD Lipase-17
[**2180-6-20**] 04:50AM BLOOD CK-MB-4 cTropnT-0.07*
[**2180-6-20**] 04:39PM BLOOD CK-MB-4 cTropnT-0.07*
[**2180-6-23**] 04:40AM BLOOD VitB12-1387* Folate-GREATER TH
[**2180-6-20**] 10:35AM BLOOD Ammonia-30
[**2180-6-20**] 04:39PM BLOOD TSH-1.6
[**2180-6-20**] 04:50AM BLOOD Phenyto-1.4*
[**2180-6-21**] 04:40AM BLOOD Phenyto-17.9 Phenyfr-3.7* %Phenyf-21*
[**2180-6-24**] 02:28PM BLOOD Phenyto-12.8
[**2180-6-20**] 04:50AM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
[**2180-6-20**] 08:40AM BLOOD Lactate-1.3
.
IMAGING:
CT HEAD [**2180-6-20**]: Lobulated mass in the left ventricular atrium.
No clear evidence of acute hemorrhage or territorial infarction.
.
CXR [**2180-6-20**]: Lungs clear. Small left pleural effusion. Mild
cardiomegaly. Atherosclerotic calcification above the aortic
knob suggests aberrant right subclavian artery. Tips of dual R
supraclavicular catheter project over the SVC and superior
cavoatrial junction respectively.
.
EKG: NSR, rate 54, LAD, TWI in V1 and V2 with j-point elevation
and 2mm ST elevation, poor R wave progression, no other st/tw
changes.
.
MRI [**2180-6-21**]: Lobulated mass in the left ventricular atrium,
which
could represent an intraventricular meningioma. There are no
signs of recurrent meningioma in the right frontal postoperative
region.
An additional tiny focus of enhancement and signal abnormality
is noted along the right side of the cerebellum.
.
EEG [**2180-6-21**]: Prelim - diffuse encephalopathy
.
Brief Hospital Course:
81 yo [**Hospital3 2558**] resident with ESRD on HD, meningioma s/p
resection/regrowth, HTN, DM, and Sz d/o initially admitted to
the intesive care unit with altered MS, hypertension, and
hyperkalemia.
.
1) Altered Mental Status likely [**3-16**] to hypertensive
leukoencephalopathy: The patient presented unresponsive from
[**Hospital3 2558**]. At presentation she was found to be
hypertensive in the 200s and started on a labetolol drip. Her K
was found to be 7.1 and resolved with insulin and bicarb. A CT
head did not show evidence of stroke or hemmorrhage, but a
lobulated mass was seen in the left ventricular atrium. A
urine tox screen was found to be negative and TSH, ammonia and
LFTs were wnl. She was given empiric ceftriaxone 2g,
ampicillin, vanco, and acyclovir for possible meningitis and
transferred to the unit. The differential included toxic
metabolic derangements, leukoencephalopathy secondary to HTN,
HSV encephalitis, or post-ictal state as pt had h/o recent
seizures. An EEG revealed diffuse encephalopathy without
evidence of non-convulsive status epilepticus. An MRI revealed
slight increase in size of her known meningioma since [**2178**]
without mass effect, bleed or CVA. An LP was performed by IR
(noted to be difficult to perform) and revealed many RBC's, no
WBC's, high protein, and normal glucose. All culture data was
negative and cytology was negative as well. Empiric
Vanco/Amp/CTX for bacterial meningitis was d/c'ed on [**2180-6-22**]
given the LP results. Her acyclovir was continued until [**2180-6-26**]
(started [**6-20**]) when her HSV PCR came back as negative. The
patient's mental status started improving during her stay as her
blood pressures improved. She was noted to have a significant
expressive aphasia. Neurology was consulted and thought the
patient's symptoms were related to her hypertension and
toxic/metabolic derangements. They though her symptoms would
improve over time. Her blood pressures were controlled to a
goal of SBPs 140-170 on IV medications and she was then switched
to PO medications as her MS improved. Lisinopril, hydralazine,
norvasc and metoprolol were used for BP control. She will need
neurosurg to follow up her enlarging meningioma. She was also
instructed to follow-up with her outpatient neurologist, Dr.
[**Last Name (STitle) **].
.
2) Seizure disorder: The patient was noted to have a recent
recurrence of seizures. The differential included recent d/c of
phenobarbitol, known meningioma acting as foci, and electrolyte
disturbances in the setting of ESRD. Patient did have a seizure
on [**6-20**] in the setting of low calcium after HD. She was initially
loaded with Fosphenytoin. Neurology followed the patient and
recommended that she start dilantin 200 [**Hospital1 **]. Her free and total
dilantin levels were followed as well as her LFTs. EEG was done
and showed diffuse encephalopathy but no evidence of
non-convulsive status. She had no further seizures during her
stay. She was discharged on 200 PO BID of dilantin. Her level
was to be checked in one week and she was to follow-up with her
outpatient neurologist, Dr. [**Last Name (STitle) **].
.
3) Complete heart block: She had complete heart block during
her phenytoin infusion. This was thought to be secondary to
phenytoin infusion and after that time the infusion was done
slowly. She had no further episodes of heart block.
.
4) HTN: She was initially on labetolol gtt for SBP >200. Her
goal SBP was 140-170. It was noted that her BPs were higher in
the right arm than the left, so BPs were taken from the left
arm. When she was transferred to the floor she had been
receiving PRN metoprolol, but this was not enough to control her
blood pressures. She was initially started on IV
antihypertensives and then changed to PO meds including
lisinopril, norvasc, metoprolol and hydralazine. Aggressive
blood pressure control was attempted as it was thought her MS
changes were due to hypertensive leukoencephalopathy. Her blood
pressures were in the 160s on the day of discharge.
.
5) ESRD on HD T/th/Sa: Pt receives dialysis on T/Th/Sa. She
was followed by the renal team during her stay. Initially it was
thought her dialysis port was not working well, but she had
excellent flows through the port during the second half of her
admission. Her electrolytes were followed and she was given phos
binders once she could tolerate PO meds.
.
6) ?Hyperthyroidism: Her TSH was drawn and noted to be normal
off medications.
.
7) DM2: She was continued on a RISS and qid FS were checked.
.
8) Hypercholesterolemia: She was continued on Lipitor 10 mg qd
.
9) FEN: She was initially unable to perform a speech and swallow
due to her mental status. As her MS improved she had an
evaluation and she was changed to a diet of ground, thin liquids
with 1:1 supervision during meals. She was given liquids by
straw with cuing, crushed meds and given with purees. She was
continued on a diabetic/renal/low salt diet.
.
10) Ppx: She was continued on SC heparin, PPI and was kept on
aspiration/seizure precautions.
.
11) Code: Full as per chart (discussed with daugther in [**Hospital Unit Name 153**])
.
12) Communication: Daughter - [**First Name8 (NamePattern2) **] [**Known lastname 805**] ([**Telephone/Fax (1) 101605**])
.
13) Access: R groin line removed. R SC HD line in place. Pt has
had fistulas in arms bilat, therefore, unable to place PICC
line. R EJ placed 5/10/1/06 and removed on [**6-26**].
Medications on Admission:
.
Medications at Home:
- metoprolol 100mg po tid
- lisinopril 20mg po daily
- ASA 81mg po daily
- dilantin 200mg po bid
- lipitor 10mg po daily
- nephrocaps 1 tab po qam
- phoslo 667mg po tid
- compazine prn
- ?RISS
.
Transer Meds:
- Metoprolol 5 mg IV Q6H:PRN
- Acyclovir 300 mg IV Q24H
- Pantoprazole 40 mg IV Q24H
- Acetaminophen 325-650 mg PO/PR Q4-6H:PRN
- Phenytoin 200 mg IV Q12H
- Aspirin 300 mg PR DAILY
- Prochlorperazine 10 mg IV Q6H:PRN
- Heparin 5000 UNIT SC TID
- Insulin SS
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 units
Injection TID (3 times a day).
2. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
3. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2) Capsule
PO BID (2 times a day).
4. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
6. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
8. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
9. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
12. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
15. Prochlorperazine 10 mg IV Q6H:PRN
16. insulin
please place patient on a regular insulin sliding scale per the
protocol of your institution
17. Outpatient Lab Work
Please have dilantin level checked in one week [**2180-7-5**] and send
the results to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], in [**2-14**] weeks. His phone
number is [**Telephone/Fax (1) 25666**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Primary diagnosis:
Toxic metabolic and Hypertensive encephalopathy
Seizure disorder
.
Secondary Diagnosis:
Diabetes type 2
Discharge Condition:
stable wtih baseline expressive aphasia
Discharge Instructions:
You are being discharged to a rehabilitiation facility.
.
Please take your medications as prescribed.
.
Please call your doctor or return to the ER if you become more
confused, have very elevated blood pressures, have chest pain,
shortness of breath, headaches, dizziness or other concerning
symptoms.
Followup Instructions:
Please follow-up with neurosurgery regarding the meningioma in
your brain. Please call ([**Telephone/Fax (1) 88**] to make an appointment
in the next [**2-14**] weks.
.
Please follow-up with your neurologist, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], in
[**2-14**] weeks. His phone number is [**Telephone/Fax (1) 25666**]. You should have a
dilantin level checked in one week and have the results sent to
his office.
.
Please follow-up with your primary care doctor, Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 4223**], in [**2-14**] weeks. His phone number is [**Telephone/Fax (1) 59410**].
|
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icd9cm
|
[
[
[]
]
] |
[
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
13546, 13616
|
5887, 11350
|
299, 305
|
13783, 13825
|
3774, 5864
|
14175, 14823
|
2915, 2978
|
11889, 13523
|
13637, 13637
|
11376, 11378
|
13849, 14152
|
11399, 11866
|
3008, 3755
|
224, 261
|
333, 2076
|
13744, 13762
|
13656, 13723
|
2098, 2549
|
2565, 2899
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,583
| 147,623
|
45190
|
Discharge summary
|
report
|
Admission Date: [**2191-7-10**] Discharge Date: [**2191-8-1**]
Date of Birth: [**2118-1-16**] Sex: F
Service: NEUROSURGERY
Allergies:
Latex / metformin
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
SAH
Major Surgical or Invasive Procedure:
[**2191-7-11**]: Cerebral Angiogram w/coiling of the R PCOMM aneurysm
[**2191-7-21**]: PEG placement
[**2191-7-23**]: R EVD placement
History of Present Illness:
HPI: Patient is a 73-year-old right-handed-woman with known
aneurysms s/p coiling of nine months ago at [**Hospital1 2025**] here after being
found down per her son. [**Name (NI) **] history obtained per son, [**Name (NI) **]
[**Name (NI) **] who is also her HCP.
He reports that she had undergoing head imaging for ?stroke
symptoms and found to have two intracranial aneurysms and had
one
coiled 9 months ago at [**Hospital1 2025**] but the other one was too small to
intervene. She had TIA symptoms afterwards but no lasting
deficit. Her outpatient neurologist is Dr. [**Last Name (STitle) **] at [**Hospital1 2025**].
She was doing well and actually played cards with the son last
night. This afternoon, he went to check on her and found her on
the floor faced down with vomit on the floor. When he turned
her
over, she was responsive and verbal but was not ambulating well
hence EMT was called. In the ED, head CT showed bilateral,
extensive SAH and coiling artifact of L MCA distribution.
Past Medical History:
1. Aneurysms - as above
2. Hx of lung cancer s/p chemotherapy 9 years ago
3. Hx of throat cancer s/p radiation therapy 18 years ago
4. Hx of breast cancer s/p lumpectomy 5 years ago
5. HTN
6. DM
7. GERD
8. HLD
Social History:
Lives alone and ambulates with a cane. Retired production line
supervisor for Ford. Quit smoking 20 years ago.
Son, [**Name (NI) **] [**Name (NI) **] ([**Telephone/Fax (1) 96574**]) is HCP and she is full code.
Family History:
Brother and nephew also have aneurysms.
Physical Exam:
On admission:
PHYSICAL EXAM:
O:T: 97.1 BP: 179/90 HR:99 R: 16 O2Sats: 100% NRB
Gen: Has a NRB - appears comfortable.
Lungs: Clear anteriorly
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused. No C/C/E.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, hospital ([**Hospital1 2025**]) but thinks its
[**Month (only) 547**].
Language: Speech fluent and intact repetition.
Naming intact. No dysarthria.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2mm
bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
IX, X: Palatal elevation symmetrical.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Mild pronation of RUE. Strength full power [**4-14**]
throughout except for mild R deltoid and bilateral IP weakness.
Sensation: Intact to light touch, cold and vibration.
Reflexes: B T Br Pa Ac
Right 2 1 2 1 0
Left 2 1 2 1 0
Toes upgoing bilaterally
Coordination: Normal FTF
Gait: Deferred.
On Discharge:
a&o to self and hospital
MAE to commands
Pertinent Results:
[**2191-7-10**] CTA HEAD:
IMPRESSION:
1. Extensive bilateral subarachnoid hemorrhage involving the
sulci,
interhemispheric fissure and sylvian fissures. Component of
intraventricular hemorrhage involving the frontal [**Doctor Last Name 534**] of the
left lateral ventricle and the third ventricle.
2. Areas of outpouching at the origin of the right posterior
communicating
artery and left posterior communicating artery, possibly
representing
aneurysms. Would recommend catheter angiography to further
evaluate for the presence of intracranial aneurysms.
3. Streak artifact from the coil pack in the left MCA on its
evaluation at
this level. Unable to determine if there is filling of the prior
aneurysm in this location due to artifacts.
[**2191-7-10**] CTA CHEST:
IMPRESSION:
1. No evidence of pulmonary embolism, aortic dissection or acute
aortic
injury.
2. Status post right upper lobectomy and left lower lobe wedge
resection.
Focal opacities along the left lower lobe suture line and
periphery of the
right lower lobe are likely areas of scarring. Peripheral
opacity in the right lower lobe with a linear geographic border
is likely due to post-radiation changes. Correlation of these
findings with prior imaging, however, is recommended.
3. Diffusely enlarged thyroid gland for which clinical
correlation is
recommended.
[**2191-7-10**] CT [**Month/Day/Year 12784**]:
IMPRESSION:
1. No evidence of prevertebral soft tissue swelling or acute
fracture.
2. Extra-axial, extra-dural circumferential hyperdensity within
the spinal
canal at the level of C3-C4 vertebral bodies may be due epidural
or subdural hematoma at this level. MRI is recommended for
further evaluation if not contraindicated.
3. Diffusely enlarged thyroid gland.
4. Right carotid artery stent with probable post treatment and
post radiation changes as noted above.
[**2191-7-11**] MRI [**Month/Day/Year 12784**]:
FINDINGS: There is no evidence of hemorrhage in the cervical
spine. There is multilevel degenerative joint disease. At the
level of C3 and C4, there is protrusion of the disc, with
flattening of the cord and narrowing of the canal. There is
elevation of the posterior longitudinal ligament with
widening of the epidural space at this level. At the level of C4
and C5,
there is a disc protrusion with flattening of the cord, but no
canal narrowing at this level. At the level of C5 and C6, there
is bilateral neural foraminal narrowing due to uncovertebral
osteophytes. There is also narrowing of the canal by
intervertebral osteophytes at this level. There is
retrolisthesis of C5 on C6, as seen on prior study and likely
due to degenerative changes.
There is a nodular cyst in the left lobe of the thyroid gland.
IMPRESSION:
1. No evidence of intraspinal hemorrhage.
2. Multilevel degenerative changes as outlined above with disc
protrusion and narrowing of the canal at the level of C3-C4 and
C5-C6 as well as bilateral neural foraminal narrowing at the
level of C5-C6.
3. Nodular cyst in the left lobe of the thyroid. Would consider
ultrasound
if not already completed.
[**2191-7-12**] Head CT:
1. Extensive bilateral subarachnoid hemorrhage involving the
sulci and
sylvian fissures unchanged from prior study. Intraventricular
hemorrhage in the third ventricle as well as the occipital horns
of the lateral ventricles, likely from redistribution from
subarachnoid hemorrhage.
2. Hydrocephalus, with the left lateral ventricle being
asymmetrically
enlarged when compared to the right but unchanged from prior
study.
3. Streak artifact from the coil pack in the left MCA aneurysm
as well as
from the new coil in the right posterior communicating artery
aneurysm.
Unable to determine if there is filling of the prior aneurysms
in these
locations due to artifact.
[**2191-7-13**] Head CT:
IMPRESSION: Study is severely limited by motion artifact, with:
1. Enlargement of the ventricles bilaterally consistent with
progressive
hydrocephalus.
2. Stable bilateral subarachnoid and intraventricular hemorrhage
when compared to prior study.
3. Coil packs in the left MCA and right posterior communicating
artery with streak artifact at those locations.
[**2191-7-13**] Head CTA:
IMPRESSION:
1. Evolution of the subarachnoid hemorrhage along bilateral
cortical sulci
and sylvian fissures. There is decrease in the amount of
intraventricular
hemorrhage.
2. Asymmetric dilatation of bilateral lateral ventricles, left
being dilated more than right.
3. Streak artifact from coil pack in left MCA and right
posterior
communicating artery. It is difficult to determine if there is
filling of the prior aneurysm in these locations due to the
streak artifact from the coil pack.
4. No evidence of new aneurysm/ vasospasm.
[**2191-7-15**] RUE US:
IMPRESSION: No evidence of right upper extremity DVT.
[**2191-7-17**] Head CTA:
HEAD CTA: The intracranial internal carotid and vertebral
arteries, and their major branches, are patent. Allowing for
streak artifact from the
above-described coil packs, no change in caliber of the
intracranial vessels is seen to suggest vasospasm. Evaluation
for residual filling of the previously coiled aneurysms is
limited by streak artifact. Extensive
calcification of the cavernous and supraclinoid internal carotid
arteries is again seen bilaterally. Fetal configuration of the
right posterior cerebral artery is again noted.
IMPRESSION:
1. Unchanged extensive subarachnoid hemorrhage.
2. Unchanged intraventricular hemorrhage and ventricular
dilatation.
3. No evidence of vasospasm.
[**2191-7-18**] LENIS:
IMPRESSION: No evidence of DVT.
[**2191-7-20**] CXR: IMPRESSION: Right approach PICC in standard
position within the mid SVC. Stable nodular opacity since CT
examination from [**2191-7-10**].
[**2191-7-22**]: IMPRESSION: Right PICC Line is ending into the SVC.
Since [**2191-7-20**], no significant interval changes are seen
in bilateral lungs. Lungs remain low volume and the vascular
congestion is persisting. There are no lung opacities of concern
for pneumonia. Heart size is normal. No pleural effusion or
pneumothorax.
[**2191-7-22**] Abdomen xray: There is a nonspecific bowel gas pattern
with no evidence of obstruction. Multiple drains and catheters
are visualized overlying the abdomen and pelvis. No evidence of
overt free air. Evaluation for free air is limited due to supine
position.
[**2191-7-22**] CXR: There are new opacities in the left lower lobe.
This could represent aspiration. Cardiomediastinal contours are
unchanged. The patient is status post right upper lobectomy.
There are low lung volumes. Right PICC remains in standard
position. There is no pneumothorax or pleural effusion. Mild
vascular congestion is unchanged .
[**2191-7-22**] CXR: An ET tube is present, tip at the level of the
clavicular heads, approximately 7 cm above the carina. A
right-sided PICC line is present -- the tip is not optimally
visualized but appears to overlie the upper SVC.
[**2191-7-23**]: CT Head: IMPRESSION:
1. Unchanged distribution and volume of subarachnoid hemorrhage.
2. Decreased size of bilateral lateral intraventricular
hemorrhages, though there appears to be subtle increase in
ventricular dilatation of the lateral, third, and fourth
ventricles.
3. No new intraparenchymal process.
ATTENDING NOTE: The temporal horns are not significantly
changed. The apparent prominence of lateral ventricules since
previous study may be related to differences in angulation.
However, follow up recommended.
[**2191-7-23**] CT HEad: IMPRESSION: Placement of a right frontal
ventricular drain with the tip in the upper third ventricle
through the foramen of [**Last Name (un) 2044**]. No significant change in
ventricular size is seen. No new hemorrhage is identified.
[**2191-7-24**] CHEST (PORTABLE AP)
As compared to the previous radiograph, there is no relevant
change. Lung volumes have minimally decreased, potentially
caused by changed respiratory pressures. The size of the cardiac
silhouette is slightly larger than on the previous image.
Minimal fluid overload is present, but there is no evidence of
new focal parenchymal opacity suggesting pneumonia. In unchanged
manner, a small parenchymal opacity projecting over the left
costophrenic sinus is present.
[**2191-7-25**] LENIS
IMPRESSION: No DVT
[**2191-7-27**] Head CT
Stable appearance of ventricle size.
[**2191-7-30**] CXR
The endotracheal tube has been removed. There is a right-sided
central venous catheter with distal lead tip in the mid SVC.
Cardiac size is within normal limits. There is coarsening of the
bronchovascular markings; however, there are no signs of overt
pulmonary edema. There is no focal consolidation. There is
possibly a small effusion on the right base.
Brief Hospital Course:
73F who was admitted to the Neuro ICU under Neurosurgery after
she presented to the ER with a SAH and history of aneurysms. She
was started on Nimodipine and Dilantin.
A [**Month/Day/Year 12784**] CT was done to r/o any fractures as she was found down-
the CT noted some blood at C3-4, there was a question whether
this was extension of the SAH or a separate hemorrhage. A MRI
was recommended but unable to obtain until confirmation of coil
brand/make from [**Hospital1 2025**] is obtained.
On [**7-11**], the [**Hospital1 2025**] info was obtained and the patient had an MR
[**Name13 (STitle) 12784**] which excluded a spinal hematoma. She went to angio and a
PCOMM aneurysm was discovered and coiled without difficulty. She
returned to the ICU and her exam remained stable. Her SBP was
allowed to autoregulate 100-200.
On [**7-12**], she was noted to be more lethargic and confused. A CT
head was obtained which showed interval increase in her vent
size, but because has brain atrophy, she can accommodate
increase in size of ventricles, no EVD was place. Exam improved
over the course of the day. Dilantin level corrected was found
to be 10 and a bolus was given. Also, her systolic BP was seen
into the 210s, she was given 25mg of metoprolol which helped
resolved her HTN. On [**7-13**], patient was destating in the AM with
weak cough and secretions. A chest x-ray was done, which showed
no change from previous scan. She was placed on venti mask on
50%FIO2. On examination, patient EO to voice, follows commands
and was MAEs. Her IVF were decreased by half to 50cc/hr and CTA
was done which showed no vasospasm.
On [**7-14**], there was a wbc increase w/low grade fevers and a CXR
showed possible RLL consolidation vs atelectasis. Started on
Vanco/ Cefepime. On [**7-15**], she remained febrile and antibiotics
were continued. A PICC line was placed. On [**7-16**] she had RUE edema
and an US was negative for DVT. On [**7-17**], CTA showed no evidence
of vasospasm.
On [**7-18**], her neurological exam remained stable. She still
required tent mask at 70% and frequent suctioning. Medicine was
consulted for transfer but the frequency of suctioning and
amount of O2 therapy was not floor suitable. On [**7-19**], her
respiratory status improved as she was weaned down to 3L nasal
cannula and did not need suction for many hours. She had one
desat overnight to 90% once. Her neuro exam remained stable thus
transfer orders were written for the Step Down Unit.
Patient was stable in the step down unit from [**7-19**] to [**7-21**]. on
[**7-21**] she was taken to the operating roomm for PEG placement.
On the morning of [**7-22**], patient was found to be in respiratory
distress with tachycardia, tachypnia and difficulty managing
upper airway secreations. An ABG on RA revealed a PaO2 of 44.
MICU was consulted for a possible transfer but they declined and
patient was transferred to the SICU. Shortly after transfer to
the ICU patient was intubated for respiratrory failure.
CT Head was obtained on [**7-23**] and demonstrated slight enlargement
of the ventricles and so a right frontal EVD was placed. Post
procedure imaging demonstrated the EVD catheter to be within the
right lateral ventricle, no hemorrhage. On [**7-24**]. patient was
slightly more lethargic, but followed commands in all 4
extremities. ICP remained stable. On [**7-25**], exam stable, EVD was
clamped. ICPs were within normal range and a bronch was done by
the ICU for evaluation of airway. Cultures have been negative to
date. There was no cuff leak so the patient remained intubated.
On [**7-26**], the patient remained stable, her EVD remained clamped,
and ICPs remained stable. There was concern that a Trach
placement would be needed and the conversation was started with
the family.
On [**7-27**], a repeat Head CT was stable and her EVD was removed
without difficulty. She remained in the ICU for further care and
monitoring. On [**7-29**] she remained stable and she was transferred
to the SDU. She was seen by the speech and swallow team and she
failed a video swallow. She remained strict NPO with PEG tube
feedings. On [**7-30**] she was transferred to the floor in stable
condition. On [**7-31**] she was seen by the geriatrics team for blood
pressure control and further pulmonary management after her PNA.
She was started on lisinopril per there recommendations as well
as Nystatin for treatment of thrush. On [**8-1**], patient remained
stable and was discharged to rehab.
Medications on Admission:
1. Simvastatin 80mg daily
2. Metoprolol 50mg [**Hospital1 **]
3. Omeprazole 20mg daily
4. MVI
5. Ca2+
6. Oxycodone PRN
7. Armidex
8. Humulin 16/11
9. 2L oxygen at bedtime
Discharge Medications:
1. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
2. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
3. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for Wheezing .
4. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime).
5. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal Q6H (every 6 hours) as needed for Fever.
7. aspirin 300 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily).
8. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
9. insulin regular human 100 unit/mL Solution Sig: One (1) units
Injection as directed.
10. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day) as needed for BP>160.
11. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
12. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Six (6) Puff Inhalation Q6H (every 6 hours) as needed for
wheeze.
13. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for thrush.
15. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
16. Morphine Sulfate 1-2 mg IV Q4H:PRN pain
hold for rr < 12
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital - [**Hospital1 8**]
Discharge Diagnosis:
Subarachnoid hemorrhage
Intraventricular hemorrhage
HAP
Resipiratory failure
Protien/calorie malnutrition
Hydrocephalus
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:
Angiogram with Embolization and/or Stent placement
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily.*****
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort.
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs.
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal).
?????? After 1 week, you may resume sexual activity.
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate.
?????? No driving until you are no longer taking pain medications
What to report to office:
?????? Changes in vision (loss of vision, blurring, double vision,
half vision)
?????? Slurring of speech or difficulty finding correct words to use
?????? Severe headache or worsening headache not controlled by pain
medication
?????? A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
?????? Trouble swallowing, breathing, or talking
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
*SUDDEN, SEVERE BLEEDING OR SWELLING
(Groin puncture site)
Lie down, keep leg straight and have someone apply firm pressure
to area for 10 minutes. If bleeding stops, call our office. If
bleeding does not stop, call 911 for transfer to closest
Emergency Room!
Followup Instructions:
Please follow-up with Dr. [**First Name (STitle) **] in 4 weeks with MRI/MRA
([**Doctor Last Name **]) protocol.
PLEASE SEE YOUR PCP FOR [**Name Initial (PRE) **] Nodular cyst in the left lobe of the
thyroid. YOU [**Month (only) **] REQUIRE AN ULTRASOUND OF THE THYROID.
Completed by:[**2191-8-1**]
|
[
"331.4",
"250.00",
"530.81",
"272.4",
"518.81",
"486",
"V10.11",
"112.0",
"401.9",
"729.81",
"331.9",
"430",
"V10.3",
"V10.02",
"263.9",
"V58.67",
"721.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"96.56",
"38.91",
"43.11",
"33.22",
"38.93",
"96.04",
"39.75",
"88.41",
"96.6",
"02.2"
] |
icd9pcs
|
[
[
[]
]
] |
18258, 18329
|
11979, 16461
|
283, 419
|
18493, 18493
|
3254, 6341
|
20551, 20853
|
1932, 1974
|
16683, 18235
|
18350, 18472
|
16487, 16660
|
18671, 19609
|
19635, 20528
|
2018, 2227
|
3192, 3235
|
240, 245
|
447, 1451
|
2495, 3178
|
10738, 11956
|
7042, 10193
|
2003, 2003
|
18508, 18647
|
1473, 1685
|
1701, 1916
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,608
| 175,127
|
35011
|
Discharge summary
|
report
|
Admission Date: [**2118-9-20**] Discharge Date: [**2118-10-10**]
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2118-9-20**] Aortic Valve Replacement(21mm St. [**Male First Name (un) 923**] Porcine Valve)
and Three vessel coronary artery bypass grafting(LIMA to LAD,
svg to obtuse marginal, svg to posterior descending artery)
History of Present Illness:
Mr. [**Known lastname **] is an 85 year old male with known aortic stenosis
and long standing dyspnea on exertion. Recent cardiac
catheterization showed severe three vessel coronary artery
disease including a left main disease. Given his severe aortic
stenosis and multivessel coronary artery disease, he was
referred for cardiac surgical intervention.
Past Medical History:
Aortic Stenosis
Coronary Artery Disease
Non-Insulin Dependent Diabetes Mellitus
Dyslipidemia
Obesity
Benign Prostatic Hypertrophy
Spinal Stenosis
History of Herpes Zoster
Appendectomy
Lumbar Laminectomy
Umbilical Hernia Repair
Carpal Tunnel Repair
Hemorrhoid Surgery
Social History:
20 pack year history of tobacco, quit 40 years ago. No prior
ETOH abuse, drinks wine with dinner. Married, lives with wife.
Family History:
Denies premature coronary artery disease
Physical Exam:
discharge exam:
VS T 97.8 HR 92 SR BP 128/54 RR 24 99%RA
Awake and alert.MAE.Some dysphagia to thin liquids, receiving
tube feedings.
Lungs- slightly dece=reased BS at bases. No rales/ rhonchii.
Cor- RRR, no murmur. Crisp heart sounds.
Exts- warm, palpable pulses. Trace edema.
Wounds- clean and dry with stable sternum.
Pertinent Results:
[**2118-9-20**] 06:07PM WBC-15.4* RBC-3.02* HGB-9.6* HCT-26.5* MCV-88
MCH-32.0 MCHC-36.3* RDW-14.8
[**2118-9-20**] 06:07PM PLT COUNT-179
[**2118-9-20**] 04:16PM GLUCOSE-117* NA+-139 K+-3.8
[**2118-9-20**] 03:53PM UREA N-13 CREAT-0.7 CHLORIDE-115* TOTAL
CO2-20*
[**2118-10-9**] 05:00AM BLOOD WBC-10.0 RBC-3.75* Hgb-11.3* Hct-33.3*
MCV-89 MCH-30.1 MCHC-33.9 RDW-15.0 Plt Ct-556*
[**2118-10-9**] 05:00AM BLOOD Glucose-130* UreaN-27* Creat-0.8 Na-135
K-4.2 Cl-99 HCO3-28 AnGap-12
[**2118-10-9**] 05:00AM BLOOD Glucose-130* UreaN-27* Creat-0.8 Na-135
K-4.2 Cl-99 HCO3-28 AnGap-12
[**2118-10-8**] 03:22AM BLOOD Glucose-105 UreaN-27* Creat-0.7 Na-136
K-4.2 Cl-100 HCO3-29 AnGap-11
PRE-BYPASS:
The left atrium is moderately dilated. No atrial septal defect
is seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. 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. There are three aortic valve leaflets. The aortic valve
leaflets are severely thickened/deformed. There is moderate to
severe aortic valve stenosis (area 0.8-1.0cm2). Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are moderately
thickened. There is mild valvular mitral stenosis (area
1.5-2.0cm2). Mild to moderate ([**11-24**]+) mitral regurgitation is
seen. There is no pericardial effusion.
POST- BYPASS:
The patient is in sinus rhythm. Left and right ventricular
function is preserved. An aortic valve replacement (tissue) is
in good position. There is no AI. The AV peak and mean gradients
are 20 and 8 mmHg. Mitral regurgitation is now mild. The aorta
is intact. Otherwise, the examination is unchanged.
Dr. [**Last Name (STitle) **] was notified in person of the results at the time of
study.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2118-9-23**] 10:52
[**Known lastname **],[**Known firstname **] [**Medical Record Number 80049**] M 86 [**2032-9-30**]
Radiology Report CHEST (PORTABLE AP) Study Date of [**2118-10-9**] 7:24
AM
[**Hospital 93**] MEDICAL CONDITION:
86 year old man with s/p cabg
REASON FOR THIS EXAMINATION:
evaluate for infiltrates and effusion
Final Report
HISTORY: CABG.
FINDINGS: In comparison with the study of [**10-8**], there is little
change. The aberrant Dobbhoff tube is again seen and there is
consistent increased
opacification at the left base.
DR. [**First Name8 (NamePattern2) 1569**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11006**]
Approved: SUN [**2118-10-9**] 9:08 AM
Brief Hospital Course:
The patient was admitted and underwent AVR/CABG x3 with Dr.
[**Last Name (STitle) **] as noted. He was transferred to the CVICU in stable
condition on titrated phenylephrine and propofol The evening of
surgery he developed facial twitching and benzodiazepines were
started. Head CTs were done twice in the postop period with no
evidence of CVA. A neurology consultation was obtained and this
was felt to not clearly represent seizure activity, as confirmed
by continuous EEG monitoring. Keppra was started, however,
seizures did not resolve. Dilantin was added to his treatment
and a MRI of head done on POD #5 showed multiple areas of
infarction. Repeat EEGs were done, again inconsistent with
seizures The facial twitching slowly resolved. The Keppra was
discontinued and the patient had slow neurologic advancement
over the next few days.
Hemodynamically he remained stable and pressors were weaned and
discontinued over several days. He continued to improve
neurologically and was extubated. There is some dysphagia and
because of this a Dobhoff tube was placed and tube feeds begun.
Speech and swallowing will need to be reassessed as he continues
to rehabilitate.
He remained stable and his respiratory status stabilized with
some need for suctioning. He was kept in the ICU setting prior
to transfer to rehab to optimize his care. He is ready for
transfer at this time. Discharge medications and follow up
appointment requirements are as noted in the discharge
paperwork.
Medications on Admission:
Coreg 3.125 [**Hospital1 **], Detrol 4 qd, Flomax 0.4 qd, Simvastatin 80 qd,
Aspirin 81 qd, Calcium
Discharge Medications:
1. Acetaminophen 325 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Q4H (every
4 hours) as needed for temperature >38.0.
2. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: Two (2) PO BID (2
times a day).
3. Magnesium Hydroxide 400 mg/5 mL Suspension [**Hospital1 **]: Thirty (30)
ML PO DAILY (Daily) as needed for constipation.
4. Simvastatin 40 mg Tablet [**Hospital1 **]: Two (2) Tablet PO HS (at
bedtime).
5. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr [**Hospital1 **]: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
6. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette [**Hospital1 **]: [**11-24**]
Drops Ophthalmic PRN (as needed).
7. Heparin (Porcine) 5,000 unit/mL Solution [**Month/Day (2) **]: One (1)
Injection TID (3 times a day).
8. Bisacodyl 10 mg Suppository [**Month/Day (2) **]: One (1) Suppository Rectal
DAILY (Daily).
9. Aspirin 81 mg Tablet, Chewable [**Month/Day (2) **]: One (1) Tablet, Chewable
PO once a day.
10. Amiodarone 200 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO once a day.
11. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
12. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID
(3 times a day).
13. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Last Name (STitle) **]: Three (3) ml Inhalation Q2H (every 2 hours) as
needed.
14. Furosemide 40 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
15. Insulin Glargine 100 unit/mL Solution [**Last Name (STitle) **]: Thirty Five (35)
units Subcutaneous once a day: Give at 2200 hours.
16. Insulin Regular Human 300 unit/3 mL Insulin Pen [**Last Name (STitle) **]: see
sliding scale Subcutaneous AC & HS: 120-160:2 units SQ
161-200:4 units SQ
201-240:6 units SQ
241-280:8 units SQ
.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Aortic Stenosis
Coronary Artery Disease
s/p Aortic Valve replacement & coronary artery grafting
Non-Insulin Dependent Diabetes Mellitus
Dyslipidemia
Obesity
Benign Prostatic Hypertrophy
Spinal Stenosis
postop CVA
Discharge Condition:
Good
Discharge Instructions:
no lifting more than 10 pounds for 10 weeks
no driving for 4 weeks and off all narcotics
report any drainage from, or redness of incisions
report any temperature greater than 100.5
report any weight gain greater than 2 pounds a day or 5 pounds a
week
shower daily, no simming or baths
no lotions, creams or powders to incisions
take all medications as directed
Followup Instructions:
Dr. [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**])
Dr. [**Last Name (STitle) **] in [**12-26**] weeks
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**12-26**] weeks
Please call for appointments
Completed by:[**2118-10-10**]
|
[
"600.00",
"V58.67",
"780.39",
"V45.79",
"272.4",
"728.87",
"250.00",
"997.02",
"427.31",
"414.01",
"278.00",
"724.00",
"424.1",
"458.29",
"E878.2",
"787.20",
"434.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"99.04",
"96.72",
"39.61",
"36.15",
"35.22",
"36.12"
] |
icd9pcs
|
[
[
[]
]
] |
8136, 8208
|
4611, 6099
|
289, 509
|
8465, 8472
|
1741, 4081
|
8881, 9155
|
1339, 1381
|
6249, 8113
|
4121, 4151
|
8229, 8444
|
6125, 6226
|
8496, 8858
|
1396, 1396
|
1412, 1722
|
230, 251
|
4183, 4588
|
537, 891
|
913, 1182
|
1198, 1323
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,471
| 104,884
|
7560
|
Discharge summary
|
report
|
Admission Date: [**2122-8-10**] Discharge Date: [**2122-8-13**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 663**]
Chief Complaint:
Hematochezia and weakness
Major Surgical or Invasive Procedure:
3 PRBC Blood transfusion.
Flexible Sigmoidoscopy.
History of Present Illness:
[**Age over 90 **] year old man with history of alcohol abuse, paroxysmal atrial
tachycardia and frequent lower gastrointestinal bleeding,
presenting with 1 week history of bright red blood per rectum
with bowel movements. Patient reports he was in his otherwise
good state of health until last Monday, when he began having
diarrhea with bright red blood, which stained his toilet water
red. Patient also complains of weakness, fatigue when going up a
single set of stairs (different than his baseline)
The patient also Complaints of "nose/throat issues" and reports
a scratchy feeling in his throat. Denies any recent travel,
fevers, chills, nausea, vomiting, chest pain, but does report
feeling dizzy.
In ED, Temp: 99.4 HR: 86 BP: 89/51 RR: 19 O2 Sat:99% RA.
Patient given 1 unit of PRBC with improvement in SBP to 100's.
Hct found to be 18 (baseline 34). Patient admitted to MICU for
further management.
Past Medical History:
- alcohol abuse; drank an average of 2 large bottles of [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 5261**] per week (per prior OMR notes) patient reports he has
since quit (x 1 month)
- paroxysmal atrial tachycardia
- anemia, mild leukopenia
- dementia (baseline oriented to person, place)
- BPH s/p TURP
- chronic LGIB (question of AVM vs Diverticuli)
- gout
Social History:
Patient had history of [**1-22**] drinks of [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5261**] per day as
documented in OMR. Prior tobacco, quit in 60s. Lives with his
wife. [**Name (NI) **] has two kids and 2 grandkids.
Family History:
Non-contributory, no colon CA
Physical Exam:
Vital signs:
Temp: 99.4 HR: 92 BP: 133/50 RR: 25 O2 Sat: 100%
GEN: Elderly man in no acute distress, well appearing. Alert,
oriented to self, place, year, month and day of the week.
HEENT: PERRL with anicteric sclera, pale conjuctivae.
CV: Irregular rate with frequent beats out of sequence. No
murmurs, rubs or gallops.
Lungs: Clear to auscultation bilaterally, no rales, rhonchi or
wheezes.
Abdomen: Soft, non tender, non distended.
Ext: Warm, well perfused.
Pertinent Results:
==================
ADMISSION LABS
==================
WBC-7.6 RBC-1.84* Hgb-5.3* Hct-18.3* MCV-100* MCH-28.8
MCHC-28.9* RDW-14.3 Plt Ct-323
Neuts-73.2* Lymphs-19.9 Monos-6.2 Eos-0.6 Baso-0
PT-13.3 PTT-26.4 INR(PT)-1.1
Glucose-117* UreaN-12 Creat-1.2 Na-143 K-3.8 Cl-106 HCO3-26
AnGap-15
ALT-10 AST-15 AlkPhos-47 TotBili-0.3
Lipase-20
===============
SIGMOIDOSCOPY
===============
[**2120-1-21**]
Findings: Protruding Lesions Medium internal hemorrhoids with
stigmata of recent bleeding were noted. There was erythema and
red spots on the internal hemorrhoids.
Excavated Lesions Multiple severe diverticula with wide-mouth
openings were seen in the sigmoid colon and descending colon.
[**2118-1-20**]
Impression: Diverticulosis of the sigmoid colon and descending
colon internal and external hemorrhoids
Flat Lesions A few angioectasias that were not bleeding were
seen in the rectum. An Argon-Beam Coagulator was applied for
hemostasis successfully. Excavated Lesions Multiple diverticula
were seen in the left colon.
Brief Hospital Course:
[**Age over 90 **] year old man with h.o. alzheimers dementia, Etoh abuse, HTN,
paroxysmal atrial tachycardia s/p 3u PRBC transfusion for GI
bleed admitted to the ICU with dizziness and hematochezia.
##. Hematochezia: Mr. [**Known lastname **] presented to the ED with a 1 week
history of hematochezia, weakness, fatigue. In the ER he was
noted to have a Hct 18 and was thus transfused 3units of PRBCs
and transferred to the ICU. In the ICU he was noted to have a
post transfusion Hct of 27 that remained stable. Pt was
transferred back to the floor and received a sigmoidoscopy that
showed sigmoidal polyp and grade II internal hemorrhoid. Pt has
been seen in the past by Dr. [**Last Name (STitle) **] for hemorrhoidal banding,
on discharge pt was given instructions to contract Dr. [**Last Name (STitle) **]
to band his hemorrhoid.
##. Alcohol abuse: Pt had an extensive history of Alcohol abuse
however he has not had an alcoholic drink for 4 weeks. Whilst in
the hospital Mr. [**Known lastname **] showed no signs of withdrawal and was
given thiamine, folate, and multivitamin supplementation.
##. Paroxysmal atrial tachycardia: Patient was controlled on his
home regimen of Diltiazem.
##. Glaucoma: Patient was continued on his outpatient eye drops.
Medications on Admission:
ALLOPURINOL - 300 mg Tablet - [**1-21**] Tablet(s) by mouth once a day
BRIMONIDINE TARTRATE - 0.15% Drops - ONE DROP EACH EYE EVERY 8
HOURS
DILTIAZEM HCL [DILT-XR] - 180 mg Capsule
POTASSIUM CHLORIDE - 8 mEq Tablet Sustained Release - 1
Tablet(s)
by mouth once a day
TIMOLOL MALEATE - 0.25% Drops - ONE DROP EACH EYE TWO TIMES A
DAY
FERROUS SULFATE - 250 mg Capsule, Sustained Release
Discharge Medications:
1. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H
(every 8 hours).
2. Timolol Maleate 0.25 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
6. Allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Lower GI Bleed, likely internal hemorrhoids
Discharge Condition:
Stable, afebrile.
Discharge Instructions:
You were admitted to the hospital for a lower gastrointestinal
bleed, you needed a blood transfusion as your blood level was
low. Please go to the surgery clinics as scheduled on [**2122-8-19**] to have further treatment of your hemorrhoids.
Before you left the hospital you were able to eat a full meal
without bleeding again.
We stopped your diltiazem medication. Please do not take this
medication at home.
You will be given a presciption for Pantoprazole (Protonix)
which is an indigestion pill, please take it as instructed. You
will also be given a medication called Docusate Sodium (Colace)
which will help soften your bowel movements, please take as
instructed.
If you start bleeding again please return to the ER.
Followup Instructions:
1. Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2122-9-1**] 2:30
2. Please call Dr. [**Last Name (STitle) **] for an appointment next week to have
your stage II internal hemorrhoid banded.
|
[
"285.1",
"455.2",
"401.9",
"331.0",
"211.3",
"274.9",
"365.9",
"294.10",
"427.0",
"305.01",
"458.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"45.42"
] |
icd9pcs
|
[
[
[]
]
] |
5863, 5869
|
3541, 4801
|
287, 339
|
5957, 5977
|
2490, 3518
|
6751, 7061
|
1957, 1989
|
5236, 5840
|
5890, 5936
|
4827, 5213
|
6001, 6728
|
2004, 2471
|
222, 249
|
367, 1280
|
1302, 1682
|
1698, 1941
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,990
| 189,150
|
25084
|
Discharge summary
|
report
|
Admission Date: [**2148-12-18**] Discharge Date: [**2148-12-25**]
Date of Birth: [**2086-2-5**] Sex: F
Service: MEDICINE
Allergies:
Aspirin
Attending:[**First Name3 (LF) 3561**]
Chief Complaint:
transfer from OSH for ? failed TIPS
Major Surgical or Invasive Procedure:
paracentesis
History of Present Illness:
Ms. [**Known lastname 19755**] is a 62 y/o female with alcoholic ESLD s/p TIPs
for variceal bleed 2y ago, h/o ascites who was admitted to
[**Hospital3 3583**] on [**12-15**] with 2 weeks of increasing left leg
edema, pain and erythema non-responsive to 5 days of Kelfex for
presumed cellulitis. (Pt was afebrile throughout her admission
at [**Hospital1 46**] and WBC max was 10.6 with 84% polys.) She also had
abdominal pain and increasing abd girth. She had no fever or
chills, and had decreased appetite but says this is her
baseline. Patient had also noticed increased abdominal girth.
Otherwise had no complaints. She was admitted to [**Hospital1 46**] for IV
abx and diuresis.
.
At [**Hospital3 3583**], she was treated with Iv Zosyn for LLE
cellulitis. LENI of the L leg was negative for DVT, and doppler
U/S of her abd showed a patent TIPS with high velocities,
causing concern for TIPS stenosis. She had a diagnostic and
therapeutic tap (3L removed) which showed no evidence of SBP.
she was transfused 1 unit pRBCs [**12-16**] at OSH. She was
transferred to [**Hospital1 18**] for further care and ? revision of TIPS.
Interestingly, her ammonia level was 19 at [**Hospital1 46**] compared to
her baseline there of 40-80. Blood cultures from [**12-15**] final
read is negative.
.
At present, pt reports she is tired and lightheaded with
decreased appetite. Continues to have abdominal and B leg pain
and states these are only slightly decreased from admission.
.
ROS: denies HA, CP, SOB, cough, N/V, dysuria, constipation.
Notes bilateral leg pain, abd pain, decreased appetite,
diarrhea.
Past Medical History:
1. Parkinson's: ? new diagnosis. Off transplant list.
2. ESLD from EtOH cirrhosis: esophageal variceal bleed in [**10-2**],
Stage III varices s/p 4 bands with rebleeding requiring
intubation, [**Last Name (un) 10045**] placement and TIPS. h/o encephalopathy.
3. Type 2 DM on insulin therapy
4. HTN
4. GERD
5. h/o carpal tunnel surgery
6. Chronic Edema
7. h/o cellulitis
8. thrombocytopenia in setting of liver disease
9. [**Name (NI) **] (unclear site)
Social History:
currently living at [**Hospital 62931**]. Quit tobacco 20y ago,
quit EtOH 20y ago per pt, denies other drugs. Previously lived
at home with her son, daughter and [**Name2 (NI) 12496**].
Family History:
pt denies any illnesses in family.
Physical Exam:
PE: 98.2, 128/62, 88, 20, 100% RA, FS 139
Gen: NAD, lying in bed, answers questions appropriately
HEENT: scleral icterus, PERRL, NCAT, erythematous cheeks and
nose
Neck: no LAD, supple
Cor: RRR, s1s2, flow murmur
Pulm: decreasd B bases, otherwise CTAB
Abd: protuberant, decreased BS, tender to mild palpation, unalbe
to assess for HSM due to extreme discomfort
Skin: jaundiced, spider angiomata on face, chest, arms, palmar
erythema. BLE skin appears thickened, dry, scaly and
erythematous, although not definitely warm or cellulitic.
Ext: BLE pitting edema - on R leg edema up to knee, on L leg
edema at least halfway up thigh.
Neuro: oriented x 3, slow talking but alert, 4/5 strength B
grips/biceps/triceps/plantarflexion/dorsiflexion. + asterixis
Pertinent Results:
ON ADMISSION:
[**2148-12-19**] 06:20AM BLOOD WBC-8.5# RBC-2.73* Hgb-9.2* Hct-28.3*
MCV-104* MCH-33.7* MCHC-32.5 RDW-17.3* Plt Ct-87*#
[**2148-12-19**] 06:20AM BLOOD Neuts-81.6* Lymphs-10.6* Monos-6.3
Eos-1.4 Baso-0.1
[**2148-12-19**] 06:20AM BLOOD PT-20.0* PTT-43.7* INR(PT)-1.9*
[**2148-12-19**] 06:20AM BLOOD Glucose-70 UreaN-20 Creat-1.2* Na-138
K-4.0 Cl-99 HCO3-33* AnGap-10
[**2148-12-19**] 06:20AM BLOOD ALT-5 AST-49* AlkPhos-162* TotBili-8.4*
[**2148-12-19**] 06:20AM BLOOD Albumin-2.2* Calcium-8.2* Phos-3.3 Mg-1.9
.
IRON STUDIES:
[**2148-12-20**] 05:15AM BLOOD calTIBC-94* VitB12-1336* Folate-7.8
Ferritn-570* TRF-72*
.
ON DISCHARGE
[**2148-12-22**] 07:10AM BLOOD WBC-6.5 RBC-2.42* Hgb-8.7* Hct-26.2*
MCV-108* MCH-35.9* MCHC-33.2 RDW-16.7* Plt Ct-75*
[**2148-12-22**] 07:10AM BLOOD PT-21.2* INR(PT)-2.0*
[**2148-12-22**] 07:10AM BLOOD Glucose-113* UreaN-16 Creat-1.1 Na-138
K-3.7 Cl-97 HCO3-33* AnGap-12
[**2148-12-22**] 07:10AM BLOOD TotBili-9.3*
[**2148-12-22**] 07:10AM BLOOD Calcium-8.7 Phos-2.8 Mg-1.8
.
[**2148-12-19**] 11:05 am FLUID RECEIVED IN BLOOD CULTURE BOTTLES
PERITONEAL FLUID.
AEROBIC BOTTLE (Preliminary): NO GROWTH.
ANAEROBIC BOTTLE (Preliminary): NO GROWTH.
WBC 215*
RBC 2874*
N 2* L 31* M 0 Meso 1* Macrophages 66*
TotPro 1
Glucose 108
Creat 1.1
Albumin LESS THAN 1.0
.
[**2148-12-21**] 03:00PM URINE RBC-2 WBC-12* Bacteri-RARE Yeast-NONE
Epi-5
[**2148-12-21**] 03:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-SM
[**2148-12-21**] 03:00PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.013
[**2148-12-21**] 3:00 pm URINE Source: CVS.
URINE CULTURE (Final [**2148-12-22**]): <10,000 organisms/ml.
.
Blood Cultures 11/23 and [**12-21**] no growth at time of discharge
.
CT Abd/Pelvis W and W/O CONTRAST [**2148-12-19**]
IMPRESSION: 1. No evidence of pyelonephritis or diverticulitis.
2. Evidence of chronic liver disease with ascites and irregular
liver outline. Ascites has worsened from prior study. 3. Basal
pleural effusions and atelectasis worse than on previous
examination. 4. Lumbar spine degenerative change with spinal
canal stenosis at L2-3 and L4-5. 5. Non-specific pancreatic head
cystic abnormality--MRCP is recommended for further
characterization. These have not changed form previous study.
[**2148-10-23**] comparison.
.
DOPPLER ABDOMINAL [**Year (4 digits) **] [**2148-12-20**]: 1. Patent TIPS shunt with
appropriate velocities which appear to be unchanged from the
prior exam. 2. Slight increase in size of simple right liver
cyst. 3. Single gallstone. 4. Splenomegaly. 5. Ascites.
Brief Hospital Course:
Ms. [**Known lastname 19755**] is a 62yo woman with h/o EtOH cirrhosis s/p TIPS
after variceal bleed who is transferred from [**Hospital3 3583**]
after presenting there with increasing BLE (L>R) edema and
abdominal girth and found to have likely stenosed TIPS.
.
MEDICAL FLOOR HOSPITAL COURSE:
.
# Cirrhosis
Patient carries a history of ESLD s/p TIPS. Given increased LE
swelling, there was a concern that the TIPS was stenosed.
Abdominal [**Hospital3 950**] showed no stenosis, however with increased
(albeit unchanged) velocities. A venogram study was planned but
was unable to be performed given medical decompensation (below).
.
The patient underwent diagnostic paracentesis on hospital day 2
which did not show evidence of SBP. On hospital day 6 the
patient's ascites had increased, her abdomen became distended,
and respirations were mildly impaired. She underwent
therapeutic paracentesis, as is customarily performed on a
weekly basis given her proclivity to re-accumulate ascitic
fluid. Paracentesis was attempted on the right lower abdomen,
where she normally undergoes drainage, but was unsuccessful.
Repeat attempt on the left lower abdomen several hours later was
successful in draining 5 L of serosanguinous fluid. Fluid
evaluation was negative for SBP and cultures were negative 2
days later.
.
She was also continued on Nadolol 10mg po qday to prevent
variceal bleeding. Lactulose 30mL po qid was also titrated to 3
bowel movements per day for encephalopathy.
.
# BLE edema and erythema
BLE edema was considered secondary to volume overload and not
infection, as wbc was wnl and she was afebrile. Diuresis was
pursued w/ spironalactone / lasix.
.
# Parkinsons
Home dose sinemet was continued.
.
# DM
Controlled with home lantus 50 units qhs and sliding scale.
.
# Pancreatic Cyst
On CT scan patient was found to have a pancreatic head cyst
abnormality. She would have followed up with an MRCP in [**3-3**]
weeks as an outpatient for further evaluation.
.
# Psych:
She was continued on citalopram and methylphenidate.
.
[**Hospital 12145**] HOSPITAL COURSE:
On [**12-23**], patient was noted to have spontaneous bleeding from
her mouth / gums and oozing from all her IV sites. Coags were
checked and INR was elevated at 2.5. Although her mental status
since admission was impaired (waxing/[**Doctor Last Name 688**] level of
consciousness and level of interaction), at approximately 5 pm
she was noted to have increased somnolence and difficulty to
arouse. Furthermore, she was found to have several focal
neurologic signs worrisome for a CNS insult. Given concern for
intracranial pathology and coagulopathy, she was sent for a
noncontrast CT of the head which was negative for ICH.
Subsequently she developed a fever; labs were sent to work up
DIC. Lab data was consistent with DIC as well as ongoing blood
loss. Differential on CBC showed stippled cells but no
schistocytes. Neurology was consulted for altered mental status
of unclear etiology. Of note, labs drawn amidst the
decompensation showed neutropenia w/ WBC of 600 (although this
was likely a lab error as repeat WBC was 5600). She was written
for cefepime and vanco for neutropenic coverage, although no
doses were received. At the time of Neurology evaluation,
patients temperature was noted to be 103 F and SBPS dropped into
the 90s. Repeat BP measurements then showed SBPs in 70s. IVFs
were started and a CODE BLUE was called.
.
At the time of the CODE BLUE, patient was noted to be breathing
spontaneously without difficulty. ABG checked at that time was
7.45/42/297 on NRB. Patient had pulses but was unresponsive.
SBPs were 60s-70s. IVF was hung in pressure bags through PIV
until L femoral CVL was placed. Dopamine gtt was also started
with improved SBPs to 110s w/ HRs to the 120s. She was then
transferred to the MICU for further management. Code status was
discussed with her healthcare proxy and she was reported to be
DNR/DNI but pressors were okay to use.
.
In the MICU she was treated for presumed septic shock and DIC.
She was given cefepime, vanco, and flagyl and was volume
resuscitated with PRBCs, FFP, platelets, and cryogloblin. She
required levophed and vasopressin to maintain MAPs >65. DIC labs
improved with blood products. Blood cultures grew gram negative
rods. Overnight, repeating a CT of the abdomen was considered
but the patient was felt to be too unstable to transport. By the
following morning, pressors were weaned off and patient was more
alert but complaining of severe abdominal pain with some
rebounding. Also required BiPAP for respiratory distress
presumed secondary to volume overload in the setting of
oliguria. Surgery was consulted for possible acute abdomen.
Upon review of CT abdomen/pelvis performed on the previous day,
there was concern for potential mesenteric ischemia. This was
relayed to patient's son who was also her healthcare proxy.
Surgical options were discussed but it was decided to make the
patient CMO. She died the following day from cardiopulmonary
arrest at 0952 on [**12-25**].
Medications on Admission:
Lasix 40mg po bid
protonix 40mg po qday
celexa 10mg po qday
lantus 50 units qhs
lactulose 2 tblspoons qid
ritalin 5mg po bid
MVI po qday
nadolol 10mg po qday
rifaximin 400mg po tid
thiamine 100mg po qday
zofran 4mg po q12h prn nausea
robitussin prn cough
benadryl 12.5mg po qhs prn itch
potassium 20meQ po qday
sinemet 25/100 3 half tabs po tid
aldactone 100mg po qday
percocet qday prn pain
novolog 5 units [**Hospital1 **]
insulin slide scale
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
|
[
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"572.2",
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"V58.67",
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] |
icd9cm
|
[
[
[]
]
] |
[
"54.91",
"99.07",
"00.17",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
11696, 11705
|
6115, 6392
|
305, 319
|
11756, 11765
|
3464, 3464
|
11821, 11831
|
2641, 2677
|
11664, 11673
|
11726, 11735
|
11195, 11641
|
8198, 11169
|
11789, 11798
|
2692, 3445
|
230, 267
|
347, 1945
|
3478, 6092
|
1967, 2422
|
2438, 2625
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,432
| 139,364
|
673
|
Discharge summary
|
report
|
Admission Date: [**2159-8-17**] Discharge Date: [**2159-8-22**]
Date of Birth: [**2074-12-4**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 983**]
Chief Complaint:
Lethargy, hypoxia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
84M h/o COPD, dCHF, AF, AS (valve area 0.8cm2), s/p superior
segmentectomy of right lower lobe [**12/2158**], now presenting with
lethargy and hypoxia.
The patient's family reports increasing lethargy for the past 2
days, and was found to be hypoxic to the 60's by the VNA. His
daughter had called his PCP [**Last Name (NamePattern4) **] [**8-13**] for weight gain but the
decision was made not to increase the Lasix at that time. He
denies shortness of breath, chest pain, fevers/chills, cough,
nausea, vomiting, abdominal pain.
The patient was admitted [**Date range (1) 5081**] for community acquired
pneumonia and acute on chronic diastolic CHF. During that
admission, the patient was diuresed with Lasix in the MICU for
his acute CHF exacerbation. However, the patient was called out
to the floor and prior to discharge, his Lasix dose was
decreased from 40 mg [**Hospital1 **] to 40 mg every other day for an
elevated bicarb on labs which was attributed to contraction
alkalosis. His Spironolactone 25 mg daily was also discontinued
during that admission for unclear reasons. He was treated for
the pneumonia with Levofloxacin x7 days and a prednisone burst,
and PO2 was 95% on 3L at time of discharge with ambulatory sats
of 85% RA, unknown ambulatory PO2 on 3L NC. He has been on
supplemental O2 at 2L NC since discharge from his recent
hospitalization.
In the ED, initial VS were: 117/57, 59, 18, 93% BIPAP (fiO2
30%)
Exam: shallow breathing, +use of accessory muscles, crackles at
bases bilaterally, 1+ edema bilaterally, belly a little more
distended. MS improved after BIPAP and breathing better, now at
FIO2 at 30% on BIPAP.
labs - K 5.4 - no peaked T's on EKG, given kayexalate 15gm,
BNP: 4239 same as last CHF exacerbation, trop was at baseline,
CXR was done and showed heart mod enlarged, worsened pulm edema,
small b/l pleural effusions. Bipap started ~10:45, no IV lasix
or nitro drip due to critical AS and didn't want to reduce
preload, tried to bump down to nc at 12:45, sats dropped to
low-mid 80's
On arrival to the MICU, patient was on BIPAP, awake alert
following commands and a little irritated wanting to leave the
hospital emergently. He said he was not gonna waste his time
here.
Past Medical History:
- Right lung nodule s/p R VATS superior segmentectomy of right
lower lobe. [**2158-12-12**], 3.0 x 2.5 x 2.0 cm poorly differentiated
pleomorphic carcinoma T2aN0, Stage 1B
- COPD (last PFTs [**2148**] FEV1/FVC 98%, FEV1 55)
- Coronary artery disease
- CHF (last echo [**2158**] showed preserved EF >70%, diastolic
dysfunction)
- Severe Aortic Stenosis (valve area 0.8-1.0cm2) [**8-/2159**]
- BPH
- Osteoarthritis bilateral hips s/p right total hip replacement
- Hypercholesterolemia
- Atopic dermatitis
- Cervical spondylosis
- s/p tonsillectomy
Social History:
- Tobacco: Smoked x60yrs, quit [**2147**]
- Alcohol: Less than once daily
- Illicits: Denies
Lives with his daughter, wife recently passed away [**2159-7-14**],
retired plumbing/heating.
Family History:
Mother d. 69, father d. 72, 3 brothers and 1 sister, all passed
away.
Physical Exam:
Admission Physical
General: Alert, oriented, on BIPAP and uncomfortable
HEENT: PERRL, EOMI, Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP difficult to assess no LAD
CV: Regular rate and rhythm, normal S1 + S2, Low pitch
crescendo-decrescendo murmur heard best at the RUSB with some
radiation to the carotids, No rubs or gallops
Lungs: Diffuse crackles in the posterior lung fields right>left
Abdomen: Distended and tense, non-tender, bowel sounds present,
organomegaly difficult to assess
GU: Foley in place
Ext: Cold distal extremity, 2+ radial pulses bilaterally with 1+
DP pulses bilaterally
Discharge Physical
VS - 97.0 118/58 61 18 93% 3L (84% on 3L with ambulation), -500
net negative over 24 hours, weight 103kg (stable over past 2
days)
GENERAL - NAD, comfortable, sitting in chair
NECK - supple, no thyromegaly, no JVD, delayed carotid upstrokes
LUNGS - bibasilar rales [**Date range (1) 5082**] up bilaterally, decr BS at bases
HEART - RRR, harsh [**3-7**] holosystolic murmur at RUSB with
radiation to the carotids
ABDOMEN - +BS NT moderately distended, tympanic to percussion
throughout.
EXTREMITIES - 2+ peripheral pulses (radials, DPs), wwp, no edema
SKIN - no rashes or lesions
Neuro - AOx3, appropriate, follows commands
Pertinent Results:
Reports:
CXR [**2159-8-17**]: Mild congestive heart failure which is slightly
worse when
compared to the prior exam.
[**2159-8-17**] 10:45AM BLOOD WBC-10.6 RBC-4.20* Hgb-12.0* Hct-38.3*
MCV-91 MCH-28.6 MCHC-31.4 RDW-14.7 Plt Ct-191
[**2159-8-18**] 05:18AM BLOOD WBC-8.0 RBC-3.77* Hgb-10.7* Hct-33.2*
MCV-88 MCH-28.5 MCHC-32.4 RDW-15.1 Plt Ct-169
[**2159-8-19**] 07:47AM BLOOD WBC-7.4 RBC-3.83* Hgb-11.0* Hct-33.4*
MCV-87 MCH-28.7 MCHC-32.9 RDW-14.9 Plt Ct-216
[**2159-8-20**] 09:00AM BLOOD WBC-10.4 RBC-3.78* Hgb-10.7* Hct-32.9*
MCV-87 MCH-28.4 MCHC-32.6 RDW-15.1 Plt Ct-211
[**2159-8-21**] 07:25AM BLOOD WBC-4.6# RBC-3.39* Hgb-9.6* Hct-29.7*
MCV-88 MCH-28.3 MCHC-32.3 RDW-15.2 Plt Ct-212
[**2159-8-22**] 06:15AM BLOOD WBC-5.5 RBC-3.28* Hgb-9.3* Hct-28.3*
MCV-86 MCH-28.4 MCHC-32.9 RDW-15.5 Plt Ct-225
[**2159-8-17**] 10:45AM BLOOD Neuts-90.8* Lymphs-5.2* Monos-2.5 Eos-0.3
Baso-1.2
[**2159-8-17**] 10:45AM BLOOD PT-29.2* PTT-32.4 INR(PT)-2.8*
[**2159-8-18**] 05:18AM BLOOD PT-30.0* PTT-33.6 INR(PT)-2.9*
[**2159-8-19**] 07:47AM BLOOD PT-28.2* PTT-31.6 INR(PT)-2.7*
[**2159-8-21**] 07:25AM BLOOD PT-30.3* PTT-34.0 INR(PT)-3.0*
[**2159-8-22**] 06:15AM BLOOD PT-34.1* PTT-35.1* INR(PT)-3.4*
[**2159-8-17**] 10:45AM BLOOD Glucose-145* UreaN-29* Creat-1.2 Na-141
K-5.4* Cl-99 HCO3-39* AnGap-8
[**2159-8-17**] 04:34PM BLOOD UreaN-27* Creat-1.0 Na-141 K-4.9 Cl-98
HCO3-36* AnGap-12
[**2159-8-17**] 11:02PM BLOOD UreaN-27* Creat-1.1 Na-141 K-4.2 Cl-96
HCO3-38* AnGap-11
[**2159-8-18**] 05:18AM BLOOD Glucose-104* UreaN-25* Creat-1.1 Na-141
K-3.9 Cl-94* HCO3-38* AnGap-13
[**2159-8-18**] 12:50PM BLOOD Glucose-135* UreaN-27* Creat-1.0 Na-139
K-4.2 Cl-91* HCO3-41* AnGap-11
[**2159-8-19**] 07:47AM BLOOD Glucose-141* UreaN-34* Creat-1.2 Na-139
K-3.7 Cl-91* HCO3-41* AnGap-11
[**2159-8-20**] 09:00AM BLOOD Glucose-221* UreaN-41* Creat-1.1 Na-139
K-4.1 Cl-93* HCO3-40* AnGap-10
[**2159-8-21**] 07:25AM BLOOD Glucose-122* UreaN-40* Creat-1.0 Na-141
K-4.5 Cl-98 HCO3-36* AnGap-12
[**2159-8-22**] 06:15AM BLOOD Glucose-125* UreaN-41* Creat-1.0 Na-136
K-4.5 Cl-93* HCO3-37* AnGap-11
[**2159-8-17**] 10:45AM BLOOD ALT-30 AST-31 CK(CPK)-208 AlkPhos-73
TotBili-0.4
[**2159-8-17**] 10:45AM BLOOD CK-MB-9 proBNP-4239*
[**2159-8-17**] 10:45AM BLOOD cTropnT-0.04*
[**2159-8-17**] 11:02PM BLOOD CK-MB-7 cTropnT-0.05*
[**2159-8-22**] 06:15AM BLOOD Calcium-8.2* Phos-3.5 Mg-2.4
[**2159-8-17**] 10:45AM BLOOD T4-3.0*
[**2159-8-17**] 10:45AM BLOOD TSH-19*
[**2159-8-17**] 11:17AM BLOOD Type-ART Rates-/16 pO2-261* pCO2-91*
pH-7.25* calTCO2-42* Base XS-9 Intubat-NOT INTUBA
[**2159-8-17**] 10:52AM BLOOD Lactate-0.7 K-5.4*
Brief Hospital Course:
84M h/o COPD, dCHF, AF, AS (valve area 0.8cm2), s/p superior
segmentectomy of right lower lobe [**12/2158**], now presenting with
lethargy and hypoxia.
#. Hypoxia/CHF: He was admitted with hypoxia felt to be related
to an acute exacerbation of his chronic CHF. This was felt to
be caused by inadequate diuresis prior to admission as his
outpatient lasix dosing had been decreased prior to admission.
He was put on a lasix drip in the MICU and given Bipap and his
oxygenation improved substantially. He was then changed to IV
bolus dosing with good effect and he was transferred to the
floor. On the floor, he was transitioned back to his home
diuretics with good effect. He was satting 92% on 2-3L
throughout his admission, and was satting the same on discharge.
Of note he does tend to desat to mid 80% on ambulation, however
he is asymptomatic during these episodes and returns to baseline
90-92% quickly with rest. His chest xray on discharge showed no
pulmonary edema but some bibasilar atelectasis. He has
outpatient follow up with cardiology scheduled soon after
discharge for evaluation of his CHF in relation to his aortic
stenosis.
#. Delirium: He had altered mental status felt to be consistent
with delirium after admission. It is unclear if at baseline he
has some mild cognitive impairment as well. He required
initially PRN zyprexa but eventually was changed to PRN haldol
PO and IM, as his agitation was quite pronounced. Two days
prior to discharge, his delerium cleared and he no longer
required any medication. Upon discharge, he was alert and
oriented x3, appropriate without any signs of inattention.
#. COPD: He was continued on his home medications and was not
felt to have an acute COPD exacerbation on this admission. Of
note, his PFTs from earlier this year show a decreased FEV1 but
a ratio of FEV1/FVC of 103%, suggestive of a restrictive
pathology, however his DLCO was normal. It is quite possible
that the large size of his abdomen is contributing to a
hypoventilation syndrome as opposed to an intrinsic interstitial
process.
# Aortic stenosis: Echo [**8-/2159**] with valve area of 0.9, mean
gradient 56mm placing the patient as severe aortic stenosis.
Due to his preload dependance and blood pressures near 110, his
diuresis was gentle on the floor to prevent hypotension and
needing to fluid bolus.
#. Hematuria: He self-discontinued his foley catheter on HD1 and
subsequently had hematuria which gradually resolved.
#. Hypothyroidism: Continued on home levothyroxine which was
increased to 50mcg for a TSH of 19 and decreased T4 on
admission.
# Atrial Fibrillation: past hx of afib, normal sinus rhythm
throughout hospitalization. Maintained on his home regimen of
amiodarone 200mg and coumadin. On the day of discharge, his INR
was supratherapeutic at 3.4, so his coumadin was held. He
should have his INR rechecked in [**1-4**] days to ensure that he is
not still supratherapeutic and to resume his coumadin dosing.
#. Coronary artery disease: Continued on ASA and atorvastatin.
#. BPH: Continued Finasteride 5 mg daily
#. Hypercholesterolemia: Continued home atorvastatin 10 mg
daily
#. Atopic dermatitis: Continued triamcinolone cream as above.
# Transitional Care:
He will need his INR monitored to ensure that he is not
supratherapeutic in the next 3-5 days.
He will need daily weights and O2 requirement monitoring, as his
lasix might need to be adjusted upwards if his weight increases
or his O2 requirement changes dramatically.
Medications on Admission:
- Lasix 40 mg qod ---- Recently changed from Lasix 40 mg [**Hospital1 **]
prior to admission [**Date range (1) 5081**]
------- Previously on Spironolactone 25 mg daily which was
discontinued for unclear reasons on recent discharge
- Amiodarone 200 mg daily
- Atorvastatin 10 mg daily
- Aspirin 81 mg daily
- Levothyroxine 25 mcg daily
- Warfarin 2.5 mg qod alternating with Warfarin 1.25 mg qod
- Fluticasone-salmeterol 500-50 mcg/dose Disk 1 inhalation [**Hospital1 **]
- Tiotropium bromide 18 mcg Capsule, 1 inhalation daily
- Albuterol sulfate 90 mcg/Actuation HFA 2 puffs Q4H prn SOB,
wheeze
- Finasteride 5 mg daily
- Mirtazapine 7.5 mg qhs
- Centrum Silver daily
- Triamcinolone acetonide 0.5 % Cream [**Hospital1 **] prn
- Home Oxygen - 2L continuous oxygen via nasal cannula.
Discharge Medications:
1. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO once a
day.
5. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
6. warfarin 1 mg Tablet Sig: 1.25 Tablets PO EVERY OTHER DAY
(Every Other Day).
7. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
8. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
9. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q4H (every 4 hours) as needed for
shortness of breath or wheezing.
10. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
12. triamcinolone acetonide 0.1 % Cream Sig: One (1) Appl
Topical [**Hospital1 **] (2 times a day) as needed for dermatitis.
13. furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
14. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. multivitamin,tx-minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
16. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
17. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
18. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
PO BID (2 times a day) as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 3137**] Care Center - [**Location (un) 1468**]
Discharge Diagnosis:
Heart failure exacerbation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
It was a pleasure taking care of you at [**Hospital1 18**].
You were admitted for difficulty breathing and altered mental
status. You were found to have a low oxygen saturation in your
blood due to an exacerbation of your heart failure.
You should weigh yourself daily, and if your weight increases by
3 pounds or more you should call your primary care physician to
let them know.
We made the following changes to your medications:
Please INCREASE furosemide (lasix) to 40mg by mouth twice per
day
Please START spironolactone 25mg by mouth once per day
Please INCREASE levothyroxine to 50mcg by mouth once per day
Please INCREASE mirtazipine to 15mg by mouth before bed
Please START Colace 100mg by mouth twice per day
Please START Senna 1 tab by mouth twice per day
Please START Miralax 17g by mouth twice per day as needed for
constipation
Followup Instructions:
Department: CARDIAC SERVICES
When: TUESDAY [**2159-8-28**] at 10:45 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. [**Telephone/Fax (1) 127**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: RADIOLOGY
When: MONDAY [**2159-11-12**] at 10:30 AM
With: CAT SCAN [**Telephone/Fax (1) 327**]
Building: [**Hospital6 29**] [**Location (un) 861**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2159-11-15**] at 10:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD [**0-0-**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"293.0",
"414.01",
"428.33",
"244.9",
"599.70",
"294.8",
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"564.09",
"496",
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"427.31",
"424.1",
"V43.64",
"V10.11",
"691.8",
"428.0",
"272.0",
"600.00",
"348.30"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
13295, 13380
|
7355, 10861
|
321, 327
|
13451, 13451
|
4734, 7332
|
14505, 15372
|
3375, 3447
|
11695, 13272
|
13401, 13430
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10887, 11672
|
13634, 14041
|
3462, 4715
|
14071, 14482
|
264, 283
|
355, 2581
|
13466, 13610
|
2603, 3152
|
3168, 3359
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,857
| 190,898
|
48913
|
Discharge summary
|
report
|
Admission Date: [**2105-9-11**] Discharge Date: [**2105-9-19**]
Date of Birth: [**2037-7-18**] Sex: M
Service:
HISTORY OF THE PRESENT ILLNESS: This is a 68-year-old
gentleman status post coronary artery bypass graft with
coronary artery disease, who approximately a month prior to
admission noticed chest discomfort while walking quickly up a
[**Doctor Last Name **], which resolved spontaneously. He had a similar
episode, while playing tennis prior to admission. The
patient states that the symptoms are very similar to the
symptoms of the previous myocardial infarctions.
The patient had the onset of angina in [**2088**]. Catheterization
revealed high grade circumflex and LAD disease. He underwent
CABG at [**Hospital1 2025**] with LIMA to diagonal, SVG to LAD, SVG to IM.
The patient had a heart attack in [**2105-2-3**] while in
[**State 108**] with cardiac catheterization revealing 60% distal LM
stenosis, LAD subtotally occluded left diagonal, RCA with
mild disease, SVG to OM, totally occluded with large amount
of thrombus and SVG to LAD with 95% stenosis; LIMA to
diagonal totally occluded. The patient underwent AngioJet
stenting of OM vein graft along with stenting of SVG-LAD.
Echocardiography in [**2105-3-6**] showed EF of 55% and mild
aortic stenosis.
PAST MEDICAL HISTORY: History revealed the following:
Coronary artery disease status post prior MI, status post
PTCA, status post CABG, mild AS; spinal meningitis at the age
of 2; mild hypertension; and hyperlipidemia.
PAST SURGICAL HISTORY:
1. Coronary artery bypass graft in [**2088**].
2. Precancerous lesion removed from the lip.
3. Removal of lipoma from the neck.
ALLERGIES: The patient is allergic to PENICILLIN (unknown).
CODEINE (nausea). The patient reports getting VERY SICK WITH
GENERAL ANESTHESIA. SHELLFISH.
MEDICATIONS:
1. Enteric coated aspirin 325 mg q.d.
2. Plavix 75 mg q.h.s.
3. Lisinopril 5 mg q.a.m.
4. Lipitor 80 mg q.h.s.
5. Atenolol 50 mg q.h.s.
6. Folic acid 400 mcg q.d.
7. Multivitamins.
LABORATORY DATA: Labs on admission revealed the following:
White blood cells 8.0; hematocrit 45.6; platelet count
208,000; potassium 4.5; BUN 16; creatinine 1.0; INR 1.1.
HOSPITAL COURSE: The patient was admitted to the hospital on
[**2105-9-11**]. The patient underwent cardiac
catheterization, which showed 90% LAD stenosis, 100%
circumflex stenosis with 50% RCA stenosis, SVG to OM 50%
stenosis, SVG to LAD 100% stenosis; normal ejection fraction.
The patient remained asymptomatic with stable vital signs in
the hospital. Cardiac surgery was consulted and CABG was
recommended. The patient was taken to the operating room on
[**Month (only) 216**] 12t, [**2105**], where redo CABG times three was performed
with LIMA to LAD, SVG to RCA, SVG to OM. Pacing wires, as
well as mediastinal pleural tubes were placed. The operation
was without complications. The patient was transferred to
the PACU in a stable condition.
On postoperative day #1, the patient was extubated without
complications. The patient remained afebrile with stable
vital signs. He was started on beta blocker on postoperative
day #2. The patient continues intermittent pressor support
for mild hypertension. The patient was transferred to the
floor in stable condition.
On postoperative day #3, the patient was afebrile. Vital
signs were stable. The chest tube was removed. The Foley
was removed. The patient was ambulating and working with
physical therapy.
On postoperative day #4, the patient remained afebrile. Vital
signs were stable. The patient was working with physical
therapy. The pacing wires were removed without
complications.
By the time of discharge, the patient has no complaints.
There were active issues.
DISCHARGE MEDICATIONS:
1. Lopressor ...................PO b.i.d.
2. Docusate 100 mg PO b.i.d.
3. Aspirin 325 mg PO q.d.
4. Tylenol 625 PO q.4h.to 6h.p.r.n.
5. Hydromorphone 2 mg PO q.4h.to 6h.p.r.n.
6. Ibuprofen 100 mg PO q.6h.p.r.n.
7. Ambien 5 mg PO q.h.s.p.r.n.
8. Bisacodyl 10 mg PO q.d.p.r.n.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: The patient is discharged home.
FOLLOW-UP CARE: The patient should follow up with
Dr. [**Last Name (STitle) **] in four weeks for postoperative follow up.
DISCHARGE DIAGNOSES:
1. Coronary artery disease status post redo CABG.
2. AS stable.
3. Hypertension.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern4) 28894**]
MEDQUIST36
D: [**2105-9-18**] 11:14
T: [**2105-9-18**] 11:24
JOB#: [**Job Number **]
|
[
"401.9",
"414.01",
"411.1",
"424.1",
"414.04",
"429.9",
"412",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"37.22",
"88.56",
"88.53",
"36.12",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
4290, 4635
|
3776, 4060
|
2225, 3753
|
1544, 2207
|
1323, 1521
|
4085, 4269
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,893
| 185,759
|
35020+35021+35022
|
Discharge summary
|
report+report+report
|
Admission Date: [**2125-8-19**] Discharge Date: [**2125-9-27**]
Date of Birth: [**2062-8-5**] Sex: F
Service: SURGERY
Allergies:
Ceftriaxone / Vancomycin
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
hypotension
Major Surgical or Invasive Procedure:
[**2125-8-23**]: Diagnostic paracentesis
[**2125-8-21**]: [**Last Name (un) 1372**]-intestinal tube placement
[**2125-8-24**]: Cardiac Cath
[**2125-9-5**]: [**Last Name (un) 1372**] intestinal tube placement
[**2125-9-10**]: [**Last Name (un) 1372**] intestinal tube placement
[**2125-9-13**] Orthotopic liver transplant
[**2125-9-23**]: [**Last Name (un) 1372**] intestinal tube reposition
History of Present Illness:
63 yo female with ETOH cirrhosis on the transplant list who was
just discharged recently from the Hepatorenal service with noted
acute kidney injury that had resolved. Over the last 2 days,
she has made minimal amounts urine, and called her hepatologist
who had her direct admitted to [**Wardname 13487**]. Upon arrival, the
patient was noted to have SBPs in the low 80s, lowest BP [**Location (un) 1131**]
was 72/42. Despite 2 liters of saline, she was still 78/46.
The patient's creatinine was noted to be 4.0, and hyperkalemic
with K of 5.5 without ECG changes. Kayexalate was also given
prior to transfer. Of note, patient's INR is 2.7. Type and
cross was ordered prior to transfer.
.
Patient denies chest pain, fevers, chills. She does report some
dyspnea, but states it is more from her distended abdomen. She
denies any nausea or vomiting at this time. She has no other
complaints.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough. Denied chest pain or tightness,
palpitations. Denied nausea, vomiting, diarrhea, constipation or
abdominal pain. No recent change in bowel or bladder habits. No
dysuria. Denied arthralgias or myalgias.
Past Medical History:
- Alcoholic cirrhosis complicated by varices (grade II), mild
encephalopathy, ascites and coagulopathy.
- Alcohol abuse for 30 years. Quit on [**2124-11-5**].
- Iron deficiency anemia
- GERD
- Basal cell carcinoma status post excision
- Intrapyloric duodenal mass status post EUS and EGD with
biopsy
-[**2125-9-13**] liver transplant
Social History:
Lives with her husband. [**Name (NI) **] alcohol or tobacco. Denies illicit
drug use, including IVDU.
Family History:
Father died of alcohol-related disease
Physical Exam:
Vitals: T: BP: P: R: 18 O2:
General: Alert, oriented, no acute distress
HEENT: Sclera icteric, MMM, oropharynx clear
Neck: supple, JVP approx 8 cm, no LAD
Lungs: bibasilar crackles, no rhonci or wheezes
CV: Regular rate and rhythm, normal S1 + S2, 2/6 systolic murmur
at base
Abdomen: distended, + fluid wave with dullness to percussion.
nontender. hypoactive bowel sounds
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis 1+
edema BLE
Pertinent Results:
Labs on Admission: [**2125-8-19**]
WBC-11.0# RBC-2.97* Hgb-9.7* Hct-29.6* MCV-100* MCH-32.5* Plt
Ct-191
Neuts-60.3 Lymphs-14.3* Monos-6.6 Eos-18.5* Baso-0.4
PT-27.9* PTT-58.6* INR(PT)-2.7*
Glucose-120* UreaN-71* Creat-4.0*# Na-131* K-5.5* Cl-98 HCO3-19*
AnGap-20
ALT-24 AST-35 LD(LDH)-310* AlkPhos-105 TotBili-18.5*
Albumin-3.6 Calcium-9.2 Phos-5.8*# Mg-3.2*
URINE Eos-NEGATIVE
URINE Osmolal-322
URINE Hours-RANDOM Creat-204 Na-LESS THAN
ASCITES WBC-0 RBC-310* Polys-10* Lymphs-74* Monos-16*
ASCITES Albumin-<1.0
PERITONEAL FLUID
Anaerobic Bottle Gram Stain (Final [**2125-8-20**]):
IN PAIRS AND CHAINS IN PAIRS AND CLUSTERS.
At Diacharge:[**2125-9-21**]
WBC-11.4* RBC-3.04* Hgb-8.8* Hct-26.9* MCV-89 MCH-29.0 MCHC-32.7
RDW-16.9* Plt Ct-183
PT-12.4 PTT-25.3 INR(PT)-1.0
Glucose-108* UreaN-59* Creat-1.4* Na-130* K-5.2* Cl-106 HCO3-13*
AnGap-16
ALT-63* AST-16 AlkPhos-91 TotBili-1.8*
Albumin-2.5* Calcium-7.7* Phos-3.8 Mg-2.0
tacroFK-8.5
Brief Hospital Course:
In summary, this pt had a desquamative rash that preceded
decreased urine output. She was admitted with hypotension and
ARF, treated for a night in the MICU and transferred to the
floor for management of hepatorenal syndrome with or without
AIN. After the ARF resolved, she developed a LGIB related to
hemorrhoids that required 8 pRBC and FFP as well as a surgical
intervention in the MICU. There, she developed another
desquamative rash. She stabilized, was listed for a transplant,
actually being called for a liver only to discover that the
explant was not appropriate.
.
Prior to transplant [**Last Name **] problem list was as follows:.
# Hypotension- Per the patient, her baseline systolic pressure
is in the 80s-90s. Her hypotension likely likely related to
dehdryation vs. hepatorenal syndrome. A dopper U/S of the
abdomen showed sluggish flow in the portal system. While in the
MICU the patient continued to have low urine output. No episodes
of hypotension while on the floor.
.
# ARF- Likely pre-renal vs. hepatorenal syndrome. The patient
was bolused fluids as needed. Renal ultrasound was normal and
urine eos were negative but had persistent peripheral
eosinophilia. All potential offending medications were witheld,
and an octreotide drip with midodrine were started. Her
creatinine returned to baseline in roughly 7 days.
.
# GI bleed. Patient was transferred to the MICU on [**2125-8-27**] due
to gastrointestinal bleeding. EGD showed non-bleeding
esophageal varices. A colonoscopy showed bleeding hemorroids,
but they were unable to intervene upon them. Given the degree
of bleeding, the patient was intubated for airway protection in
setting of large volume resucscitation. A Cordis was placed.
Surgery performed an anoscopy and sutured the hemorroids and
then placed rectal packing. In total she received 8 units of
PRBCs and 9 units of FFP while in the MICU. Her Hct was stable.
It took several days for her sedative medications (fentanyl and
versed) to clear likely due to impaired hepatic metabolism, but
she was ultimately extubated on [**2125-9-3**]. Pt had no issues w/
bleeding while on the floor after transfer from MICU.
.
# Drug rash. Patient developed a drug rash and low grade fever
in setting of being started on Ceftriaxone for SBP prophylaxis
while in the MICU. She also developed eosinophilia. Drug rash,
fever, and eosinophilia resolved with removal of ceftriaxone.
The ICU also used steroids. The rash returned when the pt was on
the floor. This was either related to the use of Vancomycin or
the clearance of the steroids. Derm was reconsulted, abx were
switched to linezolid and triamcinolone creams used liberally.
Rash resolved after abx discontinuation and treatment (as per
derm).
.
# Coag Negative Staphyllococcemia - During the time that she
re-desquamated on the floor, she was febrile. Cultures were
ordered and [**2-9**] were positive for coag neg staph. Her PICC was
pulled and she was started on linezolid given her potential
sensitivity to vanc. Pt remained afebrile, w/ no signs of
infection while on the floor. She finished a 5 day course of
linezolid.
.
# ETOH cirrhosis- Pt was taken to liver transplant on [**2125-9-12**].
.
Patient was taken to OR with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] for liver
transplant following visual and surgical inspection for gastric
mass. At time of surgery, per Dr [**Last Name (STitle) 9411**] note; "The liver was
small, nodular and shrunken. There was about 8 liters of ascites
and extensive varices throughout the peritoneal cavity.
Dissection and inspection of the stomach from the fundus to the
pyloric area was done. Nothing pathologic was identified. There
did not appear to be any lesions identified by palpation of the
pylorus and prepyloric area. There were no areas of external
puckering or pathologicabnormality on the stomach to suggest
ulcerated lesions, mass
lesions or abnormality. Based upon the patient's extensive
portal hypertension and varices, performing a gastrotomy to try
to visualize or to palpate a lesion that we could not palpate
externally was not warranted and so that portion of the
procedure was terminated and the liver transplant procedure
moved forward. Two [**Doctor Last Name 406**] drains were placed, one behind the
right lobe, one behind the porta hepatis. The biliary
anastomosis has a size mismatch. She received 20 units of RBCs,
24 units FFP, 3 bags of platelets and received 3500 cc
plasmalyte
The patient tolerated the surgery and was transferred to the
SICU where she received and additional 2 units RBCs and 1 bag
platelets.
She was extubated on POD one and was called out to the floor on
the evening of POD 1.
She was restarted on tube feeds, which was eventually changed
over to cycled tube feeds. She was started on PO intake on POD 3
and the tube feeds were ramped up to goal. She has some
abdominal pain when the tube feeds were cut to 14 hour cycle and
the time was lengthened and volume decreased to evaluate her
tolerance, however by time of discharge she returned to
continuous tube feeds and was changed to a renal formula due to
hyperkalemia
The drain behind the liver continued with very high ascitic
fluid output, 2-3 Liters daily. The output was replaced
initially, and then nearing time of discharge, fluid boluses
were given several days in a row as her creatinine rose to 1.4
from a nadir of 1.0. This eventually settled out at 1.3. The
drain was pulled on the day of discharge and a suture placed
with good effect.
She was seen by [**Last Name (un) **] and will be discharged to home on
insulin. Teaching was done with patient and family. She was
having reservations about doing her own insulin injections.
PT evaluation found her to be safe for home with home PT and
assistive devices which are being sent home with her. She was
ambulating and was able to navigate the stairs with assist.
She remained afebrile throughout the post transplant period.
Her liver function tests improved daily, and her weight
stabilized, although she still had a small amount of peripheral
edema and some ascites.
Medications on Admission:
Ciprofloxacin 250 mg daily
Folic Acid 1 mg Tablet daily
Lactulose 30ml TID
Omeprazole 40 mg daily
Rifaximin 400 mg TID
Ursodiol 300 mg TID
Ferrous Sulfate 325 mg daily
Thiamine HCl 100 mg daily
Zinc Sulfate 220 mg daily
Vitamin K 100 mcg daily
nadolol 20 daily
Discharge Medications:
1. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO 1X/WEEK (TU).
Disp:*4 Capsule(s)* Refills:*2*
2. Valcyte 450 mg Tablet Sig: One (1) Tablet PO once a day.
3. Triamcinolone Acetonide 0.1 % Cream Sig: One (1) application
Topical four times a day.
4. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO twice a day.
5. Bactrim 80-400 mg Tablet Sig: One (1) Tablet PO once a day.
6. Prednisone 5 mg Tablet Sig: Four (4) Tablet PO once a day:
Follow transplant clinic taper.
7. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
8. CellCept [**Pager number **] mg Tablet Sig: Two (2) Tablet PO twice a day.
9. Morphine 15 mg Tablet Sig: One (1) Tablet PO every four (4)
hours as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
10. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO once a day.
11. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
12. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Six (6)
units Subcutaneous once a day.
13. Insulin Lispro 100 unit/mL Solution Sig: per sliding scale
Subcutaneous four times a day: Per Sliding Scale.
Discharge Disposition:
Home With Service
Facility:
VNA of Upper [**Hospital3 **]
Discharge Diagnosis:
cirrhosis
s/p liver transplant
DM
malnutrition
Discharge Condition:
good/stable
Discharge Instructions:
Please call the Transplant Office [**Telephone/Fax (1) 673**] if fever, chills,
nausea, vomiting, inability to take any of your medications,
jaundice, abdominal distension, malfunction of feeding tube or
incision redness/bleeding/drainage
Labs every Monday and Thursday
[**Month (only) 116**] shower, but no tub baths/swimming
No heavy lifting/straining
Followup Instructions:
[**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2125-10-4**] 2:20
[**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2125-10-11**] 1:40
Completed by:[**2125-9-28**] Admission Date: [**2125-10-2**] Discharge Date: [**2125-10-5**]
Date of Birth: [**2062-8-5**] Sex: F
Service: SURGERY
Allergies:
Ceftriaxone / Vancomycin
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
Abnormal outpatient labs
Major Surgical or Invasive Procedure:
None
History of Present Illness:
63F with ETOH Cirrhosis s/p OLT [**2125-9-13**]. Discharged [**9-27**] to
home with services with dobloff feeding tube. Has been doing
well
since then. TF are not being cycled as she gets abdominal pain
with cycling. Her appetite she admits is not too well, however
she has been maintaining her weight at home per records. She
denies f/c or diarrhea. Labs drawn by the nurse indicate
"abnormalities." The patient recalls that her Creatinine was
elevated to 1.5 (discharged with 1.3). She does not remember
any
other values. I currently do not have these most recent labs
here. Given the abnormal labs, she was instructed to return to
[**Hospital1 18**] for admission.
Past Medical History:
- Alcoholic cirrhosis complicated by varices (grade II), mild
encephalopathy, ascites and coagulopathy.
- Alcohol abuse for 30 years. Quit on [**2124-11-5**].
- Iron deficiency anemia
- GERD
- Basal cell carcinoma status post excision
- Intrapyloric duodenal mass status post EUS and EGD with
biopsy
-[**2125-9-13**] liver transplant
Social History:
Lives with her husband. [**Name (NI) **] alcohol or tobacco. Denies illicit
drug use, including IVDU.
Family History:
Father died of alcohol-related disease
Physical Exam:
97.5, 88, 136/87, 18, 100RA
Frail appearing, dobloff in place, non-jaundice
RRR
CTAB
Soft, slightly distended, NT, incision is c/d/i, previous JP
site
c/d/i
1+ pitting edema, L>R
Pertinent Results:
On Admission: [**2125-10-2**]
WBC-8.4 RBC-2.77* Hgb-8.0* Hct-24.5* MCV-88 MCH-28.7 MCHC-32.5
RDW-17.4* Plt Ct-399
PT-11.4 PTT-24.7 INR(PT)-0.9
Glucose-225* UreaN-85* Creat-1.6* Na-119* K-5.0 Cl-98 HCO3-13*
AnGap-13
ALT-79* AST-27 AlkPhos-159* TotBili-0.8
Albumin-2.8* Calcium-8.1* Phos-3.9 Mg-2.1
On Discharge [**2125-10-5**]
WBC-6.9 RBC-3.17* Hgb-9.2* Hct-28.1* MCV-89 MCH-29.0 MCHC-32.7
RDW-17.6* Plt Ct-358
Glucose-162* UreaN-52* Creat-0.8 Na-135 K-4.3 Cl-108 HCO3-16*
AnGap-15
ALT-62* AST-26 AlkPhos-160* TotBili-0.8
BLOOD tacroFK-3.6*
Brief Hospital Course:
63 y/o female s/p liver transplant sent home on tube feeds who
returns with electrolyte derangements and an elevated Prograf
level.
On admission her sodium was noted to be 119 and she was started
on normal saline. In addition her creatinine was 1.6 which was
double her baseline value.
Over the next three days we continued to hydrate her and the
labs normalized significantly.
Tube feeds were reinstated.
She received counseling regarding the lasrge amount of free
water she was apparently drinking at home and medications were
reviewed as well to assure compliance especially with the
immunosuppression regimen.
She made an excellent recovery. The alk phos remained slightly
elevated but all other LFTs trended back or were normal. There
was discussion of further testing but it was determined at this
time that no other tests were required and she was sent home
still on tube feeds which are now being cycled as she did well
with the cycle trial initiated on this admission.
Medications on Admission:
Ergocalciferol (Vitamin D2) 50,000U 1X/WEEK (TU), valcyte
450', Triamcinolone Acetonide 0.1 % Cream QID, Tacrolimus 2",
Bactrim SS', Prednisone 20' (WITH TAPER), Omeprazole 40',
Cellcept [**Pager number **]", Morphine 15 q4 PRN, Fluconazole 400', Colace
100", NPH 6', Lispro SS
Pred Taper Scale:
[**Date range (1) 80059**]: 17.5 mg
[**Date range (1) 80060**]: 15 mg
[**Date range (1) 41831**]: 12.5 mg
[**Date range (1) 32799**]: 10 mg
[**Date range (1) 80061**]: 7.5 mg
[**Date range (1) 80062**]: 5 mg
[**Date range (1) 80063**]: 2.5 mg
Discharge Medications:
1. Prednisone 5 mg Tablet Sig: 3.5 Tablets PO DAILY (Daily).
2. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO 1X/WEEK (TU).
8. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Six (6)
units Subcutaneous once a day.
9. Insulin Lispro 100 unit/mL Solution Sig: per sliding scale
Subcutaneous four times a day: per sliding scale.
10. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
QID (4 times a day).
11. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
12. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO twice a day.
Discharge Disposition:
Home With Service
Facility:
vna of cpe cod
Discharge Diagnosis:
Hyponatremia
acute renal failure
s/p liver transplant [**2125-9-13**]
Discharge Condition:
Stable/good
Discharge Instructions:
Please call the transplant clinic at [**Telephone/Fax (1) 673**] for fever,
chills, nausea, vomiting, diarrhea, constipation, inability to
take or keep down food, fluids or medications or difficulty
tolerating your tube feeds.
Continue labwork per transplant clinic recommendations
Drink to your thirst, no need to drink a lot of plain water.
Drink fluids such as supplements, gatorade or juices
Labs Saturday and Monday, faxed to [**Telephone/Fax (1) 697**]
Followup Instructions:
[**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2125-10-11**] 1:40
[**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2125-10-18**] 1:00
[**Last Name (LF) **],[**First Name3 (LF) 156**] TRANSPLANT SOCIAL WORK Date/Time:[**2125-10-25**] 11:30
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2125-10-5**] Admission Date: [**2125-10-9**] Discharge Date: [**2125-10-13**]
Date of Birth: [**2062-8-5**] Sex: F
Service: SURGERY
Allergies:
Ceftriaxone / Vancomycin / Heparin Agents
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Abnormal LFTs
Major Surgical or Invasive Procedure:
Dobhoff postpyloric tube placement
PICC placement
History of Present Illness:
63F w/ alcoholic cirrhosis s/p OLT on [**2125-9-13**] recently admitted
for elevated Prograf levels and electrolyte abnormalities,
discharged on [**9-27**] to home returns to our service for abnormal
LFT from labs drawn on [**10-8**]. Patient reports normal state of
health. She is fairly active and feeling more energetic.
Appetite has been improving since discharge. Currently on daily
Dobbhoff tube feeds starting from 1700 to 1200 the next day. She
claims to have no abdominal pain or discomfort. Normal bowel
habits. Remained afebrile. Denies N/V
Past Medical History:
- Alcoholic cirrhosis complicated by varices (grade II), mild
encephalopathy, ascites and coagulopathy.
- Alcohol abuse for 30 years. Quit on [**2124-11-5**].
- Iron deficiency anemia
- GERD
- Basal cell carcinoma status post excision
- Intrapyloric duodenal mass status post EUS and EGD with
biopsy
-[**2125-9-13**] liver transplant
Social History:
Lives with her husband. [**Name (NI) **] alcohol or tobacco. Denies illicit
drug use, including IVDU.
Family History:
Father died of alcohol-related disease
Physical Exam:
97.5, 88, 136/87, 18, 100RA, weight on admission 104.6
General: thin, Dobbhoff in place, NADS, AAO x 3, tremor with
movement
Eyes: no scleral icterus
Lungs: CTAB
Cardio: RRR
Abd: Soft, slightly distended with ascites, NT, chevron incision
is c/d/i, R previous JP site with stitch but otherwise c/d/I, L
previous JP site with scab and otherwise c/d/i
Ext: Min to trace pitting edema, palpable pulses
Pertinent Results:
Admission Labs
[**10-9**]: WBC 4.9 Hct 28.6 Plate 303
[**10-8**]: WBC 5.2 Hct 29.7 Plate 317
(Prior D/C) [**9-27**]: WBC 12.4 Hct 27.7 Plate 342
[**10-9**]: PT 12.3 PTT 23.4 INR 1.0
[**10-9**]: Na 137 K 4.5 Cl 108 CO2 20 BUN 49 Cr 0.9
[**10-8**]: Na 139 K 5.1 Cl 112 CO2 17 BUN 47 Cr 0.94
(Prior D/C) [**9-27**]: Na 129 K 4.8 Cl 104 CO2 16 BUN 58 Cr 1.3
[**10-9**]: AST 56 ALT 192 AP 398 Tbili 0.7
[**10-8**]: AST 109 ALT 224 AP 487 Tbili 1.1 Prograf 7.8
(Prior D/C) [**9-27**]: AST 11 ALT 22 Tbili 1.0 Prograf 11.6
Discharge Labs
[**2125-10-13**] 06:00AM BLOOD WBC-2.7* RBC-3.48* Hgb-10.0* Hct-30.7*
MCV-88 MCH-28.9 MCHC-32.7 RDW-16.3* Plt Ct-142*
[**2125-10-13**] 06:00AM BLOOD Glucose-186* UreaN-29* Creat-0.8 Na-136
K-3.4 Cl-105 HCO3-21* AnGap-13
[**2125-10-13**] 06:00AM BLOOD ALT-67* AST-23 AlkPhos-253* TotBili-0.7
Imaging:
Ultrasound 9/2:1. Visual focal narrowing in the proximal main
portal vein, with corresponding velocity change and turbulent/
helical flow distal to the area of narrowing. While the
significance of the velocity change is uncertain, this change
combined with the visible focal narrowing is concerning for
portal vein stenosis.
2. Interval development of moderate ascites.
3. Probable subcapsular hematoma in the posterior right hepatic
lobe.
\
CT [**10-10**]: Area of stenosis at the proximal main portal vein as
seen on recent US. This measures 4mm at its narrowest. However,
patent hepatic vasculature, no thrombus seen. Subcapsular
hepatic hematoma at posterior right lobe, 6.3 x 4 cm, with
little change in size from previous ultrasound study. Moderate
ascites
ERCP [**10-11**]:
Images demonstrate cannulation of the common bile duct with
narrowing seen at the anastomotic site in the CBD. There is no
evidence of leakage or
fistulization. The cystic and intrahepatic bile ducts are well
visualized
without evidence of filling defects or dilatation. Balloon
angioplasty and
plastic biliary stenting were performed. Please refer to the
operative note for further details.
ERCP Procedure Note:Antrum deformity Smooth narrowing at the
site of anastamosis which could be due to edema from recent OLTx
Single biliary stent placed across the narrowing due to
possibility of cholangitis
Brief Hospital Course:
The patient was admitted to the transplant surgery service. She
underwent liver ultrasound and biopsy. See results section.
She also had a CTA of her liver which confirmed PV stenosis at
the anastamosis. Due to a concern for stenosis of her bile duct
anastamosis as well from the ultrasound images she underwent
ERCP and a stent was placed. Blood cultures from [**10-10**] showed
ENTEROBACTER CLOACAE (ESBL, sensitive to meropenem). She had a
replacement of her dobhoff (postpyloric) done the following day
as well as a PICC line placed given a need for IV antibiotics
for her bacteremia.
Her TF were resumed post-dobhoff and she was tolerating a
regular diet, ambulating independently, and tolerating her
immunosuppression medications. Her LFTs improved upon admission
and continued improvement and stabilization through her hospital
stay. She was discharged to home on [**10-13**] with plans to return to
[**Hospital Ward Name 121**] 10 for admission Tuesday morning 6am for a planned venogram
for her PV stenosis. She was discharged on Tacrolimus 1mg [**Hospital1 **].
A tacrolimus blood level will be checked upon admission on
Tuesday. Her steroid taper was at 15mg on discharge (1st day of
15).
Medications on Admission:
Prograf 2'', CellCept [**Pager number **]'''', pred 17.5, valcyte 450,
bactrim ss, diflucan 400, prilosec 40, colace, tums, sliding
scale insulin
Discharge Medications:
1. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
3. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO 1X/WEEK (TU).
7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
8. Prednisone 5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
9. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
QID (4 times a day).
10. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO every twelve
(12) hours.
11. Ertapenem 1 gram Recon Soln Sig: One (1) Intravenous once a
day for 3 days.
Disp:*3 gm* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VNA of [**Hospital3 **]
Discharge Diagnosis:
cholangitis
Discharge Condition:
Good
Discharge Instructions:
Please call if you have any issues at home. [**Telephone/Fax (1) 673**]. Call
if you experience fevers or chills, abdominal pain, dizziness,
weakness, nausea or vomiting.
Followup Instructions:
Please return to [**Hospital Ward Name 121**] 10 for readmission Tuesday morning in
preparation for your interventional radiology study on Tuesday.
Do not eat or drink anything past midnight on Monday night.
Your tube feeds can stay on until you stop them in the morning
to come into the hospital.
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31,664
| 166,237
|
12740
|
Discharge summary
|
report
|
Admission Date: [**2186-10-11**] Discharge Date: [**2186-12-19**]
Service: MEDICINE
Allergies:
Wellbutrin / Kaopectate
Attending:[**First Name3 (LF) 4052**]
Chief Complaint:
Non-responsiveness and hypotension
Major Surgical or Invasive Procedure:
T tube placement and cholangiogram
EGD x 4
History of Present Illness:
Patient is an 84 year old female with history of dementia,
hypertension, type two diabetes mellitus, bipolar disease who
presents with two weeks of declining social functioning and PO
intake, usually able to walk with walker and perform ADL. CT
scan at [**Hospital1 2025**] showed (-)CT and (-) troponins. Admitted to [**Hospital1 18**]
[**10-12**], tox screen (-), CEs (-), primary team managing BP meds
and psyche meds. Was being worked up on [**Wardname 836**] for renal failure
and balancing HTN meds, when found by NSG staff to be
'unresponsive' with no breathing or radial pulse for 20 seconds.
Code blue called, initial blood pressure 80/50 with improvement
in mentation to baseline. Two hours after event, noted to have
decreasing BPs to 60s with concurrent mental status changes.
Repeat BPs in trendelenburg resolved to 110 with return of
mentation. She was transferred to the MICU on [**2186-10-15**] for NSG
concern of hypotension.
.
In the MICU she had three more episodes. These were
characterized by unresponsiveness, lack of a radial pulse (no
femoral pulse was taken), and a post-ictal confusional state
most consistent with seizures. Her EKG during these episodes was
unremarkable, although she does have a baseline RBBB. Hence,
heart block was deemed unlikely. MICU team was suspicious of
seizure activity, given complete unresponsiveness to verbal and
tactile stimuli, then confusion and return to baseline after
episode. Further, given her diabetes and her labile blood
pressure, autonomic seizures were of particular concern. She was
worked up by multiple teams, including Neurology. Per neurology
a head CT was obtained which indicated atrophy w/ mild
microangiopathic changes. She was put on EEG monitoring to
capture seizure activity however she did not have an episode
during monitoring. Other considerations were her baseline
psyciatric disorder or medication regimen. She was seen by
Psychiatry who do not feel her episodes of hypotension are
entirely explained by her bipolar disorder. Finally nephrology
was consulted to evaluate a renal source of her labile BP and
possible source of hypotensive episodes. Nephrology determined
she did not have RAS by US and Captopril study and did not feel
that her labile BP was renal in origin. Ultimately, it was felt
that a polypharmacy of her BP and anti-psychotic medications
were responsible for these episodes. Her BP/ Psych med regimen
were tapered and she has been stable for 3 days. She was
transferred to [**Wardname **] [**2186-10-17**] for further workup of an anion gap
and elevated WBC prior to anticipated discharge to a rehab
facility.
.
Of note, recently hospitalized @QuincyMC for mania, had episode
of syncope; workup head CT, head MRI, neck MRA, carotid doppler
studies, EEG, CXR, and echocardiogram. Head MRI notable for
periventricular white matter changes suggesting small vessel
disease. TTE showed normal sized LV with hyperdynamic systolic
function and EF of 75%. EEG normal. MRA of neck showed 65-70%
stenosis of internal carotids bilaterally.
Past Medical History:
1. Bipolar d/o (recent hospitalization at [**Hospital1 392**] for manic
episode: [**Date range (1) 39296**]; peridiocally on medical floor for syncope
eval)
2. Mild dementia
3. Refractory HTN
4. DM type II
5. Hypothyroidism
6. Chronic Kidney Disease
7. Bilateral hearing loss
8. Arthritis
9. Bilateral carotid stenosis
Social History:
Lives at [**Doctor Last Name **] house, Has 4 kids all living locally, widowed.
Distant smoking history, distant social EtOH.
Family History:
Mother had psychiatric disease with multiple psychiatric
admissions, died in a state hospital.
Physical Exam:
ON ADMISSION:
Vitals - T 97.6, BP 175/57, HR 69, RR 20, O2 sat 96% 3L NC
General - elderly female, pleasant, NAD
HEENT - PERRL, OP clr, MMM, JVP flat
CV - RRR, [**1-17**] syst mur at apex
Chest - coarse R basilar crackles
Abdomen - NABS, soft, NT/ND, no g/r; soft abdominal bruit
Ext - trace bilat edema
.
ON TRANSFER to [**Hospital Ward Name **] 7:
Physical Examination
Vitals - T 96.9, BP 160/60, HR 68, RR 20, O2 sat 99% RA
General - elderly female, pleasant, NAD
HEENT - PERRL, sclera are erythematous, OP clr, MMM, JVP flat
CV - RRR, [**1-17**] syst mur at apex
Chest - clear to ascultation bilaterally
Abdomen - NABS, soft, NT/ND, no g/r; soft abdominal bruit
Ext - bilat edema 4+ on hands, 2+ on LE, WWP
Neuro - AOx3, [**3-17**] bl UE and LE strenght bl. sensation intact
throughout symmetrically.
Pertinent Results:
LABS ON ADMISSION [**2186-10-11**]:
[**2186-10-11**] 04:45PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.016
[**2186-10-11**] 04:45PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-250 KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2186-10-11**] 04:45PM URINE RBC->50 WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-0-2
[**2186-10-11**] 04:45PM URINE HYALINE-0-2
[**2186-10-11**] 12:55PM GLUCOSE-209* UREA N-36* CREAT-1.6* SODIUM-144
POTASSIUM-3.5 CHLORIDE-104 TOTAL CO2-28 ANION GAP-16
[**2186-10-11**] 12:55PM ALT(SGPT)-16 AST(SGOT)-23 LD(LDH)-196 ALK
PHOS-67 TOT BILI-0.5
[**2186-10-11**] 12:55PM ALBUMIN-3.6 CALCIUM-8.4 PHOSPHATE-3.7
MAGNESIUM-2.5 IRON-40
[**2186-10-11**] 12:55PM calTIBC-263 VIT B12-609 FOLATE-16.5
FERRITIN-102 TRF-202
[**2186-10-11**] 12:55PM TSH-0.089*
[**2186-10-11**] 12:55PM CRP-9.1*
[**2186-10-11**] 12:55PM WBC-9.4 RBC-3.66* HGB-11.4* HCT-34.1* MCV-93
MCH-31.1 MCHC-33.3 RDW-13.9
[**2186-10-11**] 12:55PM PLT COUNT-273
[**2186-10-11**] 12:55PM PT-11.3 INR(PT)-1.0
[**2186-10-11**] 12:55PM SED RATE-46*
[**2186-10-11**] 12:10AM GLUCOSE-170* UREA N-41* CREAT-1.7* SODIUM-145
POTASSIUM-3.4 CHLORIDE-105 TOTAL CO2-27 ANION GAP-16
[**2186-10-11**] 12:10AM estGFR-Using this
[**2186-10-11**] 12:10AM CK(CPK)-314*
[**2186-10-11**] 12:10AM CK-MB-3 cTropnT-0.02*
[**2186-10-11**] 12:10AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2186-10-11**] 12:10AM WBC-10.9 RBC-3.61* HGB-11.4* HCT-33.6* MCV-93
MCH-31.6 MCHC-33.9 RDW-13.6
[**2186-10-11**] 12:10AM NEUTS-80.1* LYMPHS-14.7* MONOS-3.4 EOS-0.8
BASOS-0.9
[**2186-10-11**] 12:10AM PLT COUNT-298
.
.
Laboratory Studies (on transfer to [**Wardname **]):
ABG: 94, 28, 7.42, 19, base -4
CBC: 17.4, 38.8, 315
Chem7: 139, 3.8, 102, 19, 43, 1.2, 243
CK 18, Ca 8.9, Mg 2.4, P 3.4
PT 11.5, PTT 26.3, INR 1.0
UA: straw, clear, 1.017, 5.0, bld large, prot 30, gluc 1000, ket
50, RBC 84, WBC 0, Bact none, Yest none, epi <1, (negative for
Urobbil, Bili, Leuk, Nitr)
Urine Cre 77, Prot 51, Prot/Cre 0.7
.
Radiographic Studies:
Chest AP (prelim) - Allowing for difference in technique,
cardiomediastinal silhouette is unchanged with mild
cardiomegaly. There is no pneumothorax or pleural effusion. The
lungs are clear.
.
([**2186-10-13**]) ECG: NSR, RBBB, LAFB, LVH. unchanged from prior
.
([**2186-10-16**]) EEG IMPRESSION: This telemetry captured no pushbutton
activations for symptoms. Routine sampling and automated
detection programs recorded no epileptiform features or
electrographic seizures. There was some multifocal slowing
admixed to the waking background, but this would be assessed
better through routine EEG tracings. There were no areas of
fixed focal slowing, and there were no epileptiform features.
.
([**2186-10-14**]) EEG IMPRESSION: This is an abnormal portable EEG in
the waking and drowsy states due to intermittent brief bursts of
mixed frequency slowing seen in the temporal regions
bilaterally, independently and asynchronously. The findings
suggest underlying subcortical dysfunction in those regions. In
a patient of this age, vascular disease would be among the
common causes. In addition, there were brief bursts of
generalized mixed frequency slowing, more non-specific in
etiology. There were no clearly epileptiform features. No
electrographic seizures were noted.
.
([**2186-10-13**])CT HEAD IMPRESSION: Moderate degree of atrophy with
mild microangiopathic changes.
.
([**2186-10-13**]) RENAL US IMPRESSION: Study limited by patient
factors: blood flow to both kidneys, there is no hydronephrosis,
nephrolithiasis, simple cysts in both kidneys
.
([**2186-10-16**]) RENAL CAPTOPRIL SCAN IMPRESSION: Essentially normal
captopril renal scan. Specifically, no evidence
of renal artery stenosis.
.
([**10-17**] and [**2186-10-17**]) EEG:
IMPRESSION: This telemetry captured no pushbutton activations
for
symptoms. Routine sampling and automated detection programs
recorded no
epileptiform features or electrographic seizures. There was some
multifocal slowing admixed to the waking background, but this
would be
assessed better through routine EEG tracings. There were no
areas of
fixed focal slowing, and there were no epileptiform features.
.
([**2186-10-20**]): Chest X-ray
IMPRESSION: Improving right lower lobe opacity.
.
([**2186-10-20**]): Transthoracic Echo:
The left atrium is moderately dilated. There is mild symmetric
left ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. 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. Trivial mitral regurgitation is
seen. The pulmonary artery systolic pressure could not be
determined. There is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional systolic function.
.
([**2186-10-22**]): EKG:
Artifact is present. Probable sinus rhythm. Left axis deviation.
Left
anterior fascicular block. There is an early transition which is
non-specific
with subsequent loss of anterolateral R waves associated with
anterior
and anterolateral ST-T wave changes consistent with probable
myocardial
infarction. Left ventricular hypertrophy with associated ST-T
wave
changes. Incomplete right bundle-branch block. Compared to the
prior
tracing right bundle-branch block is now incomplete.
.
([**2186-10-26**]): Liver Ultrasound
IMPRESSION:
1. Findings are suspicious for acute cholecystitis and possible
focal necrosis and perforation of the gallbladder wall.
2. Right renal cysts.
.
([**2186-10-26**]): CT Pelvis/Abdomen/Chest:
IMPRESSION:
1. Small amount of free fluid in deep pelvis posterior to the
rectum and anterior to the sacrum, without fluid collection or
free air. Diverticulosis, without evidence of diverticulitis.
Atelectasis and patchy opacities in the lungs, without discrete
consolidation suggestive of pneumonia.
2. Renal cysts.
3. Nonspecific fluid-filled distended second portion of duodenum
surrounded by mild fat stranding, with slight fat stranding
surrounding the pancreatic head. The finding is nonspecific;
however, in this patient with elevated white blood cell,
duodenitis or early pancreatitis cannot be excluded. Please
correlate with laboratory values.
4. Small amount of pericholecystic fluid with questionable
sludge. If indicated, please consider gallbladder ultrasound.
.
([**2186-10-28**]): CT Abdomen/Pelvis:
IMPRESSION: Percutaneous gallbladder drain contained within the
gallbladder. The gallbladder is decompressed. No perihepatic or
intra-abdominal fluid or hemorrhage is identified. Stable
stranding surrounding the second and third portions of the
duodenum and pancreatic head
.
([**2186-10-30**]): Ultrasound of lower extremities:
IMPRESSION: No evidence for deep venous thrombus in bilateral
lower extremities.
.
([**2186-10-30**]): Head CT w/out contrast:
IMPRESSION: Aerosolized secretions in the sphenoid sinus and
increased opacity in the right frontoethmoid recess. Please
correlate clinically. Otherwise, no significant change,
including no evidence of intracranial hemorrhage or large recent
infarction.
.
([**2186-11-3**]): Gallbladder scan:
IMPRESSION: 1. Prompt filling of the gallbladder and exit into
the duodenum.
2. Patent cholecystostomy drainage tube. 3. No evidence of leak
outside of the
gallbladder.
.
([**2186-11-5**]): Ultrasound of abdomen:
IMPRESSION:
1. No evidence of main portal vein thrombosis. The more distal
branches of the portal vein were not interrogated. If there is
further clinical concern, additional dedicated views of the
portal vein vasculature can be performed.
2. Nonvisualization of the gallbladder, likley due to collapsed
state.
3. Stable simple-appearing right renal cysts.
.
([**2186-11-27**]) Ultrasound of thyroid:
IMPRESSION:
1. Completely absent right lobe of the thyroid. Small remnant of
the left thyroid lobe is unchanged compared to the prior study.
.
Brief Hospital Course:
Patient is an 84 year old female with mild dementia,
hypertension, diabetes mellitus type two, and bipolar disease,
who presented on [**2186-10-11**] from [**Hospital3 **] with failure to
thrive, and was being worked up for renal failure and balancing
hypertension medications, who was found by nursing staff to be
'unresponsive' with no breathing or radial pulse for 20 seconds
and transferred to intensive care unit.
.
# Unresponsive episodes -
Patient had initial episode of unresponsiveness, and additional
episodes witnessed by the intensive care team. There was concern
for seizure activity, given complete unresponsiveness to verbal
and tactile stimuli, then confusion and return to baseline after
episode. Given her diabetes and her labile blood pressure,
autonomic seizures were of particular concern, as was complete
heart block (given known RBBB with LAFB) however telemetry
tracings remained within normal limits. It was also concerning
that her medications could be playing role. She was monitored on
telemetry which was unrevealing for a cause, a transthoracic
echo did not reveal clear cause, nor did continuous EEG
monitoring. Several of her blood pressure medications were held
to avoid hypotensive episodes, which ultimately felt to be the a
large part of the cause.
She had no further episodes after her first transfer out of the
intensive care unit on [**2186-10-17**].
.
# Hypertension - Patient has historically difficult to control
blood pressure, with typical systolic blood pressure of 180's as
an outpatient. An abdominal bruit was appreciated on exam. A
renal ultarsound showed bilateral flow with doplers. Imaging
with captopril was obtained to further evaluate for renal artery
stenosis, and was within normal limits. A work up for other
secondary causes was initiated, including hyperaldosterone,
hyper-renin, hyper-ACTH, and pheochromocytoma. Her work up
revealed slightly elevated normetanephrine in serum and urine,
as well as very mildly elevated epinephrine, norepinephrine,
dopamine, and catecholamines; it was not felt that these were
consistent with a pheochromocytoma. An AM cortisol was found to
be elevated and resistant to supression by 1mg dexamethasone
overnight. Because of that, a CT abdomen/pelvis was obtained on
[**2186-10-26**] to look for source of Cushings syndrome or ectopic
ACTH secretion-- it showed inflammation around the duodenum and
head of the pancreas but no adrenal masses.
.
Her blood pressure medications were slowly re-introduced, to
avoid hypotension, with goal systolic blood pressure greater
than 130's to 140's.
.
At time of discharge, her blood pressure medications were:
- Metoprolol 100 mg q8 hours
- Clonidine TTS 2 patch weekly
- Captopril 75 mg q8 hours
.
# Arrythmias: Cardiology was consulted early in her stay after
episodes of V-[**Last Name (LF) **], [**First Name3 (LF) **], and PVCs. It was recommended to
continue rate control metoprolol, as well as continue her ACE-I.
Electrophysiology was asked to see patient again on [**2186-10-22**]
for repeated episodes of V-[**Year (4 digits) **]. At that time, amiodarone was
initiated at 200 TID,
tapered to 200 mg [**Hospital1 **] on [**11-1**], and finally continued at 200 mg
daily since [**2186-11-14**]. She had no further arrythmias noted.
.
# Renal insufficiency - Upon admission, she had worsening of her
renal function with a creatinine to 1.7. It was felt that her
renal insufficiency was pre-renal in nature, and she was given
gentle intravenous fluids. It was thought she had an element of
diabetic nephropathy as well. The renal team was consulted and
assisted with management of her care. Her creatinine rose to 2.0
at its peak, coinciding with her hypotensive episodes. At time
of discharge, her renal function was stable at 0.8-1.2, and she
continued to put out good amounts of urine..
.
# Type two diabetes mellitus - Patient was on glipizide at home,
however with her worsening renal function and very little PO
intake, a sliding scale of insulin was started, and basal
insulin was added as needed.
At time of discharge, she was on 30 units of lantus in addition
to a humalong sliding scale.
.
# Hypothyroidism - Patient has history of thyroid carcinoma and
is status-post thyroidectomy. At time of admission, her TSH was
very suppressed, but her free T4 level was within normal limits.
Her TSH rose during her stay, peaking at 32. Her T4 studies were
found to be low. Endocrine consultation was obtained to assist
with management of her thyroid disease, especially with
concurrent use of amiodarone and lithium. Her dose of
levothyroxine was increased to 300 mcg for several days, then
brought down to 175 mcg prior to discharge. Her TSH remained
elevated (15) on a subsequent check on [**12-13**]. This was associated
with a normal free T4 (1.5). After discussion with
endocrinology, it was felt that she may not be absorbing well
and may be becoming progressively more hypothyroid. Her tube
feeds should be held 30 minutes before and after administering
synthroid; she should have her levels followed to ensure that
this is effective. If she is still underreplaced, she may need
to have IV levothyroxine.
- Her thyroid function tests should be checked and followed up
1-2 weeks after discharge.
- An ultrasound of her thyroid was checked to assess for any
thyroid disease or cancer recurrence in light of her elevated
TSH. The ultrasound was unchanged from prior studies.
.
# Upper gastrointestinal bleed: On [**2186-11-4**] patient developed
a decline in her hematocrit to 19, with guaiac positive stools,
then melena and bright red blood per rectum. She was transferred
to the intensive care unit, and gastroenterology was consulted.
An upper endoscopy revealed bleeding duodenal ulcers that were
injected and cauterized. She required a total of 9 units of
packed red blood cells during her intensive care stay.
Her hematocrit remained relatively stable after her transfer
back to the general floors on [**2186-11-8**], until [**2186-11-15**], at
which time her hematocrit continued to drift downward and her
stools were guaiac positive. Plans were made for a colonoscopy,
however, in light of an additional hematocrit drop to 20, a
repeat endoscopy was completed on [**2186-11-17**], and a new third
duodenal ulcer was noted which was also treated. She received
two additional units of red blood cells.
.
Testing for h. pylori was negative, and gastrin levels were
elevated; the elevated gastrin levels were expected in setting
of PPI use, and endocrine consultation did not feel there was
any additional pathology contributing to the elevated gastrin
levels.
- [**Hospital1 **] PPI was initiated and should be continued for at least 4
additional weeks, then continued daily.
- Patient will need follow up with gastroenterology after
discharge, for possible further evaluation of nodules seen
during her first endoscopy.
.
# C. Difficile Colitis: Patient developed diarrhea on
[**2186-11-24**], and stool samples revealed c. difficile. She was
initiated on treatment with flagyl on [**2186-11-25**], however was
refusing oral medications, so intravenous flagyl was
administered until [**2186-12-2**] at which time she could receive
oral medications via her PEG.
She did not have any abdominal pain or distention.
Her white blood cell count bumped to >20 at the time of her c.
difficile infection. Then improved. Around [**12-5**] her WBC count
again increased, with no other clear etiology found. It was
decided to change flagyl back to IV, and to add PO vanco. The
plan is to continue IV flagyl and PO vanco until about a week
after WBC stopping other antibiotics (cipro for UTI).
.
# Bipolar Disorder:
Patient had recent hospitalization for manic episode at outside
hospital. She has long standing history of depression and manic
episodes, with numerous prior psychiatric admissions. Her family
gave history that many of her prior depressive episodes had
started with refusal to eat.
.
Psychiatry team was consulted at the start of her stay and
followed along the entire time. Therapeutic options for her
bipolar disease were limited given her multiple serious medical
co-morbidities. There was concern during her stay for seizures
and serotonin syndrome, however neither was felt to have taken
place. She was titrated upward on citalopram to 40 mg (increased
from 20 mg on [**2186-11-24**] and increased from 30mg on [**2186-12-11**]).
Given her prior success on lithium, which had been stopped due
to "toxicity" of unclear etiology, the decision was made to
re-introduce lithium while in the inpatient setting where the
patient could be carefully monitored. 150 mg qHS was started on
[**2186-11-8**], and levels were closely followed, with goal level
about 0.5.
.
ECT: Psychiatry felt that one of the best options would be ECT,
however the patient continued to adamantly voice her refusal.
Several family meetings took place with her primary care
physician, [**Name10 (NameIs) **], primary medical, and psychiatric teams to
discuss various options for her severe depression, which was
felt to be the main reason for her failure to thrive and poor PO
intake.
Given her refusal to ECT, legal guardianship would need to be
pursued if the patient's family desired to pursue ECT and it was
necessary to deem the patient incompetent to make a decision
regarding ECT due to her depression.
- Remeron was considered, but contraindicated with use of
clonidine.
- Rilatin was also considered, but contraindicated with her
cardiac arrhythmias.
- Patient will need continued follow up with psychiatry as an
outpatient.
.
At time of discharge, the patient's mood and affect had improved
greatly since her initial presentation, and she appeared much
less flat. She was answering questions with complete sentences
with improved, though still limited, range of emotions.
.
# Failure to thrive/Anorexia - Patient continued to refuse to
eat and take her medications during most of her stay. As her
medical problems cleared, she became more interactive and
started to eat small amounts and take her medications. After
much discussion and a trial of one week once medically stable to
improve PO intake, decision was made to place PEG tube, which
was completed on [**2186-12-1**].
- Physical therapy and occupational therapy were consulted and
followed along during the patient's stay.
- Thyroid management as detailed above.
.
# Dementia: Patient has history of mild dementia. She was
initially on Namenda, however it was held due to her
unresponsive episodes, contribution to hypertension, and
possible serotonin syndrome.
.
# Tachypnea: Patient had intermittent episodes of increased
respiratory rate, ranging 25 - 30. Her oxygenation remained
normal, and her lungs were clear, and she denied any complaints.
Several chest x-rays were unrevealing. Her tachypnea improved
overall, but she would occasionally have episodes of increased
respiratory rate when aroused, agitated (eg by asking several
questions).
.
# Acalculus Cholecystitis:
A RUQ US showed possible GB wall necrosis and microperforation.
Surgery was consulted and recommended a percutaneous GB tube,
which was placed on [**2186-10-27**]. It was assumed that this was
the source of her persistent leukocytosis, since her WBC fell to
15 after placement of the tube, but the WBC has since increased.
On [**10-28**] after the procedure, levo/flagyl was switched to zosyn
for better gram negative coverage. Vanco was continued.
Throughout all this, she has had no fevers, denies abdominal
pain and has a relatively benign abd exam w/ no guarding,
rebound or RUQ tenderness. Surgery strongly feels that she does
not have an "acute abdmonial process" and they want to revisit
the idea of an elective cholecystectomy in [**3-18**] weeks. However,
it seems most likely that the necrotic GB was the course of the
persistent leukocytosis.
- Her drain site remained clean, dry, and intact.
- Several cultures from her bile drain were without growth
except for one that haad coagulase negative staph, felt to be a
contaminant.
- Patient's percutaneous gall bladder drain was clamped on [**12-8**]
and removed on [**2186-12-11**].
.
# Conjunctivitis: Patient completed course of treatment with
erythromycin eye drops.
.
# Oral Thrush: Patient occasionally had evidence of white
exudate on her tongue, which was possibly thrush given her very
poor PO intake and refusal of mouth care ans swabs. It was
possible that thrush was also contributing to her lack of
appetite.
- Nystatin S+S was initiated. It can be given on a prn basis
for recurrence.
.
# Elevated Cardiac Enzymes: Patient's cardiac enzymes bumped
slightly in setting of her gastrointestinal bleed and relative
hypotension. She had no chest pain or EKG changes, and it was
felt that she had an episode of demand ischemia.
.
# Tranaminitis: Patient's transaminases were elevated into the
[**2178**], which occurred following her gastrointestinal bleed and
episode of relative hypotension when her systolic blood pressure
was into the 100s in setting of bleed. It was suspected that she
suffered from ischemic process (CEs also bumped) due to
hypotension. She had also been getting tylenol during her
during intensive care stay, but not greater than 2 grams per
day.
- A RUQ US was obtained to rule out thrombosis or other process
was completed without any apparent new pathology.
.
# Thrombocytopenia- Patient developed thrombocytopenia down to
127 at the lowest. This resolved during her stay, and it was
thought to be due to her poor nutritional status.
- There were no clear offending medications on her medication
list.
- HIT testing was negative.
.
# Leukocytosis, fevers: Patient had fevers and leukocytosis
intermittently during her stay. Patient's fevers have resolved,
but she has had continued leukocytosis. Patient had definite
spike to > 20 with c. difficle infection.
- Patient had multiple sets of blood, urine, stool, and bile
cultures drawn; her chest x-ray was unchanged.
.
# Anemia: As discussed above in regards to GIB. Her hematocrit
remained stable at 26-28 range prior to discharge. Her anemia
was that of chronic disease as well as losses from GI tract.
.
# Urinary retention: Patient had several voiding trials with
removal of her foley with persistent urinary retention. There
were no clear offending medications.
- Foley replaced.
- Patient may need follow up with urology to further management
of her foley and retention. She will be discharged with foley
in place.
.
# Tremor: Patient had intermittent tremor of her left arm and
bilateral feet, which was stable. It was not present except when
asked several questions and stimulated. Does not cause patient
any distress. Tremor only present when patient stimulated or
agitated, not present in sleep or when calm. No other evidence
of toxicity or increased tone.
.
Medications on Admission:
Home Medications:
risperdal 2 mg qhs
trazodone 25 mg qhs
Atorvastatin 10 mg PO HS
CloniDINE 0.3 mg PO BID
Diltiazem Extended-Release 120 mg PO DAILY
GlipiZIDE 2.5 mg PO DAILY
Hydrochlorothiazide 25 mg PO DAILY
Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
Metoprolol XL (Toprol XL) 200 mg PO DAILY
Sertraline 50 mg PO DAILY
Levothyroxine Sodium 150 mcg PO DAILY
.
Medications (on transfer):
Atorvastatin 10 mg PO HS
CloniDINE 0.3 mg PO BID
Namenda *NF* 5 mg Oral [**Hospital1 **]
Levothyroxine Sodium 150 mcg PO DAILY
Metoprolol XL (Toprol XL) 200 mg PO DAILY
Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
Diltiazem Extended-Release 120 mg PO DAILY
Docusate Sodium 100 mg PO BID
GlipiZIDE 2.5 mg PO DAILY
Heparin 5000 UNIT SC TID
Hydrochlorothiazide 25 mg PO DAILY
traZODONE 25 mg PO HS
Senna 2 TAB PO DAILY
Sertraline 50 mg PO DAILY
Risperidone 2 mg PO HS
.
Allergies:
Wellbutrin - nausea and vomiting
Kaopectate - loss of balance and alopecia
Discharge Medications:
1. Levothyroxine 175 mcg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily): hold tube feeds 30 minutes before and 30 minutes after
administration. Do not given within 30 minutes of any other
medication.
2. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: One (1) PO BID (2
times a day).
3. Atorvastatin 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO HS (at
bedtime).
4. Senna 8.6 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily).
5. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette [**Hospital1 **]: [**12-13**]
Drops Ophthalmic PRN (as needed).
6. Lithium Carbonate 150 mg Capsule [**Month/Day (2) **]: One (1) Capsule PO QHS
(once a day (at bedtime)).
7. Amiodarone 200 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY
(Daily).
8. Calcium Carbonate 500 mg Tablet, Chewable [**Month/Day (2) **]: One (1)
Tablet, Chewable PO TID (3 times a day).
9. Sucralfate 1 gram Tablet [**Month/Day (2) **]: One (1) Tablet PO QID (4 times
a day).
10. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR PO BID (2 times a day).
11. Clonidine 0.2 mg/24 hr Patch Weekly [**Last Name (STitle) **]: One (1) Patch
Weekly Transdermal QTHUR (every Thursday).
12. Citalopram 40 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day.
13. Captopril 25 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO Q8H (every 8
hours).
14. Metoprolol Tartrate 50 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO Q8H
(every 8 hours).
15. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation. Tablet, Delayed Release (E.C.)(s)
16. Nystatin 100,000 unit/mL Suspension [**Last Name (STitle) **]: Five (5) ML PO QID
(4 times a day) as needed for thrush.
17. Miconazole Nitrate 2 % Powder [**Last Name (STitle) **]: One (1) Appl Topical TID
(3 times a day) as needed for rash.
18. Sodium Chloride 0.65 % Aerosol, Spray [**Last Name (STitle) **]: [**12-13**] Sprays Nasal
QID (4 times a day) as needed.
19. Heparin (Porcine) 5,000 unit/mL Solution [**Month/Day (2) **]: One (1)
Injection TID (3 times a day).
20. Vancomycin 250 mg Capsule [**Month/Day (2) **]: One (1) Capsule PO Q6H (every
6 hours) for 5 days.
21. Insulin
Insulin therapy as per sliding scale
22. Outpatient Lab Work
TSH, free T4 to be checked on or around [**2186-12-26**]. To be followed
by [**Location (un) 583**] House and/or Dr. [**Last Name (STitle) 1266**].
23. Outpatient Lab Work
CBC, chem 7 to be checked on or around [**2186-12-22**]; to be followed
by [**Location (un) 583**] House and/or Dr. [**Last Name (STitle) 1266**].
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 583**] House
Discharge Diagnosis:
Primary Diagnosis:
depression
new mulifocial atrial tachycardia, ventricular tachycardia on
EKG
Secondary Diagnosis:
failure to thrive
labile hypertension
poorly controlled diabetes mellitus
Discharge Condition:
improved.
Discharge Instructions:
You were admitted to the hosptial for depression and failure to
thrive. For your depression and failure to thrive, you were
evaluated by our psychiatrists who started you on two new
medications called celexa and lithium. These medications seemed
to help your mood and improved your communication. While you
were here, you also had several other medical problems including
labile hypertension, uncontrolled blood sugars, gastrointestinal
bleeding, episodes of unresponsiveness, and infection of your
gall bladder.
.
Your blood pressure and blood sugars were controlled. You were
given nutrition via intravenous administration and via a tube
going from your nose to your stomach. You were also found to
have a new heart arrythmia and transient renal failure. You were
seen by psychiatry and treated daily for your depression as we
stabilized you medically.
.
You also developed a bleed from your gastrointestinal tract, and
required blood transfusions.
.
The medicines we stopped were: risperdal, trazodone, diltiazem,
glipizide, HCTZ, Imdur, sertraline.
The medicines we started were: amiodarone, lansoprazole,
insulin, captopril, citalopram, calcium, colace, sucralfate,
senna, lithium, vancomycin oral liquid (thru [**12-23**]).
The medications we changed were: clonidine (now taking as a
patch), levothyroxine (increased to 175 mcg per day), metoprolol
(increased to 300 per day).
Please take all of your medications as directed.
Followup Instructions:
Please continue your stay at the rehabilitation facility until
you are deemed ready to leave. Please follow-up closely with an
outside hosptial psychiatrist.
.
Once you are discharged from you rehabilitation facility please
follow-up with a cardiologist of your choice to address your new
heart arrhythmia.
.
Please call your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1266**],
[**Telephone/Fax (1) 608**] to schedule an appointment for 2 weeks after
discharge.
.
You will need to have your thyroid function tests checked in [**12-13**]
weeks. You should also have your blood counts and electrolytes
checked on Friday, [**12-22**].
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 4055**]
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83,093
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Discharge summary
|
report
|
Admission Date: [**2104-9-2**] Discharge Date: [**2104-10-8**]
Date of Birth: [**2038-4-25**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5810**]
Chief Complaint:
right lower extremity swelling, abdominal distension, fevers
Major Surgical or Invasive Procedure:
Paracentesis (Diagnostic and Therapeutic) X 2
History of Present Illness:
66 year old Egyptian male, had been in [**Location (un) 84482**] for the past 8
months. He was brought from [**Country 3399**] [**9-1**] for medical care,
transferred to [**Hospital1 18**] from [**Hospital3 934**] with RLE cellulitis
concerning for necrotizing fasciitis. Febrile at OSH to 102.1.
Plain films and CT of RLE at OSH with no subcutaneous air or
fluid collections, no evidence of osteomyelitis. Prior to
transfer, he was given Clindamycin 600mg IV and gentamicin 100mg
IV.
.
Patient had been experiencing RLE leg swelling for 8-9 days
while in [**Country 3399**]. Started as small area of erythema on his right
leg, then rapidly spread up to the knee with signficant swelling
and erythema. The son reports that the leg was weeping clear and
purulent fluid, as well as blistering. Apparently, the son took
him to an Egyptian [**Name (NI) **] 5 days ago, at which time he was given
antibiotics (Augmentin?), and received daily wound care with an
antibiotic spray and dressing changes. There was also an
injectable antibiotic apparently prescribed by the patient's
brother, a physician in [**Country 3399**]. The son has now flown his dad to
the US for further management. The son states that the leg is
significantly improved, with decreased erythema, swelling, and
no more drainage.
.
The patient has reportedly had daily fevers and chills over the
last week. Son denies any water or animal exposures or bites. No
pets at home. No history of TB in patient or in known contacts.
The patient has been known to sleep outside on the balcony, and
the son is concerned that this infection could have started as a
mosquito bite.
.
Patient also has been experiencing abdominal distention and
upper abdominal pain x 4-5 days. No N/V/D. Had normal BM
yesterday. [**Name (NI) **] son states that the patient has had 30lb
weight loss over the last 2 months. CT abdomen suggestive of a
cirrhotic liver with splenomegaly and ascites. Patient has no
known prior history of liver disease.
.
In the ED, VS: 98.2 HR 95 BP 147/80 RR 16 98% on RA.
In ED, the patient got another dose of Clindamycin 600mg IV. A
diagnostic paracentesis was done. Surgery was consulted, who
felt there was no indication for urgent debridement, but may
need plastics consult for debridement/graft at some point. On
speaking with [**Hospital3 934**] micro lab, no growth on their
blood cultures after 24h. Plastics did bedside debridement after
admission.
.
Of note, when entering room to see patient today, noted
melanotic stool on bed. Exam aborted for time being, and patient
transferred to MICU for further care. Underwent urgent EGD,
which demonstrated non-bleeding grade 2 esophageal varices,
portal gastropathy, and multiple superficial duodenal ulcers s/p
epi
injection. Stable overnight.
Past Medical History:
DM
HTN
Social History:
Non smoker, no etoh, no drug use. Mormon, very religious. Runs 2
miles per day. Retired now, worked as a mechanic. Denies going
into any rivers recently, any work with river water.
Family History:
NC
Physical Exam:
VS: HR 83, BP 116/46, RR 22, 95% sat on RA
GEN: Lying in bed in no apparent distress
HEENT: Anicteric
NECK: no JVP, supple
CHEST: crackles at bases bilaterally
CV: Nl s1/S2, RRR
ABD: Distended, +fluid wave, nontender, tympanic to percussion;
no stigmata of liver disease
EXT: Large, superficial ulcerous region 5 X 5 cm along lower
aspect of right leg
NEURO: A+O X3
Pertinent Results:
[**2104-9-2**] 11:30PM WBC-13.7* RBC-3.40* HGB-9.8* HCT-30.8* MCV-91
MCH-28.8 MCHC-31.9 RDW-15.9*
[**2104-9-2**] 11:30PM PLT COUNT-574*
[**2104-9-2**] 06:38PM WBC-14.3* RBC-3.72* HGB-10.5* HCT-33.3*
MCV-89 MCH-28.3 MCHC-31.7 RDW-15.9*
[**2104-9-2**] 12:50PM GLUCOSE-160* UREA N-76* CREAT-1.9* SODIUM-135
POTASSIUM-5.1 CHLORIDE-106 TOTAL CO2-19* ANION GAP-15
[**2104-9-2**] 12:50PM ALT(SGPT)-24 AST(SGOT)-45* LD(LDH)-255* ALK
PHOS-174* TOT BILI-1.8* DIR BILI-1.1* INDIR BIL-0.7
[**2104-9-2**] 12:50PM ALBUMIN-2.5* CALCIUM-7.2* PHOSPHATE-4.2
MAGNESIUM-2.7* IRON-25*
[**2104-9-2**] 12:50PM HBsAg-NEGATIVE HBs Ab-NEGATIVE HBc
Ab-NEGATIVE HAV Ab-POSITIVE
[**2104-9-2**] 12:50PM HCV Ab-POSITIVE*
[**2104-9-2**] 12:50PM PARST SMR-NEG
[**2104-9-2**] 12:11PM URINE HOURS-RANDOM CREAT-84 SODIUM-LESS THAN
[**2104-9-2**] 12:11PM URINE OSMOLAL-566
[**2104-9-2**] 02:00AM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2104-9-2**] 02:00AM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-0
[**2104-9-1**] 10:59PM LACTATE-2.1*
Brief Hospital Course:
A/P: 66 yo M with PMH of DM, HTN presents with newly diagnosed
cirrhosis, GI bleed, RLE cellulitis, acute vs chornic renal
failure and transferred from the MICU to the floor for further
management.
.
#. Right lower extremity pain, swelling: The patient was
admitted and treated for extensive lower extremety cellulitis.
Dermatology, infectious disease, and plastics were consulted.
The patient underwent multiple debridment, vac placement, and
skin graft by the plastics team. Initial culture and pathology
data were unrevealing. The history of lower extremity swelling
and new onset liver disease (see below) raised red flags for
schistosomiasis given its endemicity in [**Country 3399**]. Schistosomal
antibodies were however negative. No infectious organism
responsible for the cellulitis was convincingly found, with
wounds growing only [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 29361**] thought to be a
contaminant and treated for several days with IV micafungin.
Broad spectrum antibiotics (vancomycin and zosyn) were started,
picc line placed, and abx continued throughout hospitalization
([**2104-9-2**] - [**2104-10-8**]). All blood cx to date have been negative,
CXR clear, and dopplers of lower extremity were negative for
DVT. Ultimately patient defervesced and respiratory status
improved wth diuresis and large volume paracentesis of ascites
fluid (see below). By the end of discharge, the right extremity
cellulitis looked good. Patient discharged with the following
instructions:
- Daily dressing changes with xeroform, kerlix, ACE wrap
- Skin graft donor sites on thigh open to air
- Can perform nonweight bearing ambulation with crutches for
short periods
- Follow up with ortho as outpatient
.
#. HCV Cirrhosis: CT from OSH showed ascites, cirrhosis,
esophageal varices, and portal hypertension. Diagnostic
paracentesis in ED was consistent with transudative ascites
fluid, no SBP. Initially AST, AP, and t bili slightly elevated,
but trended down. Right upper quadrant ultrasound showed no
thromboses. Anti-smooth muscle and RF were mildly elevated.
Hepatitis C serologies came back positive. Schistosoma
antibodies were negative. Hepatology consulted and attributed
new cirrhosis to HCV. During hospitalization, the patient
experienced tachycardia and tachypnea with progressive abdominal
distension. Therapeutic paracentesis were performed x2 with
between 3.5 to 4 L of ascites fluid removed; peritoneal data was
without evidence of SBP. Patient was started on lasix and
spironolactone to control significant abdominal ascites and
scrotal edema. Diuretics were uptitrated with improvement in
ascites. Patient was vaccinated with first dose of HBV vaccine
on [**2104-10-3**] and he will need repeat doses in one month and in 6
months. He is immune to hepatitis A per serology, so does not
need to be vaccinated for this.
.
3. Increased Creatinine: Cr 1.9-2.1 (Fena was < 1% and Una ~
11). Patient's baseline was unknown, with some improvement
after fluids. Other etiologies were thought to be possible
given HCV status (see above) including MPGN, although normal
C3/C4 made this less likely. Cryoglobulins were sent which were
negative. Patient was thought to have underlying CKD from hx of
DM and HTN. Blood pressure was optimized and urine output
remained appropriate. Throughout hospitalization Cr remained
stable at 1.5-1.7.
.
4. Upper GI Bleed: On admission, EGD report showed multiple
superficial bleeding duodenal ulcers that were injected [**9-2**] and
non-bleeding grade II-III esophageal varices. H pylori test came
back positive. Per infectious disease recommendations,
clarithromycin was added to his antibiotic regimen and zosyn was
shown to have some in [**Last Name (un) 5153**] effect on h. pylori. Patient was
thus treated for h. pylori with triple therapy and the plan for
a follow up EGD as an outpatient to evaluate healing ulcer.
Patient was maintained on a ppi and nadolol throughout
hospitalization.
.
5. Hyponatremia: Thought to be secondary to cirrhosis. On
admission, Na was 131 and remained stable throughout
hospitalization. On discharge Na was 133.
.
6. Normocytic Anemia: Hct 26-30 with unknown baseline. Patient
remained hemodynamically stable following sclerosis of ulcers
(see above) and did not actively bleed throughout rest of
hospitalization. Hemolysis work up negative and iron panel
consistent w/ anemia of chronic disease.
.
7. DM: Initially FS fluctuated between 200 and 400. Lantus was
progressively increased in the evening from 10 to 25 with
improved control.
.
8. Nutrition: Patient was supported by NGT feeds, given high
nutritional requirements. A nutrition consult was done with a
calorie count. NGT pulled [**9-26**] and patient maintained good po
intake.
Medications on Admission:
Nifedipine
Insulin (unknown type)
Discharge Medications:
1. Nadolol 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*15 Tablet(s)* Refills:*2*
2. Lantus 100 unit/mL Cartridge Sig: Twenty Five (25) U
Subcutaneous at bedtime.
Disp:*1 vial* Refills:*2*
3. 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*
4. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain for 10 days.
Disp:*35 Tablet(s)* Refills:*0*
5. lancets
one touch ultra soft lancets, use as directed. dispense 1 box,
2 refills
6. test strips
Use as directed three times a day. Dispense 1 box, 2 refills.
7. Lasix 40 mg Tablet Sig: 1.5 Tablets PO once a day.
Disp:*45 Tablet(s)* Refills:*2*
8. Spironolactone 50 mg Tablet Sig: 2.5 Tablets PO once a day.
Disp:*75 Tablet(s)* Refills:*2*
9. Xeroform Petrolatum Dressing 2 X 2 Bandage Sig: One (1)
Topical once a day for 3 weeks: please apply to wound daily.
Disp:*1 box* Refills:*0*
10. Insulin Syringe-Needle U-100 0.3 mL 30 x [**5-3**] Syringe Sig:
see below Miscellaneous once a day: Please use as instructed.
Please take 25U lantus daily with syringe.
Disp:*1 box* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
- Right lower leg cellulitis
- Hepatitis C cirrhosis
- Refractory ascites
- Grade II esophageal varices
- Duodenal ulcer w/ bleeding
- H.pylori
- CKD stage IV
Discharge Condition:
Stable for home
Discharge Instructions:
You were admitted with swelling in your right leg and an
infection of the skin of the right leg. While in the hospital,
plastic surgery operated on this area and cleared out the
diseased tissue to help your infection heal. We also treated
you with antibiotics for your leg infection. We also started
you on nutrition through tube feeds that go through a nasal
tube, because you needed a lot of protein to heal the leg.
During your hospitalization, we also found that your liver was
injured, probably because of infection by hepatitis C. It's
unclear how you got hepatitis C, but it is very prevalent in
[**Country 3399**]. You will need to follow up with a gastroenterology to
discuss treatment of your hepatitis C as an outpatient. Given
your liver disease, please do not take more than 2gm of tylenol
per day.
.
While in the hospital, we also found that you had several ulcers
in part of your intestine called the duodenum. It's likely
that these ulcers formed because of an infection by a bacterium
called H. pylori. You were treated with antibiotics for this.
You should also avoid taking medications such as NSAIDS
(anything containing ibuprofen) as well as alcohol, as these
things can make the ulcers worse.
.
The medication changes we made during this hospitalization were:
(1). Omeprazole for your ulcer disease
(2). Percocet for pain, this has tylenol and codeine in it.
Please do not take more than 2gm a day of tylenol. Please take
percocet as instructed, this is a sedating medication.
(3). Nadolol for your esophageal varices.
(4). Lasix and Spironolactone. These will help get rid of the
fluid in your abdomen.
(5). We have started you on lantus at night.
(6). We have given you dressing changes: Please apply xerform to
right calf, then apply kerlex wrap, and then the ACE wrap. Your
leg will need to be in a boot at all times. You can dangle your
leg for 30min a day 4 times a day. For the next three weeks,
you must use crutches when walking at all times.
If you experience any chest pain, shortness of breath, worsening
leg pain, abdominal swelling or tenderness, or any other
concerning symptoms, please let your primary care doctor know or
return to the emergency department.
Followup Instructions:
Please follow up with Gastroenterology [**2104-10-17**] at 2:00pm with
Dr. [**First Name (STitle) 2643**]. His number is ([**Telephone/Fax (1) 2233**] in [**Hospital Unit Name **] [**Last Name (NamePattern1) 10357**] Suit 8E.
Please follow up with Plastic Surgery [**2104-10-24**] at 2:300 pm with
Dr. [**First Name (STitle) **]. Their number is ([**Telephone/Fax (1) 7138**]. The clinic is located
in [**Hospital Ward Name 23**] Clinical Center [**Location (un) 470**], Surgical Specialties on
[**Location (un) **].
Please follow up with Infectious disease [**2104-10-24**] at 11:00 am
with Dr. [**First Name (STitle) **]. Their number is ([**Telephone/Fax (1) 4170**].
Completed by:[**2104-10-10**]
|
[
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"276.2",
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"456.21",
"537.89",
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"070.70",
"707.12",
"571.5",
"532.40",
"403.90",
"250.42",
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icd9cm
|
[
[
[]
]
] |
[
"44.43",
"86.22",
"86.69",
"54.91",
"38.93",
"86.11",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
11069, 11075
|
4995, 9770
|
375, 422
|
11278, 11295
|
3871, 4972
|
13555, 14264
|
3465, 3469
|
9855, 11046
|
11096, 11257
|
9796, 9832
|
11319, 13532
|
3484, 3852
|
275, 337
|
450, 3219
|
3241, 3249
|
3265, 3449
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,938
| 121,789
|
49981+59217
|
Discharge summary
|
report+addendum
|
Admission Date: [**2168-12-7**] Discharge Date: [**2168-12-11**]
Service: Medical Intensive Care Unit
CHIEF COMPLAINT: Nausea, vomiting and abdominal pain
HISTORY OF PRESENT ILLNESS: The patient is a [**Age over 90 **] year old
woman with multiple medical problems as listed below
including recurrent pancreatitis attributed to microlithiasis
who was in her usual state of health until the day prior to
presentation when she developed abdominal pain, radiating to
her back and side and had some nausea. She was brought to
the Emergency Department where she was found to have
laboratory values consistent with pancreatitis (as summarized
below). Nasogastric lavage was also performed and occult
blood was present in the form of coffee ground.
In the Emergency Department, the patient received
Pantoprazole 40 mg intravenously 1.5 liters of normal saline
bolus, nitroglycerin 0.3 mg sublingually and Ondansetron 12
mg intravenously. The patient was initially slated for
admission to the Medical Service, however, the presence of
upper gastrointestinal bleeding prompted admission to the
Medical Intensive Care Unit.
Evaluation of cardiac markers in the Emergency Room also were
suggestive of acute myocardial infarction. The patient was
seen by the Cardiology Service and reiterated her desire to
not undergo coronary angiography as described in her previous
discharge summary. She received intravenous heparin, Aspirin
and Clopidogrel. Shortly thereafter she had an episode of
coffee ground emesis with nasogastric lavage as described
above.
ALLERGIES: Penicillin as documented previously.
OUTPATIENT MEDICATIONS:
1. Aricept 10 mg daily
2. Aspirin 81 mg daily
3. Glipizide 20 mg twice a day
4. Furosemide 60 mg daily
5. Levothyroxine 75 mcg daily
6. Atorvastatin 10 mg daily
7. Lisinopril 10 mg daily
8. Nitroglycerin 0.6 mg as needed
9. Pepcid 20 mg daily
10. Clopidogrel 75 mg daily
11. Pantoprazole 40 mg daily
PAST MEDICAL HISTORY: 1. Pancreatitis, she has had several
episodes since [**2168-8-1**]. She was initially scheduled
for outpatient endoscopic retrograde cholangiopancreatography
through the [**Hospital **] Clinic, however, she failed to
meet her appointment and as described below has refused to
have further evaluations. 2. Coronary artery disease, the
patient had a myocardial infarction in [**2168-8-1**],
however, she and her family declined angiographic evaluation.
Her last echocardiogram showed a systolic congestive heart
failure with a left ventricular ejection fraction of 35 to
40% with apical left ventricular aneurysm and diffuse wall
motion abnormality. The left ventricle was 1+ aortic
insufficiency. 3. Type 2 diabetes controlled with oral
Sulfonylurea as described above. 4. Mild Alzheimer's
disease for which she received Aricept as described above and
Quatiapine for sleep. 5. Hypothyroidism, stable regimen
with replacement as described above. 6. Hypertension, well
controlled with an ACE inhibitor. 7. Recurrent urinary
tract infection. 8. Symptomatic bradycardia necessitating a
DDD cardiac pacemaker placement. 9. Colon cancer at age 78,
status post surgical resection, there no radiation or
chemotherapy performed. 10. Previous right-sided stroke.
11. Hysterectomy.
FAMILY HISTORY: Non-contributory, her daughter is involved
in her care.
SOCIAL HISTORY: She lives with her daughter. She does not
smoke, drink alcohol or abuse drugs.
PHYSICAL EXAMINATION: Temperature 98.7, heartrate 81, blood
pressure 137/91, respiratory rate 22, pulse oxygen saturation
99% on 2 liters of nasal cannula.
General: She is a pale-appearing elderly woman lying in
moderate distress.
Head, eyes, ears, nose and throat: Normocephalic,
atraumatic, anicteric, normal conjunctiva. Pupils equal,
round and reactive to light. Extraocular movements intact
without nystagmus. Clear oropharynx. Dry mucous membranes.
Neck: Supple, full range of motion. Jugulovenous pressure
is inappreciable. No carotid bruit. No thyromegaly.
Nodes: No anterior cervical, posterior cervical,
supraclavicular or infraclavicular, axillary or inguinal
adenopathy.
Heart: Point of maximal impulse is in the fifth rib space in
the midclavicular line. Heartrate is regular with normal S1
and S2, there is no S3 or S4, murmurs, rubs or gallops.
Lungs: Good effort, normal excursions. Clear to
auscultation and percussion bilaterally.
Abdomen: Protuberant, normal bowel sounds, soft, nontender
or nondistended. Scars as noted previously.
Back: There is no costovertebral angle tenderness.
Vascular examination: Carotid, femoral, dorsalis pedis
pulses are brisk and equal.
Extremities: There is no rash, cyanosis, clubbing or edema.
Neurological examination: Mental status is alert, oriented
to person, place and time. Normal grossly full visual
fields. Writing sample was not obtained. Detailed
assessment of tension was not performed.
Cranial nerves: I, not tested formally; II, III, IV and VI,
pupils equal, round and reactive to light, extraocular
movements intact without nystagmus as described above; V and
VII symmetric, she would not cooperate with the sensory
assessment; VIII not tested formally; IX, X and XII tongue is
midline. There is normal gage. Clear phonation. [**Doctor First Name 81**], normal
shoulder shrug.
Motor: Decreased bulk and tone.
Upper extremities: Moves arms spontaneously but does not
follow commands.
Lower extremities: Moves legs spontaneously but does not
follow commands.
Sensory: Normal vibration, light touch, proprioception and
pinprick.
Coordination: Gait was not assessed, normal rapid
alternating hand movement.
Deep tendon reflexes: Biceps, brachioradialis, triceps,
quadriceps, femoris and gastrocnemius, deep tendon reflexes
+2 bilaterally, plantar reflex flexor bilaterally.
LABORATORY DATA: On presentation the white blood cell count
was 8,100, hemoglobin 12.5, hematocrit 37.7, platelets 293.
Mean corpuscular volume was 93 semptolitiers.
Sodium 140, potassium 4.4, chloride 105, blood urea nitrogen
36, bicarbonate 23, creatinine 1.2, glucose 236, calcium
10.6, magnesium 2.0, phosphate 2.4.
ALT 13, AST 31, alkaline phosphatase 77, total bilirubin 0.2,
albumin 4.1, lactate dehydrogenase 180, lipase 2,434 (when
assessed 8 hours lipase was 5,335 and amylase was 1315), TSH
6.5, creatinine kinase 50, troponin T 0.06.
Electrocardiogram showed sinus rhythm of 70 beats/minute with
PR interval of 0.2, QRS was 0.15 with old right bundle branch
block, QT was 0.4 with an axis of 0 to -30 degrees and early
R wave progression. There were unchanged ST-T segment
elevations in the inferior lead 2, 3 and AVF as well as
dynamic T wave inversions in that lead, there were stable T
wave inversions in anterior and precordial leads V1 through
V3.
Chest x-ray showed no evidence of congestive heart failure or
pneumonia.
Computed tomograph of the abdomen showed fat stranding around
the pancreas consistent with a laboratory evaluation
described above. There was no evidence of biliary ductal
dilation or pericystic fluid collection.
HOSPITAL COURSE: 1. Pancreatitis - Following admission to
the Medical Intensive Care Unit the patient required modest
volume resuscitation as she was briefly hemoconcentrated. On
hospital day #3 her amylase and lipase dropped precipitously
consistent with her previous presentation of transient
pancreatitis. Since stones had not been identified in her
gallbladder it was suspected that her pancreatitis was due to
medications or other nonstone causes. In reviewing her
medication list, it was decided to ultimately withhold her
Atorvastatin as her cholesterol panel was well within the
normal range and this is a medication known to cause
pancreatitis, however, Ursodeoxycholic, a medication not
listed above, in her outpatient medication that she was
discharged with on her last presentation and this medication
may have to be withheld in the future as may Furosemide.
2. Gastrointestinal bleeding - Serial evaluations of her
hemoglobin and hematocrit showed a stable vascular supply.
She received Proton pump inhibitor and it was decided to
withhold Clopidogrel indefinitely owing to her
gastrointestinal bleeding.
3. Coronary artery disease - Following admission to the
Medical Intensive Care Unit serial evaluation of her cardiac
markers supported evidence of myocardial infarction, medical
management was pursued exclusively. Clopidogrel was held
indefinitely. Metoprolol was added to her regimen and
Lisinopril was ultimately restarted. Atorvastatin was
discontinued as described above.
4. Hypothyroidism - Her TSH was slightly elevated on
admission, however, interval evaluation of her free
Levothyroxine showed it to be normal. There were no changes
made to her outpatient regimen.
5. Diabetes - A modest sliding scale of subcutaneous insulin
was administered. Her Sulfonylurea was withheld while she
was in the hospital. She achieved good glycemic control
throughout.
The remainder of the [**Hospital 228**] hospital course was
significant for one episode of flash pulmonary edema for
which she received Furosemide, Nitroglycerin and
nonmechanical ventilation as she and her daughter had stated
previously that she does not wish to have mechanical
ventilation during this hospitalization. Her daughter
reiterated her mother's desire to have a Do-Not-Resuscitate,
Do-Not-Intubate order written. Once her pancreatitis
resolved and her cardiac issues were stabilized she was
transferred to the Medical Floor for further titration of her
medication.
[**Name6 (MD) **] [**Last Name (NamePattern4) 5837**], M.D. [**MD Number(1) 8285**]
Dictated By:[**Name8 (MD) 7102**]
MEDQUIST36
D: [**2168-12-10**] 19:30
T: [**2168-12-10**] 20:07
JOB#: [**Job Number 104364**]
Name: [**Known lastname 16935**], [**Known firstname 888**] Unit No: [**Numeric Identifier 16936**]
Admission Date: [**2168-12-7**] Discharge Date: [**2168-12-13**]
Date of Birth: [**2074-1-1**] Sex: F
Service:
ADDENDUM: Covering [**2168-12-11**], to [**2168-12-13**].
HOSPITAL COURSE: For the remainder of the patient's
hospitalization course, she remained stable and in good
condition. She was discharged on hospital day nine to home.
MEDICATIONS ON DISCHARGE:
1. Aspirin 81 mg p.o. once daily.
2. Seroquel 25 mg p.o. once daily.
3. Levothyroxine 75 mcg once daily.
4. Protonix 40 mg once daily.
5. Ursodiol 300 mg twice a day.
6. Iron 150 mg once daily.
7. Metoprolol 25 mg twice a day.
8. Docusate.
9. Senna.
10. Glipizide 20 mg twice a day.
11. Donepezil 10 mg once daily.
12. Lisinopril 5 mg once daily.
DISCHARGE DIAGNOSES:
1. Pancreatitis.
2. Hypertension.
FOLLOW-UP PLANS: The patient is to follow-up with her
primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 2861**] [**Last Name (NamePattern1) **], within one week.
[**Name6 (MD) 3354**] [**Name8 (MD) **], M.D.
Dictated By:[**Last Name (NamePattern1) 1061**]
MEDQUIST36
D: [**2169-3-6**] 14:40
T: [**2169-3-6**] 20:05
JOB#: [**Job Number 16937**]
|
[
"428.0",
"414.01",
"578.0",
"V45.01",
"410.71",
"250.00",
"V10.05",
"577.0",
"412"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
3282, 3339
|
10678, 10715
|
10300, 10657
|
10121, 10274
|
1639, 1949
|
3460, 4912
|
10733, 11135
|
132, 169
|
198, 1615
|
4929, 7065
|
1972, 3265
|
3356, 3437
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,857
| 173,189
|
11552+11553
|
Discharge summary
|
report+report
|
Admission Date: [**2116-10-6**] Discharge Date: [**2116-12-4**]
Date of Birth: [**2042-8-14**] Sex: F
Service: Thoracic Surgery
DISCHARGE DIAGNOSIS:
1. Status post left thoracotomy [**2116-10-6**], status post left
upper lobectomy [**2116-10-6**], status post a mediastinal lymph
node dissection [**2116-10-6**].
2. Squamous cell cancer of the lung.
3. Status post tracheostomy [**2116-10-27**] with Passy-Muir valve
for respiratory failure.
4. Hypothyroidism.
5. CMV colitis.
6. Ischemic colitis.
7. Lower GI bleeding.
8. Hypertension.
9. Heparin induced thrombocytopenia.
10. Myocardial infarction.
11. Coronary artery disease.
12. Intermittent atrial fibrillation.
13. History of angina.
14. History of asthma.
15. Chronic obstructive pulmonary disease.
16. Sepsis.
17. MRSA pneumonia.
18. Pseudomonas pneumonia.
19. Sepsis.
20. Partial small bowel obstruction.
21. History of C. difficile colitis.
22. History of right breast cancer status post mastectomy.
23. PICC placed [**2116-12-4**].
24. Hyperalimentation for nutrition with TPN.
DISCHARGE MEDICATIONS: Include Tamoxifen 20 mg po or through
a tube q day, Nystatin powder q 2 hours to affected areas
prn, Ganciclovir 300 mg IV q 12 hours started [**2116-11-4**] and
needs a 6 week course, Synthroid 75 mg IV q day, Aspirin 81
mg po q day, Albuterol nebs q 2 hours and prn, Atrovent nebs
q 2 hours prn, Paxil 20 mg po q day, Epogen 40,000 units
subcu q Wednesday (one time a week), Levaquin 250 mg IV q
day, to be stopped or discontinued on [**2116-12-10**], Ceftazidime 1
gm IV q 12 hours to be discontinued on [**2116-12-10**]. Amiodarone
200 mg po bid. Prn orders are as follows: Magnesium Sulfate
2 gm IV prn magnesium less than 1.8, Calcium Gluconate 2 gm
IV prn calcium ionized lab value less than 1.12, KCL 20 mEq
IV prn potassium less than 4.0, Tylenol 650 mg po or pr q 6
hours prn pain.
ALLERGIES: No known drug allergies.
HOSPITAL COURSE: The patient is a 74-year-old lady with past
medical history significant for breast cancer, status post a
right mastectomy in the year [**2114**], status post a VATS
procedure, mediastinoscopy, multiple bronchoscopies who ruled
in for an MI during this hospitalization which led to the
discovery of two vessel disease and a stent placement at
cardiac catheterization. Status post left upper lobectomy
and mediastinal lymph node excision on [**2116-10-6**] for a left
sided lung mass. She is PPD negative. She has had a
complicated medical course since her admission the day of
surgery, marked by respiratory decompensation due to mucus
plugging, pseudomonas and Klebsiella pneumonia, MRSA
pneumonia, also has had atrial fibrillation, C. difficile
colitis, ischemic colitis by colonoscopy, CMV colitis by
colonoscopy, pathology results treated with Ganciclovir. She
had a colonoscopy on [**2116-10-29**]. She has had a very complicated
respiratory status course which includes high oxygen
requirements, aggressive pulmonary toilet, multiple
bronchoscopies, a prolonged antibiotic course including
Ceftazidime, Levaquin and had had her hospital course
complicated as well by maroon colored guaiac positive stools.
The patient initially on postoperative day #1 was extubated,
transferred from the PACU to the patient floor and then
eventually, 14 days into her hospitalization, was sent to the
Intensive Care Unit for respiratory failure requiring
intubation. Since then patient has been unable to wean
completely from ventilator and subsequently had a
tracheostomy placed. The patient had a full course of Flagyl
for C. difficile colitis. The patient has had a presumed
partial small bowel obstruction. She has had multiple
surgical consults and follow-ups and abdominal CT which
showed a gallstone, somewhat abnormal gallbladder but not
frank cholecystitis as well as some dilated loops of
intestine with no specific bowel obstruction. The patient
has had a very difficult time tolerating enteral feeding and
currently is undergoing hyperalimentation through a PICC
central line. The patient has had multiple episodes of
hypotension and has had a prolonged course of alpha agonist
pressor requirements, presumably in the setting of bacteremia
and sepsis, likely secondary to her courses with pneumonia.
The patient also has been seen by speech and swallow and had
a Passy-Muir valve placed and was able to phonate. The
patient has been followed by the infectious disease
specialist, by the cardiologist, general surgery, thoracic
surgery and Intensive Care Unit team as well as the GI
consult service. The patient was noted to have a drop in her
platelets, Heparin induced antiplatelets antibodies were sent
and were positive and the patient has a diagnosis of Heparin
induced thrombocytopenia. The patient also was noted to have
drop in her hematocrit with maroon colored stool and a CT
scan with possible ischemic bowel but no progression and no
worsening and was not operated on, was just followed
clinically. Then subsequently patient was also found to have
a CMV colitis.
CONDITION ON DISCHARGE: The patient currently in stable
condition, awaiting rehab placement.
DISCHARGE DIAGNOSIS: As listed above.
FOLLOW-UP: The patient should follow-up with her primary
care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 175**] at [**Hospital1 190**]. Case worker there should call Dr.[**Name (NI) 14732**]
office for specific guidelines for follow-up appointments.
PCP already said prn and in one month. Patient should have
infectious disease follow-up. Patient should call the
infectious disease clinic at the [**Hospital1 190**] or patient's social worker for follow-up of
the CMV colitis therapy.
[**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 178**], M.D. [**MD Number(1) 179**]
Dictated By:[**Last Name (NamePattern1) 8344**]
MEDQUIST36
D: [**2116-12-4**] 13:51
T: [**2116-12-4**] 14:02
JOB#: [**Job Number 12943**]
Admission Date: [**2091-1-22**] Discharge Date: [**2116-12-8**]
Date of Birth: [**2042-8-14**] Sex: F
Service: CARDIOTHOR
The Discharge Summary for this hospital admission had already
been dictated and transcribed. It is dated [**2116-12-4**].
The patient remained in the hospital for additional days for
rehabilitation placement. There were no significant changes
from the previously discharge summary.
The initial correction of this discharge summary was
inadvertently dated [**2117-10-8**].
[**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 178**], M.D. [**MD Number(1) 179**]
Dictated By:[**Last Name (NamePattern4) 36759**]
MEDQUIST36
D: [**2117-6-7**] 07:43
T: [**2117-6-9**] 11:26
JOB#: [**Job Number 36760**]
|
[
"162.3",
"038.9",
"414.01",
"410.91",
"427.31",
"482.41",
"482.0",
"560.9",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"32.3",
"38.93",
"40.3",
"36.06",
"36.01",
"45.25",
"31.1",
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] |
icd9pcs
|
[
[
[]
]
] |
1095, 1928
|
5154, 6802
|
1946, 5037
|
5062, 5132
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21,769
| 119,565
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54610
|
Discharge summary
|
report
|
Admission Date: [**2203-6-10**] Discharge Date: [**2203-6-21**]
Service: MEDICINE
Allergies:
Percocet / Tylenol
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
bloody emesis
Major Surgical or Invasive Procedure:
Debridement of right 3rd toe and excision of the distal phalanx.
PICC line placed.
History of Present Illness:
History of Present Illness (source - patient who is tangential,
though oriented): 86 y.o. male with PMHx of atrial fibrillation
on Coumadin, COPD, DM, colon CA s/p left colectomy and iron
deficiency anemia who presents to the ED with a chief complaint
of vomiting blood. Patient reports a history of 4 days of
antibiotics (Augmentin) for a foot infection. He had been
experiencing foot pain for appoximately 2 weeks prior to the
initiation of antibioitics and for this, he was taking Advil [**Hospital1 **]
every day. He reports experiencing some dark stools throughout
this time and on the day of presentation, experienced an episode
of hematemesis for which he presented to the ED. He denies
abdominal pain, fevers/chills, chest pain, shortness of breath,
palpitations. He does also note some drops of blood in the
toilet, but no frank hematochezia.
.
In the ED, initial vitals were: T - 97.7, BP - 131/45, HR - 77,
RR - 16, O2 - 97% RA. Hct was low at 15, down from baseline of
low 20s and INR was elevated to 8.3. NG lavage showed coffee
grounds which did not clear with 500ccs and rectal exam revealed
black stool that was frankly guaiac positive. GI was consulted
and planned for EGD once admitted. Patient was ordered for 10 mg
of vitamin K as well as 2 units of FFP and PRBCs. Patient's labs
were also notable for acute on chronic renal failure with
BUN/creatinine of 124/3.6 (creatinine up from baseline of 1.5 -
2.0). In the setting of this acute renal failure, troponin was
elevated to 0.13 without ischemic changes on EKG. Patient was
thus admitted to the MICU for further management of his severe
anemia with renal failure and a troponin leak.
.
Upon arrival to the ICU, patient was interactive and in no acute
distress with stable vitals.
Past Medical History:
DM2
Paroxysmal Atrial Fibrillation on anticoagulation
CRI- baseline Cr 1.5 - 2.0
HTN
Gout
COPD
OA
h/o GIB ([**2198**]; found to have gastritis, ulcerations, no active
bleeding, and angioectasia in colon)
h/o hip fx s/p ORIF/IM nail R hip, L hip [**2201**]
[**Name (NI) 3674**] unclear etiology, previously treated with regular
transfusions, now on procrit, baseline 30
h/o pericardial effusion in setting of AF with RVR, CHF, pleural
effusions ([**2198**])
s/p TURP for prostate enlargement and urinary retention
h/o sigmoid colon ca s/p sigmoid colectomy [**2192**]
right cheek SCC s/p skin graft
Diastolic CHF
Social History:
Patient denies tobacco or illicit drugs. He reports occasional
alcohol consumption.
Family History:
NC
Physical Exam:
On Admission
Vitals: T: 99.2, BP: 119/38, P: 76, R: 22, O2: 96% RA
General: Awake,alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Rectal: Deferred as bed with frank melena
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Labs on admission:
[**2203-6-10**] 10:45AM BLOOD WBC-7.4 RBC-1.82*# Hgb-4.8*# Hct-15.6*#
MCV-86 MCH-26.5* MCHC-30.9* RDW-19.6* Plt Ct-245
[**2203-6-10**] 10:45AM BLOOD Glucose-175* UreaN-124* Creat-3.6*#
Na-142 K-4.5 Cl-106 HCO3-25 AnGap-16
[**2203-6-10**] 10:45AM BLOOD PT-67.8* PTT-37.0* INR(PT)-8.3*
.
HCT trend [**6-10**] 15.6 -> [**6-10**] 16 -> [**6-11**] 20 -> [**6-11**] 22 -> [**6-11**]
23.6 -> [**6-12**] 25 -> [**6-21**] 28.3
.
INR trend [**6-10**] 8.3 -> [**6-10**] 2.2 -> [**6-10**] 1.6 -> [**6-11**] 1.3 -> [**6-12**]
1.2 -> [**6-21**] 1.8
.
[**2203-6-19**] 05:19AM BLOOD Glucose-115* UreaN-23* Creat-1.3* Na-140
K-4.7 Cl-108 HCO3-24 AnGap-13
[**2203-6-17**] 07:20PM BLOOD Vanco-15.1
.
Urine cx [**2203-6-10**]: negative
.
[**2203-6-13**] 4:50 pm SWAB Source: right foot.
**FINAL REPORT [**2203-6-17**]**
GRAM STAIN (Final [**2203-6-13**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI IN
PAIRS.
SMEAR REVIEWED; RESULTS CONFIRMED.
WOUND CULTURE (Final [**2203-6-16**]):
STAPH AUREUS COAG +. MODERATE GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations
Rifampin
should not be used alone for therapy.
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). MODERATE
GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=1 S
ANAEROBIC CULTURE (Final [**2203-6-17**]): NO ANAEROBES ISOLATED.
.
[**2203-6-14**] 12:56 pm TISSUE RT 3RD TOE.
**FINAL REPORT [**2203-8-15**]**
GRAM STAIN (Final [**2203-6-14**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
TISSUE (Final [**2203-6-18**]):
Due to mixed bacterial types (>=3) an abbreviated workup
is
performed; P.aeruginosa, S.aureus and beta strep. are
reported if
present. Susceptibility will be performed on P.aeruginosa
and
S.aureus if sparse growth or greater..
STAPH AUREUS COAG +. SPARSE GROWTH.
SENSITIVITIES PERFORMED ON CULTURE # 273-9328S [**2203-6-13**].
ANAEROBIC CULTURE (Final [**2203-6-18**]): NO ANAEROBES ISOLATED.
ACID FAST SMEAR (Final [**2203-6-15**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Final [**2203-8-15**]): NO MYCOBACTERIA
ISOLATED.
FUNGAL CULTURE (Final [**2203-6-30**]): NO FUNGUS ISOLATED.
.
CXR [**2203-6-10**]:
SINGLE PORTABLE UPRIGHT CHEST RADIOGRAPH: There are low lung
volumes.
Mediastinal and hilar contours are unchanged. There is left
basilar
atelectasis. There is no right effusion or pneumothorax.
Pulmonary
vasculature is normal. Osseous structures are grossly normal.
IMPRESSION: Left basilar likely atelectasis.
.
X-rays of right toes [**2203-6-17**]:
FINDINGS: There is abnormal soft tissue swelling and ulceration
in the distal aspect of the right third toe. There appears to be
exposed bone, as well as gas at the distal tip of the third toe,
highly suspicious for osteomyelitis.
The cortical definition of the third distal to until [**Hospital1 **] is
also irregular consistent with cortical destruction. There is
extensive osteopenia. Vascular calcifications are present. There
is cortical thickening along several of the metatarsal shafts,
likely chronic.
.
Right third toe debridement [**2203-6-14**]:
Acute osteomyelitis.
.
Fundoscopic mucosa biopsy [**2203-6-16**]:
Gastric fundic mucosa, biopsy: Focal foveolar hyperplasia.
.
DUPLEX DOP ABD/PELVIS LIMITED & Abd ultrasound complete [**2203-6-17**]:
FINDINGS: There is somewhat limited evaluation of the liver due
to body
habitus and inability to suspend respiration. No intrahepatic
biliary ductal dilatation is seen. On dedicated Doppler
interrogation, there is normal flow and waveforms within the
portal and hepatic veins, as questioned. The proximal common
duct measures 3 mm in diameter. There is significantly limited
visualization of the pancreas. There is limited visualization of
theaorta. The gallbladder is normal. The right kidney is normal
in size, measuring 9.6 cm, containing a simple, 3.7-cm cyst at
the lower pole. The spleen is normal, measuring 11.7 cm. The
left kidney is normal in size, measuring 11.0 cm, containing
cysts, one of which had a punctate wall calcification. On
Doppler interrogation, no images of the hepatic artery were
obtained due to technical factors.
IMPRESSION: Normal portal vein flow, as questioned. Somewhat
limited
evaluation of the liver with no intra- or extra-hepatic biliary
ductal
dilatation. Bilateral renal cysts.
.
CXR [**2203-6-18**]:
One AP portable view. Comparison with the prior study. Lung
volumes are
somewhat low. Streaky density at the lung bases consistent with
subsegmental atelectasis and possibly retrocardiac consolidation
persists. There is blunting of the left costophrenic sulcus
consistent with a small effusion, not apparent previously. A
PICC line has been inserted on the left and terminates in the
region of the mid superior vena cava.
IMPRESSION: Evidence for small left pleural effusion. PICC line
in place. No other significant change.
Brief Hospital Course:
Assessment and Plan: Mr. [**Known lastname 1968**] is a 86 year old male with
history of GIBs, colon CA s/p colectomy, atrial fibrillation on
coumadin and DM who presents with Hct of 15, hematemesis and
melena in the setting of a supratherapeutic INR found to have
AVM s/p clipping. Pt also s/p right distal toe amuptation.
.
# GIB: The patient presented to the ED with bloody emesis. NG
lavage showed coffee grounds which did not clear with 500ccs and
rectal exam revealed black stool that was frankly guaiac
positive on arrival. In the ED GI was consulted and the pt
received 10 mg of vitamin K as well as 2 units of FFP for INR of
8.3 (in the setting of being on amoxicillin/clavulanate for his
toe) and his HCT was 15. He received 6 units of blood in the
ICU and his HCT increased to 28 which was above his baseline of
25. He was plaved on an IV PPI and his ASA, CCB, and ACE were
held. During his admission he required 2 EGDs. The first
showed an area of eythema with an overlying clot in the fundus
with question of AVM below. The clot was unable to be suctioned
off. A single red non bleeding angioexctasia was seen in the
fundus and was thought to be the source of his bleeding given
that his INR was supratherapeutic on admission. Three endoclips
were placed. The EGD was also notable for varices at the
gastroesophageal junction, an esophageal ring, and a small
hiatal hernia. His second EGD was notable for a 1 cm X 2 cm area
of localized nodularity of the mucosa of the fundus which was
biopsied and showed focal foveolar hyperplasia and no evidence
of malignancy. The previously placed clips were present in the
gastric junction and a dilated vein was noted at the GE
junction. He was discharged on a po PPI. His calcium dose was
increased and changed to calcitrol since it is better absorbed
when taking protonix.
.
# Likely osteomyelitis of right middle toe: During his admission
he required debridement of right 3rd toe and excision of the
distal phalanx. Tissue cx grew MRSA and CORYNEBACTERIUM. The
patient was started on vancomycin, flagyl, and cipro. A PICC
line was placed and the patient was discharged with VNA on long
term vancomycin with last dose planned for [**2203-7-25**]. He was
discharged with lab checks (CBC AST, ALT, A ph, Tbili Chem 7) q
Friday as well as a vanco trough check on [**2203-6-24**]. His wound was
dressed with betadine dressing. A special brace was obtained as
patient needed to be able to ambulate and even do some stairs at
home. Rehab was offered but patient declined for social reasons.
He was discharged on calcium and vitamin D.
.
# A fib with RVR: The patient had an episode of A fib with RVR
on [**2203-6-20**] and received diltiazem 10 IV x2, lopressor 10 IVx1,
and an additional dose of diltiazem 60mg po. Of note his
diltiazem had been held earlier in the day. His diltiazem dose
was increased to 240mg daily which was his previous home dose.
His coumadin was restarted prior to discharge as his [**Country **] score
was 3. At the time of discharge his INR was subtherapeutic at
1.8. He was discharged with plan for INR check on [**2203-6-24**] and to
have this result faxed to his PCP.
.
#. Iron deficiency anemia: His HCT was above his baseline of 25
at the time of discharge. He is being continued on his home iron
supplementation. He is on epogen at home.
.
# Acute Renal Failure: On admission his creatinine was initially
elevated to 3.6 from baseline of 1.5 - 2.0. The ARF was likely
secondary to inadequate renal perfusion secondary to blood loss.
His creatinine was 1.3 at discharge.
.
#. HTN: He was discharged on his home lisinopril and CCB.
.
# COPD: Patient had intermittent wheezes in the beginning of his
hospitalization. He was treated with prn nebs. Albuterol prn for
SOB or wheeze was added to his home regimen of medications
including ipratropium inh, fluticasone inh, and montelukast.
.
# Gout: His allopurinol was renally dosed during his ARF. He was
discharged on his home allopurinol. His colchicine was
discontinued as he was doing well off this medication.
.
#. Psych: His home dose of buproprion was continued.
.
#. DM: He was discharged on his rosiglitazone and was maintained
on a diabetic diet while in the hospital.
.
#. Diastolic CHF: He lasix was originally held in the setting of
decreased UOP due to GI bleed and in the setting of ARF. He was
discharged on his home lasix.
.
# PPx: pneumoboots, sc heparin, PPI PO
.
# Code: Full
.
# Emergency contact: [**Name (NI) **] and [**First Name5 (NamePattern1) **] [**Name (NI) **] [**Telephone/Fax (1) 111706**] (friends-
pt has no family)
Medications on Admission:
Ipratropium-Albuterol
Lisinopril 10 mg PO QD
Montelukast 10 mg PO QD
Pantoprazole 40 mg PO QD
Rosiglitazone 4 mg PO QD
Coumadin 4 mg PO QD
Iron 325 mg PO QD
MVI
Discharge Medications:
1. Bupropion HCl 75 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
2. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 inhaler* Refills:*0*
3. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
5. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4
PM.
Disp:*60 Tablet(s)* Refills:*0*
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:*0*
7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
Intravenous Q 24H (Every 24 Hours) for 5 weeks: last dose
[**2203-7-25**].
Disp:*qs * Refills:*2*
9. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Two
(2) puff Inhalation twice a day.
Disp:*1 inh* Refills:*2*
10. Rosiglitazone 4 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
11. Vitamin D 1,000 unit Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*0*
12. Calcium Citrate 250 mg Tablet Sig: Two (2) Tablet PO twice a
day.
Disp:*120 Tablet(s)* Refills:*0*
13. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
14. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
[**1-21**] Inhalation every four (4) hours as needed for shortness of
breath or wheezing.
Disp:*1 inhaler* Refills:*0*
15. Outpatient Lab Work
Please have the folllowing labs drawn every Friday and have them
faxed to your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] at [**Telephone/Fax (1) 12227**]
CBC
AST, ALT, A ph, Tbili
Chem 7
16. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
17. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
18. Outpatient Lab Work
INR check on Friday [**2203-6-24**] and fax to Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 12227**]
19. Outpatient Lab Work
Check vancomycin trough on [**2203-6-24**] and fax to Dr. [**Last Name (STitle) **]
[**Telephone/Fax (1) 12227**].
20. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO once a day.
Disp:*30 Capsule, Sustained Release(s)* Refills:*0*
21. Epogen 10,000 unit/mL Solution Sig: One (1) ml sc Injection
once a week: on Fridays.
Disp:*qs * Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary:
1) Upper GI bleed
2) Toe osteomyelitis
.
Secodary:
1) DM2
2) Paroxysmal Atrial Fibrillation on anticoagulation
3) CRI- baseline Cr 1.5 - 2.0
4)HTN
5) Gout
6) COPD
7) OA
8) h/o GIB ([**2198**]; found to have gastritis, ulcerations, no
active
bleeding, and angioectasia in colon)
9) h/o hip fx s/p ORIF/IM nail R hip, L hip [**2201**]
10) [**Name (NI) 3674**] unclear etiology, previously treated with regular
transfusions, now on procrit, baseline 30
11) h/o pericardial effusion in setting of AF with RVR, CHF,
pleural
effusions ([**2198**])
12) s/p TURP for prostate enlargement and urinary retention
13) h/o sigmoid colon ca s/p sigmoid colectomy [**2192**]
14) right cheek SCC s/p skin graft
15) Diastolic CHF
Discharge Condition:
Stable on Vancomycin IV for osteomyelitis.
INR subtherapeutic at 1.8.
Discharge Instructions:
You were admitted to the hospital for an upper gastrointestinal
bleed. A source of bleeding was found in your stomach and it was
clipped. You received blood transfusions and now your blood
count is stable. While in the hospital you were also found to
have osteomyelitis in your toe which is an infection of the
bone. You were started on a long-term IV antibiotic called
vancomycin. You stayed in the hospital for one day longer than
expected because your heart was in atrial fibrillation and
beating quickly. We restarted your diltiazem at it's previous
dose.
.
The following changes were made to your medications:
-vancomycin was started for your osteomyelitis
-albuterol was added to be taken as needed for shortness of
breath or wheeze
-colchicine was discontinued since you are doing well off of it
-your calcium dose was increased and changed to calcitrol since
it is better absorbed when you are taking protonix
.
No other changes were made to your medications. You should take
all medications as detailed on the attached sheets.
.
You should return to the emergency room if you develop any of
the following:
- vomiting of blood or coffee grounds like substance
- black tarry stools
- lightheadedness or palpitations
- chest pain
- shortness of breath
- persistent fever > 100.4
- worsening pain or redness/blackness around the toe
Followup Instructions:
Please call Dr.[**Name (NI) 14868**] [**Telephone/Fax (1) 543**] office and make an
appointment for 2 weeks from now for podiatry
.
Please call Dr.[**Name (NI) 12755**] office and make a follow up appointment
for sometime in the next 1-2 weeks [**Last Name (LF) 7476**],[**First Name3 (LF) **] [**Telephone/Fax (1) 7477**].
.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7476**], MD Phone:[**Telephone/Fax (1) 7477**] Date/Time:[**2203-8-10**]
8:00
Provider: [**Known firstname 2053**] [**Last Name (NamePattern1) 6751**], MD Phone:[**Telephone/Fax (1) 6742**]
Date/Time:[**2203-10-4**] 11:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2203-10-21**] 10:00
Completed by:[**2204-1-7**]
|
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icd9cm
|
[
[
[]
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] |
[
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icd9pcs
|
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[
[]
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|
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|
239, 324
|
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|
3464, 3469
|
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352, 2106
|
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|
2757, 2842
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,275
| 159,163
|
43682+58652
|
Discharge summary
|
report+addendum
|
Admission Date: [**2140-4-6**] Discharge Date: [**2140-4-11**]
Date of Birth: [**2078-11-11**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Iodine; Iodine Containing / Carbamazepine
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
seizure, vomiting, inability to protect airways, intubation
Major Surgical or Invasive Procedure:
Mechanical Intubation and Ventilation
Hemodialysis
Exchange of Catheter of [**First Name3 (LF) **] Line
History of Present Illness:
61-year-old man with ESRD on [**First Name3 (LF) 2286**] MWF, liver disease,
seizure disorder presented from [**Hospital3 **] facility with
2-3 days of diarrhea, nausea, vomiting. Norovirus has been
affected his co-residents.
.
In the ED, initial VS: T 98.8, HR 97, BP 218/127, RR 16, 98%RA.
Patient initially "did not communicate much," raising concerns
for hypertensive encephalopathy or active seizure. He then
seized x 30 seconds, became alert again, but then vomited
profusely and was intubated for airway protection. His head CT
was unremarkable. CXR was unremarkable. He then spiked to
100.6F. Had a few more loose stools in ED. Was briefly on
nicardipine gtt, but once on propofol for the intubation, his BP
dropped and nicardipine was d/c'ed. CXR negative. Was given
ceftriaxone 1 gm x 2, vanco 1 gm x 1, acyclovir 800 mg IV x 1.
By the time of transfer to MICU, T 98.0, HR 95, BP 180/91.
.
[**Hospital3 **]: not obtained due to patient being intubated
Past Medical History:
- Multiple pulm infiltrates on CT scan [**12/2139**] concerning for
malignancy.
- ESRD on HD [**3-15**] idiopathic glomerulonephritis
- Liver failure secondary to Hepatitis C
- Epilepsy - This began in childhood with generalized
tonic-clonic seizures. His usual seizure is nonconvulsive and
characterized by confusion, disorientation. He was admitted in
[**Month (only) 116**] and [**2139-9-12**] for a seizure that presented with confusion.
He is followed closely by neurologist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 437**], for
seizure prevention takes Lamictal 250 mg [**Hospital1 **], Keppra 375 mg [**Hospital1 **]
plus an additional 250 mg [**Hospital1 **] after each hemodialysis session,
Dilantin 200 mg [**Hospital1 **].
- coagulase negative staph bacteremia secondary to HD line
sepsis
- History of CHF now with transesophogeal [**Hospital1 461**] in
[**2139-9-12**] showing normal left ventricular function.
- Hypertension
- VRE
- Septic arthritis of left shoulder
- AVNRT s/p ablation [**2133**]
PSH:
- s/p two failed renal transplants
- s/p arthroscopic debridement of L shoulder
- synovectomy and tenotomy L shoulder,
Social History:
Lives at [**Hospital3 **] facility on Mission [**Doctor Last Name **] called
[**Hospital1 **] at [**Hospital1 1426**]; the facility, per his son does not help
him take medications or provide any other care besides ensuring
that the patient has 3 meals per day and that he is accounted
for on a daily basis. He is on disability, has two sons. Smokes
1ppd x 40 yrs, no Etoh, no drugs.
Family History:
Mother died of breast cancer. Father has coronary artery disease
and congestive heart failure, alive at [**Age over 90 **] yo. Two sons are
healthy.
Physical Exam:
Lungs: CTAB
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, mildly distended, bowel sounds
present
Ext: Warm, well perfused, 2+ pulses, No edema. Right and L sided
fistula with palpable pulses, L subclavian tunnelled line C/D/I
Pertinent Results:
Imaging
Head CT [**2140-4-6**]: No acute intracranial process.
.
CXR [**2140-4-6**]: An endotracheal tube tip terminates 4.5 cm from
the carina. NG tube extends into the stomach. A [**Month/Day/Year 2286**]
catheter tip lies within the proximal right atrium. The lung
volumes are low, with accentuation of the cardiomediastinal and
hilar contours. The heart is normal in size, with a mildly
unfolded aorta. There is a right hilar opacity, which appears
new from the prior study. Known right lower lobe pulmonary
nodule is better appreciated on prior CTs. The lungs are
otherwise clear. There is no pleural effusion or pneumothorax.
IMPRESSION:
1. Endotracheal tube tip 4.5 cm above the carina.
2. Right hilar opacity, may reflect adenopathy.
3. Known pulmonary nodules are better assessed on recent CT.
.
MR [**Name13 (STitle) 430**] [**2140-4-9**]
FINDINGS:
There is no evidence for acute ischemia. Extensive supra- and
infratentorial volume loss is seen with presumed small vessel
ischemic changes in the subcortical white matter. Appearance is
stable compared to the previous MRI. Bilateral mastoid
opacification is noted. Intracranial flow voids are maintained.
There is a stable small slit-like encephalomalacia in the left
inferior basal ganglion which likely represents an old small
slit hypertensive hemorrhage. There are unchanged
susceptibility focii in the left temporal and right occipetal
lobe which may represent remote microhemorrhage or amyloid
angiopathy.
IMPRESSION:
No acute ischemia. Stable supra- and infratentorial volume loss
and presumed small vessel ischemic changes.
.
Laboratory Data
[**2140-4-6**] 02:40PM BLOOD WBC-3.8* RBC-5.05# Hgb-13.1*# Hct-41.5#
MCV-82 MCH-25.9* MCHC-31.5 RDW-20.3* Plt Ct-161
[**2140-4-7**] 04:18AM BLOOD WBC-2.6* RBC-3.83* Hgb-10.0*# Hct-31.0*#
MCV-81* MCH-26.2* MCHC-32.4 RDW-20.5* Plt Ct-137*
[**2140-4-7**] 03:41PM BLOOD Hct-30.3*
[**2140-4-8**] 05:19AM BLOOD WBC-3.5* RBC-3.83* Hgb-10.1* Hct-31.2*
MCV-81* MCH-26.2* MCHC-32.3 RDW-21.1* Plt Ct-146*
[**2140-4-9**] 06:42AM BLOOD WBC-4.1 RBC-3.69* Hgb-9.5* Hct-29.7*
MCV-80* MCH-25.8* MCHC-32.1 RDW-20.9* Plt Ct-124*
[**2140-4-10**] 05:48AM BLOOD WBC-3.5* RBC-3.48* Hgb-9.3* Hct-28.0*
MCV-80* MCH-26.7* MCHC-33.2 RDW-21.3* Plt Ct-131*
[**2140-4-6**] 02:40PM BLOOD PT-13.4 PTT-30.9 INR(PT)-1.1
[**2140-4-7**] 04:18AM BLOOD PT-13.5* PTT-30.0 INR(PT)-1.2*
[**2140-4-8**] 05:19AM BLOOD PT-14.2* PTT-30.2 INR(PT)-1.2*
[**2140-4-6**] 02:40PM BLOOD Glucose-95 UreaN-33* Creat-6.0*# Na-141
K-6.9* Cl-95* HCO3-28 AnGap-25*
[**2140-4-7**] 04:18AM BLOOD Glucose-81 UreaN-39* Creat-7.1*# Na-142
K-4.8 Cl-98 HCO3-27 AnGap-22*
[**2140-4-8**] 05:19AM BLOOD Glucose-93 UreaN-27* Creat-4.9*# Na-141
K-4.4 Cl-100 HCO3-26 AnGap-19
[**2140-4-9**] 06:42AM BLOOD Glucose-82 UreaN-36* Creat-5.7* Na-139
K-4.6 Cl-97 HCO3-26 AnGap-21*
[**2140-4-10**] 05:48AM BLOOD Glucose-89 UreaN-16 Creat-3.6*# Na-138
K-3.8 Cl-97 HCO3-29 AnGap-16
[**2140-4-7**] 04:18AM BLOOD ALT-13 AST-36 AlkPhos-152* TotBili-0.4
[**2140-4-8**] 05:19AM BLOOD ALT-14 AST-67* AlkPhos-158* TotBili-0.6
[**2140-4-6**] 02:40PM BLOOD Phenyto-5.8*
[**2140-4-7**] 11:36AM BLOOD Phenyto-4.8*
[**2140-4-8**] 05:19AM BLOOD Phenyto-6.5*
[**2140-4-9**] 06:42AM BLOOD Phenyto-7.8*
[**2140-4-10**] 05:48AM BLOOD Phenyto-8.3*
[**2140-4-11**] 06:40AM BLOOD Phenyto-9.8*
Brief Hospital Course:
Mr. [**Known lastname 93850**] is a 61-year-old man with ESRD on [**Known lastname 2286**], liver
disease, and seizure disorder who presented from [**Hospital3 **]
facility with 2-3 days of diarrhea, nausea, vomiting.
.
Airway Protection: Following the seizure he had several episodes
of emesis and was unable to protect his airway. He was
intubated. He was extubated the following day.
.
# Seizures: Mr. [**Known lastname 93850**] had a seizure while in the ED. Following
the seizure he had several episodes of emesis and was unable to
protect his airway. He was intubated. In the MICU neurology was
consulted and recommended continuing him on his home dose of
lamotrigine, phenytoin, and levetiracetam. An MRI of the head
was done per neurology which showed no acute ischemia and stable
supra- and infratentorial volume loss. He remains on the same
dose of keppra and dilantin, and will follow up with Dr. [**First Name (STitle) 437**],
his neurologist.
.
# Acute diarrhea, nausea, vomiting: Likely norovirus given an
outbreak at his living facility. His diarrhea stopped during his
MICU stay. He had no more episodes of emesis. He was able to
tolerate a regular diet.
.
# Hypertension: SBP was over 200 in ED. He required a
nicardipine gtt for a period of time. He was continued on a
clonidine patch, lisinopril, and an increased dose of
nifedipine.
.
# ESRD: Cr. 6.0 on admission. He had his scheduled [**First Name (STitle) 2286**]
sessions. He had an exchange of his [**First Name (STitle) 2286**] line on [**4-8**]. He
will continue on his MWF [**Month/Year (2) 2286**] schedule.
.
# Lung Nodules: He has known pulmonary nodules which are
concerning for malignancy. He deferred inpatient workup.
Thoracic surgery was consulted for a potential biopsy, but
recommended CT guided biopsy. This will be arranged as an
outpatient by his pulmonologist, Dr. [**Last Name (STitle) **].
.
# Liver Disease: Continued on rifaximin.
.
# CODE: Full
Medications on Admission:
1. B Complex-Vitamin C-Folic Acid 1 mg Capsule [**Last Name (STitle) **]: One (1) Cap
PO DAILY (Daily).
2. Clonidine 0.2 mg/24 hr Patch Weekly [**Last Name (STitle) **]: One (1) Patch Weekly
Transdermal QSAT (every Saturday).
3. Lamotrigine 100 mg Tablet [**Last Name (STitle) **]: 2.5 Tablets PO BID (2 times a
day).
4. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
5. Levetiracetam 250 mg Tablet [**Last Name (STitle) **]: 1.5 Tablets PO BID (2 times
a day).
6. Lisinopril 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day).
7. Levetiracetam 250 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO AFTER
[**Last Name (STitle) **] ().
8. Calcium Carbonate 500 mg Tablet, Chewable [**Last Name (STitle) **]: Two (2)
Tablet, Chewable PO QID (4 times a day).
9. Aspirin 81 mg Tablet, Chewable [**Last Name (STitle) **]: One (1) Tablet, Chewable
PO DAILY (Daily).
10. Nifedipine 30 mg Tablet Sustained Release [**Last Name (STitle) **]: Two (2)
Tablet Sustained Release PO TID (3 times a day).
11. Phenytoin Sodium Extended 100 mg Capsule [**Last Name (STitle) **]: Two (2)
Capsule PO BID (2 times a day).
12. Rifaximin 200 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID (3 times
a day).
Discharge Medications:
1. Clonidine 0.2 mg/24 hr Patch Weekly [**Last Name (STitle) **]: One (1) Patch Weekly
Transdermal QSAT (every Saturday).
2. Lamotrigine 100 mg Tablet [**Last Name (STitle) **]: 2.5 Tablets PO BID (2 times a
day).
3. Aspirin 81 mg Tablet, Chewable [**Last Name (STitle) **]: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Rifaximin 200 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID (3 times a
day).
5. Levetiracetam 250 mg Tablet [**Last Name (STitle) **]: 1.5 Tablets PO BID (2 times
a day).
6. Levetiracetam 250 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO AFTER EACH
[**Last Name (STitle) **] ().
7. Phenytoin Sodium Extended 100 mg Capsule [**Last Name (STitle) **]: Two (2) Capsule
PO BID (2 times a day).
8. Lisinopril 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day).
9. Nifedipine 90 mg Tablet Sustained Release [**Last Name (STitle) **]: One (1) Tablet
Sustained Release PO BID (2 times a day).
Disp:*30 Tablet Sustained Release(s)* Refills:*2*
10. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] once a day.
11. Calcium 500 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO four times a
day.
12. B Complex-Vitamin C-Folic Acid 1 mg Capsule [**Last Name (STitle) **]: One (1)
Capsule PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary Diagnosis:
Viral Gastroenteritis
Secondary Diagnosis:
Hypertension
Seizure Disorder
Lung Nodules
Hepatitis C
End Stage Renal Disease
Discharge Condition:
Mental Status: Confused - sometimes
Level of Consciousness: Alert and interactive
Discharge Instructions:
Thank you for allowing us to take part in your care. You were
admitted to the hospital with vomiting and diarrhea. This was
most likely related to a virus. Your diarrhea and vomiting
resolved. When you were admitted, you had a seizure and required
a assistance to help you breathe.
We adjusted the dose of your blood pressure medications because
your blood pressure was elevated. Please take your nifedipine
twice a day. Your new dose is 90 mg.
Please weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up
more than 3 lbs.
Followup Instructions:
Your lung doctor would like for you to have a biopsy of one of
the lesions in your lungs. Dr.[**Name (NI) 6005**] office will call you
with an appointment for a follow up of your hospitalization. If
you do not hear from the office within 2 business days please
call to book appointment ([**Telephone/Fax (1) 612**])
Please follow up with your neurologist, Dr. [**First Name (STitle) 437**]. You were
scheduled for an appointment on [**2140-5-13**] at 9:00am. Please call
[**Telephone/Fax (1) 2928**] with any questions.
Please follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 4321**] at
[**Telephone/Fax (1) 608**]. Please call on Monday to let her know you were
discharged from the hospital.
Your left foot was found to be a little cold and there was
difficulty finding one of the arterial pulses. You were given
an appointment with [**Telephone/Fax (1) 1106**] surgery to further evaluate.
Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] on [**2140-4-20**] at 9:30AM. His
office is located at [**Last Name (NamePattern1) 439**] [**Hospital Unit Name **] [**Location (un) **], [**Location (un) 86**] MA.
Name: [**Known lastname 14821**],[**Known firstname 1080**] W Unit No: [**Numeric Identifier 14822**]
Admission Date: [**2140-4-6**] Discharge Date: [**2140-4-11**]
Date of Birth: [**2078-11-11**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Iodine; Iodine Containing / Carbamazepine
Attending:[**First Name3 (LF) 161**]
Addendum:
#. left foot pain - patient was noted to have a slightly cool
left foot. Patient still had an easily palpible DP pulse, but
the PT pulse was difficult to find even with Doppler. Patient
has experienced occassional left foot pain for the last few
months. He likely has some degree of claudication. The foot is
nontender and he has full function of the foot with good
sensation. He was set up with a vascular appointment to further
evaluate as an outpatient
Discharge Disposition:
Home With Service
Facility:
[**Hospital 136**] Homecare
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 165**] MD [**MD Number(1) 166**]
Completed by:[**2140-4-14**]
|
[
"E879.1",
"996.1",
"289.59",
"070.70",
"403.91",
"518.81",
"263.9",
"585.6",
"E878.0",
"345.00",
"285.9",
"250.00",
"996.81",
"574.20",
"428.0",
"428.22",
"E849.7",
"583.9",
"E849.8",
"008.8",
"518.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"39.95",
"38.95",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
14551, 14764
|
6856, 8801
|
375, 481
|
11804, 11804
|
3527, 6833
|
12479, 14528
|
3072, 3223
|
10187, 11537
|
11639, 11639
|
8827, 10164
|
11912, 12456
|
3238, 3508
|
276, 337
|
509, 1472
|
11702, 11783
|
11658, 11681
|
11819, 11888
|
1494, 2655
|
2671, 3056
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,439
| 127,154
|
15907+15868
|
Discharge summary
|
report+report
|
Admission Date: [**2199-10-5**] Discharge Date: [**2199-10-9**]
Date of Birth: [**2149-1-7**] Sex: M
Service: MEDICINE
ADDENDUM: Of note, on admission the patient's creatinine was
1.3, which trended upward the following day to 1.6. Due to
the patient's significant abdominal distention, tension, an
intra-abdominal pressure was transduced, which was found to
be elevated at 25. Thus it was hypothesized that the
increased creatinine could be secondary to a pre-renal-type
process of abdominal compartment syndrome, thus making the
assumption that the increased abdominal pressure was
compressing the inferior vena cava, thus decreasing flow to
the kidneys.
The patient received both TIPS and a large-volume
paracentesis on [**10-7**], which decompressed the abdomen.
The day following TIPS, [**10-8**], the patient's creatinine
normalized to 1.0, thus supporting the abdominal compartment
theory for the elevated creatinine.
No other steps were taken to normalize renal function. The
patient's urine output also improved from 5 to 20 cc/hour to
greater than 30 per hour post-TIPS and paracentesis.
DR.[**First Name (STitle) **],[**First Name3 (LF) **] 12-ADP
Dictated By:[**Male First Name (un) 32816**]
MEDQUIST36
D: [**2199-10-9**] 23:55
T: [**2199-10-9**] 02:25
JOB#: [**Job Number 26434**]
Admission Date: [**2199-10-5**] Discharge Date: [**2199-10-9**]
Date of Birth: [**2149-1-7**] Sex: M
Service: MEDICINE
HISTORY OF PRESENT ILLNESS: This is a 50-year-old gentleman,
transferred from the [**Location 1268**] VA for management of an
esophageal bleed. The patient initially presented on [**9-28**] to the [**Location 1268**] VA with complaints of nausea, vomiting,
abdominal distention, and jaundice. At that time, he was
felt to have alcoholic hepatitis, and was treated
supportively. On [**10-4**], the patient had an episode of
coffee-ground emesis, followed by an episode of bright red
hematemesis the morning of transfer to [**Hospital1 190**]. By report from the house officer at [**Location 11206**] VA, it was approximately 1 to 1.5 liters of blood
that was suctioned, vomited. His hematocrit dropped from 30
to 17, his blood pressures were in the 80s systolic at that
time. The patient was intubated in the setting of aspiration
of the blood. He was put on an octreotide drip of 50
mcg/hour, and had an esophagogastroduodenoscopy. In
addition, he had bronchoscopy to remove the hemorrhagic
aspiration materials. The esophagogastroduodenoscopy, by
report, showed numerous esophageal varices, which were
banded. The visualization was suboptimal due to the amount
of blood. The Gastroenterology team at the [**Location 1268**] VA
felt that the esophagogastroduodenoscopy with banding was
suboptimal for treatment of this upper gastrointestinal
bleed, thus arranged for a transfer to [**Hospital1 190**] for possible TIPS procedure.
While at [**Location 1268**] VA, the patient received six units of
packed red blood cells as well as approximately eight units
of fresh frozen plasma. His INR decreased from 3.8 to 2.1
following the fresh frozen plasma infusions. While at [**Location 11206**] VA prior to admission, sodium was 140, potassium 4.5,
chloride 111, bicarbonate 22, BUN 24, creatinine 1.3, glucose
163. White blood cells 26.8, hematocrit 19.6, platelets 79.
PT 17.8, PTT 45.3, INR 2.1. Fibrinogen 141.
PHYSICAL EXAMINATION: On transfer, blood pressure 130/96,
pulse 106, ventilator support SIMV. The patient was
intubated, responded to hard palpation of abdomen, otherwise
unresponsive. Head, eyes, ears, nose and throat:
Normocephalic, atraumatic, sclerae grossly icteric, eyes
shut. Neck with no lymphadenopathy. Chest: Decreased
breath sounds bilaterally, otherwise clear to auscultation
anteriorly. Cardiovascular: S1, S2, tachycardic, no
murmurs, rubs or gallops. Abdomen: Grossly distended,
tympanitic, bowel sounds absent. Extremities: Left lower
extremity greater than right lower extremity with gross
pitting edema approximately 2+ to mid-thigh bilaterally.
Extremities were cool, mottled, pulses present. Skin:
Patient with maculopapular rash on torso bilaterally.
PAST MEDICAL HISTORY: Alcohol abuse, hepatitis B, hepatitis
C, hypercholesterolemia, asthma, hypertension,
gastroesophageal reflux disease.
SOCIAL HISTORY: Positive for intravenous drug use in the
past, three to five cigarettes per day for 35 years, positive
alcohol approximately a quart of vodka per day.
FAMILY HISTORY: Noncontributory.
ALLERGIES: Peanuts.
MEDICATIONS ON TRANSFER: Octreotide drip 50 mcg/hour,
albuterol metered dose inhaler as needed, albuterol nebulizer
as needed, Valium 10 mg every two hours as needed, folate 1
mg, gadofloxacin 400 x 1, Atrovent nebulizers as needed,
Phenergan 25 mg every six hours as needed, Aldactone 25 mg
once daily, thiamine 100 once daily, Protonix 40 mg
intravenously twice a day, Flagyl 500 mg intravenously three
times a day.
HOSPITAL COURSE: On transfer, the patient was stable, with
no active bleeding noted, since he was status post banding at
the [**Location 1268**] VA, and he also remained hemodynamically
stable. He was followed with every six hours hematocrit
checks and continued on the octreotide drip, Protonix 40 mg
twice a day, and was started on intravenous levofloxacin and
continued on intravenous Flagyl empirically for coverage in
the setting of a likely variceal bleed.
The morning after transfer, the patient was noted to have
some active bleeding from the mouth. The Gastroenterology
team was consulted for an emergent
esophagogastroduodenoscopy. The esophagogastroduodenoscopy
at that time showed a medium hiatal hernia, Barrett's
esophagus, blood in the stomach body, congestion and erythema
in the antrum, stomach, body and fundus compatible with
portal gastropathy. Varices were noted at the fundus. Final
recommendations were for intrahepatic portal systemic shunt
should he rebleed, or to prevent rebleeding.
In the setting of the bleed, the patient was transfused one
unit of packed red blood cells, as well as two units of fresh
frozen plasma prior to the esophagogastroduodenoscopy. Goal
hematocrit was greater than 25, since he had no known history
of coronary artery disease, and INR goal was for 1.6 to 1.7
for procedures.
On transfer, the patient was noted to have significant
abdominal distention, thus an ultrasound was obtained to
evaluate for the presence of ascites. A moderate amount of
ascites was noted on ultrasound. Thus a diagnostic
paracentesis was performed in order to rule out spontaneous
bacterial peritonitis in the setting of the upper
gastrointestinal bleed. The diagnostic paracentesis revealed
no evidence of peritonitis.
It was determined post-esophagogastroduodenoscopy that it
would be in the patient's best interest to proceed to TIPS,
performed by Interventional Radiology on [**10-7**]. Consent
was obtained by the patient's 18-year-old son, [**Name (NI) 916**] [**Name (NI) **],
whose phone number is [**Telephone/Fax (1) 45584**]. Prior to TIPS,
Interventional Radiology performed a large volume
paracentesis, at which time 3 liters of clear straw-colored
fluid was removed. TIPS was performed without complications,
and the patient was returned to the floor.
After the TIPS procedure, the patient was continued to be
monitored. He remained hemodynamically stable, with systolic
blood pressure in the 120s, though mildly tachycardic in the
low 100s. His hematocrit remained stable, and it was thus
determined that he should be extubated since the primary
reason for intubation was airway protection in the setting of
massive upper gastrointestinal bleed.
The patient was eventually weaned to pressure support and
PEEP of 5 and 5. The patient did well, with a mild
alkalosis, thought to be chronic in the setting of known
liver disease, cirrhosis. After being monitored on pressure
support, the patient was extubated on the morning of [**10-8**] without difficulty, and maintained on face mask oxygen.
The patient remained hemodynamically stable, and was in no
respiratory distress. Thus it was determined that the
patient no longer required Intensive Care Unit level of care,
and then thus was called down to the floor. The patient was
discharged to the floor in stable condition, with intentions
to transfer the patient back to the [**Location **]
for continued care post-TIPS.
DISCHARGE MEDICATIONS:
1. Atrovent nebulizers every six hours as needed
2. Albuterol nebulizers every six hours as needed
3. Lactulose 30 by mouth three times a day
4. Combivent one to two puffs every six hours as needed
5. Levofloxacin 500 mg intravenously every 24 hours, [**10-8**] day five, planned seven to ten day course
6. Metronidazole 500 mg intravenously every eight hours,
[**10-8**] day five, also with a planned seven to ten day
course
7. Pantoprazole 40 intravenously every 12 hours
8. Octreotide 50 mcg/hour, today day four, planned course
five days
DISCHARGE STATUS: Stable, to the [**Location 1268**] VA
DISCHARGE DIAGNOSIS:
1. Upper gastrointestinal bleed
2. Portal gastropathy
3. Transjugular intrahepatic portosystemic shunt
4. Alcoholic hepatitis
5. Hepatitis B
6. Hepatitis C
DR.[**First Name (STitle) **],[**First Name3 (LF) **] 12-ADP
Dictated By:[**Male First Name (un) 32816**]
MEDQUIST36
D: [**2199-10-8**] 23:51
T: [**2199-10-9**] 01:24
JOB#: [**Job Number 45585**]
cc:[**Location 45586**]
|
[
"305.01",
"276.5",
"070.54",
"070.32",
"789.5",
"584.9",
"276.4",
"518.81",
"571.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.1",
"96.72",
"96.33",
"54.91",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
4541, 4581
|
8467, 9076
|
9097, 9517
|
5019, 8444
|
3449, 4213
|
1527, 3426
|
4607, 5001
|
4236, 4355
|
4372, 4524
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,576
| 199,529
|
30656
|
Discharge summary
|
report
|
Admission Date: [**2164-6-25**] Discharge Date: [**2164-6-29**]
Date of Birth: [**2104-1-24**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Fatigue with shortness of breath
Major Surgical or Invasive Procedure:
[**2164-6-25**] Coronary Artery Bypass Graft x 2 (LIMA-LAD, SVG-Diag)
History of Present Illness:
60 y/o male with prior PMH of CAD with myocardial infarction and
multiple PCS's who presented with continued symptoms. Had +ETT
and most recent cardiac cath showed severe proximal LAD disease.
Past Medical History:
Coronary Artery Disease, Myocardial Infarction [**2160**] s/p cypher
stent of RCA/LAD, Hypertension, Hypercholesterolemia, s/p
Appendectomy, s/p Tonsillectomy, s/p removal of moles on back
Social History:
Quit smoking 30 yrs ago after approx. 1ppd x 15 yrs and 1/2ppd x
10 yrs. Denies ETOH use. Truck driver.
Family History:
Uncle died from MI in 40's
Physical Exam:
VS: 72 12 140/92 6' 194#
Gen: WD/WN male in NAD
Skin: Small rash on left calf
HEENT: EOMI, PERRL, NC/AT, OP benign
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, -varicosities
Neuro: MAE, non-focal, A&O x 3
Pertinent Results:
[**2164-6-29**] 06:40AM BLOOD WBC-9.1 RBC-3.74* Hgb-11.1* Hct-32.4*
MCV-87 MCH-29.7 MCHC-34.2 RDW-13.3 Plt Ct-183#
[**2164-6-25**] 11:33AM BLOOD WBC-13.8*# RBC-4.19* Hgb-12.8*#
Hct-36.2*# MCV-86 MCH-30.6 MCHC-35.4* RDW-13.3 Plt Ct-156
[**2164-6-29**] 06:40AM BLOOD Plt Ct-183#
[**2164-6-26**] 02:59AM BLOOD PT-13.4* PTT-27.8 INR(PT)-1.2*
[**2164-6-25**] 11:33AM BLOOD PT-13.1 PTT-26.4 INR(PT)-1.1
[**2164-6-29**] 06:40AM BLOOD Glucose-119* UreaN-16 Creat-1.1 Na-140
K-4.8 Cl-101 HCO3-35* AnGap-9
[**2164-6-25**] 11:33AM BLOOD UreaN-21* Creat-1.1 Cl-110* HCO3-26
[**2164-6-29**] 06:40AM BLOOD Mg-2.6
[**2164-6-26**] 02:59AM BLOOD Calcium-8.2* Phos-3.2 Mg-2.2
RADIOLOGY Final Report
CHEST (PA & LAT) [**2164-6-29**] 10:46 AM
CHEST (PA & LAT)
Reason: r/o inf, eff
[**Hospital 93**] MEDICAL CONDITION:
60 year old man s/p cabg x2
REASON FOR THIS EXAMINATION:
r/o inf, eff
REASON FOR EXAMINATION: Followup of patient after CABG.
PA and lateral upright chest radiograph was compared to [**2164-6-27**].
No pneumothorax is currently visible in the right apex. The
cardiomediastinal silhouette is stable. There is a decrease in
amount of pleural effusion but the basal left more than right
atelectasis is still present.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name4 (NamePattern1) 2618**] [**Last Name (NamePattern1) 2619**]
DR. [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 1508**]Approved: FRI [**2164-6-29**] 12:15 PM
Cardiology Report ECHO Study Date of [**2164-6-25**]
PATIENT/TEST INFORMATION:
Indication: cabg
Status: Inpatient
Date/Time: [**2164-6-25**] at 08:55
Test: TEE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2007AW-1:
Test Location: Anesthesia West OR cardiac
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name (STitle) **] R. [**Doctor Last Name **]
MEASUREMENTS:
Left Ventricle - Inferolateral Thickness: 1.1 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 4.5 cm (nl <= 5.6 cm)
Left Ventricle - Ejection Fraction: 50% to 55% (nl >=55%)
[**Doctor Last Name **] - Ascending: 3.3 cm (nl <= 3.4 cm)
[**Doctor Last Name **] - Descending Thoracic: 2.5 cm (nl <= 2.5 cm)
Aortic Valve - Valve Area: 3.0 cm2 (nl >= 3.0 cm2)
INTERPRETATION:
Findings:
LEFT ATRIUM: No mass/thrombus in the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D
images. Normal LV wall thicknesses and cavity size.
LV WALL MOTION: basal anterior - normal; mid anterior - normal;
basal
anteroseptal - normal; mid anteroseptal - normal; basal
inferoseptal - normal;
mid inferoseptal - normal; basal inferior - normal; mid inferior
- normal;
basal inferolateral - normal; mid inferolateral - normal; basal
anterolateral
- normal; mid anterolateral - normal; anterior apex - normal;
septal apex -
normal; inferior apex - normal; lateral apex - normal; apex -
normal;
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
[**Last Name (Prefixes) **]: Normal ascending [**Last Name (Prefixes) 5236**] diameter. Normal descending [**Last Name (Prefixes) 5236**]
diameter.
Simple atheroma in descending [**Last Name (Prefixes) 5236**].
AORTIC VALVE: Normal aortic valve leaflets (3). No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial
MR.
TRICUSPID VALVE: Physiologic TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify
I was present in compliance with HCFA regulations. No TEE
related
complications. The TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. The patient was
under general
anesthesia throughout the procedure.
Conclusions:
Pre-CPB: No mass/thrombus is seen in the left atrium or left
atrial appendage.
Left ventricular wall thicknesses and cavity size are normal.
Right
ventricular chamber size and free wall motion are normal. There
are simple
atheroma in the descending thoracic [**Last Name (Prefixes) 5236**]. The aortic valve
leaflets (3)
appear structurally normal with good leaflet excursion. No
aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Trivial
mitral regurgitation is seen. There is no pericardial effusion.
Post-CPB: Preserved biventricular systolic fxn. No AI. Trivial
MR. [**First Name (Titles) **] [**Last Name (Titles) 72673**]ct. Other parameters as pre-bypass.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**], MD on [**2164-6-25**] 13:16.
[**Location (un) **] PHYSICIAN:
Brief Hospital Course:
Mr. [**Known lastname 72674**] was a same day admit after undergoing all
pre-operative work-up as an out patient. On day of admission he
was brought directly to the operating room where he underwent a
coronary artery bypass graft x 2. Please see operative report
for details. Following surgery he was transferred to the CSRU
for invasive monitoring in stable condition. Later on op day he
was weaned from sedation, awoke neurologically intact and
extubated. On post-op day one he was started on beta blockers
and diuretics. He was gently diuresed towards his pre-op weight.
Later on this day he was transferred to the telemetry floor for
further care. Chest tubes and epicardial pacing wires were
removed per protocol. He continued to progress and was ready for
discharge home on POD #4 with services.
Medications on Admission:
Lisinopril 5mg qd, Isosorbide 60mg qd, Aspirin 325mg qd,
Protonix 40mg [**Hospital1 **], Lipitor 80mg qd, Toprol XL 25mg qd
Discharge Medications:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
5. 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:*0*
6. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*0*
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 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours) for 7
days.
Disp:*28 Capsule, Sustained Release(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 2
PMH: Myocardial Infarction [**2160**] s/p cypher stent of RCA/LAD,
Hypertension, Hypercholesterolemia, s/p Appendectomy, s/p
Tonsillectomy, s/p removal of moles on back
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 ([**Telephone/Fax (1) 170**]) please call for appointment
Dr [**Last Name (STitle) 72675**] in 1 week ([**Telephone/Fax (1) 72676**]) please call for
appointment
Dr [**Last Name (STitle) 14522**] in [**1-21**] weeks - please call for appointment
Wound check appointment [**Hospital Ward Name 121**] 2 as instructed by nurse
([**Telephone/Fax (1) 3633**])
Completed by:[**2164-6-29**]
|
[
"272.0",
"401.9",
"V45.82",
"412",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"36.11",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
8280, 8335
|
6130, 6933
|
354, 425
|
8608, 8614
|
1355, 2126
|
9126, 9553
|
997, 1025
|
7107, 8257
|
2163, 2191
|
8356, 8587
|
6959, 7084
|
8638, 9103
|
2920, 6070
|
1040, 1336
|
282, 316
|
2220, 2894
|
453, 647
|
6107, 6107
|
669, 860
|
876, 981
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,391
| 101,767
|
17611
|
Discharge summary
|
report
|
Admission Date: [**2158-12-13**] Discharge Date: [**2158-12-13**]
Date of Birth: [**2091-4-21**] Sex: M
Service: SURGERY
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 974**]
Chief Complaint:
unresponsive
Major Surgical or Invasive Procedure:
none
History of Present Illness:
67 M with extensive PMH found unresponsive by family, found to
have SDH with midline shift and uncal herniation, transferred
here for further management
Past Medical History:
Esophageal varices, GIB, h/o MI x 2, h/o lung ca
Brief Hospital Course:
The patient was admitted to the trauma ICU. After discussion
with the family, given the patient's ICH, midline shift, and
uncal herniation, further aggressive treatment was felt to be
futile. He was made CMO and expired the night of [**2158-12-13**].
Discharge Disposition:
Expired
Discharge Diagnosis:
SDH, uncal herniation
Discharge Condition:
expired
|
[
"348.4",
"432.1",
"303.91",
"V10.11",
"412",
"414.01",
"456.1"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
867, 876
|
592, 844
|
309, 315
|
941, 951
|
897, 920
|
257, 271
|
343, 497
|
519, 569
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,801
| 142,880
|
54575
|
Discharge summary
|
report
|
Admission Date: [**2151-5-18**] Discharge Date: [**2151-6-1**]
Service: SURGERY
Allergies:
Cipro Cystitis
Attending:[**Last Name (NamePattern1) 4659**]
Chief Complaint:
Abdominal pain - Acute cholecystitis with impacted stone in
gallbladder neck
Major Surgical or Invasive Procedure:
laparoscopic cholecystectomy
History of Present Illness:
88-year-old man with history of CAD and MI s/p stenting and
CABG presents with chest and abdominal pain. The patient reports
pain across his chest beginning before dinner last night along
with nausea but no vomiting. The patient ate dinner hoping that
it would help but reported that it made no difference for the
pain and made the nausea worse. He slept but was awoken off and
on throughout the night by his pain which gradually got worse
and
migrated to his RUQ throughout the night and the next day
(during
which he could not eat) until he presented to the [**Hospital1 18**] ED.
During this course, the patient denies fevers, chills. He
reports
no changes in his bowel/bladder habits and denies pain with
either. He had his most recent bowel movement this morning which
did not have blood and was otherwise normal. Notably, the
patient
denied feeling lightheaded, diaphoretic, or palpitations during
this course.
At the ED, given the patient's cardiac history, nitro and
aspirin
were given due to concern for acute coronary syndrome. EKG was
done which showed no acute changes. CTA-abdomen was done which
showed gallstone impacted in the neck with GB distention and
pericholecystic fluid, and liver/GB US was done which
corroborated these findings.
Past Medical History:
Past Medical History:
- Hypertension
- CAD and h/o MI and CABG in [**2139**] at [**Hospital1 2025**]
- Prostate CA (s/p XRT), urethral stricture - Evaluation on
[**2149-4-29**] revealed a negative bone scan as well as CT scan for
metastatic disease. Per urology hormonal therapy could be
started in the next 2 years.
Past Surgical History:
- Stenting x 3 at [**Hospital1 18**] for CAD and MI in [**10-15**]
- CABG in [**2139**] at [**Hospital1 2025**]
- Melanoma on his back resected in [**2124**] at [**Hospital1 2025**]
- Right inguinal hernia repair 2mo ago [**Hospital1 2025**]
- Left inguinal hernia repair
Social History:
Lives in [**Location 583**] with his wife. Stopped smoking in [**2088**].
Occasional EtOH use. No recreational drugs.
Family History:
Father: "Heart Problems" Lived to 91
Mother: [**Name (NI) **], Lived to 70
Physical Exam:
PHYSICAL EXAMINATION: upon admission
Temp:97.8 HR:70 BP:161/72 Resp:14 O(2)Sat:100 Normal
Constitutional: Comfortable
HEENT: Normocephalic, atraumatic
Chest: coarse
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, min ttp in epigastrium, Nondistended
GU/Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing or edema
Skin: No rash
Neuro: Speech fluent
Psych: Normal mood, Normal mentation
Pertinent Results:
[**2151-6-1**] 04:09AM BLOOD WBC-12.3* RBC-3.22* Hgb-9.5* Hct-28.6*
MCV-89 MCH-29.5 MCHC-33.3 RDW-15.5 Plt Ct-614*
[**2151-5-29**] 05:43AM BLOOD WBC-11.7* RBC-3.11* Hgb-9.9* Hct-28.8*
MCV-93 MCH-32.0 MCHC-34.6 RDW-22.2* Plt Ct-491*
[**2151-5-28**] 01:46AM BLOOD WBC-14.6* RBC-3.35* Hgb-10.5* Hct-30.5*
MCV-91 MCH-31.3 MCHC-34.3 RDW-18.4* Plt Ct-439
[**2151-5-27**] 02:07AM BLOOD WBC-22.3* RBC-3.07* Hgb-9.8* Hct-28.5*
MCV-93 MCH-32.0 MCHC-34.5 RDW-22.6* Plt Ct-335
[**2151-5-19**] 01:46AM BLOOD WBC-13.0*# RBC-3.86* Hgb-12.1* Hct-34.6*
MCV-90 MCH-31.5 MCHC-35.1* RDW-15.9* Plt Ct-187
[**2151-5-18**] 12:41PM BLOOD WBC-5.2 RBC-4.33* Hgb-14.0 Hct-39.7*
MCV-92 MCH-32.3* MCHC-35.2* RDW-18.6* Plt Ct-221
[**2151-5-17**] 05:10PM BLOOD WBC-9.1 RBC-4.09* Hgb-13.0* Hct-36.7*
MCV-90 MCH-31.8 MCHC-35.5* RDW-18.1* Plt Ct-192
[**2151-5-17**] 05:10PM BLOOD Neuts-70.6* Lymphs-19.6 Monos-6.2 Eos-3.3
Baso-0.3
[**2151-6-1**] 04:09AM BLOOD Plt Ct-614*
[**2151-5-31**] 04:24AM BLOOD PT-33.1* PTT-34.5 INR(PT)-3.3*
[**2151-5-30**] 05:50AM BLOOD PT-24.5* INR(PT)-2.3*
[**2151-5-29**] 05:43AM BLOOD Plt Ct-491*
[**2151-5-29**] 05:43AM BLOOD PT-20.1* INR(PT)-1.8*
[**2151-5-26**] 06:06AM BLOOD PT-32.6* INR(PT)-3.2*
[**2151-6-1**] 04:09AM BLOOD Glucose-101* UreaN-15 Creat-0.8 Na-129*
K-4.1 Cl-94* HCO3-26 AnGap-13
[**2151-5-31**] 04:24AM BLOOD Glucose-116* UreaN-14 Creat-0.9 Na-132*
K-3.6 Cl-98 HCO3-28 AnGap-10
[**2151-5-30**] 03:43PM BLOOD Glucose-110* UreaN-19 Creat-1.0 Na-133
K-3.8 Cl-100 HCO3-24 AnGap-13
[**2151-5-21**] 12:41AM BLOOD CK(CPK)-39*
[**2151-5-19**] 01:47PM BLOOD CK(CPK)-114
[**2151-5-25**] 05:10AM BLOOD CK-MB-2 cTropnT-0.02*
[**2151-5-21**] 12:41AM BLOOD CK-MB-4 cTropnT-0.03*
[**2151-5-19**] 01:47PM BLOOD CK-MB-3 cTropnT-0.05*
[**2151-6-1**] 04:09AM BLOOD Calcium-8.2* Phos-2.4* Mg-1.9
[**2151-5-31**] 04:24AM BLOOD Calcium-8.4 Phos-3.0 Mg-2.1
[**2151-5-17**] 05:30PM BLOOD Lactate-1.6
[**2151-5-17**]: chest x-ray:
IMPRESSION:
1. No acute cardiopulmonary process.
2. Discontinuity of the second sternal wire, again seen.
[**2151-5-17**]: cat scan of abdomen:
IMPRESSION:
1. Large laminated gallstone in the gallbladder neck with mild
gallbladder
distention and pericholecystic fluid, new compared to prior
study of [**Month (only) 205**]
[**2145**], concerning for acute cholecystitis. Ultrasound of the
liver and
gallbladder might be considered for further evaluation.
2. Loculated inferior pericardial fluid, present on prior exam,
but appears
slightly larger.
3. Splenic calcifications most likely from prior granulomatous
disease.
4. No evidence of mesenteric ischemi
[**2151-5-17**]: gallbladder ultrasound:
IMPRESSION:
1. Cholelithiasis with constellation of features concerning for
acute
cholecystitis as described above.
2. Right upper pole renal cyst.
[**2151-5-19**]: ECHO:
Conclusions
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). Tissue Doppler imaging suggests an increased
left ventricular filling pressure (PCWP>18mmHg). Right
ventricular chamber size and free wall motion are normal. The
aortic root is mildly dilated at the sinus level. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen. There is mild pulmonary artery systolic hypertension.
There is no pericardial effusion.
IMPRESSION: Normal global and regional biventricular systolic
function. Elevated left ventricular filling pressures. Mild
mitral regurgitation.
[**2151-5-22**]: chest x-ray:
There is minimal improvement in the degree of moderate pulmonary
edema. Small
bilateral pleural effusions and left retrocardiac opacity are
again noted.
The heart remains stably enlarged. There is no pneumothora
[**2151-5-25**]: EKG:
Probable atrial fibrillation or possible flutter with a rapid
ventricular
response. Low limb lead QRS voltage. Consider left ventricular
hypertrophy.
Delayed R wave progression may be due to left ventricular
hypertrophy or
possible prior septal myocardial infarction, although is
non-diagnostic.
ST-T wave changes are non-specific. Clinical correlation is
suggested. Since
the previous tracing of [**2151-5-24**] the ventricular rate is faster
and further
ST-T wave changes are present.
[**2151-5-27**]: chest-xray:
FINDINGS: As compared to the previous radiograph, there is
unchanged moderate
cardiomegaly and evidence of bilateral pleural effusions.
Moderate
overhydration. No newly appeared focal parenchymal opacities. No
pneumothorax.
[**2151-5-28**]: chest- xray:
FINDINGS: In comparison with the study of [**5-27**], there is
continued
enlargement of the cardiac silhouette with pulmonary vascular
congestion and
bilateral pleural effusions. Some increased opacification at the
right base could reflect worsening if effusion on this side in
this patient who has undergone a previous CABG procedure with
midline sternal wires, the second of which is not tightly tied.
[**2151-5-31**]: echo:
IMPRESSION: Mild spontaneous echo contrast in left atrium but no
thrombus in left atrium, left atrial appendage, right atrium, or
right atrial appendage. Mild mitral regurgitation.
Brief Hospital Course:
Patient was admitted to the ACS service from the ER, and went
promptly to the operating room for laparoscopic cholecystectomy.
The operation was uneventful and the patient was taken to the
PACU in stable condition. He developed hypotension post
operatively and was maintained in the PACU for several hours.
His BP did not rise appropriately, hovering instead around 80-90
systolic, and so it was decided he needed to be admitted to the
surgical ICU. There, he underwent careful resuscitation, as he
had a cardiac history and we were concerned for CHF. Hi
cardiologist was involved in his care while in the hospital.
Over the course of two days, his creatinine stabilized, his
urine output improved and his blood pressure remained stable.
He was therefore cleared for transfer to the surgical floor.
On POD #5 he was transferred to the surgical floor. He was
started on a heparin drip for anti-coagulation of his atrial
fibrillation. He was started on a regular diet. He continued
to have episodes of rapid heart rate and required addtional
doses of lopressor. Because he continued to have increases in
his heart rate, he was evaluated by cardiology and his oral
anti-arrthymics were increased. His foley catheter was
discontinued and he is voiding via a condom catheter. He is
tolerating a regular diet without difficulty. He has maintained
his oxygen saturation at 93-94%on room air.
He was evaluated by PT/OT to assess his mobility status and made
recommendations for his rehabilitation because of his
de-conditioning.
Despite changes in his oral anti-arrythimics, he continued to
have episodes of rapid heart rate and hemodynamic instability.
He returned to the intensive care unit on POD# 7. He was
started on a diltiazem drip for additional rate control.
Because he was also febrile, he underwent a cat scan of his
torso which showed a thickening of his colon, at this time he
was also reported to have a klebsella UTI. He was started on
Unasyn. As his hemodynamic status improved, his diltiazem drip
was discontinued on POD # 8 and he received it orally. His
coumain had been resumed, but by became supra-therapeutic on it
with INR 7.1 for which he required FFP and vitamin K with
correction of his INR to 1.7.
He was transferred back to the surgical floor on POD #10. A
PICC line was placed for intravenous access and completion of
the antibiotic for UTI. His atrial fibrillation resumed and he
was cardioverted on POD #13. An echocardiogram done prior to
cardioversion showed no thrombus. He is preparing for discharge
to a extended care facility. His PICC line was discontinued.
He will follow up with the acute care service in 2 weeks and
with his Cardiologist, Dr. [**Last Name (STitle) **] in 4 weeks. His coumadin will
be resumed this evening with careful monitoring of his INR.
Medications on Admission:
Medications:
-Atorvastatin 10 mg daily
-Ranitidine 150 mg daily
-Clopidogrel 75 mg daily
-Atenolol 25 mg daily
-Aspirin 325 mg daily
-Acetaminophen 500 mg Q6-8h
-Valsartan 160 mg daily
-Oxycodone 5mg PRN pain
Discharge Medications:
1. tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours)
as needed for pain.
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): hold for diarrhea.
3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
4. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
5. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for fever.
6. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) INH Inhalation Q6H (every 6 hours) as
needed for wheeze.
7. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itching.
8. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
11. valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): hold for blood pressure <120 ( as per cards.
recommendation).
12. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
14. Coumadin 1 mg Tablet Sig: 1 mg Tablet PO [**6-1**] for 1 doses:
please follow-up on INR/PT [**6-2**]...maintain INR 2.0-3.0.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - LTC
Discharge Diagnosis:
cholecystitis
atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital with right upper quadrant
pain. You went found to have gallstones. You were taken to the
operating room where you had your gallbladder removed.
Post-operatively, you developed a urinary tract infection which
you on antibiotics. You alos developed a rapid heart rate and
this was controlled with medication and cardioversion. You are
now preparing for discharge to an extended care facility with
the following 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.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**6-15**] lbs until you follow-up with your
surgeon
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **] in [**3-11**] weeks; call [**Telephone/Fax (1) 8792**] for
an appointment.
Please follow up with Dr. [**Last Name (STitle) **] in 4 weeks. The telephone number
is #[**Telephone/Fax (1) 5768**]
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **] MD, [**MD Number(3) 4661**]
Completed by:[**2151-6-1**]
|
[
"428.30",
"413.9",
"998.59",
"412",
"414.00",
"599.0",
"V15.3",
"V10.82",
"458.29",
"575.3",
"788.29",
"276.51",
"V45.82",
"V45.81",
"995.91",
"574.01",
"V10.46",
"038.9",
"427.31",
"401.9",
"427.89",
"E878.6",
"428.0",
"790.92"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"51.23",
"38.93",
"99.62"
] |
icd9pcs
|
[
[
[]
]
] |
12770, 12835
|
8285, 11107
|
305, 335
|
12913, 12913
|
2980, 8262
|
14775, 15187
|
2408, 2485
|
11367, 12747
|
12856, 12892
|
11133, 11344
|
13096, 14752
|
1982, 2256
|
2500, 2500
|
2522, 2961
|
189, 267
|
363, 1619
|
12928, 13072
|
1663, 1959
|
2272, 2392
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,384
| 186,807
|
50326
|
Discharge summary
|
report
|
Admission Date: [**2151-5-21**] Discharge Date: [**2151-6-2**]
Date of Birth: [**2105-10-14**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Quinolones
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
fever, cough, abdominal pain
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
45yo man with h/o HIV (dx'd [**2137**], off HAART since [**11-4**], last
CD4 291 in [**3-6**]), MRSA, VRE, multiple small and large bowel
infarcts s/p R hemicolectomy and partial small bowel resection,
resultant short gut syndrome with poor absorption, pancreatitis,
splenic infarcts, who p/w fever to 103F, productive cough, abd
pain. In the ED, he was found to be in abd pain requiring
morphine and then dilaudid for control (in addition to his
Fentanyl patch). He was initially not hypoxemic, but did have a
cough without significant sputum production.
His labs were notable for: leukocytosis with L shift and 4%
bands (nl SBP and lact 1.9); new thrombocytopenia; baseline
anemia with Hct 23%; baseline elevated LFTs and pancreatic
enzymes; hyponatremia and hypokalemia; PTT elevated at 40.2; UA
with many bacteria. He had a room air ABG that was 7.42/42/89,
but subsequently was found to be hypoxemic to 85% on RA, up to
100% on 4LNC. Repeat CXR was performed, which showed development
of RML or RLL infiltrate. He received broad-spectrum abx
coverage, given his h/o MRSA and VRE, with meropenem, linezolid,
bactrim. He did not receive steroids for PCP.
Past Medical History:
Pancreatitis
. HIV diagnosed in [**2137**] (MSM unprotected sex)
(CD4 381 [**2-3**])
. Herpes zoster
. Condylomata accuminata (surgery scheduled for [**8-9**])
. Thyroid cyst (childhood)
PSH: 1.Retrograde SMA stenting with vein patch angioplasty using
right greater saphenous vein.
2.Second look exploratory laparotomy and small bowel resections
x
2.
3. Third look exploratory laparotomy.
Ileocecectomy with hand-sewn two-layer side-to-side
ileocolostomy.
Small bowel resections x 2 with hand-sewn two-layer
anastomoses x 2.
Gastrostomy tube placement.
Social History:
Lives alone in [**Location (un) 86**]. Worked in ed. adminstration at
[**University/College 5130**]. Had been isolated from family, sister is HCP, but
has some friends who knew the patient well and was involved in
his care while in the hospital
Smokes 1 ppd for several yrs. Planned on quitting in [**Month (only) **].
EtOH: 2 martinins/day
Drugs: occ. marajuana, cocaine (snorted) in past
Family History:
Non-contributory
Physical Exam:
Gen: cachectic ill-appearing caucasian man, lying in bed,
anxious, in distress with minimal movement
Skin: no rash, purpura; multiple nevi over abdomen
HEENT: EOMI, anicteric, temporal wasting, dry MM
Neck: JVP flat, supple
CV: tachy, regular, no m/g/r
Resp: CTA, no rales, no change in R lower lung field
Abd: G-tube in LUQ, ileostomy tubes RLQ, absent bowel sounds,
diffusely mildly TTP, no r/g
Back: no spinal tenderness
GU: Foley in place, draining dark urine
Ext: thin, decreased bulk, no edema
Neuro: anxious, FROM x 4, sensation grossly intact to LT
Pertinent Results:
CXR [**2151-5-20**]
Left subclavian catheter terminates in the junction of the
superior vena cava and right atrium. The heart size is normal.
Diffuse interstitial opacities have developed with perihilar
haziness and bilateral peripheral septal thickening. This is
most likely due to edema from mild fluid overload, but atypical
infection is also possible in the appropriate clinical setting.
CT ABD [**2151-5-21**]
1. Patient is status post right hemicolectomy and resection of a
significant portion of small bowel. There is again seen
abnormally thickened loops of distal jejunum at the ostomy site;
however, this is unchanged in appearance from [**2151-3-15**]. No
intraabdominal abscess is identified.
2. Patient is status post stenting of the proximal SMA. There is
a filling defect identified in the proximal SMA after the stent;
however, there is distal reconstitution of the vessel.
3. Stable appearance of low density areas within the spleen,
representing known infarcts.
4. Stable areas of low density within the pancreas, which is
inseparable from the duct may represent pseudocyst or IPMT,
which is unchanged.
5. Mild bibasilar atelectasis and tiny right pleural effusion.
ECHO [**2151-5-25**]
Minimally thickened mitral leaflets with mild mitral
regurgitation. No discrete vegetation identified.
CT CHEST [**2151-5-28**]
1. Multiple nodules throughout both lungs, some of which have
ground-glass density. This is most concerning for atypical
infection such as fungal infection.
2. Large bilateral pleural effusions with compressive
atelectasis of the lower lobes.
CXR [**2151-5-31**]
IMPRESSION: AP chest compared to [**2151-5-28**] through [**2151-5-30**]:
Pulmonary vascular congestion and moderate right pleural
effusion have both increased slightly since [**2151-5-30**].
Cardiomediastinal silhouette is normal. Opacification at the
lung bases medially has been present on the left since [**6-27**],
but is more pronounced on the right. Changes are consistent with
atelectasis, but pneumonia, particularly aspiration, cannot be
excluded. No pneumothorax
LABS
CBC - was given trasfusion on [**2151-5-31**]
[**2151-5-20**] 08:18PM BLOOD WBC-11.09*# RBC-2.71* Hgb-8.5* Hct-23.7*
MCV-88 MCH-31.4 MCHC-35.9* RDW-19.0* Plt Ct-70*#
[**2151-5-21**] 08:04AM BLOOD WBC-8.9 RBC-2.64* Hgb-8.3* Hct-24.6*
MCV-93 MCH-31.5 MCHC-33.7 RDW-18.6* Plt Ct-54*
[**2151-5-31**] 04:00AM BLOOD WBC-7.5 RBC-2.37* Hgb-7.3*# Hct-21.5*
MCV-91 MCH-30.9 MCHC-34.2 RDW-16.7* Plt Ct-235
[**2151-5-31**] 03:18PM BLOOD Hct-26.8*
[**2151-5-31**] 11:41PM BLOOD Hct-24.6*
[**2151-6-1**] 05:26AM BLOOD WBC-8.6 RBC-2.82* Hgb-8.7* Hct-25.5*
MCV-90 MCH-30.8 MCHC-34.1 RDW-17.0* Plt Ct-304
[**2151-5-20**] 08:18PM BLOOD Neuts-93* Bands-4 Lymphs-0 Monos-1* Eos-0
Baso-1 Atyps-0 Metas-1* Myelos-0
[**2151-5-21**] 08:04AM BLOOD Neuts-90.5* Bands-6.3* Lymphs-2.1*
Monos-1.1* Eos-0 Baso-0
[**2151-5-29**] 04:21AM BLOOD Neuts-78.3* Lymphs-16.6* Monos-3.5
Eos-1.5 Baso-0.2
RBC morphology
[**2151-5-20**] 08:18PM BLOOD Hypochr-NORMAL Anisocy-2+ Poiklo-1+
Macrocy-NORMAL Microcy-1+ Polychr-1+ Target-1+ Stipple-1+
[**2151-5-27**] 04:52AM BLOOD Hypochr-NORMAL Anisocy-OCCASIONAL
Poiklo-OCCASIONAL Macrocy-OCCASIONAL Microcy-NORMAL
Polychr-NORMAL Burr-OCCASIONAL
[**2151-5-22**] 10:04AM BLOOD FDP-10-40
[**2151-5-22**] 10:04AM BLOOD Fibrino-340 D-Dimer-2513*
[**2151-5-21**] 11:00AM BLOOD ESR-102*
CHEM
[**2151-5-20**] 08:18PM BLOOD Glucose-106* UreaN-24* Creat-0.9 Na-131*
K-2.9* Cl-97 HCO3-25 AnGap-12
[**2151-5-21**] 08:04AM BLOOD Glucose-82 UreaN-17 Creat-0.6 Na-134
K-4.0 Cl-106 HCO3-21* AnGap-11
[**2151-5-31**] 04:00AM BLOOD Glucose-129* UreaN-23* Creat-0.9 Na-134
K-4.3 Cl-104 HCO3-23 AnGap-11
[**2151-6-1**] 05:26AM BLOOD Glucose-120* UreaN-23* Creat-0.9 Na-134
K-4.7 Cl-106 HCO3-21* AnGap-12
OTHER LABS
[**2151-5-20**] 08:18PM BLOOD Lipase-502*
[**2151-5-22**] 02:46AM BLOOD Lipase-90*
[**2151-5-27**] 04:52AM BLOOD Lipase-72*
[**2151-5-29**] 04:21AM BLOOD Lipase-74*
[**2151-5-24**] 09:40PM BLOOD CK-MB-3 cTropnT-0.07*
ABGs
[**2151-5-21**] 12:30AM BLOOD pO2-89 pCO2-42 pH-7.42 calTCO2-28 Base
XS-2
[**2151-5-21**] 11:19AM BLOOD Type-MIX Temp-37.8 pO2-42* pCO2-39
pH-7.32* calTCO2-21 Base XS--5 Intubat-NOT INTUBA
[**2151-5-28**] 08:51AM BLOOD Type-ART Temp-37.8 Rates-/24 Tidal V-400
PEEP-5 pO2-71* pCO2-52* pH-7.43 calTCO2-36* Base XS-8
Intubat-INTUBATED Vent-SPONTANEOU
[**2151-5-29**] 09:37AM BLOOD Type-ART Temp-37.7 Rates-20/0 Tidal V-500
PEEP-5 FiO2-50 pO2-135* pCO2-37 pH-7.48* calTCO2-28 Base XS-4
-ASSIST/CON Intubat-INTUBATED
MICRO
Staph from BCx, UCx,
Brief Hospital Course:
45 yo male with HIV (CD4 231 (20%), HIV VL: 21,902 from [**5-13**] -
off of HAART) who was previously admitted [**1-14**] - [**2-25**] with
pancreatitis which required ex-lap and bowel resection x2
(distal and proximal ileum) for ischemic bowel due to sma
occlusion. Pt had a short gut requiring nutrition through TPN
and J tube. He was discharged on [**2-25**] to rehab and returned on
[**3-11**] with a PICC line infection and found to have VRE and MSSA
bacteremia from Bcx on [**3-14**] and [**3-15**]. Line pulled, also showing
VRE, MSSA. Treated with Linezolid. Went to rehab and then sent
home in [**Month (only) **].
This admission, on [**2151-5-21**], patient presented with fevers to 102
- came in hypotensive - and was intubated in setting of high
grade Staph Bacteremia and Hickman with frank pus on it. The
line was pulled on [**5-21**] but patient found to have ARDS. During
the hospital course, the patient was sedated and intubated, but
when sedation was titrated down, patient was agitated and self
extubated. He was unable to maintain adequate breathing and
required immediate reintubation. He has been difficult to
extubate since then - although it appeared to be more mental
status related. Throughout the rest of the hospital course, the
patient continued to be intubated and sedated for ARDS and
hypoxemia.
Also, starting [**5-26**], patient began spiking low-grade fevers of
unknown etiology on vancomycin for MRSA positive wrist infection
and other cultures from [**2151-5-20**].
He has been spiking fevers - unclear etiology. He was continued
on Vancomycin for MRSA on cultures (BAL, joint culture, Ucx).
Only positive Bcx was on [**2151-5-20**]. He had multiple negative
surveillance blood cultures [**Date range (1) **]. The ID team suggested
broadening coverage with aztreonam to include VAP and c.diff if
pt remained persistently febrile without clear source. On CT
C/A/P [**5-28**] found multiple pulmonary nodules (very small) and
large bilat pleural effusions. No clear source for the infection
was found.
On [**2151-5-29**] overnight, the patient had frank GI bleeding with BRB
hematemesis, and bleeding from his gastric drains. GI was
[**Date Range 4221**] and an EGD showed 2 large gastic ulcers and one large
clot in the proximal gastric body and fundus. No active bleeding
was found. A protonix bolus and drip was started at 8 mg/hr IV.
Patient's hct remained stable but starting around this point,
the ICU team began discussions with the [**Hospital 228**] health care
proxy and close friends regarding goals of care as those who
knew him well reported that before this hospitalization, he
stated that he was tired of life and living this way.
On [**2151-5-31**], with the involvement of the team and palliative care,
a family meeting was held where comfort issues were discussed.
The friends were gathering other people who knew the patient
well to come to a consensus regarding goals of care.
On [**2151-6-1**], the patient was made comfort-measures only by his
health care proxy. There was a family gathering to be present as
the patient was extubated that evening. Friends were present
including his 2 sisters. Off the ventilator, the patient's O2
sat decreased, patient unable to take effective breaths, and
patient expired on [**2151-6-2**].
Discharge Disposition:
Expired
Discharge Diagnosis:
Patient expired on [**2151-6-2**].
Discharge Condition:
Expired
Discharge Instructions:
[**Name (NI) **] HCP did not wish to have autopsy
Followup Instructions:
None
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"599.0",
"305.1",
"286.9",
"518.81",
"V09.0",
"785.52",
"799.4",
"995.92",
"578.0",
"V09.80",
"038.11",
"V02.59",
"V55.4",
"577.1",
"287.5",
"996.62",
"579.3",
"482.41",
"788.20",
"042",
"711.03"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"99.15",
"45.13",
"96.04",
"00.14",
"81.91",
"86.05",
"38.93",
"96.72",
"33.24",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
11025, 11034
|
7709, 11002
|
321, 333
|
11112, 11122
|
3138, 7686
|
11220, 11363
|
2527, 2545
|
11055, 11091
|
11146, 11197
|
2560, 3119
|
253, 283
|
361, 1522
|
1544, 2103
|
2119, 2511
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,607
| 134,794
|
27241
|
Discharge summary
|
report
|
Admission Date: [**2155-5-1**] Discharge Date: [**2155-5-9**]
Date of Birth: [**2123-4-6**] Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Dilaudid
Attending:[**First Name3 (LF) 16911**]
Chief Complaint:
Abdominal cramping
Major Surgical or Invasive Procedure:
- Uterine packing, exploratory laparotomy, uterine massage,
intrauterine injection of uterotonics, supracervical
hysterectomy, control of hemorrhage.
- Transfusion of 5 units packed RBCs, 4 units of fresh frozen
plasma, 1 unit cryoprecipitate
History of Present Illness:
The patient is a 32 yo G2P0 woman at 17 and [**3-23**] wks who awoke
from sleep at 4am with cramping. The cramping has been coming
more and more frequently, and now occurs at 30 second intervals.
She has had three episodes of emesis since this AM, which has
not
been usual for her for the past few weeks.
*
She is also having some vaginal bleeding, though she has had
intermittent bleeding throughout the past 5 weeks, ranging from
spotting to more heavy flow. She has been followed for
perigestational bleed growing per Ultrasound with last US [**2155-4-28**]
showing 6.4cm x 2.2cm x 11.1cm anterior bleed with no
retroplacental clot.
*
The patient was seen in the office by Dr. [**First Name (STitle) **] this AM who
found her cervix to be closed but with the lower uterine segment
slightly ballooning. Additionally she was having significant
back pain. THere was a small amount of brown/maroon blood in
the vault. She was sent to GYN triage for further observation
and pain managment. She was initially put on bed
rest in early [**Month (only) 958**] for bleeding complications. Denies any F/C,
CP, SOB.
Past Medical History:
1. Labs: AB Pos/ Antibody Neg/RPR NR/RI/HBSAG neg
2. Dating: By LMP and First Trimester US [**2155-3-4**]
3. Prior Ultrasounds:
[**2155-4-28**]: single uterine gestation. placenta posterior. normal
amt
amniotic fluid, no morphologic abnormalities. moderate anterior
perigestational bleed 6.4x2.2x11.1 cm extending to the lower
uterus consistent with marginal bleed. no retroplacental bleed.
[**2155-5-1**]: Bedside U/S: single fetus identified and fetal HR
visualized. clot visible anteriorly
.
PMH: only seasonal allergies
PSurgicalHx: D+C for TAB
OBHx: TAB x1
.
Social History:
Non-smoker, no EtOH, no drugs or herbal supplements. She lives
with her husband. [**Name (NI) **] [**Name2 (NI) **] live in [**Country 651**].
Family History:
Non contributory
Physical Exam:
Vitals: 99.8, 80, 107/61, 18
Patient lying in bed, very uncomfortable, holding abdomen
RRR
CTAB
Abd: gravid abdomen S=D, tender over uterus superior to pubic
symphysis but otherwise non-tender without rebound/guarding.
Pelvic: Mod old blood in os. Cx FT at ext os Long. NT.
Extr: without edema or cords
Pertinent Results:
[**2155-5-1**] 09:36PM TYPE-ART RATES-8/ TIDAL VOL-550 PEEP-10
PO2-80* PCO2-49* PH-7.34* TOTAL CO2-28 BASE XS-0
INTUBATED-INTUBATED
[**2155-5-1**] 09:36PM LACTATE-3.7* K+-2.9*
[**2155-5-1**] 09:36PM freeCa-1.17
[**2155-5-1**] 09:24PM GLUCOSE-112* UREA N-7 CREAT-0.6 SODIUM-142
POTASSIUM-2.9* CHLORIDE-105 TOTAL CO2-23 ANION GAP-17
[**2155-5-1**] 09:24PM estGFR-Using this
[**2155-5-1**] 09:24PM CALCIUM-8.9 PHOSPHATE-4.4
[**2155-5-1**] 09:24PM WBC-16.8* RBC-3.29* HGB-10.2* HCT-28.1*
MCV-85 MCH-31.0 MCHC-36.4* RDW-17.0*
[**2155-5-1**] 09:24PM PLT COUNT-78*
[**2155-5-1**] 09:24PM PT-14.3* PTT-39.2* INR(PT)-1.3*
[**2155-5-1**] 09:24PM FIBRINOGE-149*
[**2155-5-1**] 09:24PM RET AUT-1.7
[**2155-5-1**] 08:28PM TYPE-ART PO2-95 PCO2-48* PH-7.30* TOTAL
CO2-25 BASE XS--2 INTUBATED-INTUBATED VENT-CONTROLLED
[**2155-5-1**] 07:00PM GLUCOSE-122* LACTATE-3.7* NA+-135 K+-2.8*
CL--109
[**2155-5-1**] 07:00PM HGB-8.9* calcHCT-27
[**2155-5-1**] 07:00PM freeCa-0.99*
[**2155-5-1**] 07:00PM PT-16.2* PTT-57.5* INR(PT)-1.5*
[**2155-5-1**] 07:00PM FIBRINOGE-114*#
[**2155-5-1**] 05:59PM TYPE-ART PO2-140* PCO2-31* PH-7.40 TOTAL
CO2-20* BASE XS--3
[**2155-5-1**] 05:59PM GLUCOSE-108* LACTATE-4.4* NA+-133* K+-3.1*
CL--107
[**2155-5-1**] 05:59PM HGB-9.4* calcHCT-28
[**2155-5-1**] 05:59PM freeCa-0.62*
[**2155-5-1**] 04:08PM PT-18.9* PTT-57.9* INR(PT)-1.8*
[**2155-5-1**] 04:08PM FIBRINOGE-72*#
[**2155-5-1**] 03:48PM HCT-28.3*
[**2155-5-1**] 03:48PM PLT COUNT-148*
[**2155-5-1**] 11:20AM WBC-18.7*# RBC-3.42* HGB-11.1* HCT-31.9*
MCV-93 MCH-32.6* MCHC-35.0 RDW-13.7
[**2155-5-1**] 11:20AM NEUTS-93.5* BANDS-0 LYMPHS-3.2* MONOS-3.0
EOS-0.2 BASOS-0.1
[**2155-5-1**] 11:20AM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2155-5-1**] 11:20AM PLT SMR-NORMAL PLT COUNT-196
[**2155-5-1**] 11:20AM PT-11.8 PTT-21.4* INR(PT)-1.0
[**2155-5-1**] 11:20AM FIBRINOGE-576*
[**2155-5-1**] 10:48AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.026
[**2155-5-1**] 10:48AM URINE BLOOD-LGE NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-9.0*
LEUK-MOD
[**2155-5-1**] 10:48AM URINE RBC-35* WBC-45* BACTERIA-RARE YEAST-NONE
EPI-3
Brief Hospital Course:
32 yo G2P0 at 17 [**6-26**] wks gestational age admitted with
inevitable abortion. Pt developed a low grade fever soon after
admission; she was presumed to have chorioamnionitis and was
started on ampicillin/gentamycin/clindamycin. Spontaneous
vaginal delivery of the fetus occurred [**2155-5-1**]. Pt developed
postpartum hemorrhage and was taken to the OR for
ultrasound-guided dilation and curettage. D&C was complicated
by continued hemorrhage. Pt received uterine packing,
exploratory laparotomy, uterine massage, intrauterine injection
of uterotonics, blood transfusions, supracervical hysterectomy,
control of hemorrhage in the setting of hemorrhage, DIC and
sepsis. Please see operative report for full details of the
procedure.
*
Following the OR, she was transferred to the ICU for further
monitoring. She was transfered from the ICU to the floor on POD
2.
*
RESPIRATORY/HEMODYNAMICS: She was extubated on the 13th. On [**5-3**]
she desated to 93% 3L. CXR showed atelectasis. Transfusion
reaction studies were negative. Desaturation resolved
spontaneously. She remained well oxygenated and hemodynamically
stable throughout the rest of her hospitalization.
INFECTIOUS: ID was consulted and her antibiotics were switched
from amp/gent/clinda to ceftriaxone IV. Urine and blood
cultures collected on [**5-1**] and [**5-2**] returned with E coli
pansensitive except to ampicillin. Pathology specimens of
fetus, placenta and uterus confirmed diagnosis of
chorioamnionitis. She spiked a fever again on the 14th to 102,
but remained afebrile throughout the rest of her
hospitalization. Ceftriaxone was discontinued on [**5-4**] and
Unasyn started. CT of the abdomen and pelvis [**5-4**] were negative
for abscess. Echocardiogram [**5-7**] obtained secondary to recent
sepsis was negative for endocarditis. Blood and urine cultures
were negative from [**5-3**] onward. Pt was transitioned from Unasyn
to po Levofloxacin on [**5-8**]. She will continue outpt
Levofloxacin until 4/27 per ID recommendations.
HEME: Pt received 4 units pRBCs, 4 u FFP, 1 u cryo for acute
blood loss anemia and DIC in the setting of sepsis and uterine
atony. Acute blood loss resolved after a supracervical
hysterectomy, see full operative note for full interventions.
Her Hct was low to 21.5 on POD 1 and received 1 additional u
pRBCs. Her Hct remained stable at approximately 26 throughout
the rest of her hospitalization. DIC resolved after treatment
of infection, above transfusions, and supportive treatment for
the pt. Transfusion reaction labs were negative. The pt will
resume iron treatment as an outpt once the course of
levofloxacin is complete.
GU: Pt complained of dysuria throughout the course of
hospitalization. Repeat UA and urine cultures were negative
after [**5-2**]. It is thought that the synthetic hemostatic
material placed intraoperatively over the cervix and bladder is
causing bladder irritation.
The pt was discharged on post-op day 8 in good condition.
Medications on Admission:
Zantac
Tums
Reglan
Prenatal vitamins
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
3. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO q 6 hrs prn as
needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
4. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q24H
(every 24 hours).
Disp:*10 Tablet(s)* Refills:*0*
5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO q
24 hrs: start when stop antibiotic.
Disp:*90 Tablet(s)* Refills:*2*
6. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)) as needed for nausea.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
spontaneous abortion with spontaneous vaginal delivery
postpartum hemorrhage
sepsis
DIC
Discharge Condition:
good
Discharge Instructions:
Please call for fevers, chills, chest pain, shortness of breath,
vaginal bleeding more than spotting, leg pain, increase in
abdominal pain, foul smelling discharge, redness or drainage
from incision, increase in pain with urination, blood in urine,
depression, any concerns.
No driving while on narcotics.
No heavy lifting for 6 weeks (nothing more than a jug of milk).
Nothing in the vagina for 6 weeks (douche, tampons,
intercourse).
No baths, swimming, hot tubs for 4 weeks.
Followup Instructions:
Please call Dr [**First Name (STitle) **] for a follow up appointment
Completed by:[**2155-5-9**]
|
[
"518.81",
"286.6",
"038.42",
"632",
"287.5",
"780.6",
"280.0",
"458.9",
"634.01",
"995.92",
"634.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"69.02",
"68.39",
"99.07",
"68.23",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
8981, 8987
|
5102, 8098
|
299, 544
|
9119, 9126
|
2818, 5079
|
9656, 9756
|
2459, 2477
|
8185, 8958
|
9008, 9098
|
8124, 8162
|
9150, 9633
|
2492, 2799
|
241, 261
|
572, 1690
|
1712, 2282
|
2298, 2443
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,060
| 135,446
|
7384
|
Discharge summary
|
report
|
Admission Date: [**2127-5-12**] Discharge Date: [**2127-5-15**]
Date of Birth: [**2053-7-24**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1234**]
Chief Complaint:
Asymptomatic carotid artery stenosis
Major Surgical or Invasive Procedure:
Left carotid stent [**2127-5-12**]
History of Present Illness:
The patient is a 73-year-old male who has been followed for a
high-grade, asymptomatic, left carotid stenosis and was unable
to get his cardiac workup due to a severe syncopal episode.
Therefore, he was evaluated for the
possibility of a carotid stent given the fact that he is also a
high risk with COPD and diabetes. He was enrolled in the EMPiRE
trial.
Past Medical History:
HTN
Hyperlipidemia
Diabetes Mellitus
Carotid Stenosis
Peripheral [**Month/Day/Year 1106**] stenosis
cataracts
anxiety
Hypothyroidism
Social History:
He grew up in [**Location (un) 3146**], [**State 350**]. He is a veteran of the
armed forces. He is married, has a wife, and three grown
children. He is a retired laborer. Continues to smoke 10
cigarettes a day. There is no history of alcohol abuse.
Family History:
There is no family history of premature coronary artery disease
or sudden death. Fam Hx of hypertension, diabetes, CAD, and lung
cancer.
Physical Exam:
AFVSS
Nuerologically intact
OD mild erythema
Supple
FAROM
Neg lymphandopathy
CTA
RRR|
ABD - Benign
GU defrred
Distal Pulse
Pertinent Results:
[**2127-5-14**] 05:54AM BLOOD
WBC-7.1 RBC-3.31* Hgb-9.5* Hct-28.3* MCV-85 MCH-28.7 MCHC-33.6
RDW-15.9* Plt Ct-79*
[**2127-5-14**] 05:54AM BLOOD
Plt Ct-79*
[**2127-5-14**] 05:54AM BLOOD
Glucose-113* UreaN-22* Creat-1.4* Na-144 K-4.1 Cl-113* HCO3-24
AnGap-11
[**2127-5-14**] 05:54AM BLOOD
Calcium-9.5 Phos-2.3* Mg-1.9
Brief Hospital Course:
Pt admitted
Neurologically intact
Left carotid artery stent
Perclosed in the room
Pt hypotensive / neo drip immmediatly post operative period
Venous sheath pulled without sequele
POD # 1 Became Brady into 50's. All BP medications held. R/O for
MI.
Review of strip showed complete heart block - Pt did take toprol
xl morning of surgery.
Dr [**Last Name (STitle) **] out of town. Called Cardiology consult.
Pt sent to CVICU. Maxed out on the neo. Where going to start
Dobutamine in the CVICU. Did not do. Pt BP improved.
POD # 2 Pt transfered to the VICU for further monitering
BP stable in the VICU
Foley DC - pt voiding on DC
Pt DC home in stable condition. No blood pressure medication on
DC
Pt to be sent home with BP monitering.
To follow-up with PCP or [**Name9 (PRE) **] early next week
Medications on Admission:
Plavix 75', Amlodipine 10', Lipitor 80', Clonidine 0.1'',
Glipizide 10'', HCTZ 50', Insulin Detemir 20U qhs, LISINOPRIL
40', Toprol XL 200', Actos 30', ASA 81'
Discharge Medications:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Pioglitazone 15 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Glipizide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
6. Pioglitazone 15 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Insulin Detemir 100 unit/mL Solution Sig: One (1) 20 units
Subcutaneous at bedtime.
8. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: Two (2)
Drop Ophthalmic PRN (as needed).
Disp:*1 Polyvinyl Alcohol-Povidone (Ophthalmic) 1.4-0.6 %
Dropperette* Refills:*0*
9. Erythromycin 5 mg/g Ointment Sig: One (1) Ophthalmic QID (4
times a day) for 3 days.
Disp:*1 Erythromycin (Ophthalmic) 5 mg/g Ointment* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 1952**], [**Location (un) 86**]
Discharge Diagnosis:
Left carotid stenosis
Complete heartblock post operative
corneal abrassion
Discharge Condition:
Stable
Discharge Instructions:
Division of [**Location (un) **] and Endovascular Surgery
Carotid Stent Discharge Instructions
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily
?????? Take Plavix (Clopidogrel) 75mg once daily
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs
?????? You may shower (let the soapy water run over groin 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 or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)
?????? After 1 week, you may resume sexual activity
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate
?????? No driving until you are no longer taking pain medications
?????? You should not have an MRI scan within the first 4 weeks after
carotid stenting
?????? Call and schedule an appointment to be seen in [**4-8**] weeks for
post procedure check and ultrasound
What to report to office:
?????? Changes in vision (loss of vision, blurring, double vision,
half vision)
?????? Slurring of speech or difficulty finding correct words to use
?????? Severe headache or worsening headache not controlled by pain
medication
?????? A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
?????? Trouble swallowing, breathing, or talking
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site)
?????? Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
[**Date Range 1106**] office. If bleeding does not stop, call 911 for
transfer to closest Emergency Room.
ALL BLOOD PRESSURE MEDICATIONS HAVE BEEN HELD. THESE INCLUDE
AMLODIPINE, CLONIDINE, LISINOPRIL AND TOPROL XL. DO NOT TAKE.
YOU MUST FOLLOW-UP WITH YOUR PCP DR [**Last Name (STitle) **] OR YOUR CARDIOLOGIST
DR [**Last Name (STitle) 2052**] [**Name (STitle) **] ON DC (EARLY NEXT WEEK). TO HAVE THEM
CHECK YOUR BLOOD PRESSURE AND ADJUST YOUR MEDICATIONS.
Followup Instructions:
Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2127-6-10**]
2:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2127-6-10**] 2:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1143**], MD Phone:[**Telephone/Fax (1) 1144**]
Date/Time:[**2127-7-1**] 9:30
([**Telephone/Fax (1) 5909**], Dr [**Last Name (STitle) **]. Please call and schedule an
appointmnet asap. Your medications have been changed. He may
want to adjust your medications
Completed by:[**2127-5-15**]
|
[
"426.0",
"585.9",
"433.10",
"918.0",
"496",
"403.90",
"E878.8",
"997.1",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.61",
"00.40",
"00.63",
"00.45"
] |
icd9pcs
|
[
[
[]
]
] |
3770, 3845
|
1857, 2665
|
351, 388
|
3964, 3973
|
1510, 1834
|
6622, 7244
|
1214, 1352
|
2875, 3747
|
3866, 3943
|
2691, 2852
|
3997, 5302
|
5328, 6599
|
1367, 1491
|
275, 313
|
416, 773
|
795, 930
|
946, 1198
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,493
| 112,083
|
7078
|
Discharge summary
|
report
|
Admission Date: [**2172-3-11**] Discharge Date: [**2172-3-16**]
Date of Birth: [**2110-7-17**] Sex: M
Service: NEUROLOGY
Allergies:
Penicillins / Shellfish
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
RIght sided weakness
Major Surgical or Invasive Procedure:
MRI/MRA
TTE
History of Present Illness:
61yo M with recent admission for Fournier's gangrene s/p
debridement, longstanding DM1, HTN, CRI now presenting with
sudden onset nonfluent aphasia and right hemiparesis. He has
been
doing quite well at home following a prolonged hospitalization
one month ago, ambulating without assist, feeling well. Off all
antibiotics. His wife heard him yelling upstairs around 4:45pm.
She went to him to notice him slumped to his right side and she
inquired what was wrong and he reported "I don't know." No
apparent speech deficit at that time per wife. taken to [**Hospital3 **] where head CT revealed left thalamic hemorrhage with
left posterior [**Doctor Last Name 534**] lateral ventricle spread. The patient given
dilantin IV, and was med-flighted to [**Hospital1 18**] for further care.
Here the patient has a nonfluent aphasia and cannot provide
further history, his speech comprehension is intact and he is
quite frustrated by his productive speech deficit. He denies any
headache at present. He is aware of his right arm weakness.
Denies diplopia.
He is now off all antiobiotics and has been afebrile recently.
No
chills. no SOB. no CP. No diarrhea or constipation of late. No
change in urinary habits. no new rashes.
Past Medical History:
IDDM diagnosed age 10, CRI baseline 2.0, CAD s/p MI [**2165**], HTN,
Depression, PVD, Hypercholesterolemia, GERD, OA, Carotid artery
disease (L ICA occlusion, R ICA 39% stenosis)
PAST SURGICAL HISTORY:
s/p CABG x4 [**2-21**], s/p L CFA-AKPop BPG w/ NRSVG [**6-18**], s/p R TMA
[**6-17**], s/p R BKPop-Peroneal w/ NRVSG [**4-17**], s/p L cataract [**2166**], R
cataract [**2165**]
Social History:
Married, no alcohol, no tobacco use, no illicit drug use.
Family History:
Patient with strong family history of DM-I with his father and
siblings affected at age < 15, most with chronic sequelae of
disease. Father passed away from MI.
Physical Exam:
T 98, BP 162/85, HR 72, R 18, 100% RA
gen- well appearing, cooperative with exam, NAD
HEENT- NCAT, MMM, OP clear
Neck- no nuchal rigidity, no bruits bilat
CV- RRR, no MRG
Pulm- CTA B
Abd- soft, nt, nd, BS+
Groin/genitalia- granulating tissue with surgical packing, no
eschar or apparent purulent discharge.
Skin- chronic venous changes, weak distal pulses (1+) but
present.
-Mental Status: Speech is nonfluent. he follows all midline and
appendicular commands. He is Attentive to the exam. he is unable
to read.
-Cranial Nerves: Olfaction not tested. pupils with slight
irregularity barely reactive 3 to 2mm and sluggish. He appears
to have a slight R sided field cut to visual threat. There is no
ptosis bilaterally. Funduscopic exam revealed multiple cotton
wool spots, no hemorrhages, unable to see optic discs. EOMI
without nystagmus. No gaze preference. Facial sensation reduced
to light touch. Slight R NLF effacement. Hearing intact to
finger-rub bilaterally. Palate elevates symmetrically. 5/5
strength in trapezii and SCM bilaterally. Tongue protrudes in
midline.
-Motor: Normal bulk. No adventitious movements noted. No
asterixis noted. prominent right drift.
Delt Bic Tri WrE FFl FE IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB
L 5 5 5 5 5 5 5 5 5 5 5 5 5
R 3 4 4 3 4 4 3 5 * * * * *
* unable to test
-Sensory: Diminished to all modalities on the left. s/p R
metatarsal amp.
-Coordination: No intention tremor. [**Doctor First Name 6361**] nl on the left. No
dysmetria on FNF on the left.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 1 1 1 1 0
R 1 1 1 2 0
Plantar response was flexor bilaterally.
Pertinent Results:
[**2172-3-13**] 06:25AM BLOOD WBC-7.7# RBC-3.77* Hgb-12.0* Hct-34.0*
MCV-90 MCH-31.7 MCHC-35.2* RDW-14.4 Plt Ct-343
[**2172-3-12**] 02:03AM BLOOD WBC-4.4 RBC-3.63* Hgb-11.3* Hct-32.2*
MCV-89 MCH-31.2 MCHC-35.2* RDW-14.5 Plt Ct-268
[**2172-3-11**] 07:27PM BLOOD WBC-5.4 RBC-3.75* Hgb-11.5* Hct-33.2*
MCV-88# MCH-30.7 MCHC-34.7 RDW-14.4 Plt Ct-303
[**2172-3-11**] 07:27PM BLOOD Neuts-61.1 Lymphs-24.1 Monos-8.2 Eos-6.1*
Baso-0.6
[**2172-3-13**] 06:25AM BLOOD PT-14.0* PTT-27.5 INR(PT)-1.2*
[**2172-3-12**] 02:03AM BLOOD PT-13.3 PTT-28.6 INR(PT)-1.1
[**2172-3-11**] 07:27PM BLOOD PT-13.2 PTT-27.7 INR(PT)-1.1
[**2172-3-12**] 03:50PM BLOOD Glucose-154* UreaN-27* Na-135 K-4.6
Cl-103 HCO3-27 AnGap-10
[**2172-3-11**] 07:27PM BLOOD Glucose-69* UreaN-38* Creat-1.4* Na-134
K-4.8 Cl-99 HCO3-29 AnGap-11
[**2172-3-12**] 02:03AM BLOOD Glucose-103 UreaN-35* Creat-1.1 Na-135
K-7.0* Cl-104 HCO3-29 AnGap-9
[**2172-3-12**] 03:50PM BLOOD CK(CPK)-50
[**2172-3-12**] 02:03AM BLOOD CK(CPK)-51
[**2172-3-13**] 06:25AM BLOOD Calcium-9.3 Phos-3.3 Mg-1.5*
[**2172-3-12**] 02:03AM BLOOD Calcium-8.4 Phos-4.1 Mg-1.7 Cholest-115
[**2172-3-12**] 02:03AM BLOOD %HbA1c-7.0*
[**2172-3-12**] 02:03AM BLOOD Triglyc-52 HDL-36 CHOL/HD-3.2 LDLcalc-69
CY Head: Left basal ganglia hemorrhage with intraventricular
extension and
mild mass effect, unchanged in copmarison to CT from
approximately two hours prior.
MRI Head: Absence of flow signal in the left internal carotid
which could
be secondary to occlusion in the neck. MRA of the neck can help
for further assessment. Faint flow in the left middle cerebral
artery secondary to collateral across the circle of [**Location (un) 431**].
Brief Hospital Course:
Pt admitted to the Neuro-ICU for further management of his
hemorrhage. He was monitored with cardiac telemetry and
frequent neuro checks. He had follow-up imaging which revealed
stable size of bleed. He was transfered to the neuro step down
unit. On the floor he had elevated BP's and was started on his
home medications. His blood sugars were markedly elevated and
[**Last Name (un) 3208**] was consulted for help with control. He was restarted on
his home regemin and a sliding scale. PT/OT and Speech were
consulted. Plastics was contact[**Name (NI) **] to help in wound care recs
for his recent sacral infection. They recommended wet to dry
dressing changes twice a day. His BP improved on his home
medications. He continued to imrpove throughout the stay. He
will follow-up in stroke clinic as an outpt.
Medications on Admission:
Aspirin 325mg daily
Piroxicam (? paroxitine) 20mg daily
Gabapentin 600mg TID
metoprolol 50mg [**Hospital1 **]
HCTZ 25mg daily
Omeprazole 40mg daily
Diovan 320mg QPM
Atorvastatin 80mg daily
temazepam 15mg QHS
Protonix 40mg daily
Humalin
Humalog sliding scale
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever.
2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Insulin Regular Human Injection
5. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q8H (every 8 hours)
as needed for pain.
6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q8H (every 8 hours)
as needed for pain.
10. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
11. Valsartan 160 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
12. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
13. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
14. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Temazepam 15 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
16. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
17. Isosorbide Dinitrate 10 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
18. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety.
19. Insulin NPH & Regular Human Subcutaneous
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Left thalamic hemorrhage
Discharge Condition:
Right hemiparesis, aphasia
Discharge Instructions:
You were admitted because of a bleed in your brain. It has
caused weakness and numbness on your right side and difficulty
speaking. You will need rehab after discharge. If you have any
new weakness or tingling, please return to the ER.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2172-3-20**] 10:00
Provider: [**Name10 (NameIs) 4267**] [**Last Name (NamePattern4) 4268**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 657**]
Date/Time:[**2172-4-28**] 3:00
Provider: [**Name10 (NameIs) **] STUDY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2172-7-1**]
10:00
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
|
[
"V58.66",
"530.81",
"585.9",
"311",
"715.98",
"412",
"443.9",
"V45.81",
"272.0",
"414.00",
"V58.67",
"403.90",
"431"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.91"
] |
icd9pcs
|
[
[
[]
]
] |
8292, 8389
|
5706, 6528
|
306, 320
|
8458, 8487
|
4024, 5683
|
8774, 9305
|
2066, 2228
|
6837, 8269
|
8410, 8437
|
6554, 6814
|
8511, 8751
|
2774, 4005
|
1794, 1974
|
2243, 2619
|
246, 268
|
348, 1569
|
2634, 2757
|
1591, 1771
|
1990, 2050
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,072
| 177,366
|
5107+5108
|
Discharge summary
|
report+report
|
Admission Date: [**2201-5-31**] Discharge Date: [**2201-6-4**]
Service: Medicine
CHIEF COMPLAINT: Black stools.
HISTORY OF PRESENT ILLNESS: This is a [**Age over 90 **] year old female
with a history of gastroesophageal reflux disease and peptic
ulcer disease, now with black stools times two days. She has
had nauseousness but denies vomiting. She has had
epigastric/sternal pain for a few days, but currently she
denies any chest pain or shortness of breath. She also
denies lightheadedness or dizziness. The patient is a poor
historian and has been transferred from [**Hospital3 **]
Center.
PAST MEDICAL HISTORY: 1. Gastroesophageal reflux disease;
2. Hypertension; 3. Left lazy eye; 4. History of multiple
falls; 5. Benign positional vertigo; 6. History of pelvic
ulcer disease; 7. Dementia; 8. Depression; 9. NPH.
MEDICATIONS ON ADMISSION: 1. Norvasc 2.5 mg q. day; 2.
Zoloft 50 mg q. day; 3. Aspirin 81 mg q. day; 4. Os-Cal 500
mg q. day; 5. Pepcid 20 mg b.i.d.; 6. Vioxx 25 mg q. day;
7. Miacalcin 2 tablets per day.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Lives at [**Hospital3 **] Center.
There is a remote history of tobacco smoking but is not
currently a smoker.
PHYSICAL EXAMINATION: Vital signs, temperature 98.4,
heartrate 77, blood pressure 135/79, respirations 24, oxygen
saturation 94% on room air. In general, elderly female in no
apparent distress. Head, eyes, ears, nose and throat
examination, anicteric sclera, moist mucous membranes. Neck
examination, no jugulovenous distension. Cardiovascular
examination, regular rate, normal rhythm with a II/VI
systolic ejection murmur best heard at the left lower sternal
border. Pulmonary examination was clear to auscultation
bilaterally. Abdominal examination, positive bowel sounds,
soft, nontender, nondistended. Extremities examination was
warm, no edema. Neurological examination, alert and
appropriately responsive.
LABORATORY DATA: Electrocardiogram showed normal sinus
rhythm at 69 beats/minute, no ST changes when compared to an
electrocardiogram done on [**2201-1-22**]. Complete blood
count, white count 7.7, hematocrit 32.1, platelets 250,
neutrophils 84% lymphocytes 10%, INR 1.1. Chem-7 145, 3.8,
109, 25, 28, 0.5 and 96. Creatinine kinase was 29.
HOSPITAL COURSE: 1. Gastrointestinal bleed - This was
likely to be an upper gastrointestinal bleed. She was typed
and crossed for 4 units. She had her hematocrit checked
every eight hours initially. The patient was initially
started on Protonix 40 mg intravenously b.i.d. and was kept
NPO and her Aspirin and Vioxx was held. Upon admission her
hematocrit was 32.1%. She appeared stable and alert and
oriented appropriately. She had a negative nasogastric
lavage in the Emergency Department. Two large intravenous
needles were placed. However, later that afternoon the
patient's hematocrit was rechecked. It was 27.4%. Again,
the patient seemed to remain hemodynamically stable, but she
was transfused 2 units of blood. The patient's hematocrit
rose appropriately by hospital day #2 to 39.4%. However, the
patient did have one episode of hematest with about 100 to
150 cc of bright red blood that did not clear this time with
nasogastric lavage. The patient was found to be
tachycardiac, however, her blood pressure remained stable.
The patient was at this time transferred to the Medicine
Intensive Care Unit for further treatments. The patient was
transfused another 2 units of packed red blood cells. She
remained stable over night. Her hematocrit on hospital day
#3 rose appropriately to 41.4% and upon dictation of this
discharge summary her hematocrit remained stable at 41.8%.
She did not have any other episodes of hematemesis. An
nasogastric tube was initially placed and approximately 400
cc of dark red blood was suctioned out of her stomach. Her
nasogastric tube was discontinued on hospital day #3.
Gastroenterology was consulted for this gastrointestinal
bleed, but after extensive discussions with family members,
given the patient's elderly status and her Do-Not-Intubate
Do-Not-Resuscitate code status, it was thought in the best
interest that they did not do an endoscopy to see the source
of her bleeding because this would require further sedation
and anesthesia with risks that would accompany the procedure.
The patient remained hemodynamically stable throughout the
rest of her hospital stay.
2. Chest pain - The patient was ruled out for a heart attack
with three negative sets of cardiac enzymes. Her chest pain
was attributed likely to gastroesophageal reflux disease.
The patient was started on Protonix 40 mg intravenously
b.i.d. initially and did not complaint of any chest pain or
shortness of breath past this point. An electrocardiogram
was initially done in the Emergency Room which was normal. A
chest x-ray was obtained which was unchanged from previous
chest x-ray.
3. Fluids, electrolytes and nutrition - The patient's
electrolytes remained stable throughout the hospital course.
She was initially kept NPO until hospital day #4 which time
her diet was advanced to a thick liquid diet and then to a
full pureed diet. The patient tolerated this without
difficulties. Nutrition consult was obtained, and their
recommendations were followed.
4. Cardiovascular status - The patient's blood pressure
remained stable throughout the hospital course. She was
initially started on Amlodipine 2.5 mg q. day. This was
discontinued on hospital day #4 per Gerontology's request.
The patient was also continued on Telemetry throughout this
hospital course. There were no arrhythmias and no further
issues.
5. Infectious disease - The patient complained of some
dysuria on hospital day #3 at which time a urinalysis was
obtained. She had large blood, small leukocyte esterase,
white blood cells 21 through 50 and many bacteria and no
epithelial cells. It was thought that the patient had a
urinary tract infection. She was started and will continue a
three day course of Ciprofloxacin 250 mg b.i.d.
CODE STATUS: The patient remained Do-Not-Intubate,
Do-Not-Resuscitate throughout her hospital stay.
DISCHARGE DISPOSITION: The patient will be discharged back
to [**Hospital3 **].
DISCHARGE DIAGNOSIS:
1. Upper gastrointestinal bleed
2. Gastroesophageal reflux disease
3. Hypertension
4. History of multiple falls
5. Left lazy eye
6. Benign positional vertigo
7. History of peptic ulcer disease
8. Dementia
9. Depression
DISCHARGE MEDICATIONS:
1. Norvasc 2.5 mg q. day
2. Zoloft 50 mg
3. Aspirin 81 mg q. day
4. OsCal 500 mg q. day
5. Pepcid 20 mg b.i.d.
6. Vioxx 25 mg q. day
7. Miacalcin two tablets q. day
DISCHARGE FOLLOW UP PLANS:
1. Follow up by Gerontology on an outpatient basis at the
[**Hospital3 **] Center.
2. Will need follow up with primary care provider within one
week of discharge status.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1604**], M.D.
[**MD Number(1) 1605**]
Dictated By:[**Last Name (NamePattern1) 1892**]
MEDQUIST36
D: [**2201-6-3**] 18:03
T: [**2201-6-3**] 18:11
JOB#: [**Job Number 20984**]
Admission Date: [**2201-5-31**] Discharge Date: [**2201-6-7**]
Service:
ADDENDUM:
The patient was kept in house three days longer than expected
secondary to altered mental status. On hospital day number
seven, it was thought that the patient had some right sided
weakness and worsening dementia. She had received a lot of
Ativan as well as Risperdal while she was in the Medical
Intensive Care Unit and it was thought that these medications
were now causing her to be confused and demented. The
patient was continued of these psychotropic medications and
continued to do very well. Her mental status cleared to
baseline. The patient was able to mentate and to remember
long term events. She was compliant with her medications and
she was feeding herself. Her muscle strength remained stable
at her discharge at 4+/5 bilaterally in all extremities.
It was also thought that there might be an infectious
etiology as well. A urinalysis and urine culture as well as
repeat chest x-ray and complete blood count were obtained.
The patient still does have a urinary tract infection for
which she will be treated with Bactrim times seven more days,
double strength, twice a day. Other than that, her chest
x-ray was clear without evidence of a focal pneumonia and her
white blood cell count remained stable upon discharge at 8.2.
MEDICATIONS ON DISCHARGE:
1. Sertraline 50 mg p.o. once daily.
2. Protonix 40 mg p.o. twice a day.
3. Colace 100 mg twice a day.
4. Risperdal 0.5 mg p.o. twice a day.
5. Bactrim double strength one p.o. twice a day times seven
days total.
6. Os-Cal 500 mg plus Vitamin D one tablet a day.
7. Miacalcin 100 international units one subcutaneous
injection a day.
8. Menthol Cetylpyrid 2 mg lozenges as needed for cough.
9. Maalox 15 to 30cc four times a day.
Dictated By:[**Last Name (NamePattern1) 1892**]
MEDQUIST36
D: [**2201-6-7**] 10:41
T: [**2201-6-7**] 13:03
JOB#: [**Job Number 20985**]
|
[
"599.0",
"292.81",
"294.8",
"401.9",
"530.81",
"578.0",
"E937.9",
"280.0",
"578.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.34"
] |
icd9pcs
|
[
[
[]
]
] |
6183, 6241
|
6514, 8509
|
6262, 6491
|
8535, 9122
|
877, 1101
|
2314, 6159
|
1252, 2296
|
111, 126
|
155, 614
|
637, 850
|
1118, 1229
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,659
| 196,784
|
3538
|
Discharge summary
|
report
|
Admission Date: [**2142-2-12**] Discharge Date: [**2142-2-16**]
Date of Birth: [**2082-6-24**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
recent MI with stenting of OM
Major Surgical or Invasive Procedure:
CABG x3 (LIMA>LAD, SVG>DIAG, SVG>RAMUS) [**2142-2-12**]
History of Present Illness:
59 yo M with h/o smoking and borderline htn with recent NSTEMI.
At Cath OM was stented, buit he also had 75 % ostial LAD and
ramus lesion.
Past Medical History:
CAD, MI, CKD, HTN, skin CA, s/p kidney pyeloplasty
Social History:
unemployed
quit tobacco 24 years ago
occasional etoh
lives with wife
Family History:
NC
Physical Exam:
WDWN M in NAD
HR 52 RR 12 BP 112/58
Lungs CTAB
Heart RRR
Abdomen benign
Extrem warm, no edema
No varicose [**Last Name (un) **]
Neuro grossly intact
Brief Hospital Course:
He was taken to the operating room on [**2-12**] where he underwent a
CABG x 3. He was transferred to the ICU in stable condition. He
was extubated later that same day. He was transferred to the
floor on POD #1. He did well postoperatively, his chest tubes
and wires were dc;d without incident.Gently diuresed toward his
preop weight. He was ready for discharge to home with services
on POD #4. Pt. is to make all follow appts. as per discharge
instructions.
Medications on Admission:
ASA 815', lipitor 80', allopurinol 300', lisinopril 20',
lopressor 25", foltx 2.5/2.5/2'
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
as needed for stent.
Disp:*30 Tablet(s)* Refills:*0*
3. Allopurinol 100 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*0*
4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Foltx 2.5-25-2 mg Tablet Sig: One (1) Tablet PO once a day.
6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 1 months.
Disp:*30 Tablet(s)* Refills:*0*
7. Aspirin EC 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
8. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
9. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*2*
10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12
hours) for 5 days.
Disp:*10 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
11. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 5
days.
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
CAD now s/p CABG
CAD, MI, CKD, HTN, skin CA, s/p kidney pyeloplasty
Discharge Condition:
Good.
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions, creams or powders to incisions.
No lifting more than 10 pounds for 10 weeks.
No driving until follow up with surgeon.
Followup Instructions:
Dr. [**Last Name (STitle) 4922**] 2 weeks
Dr. [**Last Name (STitle) **] 2 weeks
Dr. [**Last Name (STitle) **] 4 weeks
Already scheduled appointments:
Provider: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 720**], M.D. Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2142-10-17**] 11:30
Completed by:[**2142-2-16**]
|
[
"403.90",
"285.9",
"410.72",
"414.01",
"V45.82",
"585.9",
"V10.83"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"39.61",
"36.12"
] |
icd9pcs
|
[
[
[]
]
] |
2888, 2946
|
947, 1407
|
351, 409
|
3058, 3066
|
3379, 3717
|
755, 759
|
1546, 2865
|
2967, 3037
|
1433, 1523
|
3090, 3356
|
774, 924
|
282, 313
|
437, 578
|
600, 652
|
668, 739
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,306
| 191,907
|
4009
|
Discharge summary
|
report
|
Admission Date: [**2186-10-3**] Discharge Date: [**2186-11-25**]
Date of Birth: [**2115-9-8**] Sex: F
Service: SURGERY
Allergies:
Sulfonamides / Edecrin / Iodine / Cipro / Piroxicam / Questran /
Keflex
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Fever and cellulitis
Major Surgical or Invasive Procedure:
[**2186-10-17**] Exploratory laparotomy, sigmoid
colectomy with Hartmann's procedure, small bowel resection,
removal of Marlex mesh, and repair of incisional ventral
hernia.
History of Present Illness:
71 y.o. Female w/ Cryptogenic Cirrhosis, CKD p/w 3 days of
malaise, fever, decreased PO, and progressing ascites.
.
Pt states that 6 days ago she noted some erythema, increased
warmth of her legs bilaterally, she went to see her PCP who
prescribed her a regimen of Cephalexin after noticing the
erythema with drainage. She did notice some sweats 2 days later
and called her PCP with concerns for a possible allergy to the
medication. Per OMR her PCP called her stating to continue the
Keflex given that her symptoms may be related to her cellultis.
Pt did notice an improvement with the erythema around her legs
on the course of Cephalexin. 2 days prior to admission she noted
some fevers up to 102 as well as feeling of lethargy. She also
reported an episode of non-bloody emesis during the night that
she does not remember having (pt woke up with emesis right next
to her).
.
She also endorses a progressive weight gain of 10lbs over the
past month and after seeing her nephrologist she had her
Furosemide increased from 20mg to 40mg. She has also noted a
slow increase in her abdominal growth and LE edema over the past
month. She denies any chills, nausea, abdominal pain, chest
pain, SOB, diarrhea, constiption, episodes of confusion. She
does endrose intermittent dysuria over the past month.
Past Medical History:
- Chronic kidney disease, new baseline of 3.3-3.5 (per [**8-3**]
hospitalization), s/p AIN from cipro-induced renal failure
- Anemia, macrocytic, s/p procrit
- CAD s/p "silent" MI 4years ago per chart
- HTN c diastolic CHF; last ECHO in [**3-6**] showing EF>55%, with
moderate aortic stensois and mild LVg
- cryptogenic cirrhosis with h/o ascites s/p TIPS
- psoriasis
- Gout-- on prednisone for 2years (every time she tapers
completely off, she gets another flare), also allopurinol
- Depression/Anxiety, controlled with citalopram
- T1NoMo inf. ductal breast ca, Left, dx 5 years ago s/p
lumpectomy and XRT/aromatase inhibitor; normal mammogram in
[**Month (only) 359**]
- Lumbar DJD with L4/L5 radiculopathy (RLE) s/p ESI, last [**2-3**]
- venous stasis dermatitis
- peripheral neuropathy
- PNA [**2-2**]
- VRE
- MRSA
Social History:
Patient lives in a condominium in [**Location (un) **] with her partner of 20
years. She is a retired book-keeper and has five children and 15
grandchildren. She reports she has no smoking history and drinks
3 drinks/week but past EtOH use was 1 drink/day. She denies
illicit drug use. She is sexually active with her partner only.
She has used a walker to get around for the past year and
started physical therapy two weeks ago for balance/gait
disturbances.
Family History:
Mother died at 76--several strokes. Father died in 80s of "old
age." She reports all five of her children are in good health.
Sister had uterine cancer but denies FH of other cancers,
depression, alcholism, heart disease, liver disease, DM, or HTN.
Physical Exam:
PHYSICAL EXAM AT ADDMISSION:
Vitals - T:97.3, BP:113/59, HR:92, RR:18, 02 sat:18
GENERAL: Elderly Caucasian Female lying down in NARD.HEENT:
Normocephalic, atraumatic, no scleral icterus, EOMI, MMM.
Neck: no JVP appreciated.
CARDIAC: S1, S2, II/VI mid peaking systolic murmur in the right
sternal border, II/VI decresendo systolic murmur in in the apex
radiating to the axilla.
LUNGS: CTAB, good air movement biaterally.
ABDOMEN: Distended, soft, not warm to touch, non-tender, fluid
level percussed.
EXTREMITIES: 2+ edema noted b/l, mild erythema noted b/l, worse
on RLE than LLE. Not warm out of proportion. 2+ dorsalis pedis/
posterior tibial pulses.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout. No asterixis
noted.
.
Pertinent Results:
CXR [**2186-10-3**]: IMPRESSION: Mild right basilar atelectasis,
otherwise unchanged.
.
ABD u/s: IMPRESSION: Four quadrant ascites, site marked in the
right lower quadrant.
.
CT ABDOMEN [**2186-10-8**]: IMPRESSIONS:
1. Large left rectus sheath hematoma. Apparently, the patient
had had
paracentesis several days ago, after a spot was marked in the
right lower
quadrant with ultrasound guidance. The patient has also been
receiving
Lovenox injections.
2. Liver again demonstrates cirrhotic morphology, with TIPS in
place.
Moderate ascites redemonstrated. However, flow within TIPS and
area of
relative decreased density in medial right hepatic lobe not
evaluated due to lack of IV contrast.
3. Degenerative change of the spine, with minimal grade 1
anterolisthesis of L4 on L5 is new compared to CT of [**2183-11-3**].
4. Diffuse subcutaneous edema. Small left pleural effusion.
5. Renal cysts.
.
[**10-9**] - Successful placement of a tunneled right internal
jugular 15.5
French x 23 cm tip-to-cuff hemodialysis catheter with tip
terminating in the right atrium. The line is ready for use.
.
[**2186-10-3**] WBC-3.9* RBC-3.10* Hgb-9.8* Hct-32.9* MCV-106*
MCH-31.6 MCHC-29.8* RDW-20.4* Plt Ct-68*
[**2186-10-4**] PT-14.3* PTT-33.4 INR(PT)-1.2*
[**2186-10-3**] UreaN-77* Creat-4.7* Na-140 K-3.6 Cl-110* HCO3-16*
AnGap-18
[**2186-10-3**] ALT-13 AST-25 AlkPhos-160* TotBili-0.7 Lipase-33
Calcium-8.1* Phos-3.8 Mg-1.8 Albumin-2.6*
[**2186-10-17**] CK-MB-3 cTropnT-0.01
[**2186-10-23**] calTIBC-66* Ferritn-968* TRF-51*
[**2186-10-27**] TSH-2.2
[**2186-10-11**] HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE IgM
HBc-NEGATIVE
[**2186-10-12**] ANCA-NEGATIVE B HCV Ab-NEGATIVE
[**2186-10-17**] 09:00AM BLOOD WBC-9.6 RBC-3.00* Hgb-10.0* Hct-30.7*
MCV-102* MCH-33.2* MCHC-32.5 RDW-19.2* Plt Ct-227
[**2186-10-17**] 09:44PM BLOOD WBC-19.5* RBC-1.93*# Hgb-6.1*# Hct-20.2*
MCV-105* MCH-31.4 MCHC-30.0* RDW-20.0* Plt Ct-231
[**2186-10-18**] 06:20PM BLOOD WBC-23.3* RBC-2.39* Hgb-7.2* Hct-22.1*
MCV-93 MCH-30.1 MCHC-32.5 RDW-23.0* Plt Ct-231
[**2186-10-20**] 03:02AM BLOOD WBC-19.3* RBC-2.88*# Hgb-8.6*# Hct-25.6*
MCV-89 MCH-29.9 MCHC-33.7 RDW-21.2* Plt Ct-154
[**2186-10-22**] 07:45AM BLOOD WBC-28.6* RBC-3.25* Hgb-9.5* Hct-29.5*
MCV-91 MCH-29.2 MCHC-32.1 RDW-20.2* Plt Ct-168
[**2186-10-25**] 07:00AM BLOOD WBC-33.9* RBC-3.34* Hgb-9.9* Hct-31.4*
MCV-94 MCH-29.5 MCHC-31.4 RDW-20.6* Plt Ct-168
[**2186-10-26**] 04:50AM BLOOD WBC-33.8* RBC-3.18* Hgb-9.1* Hct-29.7*
MCV-94 MCH-28.6 MCHC-30.6* RDW-20.9* Plt Ct-160
[**2186-10-29**] 05:21AM BLOOD WBC-15.8* RBC-2.70* Hgb-8.2* Hct-25.0*
MCV-93 MCH-30.3 MCHC-32.7 RDW-20.1* Plt Ct-127*
[**2186-10-31**] 05:18AM BLOOD WBC-19.2* RBC-2.98* Hgb-8.7* Hct-27.3*
MCV-92 MCH-29.1 MCHC-31.8 RDW-19.5* Plt Ct-144*
[**2186-11-1**] 10:13PM BLOOD WBC-12.9* RBC-2.52* Hgb-7.7*# Hct-23.5*
MCV-93 MCH-30.5 MCHC-32.7 RDW-19.3* Plt Ct-85*
[**2186-11-3**] 05:52AM BLOOD WBC-11.7* RBC-2.90* Hgb-8.4* Hct-26.2*
MCV-90 MCH-29.1 MCHC-32.1 RDW-18.6* Plt Ct-89*
[**2186-11-4**] 06:00AM BLOOD WBC-9.7 RBC-2.88* Hgb-8.5* Hct-26.2*
MCV-91 MCH-29.7 MCHC-32.6 RDW-18.8* Plt Ct-81*
[**2186-11-6**] 07:20AM BLOOD WBC-14.8* RBC-3.04* Hgb-8.8* Hct-27.0*
MCV-89 MCH-28.9 MCHC-32.6 RDW-17.9* Plt Ct-134*
[**2186-11-9**] 05:00AM BLOOD WBC-12.7* RBC-2.94* Hgb-8.7* Hct-26.1*
MCV-89 MCH-29.8 MCHC-33.5 RDW-19.5* Plt Ct-199
[**2186-11-10**] 05:00PM BLOOD WBC-12.2* RBC-3.69*# Hgb-11.0*#
Hct-33.2*# MCV-90 MCH-29.8 MCHC-33.1 RDW-17.8* Plt Ct-189
[**2186-11-11**] 07:20AM BLOOD WBC-9.6 RBC-UNABLE TO Hgb-8.3* Hct-26.3*
MCV-UNABLE TO MCH-UNABLE TO MCHC-28.3*# RDW-UNABLE TO Plt
Ct-171
[**2186-11-14**] 06:29AM BLOOD WBC-12.2* RBC-3.06* Hgb-9.3* Hct-27.7*
MCV-91 MCH-30.4 MCHC-33.5 RDW-17.6* Plt Ct-167
[**2186-11-17**] 07:30AM BLOOD WBC-10.8 RBC-2.80* Hgb-8.2* Hct-25.6*
MCV-92 MCH-29.4 MCHC-32.2 RDW-17.6* Plt Ct-191
[**2186-11-20**] 02:44AM BLOOD WBC-13.3* RBC-3.03* Hgb-9.1* Hct-27.7*
MCV-91 MCH-30.1 MCHC-32.9 RDW-16.7* Plt Ct-162
[**2186-11-21**] 03:28AM BLOOD WBC-7.1 RBC-2.94* Hgb-8.6* Hct-26.4*
MCV-90 MCH-29.2 MCHC-32.5 RDW-16.6* Plt Ct-106*
[**2186-11-24**] 07:10AM BLOOD WBC-11.4* RBC-3.14* Hgb-9.1* Hct-28.7*
MCV-92 MCH-29.1 MCHC-31.8 RDW-16.8* Plt Ct-170
Brief Hospital Course:
71 y.o. Female with cryptogenic cirrhosis s/p TIPs, CKD, recent
hospitalization for AIN [**2-27**] cipro, MI, diastolic dysfunction p/w
fevers, ?cellulitis, progressive ascites.
.
##. LE Erythema/Fevers: On presentation, pt's legs were
erythemetetous and due to low grade fevers. Blood cultures, U/A
and urine cultures were drawn and came back negative. An
alternate source of infection was pursued. Peritoneal fluid
cultures showed no SBP and as pt had no abdominal pain was not
treated. Pt had a negative CXR and no URI symptoms. Pt also
reported no diarrhea. No further treatment was pursued.
.
##. CRI: Following pt's last discharge for possible AIN [**2-27**]
cipro, pt's Creatinine had been noted to be in the range from
3.3-4.6. Upon admission, her creatinine was noted to be 4.7 and
trending upward. The renal team under Dr. [**Last Name (STitle) 4090**] was consulted
and followed the patient throughout her hospital course. With a
positive urine eos, the patient was started on stress dose
steroids of hydrocortisone 100mg TID IV for treatment recurrent
AIN. With a rising creatinine and since she was not responding
to the stress steroids, a tunneled IJ catheter was placed and
she was started on dialysis [**2186-10-10**]. A CXR, EKG, PPD, Hep B and
C serologies were obtained for possible outpatient dialysis. She
was continued on three times weekly hemodialysis throughout the
hospitalization and will be discharged on this therapy. Last
hemodialysis session was [**11-24**].
.
## Neutropenia - On the day following dialysis, pt's white count
started to drop from 5.0 to 2.1 on [**10-11**] (the day after dialysis)
to a nadir of 0.4 on [**10-12**], ANC was 12. Over the course of that
time no new medications were introduced. Hematology was
consulted and recommended the discontinuation of allopurinol
given possible agranulocytosis. They also suggested a
complement activation of from the filter used during
hemodialysis as a potential etiology of the infection.
Anti-neutrophillic antibodies were negative. Flow cytometry was
done which was negative. No etiology was discovered regarding
her neutropenia when she developed a fever to 100.6 on [**10-14**],
Tmax to 101. She was started on filgastrim as well as broad
spectrum coverage with Vancomycin and Meropenem. She had fever
again on [**10-15**], but no source was identified however she did
develop abdominal pain in that time.
## Diverticulitis - On [**10-17**], pt awoke with mild abdominal pain
worse with palpation, her abdomen was also distended, slightly
more than the day prior. At 9:05, her pain was suddenly worse
[**11-4**] pain with one episode of emesis. She had a BM the morning
of with no bloody stools. BP was in 90s systolic and IV fluids
were given, but BP fell to the 80s systolic. KUB showed ascites
but no free air. Blood gas showed mild respiratory and
metabolic alkylosis. Her abdomen was tender to palpation with
rebound tenderness and no guarding. Surgery was consulted. She
was taken to the MICU for monitoring of hypotension. CT abdomen
was performed showing multiple tiny foci of free intraperitoneal
air along the left abdominal wall, adjacent to a segment of
sigmoid colon demonstrating numerous diverticula and mild
surrounding inflammatory stranding. She was taken to the OR by
Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**10-17**] for exploratory laparotomy, sigmoid
colectomy with Hartmann's procedure, small bowel resection,
removal of Marlex mesh, and repair of incisional ventral hernia.
Several days postop, the ostomy there was stool via the ostomy.
The stoma appeared pink.
## Rectus sheath hematoma - Pt was noted to have new LLQ
abdominal pain on [**10-8**], with decrease in hematocrit. CT
abdomen/pelvis was obtained which showed a large rectus sheath
hematoma on the left side. Heparin was discontinued and
hematocrit was followed closely. She received blood transfusion
to maintain Hct>25.
##. Cryptogenic Cirrhosis with progressive ascites: MELD Score
22/Childs-[**Doctor Last Name 14477**] B. Pt has history of TIPs in the past, noted to
have progressive increase in ascites over the past month. Pt
received diagnostic tap in the ED with no SBP noted and negative
cultures. The liver team was consulted to evaluate for possible
hepatorenal syndrome. In the setting of normal LFTs, they did
not feel the patient had a hepatorenal syndrome. Postop from
SBR, she had large volume output via the JP averaging
1100-1900cc of ascitic fluid. IV fluid was given.
##Leukocytosis: WBC started to rise on [**10-8**]. This increased to
as high as 33. She was pan cultured. The CVL was removed and on
[**10-22**], abd CT was done to evaluate WBC in 30s. CT demonstrated a
2.5 x 4.7 cm hypoattenuation with heterogeneous enhancement in
segment IV of the liver associated with atrophy of this segment.
This was stable since [**2186-10-8**], but new from [**2181-4-20**]. A liver
abscess seemed unlikely. Although the appearance was atypical
for a neoplasm. MRI was recommended to exclude this possibility.
There was interval reduction in ascites with unchanged
cirrhosis, unchanged left rectus sheath hematoma, calcified
fibroids and atrophic kidneys with multiple cysts. Antibiotics
were restarted ([**Last Name (un) **], flagyl, linezolid). WBC slowly trended
down from 33 to 11.4. Antibiotics were stopped on [**2186-11-21**] and
patient remained afebrile with normal without leukocytosis.
##. Thrombocytopenia: Likely due to her hepatic dysfunction, as
her prior Plt counts have been 51-118. On [**11-24**] platlets were
170.
.
##. Depression: She had been on Citalopram, but postop
colectomy, the patient became withdrawn and had a flat affect
and informed all of her caretakers that she did not wish to
continue "living like this". A Psych consult was obtained. She
appeared to have a delerium and recommendations were made.
Medications were altered (Citalopram d/c'd as she was on
Linezolid), steroids were decreased, pain medication was
decreased (morphine d/c'd and fentanyl patch decreased). Head CT
was negative for bleed. Antibiotics were continued to rule out
infectious causes. Dialysis was also continued though she had
one treatment for which she signed off early. Delerium improved
as well as affect. She verbalized her wish to continue with
treatments and adhere to treatment regimen.
.
##. GERD: Pt was continued on Omeprazole [**Hospital1 **].
.
##. Anemia: Pt was continued on iron supplements and epo by
mouth and then patient recieved supplements during dialysis.
.
##. Decreased po intake: Until returen of bowel function, TPN
was given. Once bowel function returned, diet was advanced, but
appetite and intake were poor. Nutrition was consulted and
followed throughout the hospitalization. She developed a fever
and had an elevated WBC. Central line was d/c'd with tip sent
for culture. During her depressed/delirium period she was not
taking anything PO and she refusing Dobhoff placement. A PICC
was replaced on [**10-31**] and TPN was resumed on [**10-31**]. As patient
continued to progress dobhoff tube was readdressed several
times, however patient adamently refused the dobhoff. On
[**2186-11-14**] after several discussions with patient and family
members present patient agreed to have dobhoff place at IR with
mild sedation. Dobhoff was placed uneventfully by IR. On [**11-22**]
dobhoff tube was noted to be clotted. After a failed attempt at
replacing dobhoff patient refused to have the tube placed. She
has been kept on TPN with nutrional supplementation at lib.
##. Tachyarrythmia: Patient with cardiac history notable for
moderate aortic stenosis, diastolic dysfunction, paroxysmal SVT.
Patient was transferred the ICU [**11-19**] for several episodes of
hyptention and tachycardia. She quickyl converted to sinus
tachycardia in the low 100s with systolic pressures at her
baseline of 100-109. She denies palpitations, history of chest
discomfort, orthopnea, PND. She has been experiencing shortness
of breath throughout the day which she attributes to her
distended abndomen. Last echo [**2186-3-14**] demonstrated moderate
aortic stensois. Mild symmetric left ventricular hypertrophy
with preserved global and regional biventricular systolic
function. Dilated thoracic aorta. Mild pulmonary hypertension.
Following return from the ICU [**11-22**] patient has had a sinus
tachycardia to 110's and no further episodes of hypotention.
Medications on Admission:
Cephelexin 500 mg [**Hospital1 **]
Ferrous Sulfate 325mg daily
Metoprolol XL 50mg daily
Furosemide 40mg daily
Citalopram 10mg daily
Lorazepam 1mg QHS PRN
Calcitriol 0.25mcg daily
Allopurinol 100mg QOD
Hydromorphone 4mg QID PRN
Omeprazole 20mg [**Hospital1 **]
ISMN SR 30mg daily
Discharge Medications:
1. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
2. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
3. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
4. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY 3 DAYS
(Every 3 Days).
5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
6. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
8. Epoetin Alfa 2,000 unit/mL Solution Sig: One (1) Injection
QTHUR (every Thursday).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2358**]
Discharge Diagnosis:
Primary:
acute renal failure
cirrhosis
ascites
Secondary:
anemia
depression
gerd
CAD
Discharge Condition:
stable
Discharge Instructions:
You were admitted to the hospital because you had a fever, renal
failure and ascites. An intravenous line was inserted into your
arm and you were given fluids. Blood work and lab tests were
performed that showed you had another reaction to the antibiotic
you were started on causing acute renal failure. You were given
medications that helped with your symptoms and were discharged
home in stable condition.
The following medications were changed/added during your
admission.
1. Prednisone 30mg daily
Please contact PCP or the hospital if you experience any fever
greater than 101, chills, nausea, vomiting, increased pain, pain
upon urination, or any other signs concerning of infection.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2186-11-10**] 2:00
Please contact Dr. [**First Name (STitle) 4102**] [**Name (STitle) 4090**] at [**Telephone/Fax (1) 3637**] for follow up.
Please contact your PCP [**Name (NI) **],[**Name9 (PRE) 278**] [**Telephone/Fax (1) 3070**] for follow
up
Provider: [**First Name8 (NamePattern2) 26**] [**Last Name (NamePattern1) 17711**], RN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2187-1-30**]
1:30
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339
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27345+57535
|
Discharge summary
|
report+addendum
|
Admission Date: [**2187-4-20**] Discharge Date: [**2187-6-19**]
Date of Birth: [**2120-7-17**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Severe pancreatitis
Major Surgical or Invasive Procedure:
PICC placement
Percutaneous Tracheostomy
History of Present Illness:
This is a 66 year old female who woke up the morning of [**2187-4-19**]
with severe periumbilical abdominal pain, nausea and vomitting.
She vomitted 7 times, and reports no blood. Her pain became
epigastric in nature but did not radiate, stayed in midline of
her abdomen. She reports normal bowel movements, no diarrhea
and no RUQ pain. She had been in her USOH before this time and
denies any other concerns. She presented to [**Hospital3 **]
that day, and her vitals there were significant for low-grade
temp (100.4), blood pressure was stable in the 120s-140s, and
persistently tachycardic in the 120s. Her ALT was 380, AST 514,
T bili 1.1, Alk phos 242, amylase 2960, lipase 3990, and she was
admitted to [**Hospital1 **] ICU with a presumed diagnosis of gallstone
pancreatitis.
While there, she initial received not enough IVF per their
notes, and her creatinine increased from 1.6 on admit to 2.9
this AM. She received 2L NS bolus and her UOP remained low
(15-30 cc/hr). Her LFTs decreased, amylase decreased, calcium
was very low at 6.0. Her creatinine increased to 2.6 this
afternoon. Her imaging studies demonstrated diffusely enlarged
pancreas c/w pancreatitis, cholelithiasis, ascites. MRCP showed
pancreatitis, normal bile and pancreatic ducts, diffusely
swollen and edematous pancreas, peripancreatic soft tissue
stranding, no pseudocyst or abscess. Her gallbladder was
distended.
Past Medical History:
1. HTN
2. Diverticulitis
3. ETOH Abuse
Social History:
Used to drink alcohol heavily until [**2174**]. Smoked [**1-12**] cigs/day,
quit years ago. Lives in [**Location 2624**] with her daughter and
son-in-law. Does not work. Came here from [**First Name8 (NamePattern2) 466**] [**Country 467**] 5 years
ago.
Family History:
NC
Physical Exam:
100.5 141/80 127 31 95% 2L
Gen: awake, alert, oriented, interactive, NAD
HEENT: anicteric, MM very dry
Neck: supple
Lungs: decreased breath sounds with scattered bibasilar crackles
CV: tachycardic, reg, no m/r/g
Abd: distended, tympanic, no bowel sounds, TTP over epigastrium
without rebound
Ext: no edema, 2+ distal pulses, feet warm
Pertinent Results:
TTE [**2187-4-23**]:
Conclusions:
The left atrium is normal in size. IVC appears collapsed and
underfilled. Left ventricular wall thicknesses and cavity size
are normal. Regional left ventricular wall motion is normal.
Left ventricular systolic function is hyperdynamic (EF>75%).
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.
Trivial mitral regurgitation is seen. The left ventricular
inflow pattern suggests impaired relaxation. There is moderate
pulmonary artery systolic hypertension. There is an anterior
space which most likely represents a fat pad.
.
CT Abd [**2187-4-25**]:
IMPRESSION:
1. Dilated small bowel to 3.1 cm consistent with ileus, although
early small bowel obstruction cannot be excluded.
2. Heterogeneous-appearing pancreas with significant amount of
stranding consistent with severe pancreatitis. Comment on
necrosis cannot be made without IV contrast, but the appearance
is highly supicious.
3. Ascites.
4. Subcutaneous soft tissue nodule in the posterior tissues of
uncertain clinical significance.
.
CT Abd with IV contrast [**2187-4-27**]:
IMPRESSION: Severe pancreatitis with marked inflammatory change
about the pancreas and into the mesentery. This follow-up CT
with contrast confirms the prior impression that most of the
pancreas is replaced by a necrotic fluid collection. Other than
increased ascites, the appearance is likely little changed.
.
[**2187-5-1**] CT ABD:
IMPRESSION: Interval stable appearance of severe pancreatitis
with replacement of the neck and body of the pancreas with an
inflammatory phlegmon. No residual enhancement of normal
pancreas tissue is identified in these regions. Pancreatic and
head tissue do enhance. Persistent ileus.
CHEST (PORTABLE AP) [**2187-5-3**] 7:07 PM
CHEST (PORTABLE AP)
Reason: ET tube
[**Hospital 93**] MEDICAL CONDITION:
66 year old woman on vent, oxygern desat, R mainstem intubation
s/p pulling tube out ET tube
REASON FOR THIS EXAMINATION:
ET tube
INDICATION: 66-year-old female on ventilator with O2
desaturation and right mainstem intubation, status post pulling
ET tube back.
COMPARISON: [**2187-5-2**].
AP SEMI-UPRIGHT CHEST RADIOGRAPH:
After withdrawal of the endotracheal tube, the tube tip now
appears 2 cm above the carina with the neck in flexed position.
Persistent small effusions versus atelectasis bilaterally.
CT ABDOMEN W/CONTRAST [**2187-5-9**] 2:50 PM
CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST
Reason: eval interval change in pancreas, r/o free air in
pancreas,
Field of view: 48 Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
66 year old woman with necrotizing pancreatitis w/ persistant
fever. Pt. also w/ recent ileus.
REASON FOR THIS EXAMINATION:
eval interval change in pancreas, r/o free air in pancreas, eval
ileus/obstruction
CONTRAINDICATIONS for IV CONTRAST: None.
CT TORSO
TECHNIQUE: Multidetector CT through the chest, abdomen, and
pelvis with oral and IV contrast.
HISTORY: 66-year-old woman with necrotizing pancreatitis with
persistent fever. Evaluate interval change in pancreas and
ileus, rule out SBO.
Comparison is made with prior study dated [**2187-5-1**].
CHEST CT:
The aorta, pulmonary artery, and great vessels are unremarkable.
There is mild cardiomegaly. There are no mediastinal or axillary
lymph nodes.
There is an endotracheal tube in place. There are bilateral
subclavian IV lines with tips in the proximal IVC and left
brachiocephalic vein.
Unchanged bibasilar segmental atelectasis and bilateral pleural
effusions.
ABDOMEN CT:
The liver, spleen, adrenal glands, and right kidney are
unremarkable. There is an unchanged simple cyst in the left
kidney. There is no hydronephrosis. The gallbladder is mildly
dilated. There is no biliary duct dilatation.
There is a feeding tube with distal tip within the fourth
portion of the duodenum.
There is an unchanged mild amount of ascites. Unchanged multiple
splenules adjacent to the spleen.
There is an unchanged lack of-enhancement of the neck and body
of the pancreas, which are replaced by a phlegmon/ fluid.
Redemonstration of enhancement within the head and tail of the
pancreas. There is no evidence of gas or air within the
pancreatic phlegmon.
The mesenteric vessels are patent without evidence of
pseudoaneurisms
Stable extensive peripancreatic stranding.
The bowel loops are unremarkable.
The aorta is normal in caliber.
PELVIC CT:
The bladder is not distended with Foley catheter in its
interior. The uterus is unremarkable. Multiple diverticula are
seen in the sigmoid colon.
There is free fluid within the pelvis.
BONE WINDOWS: There are no concerning bone lesions.
IMPRESSION:
1. Interval resolution of the small [**Last Name (un) 12376**] dilatation.
2. Stable appearance of severe pancreatitis with inflammatory
phlegmon/fluid within the neck and body of the pancreas with
retained enhancement of head and tail of pancreas and no new gas
collections.CHEST (PORTABLE AP) [**2187-5-9**] 3:28 AM
CHEST (PORTABLE AP)
Reason: eval pleural effusions/ pneumonia
[**Hospital 93**] MEDICAL CONDITION:
66 year old woman w/ pancreatitis, eval for pleural effusions/
pneumonia
REASON FOR THIS EXAMINATION:
eval pleural effusions/ pneumonia
AP CHEST, 3:49 A.M., [**5-9**]
HISTORY: Pancreatitis, evaluate for effusions and pneumonia.
IMPRESSION: AP chest compared to [**5-2**] through 28.
Moderate-sized bilateral pleural effusions layer posteriorly a
function of supine positioning but have probably increased as
well. Moderate enlargement of the cardiac silhouette is stable.
Left lower lobe consolidation present since [**5-2**] is probably
atelectasis. Lungs are free of consolidation elsewhere but mild
interstitial edema is probably present.
Tip of the endotracheal tube is at the sternal notch, right
subclavian line tip projects over the junction with the jugular
vein while a left subclavian line ends at the origin of the SVC.
No pneumothorax.
CHEST (PORTABLE AP) [**2187-5-20**] 10:28 AM
CHEST (PORTABLE AP)
Reason: dobhoff placemtn
[**Hospital 93**] MEDICAL CONDITION:
66 year old woman w/ pancreatitis, intubated, w/ fever, s/p R
subcl CVL change, and pull-back of line now
REASON FOR THIS EXAMINATION:
dobhoff placemtn
STUDY: AP chest.
HISTORY: 66-year-old woman with pancreatitis. The patient is
intubated and has fevers. Evaluate for placement of Dobhoff
tube.
FINDINGS: There is a Dobbhoff tube whose distal tip is not seen.
However, there is at least one loop seen within the fundus of
the stomach. There is a tracheostomy and a right-sided central
venous catheter, which are unchanged in position. There is
cardiomegaly. There is persistent left retrocardiac opacity and
likely bilateral effusions. The effusion on the left side is
improved.
[**Last Name (un) **]-INTESTINAL TUBE PLACEMENT (W/FLUORO) [**2187-5-22**] 12:58 PM
[**Last Name (un) **]-INTESTINAL TUBE PLACEMENT
Reason: needs post-pyloric feeding tube
[**Hospital 93**] MEDICAL CONDITION:
66 year old woman with severe pancreatitis, needs post-pyloric
feeding tube
REASON FOR THIS EXAMINATION:
needs post-pyloric feeding tube
INDICATION: Patient with pancreatitis and need for post pyloric
feeding tube.
NASOINTESTINAL TUBE PLACEMENT UNDER FLUOROSCOPY: A feeding tube
was advanced via the right nostril under fluoroscopic
visualization to the fourth portion of the duodenum with
approximately 5 cc of water soluble contrast administered via
the tube to confirm placement. No immediate complications were
seen.
IMPRESSION: Successful placement of 8 French [**First Name8 (NamePattern2) 2174**] [**Last Name (NamePattern1) 1557**]
feeding tube into fourth portion of the duodenum.
CT ABD W&W/O C [**2187-5-25**] 1:11 PM
CT ABD W&W/O C; CT PELVIS W/CONTRAST
Reason: Please eval for pseudocyst, abscess, intrabdominal
process.
Field of view: 36 Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
66 yo female with necrotizing pancreatitis.
REASON FOR THIS EXAMINATION:
Please eval for pseudocyst, abscess, intrabdominal process.
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: Necrotizing pancreatitis.
TECHNIQUE: After administration of oral contrast, MDCT was used
to obtain contiguous axial images through the abdomen, followed
by IV contrast-enhanced images through the abdomen and pelvis.
This study is compared to [**2187-5-9**].
CT ABDOMEN BEFORE AND AFTER IV CONTRAST: There is dependent
atelectasis at both lung bases. Small pleural effusions are
seen. There is a nasogastric tube coursing below the diaphragm.
The liver, gallbladder, spleen, adrenals, and right kidney are
within normal limits. The left kidney has a 22 x 25 mm fluid
density round lesion in its anterior aspect, representing a
cyst. The nasogastric tube can be seen coursing into the fourth
portion of the duodenal. The bowel loops appear normal, without
evidence of obstruction or perforation. There is no free air. A
13 mm and a 7-mm round soft tissue densities near the
anterior-inferior aspect of the spleen are identified,
representing splenules.
The pancreatic head, body, and tail are mostly replaced by a
large hypoattenuating lesion, consisting of fluid density and
some soft tissue, 42 mm in greatest AP diameter. There is
residual enhancement of the pancreatic head and tail. The fluid
collection extends into the mesentery, where there is extensive
nodularity indicating likely fat necrosis. Fluid is seen
tracking along the anterior pararenal spaces into the right and
left pericolic gutters; some surrounds the liver and the spleen
and tracks along into the pelvis.
Celiac axis and SMA are both well identified. However, the SMV
and splenic vein confluence are very attenuated, and the splenic
vein is not well identified. Some collateral vessels have
appeared in the interim including short gastrics. The portal
vein and hepatic veins appear patent. No saccular outpouchings
to suggest pseudoaneurysms are seen, although this is not a CTA
study targeted to the abdominal vessels. There is no free air in
the abdomen.
CT PELVIS WITH IV CONTRAST: As described above, a small amount
of free fluid is seen tracking along the pericolic gutters and
into the pelvis. A Foley is seen in the collapsed bladder and a
rectal tube is seen. The uterus is small. Bowel loops are
normal, without evidence of an obstruction or perforation. No
lymphadenopathy is identified.
Bone windows show no suspicious sclerotic or lytic lesions.
IMPRESSION:
1. essentailly unchanged appearance of severe pancreatitis with
large phlegmonous/fluid collection within the neck and body of
the pancreas. No new gas collections to suggest abscess are
seen. There is extensive fat necrosis of the mesentery.
2. Splenic vein thrombosis and interval development of
left-sided varices.
CT ABDOMEN W/CONTRAST [**2187-6-6**] 5:53 PM
CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST
Reason: Compare to CT abdomen on [**5-25**] to make sure that there
are no
Field of view: 36 Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
66 yo female with necrotizing pancreatitis.
REASON FOR THIS EXAMINATION:
Compare to CT abdomen on [**5-25**] to make sure that there are no new
processes and that she is clear to go home.
CONTRAINDICATIONS for IV CONTRAST: None.
66-year-old female with necrotizing pancreatitis.
COMPARISON: [**2187-5-25**].
TECHNIQUE: MDCT continuously acquired axial images of the
abdomen were obtained without IV contrast followed by images of
the abdomen and pelvis after 150 mL Optiray IV contrast.
CT OF THE ABDOMEN WITHOUT AND WITH IV CONTRAST: The visualized
lung bases are clear. The liver, gallbladder, spleen, adrenal
glands, and right kidney are unremarkable. Again demonstrated is
a 2 cm cyst of the left kidney. The stomach, duodenum, and
intra-abdominal loops of large and small bowel are unremarkable
without evidence of obstruction or perforation. There is no free
intra-abdominal air.
Again demonstrated is replacement of most of the pancreatic
head, body, and a portion of the tail with a large fluid density
lesion, which has decreased in size compared to [**2187-5-25**]
now with greatest AP diameter of 3 cm. There has also been
improvement in adjacent mesenteric fat necrosis. There has been
interval resolution of ascites previously seen to track along
the pericolic gutters and pararenal spaces. No new fluid
collection or abscess is identified. The splenic vein appears
less compressed on today's study and opacifies with contrast
without definite evidence of thrombosis. No saccular
outpouchings to suggest pseudoaneurysms of the adjacent arteries
are identified. Please note this is not a CT angiogram study
targeted for the abdominal vessels. The celiac trunk, SMA, and
[**Female First Name (un) 899**] opacify well.
CT OF THE PELVIS WITH IV CONTRAST: The rectum, urinary bladder,
uterus, adnexa, and pelvic loops of bowel are unremarkable.
There is free passage of oral contrast through to the rectum.
There is no free pelvic fluid or lymphadenopathy.
BONE WINDOWS: No suspicious lytic or sclerotic osseous lesions
are identified.
IMPRESSION:
Interval improvement in pancreatitis with decrease in size of
large phlegmonous/fluid collection of the neck and body of the
pancreas. No new fluid collections or abscesses are identified.
Mesenteric fat necrosis also appears mildly improved.
[**2187-5-31**] 09:12PM
COMPLETE BLOOD COUNT
White Blood Cells 10.7 K/uL 4.0 - 11.0
PERFORMED AT WEST STAT LAB
Red Blood Cells 3.19* m/uL 4.2 - 5.4
PERFORMED AT WEST STAT LAB
Hemoglobin 8.2* g/dL 12.0 - 16.0
PERFORMED AT WEST STAT LAB
Hematocrit 25.3* % 36 - 48
PERFORMED AT WEST STAT LAB
MCV 79* fL 82 - 98
PERFORMED AT WEST STAT LAB
MCH 25.8* pg 27 - 32
PERFORMED AT WEST STAT LAB
MCHC 32.6 % 31 - 35
PERFORMED AT WEST STAT LAB
RDW 18.8* % 10.5 - 15.5
DIFFERENTIAL
Neutrophils 55.8 % 50 - 70
PERFORMED AT WEST STAT LAB
Lymphocytes 31.6 % 18 - 42
PERFORMED AT WEST STAT LAB
Monocytes 6.0 % 2 - 11
PERFORMED AT WEST STAT LAB
Eosinophils 4.1* % 0 - 4
PERFORMED AT WEST STAT LAB
Basophils 2.6* % 0 - 2
PERFORMED AT WEST STAT LAB
RED CELL MORPHOLOGY
Hypochromia 1+
Anisocytosis 2+
Microcytes 2+
BASIC COAGULATION (PT, PTT, PLT, INR)
Platelet Count 427 K/uL 150 - 440
PERFORMED AT WEST STAT LAB
[**2187-6-3**] 05:50AM
Report Comment:
LINE: PICC
RENAL & GLUCOSE
Glucose 112* mg/dL 70 - 105
PERFORMED AT WEST STAT LAB
Urea Nitrogen 29* mg/dL 6 - 20
PERFORMED AT WEST STAT LAB
Creatinine 0.8 mg/dL 0.4 - 1.1
PERFORMED AT WEST STAT LAB
Sodium 138 mEq/L 133 - 145
PERFORMED AT WEST STAT LAB
Potassium 4.2 mEq/L 3.3 - 5.1
PERFORMED AT WEST STAT LAB
Chloride 106 mEq/L 96 - 108
PERFORMED AT WEST STAT LAB
Bicarbonate 24 mEq/L 22 - 32
PERFORMED AT WEST STAT LAB
Anion Gap 12 mEq/L 8 - 20
CHEMISTRY
Calcium, Total 9.5 mg/dL 8.4 - 10.2
PERFORMED AT WEST STAT LAB
Phosphate 3.7 mg/dL 2.7 - 4.5
PERFORMED AT WEST STAT LAB
Magnesium 2.1 mg/dL 1.6 - 2.6
PERFORMED AT WEST STAT LAB
[**2187-6-11**] 07:08AM
CHEMISTRY
Albumin 3.5 g/dL 3.4 - 4.8
PERFORMED AT WEST STAT LAB
Iron 68 ug/dL 30 - 160
HEMATOLOGIC
Iron Binding Capacity, Total 218* ug/dL 260 - 470
Ferritin 549* ng/mL 13 - 150
Transferrin 168* mg/dL 200 - 360
Brief Hospital Course:
A/P: 66 year old female with HTN, who presents with severe
acute pancreatitis and admitted on [**2187-4-20**].
1. Pancreatitis:
The patient initially presented as a transfer from [**Hospital1 **] with severe pancreatitis. The etiology was unclear
thought likely secondary to alcohol, although the patient
denies, rather than obstructing gallstone. There was no evidence
of biliary ductal dilatation from CT scan at [**Hospital1 **]. The patient
was hydrated aggressively with IVF on her first day after
transfer. She was found to have high fevers and was tachycardic,
she was started on empiric antibiotics for pancreatitis. A CT
abdomen shows pancreatic necrosis. LFT's were elevated with ALT
380, AST 514, Tbili 1.1, AP 242, Amylase 2960, Lipase 3990.
An abdominal CT on [**2187-5-9**] showed stable appearance of severe
pancreatitis with inflammatory phlegmon within the neck and body
of the pancreas. Per surgery, it is unlikely infected, at
present, fevers may be due to cytokine release. A operation was
deferred at present and can be readdressed later if persistent
fevers occur without a source. A repeat CT on [**2187-5-25**] showed
essentially unchanged appearance of severe pancreatitis with
large phlegmonous/fluid collection within the neck and body of
the pancreas. On [**2187-6-6**] a CT showed interval improvement in
pancreatitis with decrease in size of large phlegmonous/fluid
collection of the neck and body of the pancreas. No new fluid
collections or abscesses are identified.
2. Abdominal Distension/Ileus:
The patient had good stool output, and her abdominal exam was
stable. On [**2187-4-24**] she was noted to have abundant bilious output
from NG tube. There was concern for ileus vs obstruction on CT
abdomen. A surgery consult was obtained and it was thought to be
an ileus. The NGT was left in place and TPN started. Next, a
Dobbhoff was placed and trophic tube feedings were started and
she was tolerating them fine. A rectal tube was placed for
liquid stool. There was an increased amount of fecal leakage
around the tube. A new tube was inserted. She had no skin
breakdown. After several days, the stool became more formed. She
continued to have incontinence. She was seen by Speech and
Swallow after her tracheostomy was downsized and passed a speech
and swallow evaluation. [**5-30**], a PICC was placed and TPN started
after her Dobbhoff was self D/C'd. She was started on a soft
diet [**2187-5-31**] and calorie counts revealed that she was not taking
in enough calories by mouth. TPN continues at this time.
3. Fever/leukocytosis:
Upon admission, she was febrile to 101.3 with an increasing
white count. She was on Vanco and Zosyn for PNA. Also must
consider possible pancreatic infected pseudocyst. A CXR on
[**2187-5-9**] showed bilateral pleural effusions, left lower lobe
consolidation.
4. ARF: Creatinine improving from OSH, likely volume depletion.
Her Bun 38 and Cr 2.3 on admission improved with adequate
hydration.
5. Tachycardia: Likely related to volume depletion so would
discontinue beta-blocker. Other possibility is alcohol
withdrawal as she would now be about 48 hours from last possible
drink. TTE shows hyperdynamic EF, impaired relaxation, TR grad
48. A ECHO showed an EF>75%. She was on Metoprolol and Enalapril
for HR and BP control.
6. Hypoxia/Wheezing: 91% on RA with decreased breath sounds at
bases and now audible expiratory wheezes. [**Month (only) 116**] develop pulmonary
edema as a result of her fluid resuscitation and require
intubation. The patient had Respiratory Failure on [**2187-4-20**] and
was intubated. Likely multifactorial, PNA and CHF. CHF in
setting of aggressive volume repletion, interstitial infiltrates
on CXR, BNP 1305. She was sedated for 22 days while intubated.
The sedation was stopped. A tracheostomy was placed on [**2187-5-10**].
She had a prolonged intubation and was weaned off the ventilator
on HD 30. She requires frequent suctioning for thick, white
secretions. Passy-Muir valve was attempted with this patient,
but she was unable to tolerate it. On [**2187-5-28**], her tracheostomy
was downsized from a 8 to 6 for a PMV trial. She was able to
tolerate the Passy-Muir. A trigger was called for a drop in O2
saturation secondary to a mucus plug. She was suctioned and her
inner cannula was removed. After suctioning, humidification, and
nebulizers, her O2 sats came back up to 98%. She continued to do
well with the Trach and Passy-Muir and able to vocalize.
7. Occupational Therapy
Initially, the patient did not follow simple commands in Creole
or English. She was able to squeeze hand once when asked, but
otherwise was not answering questions appropriately. She
attempted verbalization x 3, but it was unintelligible secondary
to Trach.
After the Passy-Muir, she was able to communicate with the staff
and family members. She was highly motivated to return to her
baseline.
8. Physical Therapy
After the Passy-Muir was placed and tolerable, she seemed highly
motivated to ambulate and increase daily activity. She improved
from basic transfers to the chair, to being able to ambulate the
halls short distances. She will continue to need physical
therapy to improve functional activity,
Comm: with patient and son-in-law, [**Name (NI) **]. Daughter, [**Name (NI) **]
[**Telephone/Fax (1) 67011**], home [**Telephone/Fax (1) 67012**], son-in-law ce: [**Telephone/Fax (1) 67013**]
Medications on Admission:
Medications at home:
Vicodin prn
Atenolol 50 mg daily
Lisinopril 10 mg daily
*
Medications on transfer:
Colace prn
Morphine 2 mg IV prn, last dose today at 9:45 pm
Metoprolol 5 mg IV q6hTylenol 650 mg pr q6h, last at 5 pm today
Hydralazine 20 mg IV q4h prn last dose at 1:30 this am
Protonix 40 mg IV daily
Unasyn 3 gm q6h (day 1 = [**2187-4-20**])
NS, 2L since 3 pm today
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
3. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q4-6H (every 4 to 6 hours) as needed.
4. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
5. Amylase-Lipase-Protease 468 mg Tablet Sig: Two (2) Tablet PO
TID (3 times a day).
6. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
7. Enalapril Maleate 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day). ML(s)
10. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours).
11. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day).
12. Iron 325 (65) mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2222**] - [**Location (un) 538**]
Discharge Diagnosis:
Epigastric Pain
Pancreatitis with rising LFT's
Discharge Condition:
Good
Discharge Instructions:
* Increasing pain
* Fever (>101.5 F) or Vomiting
* Inability to pass gas or stool
* Other symptoms concerning to you
Please take all your medications as ordered
Continue Trach Care - suction PRN, humidification at all times,
change trach sponge and ties PRN, change inner cannula daily
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] in 2 weeks. Call ([**Telephone/Fax (1) 15807**] for an appointment.
Completed by:[**2187-6-13**] Name: [**Known lastname **],[**Known firstname 5139**] Unit No: [**Numeric Identifier 11619**]
Admission Date: [**2187-4-20**] Discharge Date: [**2187-6-19**]
Date of Birth: [**2120-7-17**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2083**]
Addendum:
She stayed in the hospital a few more days due to lack of bed
availability. The only significant change was that she got
another interval CT scan on [**6-18**] of the abdomen and pelvis which
was unchanged from her previous CT scan on [**6-6**]. Also on [**6-16**]
she pulled out her PICC line and since then she has not recieved
TPN. She is taking food by mouth but on [**6-19**] we were going to
do a calorie count to make sure that she was taking enough food
by mouth. Instead she is getting discharged today and [**Hospital1 1238**]
will have to do the calorie count. She will also follow up with
Dr. [**Last Name (STitle) **] in 3 weeks to discuss cholecystectomy.
Chief Complaint:
Severe pancreatitis
Major Surgical or Invasive Procedure:
Percutaneous Tracheostomy
PICC Line Placement.
History of Present Illness:
This is a 66 year old female who woke up the morning of [**2187-4-19**]
with severe periumbilical abdominal pain, nausea and vomitting.
She vomitted 7 times, and reports no blood. Her pain became
epigastric in nature but did not radiate, stayed in midline of
her abdomen. She reports normal bowel movements, no diarrhea
and no RUQ pain. She had been in her USOH before this time and
denies any other concerns. She presented to [**Hospital3 3287**]
that day, and her vitals there were significant for low-grade
temp (100.4), blood pressure was stable in the 120s-140s, and
persistently tachycardic in the 120s. Her ALT was 380, AST 514,
T bili 1.1, Alk phos 242, amylase 2960, lipase 3990, and she was
admitted to [**Hospital1 **] ICU with a presumed diagnosis of gallstone
pancreatitis.
While there, she initial received not enough IVF per their
notes, and her creatinine increased from 1.6 on admit to 2.9
this AM. She received 2L NS bolus and her UOP remained low
(15-30 cc/hr). Her LFTs decreased, amylase decreased, calcium
was very low at 6.0. Her creatinine increased to 2.6 this
afternoon. Her imaging studies demonstrated diffusely enlarged
pancreas c/w pancreatitis, cholelithiasis, ascites. MRCP showed
pancreatitis, normal bile and pancreatic ducts, diffusely
swollen and edematous pancreas, peripancreatic soft tissue
stranding, no pseudocyst or abscess. Her gallbladder was
distended.
Past Medical History:
1. HTN
2. Diverticulitis
3. ETOH Abuse
Social History:
Used to drink alcohol heavily until [**2174**]. Smoked [**1-12**] cigs/day,
quit years ago. Lives in [**Location 271**] with her daughter and
son-in-law. Does not work. Came here from [**First Name8 (NamePattern2) 11620**] [**Country **] 5 years
ago.
Family History:
NC
Physical Exam:
100.5 141/80 127 31 95% 2L
Gen: awake, alert, oriented, interactive, NAD
HEENT: anicteric, MM very dry
Neck: supple
Lungs: decreased breath sounds with scattered bibasilar crackles
CV: tachycardic, reg, no m/r/g
Abd: distended, tympanic, no bowel sounds, TTP over epigastrium
without rebound
Ext: no edema, 2+ distal pulses, feet warm
Pertinent Results:
TTE [**2187-4-23**]:
Conclusions:
The left atrium is normal in size. IVC appears collapsed and
underfilled. Left ventricular wall thicknesses and cavity size
are normal. Regional left ventricular wall motion is normal.
Left ventricular systolic function is hyperdynamic (EF>75%).
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.
Trivial mitral regurgitation is seen. The left ventricular
inflow pattern suggests impaired relaxation. There is moderate
pulmonary artery systolic hypertension. There is an anterior
space which most likely represents a fat pad.
.
CT Abd [**2187-4-25**]:
IMPRESSION:
1. Dilated small bowel to 3.1 cm consistent with ileus, although
early small bowel obstruction cannot be excluded.
2. Heterogeneous-appearing pancreas with significant amount of
stranding consistent with severe pancreatitis. Comment on
necrosis cannot be made without IV contrast, but the appearance
is highly supicious.
3. Ascites.
4. Subcutaneous soft tissue nodule in the posterior tissues of
uncertain clinical significance.
.
CT Abd with IV contrast [**2187-4-27**]:
IMPRESSION: Severe pancreatitis with marked inflammatory change
about the pancreas and into the mesentery. This follow-up CT
with contrast confirms the prior impression that most of the
pancreas is replaced by a necrotic fluid collection. Other than
increased ascites, the appearance is likely little changed.
.
[**2187-5-1**] CT ABD:
IMPRESSION: Interval stable appearance of severe pancreatitis
with replacement of the neck and body of the pancreas with an
inflammatory phlegmon. No residual enhancement of normal
pancreas tissue is identified in these regions. Pancreatic and
head tissue do enhance. Persistent ileus.
CHEST (PORTABLE AP) [**2187-5-3**] 7:07 PM
CHEST (PORTABLE AP)
Reason: ET tube
[**Hospital 5**] MEDICAL CONDITION:
66 year old woman on vent, oxygern desat, R mainstem intubation
s/p pulling tube out ET tube
REASON FOR THIS EXAMINATION:
ET tube
INDICATION: 66-year-old female on ventilator with O2
desaturation and right mainstem intubation, status post pulling
ET tube back.
COMPARISON: [**2187-5-2**].
AP SEMI-UPRIGHT CHEST RADIOGRAPH:
After withdrawal of the endotracheal tube, the tube tip now
appears 2 cm above the carina with the neck in flexed position.
Persistent small effusions versus atelectasis bilaterally.
CT ABDOMEN W/CONTRAST [**2187-5-9**] 2:50 PM
CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST
Reason: eval interval change in pancreas, r/o free air in
pancreas,
Field of view: 48 Contrast: OPTIRAY
[**Hospital 5**] MEDICAL CONDITION:
66 year old woman with necrotizing pancreatitis w/ persistant
fever. Pt. also w/ recent ileus.
REASON FOR THIS EXAMINATION:
eval interval change in pancreas, r/o free air in pancreas, eval
ileus/obstruction
CONTRAINDICATIONS for IV CONTRAST: None.
CT TORSO
TECHNIQUE: Multidetector CT through the chest, abdomen, and
pelvis with oral and IV contrast.
HISTORY: 66-year-old woman with necrotizing pancreatitis with
persistent fever. Evaluate interval change in pancreas and
ileus, rule out SBO.
Comparison is made with prior study dated [**2187-5-1**].
CHEST CT:
The aorta, pulmonary artery, and great vessels are unremarkable.
There is mild cardiomegaly. There are no mediastinal or axillary
lymph nodes.
There is an endotracheal tube in place. There are bilateral
subclavian IV lines with tips in the proximal IVC and left
brachiocephalic vein.
Unchanged bibasilar segmental atelectasis and bilateral pleural
effusions.
ABDOMEN CT:
The liver, spleen, adrenal glands, and right kidney are
unremarkable. There is an unchanged simple cyst in the left
kidney. There is no hydronephrosis. The gallbladder is mildly
dilated. There is no biliary duct dilatation.
There is a feeding tube with distal tip within the fourth
portion of the duodenum.
There is an unchanged mild amount of ascites. Unchanged multiple
splenules adjacent to the spleen.
There is an unchanged lack of-enhancement of the neck and body
of the pancreas, which are replaced by a phlegmon/ fluid.
Redemonstration of enhancement within the head and tail of the
pancreas. There is no evidence of gas or air within the
pancreatic phlegmon.
The mesenteric vessels are patent without evidence of
pseudoaneurisms
Stable extensive peripancreatic stranding.
The bowel loops are unremarkable.
The aorta is normal in caliber.
PELVIC CT:
The bladder is not distended with Foley catheter in its
interior. The uterus is unremarkable. Multiple diverticula are
seen in the sigmoid colon.
There is free fluid within the pelvis.
BONE WINDOWS: There are no concerning bone lesions.
IMPRESSION:
1. Interval resolution of the small [**Last Name (un) 3888**] dilatation.
2. Stable appearance of severe pancreatitis with inflammatory
phlegmon/fluid within the neck and body of the pancreas with
retained enhancement of head and tail of pancreas and no new gas
collections.CHEST (PORTABLE AP) [**2187-5-9**] 3:28 AM
CHEST (PORTABLE AP)
Reason: eval pleural effusions/ pneumonia
[**Hospital 5**] MEDICAL CONDITION:
66 year old woman w/ pancreatitis, eval for pleural effusions/
pneumonia
REASON FOR THIS EXAMINATION:
eval pleural effusions/ pneumonia
AP CHEST, 3:49 A.M., [**5-9**]
HISTORY: Pancreatitis, evaluate for effusions and pneumonia.
IMPRESSION: AP chest compared to [**5-2**] through 28.
Moderate-sized bilateral pleural effusions layer posteriorly a
function of supine positioning but have probably increased as
well. Moderate enlargement of the cardiac silhouette is stable.
Left lower lobe consolidation present since [**5-2**] is probably
atelectasis. Lungs are free of consolidation elsewhere but mild
interstitial edema is probably present.
Tip of the endotracheal tube is at the sternal notch, right
subclavian line tip projects over the junction with the jugular
vein while a left subclavian line ends at the origin of the SVC.
No pneumothorax.
CHEST (PORTABLE AP) [**2187-5-20**] 10:28 AM
CHEST (PORTABLE AP)
Reason: dobhoff placemtn
[**Hospital 5**] MEDICAL CONDITION:
66 year old woman w/ pancreatitis, intubated, w/ fever, s/p R
subcl CVL change, and pull-back of line now
REASON FOR THIS EXAMINATION:
dobhoff placemtn
STUDY: AP chest.
HISTORY: 66-year-old woman with pancreatitis. The patient is
intubated and has fevers. Evaluate for placement of Dobhoff
tube.
FINDINGS: There is a Dobbhoff tube whose distal tip is not seen.
However, there is at least one loop seen within the fundus of
the stomach. There is a tracheostomy and a right-sided central
venous catheter, which are unchanged in position. There is
cardiomegaly. There is persistent left retrocardiac opacity and
likely bilateral effusions. The effusion on the left side is
improved.
[**Last Name (un) 11621**]-INTESTINAL TUBE PLACEMENT (W/FLUORO) [**2187-5-22**] 12:58 PM
[**Last Name (un) 11621**]-INTESTINAL TUBE PLACEMENT
Reason: needs post-pyloric feeding tube
[**Hospital 5**] MEDICAL CONDITION:
66 year old woman with severe pancreatitis, needs post-pyloric
feeding tube
REASON FOR THIS EXAMINATION:
needs post-pyloric feeding tube
INDICATION: Patient with pancreatitis and need for post pyloric
feeding tube.
NASOINTESTINAL TUBE PLACEMENT UNDER FLUOROSCOPY: A feeding tube
was advanced via the right nostril under fluoroscopic
visualization to the fourth portion of the duodenum with
approximately 5 cc of water soluble contrast administered via
the tube to confirm placement. No immediate complications were
seen.
IMPRESSION: Successful placement of 8 French [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
feeding tube into fourth portion of the duodenum.
CT ABD W&W/O C [**2187-5-25**] 1:11 PM
CT ABD W&W/O C; CT PELVIS W/CONTRAST
Reason: Please eval for pseudocyst, abscess, intrabdominal
process.
Field of view: 36 Contrast: OPTIRAY
[**Hospital 5**] MEDICAL CONDITION:
66 yo female with necrotizing pancreatitis.
REASON FOR THIS EXAMINATION:
Please eval for pseudocyst, abscess, intrabdominal process.
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: Necrotizing pancreatitis.
TECHNIQUE: After administration of oral contrast, MDCT was used
to obtain contiguous axial images through the abdomen, followed
by IV contrast-enhanced images through the abdomen and pelvis.
This study is compared to [**2187-5-9**].
CT ABDOMEN BEFORE AND AFTER IV CONTRAST: There is dependent
atelectasis at both lung bases. Small pleural effusions are
seen. There is a nasogastric tube coursing below the diaphragm.
The liver, gallbladder, spleen, adrenals, and right kidney are
within normal limits. The left kidney has a 22 x 25 mm fluid
density round lesion in its anterior aspect, representing a
cyst. The nasogastric tube can be seen coursing into the fourth
portion of the duodenal. The bowel loops appear normal, without
evidence of obstruction or perforation. There is no free air. A
13 mm and a 7-mm round soft tissue densities near the
anterior-inferior aspect of the spleen are identified,
representing splenules.
The pancreatic head, body, and tail are mostly replaced by a
large hypoattenuating lesion, consisting of fluid density and
some soft tissue, 42 mm in greatest AP diameter. There is
residual enhancement of the pancreatic head and tail. The fluid
collection extends into the mesentery, where there is extensive
nodularity indicating likely fat necrosis. Fluid is seen
tracking along the anterior pararenal spaces into the right and
left pericolic gutters; some surrounds the liver and the spleen
and tracks along into the pelvis.
Celiac axis and SMA are both well identified. However, the SMV
and splenic vein confluence are very attenuated, and the splenic
vein is not well identified. Some collateral vessels have
appeared in the interim including short gastrics. The portal
vein and hepatic veins appear patent. No saccular outpouchings
to suggest pseudoaneurysms are seen, although this is not a CTA
study targeted to the abdominal vessels. There is no free air in
the abdomen.
CT PELVIS WITH IV CONTRAST: As described above, a small amount
of free fluid is seen tracking along the pericolic gutters and
into the pelvis. A Foley is seen in the collapsed bladder and a
rectal tube is seen. The uterus is small. Bowel loops are
normal, without evidence of an obstruction or perforation. No
lymphadenopathy is identified.
Bone windows show no suspicious sclerotic or lytic lesions.
IMPRESSION:
1. essentailly unchanged appearance of severe pancreatitis with
large phlegmonous/fluid collection within the neck and body of
the pancreas. No new gas collections to suggest abscess are
seen. There is extensive fat necrosis of the mesentery.
2. Splenic vein thrombosis and interval development of
left-sided varices.
CT ABDOMEN W/CONTRAST [**2187-6-6**] 5:53 PM
CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST
Reason: Compare to CT abdomen on [**5-25**] to make sure that there
are no
Field of view: 36 Contrast: OPTIRAY
[**Hospital 5**] MEDICAL CONDITION:
66 yo female with necrotizing pancreatitis.
REASON FOR THIS EXAMINATION:
Compare to CT abdomen on [**5-25**] to make sure that there are no new
processes and that she is clear to go home.
CONTRAINDICATIONS for IV CONTRAST: None.
66-year-old female with necrotizing pancreatitis.
COMPARISON: [**2187-5-25**].
TECHNIQUE: MDCT continuously acquired axial images of the
abdomen were obtained without IV contrast followed by images of
the abdomen and pelvis after 150 mL Optiray IV contrast.
CT OF THE ABDOMEN WITHOUT AND WITH IV CONTRAST: The visualized
lung bases are clear. The liver, gallbladder, spleen, adrenal
glands, and right kidney are unremarkable. Again demonstrated is
a 2 cm cyst of the left kidney. The stomach, duodenum, and
intra-abdominal loops of large and small bowel are unremarkable
without evidence of obstruction or perforation. There is no free
intra-abdominal air.
Again demonstrated is replacement of most of the pancreatic
head, body, and a portion of the tail with a large fluid density
lesion, which has decreased in size compared to [**2187-5-25**]
now with greatest AP diameter of 3 cm. There has also been
improvement in adjacent mesenteric fat necrosis. There has been
interval resolution of ascites previously seen to track along
the pericolic gutters and pararenal spaces. No new fluid
collection or abscess is identified. The splenic vein appears
less compressed on today's study and opacifies with contrast
without definite evidence of thrombosis. No saccular
outpouchings to suggest pseudoaneurysms of the adjacent arteries
are identified. Please note this is not a CT angiogram study
targeted for the abdominal vessels. The celiac trunk, SMA, and
[**Female First Name (un) **] opacify well.
CT OF THE PELVIS WITH IV CONTRAST: The rectum, urinary bladder,
uterus, adnexa, and pelvic loops of bowel are unremarkable.
There is free passage of oral contrast through to the rectum.
There is no free pelvic fluid or lymphadenopathy.
BONE WINDOWS: No suspicious lytic or sclerotic osseous lesions
are identified.
IMPRESSION:
Interval improvement in pancreatitis with decrease in size of
large phlegmonous/fluid collection of the neck and body of the
pancreas. No new fluid collections or abscesses are identified.
Mesenteric fat necrosis also appears mildly improved.
[**2187-5-31**] 09:12PM
COMPLETE BLOOD COUNT
White Blood Cells 10.7 K/uL 4.0 - 11.0
PERFORMED AT WEST STAT LAB
Red Blood Cells 3.19* m/uL 4.2 - 5.4
PERFORMED AT WEST STAT LAB
Hemoglobin 8.2* g/dL 12.0 - 16.0
PERFORMED AT WEST STAT LAB
Hematocrit 25.3* % 36 - 48
PERFORMED AT WEST STAT LAB
MCV 79* fL 82 - 98
PERFORMED AT WEST STAT LAB
MCH 25.8* pg 27 - 32
PERFORMED AT WEST STAT LAB
MCHC 32.6 % 31 - 35
PERFORMED AT WEST STAT LAB
RDW 18.8* % 10.5 - 15.5
DIFFERENTIAL
Neutrophils 55.8 % 50 - 70
PERFORMED AT WEST STAT LAB
Lymphocytes 31.6 % 18 - 42
PERFORMED AT WEST STAT LAB
Monocytes 6.0 % 2 - 11
PERFORMED AT WEST STAT LAB
Eosinophils 4.1* % 0 - 4
PERFORMED AT WEST STAT LAB
Basophils 2.6* % 0 - 2
PERFORMED AT WEST STAT LAB
RED CELL MORPHOLOGY
Hypochromia 1+
Anisocytosis 2+
Microcytes 2+
BASIC COAGULATION (PT, PTT, PLT, INR)
Platelet Count 427 K/uL 150 - 440
PERFORMED AT WEST STAT LAB
[**2187-6-3**] 05:50AM
Report Comment:
LINE: PICC
RENAL & GLUCOSE
Glucose 112* mg/dL 70 - 105
PERFORMED AT WEST STAT LAB
Urea Nitrogen 29* mg/dL 6 - 20
PERFORMED AT WEST STAT LAB
Creatinine 0.8 mg/dL 0.4 - 1.1
PERFORMED AT WEST STAT LAB
Sodium 138 mEq/L 133 - 145
PERFORMED AT WEST STAT LAB
Potassium 4.2 mEq/L 3.3 - 5.1
PERFORMED AT WEST STAT LAB
Chloride 106 mEq/L 96 - 108
PERFORMED AT WEST STAT LAB
Bicarbonate 24 mEq/L 22 - 32
PERFORMED AT WEST STAT LAB
Anion Gap 12 mEq/L 8 - 20
CHEMISTRY
Calcium, Total 9.5 mg/dL 8.4 - 10.2
PERFORMED AT WEST STAT LAB
Phosphate 3.7 mg/dL 2.7 - 4.5
PERFORMED AT WEST STAT LAB
Magnesium 2.1 mg/dL 1.6 - 2.6
PERFORMED AT WEST STAT LAB
[**2187-6-11**] 07:08AM
CHEMISTRY
Albumin 3.5 g/dL 3.4 - 4.8
PERFORMED AT WEST STAT LAB
Iron 68 ug/dL 30 - 160
HEMATOLOGIC
Iron Binding Capacity, Total 218* ug/dL 260 - 470
Ferritin 549* ng/mL 13 - 150
Transferrin 168* mg/dL 200 - 360
CT ABD W&W/O C [**2187-6-18**] 3:46 PM
CT ABD W&W/O C; CT PELVIS W/CONTRAST
Reason: Please assess for progression/resolution of
pancreatitis. As
Contrast: OPTIRAY
[**Hospital 5**] MEDICAL CONDITION:
66 yo female with necrotizing pancreatitis.
REASON FOR THIS EXAMINATION:
Please assess for progression/resolution of pancreatitis. Assess
for fluid collections. Please give PO and IV contrast.
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 66-year-old woman with necrotizing pancreatitis.
TECHNIQUE: Contiguous axial CT images of the abdomen and pelvis
were obtained with and without the administration of intravenous
contrast [**Doctor Last Name 932**], 145 cc of Optiray.
COMPARISON: Comparison is made with the prior CT studies,
including the most recent prior CT study dated [**2187-6-6**].
FINDINGS: Again note is made of a large intrapancreatic fluid
collection located at the center of the pancreas, measuring 3.5
x 8.4 cm, not significantly changed compared to the prior study.
Surrounding pancreatic parenchyma is homogeneously enhanced.
Again note is made of mild fat stranding around the pancreas, in
this patient with known pancreatitis. Major branches of SMA and
SMV are patent, however, part of the fluid collection abuts SMV.
The liver is unremarkable without evidence of focal liver
lesion. Gallbladder, pancreas, adrenal glands, and the
visualized portion of large and small intestine are within
normal limits. Note is made of diverticulosis of the hepatic
flexure. Again note is made of left renal cyst, unchanged
compared to the prior study. No hydronephrosis. No ascites. No
significant lymphadenopathy. Normal appendix is noted.
PELVIS: The visualized portion of large and small intestine are
within normal limits. No ascites. No significant
lymphadenopathy.
The visualized portion of lung bases are clear with atelectasis.
There is no suspicious lytic or blastic lesion in skeletal
structures.
IMPRESSION:
1. Persistent intrapancreatic fluid collection versus
pseudocyst, not significantly changed compared to the prior
study. Homogeneous enhancement in surrounding pancreatic tissue,
with mild fat stranding in peripancreatic fat.
2. Left renal cyst.
Test Name Value Units Reference Range
[**2187-6-13**] 05:39AM
COMPLETE BLOOD COUNT
White Blood Cells 8.7 K/uL 4.0 - 11.0
PERFORMED AT WEST STAT LAB
Red Blood Cells 3.02* m/uL 4.2 - 5.4
PERFORMED AT WEST STAT LAB
Hemoglobin 7.6* g/dL 12.0 - 16.0
PERFORMED AT WEST STAT LAB
Hematocrit 24.3* % 36 - 48
PERFORMED AT WEST STAT LAB
MCV 81* fL 82 - 98
PERFORMED AT WEST STAT LAB
MCH 25.0* pg 27 - 32
PERFORMED AT WEST STAT LAB
MCHC 31.1 % 31 - 35
PERFORMED AT WEST STAT LAB
RDW 19.1* % 10.5 - 15.5
BASIC COAGULATION (PT, PTT, PLT, INR)
Platelet Count 340 K/uL 150 - 440
PERFORMED AT WEST STAT LAB
[**2187-6-18**] 05:30AM
RENAL & GLUCOSE
Glucose 132* mg/dL 70 - 105
PERFORMED AT WEST STAT LAB
Urea Nitrogen 37* mg/dL 6 - 20
PERFORMED AT WEST STAT LAB
Creatinine 0.9 mg/dL 0.4 - 1.1
PERFORMED AT WEST STAT LAB
Sodium 137 mEq/L 133 - 145
PERFORMED AT WEST STAT LAB
Potassium 4.3 mEq/L 3.3 - 5.1
PERFORMED AT WEST STAT LAB
Chloride 106 mEq/L 96 - 108
PERFORMED AT WEST STAT LAB
Bicarbonate 21* mEq/L 22 - 32
PERFORMED AT WEST STAT LAB
Anion Gap 14 mEq/L 8 - 20
CHEMISTRY
Albumin 3.6 g/dL 3.4 - 4.8
PERFORMED AT WEST STAT LAB
Calcium, Total 10.2 mg/dL 8.4 - 10.2
PERFORMED AT WEST STAT LAB
Phosphate 5.3* mg/dL 2.7 - 4.5
PERFORMED AT WEST STAT LAB
Magnesium 2.3 mg/dL 1.6 - 2.6
PERFORMED AT WEST STAT LAB
Iron 75 ug/dL 30 - 160
HEMATOLOGIC
Iron Binding Capacity, Total 221* ug/dL 260 - 470
Ferritin 546* ng/mL 13 - 150
Transferrin 170* mg/dL 200 - 360
Brief Hospital Course:
A/P: 66 year old female with HTN, who presents with severe
acute pancreatitis and admitted on [**2187-4-20**].
1. Pancreatitis:
The patient initially presented as a transfer from [**Hospital1 11622**] with severe pancreatitis. The etiology was unclear
thought likely secondary to alcohol, although the patient
denies, rather than obstructing gallstone. There was no evidence
of biliary ductal dilatation from CT scan at [**Hospital1 **]. The patient
was hydrated aggressively with IVF on her first day after
transfer. She was found to have high fevers and was tachycardic,
she was started on empiric antibiotics for pancreatitis. A CT
abdomen shows pancreatic necrosis. LFT's were elevated with ALT
380, AST 514, Tbili 1.1, AP 242, Amylase 2960, Lipase 3990.
An abdominal CT on [**2187-5-9**] showed stable appearance of severe
pancreatitis with inflammatory phlegmon within the neck and body
of the pancreas. Per surgery, it is unlikely infected, at
present, fevers may be due to cytokine release. A operation was
deferred at present and can be readdressed later if persistent
fevers occur without a source. A repeat CT on [**2187-5-25**] showed
essentially unchanged appearance of severe pancreatitis with
large phlegmonous/fluid collection within the neck and body of
the pancreas. On [**2187-6-6**] a CT showed interval improvement in
pancreatitis with decrease in size of large phlegmonous/fluid
collection of the neck and body of the pancreas. No new fluid
collections or abscesses are identified. 0n [**2187-6-19**] a CT of
abdomen and pelvis is unchanged from [**6-6**]. She will follow up
with Dr. [**Last Name (STitle) **] in 3 weeks to discuss cholecystectomy and
another CT scan to see any interval changes before her follow up
with Dr. [**Last Name (STitle) **].
2. Abdominal Distension/Ileus:
The patient had good stool output, and her abdominal exam was
stable. On [**2187-4-24**] she was noted to have abundant bilious output
from NG tube. There was concern for ileus vs obstruction on CT
abdomen. A surgery consult was obtained and it was thought to be
an ileus. The NGT was left in place and TPN started. Next, a
Dobbhoff was placed and trophic tube feedings were started and
she was tolerating them fine. A rectal tube was placed for
liquid stool. There was an increased amount of fecal leakage
around the tube. A new tube was inserted. She had no skin
breakdown. After several days, the stool became more formed. She
continued to have incontinence. She was seen by Speech and
Swallow after her tracheostomy was downsized and passed a speech
and swallow evaluation. [**5-30**], a PICC was placed and TPN started
after her Dobbhoff was self D/C'd. She was started on a soft
diet [**2187-5-31**] and calorie counts revealed that she was not taking
in enough calories by mouth. [**6-16**] She pulled out her PICC line
and the TPN has been stopped since then. We are going to see
how she does with out TPN and see if she will take enough
calories by mouth. We would recommend a calorie count.
3. Fever/leukocytosis:
Upon admission, she was febrile to 101.3 with an increasing
white count. She was on Vanco and Zosyn for PNA. Also must
consider possible pancreatic infected pseudocyst. A CXR on
[**2187-5-9**] showed bilateral pleural effusions, left lower lobe
consolidation.
4. ARF: Creatinine improving from OSH, likely volume depletion.
Her Bun 38 and Cr 2.3 on admission improved with adequate
hydration.
5. Tachycardia: Likely related to volume depletion so would
discontinue beta-blocker. Other possibility is alcohol
withdrawal as she would now be about 48 hours from last possible
drink. TTE shows hyperdynamic EF, impaired relaxation, TR grad
48. A ECHO showed an EF>75%. She was on Metoprolol and Enalapril
for HR and BP control.
6. Hypoxia/Wheezing: 91% on RA with decreased breath sounds at
bases and now audible expiratory wheezes. [**Month (only) 412**] develop pulmonary
edema as a result of her fluid resuscitation and require
intubation. The patient had Respiratory Failure on [**2187-4-20**] and
was intubated. Likely multifactorial, PNA and CHF. CHF in
setting of aggressive volume repletion, interstitial infiltrates
on CXR, BNP 1305. She was sedated for 22 days while intubated.
The sedation was stopped. A tracheostomy was placed on [**2187-5-10**].
She had a prolonged intubation and was weaned off the ventilator
on HD 30. She requires frequent suctioning for thick, white
secretions. Passy-Muir valve was attempted with this patient,
but she was unable to tolerate it. On [**2187-5-28**], her tracheostomy
was downsized from a 8 to 6 for a PMV trial. She was able to
tolerate the Passy-Muir. A trigger was called for a drop in O2
saturation secondary to a mucus plug. She was suctioned and her
inner cannula was removed. After suctioning, humidification, and
nebulizers, her O2 sats came back up to 98%. She continued to do
well with the Trach and Passy-Muir and able to vocalize.
7. Occupational Therapy
Initially, the patient did not follow simple commands in Creole
or English. She was able to squeeze hand once when asked, but
otherwise was not answering questions appropriately. She
attempted verbalization x 3, but it was unintelligible secondary
to Trach.
After the Passy-Muir, she was able to communicate with the staff
and family members. She was highly motivated to return to her
baseline.
8. Physical Therapy
After the Passy-Muir was placed and tolerable, she seemed highly
motivated to ambulate and increase daily activity. She improved
from basic transfers to the chair, to being able to ambulate the
halls short distances. She will continue to need physical
therapy to improve functional activity,
Comm: with patient and son-in-law, [**Name (NI) **]. Daughter, [**Name (NI) **]
[**Telephone/Fax (1) 11623**], home [**Telephone/Fax (1) 11624**], son-in-law ce: [**Telephone/Fax (1) 11625**]
Medications on Admission:
Vicodin prn
Atenolol 50 mg daily
Lisinopril 10 mg daily
*
Medications on transfer:
Colace prn
Morphine 2 mg IV prn, last dose today at 9:45 pm
Metoprolol 5 mg IV q6hTylenol 650 mg pr q6h, last at 5 pm today
Hydralazine 20 mg IV q4h prn last dose at 1:30 this am
Protonix 40 mg IV daily
Unasyn 3 gm q6h (day 1 = [**2187-4-20**])
NS, 2L since 3 pm today
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
3. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q4-6H (every 4 to 6 hours) as needed.
4. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
5. Amylase-Lipase-Protease 468 mg Tablet Sig: Two (2) Tablet PO
TID (3 times a day).
6. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
7. Enalapril Maleate 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day). ML(s)
10. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours).
11. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day).
12. Iron 325 (65) mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*90 Tablet(s)* Refills:*2*
13. Outpatient Physical Therapy
Physical Therapy should see her every day to continue her
rehabilition and ambulation.
14. Respiratory Therapy
Need to see her for Trach care.
15. Calorie Count
Would recommend doing a calorie count to make sure that she is
taking in enough calories by mouth.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 4356**] - [**Location (un) 164**]
Discharge Diagnosis:
Severe Pancreatitis with rising LFTs
Discharge Condition:
Good
Discharge Instructions:
You should contact your MD if you experience:
* Increasing pain
* Fever (>101.5 F) or Vomiting
* Inability to pass gas or stool
* Other symptoms concerning to you
Please take all your medications as ordered
Continue Trach Care - suction PRN, humidification at all times,
change trach sponge and ties PRN, change inner cannula daily
Followup Instructions:
1. CAT SCAN on [**2187-7-3**] at 11:00am. It is in the Sharpio
building on the fourth floor. Do not eat solid food three hours
before your appointment. The office number is [**Telephone/Fax (1) 491**].
2. Follow up appointment with Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] on [**2187-7-6**]
at 8:30am. Office phone number is [**Telephone/Fax (1) 11626**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2084**] MD [**MD Number(2) 2085**]
Completed by:[**2187-6-19**]
|
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"574.21",
"518.81",
"427.89",
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] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
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"96.6",
"38.93",
"96.04",
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icd9pcs
|
[
[
[]
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] |
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|
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|
26470, 26519
|
55333, 55340
|
28675, 30582
|
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|
28300, 28304
|
53821, 55156
|
13605, 13649
|
55273, 55312
|
53445, 53503
|
55364, 55700
|
23232, 23290
|
28319, 28656
|
26411, 26432
|
44122, 47519
|
44049, 44093
|
26547, 27949
|
53528, 53798
|
27971, 28011
|
28027, 28284
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,990
| 120,729
|
53445+59521+59522+59523+59524
|
Discharge summary
|
report+addendum+addendum+addendum+addendum
|
Admission Date: [**2153-3-27**] Discharge Date: [**2153-4-13**]
Date of Birth: [**2101-2-9**] Sex: M
Service: MICU
CHIEF COMPLAINT: Dyspnea on exertion.
HISTORY OF PRESENT ILLNESS: A 52-year-old man, with coronary
artery disease status post one-vessel CABG, MVR, congestive
heart failure with EF 20-25%, who presents with increased
dyspnea on exertion worsened over the last 2 days. He also
reports increase in fatigue and anorexia over the last month
with approximately a 10 pound weight loss. He initially
describes the shortness of breath as intermittent and
occurring over the last month, however significantly worsened
over the last few days. He denies ever having any chest
pain. He was evaluated by his primary cardiologist and
electively admitted for right heart cath.
On [**2153-3-29**], the patient underwent right heart
catheterization which showed cardiac output 4.13, cardiac
index 2.33, pulmonary capillary wedge pressure 46, PA
pressure 73/27. Left heart catheterization was also
performed which showed widely patent LIMA to LAD with normal
left main, occluded midvessel LAD, midvessel 30% left
circumflex lesion, and luminal irregularities in the RCA.
After the cardiac catheterization, he was admitted to the
Cardiac Intensive Care Unit for tailored CHF management.
Secondary to sedation received in the Cardiac Cath Lab and
increasing hypercapnia, the patient was electively intubated
on [**2153-3-29**].
The patient was extubated on [**2153-3-30**]. However, due to fever
to 103, right lower lobe infiltrate and respiratory distress,
he was reintubated.
Over the course of the next 4 days, the patient was diuresed
with Natrecor for a short period of time, as well as
intravenous lasix. His cardiac output and index
progressively improved to a point where his cardiac output
was roughly 6, and his index was 3.3. As his CHF management
was felt to be optimized, he was placed no pressure support
ventilation on numerous occasions and was not deemed able to
be weaned from the ventilator. He was, therefore,
transferred to the Medical Intensive Care Unit for further
respiratory management and possible tracheostomy.
PAST MEDICAL HISTORY:
1. Congestive heart failure with EF of 20-25%.
2. Coronary artery disease status post CABG in [**2132**],
one-vessel, LIMA to LAD.
3. Status post mitral valve repair x 2 in [**2132**] and [**2143**], with
his last MVR being a St. Jude valve secondary to significant
staph endocarditis.
4. Atrial fibrillation on Coumadin.
5. Type 2 diabetes.
6. Duodenal ulcer with history of upper GI bleed.
7. Endocarditis complicated by septic emboli.
8. Restrictive lung disease thought secondary to ankylosing
spondylitis. PFTs in [**2142**] showed an FEV1 of 1.62, FVC 2.51.
PFTs repeated in [**2144**] showed similar FEV1 to FVC ratio with a
total lung capacity of 48%. PFTs in [**2151**] similarly showed an
FEV1 of 1.39 and FVC of 1.56.
9. History of varicose veins.
10.Clinically diagnosed ankylosing spondylitis, however no
official diagnosis.
11.History of brain abscesses secondary to septic emboli from
endocarditis.
12.History of gout.
13.History of left lower extremity cellulitis, hospitalized
in [**2153-1-25**].
FAMILY MEDICAL HISTORY: Significant for coronary artery
disease, as well as other family members with MVR and [**Name (NI) 1291**].
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: No current tobacco or alcohol use. Remote
smoking history, quit 20 years ago.
HOME MEDICATIONS:
1. Digoxin 0.125 mg po qd.
2. Carvedilol 6.25 mg po bid.
3. Glyburide 10 mg q am
4. Rosiglitazone 2 mg q am.
5. Lisinopril 10 mg qd.
6. Allopurinol 100 mg qd.
7. Bumex 2 mg qd.
8. Coumadin 3 mg/4 mg alternating qod.
PHYSICAL EXAMINATION ON TRANSFER TO THE MEDICAL INTENSIVE
CARE UNIT ON [**2153-4-2**] (UNFORTUNATELY, THERE IS NO ADMISSION
NOTE AVAILABLE AT THIS TIME.): Temperature 99.3, blood
pressure 91/46, heart rate 77-95, pulmonary artery pressure
53/21, pulmonary capillary wedge pressure 12, CVP 12,
ventilated on assist control 500x10, PEEP of 5, FIO2 30% with
SAO2 of 98-100%. In general, the patient was intubated and
sedated.
HEENT EXAM: Pupils were equal, round and reactive. Sclerae
were anicteric. ET tube and OG tube were in place.
NECK: Demonstrated a right internal jugular Cordis which was
in place which was clean, dry and intact. There was a
hematoma tracking into the right scapular area secondary to
traumatic line placement.
THORAX: Demonstrated limited chest wall movement with
inspiration. Bilateral rhonchi were noted. There was a
question of paradoxical movement of the chest wall.
CARDIOVASCULAR EXAMINATION: An irregularly irregular heart
rate, loud metallic S2, with a III/VI systolic murmur
diffusely across the precordium.
ABDOMEN: Tense but there was no rebound or guarding.
Normoactive bowel sounds.
EXTREMITIES: Showed chronic venous stasis changes bilateral
lower extremities, but there was no edema on exam. He had
decreased peripheral pulses bilaterally, which have been
noted to be dopplerable in the past.
SKIN: Demonstrated no other rashes or skin breakdown. There
were no sacral decubitus ulcers.
NEURO EXAM: He was awake and alert, and he was following
commands appropriately once sedation was weaned.
LABORATORY VALUES ON [**2153-4-2**]: White count 12.0 with normal
differential, hematocrit at baseline 39 which decreased to
29, platelets 108, MCV 89, PT 12, INR 1.1, PTT 58, sodium
139, potassium 3.8, chloride 98, bicarb 33, BUN 24,
creatinine 0.8, glucose 110, calcium 8.3, phosphorus 3.4,
magnesium 2.3, ALT 14, AST 33, alk phos 62, total bili 1.4,
hemoglobin A1C 9.0. Blood cultures [**3-30**] and [**2153-4-1**] were
negative. Sputum culture from [**3-30**] showed 4+ gram-positive
cocci in pairs, chains and clusters. However, respiratory
culture showed only moderate growth of oropharyngeal flora.
EKG from [**2153-3-27**] on admission showed atrial fibrillation,
poor R wave progression, low voltage, but essentially
unchanged from EKG dated [**2152-8-25**].
PERTINENT RADIOGRAPHIC EXAMINATIONS DURING HOSPITAL COURSE:
1. CT of the abdomen [**2153-3-31**] showed diffuse bibasilar
central lobular and nodular pulmonary opacities likely
consistent with infectious etiology. Simple cyst within the
right kidney. No evidence of bowel obstruction, perforation,
or an abscess within the abdomen.
2. Chest x-ray [**2153-4-1**] showed improving right lower lobe
process related to area of resolving aspiration or pneumonia.
3. Transthoracic echocardiogram [**2153-3-28**] showed an EF of 25%,
left atrial enlargement, global left ventricular hypokinesis,
paradoxical septal motion consistent with right ventricular
pressure volume overload, and increased pulmonary
hypertension when compared with transthoracic echocardiogram
performed in [**2152-4-25**].
4. Cardiac catheterization [**2153-3-29**] showed cardiac output
4.13, cardiac index 2.33, PA pressure 73/27, pulmonary
capillary wedge pressure mean of 46. There was a widely
patent LIMA to LAD with the left main showing no
angiographically apparent lesion. His LAD was occluded
midvessel. There was a left circumflex midvessel lesion of
approximately 30%. RCA demonstrated luminal irregularities.
IMPRESSION: A 52-year-old,with congestive heart failure, EF
of 20-25%, coronary artery disease status post one-vessel
CABG in [**2132**], MVR x 2 complicated, first one complicated by
endocarditis with current St. Jude valve, atrial
fibrillation, and restrictive lung disease known to be
present since [**2142**] which is thought secondary to ankylosing
spondylitis, who was transferred from the Cardiac Intensive
Care Unit to the Medical Intensive Care Unit for difficulty
to wean from the ventilator despite optimal diuresis.
HOSPITAL COURSE - 1) RESPIRATORY FAILURE: The patient's
initial presenting symptoms included dyspnea on exertion and
shortness of breath for 1 month which increased over the last
2 days. However, his symptoms also included significant
fatigue, anorexia and a 10-pound weight loss. Given his
clinical history and chest x-ray findings, he was felt to
have a right lower lobe pneumonia which, in combination with
congestive heart failure, was contributing to his symptoms at
home. However, postcatheterization on [**2153-3-29**], the patient
was noted to be overly sedated secondary to medications
received in the Cardiac Catheterization Lab, and had an ABG
performed. The gas at that time showed a pH of 7.12, PCO2
96, PO2 103. It was unclear what the patient's baseline PCO2
was; however, it was suspected to be elevated given his
history of restrictive lung disease and likely poor
ventilatory ability.
The patient was extubated on [**2153-3-30**] with immediate
postextubation ABG showing pH 7.31, PCO2 74, PO2 154 which,
over the next few hours, worsened to ABG with pH 7.20, PCO2
95, PO2 93. He was reintubated for hypercapnic respiratory
failure a few hours after initial extubation. He was tried
on pressure support ventilation over the next 48 hours and
failed multiple weaning trials. He was, therefore,
transferred to the Medical Intensive Care Unit [**2153-4-2**],
after being intubated 4 days and deemed unable to wean from
the ventilator.
It was the opinion of the Medical Intensive Care Unit team
that the patient's primary respiratory difficulties were
secondary to restrictive lung disease, which acutely worsened
secondary to a right lower lobe pneumonia. He was treated
with intravenous antibiotics for a total of 14 days with
improvement in the right lower lobe pneumonia. Numerous
trials were performed in hopes of extubating the patient.
However, at the time of this dictation, the patient's RSBI
still remained greater than 100, and he is currently on
pressure support ventilation of 20/5. He has been weaned
down on numerous occasions to pressure support ventilation of
[**5-30**]. He currently is off all sedation and appears to be
breathing comfortably without signs of respiratory distress.
Of note, his tidal volumes are approximately 200-300 with
respiratory rates in the mid to high 20s.
A VD/VT was performed while still intubated which showed a
percentage greater than 60. It was likely felt secondary to
the amount of dead space, and that he would be unlikely to
tolerate extubation, and plans were still in place for a
tracheostomy.
Due to his chronic restrictive lung disease, it was felt that
his baseline PCO2 ran in the range of 50-60, and his PO2 was
adequate in the 80-90 range. His vent settings were titrated
for these goals, and the patient had no apparent respiratory
distress.
2) CONGESTIVE HEART FAILURE: Mr. [**Known lastname 109906**] was initially
admitted with symptoms which appeared to be consistent with
congestive heart failure exacerbation over the last month.
At the time of admission, his pulmonary capillary wedge
pressure was 46. He was diuresed appropriately with lasix
and Natrecor down to a pulmonary capillary wedge pressure of
14. However, at this time he appeared to be volume deplete,
and he was given intermittent intravenous fluid boluses until
his hemodynamics were optimized. He appeared to be optimized
with a capillary wedge pressure of approximately 22, and a
CVP in the 12-14 range. With these settings, his cardiac
output was 6.0, and his cardiac index was 3.3. His Swan was
pulled on [**2153-4-4**].
Attempts to restart his outpatient CHF management, including
ACE inhibitor and lasix, was attempted. However, the patient
dropped his pressure to these interventions. Per his
outpatient cardiologist, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], these medications
were placed on hold until he was stable off the ventilator.
He was continued on his digoxin 0.25 mg qd with normal dig
levels maintained.
3) INFECTIOUS DISEASE: He was found to have a right lower
lobe infiltrate on chest x-ray, and a sputum culture with
gram-positive cocci, 4+, in pairs and clusters. It was
assumed that he had a staph pneumonia and was appropriately
treated with vancomycin and ceftriaxone for plans to complete
a 14-day course. He received an additional 5 days of
azithromycin at the beginning of his course. Blood cultures
were performed on 2 separate occasions and found to be no
growth both times.
4) ACUTE RENAL FAILURE: On two separate occasions, Mr.
[**Known lastname 109907**] creatinine bumped with diuresis. Urine
electrolytes were performed, and on each occasion showed
evidence of prerenal physiology. Lasix was held, and he was
given mild hydration with improvement in creatinine.
5) MITRAL VALVE REPLACEMENT: He is status post MVR x 2,
currently with a St. [**Male First Name (un) 923**], well-seated per transthoracic
echocardiogram [**2153-3-28**]. After cardiac catheterization, he
was maintained on a heparin drip with a goal PTT of
approximately 60-80. Coumadin is planned to be started after
the patient's tracheostomy.
6) ARRHYTHMIA: The patient known to be in chronic AFIB.
However, he had a few episodes of NSVT ranging from 10-17
beats while he was on Levophed. As he was felt to have
nonischemic cardiomyopathy, there was no role for
antiarrhythmic therapy or ICD placement. Once he was
discontinued from pressor therapy, his NSVT resolved.
7) ANEMIA: Mr. [**Known lastname 109907**] baseline creatinine is
approximately 39, which dropped to 29 over the first few days
in the Intensive Care Unit. It was felt that his anemia was
secondary to blood loss, as he had a traumatic right
intrajugular central line placed with surrounding
ecchymoses/hematoma. He was transfused on several occasions
to maintain his hematocrit above 30. He tolerated these
transfusions without incident. His neck hematoma appeared to
be improving at the time of this dictation and it was likely
that his heparin use contributed to this process.
8) RHEUMATOLOGY: Due to the confusion over the patient's
diagnosis of ankylosing spondylitis, the rheumatology service
was consulted. Per their request, an HLA-B27 level was sent
which was found to be negative. Using this information, they
felt that his most likely diagnosis was DISH and; therefore,
his intercept was discontinued.
9) FEN: The patient was on tube feeds, ProBalance, at a goal
rate of 65 cc/h while an OG tube was placed. A PEG tube will
be placed after tracheostomy, and continue tube feeding as
appropriate.
DISPOSITION: Mr. [**Known lastname 109906**] will remain in the Medical
Intensive Care Unit until tracheostomy is performed, at which
time screening for a pulmonary rehabilitation facility will
take place.
DISCHARGE DIAGNOSES:
1. Restrictive lung disease secondary to abnormal chest wall
compliance secondary to diffuse idiopathic skeletal
hyperostosis (DISH).
2. Respiratory failure requiring prolonged intubation.
3. Right lower lobe pneumonia thought secondary to
Staphylococcus aureus.
4. Congestive heart failure, systolic, nonischemic.
5. Acute renal failure, prerenal in etiology.
6. Atrial fibrillation.
7. Nonsustained ventricular tachycardia.
8. Type 2 diabetes.
9. Chronic atrial fibrillation.
DISCHARGE MEDICATIONS: To be dictated in discharge summary
addendum.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3795**]
Dictated By:[**Last Name (NamePattern1) 18697**]
MEDQUIST36
D: [**2153-4-13**] 14:54
T: [**2153-4-13**] 15:50
JOB#: [**Job Number 109908**]
Name: [**Known lastname 18020**], [**Known firstname 126**] Unit No: [**Numeric Identifier 18021**]
Admission Date: [**2153-3-27**] Discharge Date: [**2153-4-28**]
Date of Birth: Sex: M
Service: Medical Intensive Care Unit
ADDENDUM: Day of discharge is unknown at the present time.
This Discharge Summary is an Addendum to the Discharge
Summary dictated up until [**2153-4-13**].
The patient is a 52-year-old gentleman with coronary artery
disease, status post coronary artery bypass graft and mitral
valve replacement, congestive heart failure, and interstitial
lung disease who was on the Intensive Care Unit due to
respiratory decline. This Discharge Summary will dictate the
hospital course from the date of [**2153-4-13**] through the
date of [**2153-2-27**].
BRIEF SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM (CONTINUED):
1. RESPIRATORY FAILURE ISSUES: The patient continued to
have respiratory failure which was thought to be
multifactorial due to congestive heart failure,
deconditioning, interstitial lung disease, and pneumonia.
Despite completing his course of antibiotics, he did not show
improvement to the point it was thought he could be safely
extubated.
Thus, on [**4-10**], the patient had a tracheostomy and also
had a percutaneous enteral feeding tube placed at the same
time. The patient seemed to tolerate the procedure well.
Following this, he was slowly weaned from the ventilator, and
in fact had a several day course off of the ventilator on a
tracheostomy mask when he was safely discharged to the floor.
Unfortunately, while on the floor he developed a hematoma
related to his gastrojejunostomy tube placement, the details
of which are dictated down below. Because of this, he
required multiple amounts of fluid. He developed congestive
heart failure and was again transferred back to the Intensive
Care Unit and had to be put back on the ventilator. At the
time of this dictation, he is having daily trials of
tracheostomy mask which he is tolerating goal. The goal was
to get him to be on the tracheostomy mask all day and then
rested overnight on the ventilator. Of note, he has
difficulty tolerating the pressure-support ventilation mode.
He seems to like to be rested on assist control and then go
directly to tracheostomy mask over ventilation. He seemed to
be tolerating this well, and we expect a slow continued wean
here in the hospital, possibly to be continued at a
rehabilitation facility.
2. CONGESTIVE HEART FAILURE ISSUES: As of [**4-13**], it was
thought that the patient was clinically dry given that he was
dry on examination and that his blood urea nitrogen and
creatinine were elevated, thought to be due to prerenal
failure. Thus, he was allowed to take in fluids to be point
of being positive 500 cc to 1 liter per day.
Unfortunately, after several days of doing this, he developed
lower extremity edema and developed extended jugular venous
distention and it looked like he had a cross from being dry
into congestive heart failure without normalizing his renal
function. Thus, he was started on Natrecor and Lasix. He
made good progress on this; however, his progress was
interrupted when he developed his hematoma and was given
multiple amounts of fluids, and all his hypertensive
medications and diuretics had to be held for several days.
At the time of this dictation, he is on Natrecor 0.015 mg per
hour and a Lasix drip at 3 mg per hour, and he was diuresing
approximately 1 liter per day. We expect to continue to
diurese him until he is clinically euvolemic and then start
him on a daily standing dose of Lasix. Additionally, at the
present time, he is on 3.125 mg per G-tube twice per day of
carvedilol. We expect to titrate this up once he is off the
Natrecor and on a stable dose of Lasix. Also, in the future,
when his fluid status is euvolemic and his renal function is
better he should be started on an ACE inhibitor.
Additionally, he has been maintained on digoxin currently at
a dose of 0.625 every other day.
3. RENAL ISSUES: As of [**4-13**], the patient's creatinine
was elevated to approximately 2.5. It was thought that he
was dry based on his clinical examination. He was given
fluids; however, his renal function did not improve despite
the fact that clinically he crossed over into congestive
heart failure and developed edema and elevated jugular venous
distention.
Thus, he was restarted on Natrecor and Lasix for his
congestive heart failure. A Renal consultation was obtained
who thought that his renal failure may be prerenal or may be
due to some mild acute tubular necrosis. At the time of this
dictation, he was on Natrecor and Lasix diuresing 1 liter per
day, and his creatinine had improved down to the point of
approximately 1.6. It was thought that with continued
diuresis, and time, his renal function will stabilize. Once
his renal function is normal, which is at about approximately
a creatinine of 0.9, he should be restarted on an ACE
inhibitor. Also at that time he will be on standing dose of
Lasix for his congestive heart failure.
4. GASTROINTESTINAL ISSUES: The patient had a difficult
percutaneous endoscopic gastrostomy tube placement on [**4-10**]. The night of this, he developed intense abdominal pain.
A computed tomography scan was performed urgently which did
not reveal any perforation or an extravasation of blood.
The patient continued to have intermittent gastrointestinal
pain for approximately one more week. Then, unfortunately,
on [**4-21**], he experienced intense abdominal pain and had
approximately an 8-point hematocrit drop on the floor. An
urgent computed tomography scan was done which revealed an
approximately 9-cm X 14-cm hematoma on the posterior wall of
the stomach. An urgent Surgery consultation was obtained.
They recommended reversing the patient's anticoagulation
which was performed with fresh frozen plasma. He was given
several units of packed red blood cells, and his hematocrit
stabilized. Given the location of the hematoma and the
patient's co-existing conditions, and the fact that the
surgery was thought to be difficult, the surgical team did
not think that there was any intervention necessary for the
hematoma. They recommended transfusing with packed red blood
cells and monitoring his hematocrit. We did so, and on the
night of [**4-22**], he again experienced a hematocrit drop of
approximately seven points and had some borderline
hypotension and increasing abdominal pain.
The Interventional Radiology team was urgently called. The
patient was taken for angiography. However, unfortunately,
no bleeding blood vessel could be identified or embolized.
The patient was brought back to the floor. His hematocrit
bumped appropriately with units of blood, and he continued to
be monitored with hematocrit checks several times per day.
From that point on, his hematocrit remained stable and his
belly pain steadily improved. After being off
anticoagulation for approximately three days, his heparin and
Coumadin were restarted. At the time of this dictation, he
was on heparin 1300 units an hour with a partial
thromboplastin time in the 50 to 70 range and Coumadin 2.5 mg
by mouth at hour of sleep with a goal INR of about 2 to 2.5.
Ideally, his INR should be 2.5 to 3.5 for his mitral valve;
however, in consultation with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] from the
Cardiology Service, it was felt that we aim for a slightly
lower INR of 2 to 2.5 until such a time as he had been stable
from a gastrointestinal bleed standpoint given that he had
such a severe hematoma in his belly.
His belly pain appeared to be getting better, and as of today
we have restarted his tube feeds at a slow rate of 10 per
hour, and he seems to be tolerating these well.
5. HEMATOLOGIC ISSUES: As noted above, his Coumadin and
heparin were discontinued following his hematoma. At the
time of this dictation, they had been restarted with a goal
INR of 2 to 2.5 for his Coumadin.
6. NUTRITIONAL ISSUES: Because the patient could not
tolerate tube feeds from his hematoma, tube feeds seemed to
cause his intensive belly pain, he was started on total
parenteral nutrition. At the time of this dictation, he was
still taking total parenteral nutrition. His tube feeds have
been started today at 10 cc per hour. If they can be
advanced, he can hopefully be weaned from the total
parenteral nutrition.
DISPOSITION ISSUES: Discharge date to be determined by the
following dictation.
DISCHARGE DIAGNOSES:
1. Congestive heart failure.
2. Interstitial lung disease.
3. Respiratory failure due to multiple causes.
4. Pneumonia.
5. Gastrointestinal bleed; status post percutaneous
endoscopic gastrostomy tube resulting in hematoma.
6. Acute renal failure.
MEDICATIONS ON DISCHARGE: To be dictated in the next
Discharge Summary.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3662**]
Dictated By:[**Last Name (NamePattern1) 1032**]
MEDQUIST36
D: [**2153-4-28**] 19:31
T: [**2153-5-1**] 16:21
JOB#: [**Job Number 18022**]
Name: [**Known lastname 18020**], [**Known firstname 126**] Unit No: [**Numeric Identifier 18021**]
Admission Date:[**2153-4-29**] Discharge Date:[**2153-5-20**]
Date of Birth: Sex:
Service:
ADDENDUM: This is a discharge Addendum from [**2153-4-29**]
until [**2153-5-20**].
The patient is a 52-year-old man with coronary artery
disease, status post coronary artery bypass graft and mitral
valve replacement times two, with congestive heart failure,
and interstitial lung disease who had been admitted to the
Intensive Care Unit secondary to respiratory decline. His
course had been complicated by difficulty weaning off the
ventilator requiring a tracheostomy and as needed assist
control. The [**Hospital 1325**] hospital course was also complicated
by abdominal bleed times two; most recently in early [**Month (only) **].
SUMMARY OF HOSPITAL COURSE (CONTINUED):
1. CONGESTIVE HEART FAILURE: The patient was aggressively
diuresed from [**4-29**] until about [**5-5**]. The patient had
been on a Lasix drip and then occasionally required
intravenous Lasix boluses. His urine output continued to
drop off, and his creatinine began to increase; consistent
with acute renal failure.
The patient had been initially started on Coreg 3.125 mg
twice daily and lisinopril 2.5 mg once daily was added. The
patient's blood pressure was tenuous and often required
medications to be held. He was also maintained on digoxin
0.0625 mg every other day. This was increased to 0.125 mg
once per day to have a goal digoxin level of 1.6 to 2.
However, he never had any signs or symptoms of digoxin
toxicity.
The patient had been maintained on a Natrecor and Lasix drip.
This was finally discontinued in early [**Month (only) **]. In addition,
dopamine was begun causing sinus tachycardia and dobutamine
which caused some nonsustained ventricular tachycardia.
However, this was discontinued as the CHF attending
felt this may not be helping his cardiac status.
2. RENAL FAILURE: The patient's creatinine had been
improving to a minimum of 1.7. He had no chronic renal
insufficiency and apparently has normal renal function
usually. However, his creatinine started to increase around
[**5-6**] and [**5-7**].
He was assessed by Renal who felt that his acute renal
failure could be secondary to nonsteroidal antiinflammatory
drugs, ACE inhibitors, and some acute tubular necrosis.
However, this was complicated by his severe congestive heart
failure and poor forward flow. He was started on
hemodialysis finally on [**2153-5-12**]. A temporary left
internal jugular hemodialysis catheter was placed, which was
replaced by a long-term catheter on [**5-14**] without
difficulty.
A renal ultrasound was also checked to evaluate for the size
of his kidneys. The left kidney was 8.8 cm and the right
kidney was 10.5 cm. This was consistent with possible hope
in improvement of his acute renal failure. However, he has
not had increased urine output nor has he had improving blood
urea nitrogen or creatinine without dialysis. He has
undergone dialysis and ultrafiltration for approximately one
week continuously, and he will be transitioned to three times
per week. In addition, the patient was started on
Nephrocaps. Lasix, ACE inhibitor, nonsteroidal
antiinflammatory drugs, and other nephrotoxins were avoided.
All of his medications were renally dosed.
3. NONSUSTAINED VENTRICULAR TACHYCARDIA: The patient had
occasional nonsustained ventricular tachycardia with
occasional beats lasting approximately 30 beats. He was
asymptomatic throughout this. It was found that his
nonsustained ventricular tachycardia was very electrolyte
sensitive, and he usually responded to 20 mg of intravenous
or by mouth potassium. The patient will eventually need an
implantable cardioverter-defibrillator once he is deemed
medically able.
He was seen by Electrophysiology in late [**Month (only) 880**] who thought
that medications or antiarrhythmics such as amiodarone were
contraindicated secondary to the patient's interstitial lung
disease. Moreover, lidocaine might be contraindicated
because of his renal disease.
4. RESPIRATORY FAILURE: The patient continued to have
respiratory failure which was thought to be multifactorial
secondary to congestive heart failure, deconditioning, and
interstitial lung disease. Through the course of this month,
he has been weaned down to a tracheostomy mask which he has
maintained for up to 96 hours in a row.
However, on [**2153-5-20**] the patient was noted to have
tachypnea and increased sputum and was placed back on the
ventilator for rest.
5. INFECTIOUS DISEASE: The patient required an 11-day
course for Pseudomonas bronchitis versus
ventilator-associated pneumonia as well as Enterococcus in
his blood. The patient's blood culture was drawn from an
arterial line which was subsequently removed. The
Enterococcus was ceftazidime sensitive. As he had become
febrile to 101.7, tachypneic to 40s, tachycardic to 130, and
hypotensive he has been started at this time on cefepime 500
mg q.24h., vancomycin times one, and gentamicin times one
(per Infectious Disease recommendations). A chest x-ray was
not notable for a new infiltrate.
6. HEMATOMA: The patient had no further bleeding into his
abdomen. His partial thromboplastin time was maintained
between 50 to 70. He was kept on his twice per day
hematocrit checks and did occasionally require transfusions
of packed red blood cells.
7. FLUIDS/ELECTROLYTES/NUTRITION: The patient was
maintained on tube feeds. This was changed on the 23rd into
bolus feedings overnight. However, these bolus feedings were
held on [**2153-5-20**] secondary to nausea and some abdominal
pain.
8. HEMATOLOGY: Heparin has been continued. Coumadin was
started on [**2153-5-15**] with a goal INR between 2.5 to 3.
Currently, his INR is 1.2.
9. PSYCHIATRY: The patient has been seen by Psychiatry
since [**2153-5-2**]. Initially, the patient was deemed not
to have depression and needed no further medications.
However, on [**2153-5-19**] another psychiatrist came onto the
case and recommended Lexapro 5 mg once per day.
10. ACCESS: The patient has a right peripherally inserted
central catheter in place. A left tunnel internal jugular
was placed for hemodialysis.
11. PROPHYLAXIS: The patient was placed on Prevacid and
heparin for deep venous thrombosis prophylaxis.
12. CODE STATUS: Full.
13. DISPOSITION: The patient currently has a new infection.
Eventually, he will need to go to rehabilitation for further
physical therapy and occupational therapy.
Dictated By:[**Name8 (MD) 9549**]
MEDQUIST36
D: [**2153-5-20**] 14:52
T: [**2153-5-20**] 15:11
JOB#: [**Job Number 18023**]
Name: [**Known lastname 18020**], [**Known firstname 126**] Unit No: [**Numeric Identifier 18021**]
Admission Date: [**2153-3-27**] Discharge Date: [**2153-5-28**]
Date of Birth: [**2101-2-9**] Sex: M
Service:
This dictation will dictate the course from [**5-20**] until
[**2153-5-27**].
HISTORY OF PRESENT ILLNESS: This is a 62 year old gentleman
with a history of coronary artery disease, status post
coronary artery bypass graft and mitral valve replacement
times two, history of congestive heart failure who was
admitted to the Intensive Care Unit in [**2153-3-26**] with
respiratory distress.
HOSPITAL COURSE: He has had a prolonged course including
difficulty weaning off of the ventilator, requiring
tracheostomy, requiring a percutaneous endoscopic
gastrostomy. His percutaneous endoscopic gastrostomy was
complicated by hematoma in his intra-abdominal area and it
was also complicated by renal failure, necessitating dialysis
as well as multiple aspiration pneumonias.
1. Respiratory failure - On [**2153-5-20**], the patient had
an acute worsening of his respiratory failure with a
temperature of 101.7, respiratory rate in the 40s. He was
diagnosed with an aspiration pneumonia and [**Location (un) **] sepsis.
He was treated with Ceftazidime, Vancomycin and one dose of
intravenous Gentamicin. Eventually his gram negative rods
grew out of his sputum which were speciated as Enterobacter
and Pseudomonas. He was treated initially with Ceptaz,
single coverage and then Levaquin was added to double cover
for Enterobacter. His respiratory status improved. He was
able to be weaned off of pressor support and eventually onto
tracheostomy collar. At the time of discharge, he was
tolerating a trach collar for 12 hours during the day with
resting pressor support [**10-30**] overnight. The patient will
complete a 14 day course of Ceptaz which will be completed on
[**6-3**], as well as a seven day course of Levaquin which also
be completed on [**6-3**] and the patient will continue to be
weaned off of the ventilator, hopefully achieving trach
collar 24 hours a day.
2. Hypotension - The patient became hypotensive again on
[**5-21**], thought secondary to pneumonia and sepsis. He was
initially on pressors, however, we were able to wean off of
the Levophed, and with broad-spectrum antibiotics his blood
pressure improved and he is maintaining MAPs in the 50s and
60s off all of blood pressure medications.
3. Renal failure - The patient has become
dialysis-dependent, receiving hemodialysis three times a
week. Currently the plan is to continue to remove fluid as
tolerated. He will continue his hemodialysis three times a
week. He will receive Erythropoietin with dialysis per Renal
recommendations.
4. Abdominal hematoma - The patient initially suffered a
large abdominal hematoma in the setting of percutaneous
endoscopic gastrostomy placement and anticoagulation.
However, with maintaining the INRs in the 2.5 to 3 range, he
has maintained his hematocrit as stable and he has not had
any further intra-abdominal bleeding.
5. Mitral valve replacement/atrial fibrillation - The
patient requires anticoagulation for prosthetic valve as well
as atrial fibrillation. The INR goal is 2.5 to 3. Currently
he is going to be discharged on Coumadin 3 mg. Should his
INR drop below 2.5 we need to restart heparin without a
bolus. Should his INR get above 3, Coumadin needs too be
decreased because he has had large intra-abdominal bleeds in
the setting of INR greater than 3.
6. Diabetes - The patient is tolerating tube feeds at goal
and subsequently has required insulin requirement. We are
planning to discharge him on 24 units of Lantus in the
evening, covering with regular insulin sliding scale with
goal fingersticks in the 80 to 140 range.
7. Nutrition - The patient has been maintained on tube
feeds, Nepro at full strength at 35 cc/hr, through his
percutaneous endoscopic gastrostomy tube. Upon further
improvement, he will need a repeat speech and swallow
evaluation to dictate whether or not p.o. foods can be
initiated.
8. Access - The patient will be discharged with a right PICC
line and a left subclavian hemodialysis catheter.
9. Prophylaxis - The patient will be discharged on Coumadin
and Lansoprazole proton pump inhibitor.
CODE STATUS: The patient is full code.
DISPOSITION: The patient will be discharged to [**Hospital **]
Rehabilitation where he will undergo further rehabilitation
on the ventilator, hopefully coming off the ventilator full
time as well as physical therapy as well as speech and
swallow therapy to initiate feeding p.o. once again.
DISCHARGE DIAGNOSIS:
1. Coronary artery disease, status post coronary artery
bypass graft, mitral valve replacement.
2. Congestive heart failure with ejection fraction of 20 to
25%.
3. Atrial fibrillation on Coumadin.
4. Prolonged ventilation secondary to congestive heart
failure plus aspiration pneumonia, now status post trach and
percutaneous endoscopic gastrostomy, requiring a prolonged
trach wean.
5. Restrictive lung disease thought secondary to ankylosing
spondylitis.
6. Type 2 diabetes, requiring Lantus and sliding scale.
7. History of gastrointestinal bleed and duodenal ulcer.
8. Intra-abdominal hematoma secondary to percutaneous
endoscopic gastrostomy and anticoagulation.
9. Renal failure, now necessitating hemodialysis.
10. History of gout.
11. History of brain abscesses, secondary to septic emboli
from endocarditis.
DISCHARGE MEDICATIONS:
1. Ceptaz 1 gm dose at dialysis, to be completed on [**6-3**].
2. Levofloxacin 250 mg q. 24, also to be completed [**6-3**].
3. Coumadin 3 mg p.o. q.h.s., INR goal 2.5 to 3.
4. Lantus 23 units at night, regular insulin sliding scale
as needed.
5. Lexapro 10 mg q.d.
6. Digoxin .125 mg q. 3 days, to check periodic Digoxin
level.
7. Carvedilol 3.125 mg b.i.d.
8. Erythropoietin 500 intravenously with dialysis.
9. Reglan 5 mg p.o. q.h.s. intravenously prn.
10. Vitamin C.
11. Zinc.
12. Albuterol/Atrovent nebulizers as needed.
13. Prn Oxycodone one q. 6 prn.
14. Ativan 1 mg q.h.s. prn.
FOLLOW UP: The patient will follow up with primary care
physician after prolonged hospitalization and rehabilitation.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1729**], M.D. [**MD Number(1) 6268**]
Dictated By:[**Name8 (MD) 7039**]
MEDQUIST36
D: [**2153-5-27**] 14:15
T: [**2153-5-27**] 14:48
JOB#: [**Job Number 18024**]
Name: [**Known lastname 18020**], [**Known firstname 126**] Unit No: [**Numeric Identifier 18021**]
Admission Date: [**2153-3-27**] Discharge Date: [**2153-5-29**]
Date of Birth: [**2101-2-9**] Sex: M
Service:
ADDENDUM: This is an addendum to complete the last 2 days of
the patient's hospitalization on [**2153-5-28**] and [**2153-5-29**].
The patient underwent 1 final dialysis treatment on [**5-29**] and
was successfully discharged to [**Hospital **] Rehab on [**2153-5-29**],
where he will continue to receive dialysis treatments and
will follow up with his primary cardiologist.
DR,[**Doctor Last Name 578**],[**Doctor First Name 577**] 12-ABZ
Dictated By:[**Last Name (NamePattern4) 18025**]
MEDQUIST36
D: [**2153-7-9**] 11:41:32
T: [**2153-7-9**] 21:18:40
Job#: [**Job Number 18026**]
|
[
"584.5",
"428.0",
"515",
"998.11",
"482.40",
"518.84",
"427.1",
"038.9",
"507.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"38.95",
"31.1",
"39.95",
"96.72",
"99.04",
"43.11",
"88.56",
"37.23",
"96.04",
"00.13",
"88.47",
"96.71",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
24003, 24257
|
36907, 37503
|
36057, 36884
|
24284, 31699
|
32029, 36036
|
3498, 6081
|
37515, 38749
|
154, 176
|
31728, 32011
|
2194, 3383
|
3400, 3480
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,450
| 176,970
|
39036
|
Discharge summary
|
report
|
Admission Date: [**2162-2-28**] Discharge Date: [**2162-3-9**]
Date of Birth: [**2120-1-15**] Sex: F
Service: SURGERY
Allergies:
Augmentin
Attending:[**First Name3 (LF) 598**]
Chief Complaint:
s/p Motor vehicle crash
Major Surgical or Invasive Procedure:
1. Open reduction, internal fixation right intertrochanteric hip
fracture with dynamic hip screw.
2. Closed treatment right femoral shaft fracture with
manipulation.
3. Closed treatment right intercondylar, supracondylar femur
fracture with manipulation.
4. Application of uniplanar external fixator.
5. Washout and closure wound over anterior knee, 3 cm in length.
6. Open reduction internal fixation femoral shaft segmental
fracture.
7. Open reduction internal fixation distal femur intra-articular
fracture.
8. Open reduction internal fixation tibial plateau fracture.
9. Open reduction internal fixation ankle fracture.
10. Examination under anesthesia of wrist, all right lower
extremity and right upper extremity.
11. Removal of external fixator.
12. Lateral meniscal attachment and examination under anesthesia
ankle mortise.
History of Present Illness:
42 F restrained driver s/p motor vehicle crash head on collision
with another car, ~30-50 mph, no LOC, +airbags, prolonged
extrication. transportedto [**Hospital1 18**] for further care.
Past Medical History:
Colon CA
PSH: s/p resection for colon CA
Social History:
Has 3 children
Family History:
Noncontributory
Physical Exam:
Upon admission:
HR:110 BP:130/80 Resp:30 O(2)Sat:98% normal
Constitutional: Patient is in severe pain
Head / Eyes: Extraocular muscles intact
ENT / Neck: In c-collar
Chest/Resp: Equal breath sounds without
chest wall tenderness
Cardiovascular: Heart sounds
GI / Abdominal: Soft, Nontender
Musc/Extr/Back: Back is negative\npatient
has a obviously deformed
right proximal femur.\nThere
is a laceration over her
right knee.\nThe ankle is
obviously dislocated on the
right.\nHer dorsalis pedis
pulse is present by Doppler
on the right.\nShe seems to
have decreased sensation on
the right foot dorsum.
Neuro: Speech fluent and can move
all 4 extremities
Pertinent Results:
[**2162-2-28**] 11:37PM GLUCOSE-152* UREA N-6 CREAT-0.4 SODIUM-141
POTASSIUM-4.0 CHLORIDE-115* TOTAL CO2-21* ANION GAP-9
[**2162-2-28**] 11:37PM CALCIUM-7.0* PHOSPHATE-3.1 MAGNESIUM-1.4*
[**2162-2-28**] 11:37PM CALCIUM-7.0* PHOSPHATE-3.1 MAGNESIUM-1.4*
[**2162-2-28**] 11:37PM WBC-6.3# RBC-3.91* HGB-11.4* HCT-32.8* MCV-84
MCH-29.2 MCHC-34.9 RDW-13.9
[**2162-2-28**] 11:37PM PLT COUNT-215#
[**2-28**] Abdominal CT:
1. Acute minimally displaced fracture of the sternal manubrium
with possible minimal associated underlying anterior mediastinal
hematoma. No evidence of acute visceral injury in the abdomen or
pelvis.
2. Mildly displaced right-sided intratrochanteric femur
fracture.
3. Rounded 2.0 x 1.2cm asymmetric hypodense area involving the
left breast, may represent a cyst. However, recommend
correlation with
mammography/ultrasound to exclude a more aggressive lesion.
4. Multiple splenic hypodensities involving the spleen,
non-specific. Differential diagnosis is broad and includes
neoplastic/lymphomatous/metastatic involvement or microabcesses.
Other considerations include sarcoidosis although there are no
findings of sarcoidosis in the chest. Recommend clinical
correlation with history of malignancy (chain sutures in rectal
region, question history of colorectal carcinoma) or
immunocompromise.
5. 9mm incompletely characterized hypoattenuating liver lesion.
Area of nodularity involving the mid aspect of the gallbladder,
non-specific may represent atypical adenomyosis or polyp.
Recommend further evaluation of these findings, in addition to
the splenic lesions, with MRI (preferred) or ultrasound.
6. Subcentimeter hypodensity seen within the interpolar region
of the left kidney, incompletely characterized. Attention at the
aforerecommended MRI/ultrasound.
[**2162-3-5**] MRCP
IMPRESSION:
1. No evidence of bile duct injury.
2. Hepatic steatosis.
3. Multiple, nonspecific T2 hyperintense splenic lesions. Unless
the patient has a known primary malignancy or systemic disease,
this finding is most likely in keeping with benign cysts versus
hamartomas.
[**2162-3-8**] LENIS
IMPRESSION: No evidence of DVT in the left lower extremity.
Brief Hospital Course:
She was admitted to the Trauma service. Orthopedics was
consulted for her lower extremity injuries. She was taken to the
operating room on [**2-28**] & [**3-1**] for washout and repair of her
injuries. Postoepratively she remained in the Trauama ICU and
was dificult to wean for extubation. It was felt that this was
primarily due to large amounts of intravenous narcotics required
to control her pain; 0.1% bupivacaine at 10 mL/hr was infused
with adequate pain control. Neurology was very briefly involved
in her care after consult request per ICU team for her decreased
mental status. This was also felt per Neurology to be a result
of her narcotics and not related to seizures or other
intracranial processes. She eventually was more awake and able
to be weaned and extubated. She was then transferred to the
regular nursing unit.
Her LFT's were noted to be elevated during her stay and a GI
consult was requested. An MRCP was done which was normal. Her
LFT's were trending down during her stay and will need to be
checked weekly while at rehab. Given her history of colon CA a
CEA was checked and was less than 1.0. She has given us
permission to forward these results to her primary
hematologist/oncologist. The GI team recommends that she have an
ECHO at some point as an outpatient.
She did have pain control issues once on the nursing unit and it
was recommended per pain service to add Nortriptyline at HS; she
is also receiving po Dilaudid.
Physical therapy has been working with her regularly and she is
being recommended for acute rehab.
Medications on Admission:
Meds: iron
All: augmentin
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Enoxaparin 30 mg/0.3 mL Syringe Sig: Thirty (30) MG
Subcutaneous Q12H (every 12 hours).
3. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime as
needed for constipation.
4. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
5. Nortriptyline 10 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Hydromorphone 4 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at
[**Hospital6 1109**] - [**Location (un) 1110**]
Discharge Diagnosis:
s/p Motor vehicle crash
Injuires:
- Manubrial fracture with retrosternal fluid collection
- Right mid-shaft femur fracture
- Right tibial plateau with lateral split-depression
- Right [**Doctor Last Name 11586**] B bimalleolus equivalent
- Right comminuted talar neck fracture
- Right knee laceration
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - requires assistance or aid
(platform walker or cane)
Discharge Instructions:
Wound Care:
-Keep Incision dry.
-Do not soak the incision in a bath or pool.
-Staples will be removed at your first post-operative visit.
Activity:
-Continue to be touch down weight bearing on your right leg.
-Continue to be non weight bearing on your right wrist and
weight bearing as tolerated on your elbow.
Other Instructions
- Resume your regular diet.
- Avoid nicotine products to optimize bone healing.
- Resume your home medications. Take all medications as
instructed.
- Continue taking the Lovenox to prevent blood clots.
-If you have questions, concerns or experience any of the below
danger signs then please call your doctor at [**Telephone/Fax (1) 1228**] or go
to your local emergency room.
Followup Instructions:
It is important that you follow up with your
Hematologist/Oncologist at [**Hospital3 2576**] [**Hospital3 **] upon discharge
from rehab. You will need to call for an appointment. It is
being recommended that you follow up with a liver specialist
within 3 months and this can be arranged through Dr. [**First Name (STitle) 916**].
2 weeks in the [**Hospital **] clinic with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP.
Please call [**Telephone/Fax (1) 1228**] to make this appointment. Clinic held
on Tuesday's.
Follow up in Hand Surgery clinic next Tuesday. Call
[**Telephone/Fax (1) 3009**] to schedule this appointment.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]
Completed by:[**2162-3-9**]
|
[
"807.2",
"891.0",
"823.02",
"820.21",
"824.8",
"821.23",
"814.00",
"821.01",
"V10.05",
"E812.0",
"864.05",
"844.8",
"782.4",
"276.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"79.05",
"78.15",
"96.71",
"79.03",
"96.04",
"79.36",
"81.47",
"86.59",
"78.65",
"79.35"
] |
icd9pcs
|
[
[
[]
]
] |
7216, 7361
|
4868, 6424
|
291, 1125
|
7711, 7711
|
2671, 4845
|
8634, 9422
|
1454, 1471
|
6501, 7193
|
7382, 7690
|
6450, 6478
|
7900, 7900
|
1486, 1488
|
228, 253
|
7912, 8611
|
1153, 1341
|
1503, 2652
|
7726, 7876
|
1363, 1406
|
1422, 1438
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,096
| 180,918
|
8528
|
Discharge summary
|
report
|
Admission Date: [**2198-5-10**] Discharge Date: [**2198-5-12**]
Date of Birth: [**2140-11-19**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
abdominal pain/hemoperitoneum
Major Surgical or Invasive Procedure:
none
History of Present Illness:
57M with history of Hep B and questionable hepatoma (no biopsy)
presents with abdominal pain and swelling. The patient was
recently admitted to Oncology service from [**4-7**] - [**4-9**] with
complaintsw of abdominal pain and swelling. A RUQ US at that
time demonstrated likely infiltrating HCC. His ascites was
tapped and was frankly bloody without evidence of SBP. He was
discharged from the hospital on the day prior to readmission
with plans for palliative chemotherapy as an outpatient as he
was deemed to be not a candidate for surgery or chemo-embo. Over
the last day, he has had increaed abdominal pain and swelling.
He denied fevers, chills, night sweats. He has had some nausea
without vomiting, diarrhea, melean, hematochezia.
.
In the ED, a CT showed active bleeding from the left lobe of the
liver with a HCT drop from 28 - 23. He was given ceftrixaone,
flagyl, morphine, anzemet and 2U PRBC and admitted to the MICU.
.
In the MICU, the patient had a pericentesis which was grossly
bloody. IR attempted embolization to stop blood loss, but was
unsuccessful. Family decided to make the patient as comfortable
as possible given his grave prognosis.
Past Medical History:
1. Chronic active Hep B, failed 3TC, last AFP [**2202**]
2. Likely HCC - no bx
Social History:
Lives with his wife. [**Name (NI) **] two sons. [**Name (NI) 1403**] in a restaurant as a
cook. He is a current heavy smoker (over one ppd for many
years). Quit alcohol twelve years ago, unclear if he was a
previous heavy drinker. No hx of IVDA or blood transfusions. He
imigrated from [**Country 651**] in [**2183**].
Family History:
His brother had liver problems of unclear etiology. It is
unclear as to whether his children and his wife have been
vaccinated or exposed. He denies any other liver or GI
pathology in his family.
Physical Exam:
Vitals: T 96.5 BP 128/78 HR 89 RR 19 95% 3L
Gen: ill-appearing man, appears older than stated age
HEENT: dry mucous membranes
Lung: CTA bilaterally
Cor: hyperdynamic, RRR, nml S1S2
Abd: tense/rigid and distended
Ext: no edema
Pertinent Results:
[**2198-5-10**] 12:30PM WBC-24.7*# RBC-2.94*# HGB-8.8* HCT-27.7*
MCV-94# MCH-30.0 MCHC-31.8 RDW-20.0*
[**2198-5-10**] 03:10PM GLUCOSE-81 UREA N-32* CREAT-1.3* SODIUM-140
POTASSIUM-6.5* CHLORIDE-112* TOTAL CO2-11* ANION GAP-24*
[**2198-5-10**] 03:15PM LACTATE-8.5*
[**2198-5-10**] 03:15PM TYPE-ART PO2-103 PCO2-28* PH-7.15* TOTAL
CO2-10* BASE XS--17
.
Perotineal fluid bloody SAAG 1.1, WBC [**2142**] with 25% polys = 565
polys. NO SBP. HCT on fluid 16.
.
CXR: left mid granuloma
.
RUQUS: acties, GB edema without distension.
.
Abd CT: RLL small consolidation. large acties. nodular liver
replaced by tumor with extravasation of blood. +tumor thrombis
in left portal vein. no vessel injury noted.
.
Cytology: neg from prior tap.
Brief Hospital Course:
A/P: 57 yo M with chronic active hepatitis B having failed 3TC
now with hemoperitoneum having failed IR embolization procedure,
now CMO with extremely grave prognosis.
.
1. Hemoperitoneum: The patient was found to have a large
hemoperitoneum that quickly reaccumulated after paracentesis.
IR tried to embolize the source of bleeding but failed. After
discussion with the famly, the decision was made to make the
patient CMO. He was continued on morphine and fentanyl for pain
relief and haldol and ativan to control agitation. He expired
two days after admission.
Medications on Admission:
afodovir, aldactone, and percocet prn
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
|
[
"276.2",
"070.30",
"789.5",
"593.9",
"276.5",
"788.20",
"568.81",
"155.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.47",
"39.79",
"57.94",
"99.04",
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
3901, 3910
|
3215, 3784
|
344, 350
|
3961, 3970
|
2455, 3192
|
4023, 4030
|
1994, 2194
|
3872, 3878
|
3931, 3940
|
3810, 3849
|
3994, 4000
|
2209, 2436
|
275, 306
|
378, 1540
|
1562, 1642
|
1658, 1978
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,749
| 144,476
|
54161
|
Discharge summary
|
report
|
Admission Date: [**2197-10-18**] Discharge Date: [**2197-10-24**]
Date of Birth: [**2134-6-28**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Iodine; Iodine Containing / Naproxen / Codeine /
Demerol / Latex / Nsaids
Attending:[**First Name3 (LF) 1148**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
intubation, ART line
History of Present Illness:
63F w/ DMII, HTN, CKD, presented to the ED with pleuritic CP and
lightheadedness that started on the afternoon of [**10-17**]. She
states the pain was in the middle of her chest, radiating
through to her back, intermittent, combination of sharp pain and
pressure. It was associated with some shortness of breath and
mild nausea, and the pain was much worse with deep breathing.
She states the pain progressed throughout the day, and
overnight, she had diaphoresis soaking through her bedclothes.
She states she developed bilateral LE edema and calf pain 4 days
ago. She denies fever/chills, cough, hemoptysis, vomiting,
bloody or black stools, abdominal pain. ROS was positive for 1
episode of loose stool last night.
.
In the ED, her VS on presentation were T 96.9, HR 40, BP 91/40,
RR 25, O2sat 98% RA. She appeared to be in mild respiratory
distress, with clear lungs, regular heart rate, and bilateral LE
edema. ECG showed sinus bradycardia with no concerning ST/T
changes. Her labs showed ARF with a creatinine of 2.3.
Cardiology was consulted for her bradycardia, and it was felt to
be most likely [**2-16**] beta blocker or calcium channel blocker
toxicity, so she was given glucagon 1mg IV x 2 and calcium
gluconate 2g IV, but had no response. Her SBP dropped to mid-80s
and 70s with standing, and she was given 2L NS bolus. Her O2
sats dropped to high 80s on RA, was put on NRB, satting 94-97%.
CXR was clear. Cardiology performed a bedside TTE, which showed
normal biventricular function, normal bubble study, no RV
strain. She was started on IV heparin for empiric treatment for
PE, as a CTA could not be performed due to ARF and iodine
allergy and she was felt to be too unstable for a V/Q scan. She
was admitted to the MICU for further management.
.
On arrival to the MICU, she was complaining of severe L rib/LUQ
pain. Her HR was 40, BP 90s/40s, and O2sat 92-96% on NRB. She
was intubated semi-urgently for hypoxia.
Past Medical History:
1. Type 2 diabetes.
2. Sickle cell trait.
3. C5 radiculopathy.
4. Myelopathy.
5. Osteoarthritis.
6. Hypercholesterolemia.
7. Chronic lower back pain.
8. Adrenal adenoma.
9. Glaucoma.
10. Status post appendectomy in [**2157**].
11. Status post bilateral cataract surgery.
12. Status post hysterectomy in [**2178**].
Social History:
Divorced, no children, lives alone, some family in [**Location (un) 17004**], NY
(sister, [**Name (NI) 17**] [**Name (NI) **]), very involved in church. The patient
denies any history of tobacco,
alcohol, or drug use. She states that she lives with a
roommate.
Family History:
One brother has lung cancer and one brother has [**Name2 (NI) 499**] cancer,
and multiple siblings and a niece had coronary artery disease at
a young age.
Physical Exam:
Vitals- T 97.1, HR 36, BP 93/43, RR 18, O2sat 92-96% NRB
General- appears younger than stated age, tearful, appears very
uncomfortable, A&Ox3, tachypneic
HEENT- PERRL, sclerae anicteric, dry MM, OP clear
Neck- supple, no JVD
Pulm- bibasilar crackles, otherwise clear
CV- bradycardic but regular, no murmur/rub/gallop
Abd- + BS, nondistended, + TTP over L rib, + LUQ pain to
moderate palpation with no rebound/guarding, no hepatomegaly, no
palpable spleen tip although exam somewhat limited by pain
Extrem- 2+ LE edema to mid calf b/l, + calf tenderness to
palpation b/l, + [**Last Name (un) 5813**] sign bilaterally.
Pertinent Results:
[**2197-10-18**] 11:05AM BLOOD WBC-7.0# RBC-3.39* Hgb-10.4* Hct-30.0*
MCV-88 MCH-30.7 MCHC-34.7 RDW-13.5 Plt Ct-193
[**2197-10-18**] 11:05AM BLOOD Neuts-52.7 Lymphs-35.0 Monos-4.9 Eos-7.4*
Baso-0
[**2197-10-18**] 11:05AM BLOOD PT-11.1 PTT-24.9 INR(PT)-0.9
[**2197-10-18**] 11:05AM BLOOD Glucose-178* UreaN-39* Creat-2.3* Na-141
K-5.5* Cl-106 HCO3-27 AnGap-14
[**2197-10-18**] 11:05AM BLOOD Calcium-8.9 Phos-4.6*# Mg-3.0*
[**2197-10-18**] 03:55PM BLOOD Lipase-8
[**2197-10-18**] 11:05AM BLOOD cTropnT-<0.01
[**2197-10-19**] 05:52AM BLOOD CK-MB-3 cTropnT-0.01
[**2197-10-19**] 11:12AM BLOOD CK-MB-4 cTropnT-<0.01
[**2197-10-19**] 05:52AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE IgM
HAV-NEGATIVE
[**2197-10-23**] 11:35AM BLOOD ANCA-NEGATIVE B
[**2197-10-19**] 05:52AM BLOOD HCV Ab-NEGATIVE
[**2197-10-18**] 03:56PM BLOOD Glucose-233* Lactate-1.1 K-5.2
.
CXR [**2197-10-18**]:
1. Possible pericardial effusion.
2. Probable small left pleural effusion.
.
LENIS [**2197-10-18**]:
No evidence of DVT.
.
TTE [**2197-10-18**]:
EF > 55%. Borderline pulmonary hypertension. Normal
biventricular size and systolic function. No ASD or PFO seen.
.
MRI [**2197-10-19**]:
1. No central or segmental pulmonary embolus. Tiny filling
defects in subsegmental branches in the left lower lobe entering
atelectatic lung may be due to flow-related artifact, though
tiny pulmonary emboli cannot be excluded.
2. Moderate layering bilateral pleural effusions and associated
bibasilar atelectasis.
.
Brief Hospital Course:
A/P: 63F w/ DM, HTN, and CKD presented with chest pain,
bradycardia, hypotension, and hypoxia.
.
While in the ED, she was bradycardic w/ HR 40 and hypotensive w/
BP 91/40. +mild respiratory distress, although clear lungs. ECG
showed sinus bradycardia w/o ST/T changes. Also ARF w/
creatinine of 2.3. Cardiology consulted for bradycardia; felt to
be [**2-16**] beta blocker or calcium channel blocker toxicity. She was
given glucagon 1mg IV x 2 and calcium gluconate 2g IV, but had
no response. SBP dropped to mid-80s and 70s with standing, and
she was given 2L NS bolus. Her O2 sats dropped to high 80s on
RA, was put on NRB, satting 94-97%. CXR clear. Cardiology
performed bedside TTE, which showed normal biventricular
function, normal bubble study, no RV strain. CTA could not be
performed due to ARF and iodine allergy and she was felt to be
too unstable for a V/Q scan. IV heparin started for empiric PE
treatment. She was then admitted to the MICU.
.
On arrival to the MICU, she was complaining of severe L rib/LUQ
pain. Her HR was 40, BP 90s/40s, and O2sat 92-96% on NRB. She
was intubated semi-urgently for hypoxia. BP improved w/ IVF. HR
improved w/ holding CCB and BB. Cause of hypoxia unclear, but
thought to be [**2-16**] to PE given her pleuritic chest pain, dyspnea
and hypoxia. MRA chest done which ruled out central or segmental
PE. Small filling defects seen which could be artifact, but tiny
subsegmental PE could not be ruled out. The MICU team felt this
was unlikely to be cause of her presentation so heparin was
stopped. Patient extubated successfully on [**2197-10-19**]. Patient
found to be hypertensive, so she was restarted on BB and CCB.
Transferred from MICU to the floor.
.
While on medicine wards, the patient was stable without oxygen
supplementation and was ambulatory. She was kept on telemetry
and was without events. However, she did have HRs in the
50's-60's. For this reason, her CCB and BB were held on
occasion and her BP was slightly elevated. A note of
transaminitis was made in ICU and rechecked on wards that showed
mild improvement. Additionally 2 days prior to discharge patient
had several episodes of hematuria. Urinalysis showed only RBCs
without signs of infection. Given previous renal failure and
pulmonary distress, there was concern of a renal-pulmonary
syndrome. For this reason, ANCA and ASO were sent, but were
negative. The hematuria cleared after one day. Additionally,
the patient had increasing sore throat on day of discharge.
Cultures were sent and the patient was given an Rx for lidocaine
and instructed to treat symptomatically. Viral titers were also
sent which were negative. Cause of sore throat unknown but the
patient did have symptomatic improvement with rx.
MICU course by problem list:
# Hypoxia: Initially, it was thought that the patient had a PE
given hx of pleuritic chest pain and hypoxia with a clear xray.
Heparin was started emperically. CTA was not done due to ARF.
MRI showed small subsegmental PE's that were reviewed personally
with the radiologist. It is thought that PE is not the cause of
her hypoxia and give the small size of the clots, it is unlikely
that they caused her chest pain. She was then treated for
presumptive pneumonia, and her chest pain was attributed to
pleurisy. Heparin was stopped at this time because the risk of
bleeding outweight likely outweigh the risk of benefit.
.
She was intubated upon arrival at the MICU for control of her
oxygenation. She was weaned off the vent and extubated in three
days. After transfer out of the ICU she was not hypoxic without
oxygen supplementation. She had mild dyspnea but felt that it
was due to her persistent left sided chest wall pain.
.
# Hypotension: The patient was hypotensive in the ED and
rescucitated aggresively with IVF. In the MICU, her MAPs were
kept > 65 with IVFs. She did not require any pressors. Her
hypotension was attributed to poor cardiac output due to
junctional rhythm +/- sepsis.
.
# Bradycardia: Cardiology was consulted and it is thought that
the patient developed beta-blocker toxicity in the setting of
acute on chronic renal failure. She was given glucagon in the
ED. She was in junctional rhythm on admission to the MICU at
rates of 40. Her home atenolol and any nodal blocking agents
were held. Overnight, she regained sinus rhythm to the 60's and
remained hemodynamically stable. Atenolol was restarted when
the pt left the MICU.
.
# ARF: FENA was 0.3%. It is thought that she was dehydrated,
although she reports no hx of decreased PO intake or blood loss.
Her low cardiac output also exacerbated her acute on chronic
renal failure. During her MICU course, she was rehydrated with
fluid boluses and her renal failure improved back to baseline.
Her Ace-i were held in the acute setting.
.
# Chest pain: No ischemic changes on ECG, CE negative x 3 sets.
Her CP is possibly from pleurisy from pneumonia. Over her MICU
course, her chest pain improved and was only tender on
palpation.
.
# FEN: She was hypotension fluid but responsed to IVF.
Initially she was hyperkalemia but it resolved with lactulose
and insulin+glucose. Calcium gluconate was also given.
.
Medications on Admission:
Atenolol 25mg qd
Diovan 320mg qd
ASA 325mg qd
HCTZ 25mg qd
Lipitor 40mg qd
Nifedipine ER 90mg qd
Lisinopril 40mg qd
Lantus 20 qHS
Humalog SS
Neurontin 300mg tid
Reglan 10mg qachs
Lactulose qd
Flonase qd
Claritin 10mg qd prn
Discharge Medications:
1. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic
DAILY (Daily).
4. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 4 days.
Disp:*4 Tablet(s)* Refills:*0*
5. Baclofen 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) as needed for muscle spasm.
6. Atenolol 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
7. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
Disp:*30 Tablet Sustained Release(s)* Refills:*2*
8. Cepacol 2 mg Lozenge Sig: [**1-16**] Lozenges Mucous membrane PRN
(as needed) as needed for throat pain.
9. Lidocaine HCl 2 % Solution Sig: Twenty (20) ML Mucous
membrane TID (3 times a day) as needed for throat pain.
Discharge Disposition:
Home
Discharge Diagnosis:
Viral infection
Renal failure
Respiratory distress
Discharge Condition:
stable, improved
Discharge Instructions:
You were admitted for fatigue and respiratory problems. [**Name (NI) **]
spent time in the ICU and were intubated. You have been treated
for an infection with levaquin. Please continue to take this
medication for 3 more days.
Followup Instructions:
PLEASE CALL [**Telephone/Fax (1) 1247**] on Thursday to get an URGENT care
appointment for follow up.
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], M.D. Date/Time:[**2197-12-20**] 8:50
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 252**], M.D. Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2198-2-6**] 9:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4853**], M.D. Date/Time:[**2197-12-20**] 9:15
|
[
"403.90",
"427.89",
"585.9",
"276.51",
"362.01",
"079.99",
"428.0",
"458.8",
"518.81",
"276.2",
"486",
"462",
"276.7",
"599.7",
"V58.67",
"250.52",
"285.9",
"792.1",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
11775, 11781
|
5282, 8039
|
361, 384
|
11875, 11893
|
3788, 5259
|
12168, 12623
|
2980, 3136
|
10731, 11752
|
11802, 11854
|
10483, 10708
|
11917, 12145
|
3151, 3769
|
311, 323
|
412, 2344
|
8053, 10457
|
2366, 2683
|
2699, 2964
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,217
| 141,326
|
3153
|
Discharge summary
|
report
|
Admission Date: [**2125-3-6**] Discharge Date: [**2125-3-13**]
Date of Birth: [**2041-8-31**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**3-7**] Aortic Valve Replacement (21mm St. [**Male First Name (un) 923**] Ultra Epic Porcine
Valve)
[**3-6**] Cardiac Catherization
History of Present Illness:
83 year old female with dyspnea on exertion that was referred
for evaluation of aortic valve.
Past Medical History:
Aortic Stenosis
Coronary Artery Disease s/p PTCA
Chronic diasystolic heart failure
Hypertension
Hyperlipidemia
Glaucoma
Osteoporpsis
Social History:
Lives with spouse
ETOH social
[**Name (NI) 14883**] denies
Family History:
Sister deceased at 79 from CVA or MI not sure
Physical Exam:
VS: 80 16 130/82
Gen: Well-developed, well-nourished female in no acute distress
Skin: Unremarkable
Neck: Supple, full range of motion
Chest: Clear lungs bilat.
Heart: Regular rate and rhythm, 4/6 systolic murmur
Abd: Soft, non-tender, non-distended
Ext: Warm, well-perfused -edema, -varicosities
Neuro: Alert and oriented x 3, non-focal
Pertinent Results:
[**2125-3-13**] 06:35AM BLOOD WBC-8.3 RBC-3.30* Hgb-10.0* Hct-30.0*
MCV-91 MCH-30.3 MCHC-33.3 RDW-14.0 Plt Ct-232
[**2125-3-6**] 10:10PM BLOOD WBC-7.4 RBC-3.84* Hgb-12.2 Hct-34.4*
MCV-90 MCH-31.8 MCHC-35.6* RDW-13.3 Plt Ct-216
[**2125-3-13**] 06:35AM BLOOD Plt Ct-232
[**2125-3-13**] 06:35AM BLOOD PT-15.0* INR(PT)-1.3*
[**2125-3-6**] 10:10PM BLOOD PT-13.4 PTT-35.0 INR(PT)-1.2*
[**2125-3-6**] 10:10AM BLOOD PT-13.4 PTT-39.0* INR(PT)-1.1
[**2125-3-7**] 03:00PM BLOOD Fibrino-154
[**2125-3-13**] 06:35AM BLOOD Glucose-91 UreaN-36* Creat-1.0 Na-138
K-3.4 Cl-97 HCO3-31 AnGap-13
[**2125-3-6**] 10:10PM BLOOD Glucose-98 UreaN-23* Creat-0.9 Na-135
K-4.2 Cl-100 HCO3-26 AnGap-13
[**2125-3-13**] 06:35AM BLOOD ALT-57* AST-30 LD(LDH)-291* AlkPhos-205*
Amylase-44 TotBili-0.4
[**2125-3-13**] 06:35AM BLOOD Lipase-86*
[**2125-3-13**] 06:35AM BLOOD Albumin-3.1* Mg-2.3
[**2125-3-6**] 10:10AM BLOOD VitB12-687
[**2125-3-6**] 10:10PM BLOOD %HbA1c-5.9
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname 95**] [**Hospital1 18**] [**Numeric Identifier 14884**] (Complete)
Done [**2125-3-7**] at 1:39:58 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
[**Hospital1 18**], Division of Cardiothorac
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2041-8-31**]
Age (years): 83 F Hgt (in): 60
BP (mm Hg): 132/74 Wgt (lb): 120
HR (bpm): 72 BSA (m2): 1.50 m2
Indication: Intra-op TEE for AVR
ICD-9 Codes: 786.05, 440.0, 424.1, 424.0
Test Information
Date/Time: [**2125-3-7**] at 13:39 Interpret MD: [**Name6 (MD) 928**]
[**Name8 (MD) 929**], MD, MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 929**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Suboptimal
Tape #: 2009AW02-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: *1.3 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.3 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.8 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 3.5 cm
Left Ventricle - Fractional Shortening: *0.27 >= 0.29
Left Ventricle - Ejection Fraction: 55% to 60% >= 55%
Aorta - Sinus Level: 2.1 cm <= 3.6 cm
Aorta - Ascending: *3.5 cm <= 3.4 cm
Findings
RIGHT ATRIUM/INTERATRIAL SEPTUM: Dynamic interatrial septum. No
ASD by 2D or color Doppler.
LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size.
Suboptimal technical quality, a focal LV wall motion abnormality
cannot be fully excluded. Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in aortic root. Normal ascending aorta diameter.
Normal aortic arch diameter. Simple atheroma in aortic arch.
Normal descending aorta diameter. Simple atheroma in descending
aorta.
AORTIC VALVE: Three aortic valve leaflets. Moderately thickened
aortic valve leaflets. Severe AS (AoVA <0.8cm2). Moderate (2+)
AR.
MITRAL VALVE: Moderate to severe (3+) MR.
TRICUSPID VALVE: Physiologic TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient appears to be in sinus rhythm. Results
Conclusions for post-bypass data The post-bypass study was
performed while the patient was receiving vasoactive infusions
(see Conclusions for listing of medications).
Conclusions
PRE-BYPASS:
1. No atrial septal defect is seen by 2D or color Doppler.
2. There is mild symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Overall left ventricular systolic function is
normal (LVEF>55%).
3. Right ventricular chamber size and free wall motion are
normal.
4. There are simple atheroma in the aortic arch. There are
simple atheroma in the descending thoracic aorta.
5. There are three aortic valve leaflets. The aortic valve
leaflets are moderately thickened. There is severe aortic valve
stenosis (area <0.8cm2). Moderate (2+) aortic regurgitation is
seen.
6. Moderate to severe (3+) mitral regurgitation is seen.
Dr. [**Last Name (STitle) **] notified in person.
POST-BYPASS: For the post-bypass study, the patient was
receiving vasoactive infusions including phenylephrine and is
being AV paced.
1. A well-seated bioprosthetic valve is seen in the aortic
position with normal leaflet motion and gradients (mean gradient
= 15 mmHg). No aortic regurgitation is seen.
2. MR is improved to [**1-26**] +
3. Ascending aorta is intact post decannulation
4. Other findings are unchanged
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 928**] [**Name8 (MD) 929**], MD, MD,
Interpreting physician [**Last Name (NamePattern4) **] [**2125-3-7**] 15:35
[**Known lastname **],[**Known firstname 95**] [**Medical Record Number 14885**] F 83 [**2041-8-31**]
Cardiology Report ECG Study Date of [**2125-3-7**] 5:23:40 PM
Normal sinus rhythm. Right bundle-branch block. ST-T wave
changes
in leads I, II, III, aVF and V4-V6. Compared to the previous
tracing
of [**2125-3-6**] no diagnostic interval change.
Read by: [**Last Name (LF) **],[**First Name3 (LF) 125**] M.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
75 160 126 438/464 71 51 -45
Brief Hospital Course:
Ms. [**Known lastname 2643**] was admitted and underwent cardiac catherization which
revealed no significant coronary artery disease but did confirm
severe aortic stenosis. On [**3-7**] she was brought to the operating
room, in holding area prior to surgery she was noted for
hematuria. Urology was consulted, three wat foley was placed,
no cystoscopy indicated and was okay to heparinize for valve
replacement surgery. She under went an aortic valve
replacement, please see operative report for further details.
She was transferred to the intensive care unit for hemodynamic
monitoring. In the first twenty four hours she was weaned from
sedation, awoke neurologically intact and was extubated without
complications. On post operative day one she was started on
beta blockers and diuretics. Her foley remained in but she had
no hematuria post operatively, it was discussed with urology,
urine for cytology sent, and plan for follow up as outpatient
with Dr [**Last Name (STitle) 11189**], appointment [**2125-4-26**]. She was transferred to the
floor for the remainder of her care. Physical therapy worked
with her on strength and mobility. On post operative day two
she experienced rapid atrial fibrillation and remained
hemodynamically stable. Beta-blockers were optimized, Amiodarone
was bolused than converted to oral dosing. She continued to go
in and out of atrial fibrillation, anticoagulation was started.
She also had episodes of diarrhea which were negative for
clostridum difficle, and progressively the diarrhea decreased.
She was ready for discharge home with services postoperative day
six. Last episode of atrial fibrillation [**3-12**], remained in
normal sinus rhythm in the 60's. Plan for coumadin to be
followed by Dr [**Last Name (STitle) 14886**] office, coumadin nurse [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 17**], with
first draw by VNA [**3-15**].
Sternal incision healing no erythema, no drainage, sternum
stable
Lower extremities +1 edema upper extremeties no edema
Weight 57kg preop 54kg
Medications on Admission:
Prinivil 10mg twice a day
Zocor 10mg daily
Toprol XL 25mg daily
Aspirin 325mg daily
Oscal
NTG prn
Xalantan eye gtts
Discharge Medications:
1. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
Disp:*qs qs* Refills:*0*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO twice
a day.
Disp:*60 Tablet(s)* Refills:*0*
6. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
7. Warfarin 2 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for 1
doses: please take 2 mg [**3-14**] - your INR will be checked [**3-15**] and
further dosing by Dr [**Last Name (STitle) 14886**].
Disp:*60 Tablet(s)* Refills:*0*
8. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. Prinivil 5 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*0*
10. Outpatient [**Name (NI) **] Work
PT/INR for coumadin dosing
Results to Dr [**Last Name (STitle) 14887**] [**Name (STitle) 14886**] office #[**Telephone/Fax (1) 14888**] fax #
[**Telephone/Fax (1) 14889**] ([**First Name9 (NamePattern2) 5035**] [**First Name8 (NamePattern2) **] [**Doctor First Name **] coumadin nurse)
goal 2.0-2.5 for atrial fibrillation
11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day
for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
vna assoc. of [**Hospital3 635**]
Discharge Diagnosis:
Aortic Stenosis s/p AVR
Post operative atrial fibrillation
Acute on chronic diasystolic heart failure
Hematuria
Hypertension
Hyperlipidemia
Cerebrovascular disease
Osteoporosis
Glaucoma
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**]
If you develop any blood in urine please call - you are set up
for follow up with Dr [**Last Name (STitle) 11189**] from urology due to blood in your
urine preoperatively
Followup Instructions:
Please call to schedule all appointments
Dr. [**Last Name (STitle) **] in 4 weeks - [**Telephone/Fax (1) 170**]
Dr. [**Last Name (STitle) 14890**] in [**2-27**] weeks
Dr. [**Last Name (STitle) 14886**] in 1 week - [**Telephone/Fax (1) 14888**]
Dr. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 770**] in [**3-28**] weeks (urology) [**Telephone/Fax (1) 5727**] You have an
appointment [**4-26**] at 2:10 pm [**Hospital Ward Name 23**] [**Location (un) 470**]
[**Name (NI) **] PT/INR for coumadin dosing
Results to Dr [**Last Name (STitle) 14887**] [**Name (STitle) 14886**] office #[**Telephone/Fax (1) 14888**] fax #
[**Telephone/Fax (1) 14889**] ([**First Name9 (NamePattern2) 5035**] [**First Name8 (NamePattern2) **] [**Doctor First Name **] coumadin nurse)
goal 2.0-2.5 for atrial fibrillation
Completed by:[**2125-3-13**]
|
[
"428.0",
"401.9",
"424.1",
"E849.7",
"733.00",
"599.70",
"414.01",
"428.33",
"998.11",
"E878.8",
"365.9",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.21",
"37.22",
"88.56",
"88.72",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
10727, 10792
|
6898, 8949
|
297, 433
|
11022, 11028
|
1225, 6875
|
11710, 12554
|
805, 852
|
9115, 10704
|
10813, 11001
|
8975, 9092
|
11052, 11687
|
867, 1206
|
238, 259
|
461, 556
|
578, 712
|
728, 789
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,489
| 168,342
|
27194
|
Discharge summary
|
report
|
Admission Date: [**2103-4-11**] Discharge Date: [**2103-4-17**]
Date of Birth: [**2052-9-17**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
hemoperitoneum
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Pt is a 50M with HCC (4.5 cm) in R lobe, s/p resection. Pt
developed nodule in R lobe in [**2101-6-26**], s/p RFA x 2. + lesion in
liver, + lesion in lung. + Abd pain for previous 3-4 days. +
dull, intermitant pain in lower abdomen. no N/V. +BM day of
admission. +flatus.
Past Medical History:
1. Hep B
2. Hepatocellular carcinoma
3. DM-II
Social History:
no EtOH, no tobacco
Family History:
mother: h/o uterine cancer
sister: uterine cancer
Physical Exam:
98.1, 81, 104/64, 11 97%
AOx3
RRR
CTA B/L
soft, NT, ND
guiac +, nl tone
Pertinent Results:
[**2103-4-10**] 11:26AM WBC-6.2# RBC-2.89*# HGB-9.9*# HCT-28.2*#
MCV-98 MCH-34.4* MCHC-35.2* RDW-15.8*
[**2103-4-10**] 11:26AM TOT BILI-6.9* DIR BILI-1.4* INDIR BIL-5.5
.
CT PELVIS W/CONTRAST [**2103-4-10**] 3:22 PM
CT ABD W&W/O C; CT PELVIS W/CONTRAST
IMPRESSION: Large amount of new high-density free fluid within
the abdomen consistent with hemoperitoneum suggesting rupture or
bleeding from a hepatoma.
These findings were directly communicated to Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] at the moment of the interpretation of the study [**4-11**], [**2102**], at 10 a.m.
Otherwise, there are no new findings compared to prior study
dated [**2103-4-6**].
Brief Hospital Course:
The patient was admitted to the the SICU and transfused with red
cells, platletts and FFP. Serial hematocrits were followed.
Interventional radiology was consulted. Interventional radiology
was unable to isolate the location of the bleed during hepatic
angiography. On HD 2 the patient and his hematocrits were
stable and he was subsequently transfered to the floor. His diet
was advanced. On the evening of HD the patient was febrile to
102.3. A fever work-up was undertaken which ultimately to not
reveal any abnormalities. IV antibiotics were started. On [**4-16**]
the antiobiotics were changed to oral levofloxacin/flagyl. He
was seen by [**Last Name (un) **] for elevated blood sugars. On [**4-17**] the
patient was tolerating a regular diet, had decrease in abdominal
pain, a stable hematocrit and he was subsequently discharged
home.
Medications on Admission:
lamivudin, RISS
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. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
4. Lamivudine 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
6. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 7 days.
Disp:*21 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
1. metastatic hepatocellular carcinoma
2. hepatitis B
3. DM-II, uncontrolled
4. acute blood loss anemia
Discharge Condition:
stable
Discharge Instructions:
Restart you home medications as usual. Regular diet. You may
resume activity as tolerated. Complete your course of
Antibiotics as directed.
* Increasing pain
* Fever (>101.5 F) or Vomiting
* Inability to eat or drink
* Inability to pass gas or stool
* Other symptoms concerning to you
Followup Instructions:
1. Follow-up with Dr. [**Last Name (STitle) 66718**] with in the next week. Call to
schedule an appointment [**Telephone/Fax (1) 2115**]
|
[
"250.00",
"568.81",
"070.32",
"155.0",
"197.0",
"285.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.47",
"99.05",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
3302, 3308
|
1637, 2485
|
328, 335
|
3456, 3465
|
916, 1614
|
3802, 3942
|
758, 809
|
2551, 3279
|
3329, 3435
|
2511, 2528
|
3489, 3779
|
824, 897
|
274, 290
|
363, 636
|
658, 705
|
721, 742
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
105
| 128,744
|
1072
|
Discharge summary
|
report
|
Admission Date: [**2189-2-21**] Discharge Date: [**2189-2-25**]
Date of Birth: [**2153-9-26**] Sex: F
Service: MEDICINE
Allergies:
Haldol
Attending:[**First Name3 (LF) 6994**]
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 6995**] is a 36 yo F w/end-stage [**Location (un) 6988**] disease who
was recently dc'd from the MICU on [**2189-2-2**] after tx for PNA and
SVT (requiring cardioversion) who was brought in by family after
she was noted to be febrile to 102F. Her sister and caregivers
noted a productive cough, congestion, but deny witnessing
diarrhea/vomiting. She was also noted to have depressed mental
status and decreased po intake over the past few days. Family
denies noticing respiratory distress. Per the family, her
baseline SBPs in 80's-90's.
.
In the ED, the pt was noted to be febrile to 103.2 and
tachycardic to 104. Her BP was 107/63 with a respiratory rate of
20 and a room air O2 saturation of 97%. She had poor air
movement on lung exam and cool extremities. Of note, the patient
is nonverbal at baseline and does not follow commands.
.
A CXR in the ED did not show any new focal infiltrates or
effusions. There was no evidence for active CHF. It appeared
improved vs. [**2189-2-2**].
An EKG revealed old, nonspecific ST/TW changes laterally and
diffuse low-voltage. Blood cultures and urine culture were sent
from the ED. She was started on levofloxacin/flagyl.
Past Medical History:
[**Location (un) 6988**] Disease
Anemia
CHF: EF 10%
Nonverbal at baseline
Social History:
MEDS:
Tylenol
Ensure
.
SocHX: Patient lives at home with sister and brother. She also
goes to daycare. She is non-verbal at baseline.
.
Family History:
father who passed away of [**Name (NI) **] dz
Physical Exam:
97.7, 67, 84/51, 16,
GEN: Awake, occasional tracks to voice, nonverbal. Appears in
NAD.
HEENT: PERRL bilat., MM moist, no LAD.
CV: RRR, difficult exam secondary to pt motion
RESP: diffusely diminished breath sounds at bases, coarse upper
airway sounds bilaterally at apices.
ABD: soft, NT/ND. +bs
EXT: wdwp.
NEURO: ++choreoathetoid movements. unable to test.
Brief Hospital Course:
A/P: 35 yo F w/end stage [**Location (un) 6988**], recent dc from MICU for
PNA/SVT, who presented with fever, cough, and altered mental
status. Despite improved CXR, concern for PNA.
.
1. Fever: Pt with fever at home to 103, recent hospitalization
and tx for PNA. Despite improved cxr, lungs are most likely
source of infection. UA was negative. Blood cultures from prev
hospitalization NGTD. Cultures from ED were also neagitve. The
patient was started on broad spectrum antibiotics initially but
then converted to oral levaquin and flagyl. The patient was
afebrile while hospitalized.
.
2. [**Location (un) 6988**]: Pt has end-stage [**Location (un) 6988**] disease. Dr
[**Last Name (STitle) **] was aware that the patient was hospitalized and spoke
with the family about goals of care.
.
3. SVT: Hx of recent SVT requiring cardioversion. Started on
amiodarone at d/c from hospital on last admission. The patient
had no issues with tachycardia this admission.
.
4. CHF: Pt has CHF w/EF 10% by report. No clinical evidence of
failure. Pt did not have any fluid overload issues while
hospitalized.
Medications on Admission:
-lasix
-asa
-amiodarone
-amoxicillin
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 4 days.
Disp:*qs Tablet(s)* Refills:*0*
5. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 4 days.
Disp:*4 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] [**Location (un) 269**]
Discharge Diagnosis:
Fever
--------
Secondary
Hunnington's Disease
Congestive Heart Failure
Discharge Condition:
Stable, afebrile
Discharge Instructions:
You were treated in the hospital for fever. We did not find a
source of infection. You were treated in the ICU because your
initial blood pressure was low but then transferred to the
floor. You were treated with antibiotics for a presumed
pneumonia given the symptoms that you came in with. You should
finish the course of antibiotics when at home.
Call your primary care provider or return to the emergency
department for any of the following:
fever, chills, chest pain, shortness of breath, nausea,
vomiting, diarrhea, constipation, or other concerning symptoms
Other than the new prescription for antibiotics, we did not make
any changes to your home medications. Please resume your home
medications upon discharge
Followup Instructions:
Follow up with Dr [**Last Name (STitle) **] in one week. Please call [**Telephone/Fax (1) **]
to schedule an appointment.
Follow up with Dr [**Last Name (STitle) **] for further care.
|
[
"333.4",
"780.6",
"428.0",
"486"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
3877, 3954
|
2213, 3315
|
273, 280
|
4069, 4088
|
4861, 5050
|
1767, 1814
|
3402, 3854
|
3975, 4048
|
3341, 3379
|
4112, 4838
|
1829, 2190
|
228, 235
|
308, 1497
|
1519, 1595
|
1611, 1751
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,226
| 178,316
|
53722+59545
|
Discharge summary
|
report+addendum
|
Admission Date: [**2184-4-7**] Discharge Date: [**2184-4-15**]
Date of Birth: [**2112-3-16**] Sex: F
Service: NEUROSURGERY
Allergies:
Sulfa(Sulfonamide Antibiotics) / Heparin Agents
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Enlarging brain abcess
Major Surgical or Invasive Procedure:
[**4-9**] Left Craniotomy for evacuation of brain abscess
History of Present Illness:
Ms. [**Known lastname **] is a 72 y.o. RH female with PMH of HTN,
hyperlipidemia, ulcerative colitis and known left tempoparietal
brain abscess s/p stereotactic brain abscess drainage on [**2184-3-8**]
who presented to ED with multiple brain abscessed. She was
discharged on ceftriaxone, vancomycin and Flagyl. She was
followed by neurology and ID. She was recently found have
thrombocytopenia and ceftriaxone was changed to penicillin.
However, she was found to have Heparin-Induce Thrombocytopenia.
She was changed from Ceftriaxone to penicillin IV.
Now for the past several days, she has had increasing HAs,
agitation, nausea, vomiting and fevers. She had a head CT
yesterday which showed multiple ring enhancing lesion. Patient
presented to ED for further management. Neurosurgery consulted
for further management.
On review of systems patient reports chills and rigors. She has
no visual loss or paresthesia. No chest pain, abdominal pain or
SOB. All other systems are essentially non-contributory.
Past Medical History:
-HTN
-HLD
-Ulcerative colitis - per PCP/GI doc, trivial 15-30 cm of
colitis in distal sigmoid sparing rectum. Pathology showed mild
IBD. PCP/GI doc does not consider this UC.
-Femur fracture s/p rod + pins ([**9-/2183**])
-viral tongue lesion (dx 1 month ago) - s/p biopsy and ~4 wks
abx
-left cheeck skin cancer s/p topical/surgical removal - unclear
if basal cell vs melanoma. PCP [**Name Initial (PRE) 72520**]'t recall melanoma hx but
does not have in records. Derm: Dr. [**Last Name (STitle) 11487**] at [**Hospital1 **]
Screening tests (per PCP/GI Dr. [**Last Name (STitle) 110284**] - Pt often
refused.
- last colonoscopy [**2181**] - focal ischemia, no polyps
- mammogram [**2174**] - no abnl
- prev CXR [**2170**]
Social History:
She previously lived with her husband. She had been in rehab in
CT for her femur fx in [**9-/2183**] and subsequently living with
daughter in CT for further rehab; moved back with her husband
prior to her recent admission to [**Hospital1 18**] in [**2184-2-15**]. She is
now at Newbridge on the [**Hospital **] Rehab after that admission.
Family History:
Unable to obtain from patient
Physical Exam:
ADMISSION PHYSICAL EXAM:
O: T: 101.0 103 146/73 22 97%
Gen: WD/WN, comfortable, NAD, warm to touch, with rigors
HEENT: head: incision well-healed, disheveled, eye; clear, no
jaundice, ears: hearing intact, no drainage Nose: patent, no
drainage
Neck: Supple.
Lungs: CTA bilaterally, no w/c/r.
Cardiac: RRR. S1/S2.
Abd: Soft, obese, NT, BS+
Extrem: Warm and well-perfused, no c/c/e
Neuro:
Mental status: Awake and alert, distressed and agitate.
Orientation: Oriented to person and hospital, thinks it is [**2194**].
Language: Speech fluent with good comprehension, following
commands, able to repeat
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2
mm bilaterally, fundoscopic - no papilledema, Visual fields are
full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: 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 [**3-20**] throughout. No pronator drift
Sensation: Intact to light touch
Reflexes: B T Br Pa Ac
Right 2+----------
Left 2+----------
No clonus
Toes downgoing bilaterally
Bilateral rigors on coordination exam, but appropriate
Handedness Right
On Discharge:
Stable
Pertinent Results:
ADMISSION LABS:
[**2184-4-7**] 04:05PM BLOOD WBC-9.2# RBC-4.29 Hgb-12.4 Hct-38.4
MCV-90 MCH-29.0 MCHC-32.4 RDW-14.2 Plt Ct-270#
[**2184-4-7**] 04:05PM BLOOD Neuts-84.8* Lymphs-12.5* Monos-2.1
Eos-0.4 Baso-0.3
[**2184-4-7**] 04:05PM BLOOD PT-12.9* PTT-27.4 INR(PT)-1.2*
[**2184-4-7**] 04:05PM BLOOD Glucose-126* UreaN-3* Creat-0.6 Na-130*
K-4.1 Cl-96 HCO3-19* AnGap-19
[**2184-4-7**] 04:05PM BLOOD CRP-1.5
[**2184-4-7**] 04:20PM BLOOD Lactate-1.7
REPORTS:
CT HEAD [**2184-4-6**]: IMPRESSION: Four rim-enhancing left parietal
fluid collections encompassing a larger area in comparison to a
previously-seen single abscess at this location. The findings
are concerning for recurrent or expanding infection. MR could
be considered for further evaluation.
Cardiovascular Report ECG Study Date of [**2184-4-7**] 3:45:24 PM
Sinus tachycardia. Possible prior septal myocardial infarction,
age
undetermined. Left ventricular hypertrophy with secondary
repolarization
changes. Compared to the previous tracing of [**2184-3-2**] lateral
ST-T wave changes are more prominent on the current tracing.
Other findings are similar.
[**4-7**] MR HEAD W & W/O CONTRAST
IMPRESSION:
1. Multiseptated, multiloculated peripherally enhancing lesion
in left
temporoparietal lobe is suggestive of an abscess with associated
significant perilesional edema causing mass effect on the atrium
and body of left lateral ventricle.
2. Enhancement along the atrium of left lateral ventricle which
likely
represents subependymal spread of infection.
3. Changes of chronic small vessel ischemic disease.
[**4-7**] CHEST (PORTABLE AP) FINDINGS: The patient has received a
right PICC line. The course of the line is unremarkable, the
line appears to terminate in the mid SVC. There is no evidence
of complications, notably no pneumothorax.
MR HEAD W/O CONTRAST Study Date of [**2184-4-8**] 11:51 AM
IMPRESSION:
1. Limited examination due to patient motion, functional MRI
sequences of the brain were cancelled due to lack of patient
cooperation.
2. DTI tractography images demonstrate significant deviation of
the
corticospinal fibers and association fibers; however, apparently
there is
evidence of cortical spinal tracts adjacent to this mass lesion.
3. In comparison with the prior examinations, no significant
changes are
visualized in the left occipital mass with persistent vasogenic
edema, slow diffusion and mass effect.
MR HEAD W/ CONTRAST Study Date of [**2184-4-9**] 4:44 AM
IMPRESSION:
1. Pre-operative planning study with stable multiseptated,
multiloculated
peripherally enhancing lesion in left temporoparietal lobe with
associated
significant perilesional edema causing mass effect on the atrium
and body of left lateral ventricle.
2. Enhancement along the atrium of left lateral ventricle which
likely
represents subependymal spread of infection.
[**4-9**] CT head postop: Status post craniotomy and drainage of left
parietal abscesses with small amount of post procedural
intraparenchymal and extra-axial hemorrhage and unchanged
vasogenic edema without evidence of significant mass effect.
[**4-10**] Chest Xray: There is an endotracheal tube whose distal tip
is 5 cm above the carina at the level of the aortic knob and
appropriately sited. Cardiac silhouette is upper limits of
normal. There is mild prominence of the pulmonary interstitial
markings without overt pulmonary edema. No large pleural
effusions or pneumothoraces are seen. There is a right-sided
PICC line whose distal tip is at the cavoatrial junction,
unchanged from prior.
[**4-10**] MR brain with & without Contrast:
IMPRESSION:
1. Post-surgical changes in the left parietal region, with
heterogeneous
enhancement in the left parietal lobe extend into the atrium of
the left
lateral ventricle with mild subependymal enhancement and
moderate surrounding edema. This is decreased since the
pre-operative study, with a few persistent blood products and
possible purulent material. Other details as above.
2. A faint focus of enhancement in the pons, likely represents
a capillary telangiectasia and is unchanged.
[**4-14**] Transthoracic Echocardiogram
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). Tissue Doppler imaging suggests a normal
left ventricular filling pressure (PCWP<12mmHg). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No masses or vegetations are seen on
the aortic valve. Trace aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. No mass or vegetation is seen on the mitral valve.
Mild (1+) mitral regurgitation is seen. The estimated pulmonary
artery systolic pressure is normal. There is no pericardial
effusion.
IMPRESSION: No echocardiographic evidence of endocarditis.
Normal global and regional biventricular systolic function. Mild
mitral regurgitation.
Brief Hospital Course:
This is a 72 year old female with known left tempoparietal brain
abscess who presented with increased headaches,nausea, vomiting,
and agitation who presented on [**2184-4-7**] with more enhancing
lesions (probable abcess) and cerebral edema. On [**2184-4-7**] the
patient was admitted to the neurosurgery service to the SICU
additional evaluation and treatment. The patient had a brain MRI
with and without contrast to assess the extent ofthe multiple
brain abscesses which was consistent with multiseptated,
multiloculated peripherally enhancing lesion in left
temporoparietal lobe is suggestive of an abscess with associated
significant
perilesional edema causing mass effect on the atrium and body of
left lateral
ventricle. Enhancement along the atrium of left lateral
ventricle which likely
represents subependymal spread of infection.Changes of chronic
small vessel ischemic disease. A functional MRI was performed as
this lesion is near her motor and speech centers of her brain
because she is right-handed and left hemisphere dominate which
was consistent with limited examination due to patient motion,
functional MRI sequences of the brain were cancelled due to lack
of patient cooperation. DTI tractography images demonstrate
significant deviation of the corticospinal fibers and
association fibers; however, apparently there is evidence of
cortical spinal tracts adjacent to this mass lesion. In
comparison with the prior examinations, no significant changes
are visualized in the left occipital mass with persistent
vasogenic edema, slow diffusion and mass effect. The patient
exhibited "red man's syndrome" and was given benadryl.
On [**4-8**],Infectious Disease was consulted and recommendations
were as follows:The failure to resolve her brain abscess after a
long course of metronidazole and ceftriaxone suggests that
either her infection was polymicrobial at the outset or she
developed a superinfection, perhaps via an organism introduced
at the time of
her prior surgery. Would cover gram positive organismsby adding
vancomycin to her regimen, and would monitor vancomycin levels
and renal function. For now would continue metronidazole and
ceftriaxione, since she initially seemed to
improve. Based on the results of new brain aspiration, would
adjust antibiotics accordingly, possibly to cover more resistant
gram negative rods or to cover yeast or other atypical
pathogens. On exam, the patient's mental status was improved.
On [**4-9**], A Wand MRI was performed for OR planning. The patient
went to the OR for a left craniotomy for evacuation and washout
of the brain abscess. The patient tolerated the procedure well
and she was transferred intubated to the ICU. Postoperative
head CT demonstrated no postoperative hemorrhage.
She remained intubated until after a postoperative MRI could be
obtained on [**4-10**]. Post extubation the patient remained
neurologically intact.
On [**4-11**] she was transferred to the regular floor. She was
repleted in the AM via IV for a Potassium of 2.8. Repeat
evening K was 3.4 for which she was repleted orally with a plan
to recheck in the AM. Vancomycin dosing was increased to 1250
IV BID per ID recommendations and a trough was scheduled for
prior to the 4th dose. On [**4-13**], she was screened for rehab and
ceftriaxone was changed to daily per ID. On [**4-14**], ID changed
flagyl to PO 500mg Q8H which patient could not tolerate due to
nausea so it was made IV once again. She continued to have
nausea around the administration of Flagyl and thus was managed
with oral and IV antiemetics. TTE was obtained on [**4-14**] which
demonstrated a normal EF of 55% with no evidence of vegetations.
She remained neurologically stable during her hospital stay and
at the time of discharge on [**4-15**] she was tolerating a regular
diet, ambulating with an assistive device, afebrile with stable
vital signs.
She is sheduled for follow up with ID in two weeks with a plan
to continue triple antibiotic therapy until then. Vancomycin
levels should be followed to maintain a goal trough level of
15-20.
Medications on Admission:
Penicillin 4 million units IV Q4h
CITALOPRAM [CELEXA] - (Prescribed by Other Provider) - 20 mg
Tablet - 1 Tablet(s) by mouth once a day This Rx has been called
into your mail order pharmacy
LEVETIRACETAM [KEPPRA] - (Prescribed by Other Provider) - 500
mg
Tablet - 2.5 Tablet(s) by mouth twice a day This Rx has been
called into your mail order pharmacy
LOPERAMIDE - (Prescribed by Other Provider) - 2 mg Capsule - 1
Capsule(s) by mouth four times a day as needed for diarrhea
METOPROLOL TARTRATE - (Prescribed by Other Provider) - 50 mg
Tablet - 1 Tablet(s) by mouth twice a day
METRONIDAZOLE [FLAGYL] - (Prescribed by Other Provider) - 500
mg
Tablet - 2 Tablet(s) by mouth two times a day and 1 tablet QHS
ONDANSETRON HCL - (Prescribed by Other Provider) - 4 mg Tablet
-
2 Tablet(s) by mouth every eight (8) hours as needed for nausea
SIMVASTATIN - (Prescribed by Other Provider) - 10 mg Tablet - 1
Tablet(s) by mouth DAILY (Daily)
heparin flushes - was discontinued prior to arrival
Discharge Medications:
1. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed for diarrhea.
3. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. insulin regular human 100 unit/mL Solution Sig: per insulin
sliding scale Units Injection ASDIR (AS DIRECTED).
6. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
7. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for irritation.
8. acetaminophen-codeine 300-30 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for Pain.
9. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. levetiracetam 500 mg Tablet Sig: 2.5 Tablets PO BID (2 times
a day).
11. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
12. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
13. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
14. Vancomycin 1250 mg IV Q 12H
15. Ondansetron 4 mg IV Q8H
Please give prior to flagyl dosing
16. CeftriaXONE 2 gm IV Q24H
17. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H
18. Ondansetron 4 mg IV Q4H:PRN nausea
Discharge Disposition:
Extended Care
Facility:
Newbridge on the [**Doctor Last Name **] - [**Location (un) 1411**]
Discharge Diagnosis:
Cerebral Abcess
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
General Instructions
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You have dissolvable sutures. You may wash your hair.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? You have been discharged on Keppra (Levetiracetam) for seizure
prevention, you will not require blood work monitoring.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101.5?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
?????? Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in 4 weeks.
?????? You will need a CT scan of the brain with and without
contrast.
- You are also scheduled to follow up with infectious disease in
2 weeks. You will see [**Name6 (MD) 14621**] [**Last Name (NamePattern4) 14622**], MD Phone:[**Telephone/Fax (1) 457**] on
[**2184-4-26**] at 10:00am.
- You also have an appointment to follow up with Neurology:
Department: NEUROLOGY
When: MONDAY [**2184-6-28**] at 4:30 PM
With: DRS. [**Name5 (PTitle) 43**] & [**Doctor Last Name 2336**] [**Telephone/Fax (1) 44**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2184-4-15**] Name: [**Known lastname **],[**Known firstname **] Unit No: [**Numeric Identifier 18069**]
Admission Date: [**2184-4-7**] Discharge Date: [**2184-4-15**]
Date of Birth: [**2112-3-16**] Sex: F
Service: NEUROSURGERY
Allergies:
Sulfa(Sulfonamide Antibiotics) / Heparin Agents
Attending:[**First Name3 (LF) 599**]
Addendum:
Medication list updated to include the following as patient has
a PICC line but cannot have heparin flushes because she is HIT
positive:
Sodium Citrate 4%, 2ml ASDIR for PICC line
instill after medication and withdraw prior to next medication
Discharge Medications:
1. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed for diarrhea.
3. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. insulin regular human 100 unit/mL Solution Sig: per insulin
sliding scale Units Injection ASDIR (AS DIRECTED).
6. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
7. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for irritation.
8. acetaminophen-codeine 300-30 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for Pain.
9. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. levetiracetam 500 mg Tablet Sig: 2.5 Tablets PO BID (2 times
a day).
11. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
12. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
13. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
14. Vancomycin 1250 mg IV Q 12H
15. Ondansetron 4 mg IV Q8H
Please give prior to flagyl dosing
16. CeftriaXONE 2 gm IV Q24H
17. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H
18. Ondansetron 4 mg IV Q4H:PRN nausea
19. sodium citrate 4 % (3 mL) Syringe Sig: Two (2) ML
Miscellaneous ASDIR for PICC line : ASDIR for PICC line
instill after medication and withdraw prior to next medication.
20. NO Heparin as patient is HIT positive
Discharge Disposition:
Extended Care
Facility:
Newbridge on the [**Doctor Last Name **] - [**Location (un) 1502**]
Discharge Instructions:
General Instructions
**PICC line: must be flushed with citrate per medication list.
Patient cannot have Heparin as she is HIT positive**
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You have dissolvable sutures. You may wash your hair.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? You have been discharged on Keppra (Levetiracetam) for seizure
prevention, you will not require blood work monitoring.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101.5?????? F.
[**Name6 (MD) **] [**Last Name (NamePattern4) 603**] MD [**MD Number(2) 604**]
Completed by:[**2184-4-15**]
|
[
"276.8",
"272.4",
"348.5",
"324.0",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.59"
] |
icd9pcs
|
[
[
[]
]
] |
20792, 20886
|
9150, 13233
|
334, 393
|
15914, 15914
|
4097, 4097
|
17596, 19067
|
2559, 2591
|
19090, 20769
|
15876, 15893
|
13259, 14253
|
20910, 22639
|
2631, 2995
|
4070, 4078
|
272, 296
|
421, 1437
|
3223, 4056
|
4114, 9127
|
15929, 16074
|
1459, 2185
|
2201, 2543
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,901
| 171,358
|
7214
|
Discharge summary
|
report
|
Admission Date: [**2186-2-27**] Discharge Date: [**2186-3-21**]
Service: MEDICINE
Allergies:
Oxacillin
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Percutaneous endoscopic jejunostomy
History of Present Illness:
82yo Russian speaking male w/ h/o CAD, s/p CABG ([**2173**]) and
NSTEMI ([**1-2**]) presents with SOB, dypnea on exertion, congestion
and difficulty mobilizing sputum. After being recently d/ced
from [**Hospital1 **] on [**2186-2-13**] after hospitalization for GIB/CP/and RLL
PNA. Patient's hx difficult to obtain due primarily to
significant confusion as well as language barrier. Per hx from
rehab facility pt.has several days of cough and SOB, for which
he was started on Levo/Flagyl.
Pt. also reports some intermittent CP of unclear duration, that
is reported as non-pleuritic, inc. peripheral edema, + fever
(undocumented). His last vital signs at [**Hospital3 **], VS WNL
for pt. were BP 91/71, P 68, Temp 97.2, 97%RA.
In the ED, VS-Temp 100.2 rectal HR 71-82 BP 94/63 RR 30 96% RA.
Was found to have a large pleura effusion. Patient was given
ASA, Vanco 1gm and CTX 1gm. On thoracentesis removed approx. 2L
fluid, which was sent for GS/Cx/Cytology.
Past Medical History:
Past Medical History:
1. CAD
2. NSTEMI ([**1-2**])
3. CABG ([**2173**])
4. DM2
5. HTN
6. PID w/ claudication mostly RLE (involvement of RT aorto-iliac
arteries, and B superficial femoral arteries)
7. CHF w/ EF of 30% (moderate AR and MR)
8. Mild oro-pharyngeal dysphagia
9. B12 Anemia
10. DJD
11. [**Year (4 digits) **] nails
Social History:
denies alcohol/tobacco, currently lives at rehab facility with,
wife and son make medical decisions. DNR/DNI.
Family History:
noncontributory
Physical Exam:
Vitals: Tc 97.3 110/68 76 20 93%RA
Gen: Thin man appearing stated age, alert but confused
HEENT: NCAT, unable to assess JVD due to poor pt. cooperation
CV: Unable to assess due to diffuse rhonchi
Lungs: diffuse coarse rhonchi B, [**Month (only) **] BS at base of rt. lung,
rales at lt. base
Abd: S/NT/ND
Ext: 3+ pitting edema to the knees
Pertinent Results:
Admission Labs
[**2186-2-27**] 02:00PM WBC-12.9*# RBC-4.08* HGB-10.9* HCT-33.8*
MCV-83 MCH-26.8*# MCHC-32.3# RDW-14.7
[**2186-2-27**] 02:00PM NEUTS-89.5* LYMPHS-5.1* MONOS-4.7 EOS-0.1
BASOS-0.6
[**2186-2-27**] 02:00PM PT-15.3* PTT-28.3 INR(PT)-1.4*
[**2186-2-27**] 02:00PM GLUCOSE-294* UREA N-41* CREAT-1.3* SODIUM-141
POTASSIUM-4.3 CHLORIDE-106 TOTAL CO2-28 ANION GAP-11
[**2186-2-27**] 02:00PM CALCIUM-8.5 PHOSPHATE-3.9 MAGNESIUM-1.8
[**2186-2-27**] 07:21PM TOT PROT-5.0* ALBUMIN-2.2* GLOBULIN-2.8
[**2186-2-27**] 02:00PM CK(CPK)-29*
[**2186-2-27**] 02:00PM cTropnT-0.04*
[**2186-2-27**] 07:21PM CK-MB-NotDone cTropnT-0.04*
[**2186-2-27**] 02:00PM CK-MB-NotDone proBNP-[**Numeric Identifier 26732**]*
[**2186-2-27**] 08:42PM PLEURAL WBC-3000* RBC-[**Numeric Identifier 17260**]* POLYS-70*
LYMPHS-15* MONOS-15*
[**2186-2-27**] 08:42PM PLEURAL TOT PROT-2.4 GLUCOSE-165 LD(LDH)-328
AMYLASE-13 ALBUMIN-1.2
[**2186-2-27**] 08:57PM PH-7.47* COMMENTS-PLEURAL FL
[**2186-3-1**] 05:30PM PLEURAL WBC-1500* RBC-[**Numeric Identifier 26733**]* POLYS-86*
BANDS-1* LYMPHS- 12*MONOS-0 MACRO-1*
[**2186-3-1**] 5:30PM PLEURAL TOT PROT-2.2 GLUCOSE-165 LD(LDH)-222
AMYLASE-13
ALBUMIN-1.1
[**2186-2-27**]
CXR
There is new consolidation in the perihilar right lung
concerning for
pneumonia or pulmonary hemorrhage. Mod rt. pleural effusion has
begun to reaccumulate, and new interstitial edema is present.
Small Lt. pleural effusion is stable. Azygous distention
indicates volume overload or right heart decompensation. Mod.
cardiomegaly and calcified left ventricular apical aneurysm are
longstanding.
EKG
[**2186-2-28**]
Unchanged from previous. NSR, HR 73, 1st degree heart block,
poor R-wave progression.
Brief Hospital Course:
82yo Russian speaking male w/ h/o CAD, s/p CABG ([**2173**]) and
NSTEMI ([**1-2**]) presents with SOB, dyspnea on exertion,
congestion and difficulty mobilizing sputum:
.
1. Bilateral parapneumonic effusions:
On previous d/c ([**2-13**]) the pt had a RLL PNA that was Tx w/ 10d
of course of Levofloxacin. The PNA remained unresolved on this
admission. CXR on admission demonstrated a RLL PNA and large R
pleural effusion. The patient was started on
Ceftriaxone/Clindamycin for empiric Tx of Gram+ PNA. However
despite this coverage the patient's WBC continued to trend up.
Given that the patient was in rehab, and multiple
hospitalizations, pt was covered with Linezolid. The pt's WBC
count decreased from 17.3 to 8.4 on
Linezolid/Ceftriaxone/Clindamycin.
.
Interventional pulm performed a thoracentesis on [**2-28**] [**Last Name (un) 26734**]
1800cc of bloody fluid with obvious fibrin stranding, +MRSA.
Pleural fluid was exudative. Chest CT demonstrated a loculated
effusion. On [**3-3**], linezolid was changed to Vancomycin. Pt
remained afebrile on this antibiotic regimen. ID was consulted
and recommended treatment w/ Vancomycin until [**4-9**], and
following w/ suppressive oral abx regimen thereafter.
Interventional pulmonology performed a repeat throacentesis on
[**3-1**] [**Last Name (un) 26734**] 300cc of fluid of. Pleural fluid from second tap
did not grow any organisms. Given the loculated nature of the
effusion, IP felt that a chest tube/pigtail would not be
efficacious, and recommended VATS and decortication. CT surgery
did not recommend VATS, since pt was deemed a poor surgical
candidate due to his cardiovascular hx and overall poor
functional status.
.
After being on this antibiotic regimen, the pt started having
thick pink-tinged, yellow, white sputum, with frequent mucus
plugging, requiring Q4H suctioning and chest PT. Sputum culture
gram stain on [**3-17**] was positive for 4+ Gram neg rods.
Meropenem was started for Gram neg covereage. Sputum Cx later
grew out Pseudomonas, [**Last Name (un) 36**] to Meropenem. A PICC line was placed
for long-term access for abx.
.
MRSA was sensitive to Bactrim and Doxycycline, which was planned
to be used for suppression once Vanco course is complete. On
[**3-9**] the patient desaturated, likely from mucus plugging. CXR
[**3-9**] showed pt was fluid overloaded. Third spacing and 1+ to
2+ pitting dependent edema was due to hypoalbuminemia. The
patient was aggressively diuresed with 20-40 of IV Lasix, and
then increased to 80 Lasix IV doses for a goal of 500-1000cc
negative each day.
.
# Cardiac:
The pt. was s/p CABG in [**2173**], NSTEMI [**1-2**]. His EKG demonstrated
1st degree heart block and poor R-wave progression unchanged
from his previous baseline. The pt. ruled out for MI by serial
cardiac enzymes on admission. He was monitored on telemetry w/o
any events.
.
The pt. has a Hx of CHF and on admission his CXR did demonstrate
some interstitial edema. On exam the pt had bilateral rales and
dependent edema. The pt. was aggressively diuresed for a goal
of 1000cc neg QD. Digoxin and Losartan were added to his
regimen and his Lisinopril was titrated up in an effort to
improve his forward output. Initially the patient's BP
responded well to diuresis and afterload reduction, and SBP
improved to 120-130s. However, overall the pt's exam remained
clinically unchanged, neck veins remained distended, and he
developed anasarca. Repeat CT chest and CXR demonstrated
interval increase in his pleural effusion particularly on the L
side, likely a transudatve effusion secondary to his CHF. He
had poor UO likely attributable to endstage CHF, ACEi and [**Last Name (un) **]
were d/c ([**1-12**])to maximize renal adjustment to poor effective
arterial volume and Imdur and hydralazine were added for
afterload reduction, but then eventually discontinued when the
pt began to become hypotensive to SBP 90s.
.
# CHF:
Pt was maintained on ASA, statin, and BB. ASA was discontinued
for GIB.
.
# ARF:
Baseline Cr was 0.9, with low UO, which was deemed to be due to
prerenal etiology and was treated with NS boluses with good UO
in response. Fluid status and UO was very difficult to
maintain, for necessary diuresis for respiratory status. After
several days of diuresis the Pt's Cr increased to 1.5. Etiology
was likely poor cardiac output secondary to CHF, as well as
intravascular volume depletion, due to hypoalbuminemia and
aggressive diuresis. Pt was transfused with RBC to maintain
intravascular volume, but pt continued to have poor UO. Cr
remained stable at around 1.5. Renal was consulted, and
examination of urine sediment found no muddy brown casts.
.
# Urinary Retention:
Urinary retention was new during this admission (starting [**3-1**]).
Pt had no evidence of prostate CA visualized on CT Abd/Pelvis
but did have a PSA of 9.2. His retention was thought to be
likely attributable to BPH. A Coude catheter was inserted and
remained in place given the urinary retention and aggressive
diuresis.
.
# Anemia:
Due to anemia of chronic disease. Baseline Hct was around 30,
microcytic. Pt was guaiac negative until GIB after placement of
PEG tube. B12 and folate were repleted.
.
# Upper GI bleeding:
Pt started having melena on [**3-15**]. After placement of his PEG
tube the patient's Hct began to slowly trend down from 31
([**3-11**]) to 26 ([**3-14**]). Etiology was thought likely due to PEG
tube placement, although pt had previous history of GIB from
gastritis. RBC were transfused for Hct goal 28. Pt had a Hx of
GIB on last admission requiring PRBCs x4, EGD at that time
showed evidence of gastritis. He was at risk for GIB due to ASA
and stress ulcers, but pt had been maintained on PPI since
admission. Regimen was changed to PPI IV BID and carafate. He
was seen by GI and had a negative gastric lavage. His ASA was
discontinued.
.
# Abdominal pain:
Pt. had intermittent RUQ pain and had an Abd US demonstrating
cholelithiais. However since surgery would be inappropriate in
this patient w/ poor functional status, he was maintained on
Morphine standing for good pain control. Pt's PEG
.
# PEG site infection:
Pt had pus milked from the PEG site, and grew pseudomomas, [**Last Name (un) 36**]
to Meropenem.
.
# Hypotension:
Baseline BP for pt was SBP 90's, but was 100-120 during
admission.
.
# Mental status change:
Pt became progressively more confused and less able to
communicate clearly with his family during admission.
.
# DM2:
Pt. was maintained on a daily baseline dose of Glargine and ISS
with good BG control.
.
# Skin:
The pt. had stage 1 pressure ulcer on coccyx, and stage 1
pressure ulcer on L heel. He was treated with standard Q2
movement, duoderm applied to area, aloe [**Doctor First Name **] cream to both legs
and feet, and waffle boots to heels.
.
FEN: Pt failed speech and swallow evals and video swallow, and
was kept NPO during admission due to aspiration risk. PEG was
placed under CT guidance on [**3-11**] and was kept on TF throughout
admission.
.
PPX: PPI IV BID, heparin sc was stopped after GIB started.
.
CODE: CMO
Given the pt's very complex medical course and continued
detrioration despite the most aggressive interventions by the
team a family meeting was called to discuss transitioning to
CMO. The pt's condition was discussed with his wife (health care
proxy) who felt that the pt would not have wished continued
medical care. The pt was transitioned to CMO, and was kept on
morphine as needed to be kept pain-free. Palliative Care was
consulted for recommendations. The patient passed away on the
same night as transition to CMO.
Medications on Admission:
Medications from [**Hospital3 2558**]:
1. Prilosec 20mg po qd
2. Flagyl 500mg po TID (unclear when started)
3. Levoquin 250mg po qd (unclear when started)
4. Nitro prn
5. Imdur 30mg po qd
6. Lasix 20mg po bid
7. Duoneb q4 prn
8. RISS Lantus 5units qHS
9. Glyburide 10mg po bid
10. ASA 81 mg po qd
11. Lopressor 12.5mg po bid
12. Atorvastatin 40mg po qd
13. Tylenol 650mg po qd
14. Milk of magnesia prn
15. Zestril 5mg po qd
Discharge Medications:
Patient passed away.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Bilateral parapneumonic effusions, upper GI bleeding, CHF, acute
on chronic renal insufficiency, anemia
Discharge Condition:
Patient passed away.
Discharge Instructions:
Patient passed away.
Followup Instructions:
Patient passed away.
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
Completed by:[**2186-3-26**]
|
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icd9cm
|
[
[
[]
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[
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icd9pcs
|
[
[
[]
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|
1622, 1735
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,657
| 112,074
|
47612
|
Discharge summary
|
report
|
Admission Date: [**2110-6-5**] Discharge Date: [**2110-6-6**]
Date of Birth: [**2032-12-15**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Sulfonamides
Attending:[**Last Name (NamePattern1) 495**]
Chief Complaint:
Tachypnea/ectopy/altered mental status
Major Surgical or Invasive Procedure:
Endotracheal intubation
Central venous line placement
History of Present Illness:
Ms. [**Known lastname 6930**] is a 77 yo F with h/o COPD and h/o NSCLC, CAD,
longstanding hypertension, CHF with preserved EF, recurrent c
diff infections and diabetes who was brought into the hospital
for dyspnea, transferred to the floor initially and then
transferred soon after to the MICU for tachypnea, ectopy, and
altered mental status.
According to her family, she did not sound like her usual self
on the day of admission, and they stopped by to check on her as
they live in adjacent apartments. She was found to be short of
breath and tripoding. She was hypertensive on arrival of EMTs to
200 systolic.
In the ED, she was initiated on CPAP but was off around one half
hour later. She was thought to be in CHF exacerbation, and
received lasix 80mg IV x1 and SL NTG x2.
When she arrived to the floor, she was tachypneic and
tachycardic with frequent ectopy. She was sent to the unit for
further management shortly after arrival to medical floor.
Past Medical History:
1. Non-small-cell lung cancer: CT guided needle biopsy for
diagnosis. PET/CT scan [**10-20**] demonstrated left lower lobe cancer
and 1.1cm left upper lobe nodule. s/p RFA and fiducial seed
placement [**2-20**] since patient is not a surgical candidate for
wedge resection. Saw Dr. [**Last Name (STitle) **] with radiation oncology.
2. COPD: on 2L O2 at home, spirometry [**10-21**] showed FEV1
0.84L(42% predicted)
3. CHF: ECHO [**1-20**] showed severe TR and EF ~ 55-60%
4. 3 vessel CAD s/p drug-eluting stent to mid-LAD and OM1 in
[**1-19**]
5. Atrial Fibrillation on coumadin
6. HTN s/p bilateral renal artery stenting
7. Anemia
8. Type 2 Diabetes Mellitus: on insulin
9. Peripheral Neuropathy
10. Ischemic ulcer s/p femoral-popliteal bypass
11. s/p Amputation of right and left second toes ([**1-20**])
12. s/p R hallux arthroplasty ([**8-20**])
13. s/p bilateral cataract surgery
[**16**]. Depression
15. s/p Cholecystectomy
[**18**]. s/p Hysterectomy
17. Chronic low back pain
18. Lumbar radiculopathy
19. Hemorrhoids
20. Ulcerative proctitis
Social History:
[**Female First Name (un) 100604**] lives in [**Location 686**] on the [**Location (un) 448**] of the family
house. She has to climb 13 steep steps to reach her home, which
she finds very difficult and tiring. She sleeps upright in bed
and uses a walker at baseline. Her sister, cousin, nephew and
[**Name2 (NI) 802**] live in the same building and they are in frequent
contact. [**Name (NI) **] boyfriend, aged 71, stays with her on the [**Location (un) 19201**] and takes good care of her, doing most of the household
chores. She is also cared for by a visiting nurse who comes
every day, a home health aide 3x/week, a homecare provider
2x/week, PT 2x/week, and a social worker 1x/week.
The patient was previously a hairdresser, beautician and
saleslady. Until the age of 40, she smoked 2 packs per day and
drank a 6-pack of beer almost every day. When she turned 40, she
quit her alcohol and tobacco use and returned to school to
become a social worker. She [**Location (un) **] ever working in a shipyard or
plumbing. She attends St. [**First Name4 (NamePattern1) 26785**] [**Last Name (NamePattern1) 9125**] in [**Location (un) 65712**] with
her family.
Family History:
Diabetes, CHF: Mother, Brother, Grandparents, Uncle
Does not know information about father's health.
Son is age 60 and is healthy. Daughter is age 58 and had a
cancerous growth excised from her knee.
Physical Exam:
VS - 96.6 101 122/72 30 97% 2L NC
Gen: 77 yo F with mild agitation, mild respiratory distress
HEENT: EOMI, anicteric, PERRL. MM moist. OP clear.
Neck: Large neck veins, JVP at earlobes
CV: irregularly irregular distant
Chest: scattered rhonchi with basilar rales
Abd: soft distended, hypoactive BS nontender
Ext: no edema, cool feet
Neuro: a&o x 2. strange affect.
Pertinent Results:
[**2110-6-5**] 10:00AM WBC-22.7* RBC-5.47* HGB-12.5 HCT-43.2 MCV-79*
MCH-22.8* MCHC-28.9* RDW-17.0*
[**2110-6-5**] 10:00AM NEUTS-87* BANDS-7* LYMPHS-6* MONOS-0 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2110-6-5**] 10:00AM cTropnT-0.05*
[**2110-6-5**] 10:00AM CK-MB-NotDone proBNP-[**Numeric Identifier **]*
[**2110-6-5**] 10:00AM GLUCOSE-134* UREA N-14 CREAT-0.9 SODIUM-148*
POTASSIUM-2.5* CHLORIDE-96 TOTAL CO2-27 ANION GAP-28*
[**2110-6-5**] 10:10AM LACTATE-7.7*
[**2110-6-5**] 11:53AM LACTATE-5.0*
[**2110-6-5**] 04:00PM cTropnT-0.15*
[**2110-6-5**] 07:45PM WBC-18.7* RBC-5.43* HGB-12.7 HCT-42.2 MCV-78*
MCH-23.4* MCHC-30.1* RDW-18.0*
[**2110-6-5**] 07:45PM CK-MB-NotDone cTropnT-0.16*
[**2110-6-5**] 07:53PM LACTATE-8.4*->17
INR 8 -> 16
Brief Hospital Course:
Ms. [**Known lastname 6930**] is a 77yo female with history of COPD, NSCLC, CAD,
longstanding hypertension, CHF and recurrent c. diff infections
presents with septic shock and profound lactic acidosis and
ultimately abdominal catastrophe.
1)Respiratory Failure: The patient was breathing in the 40's to
compensate for her acidemia and was beginning to tire out
overnight, neccesitating intubation. She is being maximized on
her minute ventilation to facilitate blowing off the acid, while
avoiding breath stacking given her severe underlying obstructive
disease. Once the lactate returned so high, this seemed to
explain that her hyperventilation was in compensation for
significant acidosis and not because of heart failure as
initially believed. ABGs were closely monitored and she remained
acidemic. Once the decision was made to withdraw care by her
family, the breathing tube was removed and the she expired soon
after.
2)Septic Shock: Unclear source. The assumption is an
intraabdominal catastrophe, possibly bowel ischemia given her
distended abdomen (which was not present on presentation to the
ED). While it is possible that the bowel abnormalities developed
secondary to hypotension, it still remains the only obvious
source of infection, given that she has a history of recurrent
c. diff infections. KUB was unrevealing. She was not stable
enough to undergo CT scan. She may have had a cardiac event with
a sudden decrease in CO, resulting in lactic acidosis and gut
ischemia. More likely she has stunned myocardium in the setting
of sepsis. Once the central line was placed, she was agressively
resuscitated with normal saline to maintain MAP>65 and CvO2>70.
Surgical consult was obtained and declined the patient as a
surgical candidate.
.
#. Rhythm: afib. patient has frequent short runs of NSVT which
improved on amiodarone. The ectopy was likely secondary to her
profound acidemia and electrolyte derangements.
.
#. Coronaries: shock could have been ischemic in etiology, ekg
was concerning for ectopy with NSVT, afib with RVR, but no
STTWC. Initial troponins were slightly elevated in the setting
of renal failure, tachycardia and sepsis. Held [**Known lastname 4532**] and
statin.
.
#. Leukocytosis: See sepsis discussion above. Had history of
recurrent c diff infections. She was pancultured. CXR did not
reveal consolidation. We were considering GI source with
elevation in LDH, concern for ischemic bowel.
She was maintained on vanco po, vanco iv and levo, zosyn for
double gram negative coverage.
.
#. Acute renal failure: creatinine was elevated above baseline -
it has bumped in the past when dehydrated from infection. This
was likely secondary to prerenal azotemia with poor forward
flow.
.
#. Coagulopathy: Patient appeared to be in DIC, but never bleed
actively.
.
.
.
.
.
.
Medications on Admission:
Albuterol Sulfate
Chlorothiazide 250 mg DAILY
Citalopram 40 mg every morning
Clopidogrel 75 mg Tablet DAILY
Fluticasone-Salmeterol 250-50 twice a day
Furosemide 100 mg twice a day
Gabapentin 600 mg twice a day
Hydromorphone 4 mg every four (4) hours as needed for pain
Humalog Mix 75-25 36 units am and 16 units pm
Ipratropium Bromide
Imdur 60 mg once a day
Metoprolol XL 150 mg twice a day
OxyContin 10 mg twice a day
oxygen - 2 liters per minute continuous flow as needed. O2
saturation at rest 93%, with minimal execise 84%
Potassium Chloride 60 mEq Tab once a day
Simvastatin 40 mg once a day
Trazodone 100 mg HS as needed
Warfarin 2 mg once a day
Aspirin 325 mg DAILY
Discharge Disposition:
Expired
Discharge Diagnosis:
Patient expired on [**2110-6-6**] at 3:15pm.
|
[
"286.9",
"518.81",
"427.31",
"428.33",
"428.0",
"V46.2",
"038.9",
"584.9",
"401.9",
"785.52",
"276.2",
"427.41",
"250.00",
"V10.11",
"496",
"995.92",
"414.01",
"443.9",
"427.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.07",
"38.93",
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
8560, 8569
|
5027, 7837
|
328, 383
|
4240, 5004
|
3633, 3835
|
8590, 8637
|
7863, 8537
|
3850, 4221
|
250, 290
|
411, 1367
|
1389, 2440
|
2456, 3617
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,633
| 147,072
|
10724
|
Discharge summary
|
report
|
Admission Date: [**2157-12-6**] Discharge Date: [**2157-12-21**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
acute on chronic L SDH after MVA
Major Surgical or Invasive Procedure:
Left craniotomy for evacuation of left subdural hematoma.
History of Present Illness:
89 yo male with history of sick sinus syndrome s/p pacer. Pt was
admitted to [**Hospital1 **] on [**2157-12-6**] after being an unrestrained
passenger in a car. Pt fell forward and hit head on the
dashboard. He was taken to [**Hospital **] hospital where CT head
showed a 2 cm L SDH with 3 mm midline shift. He was transferred
to [**Hospital1 18**] and admitted to the SICU under neurosurgery service.
Past Medical History:
Subdural hematoma
AAA s/p repair [**2151**]
bilateral iliac stents
Sick sinus syndrome s/p pacer
hypertension
stable angina when he is nervous
anxiety
asthma
hip arthritis
prostate cancer with an XRT in [**2146**]
gastritis which was diagnosed via endoscopy
tracheal tumor excision in [**2120**]'s.
s/p left hip replacement
bilateral cataract removal that was performed in [**2152-6-25**]
right internal iliac artery embolization for aneurysm in [**Month (only) 216**]
[**2151**]
Social History:
lives with wife, has one son
Family History:
noncontributory
Physical Exam:
Eam on transfer from MICU to floor:
VS: T: 99.4; BP: 136/70; HR: 92; RR: 26; O2: 96% RA
Gen: using excessory muscles while breathing, able to speak in
full sentences in NAD.
HEENT: PERRL; EOMI; sclera anicteric; OP clear. + left
craniotomy scar with staples.
Neck: Large hematoma tracking down R neck; JVD difficult to
assess.
CV: RRR; S1, S2
Lungs: CTAB
Abd: Soft, NT, ND.
Ext: no edema b/l. + DP bilaterally
Neuro: Stated that he was in a skyscraper, but able to state
[**12-14**]. Unclear of year. He often said non-sensicle things
but would answer all questions appropriately.
Pertinent Results:
Admission labs:
[**2157-12-6**] 05:44PM BLOOD WBC-11.0# RBC-3.62* Hgb-12.6* Hct-34.5*
MCV-95 MCH-34.8* MCHC-36.5* RDW-14.8 Plt Ct-184
[**2157-12-6**] 05:44PM BLOOD PT-12.1 PTT-29.2 INR(PT)-1.0
[**2157-12-6**] 09:38PM BLOOD Glucose-127* UreaN-10 Creat-0.7 Na-128*
K-4.2 Cl-98 HCO3-20* AnGap-14
Discharge Labs:
[**2157-12-15**] 05:35AM BLOOD WBC-5.0 RBC-2.48* Hgb-8.4* Hct-23.9*
MCV-97 MCH-33.7* MCHC-35.0 RDW-15.6* Plt Ct-257
[**2157-12-15**] 05:35AM BLOOD Glucose-97 UreaN-14 Creat-0.7 Na-136
K-3.4 Cl-103 HCO3-28 AnGap-8
EKG: ? underlying afib v paced. Reviewed with EP. APCs with v
paced and regular intervals at upper and lower limits of pacer.
.
Radiology:
CXR AP-bilateral pleural effusions unchanged from prior.
Retrocardiac opacification. Minor fissure with fluid.
.
Echo:
Left ventricular wall thicknesses are normal. Left ventricular
systolic function is normal (LVEF>55%). Normal RV. No AR;
Trivial MR. [**First Name (Titles) **] [**Last Name (Titles) **]; mild PA systolic hypertension. No
effusion.
[**12-6**] head CT: 1. 2-cm left subdural hematoma with mass effect
and mild shift of normally midline structures.
2. Right scalp hematoma.
NOTE ADDED IN ATTENDING REVIEW: There is a moderately large and
relatively
acute, probably superimposed on chronic, subdural hematoma
layering over the left convexity. There is significant mass
effect, with flattening of subjacent gyri, relative effacement
of ipsilateral sylvian fissure and components of the lateral
ventricle, and up to 8mm rightward shift of the right leaf of
the CSP. No other hemorrhage is seen. There is no skull fracture
associated with the large right frontal scalp subgaleal
hematoma.
[**12-10**] Head CT: 1. Stable appearance status post evacuation of
left subdural hematoma, with persisting pneumocephalus and
hyperdense component, unchanged from the prior day's study.
2. Stable appearance of the small focal hypodensity in the left
posterior
parietal cortex, of unclear etiology. This may represent
evolving infarction versus contusion. This could be reassessed
on followup study.
Brief Hospital Course:
Pt is a 89 yo male with SSS s/p pacer, admitted to Neurosurgery
with SDH with acute respiratory distress/ wheezing on the floor.
Pt was transferred to the MICU diuresed then transferred to the
floor.
# SDH: Head CT at [**Hospital1 **] showed a moderately large and relatively
acute, subdural hematoma with significant mass effect 7 mm
midline shift. s/p L subdural evacuation on [**2157-12-8**]. The
patient will follow up with neurosurgery on [**2157-12-29**]. He has had
socme word finding difficulties since the accident, but
otherwise is well. On last Head CT [**2157-12-10**], pt had a stable
appearance status post evacuation of left subdural hematoma
persisting pneumocephalus unchanged.
In discussion with neurosurgery, aspirin was to be restarted in
4 weeks, given his SDH; note that pt. inadvertently received ASA
during this hospitalization; it should be restarted as an outpt.
in 4 weeks.
# Seizure: On [**12-16**] pt had an episode where he was awake, alert,
but unable to communicate. Stat head CT showed no new bleed or
stroke. the episode resolved in less than 3 hours. Neuro consult
felt this was a partial complex seizure. He was restarted on
dilantin (had been on it for 1 week after the surgery before).
His levels were monitored and found to be subtherapeutic, and he
was noted to have decreased communication and was reloaded on
dilantin per neurology recommendation. Dilantin reloaded at 1 g
[**12-20**]; needs to have a dilantin and albumin level checked Friday
as per instructions in page 1.
# CHF: On [**2157-12-10**] in nursing notes, it is noted that pt was
wheezing. He was given albuterol and atrovent nebulizers. He
also received 10 mg IV lasix with 600 cc urine output which led
to improved respiratory status. Medicine consult was asked to
evaluate pt for respiratory distress. At time of MICU transfer,
he was diffusely wheezy, tachypnic to the 40s, with upper airway
sounds. ABG at that time was 7.47/30/154. CXR showed bilateral
pleural effusions unchanged from prior. Retrocardiac
opacification. Minor fissure with fluid. Pt stated that he could
not get enough air in and felt short of breath. He denied chest
pain. He was given albuterol and atrovent nebulizer treatments
as well as 20 mg IV lasix.
In MICU, pt sounded bronchospastic with diffuse wheezing
throughout. It also had a very large upper airway wheezing
component. He received nebulizers and lasix. After putting out
to the lasix a few hundred ccs, there was a dramatic improvement
in respiratory status (now -600 cc on 2 L NC). His Admit weight
was 62.4 kg which was 68 kg on transfer. He was diuresed in the
MICU with improvement in respiratory status. He responds well to
20mg IV lasix. Ecchocardiogram showed preserved systolic
function and tricuspid regurgitation. His medications were
changed with d/c of hydralazine, addition of captopril 12.5 tid
and increase of metoprolol to 37.5 tid. He has had good BP
control, he has diuresed 3L/2 days. He was also started on
salmeterol in addition to prn nebulizers and his respiratory
status is much improved, satting 98% on 2L n/c. He was then
started on tiotropium.
# UTI- He demonstrated dysuria, and given a change in mental
status, was treated empirically with ciprofloxacin.
# SSS s/p pacer- EP interrogated pacer. It was frequent APCs and
not afib. Uptitrated metoprolol to 37.5 tid.
# Anemia- Likely [**1-27**] OR and anemia od chronic disease. Ferritin
454. His hematocrit remained stable during his hospital course.
# Depression: Pt has had problems with anxiety for many years
was was taking xanax prn before admission. he was clonazepam and
was started on celexa.
# Swallowing: Ground; Nectar prethickened liquids after swallow
exam mainly because the patient refused to wear bottom dentures.
Contact: Wife [**Name (NI) **] [**Name (NI) 35094**] [**0-0-**]
Medications on Admission:
On transfer from ICU:
Metoprolol 25 mg po bid
Albuterol neb prn
Ipratropium nebs prn
Pantoprazole 40 mg IV mg qday
Bisacodyl po/pr prn
Colace 100 mg [**Hospital1 **]
Salmeterol diskus 50 mcg q 12
Heparin 5000 mg tid
Hydralazine 20 mg IV q 6 hr
Insulin SS
Terazosin 2 mg po qhs
.
.
Home medication regimen:
ASA 81 QD
B12 500 mg QD
Toprol XL 50 QD
Hytrin 2mg QPM
Nexium 40 mg QPM
Discharge Medications:
1. Terazosin 1 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation. Tablet(s)
3. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
4. Salmeterol 50 mcg/Dose Disk with Device Sig: One (1) Disk
with Device Inhalation Q12H (every 12 hours).
5. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours) as
needed for heartburn.
8. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
9. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
10. Celexa 20 mg Tablet Sig: One (1) Tablet PO once a day.
11. Epogen 40,000 unit/mL Solution Sig: One (1) Injection once
a week: Titrate to HCT ~ 32.
12. Xanax 0.25 mg Tablet Sig: One (1) Tablet PO every 6-8 hours
as needed for anxiety.
13. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
14. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1)
Capsule PO Q 8H (Every 8 Hours): Titrate to level (corrected for
albumin level of 2.5) 10-20 ug/ml.
15. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 3 days.
16. Outpatient Lab Work
Please check dilantin and albumin levels Friday [**12-23**]; if
subtherapeutic corrected level, will need to be given additional
300 mg dilantin.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 1294**]
Discharge Diagnosis:
Primary:
1. Traumatic subdural hematoma - unrestrained passenger MVA.
2. S/P craniotomy for evacuation of left subdural hematoma.
3. Pre-existing chronic subdural hematoma.
4. Left frontal ischemic stroke.
5. Partial-complex seizure NOS.
6. Diastolic Heart Failure.
7. Transient PM induced tachycardia.
8. Anxiety State.
9. Blood Loss Anemia.
10. Delirium.
11. Urinary tract infection.
12. Malnutrition - [**Location (un) **] Degree.
Secondary:
1. St. [**First Name4 (NamePattern1) 923**] [**Last Name (NamePattern1) 35095**] XLDR DDD Pacemaker (SSS).
2. Stable Angina Pectoris.
3. Anemia of chronic inflammation
4. Abdominal aortic aneurysm s/p endoluminal stent graft.
5. Paget's disease.
6. S/P total left hip replacement.
7. Bilateral cataract removal.
8. Right internal iliac artery embolization
9. Chronic obstructive pulmomary disease
10. Prostate cancer s/p XRT
11. Tracheal tumor excision.
12. Hypertension.
13. Gastritis.
14. Chronic Anxiety.
Discharge Condition:
96% sat on room air. walking with assist.
Discharge Instructions:
Continue all medications as ordered.
Followup Instructions:
Neurosurgery - You will need a head CT scan prior to this
appointment. This has been scheduled for [**2158-1-12**] at 11:30AM at
the [**Location (un) 470**] of the clinical center ([**Telephone/Fax (1) 327**]). You then
have an appoitment with Dr. [**Last Name (STitle) 739**] on [**2158-1-12**] 1:30 PM 110
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2577**] 3b (([**Telephone/Fax (1) 88**]).
.
Primary Care - Please make an appointment to follow-up with your
primary care physician after you are discharged from rehab
.
Neurology - You need to have a dilantin level checked along with
an albumin level on Friday. If the corrected dilantin level is
subtherapeutic, you need to be given additional dilantin for one
day (300mg) and have your level checked 3 days after. Please
contact Dr. [**Last Name (STitle) **] (hospitalist at [**Hospital1 18**] - ([**Telephone/Fax (1) 35096**]) if
you have questions re: this.
|
[
"V45.01",
"V15.3",
"285.29",
"E812.1",
"285.1",
"311",
"428.0",
"428.30",
"599.0",
"780.39",
"434.91",
"852.20",
"427.81",
"784.3",
"263.0",
"276.1",
"V10.46",
"300.00",
"920",
"293.0",
"401.9",
"496"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.05",
"01.39"
] |
icd9pcs
|
[
[
[]
]
] |
9988, 10062
|
4086, 7918
|
294, 354
|
11060, 11104
|
1985, 1985
|
11189, 12127
|
1351, 1368
|
8348, 9965
|
10083, 11039
|
7944, 8325
|
11128, 11166
|
2295, 3011
|
1383, 1966
|
222, 256
|
382, 786
|
3678, 4063
|
2001, 2279
|
808, 1289
|
1305, 1335
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,458
| 146,852
|
3055
|
Discharge summary
|
report
|
Admission Date: [**2201-1-15**] Discharge Date: [**2201-1-28**]
Date of Birth: Sex: F
Service: CCU
REASON FOR ADMISSION: Acute renal failure.
HISTORY OF PRESENT ILLNESS: [**Known lastname 14537**] is a 48 year old
African-American female with severe hypertension recently
diagnosed with diastolic dysfunction and heart failure,
chronic renal insufficiency, recently admitted to [**Hospital1 346**] between [**12-12**] until [**2201-1-2**], for pulmonary edema and uncontrolled hypertension.
During that admission, the patient was started on a whole new
regimen of anti-hypertensive pills including Coreg,
Enalapril, Norvasc. The patient was discharged home on high
doses of these anti-hypertensive medications and was followed
by Dr. [**First Name4 (NamePattern1) 3742**] [**Last Name (NamePattern1) **], M.D., as well as Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in
the Heart Failure Clinic.
During one of her follow-ups at her Heart Failure Clinic the
patient had labs drawn on [**2201-1-8**]. The results of
these labs revealed an increased creatinine of 3.4, up from a
baseline of 2.5 on [**2201-1-1**]. Between [**2201-1-10**] and [**2201-1-15**], multiple attempts were made to
call the patient to return to the estimated date of delivery
for evaluation of her worsening renal failure. Unfortunately
the patient's phone line was disconnected at this time. The
patient incidentally called in to the [**Hospital 191**] Clinic to speak to
her physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 3742**] [**Last Name (NamePattern1) **], and she was feeling
unwell. She was told to come straight to the Emergency
Department for examination.
On discussion with that patient it appears that over the week
prior to her current admission, the patient has had increased
nausea, increased lightheadedness, and worsening ankle
swelling. The patient reported that she had followed a
strict 2 gram salt diet as instructed on the last hospital
discharge and was compliant with all of her medications. The
patient was noted to be in extreme financial difficulties on
last admission and multiple resources were elicited in an
attempt to help the patient with her financial difficulty and
in coping with her heart failure. Unfortunately, the
patient's telephone had been disconnected during the early
week of [**Month (only) 1096**].
The patient reported that in the week leading to this current
admission, she had been experiencing increased fatigue and
increased shortness of breath with occasional headaches. She
had been taking her blood pressure once a day at home and it
remained in the normal range from 100 over 70s and 60s. She
did, however, notice her urination was decreased from two to
three times a night with her evening Lasix down to once a
night. The patient had no chest pain, no orthopnea, no
paroxysmal nocturnal dyspnea, no dysuria and no change in
bowel habits and no vomiting or abdominal pain. She denied
any fever or chills.
PAST MEDICAL HISTORY:
1. Recently diagnosed heart failure due to chronic
uncontrolled hypertension. A recent echocardiogram on
[**12-17**] showed small ASD with some left-to-right shunt,
moderate symmetric left ventricular hypertrophy with a
hyperdynamic left ventricular, ejection fraction greater than
75%, right ventricular hypertrophy, one plus mitral
regurgitation, consistent with hypertrophic hypertensive
heart disease. Cardiac catheterization on [**12-22**]
revealed right dominant system, severe systolic systemic and
pulmonary hypertension, with an elevated left ventricular
end-diastolic pressure at 33 and no flow limiting renal
artery disease.
2. Peripheral vascular disease status post left
femoral-popliteal bypass.
3. Question of history of asthma.
4. Fibroid uterus status post tubal ligation.
5. Chronic O2 requirement on home O2 since [**2200-8-3**].
6. History of positive PPD in [**2195**] with a negative chest
x-ray.
7. Status post gunshot wound to right arm with foreign body
and metal place in place.
MEDICATIONS ON ADMISSION:
1. Enteric-coated aspirin 325 mg.
2. Iron sulfate 325 mg three times a day.
3. Colace 100 mg twice a day.
4. Norvasc 20 mg two times a day.
5. Lasix 20 mg two times a day.
6. Enalapril 20 mg two times a day.
7. Carvedilol 75 mg two times a day.
8. Tylenol as needed.
9. Oxy-Codon as needed.
10. PhosLo two tablets three times a day.
ALLERGIES: The patient is allergic to penicillin which gives
her hives.
SOCIAL HISTORY: The patient is currently applying for SSDI
and SSI as well as Mass Health. This is mediated by Social
Work from her last admission. The patient lives with
boyfriend for the past 38 years. The patient has three or
four grown children. The patient denies any intravenous drug
use. Has occasional alcohol use. Has quit smoking for a few
months.
FAMILY HISTORY: The patient's mother died of an myocardial
infarction at age 27. The patient has two sisters who died
of heart disease in their twenties. The patient has several
maternal uncles with coronary artery disease and also has a
positive family history in numerous family members.
PHYSICAL EXAMINATION: On admission, the patient had a
temperature of 98.2 F.; heart rate of 58; respiratory rate of
16; blood pressure of 120/60, saturating 89% on two liters
and 94% on four liters. General examination revealed an
alert and awake woman in no acute distress. Head, Eye, Ear,
Nose and Throat examination revealed mucous membranes moist
with no icterus. Of note, on the general examination, the
patient has whole body edema, most markedly in her face and
neck compared to discharge three weeks ago. Cardiovascular
examination revealed regular rate and rhythm with a II/VI
systolic ejection murmur in right upper sternal border.
There was no jugular venous distention. Lung examination
revealed minimal rales at both lung bases. Abdomen
examination revealed a soft nondistended abdomen with minimal
epigastric tenderness and normoactive bowel sounds. There
was no guarding and no rebound. Extremities revealed trace
ankle edema bilaterally.
LABORATORY STUDIES: On admission revealed a hematocrit of
32.3, white count of 6.0, and a platelet count of 176.
Differential on her white count revealed 54% neutrophils, 20%
lymphocytes, 6% monocytes, 17% eosinophils and 3% basophils.
Serum chemistry revealed a sodium of 140, potassium of 4.7,
chloride of 99, bicarbonate of 32, BUN of 65 and a creatinine
of 3.7. Blood sugar was 87.
Liver function studies revealed an ALT of 9, AST of 19,
alkaline phosphatase of 97. Her CK was 55, troponin of less
than 0.3, amylase of 61 and total bilirubin of 0.3.
Urinalysis revealed 30 of protein. Urine electrolytes
revealed urine sodium of 15, urine creatinine of 118, giving
free urinary sodium excretion of 0.3%.
Chest x-ray on admission revealed congestive heart failure,
slightly worse compared to chest x-ray on [**2200-12-26**].
There were small bilateral pleural effusions. EKG showed
sinus bradycardia in the 50s, T wave inversion in lead I, AVL
and leads V5 to 6, T-wave flattening in lead V4. There were
no changes compared to her old EKG on [**2200-12-22**].
COURSE IN HOSPITAL: The patient was admitted to the hospital
on Cardiology Service for her new acute renal failure likely
secondary to decreased renal perfusion in setting of
over-controlling systemic hypertension. Upon admission, the
patient's diuretics and ACE inhibitors were discontinued due
to her increased creatinine and worsening renal failure. Her
Coreg was continued and her blood pressure was continued to
be kept at 110s to 130s range systolic with the use of Coreg.
Dr. [**Last Name (STitle) **], who is the patient's regular nephrologist, was
re-consulted to follow the patient in the setting of acute
renal failure.
Over the two days of [**1-15**] and [**1-16**], the
patient's creatinine continued to worsen to 3.9 on [**2201-1-16**]. At this time, Dr. [**Last Name (STitle) **], the patient's
Cardiologist, brought the patient back to the Catheterization
Laboratory and re-performed a cardiac catheterization. On
this catheterization, the patient was found to have a
pulmonary wedge pressure of 32, a right atrial pressure of
23, and severely elevated pulmonary arterial pressure at
70/31 with a mean of 44.
Given the patient's severe pulmonary hypertension, the
patient was now transferred to the Coronary Care Unit and
given Milrinone infusion overnight with continuation of her
Coreg for blood pressure control. Over the first 24 hours in
the Coronary Care Unit, the patient was noted to be oliguric,
putting out 5 to 10 cc. of urine per hour. Her creatinine
now is worsened to a serum creatinine of 4.5. There was no
increase in her urine output after being placed on Milrinone.
The patient now has a heightened oxygen requirement,
saturating between 84 to 97% at rest on five liters of oxygen
by nasal cannula.
On [**2201-1-17**], the patient was tried on high dose
intravenous diuretics to increase her urine output. The
patient made minimal response to high dose Lasix with
Zaroxolyn. The patient was then tried on a trial of Dopamine
and Nitroglycerin drip to decrease pulmonary arterial
pressure and increase renal perfusion. The patient developed
anginal symptoms with the use of Dopamine drip and there was
no response to her pulmonary arterial pressure to these two
medications. There was no increase in urine output observed.
By 03:00 p.m. of [**2201-1-17**], the patient's urine
output had decreased to 5 cc. per hour. Analysis of her
urine revealed numerous muddy brown casts. A repeat trial of
high dose diuretics of Lasix plus Zaroxolyn again did not
increase her urine output. At this time, the patient was
also noted on repeated blood pressure monitoring that she had
hypotensive episodes down to systolic blood pressures of 87.
Her Coreg was decreased to 12.5 mg twice a day, down from 75
mg twice a day for blood pressure control and to maintain
renal perfusion.
At this time, the decision was made in the setting of
worsening pulmonary hypertension and risk of flash pulmonary
edema, that the patient will require hemofiltration for her
fluid control. The renal consultants were called and the
patient had a right internal jugular Quinton catheter
inserted after failed attempts of inserting groin Quinton
catheters. The patient had undergone hemofiltration and two
liters of fluids were removed. The patient had minimal
improvement of her pulmonary arterial hypertension.
Overnight, between [**1-17**] and [**1-19**], the patient's
urine output began to improve drastically. By the morning of
[**1-18**], the patient was putting out 100 to 120 cc. of
urine per hour. The patient's pulmonary arterial pressure at
this time dropped down to 59/20 from an average of 60 to 87
over 30 to 42 on the previous day. The patient's systolic
blood pressure also increased up to 110 with 120s with a MAP
in the 60 to 80 regions, up from 50s to 60s.
From [**1-18**] and on, the patient had started an
auto-diuresis, putting out urine output from 100 to 200 cc.
per hour. Her creatinine in the serum peaked at 5.3 on
[**2201-1-18**]. Her Coreg is now dosed to maintain a
systolic blood pressure in the 110s to 130s range. This is
in the setting of continuous Nitroglycerin drip for pulmonary
hypertension control as well as increasing diuresis.
The patient's Swan-Ganz catheter as well as her Quinton
catheter in her right internal jugular vein were removed on
[**2201-1-20**], when she was transferred out of the
Intensive Care Unit back to Cardiology Floor.
From [**1-21**] until the patient's discharge on [**1-28**], the patient continued to diurese at a rate of negative
one to two liters per day. She was initially maintained on a
Nitroglycerin drip for her diuresis as well as titration of
her blood pressure, the new goal of which is now 110 to 130
systolics. With her diuresis, the patient's oxygen
saturation also improved with improving lung examinations and
decreasing crackles.
By [**2201-1-22**], the patient was back to her discharge
weight on her last admission which was 173 pounds. At this
time, the patient still required four liters of oxygen by
nasal cannula at rest. The patient's serum creatinine also
continued to improve as she auto-diureses. Her serum
creatinine level plateaued in [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1131**] from 2.6 to 2.8 by
[**2201-1-24**]. The patient was kept within the hospital
to monitor her serum creatinine daily as well as her blood
pressure for careful titration for medication and for
potential re-introduction of an ACE inhibitor into her
anti-hypertensive regimens.
By the time of discharge, it was decided that the patient is
currently not ready to restart her ACE inhibitor given her
creatinine clearance ranges between 2.6 to 2.8.
During this current admission, the patient was also noted to
have eosinophilia with a persistent 17 to 22% eosinophil
count on the differential of her white blood cells. As the
patient showed no allergic symptoms and had no symptoms and
signs of parasitic infection, this was thought to be drug
related. On [**2201-1-25**], Protonix was discontinued
from the patient's medication regimen for a question of
etiology for her eosinophilia being Protonix.
By [**2201-1-26**], [**Known lastname 14537**] no longer required
supplemental oxygen at rest and was saturating 94% on room
air. Her weight at this time was 165 pounds. Her creatinine
at this time was 2.6 in her serum. She, however, continued
to have a 19% eosinophilia in her blood and the question now
is whether Coreg was the cause of her eosinophilia. By
[**2201-1-28**], the decision was made to stop Coreg and to
start Toprol XL for blood pressure control and discharge the
patient home.
The patient was to follow-up in Heart Failure Clinic with Dr.
[**Last Name (STitle) **] as well as in [**Hospital 191**] Clinic with Dr. [**First Name4 (NamePattern1) 3742**] [**Last Name (NamePattern1) **] for
repeat blood draws to monitor her serum creatinine level as
well as her eosinophilia. The patient was to undergo a trial
of one to two weeks off Coreg and be monitored for resolution
of her eosinophilia. If the eosinophilia is not resolved by
then, the plan is to re-introduce Coreg into her heart
failure medication regimens and continue work-up for the
etiology of her eosinophilia.
Upon discharge, the patient's weight was 161 pounds. She was
saturating 100% on one liter by nasal cannula. The patient
still requires supplemental oxygen, one liter, on ambulation.
She had no oxygen requirements at rest. Her serum creatinine
on discharge was 2.7.
DISCHARGE DIAGNOSES:
1. Acute renal failure due to acute tubular necrosis.
DISCHARGE MEDICATIONS:
1. Enteric-coated aspirin 325 mg p.o. q. day.
2. Iron sulfate 325 mg p.o. three times a day.
3. Colace 100 mg p.o. twice a day as needed.
4. Lasix 20 mg p.o. q. day.
5. Toprol XL.
6. Isosorbide mononitrate 10 mg p.o. twice a day.
7. PhosLo two tablets p.o. three times a day with meals.
8. Tylenol 650 mg p.o. q. four to six hours as needed.
[**First Name8 (NamePattern2) 2053**] [**Last Name (NamePattern1) 2052**], M.D.
Dictated By:[**Name8 (MD) 9921**]
MEDQUIST36
D: [**2201-3-12**] 17:44
T: [**2201-3-14**] 14:49
JOB#: [**Job Number 14543**]
|
[
"403.91",
"416.0",
"402.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.21"
] |
icd9pcs
|
[
[
[]
]
] |
4895, 5172
|
14737, 14793
|
14816, 15405
|
4095, 4512
|
5195, 14716
|
198, 3032
|
3054, 4069
|
4529, 4878
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,619
| 158,365
|
54661
|
Discharge summary
|
report
|
Admission Date: [**2119-5-27**] Discharge Date: [**2119-6-26**]
Date of Birth: [**2055-3-25**] Sex: M
Service: NEUROLOGY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
found down, ICH
Major Surgical or Invasive Procedure:
tracheotomy, PEG placement
History of Present Illness:
HPI: This is a 63 yo male with no known PMHx (doesn't see
doctors) presents from a [**Hospital 8641**] Hospital after being found down
at home. History was obtained from pt's wife and [**Name (NI) 8641**] medical
records as he is intubated and sedated. For the last few days
he
has been c/o mild headaches. Starting Thursday ([**5-25**]) patient
c/o "really bad headache", but was otherwise normal. He took
Alleve for the headache. Today ([**5-26**]), he was still at his
baseline (fully independent) when in the evening he went to
garden. He stopped because he felt "dizzy". He walked into the
house, but "seemed stumbly", and leaned against the door frame
on
the way in. He was in the bathroom when his wife heard a thud.
She went to check on him and was able to help him to a standing
position. He kept his L arm down at his side and used his R
hand
to splash water on his face. She then went to get her son to
help
when she heard another thud and found her husband on the floor
again. She sat him on the toliet but he fell down onto the
ground
again. He was initially still responding to her, saying not to
take him to the hospital because "what could they do?" Then he
started mumbling incoherently and stopped responding to
questions. EMS came around 9pm and brought him to [**Hospital 8641**]
Hospital. There his BP was 217/90. His pupils were noted to be
asymmetric, R 3mm, L 2mm. He was withdrawing all extremities but
comatose. Head CT showed ICH that started in the R pons and
extended upward through the R cerebral peduncle, thalamus, and
internal capsule, with petichiae hemorrhages in the bilateral
thalami. He was intubated with Etomidate, and succ. He received
versed 5mg x 2 prior to transport on propofol gtt at 80. Out of
concern for uncal herniation, he received mannitol 50g IV x 1
from [**Location (un) 8641**].
Past Medical History:
per pt's wife he never sees a doctor, so hasn't been
diagnosed with any medical problems
Social History:
lives with wife and son, they have 2 children (one is
in [**Country 14635**] in the marines), pt smoked for many years, but quit 25
years ago. He used to drink 3-4 beers per night for many years,
but also quit 25 years ago. No illicits. Works as a nighttime
janitor at a restaurant.
Family History:
younger brother had a stroke in his late 50's
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
O: T: 98.7 BP: 122/80s on propofol; off propofol for 10 min -->
200/99 HR: 70's R 18 O2Sats 98% on ETT
Gen: intubated, sedated
HEENT: ETT in place, C-collar on
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro: (off propofol for 10 minutes)
Mental status: Intubated, slight grimace to nasal noxious
Brainstem: R Pupil 3mm; L pupil 2mm, both minimally reactive to
light. No blink to threat bilaterally. No corneals bilaterally.
Face obscured by ETT. +gag
Motor: Localizes pain in all extremities, withdraws R side more
briskly than L.
Sensation: Grimaces and localizes to noxious as above
Reflexes: B T Br Pa Ac
Right 1 1 1 1 0
Left 2+2+ 2+ 3 0
Toes extensor on left and flexor on right
********************
PHYSICAL EXAM ON DISCHARGE:
Neurological exam:
The patient arousable with voice. It takes some encouragement to
get him to nod yes or no to questions, but he is able to do so.
He has spontaneous movement in his left arm and leg. His right
arm and leg function relatively normally. He has some rightward
nystagmus on gaze, and his eyes are misaligned at baseline. We
did not evaluate gait, sensation, co-ordination, or cerebellar
function.
Pertinent Results:
[**2119-5-27**] 07:58AM TYPE-ART TEMP-36.7 RATES-12/16 PEEP-5 O2-40
PO2-183* PCO2-41 PH-7.45 TOTAL CO2-29 BASE XS-4 -ASSIST/CON
INTUBATED-INTUBATED
[**2119-5-27**] 07:27AM GLUCOSE-128* UREA N-14 CREAT-0.8 SODIUM-140
POTASSIUM-3.4 CHLORIDE-104 TOTAL CO2-26 ANION GAP-13
[**2119-5-27**] 07:27AM CK(CPK)-390*
[**2119-5-27**] 07:27AM CK-MB-7 cTropnT-<0.01
[**2119-5-27**] 07:27AM CALCIUM-9.0 PHOSPHATE-3.3 MAGNESIUM-2.2
[**2119-5-27**] 07:27AM WBC-10.9 RBC-4.72 HGB-13.1* HCT-40.7 MCV-86
MCH-27.8 MCHC-32.3 RDW-13.9
[**2119-5-27**] 07:27AM PLT COUNT-256
[**2119-5-27**] 07:27AM PT-11.4 PTT-26.1 INR(PT)-1.1
[**2119-5-27**] 01:14AM TYPE-ART RATES-/12 TIDAL VOL-500 PEEP-5 O2-40
PO2-169* PCO2-41 PH-7.45 TOTAL CO2-29 BASE XS-4 -ASSIST/CON
INTUBATED-INTUBATED
[**2119-5-27**] 01:14AM GLUCOSE-134* LACTATE-1.0 NA+-140 K+-3.0*
CL--101
[**2119-5-27**] 01:14AM HGB-13.2* calcHCT-40 O2 SAT-99
[**2119-5-27**] 01:14AM freeCa-1.16
[**2119-5-27**] 01:00AM UREA N-14 CREAT-0.8
[**2119-5-27**] 01:00AM estGFR-Using this
[**2119-5-27**] 01:00AM LIPASE-25
[**2119-5-27**] 01:00AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-POS barbitrt-NEG tricyclic-NEG
[**2119-5-27**] 01:00AM URINE HOURS-RANDOM
[**2119-5-27**] 01:00AM URINE HOURS-RANDOM
[**2119-5-27**] 01:00AM URINE GR HOLD-HOLD
[**2119-5-27**] 01:00AM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2119-5-27**] 01:00AM WBC-10.3 RBC-4.76 HGB-13.4* HCT-40.9 MCV-86
MCH-28.1 MCHC-32.7 RDW-13.8
[**2119-5-27**] 01:00AM PLT COUNT-260
[**2119-5-27**] 01:00AM PT-11.6 PTT-24.8* INR(PT)-1.1
[**2119-5-27**] 01:00AM FIBRINOGE-292
[**2119-5-27**] 01:00AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.018
[**2119-5-27**] 01:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-7.5
LEUK-NEG
[**2119-5-27**] 01:00AM URINE RBC-3* WBC-1 BACTERIA-NONE YEAST-NONE
EPI-<1
Discharge LABS: Patient was stable so discharge labs were not
performed.
..
CT head [**5-27**]:
IMPRESSION:
1. Unchanged size of right pontine and basal ganglia
intraparenchymal
hemorrhage, without significant mass effect.
2. Left cerebellar encephalomalacia.
NOTE ON ATTENDIGN REVIEW;
The hypodense area in the left cerebellar hemisphere can
alternatively relate to some degree of focal edema adjacent to a
small focus of hemorrhage. A small focus of acute
hemorrhage/mineralization is also seen in right posterior
parietal lobe. Possibilities include HTN, amyloid
angiopathy/cavernomas. Pl. see subseqeunt MRI for other details.
CT C spine [**5-27**]:
IMPRESSION: No fracture or malalignment of the cervical spine.
Small
protrusions and multilevel, multifactorial deg. changes.
Correlate clinically to decide on the need for further workup.
Pl. see concurrent CT Head for other imp. details.
CTA head/neck [**5-27**]:
1. Study is suboptimal due to delayed acquisition due to
problem with the IV line. Within this limitation, grossly
patent major intra- and extra-cranial arteries without
flow-limiting stenosis, occlusion or obvious aneurysm more than
2-3 mm within the resolution.
2. Atherosclerotic disease involving the aortic arch, common
carotid
bifurcations and the proximal cervical internal carotid artery,
without focal flow-limiting stenosis.
3. Extent of carotid stenosis can be better assessed with color
Doppler
ultrasound if needed at the common carotid bifurcation and
proximal cervical internal carotid arteries.
4. No large vascular channels are noted adjacent to the area
of hemorrhage in the right side of the pons to suggest a high
flow A-V communication lesion.
MR head [**5-27**]:
IMPRESSION:
1. Redemonstration of the large area of heterogeneous signal
intensity with negative susceptibility, representing the area of
hemorrhage in the right thalamus, extending into the right side
of the mid brain, with some
surrounding edema. No abnormal enhancement noted within to
suggest an obvious mass lesion.
2. Numerous foci of negative susceptibility scattered
throughout the brain as described above. Differential diagnosis
includes hypertensive hemorrhages, amyloid angiopathy, or
multiple cavernomas. No abnormal enhancement is noted in these
foci to suggest mass lesions.
CXR [**5-27**]:
IMPRESSION: No acute chest abnormality.
MR C spine [**5-27**]:
IMPRESSION:
1. No evidence of fracture or ligamentous injury.
2. Multilevel degenerative changes of the cervical spine as
described in
detail above, worse at C4-5 level.
3. Pontine hemorrhage, best seen on MRI from [**2119-5-27**].
CXR [**6-4**]:
FINDINGS: Compared to the study from the prior day, there is
improved
aeration in both lower lungs; however, there continues to be
increased
alveolar opacity in the lower lungs and it is unclear if this is
due to edema or infiltrate. There is mild pulmonary vascular
re-distribution, perihilar haze compatible with fluid overload.
.
[**2119-6-11**] 11:20 am SPUTUM Source: Endotracheal.
**FINAL REPORT [**2119-6-14**]**
GRAM STAIN (Final [**2119-6-11**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).
1+ (<1 per 1000X FIELD): BUDDING YEAST.
SMEAR REVIEWED; RESULTS CONFIRMED.
KUB [**2119-6-13**]: IMPRESSION: No evidence of obstruction, ileus or
large amount of free air. Air within non-dilated loops of small
bowel.
VIDEO SWALLOW [**2119-6-14**]:
IMPRESSION: Penetration with nectar-thick liquids and
significant premature spillover to the piriform sinuses with
thin liquids. Please see the speech and swallow note in OMR for
further details.
RESPIRATORY CULTURE (Final [**2119-6-14**]):
SPARSE GROWTH Commensal Respiratory Flora.
STAPH AUREUS COAG +. MODERATE GROWTH.
OF TWO COLONIAL MORPHOLOGIES.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance .
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- 4 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- 0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
Brief Hospital Course:
On Admission:
63 yo M without significant known pmh, found down at home.
.
Neuro exam with R pupil 3mm, L pupil 2mm, reactive, + corneals,
+ gag, grimaces to noxious in all limbs. No spontaneous mvmt and
withdraws all ext. except LUE. Hyperreflexic in L hemibody.
Given his arousal state, he was intubated and sedated.
.
On MRI, there were inumerable microhemorrhages scattered
throughout the cerebellum, brainstem, thalami, cerebral
hemispheres. Etiology was thought to be due to cavernomas.
.
# NEURO:
He remained intubated on a low dose of propofol and improved
slightly every day with eventually ability to follow simple
commands. Anticoagulation/antiplatelets were held. Due to
impaired arousal, he was started on Amantidine with some
improvement in his level of alertness. He has been uptitrated
to 100mg [**Hospital1 **]. At the time of discharge, he was easliy arousable
to voice and gentle stimulation. He had nystagmus on right
gaze. He was able to nod yes and no and occasionally mouth
single word answers to questions. He followed both midline and
appendicular commands. He moved all extremities spontaneously,
though less so on the left. He has been tolerating a passe-muir
valve intermittently and was able to speak in one word answers
when on the valve. He managed to pull out his trach for a brief
period of time, and did well without it, although the trach was
replaced for safety reasons.
# CV: He was markedly hypertensive on admission and this was
controlled with nicardipine gtt which was eventually switched to
lisinopril. Trial extubation failed after 1 hr on [**2119-5-30**]. He
underwent trach and PEG placement on [**6-3**]. After transfer to the
floor, his blood pressure was well controlled with 20mg
Lisinopril daily. On occasion, IV hydralazine was used
(seldomly).
# ID:
On [**2119-5-30**] he had high grade fevers which prompted VAP PNA
coverage which has been narrowed to CTX. Culture sensitivities
from mini-BAL led to narrowed coverage to CTX without subsequent
fevers. Last dose of CTX was on [**2119-6-8**]. On [**2119-6-11**], the
patient's white count started to creep up towards 12. We sent a
sputum culture and a UA. The UA was negative. Sputum culture
grew staph aureus. However, the patient had no fevers ,and his
white count went back down to 7. He displayed no signs of
infection. Antibiotics were not given.
# PULM:
Intubated as above, trach as above, stable on T piece. Stayed on
T piece throughout the remainder of his stay. The patient
developed MSSA pneumonia while in the ICU, which was treated
with 10 days of IV CTX. Repeat sputum culture showed MSSA;
however, the patient was afebrile and did not have an elevation
in white count. As above, this second culture was not treated
with antibiotics and was thought to be likely commensal.
# GI: The patient had tube feeds administered after the
placement of the PEG tube. However, he was then found to be
able to eat, and his tube feeds were stopped and he was put on a
diet.
# PPx: we held aspirin given his recent head bleed. The patient
received HSQ and bowel regimen.
# DISPO: Rehab facility.
# Code: FULL CODE
Contact: NEPHEW [**Name (NI) **] [**Name (NI) **] [**Numeric Identifier 111790**] (applying for
guardianship)
PENDING RESULTS:
None
TRANSITIONAL CARE ISSUES:
Patient will need to continue to be evaluated for ability to
have his trach removed and his PEG removed.
Medications on Admission:
PRN Aleve for headaches, otherwise no medications
Discharge Medications:
1. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever, pain.
3. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
4. senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO BID (2 times a
day).
5. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
6. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily) as needed for
constipation.
7. amantadine 100 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **]Rehabilitation Center
Discharge Diagnosis:
Intra-Cerebral Hemorrhage
Cerebral cavernomatosis
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Dear Mr. [**Known firstname **],
You were hospitalized due to symptoms of left sided weakness
resulting from Intra-Cerebral Hemorrhage.
We are changing your medications as follows:
1. Please take lisinopril 20mg daily to control your blood
pressure.
2. Please take amantadine 100mg [**Hospital1 **]
3. Please take bowel medications for constipation as needed
Please take your other medications as prescribed.
Please followup with Neurology and your primary care physician
as listed below.
It was a pleasure providing you with care during this
hospitalization.
Followup Instructions:
Please follow up with a neurologist in your area in the coming
weeks to discuss your progression. Please schedule to meet with
your primary care physician to discuss this hospitalization.
If you have any questions, please call our office at ([**Telephone/Fax (1) 76682**]
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
|
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"427.1",
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"518.81",
"348.5",
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icd9cm
|
[
[
[]
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] |
[
"31.1",
"96.72",
"43.11",
"33.24",
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icd9pcs
|
[
[
[]
]
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14999, 15062
|
10835, 10835
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289, 317
|
15156, 15156
|
3946, 5883
|
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234, 251
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14127, 14233
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345, 2187
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10850, 14101
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15171, 15271
|
2209, 2299
|
2315, 2601
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,596
| 173,710
|
33975
|
Discharge summary
|
report
|
Admission Date: [**2179-6-9**] Discharge Date: [**2179-6-16**]
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
NSTEMI
Major Surgical or Invasive Procedure:
[**2179-6-10**] CABG x 1 with Ligation of LAD aneurysm (SVG to LAD)
History of Present Illness:
85 yo F p/w chest pain [**6-8**]. Ruled in for MI.Cardiac cath showed
99% LAD with aneursym, she was started on heparin and
transferred for further management.
Past Medical History:
PMH: HTN, cholelithiasis, DJD, ? valvular disease on past ECHO
PSH: partial colectomy for benign mass ~[**2163**], c-spine surgery
[**2173**], prior abdominal incisional hernia, hysterectomy at 35 y/o
Social History:
rare etoh
no tobacco
lives alone
Family History:
brother with premature CAD
sister with sudden cardiac death
Physical Exam:
HR 73 RR 20 BP 140/70
NAD
Lungs CTAB
Heart RRR, no murmur
Abdomen benign
Extrem warm, no edema
63"
149#
Pertinent Results:
[**2179-6-16**] 06:10AM BLOOD Hct-33.2*
[**2179-6-15**] 05:15AM BLOOD Hct-28.8*
[**2179-6-14**] 05:40AM BLOOD WBC-11.4* RBC-3.20* Hgb-10.1* Hct-30.0*
MCV-94 MCH-31.5 MCHC-33.5 RDW-13.7 Plt Ct-257
[**2179-6-15**] 05:15AM BLOOD PT-11.5 INR(PT)-1.0
[**2179-6-16**] 06:10AM BLOOD UreaN-16 Creat-0.9 K-4.3
[**2179-6-15**] 05:15AM BLOOD UreaN-20 Creat-0.7 K-4.4
CHEST (PA & LAT) [**2179-6-13**] 10:09 AM
CHEST (PA & LAT)
Reason: interval change
[**Hospital 93**] MEDICAL CONDITION:
85 year old woman with POD 3 CABG
REASON FOR THIS EXAMINATION:
interval change
PA AND LATERAL CHEST ON [**2179-6-13**] AT 1008
INDICATION: Postop CABG.
COMPARISON: [**2179-6-10**].
FINDINGS:
Since the prior study, lines and tubes have been removed. There
are bilateral effusions, left greater than right with some
atelectatic changes at the bases. The upper lungs are clear, and
the pulmonary vasculature is within normal limits. There is no
pneumothorax.
IMPRESSION: Good radiographic progression after CABG. Bilateral
effusions.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 78463**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 78464**]
(Complete) Done [**2179-6-10**] at 8:50:26 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 1112**] W.
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2093-9-1**]
Age (years): 85 F Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: cabg
ICD-9 Codes: 786.05, 786.51, 799.02, 440.0, 424.0
Test Information
Date/Time: [**2179-6-10**] at 08:50 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3318**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2008AW1-: Machine: aw3
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: *1.3 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.4 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 3.5 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 45% to 50% >= 55%
Aorta - Ascending: *3.5 cm <= 3.4 cm
Aorta - Descending Thoracic: 2.2 cm <= 2.5 cm
Findings
LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending aorta diameter. Simple atheroma in
descending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets. Trace AR.
MITRAL VALVE: Moderately thickened mitral valve leaflets. Mild
(1+) MR.
TRICUSPID VALVE: Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. The TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. No TEE related
complications.
Conclusions
Pre-CPB:
The heart is rotated which limits windows. Also, baseline
frequent ventricular ectopy continues.
No spontaneous echo contrast is seen in the left atrial
appendage. Right ventricular chamber size and free wall motion
are normal.
There are simple atheroma in the descending thoracic aorta.
The aortic valve leaflets are mildly thickened. Trace aortic
regurgitation is seen.
The mitral valve leaflets are moderately thickened. Mild (1+)
mitral regurgitation is seen.
There is no pericardial effusion.
Post-CPB:
The patient is AV-Paced, on NTG infusion.
Good biventicular systolic fxn. 1+ MR, trace AI.
Aorta intact.
Brief Hospital Course:
She was started on a lidocaine drip drip for ventricular ectopy.
She was started on cipro for a UTI. She was taken to the
operating room on [**2179-6-10**] where she underwent a CABG x 1 and
ligation of LAD aneurysm. She was transferred to the ICU in
critical but stable condition. She was given 48 hours of
vancomycin as she was in the hospital preoperatively. She was
extubated postop. Lidocaine was dc'd. She was transferred to the
floor on POD #1. She did well postoperatively, chest tubes and
wires were dc'd without incident. Gently diuresed toward her
preop weight and beta blockade titrated for ectopy and short
[**Last Name (un) 24048**] of atrial fibrillation. Ready for discharge to rehab on
POD #6.
Medications on Admission:
ASA325', diovan 160', HCTZ 12.5', cartia 240 XT'
on transfer: IV heparin, ASA 325 mg, lopressor 25 mg [**Hospital1 **]
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*30 Capsule(s)* Refills:*0*
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. 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*
7. Valsartan 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 5 days. Tablet(s)
10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12
hours) for 5 days.
Discharge Disposition:
Extended Care
Facility:
[**Last Name (un) 6978**] House of [**Location (un) 5871**]
Discharge Diagnosis:
Coronary Artery Disease s/p CABG
MI
postop A fib
Hypertension
cholelithiasis
DJD
Discharge Condition:
stable
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower daily washing incision, pat dry: no tub bathing or
swimming
Report any weight gain greater than 2 pounds in 24 hours or 5
pounds in 1 week
No creams, powder or lotion on incisions
No driving for 1 month
No lifting > 10 pounds for 10 weeks
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] in 4 weeks call for an appointment
[**Telephone/Fax (1) 170**]
Follow-up with Dr. [**Last Name (STitle) 75891**] (PCP [**Name Initial (PRE) **] [**Name Initial (NameIs) 37361**]) in 2 weeks
Follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (Cards - [**Location (un) 37361**]) in 2 weeks
Completed by:[**2179-6-16**]
|
[
"997.1",
"427.31",
"715.90",
"E878.2",
"427.69",
"410.11",
"414.01",
"599.0",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.52",
"39.61",
"36.11",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
6956, 7042
|
4959, 5671
|
274, 344
|
7167, 7176
|
1026, 1470
|
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|
826, 887
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1507, 1541
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902, 1007
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228, 236
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1570, 4936
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372, 534
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556, 760
|
776, 810
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,179
| 109,627
|
37136
|
Discharge summary
|
report
|
Admission Date: [**2123-1-25**] Discharge Date: [**2123-1-31**]
Date of Birth: [**2061-9-28**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1936**]
Chief Complaint:
SOB; Transfer from OSH
Major Surgical or Invasive Procedure:
Intubation
A-line
History of Present Illness:
61 year old female with history of COPD on 3L home O2 (FEV1/FVC
33 FEV1 41%predicted), and newly diagnosed LUL mass with
negative cytology on trans-bronch bx, brushing, and BAL [**2122-12-9**]
recently admitted [**Date range (1) 82788**] for COPD exacerbation presents with
SOB. She has had trouble breathing over past 3 days but then
acutely worse at 3am when she reports the coughing began and
persisted for 14 hours staright. She went to [**Hospital **] Hospital,
gave her nebs, Solumedrol and Toradol and transferred here.
She was transferred to [**Hospital1 18**] ED given her care has been here.
On arrival to ED, vitals: 96.5 HR 82 BP 108/58 RR 18 98%2L. She
was oxygenating fine but uncomfortable per their report. CXR
showed no new infiltrate, stable LUL mass. ABG 7.39/57/189.
She was given nebs and azithromycin; but due to her discomfort
she was started on BIPAP which she did not tolerate well. She
was given ativan which improved her coughing/discomfort and was
able to remain on NC alone. She was subsequently transferred to
the MICU.
.
On arrival to the unit, Patient was in mild distress with
coughing and increased work of breathing, she was given
albuterol nebs and 0.5mg ativan wtih marked improvement. She
reports as above, worsening SOB over past 3-4 days that worsened
this AM. She denies fevers/chills, N/V, CP, or increased sputum
production. Denies new myalgias (has h/o fibromyalgia and
reports close to baseline pain). Denies sick contacts.
.
.
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies chest pain, chest pressure, palpitations, or
weakness. Denies nausea, vomiting, diarrhea, constipation,
abdominal pain, or changes in bowel habits. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias. Denies
rashes or skin changes.
Past Medical History:
1. LUL Lung Mass
-- s/p bronch w/brushings, BAL, and lymph nodes EBUS TBNA (neg
for malignancy)
2. Severe emphysema on 3L home O2; FEV1/FVC 33, FEV1
41%predicted
3. Recent Pneumonia - treated with azithromycin
4. Diastolic heart failure
5. Fibromyalgia
6. Tobacco Abuse
.
Past Surgical History
[**2122-12-9**]: Status post electromagnetic navigational bronchoscopy
with radial endobronchial ultrasound, transbronchial biopsy,
bronchoalveolar lavage, and brushing of the left upper lobe mass
as well as placement of fiducials x4 into the left upper lobe
lung mass.
Social History:
lives home alone, has two daughters, widowed x
2. Quit smoking last month when diagnosed with new lung mass,
prior smoked for 50 years. Retired. No ETOH in 17 years, no drug
use.
Family History:
brother with lung CA
Physical Exam:
Temp 96.0 141/72 80 29 96% NRB @15L
General Appearance: Anxious, slight respiratory distress
coughing
Eyes / Conjunctiva: PERRL, Pupils dilated
Head, Ears, Nose, Throat: Normocephalic
Lymphatic: Cervical WNL, Supraclavicular WNL
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Bronchial: , Wheezes : , Diminished: ), poor air movement
throughout
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right lower extremity edema: Absent, Left lower
extremity edema: Absent
Skin: Not assessed
Neurologic: Responds to: Not assessed, Movement: Not assessed,
Tone: Not assessed
Pertinent Results:
Admission:
[**2123-1-25**] 03:15PM BLOOD WBC-10.3 RBC-3.54* Hgb-10.4* Hct-31.4*
MCV-89 MCH-29.3 MCHC-33.0 RDW-14.1 Plt Ct-189
[**2123-1-25**] 03:15PM BLOOD Glucose-157* UreaN-21* Creat-0.7 Na-138
K-4.8 Cl-98 HCO3-30 AnGap-15
[**2123-1-25**] 03:15PM BLOOD proBNP-89
[**2123-1-25**] 03:15PM BLOOD Calcium-8.4 Phos-3.2 Mg-2.2
[**2123-1-25**] 04:29PM BLOOD Type-ART PEEP-6 O2 Flow-50 pO2-198*
pCO2-57* pH-7.39 calTCO2-36* Base XS-8
CXR: [**1-25**]
IMPRESSION:
1. No acute cardiopulmonary process.
2. Unchanged left upper lobe spiculated mass.
CT CHEST: [**1-26**]
FINDINGS: 6.6 x 1.6 cm left upper lobe lesion is less dense and
has slightly decreased in size since [**2122-12-2**] when it measured
6.6 x 3 cm. There is stable mild left upper lung traction
bronchiectasis. There is near complete resolution of a right
middle lobe (4:106) opacity measuring under 5 mm. 2.8 x 5 mm
consolidation near the left upper lobe fissure is unchanged
since [**2122-12-2**]. Severe centrilobular emphysema is unchanged since
[**2122-12-2**]. There is no pleural effusion. ET tube tip is 1 cm above
the carina. An NG tube courses through the esophagus and stomach
with its tip outside the plane of imaging.
Heart size is normal. The main pulmonary artery measures 3.2 cm
in diameter. Scattered enlarged mediastinal nodes measuring up
to 1.2 cm in diameter are little change since [**2122-12-2**].
Although this exam was not tailored for subdiaphragmatic
diagnosis, the imaged intra-abdominal organs are unremarkable.
Bone windows demonstrate no lesion concerning for metastasis or
infection.
IMPRESSION:
1. Given minimal improvement and benign histology of spiculated
left upper
lobe mass followup in 6 months can be obtained.
2. Resolution of opacity in the right lung at the junction of
the major and minor fissure.
3. Stable severe centrilobular emphysema.
4. ET tube tip is just above the carina in this study, but is in
satisfactory position on chest radiograph performed 6 hours
after and thus does not need to be repositioned.
Brief Hospital Course:
61 year old female with COPD on 3L home O2 s/p recent admission
[**12-2**] for COPD exacerbation and newly diganosed LUL mass now
admitted with respiratory distress.
.
#. Acute hypercarbic respiratory distress/Cough: On admission,
the patient was complaining of 3 days of cough and SOB that
acutely worsened overnight. She presented to an OSH and was
transferred to the [**Hospital1 18**] ED for further managment. She was
placed on BiPAP in the ED and transferred to the MICU. She had
hypercapneia with a PCO2 of 57 initially, and was placed on non
rebreather mask with little improvement, and was then started on
non invasive positive pressure ventilation. Patient however
tolerated this poorly and required intubation for severe
respiratory distress.
During acute decompensation, It was noted that patient was
taking very high frequency shallow breaths with a constant cough
like sound generated in the upper airway. Patient was relatively
easy to ventilate and this raised question of paradoxycal vocal
cord dysfunction, phrenic nerve injury, etc. During intubation
however, vocal cords were noted to be normal in appearance and
during serial imaging diaphragms remained symmetrical.
Patient was treated with pulse dose steroids and started on
Azithromicyn. Given known left upper lobe nodule, a CT scan of
the chest was performed and did not show any significant
interval change. Patient was sucessfully extubated on [**1-28**] with
short NIVPPV bridge. Patient was transfered to medical floor on
[**1-28**]. She had an uneventful course and was discharged in stable
condition.
Pt has been having financial problems and has not been able to
afford Tiotropium (Spiriva). Social work was consulted and she
was given Ipratropium instead.
Patient was slowly weaned off steroids with taper over the next
2-3 weeks.
#. Fibromyalgia: Difficult to control, with overt anxiety in
spite of [**Hospital 17073**] medical regimen. We continued regimen with
fentanyl patch, gabapentin, SOMA, darvocet, amitryptline and
Propoxyphene
#. Anxiety: Patient with many social stressors and difficult to
control anxiety. Given progression of symptoms inspite of
agressive therapy, she was to follow up her outpatient
psychiatrist to address her anxiety.
# Anemia: During admission noted to be near baseline of 31.
There was no overt bleeding or hemolysis.
Medications on Admission:
Amitriptyline 150mg qhs
aspirin 81 daily
Darvocet A[**Telephone/Fax (3) **] q6 prn
duonebs
valium 5mg TID
fentanyl patch 25mcg q72 hr
flurbiprofen 100mg TID
lasix 80mg daily
gabapentin 900mg TID
hydrocodone-acetaminophen 5-500 [**Hospital1 **] prn pain
Potassium Chloride 8mEQ QID
Pulmicort
Soma 350mg TID
MVI
Omega 3
Discharge Medications:
1. Carisoprodol 350 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
2. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for anxiety.
3. Diazepam 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
4. Amitriptyline 50 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Darvocet A[**Telephone/Fax (3) **] mg Tablet Sig: One (1) Tablet PO every
six (6) hours as needed for fever or pain.
7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q4H (every 4 hours) as
needed for SOB.
8. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for SOB.
9. Fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
10. Furosemide 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
11. Gabapentin 300 mg Capsule Sig: Three (3) Capsule PO TID (3
times a day).
12. Pulmicort Inhalation
13. Omega-3 Fatty Acids Capsule Sig: One (1) Capsule PO
DAILY (Daily).
14. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Flurbiprofen 100 mg Tablet Sig: One (1) Tablet PO three
times a day.
16. Azithromycin 250 mg Tablet Sig: Two (2) Tablet PO Q24H
(every 24 hours) for 3 days.
Disp:*6 Tablet(s)* Refills:*0*
17. Prednisone 5 mg Tablet Sig: see directions Tablet PO once a
day for 2 weeks: take 8 pills on [**2123-1-31**], then take 6
pills on [**2-26**], then take 4 pills on [**2123-2-7**],
then take 2 pills on [**3-6**], then take 1 pills on
[**3-10**].
Disp:*84 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
COPD exacerbation
Fibromyalgia
Lung mass
Possible h/o diastolic heart failure
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
You came to the hospital with shortness of breath that is likely
due to COPD exacerbation. As you were tiring out, we put you
temporarily on a ventilator to help you breath. You recovered
after one day and returned to your baseline functional status.
We found on CT scan a lung nodule that needs to be followed up.
Please see f/u appointments. You were discharged in stable
condition.
.
Please follow up with your doctors, see below.
Followup Instructions:
Please follow up with Chest CT scan for the lung nodule in 6
month.
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 83672**], MD Phone:[**Telephone/Fax (1) 2664**]
Date/Time:[**2123-2-19**] 10:30
|
[
"300.00",
"V16.1",
"491.21",
"518.89",
"428.32",
"518.81",
"288.60",
"428.0",
"276.2",
"285.9",
"729.1",
"276.8",
"305.1",
"E932.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04",
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
10311, 10360
|
5944, 8291
|
338, 358
|
10482, 10482
|
3901, 5921
|
11088, 11311
|
3065, 3087
|
8660, 10288
|
10381, 10461
|
8317, 8637
|
10627, 11065
|
3102, 3882
|
276, 300
|
386, 2265
|
10496, 10603
|
2287, 2852
|
2868, 3049
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,919
| 145,378
|
11308
|
Discharge summary
|
report
|
Admission Date: [**2100-9-24**] Discharge Date: [**2100-9-29**]
Date of Birth: [**2038-4-21**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Iodine
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
chest pain, DOE
Major Surgical or Invasive Procedure:
s/p CABGx4(LIMA->LAD, SVG->[**Last Name (LF) **], [**First Name3 (LF) **], RCA) [**2100-9-23**]
History of Present Illness:
62F with h/o CAD, s/p stents to LAD and RCA. She has recently
experienced chest pain and dyspnea on exertion. Stress test was
abnormal and cardiac cath today reveals 3vessel disease. She is
referred for CABG.
Past Medical History:
CAD
NSTEMI [**2090**] (PCI of LAD and RCA)
htn
hyperlipidemia
diabetes
mild PVD
GERD
insomnia
left parietal CVA [**2091-11-17**] (?[**Name (NI) **] pt reports sx <24h, no
residual)
depression
moderate arthritis
restless leg syndrome
Past Surgical History:
cholecystectomy
bladder extension
Social History:
Lives with: husband and son
Occupation: retired (worked in quality control of books)
Tobacco: none
ETOH: none
Family History:
mother died at 54 with [**Name (NI) 1932**]
father died 62 MI
sister died 46 MI
sister died 54 MI
brother died 50 MI
Physical Exam:
Pulse: 74 Resp: 16 O2 sat: 94%RA
B/P Right: Left: 177/71
Height: Weight: 230lb
General: NAD, overweight female
Skin: Dry [x] intact [x]
HEENT: PERRLA [] EOMI [x] left pupil sluggish, fixed @4mm
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] obese
Extremities: Warm [x], well-perfused [x]
Edema 1+edema bilateral ankles/feet
Varicosities: None [] small spider veins
Neuro: Grossly intact x
Pulses:
Femoral Right: 1+ Left: NP
DP Right: 1+ Left: 1+
PT [**Name (NI) 167**]: NP Left: NP
Radial Right: cath site Left: 2+
Carotid Bruit Right: Left:
no bruits
Pertinent Results:
[**2100-9-29**] 06:35AM BLOOD WBC-11.0 RBC-3.42* Hgb-9.8* Hct-28.8*
MCV-84 MCH-28.7 MCHC-34.0 RDW-14.7 Plt Ct-284
[**2100-9-24**] 02:10PM BLOOD PT-14.7* PTT-32.8 INR(PT)-1.3*
[**2100-9-28**] 04:28AM BLOOD Glucose-159* UreaN-22* Creat-0.7 Na-133
K-4.5 Cl-100 HCO3-28 AnGap-10
[**Known lastname 36272**],[**Known firstname **] [**Medical Record Number 36273**] F 62 [**2038-4-21**]
Radiology Report CHEST (PORTABLE AP) Study Date of [**2100-9-28**] 7:54
AM
[**Last Name (LF) **],[**First Name3 (LF) **] CSURG FA6A [**2100-9-28**] 7:54 AM
CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 36274**]
Reason: eval for effusion
Final Report
INDICATION: Status post CABG, evaluation for pleural effusion.
COMPARISON: [**2100-9-26**].
FINDINGS: As compared to the previous radiograph, there is no
relevant
change. Small right pleural effusion, no evidence of larger left
pleural
effusion. Unchanged moderate cardiomegaly and bilateral areas of
basal
atelectasis. No newly occurred focal parenchymal opacities
suggesting
pneumonia. Unchanged position of the right central venous access
line.
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4130**]
Approved: TUE [**2100-9-28**] 2:16 PM
Conclusions
No spontaneous echo contrast is seen in the body of the left
atrium or left atrial appendage. No spontaneous echo contrast is
seen in the body of the right atrium. No atrial septal defect or
patent foramen ovale is seen by 2D, color Doppler or saline
contrast with maneuvers. Left ventricular wall thicknesses are
normal. The left ventricular cavity size is normal. Overall left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size is normal. with normal free wall
contractility. There are simple atheroma in the descending
thoracic aorta. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Trivial mitral regurgitation is seen. There is no
pericardial effusion.
POST CPB:
1. Preservred [**Hospital1 **]-ventricular systolci function.
2. No change in valve structure and function
3. Intact aorta
Brief Hospital Course:
The patient was admitted on [**2100-9-24**] and underwent
CABGx4(LIMA->LAD, SVG->[**Last Name (LF) **], [**First Name3 (LF) **], and RCA) and had a cross clamp
time of 105 mins. and total bypass time of 122 mins. She
tolerated the procedure well and was transferred to the CVICU on
insulin and propofol. She was extubated on the post op night and
remained on an insulin drip.
She went into rapid atrial fibrillation on POD#1 and was started
on an amiodorone drip. She also required Neo and was eventually
weaned off and transferred to the floor on POD#3. Her chest
tubes were d/c'd on POD#2 and her epicardial pacing wires were
d/c'd on POD#3. She had a few more episodes of atrial
fibrillation but converted to sinus rhythm and remained in it
since POD#4. She was discharged to [**Hospital **] Healthcare Center in
[**Last Name (un) 17679**] on POD#5 in stable condition.
Medications on Admission:
Atenolol 50mg [**Hospital1 **]
Diltiazem HCl 240mg daily
Glargine 80 Units am
ISMN 90mg daily
lisinopril 20mg daily
Metformin 1000mg [**Hospital1 **]
Oxybutynin 10mg daily
Paroxetine 20mg daily
Pramipexole 0.25mg [**Hospital1 **]
Prasugrel 10mg daily
Simvastatin 40mg daily
Omeprazole 20mg daily
Aspirin 81mg daily
FeSO4 325mg daily
Glucosamine
MVI
Discharge Medications:
1. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours)
for 5 days.
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
5. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. oxybutynin chloride 5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
7. paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. pramipexole 0.25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
9. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
10. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
11. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
12. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. prasugrel 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
15. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 5 days: Decrease dose to 400 mg PO daily after this
dose is finished. Give 400 mg PO daily for 7 days, then
decrease the dose to 200 mg PO daily.
16. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
17. insulin glargine 100 unit/mL Solution Sig: Eighty (80) units
Subcutaneous q AM.
18. glargine Sig: Twenty (20) units q PM.
19. furosemide 10 mg/mL Solution Sig: Two (2) Injection Q12H
(every 12 hours) for 5 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Healthcare Center - [**Hospital1 1559**]
Discharge Diagnosis:
Coronary artery disease-s/p CABG [**2100-9-23**]
s/p NSTEMI [**2090**] w/ PCI of LAD and RCA
HTN
hyperlipidemia
IDDM
PVD
GERD
insomnia
s/p CVA [**11-17**]
depression
OA
restless leg syndrome
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Percocet
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage. Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Recommended Follow-up:
You are scheduled for the following appointments
Surgeon:
Cardiologist:
Please call to schedule appointments with your
Primary Care Dr..... in [**3-22**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**First Name (STitle) **] [**2100-10-11**] @ 2:30 PM
Cardiologist: Dr. [**Last Name (STitle) 11493**] [**2100-10-8**] @ 9:45 AM
Please call to schedule appointments with your
Primary Care Dr.[**Last Name (STitle) 19219**] in [**3-22**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2100-9-29**]
|
[
"250.00",
"427.31",
"276.69",
"272.4",
"780.52",
"311",
"411.1",
"401.9",
"414.01",
"356.9",
"715.90",
"530.81",
"333.94",
"412",
"V45.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.13",
"39.61",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
7206, 7289
|
4170, 5048
|
288, 386
|
7524, 7747
|
1978, 4011
|
9020, 9611
|
1086, 1205
|
5448, 7183
|
7310, 7503
|
5074, 5425
|
7771, 8997
|
906, 942
|
1220, 1959
|
233, 250
|
414, 628
|
650, 883
|
958, 1070
|
4022, 4147
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,844
| 103,949
|
29668
|
Discharge summary
|
report
|
Admission Date: [**2136-2-12**] Discharge Date: [**2136-2-22**]
Date of Birth: [**2056-8-9**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
79 yo F w/ unknown PMH who lives with elder brothers was brought
to [**Hospital1 18**] ED by EMS after being found at home by niece to be
unfed wearing clothes soiled with urine. Per family report, she
had been increasingly lethargic over the last week. Family not
present at time of MICU admission. ED note statues pt's brother
reported 1 week h/o decreased PO intake. EMS notes state niece
reported she "believes elderly brother unable to care for her
now, may not be feeding her." EMS also notes h/o "fall" 2-3 days
ago. ED notes say that patient's brother denied h/o patient
falling, but report her sliding to floor. EMS notes also state
that patient's bed found to have large urine stains. There was a
question of elder abuse raised in the ED.
.
In the ED, her triage VS were T=95 HR=94 BP=89/61 RR=16 96=RA.
Initally, she was given 1400cc. Also started on D5 1/2NS for
hypernatremia (Na=154). CXR and UA unremarkable. CT c-spine
negative for fracture. CT head negative for bleed, but showed
prominent ventricles. Admission to medicine service was planned.
After it was noticed that she made no UOP to the inital IVF, she
was then given an additional 6L NS (total 7L NS). SBP remained
relatively low in the 90's, so she was admitted to the MICU for
further management. A dose of vanco and zosyn were ordered in
the ED prior to transfer. Vancomycin 1gm IV x1 was given. Blood
cultures not done in ED.
.
On arrival to MICU, BP initially 88/52, but improved to 128/57
without intervention. Denies all complaints, including CP, SOB,
diarrhea, abd pain; but pt clearly confused, only A&Ox1.
.
In the MICU, the patient was treated with Zosyn x 1 day and
Vanco for 2 days. Found to have RLE DVT. Started on heparin
drip. Guaic negative prior to heparin.
Past Medical History:
- PNA, [**2134**]
- Dementia, began approx 5 years ago
Social History:
Previously a school teacher - 1st grade. Never married. No
children. She is one of 9 children. Lives with younger brother
in [**Name (NI) **]. No EtOH or tobacco in 15 years, but was a social
user of alcohol/tobacco. Brother does shopping, cooking,
cleaning, laundry. During the day, she watches television and
sleeps.
Family History:
[**Name (NI) 2481**] - sister, passed at age 75
Father passed at age 76y, mother passed at age 73y of natural
causes
Physical Exam:
PHYSICAL EXAM on TRANSFER from MICU:
VS: Tm: 98.7, Tc: 97.7; HR: 78; BP: 101/51; RR 17; O2 97% RA
I/Os: [**Telephone/Fax (1) 71085**], LOS +10L
GEN: elderly woman, lying in bed, NAD, pleasant, awake
HEENT: PERRL bilat, EOMI bilat, anicteric, dry MM, OP clear
NECK: JVP not elevated, no carotid bruits
CV: RRR, distant HS, no S3, ?S4 vs systolic murmur heard best at
apex
CHEST: CTA bilat. no crackles/wheezes.
ABD: NABS, soft, ND, NT, no masses
EXT: ++ firm edema RLE, approx 2x LLE, 1+ DP pulses
SKIN: erythematous rash w/ some excoriations on buttocks and
sacrum, no skin breakdown.
NEURO: A&O x person and city only, not hospital or year; CN 2-12
grossly intact
Pertinent Results:
[**2136-2-11**] 09:45PM PT-15.7* PTT-38.8* INR(PT)-1.4*
[**2136-2-11**] 09:45PM WBC-13.6* RBC-4.58 HGB-15.1 HCT-45.4 MCV-99*
MCH-33.0* MCHC-33.2 RDW-14.9
[**2136-2-11**] 09:45PM LIPASE-31
[**2136-2-11**] 09:45PM ALT(SGPT)-23 AST(SGOT)-29 ALK PHOS-45
AMYLASE-48 TOT BILI-1.5
[**2136-2-11**] 09:45PM UREA N-45* CREAT-1.4* SODIUM-154*
POTASSIUM-3.5 CHLORIDE-122* TOTAL CO2-23 ANION GAP-13
[**2136-2-11**] 10:00PM URINE RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-RARE
EPI-0-2
[**2136-2-11**] 10:00PM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-4* PH-5.0 LEUK-TR
[**2136-2-11**] 10:43PM LACTATE-3.0*
[**2136-2-12**] 02:20AM LACTATE-2.1*
.
IMAGING:
[**2136-2-11**] PORTABLE CXR:
Mild right lower lobe atelectasis and elevation of the right
hemidiaphragm
.
[**2136-2-11**] CT HEAD:
1. Prominence of the ventricular system without obstructing
lesion
identified. No definite evidence of acute dilation. Please
correlate clinically to exclude normal pressure hydrocephalus.
2. No evidence of intracranial hemorrhage or fracture.
.
[**2136-2-11**] CT C-SPINE:
No fracture or malalignment; facet degenerative changes; minor
scarring at the lung apices; minor polypoid mucosal thickening
in the left maxillary sinus.
.
[**2136-2-13**] LE DOPPLER U/S: Positive study for DVT in the right
lower extremity. Occlusive thrombus is present in the distal
superficial femoral vein and popliteal vein. Non-occlusive
thrombus is present in the mid superficial femoral vein. Right
common femoral and proximal superficial femoral veins are
patent.
Brief Hospital Course:
Ms. [**Known lastname 71086**] is a 79 year old female with past medical history
significant for dementia who presented with failure to thrive
and sub-acute decline in mental status. She also demonstrated
signs of failure to thrive. Full neurologic work up was
performed and there was no clear explanation for her recent
decline. Per discussion with Neurology, NPH was considered as a
possible cause of worsening dementia. However, given the
chronicity of her illness, the likelihood of clinical benefit
from shunt placement was considered to be quite low, especially
in light of the known potential morbidity associated with shunt
placement. Therefore, the decision was made to not pursue this
diagnositic workup further.
.
The patient continued to have poor oral intake of both food and
liquid during her stay. Per the patient's brother, who is also
the [**Hospital 228**] Health Care Proxy, the family was not interested
in nutrition support via JPEG or TPN. Her HCP expressed his wish
that the patient receive comfort measures only.
Medications on Admission:
None.
Discharge Medications:
1. Zinc Oxide-Cod Liver Oil 40 % Ointment Sig: One (1) Appl
Topical TID (3 times a day).
2. Bisacodyl 10 mg Suppository Sig: One (1) supp Rectal once a
day as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Primary:
1. dementia
Discharge Condition:
Stable. Afebrile. Not taking PO. Patient is comfort measures
only.
Discharge Instructions:
Ms. [**Known lastname 71086**] was admitted to the hospital for altered mental
status. The change in mental status was likely related to
dementia. Primary focus is comfort measures. Further care per
nursing home medical director, ideally patient should be do not
hospitalization.
Followup Instructions:
None.
|
[
"276.0",
"453.40",
"294.8",
"276.51",
"458.9",
"276.2"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6269, 6339
|
4966, 6004
|
334, 340
|
6404, 6473
|
3372, 4185
|
6801, 6810
|
2552, 2671
|
6060, 6246
|
6360, 6383
|
6030, 6037
|
6497, 6778
|
2686, 3353
|
273, 296
|
368, 2121
|
4194, 4943
|
2143, 2199
|
2215, 2536
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,486
| 150,782
|
48453
|
Discharge summary
|
report
|
Admission Date: [**2196-3-29**] Discharge Date: [**2196-4-4**]
Date of Birth: [**2133-2-22**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 10370**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
intubation/extubation
tunnelled hemodialysis catheter placed by IR
cardiac catheterization, s/p stents to OM1 and OM2
History of Present Illness:
63 y/o M with CAD (POBA D1 in 95), htn, CKD stage 5 secondary to
FSGS, chronic LLE peroneal nerve palsy, microcytosis from
thalassemia trait, who p/w acute SOB this AM. Pt was scheduled
to have tunneled HD cath placed today; followed by Dr.[**Last Name (STitle) 1860**]. Per
GF, since Sat has been using inhaler more often and been little
more "SOB." GF noted decreased Uop over last 3 days. He awoke
her this AM, c/o severe SOB and EMS was called. They found him
to be tachypneic in the 40's with SBP 220's and intubated him in
field. In ED, SBP 160 after lasix 80mg IV, fentanyl 125mg,
valium 10mg and was started on ntg gtt. No hx SSCP. ECG shows
LBBB new from '[**94**].
Past Medical History:
CAD [**7-/2185**] angioplasty with 80% stenosis at D1, 40% post
procedure.
CKD (started [**2-/2195**]) from FSGS with high-grade proteinuria and
renal insufficiency due to secondary FSGS, followed by Dr. [**Last Name (STitle) 1860**].
HTN
chronic LLE peroneal nerve palsy
chronic narcotic analgesia
obesity
microcytosis from thalassemia trait
tobacco use, remote IVDU (heroin, cocaine), abstinent since [**2163**]
Social History:
lives with girlfriend, has 2 sons, used to work in construction,
+smoker 1 PPD for many years, rare ETOH, no drugs.
Family History:
Brother with CAD, and kidney disease req hemodialysis
Physical Exam:
98.8 (rectal) 62 162/81 20 100% on AC 650 X 12 Peep 5
Gen: Int/Sedated
Heent: PERRL, ETT in place
Neck: 10 cm JVD
Heart: RRR +summation gallop [**1-11**] sys murmur at apex
Lungs: bibasilar crackles 2/3 up thorax
Abd: Soft nt/nd NABS
Ext: 2+LE edema
Pertinent Results:
Admission Labs:
[**2196-3-29**] 09:16PM TYPE-ART PO2-94 PCO2-38 PH-7.33* TOTAL CO2-21
BASE XS--5 INTUBATED-INTUBATED
[**2196-3-29**] 09:16PM O2 SAT-97
[**2196-3-29**] 09:06PM WBC-7.5 RBC-5.25 HGB-11.3* HCT-36.5* MCV-70*
MCH-21.4* MCHC-30.8* RDW-17.5*
[**2196-3-29**] 09:06PM PLT COUNT-256
[**2196-3-29**] 04:55PM GLUCOSE-107* UREA N-59* CREAT-6.2* SODIUM-138
POTASSIUM-4.3 CHLORIDE-106 TOTAL CO2-20* ANION GAP-16
[**2196-3-29**] 04:55PM CK(CPK)-64
[**2196-3-29**] 04:55PM CK-MB-NotDone cTropnT-0.17*
[**2196-3-29**] 04:55PM IRON-25*
[**2196-3-29**] 04:55PM calTIBC-239* FERRITIN-115 TRF-184*
[**2196-3-29**] 04:55PM PTH-506*
[**2196-3-29**] 04:27PM TYPE-ART PO2-123* PCO2-39 PH-7.33* TOTAL
CO2-21 BASE XS--4
[**2196-3-29**] 04:27PM LACTATE-0.9
[**2196-3-29**] 03:15PM GLUCOSE-86 UREA N-59* CREAT-6.3* SODIUM-136
POTASSIUM-6.9* CHLORIDE-106 TOTAL CO2-18* ANION GAP-19
[**2196-3-29**] 03:15PM IRON-35*
[**2196-3-29**] 03:15PM calTIBC-230* FERRITIN-113 TRF-177*
[**2196-3-29**] 11:34AM TYPE-ART PO2-282* PCO2-39 PH-7.27* TOTAL
CO2-19* BASE XS--8
[**2196-3-29**] 11:08AM GLUCOSE-147* LACTATE-2.3* NA+-142 K+-4.0
CL--107 TCO2-19*
[**2196-3-29**] 11:00AM CK(CPK)-74 AMYLASE-184*
[**2196-3-29**] 11:00AM CK(CPK)-74 AMYLASE-184*
[**2196-3-29**] 11:00AM CK-MB-NotDone cTropnT-.17* proBNP-[**Numeric Identifier 47026**]*
[**2196-3-29**] 11:00AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-POS barbitrt-NEG tricyclic-NEG
[**2196-3-29**] 11:00AM WBC-9.4 RBC-5.28 HGB-11.8* HCT-37.1* MCV-70*
MCH-22.3* MCHC-31.8 RDW-17.2*
[**2196-3-29**] 11:00AM PT-12.8 PTT-24.8 INR(PT)-1.1
[**2196-3-29**] 11:00AM PLT COUNT-305
[**2196-3-29**] 11:00AM FIBRINOGE-619*
.
[**3-29**] CXR: Cardiomegaly with moderate-to-severe CHF. Cuff of the
ET tube appears slightly over inflated.
.
[**3-29**] CTA Chest: 1. Malpositioned endotracheal tube. Housestaff
was informed in person of misposition.
2. Ill-defined right upper lobe opacity given emphysematous
lungs, followup imaging is advised to ascertain resolution.
3. Bibasilar collapse with right pleural effusion.
4. Cardiomegaly and pulmonary congestion.
5. Multiple enlarged 12-mm mediastinal nodes.
6. No evidence for PE.
.
[**3-29**] Echo: The left atrium is elongated. There is mild symmetric
left ventricular hypertrophy. The left ventricular cavity is
moderately dilated. Overall left ventricular systolic function
is mildly to moderately depressed with mild global hypokinesis
and severe hypokinesis in the basal to mid inferior and
infero-lateral walls.. Right ventricular systolic function is
borderline normal. The aortic root is mildly dilated. The
ascending aorta is mildly dilated. The number of aortic valve
leaflets cannot be determined. The aortic valve leaflets are
moderately thickened. There is a minimally increased gradient
consistent with minimal aortic valve stenosis. Mild to moderate
([**12-7**]+) aortic regurgitation is seen. Mild (1+) mitral
regurgitation is seen. The left ventricular inflow pattern
suggests impaired relaxation. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion. Compared with the prior study (images reviewed) of
[**2195-11-4**], the overall LVEF has decreased.
.
[**3-30**] CXR: Pulmonary edema has nearly resolved, cardiac diameter,
mediastinal and hilar vascular engorgement has improved
substantially. Bibasilar atelectasis persists and there may be
small bilateral pleural effusions. No pneumothorax. Tip of the
ET tube is in standard placement. Right supraclavicular line
ends in the SVC. Nasogastric tube passes into the stomach and
out-of-view. No pneumothorax.
.
[**4-1**] Cardiac Catheterization:
1. Selective coronary angiography of this right dominant system
revealed evidence of two vessel coronary artery disease. The
left main coronary artery is without angiographic evidence of
obstructive coronary artery disease. The left anterior
descending coronary artery has mild luminal irregularities
throughout. The left circumflex coronary artery is without
angiographic evidence of obstructive coronary artery disease in
the proximal portion. There is a 40-50% mid LCX stenosis.
There is no evidence of significant CAD in the distal LCX. OM1
is totally occluded and fills via left to left collaterals. OM2
has a 70-80% stenosis. OM3 has a 70% stenosis. The right
coronary artery is the dominant vessel and is without evidence
of obstructive coronary artery disease in the proximal and mid
vessel. The distal RCA is totally occluded beyond the PDA.
There is diffuse 80% disease in the acute marginal branch.
2. Right heart catheterization revealed elevated right and left
sided filling pressures (RVEDP 16 mmhg, PCW = 23 mmhg), with
depressed cardiac index.
3. Left heart catheterization revealed systemic hypertension.
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Elevated right and left sided filling pressures, with
depressed cardiac index.
3. Systemic hypertension.
Brief Hospital Course:
63 yo M with ESRD [**1-7**] FSGS, CAD s/p PTCA of D1, HTN, and other
medical problems who presents with acute pulmonary edema.
.
1. Dyspnea: The patient initially presented to the MICU on
[**2196-3-29**] with complaints of acute onset SOB and decreased UOP
over the past 3 days before admission. The patient was intubated
in the field and found to have a SBP of 220's. He had a Right IJ
tunneled HD line placed and hemodialysis was initiated with
fluid removal of 1.5 L. He was then successfully extubated,
with good O2sat subsequently on room air. Serial CKs were
negative with mild elevation of troponins (0.21 peak). Echo
revealed global LV HK and severe HK of the PDA territory.
Cardiology was consulted and recommended catheterization. This
was done on [**2196-4-1**], with stents placed to OM1 and OM2.
Following catheterization the patient had no further chest pain
or dyspnea.
.
2. ESRD [**1-7**] FSGS- As above, hemodialysis was initiated on this
admission. The renal service followed the patient during his
hospital course. Calcium acetate was started as a phosphate
binder, and he was also given epogen with dialysis.
.
3. CAD s/p PTCA [**7-/2185**] with 80% D1 lesion and now new EKG changes
and EHCO abnormalities. Continued medical regimen with
ASA/statin/bb/ACE-I. As above, patient underwent cardiac
catheterization with stents to OM1/2. Patient remained chest
pain free post-cath.
.
4. CHF with EF 40%: As above, volume control with hemodialysis
which was initiated this admission. ACE-I and BB were
continued. Patient was given a low-sodium diet and I/O and
daily weight were monitored.
.
5. HTN- continued home medications (bb/ACE-I) and titrated up
dose for good BP control.
.
6. Hyperlipidemia - continued statin
Medications on Admission:
Meds at home:
ASA 325
lopressor 75 [**Hospital1 **]
procardia XL 90
calcitriol 0.5 daily
lasix 40 oral [**Hospital1 **]
imdur 30 daily
mevacor 40 daily
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
Disp:*180 Tablet(s)* Refills:*2*
3. Mevacor 40 mg Tablet Sig: One (1) Tablet PO once a day.
4. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*90 Capsule(s)* Refills:*2*
5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Captopril 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
end-stage renal disease, now initiated hemodialysis
coronary artery disease, s/p cardiac catheterization
Discharge Condition:
good
Discharge Instructions:
If you experience fever, chills, chest pain, shortness of
breath, or any other new or concerning symptoms, please call
your doctor or return to the emergency room for evaluation.
.
Please take all medications as prescribed.
-We have increased the dose of your metoprolol.
-We have stopped your procardia.
-We have started new medications, including captopril, calcium
acetate, nephrocaps, plavix, and an iron supplement, which
should be taken as prescribed.
.
Please attend your appointment for dialysis on Thursday, [**4-7**].
Followup Instructions:
You should follow up with your PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5717**] within 2
weeks after discharge from the hospital. Please call
[**Telephone/Fax (1) 250**] for an appointment.
.
Please keep your appointment for hemodialysis on Thursday, [**4-7**].
.
You also have the following appointment already scheduled.
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D., PH.D. Date/Time:[**2196-4-13**] 12:00
Completed by:[**2196-4-15**]
|
[
"396.3",
"518.81",
"585.6",
"414.01",
"403.91",
"398.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.47",
"39.95",
"00.41",
"96.04",
"99.20",
"36.07",
"88.52",
"00.66",
"96.71",
"37.23",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
9784, 9790
|
7026, 8770
|
280, 400
|
9958, 9965
|
2036, 2036
|
10541, 11094
|
1694, 1750
|
8973, 9761
|
9811, 9937
|
8796, 8950
|
6854, 7003
|
9989, 10518
|
1765, 2017
|
233, 242
|
428, 1104
|
2052, 6837
|
1126, 1544
|
1560, 1678
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,095
| 115,123
|
12304
|
Discharge summary
|
report
|
Admission Date: [**2124-6-20**] Discharge Date: [**2124-7-4**]
Date of Birth: [**2056-3-3**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
Neck and left arm numbness and tingling
Major Surgical or Invasive Procedure:
Cervical laminectomy and fusion, ACDF C3-6
History of Present Illness:
Mr. [**Known lastname 1968**] is a 68 y/o male with hyperlipidemia, HTN, cervical
radiculopathy, who was admitted to the orthopedics service on
[**2124-6-20**] for a cervical laminectomy and C3-C6 anterior/posterior
fusion. He underwent the procedures successfully and was
recovering on the ortho service, when on [**6-26**] he had an episode
of hypotension with SBP's in the 60's and tachycardia with
confusion. This resolved spontaneously, work-up was initiated,
and his opiate dose was decreased. However, a similar episode of
hypotension occured again at approximately 10 pm on the same
day, resulting in a Code Blue, intubation for airway protection
and transfer to the tramua ICU on [**6-26**]. He was started on
vancomycin and zosyn and levophed. CXR was significant for
infiltrates. He underwent a bronchoscopy and BAL on [**2124-6-27**] and
was noted to have copious secretions in LUL and LLL. He had a
bump in his troponin on [**2124-6-27**] with peak to 0.37. He was
extubated successfully on [**2124-6-28**].
.
Of note, his course was complicated by a troponin leak from 0.04
to >0.39. Cardiology was consulted and felt that the patient
likely sustained an NSTEMI in the setting of his hypotension,
recommendation was for medical management.
.
Past Medical History:
1. Cervical radiculopathy s/p cervical laminectomy and C3-C6
fusion [**6-20**]
2. HTN
3. Hyperlipidemia
4. Remote history of stroke with residual mild left-sided
hemiparesis
5. gout
Social History:
He lives alone. Previously worked
at a meat cutter. Smokes about half pack per day for over 40
years. History of heavy alcohol use in the past. Denies drug
use.
Family History:
N/C
Physical Exam:
NAD
RRR
CTA B
Abd soft NT/ND
BUE- good strength at right biceps, triceps, wrist extension and
flexion, finger extension and flexion and intrinsics, Left sided
weakness 4/5 from previous stroke; sensation diminished in left
arm C5-7 dermatomes; hyperreflexic at biceps, triceps and
brachioradialis; + [**Doctor Last Name 937**] bilaterally
BLE- good strength at hip flexion and
extension/abduction/adduction, knee flexion and extension, ankle
dorsiflexion and plantar flexion, [**Last Name (un) 938**]/FHL; sensation intact
distally; reflexes diminished at quads and Achilles; + clonus;
equivical Babinski
.
On transfer out of the MICU:
PHYSICAL EXAM:
VS:T 98.6 122/80 HR 92 RR 18 84% RA -> 88% 2L -> 94% 3L
General: Awake, alert, resting comfortably in bed, NAD
HEENT: NC, AT, EOMI no scleral icterus
Neck: supple, no LAD, steri-strips in place on left anterior
neck and posterior neck, no erythema or exudate at operative
sites
CV: RRR s1 s2 no appreciable murmur
Chest: coarse crackles diffusely, loudest at bases, no wheezes
Abd: soft, NT ND BS hyperactive
Ext: no LE edema, DP's 2+ Bilaterally
.
Pertinent Results:
WBC-23.8* RBC-3.31* Hgb-10.0* Hct-28.2* MCV-85 MCH-30.1
MCHC-35.3* RDW-13.6 Plt Ct-316
PT-15.5* PTT-29.4 INR(PT)-1.4*
Glucose-71 UreaN-19 Creat-0.9 Na-136 K-3.8 Cl-99 HCO3-25
AnGap-16
CK(CPK)-208* <- 304 <- 467
CK-MB-6 <- 9<- 15
TropnT-0.27* <-0.39 <- 0.37
CT neck and chest: Status post C3-6 laminectomy and anterior
cervical fusion with large low- attenuation fluid collection
anterior to this region with thin enhancing rim,
likely representing post-operative change; however, superimposed
infection
cannot be excluded. The fluid collection extends into the
superior
mediastinum at the thoracic inlet.
2. Multiple lymph nodes are noted in the neck, mediastinum, and
hila.
3. Air space opacity in the left upper lobe suggestive of
pneumonia.
Bilateral subsegmental atelectasis noted.
4. Left upper lobe 3-mm pulmonary nodule. Comparison with prior
imaging is
suggested if available to establish stability; otherwise,
follow-up imaging with Ct Chest to assess for stability in a few
months can be considered based on risk for thoracic malignancy.
5. Opacification of left maxillary sinus and air- fluid level in
the sphenoid sinus may relate to recent endotracheal tube
placement.
6. 1-cm enhancing soft tissue nodule in right axilla of
uncertain etiology; this may represent a node; however, clinical
correlation is recommended.
echo: The left atrium is normal in size. No atrial septal defect
is seen by 2D or color Doppler. The estimated right atrial
pressure is 0-10mmHg. Left ventricular wall thickness, cavity
size and regional/global systolic function are normal (LVEF
>55%) Transmitral Doppler and tissue velocity imaging are
consistent with Grade I (mild) LV diastolic dysfunction. There
is no ventricular septal defect. 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. Trace aortic regurgitation is
seen. The mitral valve appears structurally normal with trivial
mitral regurgitation. The left ventricular inflow pattern
suggests impaired relaxation. There is borderline pulmonary
artery systolic hypertension. There is no pericardial effusion.
CT head: No evidence of acute intracranial hemorrhage. MRI with
diffusion-weighted images is a more sensitive evaluation for
acute
ischemia/infarct and for vascular detail.
lung scan, perfusion images only: Low likelihood ratio for
recent pulmonary embolism. Heterogeneous perfusion is compatible
with the pulmonary congestion.
intraoperative Cspine XR: Two intraoperative radiographs of the
cervical spine were obtained without a radiologist present.
These demonstrate localization of C5-C6 and subsequent anterior
spinal fusion. For additional details, please consult the
operative report.
Brief Hospital Course:
Mr. [**Known lastname 1968**] is a 68 yo M with PMH HTN, Hyperlipidemia who was
initially admitted to the service of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] for an
anterior/posterior cervical decompresion and fusion C3-6.
#. Cspine sponylosis s/p anterior/posterior cervical
decompresion and fusion C3-6: He was consented for the procedure
and elected to proceed with Dr. [**Last Name (STitle) 363**]. Please see operative
note for procedure in detail. Post-operatively he was
administered antibiotics and pain medication. He was afebrile
and his incisions were clean and dry. His post op course was
complicated by the details below, however he was ultimately seen
by physical therapy, cleared for discharge to rehab, and should
wear brace when out of bed at all times until his follow up
appoitnment with Dr. [**Last Name (STitle) 363**] in one month.
#. Pneumonia: postoperatively, he became confused and
experienced hypotension. A stat EKG was performed which was
unchanged from previous. His confusion cleared and hypotension
resolved after a 500mL blous of fluid. A second episode of
hypotension and difficulty breathing occurred and a code was
called. He was subsequently intubated and transferred to the
T/SICU. In the T/SICU he required pressors for his hypotension
and continuous mechanical ventilation. An echo was performed
which was unchanged from that [**2120**]. V/Q Scan revealed a low
likelihood ratio for recent pulmonary embolism. Neck and chest
CT showed a post-operative seroma without evidence of gas pocket
or infection.
Chest x-rays revealed a left lower lobe pneumonia and
vancomycin/zosyn were started. A brochoscopy was performed and
revealed copious secretions in the LUL and LML which were
cultured. He was subsequently extubated and transferred out of
the T/SICU and to the medical service. Sputum cultures and BAL
cultures with pan-sensitive E. coli, Klebsiella and Enterobacter
all sensitive to ciprofloxacin so vancomycin and zosyn were
discontinued and ciprofloxacin was started to complete 10 day
course of antibiotics (last day [**2124-7-7**]). Polymicrobial nature
of growth concerning for aspiration PNA so he was seen by speech
and swallow who recommended nectar thickened liquids with plan
for re-evaluation once further out from his surgery. He was
re-evaluated on the day of discharge with video swallow study
and was cleard for regular diet with thin liquids.
#. NSTEMI: He had an NSTEMI with positive troponin while
hypotensive and in the ICU. He was seen by cardiology who
[**Hospital 13131**] medical management. He was treated with
metoprolol, ASA, simvastatin and lisinopril. He had no
recurrence of hypotension during this admission and will follow
up with Dr. [**Last Name (STitle) **] as an outpatient. (Phone number given,
please call for next available appointment.) Echocardiogram
without evidence of new wall motion abnormality, normal EF.
#. CT chest with nodule: As part of the above workup for
pneumonia, CT chest was performed and revealed an incidental
Left upper lobe 3-mm pulmonary nodule. It is recommended that
this be re-imaged with follow up CT scan in approximately 6
months to assess for stability. This should be followed by PCP.
[**Name10 (NameIs) 4692**], an axillary nodule was seen, however on
examination this was consistent with a large sebaceous cyst,
which the patient says has been stable for "20 years."
The patient is stable for discharge to rehab, where he should
work with PT/OT due to deconditioning in setting of complex
stay. He should continue ciprofloxacin until [**2124-7-7**]. He should
wear his neck brace at alltimes while out of bed until he sees
Dr. [**Last Name (STitle) 363**] in one month. Please also call for an appointment to
see Dr. [**Last Name (STitle) **] in cardiology in the next 1-2 weeks to follow up
for his MI.
Medications on Admission:
Acetaminophen-Codeine [Tylenol-Codeine #3] - 300 mg-30 mg Tablet
- 1 to 2 Tablet(s) by mouth q 6 h prn
ASA 325 MG
Gabapentin 900 mg TID
Hydrochlorothiazide 25 mg daily
Hydrocodone-Acetaminophen [Vicodin] - 5 mg-500 mg Tablet - 1
(One) Tablet(s) by mouth q 6-8 h prn
Indomethacin 25 mg daily
Lisinopril 20 mg Tablet 1 (One) Tablet(s) by mouth once a day
Omeprazole 20 mg [**Hospital1 **]
Simvastatin 10 mg daily
B COMPLEX - Tablet - ONE BY MOUTH EVERY DAY
Diphenhydramine HCl - 25 mg qHS
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*2*
7. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
8. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 4 days: last day of antibiotics [**2124-7-7**].
Disp:*8 Tablet(s)* Refills:*0*
9. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q4H (every 4 hours) as needed for dyspnea.
10. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
11. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
12. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL
Injection TID (3 times a day): may stop if pt ambulates TID.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 537**]- [**Location (un) 538**]
Discharge Diagnosis:
cervical spondylosis
Non-ST segment elevation MI
Pneumonia
Hypotension
=======
s/p CVA with mild left hemiparesis
HTN
Hyperlipidemia
Gout
Discharge Condition:
good
Discharge Instructions:
You were admitted to the hospital because you were having
scheduled surgery for an anterior/posterior cervical fusion.
You had no complications during your surgery however following
your surgery you had very low blood pressure and you lost
consciousness. You were intubated and transferred to the ICU.
You had a bronchoscopy which showed likely pneumonia in your
left lung. You were treated with antibiotics. You did well and
were extubated and continued on antibiotics. You had a small
heart attack while most likely when your blood pressure dropped.
You were evaluated by the cardiology doctors and [**Name5 (PTitle) **] should
follow up with them in clinic.
Wound Care:
Keep the incisions dry. You may shower as long as you cover
the incisions with Band-aids. Do not take a bath or submerge
the incisions under water. You need to wear the brace whenever
you are out of bed. You do not need the brace when you are in
bed.
Do not lift anything heavier than a gallon of milk. do not bend
or twist from the neck.
Do not smoke.
Medications:
1)You were started on Metoprolol which is a blood pressure
medicine that you should take to protect your heart.
2) You will need to finish your course of ciprofloxacin, an
antibiotic for your pneumonia
Please call your doctor or return to the emergency department if
you have a fever over 101F or if you have an increase in pain or
discharge from the incisions, or if you have chest pain, light
headedness, fainting or any other worrisome symptoms.
Followup Instructions:
You have an appointment scheduled to follow up with Dr. [**Last Name (STitle) 363**]
(orthopedic surgeon) on [**7-12**] at 10:30. The phone number for
the office is [**Telephone/Fax (1) 3573**]. The clinic is located on the [**Location (un) 17879**] of the [**Hospital Ward Name **] building of the [**Hospital Ward Name **]. Please wear
your neck brace whenever you are out of bed until your follow up
appointment.
You should also follow up with Dr. [**Last Name (STitle) **] of cardiology as you
did have a small heart attack during your admission when your
blood pressure was low. Please call [**Telephone/Fax (1) 5003**] to schedule
this appointment.
You have an appointment scheduled to follow up your PCP, [**Last Name (NamePattern4) **].
[**First Name (STitle) 4223**] on [**Last Name (LF) 2974**], [**7-7**] at 12:15. Please call [**Telephone/Fax (1) 7976**]
if you need to reschedule this appointment.
Completed by:[**2124-7-4**]
|
[
"401.9",
"721.0",
"482.0",
"998.13",
"507.0",
"518.89",
"038.9",
"438.20",
"272.4",
"410.71",
"274.9",
"998.0",
"E878.1",
"584.9",
"482.82",
"V15.82",
"997.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"33.24",
"81.62",
"81.02",
"80.51",
"81.03",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
11761, 11832
|
6039, 9917
|
352, 397
|
12014, 12021
|
3226, 5420
|
13574, 14521
|
2084, 2089
|
10456, 11738
|
11853, 11993
|
9943, 10433
|
12045, 12712
|
2756, 3207
|
273, 314
|
12724, 13551
|
426, 1683
|
5429, 6016
|
1705, 1889
|
1905, 2068
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,791
| 176,839
|
5097
|
Discharge summary
|
report
|
Admission Date: [**2187-5-3**] Discharge Date: [**2187-5-7**]
Date of Birth: [**2133-6-11**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
s/p coronary artery bypass grafting times four (lima-lad,
v-ramus, V-D1, v-RPDA)[**5-3**]
History of Present Illness:
53 yo male with hypertension,
hyperlipidemia, DM, CAD (s/p 2 BMS to RCA in [**2177**]) who is s/p
MVA
in [**2186-11-22**]. He is scheduled to have meniscus repair and
as
part of a preop workup was found to have an abnormal ekg,
followed by abnormal pMIBI and Coronary CTA. The patient
reports
having shortness of breath and shoulder discomfort occurs with
exertion such as taking out the trash or climbing [**1-25**] flights of
stairs. He only notices these symptoms early in the morning. He
has also been experiencing left shoulder discomfort and numbness
which he primarily notices when he is driving in the car. He has
denies any chest pain. He was referred for left heart
catheterization which revealed a 90% proximal LAD lesion
extending back to the LM, a 50% mid-LAD lesion, and a 60% distal
RCA lesion. Cardiac [**Doctor First Name **] was consulted for evaluation for CABG
Past Medical History:
CAD s/p RCA stenting [**2177**]
Diabetes type II
Hypertension
Torn meniscus
Past Surgical History: Appendectomy 30 yrs ago
Social History:
Lives with: Wife, Married, Taxi cab equipment installer. Has 2
children.
Contact for discharge: Wife: [**Telephone/Fax (1) 20957**] [**Doctor First Name 391**]
Tobacco quit [**2162**] - previously smoked 1/2-1 ppd x 25 years
ETOH: Occassional
Family History:
Non-contributory
Physical Exam:
Physical Exam
Pulse: Resp:18 O2 sat:97% RA
B/P Right:106/60 Left:117/62
Height:6'0" Weight:220#
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 - none
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
Pertinent Results:
[**2187-5-5**] 02:00PM BLOOD WBC-11.2* RBC-3.38* Hgb-10.9* Hct-30.9*
MCV-92 MCH-32.3* MCHC-35.3* RDW-13.5 Plt Ct-174
[**2187-5-3**] 01:06PM BLOOD PT-13.5* PTT-25.3 INR(PT)-1.1
[**2187-5-6**] 05:11AM BLOOD UreaN-12 Creat-0.7 Na-138 K-4.0 Cl-102
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 20958**], [**Known firstname 20959**] [**Hospital1 18**] [**Numeric Identifier 20960**]
(Complete) Done [**2187-5-3**] at 9:31:26 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 177**] C.
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2133-6-11**]
Age (years): 53 M Hgt (in): 72
BP (mm Hg): 122/53 Wgt (lb): 215
HR (bpm): 50 BSA (m2): 2.20 m2
Indication: Intraop CABG. Evaluate Wall motion, LVEF, Aortic
Contours, Valves
ICD-9 Codes: 424.0
Test Information
Date/Time: [**2187-5-3**] at 09:31 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2011AW1-: Machine: us 6
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *4.8 cm <= 4.0 cm
Left Atrium - Four Chamber Length: 4.5 cm <= 5.2 cm
Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.2 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 3.9 cm
Left Ventricle - Fractional Shortening: *0.25 >= 0.29
Left Ventricle - Ejection Fraction: 55% to 60% >= 55%
Left Ventricle - Stroke Volume: 122 ml/beat
Left Ventricle - Cardiac Output: 6.08 L/min
Left Ventricle - Cardiac Index: 2.76 >= 2.0 L/min/M2
Left Ventricle - Peak Resting LVOT gradient: 6 mm Hg <= 10 mm
Hg
Left Ventricle - Lateral Peak E': 0.11 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': 6 < 15
Aorta - Sinus Level: 3.4 cm <= 3.6 cm
Aorta - Ascending: 3.1 cm <= 3.4 cm
Aorta - Arch: 2.6 cm <= 3.0 cm
Aortic Valve - Peak Velocity: 1.2 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: 14 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 9 mm Hg
Aortic Valve - LVOT VTI: 32
Aortic Valve - LVOT diam: 2.2 cm
Aortic Valve - Valve Area: 3.0 cm2 >= 3.0 cm2
Mitral Valve - Peak Velocity: 1.1 m/sec
Mitral Valve - Mean Gradient: 1 mm Hg
Mitral Valve - E Wave: 0.7 m/sec
Mitral Valve - A Wave: 0.3 m/sec
Mitral Valve - E/A ratio: 2.33
Mitral Valve - E Wave deceleration time: 230 ms 140-250 ms
Findings
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. A catheter
or pacing wire is seen in the RA and extending into the RV. No
ASD by 2D or color Doppler.
LEFT VENTRICLE: Normal LV wall thickness and cavity size.
RIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic
function.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. No atheroma in ascending aorta. Normal
aortic arch diameter. Simple atheroma in aortic arch. Normal
descending aorta diameter. Simple atheroma in descending aorta.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Normal mitral valve leaflets. No MS. Mild (1+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
No PR.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. No TEE related complications.
Conclusions
Pre Bypass: The left atrium is mildly dilated. No atrial septal
defect is seen by 2D or color Doppler. Left ventricular wall
thicknesses and cavity size are normal. The right ventricular
cavity is mildly dilated with normal free wall contractility.
There are simple atheroma in the aortic arch. There are simple
atheroma in the descending thoracic aorta. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve leaflets are structurally normal. Mild (1+) mitral
regurgitation is seen.
Post Bypass: Patient is on phenylepherine infusion, A paced.
Preseved Biventricular funciton. LVEF >55%. Aortic contours
intact. Remaining exam is unchanged. All findings discussed with
surgeons at the time of the exam.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2187-5-3**] 17:36
?????? [**2178**] CareGroup IS. All rights reserved.
Brief Hospital Course:
On [**2187-5-4**] Mr.[**Known lastname **] was taken to the operating room and
underwent Coronary bypass grafting x4 (left internal mammary
artery to left anterior descending coronary artery;reverse
saphenous vein single graft from aorta to first diagonal
coronary artery; reverse saphenous vein single graft from aorta
to ramus intermedius coronary artery; as well as reverse
saphenous vein graft from aorta to posterior descending coronary
artery).Cardiopulmonary Bypass Time:82 minutes.Cross Clamp
time=:69 minutes.Please see operative report for further
details. He tolerated the procedure well and was transferred to
the CVICU intubated and sedated. He awoke neurologically intact
and weaned to extubate without difficulty. He weaned off
pressors and was started on Beta-blockers/ASA/Statin and
diuresis. POD#1 he transferred to the step down unit for further
monitoring. Physical Therapy was consulted to evaluate strength
and mobility. The remainder of his postoperative course was
essentially uneventful and on POD 4 he was cleared for discharge
to home. All follow up appointments were advised.
Medications on Admission:
ATENOLOL - 50 mg Tablet 1 Tablet(s) by mouth once a day
FOLIC ACID 1 mg Tablet - 1 Tablet(s) by mouth once a day
GLYBURIDE 5 mg Tablet - 1 Tablet(s) by mouth twice a day
METFORMIN [GLUCOPHAGE XR] 500 mg Tablet Extended Release 24 hr -
1 Tablet(s) by mouth three times a day
OMEGA-3 ACID ETHYL ESTERS [LOVAZA] - (Prescribed by Other
Provider) - 1 gram Capsule - 2 Capsule(s) by mouth twice a day
SIMVASTATIN - (Prescribed by Other Provider) - 20 mg Tablet - 1
Tablet(s) by mouth once a day
VALSARTAN-HYDROCHLOROTHIAZIDE [DIOVAN HCT] 160 mg-12.5 mg Tablet
- 1 Tablet(s) by mouth once a day
ASPIRIN 325 mg Tablet - 1 Tablet(s) by mouth once a day
Discharge Medications:
1. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO once a day for 1 weeks.
Disp:*14 Tablet Extended Release(s)* Refills:*0*
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. tramadol 50 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
4. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
5. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
7. metformin 500 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO TID (3 times a day).
Disp:*90 Tablet Extended Release 24 hr(s)* Refills:*2*
8. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
1 weeks.
Disp:*7 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
coronary artery disease
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesia
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage. Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2187-5-29**] 2:15
Cardiologist: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2187-5-23**] 2:40
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] L. [**Telephone/Fax (1) 4606**] in [**3-27**] 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:[**2187-5-7**]
|
[
"272.4",
"V15.82",
"250.00",
"V45.82",
"414.01",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.13",
"39.61",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
10086, 10145
|
7279, 8384
|
327, 419
|
10213, 10439
|
2459, 7256
|
11363, 12067
|
1758, 1777
|
9083, 10063
|
10166, 10192
|
8410, 9060
|
10463, 11340
|
1454, 1480
|
1792, 2440
|
268, 289
|
447, 1333
|
1355, 1431
|
1496, 1742
|
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