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72,000
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|
47546
|
Discharge summary
|
report
|
Admission Date: [**2177-7-4**] Discharge Date: [**2177-7-10**]
Date of Birth: [**2096-8-17**] Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 14802**]
Chief Complaint:
Right SDH
Major Surgical or Invasive Procedure:
None
History of Present Illness:
80M sent in for elevated INR. Patient is unsure why he takes
coumadin, but has pig valve and pacer in place. INR at PCPs
office was 6.5 today and was sent in for reversal given history
of recent falls. INR 8.7 on arrival today. Patient denies any
increased bleeding. No CP/SOB. No f/c. No abdominal pain.
Patient is a relatively poor historian
Past Medical History:
1. Hypertension
2. Hyperlipidemia
3. Seizure disorder ([**Doctor Last Name 11332**] mal seizures have not occurred for
many years; complex partial seizures with behavior patterns have
not occurred for 1-2 years)
4. Sick sinus syndrome ([**Company 1543**] pacemaker placed on right
side; interrogated [**7-/2176**])
5. s/p mitral valve repair with MAZE procedure (atrial
fibrillation) complicated by total occlusion of coronary artery
- artery over-sewn during procedure and resulting CABG (RSVG
from aorta to OM2) x 1-vessel and left femoral artery
pseudoaneurysm (with thrombin injection).
6. Bilateral foot drop (resulting from coronary bypass surgery)
7. Left anterior wall acetabular fracture ([**2175**])
8. Prostate adenocarcinoma
9. Colonic adenoma
10. Rheumatoid arthritis
11. Chronic anemia
12. Gout
13. Prior subdural hematoma (required Burr hole placement)
14. Lichen simplex chronicus
Social History:
Patient lives at home with his wife (has previously been at
[**Name (NI) 1188**] [**Last Name (NamePattern1) **]). Has one adult child. Retired mechanical
engineer. Denies tobacco use or alcohol use; no recreational
substance use.
Family History:
non-contributory.
Physical Exam:
On Admission:
O: T: 98.8 BP: 119/68 HR: 80 R 18 O2Sats 97%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 3->2 EOMs: intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to 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 [**5-17**] throughout except RUE 5-. Mild
L
pronator drift
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Reflexes: Normal bilaterally
Toes downgoing bilaterally
Handedness Right
On discharge: Oriented to Person and place but not date. Motor
exam intact.
Pertinent Results:
Head CT [**7-4**]
New acute/subacute subdural hematoma overlying the right
frontoparietal convexity. Previously seen small left frontal
subdural
hematoma is unchanged. New small subgaleal hematoma overlying
the right
vertex. No fractures seen.
CT C/T spine [**7-4**]
Nondisplaced acute compression fracture of T1.
CT Head [**7-5**]
Stable appearance of right frontoparietal and left frontal
subdural hematomas with no new foci of hemorrhage. Stable
subgaleal hematoma overlying the vertex.
Brief Hospital Course:
Pt was admitted to the neurosurgery service. Orthopedics was
consulted for a T1 fracture and they felt it was not acute and
needed no intervention. His coumadin was held and he was given
FFP and vitamin K to reverse his INR and it normalized to 1.3 on
[**7-6**]. He had a repeat CT head on [**7-5**] that showed no new
hemorrhage and remained stable. He did become somewhat aggitated
and required restraints on the evening of [**7-5**]. Social work was
consulted per wife's request as she has been finding it
difficult to care for him at home and to discuss her options of
nursing facilities. On [**7-7**], patient remained stable. PT/OT was
consulted and atrius was called to help move him forward to a
nursing home facility.
On [**7-8**], patient became slightly agitated and disoriented
however this delerium began to clear the following day and he
became more cooperative during the remainder of his hospital
stay.
At the time of discharge on [**7-10**] he was tolerating a diet,
ambulating with a walker, afebrile with stable vital signs.
Medications on Admission:
amiodarone 200 mg Tab
2 Tablet(s) by mouth twice a day Please take 2 200mg tablets
twice daily for 5 days. Then 1 200mg tablet twice daily for 7
days. Then 1 200mg tablet once daily until stopped by
cardiologist.
([**First Name8 (NamePattern2) 5877**] [**Last Name (NamePattern1) **] [**2177-7-4**] 20:23)
aspirin 81 mg Chewable Tab
1 Tablet(s) by mouth DAILY (Daily)
([**First Name8 (NamePattern2) 5877**] [**Last Name (NamePattern1) **] [**2177-7-4**] 20:23)
calcium carbonate 500 mg calcium (1,250 mg) Chewable Tab
3 Tablet(s) by mouth twice a day
([**First Name8 (NamePattern2) 5877**] [**Last Name (NamePattern1) **] [**2177-7-4**] 20:23)
cholecalciferol (vitamin D3) 1,000 unit Tab
1 Tablet(s) by mouth DAILY (Daily)
([**First Name8 (NamePattern2) 5877**] [**Last Name (NamePattern1) **] [**2177-7-4**] 20:23)
digoxin 125 mcg Tab
1 Tablet(s) by mouth once a day
([**First Name8 (NamePattern2) 5877**] [**Last Name (NamePattern1) **] [**2177-7-4**] 20:23)
fluoxetine 10 mg Cap
1 Capsule(s) by mouth once a day
([**First Name8 (NamePattern2) 5877**] [**Last Name (NamePattern1) **] [**2177-7-4**] 20:23)
furosemide 20 mg Tab
1 Tablet(s) by mouth twice a day
([**First Name8 (NamePattern2) 5877**] [**Last Name (NamePattern1) **] [**2177-7-4**] 20:23)
glucosamine HCl 500 mg Tab
1 Tablet(s) by mouth once a day
([**First Name8 (NamePattern2) 5877**] [**Last Name (NamePattern1) **] [**2177-7-4**] 20:23)
levothyroxine 25 mcg Tab
1 Tablet(s) by mouth once a day
([**First Name8 (NamePattern2) 5877**] [**Last Name (NamePattern1) **] [**2177-7-4**] 20:23)
metoprolol tartrate 25 mg Tab
1 Tablet(s) by mouth twice a day
([**First Name8 (NamePattern2) 5877**] [**Last Name (NamePattern1) **] [**2177-7-4**] 20:23)
metronidazole 500 mg Tab
1 Tablet(s) by mouth three times a day
([**First Name8 (NamePattern2) 5877**] [**Last Name (NamePattern1) **] [**2177-7-4**] 20:23)
multivitamin Tab
1 Tablet(s) by mouth once a day
([**First Name8 (NamePattern2) 5877**] [**Last Name (NamePattern1) **] [**2177-7-4**] 20:23)
nystatin 100,000 unit/mL Oral Susp
5 ml by mouth four times a day swish and swallow
([**First Name8 (NamePattern2) 5877**] [**Last Name (NamePattern1) **] [**2177-7-4**] 20:23)
omeprazole 20 mg Cap, Delayed Release
1 Capsule(s) by mouth DAILY (Daily)
([**First Name8 (NamePattern2) 5877**] [**Last Name (NamePattern1) **] [**2177-7-4**] 20:23)
phenytoin sodium extended 100 mg Cap
1 Capsule(s) by mouth once a day
([**First Name8 (NamePattern2) 5877**] [**Last Name (NamePattern1) **] [**2177-7-4**] 20:23)
potassium chloride ER 20 mEq Tab, Particles/Crystals
1 Tablet(s) by mouth once a day
([**First Name8 (NamePattern2) 5877**] [**Last Name (NamePattern1) **] [**2177-7-4**] 20:23)
pravastatin 40 mg Tab
1 Tablet(s) by mouth once a day
([**First Name8 (NamePattern2) 5877**] [**Last Name (NamePattern1) **] [**2177-7-4**] 20:23)
tamsulosin ER 0.4 mg 24 hr Cap
1 Capsule(s) by mouth HS (at bedtime)
([**First Name8 (NamePattern2) 5877**] [**Last Name (NamePattern1) **] [**2177-7-4**] 20:23)
warfarin 1 mg Tab
[**1-13**] Tablet(s) by mouth once a day Adjust for a goal INR of [**2-13**].5
for atrial fibrillation. Coumadin held [**11-13**] d/t INR of 2.9.
([**First Name8 (NamePattern2) 5877**] [**Last Name (NamePattern1) **] [**2177-7-4**] 20:23)
Discharge Medications:
1. Amiodarone 200 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Calcium Carbonate 1500 mg PO BID
4. Digoxin 0.125 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Fluoxetine 10 mg PO DAILY
7. Heparin 5000 UNIT SC TID
8. Levothyroxine Sodium 25 mcg PO DAILY
9. Metoprolol Tartrate 37.5 mg PO BID
Please use IV meds if patient refused pills. Goal SBP<140
10. Phenytoin Sodium Extended 100 mg PO TID
11. Pravastatin 40 mg PO DAILY
12. Senna 1 TAB PO HS
13. Tamsulosin 0.4 mg PO HS
14. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 1820**] [**Last Name (NamePattern1) **]
Discharge Diagnosis:
Subdural hematoma
Confusion
Agitation
Chronic T1 compression fracture
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Advil, or Ibuprofen
etc.
?????? Do not Resume Coumadin until follow up and discussion with
your Neurosurgeon, Dr. [**Last Name (STitle) **].
?????? You have been prescribed Dilantin (Phenytoin) for anti-seizure
medicine, take it as prescribed and follow up with laboratory
blood drawing in one week. This can be drawn at your PCP??????s
office, but please have the results faxed to [**Telephone/Fax (1) 87**].
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion, lethargy or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? New onset of the loss of function, or decrease of function on
one whole side of your body.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in _4_weeks.
??????You will need a CT scan of the brain without contrast prior to
your appointment. This can be scheduled when you call to make
your office visit appointment.
??????We recommend you see Dr [**First Name (STitle) **] in the Traumatic Brain Injury
(TBI) clinic the phone number is [**Telephone/Fax (1) 6335**]. If you have any
problems booking this appointment please ask for [**First Name8 (NamePattern2) 16367**] [**Last Name (NamePattern1) 16368**].
Completed by:[**2177-7-10**]
|
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icd9cm
|
[
[
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,827
| 178,197
|
15702
|
Discharge summary
|
report
|
Admission Date: [**2106-4-6**] Discharge Date: [**2106-4-15**]
Date of Birth: [**2038-4-1**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
Fever, hypotension
Major Surgical or Invasive Procedure:
Bedside debridement of ulcerations by plastic surgery team
History of Present Illness:
68M with h/o t4 paraplegia x 2yrs, felt [**3-13**] "inflammatory spinal
disease", with a chronic indwelling foley, sacral decubitus
ulcers, presents to [**Hospital1 18**] from rehab after RN noted 1d of fever
(tmax 101.8). [**Name8 (MD) **] RN caring for pt at rehab, pt noted some mild
abdominal discomfort (chronic), but otherwise denied any recent
symptoms of cough, n/v, constipation, rash. Pt has been having
chronic diarrhea (x3/day, x2-3/night) for past 1yr, etiology
unclear. [**Name2 (NI) 227**] persistent fevers x24hrs, pt was brought to
[**Hospital1 18**] ED. [**Name8 (MD) **] RN BP prior to leaving rehab was 100/72.
.
Per pt, he notes chronic abdominal pain, "always there",
diffuse, sharp, sometimes awakening him from sleep, no relation
to food or BMs. somewhat worse over the preceding 4 months, but
actually improving over the past few days. At present, he
states his pain has completely resolved. ROS otherwise
significant for +orthopnea, pt also notes nonproductive cough x
3 weeks, no flu sx (body aches, congestion, sore throat). Pt
denies flut shot or pneumovax. +sick contacts (lives in [**Hospital 100**]
Rehab).
.
Upon arrival in ED VS=100.4 100 87/51 12 95%RA. UA was c/w
UTI, pt was started on vanco and zosyn, UCx and BCx sent.
sacral ulcers felt to be stage 4, no evidence of superinfection.
BP initially responded to 3L IVF (99/53), however after 3rd
litre, BP down to 85/40, pt therefore received RIJ TLC, and
possibly an additional 1L IVF bolus, afterwhich BP improved to
115/70. Pt was asymptomatic, mentating throughout without
specific complaints.
.
Pt also noted moderate abdominal tenderness. CT ABD done which
showed no acute processes. CXR unremarkable, EKG unremarkable
(old Q in III, ?mild ST changes V1).
.
Pt admitted to ICU for further monitoring given hypotension.
.
Past Medical History:
1. Inflammatory disease of the spinal cord of uncertain
etiology. MRA [**10-16**] negative for vascular malformation. Initial
CSF analysis showed elevated protein (82) without oligoclonal
bands. NMO blood titer negative, RPR negative, Lyme serology
negative, [**Doctor First Name **] negative, Ro and La negative, ACE level normal,
neuromyelitis IgG negative, ESR 70, CRP 66.8. Ultimately
treated with broad spectrum antibiotics, corticosteroids (two
weeks of Solu-Medrol followed by a prednisone taper), and 5 days
of mannitol without improvement. He is followed by neurology
for a dense paraplegia (T4) with neuropathic pain, restrictive
shoulder arthropathy, and a neurogenic bladder requiring a
chronic indwelling foley.
2. Chronic sacral decubitus ulcer, previously treated with a VAC
dressing
3. Multiple UTI (including Pseudomonas)
4. Pulmonary embolus [**11-15**] s/p IVC filter placement
5. Asthma
6. Two-vessel coronary artery disease s/p CABG 4-5 years ago
7. Systolic CHF (EF 25-30% on [**2-15**] TTE)
8. Repaired liver laceration
9. Chronic back pain
10. Vitiligo
11. Feeding tube
12. Depression
13. MRSA from sacral swab and sputum
14. Prior transient episodes of leg paralysis
15. Right frontal lobe brain lesion biopsied [**11-15**] and c/w
gliosis; resolved on repeat imaging
16. Abnormal visual evoked potentials
Social History:
He moved here from [**Country 3594**] (after living in many different
countries) in the [**2068**]. He is retired from a job in the
maritime industry. Divorced 24 years ago. Three children.
Quit smoking [**2076**]. Quit drinking [**2080**]. No history of illicit
drug use or abuse.
Family History:
No stroke, aneurysm, no seizure, no AAA.
Physical Exam:
VS: 96.6 85 105/66 15 100%2L
Gen: Well appearing male in NAD lying in bed.
HEENT: JVD <6-8cm, MMM, lips slightly pale.
Chest: CTA bilaterally, no w/r/r.
CV: RRR, physiologic splitting S2, no r/g. 3/6 SEM @ LSB.
Abd: Soft, nontender to deep palpation in all four quadrants,
distended, tympanic (?gas), negative murphys sign, well-healed
midline g-tube scar.
Extremities: Warm, well perfused, no C/C. [**2-10**]+ edema bilaterally
to knees.
Skin: Vitiligo on hands. Large round 6x4 cm diameter pressure
decubitus ulcer on sacrum and 4x3cm decub ulcer on left ischial
tuberosity. Appears clean with granulation tissue in center, no
s/sx of infection. no purulent drainage.
Neuro: CN grossly intact. A&O x 3, pleasantly conversant.
Pertinent Results:
[**2106-4-5**] 11:50PM BLOOD WBC-9.08 RBC-4.37* Hgb-11.2* Hct-34.9*
MCV-80* MCH-25.6* MCHC-32.0 RDW-15.1
[**2106-4-8**] 04:47AM BLOOD WBC-6.7 RBC-3.49* Hgb-8.9* Hct-28.5*
MCV-82 MCH-25.6* MCHC-31.4 RDW-14.9
[**2106-4-5**] 11:50PM BLOOD Glucose-125* UreaN-11 Creat-0.5 Na-137
K-4.0 Cl-101 HCO3-27 AnGap-13
[**2106-4-8**] 04:47AM BLOOD Glucose-109* UreaN-5* Creat-0.4* Na-139
K-3.7 Cl-110* HCO3-23 AnGap-10
[**2106-4-6**] 10:27PM BLOOD CK-MB-5 cTropnT-0.08*
[**2106-4-6**] 08:11AM BLOOD cTropnT-0.08*
[**2106-4-5**] 11:50PM BLOOD CK-MB-NotDone cTropnT-0.09*
[**2106-4-8**] 04:47AM BLOOD Calcium-8.2* Phos-3.0 Mg-2.0
[**2106-4-6**] 12:05PM BLOOD Cortsol-15.3
[**2106-4-6**] 12:05PM BLOOD CRP-122.0*
[**2106-4-6**] 01:45PM BLOOD Lactate-1.4
[**2106-4-6**] 12:00PM BLOOD Lactate-0.7
[**2106-4-6**] 12:02AM BLOOD Lactate-1.7
CT ABD/Pelv [**2106-4-6**]:
1. Severe sacral and right ischial tuberosity decubitus ulcers.
2. No acute intra-abdominal inflammatory process.
3. Cholelithiasis.
CXR [**4-6**] Bedside frontal chest radiograph is compared to
[**2106-1-2**] and demonstrate clear lungs, normal pulmonary
vasculature, and no evidence for pleural effusions. The heart
and mediastinal contours, remarkable for tortuous aorta, are
stable. This patient is status post median sternotomy.
IMPRESSION: No acute cardiopulmonary process.
EKGs: NSR, essentially unchanged from prior tracings
WBC scan;
IMPRESSION: 1. Unchanged appearance of residual sacrum with
adjacent posterior
focal radiotracer uptake, again apparently within adjacent soft
tissues.
However, given the proximity of the uptake, bony involvement
with infection
cannot be excluded.
2. Similar sclerotic appearance of right lower ischium and
adjacent soft
tissue thickening. Although the CT appearance suggests chronic
osteomyelitis,
immediately adjacent radiotracer activity has resolved and the
bony abnormality
appears unchanged.
3. New cellulitis along the right lower buttock, at the
interface with the
thigh and inferior to the prior site of infection.
4. More extensive radiotracer uptake in the left lower buttock,
with fat
stranding on CT suggesting cellulitis. Although the soft tissue
abnormality
extends to the ischial tuberosity, there is no CT evidence of
bone destruction
or abnormal bony radiotracer uptake in this area.
[**2106-4-6**] 6:38 pm SWAB Source: left ischial tuberosity.
**FINAL REPORT [**2106-4-10**]**
GRAM STAIN (Final [**2106-4-6**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2106-4-10**]):
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup is performed appropriate to the isolates recovered
from the
site (including a screen for Pseudomonas aeruginosa,
Staphylococcus
aureus and beta streptococcus).
Susceptibility will be performed on P. aeruginosa and S.
aureus if
sparse growth or greater.
STAPH AUREUS COAG +. SPARSE 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.
Please contact the Microbiology Laboratory ([**8-/2404**])
immediately if
sensitivity to clindamycin is required on this
patient's isolate.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=1 S
ANAEROBIC CULTURE (Final [**2106-4-10**]): NO ANAEROBES ISOLATED.
[**2106-4-6**] 6:38 pm SWAB Source: sacral decubitus ulcer.
**FINAL REPORT [**2106-4-10**]**
GRAM STAIN (Final [**2106-4-6**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2106-4-10**]):
ESCHERICHIA COLI. RARE GROWTH.
PSEUDOMONAS AERUGINOSA. RARE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| PSEUDOMONAS AERUGINOSA
| |
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S 4 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN--------- =>4 R <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
PIPERACILLIN---------- <=4 S 8 S
PIPERACILLIN/TAZO----- <=4 S 8 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
ANAEROBIC CULTURE (Final [**2106-4-10**]): NO ANAEROBES ISOLATED.
Brief Hospital Course:
A/P: 67M h/o T4 paraplegia, recurrent UTIs [**3-13**] indwelling foley,
multiple stage 4 decubs was admitted to ICU initially with fever
to 101.8, transient hypotension that resolved with 3-4L IVF but
continued on sepsis protocol.
.
# FEVER - Felt due to UTI and or osteomyelitis. Cx. all neg,
but swab suggested colonization with mrsa; also seen on swab,
pseudomonas and enterococcus. Emperically treated with
vancomycin and zosyn given this information and prior culture
data that was reviewed here. Tagged wbc scan as above. Plastic
surgery consult evaluated wounds and felt that pt. did not have
evidence of osteomyelitis. Plan two weeks of abx for empiric
treatment for complicated UTI. Foley replaced. Follow up with
[**Month/Day (2) **] arranged for evaluation for suprapubic catheter. Follow
up with plastic surgery also arranged.
.
# HYPOTENSION - resolved with IVF and treatment of infection as
above.
# H/O PE - s/p IVC filter, INR elevated, so warfarin held, then
given 5 po vitamin K given sustained inr over 4.0. INR came
down to 1.8 with this, so warfarin resumed.
Otherwise, home medication regimen continued in hospital for
other chronic medical issues as outlined in pmhx. and in
medication list below.
Medications on Admission:
vitamin c 500mg po qdaily
aspirin 81mg po qdaily
baclofen 5mg po tid
calcium carbonate 650mg po bid
citalopram 40mg po qdaily
pepcid 20mg po qdaily
advair 250/50 IH [**Hospital1 **]
gabapentin 400mg po bid
simethicone 80mg po tid
simvastatin 40mg po qdaily
tramadol 25mg po tid
ursodiol 300mg po qdaily
warfarin 3mg po qdaily
prostat 30ml oral [**Hospital1 **] (liquid protein supplement)
.
Discharge Medications:
1. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
gram Intravenous Q 12H (Every 12 Hours) for 7 days. gram
2. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback Sig:
One (1) Intravenous Q8H (every 8 hours) for 7 days.
3. Sodium Hypochlorite 0.25 % Solution Sig: One (1) Appl
Miscellaneous ASDIR (AS DIRECTED) for 1 days: apply to ischial
wounds only, for one day ([**4-16**]) in [**Hospital1 **] wet to dry dsg changes.
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Baclofen 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day).
6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
7. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) inhalation Inhalation [**Hospital1 **] (2 times a day).
9. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO TID (3 times a day) as needed.
11. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Tramadol 50 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day).
13. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO QDAILY ().
14. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
15. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
16. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed.
17. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed.
18. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
19. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: [**2-10**] Tablet,
Rapid Dissolves PO Q8H (every 8 hours) as needed.
20. Warfarin 3 mg Tablet Sig: One (1) Tablet PO once a day.
Tablet(s)
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
UTI with sepsis
Chronic sacral and ischial decubitus ulcerations
Chronic, systolic, heart failure
Hx. PE with SVC filter, on warfarin
Discharge Condition:
Stable
Discharge Instructions:
Return to the [**Hospital1 18**] Emergency Department for:
Fever
Hypotension
Followup Instructions:
Provider: [**Name10 (NameIs) **] SURGERY CLINIC Phone:[**Telephone/Fax (1) 4652**]
Date/Time:[**2106-4-23**] 1:30
For evaluation for suprapubic catheter placment:
Provider: [**Name10 (NameIs) **] UNIT Phone:[**Telephone/Fax (1) 164**] Date/Time:[**2106-4-28**]
9:30
|
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icd9cm
|
[
[
[]
]
] |
[
"86.22",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
13665, 13731
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10035, 11268
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332, 393
|
13909, 13918
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4746, 10012
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3935, 3977
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11294, 11687
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13942, 14021
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3992, 4727
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274, 294
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421, 2255
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3630, 3919
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,508
| 178,754
|
30203
|
Discharge summary
|
report
|
Admission Date: [**2124-3-12**] Discharge Date: [**2124-3-30**]
Date of Birth: [**2056-11-30**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1148**]
Chief Complaint:
Respiratory failure.
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
HPI: 67 yo M w/PMHx sx for COPD and tobacco use who presented to
an OSH today after a neighbor found him to be very dyspneic. Per
report, pt had been sick for three weeks with weakness and
fever, with a productive cough with yellow sputum production,
chills, sore throat, nasal congestion, and difficulty breathing.
He also noted chest pressure. Per family friend, patient had
lost 20 lbs over this time course, and was using only [**Last Name (un) 18774**]
Vaporub for relief, and Tylenol PM for sleep.
.
Patient was brought today to the OSH by his girlfriend. [**Name (NI) **]
report, patient had temperature to 101, with HR 120s, with O2
sats of 96% on 6L, with progressively increasing tachypnea and
cyanosis on presentation to the OSH. Patient was intubated at
OSH for hypercarbic respiratory failure thought to be [**2-18**]
pneumonia. His ABG was initially 7.19/110/278 on a
nonrebreather, then 7.24/96/67 on 2L NC prior to intubation.
Patient was also noted to have a leukocytosis with WBC of 24,
with left shift and 1% bandemia, and a CXR which per report
showed a LLL PNA. With the intubation patient received propofol,
which resulted in hypotension, for which he was started on
dopamine. At the OSH, patient also received one dose of
levofloxacin. A subclavian line was placed as well. Patient was
also noted to have dark emesis/hemoptysis with NGT placement,
and protonix was started.
.
In the ED, patient had repeat CXR performed. His initial BPs
were 70/50s. A FAST scan was performed, and was negative. He was
transitioned off propofol and dopamine and started on levophed.
Patient has received 4L IVF as well, as well as
CTX/azithromycin, and dexamethasone 10 mg x 1 dose.
.
ROS: Unable to obtain as patient intubated.
Past Medical History:
COPD
Tobacco use
Alcoholism
Abdominal hernia
Depression
Social History:
Lives at home. Has a girlfriend. [**Name (NI) **] no family nearby. Smoked
for many years. Quit one year ago. Extensive alcohol use -
drinking beer recently. Marijuana use in the past.
Family History:
Mother with CVA, died of hip fracture. Father with MI in 80s.
Physical Exam:
PE:
VS: 97.1 BP 117/96 HR 98 RR 18 100% O2 sat on A/C 550x20 FiO2
0.40 PEEP 5
Gen: intubated, sedated.
HEENT: MM dry. ET tube in place. No scleral icterus.
Hrt: Distant heart sounds. No MRG.
Lungs: No wheezes. Poor air movement throughout. No rales or
rhonchi.
Abd: Soft/NT/ND. No fluid wave. No organomegaly.
Ext: Cool. 1+pulses.
Neuro: Intubated and sedated. Pupils equally reactive. Reflexes
symmetric. Withdraws to pain.
Pertinent Results:
[**2124-3-12**] 07:00PM URINE MUCOUS-FEW
[**2124-3-12**] 07:00PM URINE GRANULAR-0-2 HYALINE-21-50*
[**2124-3-12**] 07:00PM URINE RBC-[**12-5**]* WBC-[**6-25**]* BACTERIA-FEW
YEAST-NONE EPI-[**3-20**] TRANS EPI-0-2
[**2124-3-12**] 07:00PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-NEG PH-5.0 LEUK-TR
[**2124-3-12**] 07:00PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.017
[**2124-3-12**] 07:00PM RET AUT-0.9*
[**2124-3-12**] 07:00PM FIBRINOGE-474*
[**2124-3-12**] 07:00PM PT-20.2* PTT-31.6 INR(PT)-1.9*
[**2124-3-12**] 07:00PM HYPOCHROM-1+ ANISOCYT-NORMAL POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL
[**2124-3-12**] 07:00PM NEUTS-77* BANDS-0 LYMPHS-8* MONOS-11 EOS-1
BASOS-0 ATYPS-1* METAS-2* MYELOS-0
[**2124-3-12**] 07:00PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
.
[**2124-3-15**] CT chest/abd/pelvis:
IMPRESSION:
1. Densely calcified pancreas, consistent with chronic calcific
pancreatitis.
2. Poorly-defined multifocal patchy, nodular opacities seen
distributed throughout the lungs bilaterally, with upper lobe
predominance. Findings are nonspecific but could be of
infectious or possibly inflammatory etiology.
3. Emphysema.
4. Enlarged left adrenal gland, incompletely evaluated on this
single-phase study.
5. Small low attenuation lesion seen within the left kidney,
possibly representing cyst but too small to characterize by CT.
6. Low attenuation lesion seen in the anterior subcutaneous soft
tissue, possibly representing sebaceous cyst. Clinical
correlation recommended.
7. No definite evidence malignancy identified on this study,
however, this study was only performed with a single phase of
contrast, limiting assessment for more subtle lesions,
especially within the liver.
.
LIVER AND GALLBLADDER ULTRASOUND: Liver is of normal
echogenicity and echotexture and no focal lesions are
identified. No intra- or extra-hepatic bile duct dilatation. The
CBD measures 4 mm and is normal. All the hepatic vessels are
patent including the hepatic arteries, portal veins, and hepatic
veins. The gallbladder is normal without evidence of stones.
.
[**3-21**] CT chest: FINDINGS:
As compared to the prior study, there has been interval
worsening of the multifocal areas of peribronchial consolidation
in the upper lobes bilaterally. Mild peribronchial infiltration
in the lingula, right middle lobe, and lower lobes, and two more
discrete nodular focal opacities in the right lower lobe (3A:
44) are unchanged. Bibasal posterior subsegmental atelectasis
are new.
A focal area of consolidation in the superior segment of the
left lower lobe posteriorly is new.
The airways are patent through the segmental level. There has
been interval increase in size and number of multiple
mediastinal lymph nodes, for instance, an 11-mm right lower
paratracheal lymph node was 9 mm previously; a 9-mm left lower
paratracheal lymph node was 6 mm in the past. Bilateral mildly
enlarged hilar lymph nodes are stable. Cardiac size is normal.
Dense calcification is seen in the right brachiocephalic artery.
There is no pericardial effusion. A small layering left pleural
effusion is new.
There are no bone findings of malignancy.
In the upper abdomen, the liver, gallbladder, spleen, and right
adrenal gland are unremarkable. The left adrenal gland remains
enlarged measuring up to 26 mm. Dense calcifications through the
pancreas are again noted. Previously described small cortical
lesions in the kidneys are not seen on this nonenhanced study.
There is a trace of ascites. Diffuse increase in density of the
mesentery and subcutaneous fat in the abdomen could be due to
anasarca. The 25 x 30 mm low-attenuation oval-shaped lesion in
the anterior subcutaneous abdominal wall is unchanged.
IMPRESSION: Worsening multifocal pneumonia.
Brief Hospital Course:
67 yo with h/o COPD, alcoholism, prsented to OSH with several
weeks of fever, productive cough, hemoptysis and weight loss. In
the OSH intubated for hypercarbic resp failure and transferred
here. He got solumedrol and levaquin. He self-extubated [**3-13**] but
did well and was transferred to floor. Despite improvement he
still had a leukocytosis with immature forms. A chest CT was
notable for diffuse bronchiolitis. Of note a tracheal aspirate
grew aspergillus. Patient had multiple AFBs sent that remained
negative (cultures can be followed up later but no growth now)
and negative PPD so taken off TB precautions. Patient HIV
negative, HCV negative, HBV negative. Patient started
empirically under the guidance of ID and pulmonary on
voriconazole. Also given albuterol/atrovent nebs. Also given
10 days of levofloxacin empirically. Patient also had
persistent diarrhea with multiple negative c diffs.
.
# Pneumonia: Seen by pulmonary and ID. Believe to have
aspergillous bronchiolitis. Started on voriconazole and began
to improve. Unclear how long course should be. Should be seen
by ID consult at [**Hospital1 1501**] and can contact ID group here at [**Hospital1 18**] for
further discussion. Cont pulmonary PT. With concern for
cirrhosis (although none seen on ultrasound) should get weekly
LFTs (have been normal here). Recommend repeat CT scan chest in
3 weeks to watch progression of disease.
.
# COPD: Patient breathing improved significantly once started on
steroids. Cont advair and nebs prn. Steroid taper now on
discharge. Close follow up with pulmonary.
.
# Alkalosis: Patient has mixed acid-base with metabolic
alkalosis (contraction) with chronic respiratory acidosis.
Bicarb on discharge is 38. Should get repeat checks and
continue to encourage oral fluid intake aggressively, especially
with diarrhea. Can give lomotil prn for diarrhea.
.
# Melena: Patient with episode here. With question of liver
disease might still consider outpatient EGD, especially if
repeat bleeding. Should get screening colonoscopy.
.
# Leukocytosis: Improved with treatment but should continue to
monitor.
.
# Adrenal gland: Possibly enlarged on CT scan. Should consider
repeat imaging as outpatient.
.
# Chronic pancreatitis: Found to have calcifications of pancreas
on CT scan without elevation amylase/lipase. Started on creon
empirically. Likely alcohol related. Continue to monitor as
outpatient.
.
#. Communication. Patient with close friend [**Name (NI) 1328**] [**Name (NI) 71967**]
[**Telephone/Fax (1) 71968**]. Need to contact PCP, [**Last Name (NamePattern4) **]. [**First Name (STitle) 6930**], North Central
Human Services, [**Doctor Last Name 71969**], [**Location (un) 976**] MA in AM.
Medications on Admission:
Inhalers prn
Discharge Medications:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
5. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q8H PRN
().
6. Cepacol 2 mg Lozenge Sig: One (1) Lozenge Mucous membrane PRN
(as needed).
7. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
8. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML
Mucous membrane TID (3 times a day).
9. Zolpidem 5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as
needed.
10. Voriconazole 200 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours).
11. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
12. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
13. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1)
Subcutaneous ASDIR (AS DIRECTED): Use with fingersticks qachs
with sliding scale.
14. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
15. Amylase-Lipase-Protease 33,200-10,000- 37,500 unit Capsule,
Delayed Release(E.C.) Sig: One (1) Cap PO QIDWMHS (4 times a day
(with meals and at bedtime)).
16. Prednisone 5 mg Tablet Sig: As directed in taper Tablet PO
once a day for 9 days: Take 4 tabs daily for 4 days, then 2 tabs
daily for 3 days, then 1 tab daily for 3 days then stop.
17. Diphenoxylate-Atropine 2.5-0.025 mg Tablet Sig: One (1)
Tablet PO Q6H (every 6 hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **]
Discharge Diagnosis:
Aspergillos bronchiolitis
Steroid induced hyperglycemia
COPD exacerbation
Melena
Chronic pancreatitis with calcifications
Discharge Condition:
Good
Discharge Instructions:
You have a history of COPD. You appear to have developed an
aspergillus bronchiolitis. You are getting treated for this but
will need close infectious disease and pulmonary follow up. You
are also being treated with steroids for your COPD flare.
.
You have had intermittent diarrhea here and have become
dehydrated. You need to continue to be aggressive with your
fluid intake.
.
You had an episode of melena (blood in your stool). This may
have been stress related but if it recurs you will need to get
an endoscopy. If you have not had a colonoscopy in the last 5
years we recommend that for routine screening as well.
.
You were found to have heavy calcifications in your pancreas
suggestive of possible chronic pancreatitis. You were started
on creon with meals. This can be reevaluated as an outpatient.
Followup Instructions:
You need to establish a primary care doctor and have regular
appointments.
You should seen both a pulmonary and infectious disease doctor
in the next 2-3 weeks. They can contact our staff here with
detailed questions. Dr. [**Last Name (STitle) 67369**] [**Name (STitle) 3394**] from infectious disease
(([**Telephone/Fax (1) 4170**]) and Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 20063**] from pulmonary (([**Telephone/Fax (1) 514**]).
|
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48,521
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7155
|
Discharge summary
|
report
|
Admission Date: [**2180-11-29**] Discharge Date: [**2180-12-4**]
Date of Birth: [**2102-11-22**] Sex: M
Service: NEUROLOGY
Allergies:
Lorazepam
Attending:[**First Name3 (LF) 11344**]
Chief Complaint:
witnessed seizure
Major Surgical or Invasive Procedure:
intubation, femoral line
History of Present Illness:
HPI: 78 y/o M with PMH notable for CAD s/p CABG, ESRD on HD,
history of right focal seizure with hyperperfusion syndrome and
recent d/c ([**2180-11-14**]) after L CEA by Pomposell who presents with
seizures. The patient was found at 730 am at nursing home with
seizure like acitivity, "jerking all over" for 2-3 minutes.
Vitals at that time T 97.7, BP 132/70, HR 74, RR 20, O2 97%. He
was treated with valium 5 mg IM X 1. Staff at his nursing
facility called for routine BLS transport at 930 am. En route
via EMS, the patient was noted to have seizure activity (R eye
deviation, tongue fasiculations, and beat nystagmus) again and
was given another 5 mg valium X 1.
.
On arrival in ED, the patient's vitals were T 98.8, HR 79, BP
171/74, RR 16, 99%, FSBS 268. He was noted to have a weak gag
reflex and only responsive to pain on the left side. He was
quickly intubated for airway protection with rocuronium,
lidocaine, and etomidate. He was loaded with dilantin 1000 mg X
1 and BPs were noted to decrease in setting of propofol/dilantin
IV. About one hour after paralytics given pt had a 3rd seizure
described as beat nystagmus of eyes & twitching of deltoid. A
head CT was without signs of an acute bleed. Carotid u/s done
stat given recent CEA and was normal. He was given an additional
5 mg iv valium in addition to dilantin load. No further seizure
activity after dilantin loading. Due to hypotension, a femoral
line was placed and the patient was changed to fentanyl& midaz
prior to arrival in the ICU. Given concern for meningitis, he
received ceftriaxone 2 g iv X 1, acyclovir 600 mg iv X 1, and
vanc 1 mg iv X 1. He also received 500 cc NS.
.
On arrival to ICU, the pt is intubated and sedated and
unresponsive to voice. No active seizure activity obvious on
exam. Further ROS obtained from family. The patient complained
of intermittent palpatations on [**Holiday 1451**] (Thursday) and
again on Saturday, a "thump" in his chest (not chest pain).
Yesterday the family notes that he was mildly lethargic after
taking ? tylenol. He was able to participate in PT earlier in
day without difficulty.
.
Past Medical History:
PMH: (from OMR)
- CAD - 3V disease; s/p CABG x 4V ([**5-28**]). ETT-MIBI [**4-2**]: small
territory ischemia
- CHF (Post-CABG echo EF 40%. Echo [**6-28**]: EF 40-45%.)
- CAROTID STENOSIS, S/P R CEA
- STROKE
- DIABETES TYPE II
- HYPERTENSION
- RENAL INSUFFICIENCY (Cr 6 range)
- HD- dependent (MWF)
- ALBUMINURIA
- H/O PHIMOSIS s/p circumcision
- VITILIGO
- R STAPES SURGERY
- RETINOPATHY (Laser coag [**12/2173**])
- SQUAMOUS CELL CARCINOMA - (left hand, invasive)
- RENAL ARTERY STENOSIS (left 70-90% by MRI [**5-2**])
- AORTIC STENOSIS (Echo [**11-3**]: mild)
.
Social History:
non-smoker (never smoked); occ. EtOH; no IVDU. Recently at
nursing facility but previously lived at home with wife.
Retired.
Family History:
Father- died of pulmonary edema, CHF at age 77. Mother-died age
81, had DM.
Physical Exam:
T:95.6 BP:164/65 HR:68 RR:12 O2 100% on CMV FiO2 80%/ Vt 700/
RR10/ PEEP 5
Gen: elderly male, intubated & sedated, opens eyes to voice
HEENT: no scleral icterus, tongue moist and midline, R pupil
larger than left but both reactive, + oculocephalic reflex, no
eye deviation or nystagmus noted, EEG leads in place
NECK: supple, no lymphadenopathy, no meningismus
CV: RRR, normal S1, S2,
LUNGS: clear anteriorly, no wheezing or rhonchi
ABD: soft, no grimace with palpation, normoactive bowel sounds
EXT: feet cool with + dp pulses bilaterally, not rigid in UE or
LE
SKIN: No rashes/lesions, ecchymoses.
NEURO: sedated, opens eyes to voice, weak bilateral hand grip on
command, face symmetric, R pupil > L pupil but both reactive, +
gag (coughs with tube repositioning), toes mute bilaterally,
DTRs 2+ at bilateral biceps, 1+ at bilateral patellae; withdraws
to pain mainly in RUE
Pertinent Results:
[**2180-11-29**] 10:16AM PT-12.8 PTT-29.9 INR(PT)-1.1
[**2180-11-29**] 10:16AM PLT COUNT-118*
[**2180-11-29**] 10:16AM NEUTS-92.6* LYMPHS-4.7* MONOS-2.3 EOS-0.3
BASOS-0.1
[**2180-11-29**] 10:16AM WBC-8.3# RBC-3.46* HGB-11.9* HCT-33.0* MCV-95
MCH-34.6* MCHC-36.2* RDW-14.8
[**2180-11-29**] 10:16AM ALBUMIN-4.1 CALCIUM-9.6 PHOSPHATE-5.1*
MAGNESIUM-2.0
[**2180-11-29**] 10:16AM CK-MB-3
[**2180-11-29**] 10:16AM cTropnT-0.08*
[**2180-11-29**] 10:16AM LIPASE-26
[**2180-11-29**] 10:16AM ALT(SGPT)-65* AST(SGOT)-54* CK(CPK)-62 ALK
PHOS-147* TOT BILI-0.4
[**2180-11-29**] 10:16AM GLUCOSE-234* UREA N-46* CREAT-6.8* SODIUM-139
POTASSIUM-4.5 CHLORIDE-94* TOTAL CO2-19* ANION GAP-31*
[**2180-11-29**] 10:22AM LACTATE-10.9* K+-4.4
[**2180-11-29**] 04:44PM CEREBROSPINAL FLUID (CSF) WBC-0 RBC-0 POLYS-20
LYMPHS-20 MONOS-60
[**2180-11-29**] 04:44PM CEREBROSPINAL FLUID (CSF) PROTEIN-57*
GLUCOSE-128
[**2180-11-29**] 05:03PM URINE RBC->50 WBC-[**3-1**] BACTERIA-FEW YEAST-NONE
EPI-0
[**2180-11-29**] 05:03PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-TR
[**2180-11-29**] 05:03PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.013
[**2180-11-29**] 05:03PM PT-13.1 PTT-34.4 INR(PT)-1.1
[**2180-11-29**] 05:03PM PLT COUNT-111*
[**2180-11-29**] 05:03PM NEUTS-85.5* LYMPHS-9.7* MONOS-3.9 EOS-0.7
BASOS-0.1
[**2180-11-29**] 05:03PM WBC-7.1 RBC-3.28* HGB-11.2* HCT-30.6* MCV-93
MCH-34.3* MCHC-36.7* RDW-14.6
[**2180-11-29**] 05:03PM PHENYTOIN-7.0*
[**2180-11-29**] 05:03PM CALCIUM-9.2 PHOSPHATE-4.2 MAGNESIUM-1.8
[**2180-11-29**] 05:03PM CK-MB-NotDone cTropnT-0.07*
[**2180-11-29**] 05:03PM CK(CPK)-61
[**2180-11-29**] 05:03PM GLUCOSE-244* UREA N-47* CREAT-6.7* SODIUM-139
POTASSIUM-4.3 CHLORIDE-99 TOTAL CO2-29 ANION GAP-15
[**2180-11-29**] 05:56PM LACTATE-1.3
[**2180-11-29**] 05:56PM TYPE-ART TEMP-35.3 PO2-233* PCO2-29* PH-7.57*
TOTAL CO2-27 BASE XS-5 INTUBATED-INTUBATED
.
[**11-29**] CXR: FINDINGS: The patient is status post endotracheal
intubation with the tip
residing 2.4 cm above the carina. The lungs are clear. There is
no evidence
of pleural effusions or pneumothorax. The mediastinal and
cardiac contours
are stable. There is a nasogastric tube in place that courses
below the
diaphragm. The visualized osseous structures are normal.
IMPRESSION: Endotracheal tube with tip 2.4 cm above the carina.
.
CT head: There is no evidence of hemorrhage, edema, mass effect,
or acute
infarction. There is hypodensity in the bilateral basal ganglia
consistent
with old chronic lacunar infarctions. There is periventricular
hypodensity
consistent with chronic small vessel ischemic changes. There is
hypodensity
in the right cerebral watershed territory. The ventricles and
sulci are
prominent consistent with age- related involutional changes.
There is no
shift of the normally midline structures. There are vascular
calcifications
noted in the bilateral vertebral and internal carotid arteries
consistent with
atherosclerotic disease. There is no evidence of fractures.
There is mild
bilateral mucosal thickening of the ethmoid sinuses. The
sphenoid, maxillary
sinuses and the mastoid air cells are well aerated.
IMPRESSION: No evidence of hemorrhage.
.
US carotid: 1. Patent left internal carotid artery status post
carotid endarterectomy.
Findings are consistent with 0% stenosis in the left internal
carotid artery.
The right carotid artery was not evaluated due to the emergent
nature of the
exam.
.
[**2180-11-29**] 4:44 pm CSF;SPINAL FLUID #3.
GRAM STAIN (Final [**2180-11-29**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Preliminary):
[**2180-11-30**]: MRI brain, MRA head and neck.
CLINICAL INFORMATION: Patient with diabetes and seizures, for
further
evaluation.
TECHNIQUE: T1 sagittal and FLAIR, T2, susceptibility and
diffusion axial
images were obtained. T2 coronal images acquired. 2D
time-of-flight MRA of
the neck vessels and 3D time-of-flight MRA of the circle of
[**Location (un) 431**] were
obtained. Comparison was made with the previous brain MRI
examination of
[**2176-9-8**] and CT angiography of [**2180-10-3**].
FINDINGS: The examination is limited secondary to motion. There
is now new
increased signal identified diffusely in the left cerebral
hemisphere
involving the left-sided subcortical white matter including
extension to the left corona radiata and posterior limb of the
internal capsule. There is increased signal seen both in the
genu of corpus callosum as well as on the left side of the
splenium of corpus callosum. There is no acute infarct
identified or signs of slow diffusion seen. Although, the
diffusion images are limited by motion. An area of chronic blood
products is seen in the right parietal lobe subcortical region.
Multiple prominent perivascular spaces are identified. Chronic
lacunes are seen in bilateral basal ganglia region and also
involving the periventricular white matter and the right caudate
head. There is mild-to-moderate brain atrophy seen without
hydrocephalus or midline shift.
IMPRESSION: The asymmetric finding seen in the left cerebral
hemisphere could be secondary to chronic ischemia and white
matter disease given the patient has a high-grade stenosis of
the left petrous and pre-cavernous carotid artery. However,
appearances are somewhat atypical. In presence of multiple
prominent perivascular spaces in both cerebral hemispheres and
absence of mass effect, this does not appear to be secondary to
infiltrating neoplasm. Perfusion imaging can be obtained for
further evaluation. In presence of end- stage renal disease, an
MR [**First Name (Titles) 26604**] [**Last Name (Titles) **]-labeled perfusion or CT perfusion can be
acquired for further assessment.
MRA OF THE HEAD:
The head MRA demonstrates loss of flow signal in the petrous and
pre-cavernous left internal carotid artery indicative of
atherosclerotic disease and greater than 50% stenosis.
Irregularity of the flow signal is seen in the right petrous and
pre-cavernous carotid indicative of atherosclerotic disease.
Both middle cerebral arteries demonstrate normal flow signal.
The right distal vertebral artery is not visualized.
IMPRESSION: Atherosclerotic disease with high-grade narrowing of
the left
petrous and pre-cavernous internal carotid artery. Mild
atherosclerotic
disease involving the right petrous and pre-cavernous internal
carotid. Non- visualization of the right distal vertebral artery
probably secondary to occlusion in the neck.
MRA OF THE NECK:
The neck MRA demonstrates non-visualization of the right
vertebral artery from its origin indicative of occlusion. The
left vertebral artery and both carotid arteries in the neck
demonstrate normal flow signal.
IMPRESSION: Non-visualization indicative of occlusion of right
vertebral
artery in the neck.
[**Known lastname **],[**Known firstname 177**] [**Medical Record Number 26605**] M 78 [**2102-11-22**]
Neurophysiology Report EEG Study Date of [**2180-12-1**]
OBJECT: EE, In Pt [**Name (NI) **] w/Video,[**Date range (1) 19254**]/08.
REFERRING DOCTOR: DR. [**First Name (STitle) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
FINDINGS:
PUSHBUTTONS: None were identified.
AUTOMATED INTERICTAL EPILEPTIFORM ACTIVITY: Low voltage, beta
frequency
background was seen on the time-sampled intervals.
AUTOMATED SPIKE DETECTION: This algorithm identified 98 events;
two
were for right frontocentral spike and slow wave discharges. The
remainder were artifactual in nature.
AUTOMATED SEIZURE DETECTION: This algorithm identified 28
events, all
of which were related to artifacts.
SLEEP: There were no sleep periods seen on the sampled
intervals.
CARDIAC MONITOR: Revealed a generally regular rhythm with
average rate
of 90 bpm.
IMPRESSION: This 24 hour EEG telemetry failed to capture any
epileptiform activity. Note is made of a low voltage, fast
background.
Brief Hospital Course:
This is a 78 y/o man with PMH notable for Hx of R focal seizures
with hyperperfusion syndrome, CAD s/p CABG, recent carotid
endarterectomy, and type 2 DM admitted with seizures X 3 on
[**11-29**]. In the ED, he was intubated for airway protection. He was
hypotensive while he was on propofol.
Hospital course is reviewed below by problem:
# Seizures: the patient did have a history of right focal motor
seizures following his first carotid endarterectomy in [**2172**] and
was on dilantin for a period of time (unclear for how long). He
apparently never had a generalized tonic-clonic seizure at that
time. For this episode, differential includes infectious,
stroke, toxic metabolic, and primary seizure disorder. He had a
head CT which showed no acute hemorrhage. MRI showed diffuse
white matter disease limited to the left hemisphere (see MRI
results above). This was suggestive of reperfusion injury status
post carotid endarterectomy. The vascular team suggested
transcranial Doppler to r/o reperfusion syndrome non-emergently.
A lactate of 10 on admission was likely secondary to seizure, as
it was 1 on repeat on arrival to the ICU.
- Of note, he was initially covered with Vancomycin,
Ceftriaxone, Ampicillin, and Acyclovir. CSF only showed mild
elevation of protein, therefore his antibiotics were stopped.
His Acyclovir was stopped on [**12-4**], after his HSV PCR was
negative.
- He had EEG monitoring (see results section). When he was
admitted he was loaded with dilantin. He was changed to keppra
while inpatient given renal failure on dialysis; keppra was
dosed renally.
# ESRD on HD: Renal was consulted and he had his dialysis as an
inpatient.
# Type 2 DM: Maintained on an insulin sliding scale with good
glycemic control.
# Anemia: Hct remained near a recent baseline.
# Thrombocytopenia: Stayed near baseline.
# CAD: continue ASA and Statin. Cardiac enzymes were stable.
# CODE: full code, confirmed with patient's wife, [**Name (NI) **] [**Name (NI) 26600**],
who is his HCP, [**Telephone/Fax (1) 26606**] (home), [**Telephone/Fax (1) 26607**] (cell). Son
[**Name (NI) **] [**Name (NI) 26600**] is [**Telephone/Fax (1) 26608**].
Medications on Admission:
MEDS:
MOM 30mg qhs prn
dulcolax supp 10mg daily prn
fleet enema prn
senna 8.6mg PO BID
Colace 100mg PO BID
tylenol 650mg PO TID (apparently standing)
Bisacodyl 10mg EC PO daily PRN
calcitriol 25mcg cap PO daily
Diovan 160mcg PO daily
Isosorbide Mononitrate 90mg daily
lipitor 80mg daily
metoprolol succ ER 125mg daily
nifedipine ER 120mg SA daily
sertraline 100mg daily
enalapril 30mg PO BID
bualbital-APAP-Caffeine [**12-29**] TAB q4h prn HA
[**Month/Day (2) **] One cap PO daily
Phoslo 667mg PO TID AC
ASA 81mg daily
Ferrous sulfate 325mg PO daily
Colace 100 PO BID prn
.
ALLERGIES: ativan (hallucinations)
Discharge Medications:
1. Acetaminophen 325 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO Q6H (every
6 hours) as needed.
2. Magnesium Hydroxide 400 mg/5 mL Suspension [**Month/Day (2) **]: Thirty (30)
ML PO Q12H (every 12 hours) as needed for constipation.
3. Docusate Sodium 100 mg Capsule [**Month/Day (2) **]: One (1) Capsule PO BID (2
times a day) as needed for constipation.
4. Senna 8.6 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Month/Day (2) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
6. Atorvastatin 40 mg Tablet [**Month/Day (2) **]: Two (2) Tablet PO DAILY
(Daily).
7. Sertraline 100 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY
(Daily).
8. B Complex-Vitamin C-Folic Acid 1 mg Capsule [**Month/Day (2) **]: One (1) Cap
PO DAILY (Daily).
9. Calcium Acetate 667 mg Capsule [**Month/Day (2) **]: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
10. Aspirin 81 mg Tablet, Chewable [**Month/Day (2) **]: One (1) Tablet, Chewable
PO DAILY (Daily).
11. Heparin (Porcine) 5,000 unit/mL Solution [**Month/Day (2) **]: One (1)
Injection TID (3 times a day).
12. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
13. Nifedipine 60 mg Tablet Sustained Release [**Last Name (STitle) **]: Two (2)
Tablet Sustained Release PO DAILY (Daily).
14. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
[**Last Name (STitle) **]: Five (5) Tablet Sustained Release 24 hr PO DAILY (Daily).
15. Ferrous Sulfate 325 mg (65 mg Iron) Tablet [**Last Name (STitle) **]: One (1)
Tablet PO DAILY (Daily).
16. Calcitriol 0.25 mcg Capsule [**Last Name (STitle) **]: One (1) Capsule PO DAILY
(Daily).
17. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
[**Last Name (STitle) **]: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily).
18. Enalapril Maleate 10 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO BID (2
times a day).
19. Levetiracetam 250 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2
times a day).
20. Levetiracetam 250 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO QMOWEFR
(Monday -Wednesday-Friday). GIVE AFTER DIALYSIS.
21. insulin
Insulin SC Sliding Scale Q6h
Glucose Insulin Dose
0-70 mg/dL 1 amp D50
Humalog insulin
71-150 mg/dL 0 Units
151-200 mg/dL 2 Units
201-250 mg/dL 4 Units
251-300 mg/dL 6 Units
301-350 mg/dL 8 Units
351-400 mg/dL 10 Units
> 400 mg/dL Notify M.D.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] [**Hospital **] Nursing and Rehab
Discharge Diagnosis:
1. Probable reperfusion injury
2. Seizures
Discharge Condition:
He is globally weak, but no focal neurological deficit. He is
also emotionally labile about his current weakness, and is
frustrated that he is not improving quicker.
Discharge Instructions:
You have had seizures, you must take medication for your
seizures to prevent them. If you seizures increase in frequency,
please go to your nearest ED.
You have weakness, and need rehabilitation to improve your
strength.
Followup Instructions:
VASCULAR LMOB (NHB) Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2180-12-11**] 10:45
VASCULAR: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2180-12-11**] 11:20
NEUROLOGY: Please call ([**Telephone/Fax (1) 26609**] to organize an appointment
with Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) 851**] in [**4-2**] weeks time.
PCP: [**Name10 (NameIs) **],[**First Name3 (LF) **] S. [**Telephone/Fax (1) 250**] - please organize an appointment
with your PCP [**Last Name (NamePattern4) **] [**1-31**] weeks time.
Completed by:[**2180-12-4**]
|
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"V45.81",
"518.81",
"357.2",
"250.50",
"287.5",
"E878.8",
"362.01",
"585.6",
"V10.83",
"403.91",
"414.00",
"433.10",
"997.01",
"440.20",
"780.39",
"250.60",
"433.30"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.19",
"38.93",
"03.31",
"39.95",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
17779, 17855
|
12328, 14488
|
292, 318
|
17942, 18110
|
4194, 6611
|
18380, 19021
|
3202, 3280
|
15149, 17756
|
17876, 17921
|
14514, 15126
|
18134, 18357
|
3296, 4175
|
235, 254
|
346, 2456
|
6620, 8013
|
10157, 12305
|
2478, 3044
|
3060, 3186
|
8043, 10140
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,935
| 111,887
|
13980
|
Discharge summary
|
report
|
Admission Date: [**2103-4-27**] Discharge Date: [**2103-5-1**]
Date of Birth: [**2041-11-30**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2103-4-27**] Redo Coronary Artery Bypass Grafting utilizing vein
grafts to ramus and posterior descending artery
History of Present Illness:
Mr. [**Known lastname **] is a 61 year old male who underwent CABG at the [**Hospital1 3343**] in [**2088**]. Since that time, he has undergone multiple
percutaneous interventions and stent placements to both vein
grafts back in [**2096**] and [**2101**]. Over the past several months, he
has complained of exertional chest pain and decreased exercise
tolerance. He underwent nuclear stress testing in [**2103-3-17**]
which was signifcanct for ischemic EKG changes and angina.
Imaging showed severe, predominantly reversible myocardial
perfusion defect involving lateral and inferolateral wall. There
was global HK and the LVEF was estimated at 32%. Subsequent
cardiac catheterization in [**2103-4-16**] revealed a patent LIMA to
LAD, patent SVG to RCA, and occluded SVG to OM. Based upon the
above results, he was referred for cardiac surgical
intervention.
Past Medical History:
[**2088**] CABG at [**Hospital1 1774**]: LIMA to LAD, SVG to OM, SVG to RCA.
[**2096**] [**Hospital1 1774**]: three 4.0 stents to SVG to OM
[**2102-7-3**] cath d/t moderate reversible inferior and inferolateral
wall defect: S/P 2.5 x 18mm Cypher to SVG to OM, s/p 3.5 x 23mm
Cypher to SVG to RCA. LIMA to LAD patent.
[**2102-7-25**] cath d/t c/o recurrent exertional symptoms showed patent
SVG-OM and SVG-RCA
CHF- EF- 32% on CPAP at night
Hyperlipidemia
Excision of anal tag [**1-19**]
NIDDM- BS typically 140s
Back pain - tx'd with epidural steroid injections from the
[**First Name4 (NamePattern1) 1193**]
[**Last Name (NamePattern1) 1194**] Clinic
Hemorrhoids
Cervical disc surgery [**2089**]
Cholecystectomy [**2089**]
Polyps removed 2 yrs ago
Social History:
He is married and works full-time as a computer programmer.
Denies drug or tobacco use.
Family History:
Both his parents died in their mid 50's of MI's. Sister had a
large CVA at age 64. Older brother died of an MI and a CVA at
age 66, 2 months ago.
Physical Exam:
Vitals: BP 140/74, HR 63, RR 14,
General: well developed male in no acute distress
HEENT: oropharynx benign,
Neck: supple, no JVD,
Heart: regular rate, normal s1s2, no murmur or rub
Lungs: clear bilaterally
Abdomen: soft, nontender, normoactive bowel sounds
Ext: warm, no edema, no varicosities
Pulses: 2+ distally
Neuro: nonfocal
Pertinent Results:
[**2103-5-1**] 06:14AM BLOOD WBC-4.9# RBC-2.91* Hgb-9.0* Hct-26.1*
MCV-89 MCH-31.0 MCHC-34.6 RDW-13.4 Plt Ct-160
[**2103-5-1**] 06:14AM BLOOD Glucose-133* UreaN-20 Creat-1.0 Na-140
K-4.6 Cl-103 HCO3-27 AnGap-15
[**2103-5-1**] 06:14AM BLOOD Mg-2.0
Brief Hospital Course:
Mr. [**Known lastname **] was admitted and underwent redo coronary
revascularization surgery. For surgical details, please see
seperate dictated operative note. Following the procedure, he
was transferred to the CSRU for invasive monitoring. Within 24
hours, he awoke neurologically intact and was extubated. He
maintained stable hemodynamics and weaned from inotropes without
difficulty. His CSRU course was otherwise uneventful and he
transferred to the SDU on postoperative day one. Most of his
preoperative medications were resumed. Beta blockade was slowly
advanced as tolerated. Over several days, he made clinical
improvements with diuresis. He remained in a normal sinus
rhythm. The rest of his postoperative course was uncomplicated
and he was medically cleared for discharge to home on
postoperative day four. Chest x-ray prior to discharge showed
only bilateral atelectasis with no evidence for effusions or
pneumonia.
Medications on Admission:
Atenolol 25 qd
Allopurinol 300 qd
Lisinopril 10 [**Hospital1 **]
Glyburide 2.5 [**Hospital1 **]
Aspirin 81 qd
Plavix 75 qd
Zoloft 100 qd
Etodolac 400 [**Hospital1 **]
Norvasc 5 qd
Mirapex
Lipitor 20 qd
Tricor
Neurontin
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
5. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
7. Pramipexole 0.125 mg Tablet Sig: One (1) Tablet PO q12 noon
() as needed for restless leg syndrome.
8. Pramipexole 0.25 mg Tablet Sig: One (1) Tablet PO qPM () as
needed for restless leg syndrome.
9. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
10. Metoprolol Tartrate 25 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
Disp:*120 Tablet(s)* Refills:*2*
11. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
12. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
13. Tricor 145 mg Tablet Sig: One (1) Tablet PO once a day.
14. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 3
weeks.
Disp:*21 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
s/p redo CABG
PMH:CAD/CABG '[**88**], HTN, ^chol, DM2, CCY, cervical disc [**Doctor First Name **],
hemorroids
Discharge Condition:
Good
Discharge Instructions:
keep wounds clean and dry. OK to shower, no bathing or swimming.
Take all medications as prescribed.
Callfor any fever, redness or drainage from wounds
Followup Instructions:
Dr [**Last Name (STitle) **] in [**1-19**] wks
Dr [**Last Name (STitle) **] in [**1-19**] weeks
Dr [**Last Name (STitle) 914**] in 4 weeks
Completed by:[**2103-6-1**]
|
[
"414.02",
"274.9",
"780.57",
"272.4",
"250.00",
"414.01",
"401.9",
"V45.82",
"998.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.12",
"39.57",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
5581, 5656
|
3014, 3946
|
331, 448
|
5811, 5818
|
2743, 2991
|
6018, 6187
|
2229, 2376
|
4215, 5558
|
5677, 5790
|
3972, 4192
|
5842, 5995
|
2391, 2724
|
281, 293
|
476, 1336
|
1358, 2107
|
2123, 2213
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,815
| 138,516
|
41870
|
Discharge summary
|
report
|
Admission Date: [**2187-12-11**] Discharge Date: [**2187-12-18**]
Date of Birth: [**2124-4-8**] Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3190**]
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
Anterior/posterior lumbar fusion with instrumentation L3-5
History of Present Illness:
Mr. [**Known lastname 79613**] has a long history of back pain. He has attempted
conservative therapy but has failed. He now presents for
surgical intervention.
Past Medical History:
Hypertension, history of constipation
secondary to medications, and ulnar nerve neuropathy on the
right.
Past Surgical History: Fusion x2 to his neck, bilateral rotator
cuff repairs multiple, prostate surgery, and tonsillectomy
Social History:
Denies
Family History:
N/C
Physical Exam:
A&O X 3; NAD
RRR
CTA B
Abd soft NT/ND
BUE- good strength at deltoid, biceps, triceps, wrist
flexion/extension, finger flexion/extension and intrinics;
sensation intact C5-T1 dermatomes; - [**Doctor Last Name 937**], reflexes
symmetric at biceps, triceps and brachioradialis
BLE- good strength at hip flexion/extension, knee
flexion/extension, ankle dorsiflexion and plantar flexion,
[**Last Name (un) 938**]/FHL; sensation intact L1-S1 dermatomes; - clonus, reflexes
symmetric at quads and Achilles
Pertinent Results:
[**2187-12-16**] 12:15PM BLOOD WBC-13.5* RBC-3.38* Hgb-10.5* Hct-30.7*
MCV-91 MCH-31.1 MCHC-34.3 RDW-13.5 Plt Ct-387
[**2187-12-15**] 04:15AM BLOOD WBC-14.4* RBC-3.27* Hgb-10.2* Hct-29.6*
MCV-91 MCH-31.1 MCHC-34.3 RDW-13.1 Plt Ct-285
[**2187-12-14**] 05:16AM BLOOD WBC-17.8*# RBC-3.32* Hgb-10.3* Hct-30.1*
MCV-91 MCH-31.0 MCHC-34.2 RDW-13.2 Plt Ct-230
[**2187-12-13**] 05:42AM BLOOD WBC-11.2* RBC-2.69* Hgb-8.4* Hct-24.4*
MCV-91 MCH-31.3 MCHC-34.5 RDW-12.7 Plt Ct-219
[**2187-12-16**] 12:15PM BLOOD Glucose-137* UreaN-15 Creat-0.9 Na-140
K-4.2 Cl-107 HCO3-23 AnGap-14
[**2187-12-15**] 12:17AM BLOOD Glucose-133* UreaN-12 Creat-0.9 Na-140
K-3.5 Cl-102 HCO3-32 AnGap-10
[**2187-12-14**] 01:05PM BLOOD Glucose-146* UreaN-11 Creat-1.0 Na-142
K-3.9 Cl-102 HCO3-36* AnGap-8
Brief Hospital Course:
Mr. [**Known lastname 79613**] was admitted to the [**Hospital1 18**] Spine Surgery Service on
[**2187-12-11**] and taken to the Operating Room for L3-5 interbody
fusion through an anterior approach. Please refer to the
dictated operative note for further details. The surgery was
without complication and the patient was transferred to the PACU
in a stable condition. TEDs/pnemoboots were used for
postoperative DVT prophylaxis. Intravenous antibiotics were
given per standard protocol. Initial postop pain was controlled
with a PCA. On HD#2 he returned to the operating room for a
scheduled L3-5 decompression with PSIF as part of a staged
2-part procedure. Please refer to the dictated operative note
for further details. The second surgery was also without
complication and the patient was transferred to the PACU in a
stable condition. Postoperative HCT was 37.1. A bupivicaine
epidural pain catheter placed at the time of the posterior
surgery remained in place until postop day one.
Post-operatively he developed a severe post-operative ileus. An
NGT was placed which the patient subsequently discontinued. His
physical exam was concerning for an abdominal compartment
syndrome and he was transfered to the SICU for close monitoring.
He was kept NPO until bowel function returned then diet was
advanced as tolerated. The patient was transitioned to oral pain
medication when tolerating PO diet. Foley was removed on POD#4
from the second procedure. He was fitted with a lumbar
warm-n-form brace for comfort. Physical therapy was consulted
for mobilization OOB to ambulate. Hospital course was otherwise
unremarkable. On the day of discharge the patient was afebrile
with stable vital signs, comfortable on oral pain control and
tolerating a regular diet.
Medications on Admission:
cymbalta, HCTZ, lisinopril, morphine, trazodone
Discharge Medications:
1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
Disp:*100 Tablet(s)* Refills:*0*
3. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. diazepam 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for spasms.
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
6. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q6H (every 6 hours) as needed for asthma.
7. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*100 Tablet(s)* Refills:*0*
8. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Discharge Disposition:
Home With Service
Facility:
Bayada Nurses, Inc.
Discharge Diagnosis:
Lumbar stenosis and disc degeneration
Post-op ileus
Acute post-op blood loss anemia
Abdominal compartment syndrome
Discharge Condition:
Good
Discharge Instructions:
You have undergone the following operation: ANTERIOR/POSTERIOR
Lumbar Decompression With Fusion
Immediately after the operation:
-Activity: You should not lift anything greater than 10 lbs for
2 weeks. You will be more comfortable if you do not sit or stand
more than ~45 minutes without getting up and walking around.
-Rehabilitation/ Physical Therapy:
o2-3 times a day you should go for a walk for 15-30 minutes as
part of your recovery. You can walk as much as you can tolerate.
oLimit any kind of lifting.
-Diet: Eat a normal healthy diet. You may have some constipation
after surgery. You have been given medication to help with this
issue.
-Brace: You have been given a brace. This brace is to be worn
for comfort when you are walking. You may take it off when
sitting in a chair or while lying in bed.
-Wound Care: Remove the dressing in 2 days. If the incision is
draining cover it with a new sterile dressing. If it is dry then
you can leave the incision open to the air. Once the incision is
completely dry (usually 2-3 days after the operation) you may
take a shower. Do not soak the incision in a bath or pool. If
the incision starts draining at anytime after surgery, do not
get the incision wet. Cover it with a sterile dressing. Call the
office.
-You should resume taking your normal home medications. No
NSAIDs.
-You have also been given Additional Medications to control your
pain. Please allow 72 hours for refill of narcotic
prescriptions, so please plan ahead. You can either have them
mailed to your home or pick them up at the clinic located on
[**Hospital Ward Name 23**] 2. We are not allowed to call in or fax narcotic
prescriptions (oxycontin, oxycodone, percocet) to your pharmacy.
In addition, we are only allowed to write for pain medications
for 90 days from the date of surgery.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
Physical Therapy:
Activity: Activity: Out of bed w/ assist
LSO for ambulation; may be out of bed to chair without.
Treatments Frequency:
Please continue to change the dressing
Followup Instructions:
With Dr. [**Last Name (STitle) 363**] in 10 days
Completed by:[**2187-12-27**]
|
[
"278.00",
"E878.8",
"305.00",
"338.18",
"354.2",
"722.52",
"V45.4",
"401.9",
"721.3",
"997.49",
"293.0",
"304.03",
"285.1",
"560.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.07",
"77.79",
"84.51",
"03.90",
"84.52",
"81.06",
"81.62"
] |
icd9pcs
|
[
[
[]
]
] |
4971, 5021
|
2198, 3963
|
319, 380
|
5180, 5187
|
1406, 2175
|
7358, 7439
|
866, 871
|
4061, 4948
|
5042, 5159
|
3989, 4038
|
5211, 5310
|
723, 826
|
886, 1387
|
7172, 7273
|
7295, 7335
|
5346, 5539
|
270, 281
|
5575, 6042
|
6054, 7154
|
408, 572
|
594, 700
|
842, 850
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,767
| 144,131
|
1451
|
Discharge summary
|
report
|
Admission Date: [**2176-4-26**] Discharge Date: [**2176-5-7**]
Date of Birth: [**2100-11-2**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
Transfer from OSH for cardiac catheterization
Major Surgical or Invasive Procedure:
Cardiac catheterization
IABP
Swan Ganz catheterization
History of Present Illness:
75yo man with hx of CAD s/p CABG [**2161**] (LIMA to LAD, SVG to PDA,
OM and Diagonal), PVD, HTN, hyperlipidemia who presents from OSH
with STEMI on POD#1 s/p left shoulder surgery. He tolerated
surgery well then was noted to be tachypneic and hypercarbic
last night while on dilaudid PCA. ABG 7.15/61/57 so went to ICU
for Bipap. Apparently improved then started vomitting at 5am.
EKG at 8am showed NSR, NA, Q in III and aVF, STE II and aVF,
<1mm STE V5-V6. TropI elevated to 90. He was sent here for cath.
.
In the cath lab, LIMA-LAD patent, OM and diag grafts closed, and
SVG-OM was diffusely diseased w tight distal lesion.
Thrombectomy performed on SVG-OM and dilatation with balloon
improved lumen and flow. The distal SVG-OM anastomosis was
stented with Vision x3 stents with initially normal flow. Flow
then noted to be decreased followed by drop in systemic BP and
increased STE inferiorly requiring increasing dopamine. IABP
placed for elevated LVEDP to 25 and hypotension. Lasix 40iv
given. Patient also with vomiting so anesthesia called for
urgent intubation for airway protection. Difficult to oxygenate
thereafter with O2 sat 88% which improved with increasing PEEP
and suction.
.
Upon transfer to ICU, patient stable on dopamine 15, IABP at
1:1, and intubated with AC 500/18 FiO2 100% and Peep 10. Sedate
so no ROS.
Past Medical History:
1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
-CABG: [**2161**] LIMA to LAD, SVG to PDA, OM and Diagonal
3. OTHER PAST MEDICAL HISTORY:
s/p L and R CEA
chronic impingement left shoulder w arthritis s/p acromioplasty
[**4-25**]
GERD
hyperlipidemia
ulcerative colitis
colonic polyps
lef
DJD of back
spinal stenosis
anxiety/depression
arthritis hip
carpal tunnel sx
Social History:
prior tobb quit 15 yrs ago - approx 120 pack years
social etoh
lives w wife
Family History:
Mom s/p appy
Father s/p AMI
sister w DM
brother w [**Name (NI) 5895**]
Physical Exam:
On admission -
General Appearance: intubated, sedate
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Endotracheal tube, OG tube
Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), No S3,
No S4, (Murmur: No Systolic)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Diminished), (Left DP pulse:
Diminished), dopplerable right PT pulse
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Crackles : )
Abdominal: Soft, Non-tender, Bowel sounds present, No(t)
Distended
Extremities: Right: Trace, Left: Trace, cool lower extremitites
Skin: Not assessed
Neurologic: Responds to: Not assessed, Movement: Not assessed,
Sedated, Tone: Not assessed
Pertinent Results:
=========
Labs
=========
ON DISCHARGE [**2176-5-7**]:
White Blood Cells 10.9 K/uL 4.0 - 11.0
Red Blood Cells 4.54* m/uL 4.6 - 6.2
Hemoglobin 11.7* g/dL 14.0 - 18.0
Hematocrit 35.4* % 40 - 52
MCV 78* fL 82 - 98
MCH 25.8* pg 27 - 32
MCHC 33.0 % 31 - 35
RDW 15.5 % 10.5 - 15.5
BASIC COAGULATION (PT, PTT, PLT, INR)
Platelet Count 392 K/uL 150 - 440
Glucose 98 mg/dL 70 - 105
Urea Nitrogen 32* mg/dL 6 - 20
Creatinine 1.3* mg/dL 0.5 - 1.2
Sodium 143 mEq/L 133 - 145
Potassium 3.9 mEq/L 3.3 - 5.1
Chloride 104 mEq/L 96 - 108
Bicarbonate 26 mEq/L 22 - 32
Anion Gap 17 mEq/L 8 - 20
Calcium, Total 9.0 mg/dL 8.4 - 10.2
Phosphate 2.9 mg/dL 2.7 - 4.5
Magnesium 2.1 mg/dL 1.6 - 2.6
.
MICROBIOLOGY:
Blood [**2176-4-26**]: Neg
Urine [**2176-4-26**]: Neg
Sputum [**2176-4-26**]: sparse yeast
Stool for CDiff [**2176-5-6**]: Neg
=========
Radiology
=========
LEFT shoulder XR [**4-27**]
Two AP portable views. Visualized cortical margins appear
intact. Bony
mineralization appears normal. There is no definite soft tissue
abnormality. No radiopaque foreign body is identified.
.
==========
Cardiology
==========
C. Cath [**2176-4-26**]
FINAL DIAGNOSIS:
1- Three vessel CAD and ostial total occlusion of the SVG-D2 and
SVG-RPDA.
2- Markedly elevated left-sided filling pressures
3- Successful PTCA and stenting of the SVG-OM1 with three
overlapping
BMS
4- Successful placement of IABP with good hemodynamic ersponse
.
TTE [**4-26**]
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. No masses or thrombi are seen in the left ventricle.
Overall left ventricular systolic function is mildly depressed
(LVEF= 40-45 %) with lateral hypokinesis. with depressed 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. Trivial mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. There is mild pulmonary
artery systolic hypertension. There is no pericardial effusion.
.
TTE [**4-29**]
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thicknesses and cavity size are normal. There
is mild regional left ventricular systolic dysfunction with
hypokinesis of the basal inferior and basal half of the
anterolateral wall. The remaining segments contract normally
(LVEF = 45-50 %). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. The tricuspid valve leaflets are
mildly thickened. There is mild pulmonary artery systolic
hypertension. Significant pulmonic regurgitation is seen. There
is no pericardial effusion.
TTE [**5-1**]
Patient intubated, maneuvers with saline contrast were not
performed. No evidence of PFO with rest injection. If clinically
indicated, a TEE might be more sensitive to identify PFO.
CXR [**2176-5-6**]:
Frontal and lateral chest radiographs show bibasilar
consolidation
consistent with atelectasis, most pronounced at the retrocardiac
area. The
circular area of opacity described on the previous radiograph is
not apparent and in retrospect, was likely an area of resolving
atelectasis, though repeat frontal and lateral chest radiographs
when the patient is able to take a better breath is recommended
at a later date. Evidence of previous cardiac surgery is
redemonstrated. Cardiomediastinal silhouette is stable as is the
visualized osseous and soft tissue structures.
Brief Hospital Course:
ASSESSMENT AND PLAN: 75yo man with hx of CAD s/p CABG [**2161**] (LIMA
to LAD, SVG to PDA, OM and Diagonal), PVD, HTN, hyperlipidemia
admitted with STEMI
# Cardiogenic shock and STEMI: Patient underwent cath with 3 BMS
to distal SVG to OM CK peaked at 6000 indicating a massive
amount of ischemia. Given severity of MI cardiogenic shock is
most likely due to ischemia. Hemodynamics improved with IABP,
but hypotension persisted. Levophed and dopamine were required
initially but levophed was stopped on [**4-29**] and Dopamine on [**5-2**].
Pt IABP was weaned before dopapmine, and IABP was removed
without complications. Pt also had labile blood pressures and
was treated for adrenal insufficency of critical illness and
received hydrocortisone while in the ICU for one day, which was
stopped when blood pressures stabilized. TTE showed LVEF 45-50%,
and LV lateral wall function had improved. At time of discharge
patient was hemodynamically stable. Patient was continued on
ASA, Statin, ACE-I, Beta blocker and started on plavix.
# RHYTHM: Patient remained in normal sinus rhythm. His beta
blocker was held while he required IV pressors but was restarted
following removal of IABP and pressors being weaned off.
# Anemia/thrombocytopenia: Patient developed anemia and
thrombocytopenia while on IABP. Likely this was [**1-1**] shearing
forces from IABP. Regarding thrombocytopenia, patient's H2
blocker was stopped in case this was also a contributing factor.
HIT antibody was sent and found to be negative. Hemolysis labs
were also negative. Patient did receive a total of 2 units of
PRBCs for a Hct of 26 given his recent cardiac events. Platelets
and hematocrit increased to normal values after IABP removed.
# Hypoxic Resp Failure/Aspiration: Patient required intubation
for respirtatory failure which likely occurred [**1-1**] an aspiration
event while in the Cath lab. Although this is usually chemically
mediated, abx were started given dramatically low BPs. Hypoxia
likely a manifestation of edema, consolidation, and underlying
possibly some underlying chronic lung disease. Patient received
ipratroprium daily and albuterol PRN to treat possible
underlying COPD given extensive smoking history. Patient was
weaned from vent and extubated on [**5-3**] initally requiring bipap
but later tolarated RA. Patient was started on Vanc/Zosyn but
changed over to Levofloxacin and received a 7d course for
aspiration PNA. Culture data was unrevealing.
# ARF: Creatinine found to be 2.6 on [**4-26**] likely [**1-1**] poor renal
perfusion in setting of cardiogenic shock. Creatinine steadily
improved as patient's forward flow improved.
#. HTN: The patient had hypotension requiring pressors as above.
Once he was stablized and transferred out of the CCU his BP
medications were titrated back. He was started on lisinopril
that was titrated to 20mg daily at the time of discharge.
Additionally, his atenolol was changted to metoprolol and
discharged on 25mg [**Hospital1 **]. His SBP ranged between 130-150's and
should be titrated as needed.
# Tinea Cruris: Treating with miconazole powder [**Hospital1 **]. Suggest
continuing until groin erythema improves.
# Status Post L acromioplasty: Per ortho sling for 14d post-op,
ROM as tolerated, weight-bearing < 5 lbs.
# Ulcerative colitis: No active issues. Asacol held while
patient intubated since it could not be crushed. Patient's
outpatient gastroenterologist Dr. [**Last Name (STitle) 1940**] agreed with holding.
Once pt was extuabed, but was restarted on asacol 1600 [**Hospital1 **]
# Depression: No active issues. Patient was continued on
outpatient regimen of celexa.
# GERD: No active issues. H2 blocker DC'd when it when source of
thrombocytopenia Unclear. [**Name2 (NI) **] was temporarily on sucralfate.
H2 blocker restarted on [**5-5**] and plts cont to trend up suggesting
likely source of thrombocytopenia was IABP. Pantoprazole was
discontinued given potential for interaction with plavix.
#. Hematuria: The patient had hmaturia with blood clots after
foley removal. This is likely secondary to traumatic foley
placement. He continues to be able to make urine without
problems. [**Name (NI) **] did not show signs of an infectious source. It is
recommended that he have UA performed in several days to ensure
improvement and rule out new infection. Addditionally, he
should have outpatient urology follow-up upon discharge from
rehab.
Patient was a FULL code on this admission.
Medications on Admission:
asacol 1600 [**Hospital1 **]
atenolol 25 daily
celexa 20 daily
Lisinopril 20 [**Hospital1 **]
Simvastatin 80
ASA 325 - had been on hold x10d according to OSH notes
pantoprazole 40
vitamin C and E
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
7. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Four
(4) Tablet, Delayed Release (E.C.) PO BID (2 times a day).
11. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain or temp>101.
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
14. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary:
Cardiogenic Shock
Aspiration Pneumonia
Coronary artery disease
Respiratory Failure
Peripheral vascular disease
Secondary:
hyperlipidemia
ulcerative colitis
anxiety/depression
hematuria
Discharge Condition:
Stable. VS on discharge: T 98.7, BP 128/94, HR 63, RR 18, SaO2
98% RA
Discharge Instructions:
You were transferred from an outside hospital for cardiac
catheterization. You had a severe heart attack after your
shoulder repair. A cardiac catheterization showed several
blockages in the blood vessels that feed your heart. 3 bare
metal stents were place to try to open these blockages. You had
profoundly low blood pressure from this heart attack and needed
poweful medication and a balloon pump to help improve your
heart's ability to pump blood forward. You were intubated for
airway protection and extuabted.
NEW MEDICATIONS:
Plavix: this is a medication to thin your blood.
Metoprolol: this is a medication to control your heart rate and
blood pressure.
Ranitidine: this is a medication to reduce the acidity of your
stomach
Miconazole: this is a skin medication for the rash on your
abdomen
Trazodone: this is a medication that helps you fall asleep
STOP taking:
Atenolol
Pantoprazole
Medication CHANGES:
Lisinopril decreased from 20 mg twice a day to 20mg daily
Please seek immediate medical attention if you develop chest
pain, shortness of breath, dizziness, light headedness, nauasea,
fevers, chills or any change from your baseline health status.
Followup Instructions:
-Provider: [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern4) 2761**], MD Phone:[**Telephone/Fax (1) 62**];
Date/Time:[**2176-5-20**] 1:00
-Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1005**] Phone: [**Telephone/Fax (1) 1228**]. Date/Time: [**5-28**],
9:40.
-Patient was on ipratroprium in hospital but no known COPD
history. Recommend outpatient pulmonary function testing.
-Recommend outpatient follow-up with urology
Completed by:[**2176-5-7**]
|
[
"285.9",
"401.9",
"507.0",
"287.4",
"110.3",
"785.51",
"272.4",
"410.71",
"414.02",
"997.1",
"530.81",
"584.9",
"276.2",
"E879.6",
"496",
"255.41",
"443.9",
"414.2",
"867.0",
"556.9",
"300.4",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.20",
"00.40",
"00.66",
"89.64",
"96.72",
"96.6",
"36.06",
"00.47",
"96.04",
"88.52",
"37.22",
"88.55",
"37.61"
] |
icd9pcs
|
[
[
[]
]
] |
12894, 12973
|
6879, 11345
|
359, 416
|
13212, 13223
|
3130, 4256
|
14497, 14985
|
2302, 2375
|
11592, 12871
|
12994, 13191
|
11371, 11569
|
4273, 6856
|
13308, 14205
|
2390, 3111
|
1873, 1932
|
13237, 13284
|
14225, 14474
|
274, 321
|
444, 1779
|
1963, 2192
|
1801, 1853
|
2208, 2286
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,107
| 121,045
|
21141
|
Discharge summary
|
report
|
Admission Date: [**2124-6-6**] Discharge Date: [**2124-6-9**]
Date of Birth: [**2054-7-24**] Sex: M
Service: MED
Allergies:
Penicillins
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
bradycardia and hypotension, s/p fall
Major Surgical or Invasive Procedure:
Pt was intubated for one day while in ICU
History of Present Illness:
69 y/o male who saw his PMD two days PTA. PMD switched HCTZ
from 25 mg [**Hospital1 **] to 25 mg QD, and added enalapril 5 mg QD. Pt
states that the day PTA he only took 0.5x his usual dose of
verapamil and played tennis. He says he may have been
dehydrated throughout the day. That night he took 1.5x his
usual dose of verapamil along with his first ever dose of
enalapril and drank eight gin and tonics. He and his wife were
watching television, his wife went into another room when she
heard the Pt fall. When she returned to the room the Pt was
lying on the floor with blood coming from his nose. It is not
clear whether there was a LOC, as the Pt has little recollection
from the time of the fall until arriving at [**Hospital1 **]. His wife
notes that the Pt was "foggy" in his thought process when she
found him moments after falling. His wife called EMS and he was
first taken to [**Hospital6 8283**], his BP and HR were
recorded to be 55/21 and 49, respectively. He was med flighted
to [**Hospital1 18**] ED. He denies fever, chills, headache, dizziness,
vertigo, visual changes, palpitations, SOB, N/V/D prior to this
incident. Pt admits to being a "heavy drinker." His wife
states that he drinks both liquor and wine, at most [**12-20**] gallon.
He denies ever having had a blackout or falling before.
Past Medical History:
-CAD (dx: [**2115**]) -- s/p angioplasty [**2115**] after failed stress test
secondary to exertional CP.
-HTN (dx: [**2114**])
-erectile dysfunction (started [**2122**])
Social History:
Retired professor [**First Name (Titles) **] [**Last Name (Titles) 878**] from [**Hospital1 1012**]. Lives with wife on
[**Hospital3 4298**]. Children 37 and 38 years old. Denies
Tobacco and drug use. Drinks ETOH up to 5 days per week.
Family History:
father died at 52 years old of MI, mother had parkinson's
disease
Physical Exam:
Gen: intubated, sedated.
HEENT: NC/AT. PERRL. lacerations to face, eccymoses of right
eye
Neck: Supple. No masses or LAD. No JVD. No elevated JVP.
Lungs: CTA bilaterally, No R/R/W.
Cardiac: bradycardia. regular rythm. Normal S1/S2. No M/R/G.
Abd: Soft, +BS, guiaic negative
Musculoskeletal: no external deformities, pelvis stable
Skin: warm, dry.
Extrem: warm, No C/C/E, pulses 2+ throughout.
Pertinent Results:
STUDIES:
-CT head: IMPRESSION: No mass effect or hemorrhage
-CT spine: IMPRESSION: No evidence of fractures. Mild
degenerative changes
-CT chest/abdomen/pelvis: IMPRESSION: No evidence of traumatic
injury
-ECHO [**2124-6-8**]: 1. The left atrium is mildly dilated. 2. Left
ventricular wall thickness, cavity size, and systolic function
are normal (LVEF>55%). Regional left ventricular wall motion is
normal. 3. Mild (1+) mitral regurgitation is seen.
--EKG [**2124-6-6**]: Sinus bradycardia, First degree A-V block, ST
junctional depression is nonspecific, Asymmetric peaked T waves
in leads V3 - V6 are of uncertain significance
LABS:
[**2124-6-6**] 01:40AM FIBRINOGE-335
[**2124-6-6**] 01:40AM PT-12.6 PTT-20.6* INR(PT)-1.0
[**2124-6-6**] 01:40AM PLT COUNT-213
[**2124-6-6**] 01:40AM NEUTS-85.2* LYMPHS-11.3* MONOS-3.1 EOS-0.3
BASOS-0.1
[**2124-6-6**] 01:40AM WBC-14.4* RBC-3.67* HGB-12.9* HCT-34.7*
MCV-94 MCH-35.0* MCHC-37.1* RDW-13.4
[**2124-6-6**] 01:40AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2124-6-6**] 01:40AM ALBUMIN-3.7 CALCIUM-7.8* PHOSPHATE-1.1*
MAGNESIUM-1.4*
[**2124-6-6**] 01:40AM CK-MB-4 cTropnT-<0.01
[**2124-6-6**] 01:40AM LIPASE-39
[**2124-6-6**] 01:55AM HGB-13.3* calcHCT-40
[**2124-6-6**] 01:55AM GLUCOSE-218* LACTATE-1.3 NA+-137 K+-2.8*
CL--106
[**2124-6-6**] 01:55AM TYPE-ART PO2-95 PCO2-36 PH-7.44 TOTAL CO2-25
BASE XS-0
[**2124-6-6**] 07:00AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.015
[**2124-6-6**] 11:31AM PLT COUNT-206
[**2124-6-6**] 11:31AM CALCIUM-8.2* PHOSPHATE-1.4* MAGNESIUM-1.5*
[**2124-6-6**] 11:31AM CK-MB-4
[**2124-6-6**] 11:31AM CK(CPK)-182*
[**2124-6-6**] 11:31AM GLUCOSE-134* UREA N-15 CREAT-1.0 SODIUM-142
POTASSIUM-2.5* CHLORIDE-105 TOTAL CO2-26 ANION GAP-14
[**2124-6-6**] 11:58AM TYPE-ART TEMP-36.7 RATES-0/12 TIDAL VOL-700
PEEP-5 O2-70 PO2-254* PCO2-35 PH-7.49* TOTAL CO2-27 BASE XS-4
-ASSIST/CON INTUBATED-INTUBATED
[**2124-6-6**] 02:08PM TYPE-ART TEMP-36.7 RATES-10/0 TIDAL VOL-700
PEEP-5 O2-40 PO2-141* PCO2-37 PH-7.47* TOTAL CO2-28 BASE XS-4
-ASSIST/CON INTUBATED-INTUBATED
[**2124-6-6**] 04:19PM URINE RBC-31* WBC-0 BACTERIA-NONE YEAST-NONE
EPI-0
[**2124-6-6**] 04:19PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2124-6-6**] 04:19PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.015
[**2124-6-6**] 06:24PM TSH-1.4
[**2124-6-6**] 06:24PM calTIBC-228* VIT B12-359 FOLATE-GREATER TH
FERRITIN-380 TRF-175*
[**2124-6-6**] 06:24PM CALCIUM-8.3* PHOSPHATE-2.3* MAGNESIUM-1.8
IRON-20*
[**2124-6-6**] 06:24PM GLUCOSE-125* UREA N-12 CREAT-0.8 SODIUM-143
POTASSIUM-3.7 CHLORIDE-109* TOTAL CO2-25 ANION GAP-13
[**2124-6-6**] 06:30PM TYPE-ART TEMP-38.6 RATES-23/ O2-50 PO2-148*
PCO2-40 PH-7.42 TOTAL CO2-27 BASE XS-1 INTUBATED-NOT INTUBA
COMMENTS-SIMPLE FAC
Brief Hospital Course:
Pt admitted to [**Hospital1 18**] ED s/p fall on night PTA. Noted to have BP
55/21 and HR 49 at OSH was intubated and med-flighted to [**Hospital1 18**]
ED. He received dopamine and was tranferred to the MICU, meds
held, and fluid resusitated. CT studies failed to show any mass
effect or hemorrhage in brain, no evidence of fractures, or
evidence of traumatic injury. Hypotension and bradycardia
resolved, BP 140/70 and HR 70s-80s. After 1 day in MICU Pt was
tranferred to the [**Company 191**]-A service. Home meds were reinstated with
the exception of verapamil. Enalapril was tapered-up from his
home dose of 5 mg QD to 10 mg [**Hospital1 **] to control the patient's BP
with good results, BP 120s/80s. The Pt received consults from
ETOH counseling and cardiology. An echocardiogram showed the
left atrium is mildly dilated, left ventricular wall thickness,
cavity size, and systolic function (LVEF>55%) and regional left
ventricular wall motion is normal. Mild (1+) mitral
regurgitation. Further cardiac work-up to be done outpt. Pt's
vitals remained stable and he was discharged with follow-up to
his PMD and a cardiologist.
Medications on Admission:
1. verapamil 240 mg [**Hospital1 **]
2. atenolol 25 mg QHS
3. enalapril 5 mg QD
4. HCTZ 25 mg QD
5. lipitor 20 mg QD
6. ASA 81 mg QD
7. nephrocaps 1 tab QD
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
Disp:*3 Tablet(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*6 Capsule(s)* Refills:*0*
3. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*3 Tablet(s)* Refills:*0*
4. Enalapril Maleate 10 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*14 Tablet(s)* Refills:*0*
5. Atenolol 25 mg Tablet Sig: One (1) Tablet PO QD (once a day).
Disp:*3 Tablet(s)* Refills:*0*
6. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO QD (once a day).
Disp:*3 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
7. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*3 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
unintentional verapamil overdose
HTN
CAD
hypercholesterolemia
Discharge Condition:
stable -- normal heart rate and normotensive
Discharge Instructions:
-If you have SOB, chest pain, lightheadedness/dizziness please
call your doctor and/or 911 and immediately come to the nearest
Emergency Department.
-New medications: enalapril 10 mg once in morning and 10 mg once
at night
-Discontinued medications: verapamil
Followup Instructions:
Pt to see Dr. [**First Name8 (NamePattern2) 17**] [**Last Name (NamePattern1) 56070**] (PMD) and Dr. [**First Name4 (NamePattern1) 4468**] [**Last Name (NamePattern1) 56071**]
(Cardiology) as outpt.
-follow potassium level
-stress test
-further alcohol abuse counseling
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
|
[
"427.89",
"458.29",
"E858.3",
"401.9",
"305.01",
"414.01",
"972.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
7766, 7772
|
5594, 6739
|
302, 345
|
7877, 7923
|
2670, 2681
|
8232, 8635
|
2166, 2233
|
6945, 7743
|
7793, 7856
|
6765, 6922
|
7947, 8209
|
2248, 2651
|
225, 264
|
373, 1700
|
2691, 5571
|
1722, 1893
|
1909, 2150
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,399
| 148,326
|
31722
|
Discharge summary
|
report
|
Admission Date: [**2122-7-17**] Discharge Date: [**2122-7-23**]
Date of Birth: [**2042-6-28**] Sex: F
Service: MEDICINE
Allergies:
Advair Diskus / Verapamil / Solu-Medrol
Attending:[**First Name3 (LF) 5123**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is an 80 year old woman with a history of COPD, CHF, AVR,
[**Doctor First Name **] pneumonia, with a recent [**Hospital1 18**] admission for abdominal pain
thought likely [**1-5**] gallstones, who now presents with AMS, SOB,
and LE swelling. A history was taken from the patient and her
daughters.
.
On Monday, she was discharged from the [**Hospital1 18**]; she was frustrated
by the leg swelling she continued to have, but understood that
the doctors were recommending [**Name5 (PTitle) 74510**] of lasix because
of concern over her renal function. Tuesday and Wednesday, she
became weaker, sleeping all day on Tuesday, and Wednesday
feeling generally weaker, using the bedside commode instead of
walking to the bathroom when at home, and noting that her legs
were becoming more swollen. Leg elevation did help with this,
and a visiting nurse took measurements at home that suggested no
major change in size of her LEs. Her daughters began noting some
confusion, difficulty with finding the right words sometimes,
and she had at least one illusion or hallucination in which she
thought someone was outside the window when they were not. All
in all, her daughters said, it reminded them of other times when
she has had high CO2. She seemed to have no fevers subjectively
or by VNA measurements, though she did sometimes cough up
sputum.
.
Today, her daughters brought her to the [**Hospital1 18**] [**Name (NI) **] with chief
complaint of "SOB/confusion"; her vitals at triage were: 98.4
57 16 98% on room air. However, a run sheet describes her O2
sat as 84% on room air; she was placed on 5L and reached 100%,
and stayed at this O2 saturation as this was titrated to 2L, and
1L NC. Combivent nebs x2 were given; azithromycin 500 mg PO x1
was given; albuterol was given; the patient was placed on NIPPV
by respiratory and based on possible ongoing need for NIPPV, was
admitted to the MICU. By the time she arrived in the MICU, she
was back on nasal cannula, breathing comfortably and satting
well.
.
Of note, on her previous admission, she had pulmonary and
cardiology pre-op evaluation for possible cholecystectomy. From
a cardiology standpoint, she was considered low-risk, but
pulmonary put her at a high risk for failure to wean from the
vent based on a FVC of 1.4 and an FEV1 of 0.52; ultimately, with
the resolution of her possible biliary symptoms, and these
risks, surgery elected not to go forward with an operation.
Because she desaturated to <88% while ambulating, she was sent
home with home oxygen.
Past Medical History:
1. COPD/Emphysema - Unclear disease extent, followed by Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] of [**Hospital1 1474**], currently managed on Symbicort and
Atrovent. Per [**Doctor Last Name **] consult note: "Patient suffers from a
combination of bullous emphysema with lung changes from [**Doctor First Name **], as
well, although disease has been stable for the past several
years. Occasional asthma-like symptoms, as well."
Most recent PFTs from [**2118**]:
FEV1 = 36% of predicted
FEV1/FVC = 54% of predicted
2. S/p AVR [**2119**] - Post-operative course complicated by prolonged
vent wean
3. CHF - EF >65%, so presumably diastolic
4. HTN
5. Hyperlipidemia
6. Hypothyroidism
7. Hx of [**Doctor First Name **] PNA ~20 years ago, treated
8. s/p tracheostomy [**10-10**] after AVR, stayed on vent
9. s/p cataracts
Social History:
Patient is a retired office worker. She has a 20-30 pack-year
history but quit smoking 20 years ago when she got [**Doctor First Name **]. She
current drinks approximately 3 glasses of [**Doctor First Name **] per week.
Denies illicit drug use. She has 4 children--3 girls and 1 boy--
and around a dozen grandchildren. She lives alone in her house
and can complete ADLs. She walks independently of a cane or
walker and still drives.
Family History:
Mother died at 86 of Alzheimer's. Father died at 81 of emphysema
complicated by pneumonia. Oldest daughter has asthma, mother
also had asthma. Patient has four children--all in good health.
Physical Exam:
On admission:
Vitals 97.9 65 133/58 18 96% RA
General: NAD, lying in bed conversing with family
HEENT: PERRL, moist mucous membranes, EOMI, upper and lower
dentures, oropharynx clear
NECK: supply, no JVD, no thyromegally, no carotid bruit.
LUNGS: Inspiratory crackles wheezes bilaterally, best heard at
lung bases. No rhonchi. Good respiratory effort, using accessory
muscles, decreased airlow
CV: RRR, no murmurs, gallops or rubs
ABD: Soft, NT/ND, + BS, no HSM
Ext: 1+ pitting edema in bilateral LE to the ankle. No cyanosis
or clubbing. Radial and DP pulses palpable and equal
bilaterally.
Neuro: CN II-XII intact. AxO times 3. Strength 5/5 in all 4
extremities. 3+ patellar and radial reflexes. Intact sensation
to soft touch.
Pertinent Results:
Labs on admission:
WBC-6.9 HGB-9.3* HCT-31.8* MCV-94 PLTS -
diff: NEUTS-73.8* LYMPHS-16.7* MONOS-6.2 EOS-2.7 BASOS-0.6
PT-12.3 PTT-24.0 INR(PT)-1.0
CK-MB-4 cTropnT-<0.01 proBNP-[**Numeric Identifier 74511**]*
GLU-109* BUN-28* CR-1.5* NA-145 K-4.5 CL-102 HCO3-37* ANION
GAP-11
ABG: PO2-217* PCO2-88* PH-7.28* TOTAL CO2-43* BASE XS-11
Labs on discharge:
WBC 5.8, Hgb 9.2, Hct 29.9, MCV 90 Plt 225
146 95 13 AGap=10
------------< 72
4.0 45 1.2
Ca: 8.9 Mg: 1.6 P: 3.1
Imaging:
[**2122-7-18**]: CXR
FINDINGS: Comparison is made to previous study from [**2122-7-17**].
Since the previous study, there has been no significant interval
change. There are again noted multifocal areas of cystic changes
and fibrotic bands particularly in right upper lung fields.
Pleural thickening is seen at the lung apices bilaterally and
also are stable. Patient has severe emphysematous changes. The
opacity at the right base is again seen and unchanged. No large
pleural effusions are seen. Cardiac silhouette and mediastinum
is grossly within normal limits.
[**2122-7-18**]: Head CT
FINDINGS: There is no intra- or extra-axial hemorrhage, masses,
mass effect, or shift of normally midline structures. The
ventricles and sulci are moderately prominent, suggestive of
age-appropriate involutionary changes. There is asymmetry of the
brain, which is likely due to patient positioning. There is
bilateral periventricular white matter hypoattenuation,
particularly in the frontal region suggestive of chronic
microvascular ischemic change. There are basal ganglia
calcifications in the right side. There is no acute major
vascular territorial infarct. There is a left ethmoid osteoma.
Echo [**2122-7-18**]
IMPRESSION: Suboptimal image quality. LVEF >65%. Right
ventricular cavity enlargement with mild free wall hypokinesis.
Pulmonary artery systolic hypertension. Well seated aortic valve
bioprosthesis.
Brief Hospital Course:
Mrs. [**Known lastname **] is an 80 year old female with PMH significant for
severe COPD (no home O2 at baseline), CHF with diastolic
dysfunction (>55% EF), AVR in [**2119**], remote h/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] pneumonia who
was hospitalized for altered mental status, fatigue, dyspnea and
bilateral lower extremity edema. She was seen on [**2122-7-9**] for
abdominal pain diagnosed as gallstone pancreatitis but was not
deemed a surgical candidate due to previous history of prolonged
extubation. During this prior hospitalization, she was
determined to be in acute renal failure and her PO lasix was
discontinued.
# HYPERCARBIC RESPIRATORY FAILURE - Pt came in with fatigue,
altered mental status, and some dyspnea. ABG of (7.28/88/217),
showing an acute-on-chronic hypercarbic respiratory acidosis.
Chest x-ray and PFTs suggesting advanced COPD. PFTs on [**2122-7-13**]
were consistent with severe obstructive disease. She was
admitted to the MICU secondary to NIPPV x 1 hour in the ED. She
was started on azithromycin for possible COPD exacerbation,
however due to low likelihood of this based on presentation, no
steroids were started. CE's negative x 2. Mrs. [**Known lastname **] had an
elevated BNP and on exam she had signs of right and left heart
failure. Patient was diuresed with IV Lasix in the ICU to
euvolemic state. She received nebulizer treatments q6h and
oxygen via NC, gradually being reduced to 1 L NC prior to
transfer to the floor. Azithromycin was eventually discontinued
before completing a 5 day course due to low likelihood of
infection. Repeat ABG on the floor showed improving CO2 and
patient was discharged on [**12-5**] L O2 by NC.
# CONGESTIVE HEART FAILURE - Comes with chart diagnosis of known
CHF, and elevated BNP (>11,000); prior echo does not point to
the exact nature of this diagnosis. At [**2122-7-9**] admission to the
[**Hospital1 **] her home lasix was discontinued due to renal insufficiency
and was not restarted. On admission, she had signs of both left
and right heart failure. Mrs. [**Last Name (STitle) 74512**] was diuresed both in
the MICU and on the floor. She was continued on her home beta
blocker. Lower extremity edema markedly improved. Upon discharge
proBNP level 4804 with resolution of LE swelling and pulmonary
edema.
# ALTERED MENTAL STATUS - Most likely secondary to hypercarbia
and consistent with daughter's descriptions of past behavior in
this setting. CT head was negative, reassuring given hx of
word-finding difficulty. When diruesed and with subsequent
immprovement in respiratory status, the patients altered mental
status improved. On transfer to the floor, she was alert and
oriented x 3. She did have some issues with sundowning,
however, after encouraging good sleep hygiene, her sundowning
improved.
# HYPERNATREMIA - Patient with elevated sodium after diuresis.
Unclear if she is high at baseline (at admission was 145 with
levels as high as 148 during admission). Could be due to
combination of impaired access to free water, renal losses,
insensible losses. TBW was repleted with D5W. Urine osmolals
were inapproriately low. Renal was consulted day prior to
discharge and felt laboratory and clinical picture was
consistent with free water deficit. Patient was given 1L D5W
overnight prior to discharge. Sodium corrected initally,
however returned to elevated. Renal still thought this was
likely to recovery from ATN. Patient was discharged to rehab
with instructions to drink plenty of water daily and started on
thiazide diuretic.
# RENAL INSUFFICIENCY - Recent bump of Cr in [**Month (only) 216**] with no
clear source. Diuretics stopped, has had some improvement in Cr
but not in overall clinical picture. Not a clearly pre-renal
picture by BUN/Cr ratios. Creatinine trended down during
hospitalization (1.4->1.1). Was changed from a loop diuretic to
thiazide diuretic prior to discharge.
# ANEMIA - Around her baseline of high 20s low 30s. Anemia
remained stable throughout the admission and required no acute
managment.
# HYPOTHYROIDISM - Levothyroxine continued at home dose
# HYPERCHOLESTEROLEMIA - Continued home statin
# URINARY TRACT INFECTION - She was treated with Bactrim with a
plan to complete a 7 day course for a UTI.
Medications on Admission:
(per med list brought by daughter):
MVI daily
vit D daily
ASA 325 daily
zyrtec 10 mg nightly
systane eye drop daily
ipratropium nasal [**Hospital1 **]
atrovent inhaler 2 puffs 3x/day
symbicort [**Hospital1 **]
levothyroxine 75 mcg daily
simvastatin 20 mg nightly
metoprolol 25 mg [**Hospital1 **]
NO LONGER TAKING/RECENTLY D/C'ED: digoxin (unclear indication),
furosemide 20 mg daily (chronic renal insufficiency), K 20
mEq/daily
Discharge Medications:
1. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
3. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
7. Ipratropium Bromide 0.03 % Spray, Non-Aerosol Sig: One (1)
Nasal twice a day.
8. Symbicort 160-4.5 mcg/Actuation HFA Aerosol Inhaler Sig: One
(1) Inhalation twice a day.
9. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
10. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily) for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
11. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for shortness of breath, wheezing, long exhalation.
12. Outpatient Lab Work
Check cbc, potassium, sodium, bicarb, BUN and creatinine on [**7-26**]
and give results to on call physician.
13. Hydrochlorothiazide 12.5 mg Tablet Sig: One (1) Tablet PO
once a day for 30 days.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
Life Care Center of [**Location 15289**]
Discharge Diagnosis:
Primary Diagnosis:
1. Congestive Heart Failure
2. Hypercarbic Respiratory Failure
3. Recovery from ATN
4. UTI
5. Hypernatremia
Secondary Diagnosis:
COPD
Renal insufficiency
Discharge Condition:
Vital signs stable. Patient ambulating with cane.
Discharge Instructions:
You were admitted to the hospital for confusion, shortness of
breath, and swollen legs. You were taken to the Intensive Care
Unit out of concern for your breathing. We gave you medications
to take fluid off of your legs and your lungs. You required
oxygen while in the hospital. The oxygen was gradually
decreased, however you will need to use it at home when you are
sleeping and with activity.
You were also treated for hypernatremia (sodium elevation in
blood.) Please drink [**7-13**] glasses of water a day.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet and watch for swelling of your legs.
Medication changes:
We have discontinued your lasix.
We started you on hydrocholorothiazide 12.5mg by mouth daily.
We also started you on albuterol and atrovent nebulizer
treatments to improve your breathing.
We started Bactrim 1 tablet by mouth once a day for next 5 days
to treat a urinary tract infection.
If you experience worsening shortness of breath, fever > 102,
chills, confusion, , please call Dr. [**Last Name (un) **] or go to an
emergency room.
We are sending you home oxygen that we want you to use when you
are walking or doing errands to make sure you saturations stay
>91% but <96%.
Followup Instructions:
Please call the renal clinic at ([**Telephone/Fax (1) 10135**] to arrange an
appointment for follow-up.
Please follow-up with your PCP and your pulmonologist when you
go home.
|
[
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"428.0",
"518.84",
"403.90",
"244.9",
"276.3",
"276.2",
"584.5",
"428.33",
"492.8",
"585.9",
"276.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
13126, 13193
|
7091, 11374
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320, 326
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13411, 13463
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5170, 5175
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354, 2878
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13363, 13390
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13233, 13342
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5189, 5504
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2900, 3747
|
3763, 4197
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,636
| 199,574
|
1992
|
Discharge summary
|
report
|
Admission Date: [**2109-10-31**] Discharge Date: [**2109-11-26**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 800**]
Chief Complaint:
Shortness of breath, Fractures
Major Surgical or Invasive Procedure:
Endotracheal Intubation
PEG Tube placement, Interventional Radiology, [**2109-11-22**]
Casting of left wrist
PICC placement.
History of Present Illness:
This is an 89 year old male with a history of COPD,
hypertension, chronic kidney disease, hypertension and end stage
congestive heart failure who was found down in his living [**Apartment Address(1) **]
days prior to admission. He hit his head but denied history of
loss of consciousness. He initially was taken to [**Hospital1 18**] [**Location (un) 620**]
where CT neck revealed a C2 fracture. He was tranferred to this
hospital for further management.
In the ED, initial vs were: T: 97.3 P: 130 BP: 124/78 R: 28 O2
sat 100% on NRB. Patient was given two liters of normal saline,
morhine 2 mg IV x 1, zofran 4 mg IV x 1 and metoprolol 5 mg IV x
1. He was admitted to the TSICU for further management.
Since arrival to the TSICU he has had an MRI which shows a type
II odontoind fracture. He also has had a right forearm xray
which revealed distal radial and ulnar styloid fractures which
have been casted. He has been in a c-collar throughout. While
in the TSICU he has been noted to be inattentive and
inconsistent answering questions with periods of frank agitation
where he has been combative and refusing care. He has required
haldol and zyprexa PRN for these symptoms. Per discussion with
the patient's son, at baseline his speech is interpretable 50%
of the time and that he often talks about the past.
He was briefly transferred to the floor on [**2109-11-1**]. There he
was receiving gentle hydration as well as PRN zyprexa, haldol
and morphine. He was noted to be tachycardic and received
significant doses of PRN metoprolol although telemetry strips
appear to show sinus tachycardiac versus MAT. He was initially
requiring 35% facemask but this required titration during the
day. He was also noted to be increasingly somnolent. Of note
his lasix has been held since admission and on the day of
intubation he received lasix 40 mg IV x 2 without significant
increase in his urine output. He was ultimately intubated for
hypoxic and hypercarbic respiratory failure. ABG at the time of
intubation was 7.29/65/85 on a non-rebreather. Peri-intubation
he was transiently hypotensive and required neosynephrine. He
had a non-contrast CT of the test which showed a possible
pneumonia versus atelectasis. He was started on vancomycin,
cefepime and ciprofloxacin for presumed hospital acquired
pneumonia given an isolated fever to 102 degrees. Subclavian
line was attempted but was unsuccessful and a femoral line was
placed for access. He also had an arterial line placed and an
NGT to allow for tube feeds. He is now being transferrd to the
MICU for management of respiratory failure.
Past Medical History:
COPD - has been on inhalers in the past but is not on currently
Hypertension
Stage III Chronic Kidney Disease (baseline creatinine 1.4-1.6)
Polyarticular Gout - on prednisone 2.5 mg daily
Congestive Heart Failure (preserved EF, severe aortic
regurgitation, moderate mitral regurgitation)
Benign Prostatic Hypertrophy
Home oxygen requirement (2L) for unclear reasons. [**First Name8 (NamePattern2) **] [**Location (un) 620**]
notes attributed both to emphysema and congestive heart failure
Social History:
Patient currently lives with his wife and his eldest son. [**Name (NI) **]
uses a walker and/or cane to get around. He occasionally dresses
himself, is able to toliet on his own. He cannot before IADLs.
He does not drink alcohol. He quit smoking 20 years ago but has
a 50 pack year history. [**First Name8 (NamePattern2) **] [**Location (un) 620**] notes his diet consists of
nectar thickened liquids and ground solids.
Family History:
Coronary artery disease, hypertension.
Physical Exam:
Vitals: T: 97.5 BP: 112/33 P: 83 R: 14 O2: 100% (PS 10/5, FiO2
50%)
General: intubated, sedated, no distress
HEENT: C-collar in place, sclera anicteric, MMM, oropharynx
clear
Neck: supple, bounding carotid pulse, JVP at 10 cm, no LAD
Lungs: Coarse breath sounds throughout, trace crackles
CV: Irregular, normal S1 + S2, II/IV diastolic murmur at RUSB,
high pitched II/VI systolic murmur at apex
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley draining dark urine
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, right femoral line in place, left wrist cast in place,
right arterial line in place
Pertinent Results:
LABS ON ADMISSION:
[**2109-10-31**] 12:50AM BLOOD WBC-14.4*# RBC-3.75* Hgb-10.8* Hct-33.7*
MCV-90 MCH-28.7 MCHC-32.0 RDW-18.5* Plt Ct-317
[**2109-10-31**] 12:50AM BLOOD Neuts-84.7* Lymphs-10.6* Monos-4.2
Eos-0.4 Baso-0.1
[**2109-10-31**] 12:50AM BLOOD PT-13.8* PTT-30.9 INR(PT)-1.2*
[**2109-10-31**] 12:50AM BLOOD Glucose-127* UreaN-25* Creat-1.8* Na-140
K-3.7 Cl-99 HCO3-25 AnGap-20
[**2109-10-31**] 12:50AM BLOOD ALT-5 AST-16 CK(CPK)-124 AlkPhos-92
TotBili-0.4
[**2109-10-31**] 12:50AM BLOOD Lipase-36
[**2109-10-31**] 12:50AM BLOOD CK-MB-2
[**2109-10-31**] 12:50AM BLOOD Albumin-4.0 Calcium-9.0 Phos-3.8 Mg-2.2
[**2109-11-2**] 03:01AM BLOOD calTIBC-224* VitB12-807 Folate-5.0
Hapto-131 Ferritn-88 TRF-172*
LABS ON DISCHARGE:
CBC: wbc8.4 hgb8.1* Hct26.2* platelets187
Potassium on Discharge: 4.6
Creatinine: 1.1
ARTERIAL BLOOD GASES:
[**2109-11-1**] 03:53PM BLOOD pO2-47* pCO2-58* pH-7.34* calTCO2-33*
Base XS-3
[**2109-11-1**] 06:36PM BLOOD pO2-85 pCO2-65* pH-7.29* calTCO2-33* Base
XS-2
[**2109-11-1**] 09:39PM BLOOD pO2-71* pCO2-57* pH-7.33* calTCO2-31*
Base XS-1
[**2109-11-2**] 03:26AM BLOOD pO2-263* pCO2-52* pH-7.40 calTCO2-33*
Base XS-6
[**2109-11-2**] 11:38AM BLOOD pO2-133* pCO2-58* pH-7.33* calTCO2-32*
Base XS-3
[**2109-11-6**] 02:15PM BLOOD Temp-38.3 FiO2-35 pO2-74* pCO2-51*
pH-7.41 calTCO2-33* Base XS-5 Intubat-NOT INTUBA
[**2109-11-10**] 02:10PM BLOOD FiO2-35 pO2-83* pCO2-54* pH-7.45
calTCO2-39* Base XS-11 Intubat-NOT INTUBA Comment-NEBULIZER
[**2109-11-15**] 12:38PM BLOOD pO2-67* pCO2-52* pH-7.43 calTCO2-36* Base
XS-8 Intubat-NOT INTUBA
[**2109-11-15**] 12:38PM BLOOD pO2-67* pCO2-52* pH-7.43 calTCO2-36* Base
XS-8 Intubat-NOT INTUBA
STUDIES:
CT Chest/Abdomen/Pelvis w/contrast [**2109-10-31**]:
1. Mild atelectasis at the left lung base.
2. Cardiomegaly.
3. Stable ascending aortic aneurysm measuring up to 5.8 cm.
4. Emphysema.
5. Diverticulosis.
MRI C-spine w/o contrast [**2109-10-31**]:
1. Ill-defined area of heterogeneous signal identified at the
odontoid process, the possibility of chronic degenerative
changes and an old unhealed fracture are considerations,
however, correlation with a dedicated MRI of the cervical spine
with contrast is recommended for further characterization.
2. Multilevel disc degenerative changes throughout the cervical
spine as described in detail above.
3. There is no evidence of focal or diffuse abnormalities within
the cervical spinal cord.
Right Forearm XRAY [**2109-10-31**]:
Study is limited due to the overlying cast material. Evaluation
for subtle fractures cannot be made on these images. However,
there is gross alignment of the elbow joint as well as of the
distal radioulnar joint. There is again seen innumerable
erosions within the carpal bones which appear similar to the
prior study of [**2108-9-11**]. No fractures of the distal
humeral shaft or of the ulnar and radial shafts are identified.
If there is high clinical concern for subtle fractures, imaging
without the cast may be more helpful.
Pelvis XRAY [**2109-10-31**]:
No evidence of trauma. Cardiomegaly. Subtle atelectasis at the
left lung base. Transitional vertebral body.
EKG: sinus tachycardia with frequent PACs, first degree AV
block, no acute ST segment changes, no change from prior dated
[**2109-10-31**].
MRI Head ([**2109-11-6**]): No evidence of acute infarct.
Moderate-to-severe changes of small vessel disease and moderate
brain atrophy. Small amount of fluid in both mastoid air cells.
Right Hand ([**2109-11-7**]): There are innumerable erosions consistent
with the history of gouty arthritis, little changed from
[**2108-9-11**].
Left Wrist ([**2109-11-12**]): The left distal radial fracture line is
still visible, though there is some small amount of adjacent
callus formation. Overall, the degree of angulation of the
fracture fragments is near anatomic, though small impaction
persists. A non-united ulnar styloid fragment is also
unchanged. There is no new fracture or dislocation. Extensive
cystic changes and erosions of multiple carpal bones with is
also unchanged.
ABD Xray ([**2109-11-22**]): No signs of perforation or obstruction.
Brief Hospital Course:
1. Pt to follow up with Orthopaedics re: [**Location (un) 2848**] J Collar (needed
for [**6-3**] wks) and wrist fracture
2. At this time decision was made with family to hold Coumadin
at this given the patients fall risk. Given patients history of
atrial fibrillation. The decision to restart Coumadin should
occur after patient is stabilized and not a fall risk.
3. Speech/Swallow should reevaluate patient's ability to swallow
safely without aspiration in the next one - two months. Pt
showed improvement while hospitalized.
4. Colchicine/Prednisone which patient took for gout was stopped
while hospitalized given patient was between flairs. These
should be restarted as needed. Patient discharged on
allopurinol.
5. Medication for benign prostatic hypertrophy should be
restarted after patient's delirium resolves. Patient previously
on Proscar daily and Flomax 0.4 qhs.
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89M h/o severe COPD, hypertension, chronic kidney disease,
hypertension and end stage CHF, originally found down in his
living room two days prior to admission, found to have multiple
fractires, admitted to MICU with hypoxic and hypercarbic
respiratory failure, now s/p intubation, intermittent
desaturations often relieved with sunctioning. Mental status
waxing and [**Doctor Last Name 688**], continues to improve and is better when
family is available to speek in cantonese to patient, patient
somewhat conversational in English.
# AMS: Delirium. Waxing and [**Doctor Last Name 688**] mental status but
consistently below baseline, with ongoing altered level of
sensorium and unclear level of orientation. Language barriers
contributing to difficulty in assessing, but clear some level of
change from baseline. Unclear etiology but top of differential
includes post-intubation status, intubation meds, infection,
other medications, metabolic abnormalities. Patient without
signs of infection, blood cultures, urine cultures have been
negative. Chest xray without clear pneumonia. Patient at
discharge continued to be afebrile. During the hospitalization
patient was provided olanzapine for agitation followed by soft
restraints and mittens. Geriatrics was also consulted and
provided recommendations for improving patient's delirium. Foley
was removed and we attempted to normalize sleep/wake cycle.
# ANEMIA: Anemia of Chronic Inflammation and Iron Deficiency
(low iron, low TIBC, ferritin normal). Occult positive stool on
[**11-15**], BRBPR [**11-18**] (thought to be related to supratherapeutic
INR). B12, folate, hemolysis labs normal. Trending down since,
now ~21. No previous signs of active blood loss. Retics 2.7.
During his stay an active type and screen was maintained and
transfusion goal was set at 21. When PEG tube was placed iron
was restarted.
Baseline: [**2106**] - [**4-4**] HCT ~41
Since Admission:
[**10-31**] - [**11-5**] HCT ~ 26-32
[**11-6**] - [**11-17**] HCT ~ 22-26
[**11-18**] ~ 21, INR ~ 4, given 2 units PRBC + Vit K
[**11-19**] ~ 27.9, INR = 1.2
[**11-24**] - 26.8, INR=1.2
ASPIRATION: Very high-risk. Swallowing pattern correlates to a
Functional Oral Intake Scale (FOIS) rating of 1 out of 7.
Speech/Swallow re-evaluated after pt pulled out NGT but patient
still failed. Speech/swallow evaluated again per families
reguest to determine the effect the neck collar had on
swallowing. Based on their evaluation the neck collar was not
contributing to dysphagia. On video swallow patient did show
some improvement however not enough to change from NPO. Given
the chronic nature of this problem PEG tube was placed and tube
feeds were started. Speech/swallow should re evaluate in the
future when patient gets closer to his baseline with the hopes
of continued improvement and the possibility of removing the PEG
tube. Further during the hospitalization moist spongettes or
humidified shovel mask for comfort and Q4 oral care was
provided.
# Hyperkalemia: Prior to DC to rehab facility patient developed
hyperkalemia. Thought to be nutrional as it developed after tube
feeds were initiated. Banana Flakes were dc'd from tube feed
regimen. Potassium 5.5, no EKG changes. Pt given Kayexalate and
potassium eventually resolved. Pt continued on ACE I at this
time given benefit.
# RESPIRATORY FAILURE: Patient required intubation in MICU for
hypoxic and hypercarbic respiratory failure. Multifactorial
etiology including underlying COPD and CO2 retention, possible
CAP, +/- fluid overload from IVF and cessation of CHF
medications on admission (including lasix and lisinopril). ABG
intially showed well-compensated respiratory acidosis, later
with acute decompensation. Patient now stable on RA - 2L with
sats in mid to upper 90s. Patient benefits from frequent
suctioning.
COPD: Baseline 2L O2 at home but w/unknown sats, h/o CO2
retention. He does not take inhalers at home but has been
prescribed them in the past. Prescribed inhalers in past but not
using prior to admission. Restarted albuterol and ipratropium
nebulizers on admission.
PNA: History of aspiration, some evidence of small infiltrates
versus atelectasis on his CT chest. Induced Sputem was
contaminated. Patient treated with eight day course of
Vanc/Zosyn (start date [**11-10**]) for hosptial acquired pneumonia.
After completion of course patient has been afebrile, with white
blood cell count that continues to trend down. On [**11-15**] chest
xray concern for aspiration pneumonitis. Since that time CXR has
been stable with segmental atelectasis.
CHF: End-stage diastolic CHF complicated by severe AR and
moderate MR. [**First Name (Titles) **] [**Last Name (Titles) 10942**] likely [**1-28**] fluid resuscitation
as well as withholding of CHF meds. Lasix [**Hospital1 **] held (last dose
[**11-14**]) due to rising creatinine, dry exam. During
hospitalization creatinine significantly improved and BNP began
to increase to 10,000 from 2,000 on admission. Lasix was
restarted at half home dose and captopril was restarted when
patient's peg tube was placed. Metoprolol was continued
throughout the hospitalization. Daily weights and I/0s were
followed daily.
# CKD: Baseline since [**8-/2108**] ~1.5, 1.8 on admission. Has
fluctuated while hospitalized however has remained stable at 0.9
prior to discharge. While renal function was fluctuating renal
toxic medications were held. On improvement of renal function
meds were reinitiated. Meds were renally dosed. Fluctuation in
renal function was thought to be secondary to fluctuations in
volume status.
# THROMBOCYTOSIS: platelet count rose to ~750 and is now
trending down. Likely just reactive, also could be [**1-28**] iron
deficiency. Thrombocytosis resolved without intervention.
# AF w/RVR: rate and rythm controlled on beta-blockade. HR
90-120s in ICU, now rate controlled on metoprolol. Pt receiving
SubQ heparin. Per discussion with family/attending decision was
made to hold coumadin at this time given the fall risk.
# HTN: Controlled on Metoprolol, Captopril.
# Right wrist fracture: s/p reduction and splinting. No plan for
operative intervention. Will follow up with Orthopaedics.
# Dens Fracture: [**Last Name (un) 10943**] Type II dens fracture. Non-operative.
Currently in [**Location (un) 2848**] J Collar. Per discussions with spine service
this fracture is new, and accordingly he should continue to wear
the collar for the next 8 weeks. Patient should follow up with
Orthopaedics for further evaluation.
# Gout: At discharge prednisone/colchicine held given patient
does not appear to have a current gout flair. Patient discharged
on allopurinol.
# Benign Prostatic Hypertrophy: Held while inpatient.
Medications should be restarted after patients mental status
improves.
# GOALS OF CARE: Family meeting [**11-15**]:
-- At this time patient is FULL CODE. Pt is the elder of the
family and when the patient is clear has told family that he
would like everything done. Discussion of code status has
continued.
Medications on Admission:
Lopressor 25 [**Hospital1 **]
Lisinopril 5 daily
Lasix 60 [**Hospital1 **]
Prednisone 2.5 mg daily
Allopurinol 300 [**Hospital1 **]
Iron 65 [**Hospital1 **]
Proscar daily
Flomax 0.4 qhs
Discharge Medications:
1. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours).
2. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
3. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
5. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours).
6. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet, Rapid
Dissolve PO TID (3 times a day) as needed for agitation: Please
monitor QTc daily when using medication.
7. Furosemide 40 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO QID
(4 times a day).
9. Captopril 12.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
10. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
11. 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.
12. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
13. Pantoprazole 40 mg IV Q24H
14. Heparin
5,000 Units Sub Cutaneous Three Times Daily, For DVT Prophylaxis
15. Captopril 12.5 mg Tablet Sig: One (1) Tablet PO three times
a day.
16. Insulin Sliding Scale
Please refer to provided scale.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] at [**Hospital 3278**] Medical Center
Discharge Diagnosis:
PRIMARY:
1. Respiratory Failure
2. Aspiration Pneumonitis
3. Type II dens fracture
and non-displaced right wrist lunate and distal radius fracture
4. Congestive Heart Failure
5. Acute on Chronic Renal Failure
6. Lower GI Bleed
7. Anemia
8. COPD
9. Delirium: Multifactorial
Discharge Condition:
Hemodynamically stable, Afebrile, Mental Status waxing/[**Doctor Last Name 688**]
Discharge Instructions:
Dear Mr. [**Known lastname **],
It was a pleasure participating in your care during your
admission to [**Hospital1 69**]. You were
originally admitted for fractures after falling down at home.
You then developed respiratory failure which required
intubation. When your respiratory status improved you were
transfered out of the ICU and were continued to be medically
stabilized and treated for a hospital acquired pneumonia.
Because you had difficulty swallowing with high risk of
aspiration a PEG tube was placed so you could receive tube
feeds. After intubation you also developed a delirium that has
waxed and waned.
We have changed several of your medications. Please take all of
your medications exactly as prescribed. Please see list provided
for these changes.
Please call your physician or come to the hospital if you
experience any of the following new pains that are not
controlled with your usual pain regimen, chest pain, shortness
of breath, fevers, chills, changes in your vision, weakness or
numbess in your extremities, or slurring of your speech.
Followup Instructions:
PCP: [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 10944**] [**Telephone/Fax (1) 608**]. Please follow up with
your primary care physician in the next 2-4 weeks.
MD: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1352**]
Specialty: Orthopedics
Date and time: [**Last Name (LF) **], [**1-6**] at 11:00am
Location: [**Location (un) **], [**Hospital Ward Name 23**] Bldg [**Location (un) 551**], [**Location (un) 86**], MA
Phone number: [**Telephone/Fax (1) 1228**]
Special instructions if applicable: Please arrive at 11:00am for
X-Rays and then you will see Dr. [**Last Name (STitle) 1352**] at 11:20am.
Rheumatology: [**Name6 (MD) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 2226**]
Date/Time:[**2110-3-27**] 10:30
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]
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56,440
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6646
|
Discharge summary
|
report
|
Admission Date: [**2164-2-18**] Discharge Date: [**2164-2-22**]
Date of Birth: [**2090-1-23**] Sex: F
Service: MEDICINE
Allergies:
Aspirin
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 25383**] is a 74 year-old woman, patient of Dr. [**Last Name (STitle) **], with
history of treated MAC, obstructive lung disease (FEV1/FVC 56 in
[**10-18**]), and s/p recent right TKR on [**2164-1-24**] who presents with
cough, fevers, and dyspnea and is admitted to the MICU for
respiratory distress.
She was feeling well until three days ago when her symptoms
began. She noted cough productive of yellow sputum, worsening
dyspnea, and fevers with tmax 101.5. No sick contacts. She did
receive seasonal flu vaccine but not H1N1. She has also lost 10
lbs over the last 6 weeks because of lack of appetite.
In the ED, vital signs were initially: 97.4 155 115/57 24 90%ra.
She was noted to be speaking in short sentences with pursed lip
breathing. Exam was significant for wheezes and rales. CXR was
negative for acute process. She was given 2L NS and
ceftriaxone/azithro and admitted to the MICU.
Past Medical History:
- Mycobacterium avium intracellularae - treated for MAC from
[**2-/2157**] to [**7-/2158**]
- bronchiectasis
- Right total knee replacement [**2164-1-24**], on coumadin
- cholecystitis s/p cholecystectomy
- endometrial carcinoma s/p hysterectomy in [**10/2152**]
- Obstructive lung disease (FEV1/FVC 56 IN [**10-18**]), NOT on home 02
- Anxiety
Social History:
Retired, lives alone. Friend [**Name (NI) 1312**] has been staying with her
since her surgery. Her HCP is her sister. Smoked 1 pack/week x
20 years. Has not smoked for 25 years. She drinks 6-8 drinks per
week. Last drink 3 days ago. No history of withdrawl.
Family History:
colon cancer
Physical Exam:
Admission Vitals - T:97.8 BP:117/82 HR:95 RR:22 02 sat:98% 3L
GENERAL: Thin, frail appearing elderly woman sitting in chair.
HEENT: Normocephalic, temporal wasting. MM dry. Multiple
telangiectasias.
CARDIAC: Tachycardic, regular
LUNGS: Decreased air movement. Fine crackles and distant wheeze.
can only speak [**3-14**] words at a time, is easily winded.
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses. s/p recent TKR, incision well healed.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout.
PSYCH: Listens and responds to questions appropriately, pleasant
.
Discharge Vitals: T:96.5 BP:136/65 HR:64 RR:20 02 sat:95%RA
Pertinent Results:
[**2164-2-18**] 01:18PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.016
[**2164-2-18**] 01:18PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2164-2-18**] 01:18PM URINE RBC-89* WBC-2 BACTERIA-NONE YEAST-NONE
EPI-1
[**2164-2-18**] 01:18PM URINE MUCOUS-RARE
[**2164-2-18**] 06:29AM TYPE-ART TEMP-38.1 O2 FLOW-4 PO2-98 PCO2-50*
PH-7.32* TOTAL CO2-27 BASE XS-0 INTUBATED-NOT INTUBA
COMMENTS-NASAL [**Last Name (un) 154**]
[**2164-2-18**] 04:01AM LACTATE-1.0
[**2164-2-18**] 02:19AM GLUCOSE-121* UREA N-15 CREAT-1.0 SODIUM-136
POTASSIUM-4.1 CHLORIDE-98 TOTAL CO2-29 ANION GAP-13
[**2164-2-18**] 02:19AM estGFR-Using this
[**2164-2-18**] 02:19AM CK(CPK)-41
[**2164-2-18**] 02:19AM CK-MB-NotDone cTropnT-0.01
[**2164-2-18**] 02:19AM TSH-1.4
[**2164-2-18**] 02:19AM WBC-9.2 RBC-4.35# HGB-12.9# HCT-40.4# MCV-93
MCH-29.5 MCHC-31.8 RDW-15.3
[**2164-2-18**] 02:19AM NEUTS-79.0* LYMPHS-15.0* MONOS-3.3 EOS-2.3
BASOS-0.4
[**2164-2-18**] 02:19AM PLT COUNT-515*
[**2164-2-18**] 02:19AM PT-51.9* PTT-47.4* INR(PT)-5.7*
.
[**2164-2-18**] URINE Legionella Urinary Antigen -FINAL INPATIENT
[**2164-2-18**] URINE URINE CULTURE-FINAL INPATIENT
[**2164-2-18**] Rapid Respiratory Viral Screen & Culture Respiratory
Viral Culture-FINAL {RESPIRATORY SYNCYTIAL VIRUS (RSV)};
Respiratory Viral Antigen Screen-FINAL INPATIENT
[**2164-2-18**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
INPATIENT
[**2164-2-18**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2164-2-18**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2164-2-18**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
.
BASIC COAGULATION (PT, PTT, PLT, INR)
[**2164-2-22**] 06:50AM 17.4* 29.8 1.6*
[**2164-2-21**] 04:55AM 18.8* 31.4 1.7*
[**2164-2-20**] 08:50AM 23.0* 32.8 2.2*
[**2164-2-19**] 03:51AM 51.0* 44.6* 5.6*1
[**2164-2-18**] 02:19AM 51.9* 47.4* 5.7*2
.
[**2-18**] CXR No focal consolidations. Hyperinflation suggestive of
possible
emphysema or COPD.
Brief Hospital Course:
Ms [**Known lastname 25383**] was initially admitted to the MICU given concern for
her tachypnea and tachycardia. She was treated for pneumonia
with levofloxacin and for COPD with steroids and nebulizers.
Her oxygen saturations remained in the high 90s with 3L
supplemental oxygen. Her chest-xray did not show consolidation.
She tested negative for legionella urinary antigen and was
negative for flu. She was transferred to a regular medical
floor on the second day of her hospitalization. Her warfarin
for her knee replacement was held when her INR became
supratherapeutic >5 in the setting of antibiotic use.
On the floor, the following issues were managed:
# Respiratory distress. Patient was treated for CAP/HAP with
levoquin and discharged to complete a 7 day course. CXR on
admission showed hyperinflation without focal findings and
repeat showed now interval change. No sputum culture to guide
therapy. She was also treated for COPD flare/bronchitis with
burst of prednisone 60mg daily and with aggressive nebulizer
treatment. Over the course her stay, her resp status
dramatically improved. She was discharged with a slow 10 day
taper. She was weaned off oxygen with some residual cough. Lung
exam improved with some residual crackles and wheezing at bases.
Had been ruled out for flu. PE also possible but less likely
given therapeutic on coumadin on admission. Viral culture showed
RSV and after discussion with ID the treatment is just
supportive care.
.
#.Anemia. Hct stable. Iron studies c/w mixed iron deficiency and
likely chronic disease. Recent baseline hct low 30s, however was
40 on admission likely hemoconcentrated in setting of illness.
No obvious bleeding. Hct remained stable. Her iron was increased
to [**Hospital1 **].
.
# Coagulopathy: Pt on warfarin at home for planned 4 week
post-op course since [**1-26**]. Elevated INR in setting of abx use
on admission but then became subtherapeutic after holding doses.
It was restarted but she was not yet therapeutic upon
discharge. No evidence of bleeding.
.
# Anxiety: stable, cont home PRN ativan
.
# HTN: reasonably controlled, cont home lisinopril
.
# TKR: Followed by Dr. [**Last Name (STitle) **]. Has outpatient appt with him on
Friday. Cont warfarin management as above, patient to go home
with PT, pain control with oxycodone. Given subQhep while
subtherapeutic on coumadin and TEDS.
.
# General Care: FEN: noIVFs / replete lytes prn / regular diet,
PPX: home PPI, subQ hep, bowel regimen, ACCESS: PIV, CODE: FULL,
confirmed with pt, CONTACT: [**Name (NI) **] and sister is HCP [**Name (NI) 2147**]
[**Name (NI) 5263**] [**Telephone/Fax (1) 25384**], DISPO: home with services
Medications on Admission:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
2. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO q4h PRN as needed
for pain.
3. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day for 4
weeks: goal INR 2.0-2.5
adjust dose accordingly.
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig:
15-30 MLs PO Q6H (every 6 hours) as needed for Dyspepsia.
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
8. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO BID (2 times a day) as needed for Constipation.
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
10. Multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
11. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q4H (every 4 hours) as needed for
wheeze.
12. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
13. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
15. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): hold for SBP<110.
16. Clobetasol 0.05 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
17. Desonide 0.05 % Cream Sig: One (1) Appl Topical DAILY
(Daily).
18. Triamcinolone Acetonide 0.025 % Cream Sig: One (1) Appl
Topical DAILY (Daily).
19. Ketoconazole 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
Discharge Medications:
1. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 2 days.
Disp:*2 Tablet(s)* Refills:*0*
2. Coumadin 1 mg Tablet Sig: Three (3) Tablet PO once a day for
14 days.
Disp:*42 Tablet(s)* Refills:*0*
3. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6
hours) as needed for pain.
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
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. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
7. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
8. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation four times a day as needed for shortness of
breath or wheezing.
12. Advair Diskus 100-50 mcg/Dose Disk with Device Sig: One (1)
inhalation Inhalation twice a day.
13. Prednisone 10 mg Tablet Sig: as directed Tablet PO once a
day for 10 days: Take 5 tab for 2 days([**Date range (1) 25385**]), take 4 tab
for 2 days ([**Date range (1) 25386**]), take 3 tab for 2([**2073-2-25**]), take 2 tab
for 2 days([**Date range (1) 25387**]), take 1 tab for 2 days([**Date range (1) 25388**]).
Disp:*30 Tablet(s)* Refills:*0*
14. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
Disp:*15 Tablet(s)* Refills:*0*
15. Outpatient Lab Work
Please have INR drawn twice a week starting on Thursday [**2164-2-23**] and have results called in to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 1228**]
who should call you with instructions on how to change the
coumadin dosing.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary:
Community Acquired Pneumonia
COPD flare
Iron deficient anemia
Supratherapeutic INR
.
Secondary:
bronchiectasis
anxiety
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - requires assistance or aid (walker
or cane)
Discharge Instructions:
You were admitted because of difficulty breathing which required
you to be admitted to the intensive care unit overnight. We
believe this was secondary to a pneumonia and possible
exacerbation of your chronic lung disease. You were given
antibiotics for the infection and steroids to help with the
inflammation. You slowly improved and we were able to get you
off oxygen.
.
Medication changes:
1)We started you on an antibiotic called levaquin which you
should take for 2 more days.
2)You iron was increased to twice a day.
3)We started you on prednisone with decreasing doses over the
next 10 days.
4)We started compazine if you have any nausea.
.
You should have your INR drawn and Thursday by the visiting
nurses.
.
Please keep all your follow up appontments.
.
If you develop any of the warning signs below or any other
concerning symptoms, please do not hesitate to call or your PCP
or go to your local emergency room.
Followup Instructions:
You have an appointment with Dr [**First Name8 (NamePattern2) **] [**Name (STitle) **] on Wednesday,
[**2-29**] at 10:40am. [**Telephone/Fax (1) 24396**]. Please have him follow up
your anemia.
Provider: [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3260**], [**MD Number(3) 3261**]:[**Telephone/Fax (1) 1228**]
Date/Time:[**2164-2-24**] 10:20
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9052**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2164-3-2**] 11:00
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2164-4-19**] 11:10
Completed by:[**2164-2-22**]
|
[
"494.0",
"790.92",
"E934.2",
"300.00",
"491.21",
"V43.65",
"V15.82",
"280.9",
"238.71",
"V10.42",
"486"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11311, 11368
|
4790, 7461
|
275, 281
|
11540, 11540
|
2719, 4767
|
12667, 13360
|
1889, 1903
|
9331, 11288
|
11389, 11519
|
7487, 9308
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11717, 12093
|
1918, 2700
|
12113, 12644
|
228, 237
|
309, 1230
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11554, 11693
|
1252, 1598
|
1614, 1873
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,265
| 182,166
|
35514
|
Discharge summary
|
report
|
Admission Date: [**2181-3-5**] Discharge Date: [**2181-3-8**]
Date of Birth: [**2119-7-4**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5119**]
Chief Complaint:
Rectal cancer admittted for elective laproscopic sigmoid
colostomy.
Major Surgical or Invasive Procedure:
Laproscopic sigmoid colostomy
History of Present Illness:
61 yo M with h/o CMML, nephrotic syndrome, penile squamous cell
in situ, presents for semi-elective diverting loop iliostomy for
newly diagnosed, partially obstructing rectal squamous cell
carcinoma.
.
Pt was recently hospitalized for hypoxia and rectal pain. He was
diagnosed with RSV pneumonia and rectal mass was biopsied
confirming a poorly differentiated squamous cell carcinoma of
the anus. He also developed and was treated for C difficile
colitis. Pt was discharged home, with follow up with radiation
oncology, heme onc and surgery. He returned today for diverting
loop ileostomy.
.
Surgery was technically successful with minimal amount of blood
loss. Due to worsening acidosis, pt was not extubated and was
thus transferred to the [**Hospital Unit Name 153**] for furthur monitoring.
.
Unable to obtain further ROS as pt intubated and sedated.
Past Medical History:
1) poorly differentiated squamous carcinoma of the anus, unable
to obtain anal PAP
2) Chronic metamyelocitic leukemia - Diagnosed in [**2178**] and
managed conservatively managed by Dr. [**Last Name (STitle) **] at [**Hospital1 2025**]. Possibly
secondary to cyclophosphamide exposure in treatement of
Nephrotic syndrome.
3) Nephrotic Syndrome with membranous nephropathy, bx proven per
report. Baseline creatinine 2.8. He was treated with Cytoxan
and prednisone for approximatelyfive years, but has had no
treatment for the past four to five years.
4) Hypertension
5) Diverticulosis
6) Colonic polypectomy
7) Status post right inguinal hernia
8) Vasectomy
9) Penile implant for erectile dysfunction
10) RSV pneumonia
11) C difficile colitis
12) Squamous cell carcinoma in situ on the skin of the penis
completely excised on [**2176-5-15**], by Dr. [**Last Name (STitle) **] at [**Hospital1 2025**];
squamous
cell carcinoma with focal superficial invasion of the skin of
the
penis completely excised on [**2180-9-22**], by Dr. [**Last Name (STitle) **].
Social History:
He lives with his wife and quit smoking twelve years ago but has
a 2 to 3 pack-per-day history x 35 years. He drinks [**12-22**] glasses
of wine nightly. Regarding employment, he works as an insurance
broker. All four of his children live nearby.
Family History:
Father had lung cancer. No family history of hematological
malignancies.
Physical Exam:
T=... BP= 147/68 HR= 103 RR=... O2= 98%
.
.
PHYSICAL EXAM
GENERAL: Pleasant, well appearing ..... in NAD
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No
LAD, No thyromegaly.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**]. JVP=
LUNGS: CTAB, good air movement biaterally.
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout. [**12-22**]+ reflexes,
equal BL. Normal coordination. Gait assessment deferred
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
Lactate: 2.4->0.8
ABGs 7.24/40/180; 7/12/50/215; 7.26/34/124
WBC 21.4 (30 on discharge on [**2-28**] on hydroxyurea)
HCT 25.5 (27.7 on [**2-28**])
PLT 533 (recently 90s-200s)
.
.
STUDIES:
Echocardiogram [**2181-2-8**]: LVEF 55%, 1+ TR, 1+ MR
.
V/Q scan [**2181-2-17**]: multiple subsegmental matched perfusion
defects, no unmatched perfusion defects, indeterminant result
.
Renal U/S [**2181-2-12**]: normal appearing kidneys
.
[**2-23**] MRI pelvis: IMPRESSION:
1. The anal tumor appears to extend into the distal-most rectum
for approximately the anterior margin through the left lateral
margin. There appears to be involvement of the levator muscle on
the left as well as possibly the prostate.
2. 6-mm iliac chain lymph node.
3. Bone marrow signal abnormality likely reflecting the
patient's underlying leukemia.
.
Brief Hospital Course:
Mr [**Known lastname **] is a 61 yo M with h/o CMML, nephrotic syndrome, penile
squamous cell in situ, who presented for semi-elective diverting
loop ileostomy for newly diagnosed, partially obstructing rectal
squamous cell carcinoma whom required persistent intubation for
acidosis.
.
#. Acidosis: Pt had acidosis post op. He was initially
transferred to the MICU for close monitoring. ABGs with pH
nadir at 7.12 in setting of rising CO2. Such drop is more than
to be expected due to simply chronic renal disease and acute
respiratory acidosis due to vent settings. Cause was likely
multifactorial: 1) Renal insufficiency with baseline bicarb
18-20, non anion gap acidosis; 2) Bowel prep likely decreased
bicarb to 15; 3) Increased dead space due to pulmonary disease
(DLVA elevated, expired CO2 during surgery showed Dead/V 40%)
causes "usual" settings to cause CO2 retaining. No acute changes
in expired CO2 thus do not expect operative PE as etiology of
increased dead space; 4) Perioperative lactic acid elevation
also contributed with tiny anion gap elevation. Monitored q4h
ABGs to ensure improvement back to pt's baseline (~7.35/35/18).
Once pt ventilated on his own pt's acid-base status fixed on his
own. The patient was transferred to the medicine floor and his
respiratory status remained stable. He was discharged off of
oxygen with his oxygen saturations at their baseline.
.
#. Rectal Cancer The patient had a laparoscopic sigmoid
colostomy. A port was placed by surgery on [**2181-3-8**] so that for
future chemotherapy as an outpatient. The patient will follow
up with his primary oncologist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4223**] in [**Location (un) **]
for radiation and chemotherapy. The patient's pain was minimal
during his hospitalization. He was given a prescription for
oral Dilaudid at discharge. He was instructed not to drive when
taking these medications. Patient was instructed on ostomy care
in the hospital. He will have VNA services at home. Patient
was instructed to follow up with his surgeon Dr. [**Last Name (STitle) 80876**] in [**1-23**]
weeks.
.
#. C. diff colitis: The patient recently completed a course of
Flagyl. He did not have any evidence of high frequency ostomy
output and did not have any fevers.
.
#. CMML: The patient's hydroxyurea was held as it is know to
have an effect on post op healing and infection risk. This
medication is used to control the patient's WBC count and off
the medication it rose to 25. The surgical team talked to the
pt's oncologist and he felt it was okay to hold hydroxyurea
until Monday [**3-12**]. The patient will have his CBC checked on
Monday with the results sent to his oncologist Dr. [**First Name (STitle) 4223**].
Further treatment will be determined by Dr. [**First Name (STitle) 4223**]
.
# Chronic Renal Insufficiency: The patient's' Cr remained at
baseline (~3) due to membranous nephropathy.
.
# EMERGENCY CONTACT: Mrs. [**Name (NI) 1123**] [**Name (NI) 57495**], wife, Phone:
[**Telephone/Fax (1) 80862**], [**Name2 (NI) **] Phone: [**Telephone/Fax (1) 80863**]
.
# DISPOSITION: Patient was discharge home his VNA services.
Medications on Admission:
1. Finished metronidazole 500 mg PO Q8H on [**2181-3-4**]
2. Megestrol 400 mg/10 mL PO DAILY
3. Hydroxyurea 500 mg PO twice a day.
Discharge Medications:
1. Megace Oral 400 mg/10 mL Suspension Sig: One (1) PO once a
day.
2. Dilaudid 2 mg Tablet Sig: 0.5-1 Tablet PO q4-6h prn as needed
for pain.
Disp:*10 Tablet(s)* Refills:*0*
3. Outpatient Lab Work
Please check CBC. Send results to patient's oncologist - Dr.
[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 4223**] Fax # [**Telephone/Fax (1) 80877**]
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 6136**] VNA
Discharge Diagnosis:
-Rectal cancer s/p laproscopic sigmoid colostomy.
-Post-operative acidosis likely multifactoral in nature related
to chronic renal insufficiency, bowel preparation, and underling
lung disease.
Discharge Condition:
Good
Discharge Instructions:
-Do not resume hydroxyurea until monday. Hydroxyurea can
interfere with post-operative wound healing and infection. The
surgeons discussed this with your oncologist Dr. [**First Name (STitle) 4223**].
-Take dilaudid as needed for pain.
-Have your CBC checked on Monday with the results sent to Dr. [**Name (NI) 6588**] office.
-Follow up with your oncologist, general surgery and you PCP.
[**Name10 (NameIs) **] call tomorrow and arrange these appointments.
-Return to ED if you experiecne worsening pain, nausea/vomiting,
fefvers/chills, are unable to eat or have any other worrisome
signs/symptoms.
.
Monitoring Ostomy output/Prevention of Dehydration:
-Keep well hydrated.
-Replace fluid loss from ostomy daily.
-Avoid only drinking plain water. Include Gatorade and/or other
vitamin drinks to replace fluid.
-Try to maintain ostomy output between 1000mL to 1500mL per day.
-If Ostomy output >1 liter, Call Dr. [**Last Name (STitle) 1120**]. You may be advised
to take 4mg of Imodium, repeat 2mg with each episode of loose
stool. Do not exceed 16mg/24 hours.
Followup Instructions:
-Follow up with Dr, [**Name (NI) 80876**] in General Surgery clinic within [**1-23**]
weeks. Please call [**Telephone/Fax (1) 160**] to arrange this appointment.
-Follow up with your oncologist Dr. [**First Name (STitle) 4223**] as scheduled.
-Arrange follow up with your PCP regarding this hospitalization
and your chronic medical issues.
[**First Name7 (NamePattern1) 1569**] [**Initial (NamePattern1) **] [**Name8 (MD) **] MD [**MD Number(2) 5122**]
Completed by:[**2181-3-9**]
|
[
"205.10",
"562.10",
"285.9",
"276.2",
"403.90",
"V10.49",
"581.1",
"496",
"585.4",
"V15.82",
"V12.72",
"154.1",
"V45.89",
"287.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"46.03",
"93.90",
"54.21"
] |
icd9pcs
|
[
[
[]
]
] |
8196, 8251
|
4420, 7591
|
381, 413
|
8488, 8495
|
3574, 4397
|
9609, 10121
|
2662, 2737
|
7773, 8173
|
8272, 8467
|
7617, 7750
|
8519, 9586
|
2752, 3555
|
273, 343
|
441, 1298
|
1320, 2378
|
2394, 2646
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,890
| 175,598
|
39134
|
Discharge summary
|
report
|
Admission Date: [**2183-7-19**] Discharge Date: [**2183-8-26**]
Date of Birth: [**2157-10-31**] Sex: F
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5167**]
Chief Complaint:
Status post fall from standing position
Major Surgical or Invasive Procedure:
EEG
History of Present Illness:
25 yo female history of seizures and depresison found at bottom
of stairs with positive blood bilateral tympanic membrane. Ct
with basilar skull fx with / extension into the right carotid
canal and possible facial nerve injury. Pt intubated in ED for
worsened MS [**First Name (Titles) **] [**Last Name (Titles) **]. + emesis of blood.
25 year old right handed female with a history of
generalized epilepsy (since age 8 currently on zonegran and
topamax with increasing seizures over the past year),
depression,
anxiety, ADD, who was admitted 1 day [**7-19**] ago following a fall 4
feet
down stairs onto her face and a 2 minute generalized seizure.
Per [**Last Name (LF) **], [**Known firstname **] was an ex FT girl with generalized epilepsy
since age 8 treated with depakote form age 8 until 24 with less
than 1 seizure per year until the past year. She has had about
10 seizures in the past year. She follows with Dr. [**First Name4 (NamePattern1) 714**]
[**Last Name (NamePattern1) **] in [**Hospital1 1559**], MA and in [**4-15**] started to wean off of
depakote. Keppra was tried but stopped because it worsened her
depression. Lamictal was tried with depakote but caused more
seizures. She did not have adequate control with lamictal alone
either. In [**2183-3-10**] was hospitalized with a reportedly
normal EEG and changed medications rapidly. She has been on
zonegran and topamax since [**2183-3-10**]. Dose of topamax
decreased because of weight loss and she comes in with only 25
mg
PO QD. She is on zonegran 300mg PO BID. Seizures have always
been
worsened by sleep deprivation and alcohol use. Typical seizures
per mother are always characterized by starting with stuttering
speech, falls, loss of consciousness with extremity shaking
without incontinance. She is confused afterwards and tired and
sleeps for 15 minutes to an hour.
On [**2183-7-9**] [**Known firstname **] had a generalized tonic clonic seizure at
her group home while she was smoking outside. She was taken to
the [**Hospital1 18**] ED and found to be postictal and later discharged home
to follow up with her Neurologist.
On [**2183-7-19**] around 6 pm her friend [**Name (NI) **] (who is present
today) witnessed her walking normally and then fell down stairs
outside about 4 feet onto her face. She was then noted to have
stiffening of her arms and legs and convulse for two minutes.
She
was covered with blood and EMS was called and arrived after 6
minutes. No alcohol recently per friend and father. Reported to
be taking her medications.
She was brought to the ED, had a CT head revealing IPH, SAH,
basilar skull fractures. She was loaded with dilantin,
intubated,
seen by Neurosurgery, and admitted to the ICU. CTA imaging
completed. She was extubated this [**7-20**] am and as not had
further
seizures.
Past Medical History:
Seizure disorder
Depression
Anxiety
ADHD
Social History:
Per mother, pt has a hx of polysubstance abuse, unclear when
first started using or what recent use has been like. Per
mother, has abused alcohol, stimulants, benzos, ecstacy, MJ in
the past. Has also noted pt has had "drug-seeking" in the past
with different providers. Unknown if pt has had any hx of
withdrawal phenomena.
Recently started smoking. In group home for the past
100 days secondary to depression. Was initially in the Babcock
home and recently advanced to the Gateway area where she can
function more independently. Per father when living at home
would
drink [**4-10**] glasses of wine 1x/month. Occasional marijuana use per
father. Graduated from Catholic [**Location (un) **] in DC. Was working at
[**Company 86694**] in [**Location (un) 7349**] until 1 yar ago.
Family History:
cousin with seizures
Physical Exam:
Initial Exam:
Gen: Patient intubated, sedated. NAD
Periorbital ecchymosis with multiple scattered abrasions
Ear: Two lacerations of antihelix, one of helix, 3 cm laceration
on the posterior auricular region. Patient with hematoma above
poas[**Name (NI) **] auricular laceration.
Maxilla stable.
Nose: Stable nasal bone, no active bleeding
CTA bilateral lung fields
Cardiac RRR's
Abdomen: Soft, no tender, no distended.
EXT: no edema, bilateral pulses positive
Pertinent Results:
[**2183-7-19**] 05:55PM BLOOD WBC-8.4 RBC-4.78 Hgb-14.5 Hct-42.6 MCV-89
MCH-30.4 MCHC-34.1 RDW-12.9 Plt Ct-298
[**2183-7-19**] 09:22PM BLOOD Glucose-103* UreaN-12 Creat-0.9 Na-136
K-3.7 Cl-102 HCO3-21* AnGap-17
[**2183-7-20**] 05:02PM BLOOD Glucose-106* UreaN-8 Creat-0.6 Na-142
K-3.5 Cl-111* HCO3-21* AnGap-14
[**2183-7-22**] 07:05AM BLOOD Glucose-93 UreaN-4* Creat-0.5 Na-140
K-3.7 Cl-106 HCO3-23 AnGap-15
[**2183-7-26**] 06:00AM BLOOD Glucose-101* UreaN-13 Creat-0.6 Na-136
K-3.9 Cl-103 HCO3-21* AnGap-16
[**2183-7-19**] 09:22PM BLOOD Calcium-8.6 Phos-4.0 Mg-2.0
[**2183-7-20**] 05:02PM BLOOD Calcium-8.0* Phos-3.2 Mg-1.9
[**2183-7-22**] 07:05AM BLOOD Calcium-8.5 Phos-2.1* Mg-1.9
[**2183-7-19**] 08:05PM BLOOD Type-ART Rates-12/ Tidal V-400 PEEP-5
FiO2-50 pO2-235* pCO2-44 pH-7.32* calTCO2-24 Base XS--3
-ASSIST/CON Intubat-INTUBATED
[**2183-7-20**] 02:38AM BLOOD Type-ART pO2-268* pCO2-42 pH-7.34*
calTCO2-24 Base XS--2
[**2183-7-29**] 04:20AM BLOOD WBC-6.8 RBC-4.42 Hgb-13.0 Hct-38.4 MCV-87
MCH-29.5 MCHC-33.9 RDW-13.4 Plt Ct-334
[**2183-7-27**] 05:25AM BLOOD WBC-8.9 RBC-4.06* Hgb-11.8* Hct-35.2*
MCV-87 MCH-29.1 MCHC-33.6 RDW-13.4 Plt Ct-329
[**2183-7-26**] 06:00AM BLOOD WBC-9.9 RBC-4.40 Hgb-12.7 Hct-37.6 MCV-85
MCH-28.8 MCHC-33.8 RDW-13.3 Plt Ct-338
[**2183-7-24**] 06:55AM BLOOD WBC-11.5* RBC-4.63 Hgb-13.6 Hct-40.6
MCV-88 MCH-29.5 MCHC-33.6 RDW-13.0 Plt Ct-299
[**2183-7-22**] 07:05AM BLOOD WBC-14.1* RBC-3.74* Hgb-11.1* Hct-33.5*
MCV-90 MCH-29.7 MCHC-33.2 RDW-12.8 Plt Ct-216
[**2183-7-21**] 02:18AM BLOOD WBC-18.8* RBC-3.68* Hgb-10.6* Hct-32.2*
MCV-87 MCH-28.9 MCHC-33.1 RDW-13.0 Plt Ct-228
[**2183-7-20**] 02:25AM BLOOD WBC-21.0* RBC-4.12* Hgb-12.5 Hct-36.7
MCV-89 MCH-30.3 MCHC-34.1 RDW-13.0 Plt Ct-250
[**2183-7-19**] 09:22PM BLOOD WBC-24.7*# RBC-4.52 Hgb-13.2 Hct-39.2
MCV-87 MCH-29.3 MCHC-33.7 RDW-12.8 Plt Ct-319
[**2183-7-19**] 05:55PM BLOOD WBC-8.4 RBC-4.78 Hgb-14.5 Hct-42.6 MCV-89
MCH-30.4 MCHC-34.1 RDW-12.9 Plt Ct-298
[**2183-7-27**] 05:25AM BLOOD Neuts-81.4* Lymphs-13.8* Monos-3.7
Eos-0.9 Baso-0.3
[**2183-7-19**] 09:22PM BLOOD Neuts-92.7* Lymphs-5.4* Monos-1.6*
Eos-0.1 Baso-0.2
[**2183-7-29**] 04:20AM BLOOD Plt Ct-334
[**2183-7-27**] 05:25AM BLOOD Plt Ct-329
[**2183-7-27**] 05:25AM BLOOD PT-12.0 PTT-26.3 INR(PT)-1.0
[**2183-7-26**] 06:00AM BLOOD Plt Ct-338
[**2183-7-24**] 06:55AM BLOOD Plt Ct-299
[**2183-7-22**] 07:05AM BLOOD Plt Ct-216
[**2183-7-21**] 02:18AM BLOOD Plt Ct-228
[**2183-7-20**] 02:25AM BLOOD Plt Ct-250
[**2183-7-19**] 05:55PM BLOOD Fibrino-288
[**2183-7-29**] 04:20AM BLOOD
[**2183-7-26**] 06:00AM BLOOD
[**2183-7-24**] 06:55AM BLOOD
[**2183-7-22**] 07:05AM BLOOD
[**2183-7-29**] 04:20AM BLOOD Glucose-89 UreaN-10 Creat-0.5 Na-133
K-3.9 Cl-97 HCO3-24 AnGap-16
[**2183-7-27**] 05:25AM BLOOD Glucose-96 UreaN-11 Creat-0.5 Na-134
K-3.9 Cl-101 HCO3-22 AnGap-15
[**2183-7-26**] 06:00AM BLOOD Glucose-101* UreaN-13 Creat-0.6 Na-136
K-3.9 Cl-103 HCO3-21* AnGap-16
[**2183-7-24**] 06:55AM BLOOD Glucose-105* UreaN-7 Creat-0.5 Na-137
K-3.8 Cl-101 HCO3-22 AnGap-18
[**2183-7-22**] 07:05AM BLOOD Glucose-93 UreaN-4* Creat-0.5 Na-140
K-3.7 Cl-106 HCO3-23 AnGap-15
[**2183-7-21**] 02:18AM BLOOD Glucose-101* UreaN-6 Creat-0.6 Na-139
K-3.6 Cl-109* HCO3-20* AnGap-14
[**2183-7-20**] 05:02PM BLOOD Glucose-106* UreaN-8 Creat-0.6 Na-142
K-3.5 Cl-111* HCO3-21* AnGap-14
[**2183-7-20**] 02:25AM BLOOD Glucose-101* UreaN-11 Creat-0.8 Na-136
K-3.8 Cl-102 HCO3-21* AnGap-17
[**2183-7-19**] 09:22PM BLOOD Glucose-103* UreaN-12 Creat-0.9 Na-136
K-3.7 Cl-102 HCO3-21* AnGap-17
[**2183-7-29**] 04:20AM BLOOD ALT-21 AST-13 LD(LDH)-169 AlkPhos-75
TotBili-0.2
[**2183-7-20**] 02:25AM BLOOD CK(CPK)-318*
[**2183-7-19**] 05:55PM BLOOD Lipase-29
[**2183-7-29**] 04:20AM BLOOD Calcium-9.4 Phos-3.9 Mg-1.9
[**2183-7-27**] 05:25AM BLOOD Calcium-9.0 Phos-3.3 Mg-1.7
[**2183-7-26**] 06:00AM BLOOD Calcium-8.9 Phos-4.0 Mg-1.9
[**2183-7-24**] 06:55AM BLOOD Calcium-9.2 Phos-4.0# Mg-1.8
[**2183-7-20**] 05:02PM BLOOD Osmolal-290
[**2183-7-30**] 04:20AM BLOOD Phenoba-32.3
[**2183-7-29**] 04:20AM BLOOD Phenoba-28.9
[**2183-7-27**] 05:25AM BLOOD Phenoba-17.3
[**2183-7-26**] 04:25PM BLOOD Phenoba-9.3*
[**2183-7-26**] 06:00AM BLOOD Valproa-52
[**2183-7-25**] 12:50PM BLOOD Valproa-55
[**2183-7-25**] 01:13AM BLOOD Valproa-37*
[**2183-7-22**] 07:05AM BLOOD Phenyto-10.7
[**2183-7-19**] 09:22PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2183-7-19**] 05:55PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2183-7-20**] 02:38AM BLOOD Type-ART pO2-268* pCO2-42 pH-7.34*
calTCO2-24 Base XS--2
[**2183-7-19**] 08:05PM BLOOD Type-ART Rates-12/ Tidal V-400 PEEP-5
FiO2-50 pO2-235* pCO2-44 pH-7.32* calTCO2-24 Base XS--3
-ASSIST/CON Intubat-INTUBATED
[**2183-7-20**] 02:38AM BLOOD Glucose-113* Lactate-0.8
[**2183-7-19**] 06:14PM BLOOD Glucose-100 Lactate-1.7 Na-140 K-3.3*
Cl-102 calHCO3-20*
[**2183-7-20**] 02:38AM BLOOD freeCa-1.19
[**2183-8-1**] 04:15AM BLOOD WBC-7.0 RBC-4.19* Hgb-12.6 Hct-36.9
MCV-88 MCH-30.1 MCHC-34.2 RDW-13.4 Plt Ct-332
[**2183-7-31**] 04:20AM BLOOD WBC-9.7 RBC-4.32 Hgb-13.1 Hct-38.3 MCV-89
MCH-30.3 MCHC-34.2 RDW-13.1 Plt Ct-433
[**2183-8-1**] 04:15AM BLOOD Plt Ct-332
[**2183-7-31**] 04:20AM BLOOD Plt Ct-433
[**2183-7-31**] 04:20AM BLOOD Neuts-82.5* Lymphs-13.8* Monos-3.0
Eos-0.4 Baso-0.3
[**2183-8-1**] 04:15AM BLOOD Glucose-88 UreaN-7 Creat-0.7 Na-138 K-3.9
Cl-103 HCO3-25 AnGap-14
[**2183-7-31**] 04:20AM BLOOD Glucose-90 UreaN-9 Creat-0.7 Na-138 K-3.8
Cl-102 HCO3-28 AnGap-12
[**2183-7-19**] 05:55PM BLOOD Fibrino-288
[**2183-8-1**] 04:15AM BLOOD
[**2183-8-1**] 04:15AM BLOOD Glucose-88 UreaN-7 Creat-0.7 Na-138 K-3.9
Cl-103 HCO3-25 AnGap-14
[**2183-7-31**] 04:20AM BLOOD Glucose-90 UreaN-9 Creat-0.7 Na-138 K-3.8
Cl-102 HCO3-28 AnGap-12
[**2183-8-1**] 04:15AM BLOOD ALT-24 AST-21
[**2183-8-4**] 05:25AM BLOOD Phenoba-32.6 Valproa-62
[**2183-8-2**] 06:00AM BLOOD Phenoba-29.0 Valproa-59
[**2183-8-1**] 04:15AM BLOOD Phenoba-32.7
[**2183-7-31**] 04:20AM BLOOD Phenoba-35.0 Valproa-40*
[**2183-7-30**] 04:20AM BLOOD Phenoba-32.3
[**2183-7-29**] 04:20AM BLOOD Phenoba-28.9
[**2183-7-27**] 05:25AM BLOOD Phenoba-17.3
[**2183-7-26**] 04:25PM BLOOD Phenoba-9.3*
[**2183-7-26**] 06:00AM BLOOD Valproa-52
[**2183-7-25**] 12:50PM BLOOD Valproa-55
[**2183-7-25**] 01:13AM BLOOD Valproa-37*
[**2183-7-22**] 07:05AM BLOOD Phenyto-10.7
[**2183-7-20**] 02:38AM BLOOD Glucose-113* Lactate-0.8
[**2183-7-19**] CT HEAD: HISTORY: Patient with seizure and trauma.
TECHNIQUE: Contiguous axial images were obtained through the
brain. No
intravenous contrast was administered.
COMPARISON: No prior.
FINDINGS: There are bilateral basal temporal lobe contusions,
(2:9). There
are linear foci of hyperdensity, (2:14), along the left
convexity in the
frontoparietal region, concerning for focal area of a
subarachnoid hemorrhage.
There is preserved [**Doctor Last Name 352**]-white matter differentiation. There is
no extension
of the hemorrhage within the ventricles. There is no shift of
midline
structures. There is no subfalcine or uncal herniation.
There is hyperdense material within the right maxillary sinus,
and sphenoid
sinus, concerning for blood, with fluid in the ethmoid air
cells.
There is an extensive fracture at the base of the skull.
Primarily, there is
a longitudinal right temporal bone fracture extending in the
middle ear cavity
with resultant ossicular disruption. There is fluid within the
mastoid air
cells on the right, and fluid in the external auditory canal on
the right,
presumed hemorrhage. A component of the fracture extends as a
small depressed
fracture fragment of the right squamous temporal bone, (3:15),
with foci of
pneumocephalus in the area. The fracture is extending further in
the right
carotid canal, and posterior aspect of the right pterygopalatine
fossa, (3:5),
likely into the right orbital apex. Fracture is involving the
sphenoid
sinuses, extending through sella turcica, (3:15), involving the
anterior left
anterior clinoid process. There is a locule of air in the
retroorbital,
extraconal fat lateral to the left lateral rectus muscle,
(3:12). Although no
definite fracture line is seen, there is a presumed fracture of
the left
orbit. A separate component of the right temporal bone fracture
extends
through the right basiocciput extending through the occipital
protuberance
into the left occipital bone. Foci of air seen in the transverse
sinuses.
Additionally, there is a longitudinal fracture through the left
temporal bone,
with no apparent left ossicular disruption. There is fluid
within left mastoid
air cells. There is a possible fracture of the left lateral
pterygoid plate.
IMPRESSION:
1. Bilateral foci of basal temporal lobe contusions.
2. Focal subarachnoid hemorrhage at the left temporoparietal
region.
3. No subfalcine or uncal herniation. Preserved [**Doctor Last Name 352**]-white
matter
differentiation.
4. Foci of pneumocephalus and foci of air in the transverse
sinus.
5. Fluid in the mastoid air cells and fluid in the external
auditory canals
bilaterally, presumed hemotympanum.
6. Blood in the right maxillary sinus and sphenoid sinus.
7. Extensive basal skull fractures, as described in detail in
the body of the
report.
[**7-19**]: CXRAY/PELVIS: IMPRESSION: Within limitations, no traumatic
injury of the chest or pelvis noted.
[**7-19**]: CT sinus:
IMPRESSION:
1. Hyperdense fluid in the right maxillary sinus, ethmoid air
cells and
sphenoid sinus, in keeping with hemorrhage.
2. Focus of air lateral to the lateral rectus muscle on the left
in the
extraconal fat and even though no underlying fracture is seen,
concern for
fracture due to underlying findings.
3. Extensive basal skull fracture better detailed on
accompanying head CT
report. CTA of the head and neck was recommended to evaluate for
vessel
injury given involvement of right carotid canal. Findings were
discussed with the trauma team.
CT C/A/P: FINDINGS:
CT CHEST: Airways are patent up to subsegmental level. There are
predominantly left lower lobe foci of ground-glass opacity, for
example (2:20,
2:28, 2:33), concerning for foci of aspiration. A separate
isolated focus is
seen in the right upper lobe. There is no pleural effusion.
There is no
pneumothorax. Patient has a residual thymus tissue. There is no
evidence of
lymphadenopathy according to size criteria in the mediastinum,
hilum, or
axilla. Vessels are of normal caliber. Heart size is normal.
There is no
pericardial effusion.
CT ABDOMEN: The liver enhances homogeneously with no evidence of
focal liver lesion, or injury. The gallbladder is normal. There
is no extra- or intra- hepatic biliary duct dilatation. The
spleen is unremarkable. The pancreas, loops of large and small
bowel, and adrenal glands appear unremarkable. There is no bowel
obstruction. There is no free fluid or free air. The kidneys
enhance symmetrically and excrete contrast symmetrically with no
evidence of hydronephrosis. Focal area of hypodensity in the
interpolar region of the right kidney, (2:57), too small to
characterize, could be small cysts. No retroperitoneal or
mesenteric lymphadenopathy.
CT PELVIS: The urinary bladder, uterus, loops of large and small
bowel appear unremarkable. There is no free fluid in the pelvis.
Patient has IUD in place.
OSSEOUS STRUCTURES: No evidence of fracture.
IMPRESSION: Subtle bilateral focal ground-glass opacities
concerning for
aspiration.
TECHNIQUE: CT C-spine without contrast. Coronal and sagittal
reformats.
COMPARISON: No prior.
FINDINGS: There is preserved alignment of the cervical spine.
The vertebral body height is preserved. There is no evidence of
fracture in the C-spine. There is isolated degenerative disc
disease at level C6-C7, with posterior disc osteophyte complex,
impinging anteriorly on the thecal sac with no significant canal
stenosis. Anterior osteophytes are incidentally noted at this
level as well, (501B:25). There is no prevertebral soft tissue
hematoma. Extensive basal skull fracture better detailed on
accompanying head CT report.
IMPRESSION:
1. No fracture in the cervical spine.
2. Isolated degenerative disc disease at C6-C7.
3. Extensive basal skull fracture better detailed on
accompanying head CT from the same day, [**2183-7-19**].
CTA HEAD [**7-19**]
CLINICAL INDICATION: 26-year-old woman with possible carotid
impingement,
skull base fractures.
COMPARISON: Prior CT of the head and cervical spine dated [**7-19**], [**2183**], and also prior CT of the maxillofacial structures
performed concurrently.
TECHNIQUE: Initial non-contrast images through the brain were
obtained
followed by angiographic phase images through the head after
administration of intravenous contrast material, multiplanar
reconstructions through the head and neck were acquired.
FINDINGS: The initial non-contrast images through the brain
again
demonstrates right temporal intraparenchymal hemorrhage, stable
in size and configuration. A small 4-mm hyperdensity medially
appears more apparent in this examination. The left temporal
lobe extra-axial collection has increased in size from 9 to 13
mm. Persistent extra-axial lentiform collection overlying the
left convexity appear slightly larger, measuring approximately
10 mm. No significant midline shifting is identified; however,
there is diffuse effacement of the sulci, possibly reflecting
brain edema. The perimesencephalic cisterns are patent. Complex
skull fractures remain unchanged, please see prior report of
[**2183-7-19**] for further details, opacities of the ethmoid and
maxillary sinuses remain stable.
The angiographic phase images demonstrate vascular enhancement
in the major arterial vascular structures with no flow, stenotic
lesions or aneurysms larger than 2 mm in size, no dissection or
filling defects are demonstrated. The patient is intubated. ET
and NG tubes are in place. Unchanged opacity of the right
maxillary and sphenoid sinuses, there is patchy ethmoidal
mucosal thickening. Small amount of pneumocephalus is identified
adjacent to the right temporal lobe, related with the previously
described skull base fractures.
IMPRESSION: Enlargement of the previously described subarachnoid
hemorrhage with stable right temporal intraparenchymal
hemorrhage, unchanged complex skull base fractures, see prior
report of [**2183-7-19**] for further details. Persistent
opacities of the ethmoid and maxillary sinuses and also sphenoid
sinus. The vascular structures appear patent with no flow
stenotic lesions, aneurysms, or evidence of dissection.
EEG [**7-21**]: IMPRESSION: This video EEG telemetry captured no
pushbutton
activations. No electrographic seizures were seen. Interictally,
some
broad-based bifrontal sharp waves were seen, suggesting the
possibility of underlying epileptogenesis in those regions. The
background did reach a normal alpha rhythm during wakefulness
but had
bursts of generalized slowing quite frequently and multifocal
regions of
intermittent slowing were also seen. These findings together
suggest
the presence of multiple regions of subcortical dysfunction
including
deep midline brain dysfunction.
EEG [**7-22**]: IMPRESSION: This video EEG telemetry captured no
pushbutton
activations. No electrographic seizures or interictal
epileptiform
discharges were seen. The background was disorganized and
frequently
slow during the day's recording with both generalized bursts of
slowing,
runs of bifrontal monomorphic slowing, and multiple regions of
intermittent focal slowing. These findings together suggest the
presence of a mild encephalopathy with deep midline brain
dysfunction
and multiple areas of subcortical dysfunction.
EEG [**7-23**]: IMPRESSION: This telemetry captured no clear ongoing
seizure activity; however, the background activity alternated
between relatively normal slightly slow background with focal
slowing in the right fronto-central area and markedly abnormal
background of more rhythmic delta and theta activity sometimes
with accompanying sharp waves. Although, at times, this activity
was rhythmic, it did not have a clear onset, offset, or
progression to suggest an equivocal electrographic seizure.
Interictally, there were spike and polyspike and wave activity
in a
generalized distribution with right frontal predominance.
EEG [**7-24**]: IMPRESSION: This telemetry captured a clear clinical
electrographic seizure which seemed to start bifrontally with a
right predominance and had an asymmetric offset with continuous
rhythmic activity only in the left hemisphere. There were
additional electrographic seizures seen in a generalized
distribution lasting for several seconds with no clear clinical
correlate. Interictally, there was abundant epileptic activity
of spike and wave in a generalized distribution with right
predominance and sometimes in runs of discharges. The background
activity was slow suggestive of encephalopathy.
EEG [**7-25**]:IMPRESSION: This telemetry captured no pushbutton
activations; however, the EEG activity showed frequent
interictal epileptic activity and electrographic seizures in a
generalized distribution. The background
activity was slow suggestive of encephalopathy.
EEG [**7-26**]: IMPRESSION: This telemetry captured no clear clinical
seizures;
however, it did capture rhythmic delta activity with intermixed
sharp
waves which may suggest electrographic seizure activity as well
as
interictal generalized sharp waves. The background activity was
slow
suggestive of encephalopathy.
EEG [**7-27**]: IMPRESSION: This telemetry captured no clear ongoing
seizure activity; however, it did capture numerous periods of
rhythmic generalized delta activity especially when the patient
was aroused from sleep. It also
captured many generalized sharp discharges. The background
activity was
slow suggestive of encephalopathy.
SKULL AND FACIAL BONE RADIOGRAPHS OF [**2183-7-27**].
INDICATION: Seizures.
Exam is technically limited by the presence of a multitude of
electrodes
overlying the skull and obscuring bone detail. Questionable
partial
opacification of the left frontal sinus on one of two views
could be
projectional as it is not confirmed on both projections.
However, given the limitations of the current study, a CT should
be considered if there is strong clinical suspicion for acute
facial bone or skull injury. If CT is performed, emoval of the
electrodes prior to the procedure would be helpful to avoid
artifacts, if feasible clinically.
EEG [**7-28**]: IMPRESSION: This telemetry captured no pushbutton
activations and no clear ictal epileptiform activity.
Interictally, there were generalized sharp waves with bifrontal
predominance. The background activity alternated between
semi-rhythmic delta waves and a more lower voltage intermixed
beta and theta activity.
MR [**Name13 (STitle) **]:
INDICATION: 25-year-old woman with facial nerve palsy and
temporal bone
fracture. Please assess facial nerve.
COMPARISON: CT of the head from [**2183-7-19**].
TECHNIQUE: CISS sequences through the internal auditory canal
and temporal
bones were obtained axially, sagittally on the right and left,
and axial T1 fat saturated images through the temporal bones
were also obtained. The
patient was disoriented and the entire study could not be
completed.
FINDINGS: The study is limited by motion artifacts.
The T1 fat saturated images demonstrate the previously noted
left and right temporal intraparenchymal contusions, the
left-sided subdural hematoma, and patchy areas of subarachnoid
hemorrhage in the imaged portion of the cranium. There is high
signal along the anterior right middle cranial fossa, which
appears to be another area of subdural hematoma. Please refer to
earlier dedicated head studies for a complete description of
intracranial findings.
There is also high signal on the T1W fat-saturated images in the
right
transverse sinus. This sinus demonstrated air on a prior head
CT, indicating disruption in the setting of the known skull base
fractures. Focal thrombosis cannot be excluded.
In addition, there is high T1 signal within the mastoid air
cells bilaterally, and extending anteromedially on the right to
the sphenoid sinus, which is completely opacified. This
corresponds to blood related to known temporal bone and skull
base fractures. The cisternal and canalicular segments of the
facial nerve appear normal. Due to the mastoid opacification,
the temporal segments including the tympanic, mastoid, and
labyrinthine segments as well as the geniculate ganglion cannot
be adequately evaluated.
The inner ear structures are normal in signal.
IMPRESSION:
1. Limited evaluation of the facial nerves due to blood in the
mastoids. No evidence of cisternal or canalicular abnormalities
of the seventh cranial nerves bilaterally. A CT of the temporal
bones would be beneficial to determine if the known fractures
through the facial nerve canals.
2. Extensive intracranial hemorrhage, as seen on prior head CTs.
3. High T1 signal along the right transverse sinus in an area of
known
fracture raises the possibility of focal thrombosis. An MRV or
CTV may be
valuable for further evaluation.
[**7-30**]: EEG IMPRESSION: This telemetry captured five pushbutton
activations for agitation with no electrographic correlate.
There was no ongoing
seizure activity seen in this recording. There were some
generalized
sharp waves with bifrontal predominance. The background activity
was
slow suggestive of a mild to moderate encephalopathy.
[**7-30**]: EKG Sinus tachycardia. Otherwise, normal tracing. Since
the previous tracing of [**2183-7-22**] sinus tachycardia is now
present.
[**7-31**]: EEG IMPRESSION: This telemetry captured no pushbutton
activations and no ictal epileptiform activity. Interictally,
there were generalized sharp waves with bifrontal predominance.
The background activity was slow
suggestive of a moderate encephalopathy.
[**8-1**]: IMPRESSION: This telemetry captured three pushbutton
activations for no clear clinical seizures and with no EEG
correlate. Interictally, there
were sharp waves seen bifrontally, sometimes with a right
predominance.
There was no clear ongoing seizure activity seen in this
recording.
There was right central slowing suggestive of subcortical
dysfunction in
this region. The background activity was slow suggestive of a
mild to
moderate encephalopathy.
[**8-2**]: EEG IMPRESSION: This telemetry captured one pushbutton
activation for unclear reasons with no change in the background
activity. There were
numerous entries in the seizure files for generalized as well as
more
localized rhythmic theta and delta activity in the right central
area
with no clinical correlate. There were sharp waves seen
bifrontally
with a right predominance and the background activity was slow
suggestive of a moderate encephalopathy.
[**8-3**]:IMPRESSION: This telemetry captured no pushbutton
activations and no
ongoing seizure activity or clinical seizures; however,
interictally,
there were sharp waves seen bifrontally sometimes with a right
predominance and there were times when the background activity
became
more rhythmic in the theta and delta range of frequencies with
no
clinical correlate. The background activity was slow suggestive
of a
moderate encephalopathy with additional focal slowing in the
right
central area suggestive of subcortical dysfunction in that
region
CXRAY [**8-4**]:
REASON FOR EXAM: Fever.
Cardiomediastinal contours are normal. The lungs are clear.
There is no
pneumothorax or pleural effusion.
IMPRESSION: No evidence of acute cardiopulmonary abnormality.
Brief Hospital Course:
EVENTS while on the Trauma service:
[**7-19**]: patient was admitted to TSICU, facial nerve at least
partially functioning, plastics sutured the left pinna.
CT head showed increase intraparenchymal hematoma, CTA negative,
carotids intact .
Transiently asymmetric pupils
CXR: ETT 3 cm above carina, NGT in stomach.
CT C-SPINE:extensive basal skull fx better; cspine neg for fx or
malalignment; isolated degenerative disk disease at C6-7
CT TORSO: no evidence of trauma on CT torso
CT SINUS:extensive skull base fracture, right max and sphenoid
sinus hyperdense material, blood
CT HEAD: Bilateral contusions in the brain,and foci of SAH along
left convexity. No hydrocephalus. Blood in right maxillary
sinus.
[**7-20**]: Patient was extubated
CT head: Stable Rbtem IPH, with more apparent small 4-mm focus
medially. Left temporal extra-axial collection has increased in
size from 9 to 13 mm.
[**7-21**]: S/S eval. Psych called. HSQ. EEG ordered. Patient was
transfer to floor.
[**7-22**]: Decrease mental status, patient had CT scan head, it
showed slight interval increase in right temporal parenchymal
blood products, without increased mass effect. Stable size of
extra-axial blood products along the left convexity.
[**7-24**]: Three generalized tonic clonic seizures.
Epilepsy Service Course:
# Neuro: Course noted on the trauma team as above. On [**2183-7-24**]
she had three generalized tonic clonic seizures. She was given
ativan x 1, loaded with depakote 650 mg IV, and started on
depakote 500 mg [**Hospital1 **]. She was transferred to the Epilepsy service
on [**2183-7-25**] and placed on LTM. EEG showed nonconvulsive status
epilepticus and she was started on phenobarbital and the EEG
quieted down. Levels are as listed above. We decided to wean the
depakote [**7-28**] and as we weaned the medication she developed an
encephalopathy/acute delirium on [**7-29**]. Delirium was likely
multifactorial in that she had received ativan for an MRI, sleep
wake cycle broken, and depakote weaned. The depakote was
restarted for mood stabilization. She remained encephalopathic
for two days [**Date range (1) 86695**] and then cleared. During that time we
used trazadone 25 mg at night to sleep. She did not repspond
well to seroquil and this should be avoided. We also used
zyprexa 2.5 mg one time. Psychiatry was following closely and we
avoided benzos. Regarding her AEDS, home low dose of topamax was
discontinued and she was continued on zonisamide 300 mg PO BID
(home medication). Dilantin was used for two days post injury
but then stopped. She was on on phenobarbital 60mg PO BID,
trough level was 32.6 on [**2183-8-4**] and when she became febrile
with a rash it was stopped on [**2183-8-5**]. She is on depakote 500
mg PO BID for mood stabilization and the level on [**8-4**] was 62.
She was felt to be ready for discharge on [**8-6**], however,
developed cyclic fevers, skin rash, sore throat, transammonitis,
and eosinophilia. A broad infectious workup, including formal ID
consult, was pursued, however, in the end, it was felt that the
constellation of symptoms and lab findings were consistent with
an adverse response to zonisimide. Zonisamide was stopped, and
the symptoms and lab findings resolved over about a week.
Gabapentin was added to her regimen for added seizure control.
This was chosen due to its kidney clearance and the team's
reluctance to start a new anticonvulsant cleared by the liver
while her LFT's were elevated. Keppra was reported to have side
effects in the past for her. Though she was also covered with
some standing Ativan, patient had a seizure 6 days after
stopping zonisamide. At that point, the standing Ativan was
increased in dose, and both Depakote and Gabapentin were
increased. About 5 days after this, a new diffuse skin rash
developed, which was felt to be due to either the Gabapentin or
Cymbalta that had been started for her depression in the last
few days. Thus both Cymbalta and Gabapentin were discontinued.
Dermatology was consulted and the plan was to treat the rash
symptomatically with benadryl, atarax, and Sarna lotion. The
rash has continued to reslove and on [**8-22**] the patient was able
to be discharged with close follow up with an epileptologist,
psychiatrist, Physical therapist, and neuro cognitive. The
plan is to reintroduce seizure and psychiatric medications after
30 days following most recent drug reaction.
Also to note [**Known firstname 86696**] facial droop has been improving daily. On
[**2183-8-26**] [**Known firstname **] was medically stable and able to go home.
# CV: She had periods of tachycardia with agitation and also
with walking. Orthostatics were normal. Tachycardia responded to
IVF. EKG only showed sinus tach.
# ID: Was febrile to 101 on [**8-4**]. Overnight on [**8-5**] was febrile
to 103.4. U/A and CXRAY negative. No WBC count. Blood culture
was NGTD. Developed erythematous rash thought to be possibly be
drug fever and phenobarbital was stopped. She defervesced with
tylenol and motrine. Was on ciprofloxacin ear drops for her
hospital course. EBV titers were negative for an acute
infection.
#F/E/N: Tolerating Regular diet. LFTS elevated on [**8-5**] and
trazadone stopped. LFT's have continued to trend down after
stopping Zonisamide.
# Psych: Period of delirium improved with resuming depakokte,
resuming sleep-wake cycle with trazadone at night and lowering
phenobarbital dose which is now stopped. Pscyh closely followed
inpatient given history of ADD, anxiety, and depression. They
also followed for acute delirium. Case discussed with
psychiatrist at rehab by our inpatient psychiatrist. Many of her
psych meds from home have not been resumed yet given
encephalopathy. The Duloxetine was restarted and then stopped
after rash developed.
# Plastics: Saw the patient for suturing of her ear and
posteriorly. Sutures removed on [**2183-7-25**] and also on [**2183-8-6**].
# ENT:She had MRI imaging to further evaluate her facial nerve
injury but it was a limited evaluation of the facial nerves due
to blood in the mastoids. No
evidence of cisternal or canalicular abnormalities of the
seventh cranial
nerves bilaterally. A CT of the temporal bones would help us
visualize the nerve
and this is being arranged for [**2183-9-4**] when she will also
follow up with Neurosurgery for a CT head. There was a High T1
signal along the right transverse sinus in an area of known
fracture raising the possibility of focal thrombosis, but when
CTV from admission reviewed this corresponds to an area of
decreased flow and she is not thought to have a thrombosos. A
CTV will be repeated with above imaging on [**2183-9-4**] to
better view this area. An audiology exam noted bilaterall
hearing loss. ENT was made aware and will repeat as out patient.
Follow up in Epilepsy, Neurosurgery, ENT, Neurology, Psychiatry,
Neurocognitive, PT, and therapy has been arranged.
Follow up in the [**Hospital 4695**] Clinic with Dr. [**First Name (STitle) **] as scheduled
with a Non Contrast Head CT; Patient should also have a CTV and
CT temporal bone at that time.
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2183-9-4**] 2:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8364**], MD Phone:[**Telephone/Fax (1) 1669**]
Date/Time:[**2183-9-4**] 3:00
Follow up in [**Hospital **] clinic with Dr. [**Last Name (STitle) 3878**] in [**4-10**] weeks for
audiogram; ( Appt: [**2183-9-1**] at 9:00am.
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 437**], Epilepsy
Provider: [**First Name11 (Name Pattern1) 1216**] [**Last Name (NamePattern4) 1217**], MD Phone:[**Telephone/Fax (1) 2928**]
Date/Time:[**2183-10-20**] 8:30 Location [**Hospital Ward Name 23**] 5.
Outpt Epileptologist:[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] requesting DC summ sent to
her: fax [**Telephone/Fax (1) 86697**]
[**Hospital1 **] Neuro-psych: [**2183-9-30**], [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
OT/PT: [**Name (NI) 620**]: [**2183-8-29**], 12pm, call [**Telephone/Fax (1) 86698**]
Medications on Admission:
1. Adderall 10 qpm
2. Adderral XR 30 mg q am
3. Cymbalta 30 q am/ 60 q am
4. Klonipin 1 mg [**Hospital1 **]
5. Topamax 25 mg qam
6. Trazadoe 100 qhs
7. Zonegam 300 mg [**Hospital1 **]
8. Ativan 1 mg Po for oncoming seizure and post seizure.
9. Benadryl 25 mg q4
9. Dulcolax 100 qd
10.Ibuprofen 600mg q 6
11.Melatonin 5mg qhs
12.Tyelenol 100 q4h prn.
Discharge Medications:
White Petrolatum-Mineral Oil 56.8-42.5 % Ointment Sig: One (1)
Appl Ophthalmic PRN (as needed) as needed for dry eyes.
Divalproex 500 mg Tablet Sustained Release 24 hr Sig: 1 [**2-8**]
Tablet Sustained Release 24 hr PO BID (2 times a day).
Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*2*
Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: 1-2 Drops
Ophthalmic PRN (as needed) as needed for dry eyes.
Ciprofloxacin 0.3 % Drops Sig: Five (5) Drop Ophthalmic TID (3
times a day) for 7 days.
Lorazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for itching.
Disp:*50 Tablet(s)* Refills:*0*
8. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H
(every 6 hours) as needed for itch, insomnia.
9. Petrolatum Ointment Sig: One (1) Appl Topical TID (3
times a day) as needed for pruritis.
Discharge Disposition:
Home
Discharge Diagnosis:
Seizure
Left subarachnoid hemorrhage
Right intraparenchymal hemorrhage
Bilateral temporal lobe contusions
Basilar skull fracture
Secondary diagnosis:
Seizure disorder
Resolved delirium
Facial nerve palsy
Discharge Condition:
Mental Status: Clear and coherent. Oriented and Somewhat
perseverative.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were hospitalized following being found down and having a
seizure; as a result you sustained bleeding injury to your brain
and fractures of your skull bone. Your injuries did not require
any surgeries but there was concern given your seizure history.
Neurology was closely involved in your care and several
adjustments of your medications were made.
You were transferred to the Epilepsy service during your
admission. You are now on Zonisamide 300 mg twice daily. You are
also on depakote 500 mg twice a day.
Please take all medications and go to all follow up
appointments. You are being discharged to rehab and follow up
studies will need to be done.
Followup Instructions:
Follow up in the [**Hospital 4695**] Clinic with Dr. [**First Name (STitle) **] as scheduled
with a Non Contrast Head CT; Patient should also have a CTV and
CT temporal bone at that time.
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2183-9-4**] 2:00
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2183-9-4**] 2:15
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8364**], MD Phone:[**Telephone/Fax (1) 1669**]
Date/Time:[**2183-9-4**] 3:00
Follow up in [**Hospital **] clinic with Dr. [**Last Name (STitle) 3878**] in [**4-10**] weeks for
audiogram; ([**Telephone/Fax (1) 7767**] for an appointment. Appt: [**2183-9-1**] at 9:00am.
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 437**], Epilepsy
Provider: [**First Name11 (Name Pattern1) 1216**] [**Last Name (NamePattern4) 1217**], MD Phone:[**Telephone/Fax (1) 2928**]
Date/Time:[**2183-10-20**] 8:30 Location [**Hospital Ward Name 23**] 5.
After discharge from rehab, please follow up with Dr. [**Last Name (STitle) **]
as well. Please call the office for an appointment.
Completed by:[**2183-9-4**]
|
[
"385.89",
"916.0",
"780.61",
"345.10",
"372.72",
"300.4",
"348.30",
"351.0",
"790.6",
"872.01",
"461.9",
"314.01",
"910.0",
"E939.0",
"E936.3",
"375.15",
"801.20",
"693.0",
"E937.0",
"722.4",
"921.2",
"293.0",
"E880.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31",
"97.38",
"96.04",
"18.4",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
37614, 37620
|
28128, 28706
|
357, 363
|
37869, 37869
|
4592, 10990
|
38764, 39944
|
4073, 4095
|
36656, 37591
|
37641, 37771
|
36280, 36632
|
38082, 38741
|
4110, 4573
|
278, 319
|
391, 3195
|
28881, 36254
|
37792, 37848
|
37884, 38058
|
3217, 3259
|
3275, 4057
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,690
| 174,261
|
30010
|
Discharge summary
|
report
|
Admission Date: [**2136-5-11**] Discharge Date: [**2136-5-15**]
Date of Birth: [**2054-6-10**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
angina for one day, in back, and anteriorly as well as abd. pain
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
81 yo male presented to OSH with abd. pain radiating to his
back. Also had a fever with temp of 103. He described pain as
intermittent,pulsating, and gripping with associated SOB. CT
scan at OSH suggestive of intramural hematoma of aorta.
Transferred here for further management.
Past Medical History:
Abd. aortic aneurysm
HTN
? bronchitis
PSH: none
Social History:
widowed, lives with son
quit smoking 3 years ago ( unclear as to amount)
no ETOH
Physical Exam:
T 97.2 HR 78 SR with freq. PVCs 106/53 RR 18 3L NC sat
100%
awake, uncomfortable, poor historian, but oriented
neuro grossly non-focal
RRR, no rub or murmur
BS clear with scattered wheezes
+ BS, initially firm to palpation associated with pain. but
subsequently soft and NT
extrems warm, knees mottled
fem 1+ bil., popl. NP, 1+ bil/ DP/PT, 2+ bil. radials
Pertinent Results:
[**2136-5-10**] 11:45PM BLOOD WBC-20.0* RBC-3.13* Hgb-10.0* Hct-28.8*
MCV-92 MCH-31.8 MCHC-34.7 RDW-14.2 Plt Ct-118*
[**2136-5-12**] 04:42AM BLOOD WBC-16.4* RBC-2.68* Hgb-8.6* Hct-24.0*
MCV-90 MCH-32.2* MCHC-35.9* RDW-14.4 Plt Ct-92*
[**2136-5-10**] 11:45PM BLOOD Neuts-62 Bands-25* Lymphs-3* Monos-10
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2136-5-10**] 11:45PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2136-5-12**] 04:42AM BLOOD Plt Ct-92*
[**2136-5-10**] 11:45PM BLOOD Glucose-138* UreaN-31* Creat-2.6* Na-139
K-3.5 Cl-103 HCO3-22 AnGap-18
[**2136-5-12**] 04:42AM BLOOD Glucose-153* UreaN-39* Creat-2.4* Na-136
K-3.4 Cl-100 HCO3-27 AnGap-12
[**2136-5-11**] 08:04AM BLOOD ALT-11 AST-24 LD(LDH)-238 AlkPhos-44
Amylase-23 TotBili-0.7
[**2136-5-11**] 08:04AM BLOOD Lipase-8
[**2136-5-10**] 11:45PM BLOOD CK-MB-5 cTropnT-0.02*
[**2136-5-11**] 08:04AM BLOOD Calcium-7.6* Phos-2.4* Mg-1.6
[**2136-5-14**] 05:25AM BLOOD Vanco-12.7
[**2136-5-10**] 11:51PM BLOOD Lactate-2.8*
RADIOLOGY Final Report
ESOPHAGUS [**2136-5-11**] 9:27 AM
ESOPHAGUS
Reason: R/O esophageal perforation, use thin barium
Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
81 year old man with
REASON FOR THIS EXAMINATION:
R/O esophageal perforation, use thin barium
HISTORY: 81-year-old male with probable infected aortic
hematoma. Evaluate for esophageal perforation.
Comparison is made to prior CT examination dated earlier on same
day.
ESOPHAGRAM.
Multiple thin sips of Optiray contrast was administered followed
by thin barium. No abnormal extravasation of contrast is noted
outside of the esophageal lumen, which displayed normal primary
peristaltic contractions and diffuse tertiary contractions. No
evidence of hiatal hernia or reflux is noted on this limited
exam. Contrast and thin barium was noted to pass freely through
the esophagus into the stomach.
IMPRESSION:
No evidence of esophageal perforation.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
DR. [**First Name8 (NamePattern2) 7722**] [**Last Name (NamePattern1) 7723**]
Approved: FRI [**2136-5-11**] 2:14 PM
RADIOLOGY Final Report
CTA CHEST W&W/O C&RECONS, NON-CORONARY [**2136-5-11**] 12:49 AM
CTA CHEST W&W/O C&RECONS, NON-; CTA ABD W&W/O C & RECONS
Reason: please characterize aorta
Field of view: 36 Contrast: VISAPAQUE
[**Hospital 93**] MEDICAL CONDITION:
81 year old man with known AAA and ? thoracic hematoma
REASON FOR THIS EXAMINATION:
please characterize aorta
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 81-year-old with known AAA and chest pain radiating
to the back, evaluate for dissection.
COMPARISONS: None.
TECHNIQUE: Axial MDCT images of the chest, abdomen, and pelvis
with and without 90 cc of nonionic Visipaque contrast. Please
note that despite the patient's elevated creatinine of 2.6, the
ED and the covering vascular surgery team thought that the study
with emergent enough to rule out a type A dissection for which
contrast was warranted. The risks and benefits were discussed
with the patient prior to the study.
CT VASCULAR: On the non-contrast images, there is an extensive
type B aortic intramural hematoma, extending from the takeoff of
the left subclavian artery, to just proximal to the celiac axis.
There is a tiny linear area of non- enhancement involving the
arch distal to the takeoff of the left subclavian, which could
represent a very early dissection flap. There is a large
penetrating ulcer involving the proxiaml descending thoracic
aorta. Additionally, there is a large amount of air within the
aortic wall at this level and also at several other locations in
the abdominal aorta. Specifically, there is prominent air
involving the posterior aortic wall just inferior to the renal
artery takeoff. another focus involving the anterior aortic wall
just inferior to this. Finally, there is air seen within the
proximal right common iliac artery. Note is made of stenosis at
the celiac artery origin. The SMA and [**Female First Name (un) 899**] are widely patent.
CTA CHEST WITH IV CONTRAST: There are small bilateral pleural
effusions and atelectasis. The heart, pericardium, and great
vessels are unremarkable. There is no evidence of hematoma
within the mediastinum nor pericardium. There is trace coronary
artery calcification. This nongated study does not provide
optimal evaluation of the coronary arteries. The pulmonary
arteries enhance normally.
CT ABDOMEN WITH IV CONTRAST: Hypodense lesion in segment III of
the liver anteriorly, likely a cyst or hemangioma but not fully
characterized. Small hyperenhancing lesion in segment VII. There
is left-sided intrahepatic biliary ductal dilatation and mild
prominence of the extrahepatic common duct. The native kidneys
are minimally atrophic. The spleen, pancreas, adrenal glands,
stomach, and proximal bowel are unremarkable.
CT PELVIS WITH IV CONTRAST: No acute abnormalities are seen in
the pelvis. There are bilateral fat-containing inguinal hernias.
Evaluation of the osseous structures demonstrates only diffuse
degenerative changes.
MULTIPLANAR REFORMATS: Coronal and sagittal reformatted images
confirm the above findings. There is diffuse atherosclerotic
disease throughout the abdominal aorta. There is a large
infrarenal aortic aneurysm, measuring up to 5 cm in sagittal AP
dimension.
IMPRESSION:
1) Extensive type B aortic intramural hematoma, extending from
the origin of the left subclavian artery to the upper abdominal
aorta. No definite aortic dissection, however, there is a tiny
linear hypodensity involving the mid aortic arch medially, which
may be the very beginning of an aortic dissection flap.
2) Multiple foci of air within the aortic wall, highly
suspicious for multifocal mycotic aneurysms, the most prominent
in the proximal descending aorta adjacent to the large
pseudoaneurysm/penetrating ulcer, likely the origin of the
patient's intramural hematoma.
3) No colonic lesion or evidence of diverticulitis to account
for the aortic wall air, though colonoscopy may be considered
after the patient is stabilized.
4) 5-cm infrarenal aortic abdominal aneurysm.
5) Moderate left-sided intrahepatic biliary ductal dilatation.
6) Hyperenhancing segment VII and hypodense segment III hepatic
lesions, not fully characterized on this study, the former could
be further assessed by MRI.
Findings were discussed immediately after the study with the
covering cardiothoracic surgery fellow, Dr. [**Last Name (STitle) 71624**].
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 21884**]
Approved: FRI [**2136-5-11**] 3:57 PM
Brief Hospital Course:
Admitted to CSRU from ER on [**5-11**] early AM and re-scanned
urgently. Results showed the infrerenal AAA as well as a Type B
intramural hematoma. Also noted were multiple foci of intramural
air consistent with a possible mycotic process, and a
penetrating ulcer of the thoracic aorta ( please see above
results of study). ID consult requested and pt. started on
triple antibiotic therapy with blood cultures and RPR sent.
Thoracic and vascular surgery also consulted as well as Dr.
[**Last Name (STitle) 914**] from CT surgery. Not a candidate for open repair of TAA
per vascular, but endo stent-grafting would be considered if
aorta further dilates of symptoms worsened. General surgery also
evaluated patient, with no change in plan for abx therapy and BP
control. Gram positive rods grew from blood cultures with
diagnosis of clostridium aortitis. Barium swallow did not reveal
any fistula.
High-risk surgery was discussed with the pt. and his family.
They refused surgery and opted for medical therapy. The pt. also
declined possible intubation and requested he not be
resuscitated. Pt. requested comfort measures only. PICC line
placed for continued abx therapy. Transferred to the floor on
[**5-12**]. Fentanyl patch and morphine continued for pain/palliative
care. BS coarse throughout on [**5-14**] with increasing somnolence.
Throughout the night, he became more hypotensive and
unresponsive to fluid therapy.
He did not appear to be in distress. At 5AM, he had cessation of
pulse, heart sounds and respirations. He was pronounced expired
by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
Medications on Admission:
HCTZ
lisinopril
(doses unknown)
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Mycotic Thoracoabdominal Aneurysm
HTN
Discharge Condition:
expired
Completed by:[**2136-5-15**]
|
[
"458.9",
"585.9",
"440.0",
"573.8",
"403.90",
"441.02",
"041.83"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
9856, 9871
|
8147, 9774
|
385, 393
|
9953, 9991
|
1273, 2444
|
3740, 3795
|
9892, 9932
|
9800, 9833
|
887, 1254
|
281, 347
|
3824, 8124
|
421, 702
|
724, 774
|
790, 872
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,485
| 191,428
|
21784
|
Discharge summary
|
report
|
Admission Date: [**2138-10-15**] Discharge Date: [**2138-10-30**]
Date of Birth: [**2084-1-28**] Sex: F
Service: VSURG
Allergies:
Zestril
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
[**2138-10-16**] Exploratory Laparotomy, Lysis of Adhesions, Small Bowel
Resection for Necrotic Bowel secondary to likely closed loop
obstruction
History of Present Illness:
HPI: 54 yo female presents to ED c/o cp and abdominal pain. Pt
relates that she was eating dinner last night when she
experienced a sudden onset of chest pain which radiates to the
back and the abdomen. Pt relates that she has never had this
happen before. Upon closer exam pt states that pain was always
abdominal. Pt given Morphine in ED which helped pain but Nitro
did not. Pt [**Name (NI) **] she has not had a BM since yesterday but
recalls that the have in black the past 2 days, but denies frank
blood in stool. Reports "dry heaves" last night prior to
presenting to ED.
Past Medical History:
ESRD on HD since [**5-/2138**]
HTN secondary to bilateral renal artery stenosis
Peripheral Vascular Disease
Congestive Heart Failure
Paroxysmal A fib
Pulmonary HTN
Pericardial effusion and pericarditis
CAD, EF of 40%
Past Surgical History:
Aorto-bifem at [**Hospital1 756**] [**5-/2138**], right renal artery stent, open
chole, ? appy at time of chole, right great toe amp [**9-/2138**],
pericardial window
Social History:
Works as resturant manager, 20+ pk year smoking history (No
smoking in last 7 years), Denies Etoh or Recreational drug use.
Family History:
Father deceased MI [**86**] yo, Mother deceased old age 83 yo, 2
brothers deceased from MI before 60 yo. Sister with MI.
Physical Exam:
VS: 6.9 90 138/76 100% 2l
Gen: WD, WN, A&Ox3 laying on side in pain
Cardiac: Tachycardic with regular rhythm, no rubs or gallops
without radiation to carotids. Heart was not palpably enlarged.
Chest: CTAB no w/r/c, no costophrenic tenderness
Abdom: Decreased BS x4, soft with tenderness most intensly over
suprapubic region, mild rigidity here, no ascities or
hepatosplenomegaly
GU: Guiac negative, minmally stool in the vault
Extremities: No c/c, 1+ pitting edema of the LE b/l. Right
hallux incision site minimally erythematous without signs of
hematoma or dehiscence.
Neuro: CN II-XII intact, cerebellar function intact. Grip
strength 4/5 b/l with weakness of right arm extensors. Gait not
tested
Pertinent Results:
[**2138-10-15**] 09:21PM CK(CPK)-27
[**2138-10-15**] 09:21PM CK-MB-NotDone cTropnT-0.30*
[**2138-10-15**] 12:33PM CK(CPK)-34
[**2138-10-15**] 12:33PM CK-MB-NotDone cTropnT-0.31*
[**2138-10-15**] 12:33PM CALCIUM-9.5 PHOSPHATE-3.5 MAGNESIUM-1.6
[**2138-10-15**] 05:30AM GLUCOSE-97 UREA N-9 CREAT-2.2* SODIUM-139
POTASSIUM-3.8 CHLORIDE-98 TOTAL CO2-32* ANION GAP-13
[**2138-10-15**] 05:30AM ALT(SGPT)-14 AST(SGOT)-19 LD(LDH)-265*
CK(CPK)-27 ALK PHOS-130* AMYLASE-59 TOT BILI-0.3
[**2138-10-15**] 05:30AM LIPASE-17
[**2138-10-15**] 05:30AM cTropnT-0.30*
[**2138-10-15**] 05:30AM CK-MB-NotDone
[**2138-10-15**] 05:30AM ALBUMIN-2.6*
[**2138-10-15**] 05:30AM WBC-11.2* RBC-3.18* HGB-10.1* HCT-32.4*
MCV-102* MCH-31.7 MCHC-31.0 RDW-18.4*
[**2138-10-15**] 05:30AM NEUTS-86.1* LYMPHS-9.8* MONOS-3.5 EOS-0.3
BASOS-0.2
[**2138-10-15**] 05:30AM HYPOCHROM-3+ ANISOCYT-2+ POIKILOCY-1+
MACROCYT-3+
[**2138-10-15**] 05:30AM PLT COUNT-262
[**2138-10-15**] 05:30AM PT-14.2* PTT-24.0 INR(PT)-1.3
CT- Angiogram Abdomen: 1. No evidence of aortic dissection, 2)
Large pericardial effusion, 3) Extensive atherosclerotic disease
within the abdominal aorta with short- segment occlusion of the
proximal superior mesenteric artery with distal reconstitution.
The [**Female First Name (un) 899**] is not seen and the proximal celiac axis appears patent.
No secondary signs of bowel ischemia. 4) Bilateral renal artery
stenosis. Patent aortic pypass graft. 5). Left-sided pleural
effusion with associated atelectasis.
Brief Hospital Course:
The patient was admitted to the hospital on [**2138-10-15**]. She was
taken emergently to the operating room for an exploratory
laparotomy where an acute closed loop small bowel
obstruction with bowel infarction and chronic superior
mesenteric artery thrombosis were found. Postoperatively she
was admittd to the ICU and treated with broad spectrum
antibiotics. In the perioperative period, she had a significant
fluid requirement. Given her ESRD, she was started on CVVH, but
effective dialysis was not possible secondary to hemodynamic
instability. She developed A-Fibb. chemical cardioversion was
successful with Amiodarone and esmolol. She underwent
angiography on [**2138-10-17**] with SMA stenting. Over the ensuing 12
day, the patient was gently dialyzed on CVVH and kept
approximately 1 liter negative a day. Vasopressor support was
gradually weaned and completely stopped by the evening of
[**2138-10-29**]. Her ventiliatory support was gradually weaned to CPAP
w/ PS with excellent gases. Despite her continued slow
improvement, the patient developed sudden onset asystole at
approximately 1615 on [**2138-10-30**]. The patient was resuscitated
according to ACLS protocol. Despite exhaustive efforts to
resuscitate the patient, all efforts proved futile with the
development of persistent asystole. Death was declared at
16:57.
Medications on Admission:
Marinol 2.5mg'
Trazadone 50mg'prn
Protonix 40mg'
ASA 81mg'
Folate 1mg'
Zinc 220mg''
Lipitor 10mg'
A,opdarpme 200po'
Advair 250/50''
Discharge Disposition:
Extended Care
Facility:
Patient Expired
Discharge Diagnosis:
Closed Loop Intestinal Obstruction
Superior Mesenteric Artery Occlusion
ESRD on HD since [**5-/2138**]
HTN secondary to bilateral renal artery stenosis
Peripheral Vascular Disease
Congestive Heart Failure
Paroxysmal A fib
Pulmonary HTN
Pericardial effusion and pericarditis
Coronary Artery Disease
Cardiac Arrythmia
Respiratory Failure
Septic Shock
Cardiogenic Shock
Discharge Condition:
Expired
|
[
"038.9",
"567.2",
"403.91",
"427.31",
"428.0",
"557.0",
"518.81",
"560.81",
"997.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.42",
"38.86",
"39.50",
"99.04",
"38.95",
"88.72",
"96.72",
"88.47",
"39.90",
"99.15",
"54.59",
"45.62",
"96.04",
"99.60"
] |
icd9pcs
|
[
[
[]
]
] |
5566, 5608
|
4032, 5384
|
282, 429
|
6019, 6029
|
2484, 4009
|
1625, 1747
|
5629, 5998
|
5410, 5543
|
1299, 1468
|
1762, 2465
|
228, 244
|
457, 1037
|
1059, 1276
|
1484, 1609
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,114
| 196,847
|
23200
|
Discharge summary
|
report
|
Admission Date: [**2149-11-2**] Discharge Date: [**2149-11-14**]
Service: NSU
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 59656**] is an 84-year-old
gentleman with multiple medical problems including dementia,
total knee infection, a recent adynamic ileus, hypertension,
and chronic renal insufficiency who presented today with a
change in mental status.
Early on the morning of admission, the patient was in a
nursing home and noted to have increasing somnolence and was
taken to an outside hospital. A head computer tomography at
the outside hospital was read as a right frontal subdural,
and he was transferred to [**Hospital1 188**]. He has no history of trauma. No nausea or vomiting.
He did have a history of a head trauma in [**Month (only) 216**].
PAST MEDICAL HISTORY: Adynamic ileus and constipation
(recently hospitalized and treated with rectal tubes and
bowel regimen), urinary tract infection (treated with seven
days of levofloxacin scheduled to end on approximately
[**11-6**]), also status post a left total knee with
postoperative infection, and revision of hemiarthrosis on
[**2149-10-21**], dementia (although was ambulating until his
knee problems), chronic renal insufficiency, hypertension,
benign prostatic hypertrophy, degenerative joint disease,
pyloric channel ulcer secondary to nonsteroidal
antiinflammatory drugs, and iron deficiency anemia.
MEDICATIONS ON ADMISSION: Dulcolax 10 mg three times daily,
iron 325 mg twice daily, Arixtra 2.5 subcutaneously once
daily, Levaquin 250 mg once daily (until [**11-6**]),
multivitamin once daily, Protonix 40 mg once daily, Miramax
17 grams once daily, Seroquel 25 mg in the morning and 12.5
mg at bedtime, Colace 100 mg twice daily, Senokot two in the
evening, and Milk of Magnesia as needed.
ALLERGIES: He has no known drug allergies.
SOCIAL HISTORY: A nursing home resident. No history of
smoking or alcohol abuse.
PHYSICAL EXAMINATION ON PRESENTATION: Vital signs revealed
his temperature was 97.9, his heart rate was 78, his blood
pressure was 117/62, his respiratory rate was 18, and 92
percent on room air. He was in no apparent distress. He was
awake, alert, and oriented times two. He knew his name and
knew he was in [**Location (un) 86**] and it was late Fall. He was some
cachectic. Heart revealed a regular rate and rhythm. The
lungs were clear to auscultation bilaterally. The abdomen
was minimally distended and nontender. Occasional bowel
sounds. On neurologic examination, he was awake, alert, and
oriented times two. He followed commands. Cranial nerves II
through XII were intact. The face was symmetrical. The
pupils were equal, round, and reactive to light and
accommodation. The extraocular movements were full. He did
have some left pronator drift. Strength was [**3-23**] bilaterally
in the upper and lower extremities. Reflexes were 2 plus at
triceps, knees, and plantar's were flexor. Sensation was
grossly intact to light touch. Extremities showed the left
knee to have positive hemarthrosis and staples intact.
LABORATORY DATA ON PRESENTATION: His laboratories at the
time of admission revealed sodium was 146, potassium was 3,
chloride was 106, bicarbonate was 32, blood urea nitrogen was
21, creatinine was 1.1, and blood sugar was 106. White blood
cell count was 7.7, his hematocrit was 31.9, his platelets
were 258. Prothrombin time was 14.2, partial thromboplastin
time was 31, and his INR was 1.3.
RADIOLOGY: He did have a CAT scan done here that did show
approximately a 1.5-cm subdural hematoma in the right frontal
region without edema or shift.
SUMMARY OF HOSPITAL COURSE: The patient was admitted to
Neurosurgery in the Intensive Care Unit to be followed
closely neurologically. He was loaded with Dilantin for
seizure prophylaxis. His blood pressure parameters were to
keep him less than 140 and to transfuse with fresh frozen
plasma to get an INR of less than 1.3. He had an arterial
line placed for blood pressure management and an Orthopaedic
consultation to evaluate his knee.
The patient was seen by Orthopaedics who did recommend to
check lower extremity Doppler studies to rule out a deep
venous thrombosis and to consider inferior vena cava filter
placement. They did not feel he was appropriate for going to
the Operating Room for incision and debridement. He was
treated with intravenous antibiotics for six weeks, and they
did not recommend intravenous antibiotic treatment at this
time. They did recommend gentle range of motion exercises
with physical therapy.
Neurologically, he continued to be awake and alert. He was
following commands. A repeat head computer tomography was
stable, and he was transferred to the stepdown unit where he
continued to be monitored with every one hour neurologic
checks. He continued to be neurologically stable and was
transferred to a floor bed.
He was also seen in consultation by Renal who recommended
checking laboratories and obtaining a Gastroenterology
consultation for his history of ileus. They recommended a
rectal tube which was placed. He did have a urine culture
that did come back positive for Enterobacter, for which he
was started on meropenem, which he had for five days and was
then changed to Bactrim which he was to continue until
[**11-17**]. He was also seen by and worked with Physical
Therapy and Occupational Therapy during his stay. He had a
Clostridium difficile culture that was negative. His
abdominal examination improved. His rectal tube was removed,
but he continued to be decompressed. It was noted that he
had a high partial thromboplastin time on laboratory work,
and he currently has a mixing study pending, and the patient
should follow up with his hematologist.
DISCHARGE DISPOSITION: He will be discharged to a
rehabilitation facility today ([**2149-11-14**]).
DISCHARGE FOLLOWUP: He should follow up in one month's time
with a repeat head computer tomography with Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
as well as his orthopaedic surgeon and hematologist.
DISCHARGE DIAGNOSES:
1. Subdural hematoma.
2. Dementia.
3. Adynamic ileus.
4. Urinary tract infection.
5. Left knee hemarthrosis.
6. Fresh frozen plasma transfusion for an elevated INR.
MEDICATIONS ON DISCHARGE:
1. Dulcolax 10 mg as needed.
2. Iron 325 mg once daily.
3. Colace 100 mg twice daily.
4. Senna two tablets as needed.
5. Dilantin can be stopped.
6. Tylenol as needed.
7. Labetalol 50 mg by mouth twice daily.
8. Bactrim double strength one tablet twice daily (through
[**11-17**]).
9. Famotidine 20 mg twice daily.
10. Quetiapine fumarate 25 mg twice daily.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 8632**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2149-11-14**] 10:14:03
T: [**2149-11-14**] 10:56:45
Job#: [**Job Number 59657**]
|
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icd9cm
|
[
[
[]
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[
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"99.04",
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icd9pcs
|
[
[
[]
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5764, 5842
|
6124, 6291
|
6317, 6955
|
1425, 1839
|
3644, 5740
|
5863, 6103
|
119, 780
|
803, 1398
|
1856, 3615
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,124
| 145,444
|
49716
|
Discharge summary
|
report
|
Admission Date: [**2187-12-14**] Discharge Date: [**2187-12-30**]
Date of Birth: [**2133-2-8**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6114**]
Chief Complaint:
"He's not sleeping" x 2 weeks
Major Surgical or Invasive Procedure:
Epidural abscess debridement
spinal stabilization
History of Present Illness:
54-year-old man w/ ESRD, DM2, HTN, recent E. coli sepsis, L4-L5
epidural abscess presents w/ increased confusion and low back
pain for 2 weeks. The pt was discharged from [**Hospital1 18**] 3 weeks ago
after diagnosis and treatment of L4-L5 epidural abscess, and has
been on vancomycin and levaquin since that time. His wife
reports that he has shown increased confusion over the past 2
weeks, partly manifested by talking agitatedly in his sleep
whenever he is able to fall asleep. He also has increasing low
back pain over the past 2 weeks requiring higher doses of
methadone and percocet, despite rx with antibiotics. There is
associated decrease in appetite over 2 weeks, such that he must
be prompted to eat. There is no fever, chills, night sweats,
nausea, vomiting, cough, dyspnea, diarrhea, or constipation. He
has not had any recent trauma or falls.
Of note, the pt has been receiving his vancomycin at
hemodialysis, with pre-dosing levels of approximately [**8-14**]. He
had a set of surveillance blood cultures drawn last week, which
were negative.
Past Medical History:
1. ESRD: [**2-5**] anti-GBM disease, on HD since [**3-8**]
2. DM2: dx [**2177**]
3. HTN
4. Chronic low back pain [**2-5**] herniated discs
5. CHF
6. Peripheral neuropathy
7. Anemia
8. h/o nephrolithiasis
9. s/p cervical laminectomy
10. h/o depression
11. h/o MSSA bacteremia
12. s/p L AV graft: [**7-8**]
Social History:
Lives w/ wife in [**Name (NI) 86**] area, has been unemployed [**2-5**]
disability, smokes tobacco 1 ppd, no alcohol or recreational
drug use.
Family History:
1. DM
2. Renal failure
Physical Exam:
VS: T 98.6F, BP 120/72, HR 76, RR 16, O2 Sat 98 RA
Gen: awake, alert, NAD
HEENT: [**Month/Day (2) 3899**], pupils pinpoint and equal, anicteric, OP clear w/
MMM, neck supple, no JVD, no cervical tenderness
CV: reg s1/s2, no s3/s4/m/r
Pulm: symmetrical to percussion, crackles at bases bilaterally,
no wheezes
Abd: +BS, soft, NT, ND
Ext: warm, 2+ DP pulses B, no edema
Neuro: CN 2-12 intact, muscle bulk and tone decreased in LE
bilaterally, strength 4/5 throughout UE/LE, fine
touch/proprioception intact throughout (including perineum),
reflexes [**2-7**] at patella and biceps, strong rectal tone
GU: guaiac negative
Pertinent Results:
Labs on admission:
[**2187-12-14**] 09:10AM WBC-9.3 RBC-4.54* HGB-13.4* HCT-42.3 MCV-93
MCH-29.6 MCHC-31.7
[**2187-12-14**] 09:10AM PLT COUNT-351
[**2187-12-14**] 09:10AM NEUTS-75.6* LYMPHS-12.6* MONOS-9.1 EOS-2.5
BASOS-0.2
[**2187-12-14**] 09:10AM GLUCOSE-101 UREA N-25* CREAT-6.3* SODIUM-140
POTASSIUM-4.9 CHLORIDE-95* TOTAL CO2-33* ANION GAP-17
[**2187-12-14**] 09:10AM CALCIUM-10.5* MAGNESIUM-2.1
[**2187-12-14**] 09:10AM ALT(SGPT)-9 AST(SGOT)-16 CK(CPK)-54 ALK
PHOS-127* TOT BILI-0.4
[**2187-12-14**] 09:10AM CK-MB-NotDone cTropnT-0.69*
[**2187-12-14**] 06:15PM CK-MB-NotDone
[**2187-12-14**] 06:15PM cTropnT-0.67*
[**2187-12-14**] 06:15PM CK(CPK)-41
CXR:
1) Left upper lobe oval density with central lucency,
corresponding to known necrotic pneumonic abscess. Apparent
interval decrease in size, now measuring 3.3 x 5.5 cm.
2) Possible subtle opacities in the left mid lobe and left
base, consistent with atelectasis/infiltrate. Possible small
left pleural effusion.
Head CT: No evidence of acute intracranial hemorrhage or major
territorial infarction.
Labs on discharge:
[**2187-12-30**] 05:36AM BLOOD WBC-11.9* RBC-3.76* Hgb-10.5* Hct-33.6*
MCV-89 MCH-28.0 MCHC-31.3 RDW-16.3* Plt Ct-431
Glucose-94 UreaN-21* Creat-5.9*# Na-136 K-4.6 Cl-96 HCO3-32*
Calcium-9.4 Phos-2.8 Mg-1.9
Vanco-33.2
__________________________
Other labs:
[**2187-12-25**] ESR-83*
[**2187-12-15**] ESR-22*
[**2187-12-27**] VitB12-914* Folate-7.7
[**2187-12-25**] calTIBC-117 Ferritn-927* TRF-90*
[**2187-12-27**] TSH-3.6
[**2187-12-14**] PTH-116*
[**2187-12-25**] CRP-18.05*
[**2187-12-14**] CRP-7.28*
________________________
EKG [**2187-12-25**]-Long QTc interval
Late precordial QT - is nonspecific
Left ventricular hypertrophy by voltage
Since previous tracing of [**2187-12-22**], no significant change
_________________________
Microbiology:
[**2187-12-21**] 4:00 pm TISSUE L4-5 DISC + END PLATE.
**FINAL REPORT [**2187-12-27**]**
GRAM STAIN (Final [**2187-12-21**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final [**2187-12-24**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2187-12-27**]): NO GROWTH.
[**2187-12-22**] BCx x 2-NGTD
[**2187-12-14**] BCx- NGTD
Brief Hospital Course:
1. Epidural abscess/osteomyelitis-
On admission pt had a known L4-L5 epidural abscess diagnosed by
MRI 1 month previously, which did not grow any organisms on
culture but was presumably a consequence of recent E. coli
sepsis. He had already received 4 weeks IV antibiotics
including vancomycin and Levaquin, with a set of blood cultures
the prior week that were negative. There was no evidence of
spinal cord/nerve compression on exam. MRI of L-spine on
admission demonstrated extension of L4-L5 inflammation with L4
collapse. He was continued on IV vancomycin during his
admission; Levaquin was d/c as he had completed his full course
of therapy. We consulted Neurosurgeon Dr. [**Last Name (STitle) 1338**] to assess the
need for surgical treatment, and the pt underwent L4-L5 spinal
fusion with disc biopsy on [**2187-12-21**]. The surgery went well with
no procedural complications; intraoperative wound culture was
negative, which is consistent with suppression of infection by
continuing antibiotics.
After the surgery, the pt had decreased back and leg pain.
Post-op pain was controlled initially with Dilaudid PCA, but was
transitioned after a few days to oral methadone for long-acting
analgesia, with good pain control. The pt had no signs of
active infection during his admission, except possibly his
post-op hypotension as below. At d/c, his chronic back pain is
well controlled. Strength is [**4-9**] throughout, but the pt
requires intense PT to regain prior functional status. He will
require 5 weeks of continued IV vancomycin to treat his L4/L5
osteomyelitis. He will also require follow-up in [**Hospital **] clinic as
scheduled, with repeat MRI 3-5 days prior to follow-up.
Will need to continue vancomycin 750 mg q48s after hemodialysis
for goal trough of 15-20 (day 14/42 on discharge). Today
vancomycin 33.5. Last vancomycin dose was
[**2187-12-27**] at HD as levels have been high.
2. Confusion
On admission, his wife reported that he had increased confusion
over the prior 2 weeks, with increased parasomnia manifested by
sleep talking. This was thought to be [**2-5**] overuse of opioids,
as the pt had been taking more opioid meds for back pain
recently. We stopped the long-acting opioids initially and used
morphine for analgesia. The pt had good pain control w/
morphine, and mental status improved to baseline within 2 days
of admission, most likely as a consequence of proper opioid
dosing. At discharge, pt is on oxycodone 5 mg q4-6 hrs prn with
good pain control. We should continue to avoid long acting
opioids as likely major contributor to confusion. At discharge,
pt is mentating better, though sundowns with hallucinations and
with agitation. There are no signs of osteomyelitis making
infection an unlikely source as pt also continues to improve.
Psychiatry has seen patient and changed his regimen. He is on
Haldol standing as well as prn. Seroquel and Paxil were d/cd
during this admission.
3. DM2-
Controlled with diet normally. He was treated w/ insulin during
prior admission after the pt developed poor blood glucose
control in the setting of epidural abscess. However, pt had
episodes of hypoglycemia on insulin at home, and so insulin had
been discontinued before admission. The pt was continued on [**Doctor First Name **]
diet in the hospital, and glucose remained well controlled
without medications, averaging 90-110. He will need follow-up
with his PCP for monitoring of this.
4. HTN-
BP was sub-optimally controlled on admission. He was continued
on outpt regimen of Norvasc, metoprolol, lisinopril,
hydralazine; metoprolol was titrated up to 100mg TID, with good
BP response. After episode of post-op hypotension, BP meds were
held until the pt was stabilized and sent to the Medicine floor.
At this point, BP climbed gradually, requiring the resumption
of previous medications. Metoprolol and lisinopril were added
initially. At the end of hospitalization stay, Norvasc was
added as pt with consistent BPs in the 160s systolic. At d/c, BP
is moderately controlled. He will require follow-up with his
PCP for titration of BP meds.
5. Post-operative hypotension-
After his surgery, the pt developed hypotension while in the
PACU to 80s systolic, along with tachycardia and agitation.
Central line was attempted, but complicated by a right carotid
puncture and line placement; this line was d/c'd and pressure
held with good hemostasis achieved. R subclavian line was then
placed with good positioning. The pt was started on
Neo-Synephrine gtt for hypotension with good response, and was
transferred to the MICU. He required Neo-Synephrine for BP
support for 3 days; the drip was weaned to off on [**12-23**], and the
pt was transferred back to the Medical floor. His hypotension
was most likely [**2-5**] volume depletion, as he had been taking poor
PO fluids and had been NPO before surgery, with large open
surgical wound during procedure. Another possible etiology
included sepsis, though blood cultures were persistently
negative and the pt was never febrile. After his episode of
hypotension, BP meds were held until BP increased and required
resumption of meds, as above.
6. CHF-
No signs of decompensated heart failure during his admission.
7. Low back pain-
Mr. [**Known lastname 103960**] has chronic back pain [**2-5**] disc herniation, and pain
was increased in weeks before admission likely from epidural
abscess. He had been requiring increased opioids for pain
before admission, which may have been contributing to increased
confusion. On admission, long-acting methadone was discontinued
and pain was treated w/ IV morphine prn, with good pain control.
Post-operatively, pain was managed with Dilaudid PCA, which was
then transitioned to methadone and then to oxycodone prn.
8. Anemia-
History of anemia secondary to ESRD. HCT was acceptable at 42
on admission. However, it trended down continuously during his
stay to a nadir of 26, likely secondary to hemodilution as a
result of continuous fluid therapy. He was transfused 2 units
of PRBCs during hemodialysis on [**2187-12-25**], with good HCT
response. He was also treated with Procrit during HD sessions.
At d/c, there are no symptoms or clinical sequelae of anemia and
Hct 33.6 on discharge. He will require continued Procrit therapy
during hemodialysis.
9. [**Name (NI) 1068**] Pt was seen by psychiatry team. Paxil and
Seroquel were discontinued. Haldol prn and standing.
10. Hypercalcemia: Calcium was slightly elevated during his
admission. PTH was elevated, which in the setting of
hypercalcemia indicates tertiary hyperparathyroidism [**2-5**] ESRD.
Definitive treatment would require parathyroidectomy, which may
be indicated when acute issues resolved. He will require
follow-up for monitoring of serum calcium.
11. ESRD: he has renal failure [**2-5**] anti-GBM disease. He is on
hemodialysis on Tuesday/Thursday/Saturday. He was followed by
the Renal team during his admission, and received HD on his
usual schedule during his stay, with no complications. He will
need to continue hemodialysis after d/c on Tuesdays, Thursdays,
and Saturdays. Sevelamer was decreased to 800 mg tid.
12. F/E/N- [**Doctor First Name **]/Low sodium diet. Electrolytes were followed. Pt
was refusing tube feedings a majority of the time but was
accepting them at the end. He was also eating a poor amount but
this increased when his wife brought in food from the outside.
13. Prophylaxis- PPI, subcutaneous heparin.
14. [**Name (NI) 103961**] Pt with left inside of eye irritation. Sight
without problem and [**Name (NI) 3899**]. Curbsided opthalmology. Getting NS eye
drops.
Medications on Admission:
Paxil
Norvasc
Metoprolol
Seroquel
Lisinopril
Levaquin
Oxycodone
Methadone
Protonix
Hydralazine
Renagel
Vancomycin
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for fever and pain.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. Hydralazine HCl 50 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours).
7. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
8. Oxycodone HCl 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
9. Amlodipine Besylate 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
11. Haloperidol 1 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
12. Heparin Flush CVL (100 units/ml) 1 ml IV DAILY:PRN
10ml NS followed by 1ml of 100 units/ml heparin (100 units
heparin) each lumen QD and PRN. Inspect site every shift
13. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-5**]
Drops Ophthalmic TID (3 times a day).
14. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
15. Haloperidol 1-2 mg IV Q4H:PRN agitation
16. Haloperidol 2 mg IV QHS
17. Sliding Scale insulin
PEr attached sheet
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary Diagnosis:
Epidural abscess
Pain control
Delirium
Secondary diagnosis:
End stage renal disease
Depression
Diabettes Mellitus 2
Hypertension
Congestive Heart Failure
Anemia
Hypercalcemia
Discharge Condition:
Mr. [**Known lastname 103960**] had his epidural abscess debrided and spinal
stabilization. His pain is well controlled and he is mentating
much better, though he does sundown and get agitated.
Discharge Instructions:
--Pt will need his vancomycin levels checked every day. If it is
below 15, he should get a dose of vancomycin (750 mg) after
dialysis.
-Pt should continue his hemodialysis per usual
Tuesday/Thursday/Saturday schedule.
-Long acting narcotics should be avoided for pain control.
Oxycodone should be used as it is short acting.
-Hematocrit should be followed as well.
-Pt should call doctor or go to the emergency room immediately
if he has temperature >101.4, worsening delirium, chills, or any
other health concern.
Followup Instructions:
[**Hospital **] rehabilitation.
1. [**Doctor First Name **] [**Doctor Last Name **], RNC Where: [**Hospital6 29**] [**Hospital **] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2188-1-2**] 9:00
2.-MRI of lumbar spine 3-5 days before your appointment with Dr.
[**Last Name (STitle) 11382**]
Please call infectious disease at [**Telephone/Fax (1) 457**] to find out how
to schedule it.
3.Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 13076**], MD Where: LM [**Hospital Unit Name 4341**] DISEASE Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2188-1-29**] 10:30
|
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"324.1",
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"276.5",
"292.81",
"250.00",
"730.28",
"738.4",
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icd9cm
|
[
[
[]
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[
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icd9pcs
|
[
[
[]
]
] |
14226, 14305
|
4964, 12608
|
346, 398
|
14544, 14739
|
2700, 2705
|
15303, 15896
|
2012, 2036
|
12772, 14203
|
14326, 14326
|
12634, 12749
|
14763, 15280
|
2051, 2681
|
277, 308
|
3807, 4052
|
426, 1495
|
14406, 14523
|
3709, 3788
|
14345, 14385
|
2719, 3699
|
1518, 1836
|
1852, 1996
|
4065, 4941
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,136
| 188,290
|
27415
|
Discharge summary
|
report
|
Admission Date: [**2118-6-27**] Discharge Date: [**2118-6-27**]
Date of Birth: [**2062-5-1**] Sex: M
Service: MEDICINE
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 398**]
Chief Complaint:
asystolic arrest
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Pt brought in by ambulance from nursing home where he was found
down in asystolic cardiac arrest. Pt was found down, had been
last seen awake 30 minutes prior. On the scene when EMS
arrived, pt found to be cyanotic and asystolic with dilated
pupils - pt was pulseless & without respirations for at least 10
minutes while EMS on the scene. Pt was given CPR with
epinephrine, atropine, D50, bicarb -> converted to PEA and then
afib. FSBG on scene was 37. Regained rhythm, intubated, and
taken to [**Hospital1 18**]. At [**Hospital1 18**] ED Tc99.2, HR 94, BP 88/60, intubated.
Pt required Dopamine and 1L fluid bolus for hypotension in ED,
pH 7.11/78/215 bicarb 23. In ED electrolytes were found to be
within normal with exception of elevated creatinine (Pt on HD
Sat/Tues), trop 0.56, ck nl, ekg with RBBB, qIII, inverted T
waves in V4-v6, [**Street Address(2) **] depression in v4-v6.
Past Medical History:
liver transplant
h/o alcoholic cirrhosis/ hep c cirrhosis
PVD
gangrene of LUE digit
recent amputation of LLL digits
DM
ESRD on HD
Social History:
Had been living with wife, recently living in nursing home.
Family History:
NC
Physical Exam:
PE T 98 BP 107/70 HR 60s RR 16 AC 500 X 16 X Peep 10
Non responsive
Pupils 5 mm non reactive
irreg irreg nl s1s2 no mrg
lungs clear
abd soft
ext warm, extensive tissue disease, poor vasculature, wounds at
right and left le, gangrenous rus
neuro - non reactive to sternal rub, no corneal reflex, bl
babinski up
Pertinent Results:
CXR: concerning for aortic dissection
EKG: as per HPI
CT head: infarct at right fronto-parietal and occipital areas,
both more than 48 hours old
Brief Hospital Course:
Pt presents s/p systolic arrest, family at bedside, states that
pt was to be DNR/DNI but had not told nursing home. Given
dextrose 50 for finger stick in 40s, narcan 0.4 mg since on
diluadid at nursing home, no response. Re-check of hct stable.
Upon pt's wishes dopamine, ventillation withdrawn. No further
evaluation of possible aortic dissection. Pt was made CMO and
passed away within 1 hour of arrival to the MICU. Pt's family
did not wish for an autopsy and the medical examiner denied the
case.
Medications on Admission:
Insulin
Dilaudid
Prograf
Steroids
Discharge Medications:
NONE
Discharge Disposition:
Expired
Discharge Diagnosis:
Asystolic cardiac arrest
Discharge Condition:
passed away
Discharge Instructions:
none
Followup Instructions:
none
Completed by:[**2118-6-27**]
|
[
"585.6",
"V42.7",
"427.5",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
2623, 2632
|
2004, 2509
|
311, 317
|
2700, 2713
|
1834, 1888
|
2766, 2801
|
1484, 1488
|
2594, 2600
|
2653, 2679
|
2535, 2571
|
2737, 2743
|
1503, 1815
|
255, 273
|
345, 1236
|
1897, 1981
|
1258, 1390
|
1406, 1468
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,694
| 106,790
|
33775
|
Discharge summary
|
report
|
Admission Date: [**2119-2-14**] Discharge Date: [**2119-2-20**]
Date of Birth: [**2040-10-7**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Meperidine / Ace Inhibitors / Hydrocodone / Sulfa
(Sulfonamides) / Penicillins
Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
epistaxis
Major Surgical or Invasive Procedure:
Placement of epistat
PICC line placement and removal
History of Present Illness:
78 F with ESRD, CAD, h/o CVA, COPD admitted from NH to [**Hospital 7912**] with epistaxis in the setting of ASA, Plavix,
Coumadin. She was admitted on Friday with INR 3.2 has required 3
units PRBC and 4 units FFP. Was seen by ENT and Epistat packing
with resolution of bleeding until this AM when she rebled during
HD. ENT replaced the Epistat packing with control of the
bleeding and labs from this morning HCT 30, plt 221, INR 1.2 and
she did not receive any further blood products. Patient was
transferred to [**Hospital1 18**] for ENT and possible embolization by
neuro-interventional radiology.
Upon arrival to the ICU ENT arrived and confirmed no active
bleeding.
.
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:
ESRD- patient on TTS schedule
CAD- stents last in [**1-/2118**]
Candidemia- on 4 wks
CVA
COPD
DM
Heart failure- unknown EF (diastolic per report)
Depression
h/o epistaxis
HTN
Aortic valve mass seen on TTE [**5-/2118**]
PVD
Patent foramen ovale
Dementia
Glaucoma
Atrial fibrillation
Childhood seizures
s/p hysterectomy
s/p cholecystectomy
s/p appendectomy
s/p exploratory laparotomy -age 18
Social History:
Lives in [**Hospital **] Nursing Home.
- Tobacco: none currently prior 45 pack year
- Alcohol: none
- Illicits: none
Family History:
CAD, DM, unknown cancer
Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
ADMISSION LABS:
[**2119-2-14**] 08:42PM BLOOD WBC-13.6*# RBC-3.74* Hgb-11.2* Hct-34.5*
MCV-92 MCH-30.0 MCHC-32.5 RDW-17.9* Plt Ct-251
[**2119-2-14**] 08:42PM BLOOD Neuts-88.9* Lymphs-6.9* Monos-3.5 Eos-0.4
Baso-0.3
[**2119-2-14**] 08:42PM BLOOD PT-13.7* PTT-23.9 INR(PT)-1.2*
[**2119-2-14**] 08:42PM BLOOD Glucose-126* UreaN-21* Creat-4.1*# Na-144
K-4.0 Cl-103 HCO3-27 AnGap-18
[**2119-2-14**] 08:42PM BLOOD Calcium-9.6 Phos-3.1 Mg-1.8
.
DISCHARGE LABS:
[**2119-2-15**] 05:19AM BLOOD Triglyc-98
[**2119-2-20**] 06:29AM BLOOD WBC-9.7 RBC-3.14* Hgb-9.3* Hct-28.9*
MCV-92 MCH-29.6 MCHC-32.0 RDW-20.7* Plt Ct-226
[**2119-2-18**] 05:47AM BLOOD PT-12.1 INR(PT)-1.0
[**2119-2-20**] 06:29AM BLOOD Glucose-120* UreaN-34* Creat-5.1*#
Na-128* K-4.0 Cl-88* HCO3-25 AnGap-19
[**2119-2-19**] 06:41AM BLOOD Calcium-8.6 Phos-3.5 Mg-1.9
.
Micro:
Blood Cx [**2-15**]: No growth to date (not finalized)
.
Imaging/Studies:
CXR [**2119-2-14**]: Mild cardiomegaly may be smaller. No pulmonary
edema, pulmonary vascular engorgement. A flame-shaped opacity
projecting over the right first rib anteriorly is probably
calcification, better appreciated on the [**2117-3-26**]
radiograph. Lungs are otherwise clear. There is no pleural
effusion. Mediastinal and hilar silhouettes are unremarkable.
Vascular stent and clips project over the left axilla.
.
TTE [**2119-2-15**]: The left atrium is normal in size. No atrial septal
defect is seen by 2D or color Doppler. There is mild symmetric
left ventricular hypertrophy. The left ventricular cavity is
unusually small. Due to suboptimal technical quality, a focal
wall motion abnormality cannot be fully excluded. Left
ventricular systolic function is hyperdynamic (EF>75%). 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) 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. Mild (1+)
mitral regurgitation is seen. The left ventricular inflow
pattern suggests impaired relaxation. The tricuspid valve
leaflets are mildly thickened. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion.
IMPRESSION: No aortic valve mass seen. If indicated, a TEE would
be better to assess aortic valve structure.
Brief Hospital Course:
78 yo F with PAF on coumadin, dementia, ESRD on HD, CAD who
presents with posterior nasal bleed. Pt was initially admitted
to OSH last Friday for epistaxis in the setting of elevated INR
3.2 and taking ASA, Plavix and coumadin. She received 3 units
PRBC and 4 units FFP. She was stable until rebleeding on [**2-14**] at
dialysis and transferred to [**Hospital1 18**].
.
# Epistaxis: Patient was transferred to [**Hospital1 18**] for epistaxis
requiring multiple transfusions. She was initially admitted to
the MICU, where ENT placed balloon in left nostril for posterior
bleed. Her hematocrit remained stable while in MICU and she did
not require further transfusion. She remained hemodynamically
stable and the nasal balloon was removed from her left nostril
on [**2-19**] without complication. Per ENT, if the patient has any
additional epistaxis, use afrin in each nostril, lean head
forward, pinch nostrils closed for 20 minutes. Patient should
return to the hospital for any bleeding that does not resolve
with these measures. Coumadin should continue to be held for
two weeks, and restarted thereafter. ASA should be held for an
additionally week, and restarted at 81 mg daily thereafter.
Plavix should be discontinued permanently.
.
# ESRD: Pt on TTS schedule, last HD [**2-18**]. Next dialysis planned
for Tuesday, [**2119-2-21**]. She should continue nephrocaps and
sevelamer. She will also continue to receive epogen with
dialysis. Additionally, patient should continue to receive
fluconazole with dialysis for a total four week course.
.
# HTN: Antihypertensive medications were additionally, held and
gradually restarted for goal systolic BP of 110. She should
continue home anti-hypertensive regimen with amlodipine,
metoprolol, hydralazine and Imdur at discharge.
.
# Dementia/ Hx of embolic CVA: Coumadin and antiplatelet agents
were held during this admission, given significant nasal bleed.
The patient should resume anticoagulation with coumadin 2 weeks
after discharge, and should restart ASA 81 mg 1 week after
discharge.
.
# CAD: S/p PCI with stent placement [**1-14**]. All antiplatelet
agents were held on this admission. She was continued on statin
and antihypertensive regimen. Given that last PCI was greater
than one year ago, the patient may discontinue plavix completely
at discharge. She should restart ASA 81 mg one week after
discharge for coronary artery protection.
.
# Hx COPD: Continued on inhalers prn.
.
# Hx childhood seizures: The patient was continued on home dose
keppra for seizure prophylaxis.
.
# COMM: [**Name (NI) **] and Daughter [**First Name4 (NamePattern1) 1453**] [**Known lastname 174**], MD and son are HCP.
Daughter's phone numbers: [**Telephone/Fax (3) 78112**]
# CODE: DNR/DNI during this admission (but per HCP would consent
for elective intubation for procedure or airway protection)
Medications on Admission:
Coumadin 2mg daily
Norvasc 10mg daily
Aspirin 81mg daily
Keppra 500mg daily
Paxil 40mg daily
Plavix 75mg daily
MiraLax daily
Hydralazine 25mg three times daily
Lopressor 25mg three times daily
Lipitor 80mg at bedtime
Senokot at bedtime
Travatan eye drops both eyes at bedtime
Trazodone 75mg at bedtime
Dalyvite vitamin daily
Imdur 60mg daily
Renvela 80mg three times daily with meals
Nitroglycerin 1/150 for chest discomfort
Ativan as needed
Lactulose as needed
Fluconazole 200mg after dialysis for 4 weeks. Once positive
blood cultures are negative, can be stopped after 4 weeks
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
2. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
5. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
7. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
8. Renvela 0.8 gram Powder in Packet Sig: One (1) PO three
times a day: with meals.
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
11. Multivitamin Capsule Sig: One (1) Capsule PO once a day.
12. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
13. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily).
14. Travatan 0.004 % Drops Sig: One (1) drop Ophthalmic at
bedtime: both eyes.
15. Fluconazole 100 mg Tablet Sig: Two (2) Tablet PO QHD (each
hemodialysis) for 4 weeks: 4 weeks once blood cultures negative.
16. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO once a
day.
17. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
18. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO three times
a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Rehabilitation & Nursing Center - [**Location (un) **]
Discharge Diagnosis:
Primary Diagnosis
Posterior Nasal Epistaxis
Discharge Condition:
alert and oriented
ambulating on discharge
Discharge Instructions:
You were admitted with a posterior nasal bleed. You were seen by
our ENT doctors who stopped the bleeding with a balloon
tamponade packing. That packing has since been removed. The
following changes were made to your medications.
1. STOP Plavix
2. HOLD Aspirin and coumadin. It is fine to restart your aspirin
one week after discharge and your coumadin two weeks after
discharge.
Followup Instructions:
Follow-up with your primary care physician [**Name Initial (PRE) 176**] 1-2 weeks of
discharge.
|
[
"V45.11",
"784.7",
"496",
"V12.54",
"585.6",
"294.8",
"428.30",
"428.0",
"112.9",
"427.31",
"280.0",
"V58.61",
"276.1",
"414.01",
"403.91",
"345.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"21.02",
"39.95",
"99.15",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
10300, 10397
|
5194, 8054
|
359, 413
|
10485, 10530
|
2672, 2672
|
10960, 11059
|
2146, 2171
|
8685, 10277
|
10418, 10464
|
8080, 8662
|
10554, 10937
|
3126, 5171
|
2186, 2653
|
1132, 1580
|
310, 321
|
441, 1113
|
2688, 3110
|
1602, 1994
|
2010, 2129
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,029
| 190,907
|
28353
|
Discharge summary
|
report
|
Admission Date: [**2104-11-9**] Discharge Date: [**2104-12-17**]
Service: CARDIOTHORACIC
Allergies:
Simvastatin
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Chest pain/Unstable angina
Major Surgical or Invasive Procedure:
[**2104-11-10**] - CABGx4 (Lima->LAD, SVG->OM, SVG sequential->RCA-PDA)
[**2104-11-10**] - Cardiac Catheterization. Angioplasty of LAD.
Insertion of IABP. Removal of IABP. Initiation of ECMO.
[**2104-11-11**] - Removal of ECMO. Placement of IABP.
[**2104-11-12**] - Exploration of left femoral artery, thrombectomy
of superficial femoral artery and tibial vessels. Four
compartment fasciotomy. Intraoperative angiogram with a
second order catheterization.
[**2104-11-13**] Intra-aortic balloon pump removal from right
common femoral artery with primary pursestring repair
[**2104-11-26**] Debridement of left [**Month/Day/Year **] wound and all four
compartments of the left lower extremity; debridement of the
left medial heel.Debridement of skin, SQ and Muscle
[**2104-11-28**] Diagnostic and therapeutic thoracentesis with
ultrasound guidance
[**2104-12-8**] Debridement of skin, subcutaneous tissue and
muscle, left leg.
[**2104-12-12**] Left above-knee amputation
History of Present Illness:
The patient is an 86-year-old woman who presented with unstable
angina and acute coronary syndrome. Cardiac catheterization
revealed severe three-vessel coronary disease with preserved
left ventricular function. The patient was therefore referred
for coronary artery bypass grafting.
Past Medical History:
MI
CAD
Hyperlipidemia
Ischemic Leg
Compartment syndrome
HTN
Chronic AF
Hypothyroid
Asthma
Arthritis
Social History:
Smoker who quit 30 years ago after a 30 pk/year. Lives with in
law in apartment. No alcohol use.
Family History:
Mother with CVA
Father with CVA,CAD
Son with diabetes
Physical Exam:
Admission
97.3 80 120/80 20
Negative JVD, no carotid bruit
Irreg, irreg, no M/R/G
Lungs are clear
Abdomen is soft, nontender, nondistended
Right [**Month/Day/Year **] angioseal
2+ pulses, no varicosities, no edema
Discharge
Vitals 98.7 HR 72 Afib, B/P 105/61, RR 20, Sat RA 96%
Neuro: alert, oriented to person and place, disoriented to time,
UE [**4-30**] RLE [**4-30**]
Pulmonary: clear to ausculation bilaterally
Cardiac: Irregular - AFib, no murmur/rub/gallop
Abdomen: + bowel sounds, nontender, nondistended, soft last BM
[**12-16**]
Extremities: warm, pulses palpable, L AKA, RLE +2 edema
Incisions/wounds:
Sternal midline inc. healing - distal end with erythema and open
area wet-dry dressing
Sacral decub stage I with duoderm intact
Right [**Month/Year (2) **] with 1cm circle open area 0.5cm deep W-D drsg
[**Name5 (PTitle) 2325**] [**Name5 (PTitle) **] with Vac dressing tissue pink and healing changed
[**12-17**]
Left AKA inc with staples and sutures healing no erythema no
drainage
Pertinent Results:
[**2104-12-17**] 05:41AM BLOOD Hct-25.8*
[**2104-12-16**] 06:32AM BLOOD WBC-9.2 RBC-2.76* Hgb-8.7* Hct-25.2*
MCV-91 MCH-31.5 MCHC-34.5 RDW-16.6* Plt Ct-322
[**2104-11-16**] 03:41AM BLOOD WBC-10.6 RBC-2.98* Hgb-9.7* Hct-27.2*
MCV-91 MCH-32.5* MCHC-35.6* RDW-15.8* Plt Ct-64*
[**2104-11-12**] 06:03AM BLOOD WBC-14.7* RBC-3.81*# Hgb-12.5# Hct-34.0*
MCV-89 MCH-32.8* MCHC-36.7* RDW-14.7 Plt Ct-83*
[**2104-11-9**] 06:00PM BLOOD WBC-7.9 RBC-4.13* Hgb-13.3 Hct-37.9
MCV-92 MCH-32.2* MCHC-35.1* RDW-14.5 Plt Ct-165
[**2104-12-17**] 05:41AM BLOOD PT-21.9* INR(PT)-2.1*
[**2104-12-16**] 06:32AM BLOOD Plt Ct-322
[**2104-12-16**] 06:32AM BLOOD PT-16.6* PTT-35.5* INR(PT)-1.5*
[**2104-12-14**] 01:27AM BLOOD PT-12.6 PTT-30.7 INR(PT)-1.1
[**2104-11-9**] 06:00PM BLOOD Plt Ct-165
[**2104-11-9**] 06:00PM BLOOD PT-14.9* PTT-72.2* INR(PT)-1.3*
[**2104-12-17**] 05:41AM BLOOD UreaN-21* Creat-1.4* K-4.2
[**2104-12-16**] 06:32AM BLOOD Glucose-140* UreaN-22* Creat-1.4* Na-136
K-4.5 Cl-101 HCO3-28 AnGap-12
[**2104-12-8**] 07:56PM BLOOD Glucose-153* UreaN-26* Creat-1.4* Na-139
K-4.7 Cl-99 HCO3-33* AnGap-12
[**2104-11-30**] 05:00AM BLOOD Glucose-78 UreaN-28* Creat-1.1 Na-137
K-4.0 Cl-101 HCO3-26 AnGap-14
[**2104-11-15**] 04:24AM BLOOD Glucose-98 UreaN-24* Creat-1.1 Na-135
K-4.2 Cl-103 HCO3-27 AnGap-9
[**2104-11-9**] 06:00PM BLOOD Glucose-167* UreaN-11 Creat-0.6 Na-138
K-4.0 Cl-104 HCO3-24 AnGap-14
[**2104-12-11**] 02:21AM BLOOD ALT-14 AST-22 LD(LDH)-240 AlkPhos-92
Amylase-28 TotBili-1.2
[**2104-11-28**] 03:35AM BLOOD ALT-32 AST-18 AlkPhos-136* Amylase-31
TotBili-0.5
[**2104-11-9**] 06:00PM BLOOD ALT-19 AST-17 LD(LDH)-198 AlkPhos-68
TotBili-0.7
[**2104-12-10**] 06:45PM BLOOD Lipase-19
[**2104-12-3**] 04:05AM BLOOD Lipase-34
[**2104-11-10**] 09:06PM BLOOD Lipase-20
CHEST (PORTABLE AP) [**2104-12-16**] 8:02 AM
CHEST (PORTABLE AP)
Reason: evaluate for pleural effusions
[**Hospital 93**] MEDICAL CONDITION:
86 year old woman s/p CABGx4
REASON FOR THIS EXAMINATION:
evaluate for pleural effusions
AP CHEST, 7:56 A.M., [**12-16**].
HISTORY: Pleural effusions following CABG.
IMPRESSION: AP chest compared to [**11-28**] through 9:
Small-to-moderate bilateral pleural effusion, left greater than
right, has improved minimally on the right, unchanged on the
left. Left lower lobe atelectasis is stable. Upper lungs show
vascular congestion and borderline edema, as before.
Cardiomediastinal silhouette has a normal postoperative
appearance. Right subclavian or PICC line ends in the low SVC.
No pneumothorax.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**]
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.
Conclusions:
No atrial septal defect is seen by 2D or color Doppler. There is
mild
symmetric left ventricular hypertrophy with normal cavity size
and systolic
function (LVEF>55%). Left and right pulmonary vein flow pattern
is consistent
with mild diastolic dysfunction. The transmitral propagation
velocity is
normal. Transmitral Doppler and tissue velocity imaging are
consistent with
Grade I (mild) LV diastolic dysfunction. Right ventricular
chamber size and
free wall motion are normal. There are simple atheroma in the
aortic arch.
There are simple atheroma in the descending thoracic aorta. The
aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened.
Mild (1+) mitral regurgitation is seen. The tricuspid valve
leaflets are
mildly thickened. The estimated pulmonary artery systolic
pressure is normal.
Electronically signed by [**Name6 (MD) 19047**] [**Name8 (MD) 19048**], MD on [**2104-12-15**] 17:24.
[**Location (un) **] PHYSICIAN:
UNILAT UP EXT VEINS US RIGHT
Reason: evaluate DVT
[**Hospital 93**] MEDICAL CONDITION:
86 year old woman s/p cabgx4
REASON FOR THIS EXAMINATION:
evaluate DVT
NONINVASIVE DUPLEX DOPPLER STUDY OF THE RIGHT UPPER EXTREMITY
CLINICAL INDICATION: Assess for possible DVT in a patient status
post CABG and central line placement.
The internal jugular and subclavian veins are fully patent
without evidence of any clot or occlusion. The central line can
be visualized in the subclavian vein and there is no clot
surrounding the line. The axillary, brachial and basilic veins
are patent as well. The cephalic vein could not be identified.
CONCLUSION: No evidence of DVT in the right upper extremity.
DR. [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Approved: FRI [**2104-12-5**] 10:50 PM
[**Numeric Identifier 23286**] US GUID FOR VAS. ACCESS [**2104-12-1**] 9:22 AM
Reason: S/P CABG
[**Hospital 93**] MEDICAL CONDITION:
86 year old woman with s/p CABG
REASON FOR THIS EXAMINATION:
IV access
INDICATION: 86-year-old female status post CABG. Needs IV
access.
RADIOLOGISTS: Drs. [**Last Name (STitle) **], [**Name5 (PTitle) **], and [**Doctor Last Name 380**]. Dr. [**Last Name (STitle) 380**], the
Attending Radiologist, was present throughout the procedure.
PROCEDURE/FINDINGS: The patient was brought to the Radiology
Suite and placed supine on the angiography table. Following a
preprocedural timeout including the patient's name and
additional patient identifiers, the right arm was prepped and
draped in usual sterile fashion. Son[**Name (NI) 493**] guidance was used
to identify the right basilic vein which was patent and
compressible. Approximately 3 cc of 1% lidocaine/bicarbonate
mixture was administered for local anesthesia. A 21-gauge needle
was used to access the right basilic vein. Hard copy ultrasound
images were obtained before and after venous access documenting
vessel patency. A 0.018- inch guidewire was threaded through the
needle into the vein. The needle was exchanged for a 4 French
micro puncture sheath. The guidewire was advanced into the SVC,
and based upon the markings on the wire, a PICC was trimmed to a
length of approximately 41 cm. The PICC was then advanced over
the wire into the SVC under fluoroscopic guidance. The wire and
peel-away sheath were removed. The catheter was flushed, capped,
and heplocked. Finally, the catheter was flushed, heplocked, and
statlocked in place and a sterile transparent dressing was
applied. A final fluoroscopic image was obtained demonstrating
the tip of the PICC line in the distal SVC.
IMPRESSION:
Successful placement of a 4 French single lumen 41 cm PICC by
way of right basilic vein with tip in the distal SVC. The line
is ready for use.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10270**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
DR. [**First Name (STitle) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
Approved: SUN [**2104-12-7**] 1:52 PM
Brief Hospital Course:
Ms. [**Known lastname 6105**] was admitted to the [**Hospital1 18**] on [**2104-11-9**] for surgical
management of her coronary artery disease. She was worked-up in
the usual preoperative manner including a carotid ultrasound
which did not reveal any significant carotid artery stenosis. On
[**2104-11-10**], Ms. [**Known lastname 6105**] was taken to the operating room where she
underwent coronary artery bypass grafting to three vessels.
Please see operative report for details. Postoperatively she was
taken to the intensive care unit for monitoring. She had a VT
arrest upon arrival to the SICU, she was successfully
defibrillated. She was taken back to the operating room where a
cardiac cath was performed which showed patent grafts after
administration of vasodilators and angioplasty of LAD distal to
anastamosis. An IABP was placed and subsequently converted to
ECMO. On [**11-11**] she was taken back to the operating room where
She was weaned from ECMO and placed back on IABP and was seen by
vascular surgery for a L femoral patch angioplasty. She was
later found to have no left foot pulses with no mottling and the
recommendation was for heparin. Bronchoscopy on [**11-11**] for lesion
seen on chest x ray showed secretions thoughout. On [**11-12**] she
was takent o the operating room with vascular surgery for left
leg ischemia where she underwent a left femoral thrombectomy,
LLE angiography, and 4 compartment L calf fasciotomy. She was
weaned from her IABP and again taken to the operating room on
[**11-13**] for IABP removal and primary pursestring repair of right
common femoral artery. Over the next several days her vasoactive
drips and vent support were weaned. She was extubated on [**11-18**].
She continued to improve. Vascular surgery continued to follow
for her leg and [**Month/Year (2) **] and a l [**Month/Year (2) **] vac dressing was placed on
[**11-23**]. She was taken to the operating room on [**11-26**] with
vascular surgery for debridement of her left [**Month/Year (2) **] and all four
compartments of LLE. Shw was started on vancomycine for blood
cultures positive for GPC. She remained on heparin for atrial
fibrillation. On [**11-28**] she underwent a thoracentesis for 900cc
serosanguinous fluid. She was transferred to the floor on POD
#22. Continued on anticoagulation for atrial fibrillation.
Antibiotics adjusted per infectious disease recommendations.
[**12-8**] returned to OR for wound debridement by vascular surgery
please see operative note for further detail. She was
transferred to the CSRU postoperatively for hemodynamic
management. Then [**12-11**]/ returned to the operating room for
Left AKA with vascular surgery see operative note for further
details. She was transferred to the CSRU for hemodynamic
management and continued to progress, anticoagulation restarted.
On [**2104-12-15**] she was transferred to the floor where she
continued to progress and was ready for discharge to rehab on
[**12-17**]. Plan for INR to be checked [**12-19**] for further coumadin
dosing
Medications on Admission:
Imdur
Sotalol
Norvasc
Coumadin
Thyroxine
Albuterol
Cholestid
Discharge Medications:
1. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
5. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q4H (every 4 hours) as needed.
8. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO at bedtime.
9. Warfarin 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) for
1 days: [**12-18**] 2mg then check INR [**12-19**] .
10. Haloperidol 1 mg Tablet Sig: One (1) Tablet PO at bedtime:
wean off as tolerated.
11. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) for 14 days: continue while on antibiotics .
12. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day).
13. Repaglinide 0.5 mg Tablet Sig: One (1) Tablet PO once a day.
14. Ciprofloxacin 500 mg Tablet Sig: 1.5 Tablets PO Q24H (every
24 hours) for 14 days: started [**12-17**] for 2 week course .
15. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two
(2) ML Intravenous once a day as needed: to each port daily and
prn .
16. Ceftazidime-Dextrose (Iso-osm) 2 g/50 mL Piggyback Sig: One
(1) Intravenous Q24H (every 24 hours).
17. Trimethoprim-Sulfamethoxazole 80-400 mg/5 mL Solution Sig:
One [**Age over 90 12887**]y Six (176) mg Intravenous Q12H (every 12
hours) for 8 days: start [**12-17**] for 8 day course.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 1294**]
Discharge Diagnosis:
MI
CAD
VF arrest
Compartment Syndrome
Ischemic Leg
HTN
Hypercholesterolemia
Atrial Fibrillation
Hypothyroid
Asthma
Arthritis
Osteoarthritis
Postoperative delerium
Discharge Condition:
Fair
Discharge Instructions:
1) Monitor wounds for signs of infection. These include redness,
drainage or increased pain.
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. 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.
Followup Instructions:
Dr [**Last Name (STitle) **] (vascular surgery [**Telephone/Fax (1) 1241**]) please call to
schedule appointment in 2 weeks
Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 914**] ([**Telephone/Fax (1) 170**]) please call to schedule
appointment after discharge from rehab
Dr [**Last Name (STitle) 8051**] ([**Telephone/Fax (1) 8058**]) please call to schedule
appointment after discharge from rehab
Completed by:[**2104-12-17**]
|
[
"728.89",
"411.1",
"790.7",
"729.72",
"518.5",
"401.9",
"414.01",
"427.5",
"427.31",
"412",
"293.0",
"440.24",
"997.1",
"493.90",
"511.9",
"244.9",
"997.2",
"444.22"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"00.13",
"99.60",
"39.57",
"39.32",
"36.13",
"37.22",
"84.17",
"99.29",
"37.61",
"97.44",
"86.22",
"38.93",
"34.91",
"83.39",
"88.72",
"83.45",
"39.65",
"00.66",
"00.40",
"88.48",
"88.57",
"96.72",
"88.56",
"39.61",
"83.09",
"96.6",
"36.15",
"38.08"
] |
icd9pcs
|
[
[
[]
]
] |
14813, 14887
|
9919, 12961
|
252, 1224
|
15094, 15101
|
2878, 4746
|
15612, 16060
|
1792, 1847
|
13072, 14790
|
7720, 7752
|
14908, 15073
|
12987, 13049
|
15125, 15589
|
1862, 2859
|
186, 214
|
7781, 9896
|
1252, 1538
|
6742, 6794
|
1560, 1662
|
1678, 1776
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,981
| 170,760
|
36160+58063
|
Discharge summary
|
report+addendum
|
Admission Date: [**2100-12-6**] Discharge Date: [**2100-12-16**]
Date of Birth: [**2022-7-29**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Transfer from OSH for pacemaker evaluation.
Major Surgical or Invasive Procedure:
PPM/Generator placement [**2100-12-10**]
History of Present Illness:
Mr. [**Name13 (STitle) 82030**] is a 78 year-old man with a history of chronic
atrial fibrillation and bradycardia, s/p permanent pacemaker on
[**2100-11-1**] who presents on transfer from OSH for evaluation for
epicardial pacemaker.
Recently hospitalized ([**10-24**] - [**11-9**]) at an OSH with bradycardia
and UTI. Initially treated with a temporary pacer wire with
subsequent placement of a PPM on [**11-1**]. After discharge to rehab
he was noted to have increasing errythema, itchiness and warmth
at the PPM site, followed by drainage and dehiscence. Also noted
to have weakness, fatigue and hypoxia (O2 87% on room air).
On [**11-25**], he presented to an OSH with weakness, nausea and
purulent drainage coming from a dehisced pacemaker implant wound
with chills and found to have MRSA sepsis vs. bacteremia
(unclear from records). Given this, his pacemaker was explanted
and at that time was noted to have pus inside the pocket. Since
that time he has been on vancomycin with last positive blood
culture on [**2100-11-26**].
Currently his underlying rhythm is afib at a rate of 35. Given
this, a temporary external pacemaker was placed via his right IJ
(unsure if screwed in) and is pacing almost 100% at 63bpm, with
ma of 10, [**Last Name (un) 36**] of 1.5.
He has been referred to [**Hospital1 18**] for epicardial pacemaker placement
by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 914**].
He was initially brought to the floor, but was transferred to
the ICU given temporary pacer wire. The patient was NAD, VS were
96F, 100/57, 60, 25, 88% 3L NC. Pacer capturing at 10amps. He
was A&Ox3, denied SOB, CP, weakness, chills, fever, n/v.
On further review of systems, he denies any prior history of
stroke, TIA though there is a reported history of pulmonary
embolism. Cardiac review of systems is notable for dyspnea on
exertion after walking ~50 feet at baseline.
Past Medical History:
Cardiac risk factors:
(+) Hypertension
Pacemaker/ICD: None known
Other history:
1. Atrial fibrillation
2. Cardiomyopathy with EF of 40%
3. Aortic stenosis with valve area of 1.4cm2
4. BPH/urinary retention requiring daily self catheterization
4x/day 5. Rheumatic heart disease
6. History of pulmonary embolus [**6-12**]-chronic coumadin
7. History of VRE and MRSA
8. Anemia
9. GERD
10. COPD
Social History:
Social history is significant for the absence of current tobacco
use having quite >10 years ago. There is no history of alcohol
abuse wiht no current use. Works as dispatcher for [**First Name4 (NamePattern1) 392**]
[**Last Name (NamePattern1) 15068**].
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
VS - VS were [**Age over 90 **]F, 100/57, 60, 25, 88%-92% 3L NC w/ peripheral,
on forehead > 98% RA.
Gen: Elderly male, lying in bed in no distress. Appears
chronically ill.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI, MMM. Conjunctiva
were pink, no pallor or cyanosis of the oral mucosa.
CV: PMI not palpated. RR, normal S1, S2. [**3-11**] HSM at apex
radiating to axilla. No thrills, lifts. No S3 or S4. Could not
assess JVP 2/2 line.
Chest: Resp were unlabored, no accessory muscle use. Dry, fine
crackles b/l at end expiration to 1/2 up posterior and lateral
fields, no wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation.
Ext: cool LE b/l, no snesation, multiple small ulcerations on
toes b/l, with one ucler on L leg w/ eschar. Hemosiderin colored
[**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]/l. Trace edema at ankles. Cyanotic UE/s b/l to wrist. No
central cyanosis.
Skin: Stasis dermatitis.
Neuro: A&Ox3. CNs III - XII intact grossly. Moves all
extremities. Significant cogwheel rigidy b/l in upper
extremities. No sensation to LT 1/2 up tibia b/l.
Pulses:
Right: Carotid 2+ Femoral 2+ DP Doppler +
Left: Carotid 2+ Femoral 2+ DP Doppler +
Pertinent Results:
[**2100-12-6**] 08:46PM GLUCOSE-101 UREA N-26* CREAT-1.1 SODIUM-134
POTASSIUM-4.4 CHLORIDE-103 TOTAL CO2-24 ANION GAP-11
[**2100-12-6**] 08:46PM ALT(SGPT)-13 AST(SGOT)-17 LD(LDH)-187 ALK
PHOS-130* TOT BILI-0.7
[**2100-12-6**] 08:46PM CALCIUM-9.0 PHOSPHATE-3.8 MAGNESIUM-1.8
IRON-28* CHOLEST-103
[**2100-12-6**] 08:46PM calTIBC-328 FERRITIN-84 TRF-252
[**2100-12-6**] 08:46PM TRIGLYCER-92 HDL CHOL-21 CHOL/HDL-4.9
LDL(CALC)-64
[**2100-12-6**] 08:46PM WBC-11.8* RBC-3.74* HGB-10.9* HCT-33.1*
MCV-89 MCH-29.2 MCHC-33.0 RDW-17.8*
[**2100-12-6**] 08:46PM NEUTS-76.8* LYMPHS-15.5* MONOS-5.6 EOS-1.6
BASOS-0.4
[**2100-12-6**] 08:46PM PLT COUNT-408
[**2100-12-6**] 08:46PM PT-14.6* PTT-37.6* INR(PT)-1.3*
[**2100-12-6**] 08:46PM RET AUT-2.8
[**2100-12-6**] 09:03PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-8* PH-6.0 LEUK-MOD
[**2100-12-6**] 09:03PM URINE RBC-[**3-10**]* WBC-21-50* BACTERIA-FEW
YEAST-MOD EPI-0-2
[**2100-12-6**] 09:37PM LACTATE-1.3
[**2100-12-6**] 09:37PM TYPE-ART PO2-78* PCO2-31* PH-7.49* TOTAL
CO2-24 BASE XS-1
EKG ([**2100-11-2**]): V-paced in the 60s. Underlying rhythm appears to
be afib.
TEE ([**2100-11-30**]): LVEF 55%. No vegetations. No AS. No regional
wall anl.
ETT: None.
CARDIAC CATH: None.
OSH CXR [**12-5**]: Central pulm vascular congestion with mild pulm
edema, likely underyling interstitial lung disease repeated
today and unchanged.
Microbiology at OSH Summary:
[**11-25**] BCx and wound were MRSA (Sensitive to Clindamycin,
Gentamycin, Tetracycline, Vancomycin, Bactrim).
[**11-26**] UCx enterococcus faecalis > 100K, Sensitive to Vancomycin,
PCN, Gentamycin, Ampicillin
[**11-26**] BCx ([**1-6**]) - MRSA, Wnd Cx - MRSA
[**11-26**] - [**11-28**] - BCx - no growth
[**2100-12-14**] 05:30AM BLOOD WBC-10.6
[**2100-12-14**] 05:30AM BLOOD PT-18.9* INR(PT)-1.7*
[**2100-12-14**] 05:30AM BLOOD UreaN-28* Creat-1.0
[**2100-12-16**] 03:53AM BLOOD WBC-9.4 RBC-3.55* Hgb-9.9* Hct-30.7*
MCV-87 MCH-27.8 MCHC-32.2 RDW-16.9* Plt Ct-290
[**2100-12-15**] 04:16AM BLOOD WBC-8.4 RBC-3.44* Hgb-9.6* Hct-30.2*
MCV-88 MCH-28.1 MCHC-32.0 RDW-16.9* Plt Ct-276
[**2100-12-6**] 08:46PM BLOOD WBC-11.8* RBC-3.74* Hgb-10.9* Hct-33.1*
MCV-89 MCH-29.2 MCHC-33.0 RDW-17.8* Plt Ct-408
[**2100-12-16**] 03:53AM BLOOD PT-20.1* INR(PT)-1.9*
[**2100-12-15**] 04:16AM BLOOD PT-22.3* INR(PT)-2.1*
[**2100-12-6**] 08:46PM BLOOD PT-14.6* PTT-37.6* INR(PT)-1.3*
[**2100-12-16**] 03:53AM BLOOD Glucose-96 UreaN-21* Creat-1.0 Na-134
K-4.1 Cl-103 HCO3-24 AnGap-11
[**2100-12-15**] 04:16AM BLOOD UreaN-24* Creat-1.0 Na-137 K-3.9
[**2100-12-14**] 05:30AM BLOOD UreaN-28* Creat-1.0
[**2100-12-6**] 08:46PM BLOOD Glucose-101 UreaN-26* Creat-1.1 Na-134
K-4.4 Cl-103 HCO3-24 AnGap-11
Brief Hospital Course:
78M admitted from OSH with MRSA sepsis and pacemaker infection,
transferred for epicardial pacemaker placement. [**2100-12-10**]
Mr.[**Name13 (STitle) 82030**] went to the OR and underwent placement of epicardial
leads and PPM generator via subxiphoid approach. Please refer to
operative report for further details. He was transferred to the
CVICU, hemodynamically stable, but remained intubated overnight
due to oxygen requirements. POD #1 he was extubated and
continued to do well. EP interrogated the PPM. CXR showed good
lead placement. He was transferred to the SDU later that day. He
continued to progress except for difficulty with swallowing.
Speech and swallow was consulted and nectar thickened diet per
reccommendations was instituted. Video swallow test was done on
[**2100-12-14**]. Speech and swallow added pureed solids to his diet.
ID continues to follow. Vancomycin x 4-6 weeks per ID
reccommendations required PICC line insertion. Mr.[**Name13 (STitle) 82030**] was
also placed on Ceftriaxone for a Proteus resistant UTI. His
foley catheter was discontinued and presurgical straight cathing
resumed. On POD 6 Mr.[**Name13 (STitle) 82030**] was discharged to rehab for
further recovery and increase in endurance and activity. All
follow up appointments were advised.
Medications on Admission:
Wellbutrin SR 100mg [**Hospital1 **]
Avodart 0.5mg daily
Aspirin 81mg daily
Colace 100mg [**Hospital1 **]
Aldactone 50mg daily
Protonix 40mg daily
Aricept 10mg QHS
Coumadin 4.5mg daily
Discharge Medications:
1. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Bupropion 100 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO BID (2 times a day).
7. White Petrolatum-Mineral Oil Cream Sig: One (1) Appl
Topical [**Hospital1 **] (2 times a day) as needed.
8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed.
9. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
11. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every [**6-13**]
hours as needed for pain.
12. Vancomycin 500 mg Recon Soln Sig: 1.5 Recon Solns
Intravenous Q 24H (Every 24 Hours) for 4 weeks.
13. Sodium Chloride 0.9 % 0.9 % Syringe Sig: One (1) ML
Injection PRN (as needed) as needed for line flush.
14. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
15. Ceftriaxone in Dextrose,Iso-os 1 gram/50 mL Piggyback Sig:
One (1) Intravenous Q24H (every 24 hours) for 10 days.
16. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day: INR
goal 2-2.5.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 2670**] - [**Location (un) **]
Discharge Diagnosis:
s/p PPM/Generator placement
MRSA in original PPM pocket/Bacteremia
Proteus Resistant UTI
PMH:PPM wound dehiscence, Chr.AF, BPH/urinary retention-self
catheterization 4x/day, HTN, RH.heart dz, Pulm.Embolus [**6-12**]-chr.
Coumadin,GERD, COPD,
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) 914**] in 4 weeks
Dr. [**Last Name (NamePattern4) 82031**], (Cardiologist)1-2 weeks
Dr.[**Last Name (NamePattern4) 82032**] (PCP)1-2 weeks
ID:Dr.[**Last Name (STitle) 4427**] at Infectious Disease Clinic
Completed by:[**2100-12-16**] Name: [**Known lastname 13141**],[**Known firstname **] F Unit No: [**Numeric Identifier 13142**]
Admission Date: [**2100-12-6**] Discharge Date: [**2100-12-16**]
Date of Birth: [**2022-7-29**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1543**]
Addendum:
Nutrition: ground solids with nectar thick liquids, medications
in whole puree.
Please consult ENT and Speech and swallow at rehab.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 1606**] - [**Location (un) 382**]
[**First Name11 (Name Pattern1) 33**] [**Last Name (NamePattern4) 1544**] MD [**MD Number(2) 1545**]
Completed by:[**2100-12-16**]
|
[
"584.9",
"996.61",
"E878.1",
"427.31",
"995.91",
"038.12",
"600.01",
"496",
"V58.61",
"424.1",
"V12.51",
"998.30",
"425.4",
"530.81",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.81",
"37.74"
] |
icd9pcs
|
[
[
[]
]
] |
11883, 12116
|
7125, 8412
|
365, 408
|
10555, 10562
|
4359, 7102
|
11073, 11860
|
3038, 3120
|
8647, 10176
|
10290, 10534
|
8438, 8624
|
10586, 11050
|
3135, 4340
|
282, 327
|
436, 2335
|
2357, 2750
|
2766, 3022
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,108
| 186,093
|
234
|
Discharge summary
|
report
|
Admission Date: [**2105-4-16**] Discharge Date: [**2105-4-27**]
Date of Birth: [**2044-3-8**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2344**]
Chief Complaint:
Airway monitoring
Major Surgical or Invasive Procedure:
[**2105-4-24**]: Right video-assisted thoraoscopy with decortication
History of Present Illness:
61 year old female with PMHX of HTH presented with severe sore
throat for 2 days rapidly getting worse associated with
difficulty swallowing liquids and neck pain. Also found to have
fever and tachycardia. Unable to take meds, only took BP meds
this am. Voice is hoarse and descrbed as "hot potato" by PCP.
[**Name10 (NameIs) 1403**] as a flight attendant, travelled all over Europe recently.
Sister with sore throat as well. In PCPs office, unable to open
her mouth, tender thick neck unable to evaluate pharynx. Per
report pts sore throat has progressed rapidly over past 2 days.
Unable to swallow her secretions, no tipoding or drooling
present.
.
In the ED, 100.8 81 125/77 16 99%RA. She was given Clindamycin,
Dexamethasone, Morphine Sulfate 4mg Syringe, HYDROmorphone
(Dilaudid) 1mg/1mL Syringe, Gentamicin 80mg. Labs unremarkable.
CT neck showed retropharyngeal phlegmon. ENT scoped her, has
epiglottis and supraglottic swelling. Symptoms improved. Fever
102 in ED. Prior to transfer 117/78 18 100% RA.
.
Upon arrival to the floor, patient able to phonate but voice
still hoarse. No stridor or tripoding noted. Reports inability
to get secretions up.
.
Review of systems:
(+) Per HPI
(-) Denies night sweats, recent weight loss or gain. Denies
headache, sinus tenderness, rhinorrhea or congestion. Denied
cough, shortness of breath. Denied chest pain or tightness,
palpitations. Denied nausea, vomiting, diarrhea, constipation or
abdominal pain. No recent change in bowel or bladder habits. No
dysuria. Denied arthralgias or myalgias.
Past Medical History:
Hypertension
Allergic rhinitis
Social History:
Lives with sister, smokes 1/2-1ppd for the past 40 years, drinks
on occasion, denies drugs. She was flight attendent for US Air.
Family History:
Sister with [**Name2 (NI) 499**] cancer and thyroid cancer in 50s
Physical Exam:
Admission Exam:
VS: 98.7 82 136/65 13 98% on RA
GA: AOx3, hoarse voice
HEENT: PERRLA. MMM. no LAD. no JVD. neck tender to palpation
anterior and posterioly, unable to visualize pharynx
Cards: PMI palpable at 5/6th IC space. No RVH. RRR S1/S2 heard.
no murmurs/gallops/rubs.
Pulm: rhonchi heard and left base
Abd: soft, NT, +BS. no g/rt. neg HSM. neg [**Doctor Last Name 515**] sign.
Extremities: wwp, no edema. DPs, PTs 2+.
Skin: wnl
Neuro/Psych: CNs II-XII intact. 5/5 strength in U/L extremities.
DTRs 2+ BL (biceps, achilles, patellar). sensation intact to LT,
pain, temperature, vibration, proprioception. cerebellar fxn
intact (FTN, HTS). gait WNL.
.
Pertinent Results:
[**2105-4-16**] 05:02PM LACTATE-1.4
[**2105-4-16**] 04:23PM GLUCOSE-116* UREA N-9 CREAT-0.7 SODIUM-139
POTASSIUM-4.2 CHLORIDE-106 TOTAL CO2-23 ANION GAP-14
[**2105-4-16**] 04:23PM WBC-10.1# RBC-4.27 HGB-13.6 HCT-37.9 MCV-89
MCH-31.9 MCHC-36.0* RDW-13.1
[**2105-4-16**] 04:23PM NEUTS-92.8* LYMPHS-4.1* MONOS-2.8 EOS-0
BASOS-0.2
[**2105-4-16**] 04:23PM PLT COUNT-225
.
Scope ENT (on admission): Her glottic opening is about 4mm on
scope exam without symptoms including stridor or retraction.
.
CT neck with contrast ([**2105-4-16**]): Retropharyngeal fluid
collection spanning from C2/3 to C5/6 with extensive surrounding
edema and inflammation of the hypopharynx. The airway is
narrowed to 4mm at the level of the hyoid. Patent cervical
vasculature.
.
CXR ([**2105-4-17**]): As compared to the previous radiograph, there
is no relevant change. No pathologic mediastinal widening.
Borderline size of the cardiac silhouette. Presence of minimal
pleural effusions cannot be excluded. No focal parenchymal
opacity suggesting pneumonia. No pulmonary edema.
.
CT neck and chest w/ contrast ([**2105-4-18**]):
1. Interval slight decrease of the retropharyngeal fluid
collection and
improved airway patency.
2. No evidence of Lemierre's disease or new abscess formation.
3. No evidence of extension of the fluid collection into the
mediastinum. No evidence of mediastinitis.
.
Chest CT ([**4-22**]): IMPRESSION:
1. Rapidly enlarging multiloculated right pleural effusion. This
could be due to empyema considering clinical suspicion for this
entity, but definitive diagnosis would require correlation with
thoracentesis results.
2. Small dependent left pleural effusion has also increased in
size since the prior study but does not have loculated
components.
3. Slight increase in size of pre- and sub-carinal lymph nodes
as well as right hilar nodes. These are likely reactive.
4. Ground-glass opacities in left upper lobe which are likely
infectious or inflammatory in etiology.
.
TTE ([**4-22**]): The left atrium is mildly dilated. No atrial septal
defect is seen by 2D or color Doppler. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) 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. There is borderline
pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion. There are no
echocardiographic signs of tamponade.
.
[**4-23**] CXR
REASON FOR EXAMINATION: Evaluation of the patient with
complicated pleural
effusion.
Portable AP radiograph of the chest was reviewed in comparison
to [**2105-4-21**].
There is interval increase in right pleural effusion, loculated,
better
appreciated on the prior radiograph but the change in size is
significant. No pneumothorax is seen. Left pleural effusion is
unchanged. Bibasal areas of atelectasis are noted.
.
5/28CXR
Discharge Labs
.
Micro.
Blood Culture, Routine (Preliminary):
HAEMOPHILUS INFLUENZAE, BETA-LACTAMASE NEGATIVE.
BETA- LACTAMASE NEGATIVE: PRESUMPTIVELY SENSITIVE TO
AMPICILLIN. .
BETA-LACTAMASE CONFIRMATION REQUESTED BY DR. [**Last Name (STitle) 2345**].
Aerobic Bottle Gram Stain (Final [**2105-4-18**]):
Reported to and read back by DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 2346**] ON [**2105-4-18**] AT
0720.
GRAM NEGATIVE ROD(S).
Brief Hospital Course:
61 yo F with PMHX of HTN presenting with sore throat, neck pain,
and odynophagia found to have epiglottis and retrophargyneal
phlegmon.
.
#Epiglottis/retropharyngenal phlegmon: Diagnosed on CT neck and
by ENT scope. Symptoms consistent with this. The patient did
improve clinically with steroids, Ceftriaxone and clindamycin.
The patient's airway was closely monitored in the ICU and
underwent repeat ENT scoping on [**2105-4-18**] that showed ongoing
arytenoid edema but completely patent airway. Repeat CT neck and
chest with contrast, in the setting of ongoing posterior neck
pain and inspiration pain as well as worsening erythematous
lesion (see below), did not show Lemierre's or mediastinitis.
There was minimal interval improvement in the phlegmon
collection, however. Blood cultures from admission were positive
for GNRs, later grew out HAEMOPHILUS INFLUENZAE. Planned for 14
day course from day of first negative culture. The patient
remained hemodynamically stable and re-evaluation by ENT in the
ICU showed improved of supraglottic swelling so she was
transfered to the floor. Repeat cultures were negative ???? HIV
was sent and was negative. Patient continued to be symptom free
on the floor and did not have any further airway complaints or
problems. She was treated symptomatically with cepacol lozenges
and was kept on a nicotine patch and received nebulizers PRN.
.
#Erythematous lesion: Patient developed a 3X3 inch erythematous
lesion on her anterior chest, 2 inches below cricoid and poorly
demarcated. The patient endorsed feeling warm and mildly tender
to palpation in this area with no pruritis. No
plaques/papules/bullae. The lesion was very blanching.
Dermatology was consulted on [**2105-4-18**] given spread of this
lesion to ~4X4 inches despite broadening to Vancomycin. Given
the timing of her antibiotics, this lesion was not felt due to
drug eruption, although a very early drug eruption can not be
ruled out. The erythema was felt most consistent with a toxic
exanthem, which is a vasodilation that occurs in patients with
bactermia (more often staph, strep). Supportive care was
provided. Derm followed patient while in house. by hospital day
4 the rash had significantly receeded. Derm did not feel
compelled to biopsy - they thought it was likely due to her
infectious process but did not represent a cellulitis. Her rash
improved later in her hospital course.
.
#Pneumonia and pleural effusion: She was noted to have
intermittent hypoxemia and R sided pleuritic chest pain on [**4-20**].
Medicine was consulted on [**4-22**], and in setting of new moderate
pleural effusions R>L on CXR, recommended chest CT, which showed
rapidly expanding and loculated effusion on R. She was then
transferred to medicine, and ID was consulted. Her antibiotics
were changed to ceftriaxone. Her pleural effusion was attempted
to be drained by IR, but they only withdrew 30 cc of fluid,
given loculation. Thoracic surgery was then involved and carried
out a VATS procedure which was uncomplicated and the patient was
transferred back to medicine.
.
#Hypertension: Blood pressures normal and intermittently high
(SBPs 150s) in-house. The patient's atenolol, lipitor were held
in the setting of epiglottis/retropharyngeal phlegmon but
restarted once she was able to tolerate POs. Atenolol was
initially started at half home dose 50mg, then back to her full
dose.However due to asymp. bradycardia into the 40's atenolol
was discontinued ad replaced with Chlorthalidone on [**4-25**].
.
# Intermittent bradycardia to 40s, asymptomatic: She was
monitored on telemetry with occasional intermittent bradycardia
to the 40s. her EKG was otherwise normal, without AVB. TTE was
done which showed no HD significant pericardial effusion,
abscess, or vegetations. Her bradycardia may have been due to
vagal tone in setting of pleural effusions and pleuritic pain.
.
# Lower extremity edema: She noted increased edema during this
admission. She had some baseline edema as a flight attendant but
only while standing for long durations. She had no JVD or HJR,
and TTE was normal.
.
#PPX: Heparin sq
#Full Code, confirmed.
Medications on Admission:
-Lipitor 20 mg Tab 1 Tablet(s) by mouth once a day
-atenolol 100 mg Tab 1 Tablet(s) by mouth once a day
-ProAir HFA 90 mcg/Actuation Aerosol Inhaler
two puffs(s) inhaled every 4-6 hours as needed for SOB/wheezes
-Flovent HFA 110 mcg/Actuation Aerosol Inhaler 2 puffs(s) twice
a day
-fluticasone 50 mcg/Actuation Nasal Spray, Susp 2 sprays each
nostril daily
Discharge Medications:
1. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Disp:*30 Patch 24 hr(s)* Refills:*2*
2. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
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).
Disp:*60 Capsule(s)* Refills:*2*
5. oxycodone-acetaminophen 5-325 mg/5 mL Solution Sig: Five (5)
ML PO Q4H (every 4 hours) as needed for pain.
Disp:*250 ML(s)* Refills:*0*
6. ProAir HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2)
puffs Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
7. Flovent HFA 110 mcg/Actuation Aerosol Sig: Two (2) puffs
puffs Inhalation twice a day.
8. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
puffs Nasal once a day: 2 sprays to nose daily.
9. Outpatient Lab Work
1. CBC with differential
2. ESR
3. CRP
Please obtain this blood work on [**2105-5-4**] and fax results
to infectious disease at ([**Telephone/Fax (1) 1354**]
10. 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*
11. chlorthalidone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day
for 14 days.
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Bacterial supraglottitis
Bacteremia
Loculated pleural effusions
Pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call your doctor or nurse practitioner if you experience
the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain is not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
.
General Discharge Instructions:
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**4-7**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
You were admitted with a severe throat infection and bacteremia
with H influenza. You also developed a rash on your chest
thought to be due to this bacteria. Your rash and throat
improved, but you then developed shortness of breath due to
increasing pleural effusions. You were thought to have
pneumonia, and your pleural effusion was treated by thoracic
surgery with VATS procedure. Your antibiotic course will be
levofloxacin until told to stop by the infectious disease
doctors. You will be seen by them as an outpatient.
.
Medication changes:
START Levaquin (aka Levofloxacin) for your infection
STOP Atenolol (this was stopped because your heart rate was
low)
START Chlorthalidone (for blood pressure control)
.
You should take all your other medication as prescribed by your
doctors.
.
Thoracic surgery
Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 2348**] if you experience:
-Fevers > 101 or chills
-Increased shortness of breath, cough (it is normal to cough-up
blood tinge sputum for a few days) or chest pain
-Incision develops drainage or increased redness
-Chest tube site remove dressing and cover site with a bandaid
until healed
-Should site drain cover with a clean dressing and change as
needed
Activity
-Shower daily. Wash incision with mild soap and water, rinse,
pat dry
-No tub bathing, swimming or hot tubs until incision healed
-No lifting greater than 10 pounds
-No driving while taking narcotics
Followup Instructions:
ENT (ears nose and throat):
Please follow up with Dr. [**First Name (STitle) **] in 2 weeks. Her office can be
reached at [**Telephone/Fax (1) 2349**] to make a follow-up appointment.
.
Infectious disease :
You have an appointment on [**2105-5-7**] with Dr. [**Last Name (STitle) 2350**] @
2:50pm. Please note that you also have a CT of your neck ordered
for [**2105-5-4**] (You need to call [**Telephone/Fax (1) 327**] to confirm the
time/location of this exam). Before your appointment with Dr.
[**Last Name (STitle) 2350**], you will need to have your blood drawn and have the
results faxed to ([**Telephone/Fax (1) 1353**].
Thoracic surgery:
Follow-up with Dr. [**Last Name (STitle) **] [**0-0-**] Date/Time:[**2105-5-12**]
3:00
on the [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Clinical Center, [**Location (un) **]
Chest X-Ray [**Location (un) 861**] Radiology 30 minutes before your
appointment
Please also follow up with your PCP. [**Name10 (NameIs) 2351**] your appointment you
should have your blood drawn with the following results sent to
the infectious disease team (CBC with differential; ESR;CRP).
The number to fax them to is ([**Telephone/Fax (1) 1353**].
Note that you have the following appointment scheduled:
Department: [**Hospital1 18**] [**Location (un) 2352**]- ADULT MED
When: MONDAY [**2105-5-4**] at 10:15 AM
With: [**First Name4 (NamePattern1) 2353**] [**Last Name (NamePattern1) 2354**], MD [**Telephone/Fax (1) 1144**]
Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
|
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icd9pcs
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[
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1955, 1987
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2003, 2134
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,765
| 191,202
|
42588
|
Discharge summary
|
report
|
Admission Date: [**2181-7-22**] Discharge Date: [**2181-7-25**]
Date of Birth: [**2099-2-23**] Sex: M
Service: MEDICINE
Allergies:
IV Dye, Iodine Containing
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
Presyncope
Major Surgical or Invasive Procedure:
RVOT VT ablation ([**2181-7-23**])
History of Present Illness:
82M with hx of CAD s/p DES to RCA [**2-18**], hx of symptomatic MR,
s/p MR repair with [**Company 1543**] ring placement with [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 1916**]
ligation with subsequent hx of NSVT s/p briefly on sotalol and
metoprolol, later placed on Amiodarone, recently down titrated
from 200mg to 100mg daily, that is presenting with presyncopal
like episode. The pt is followed by Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] [**Name (STitle) 2025**] and his
amiodarone has been titrated down over due to pt concerns for
toxicity. The pt was was due to be placed on a Holter monitor
this coming Monday but this has not been performed yet.
Pt reports that for the last three days he has decreased energy.
He denied chest pain, sob, nausesa or emesis. He states that
today, while sitting as his computer, he had visual changes and
felt as though he was going to pass-out. He denies LOC. He
subsequently called EMS and was brought into the [**Hospital1 18**] ED.
In the ED, initial vitals were 97.2 86 152/62 16 99%. Cardiac
exam notable for tachycardia. Labs notable for trop 0.02, Cr
1.6. Telemetry was notable for sustained VT. The pt was
amiodarone loaded with 150mg then started on 1mg/min gtt. The
sustained VT resolved prior to transfer to the CCU. Vitals prior
to transfer 97.1 86-140 99/64 18 99RA.
On arrival to the CCU the pt states he is tired but feels
otherwise fine.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
mitral regurgitation
coronary artery disease s/p RCA stenting [**3-21**]
premature vent. contractions with ventricular tachycardia
hypertension
chronic diastolic heart failure
prostate cancer
obstructive sleep apnea
glaucoma
arthritis
chronic back pain
? Parkinson's disease
Social History:
lives alone, widowed
occasional ETOH use
remote cigar use
works as a part-time headhunter
Family History:
no premature CAD
Physical Exam:
Admission Exam
VS: Afebrile BP 126/77 HR 63 NSR with occasional PVCs RR 16
96O2%
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 5cm.
CARDIAC: Regular with occasional PVCs. 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 abdominal bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
Labs:
[**2181-7-22**] 02:30AM BLOOD WBC-5.0 RBC-4.31* Hgb-14.4 Hct-42.7
MCV-99* MCH-33.4* MCHC-33.7 RDW-13.6 Plt Ct-177
[**2181-7-22**] 08:21AM BLOOD WBC-4.9 RBC-4.30* Hgb-14.2 Hct-42.3
MCV-98 MCH-33.0* MCHC-33.5 RDW-13.7 Plt Ct-172
[**2181-7-22**] 02:30AM BLOOD Glucose-145* UreaN-30* Creat-1.6* Na-140
K-3.8 Cl-105 HCO3-22 AnGap-17
[**2181-7-22**] 08:21AM BLOOD Glucose-100 UreaN-26* Creat-1.3* Na-139
K-4.0 Cl-105 HCO3-23 AnGap-15
[**2181-7-22**] 02:30AM BLOOD cTropnT-0.02*
[**2181-7-22**] 08:21AM BLOOD cTropnT-0.01
[**2181-7-22**] 08:21AM BLOOD TSH-3.9
[**2181-7-22**] 02:30AM BLOOD Calcium-8.9 Phos-3.9 Mg-2.4
.
Studies:
CXR ([**2181-7-22**])
There is stable mild cardiomegaly. Retrocardiac opacification
likely represents atelectasis, however underlying infectious
process cannot be completely excluded. No evidence of focal
consolidation, pleural effusion or pneumothorax. Partially
visualized sternotomy wires appear midline and intact.
Brief Hospital Course:
82M with coronary artery disease s/p DES to RCA in [**2179**] and
mitral regurgitation s/p [**Company 1543**] ring placement with course
complicated by NSVT post surgery. He has been on sotalol in the
past and amiodarone most recently for suppression of his NSVT.
He was admitted with monomorphic VT of same morphology as his
NSVT in setting of decreasing his amiadorone dose.
1. RHYTHM: Stable inferior axis monomorphic ventricular
tachycardia likely from right ventricular outflow tract. It
could also be due scar from his mitral valve ring placement.
With long half life of amiodarone unlikely related to decreasing
amiodarone dose. He was started on amiodarone drip on admission
without any effect on NSVT. Amiodarone drip was discontinued
and uptitrated metoprolol to 50 mg po BID which helped suppress
NSVT. No evidence of ischemia as precipitant for his
ventricular tachycardia. TSH within normal range. He underwent
EP Study on [**2181-7-24**] with ablation of RVOT. He tolerated the
procedure well without any complications.
2. CORONARIES: Single vessel disease RCA disease per last cath.
s/p DES to RCA in [**2179**]. ECG without new ST-T changes. Troponin
negative. He was continued on aspirin, statin, B-Blocker and
ACE-I.
3. PUMP: Last known EF 55%. Pt appears clinically euvolemic.
4. Glaucoma: Stable. Continued on home eye drops.
Medications on Admission:
Amiodarone 100mg Daily
ASA 81mg Daily
Pravastatin 40mg Daily
Lisinopril 10mg Daily
Metoprolol Succinate 50mg Daily
Lumigan 0.01% one drop per left eye QHS
Fluticasone Propionate 50mcg [**Hospital1 **]
Saline Nasal Spray
Colace PRN
Senna
Co Enzyme Q
Hyaluronic Acid 140mg
Fatty Acids
MVI
Melatonin 3mg QHS
Tylenol 650mg
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
3. lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
4. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
5. Lumigan 0.01 % Drops Sig: One (1) drop to left eye Ophthalmic
once a day.
6. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal [**Hospital1 **] (2 times a day).
7. Saline Nasal 0.65 % Aerosol, Spray Sig: One (1) Nasal twice
a day.
8. docusate sodium 100 mg Capsule Sig: [**2-11**] Capsules PO BID (2
times a day) as needed for constipation.
9. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
10. coenzyme Q10 Oral
11. Hyaluronic Acid Oral
12. Fatty Acid Base Miscellaneous
13. multivitamin Tablet Sig: One (1) Tablet PO once a day.
14. melatonin 3 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
1. Right ventricular outflow tract ventricular tachycardia
Secondary Diagnsois
1. Coronary artery disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with abnormal rhythm called monomorphic
ventricular tachycardia which was causing you chest discomfort.
Electrophysiology study showed a focus in your heart that
started your abnormal rhythm which was ablated. You tolerated
the procedure well without any complications.
FOLLOWING MEDICATION CHANGES WERE MADE TO YOUR MEDICAL REGIMEN
STOP AMIODARONE 100 mg by mouth daily
Followup Instructions:
Department: GERONTOLOGY
When: THURSDAY [**2181-8-2**] at 12:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2847**], MD [**Telephone/Fax (1) 719**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: CARDIAC SERVICES
When: FRIDAY [**2181-8-31**] at 1 PM
With: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 677**], M.D. [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: MEDICAL SPECIALTIES
When: TUESDAY [**2181-10-23**] at 2:15 PM
With: [**Doctor First Name **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"V45.89",
"427.1",
"716.90",
"428.32",
"327.23",
"365.9",
"414.01",
"V45.82",
"401.9",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.34",
"37.27",
"37.26"
] |
icd9pcs
|
[
[
[]
]
] |
7416, 7422
|
4671, 6031
|
296, 333
|
7591, 7591
|
3695, 4648
|
8157, 9094
|
2736, 2754
|
6400, 7393
|
7443, 7570
|
6057, 6377
|
7742, 8134
|
2769, 3676
|
246, 258
|
361, 2314
|
7606, 7718
|
2336, 2612
|
2628, 2720
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,663
| 162,078
|
27438
|
Discharge summary
|
report
|
Admission Date: [**2141-4-1**] Discharge Date: [**2141-4-7**]
Date of Birth: [**2087-6-17**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
nausea, vomitting, and weakness
Major Surgical or Invasive Procedure:
XRT to spine at level of
History of Present Illness:
53 yo male with metastatic prostate CA, CKD due to DM on HD x
weeks with an AV fistula placed [**2141-3-30**] at [**Hospital1 2177**] discharged
yesterday from [**Hospital1 2177**] presenting with vomiting, weakness, and
fatigue. He was admitted to [**Hospital1 2177**] three weeks ago for pain. He was
discharged home with no medications. He has remained sleepy and
confused since discharge. He vomited this morning and was unable
to take his medications. If he takes anything PO he vomits it.
His emesis is non-bloody, non-bilious. He has been taking very
little PO. He has been having vomiting for about 1 month.
Initially it felt like anything he ate got stuck as if he had a
blockage. Now he vomits any time he eats anything and says it
feels different than before. He has not been ambulating at all
at home because he is too weak. He has some lower abdominal pain
that is sharp and comes and goes. He has had no chest pain. He
has some shortness of breath with any exertion. He is on
dialysis for renal failure and has not voided in 2 days, however
he is still producing urine. In addition he has developed a
decubitous ulcer which is painful.
.
He was recently admitted to [**Hospital1 2177**] for fatigue, leg pain, and
abdominal pain. On that admission he was found to have a new L3
compression fracture (after a fall in the hospital). It was
determined that he was not a surgical candidate so he was
treated with a braceb. On admission his creatinine was 8.6 so he
was started on Dialysis. Pain management was initiated with
Fentanyl and morphine.
.
In the ED here he was given 2 liters IV fluids given his degree
of dehydration. He and his wife are interested in transfering
his care to [**Hospital1 18**] as they are very unhappy with the care at [**Hospital1 2177**].
.
This Am he reports feeling fine. HAs some LBP but it is well
controlled. Reports that he feels like he wants to eat, but is
afraid that he will just vomit his food up.
Past Medical History:
1. Metastatic prostate CA, last PSA 183, refractory to hormonal
therapy
2. DM type 2
3. HTN
4. ESRD on dialysis MWF (etiology thought to be DM. AV fistula
placed by vascular at [**Hospital1 2177**] on [**2141-3-30**])
5. Hx of CVA, left sided numbness, resolved
.
ONC history: Diagnosed with prostate CA 1 year ago after he had
a CVA. He was treated with 3 months of radiation to the prostate
and hormone therapy with lupron and casodex. He had back pain
that was initially felt to be musculoskeletal. In [**Month (only) **] his
PSA was found to be 381. At that time an MRI showed metastasis
to his back. He got more radiation and recent imaging shows
spread to back and ribs, Heme/Onc at [**Hospital1 2177**] planning to initiate
Taxotere
Social History:
Lives at home with his sister. Wife [**Name (NI) **] [**Name (NI) **] is his health
care proxy. Used to work as a supervisor but was on disability
prior to this. No Etoh, no smoking.
.
Family History:
No cancer, father died at 52 from heart disease, mother died at
60 from heart disease
Physical Exam:
VS: Tm 99.4 Tc 97.1 Pulse 91 (91-103), BP 131/78 (108-131/66-78)
RR 20, 94% on RA FS 97, 87
Gen: alert, oriented male in NAD answering questions
appropriately and appearing comfortable
HEENT: MMM, OP clear, PERRL
Neck: supple, no lymphadenopathy
Lungs: clear to auscultation bilaterally
CV: RRR, nl S1S2, +rub
Abd: soft, non-tender, non-distended, NABS
Ext: no edema
Neuro:
MS: alert and oriented x 3, slowed responses but with fluent
speech, appropriate, but with poor memory for medical history.
CN: II-XII tested and intact
Motor: [**5-12**] Upper and Lower extremities proximal and distal
except hip flexor on R where the exam in pain limited.
Coord: FNF intact
Sensory: No level, no dermatomal loss, no perianal anesthesia
Reflexes: UE and patella 1+ bilaterally, ankles could not be
elicited. Toes downgoing bilaterally.
Gait: Not tested.
Pertinent Results:
CXR: Small right and small-to-moderate left pleural effusions,
with apparent loculation on the left. A component of pleural
thickening is also possible.
CT Abd/Pelvis [**4-2**]:
1. There is no evidence of small or large bowel obstruction.
Note, no acute intraabdominal pathology demonstrated.
2. Diffuse metastatic disease involving lungs, pleura, liver,
adrenal glands, left retroperitoneal and mesenteric lymph nodes,
pericardial nodes and bones. The pattern of metastasis is not
typic for prostate cancer. Other type of primary malignancies
should be considered including lung cancer, colon cancer and
renal cell carcinoma. (Liver with 11x19cm mass)
3. Hypodense lesions in the kidneys were not well characterized
by CT. MRI couldbe performed if indicated.
4. Pathologic fractures of the vertebral bodies and ribs as
described above.
5. Of concern is a destructive soft tissue mass in the vertebral
body of T12, which extends into the posterior elements and into
the spinal canal, possibly causing compression of the cord.
Recommend MRI for further evaluation.
Bone Scan [**4-3**]:
Findings suspicious for multifocal osseous metastases. The
intense lesion in the left mid femoral diaphysis may be at risk
for impending fracture and assessment of structural integrity
could be performed with radiographs.
MRI Spine [**4-3**]:
CT Chest [**4-3**]:
_
_
_
_
_
_
________________________________________________________________
Labs:
[**2141-4-1**] 07:50PM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.022
[**2141-4-1**] 07:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2141-4-1**] 07:50PM URINE RBC-0 WBC-0 BACTERIA-RARE YEAST-NONE
EPI-0
[**2141-4-1**] 07:20PM LACTATE-2.0
[**2141-4-1**] 07:00PM GLUCOSE-103 UREA N-27* CREAT-5.1* SODIUM-136
POTASSIUM-4.3 CHLORIDE-94* TOTAL CO2-28 ANION GAP-18
[**2141-4-1**] 07:00PM ALT(SGPT)-8 AST(SGOT)-135* LD(LDH)-1679*
CK(CPK)-173 ALK PHOS-82 AMYLASE-84 TOT BILI-0.6
[**2141-4-1**] 07:00PM cTropnT-0.05*
[**2141-4-1**] 07:00PM CK-MB-1
[**2141-4-1**] 07:00PM ALBUMIN-3.2* CALCIUM-10.0 PHOSPHATE-3.1
MAGNESIUM-1.7
[**2141-4-1**] 07:00PM WBC-6.7 RBC-3.11* HGB-9.3* HCT-27.1* MCV-87
MCH-29.8 MCHC-34.1 RDW-18.3*
[**2141-4-1**] 07:00PM NEUTS-82.0* LYMPHS-8.1* MONOS-8.9 EOS-0.6
BASOS-0.4
[**2141-4-1**] 07:00PM ANISOCYT-2+ MICROCYT-1+
[**2141-4-1**] 07:00PM PLT COUNT-175
[**2141-4-1**] 07:00PM PT-18.0* PTT-42.5* INR(PT)-1.7*
[**2141-4-2**] 05:30AM BLOOD Ret Aut-2.1
[**2141-4-1**] 07:00PM BLOOD ALT-8 AST-135* LD(LDH)-1679* CK(CPK)-173
AlkPhos-82 Amylase-84 TotBili-0.6
[**2141-4-3**] 05:26AM BLOOD LD(LDH)-1403*
[**2141-4-2**] 05:30AM BLOOD calTIBC-124* Ferritn->[**2135**] TRF-95*
[**2141-4-3**] 05:26AM BLOOD PTH-17
[**2141-4-3**] 05:26AM BLOOD Testost-21*
[**2141-4-3**] 05:26AM BLOOD HCG-7
[**2141-4-3**] 05:26AM BLOOD CEA-183* PSA-200.2* AFP-1.4
Brief Hospital Course:
Assessment: 53 year old male with history of metastatic
prostate CA to ribs and spine presenting with vomiting,
dehydration, and weakness.
Patient had liver biopsy done, with progressive abdominal pain
and hematocrit drop. Patient was found to have intra-abdominal
bleed, and taken emergently for laparotomy on [**4-7**]. Liver was
found to be replaced with tumor and bleeding in uncontrollable
manner. For details, see operative report.
After discussion with family, care was withdrawn and patient
expired.
Medications on Admission:
Ferrous Sulfate 325 [**Hospital1 **]
Epogen 100 mcg qtuesday
Colace 100mg [**Hospital1 **]
Reglan 10mg QID
Nephrocaps 1 daily
Tamsulosin 0.8mg daily
Hydralazine 100mg q6h
Amlodipine 10mg daily
Miralax 17gm daily
Sevelamer 100mg TID
Lisinopril 40mg daily
Fentanyl patch 125mg transdermal q72h
Senna [**Hospital1 **]
Oxycodone prn, Tylenol prn
Discharge Disposition:
Expired
Discharge Diagnosis:
Metastatic prostate biopsy.
Discharge Condition:
Deceased.
Discharge Instructions:
Deceased, autopsy refused by family and medical examiner's
office.
Followup Instructions:
None.
Completed by:[**0-0-0**]
|
[
"276.7",
"578.0",
"197.7",
"198.7",
"560.1",
"733.13",
"197.2",
"998.11",
"198.3",
"458.9",
"197.0",
"403.91",
"585.6",
"707.03",
"733.19",
"285.1",
"185",
"427.31",
"196.8",
"250.40",
"198.5",
"285.21"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"50.29",
"54.19",
"50.11",
"88.47",
"39.95",
"50.12"
] |
icd9pcs
|
[
[
[]
]
] |
8141, 8150
|
7233, 7748
|
343, 369
|
8221, 8232
|
4306, 7210
|
8347, 8379
|
3336, 3424
|
8171, 8200
|
7774, 8118
|
8256, 8324
|
3439, 4287
|
272, 305
|
397, 2351
|
2373, 3116
|
3132, 3320
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,680
| 186,596
|
20708
|
Discharge summary
|
report
|
Admission Date: [**2148-9-18**] Discharge Date: [**2148-9-20**]
Date of Birth: [**2093-2-25**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 492**]
Chief Complaint:
endobronchial obstruction
Major Surgical or Invasive Procedure:
flexible bronchoscopy
rigid bronchoscopy with Y stent placement
History of Present Illness:
Ms. [**Known lastname **] has a history of non-small cell lung/breast cancer
with central airway obstruction. Transferred here from [**Hospital1 55282**] for airway evaluation and possible stent
placement.
Past Medical History:
non-small cell lung cancer
breast cancer now on chemotherapy
Social History:
patient does not smoke or use EtOH
Family History:
noncontributory
Physical Exam:
Vital signs stable, intubated
General: intubated
Heart: RRR, -MRG
Lungs: loud upper airway sounds
Abd: soft, nontender, nondistended. +BS
Pertinent Results:
[**2148-9-18**] 03:13PM GLUCOSE-151* UREA N-13 CREAT-0.5 SODIUM-136
POTASSIUM-3.6 CHLORIDE-99 TOTAL CO2-26 ANION GAP-15
[**2148-9-18**] 03:13PM estGFR-Using this
[**2148-9-18**] 03:13PM CALCIUM-8.0* PHOSPHATE-3.1 MAGNESIUM-2.0
[**2148-9-18**] 03:13PM WBC-12.0*# RBC-3.24* HGB-11.8* HCT-33.6*
MCV-104* MCH-36.3* MCHC-35.0 RDW-22.4*
[**2148-9-18**] 03:13PM PLT SMR-VERY LOW PLT COUNT-23*#
[**2148-9-18**] 03:13PM PT-11.6 PTT-19.8* INR(PT)-1.0
CXR [**9-18**] - Cardiac size is top normal. There is widening of the
mediastinum, greater on the right side in the right lower
paratracheal region and right superior perihilar region. This
could be due to lymphadenopathy and/or post-radiation changes if
the patient has had radiation. Mass-like opacity in the left
suprahilar region measures 49 x 56 mm. Ill-defined faint opacity
in the right upper lobe due to interstitial abnormality could be
secondary to radiation. Other smaller lung nodules are seen in
the lower lobes bilaterally. Left lower lobe retrocardiac
opacity likely represent atelectasis. There is no pneumothorax
or pleural effusion.
Brief Hospital Course:
Patient was admitted to the ICU for her upper airway
obstruction. She was transferred intubated from [**Hospital3 **]
for stent removal. She underwent flexible bronchoscopy for
airway evaluation on [**9-19**]. This was followed by rigid
bronchoscopy with Y-stent removal for her documented upper
airway obstruction. She did well after the procedure and was
extubated without difficulty. She was transferred back to [**Hospital1 **] for further evaluation and treatment.
Medications on Admission:
Advair 250/50 once a day, Ativan 2mg hs, Decadron 10mg once a
day, Lexapro, insulin, mucinex
Discharge Medications:
1. Codeine Phosphate 15 mg/mL Syringe Sig: One (1) Injection
Q4-6H (every 4 to 6 hours) as needed for cough.
2. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Inhalation Q4H (every 4 hours) as needed.
3. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q4H (every 4 hours) as needed.
4. Dexamethasone 4 mg Tablet Sig: 2.5 Tablets PO DAILY (Daily).
5. Lorazepam 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
6. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Guaifenesin 600 mg Tablet Sustained Release Sig: Two (2)
Tablet Sustained Release PO BID (2 times a day).
8. Dextromethorphan Poly Complex 30 mg/5 mL Suspension,
Sust.Release 12 hr Sig: Ten (10) ML PO Q12H (every 12 hours) as
needed.
9. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
12. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day).
13. Scopolamine Base 1.5 mg Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal ONCE (Once) for 1 doses.
14. Lidocaine HCl 1 % (10 mg/mL) Solution Sig: One (1) ML
Injection Q1-2H () as needed for cough.
15. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Four (4) Capsule, Sustained Release PO ONCE (Once) for 1 doses.
16. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for
1 doses.
17. Levofloxacin in D5W 750 mg/150 mL Piggyback Sig: One (1)
Intravenous DAILY (Daily).
18. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1)
Injection Q8H (every 8 hours) as needed.
19. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two
(2) ML Intravenous DAILY (Daily) as needed.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
endobronchial obstruction
Discharge Condition:
still requiring further hospitalization
Discharge Instructions:
Resume previous hospital care. Please call Dr. [**Last Name (STitle) **] with any
questions about your stent at [**Telephone/Fax (1) 10084**].
Followup Instructions:
Please call Dr.[**Name (NI) 5070**] office for a follow-up appointment in 2
weeks at [**Telephone/Fax (1) 10084**].
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**Doctor First Name 494**]
|
[
"198.0",
"197.7",
"250.00",
"V58.67",
"198.5",
"786.05",
"198.3",
"493.90",
"287.5",
"162.2",
"174.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.05",
"99.05",
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
4479, 4494
|
2071, 2547
|
297, 363
|
4564, 4606
|
941, 2048
|
4798, 5029
|
751, 768
|
2691, 4456
|
4515, 4543
|
2573, 2668
|
4630, 4775
|
783, 922
|
232, 259
|
391, 599
|
621, 683
|
699, 735
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,089
| 135,595
|
2502
|
Discharge summary
|
report
|
Admission Date: [**2181-1-8**] Discharge Date: [**2181-3-20**]
Date of Birth: [**2118-12-20**] Sex: M
Service: NEUROLOGY
Allergies:
Penicillins / Aspirin
Attending:[**First Name3 (LF) 2927**]
Chief Complaint:
ETOH withdrawal
Major Surgical or Invasive Procedure:
Midline placed by IR
Intubation
NG Tube placement
Chest tube placement
Central line placement
History of Present Illness:
The patient is a 62 year old man with a history of hypertension,
seizure disorder, and EtOH abuse with history of withdrawl
seizures, who presented with an EtOH withdrawal seizure and
subsequently developed left gaze deviation and right sided
weakness, called as CODE STROKE.
The patient was admitted on [**2181-1-8**] after being found on his
porch with an unwitnessed seizure with bowel and bladder
incontinence. In the ED, vitals were T 97.9 P 96 BP 180/90 R 32
O2 sat 97% on 2L. He was intoxicated with EtOH level 211. He was
given ativan 2 mg IV x2 and 30-40 of diazepam IV. Head CT on
admission showed no hemorrhage.
Past Medical History:
HTN
Emphysema
Childhood seizure disorder
ETOH abuse with h/o withdrawal seizures and DTs
Multiple knee surgeries s/p truck accident in [**2142**]
s/p splenectomy d/t truck accident d/t truck accident in [**2142**]
s/p right hip fracture d/t truck accident in [**2142**]
Adrenal adenoma noted on CT during admission in [**4-18**]
Liver lesion noted on CT during admission in [**4-18**]
History of unremoved IVC filter
Social History:
Heavy EtoH, Tobacco: 0.5 ppd
Family History:
Unknown
Physical Exam:
Vitals: T: 99.0 HR: 105 BP: 142/108 R: 23 96%2L O2:
General: Dishevled, Lethargic, Arousable, Alert and Oriented x3,
Speaking Slowly
HEENT: Macroglossia with whitish plaques. PEERL, Sclera
anicteric, MMM
Neck: Supple, JVP flat, no LAD
Lungs: Clear to Auscultation Bilaterally, without wheezes,
rales, ronchi
CV: Tahcycardic, S1, S2, No M/R/G
Abdomen: Soft, Obese, Non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
LABS:
[**2181-1-7**] 11:47PM BLOOD WBC-13.4*# RBC-4.89# Hgb-14.6 Hct-43.8
MCV-90# MCH-29.8# MCHC-33.3 RDW-15.6* Plt Ct-310
[**2181-2-26**] 10:45AM BLOOD WBC-6.5 RBC-3.61* Hgb-11.0* Hct-32.3*
MCV-89 MCH-30.5 MCHC-34.1 RDW-16.5* Plt Ct-464*
[**2181-1-7**] 11:47PM BLOOD Neuts-86.3* Lymphs-8.9* Monos-4.1 Eos-0.3
Baso-0.3
[**2181-1-29**] 06:00AM BLOOD Neuts-67.9 Lymphs-21.3 Monos-7.3 Eos-3.0
Baso-0.6
[**2181-1-11**] 01:15PM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+
Macrocy-1+ Microcy-NORMAL Polychr-NORMAL Ovalocy-OCCASIONAL
Target-OCCASIONAL Tear Dr[**Last Name (STitle) 833**]
[**2181-1-31**] 10:13AM BLOOD PT-12.5 PTT-32.5 INR(PT)-1.1
[**2181-1-20**] 09:05AM BLOOD Lupus-NEG
[**2181-1-28**] 09:45PM BLOOD AT III-103 ProtSFn-60
[**2181-1-28**] 09:45PM BLOOD ACA IgG-41.9* ACA IgM-39.0*
[**2181-1-31**] 10:13AM BLOOD ProtCFn-179*
[**2181-1-28**] 09:45PM BLOOD Fibrino-554*
[**2181-1-31**] 10:13AM BLOOD Fibrino-649*
[**2181-1-7**] 11:47PM BLOOD Glucose-159* UreaN-6 Creat-0.9 Na-144
K-3.9 Cl-104 HCO3-23 AnGap-21*
[**2181-2-26**] 10:45AM BLOOD Glucose-165* UreaN-15 Creat-0.7 Na-140
K-3.9 Cl-107 HCO3-24 AnGap-13
[**2181-1-7**] 11:47PM BLOOD ALT-18 AST-16 AlkPhos-145* TotBili-0.3
[**2181-1-29**] 06:00AM BLOOD ALT-20 AST-35 AlkPhos-92 Amylase-43
TotBili-0.2
[**2181-1-26**] 02:26PM BLOOD Lipase-20
[**2181-1-29**] 06:00AM BLOOD Lipase-22
[**2181-1-27**] 03:16AM BLOOD Albumin-3.1* Calcium-9.2 Phos-3.8 Mg-2.1
Iron-28* Cholest-189
[**2181-1-27**] 03:16AM BLOOD Triglyc-173* HDL-34 CHOL/HD-5.6
LDLcalc-120
[**2181-1-27**] 03:16AM BLOOD %HbA1c-5.5
[**2181-1-13**] 03:22AM BLOOD Hapto-240*
[**2181-1-27**] 03:16AM BLOOD calTIBC-199* Ferritn-223 TRF-153*
[**2181-1-26**] 02:26PM BLOOD TSH-2.8
[**2181-1-31**] 10:13AM BLOOD CEA-3.0 AFP-2.1
[**2181-2-26**] 10:45AM BLOOD Phenyto-6.0*
[**2181-1-7**] 11:47PM BLOOD ASA-NEG Ethanol-211* Acetmnp-NEG
Bnzodzp-POS Barbitr-NEG Tricycl-NEG
Factor V Leiden ([**1-20**]) negative
Prothrombin ([**1-28**]): negative
[**2181-2-12**] 09:03AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.019
[**2181-2-12**] 09:03AM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
[**2181-1-7**] 11:47PM URINE bnzodzp-POS barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
Urine Cytology ([**1-30**]): negative for malignant cells
MICRO:
Blood Cx ([**1-12**], [**1-13**]): No growth
Urine Cx ([**1-12**], [**1-20**]): No growth
Sputum Cx ([**1-12**]): SPARSE GROWTH OROPHARYNGEAL FLORA.
Sputum Cx ([**1-13**]): SPARSE GROWTH OROPHARYNGEAL FLORA.
Urine Cx ([**1-13**]): Pansensitive ENTEROCOCCUS SP
Catheter Tip Cx ([**2-25**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. >15 colonies.
ENTEROCOCCUS SP.. >15 colonies.
IMAGING:
CXR ([**1-8**]): IMPRESSION: No acute intrathoracic process.
CT Head ([**1-8**]): IMPRESSION: No hemorrhage. No change from [**5-10**], [**2180**].
NOTE ADDED AT ATTENDING REVIEW: The maxillary sinuses are
incompletely imaged, and no fluid is detected in the included
portions of them. However, there is an apparent inferior and
medial left orbital blow out fracture, of uncertain chronicity.
Elements of it appear new since the study of [**2180-5-10**], but the
absence of ethmoidal or maxillary hemorrhage argues against an
acute fracture.
Bilateral LENIs ([**1-10**]): IMPRESSION: Essentially occlusive
thrombus throughout bilateral common femoral, superficial
femoral, and popliteal veins as well as greater saphenous vein.
Abdomen Film ([**1-10**]): IMPRESSION: Filter in lower IVC.
CT Head ([**1-11**]): IMPRESSION:
1. Extensive new intraparenchymal hemorrhage within the left
posterior
parietal cortex since [**2181-1-8**], extending into the subdural
space along with the falx and tentorium cerebri. No
intraventricular extension or midline shift. No evidence of
herniation.
2. Unchanged old right thalamic lacunar infarct.
CXR ([**1-11**]): The new intended right subclavian line turns abruptly
lateral at the upper margin of the right clavicle. The position
of the tip is not consistent with a central intravenous
location. It could be in a small vein, or a pleural space. In
the absence of pulmonary hematoma it is unlikely to be in the
lung, though the new right pneumothorax projecting over the
pleural sulcus and a small right pleural effusion suggest that
the lung may have been engaged during the line placement. ET
tube in standard placement, nasogastric tube ends in the distal
stomach. Left lung grossly clear. Leftward mediastinal shift
probably a function of new right pneumothorax and pleural
effusion.
TTE ([**1-12**]): The left ventricle is not well seen. 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 number of aortic valve
leaflets cannot be determined. The aortic valve is not well
seen. No masses or vegetations are seen on the aortic valve, but
cannot be fully excluded due to suboptimal image quality. There
is no aortic valve stenosis. The mitral valve leaflets are
mildly thickened. The mitral valve leaflets are not well seen.
No masses or vegetations are seen on the mitral valve, but
cannot be fully excluded due to suboptimal image quality.
IMPRESSION: poor technical quality due to poor echo
windows/intubation. No cardiac source of embolism seen. Left
ventricular function is probably normal, a focal wall motion
abnormality cannot be fully excluded. The right ventricle has
normal size and function. No pathologic valvular abnormality
seen.
Carotid Series ([**1-12**]): IMPRESSION: Minimal focal scattered
calcific plaque, no associated ICA or CCA stenosis however.
EEG ([**1-13**]): IMPRESSION: This 24-hour video EEG telemetry captured
no pushbutton activations or electrographic seizures. No
interictal epileptiform discharges were seen. The background did
reach a normal alpha frequency during wakefulness, although
through most of the day's recording slower background activity
was suggestive of excessive drowsiness or a mild encephalopathy.
MRI/MRV ([**1-16**]): IMPRESSION:
1. Hemorrhagic infarction of the left superior parietal lobe and
small infarction of the right parietal area secondary to
thrmbosed meduallry veins.
2. Diffuse thrombosis of the sinuses including transverse,
sigmoid, straight, superior sagittal. Multiple cortical veins
also are thrombosed.
3. Opacification of mastoid sinuses bilaterally.
LUE U/S ([**1-19**]): IMPRESSION: Patency of the subclavian, axillary,
and brachial veins. The internal jugular vein was not
identified, nor was the cephalic vein. Imaging of the basilic
vein could not be performed due to overlying bandaging material.
CT/CTV Head ([**1-23**]): IMPRESSION:
1. Unchanged large hemorrhagic infarction in the left frontal
and parietal
lobes.
2. Recanalization of the straight sinus, right transverse sinus,
right
sigmoid sinus, and the imaged upper portion of the right
internal jugular
vein.
3. The posterior half of the superior sagittal sinus, the
lateral aspect of the left transverse sinus, the left sigmoid
sinus, and the imaged upper
portion of the left internal jugular vein remain largely
occluded with small amount of recanalization.
CT Torso ([**1-26**]): IMPRESSION:
1. Persistent, but somewhat less prominent hypoattenuating left
lateral liver lesion probably indicating focal fat. MRI can
confirm this..
2. Additional hypoattenuating liver lesion not appreciated on
prior non-
contrast study in segments II/III of the liver anteriorly, also
somewhat
concerning but probably representing focal fat. Again MRI may be
useful for further evaluation.
3. Loculated-appearing right pleural effusion, with subsegmental
atelectasis. Subsegmental atelectasis on the left.
4. Satisfactory position of IVC filter, right PICC line, and
gastrostomy
tube. Filter has central calcification indicating old, calcified
clot.
5. Thick-walled appearing bladder, for which correlation with
any available cystoscopy may be helpful.
6.Carotid sheath lymph node.
EEG ([**1-28**]): Impression: This 24 hour video EEG telemetry
captured 4 pushbutton activations without clear electrographic
correlate. The telemetry during these recordings was obscurred
given significant lead artifact. On video, the patient appears
to have focal tremor or shaking of the left hand and arm. One
automated seizure detection captured focal slowing over the left
central and parietal leads with spread to the left hemispheric
leads. This was correlated with a brief episode of right leg
tonic clonic movements, suggestive of an electrographic seizure.
Automated and routine sampling also was showed significant
slowing predominantly over the left central and parietal leads,
consistent with a focal area of subcortical dysfunction and
potential seizure focus.
EEG ([**1-29**]): IMPRESSION: This telemetry captured 2 events with
rhythmic activity seen over the right hemisphere and one event
with generalized rhythmic activity. The first 2 events likely
represent seizure activity accompanied by the behavioral changes
described above; however, the EEG was significantly obscured by
artifacts. The last event is consistent with a seizure with more
generalized activity during which the patient had head and mouth
tremor. Overall, the EEG during these events were obscured by
movement artifacts. The background activity was, most of the
time, slow and disorganized suggestive of encephalopathy.
Interictal sharp and slow wave complexes were seen in the right
frontal region.
EEG ([**2-2**]): IMPRESSION: This telemetry captured no pushbutton
activations, but did capture numerous periods of rhythmic theta
activity seen broadly over the right hemisphere, and with
extension to the left frontal region as well. This activity
correlated with rhythmic tremor of the left hand, arm or
shoulder, and impaired responsiveness. These findings are
consistent with ongoing seizure activity. The background was for
a substanial period of time obscured by artifacts but showed a
slow and disorganized background suggestive of encephalopathy.
EEG ([**2-3**]): IMPRESSION: This telemetry captured 4 pushbutton
activations for episodes of left arm shaking, sometimes
accompanied by unresponsiveness and rhythmic movements of the
mouth, with no clear EEG correlate. There was one event when the
patient turned to the left and the EEG showed semi-rhythmic
right frontal delta frequency activity for about 50 seconds. The
background activity showed focal slowing in the frontal regions
bilaterally, right temporal region, and bursts of generalized
slowing were also seen. Interictal sharp waves were seen in the
right temporal region.
EEG ([**2-11**]): IMPRESSION: This is an abnormal portable routine EEG
in the awake state due to possible sharp features seen in the
right frontal area suggestive of cortical irritability in that
regiona. However most of the recording was obscured by the
artifacts. In addition, the background activity was slower on
the left suggestive of significant structural subcortical
abnormality in the left hemisphere.
CT Head ([**2-22**]): IMPRESSION:
1. No acute intracranial hemorrhage.
2. Continued evolution of left parietal infarct .
CXR ([**2-23**]): UPRIGHT AP CHEST: A right PICC is seen, with tip
overlying the
subclavian/axillary vein. The tip has retracted several
centimeters compared
to the prior study where it was located in the distal SVC.
Cardiac and
mediastinal contours are stable. There is persistent
consolidation in the
right middle lobe, as before. Patchy opacities are also seen in
the left
base. The upper lungs remain clear. There is a small right
pleural effusion,
unchanged. No pneumothorax. A gastrostomy tube is noted in the
right upper
quadrant. There is evidence of remote/healed fractures of the
right proximal
humerus and a right lower rib.
IMPRESSION:
1. Right PICC retraction, now overlying the subclavian/axillary
vein.
2. Persistent right middle lobe and left basilar opacity,
possibly reflecting aspiration or infection.
3. Unchanged right pleural effusion.
Brief Hospital Course:
The patient was admitted on [**2181-1-8**] after being found on his
porch with an unwitnessed seizure with bowel and bladder
incontinence. In the ED, vitals were T 97.9 P 96 BP 180/90 R 32
O2 sat 97% on 2L. He was intoxicated with EtOH level 211. He had
minimal access (R hip IV) and had B femoral line attempts
unsuccessfully for ? clots. A neck CVL could not be placed due
to patient combativeness. He was given ativan 2 mg IV x2 and
30-40 of diazepam IV. CT head was negative for acute bleed but
did show an orbital fracture that was felt to more likely
chronic without surrounding hemorrhage. He was initially
admitted to the MICU.
Upon admission to the MICU, he became "unresponsive for
approximately 8 minutes while experiencing bilateral upper
extremity tonic-clonic jerking." He was given Ativan 2mg IV x2.
His CIWA was initially 21. He was started on Keppra 1000 mg [**Hospital1 **]
(? what his home dose is). He had another episode of "tonic UE
and eye rolling" on [**1-9**] or [**1-10**], for which he was given
Ativan 2 mg IM with ressolution in 10 minutes. He was also
treated with Valium CIWA. He was transferred to the floor on
[**2181-1-10**].
He was called out to the floor on [**1-9**]. On the floor, he was
found to have extensive B LE clots. He was also discovered to
have an infrarenal IVC filter in place. He was not
anticoagulated given suspicion that clots were chronic. He had
recurrent seizures on the floor treated with IV ativan. On [**1-11**],
patient noted to have further seizing with gaze preference,
nystagmus, and was unresponsive with flaccid paralysis of RUE.
At that time he also had respiratory arrest. CT head at that
time showed new intraparenchymal hemorrhage within the left
posterior parietal cortex and code stroke was called. Neurology
felt this was most c/w an MCA ischemic stroke with hemorrhagic
transformation.
On [**2181-1-11**], the patient was noted to be more somnolent than
before, but was otherwise conversant with the house officer
team. The patient was last noted to be normal at approximately
3:00pm on [**1-11**] by his nurse. At 4:45 pm, the medicine attending
evaluated the patient and found him to be less responsive with
left gaze preference. They were initially concerned for seizure,
and gave him Ativan 1 mg IM x2. Upon re-evalution he was
concerned that the patient had developed a right hemiparesis
with flaccid tone in the RUE. A CODE STROKE was called at 16:52,
and neurology arrived at approximately 17:00.
NEUROLOGY: The L MCA territory was likely from hemorrhagic
conversion of ischemic stroke or from venous sinus thrombosis.
No embolic source identified on ECHO. Carotid u/s unrevealing.
Repeat CT scans showed stability of his hemorrhage with expected
progression of infarction. He worked with PT and OT and improved
during his hospitalization. Speech improved. He was cleared for
a modified diet on swallow evaluation. Deficits include
expressive aphasia, RUE weakness with intermittent strength upto
anti-gravity, and L gaze preference and intermittent nystagmus.
With regards to his orbital blow out fracture seen on CT head at
admission, it appeared chronic. Discussed with Plastics. No
further intervention needed at this time as at least >5 days out
from injury and no evidence of decreased eye ROM, impingement of
EOM, or other concerning findings. Regardless, would be poor
surgical candidate.
With regards to his seizures, patient had a h/o childhood
seizures and EtOH withdrawal seizures. Unclear etiology of
initial seizures on admission. However, following hemorrhage, he
had recurrent seizures where were felt to be due to irritable
focus from hemorrhage as well as new stroke. He had multiple
dilantin loads until his corrected dilantin level was in
therapeutic range of 15-20. He was also maintained on keppra.
He had recurrent seizures despite therapeutic dilantin levels.
Typical seizure activity was LUE rhythmic shaking, sometimes
with jaw twitching and L superior gaze preference. At times his
seizure would become more generalized and he would have
alteration of his mental status. His seizures always broke with
2 mg of IV ativan. His keppra dose was uptitrated with decreased
frequency of seizures. Of note, he was strictly NPO after his
PEG tube was placed so his po dilantin was changed to
fosphenytoin. However, once his tube was ready for use he was
changed back to oral dilantin.
He is currently on Keppra 2g [**Hospital1 **], Phenytoin 200mg TID, Zonegran
200mg/500mg, and Trileptal 1200mg [**Hospital1 **] plus standing Ativan but
continues to have intermittent clinical seizures responsive to
2mg to 6mg of IV Ativan or 10mg IM Diazepam. He was discharged
on Diastat 15mg per rectum as needed for seizures. At time of
discharge, the goal Phenytoin level was 20-25 with a normal
albumin. He should have his anti-seizure medication levels
checked every 6 months.
His altered MS/agitation was likely due to stroke, venous sinus
thrombosis, recurrent seizures, and toxic metabolic
encephalopathy in the setting of infection, prolonged hospital
stay. Has improved with discontinuation of tele and foley. After
PEG placement can discontinue LUE restraint. Initially required
1:1 sitter but able to be safe with bed alarm only. Frequently
has outbursts of yelling but may be post-ictal confusion.
HEMATOLOGY:
With regards venous sinus thrombosis, it is likely due to
underlying hypercoaguable state. Anticoagulation complicated by
poor access and difficult blood draws. He was initially treated
with heparin but due to difficult blood draws this was
transitioned to lovenox. Lovenox was transitioned back to
heparin for 24 hrs for PEG tube placement and he was restarted
on lovenox 4 hours after tube placement. Ct venogram showed
partial recannalization of thromboses suggesting response to
anticoagulation. Given suspected hypercoaguable state, he will
likely require lifelong anticoagulation. However, due to
extremely difficult blood draws and poor access, the decision
was made to continue long term lovenox therapy. He was
eventually transitioned to 1.5 mg/kg dosing for once daily
administration. He was started on calcium and vitamin D for
osteoporosis prophylaxis given suspected lifelong LMWH
requirements. He should have bone density testing performed as
an outpatient. If worsening density despite calcium and vitamin
D, could consider addition of bisphosphonate or transition from
lovenox to fondaparinox or coumadin. Hematology was consulted
and of the labs ordered, he does have elevated anticardiolipin
antibody. To establish antiphospholipid antibody syndrome, he
will need repeat testing in 6 weeks. He has follow-up appt in
Heme [**Hospital **] clinic set up as outpatient.
His hypercoaguable state as evidenced by multiple clots in LEs
and diffuse venous sinus thrombosis as well as suspected
ischemic stroke all suggest hypercoagulable state.
Hypercoaguable work up limited by patient's anticoagulation
requirement. Bilateral UE ultrasounds were negative for clots.
He has an infrarenal IVC filter in place which was old, likely
placed for chronic LE clots. Lupus anticoagulant was negative.
Factor V Leiden was also negative but anticardiolipin ab
positive although not conclusive for antiphospholipid syndrome
as noted above hence will follow-up in Heme [**Hospital **] clinic as
outpatient. Likely needs life-long anticoagulation.
PULMONARY
In the setting of acute ICH and status epilepticus, he had an
aspiration pna s/p multiple intubations and multiple central
line attempts without success. R subclavian CVL attempt failed
and was complicated by a pneumothorax. He is s/p CT x 3. Last CT
was removed [**1-19**] without evidence of recurrent pneumothorax on
repeat CXRs. He self extubated twice and remained extubated
after the second. He was treated with 10 days of clindamycin and
8 days of vancomycin for presumed aspiration pna. Following
completion of his treatment he had no fevers, leukocytosis, or
other evidence of pneumonia. His hypoxia with O2 requirement
likely had multiple potential etiologies including emphysema,
recent pneumonia, recurrent aspiration, and possible PEs given
suspected thrombophilia. He was maintained on anticoagulation as
above. He should have PFTs performed as an outpatient.
GASTROENTEROLOGY:
A PEG tube was placed for nutrition and medication
administration. He was started on tube feeds per nutrition recs.
As mental status improved, he passed a swallow evaluation for a
modified diet with supervision. He still receives cycled
nutrition via PEG overnight.
IV ACCESS:
Patient had L midline which was changed to R PICC at the time of
PEG placement by IR. This PICC fell out on [**2-25**], requiring
replacement in IR. PICC line was subsequently discontinued
prior to discharge as antiepileptic levels and labs had been
within normal limits and stable.
PROPHYLAXIS:
therapeutic lovenox. Famotidine. Bowel regimen.
SOCIAL:
CODE is DNR/DNI
COMMUNICATION: Patient had no healthcare proxy on admission. He
had family consent for all procedures through his sister,
[**Name (NI) **] [**Name (NI) 4882**] (sister) (w)[**Telephone/Fax (1) 12803**], (c)[**Telephone/Fax (1) 12804**],
(h)[**Telephone/Fax (1) 12805**]. After patient's mental status improved, he
agreed to make his sister his healthcare proxy.
Medications on Admission:
? Keppra 750 mg PO Daily (1000 mg per pharmacy)
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever or pain.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day).
4. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q4H (every 4 hours) as
needed for shortness of breath or wheezing.
5. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q4H (every 4 hours) as needed for shortness of breath
or wheezing.
6. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day).
11. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
12. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
13. Levetiracetam 500 mg Tablet Sig: Four (4) Tablet PO BID (2
times a day).
14. Enoxaparin 120 mg/0.8 mL Syringe Sig: One [**Age over 90 **]y
(120) mg Subcutaneous QDAY ().
15. Oxcarbazepine 600 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
16. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
17. Quetiapine 50 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
18. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO QHS (once a day (at bedtime)) as needed for
agitation, insomnia.
19. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed.
20. Phenytoin 125 mg/5 mL Suspension Sig: Two Hundred (200) mg
PO three times a day.
21. Zonegran 100 mg Capsule Sig: Two (2) Capsule PO qAM.
22. Zonegran 100 mg Capsule Sig: Five (5) Capsule PO at bedtime.
23. Diastat AcuDial 12.5-15-17.5-20 mg Kit Sig: Fifteen (15) mg
Rectal once a day as needed for focal motor seizure: may repeat
in 4 to 12 h if necessary.
24. Diazepam 5 mg/mL Solution Sig: Ten (10) mg Injection PRN:MR1
as needed for focal motor seizures: IN AMBULANCE ONLY.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2857**] - [**Location (un) 1459**]
Discharge Diagnosis:
Primary:
- Left frontal/parietal MCA hemorrhagic stroke.
- Right small parietal infarction
- Cerebral venous thrombosis
- Bilateral femoral and popliteal DVT.
- General seizure
- Right pneumothorax
- Aspiration pneumonia
- Acute renal failure
- Thrush
- Reactive thrombocytosis
Secondary:
- COPD/Emphysema
- ETOH abuse: withdrawal seizures and delirium tremens.
- Childhood seizure disorder
- Right thalamic lacunar infarct.
- Recurrent VTE
- IVC Filter
- 2.4 x 2.0 cm right adrenal adenoma.
- 4.6 x 3.4 x 2.1 liver lesion NOS
- Left orbital blow-out fracture
- MVA [**2142**]: s/p splenectomy, s/p right hip fracture.
Discharge Condition:
Fluent aphasia, pupils equal, right arm hemiplegia, moves left
side spontaneously and purposefully.
Discharge Instructions:
You were admitted to the hospital for alcohol withdrawal. Your
hospitalization was complicated by a hemorrhagic stroke due to
clots in the veins around your brain. You had levels checked for
factors that can make you hypercoaguable, and were found to have
elevated anticardiolipin. You were started on Lovenox daily. You
had a central line placed during your ICU stay, which led to a
pneumothorax requiring chest tube placement. You developed
frequent seizures, requiring multiple medications for seizure
control.
Please take all medications as prescribed. Recheck anti-seizure
medication levels (Dilantin, Zonegram, Trileptal, Keppra) every
6 months or sooner as indicated by your outpatient
epileptologist.
Please call your doctor or return to the hospital if you have
worsening of your speech or vision, new numbness, new weakness,
worsening seizures, fevers, chills, chest pain, shortness of
breath, or any other concerns.
Followup Instructions:
Please follow up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 12806**] once you are
discharged from rehab. Please call [**Telephone/Fax (1) 12807**] to schedule an
appointment.
You have an outpatient repeat MRI and MRV of your head on
[**2181-3-20**] at 9:00 am in the [**Hospital Ward Name 517**], [**Hospital Ward Name 121**] Building, [**Location (un) **].
You have a follow up appointment with Dr. [**Last Name (STitle) **] in
Neurology/Stroke ([**Telephone/Fax (1) 2574**]) on [**2181-3-27**] at 3 pm in the
[**Hospital Ward Name 23**] Center, [**Location (un) 858**].
You have a follow up appointment with Dr. [**Last Name (STitle) **] a PCP
([**Telephone/Fax (1) 250**]) on [**2181-4-10**] at 10:10 am.
You have a follow up appointment with Dr. [**Last Name (STitle) 2442**] in
Epilepsy/Neurology ([**Telephone/Fax (1) 3506**]) on [**2181-4-11**] at 1:00 in the
[**Hospital Ward Name 23**] Center, [**Location (un) 858**].
You have a follow up appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3060**] in
Hematology [**Hospital **] Clinic ([**Telephone/Fax (1) 3062**]) on [**2181-4-13**] at 11:00
in the [**Hospital Ward Name 23**] Center, [**Location (un) 24**].
Completed by:[**2181-3-20**]
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"345.80",
"512.1",
"E849.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.14",
"96.72",
"96.6",
"38.93",
"34.04",
"94.62",
"43.11",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
25913, 25987
|
14251, 23561
|
299, 394
|
26651, 26753
|
2129, 14228
|
27732, 28997
|
1550, 1559
|
23660, 25890
|
26008, 26630
|
23587, 23637
|
26777, 27709
|
1574, 2110
|
244, 261
|
422, 1047
|
1069, 1487
|
1503, 1534
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,337
| 188,296
|
2771
|
Discharge summary
|
report
|
Admission Date: [**2150-11-15**] Discharge Date: [**2150-11-19**]
Date of Birth: [**2071-9-16**] Sex: F
Service: NEUROLOGY
Allergies:
Amoxicillin
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
found unresponsive, obtunded, not moving L [**Hospital **] transferred to
this hospital as code stroke
Major Surgical or Invasive Procedure:
None
History of Present Illness:
History obtained from her two daughters who were present at the
bedside. Patient lives by herself but in a house that is right
next to her daughter's on the same property. She is fully
independent at baseline and drives. Her daughter last saw her
nml at 5pm yesterday. The she saw that the lights turned off
around 10 pm which is her usual bedtime. In the am she gets up
between
5h30 and 7h30, has a regular routine of things she does,
starting by putting her dentures in and her dentures where found
in the sink so her daughters think she might have started her
morning routine as per usual. Today at 10 am she was found by
her daughter unresponsive on the floor by her daughter and
seemed to
have hit both sides of her head on the sink, with urinary
incontinence. She apparently had an intermittent L gaze
deviation.
She was brought to [**Hospital3 4107**] where her SBP was 136,
blood sugar 316, normal sinus rhythm. She had a head CT that was
negative for hemorrhage as well as C-spine imaging. Her gag
reflex was present and she was protecting airway so not
intubated
there. No spont mvt of L UE.
She has chronic UTIs and is on Nitrofurantoin at the moment
but her daughters report that she has been well over the last
few days, no fever, visual changes, hearing changes, headache,
neckpain, nausea, vomiting, weakness, tingling, numbness,
bowel-bladder dysfunction, chest pain, shortness of breath.
Past Medical History:
-HTN
-Hypercholesterolemia
-IDDM
-No CAD, no afib, no CVAs
-colon CA 5 yrs ago, tx colectomy, nml follow-up colonoscopies
-esophageal stricture dilation Q 2-3 months
-bilat knee replacement 2 yrs ago with post-op thoracic
vertebral
stress fracture & C.diff
Social History:
Lives alone, good family support from daughters, no tobacco
Family History:
Non-contributory
Physical Exam:
VITALS: afebrile HR 115 nsr BP 161/74 (95) RR 18 sO2 100%RA
NIHSS 23 (1a-LOC=2; 1b-LOC questions=2; 1c-commands=2; 5-Motor
arm=L-2 & R-4; 6-Motor leg= L-3 & R-3; 9-Best language=3;
10-dysarthria=2, extinction: could not check
HEENT: mmm
NECK: no LAD; no carotid bruits
LUNGS: Clear to auscultation bilaterally
HEART: Regular rate and rhythm, normal S1 and S2, no murmurs,
gallops and rub
EXTREMITIES: no clubbing, cyanosis, ecchymosis, or edema
MENTAL STATUS:
Obtunded, does not open eyes to command, no speech
CRANIAL NERVES:
II: Blinks to threat bilat, pupils equally round and reactive to
light both directly and consensually, 3-->2 mm bilaterally III,
IV, VI: oculocephalic reflex present, no fixed gaze deviation
V: positive corneal reflex
VII: Facies symmetric; no facial droop.
MOTOR SYSTEM: Normal bulk, hypertonic in L UE with some
antigravity effort, RUE no mvt to noxious stim, bilat LE min mvt
without gravity a little more mvt R>L.
REFLEXES:
DRs 2 + and symmetric, plantars upgoing bilaterally.
Pertinent Results:
[**2150-11-15**] 01:30PM BLOOD WBC-18.1* RBC-4.29 Hgb-13.5 Hct-39.3
MCV-92 MCH-31.4 MCHC-34.3 RDW-12.6 Plt Ct-403
[**2150-11-16**] 04:46AM BLOOD WBC-18.2* RBC-4.08* Hgb-12.7 Hct-36.6
MCV-90 MCH-31.0 MCHC-34.6 RDW-12.9 Plt Ct-342
[**2150-11-17**] 01:56AM BLOOD WBC-14.1* RBC-3.49* Hgb-11.0* Hct-31.9*
MCV-92 MCH-31.4 MCHC-34.3 RDW-12.6 Plt Ct-271
[**2150-11-18**] 02:15AM BLOOD WBC-10.3 RBC-3.41* Hgb-10.5* Hct-30.6*
MCV-90 MCH-30.9 MCHC-34.4 RDW-12.6 Plt Ct-266
[**2150-11-15**] 01:30PM BLOOD PT-11.4 PTT-21.1* INR(PT)-1.0
[**2150-11-18**] 02:15AM BLOOD PT-11.2 PTT-28.6 INR(PT)-0.9
[**2150-11-15**] 01:30PM BLOOD Glucose-349* UreaN-16 Creat-1.0 Na-140
K-4.1 Cl-101 HCO3-23 AnGap-20
[**2150-11-15**] 11:59PM BLOOD Glucose-187* UreaN-17 Creat-1.0 Na-142
K-3.6 Cl-107 HCO3-23 AnGap-16
[**2150-11-17**] 01:56AM BLOOD Glucose-92 UreaN-13 Creat-0.7 Na-143
K-3.2* Cl-108 HCO3-29 AnGap-9
[**2150-11-18**] 02:15AM BLOOD Glucose-216* UreaN-15 Creat-0.6 Na-137
K-3.4 Cl-103 HCO3-29 AnGap-8
[**2150-11-15**] 01:30PM BLOOD CK(CPK)-5910*
[**2150-11-15**] 11:59PM BLOOD CK(CPK)-[**Numeric Identifier 13652**]*
[**2150-11-16**] 04:46AM BLOOD CK(CPK)-9325*
[**2150-11-16**] 07:51AM BLOOD CK(CPK)-7973*
[**2150-11-17**] 01:56AM BLOOD CK(CPK)-4402*
[**2150-11-18**] 02:15AM BLOOD CK(CPK)-2723*
[**2150-11-15**] 01:30PM BLOOD CK-MB-81* MB Indx-1.4 cTropnT-<0.01
[**2150-11-15**] 11:59PM BLOOD CK-MB-85* MB Indx-0.8 cTropnT-0.02*
[**2150-11-16**] 07:51AM BLOOD CK-MB-57* MB Indx-0.7 cTropnT-<0.01
[**2150-11-15**] 01:30PM BLOOD Calcium-9.3 Phos-3.4 Mg-2.2
[**2150-11-15**] 11:59PM BLOOD Calcium-8.6 Phos-2.8 Mg-2.4
[**2150-11-16**] 04:46AM BLOOD Calcium-8.6 Phos-2.3* Mg-2.2
[**2150-11-18**] 02:15AM BLOOD Calcium-8.2* Phos-1.8* Mg-2.3
[**2150-11-18**] 02:15AM BLOOD TSH-6.2*
[**2150-11-15**] 01:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
CT Head [**11-15**]:
Large areas of hypodensities seen in the bilateral anterior
cerebral artery territorial distribution, consistent with
evolving infarcts. No evidence of acute hemorrhage or mass.
BRAIN MRI [**11-15**]:
Bilateral acute anterior cerebral artery territorial infarcts
and also infarct involving the left posterior cerebral artery
involving the occipital lobe. A small area of slow diffusion
indicating acute infarct is seen also in the right occipital
region. Given the multiple locations, the infarcts may be
embolic in nature.
MRA OF THE NECK [**11-15**]:
No vascular occlusion or high-grade stenosis on MRA of the neck.
MRA OF THE HEAD [**11-15**]:
Normal MRA of the head
CT Head [**11-17**]:
Large areas of hypodensity are seen in the bilateral anterior
cerebral artery vascular territories. These are consistent with
evolving infarcts. A smaller area of hypodensity seen in the
left central sulcus and represents an evolving infarct in the
watershed or left MCA distribution. The previously identified
left posterior occipital infarct on MRI has no corresponding
counterpart seen on today's study. There is no evidence of
hemorrhage or mass effect. There is no shift of normally midline
structures. The ventricles are unremarkable. There are air-fluid
levels seen in the sphenoid sinus and bilateral maxillary
sinuses. There is mild ethmoidal air cell opacification. The
frontal sinus is clear.
Echo [**11-18**]:
The left atrium is elongated. Left ventricular wall thickness,
cavity size, and systolic function are normal (LVEF>55%). Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Tissue Doppler imaging suggests an
increased left ventricular filling pressure (PCWP>18mmHg). 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, but cannot be fully excluded due to suboptimal
image quality. The mitral valve leaflets are mildly thickened.
No masses or vegetations are seen on the mitral valve, but
cannot be fully excluded due to suboptimal image quality. Mild
(1+) mitral regurgitation is seen. [Due to acoustic shadowing,
the severity of mitral regurgitation may be significantly
UNDERestimated.] The estimated pulmonary artery systolic
pressure is normal. There is an anterior space which most likely
represents a fat pad.
Brief Hospital Course:
Ms. [**Name14 (STitle) 13653**] was admitted to the ICU for close monitoring and
management of her bilateral ACA and left PCA infarcts.
She was allowed to autoregulate her BP between 220/105 and
120/90 and was treated with a Nicardipine drip PRN. She was
started on ASA 81 mg as Aggrenox could not be given via NG. She
had a repeat head CT on [**11-17**] which was unchanged. An echo was
also done to look for an intracardiac source of infarct. She was
monitored on tele without arrhythmias.
She was admitted with rhabdomyolysis and her CK peaked above
10,000. She was treated with IVF and her Cr did not rise. She
was treated with SSI for her DM and started on TF for nutrition.
She received Protonix for GI prophylaxis. She was also continued
on levothyroxine for hypothyroidism.
A CXR was done which showed some R hilar consolidation and as
she had a leukocytosis on admission she was treated with
levofloxacin. She was recultured and abx where stopped on the
[**11-18**]. She remained intubated until [**11-18**].
On [**11-18**] a family meeting was held to discuss her goals of care.
Her mental status had not improved and her family decided to
make her CMO. Palliative care, case management and SW helped to
arrange for home hospice. She was extubated that day and started
on morphine and scopolamine. She appeared comfortable and was
discharged with home hospice care.
Medications on Admission:
Simvastatin 80 mg Hs, Lovastatin 40 mg once daily, Lipitor 10
mg,
Vytorin 10 mg-40 mg
Nitrofurantoin 50 mg Hs
Prevacid, Folic acid
Raloxifene 60 mg once daily
Pioglitazone 15 mg
HCTZ 25 mg
Levothyroxine 50 mcg
Triamcinolone 0.1 %
Verapamil 180 mg
Humalog 3x/day, Lantus Qhs
Discharge Medications:
Atropine Sulfate
Midazolam
Morphine Sulfate
Scopolamine Patch
Discharge Disposition:
Home With Service
Facility:
Old [**Hospital **] Hospice
Discharge Diagnosis:
Stroke
Discharge Condition:
CMO
Discharge Instructions:
Hospice
Followup Instructions:
NA
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
|
[
"272.0",
"401.9",
"728.88",
"434.91",
"486",
"V10.05",
"V43.65",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
9403, 9461
|
7609, 8991
|
378, 385
|
9512, 9518
|
3276, 7586
|
9574, 9695
|
2206, 2225
|
9316, 9380
|
9482, 9491
|
9017, 9293
|
9542, 9551
|
2240, 2688
|
236, 340
|
413, 1832
|
2771, 3257
|
2703, 2755
|
1854, 2112
|
2128, 2190
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,902
| 129,468
|
37333
|
Discharge summary
|
report
|
Admission Date: [**2145-11-17**] Discharge Date: [**2145-12-13**]
Date of Birth: [**2078-11-5**] Sex: F
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
Left Leg pain
Major Surgical or Invasive Procedure:
[**2145-11-17**]
1. Right common femoral exploration
2. Embolectomy of right femoral and iliac arteries
3. Resection of right common femoral artery
4. Superficial femoral artery bypass w/reverse greater saphenous
vein
5. Left femoropopliteal embolectomy
6. Serial arteriogram of the left lower extremity
7. Primary stenting of left superficial femoral artery and
above-knee popliteal artery
[**2145-11-18**]
1. Inspection of right lower extremity fasciotomy sites and
application of medial and lateral VAC dressings
2. Left open guillotine amputation at the level of the ankle
3. Debridement of anterior left lateral fasciotomy sites
including subcutaneous tissue and muscle
[**2145-11-26**]
1. Completion left below-the-knee amputation
2. Closure of fasciotomy sites in the right lower extremity
History of Present Illness:
67 year old spanish speaking female with initial complaint of
left lower extremity pain for 4 days. She was seen at OSH and
discharges with arthritis as a diagnosis. She continued to have
pain, inability to walk, and numbness of the left foot. She
presented to an OSH with noted pain in right leg (calf/foot) and
numbness of the right medial lower leg and foot along with
increased sensory loss in the left leg from approximately the
knee down. See at OSH ED and CTA done showing occlusion of left
SFA & popliteal arteies as well as right CFA. Transferred
emergently to [**Hospital1 18**]
Past Medical History:
1. hypertension
2. hypercholesteremia
Social History:
Lives with husband and 3 kids. Patient has 12 children, half of
whom live in the [**Country 13622**] Republic. 26 grandchildren. Lives in
apartment with steps to enter.
Spanish speaking only.
Family History:
Noncontributory
Physical Exam:
Upon admission:
PE: 75 123/76 18 97
A&Ox3, pleasant female in no acute distress
RRR
CTA b/l
Abd obese, soft, nd/nt
LE cool b/l. LLE slightly dusky compared to rt with sluggish
cap
refill. sensory loss to LT lateral feet b/l and Left shin.
Poor
ROM of ankles. inability to move toes on left and some movement
on rt. Left calf swollen and tender to palpation. Pain on
passive dorsiflexion
Pulses:
RT/LT Fem [**Doctor Last Name **] DP PT
tri/2+ mono/mono -/- wk mono/-
Laboratory:
138 96 33
-----------< 230
4.3 24 1.7
CK: 9454 MB: 76 MBI: 0.8 Trop-T: 0.38
34.5 >37.3 < 461
N:86 Band:0 L:6 M:8 E:0 Bas:0
PT: 13.8 PTT: 68.8 INR: 1.2
Upon discharge:
T: 98.1 HR: 73 BP:147/74 RR:17 Spo2: 97%
NAD, spanish speaking
Cards: RRR, no mrg
Lungs: CTA bilaterally
Abd: soft, NT, ND
Wound: Left BKA site closed and improving. No active drainage.
Right le incisions stable.
Dopperable signals on the right leg.
Pertinent Results:
[**2145-12-13**] 05:35AM BLOOD WBC-7.9 RBC-3.21* Hgb-9.5* Hct-29.2*
MCV-91 MCH-29.8 MCHC-32.7 RDW-17.5* Plt Ct-295
[**2145-12-12**] 06:58AM BLOOD WBC-8.7 RBC-3.37* Hgb-9.9* Hct-31.0*
MCV-92 MCH-29.6 MCHC-32.1 RDW-17.3* Plt Ct-282
[**2145-11-24**] 02:13AM BLOOD Neuts-75* Bands-1 Lymphs-15* Monos-8
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-1*
[**2145-11-17**] 08:16AM BLOOD Neuts-82.6* Lymphs-14.7* Monos-2.1
Eos-0.4 Baso-0.2
[**2145-12-13**] 05:35AM BLOOD Plt Ct-295
[**2145-11-24**] 02:13AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2145-12-13**] 05:35AM BLOOD PT-18.7* PTT-88.3* INR(PT)-1.7*
[**2145-12-13**] 02:12AM BLOOD PTT-84.7*
[**2145-12-12**] 03:40PM BLOOD PTT-76.0*
[**2145-12-12**] 06:58AM BLOOD PT-20.5* PTT-92.3* INR(PT)-1.9*
[**2145-12-13**] 05:35AM BLOOD Glucose-118* UreaN-11 Creat-0.9 Na-142
K-3.7 Cl-106 HCO3-28 AnGap-12
[**2145-12-12**] 06:58AM BLOOD Glucose-109* UreaN-13 Creat-1.0 Na-141
K-3.7 Cl-104 HCO3-27 AnGap-14
[**2145-12-8**] 06:25AM BLOOD Glucose-103 UreaN-10 Creat-0.9 Na-142
K-3.9 Cl-104 HCO3-30 AnGap-12
[**2145-12-1**] 07:00AM BLOOD CK(CPK)-46
[**2145-11-19**] 09:56PM BLOOD CK(CPK)-5101*
[**2145-11-16**] 11:30PM BLOOD CK(CPK)-9454*
[**2145-11-30**] 06:10AM BLOOD CK-MB-NotDone cTropnT-0.99*
[**2145-11-27**] 09:00PM BLOOD CK-MB-11* MB Indx-3.0 cTropnT-0.61*
[**2145-11-27**] 01:10PM BLOOD CK-MB-22* MB Indx-4.8 cTropnT-0.54*
[**2145-11-27**] 05:00AM BLOOD CK-MB-30* MB Indx-6.5* cTropnT-0.59*
[**2145-12-13**] 05:35AM BLOOD Calcium-8.8 Phos-3.5 Mg-2.3
[**2145-12-12**] 06:58AM BLOOD Calcium-8.7 Phos-3.4 Mg-1.6
[**2145-12-7**] 07:05AM BLOOD Vanco-13.7
[**2145-11-29**] 5:32 pm STOOL CONSISTENCY: WATERY Source:
Stool.
**FINAL REPORT [**2145-11-30**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2145-11-30**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
[**2145-11-23**] 8:18 am SWAB Source: Left lower extremity wound.
**FINAL REPORT [**2145-11-27**]**
GRAM STAIN (Final [**2145-11-23**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2145-11-26**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. SPARSE GROWTH.
ESCHERICHIA COLI. RARE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ 16 I
AMPICILLIN/SULBACTAM-- 8 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 16 I
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
ANAEROBIC CULTURE (Final [**2145-11-27**]): NO ANAEROBES ISOLATED
Sinus bradycardia. Consider prior inferior myocardial
infarction. Low
precordial lead QRS voltage. Delayed R wave progression is
non-specific but
cannot exclude possible anterior wall myocardial infarction of
indeterminate
age. Prolonged QTc interval. Anterolateral lead T wave
abnormalities. Cannot
exclude myocardial ischemia. Clinical correlation is suggested.
Since the
previous tracing of [**2145-12-1**] no significant change.
TRACING #1
Read by: [**Last Name (LF) **],[**First Name3 (LF) 177**] W.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
57 160 78 500/494 49 -7 63
[**Known lastname 83979**],[**Known firstname **] [**Medical Record Number 83980**] F 67 [**2078-11-5**]
Radiology Report CHEST (PORTABLE AP) Study Date of [**2145-11-27**] 9:55
AM
[**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 6889**] VICU [**2145-11-27**] 9:55 AM
CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 83981**]
Reason: evaluate tube placement and cardiopulm disease
[**Hospital 93**] MEDICAL CONDITION:
67 year old woman POD #1 s/p fem embolectomy. Intubated
REASON FOR THIS EXAMINATION:
evaluate tube placement and cardiopulm disease
Final Report
STUDY: AP chest [**2145-11-27**].
HISTORY: 67-year-old woman post-op day 1 from femoral
embolectomy. Evaluate
tube placement.
FINDINGS: Since the previous study the right IJ central venous
catheter has
been removed. There is a left-sided PICC line whose distal tip
is in the left
subclavian/brachiocephalic vein junction, unchanged. The lungs
are clear.
There is no pneumothoraces. There are calcifications within the
thoracic
aorta.
Brief Hospital Course:
Ms [**Known lastname **] is a 67 year old female admitted to [**Hospital1 18**] on
[**2145-11-17**] for 4 day history of left lower extremity pain as well
as 1 day history of numbness of right medial lower leg and foot
as well as sensory loss in left leg distal to the knee. An
outside hospital CTA showed occlusion of the left SFA and right
CFA. She was taken to the operating room the same day with
diagnosis of lower extremity ischemia with limb threat and the
following procedures were performed: right common femoral
exploration, embolectomy of right femoral and iliac arteries,
resection of right common femoral artery, superficial femoral
artery bypass with reverse greater saphenous vein, left
femoropopliteal embolectomy, serial arteriogram of the left
lower extremity, primary stenting of left superficial femoral
artery and above-knee popliteal artery. Intraoperatively, it
was determined that the left lower extremity was non-salvageable
and would require an amputation. Post-operatively, she remained
intubated and was transferred to the intensive care unit. On
[**2145-11-18**], she was taken back to the operating room for the
following procedures: inspection of right lower extremity
fasciotomy sites and application of medial and lateral VAC
dressings, left open guillotine amputation at the level of the
ankle, and debridement of anterior left lateral fasciotomy sites
including subcutaneous tissue and muscle. Post-operatively, she
again remained intubated and was transferred to the intensive
care unit. A vac was placed to the right lower extremity on
[**11-18**] and to the left lower extremity on [**11-20**] and the patient was
placed on anticoagulation wx, aspirin, and a heparin drip. The
patient was extubated on [**11-23**]. On [**11-26**], the patient was taken
back to the operating room and the following procedures were
performed: completion left below-the-knee amputation and closure
of fasciotomy sites in the right lower extremity. On [**11-30**], she
was taken to the cardiac catheterization lab following a NSTEMI
and noted to have one vessel coronary artery disease with
successful PCI of the LAD with DES. Patient had multiple blood
and urine cultures during her hospital stay which were all
negative. On [**12-3**], she was started on Coumadin and her heparin
drip was discontinued on [**12-5**]. On [**12-4**] patient noted to have
possible blood in stool reported by nursing however patient's
rectal exam demonstrated no gross blood and was guaiac negative.
Patient continued on heparin and Coumadin. [**2145-12-5**] some
purulent discharge was noted to the BKA site. Betadine TID
dressing changes were initiated. Wound cultures were taken which
came back negative without growth. [**12-7**] Heparin was
discontinued and changed to lovenox.INR goal [**2-16**]. Continued on
IV abx for history of + wound culture [**11-23**]. [**Hospital 25403**] Rehab
placement. PT continues to follow until bed available.
Patient was discharged in stable condition to Rehab on [**2145-12-13**].
She should continue Bactrim antibiotics for her history of ecoli
wound infection. She should continue Lovenox and Coumadin until
her INR > 2. She will need daily physical therapy and continued
nursing care for her wounds at Rehab.
Medications on Admission:
atenelol 50, lisinopril 25, cholesterol med- name/dose unknown
Discharge Medications:
1. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous
[**Hospital1 **] (2 times a day): please continue until INR > 2.
2. Lisinopril 10 mg Tablet Sig: 2.5 Tablets PO DAILY (Daily).
3. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4
PM: Titrate. Continue for goal INR > 2.
4. Bactrim DS 160-800 mg Tablet Sig: One (1) Tablet PO twice a
day for 2 weeks: Continue for wound infection- ecolli. .
5. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed) as needed for yeast.
6. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever/pain.
9. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
10. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-15**] Sprays Nasal
QID (4 times a day) as needed for dry nose.
11. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for SOB/WHEEZE.
12. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for SOB/WHEEZE.
13. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
2-6 Puffs Inhalation Q4H (every 4 hours) as needed for wheezes.
Discharge Disposition:
Extended Care
Facility:
[**Doctor First Name **] Immaculate - [**Hospital1 487**]
Discharge Diagnosis:
1. bilateral lower extremity ischemia
2. non-ST elevation myocardial infarction
Discharge Condition:
Stable
Discharge Instructions:
DISCHARGE INSTRUCTIONS FOLLOWING BELOW OR ABOVE KNEE AMPUTATION
.
This information is designed as a guideline to assist you in a
speedy recovery from your surgery. Please follow these
guidelines unless your physician has specifically instructed you
otherwise. Please call our office nurse if you have any
questions. Dial 911 if you have any medical emergency.
.
ACTIVITY:
There are restrictions on activity. On the side of your
amputation you are non weight bearing until cleared by your
surgeon. You should keep this amputation site elevated when ever
possible.
.
You may use the other leg to assist in transferring and pivots.
But try not to exert to much pressure on the amputation site
when transferring and or pivoting. Please keep knee immobilizer
on at all times to help keep the amputation site straight.
.
No driving until cleared by your surgeon.
.
PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS:
1. Redness in or drainage from your leg wound(s).
2. Watch for signs and symptoms of infection. These are: a fever
greater than 101 degrees, chills, increased redness, or pus
draining from the incision site. If you experience any of these
or bleeding at the incision site, CALL THE DOCTOR.
.
Exercise:
.
Limit strenuous activity for 6 weeks.
.
Do not drive a car unless cleared by your Surgeon.
.
Try to keep leg elevated when able.
.
BATHING/SHOWERING:
.
You may shower immediately upon coming home. No bathing. A
dressing may cover you??????re amputation site and this should be
left in place for three (3) days. Remove it after this time and
wash your incision(s) gently with soap and water. You will have
sutures, which are usually removed in 4 weeks. This will be done
by the Surgeon on your follow-up appointment.
.
WOUND CARE:
.
Sutures / Staples may be removed before discharge. If they are
not, an appointment will be made for you to return for staple
removal.
.
When the sutures are removed the doctor may or may not place
pieces of tape called steri-strips over the incision. These will
stay on about a week and you may shower with them on. If these
do not fall off after 10 days, you may peel them off with warm
water and soap in the shower.
.
Avoid taking a tub bath, swimming, or soaking in a hot tub for
four weeks after surgery.
.
MEDICATIONS:
.
Unless told otherwise you should resume taking all of the
medications you were taking before surgery. You will be given a
new prescription for pain medication, which can be taken every
three (3) to four (4) hours only if necessary.
.
Remember that narcotic pain meds can be constipating and you
should increase the fluid and bulk foods in your diet. (Check
with your physician if you have fluid restrictions.) If you feel
that you are constipated, do not strain at the toilet. You may
use over the counter Metamucil or Milk of Magnesia. Appetite
suppression may occur; this will improve with time. Eat small
balanced meals throughout the day.
.
CAUTIONS:
.
NO SMOKING! We know you've heard this before, but it really is
an important step to your recovery. Smoking causes narrowing of
your blood vessels which in turn decreases circulation. If you
smoke you will need to stop as soon as possible. Ask your nurse
or doctor for information on smoking cessation.
.
Avoid pressure to your amputation site.
.
No strenuous activity for 6 weeks after surgery.
.
DIET :
.
There are no special restrictions on your diet postoperatively.
Poor appetite is expected for several weeks and small, frequent
meals may be preferred.
.
For people with vascular problems we would recommend a
cholesterol lowering diet: Follow a diet low in total fat and
low in saturated fat and in cholesterol to improve lipid profile
in your blood. Additionally, some people see a reduction in
serum cholesterol by reducing dietary cholesterol. Since a
reduction in dietary cholesterol is not harmful, we suggest that
most people reduce dietary fat, saturated fat and cholesterol to
decrease total cholesterol and LDL (Low Density Lipoprotein-the
bad cholesterol). Exercise will increase your HDL (High Density
Lipoprotein-the good cholesterol) and with your doctor's
permission, is typically recommended. You may be self-referred
or get a referral from your doctor.
.
If you are overweight, you need to think about starting a weight
management program. Your health and its improvement depend on
it. We know that making changes in your lifestyle will not be
easy, and it will require a whole new set of habits and a new
attitude. If interested you can may be self-referred or can get
a referral from your doctor.
.
If you have diabetes and would like additional guidance, you may
request a referral from your doctor.
.
FOLLOW-UP APPOINTMENT:
.
Be sure to keep your medical appointments. The key to your
improving health will be to keep a tight reign on any of the
chronic medical conditions that you have. Things like high blood
pressure, diabetes, and high cholesterol are major villains to
the blood vessels. Don't let them go untreated!
.
Please call the office on the first working day after your
discharge from the hospital to schedule a follow-up visit. This
should be scheduled on the calendar for seven to fourteen days
after discharge. Normal office hours are 8:30-5:30 Monday
through Friday.
.
PLEASE FEEL FREE TO CALL THE OFFICE WITH ANY OTHER CONCERNS OR
QUESTIONS THAT MIGHT ARISE
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 2625**]
Date/Time:[**2145-12-23**] 9:15
Completed by:[**2145-12-13**]
|
[
"728.88",
"584.9",
"410.71",
"272.0",
"041.19",
"285.9",
"729.72",
"449",
"401.9",
"997.1",
"414.01",
"041.4",
"E878.5",
"458.29",
"440.29"
] |
icd9cm
|
[
[
[]
]
] |
[
"84.15",
"83.45",
"00.45",
"83.14",
"38.93",
"86.59",
"38.68",
"39.50",
"39.29",
"37.22",
"93.57",
"84.3",
"39.79",
"38.08",
"36.07",
"88.48",
"00.66",
"88.56",
"39.90",
"00.40"
] |
icd9pcs
|
[
[
[]
]
] |
12683, 12767
|
7752, 11021
|
287, 1088
|
12891, 12900
|
3005, 7099
|
18291, 18476
|
1997, 2014
|
11134, 12660
|
7139, 7195
|
12788, 12870
|
11047, 11111
|
12924, 14667
|
2029, 2031
|
234, 249
|
7227, 7729
|
14679, 17591
|
17614, 18268
|
2727, 2986
|
1116, 1710
|
2046, 2710
|
1732, 1771
|
1787, 1981
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,900
| 119,229
|
49117
|
Discharge summary
|
report
|
Admission Date: [**2161-9-21**] Discharge Date: [**2161-9-25**]
Date of Birth: [**2107-2-1**] Sex: M
Service: MEDICINE
Allergies:
Minoxidil
Attending:[**First Name3 (LF) 7281**]
Chief Complaint:
Fever, vomiting, coffee-ground emesis
Major Surgical or Invasive Procedure:
EGD ([**2161-9-24**])
History of Present Illness:
The patient is a 54-year-old male with Type 1 Diabetes Mellitus
s/p kidney/pancreas transplant in [**2157**], presenting with a one
day history of fevers, chills, nausea, and vomiting. He was in
his usual state of health until the morning of admission
([**2161-9-21**]) when he developed chills and fevers to 103F. He
subsequently developed significant nausea, with vomiting x10-20
times - initially clear, but then became dark-red with
coffee-grounds. He denies sore throat, chest pain, shortness of
breath, cough, abdominal pain, dysuria, constipation, or
diarrhea. Two of his children have a viral syndrome with cough
but no nausea or vomiting, and he denies any recent travel or
any raw or old uncooked food ingestion. Of note, the patient
works outside on a golf course and had a recent malleolar
fracture ([**8-11**]); he has also had several bites by mosquitoes - 1
of which was recently infected (completed a full course of
Keflex).
.
In the ED, intial VS: Temp 103.4F, BP 167/84, HR 120, R 18,
O2-sat 98% RA. He was given 2L NS, 1g Tylenol x2, 1g
Vancomycin, as well as Flagyl, Levofloxacin, Protonix, and
Zofran. He continued to vomit several times, some with
coffee-ground emesis. NG lavage was clear and NG tube clamped.
He was guaiac positive on exam, and he had a single transient
episode of abdominal pain that self-resolved. He was
transferred to the MICU for monitoring.
.
Past Medical History:
1. Diabetes Mellitus, Type I - since age 21
2. ESRD s/p CRT [**3-/2157**] - post-op course complicated by delayed
graft function and hydronephrosis s/p ureteral stent and
percutaneous nephrostomy in [**3-7**]. Now with renal insufficiency
with baseline creatinine 2.0.
3. Pancreas transplant [**9-/2157**], rejected [**2158**]
4. h/o Partial SBO - treated conservatively
5. Hypertension
6. Coronary Artery Disease s/p stent of Ramus Intermedius in
[**2156**]
7. Paroxysmal Atrial Fibrillation
8. s/p ventral hernia repair with mesh in [**2153**]
9. Orthostatic hypotension
10.Medial malleolar fracture [**8-/2161**] - treated with Keflex and
Vicodin. Ortho evaluation [**9-21**] - no infection, no ulcer.
.
Social History:
golf instructor, lives with wife [**Name (NI) **], 3 children, no tob, occ
etoh (1 beer daily)
Family History:
non-contributory
Physical Exam:
vitals: 102.9, 150/79, 97, 16, 94% RA
general: tired appearing male, no distress, short answers to
questions
HEENT: OP clear, PERRL, EOMI
Neck: no JVD
Car: RRR III/VI SM apex-->axilla
Resp: CTAB
Abd: s/nt/nd/nabs, graft site nontender
Ext: LLE in cast, trace RLE edema--nonpitting
Neuro: MAE, CN II-XII intact
.
Pertinent Results:
[**2161-9-21**] 04:10PM GLUCOSE-131* UREA N-56* CREAT-2.8* SODIUM-140
POTASSIUM-3.8 CHLORIDE-104 TOTAL CO2-24 ANION GAP-16
[**2161-9-21**] 04:10PM ALT(SGPT)-14 AST(SGOT)-23 CK(CPK)-190* ALK
PHOS-86 AMYLASE-52
[**2161-9-21**] 04:10PM LIPASE-29
.
[**2161-9-21**] 04:10PM WBC-12.5*# RBC-4.97 HGB-14.9 HCT-43.2 MCV-87
MCH-30.0 MCHC-34.6 RDW-14.2
[**2161-9-21**] 04:10PM NEUTS-93.3* BANDS-0 LYMPHS-2.5* MONOS-3.0
EOS-0.8 BASOS-0.3
[**2161-9-21**] 04:10PM PLT COUNT-419
.
[**2161-9-21**] 04:10PM CK-MB-4 cTropnT-0.18*
.
[**2161-9-21**] 06:30PM URINE [**Month/Day/Year 3143**]-LG NITRITE-NEG PROTEIN-500
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-TR
.
Studies:
- portable CXR: The lungs are now well-inflated and clear,
without infiltrate or effusion. The cardiomediastinal
silhouette and pulmonary vessels are within normal limits.
There is no free subdiaphragmatic air.
- AXR: Extensively fecoloaded colon, with no evidence of
obstruction.
- Renal transplant US: No evidence of hydronephrosis of the
transplant kidney. Rounded fluid structure superomedial to the
transplant kidney, may represent an exophytic cyst, but was not
seen on the prior studies from [**2158**] (most recent available for
comparison).
- ECG: NSR @ 97, nl axis, nl intervals, 1mm STD 1 (old), II,
V4-V6 (new), TWI aVL (old)
- TTE: Moderate to severe symmetric left ventricular hypertrophy
with preserved regional and global biventricular systolic
function. Mild diastolic dysfunction with elevated left
ventricular filling pressures.
- EGD: Gastric erosion (biopsy); Erythema in the antrum
compatible with gastritis (biopsy); Possible small, healing
[**Doctor First Name **]-[**Doctor Last Name **] tear at GE junction.
.
Brief Hospital Course:
54-yo Male with Type I DM s/p kidney / pancreas transplant,
presenting with fever and vomiting.
.
1. Fever/leukocytosis: The patient was started on Vancomycin and
Levofloxacin while in the MICU. He had Gram(+)Rods on [**Doctor Last Name **]
culture from the ED, Bacillus species, sensitivities pending.
This may be related to gastroenteritis from food-borne illness,
which is consistent with nausea and vomiting on admission. UA
and urine Cx were negative, and there was no evidence of PNA on
CXR. Urine CMV VL was also negative. The patient continued to be
afebrile since admission, and his leukocytosis resolved. Once he
was transferred to the floor, ID was consulted regarding
outpatient antibiotic treatment for his [**Doctor Last Name **] culture result. ID
felt that the Bacillus was likely a contaminant from the lab, as
other [**Doctor Last Name **] culture bottles were also growing Bacillus in other
patients, who also had no clinical reason to have Bacillus
growing in their [**Doctor Last Name **]. However, given that the patient is a
transplant patient and therefore immunosuppressed, they felt it
was important to continue empiric treatment, so they recommended
completing a full 10-day course of Levofloxacin. Surveillance
[**Doctor Last Name **] cultures were sent on the morning of discharge, and the
patient was sent home with a prescription to complete the full
10-day course of empiric Levofloxacin. Pharmacy, renal, and ID
all verified that 500mg daily would be an appropriate dose given
the patient's baseline renal function.
.
2. Vomiting/coffee-ground emesis: The patient presented with
coffee-ground emesis in the setting of nausea/vomiting and
wretching, making it likely that the cause was [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-[**Doctor Last Name **]
Tear. NG lavage was done in the ED, which was negative for
persistent bleeding. The patient was admitted to the MICU for
monitoring, and was noted to have a stable hematocrit and to be
hemodynamically stable throughout his course there. GI was
consulted, and EGD was done on [**2161-9-24**], which showed gastritis
and a gastric erosion, as well as small healing [**Doctor First Name **]-[**Doctor Last Name **]
Tear at GEJ. The [**Doctor First Name **]-[**Doctor Last Name **] Tear was felt to be the cause of
the coffee-grounds. The locations of the gastritis and gastric
erosion were biosied, and results are pending. In the meantime,
the patient should continue twice daily PPI therapy for 1 month,
and avoid Aspirin and all NSAIDs for the next 10 days. He may
take Tylenol for pain or fever, and may continue on Reglan for
nausea.
.
3. ECG changes: The patient's initial ECG on admission ([**9-21**])
showed new ST depressions in V4-V6, also with elevated cardiac
enzymes. However, the cardiac enzymes were trending down, and
were felt to be elevated due to the patient's acute on chronic
renal failure. Repeat ECG done on hospital day #2 ([**9-22**]) showed
much less pronounced ST depressions in V4-V6. TTE was done,
which showed no wall-motion abnormalities or vegetations.
Dobutamine Echo was done on [**9-25**] to risk stratify the patient,
and the patient had no anginal symptoms or ischemic ECG changes.
The results showed a stable, moderate fixed inferior wall
perfusion defect, marked LV cavity dilatation, and markedly
depressed LV function (EF 48%). This should be followed-up as
an outpatient by the patient's primary care physician.
.
4. Hypertension: The patient's Lisinopril was held while in the
MICU given his acute renal failure. As the renal failure
resolved, the patient was restarted on [**1-6**]-dose Lisinopril, and
then titrated up to full-dose Lisinopril once he was on the
floor. His home doses of metoprolol and amlodipine were
continued, with oral hydralazine available as needed for very
high [**Month/Day (2) **] pressures.
.
5. s/p Renal/pancreas transplant: The patient was continued on
his home doses of Neoral, Cellcept, and Prednisone, as well as
on his Bactrim prophylaxis.
.
6. ARF on CRI: The patient has a baseline creatinine of 2.0-2.2,
but his was up to 2.8 on admission. This was believed to be
pre-renal, and it resolved with hydration. He was continued on
his home dose of Fludricort.
.
7. Diabetes Mellitus Type I: The patient was continued on his
home dose of Lantus 15units qAM and 10units qPM, with a Humalog
insulin sliding scale to cover. His finger stick [**Month/Day (2) **] sugars
remained under good control.
.
8. Coronary Artery Disease: The patient was continued on his
home doses of metoprolol and pravachol. His aspirin was held
given his coffee-ground emesis, and should continue to be held
for 10 more days.
.
Medications on Admission:
Allergies: Minoxidil
.
Medications at admission:
Cellcept [**Pager number **] mg [**Hospital1 **]
Prednisone 5 mg daily
CSA-Neoral 175 mg [**Hospital1 **]
Norvasc 10 mg daily
Bactrim SS daily
Lisinopril 10 mg [**Hospital1 **]
Lopressor 25 mg [**Hospital1 **]
Ranitidine 150 mg [**Hospital1 **]
Reglan 5 mg daily
Pravachol
Lantus/Humalog
Aspirin
Fludricort 0.1 mg po bid
Discharge Medications:
1. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
2. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Cyclosporine Modified 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours).
4. Cyclosporine Modified 50 mg Capsule Sig: One (1) Capsule PO
every twelve (12) hours.
5. Cyclosporine Modified 25 mg Capsule Sig: One (1) Capsule PO
every twelve (12) hours.
6. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
11. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO QAM (once a
day (in the morning)).
12. Pravastatin 20 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
13. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
14. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day
for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
15. Insulin Glargine 100 unit/mL Cartridge Sig: 15 (fifteen)
units Subcutaneous qAM (every morning).
16. Insulin Glargine 100 unit/mL Cartridge Sig: 10 (ten) units
Subcutaneous qPM (every evening).
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
1. Gastroenteritis
2. [**Doctor First Name **]-[**Doctor Last Name **] Tear
3. ESRD s/p cadaveric renal transplant
4. Coronary Artery Disease
Secondary Diagnoses:
1. Diabetes Mellitus Type I
2. s/p pancreas transplant
3. hypertension
4. paroxysmal atrial fibrillation
5. medial malleolar fracture [**8-/2161**] s/p casting
Discharge Condition:
afebrile, vital signs stable, without nausea or vomiting,
tolerating POs, hematocrit stable without evidence of bleeding.
Discharge Instructions:
You were admitted to [**Hospital1 69**] on
[**2161-9-21**], for fevers, chills, nausea, vomiting, and
[**Year (4 digits) **] in your vomit. You were given medications for your nausea
and vomiting. You had an upper endoscopy to look at your
esophagus, stomach, and the first part of your small intestine,
to find out where you were bleeding from. The results showed a
small tear from the vomiting, but also some inflammation and an
erosion in the stomach, which were biopsied and should be
followed up as an outpatient. You were found to have bacteria
in your [**Last Name (LF) **], [**First Name3 (LF) **] you were started on antibiotics to treat the
bacteria. The infectious disease specialists were consulted and
thought that this was likely a contaminant, but recommended
continuing antibiotic treatment for 5 more days.
You should continue your treatment with the Levofloxacin for 5
more days as below. You should follow up with your primary care
physician on Tuesday morning, as listed below, and you should
call and make an appointment to follow-up with Dr. [**Last Name (STitle) **], as
listed below as well. If you develop any fevers, chills,
worsening nausea or vomiting, or abdominal pain, you should
return to the emergency room immediately.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5377**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time: [**2161-9-29**] 8:40am
Please call and make an appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] to
follow-up in 2 weeks.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 7284**]
|
[
"414.01",
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"458.0",
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icd9cm
|
[
[
[]
]
] |
[
"45.16"
] |
icd9pcs
|
[
[
[]
]
] |
11313, 11319
|
4735, 9435
|
307, 330
|
11705, 11829
|
2984, 4712
|
13136, 13525
|
2619, 2637
|
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|
11340, 11501
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|
11853, 13113
|
2652, 2965
|
11522, 11684
|
230, 269
|
358, 1759
|
1781, 2491
|
2507, 2603
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,826
| 149,231
|
38411
|
Discharge summary
|
report
|
Admission Date: [**2182-7-4**] Discharge Date: [**2182-7-15**]
Date of Birth: [**2125-6-27**] Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Fruit Extracts
Attending:[**Attending Info 65513**]
Chief Complaint:
Ovarian cancer
Major Surgical or Invasive Procedure:
Exploratory laparotomy, optimal debulking for ovarian cancer
including omentectomy, bilateral salphingo-oopherectomy,
appendectomy, cholecystectomy, sigmoid resection with end-to-end
reanastamosis, upper vaginectomy, radical ureterolysis,
diaphragmatic resection with primary repair, resection of tumor
off liver surface and abdominal wall, proctoscopy, mobilization
of splenic flexure, and resection of implants on Gerota's
fascia.
History of Present Illness:
Ms. [**Known lastname **] is a 56-year-old, G2, P1 with an essentially
unremarkable previous gynecologic history, status post TAH in
the distant past for carcinoma in situ of the cervix, who has
had everal months of progressive abdominal discomfort, decreased
appetite, intermittent nausea, bloating, and weight loss. A CT
scan was recently performed at [**Hospital3 7362**], and there was a
large complex mass appearing to arise from the right adnexa,
measuring 11 cm, with enhancing soft tissue and cystic
components. Some ascites was noted as was extensive peritoneal
nodules and omental caking.
Past Medical History:
Past Medical History:
1. Trigeminal neuralgia.
2. Osteopenia.
3. Scoliosis.
Past Surgical History:
1. Spinal fusion.
2. Abdominal hysterectomy for carcinoma in situ of the cervix
in
[**2162**].
3. Tonsillectomy.
Past OB/GYN History: G2, P1 with one vaginal delivery.
Menarche at 15, and menopause was surgical by hysterectomy. The
ovaries were retained. She has had normal Pap smears since the
time of her hysterectomy. Last Pap was two and a half years ago
per history. No history of STIs or significant GYN problems.
[**Name (NI) **] last mammogram was two years ago, and these have always been
within normal limits. She had tubular adenoma removed on a
colonoscopy in recent past, and five-year followup was
recommended.
Social History:
Denies smoking, alcohol, or drug abuse.
Family History:
Negative for breast or ovarian cancer.
Physical Exam:
At pre-op visit:
Gen: no acute distress, affect is appropriate. Kyphoscoliosis
noted.
HEENT: Eyes anicteric. Mouth moist.
Neck: Supple. No supraclavicular lymphadenopathy.
Heart: Regular rate and rhythm.
Lungs: Clear bilaterally.
Abdomen: soft, distended, without any tenderness or
hepatosplenomegaly or hernias. No CVA tenderness. No skin
ashes. No temporal wasting.
Lower extremities: unremarkable.
External genitalia unremarkable. Cervix and uterus surgically
absent.
Rectovaginal exam: A mass appreciated in the right cul-de-sac
which is soft, but firm. No rectal lesions are noted. The left
adnexa is not appreciated.
Pertinent Results:
[**2182-7-4**] 10:32AM HGB-12.8 calcHCT-38
[**2182-7-4**] 10:32AM GLUCOSE-90 LACTATE-1.3 NA+-136 K+-3.0*
CL--99*
[**2182-7-4**] 05:00PM PLT COUNT-542*
[**2182-7-4**] 09:04PM ALBUMIN-2.1* CALCIUM-8.1* PHOSPHATE-5.0*#
MAGNESIUM-1.4*
[**2182-7-4**] 09:46PM LACTATE-1.7
[**2182-7-4**] 09:04PM ALBUMIN-2.1* CALCIUM-8.1* PHOSPHATE-5.0*#
MAGNESIUM-1.4*
[**2182-7-4**] 09:04PM WBC-21.8*# RBC-5.20 HGB-15.2# HCT-43.6 MCV-84
MCH-29.1 MCHC-34.7 RDW-12.3
Brief Hospital Course:
Ms. [**Known lastname **] was admitted to the ICU intubated post-operatively
given the extent and duration of the surgical procedure. Please
see OMR note for full details of operative report. Her hospital
course will be reviewed by system:
*) Neuro: She was initially sedated while intubated. She had a
dilaudid PCA for pain control.
*) Cardiovascular: She was briefly on pressors intra-operatively
and while in the ICU, however, these were soon discontinued.
She had persistent sinus tachycardia to the 110s. A 12-lead EKG
revealed sinus tachycardia. Her TSH was normal. A CTA on [**7-8**]
was negative for PE. She was maintained on telemetry until
[**2182-7-14**] and her tachycardia resolved.
*) Respiratory: She was extubated on POD#1 without difficulty.
Her initial CXR in the SICU revealed a small right pneumothorax
as well as a moderate right pleural effusion. She had a
persistent oxygen requirement and was taken for IR drainage of
her effusion on [**7-12**]. This was complicated by acute shortness of
breath that was attributed to pulmonary edema secondary to
negative pressure during the procedure. Her symptoms resolved
with low-dose IV Lasix. She was weaned off supplementary oxygen
after the procedure. Of note, on her CTA a small area of ground
glass opacity was seen and follow-up was recommended within 6
months to rule out broncho-aveolar carcinoma. Supplemental O2
was discontinued on [**7-14**] and she maintained her oxygen saturation
> 95% at rest.
*) FEN/GI: Her diet was advanced slowly in accordance with her
symptoms and exam. She was seen by nutrition.
*) Heme: She received two units of PRBCs intra-operatively. Her
hematocrit was stable post-operatively and she received no
further products. She received a dose of vitamin K for her
elevated INR.
*) GU: Her Foley remained in until POD #9. A urine culture from
the foley grew coag negative staph and she was started on
Macrobid for her UTI.
She was discharged home on [**2182-7-15**]. She was ambulating,
tolerating a regular diet, and had excellent po pain control.
She was cleared for discharge home by physical therapy.
Medications on Admission:
Tegretol 200mg qam/300mg qpm, calcium, multivitamin, fish oil.
Discharge Medications:
1. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for anxiety.
2. Carbamazepine 200 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. Carbamazepine 100 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO NOON (At Noon).
4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
5. Zofran 4 mg Tablet Sig: 1-2 Tablets PO three times a day as
needed for nausea.
Disp:*50 Tablet(s)* Refills:*1*
6. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
7. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for Pain.
Disp:*60 Tablet(s)* Refills:*0*
8. Nitrofurantoin (Macrocryst25%) 100 mg Capsule Sig: One (1)
Capsule PO BID (2 times a day) for 6 days.
Disp:*12 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Ovarian cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call your doctor or return to the hospital if you have:
-Increased pain
-Redness or unusual discharge from your incision
-Inability to eat or drink because of nausea and/or vomiting
-Fevers/chills
-Chest pain or shortness of breath
-Any other questions or concerns
Other instructions:
-You should not drive for 2 weeks and while taking narcotic pain
medications
-No intercourse, tampons, or douching for 6 weeks
-No heavy lifting or vigorous activity for 6 weeks
-You can shower and clean your wound, but do not use perfumed
soaps or lotions. Be sure to pat completely dry after washing.
-You may resume your regular diet and home medications.
Followup Instructions:
Provider: [**Name10 (NameIs) 35354**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 5777**]
Date/Time:[**2182-7-26**] 11:30
[**Name6 (MD) 35354**] [**Name8 (MD) **] MD [**MD Number(2) 65515**]
|
[
"198.82",
"599.0",
"197.8",
"518.5",
"197.5",
"198.89",
"280.0",
"350.1",
"276.8",
"196.6",
"197.6",
"511.9",
"998.0",
"183.0",
"197.7",
"198.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"70.4",
"34.91",
"59.02",
"99.15",
"65.61",
"40.3",
"47.09",
"54.4",
"34.81",
"51.22",
"48.69",
"50.29",
"54.3"
] |
icd9pcs
|
[
[
[]
]
] |
6512, 6518
|
3393, 5527
|
301, 735
|
6577, 6577
|
2912, 3370
|
7404, 7637
|
2200, 2240
|
5640, 6489
|
6539, 6556
|
5553, 5617
|
6728, 7381
|
1490, 2127
|
2255, 2893
|
247, 263
|
763, 1365
|
6592, 6704
|
1409, 1467
|
2143, 2184
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,812
| 139,269
|
45070
|
Discharge summary
|
report
|
Admission Date: [**2161-4-22**] Discharge Date: [**2161-4-24**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
s/p Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
89 yo M s/p fall at rehab witnessed by nephew; reportedly
patient attempted to get up when nephew was trying to leave. He
was diagnosed with myeloma 2 weeks ago, receiving chemotherapy
(velcade and dexamethasone), transfer from [**Location (un) 745**] [**Location (un) 3678**] to
[**Hospital1 18**] with right subdural hematoma, left orbital floor fracture,
maxillary fractures.
Past Medical History:
-Macular degeneration
-Atrial fibrillation on warfarin. Of note, the patient has been
off this since [**3-17**]
-Type 2 DM
-Hyperlipidemia
-Nephrolithiasis
-RUL lung nodule, noted '[**56**]. PET CT obtained at that time was
negative
-S/p tonsillectomy
-S/p cataract surgey
Social History:
The patient lives alone in [**Location (un) 1294**]. He works 4 days a week
at a Volvo dealership. He has been working there since [**2108**]. He
notes that he has been self-sufficient for the past 9 years
despite being legally blind. He is a former smoker. He smoked 3
packs per day for 30 years, but he quit over 30 years ago. He
has about 1 alcoholic beverage a month. He has not been
married. He does not have any children. He is close with a
cousin who lives in [**Name (NI) 47**].
Family History:
The patient was 1 of 4 children. He notes that he had a sister
who is deceased. He has 2 brothers who live in [**Name (NI) 108**]. He has
a cousin who lives in [**Name (NI) 47**]. His mother died of an unknown
type of cancer. He is not sure what his father died from.
Physical Exam:
Upon presentation to [**Hospital1 18**]:
T 98.1 P 67 BP 115/47 R 18 SaO2 98%
Gen: lethargic, no acute distress.
HEENT: significant bruising of soft tissue surrounding left eye
Pupils: bilateral surgical pupils
Neck: Supple.
Neuro:
Mental status: lethargic, follows commands.
Orientation: Not oriented to place or time.
Language: Mild slurring of speech.
Cranial Nerves:
I: Not tested
II: Pupils surgical.
III, IV, VI: Extraocular movements appear to be grossly intact.
Pt not cooperative with this portion of exam.
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: No abnormal movements or tremors.
Strength: B T WE WF IO IP Q AT [**Last Name (un) 938**] G
L 4- 4- 4 4 4 4 4 4- 4- 4-
R 4 4 4 4 4 4+ 4+ 4 4 4
No pronator drift
Sensation: Intact to light touch
Pertinent Results:
[**2161-4-22**] 08:55PM GLUCOSE-314* NA+-138 K+-3.9 CL--96* TCO2-32*
[**2161-4-22**] 08:43PM UREA N-32* CREAT-1.9*
[**2161-4-22**] 08:43PM WBC-4.0 RBC-3.17* HGB-9.6* HCT-28.8* MCV-91
MCH-30.2 MCHC-33.2 RDW-16.0*
[**2161-4-22**] 08:43PM PLT COUNT-140*
[**2161-4-22**] 08:43PM PT-13.8* PTT-29.4 INR(PT)-1.2*
STUDIES:
CT head showed right subdural hematoma, multiple facial
fractures, left orbital floor/lateral orbital wall/maxillary
fractures, and lytic bone lesions.
CT sinus/mandible/maxillofacial showed fractures of the left
orbital floor, left lateral orbital wall, and lateral and
posterior walls of the left maxillary sinus.
Brief Hospital Course:
He was admitted to [**Hospital1 18**]. Neurosurgery and Plastics were
consulted for his injuries. He was transferred to the Trauma ICU
where he was monitored closely. Initially he was very sleepy and
unable to participate with an examination. Over the course of 24
hours his mental status improved to back to his baseline per his
family report. His repeat head CT scan showed no short interval
changes of the right-sided subdural hematoma. He received
Dilantin and will continue for a total of 7 days (stop date
[**4-28**]). He will follow up in [**4-7**] weeks for repeat CT head scan
with Neurosurgery.
His facial fractures were evaluated by Plastic Surgery and were
deemed non-operative. He was placed on sinus precautions and
initially received Augmentin; this was stopped after only a few
doses. He will follow up as an outpatient in [**Hospital 3595**] clinic.
The Hematology/Oncology team were notified and the decision was
made to hold off on his chemotherapy treatment that was
previously scheduled for [**4-24**]. His appointment was rescheduled
for a later date.
He was evaluated by Physical therapy and will need to continue
with his rehabilitation after his acute hospital stay.
Medications on Admission:
ISS, Nystatin S&S, Allopurinol 100, Omeprazole 20, Levothyroxine
25, Lasix 20
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
2. Polyethylene Glycol 3350 17 gram/dose Powder Sig: Seventeen
(17) G PO DAILY (Daily).
3. White Petrolatum-Mineral Oil Cream Sig: One (1) Appl
Topical [**Hospital1 **] (2 times a day) as needed for scrotal irritation.
4. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Dilantin Infatabs 50 mg Tablet, Chewable Sig: Two (2) Tablet,
Chewable PO three times a day for 4 days.
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Insulin Regular Human 100 unit/mL Solution Sig: One (1) dose
Injection four times a day as needed for per sliding scale.
10. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML's
Injection three times a day.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] at [**Location (un) 620**]
Discharge Diagnosis:
s/p Fall
Right subdural hematoma
Left orbital floor and left lateral orbital wall fracture
Anterior and posterior left maxillary sinus fractures
Non-displaced right maxillary sinus fracture
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted after a fall. `You sustained facial fractures
and a bleeding injury to your brain. Your injuries did not
require any surgery. You were monitored closely in the intensive
care unit and once you became stable you were transferred to the
regular nursing unit.
Antiseizure Prophylaxsis should continue for 7 days.
DVT prophylaxis (ie subcutaneous Heparin) may be started
today([**4-23**]). Aspirin therapy should be held for 30 days
post-injury, unless overwhelming medical indication.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] [**Hospital 4695**] Clinic at ([**Telephone/Fax (1) 96327**] to schedule a follow-up appointment in 4 weeks, with a
non-contrastCT scan of the head. Their office is located in the
[**Hospital Ward Name **] MedicalBuilding, [**Hospital Unit Name 12193**].
Follow up with your Hematologist/Oncologist as directed:
Provider: [**First Name8 (NamePattern2) 539**] [**Last Name (NamePattern1) 9816**], RN Phone:[**Telephone/Fax (1) 3241**]
Date/Time:[**2161-4-28**] 1:30
Provider: [**Name10 (NameIs) 3242**] [**Apartment Address(1) 1246**] Date/Time:[**2161-4-28**] 1:30
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2161-6-3**] 11:10
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
Completed by:[**2161-4-24**]
|
[
"801.21",
"427.31",
"403.90",
"203.00",
"200.30",
"V58.61",
"E888.9",
"E849.0",
"802.6",
"585.9",
"369.4",
"274.9",
"250.00",
"162.8"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
5835, 5912
|
3520, 4717
|
270, 276
|
6146, 6146
|
2853, 3497
|
6850, 7743
|
1506, 1776
|
4845, 5812
|
5933, 6125
|
4743, 4822
|
6323, 6827
|
1791, 2026
|
222, 232
|
304, 684
|
2166, 2834
|
6161, 6299
|
706, 982
|
998, 1490
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,602
| 150,556
|
34955
|
Discharge summary
|
report
|
Admission Date: [**2181-11-1**] Discharge Date: [**2181-11-9**]
Date of Birth: [**2136-1-28**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Aspirin
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest discomfort
Major Surgical or Invasive Procedure:
[**2181-11-5**] Two Vessel Coronary Artery Bypass Grafting utilizing
saphenous vein grafts to left anterior descending artery and
PDA.
History of Present Illness:
Mrs. [**Known lastname 7563**] is a 45 year old female with significant family
history of premature coronary disease. Over the last several
months, she has complained of worsening chest discomfort. Stress
testing showed anteroseptal ischemia with abnormal ST segment
changes and anginal chest pain. Subsequent cardiac
catheterization found severe two vessel coronary artery disease
- total occlusion of proximal RCA and 85% lesion in the LAD.
Left ventriculography revealed LVEF of 50-55% and no mitral
regurgitation. Of note, injection of the RCA was complicated by
transient VF requiring defibrillation. Based upon the above, she
was referred for cardiac surgical intervention.
Past Medical History:
Coronary artery disease
Hypertension
Family History of premature CAD
Cystic Breast Disease
Aspirin Allergy
Social History:
Native of [**Country 4194**]. She came to the US about eight years ago. She
smokes [**10-31**] cigarettes per day. She denies ETOH.
Family History:
Multiple family members have premature CAD.
Physical Exam:
Admission
Vitals- 98.6, 124/70, 64, 20, 98% RA
General- wdwn female in no acute distress
Skin-two burns from defib
HEENT-oropharynx benign
Neck-supple, no jvd
Chest-clear bilaterally
Heart-regular rate and rhythm, normals1s2, no murmur or rub
Abdomen-benign
Ext-warm, trace edema
Neuro-non focal exam
Pulses-2+ distally, no carotid or femoral bruits noted
Discharge
VS T 99.2 BP 98/59 HR 70SR RR 20 O2sat 99%-RA
Gen-NAD
Neuro-A&Ox3, nonfocal exam
Pulm-CTA-bilat
CV-RRR. sternum stable. Incision CDI
Abdm-soft, NT/ND/+BS
Ext-warm, trace pedal edema bilat. EVH site L leg CDI
Pertinent Results:
[**2181-11-1**] 11:33PM BLOOD WBC-7.2 RBC-4.37 Hgb-11.5* Hct-33.0*
MCV-76* MCH-26.3* MCHC-34.8 RDW-15.6* Plt Ct-175
[**2181-11-1**] 11:33PM BLOOD PT-12.6 PTT-26.7 INR(PT)-1.1
[**2181-11-1**] 11:33PM BLOOD Glucose-94 UreaN-13 Creat-0.7 Na-136
K-3.8 Cl-101 HCO3-26 AnGap-13
[**2181-11-1**] 11:33PM BLOOD ALT-14 AST-18 LD(LDH)-121 CK(CPK)-45
AlkPhos-62 Amylase-120* TotBili-0.3
[**2181-11-1**] 11:33PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2181-11-1**] 11:33PM BLOOD Albumin-4.1 Calcium-10.1 Phos-3.5 Mg-1.8
[**2181-11-1**] 11:41PM BLOOD %HbA1c-5.4
[**2181-11-8**] 05:38AM BLOOD WBC-9.5 RBC-3.22* Hgb-8.7* Hct-24.9*
MCV-77* MCH-26.9* MCHC-34.8 RDW-16.1* Plt Ct-114*
[**2181-11-9**] 09:05AM BLOOD WBC-8.4 RBC-3.62* Hgb-9.9* Hct-28.4*
MCV-79* MCH-27.3 MCHC-34.8 RDW-15.9* Plt Ct-170
[**2181-11-9**] 09:05AM BLOOD Plt Ct-170
[**2181-11-9**] 09:05AM BLOOD ALT-19 AST-19 AlkPhos-72 Amylase-66
TotBili-0.3
[**2181-11-5**] Intraop TEE
PRE BYPASS:
The left atrium and right atrium are normal in cavity size. No
atrial septal defect is seen by 2D or color Doppler. Regional
left ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. There are simple
atheroma in the descending thoracic aorta. There are three
aortic valve leaflets. There is no aortic valve stenosis. No
aortic regurgitation is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no pericardial effusion.
POST BYPASS
Left and right ventricular function is normal. The aorta is
intact. The remainder of the study is unchanged.
[**Known lastname **],[**Known firstname **] [**Medical Record Number 79968**] F 45 [**2136-1-28**]
Radiology Report CHEST (PORTABLE AP) Study Date of [**2181-11-6**]
11:21 AM
[**Last Name (LF) **],[**First Name3 (LF) **] R. CSURG CSRU [**2181-11-6**] SCHED
CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 79969**]
[**Hospital 93**] MEDICAL CONDITION:
45 year old woman with s/p CT removal
REASON FOR THIS EXAMINATION:
r/o pneumo
Final Report
CHEST PORTABLE AP.
REASON FOR EXAM: 45-year-old woman status post chest tube
removal, rule out pneumothorax.
Since earlier today, all tubes and catheters were removed except
right
internal jugular introducer.
Minimal left axillary pneumothorax decreased and minimal left
retrocardiac
atelectasis improved. Lungs are otherwise clear. The
cardiomediastinal
silhouette and hilar contours are normal.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) 4078**] [**Name (STitle) 4079**]
DR. [**First Name4 (NamePattern1) 2618**] [**Last Name (NamePattern1) 2619**]
Approved: TUE [**2181-11-6**] 4:52 PM
Brief Hospital Course:
Mrs. [**Known lastname **] was transferred from [**Hospital6 1109**].
Given severe coronary artery disease and persistent chest pain,
she was started on intravenous Nitro and Heparin while being
observed in the CVICU. She underwent routine preoperative
evaluation and remained pain free on intravenous therapy.
Preoperative course was otherwise uneventful. She awaited Plavix
washout and was eventually cleared for surgery. On [**11-5**],
Dr. [**Last Name (STitle) **] performed coronary artery bypass grafting surgery.
For surgical details, please see seperate dictated operative
note. Following the operation, she was brought to the CVICU for
invasive monitoring. Within 24 hours, she awoke neurologically
intact and was extubated without incident. Initially
hypertensive, she was restarted on PO beta blockade and
intermittently required boluses of intravenous Metoprolol and
Hydralazine. Her CVICU course was otherwise unremarkable and she
transferred to the SDU on postoperative day one.
The patient underwent aspirin desensitization on POD 2 without
incident. She was diuresed toward her pre-operative weight.
She made excellent progress with physical therapy, showing good
strength and balance before discharge. By the time of discharge
on POD 4 the patient was ambulating freely, the wound was
healing and pain was controlled with oral analgesics. She was
discharged home with VNA services.
Medications on Admission:
Atenolol 100 qd, HCTZ 25 qd, Omeprazole 20 qd, Lipitor 80 qd,
Plavix on [**10-31**]
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. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
5. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
10. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Two (2) Capsule, Sustained Release PO once a day for 2 weeks.
Disp:*28 Capsule, Sustained Release(s)* Refills:*0*
Discharge Disposition:
Home with Service
Discharge Diagnosis:
Coronary Artery Disease - s/p CABGx2
History of VF Arrest(during catheterization)
Hypertension
Dyslipidemia
Aspirin Allergy
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) 4044**].
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 at least one month.
7) Call with any questions or concerns.
8) Take all medication as prescribed.
Followup Instructions:
Dr. [**Last Name (STitle) **] in [**4-21**] weeks, call for appt
Dr. [**Last Name (STitle) 6254**] in [**2-18**] weeks, call for appt
Dr. [**Last Name (STitle) **] in [**2-18**] weeks, call for appt
Completed by:[**2181-11-9**]
|
[
"414.01",
"401.9",
"272.4",
"V14.8",
"V07.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.12"
] |
icd9pcs
|
[
[
[]
]
] |
7667, 7686
|
4858, 6261
|
291, 428
|
7854, 7861
|
2091, 4051
|
8646, 8876
|
1432, 1477
|
6395, 7644
|
4091, 4129
|
7707, 7833
|
6287, 6372
|
7885, 8623
|
1492, 2072
|
235, 253
|
4161, 4835
|
456, 1137
|
1159, 1267
|
1283, 1416
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,994
| 166,696
|
2465
|
Discharge summary
|
report
|
Admission Date: [**2104-2-28**] Discharge Date: [**2104-3-10**]
Date of Birth: [**2047-4-2**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Known firstname 2724**]
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
T12 vertebrectomy
History of Present Illness:
This is a 56 year old male with approximately 2 weeks of
thoracolumbar back pain of sudden onset. There is no radiating
pain. He has no numbness. He has a chronic peripheral neuropathy
with paresthesias of all toes. He has had constipation
associated
with Vicodin use at home. He had one episode of hematochezia
yesterday while constipated and straining. He denies bowel and
urinary incontinence.
He was seen in the spine clinic with Dr. [**Last Name (STitle) 739**] and
review
of OSH imaging revealed a T12 compression fracture with cord
compression.
Past Medical History:
Hemorrhoids, pineal cyst excision, L knee repair, DM,
hypercholesterolemia, peripheral neuropathy, umbilical
herniorrhaphy.
Social History:
He stopped smoking >25 years ago, no ETOH abuse.
Family History:
unknown
Physical Exam:
On admission:
Gen: WD/WN, comfortable, NAD. Overweight.
Motor:
IP Q H AT [**Last Name (un) 938**] G
L 5 5 5 5 5 5
R 5 5 5 5 5 5
Sensation: Intact to light touch.
Reflexes: Pa Ac
Right 1 0
Left 2 0
There is no clonus
Mild bony and paraspinal tenderness at lower thoracolumbar
spine.
Rectal exam normal sphincter control
On Discharge: non focal / ambulatory
Pertinent Results:
Ct Torso:
1. Diffuse thickening of the right upper lobe bronchus and right
hilar mass are concerning for right lung cancer. Bronchoscopy is
recommended for further evaluation. Diffuse mediastinal
lymphadenopathy is also present. FDG PET is recommended for
evalauation of disease extent.
2. 12-mm right upper lobe and 9 mmleft upper lobe nodules may be
metastatic or inflammatory in etiology.
3. Pathologic fracture of T12 lumbar vertebra and equivocal
lucencies within the femoral necks bilaterally. Bone scan is
helpful for evaluation of extent of the osseous lesion.
Bone Scan:
1. There is increased radio-tracer uptake in the body of T12, in
keeping with patient's known wedge compression fracture at this
level.
2. Degenerative disease affecting the knees and right foot as
described.
3. No definite abnormality of the pelvis but evaluation of the
pelvis was
somewhat limited due to patients inability to void completely.
[**Known lastname 12628**],[**Known firstname **] [**Medical Record Number 12629**] M 56 [**2047-4-2**]
Radiology Report CHEST (PA & LAT) Study Date of [**2104-3-9**] 10:46
AM
[**Last Name (LF) **],[**Known firstname **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 12630**] FA11 [**2104-3-9**] 10:46 AM
CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 12631**]
Reason: re-expansion of LLL?
[**Hospital 93**] MEDICAL CONDITION:
56 year old man with LLL collapse after throacic approach to
vertebroplasty
REASON FOR THIS EXAMINATION:
re-expansion of LLL?
Final Report
PA AND LATERAL CHEST ON [**3-9**]
HISTORY: Left lower lobe collapse after thoracic approach to
vertebroplasty.
IMPRESSION: PA and lateral chest compared to [**3-7**]:
Left lower lobe collapse has not improved and although the
lateral view shows
a bulge at the left hilus, preoperative torso CT showed no hilar
mass.
Presumably, this is fluid in the major fissure. Tiny right
pleural effusion
is seen only on the lateral view. Right lung is clear. Cardiac
silhouette is
shifted into the left hemithorax, not particularly enlarged. No
pneumothorax.
[**Known lastname 12628**],[**Known firstname **] [**Medical Record Number 12629**] M 56 [**2047-4-2**]
Radiology Report T-SPINE Study Date of [**2104-3-7**] 4:20 PM
[**Last Name (LF) **],[**Known firstname **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 12630**] FA11 [**2104-3-7**] 4:20 PM
T-SPINE Clip # [**Clip Number (Radiology) 12632**]
Reason: check alignment
[**Hospital 93**] MEDICAL CONDITION:
56 year old man with s/p T12 fusion, please check standing
xrays ap and lat and
view both ends hardware on one film, check alignment
REASON FOR THIS EXAMINATION:
check alignment
Final Report
HISTORY: T12 fusion.
FINDINGS: Two views show the fusion procedure spanning T11
through L1 with
placement of a cage device at T12. Overall alignment appears to
be well
maintained.
Brief Hospital Course:
Mr. [**Known lastname 12628**] was admitted from the spine center to the [**Hospital Ward Name 121**]
11 floor under the care of Dr. [**Last Name (STitle) 739**]. A TLSO brace was
ordered and the patient was fitted. He was on Q4 hr neuro check,
he had full strength upon admission. He was on SQH for DVT
prophylaxis. A CT torso and bone scan were ordered to
investigate for other sites of malignancy. In preparation for
this study, he ingested the oral contract but his renal function
tests were elevated and he could not complete the study. These
labs were repeated and improved after hydration. The CT torso
was re-ordered on [**2014-2-28**].
Dr. [**Last Name (STitle) 724**] of Neuro-Oncology was consulted. He felt that the
differenital for this mass was MM, lymphoma, or infections.
Serum/urine protein electrophoresis/LDH/B2macroglobulin/HIV/PPD
were ordered at his request. Dr. [**Last Name (STitle) 548**] of the neurosurgery
department was consulted and he recommended an IR guided biopsy.
This was ordered on [**2104-2-29**]. On the CT torso from [**2104-2-29**] he was
found to have bilateral pulmonary nodules with lymphnode
involvement. As a result pulmonary was consulted. His TLSO
arrived on [**3-1**] but did not get out of bed with it on at that
time. He wore the brace while the HOB was >30degrees. On [**3-2**]
he had an episode of urinary retention and was straight cathed
for 950cc of residual urine and subsequently a foley was placed.
On [**3-3**] he was noted to have pain in his Left ankle so 3 view
ankle plain films were done which showed soft tissue swelling
but no bony injury. Also on the 12th he got OOB with the TLSO
on with no increase in his pain. He underwent a IR guided
biopsy with Dr. [**Last Name (STitle) **] on the 12th. pathology of the tissue
obtained from the biopsy was found to be consistent with
adenocarcinoma suggestive of a primary lung cancer so lung
biopsy was not indicated. He remained stable on [**3-4**] with plans
to be an add on case for [**3-5**] with Dr. [**Last Name (STitle) 548**] for a T12
vertebrectomy via a thoracotomy approach.
He tolerated the aforementioned procedure well. He remained in
the ICU for 2 days. His chest tube was d/c'd on POD #2. he was
transferred out to the floor on POD #3. It was here where he
was OOB with PT, and tolerated it well. A CXR revealed that he
had partial collapse of his L Lower lobe. Thoracic surgery was
consulted to review the images. They recommended aggressive
chest physiotherapy for the patient and frequent use of the
incentive spirometer. His repeat CXR on [**3-9**] was stable.
The plan is for discharge to home. Pt agrees with the plan.
Medications on Admission:
Metformin 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Calcium Carbonate 500 mg Tablet, Chewable Sig: Three (3) Tablet,
Chewable PO DAILY (Daily).
Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: 2.5 Tablets PO
DAILY (Daily).
Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
ASA 81mg po QD
Naprosyn
Vicodin
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/t>100/HA.
2. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Calcium Carbonate 500 mg Tablet, Chewable Sig: Three (3)
Tablet, Chewable PO DAILY (Daily).
4. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: 2.5 Tablets
PO DAILY (Daily).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
7. Cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) as needed for m. spasm.
Disp:*90 Tablet(s)* Refills:*0*
8. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
Disp:*1 bottle* Refills:*1*
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Metformin 500 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO DAILY (Daily). Tablet
Sustained Release 24 hr(s)
11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
12. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
2-4 Puffs Inhalation Q4H (every 4 hours) as needed for wheeze.
13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
14. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
T12 pathologic fracture
spinal cord compression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
?????? Do not smoke.
?????? Keep your wound(s) clean and dry / No tub baths or pool
swimming for two weeks from your date of surgery
?????? If you have steri-strips in place, you must keep them dry for
72 hours. Do not pull them off. They will fall off on their own
or be taken off in the office. You may trim the edges if they
begin to curl.
?????? No pulling up, lifting more than 10 lbs., or excessive bending
or twisting.
?????? Limit your use of stairs to 2-3 times per day.
?????? Have a friend or family member check your incision daily for
signs of infection.
?????? If you are required to wear one, wear your cervical collar or
back brace as instructed.
?????? You may shower briefly without the collar or back brace;
unless you have been instructed otherwise.
?????? Take your pain medication as instructed; you may find it best
if taken in the morning when you wake-up for morning stiffness,
and before bed for sleeping discomfort.
?????? Do not take any anti-inflammatory medications such as Motrin,
Advil, Aspirin, and Ibuprofen etc. unless directed by your
doctor.
?????? Increase your intake of fluids and fiber, as pain medicine
(narcotics) can cause constipation. We recommend taking an over
the counter stool softener, such as Docusate (Colace) while
taking narcotic pain medication.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? Pain that is continually increasing or not relieved by pain
medicine.
?????? Any weakness, numbness, tingling in your extremities.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, and drainage.
?????? Fever greater than or equal to 101?????? F.
?????? Any change in your bowel or bladder habits (such as loss of
bowl or urine control).
Followup Instructions:
Follow Up Instructions/Appointments
??????Please return to the office in 10 days for removal of your
staples.
??????Please call ([**Telephone/Fax (1) 2726**] to schedule an appointment with Dr.
[**Last Name (STitle) 548**] to be seen in 6 weeks.
??????You will need x-rays prior to your appointment.
Please follow up with Dr. [**Last Name (STitle) **], MD Phone:[**Telephone/Fax (1) 1844**]
Date/Time:[**2104-3-24**] 2:00 on [**Hospital Ward Name 23**] 8 [**Hospital Ward Name **]
Completed by:[**2104-3-10**]
|
[
"336.3",
"272.0",
"788.20",
"518.0",
"724.4",
"356.9",
"733.13",
"198.5",
"250.00",
"162.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.62",
"84.51",
"81.04",
"77.71",
"34.04",
"80.50",
"77.49",
"77.89"
] |
icd9pcs
|
[
[
[]
]
] |
9300, 9306
|
4552, 7222
|
327, 347
|
9398, 9398
|
1633, 2976
|
11424, 11938
|
1161, 1170
|
7682, 9277
|
4144, 4280
|
9327, 9377
|
7248, 7659
|
9549, 11401
|
1185, 1185
|
1590, 1614
|
278, 289
|
4312, 4529
|
375, 930
|
1199, 1576
|
9413, 9525
|
952, 1078
|
1094, 1145
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,210
| 162,602
|
21142
|
Discharge summary
|
report
|
Admission Date: [**2113-8-1**] Discharge Date: [**2113-8-6**]
Date of Birth: [**2054-1-7**] Sex: M
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 9554**]
Chief Complaint:
59 yo male, complex medical history,s/p fall with resultant
subdural hematoma.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Pt is a 59 yo male h/o orthotopic heart transplant in 93'
secondary to cardiomyopathy, ESRD secondary to cyclosporin (on
hemodialysis three times a week), ascites with ?liver disease,
and a new diagnosis of Large B cell lymphoma, who was on
coumadin for a superior vena cava thrombosis who fell on [**2113-7-31**]
after tripping and hit his head. Patient does not remember
timeline of day and ? LOC. Pt called 911 at 10:30 pm that day.
He was transferred from OSH to trauma service at [**Hospital1 **] on [**2113-8-1**].
CT on admission showed small epidural and bilateral subdural
hematoma bleeds. C spine showed some abnormal signal in the
suboccipital region with a somewhat prominent blood vessel in
the neighborhood thought to be consistent with a soft tissue
injury. He was transferred to the trauma ICU for frequent neuro
checks and transfusion with FFP. Repeat head CT [**2113-8-3**] showed
stable multicompartmental subdural hematomas. Patient was
transferred to medicine floors from TICU today.
Past Medical History:
1.orthotopic heart transplant in 93?????? secondary to cardiomyopathy
with organ donor +CMV, recepient CMV-
2. CMV viremia treated with CMV IgG after transplant
3. ESRD secondary cyclosporin. On cadaveric renal transplant
list. Gets hemodialysis mon,wed, and fri
3. S/P L arm A/V graft
4. Asthma
5. Gastroesophageal reflux disease
6. S/P R cataract surgery
7. History of Ascites ?liver disease
8. Large B cell lymphoma (dx end may-beg [**7-14**] at [**Hospital1 336**])
Social History:
Pt has no known toxic habits specifically has never smoked,
drank alcohol, or used recreation drugs.
Pt was a fire captain for 20 + years in [**Location (un) 56072**], NH. He was
forced to quit with his cardiac diagnosis in 93'. He is divorced
and has two sons 10 & 14. Pt served in the marine corp.
Family History:
NO known family history of cardiac problems or cancer. GF with
diabetes.
Physical Exam:
VS: T: 97.6; BP: 128/91; RR:19; P: 107; O2: 95% on RA. I/O (24
hr) 790/4300
Gen: 50-something white male, laying in bed comfortably in NAD
HEENT: NCAT, PERRL, EOMI, OP clear
Neck: multiple sub-cm left supraclavicular nodes appreciated.
CV: RRR S1 S2 SEM @ LUSB with splitting
Lungs: CTA B/L
Abd: Soft, NT, ND +BS
Ext: DP 2+ bilaterally; multiple ecchymoses on knees
bilaterally; sparse hair
growth on distal lower extremities.
Neuro: Pt conversant though with moderate expressive aphasia.
Speech also
tangential at times.
CN II-XII intact though weak left SCM muscle
Strength 5/5
b/l fine hand tremor
Pertinent Results:
[**2113-8-6**] 06:25AM BLOOD WBC-6.6 RBC-2.99* Hgb-9.9* Hct-32.2*
MCV-107* MCH-33.2* MCHC-30.9* RDW-22.7* Plt Ct-185
[**2113-8-6**] 06:25AM BLOOD Plt Ct-185
[**2113-8-5**] 06:45AM BLOOD PT-13.8* PTT-25.1 INR(PT)-1.3
[**2113-8-6**] 06:25AM BLOOD Glucose-64* UreaN-37* Creat-4.6*# Na-139
K-3.8 Cl-96 HCO3-31* AnGap-16
[**2113-8-5**] 06:45AM BLOOD Glucose-65* UreaN-24* Creat-3.2*# Na-142
K-3.7 Cl-98 HCO3-32* AnGap-16
[**2113-8-4**] 08:30AM BLOOD ALT-17 AST-15 AlkPhos-106 TotBili-0.9
[**2113-8-6**] 06:25AM BLOOD Calcium-8.6 Phos-3.5 Mg-1.7
[**2113-8-4**] 08:30AM BLOOD VitB12-414 Folate-GREATER TH
[**2113-8-4**] 08:30AM BLOOD TSH-1.3
[**2113-8-5**] 06:45AM BLOOD Cyclspr-201
Initial Lab Results from admission:
[**2113-8-1**] 10:05PM PT-18.1* PTT-29.4 INR(PT)-2.2
[**2113-8-1**] 03:35PM PT-14.5* PTT-26.2 INR(PT)-1.4
[**2113-8-1**] 09:40AM GLUCOSE-106* UREA N-33* CREAT-3.5* SODIUM-143
POTASSIUM-3.9 CHLORIDE-97 TOTAL CO2-35* ANION GAP-15
[**2113-8-1**] 09:40AM CALCIUM-8.2* PHOSPHATE-4.0 MAGNESIUM-1.6
[**2113-8-1**] 09:40AM WBC-2.5* RBC-2.51* HGB-8.3* HCT-27.6*
MCV-110* MCH-33.2* MCHC-30.2* RDW-24.0*
[**2113-8-1**] 09:40AM PLT COUNT-231
[**2113-8-1**] 09:40AM PT-14.9* PTT-26.4 INR(PT)-1.5
[**2113-8-1**] 09:40AM FIBRINOGE-303
[**2113-8-1**] 08:00AM CYCLSPRN-38*
[**2113-8-1**] 02:36AM TYPE-ART PO2-38* PCO2-47* PH-7.51* TOTAL
CO2-39* BASE XS-12
[**2113-8-1**] 02:30AM UREA N-28* CREAT-3.3*
[**2113-8-1**] 02:30AM AMYLASE-49
[**2113-8-1**] 02:30AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2113-8-1**] 02:30AM WBC-2.9* RBC-2.79* HGB-9.6* HCT-29.6*
MCV-106* MCH-34.4* MCHC-32.4 RDW-23.5*
[**2113-8-1**] 02:30AM PLT COUNT-246
[**2113-8-1**] 02:30AM PT-19.3* PTT-24.8 INR(PT)-2.5
[**2113-8-1**] 02:30AM FIBRINOGE-292
[**2113-8-1**] 02:26AM GLUCOSE-112* LACTATE-2.2* NA+-141 K+-3.8
CL--99* TCO2-40*
[**2113-8-1**] 02:26AM HGB-9.6* calcHCT-29
Brief Hospital Course:
Pt was transferred from OSH to trauma service at [**Hospital1 **] on [**2113-8-1**].
CT on admission showed small epidural and bilateral subdural
hematoma bleeds. C spine showed some abnormal signal in the
suboccipital region with a somewhat prominent blood vessel in
the neighborhood thought to be consistent with a soft tissue
injury. However, there was no evidence for fracture or
dislocation. Pt was transferred to the trauma ICU for frequent
neuro checks and transfusion with FFP. [**2113-8-2**] CT with and
without contrast showed no venous thrombosis in the superior
vena cava. Repeat head CT [**2113-8-3**] showed stable
multicompartmental subdural hematomas. Patient was transferred
to medicine floors from TICU on [**2113-8-3**].
1. Neurology
Pt was cleared by neurosurgery who recommends to avoid
anticoagulation for one month. Additionally, Mr. [**Known lastname **] had
expressive aphasia when he was first seen by medicine; something
that he said he has had for months. It is improved on
discharge.
2. CV
Patient was seen by cardiology was continuing to receive
cyclosporin 100 mg qam, 125 mg qpm. Latest level was 201 on
[**2113-8-5**]. He was also continuing on atorvastatin and lisinopril
which is his usual regimine.
3. Renal
Patient has end stage renal disease. He received dialysis while
at [**Hospital1 18**] on his usual schedule on monday, wednesday, and friday.
His last dialysis was [**2113-8-4**] and his next dialysis is
[**2113-8-7**]. He will go to his usual dialysis center near home. He
also received nephrocaps per usual.
4. abdominal
Mr. [**Known lastname **] has gastroesophageal reflux disease. He was on
pantoprazole for prophylaxis.
5. Hematology
Patient has no evidence of thrombus in his superior vena cava.
6. Lung
Patient with history of asthma. Was given albuterol nebulizer
treatments as needed, though patient did not require any.
7. Nutrition
Patient was on a renal diet.
8. Disposition
Patient was evaluated by both physical therapy and occupational
therapy. He had a few physical therapy sessions and they believe
he is ready to go [**Last Name (un) **]. Occupational therapy believes mr. [**Known lastname **]
could benefit from [**2-10**] more sessions. This will be arranged for
at home as well as a visiting nursing service for education and
other needs.
Medications on Admission:
Same as discharge medications.
Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
2. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO QD (once a day).
Disp:*30 Cap(s)* Refills:*2*
4. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
Disp:*30 Capsule(s)* Refills:*2*
5. Quinine Sulfate 325 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
Disp:*30 Capsule(s)* Refills:*2*
6. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*30 Tablet(s)* Refills:*2*
7. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
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. Cyclosporine 100 mg Capsule Sig: One (1) Capsule PO QAM (once
a day (in the morning)).
10. Cyclosporine 25 mg Capsule Sig: Five (5) Capsule PO once a
day.
Disp:*150 Capsule(s)* Refills:*2*
11. Prednisone 5 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
yourcare vna
Discharge Diagnosis:
Subdural hematoma status post a mechanical fall while on
coumadin.
Discharge Condition:
Good.
Discharge Instructions:
Patient will return to home and have OT visit and a visiting
nurse.
Followup Instructions:
Pt will be following up with his oncologist, cardiologist, and
PCP in [**Name9 (PRE) **] [**Name9 (PRE) 56073**] and at [**Hospital1 336**]. He will be going to dialysis
tomorrow morning.
[**First Name8 (NamePattern2) 2064**] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2139**]
|
[
"200.00",
"E933.1",
"V58.61",
"E885.9",
"585",
"852.41",
"V42.1",
"852.21",
"789.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"99.07",
"99.04",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
8567, 8610
|
4947, 7267
|
386, 393
|
8721, 8728
|
3006, 4924
|
8844, 9162
|
2258, 2333
|
7348, 8544
|
8631, 8700
|
7293, 7325
|
8752, 8821
|
2348, 2987
|
268, 348
|
421, 1430
|
1452, 1923
|
1939, 2242
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,243
| 111,092
|
27745
|
Discharge summary
|
report
|
Admission Date: [**2200-7-23**] Discharge Date: [**2200-7-25**]
Date of Birth: [**2129-1-11**] Sex: F
Service: MEDICINE
Allergies:
Demerol
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
Chest pain.
Transfer from OSH for inferior ST elevated MI.
Major Surgical or Invasive Procedure:
Cardiac catheterization with Cypher DES to proximal RCA.
History of Present Illness:
This 71 year old woman with a history of hypertension and
hyperlipidemia was transferred from [**Hospital3 **] ED for
emergent cardiac catheterization. She was in her USOH until
yesterday. She had taken a NSAID for R shoulder pain and
developed "sticking sensation" in the her chest - initially she
thought it was GERD. The discomfort, however continued on
through til the next morning. By that time the pain was
considerably worse and was radiating to back; she began having
symptoms of nausea/vomiting diaphoresis. Initial EKG in ER
looked OK with minor ST changes. After getting GI medication and
some narcotics, the patient continued to have pain. A repeat EKG
at noon revealed 1mm ST elevations in inferior and lateral T
wave changes. Got nitrates which resulted in hypotension.
Treated w/ ASA 325mg, plavix 600mg, heparin gtt, integrilin,
morphine, and dilaudid. The patients chest pain subsequently
resovlved and she was transferred to [**Hospital1 18**] for emergent
catheteriztion. Was pain free on arrival to [**Hospital1 18**].
.
Pt was taken to the cath lab where a 100% occluding lesion was
seen in the RCA, this appeared acute. 70-80% stenosis in OM1 was
also seen. At 1:47 PM the RCA lesion was successfully stented
with Cypher DES with successful restoration of flow.
Subsequently, the patient was noted to be bradycardic to 30-40
range with associated hypotension with SBP in 60's. The patient
was given 1x atropine with normalization of the heart rate and
SBP. While still in the laboratory however, the patient was
noted to go into atrial fibrillation.
.
Pt denies any shortness of breath, orthopnea or dyspnea. Denies
palpitations. She does say she has felt generally more fatigued
over the last 2 or 3 months.
Past Medical History:
- hypertension: no current medications, had been diagnosed this
year and only recently was started on identified medication. She
didn't tolerate the medication, getting a constant cough. They
were to try a different medication this week
- hyperlipidemia (on Zocor)
- GERD
- hemochromatosis
Oncologic:
- [**2195**] bladder cancer: s/p BCG treatment last year
- [**2194**] L kidney tumor: s/p nephrectomy
- [**2166**] Vaginal cancer s/p vagectomy
- [**2165**] Cervical cancer s/p hysterectomy
- h/o C. diff colitis
Social History:
Married, 9 grown children. Used to smoke over 50 years ago but
rarely. Drinks on rare occasions.
Family History:
Sister with arrhythmia (type unknown), diabetes on both sides of
family. No known CAD.
Physical Exam:
Wt 154lbs
Afebrile P 80-90 irregular BP 110/53 R 14 O2 98 on 2L
Gen: WD/WN woman in NAD, alert, pleasant, and cooperative.
Eyes: Sclerae anicteric
Mouth: MMM
Neck: JVP to 6 cm.
Pulm: Lungs CTA b/l no wheezes, rubs, or rhonchi
CV: Irregularly irregular, no murmur, no rub.
Abd: NT, ND, normal bowel sounds.
Groin: R groin, no hematoma, no bruit
Ext: No edema, DP pulses nl.
Pertinent Results:
[**2200-7-23**] 04:49PM BLOOD WBC-11.0 RBC-3.63* Hgb-10.6* Hct-30.6*
MCV-84 MCH-29.1 MCHC-34.5 RDW-13.4 Plt Ct-233
[**2200-7-23**] 04:49PM BLOOD Glucose-192* UreaN-16 Creat-0.8 Na-138
K-4.0 Cl-104 HCO3-24 AnGap-14
[**2200-7-23**] 04:49PM BLOOD CK(CPK)-656*
[**2200-7-23**] 04:49PM BLOOD CK-MB-100* MB Indx-15.2*
[**2200-7-23**] 11:48PM BLOOD CK(CPK)-881*
[**2200-7-23**] 11:48PM BLOOD CK-MB-105* MB Indx-11.9*
[**2200-7-24**] 05:30AM BLOOD CK(CPK)-837*
[**2200-7-24**] 05:30AM BLOOD CK-MB-77* MB Indx-9.2* cTropnT-2.93*
[**2200-7-25**] 05:25AM BLOOD CK(CPK)-397*
[**2200-7-25**] 05:25AM BLOOD CK-MB-18* MB Indx-4.5 cTropnT-2.22*
[**2200-7-23**] 04:49PM BLOOD TSH-1.0
Cardiac catheterization of [**2200-7-23**]:
1. Coronary angiography revealed a right dominant system with
RCA
occlusion. The LMCA showed mild diffuse disease with no
stenosis more
than 20%. The LAD showed a proximal and midsegment 60% stenosis
that
did not angiographically appear to be flow-limiting. The LCx
showed a
70% midsegment stenosis with an ostial 70-80% OM1 stenosis. The
RCA
showed a 100% stenosis of the midsegment which appeared acute.
2. Resting hemodynamic studies demonstrated mildly elevated
pulmonary
capillary wedge pressure mean of 15mmHg. The cardiac index was
preserved at 2.7L/min/m2. There was no pressure gradient across
the
aortic valve or between the left ventricular end diastolic
pressure and
pulmonary capillary wedge pressure to suggest aortic stenosis.
3. Left ventriculography demonstrated normal left ventricular
systolic
function with no evidence of mitral regurgitation. The ejection
fraction was calculated at 59%.
4. Successful stenting of the RCA with a 3.0 mm Cypher
drug-eluting
stent, post-dilated to 3.25 mm.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Mild diastolic ventricular dysfunction.
3. Normal systolic function with preserved cardiac output.
4. Acute inferior myocardial infarction, managed by placement of
drug-eluting stent.
5. Successful stenting of the RCA.
Brief Hospital Course:
This 71 year old woman with a history of hypertension,
hyperlipidemia, GERD, hemochromatosis, and an extensive
oncological history presented to an outside hospital with chest
pain over 12 hours and was found by EKG to have changes
consistent with an inferior ST elevated myocardial infarction.
She was started on aspirin, plavix, integrilin and heparin and
thereafter was emergently transferred to [**Hospital1 18**] for cardiac
cathetherization. On catheterizaion she was found to have a
total occlusion of the proximal RCA which appeared acute and
also a 70-80% lesion in the OM1. The RCA lesion was
successfully opened with a Cypher drug eluting stent. Procedure
complicated by bradycardia with hypotension resolved with
atropine. Also complicated by onset of atrial fibrillation
during the procedure.
.
Given the episode of hypotension and the new onset atrial
fibrillation, the patient was admitted to the CCU. On
presentation, the patient was hemodynamically stable, chest pain
free with normal respiratory function. She was still in atrial
fibrillation and low dose metoprolol was started. The night
after the catheterization the patient was noted to again become
bradycardic with hypotension. This resolved with 0.5 mg
atropine and one normal saline fluid bolus. Shortly thereafter,
the patient's rhythm returned to sinus. Metoprolol was
discontinued.
.
The patient remained hemodynamically stable and chest pain free
after this. Her enzymes trended down from a peak CK 881 MB 105
(the night after catheterization). e She was discharged with
instructions to follow up with [**Hospital1 18**] cardiology with a
persantine MIBI to determine whether she would need repeat
catheterization for the OM1 lesion. She was aslo to continue
aspirin, plavix, lipitor, and lisinopril
.
In summary, this is 71 year old woman admitted with inferior
STEMI secondary to 100% lesion of the proximal RCA. This was
successfully treated with [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 5175**]. Course complicated by
two episodes of bradycardia associated with hypotension
successfully treated with atropine. These episodes were likely
secondary to increased vagal tone associated with IMI. Course
also complicated by atrial fibrillation which spontaneously
converted to sinus.
.
Issues and plan from this hospitalization.
1)
a) Perfusion: Status post IMI, s/p DES to 100% proximal lesion
in RCA, known disease in OM1 (70-80%)
-to continue ASA, plavix, and lipitor
-will undergo repeat stress testing with imaging and then will
follow up with [**First Name4 (NamePattern1) 402**] [**Last Name (NamePattern1) 7173**], NP (who works with Dr.
[**Last Name (STitle) **] of [**Hospital1 18**] Cardiology)
-If P-Mibi reveals reversible defects in OM1 territory, will
need repeat cath and stent to OM1.
-started low dose lisinopril
-held metoprolol given bradycardic,hypotensive episodes, will
consider resumption of metoprolol as outpatient.
b)IMI vagal abnormalities. Night after admission was turned and
became acutely nauseous. HR dropped to 60's in AFib with sBP in
70's. Was given atropine and converted to NSR in 80's, sBP to
high 80's. Pt was given IV fluids and BB held.
-held metoprolol.
.
c) Pump, nl EF on LV gram, no [**Male First Name (un) 4746**] abnormalities, PA pressure only
mildly elevated.
-no need for diuretic therapy
.
d) Rhythm, atrial fibrillation initially, now converted to NSR.
AFib was likely new onset in the cath lab, although pt has felt
more fatigued as of late.
-TSH nl
-consider metoprolol at later time.
.
2) R shoulder pain, secondary to recent rotator cuff injury
-used oxycodone PRN
.
3) GERD/GI issues
-use protonix in place of nexium for hospital stay
-continue zelnorm
4) GU issues.
-pt continued to take own "Flora Q", urocit.
.
5) Extensive cancer history
-no active issues during stay.
.
6) Prophylaxis: included Anzemet, Protonix, Colace. Heparin
while pt had been in AF.
.
Code status remains full.
Medications on Admission:
Flora Q
Zocor 10 mg PO daily
Zelnorm 6 mg PO daily
Nexium 40 mg PO daily
Calcium 500 mg PO BID
MVI
Urocit 20 qHS
Medications on transfer:
- ASA 325mg daily
- plavix 75mg daily
- lipitor 80mg daily
- heparin gtt
- integrillin
- NTG SL prn
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*120 Tablet(s)* Refills:*2*
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
5. Potassium Citrate 10 mEq Tablet Sustained Release Sig: One
(1) Tablet Sustained Release PO every night ().
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
8. Tegaserod Hydrogen Maleate 6 mg Tablet Sig: One (1) Tablet PO
every morning ().
9. Flora-Q 8 Billion cells Capsule Sig: One (1) Capsule PO qd
().
10. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
ST elevated inferior MI
Discharge Condition:
Good. Chest pain free. Hemodynamically stable and breathing
normally on room air.
Discharge Instructions:
Please return to hospital if you experience chest pain,
shortness of breath or persistent nausea/vomiting.
Please continue the medications you were prescribed from this
hospital.
It is especially important you take aspirin and plavix every
day.
You will take lipitor every day also, this will replace zocor.
We will start you on lisinopril
You aren't currently on metoprolol at this time. This will be
re-addressed on your follow up appointment at [**Hospital1 18**] next week
(see below)
Please continue all other medications.
Followup Instructions:
You will undergo an exercise stress test with imaging next week
[**First Name4 (NamePattern1) 402**] [**Last Name (NamePattern1) 7173**], NP for Dr. [**Last Name (STitle) **], is arranging to schedule
this bmer. The number for the stress laboratory is
[**Telephone/Fax (1) 1566**]. Based on the stress test, it wil be determined
whether you will need another cardiac catheterization
.
Please follow up with [**First Name4 (NamePattern1) 402**] [**Last Name (NamePattern1) 7173**], within 1 week She,
along with Dr. [**Last Name (STitle) **], [**First Name3 (LF) **] review your stress test. Your
medications will be reviewed and they may decide to adjust your
antihypertension medications.
[**First Name4 (NamePattern1) 402**] [**Last Name (NamePattern1) 7173**] works with Dr. [**Last Name (STitle) **] who was your attending
physician in hospital, their office phone is [**Telephone/Fax (1) 285**].
Make sure to arrange for cardiac rehabilitation, you may do this
at [**Hospital6 33**].
Please follow up with your primary care physician/cardiologist
Dr. [**Last Name (STitle) 1637**] in one month.
|
[
"401.9",
"427.31",
"272.4",
"410.41",
"414.01",
"E879.9",
"427.89",
"997.1",
"458.29"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.20",
"88.57",
"00.45",
"88.53",
"36.07",
"00.40",
"00.66"
] |
icd9pcs
|
[
[
[]
]
] |
10542, 10548
|
5346, 9305
|
326, 385
|
10616, 10701
|
3310, 5040
|
11278, 12390
|
2813, 2901
|
9595, 10519
|
10569, 10595
|
9331, 9445
|
5057, 5323
|
10725, 11255
|
2916, 3291
|
228, 288
|
413, 2146
|
9470, 9572
|
2168, 2683
|
2699, 2797
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,195
| 190,261
|
47343
|
Discharge summary
|
report
|
Admission Date: [**2162-7-6**] Discharge Date: [**2162-9-21**]
Date of Birth: [**2086-9-23**] Sex: M
Service: SURGERY
Allergies:
Percocet
Attending:[**First Name3 (LF) 158**]
Chief Complaint:
Abdominal distension
Major Surgical or Invasive Procedure:
Colonic decompression tube placed
History of Present Illness:
75 M with history of colonic pseudoobstruction, HTN, PVD, PE,
Anemia, presents with severe abdominal distention over last 3
months. He had a complicated hospitalization in late [**Month (only) 116**] of
this year for atrial flutter which was complicated by colonic
pseudoobstruction for which he underwent a colonoscopy with
removal of 5L of liquid stool. He failed a trial of neostigmine
due to bradycardia, n/v. He was also given metaclopromide,
erythromycin and rectal stimulation therapy. He was found to
have PEs, and was started on anticoagulation, but unfortunately
developed a massive UGIB necessitating and ICU stay and this was
stopped. He has been followed for elevated PSAs and was noted
on imaging to have multiple sclerotic lesions concerning for
malignancy. Attempts at prostate biopsy thus far have been
unsuccessful. Full details on this hospitalization can be found
in the OSH records. He was discharged to a nursing home in
[**Location (un) 2624**] with f/u scheduled for yesterday with Dr. [**First Name (STitle) 2643**] of GI.
On arrival to the appointment, Dr. [**First Name (STitle) 2643**] was so concerned with
the appearance of his distended abdomen that he sent him
directly to the ED.
.
In the ED he was seen by surgery who felt he did not have acute
obstruction; CT abd showed stool-filled colon with dilation
without obstruction concerning for Olgilvie's syndrome. An NGT
was placed. Labs notable for low K, repleted. Initial VS: 97.9
130/83 75 18 96% on RA. Given 1L NS. VS at time of transfer:
96.9 65 140/97 16 97% on RA.
.
On the floor the patient is complaining chiefly of feeling
fatigued. He denies abdominal discomfort. States that the
abdominal distention has come on gradually and has been present
for several months. He has had a 20+ lb weight loss in this
time. Reports decreased appetite without n/v. Has been passing
"soupy" stools. No chest pain. Does endorse labored breathing
for several weeks. No fevers or chills. Chronic low back pain.
Chronic LE edema with venous ulcer. No heartburn.
.
ROS was otherwise essentially negative.
CT abd/pelvis
IMPRESSION:
1. Dominant perihepatic (ascitic) fluid adjacent to the liver
has a large
locule of air; peritoneal enhancement and peritoneal fluid in
the left
abdomen, and communicating via multiple lobulations of fluid
into the mid
pelvis and the right pelvis has multiple smaller loculations of
air.
In a patient with recent surgery and recent anastomotic [**First Name (STitle) 3564**],
the air may be
postoperative in nature and the peritoneal enhancement from
inflammation and
post-surgical changes; however, in a patient with leukocytosis,
we cannot rule
out superinfection. Lab analysis of the peritoneal fluid is
recommended (may
be aspirated under ultrasound or CT guidance) which may be
feasible via a
targeted paracentesis. If appearing infected, they would be
amenable for
drainage.
2. No extraluminal oral contrast, no evidence of small-bowel
obstruction up
to the level of ileostomy.
3. Due to lack of oral contrast beyond the ileostomy, our
sensitivity for
detecting anastomotic [**First Name (STitle) 3564**] is significantly decreased.
4. Bilateral pleural effusion, with adjacent atelectasis, worse
on the right.
5. Multiple sclerotic osseous lesion concerning for metastatic
disease as
described on prior CT. No clear primary.
CT [**8-15**] Abdomen Pelvis
IMPRESSION:
1. Dominant perihepatic (ascitic) fluid adjacent to the liver
has a large
locule of air; peritoneal enhancement and peritoneal fluid in
the left
abdomen, and communicating via multiple lobulations of fluid
into the mid
pelvis and the right pelvis has multiple smaller loculations of
air.
In a patient with recent surgery and recent anastomotic [**Month/Day (4) 3564**],
the air may be
postoperative in nature and the peritoneal enhancement from
inflammation and
post-surgical changes; however, in a patient with leukocytosis,
we cannot rule
out superinfection. Lab analysis of the peritoneal fluid is
recommended (may
be aspirated under ultrasound or CT guidance) which may be
feasible via a
targeted paracentesis. If appearing infected, they would be
amenable for
drainage.
2. No extraluminal oral contrast, no evidence of small-bowel
obstruction up
to the level of ileostomy.
KUB:
IMPRESSION: Massive gastric, small bowel, and colonic dilation
without clear transition point. It is unclear whether there is
gas in the rectum. This is an apparent new development as best
can be compared to the pelvis radiograph from [**Month (only) 956**] of this
year. A high-grade obstruction is suspected. Cross-sectional
imaging is advised.
CT ABD: (wet read) Massive diffuse dilation of the entire colon
and rectum filled with fluid and fecal material. The rectal
contrast id diluted and cannot be seen proximal to the sigmoid
colon. No evidence of obstruction or volvulus. These are
suggestive of [**Last Name (un) 3696**] syndrome.The rectal catheter was placed
in the rectum and a distal rectal/anal lesions cannot be
excluded in this study. No free air. Sclerotic lesions in T12
and L1 are noted.
.
Colonoscopy: [**5-17**]: Normal except evacuation of 5 liters of stool
.
Past Medical History:
Hypertension, poorly controlled, chronically low K+=3.2
Lower extremity edema, more on left side, unknown etiology.
Previous DVT in R leg.
PE [**5-/2162**]
UGIB [**5-/2162**]
BPH with increasing PSA. equivocal bone scan, bx without
adequate tissue.
CKD
Osteoarthritis Bilateral Hip
Gastric Ulcers, H.pylori negative
Rectal polyps, benign
Right incarcerated hernia
Chronic anemia, with extensive work-up, unknown etiology
?Dementia
Atrial flutter
Colonic pseudoobstruciton
Social History:
Currently at nursing home, previously lived in [**Hospital1 8**] at Y.
Previous radio talk show host. Divorced with 2 adult children.
Denied history of smoking, drinking, recreational drugs.
Family History:
Mother deceased with [**Name (NI) 2481**]. Father deceased from
appendicitis.
Physical Exam:
Vitals: T:98.1 BP:104/71 P:68 R:22 SaO2:98% on Ra
General/Neuro: A&OX3, appearing malnorished but much improved,
muscle wasting noted in upper and lower extremities.
HEENT: NCAT, PERRL, EOMI, no scleral icterus, MM moist
Neck: Supple, No significant JVD or carotid bruits appreciated
Pulmonary: CTA B/L
Cardiac: RR, nl S1 S2, no murmurs, rubs or gallops appreciated
Abdomen: Massively distended with typany and hyperactive BS.
Non-tender. No rebound or guarding. Ileostomy in upper right
quadrant putting out appropriate amounts of stool. Tolerating
regular diet within normal limits.
Extremities: Bilateral 2+ LE pitting edema, left side tender.
Left sided venous ulcer, dressed.
Lymphatics: No cervical, lymphadenopathy noted
Skin: no rashes or lesions noted.
Pertinent Results:
Admission labs:
[**2162-7-6**] 12:05PM GLUCOSE-95 UREA N-7 CREAT-1.0 SODIUM-141
POTASSIUM-2.6* CHLORIDE-105 TOTAL CO2-27 ANION GAP-12
[**2162-7-6**] 12:05PM ALT(SGPT)-9 AST(SGOT)-17 ALK PHOS-87 TOT
BILI-0.4
[**2162-7-6**] 12:05PM LIPASE-27
[**2162-7-6**] 12:05PM WBC-4.7 RBC-4.19* HGB-12.4* HCT-37.8* MCV-90
MCH-29.6 MCHC-32.8 RDW-16.1*
[**2162-7-6**] 12:05PM NEUTS-66.4 LYMPHS-20.5 MONOS-7.9 EOS-4.5*
BASOS-0.8
[**2162-7-6**] 12:05PM PLT COUNT-300
[**2162-7-6**] 12:05PM PT-14.1* PTT-26.6 INR(PT)-1.2*
[**2162-7-6**] 03:27PM LACTATE-3.0*
.
Blood Gases from [**Date range (3) 100213**]
[**2162-8-27**] 01:06PM BLOOD Type-MIX pO2-130* pCO2-42 pH-7.38
calTCO2-26 Base XS-0 Comment-GREEN TOP
[**2162-8-24**] 10:25AM BLOOD Type-CENTRAL VE Temp-36.7 pO2-36* pCO2-45
pH-7.49* calTCO2-35* Base XS-9 Intubat-NOT INTUBA
[**2162-8-23**] 08:35AM BLOOD Type-ART Temp-37.3 FiO2-40 pO2-144*
pCO2-41 pH-7.52* calTCO2-35* Base XS-10 Intubat-INTUBATED
[**2162-8-23**] 04:06AM BLOOD Type-[**Last Name (un) **] Temp-36.7 Rates-[**12-8**] Tidal V-600
PEEP-5 FiO2-40 pO2-37* pCO2-45 pH-7.48* calTCO2-34* Base XS-8
Intubat-INTUBATED
[**2162-8-22**] 06:00PM BLOOD Type-ART pO2-118* pCO2-38 pH-7.54*
calTCO2-34* Base XS-9
[**2162-8-22**] 04:20PM BLOOD Type-MIX pO2-59* pCO2-81* pH-7.26*
calTCO2-38* Base XS-6
[**2162-8-22**] 02:26PM BLOOD Type-ART pO2-136* pCO2-70* pH-7.30*
calTCO2-36* Base XS-6
[**2162-8-22**] 12:15PM BLOOD Type-ART pO2-107* pCO2-78* pH-7.24*
calTCO2-35* Base XS-2
[**2162-8-22**] 10:10AM BLOOD Type-MIX pO2-61* pCO2-80* pH-7.22*
calTCO2-34* Base XS-1
[**2162-8-22**] 10:10AM BLOOD Type-MIX pO2-61* pCO2-80* pH-7.22*
calTCO2-34* Base XS-1
[**2162-8-21**] 11:49AM BLOOD Type-ART Rates-/16 Tidal V-600 FiO2-50
pO2-128* pCO2-50* pH-7.38 calTCO2-31* Base XS-3
[**2162-8-21**] 09:39AM BLOOD Type-[**Last Name (un) **] Temp-37.4 pO2-133* pCO2-72*
pH-7.23* calTCO2-32* Base XS-0
[**2162-8-9**] 08:29PM BLOOD Type-ART pO2-85 pCO2-27* pH-7.49*
calTCO2-21 Base XS-0 Intubat-NOT INTUBA Vent-SPONTANEOU
[**2162-8-8**] 05:38PM BLOOD Type-[**Last Name (un) **] pO2-201* pCO2-27* pH-7.55*
calTCO2-24 Base XS-3 Comment-GREEN TOP
[**2162-8-4**] 09:41AM BLOOD Type-ART pO2-132* pCO2-32* pH-7.51*
calTCO2-26 Base XS-3
[**2162-8-8**] 05:38PM BLOOD Type-[**Last Name (un) **] pO2-201* pCO2-27* pH-7.55*
calTCO2-24 Base XS-3 Comment-GREEN TOP
Abdomen/pelvis CT:
IMPRESSION:
1. Massive distention of the large bowel without evidence of
obstructing mass or volvulus, suggests the possibility of
[**Last Name (un) 3696**] syndrome. The anus is not included in the study and
anal lesion cannot be excluded in this study. Mild secondary
dilation of the distal small bowel.
2. Multiple sclerotic osseous lesions, concerning for metastatic
disease.
Recommened further evaluation with bone scintigraphy, and
correlation with any history of malignancy.
3. Moderately enlarged prostate gland.
.
KUB:
Multiple studies, with massive dilation of the colon.
[**2162-9-17**] 07:15AM BLOOD WBC-7.6 RBC-2.53* Hgb-7.4* Hct-23.2*
MCV-92 MCH-29.1 MCHC-31.8 RDW-16.5* Plt Ct-372
[**2162-9-17**] 05:36AM BLOOD WBC-6.0 Hct-24.0* Plt Ct-363
[**2162-9-15**] 04:59AM BLOOD WBC-7.2 RBC-2.81* Hgb-8.1* Hct-26.7*
MCV-95 MCH-28.7 MCHC-30.2* RDW-16.4* Plt Ct-311
[**2162-9-9**] 04:54AM BLOOD WBC-7.1 RBC-3.00* Hgb-8.5* Hct-27.3*
MCV-91 MCH-28.3 MCHC-31.1 RDW-16.4* Plt Ct-503*
[**2162-9-7**] 05:56AM BLOOD WBC-8.8 RBC-2.71* Hgb-7.8* Hct-24.9*
MCV-92 MCH-28.8 MCHC-31.4 RDW-16.5* Plt Ct-536*
[**2162-9-4**] 05:42AM BLOOD WBC-8.5 RBC-2.69* Hgb-7.7* Hct-24.2*
MCV-90 MCH-28.5 MCHC-31.7 RDW-16.6* Plt Ct-553*
[**2162-9-3**] 05:31AM BLOOD WBC-10.3 RBC-2.64* Hgb-7.8* Hct-24.1*
MCV-92 MCH-29.6 MCHC-32.3 RDW-16.8* Plt Ct-589*
[**2162-9-2**] 05:20AM BLOOD WBC-9.8 RBC-2.67* Hgb-7.5* Hct-24.8*
MCV-93 MCH-28.1 MCHC-30.3* RDW-16.1* Plt Ct-562*
[**2162-9-1**] 05:01AM BLOOD WBC-10.8 RBC-2.61* Hgb-7.6* Hct-24.0*
MCV-92 MCH-29.2 MCHC-31.7 RDW-16.1* Plt Ct-530*
[**2162-8-31**] 05:24AM BLOOD WBC-10.2 RBC-2.57* Hgb-7.5* Hct-23.1*
MCV-90 MCH-29.0 MCHC-32.3 RDW-16.8* Plt Ct-552*
[**2162-8-30**] 01:55PM BLOOD WBC-10.8 RBC-2.80* Hgb-8.0* Hct-25.6*
MCV-92 MCH-28.7 MCHC-31.3 RDW-16.8* Plt Ct-608*
[**2162-8-29**] 05:00PM BLOOD WBC-10.8 RBC-2.85* Hgb-8.1* Hct-25.9*
MCV-91 MCH-28.3 MCHC-31.1 RDW-16.1* Plt Ct-540*
[**2162-8-28**] 05:59AM BLOOD WBC-12.5* RBC-2.80* Hgb-8.0* Hct-25.9*
MCV-92 MCH-28.5 MCHC-30.8* RDW-16.2* Plt Ct-479*
[**2162-8-27**] 05:59AM BLOOD WBC-11.6* RBC-2.80* Hgb-8.1* Hct-26.1*
MCV-93 MCH-28.8 MCHC-30.8* RDW-15.9* Plt Ct-479*
[**2162-8-26**] 05:54AM BLOOD WBC-9.0 RBC-3.04* Hgb-8.7* Hct-27.8*
MCV-92 MCH-28.7 MCHC-31.3 RDW-16.5* Plt Ct-584*
[**2162-8-23**] 05:23PM BLOOD WBC-9.2 RBC-2.76* Hgb-7.9* Hct-25.5*
MCV-92 MCH-28.8 MCHC-31.2 RDW-15.9* Plt Ct-576*
[**2162-8-23**] 03:24AM BLOOD WBC-10.9 RBC-2.54* Hgb-7.3* Hct-23.1*
MCV-91 MCH-28.8 MCHC-31.8 RDW-16.8* Plt Ct-587*
[**2162-8-21**] 08:57AM BLOOD WBC-13.2* RBC-3.07* Hgb-8.8* Hct-30.1*
MCV-98 MCH-28.7 MCHC-29.2* RDW-16.2* Plt Ct-707*
[**2162-8-19**] 05:43AM BLOOD WBC-15.4* RBC-2.98* Hgb-8.5* Hct-27.0*
MCV-91 MCH-28.7 MCHC-31.6 RDW-16.7* Plt Ct-735*
[**2162-8-18**] 06:00AM BLOOD WBC-15.2* RBC-3.17*# Hgb-9.3*# Hct-29.0*
MCV-91 MCH-29.4 MCHC-32.2 RDW-16.4* Plt Ct-768*
[**2162-8-17**] 06:06PM BLOOD Hct-25.7*
[**2162-8-17**] 06:02AM BLOOD WBC-15.7* RBC-2.49* Hgb-7.1* Hct-22.6*
MCV-91 MCH-28.3 MCHC-31.2 RDW-16.4* Plt Ct-770*
[**2162-8-16**] 06:50AM BLOOD WBC-16.9* RBC-2.77* Hgb-7.9* Hct-24.6*
MCV-89 MCH-28.7 MCHC-32.4 RDW-16.4* Plt Ct-756*
[**2162-8-16**] 05:04AM BLOOD WBC-15.6* RBC-2.57*# Hgb-7.3*# Hct-23.3*
MCV-91 MCH-28.5 MCHC-31.5 RDW-16.5* Plt Ct-765*
[**2162-8-15**] 06:20AM BLOOD WBC-14.5* Hct-23.7*# Plt Ct-665*
[**2162-8-15**] 05:15AM BLOOD WBC-19.5*# RBC-1.41*# Hgb-3.9*#
Hct-12.8*# MCV-91 MCH-28.0 MCHC-30.9* RDW-16.3* Plt Ct-945*
[**2162-8-14**] 12:55PM BLOOD WBC-12.4* RBC-3.08* Hgb-8.6* Hct-28.3*
MCV-92 MCH-27.8 MCHC-30.3* RDW-15.7* Plt Ct-630*
[**2162-8-18**] 10:11AM BLOOD PT-15.0* PTT-30.2 INR(PT)-1.3*
[**2162-8-16**] 06:50AM BLOOD PT-14.4* PTT-32.4 INR(PT)-1.3*
[**2162-8-16**] 05:04AM BLOOD PT-15.6* PTT-38.1* INR(PT)-1.4*
[**2162-8-3**] 08:58PM BLOOD PT-16.9* PTT-38.1* INR(PT)-1.5*
[**2162-7-30**] 07:00AM BLOOD PT-13.0 PTT-28.6 INR(PT)-1.1
[**2162-7-29**] 06:06AM BLOOD PT-13.7* PTT-33.1 INR(PT)-1.2*
[**2162-9-17**] 07:15AM BLOOD Glucose-91 UreaN-22* Creat-0.6 Na-137
K-4.8 Cl-103 HCO3-26 AnGap-13
[**2162-9-17**] 05:36AM BLOOD Glucose-1112* UreaN-21* Creat-0.7 Na-133
K-GREATER TH Cl-108 HCO3-20*
[**2162-9-15**] 04:59AM BLOOD Glucose-97 UreaN-22* Creat-0.6 Na-138
K-4.3 Cl-109* HCO3-20* AnGap-13
[**2162-9-14**] 03:48AM BLOOD Glucose-94 UreaN-21* Creat-0.7 Na-135
K-4.4 Cl-108 HCO3-21* AnGap-10
[**2162-9-9**] 04:54AM BLOOD Glucose-105* UreaN-23* Creat-0.5 Na-134
K-4.6 Cl-100 HCO3-29 AnGap-10
[**2162-9-8**] 05:33AM BLOOD Glucose-88 UreaN-22* Creat-0.5 Na-135
K-4.9 Cl-101 HCO3-27 AnGap-12
[**2162-9-7**] 05:56AM BLOOD Glucose-91 UreaN-24* Creat-0.5 Na-133
K-5.7* Cl-101 HCO3-27 AnGap-11
[**2162-9-4**] 05:42AM BLOOD Glucose-104* UreaN-29* Creat-0.4* Na-134
K-4.6 Cl-103 HCO3-24 AnGap-12
[**2162-9-3**] 05:31AM BLOOD Glucose-87 UreaN-29* Creat-0.5 Na-133
K-4.8 Cl-103 HCO3-23 AnGap-12
[**2162-9-2**] 05:20AM BLOOD Glucose-97 UreaN-32* Creat-0.5 Na-135
K-4.7 Cl-106 HCO3-23 AnGap-11
[**2162-9-1**] 05:01AM BLOOD Glucose-98 UreaN-30* Creat-0.4* Na-137
K-4.4 Cl-108 HCO3-21* AnGap-12
[**2162-8-31**] 05:24AM BLOOD Glucose-99 UreaN-29* Creat-0.5 Na-133
K-4.7 Cl-106 HCO3-21* AnGap-11
[**2162-8-30**] 01:55PM BLOOD Glucose-94 UreaN-26* Creat-0.4* Na-135
K-4.1 Cl-106 HCO3-22 AnGap-11
[**2162-8-29**] 05:00PM BLOOD Glucose-62* UreaN-26* Creat-0.5 Na-139
K-4.6 Cl-108 HCO3-21* AnGap-15
[**2162-8-28**] 07:34PM BLOOD Glucose-83 UreaN-23* Creat-0.5 Na-139
K-3.9 Cl-107 HCO3-23 AnGap-13
[**2162-8-28**] 05:59AM BLOOD Glucose-101* UreaN-26* Creat-0.5 Na-135
K-4.2 Cl-106 HCO3-23 AnGap-10
[**2162-8-27**] 05:59AM BLOOD Glucose-96 UreaN-24* Creat-0.5 Na-135
K-3.4 Cl-107 HCO3-25 AnGap-6*
[**2162-8-26**] 05:54AM BLOOD Glucose-90 UreaN-21* Creat-0.5 Na-137
K-4.0 Cl-106 HCO3-27 AnGap-8
Brief Hospital Course:
Pt was admitted for colonic distention after being seen in the
ED on [**2162-7-9**] where a CT showed massive distention without any
physical obstruction. Patient followed by GI and colorectal
surgery team while on the floor and while in ICU. CT scan on [**7-12**]
showed persistent massively dilated loops of bowel consistent
with [**Last Name (un) 3696**] syndrome. He was passing gas. Decompression
attempted with rectal tube but was unsuccessful. He was
continued on erythromycin, Reglan and magnesium and potassium
were repleted aggressively due to low electrolytes.
Decompression attempted initially on the regular floor and was
unsuccessful. Given history of atrial ectopy and GIB he was
placed in ICU for close monitoring for sedation and colonoscopy
to place a decompression tube. Patient has worsening abdominal
pain, and imaging via KUB revealed ongoing extensive dilation of
multiple large bowel loops. Underwent [**2162-7-17**] colonic
decompression w/o stent/chest tube placement-5L watery stool
evacuated successfully and patient had marked improvement in
abdominal distention and pain.But his symptoms returned and he
underwent another decompression on [**2162-7-25**]. His symptoms
improved temporarily but returned. Due to persistent symptoms,
surgical options were discussed and he elected for sub-total
colectomy. He underwent a sub-total colectomy on [**2162-7-30**]. His
post operative course was complicated by Atrial fibrillation
(chronic condition) with RVR. This did not improve with multiple
IV Lopressor pushes, and his mental status began to deteriorate.
This was concerning for an anastomotic [**Last Name (LF) 3564**], [**First Name3 (LF) **] he was urgently
taken back to the OR on [**2162-8-3**]. Intraoperatively the [**Date Range 3564**] was
confirmed and repaired, he was also given a diverting loop
ileostomy. The patient improved with this, his mental status
improved, and he was cooperating with nurses and PT, including
getting out of bed. But, after a week of improvement his overall
status began to deteriorate again. He once again had AFIB with
RVR, his white count jumped, and he was occasionally running low
grade temperatures. We got a CT scan of abdomen pelvis on [**2162-8-15**]
that showed significant abscesses in the perihepatic and pelvic
regions. These were addressed by IR guided drainage on [**2162-8-16**],
wherein a drain was placed in the pelvic abscess. On [**2162-8-18**] he
had another ultrasound of his abdomen, where it was seen that
the pelvic and perihepatic abscesses were improving with the
drain. Additionally, the drain fluid grew vancomycin resistant
enterococcus, so he was started on linezolid, ciprofloxacin, and
metronidazole.
Neuro/Pain: The patient received IV Dilaudid with good effect
and adequate pain control. When tolerating oral intake, the
patient was transitioned to oral Dilaudid 1 tab Q 4hrs with good
pain control. His mental status fluctuated. Geriatrics saw him
and determined it was a combination of delirium and personality
disorder.
CV: The patient has chronic afib. During his hospital course he
was watched closely on telemetry. He kept going into Afib with
RVR when he was on his home dose of Dilitiazem. This required IV
Lopressor pushes on multiple occasions. Therefore, he was
started on PO metoprolol as well. So he was successfully rate
controlled on diltiazam 60 TID and metoprolol 25 [**Hospital1 **]. After his
unit stay, his heart rate was controlled with diltiazem and
Lopressor by mouth.
Pulmonary: The patient's Ins and Outs were monitored closely,
and on occasion he did was tachypneic, once requiring a trigger.
It was thought his breathing difficulty was a result of fluid
overload, so he was given Lasix and had good urinary response.
On [**8-21**] he was found to have altered mental status and
hypercarbia requiring transfer to ICU and intubated. It was
determined that he was fluid overloaded requiring multiple doses
of Lasix and acetazolamide with good diuresis and he was able to
be extubated [**8-23**]. His [**Hospital Unit Name 153**] [**Last Name (un) **] was as followed: [**Hospital Unit Name 153**] Course:
Respiratory Failure: Intubated for hypercapnic respiratory
failure due to cryptogenic decrease in respiratory drive.
Ventilator settings were titrated to serial ABGs; became
hypercapnic with low MV after initial trial to CPAP prompting
him to be restarted on AC but was subsequently able to be weaned
to CPAP and extubated [**2162-8-23**]. Altered mental status: Presumed
to be due to hypercapnic respiratory failure; CT-Head showed no
acute intracranial processes.
HA-PNA: Treated broadly with cefepime, day 1 = [**2162-8-21**],
daptomycin, and metronidazole. ID following and may consider
discontinuing metronidazole.
Abdominal infection: Managed per general surgery
recommendations, including daptomycin 730 q24h, day 1 = [**8-22**],
switched per ID from Linezolid, day 1 = [**8-21**].
Atrial Flutter: Rate controlled on diltiazem, titrated up to
90mg QID.The patient returned to the floor and diuresis was
continued. The patient was ultimately approximately 20 liters
negative and his respiratory and mental status was much
improved.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection. His white count spiked
and CT revealed multiple abdominal fluid collections which were
drained- cultures were positive for VRE. He was started on
linezolid/cipro/Flagyl which was changed to
cefepime/daptomycin/Flagyl per ID recommendations. He will
continue on this antibiotic regimen for 35 days per ID
recommendations and team discussion and does not need a
follow-up CT of the abdomen at the time of discharge. Antibiotic
therapy will continue to [**2162-9-25**].
Endocrine: The patient's blood sugar was monitored throughout
his stay while on TPN; insulin dosing was adjusted accordingly.
Hematology: The patient's complete blood count was examined
routinely; no transfusions were required. The patient's
hematocrit was in the high 40's on admission and 24-27 at
discharge which was stable for over 1 month and was
asymptomatic.
Prophylaxis:Coumadin remained on hold in the setting of recent
GI bleed. He was anticoagulated, in light of his PE, with
therapeutic dose of Lovenox, which was 80 units twice daily.
Venodyne boots were used during this stay; was encouraged to get
up and ambulate as early as possible.
Concern for prostate cancer- A prostate biopsy was taken with
sub total colectomy on [**7-30**] which which described no malignancy.
The patient was followed by hematology/oncology.
Coping: Throughout this patients prolonged hospitalization, the
patient required increased emotional support and was followed
closely by case management and social work. Because of insurance
issues, the patient applied for Mass Health, however was
reluctant to supply the appropriate information to do so. The
patient was very hesitant to participate in physical therapy and
increase his PO intake however over time, as his condition began
to improve his participation increased. The surgical, nursing,
case Managen, and social work staff worked very hard to
accommodate the needs of the patient. The patient was provided
care from the wound/ostomy nursing team during his stay for the
ostomy and wound care.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient has been stable for
multiple weeks awaiting discharge to a rehabilitation hospital.
The patient was tolerating a regular diet, was out of bed,
voiding with a condom catheter, and the patient was having
minimal pain. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
<I>Medications on admission:</I> (from OSH records, needs
confirmation from NH)
Ferrous sulfate
Metaclopromide
Casodex
Sucralfate
MVI
KCL
Ensure
Protonix
Colace
Diltiazem
Senna
Erythromycin
Octreotide
Doxazosin
Furosdemide
Spironolactone
Neurontin
Vitamin C
Zinc
Tylenol
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
4. Diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
5. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) syringe
Subcutaneous Q12H (every 12 hours).
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
7. Loperamide 2 mg Capsule Sig: One (1) Capsule PO every twelve
(12) hours.
8. Psyllium 1.7 g Wafer Sig: One (1) Wafer PO TID (3 times a
day): with meals.
9. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for groin rash.
10. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
11. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) for 4 days: Therapy should end [**2162-9-25**].
12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
13. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed for puritis.
14. White Petrolatum-Mineral Oil Cream Sig: One (1) Appl
Topical [**Hospital1 **] (2 times a day).
15. Dronabinol 2.5 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
16. 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.
17. Daptomycin 730 mg IV Q24H
18. Cefepime 2 gram Recon Soln Sig: One (1) Recon Soln Injection
Q12H (every 12 hours) for 4 days: Therapy should finish [**2162-9-25**].
19. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
PICC, heparin dependent: Flush with 10 mL Normal Saline daily
and PRN per lumen.
20. Antibiotic Therapy
[**Last Name (un) 28487**]/Daptomycin/Cefepime should all be stopped [**2162-9-25**]. The
patient has completed antibiotic therapy at this time for 35
days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2222**] - [**Location (un) 538**]
Discharge Diagnosis:
Colonic pseudoobstruction
Atrial flutter
Leg ulcer
Pulmonary emboli
Hypokalemia
Hypomagnesemia
Upper GI bleed
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted with severe pseudoobstruction of your colon.
This had been persistent for several months. You did not
improve with methylnaltrexone and tube decompression and
ultimately underwent a sub-total colectomy which was complicated
by an anastamotic [**Location (un) 3564**]. You then underwent a repair of your
anastamotic [**Location (un) 3564**] and placement of ileostomy.
Your post-operative course was long and fairly complicated. You
developed intra-abdominal abscesses which were drained and
treated with antibiotics. You are still on antibiotics for
those abscesses. You also had an episode of respiratory failure
for which you were transferred to the ICU and intubated. It was
ultimately thought to be due to volume overload and you recieved
subsequent diuresis throughout your ICU stay and for the
following three weeks. Once you received diuresis your mental
status improved and you showed interest in working with physical
therapy.
The surgical incision is well healed. The surgical staples have
been removed. You may shower, do not take a bath or swim for 6
weeks after surgery. Please cooperate with the nursing staff at
the rehabilitation hospital to care for the pressure ulcers you
have developed.
Your nutritional status was poor prior to surgery and so you
were started on TPN to improve your nutritional status. After
surgery, we continued to follow your food intake and to
supplement your nutritional requirements with TPN. You have done
such a great job incresing your nutriritonal intake by mouth
that the TPN has been stopped. You should continue to take in a
a well balanced diet and drink ensure supplements with meals.
Please eat small frequent meals and keep yourself well hydrated.
You should monitor your bowel function. The ileostomy will
produce loose stool becuase it is the small intestine however
the amount of stool produced should be between 500-1200cc daily.
If it is less than 500cc or more than 1200cc please call the
office for assistance. If it is greater than 1200cc in one day
there is a risk that you could become dehydrated. You are
currently taking immodium to help reduce the stool output and
you may continue this therapy at rehab. Eat small frequent
meals, continue your boost suppplementation, and stay well
hydrated. Please continue the bowel regimen of immodium and
metamucil wafers. As your output decreases the staff at the
rehabilitaion facility can titrate your bowel regimen as needed.
They may call Dr. [**Last Name (STitle) **] or Dr. [**Last Name (STitle) 1120**] as neede.
You will be discharged to a rehabilitation facility to
participate in physical therapy and other activited to increase
your physical stamina. Please cooperate with the physical
therapists at this facility, it is curcial to continue to
improve to get yourself discharged home. You will continue you
antibiotic therapy for 4 more days to complete 5 weeks of
therapy.
Followup Instructions:
1. Please make an appoitment to see Dr. [**Last Name (STitle) **] in 2 weeks. Call
[**Telephone/Fax (1) 160**] to make this appointment.
Completed by:[**2162-9-21**]
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7139, 15158
|
25465, 25602
|
5542, 6015
|
6031, 6224
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,754
| 104,280
|
37550
|
Discharge summary
|
report
|
Admission Date: [**2186-12-1**] Discharge Date: [**2186-12-8**]
Date of Birth: [**2139-6-23**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
Hypertension
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mr. [**Known lastname **] is a 47 year old gentleman from [**State 531**] that
traveled via bus to [**Location (un) 86**] for evaluation at the [**Hospital **] clinic.
He was seen today, and given his elevated blood pressures (200
systolic) and blood sugar of 375, he was transferred to the ED
for further evaluation.
In the ED, initial vs were: 98.4 [**Telephone/Fax (2) 84313**] 100% on RA. Head
and Ab/Pelvis CT obtained. Patient was given Labetalol 80mg
total IV and gtt started; 8 units Reg Insulin, 20 units Levemir;
30 units glargine; Reglan, Comapzine, Benadryl and Zofran as
well as 2 units of NS. Neuro & [**Last Name (un) **] were consulted with
recommendations implemented (sliding scale and MRI when stable).
Vitals on transfer: 222/118 97 20 99%
On arrival to the MICU, the patient is somewhat somnolent from
anti-nausea medications, but is arousable and appropriate. He
confirms the story above, and complains only of mild nausea at
this time. He denies any chest pain, headache or vision
changes.
We discussed the issue of pork products and he is amenable to
porcine heparin.
Past Medical History:
Type II DM - for over 10 years
Chronic Kidney disease (baseline Cr 3)
Peripheral Neuropathy
HTN
Episodes of vomiting precipitated by hyperglycemia
Social History:
Lives in [**Location 7349**] with his wife, works with developmentally delayed
adults. Denies ETOH/tobacco/drugs. No children. Keeps strictly
Kosher.
Family History:
Sister with Type 2 DM
Physical Exam:
Vitals: T: 98.8 BP: 198/110 P: 102 R: 21 O2: 95%
General: Somnolent but arousable, Alert, oriented, no acute
distress
HEENT: Sclera anicteric, MMM, oropharynx clear, Dilated
fundoscopic exam without active retinal hemorrhaging
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Fast S1 & S2 without murmur
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, Ankle/pedal edema
Neuro: AAOx3, CN IV-XII intact, dilated pupils make II/III
evaluation difficult.
Pertinent Results:
ADMISSION LABS [**2186-12-1**]:
BLOOD
[**2186-12-1**] 10:00AM WBC-7.6 Hgb-11.5* Hct-33.9*
[**2186-12-1**] 10:00AM Neuts-75.5* Lymphs-16.5* Monos-4.4 Eos-2.8
Baso-0.6
[**2186-12-1**] 10:00AM Glucose-363* UreaN-46* Creat-3.3* Na-138 K-5.6*
Cl-105 HCO3-24 AnGap-15
[**2186-12-1**] 10:00AM ALT-14 AST-11 CK(CPK)-175* AlkPhos-96
TotBili-0.4
[**2186-12-1**] 10:00AM CK-MB-6 cTropnT-0.10*
[**2186-12-1**] 10:00AM ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
URINE
[**2186-12-1**] 10:10AM Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.015
[**2186-12-1**] 10:10AM Blood-MOD Nitrite-NEG Protein->300 Glucose-500
Ketone-15 Bilirub-NEG Urobiln-0.2 pH-6.0 Leuks-NEG
[**2186-12-1**] 10:10AM RBC-0-2 WBC-0-2 Bacteri-OCC Yeast-NONE Epi-0
PERTINENT LABS:
CE TREND:
[**2186-12-1**] 10:00AM CK(CPK)-175*
[**2186-12-2**] 04:07AM CK(CPK)-116
[**2186-12-1**] 10:00AM CK-MB-6 cTropnT-0.10*
[**2186-12-1**] 06:30PM CK-MB-6 cTropnT-0.07*
[**2186-12-2**] 04:07AM CK-MB-4 cTropnT-0.06*
HCT TREND:
[**2186-12-1**] 10:00AM Hct-33.9*
[**2186-12-2**] 04:07AM Hct-30.2*
[**2186-12-3**] 09:40AM Hct-31.9*
[**2186-12-4**] 06:50AM Hct-32.9*
[**2186-12-5**] 06:54AM Hct-30.3*
[**2186-12-6**] 06:20AM Hct-29.0*
[**2186-12-7**] 06:50AM Hct-33.2*
[**2186-12-8**] 07:12AM Hct-29.0*
ANEMIA WORKUP:
[**2186-12-2**] 04:07AM Ret Aut-1.3
[**2186-12-1**] 10:43PM Iron-38*
[**2186-12-1**] 10:43PM calTIBC-256* VitB12-475 Folate-10.0 Ferritn-138
TRF-197*
BUN/Cr TREND:
[**2186-12-1**] 10:00AM UreaN-46* Creat-3.3*
[**2186-12-1**] 10:43PM UreaN-47* Creat-3.3*
[**2186-12-2**] 04:07AM UreaN-47* Creat-3.3*
[**2186-12-2**] 03:18PM Creat-3.6*
[**2186-12-3**] 09:40AM UreaN-47* Creat-3.4*
[**2186-12-4**] 06:50AM UreaN-40* Creat-3.3*
[**2186-12-5**] 06:54AM UreaN-38* Creat-3.0*
[**2186-12-6**] 06:20AM UreaN-37* Creat-2.9*
[**2186-12-7**] 06:50AM UreaN-40* Creat-2.9*
[**2186-12-8**] 07:12AM UreaN-47* Creat-3.0*
MICROBIOLOGY:
[**2186-12-1**] MRSA screen: negative
[**2186-12-1**] UCx: negative
[**2186-12-3**] BCx: negative
STUDIES:
[**2186-12-1**] EKG: NSR @ 101
[**2186-12-1**] CXR: No acute cardiopulmonary abnormality
[**2186-12-1**] CT head: No acute intracranial process
[**2186-12-1**] CT abd/pelvis: No acute intra-abdominal process
[**2186-12-4**] Gastric emptying study: Normal gastric emptying study
DISCHARGE LABS [**2186-12-8**]:
[**2186-12-8**] 07:12AM WBC-7.0 Hgb-10.0* Hct-29.0* Plt Ct-133*
[**2186-12-8**] 07:12AM Glucose-285* UreaN-47* Creat-3.0* Na-136 K-4.7
Cl-102 HCO3-25 AnGap-14
Brief Hospital Course:
A 47 year old gentleman that travelled here from [**Location (un) 7349**] for [**Last Name (un) **]
evaluation transferred to the MICU for hypertensive
urgency/emergency.
#. Hypertensive Urgency: The patient was admitted with
hypertensive urgency to the 200s without clear signs of end
organ damage other than proteinuria, but his meds and old labs
suggest chronic renal disease. Given his home regimen and
history of poor compliance this does not likely represent a
great departure from baseline. Neuro evaluation was normal.
Troponins were elevated but this likely represents demand
ischemia and poor renal clearance. In the ICU he was continued
on a labetalol drip until his blood pressures dropped to the
120s systolic. The labetalol drip was stopped at that time and
he was started on carvedilol 25 mg [**Hospital1 **]. On the floor, BP
remained difficult to control, with elevations >200/100. The
patient was continued on Carvedilol 25mg PO BID, restarted on
Clonidine, increased dose of Aliskiren 300mg, Lasix 40mg qAM and
20mg qPM, and additional Nifedipine 60mg PO daily. BP was well
controlled on discharge.
#. Uncontrolled Type 2 DM: Poor history, reason for his trip to
[**Location (un) 86**]. [**Last Name (un) **] is already consulted and is following. He was
started on a regimen of lantus [**Hospital1 **] with a humalog sliding scale.
He had episodes of hypo and hyperglycemia while in house. He was
discharged on Lantus 40 units qhs with Humalog sliding scale
with FS under better control. The patient will continue to
follow with [**Last Name (un) **] as an outpatient.
#. Nausea/Vomiting: Per patient history, related to
hyperglycemia. The patient had an episode of dysconjugate gaze
in the [**Last Name (LF) **], [**First Name3 (LF) **] Compazine and Reglan were held. N/V was controlled
with Zofran and Ativan. Gastric emptying study was normal. The
patient was tolerating POs with no further nausea after the 3rd
hospital day.
#. Chronic renal insufficiency: The patient has baseline
elevated creatinine. Lasix was held initially, but restarted
with no increase in creatinine. The patient follows with a
nephrologist as an outpatient.
#. Elevated Troponin: The patient was admitted with elevated
trop, likely tachycardia induced strain with poor renal
clearance. CEs trended down overnight. No evidence of ischemic
event.
#. Anemia: No past records, no signs of active bleeding. Likely
related to chronic renal disease. HCT was stable during
hospitalization.
#. GERD: Pt was continued on home H2 blocker.
#. Hyperlipidemia: Continued on home statin.
Medications on Admission:
Lipitor 10mg daily
Donnatol 1 tab TID prn nausea/vomiting
Furosemide 20mg [**Hospital1 **]
Vitamin D 50,000 units once weekly
Famotidine 20 mg [**Hospital1 **]
Clonidine 0.3mg [**Hospital1 **]
Aliskiren 150mg Daily
Carvedilol 12.5 mg [**Hospital1 **]
Calcitriol 0.25mcg MWF
70/30 30 units with breakfast and dinner
Levamir 30 units QHS
Humalog sliding scale - 250 -> 4 units, 350 -> 6 units
Not taking aspirin as prescribed
Discharge Medications:
1. Lipitor 10 mg Tablet Sig: One (1) Tablet PO once a day.
2. Furosemide 40 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Clonidine 0.1 mg Tablet Sig: Three (3) Tablet PO BID (2 times
a day).
6. Aliskiren 150 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
8. Insulin Glargine 100 unit/mL Cartridge Sig: Forty (40) units
Subcutaneous at bedtime.
9. Humalog 100 unit/mL Cartridge Sig: sliding scale
Subcutaneous four times a day: please see attached sliding
scale.
10. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
11. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a
week.
12. Donnatal 16.2 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for nausea.
13. Nifedipine 60 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO DAILY (Daily).
Disp:*30 Tablet Sustained Release(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
- Hypertension
- Diabetes Mellitus
Discharge Condition:
Stable, improved, tolerating oral diet, ambulating at baseline.
Discharge Instructions:
You were admitted to the hospital with elevated blood pressures
and high blood sugars. You also had severe nausea and vomiting
on admission. You were given several medications for your nausea
in the emergency department, including Reglan and Compazine. You
then developed disconjugate gaze, which the Neurologists believe
were due to those nausea medications. You had a CT scan of your
head and your abdomen that were unremarkable.
Your blood pressure was brought under control in the intensive
care unit with a Labetalol drip. You were then restarted on your
home medications, which were adjusted to control your blood
pressure. You were also started on Nifedipine CR to help control
your blood pressure.
You continued to have nausea while you were hospitalized. This
was brought under control with Zofran and Ativan. You had a
gastric emptying study to rule out gastroparesis. The study was
normal.
You were evaluated by [**Last Name (un) **] Diabetes doctors to [**Name5 (PTitle) **] [**Name5 (PTitle) **]
control of your blood sugars.
The following changes have been made to your medications:
1. Increase Carvedilol 12.5mg by mouth twice daily to 25mg by
mouth twice daily
2. Increase Aliskiren from 150mg daily to 300mg daily
3. Follow the attached sliding scale, recommended by the [**Last Name (un) **]
doctors. Stop your previous insulin regimen.
4. Take Nifedipine CR 60mg by mouth daily
5. Increase Lasix to 40mg in the morning and continue taking
20mg in the evening
If you experience worsening nausea, vomiting, headache, changes
in vision, sweating, trembling, shortness of breath, chest pain,
or any other concerning symptoms, please call your primary care
doctor or return to the emergency department.
Followup Instructions:
Please follow up with your primary care doctor early next week
to have your blood pressure and your sugars checked. You should
have your blood drawn at this time to monitor your electrolytes
and creatinine. You have an appointment with Dr. [**Last Name (STitle) **] next
Tuesday morning, [**2186-12-12**], at 11:30 AM.
|
[
"276.7",
"403.90",
"250.82",
"250.42",
"276.52",
"V15.81",
"599.72",
"356.9",
"272.4",
"585.3",
"427.89",
"285.9",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9209, 9215
|
5029, 7616
|
328, 336
|
9313, 9379
|
2511, 3265
|
11150, 11473
|
1819, 1842
|
8091, 9186
|
9236, 9292
|
7642, 8068
|
9403, 11127
|
1857, 2492
|
276, 290
|
364, 1464
|
4647, 5006
|
3282, 4638
|
1486, 1635
|
1651, 1803
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,410
| 184,872
|
25408
|
Discharge summary
|
report
|
Admission Date: [**2148-5-30**] Discharge Date: [**2148-6-7**]
Date of Birth: [**2071-4-24**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 473**]
Chief Complaint:
Obstructive jaundice
Major Surgical or Invasive Procedure:
Cholecystectomy
Open Head of Pancreatic Biopsy
Hepatico-jejunostomy
History of Present Illness:
Mr. [**Known lastname 63521**] is a 77 year old, delightful gentleman who has
widespread recurrent renal cell cancer that is metastatic to
multiple locations including the flank, the pancreas and
probably the bone. He recently had the evolution
of obstructive jaundice, only to an obstructive likely tumor
metastasis in the head of his pancreas. He had an endoscopic
biliary stent placed, but developed stent failure and
cholangitis. He now presents for definitive biliary bypass
and confirmation of histopathology at the root of this
obstruction.
Past Medical History:
PMH: Pancreatic head mass, obstructive jaundice, RCC, CAD,
^chol, HTN
PSH: R nephrectomy [**2127**], CABG [**2146**]
Social History:
He stopped smoking
over 40 years ago and he does not drink alcohol.
Family History:
His mother had a gallbladder operation but
otherwise he has no pertinent family history
Physical Exam:
HR 65, BP 128/66
Gen: looks strong, fit, healthy, and well for his age. He is
very intelligent, alert, and interactive during the examination.
and physical and history. He wears bilateral hearing aids but
otherwise his head and neck exam is normal. He
has no scleral icterus.
CV: RRR, no murmurs. Sternal wound well healed.
Pulm: CTA bilat.
Abd: soft, nontender, nondistended.
Pertinent Results:
[**2148-6-5**] 05:17AM BLOOD WBC-9.8 RBC-2.69* Hgb-8.7* Hct-26.0*
MCV-97 MCH-32.4* MCHC-33.5 RDW-14.5 Plt Ct-196
[**2148-6-5**] 06:00PM BLOOD Hct-29.0*
[**2148-5-31**] 08:10AM BLOOD WBC-16.8*# RBC-3.07* Hgb-10.2* Hct-30.2*
MCV-99* MCH-33.1* MCHC-33.6 RDW-15.8* Plt Ct-177
[**2148-6-5**] 03:55AM BLOOD Glucose-142* UreaN-11 Creat-0.9 Na-137
K-3.8 Cl-104 HCO3-24 AnGap-13
[**2148-6-5**] 03:55AM BLOOD ALT-38 AST-52* AlkPhos-87 Amylase-58
TotBili-0.6
[**2148-5-31**] 08:10AM BLOOD Lipase-290*
[**2148-6-5**] 03:55AM BLOOD Lipase-105*
[**2148-5-31**] 08:10AM BLOOD ALT-26 AST-38 AlkPhos-107 Amylase-337*
TotBili-0.8
[**2148-6-5**] 03:55AM BLOOD Calcium-7.8* Phos-2.8 Mg-1.9
.
CT HEAD W/O CONTRAST [**2148-6-4**] 3:27 PM
IMPRESSION: No evidence of an intracranial hemorrhage or mass
effect.
.
CAROTID SERIES COMPLETE [**2148-6-5**] 2:58 PM
IMPRESSION: Less than 40% stenosis of the proximal internal
carotid arteries bilaterally.
.
Brief Hospital Course:
He was admitted on [**2148-5-30**] for a
hepaticojejunostomy/cholecystectomy for biliary obstruction.
His post-op course was complicated by three unresponsive
episodes, with stable VS, requiring transfer to the SICU on
[**6-4**]. Pt transferred back to floor on following day and
unresponsive episodes did not reoccur
GI/Abd: He was NPO, with IVF and a NGT. The NGT was removed on
POD 3. He was started back on a diet on POD 4 and this was
slowly advanced. He was tolerating a regular diet at time of
discharge. His incision was C/D/I. The staples were D/C'd prior
to discharge.
Pain: He had good pain control with an epidural - APS was
following along. His epidural remained in place until POD 5. He
was transitioned to PO meds.
Event [**6-4**]: pt found unresponsive, however his vitals were
stable--> stat CT head/CT torso.CT Head [**6-4**]: No evidence of an
intracranial hemorrhage or mass effect
CT Torso: 1.No pulmonary embolism. 2. Multiple pancreatic
masses unchanged.
3.Post-hepaticojejunostomy without fluid surrounding the
hepaticojejunostomy site.
CAROTID ULTRASOUND [**6-5**]: Less than 40% stenosis of the proximal
internal carotid arteries bilaterally.
Neuro consult obtained:
His exam was notable for anisocoria but reactive pupils and
asterixis. The asterixis indicates that there is likely a
metabolic abnormality which may be the etiology of these
episodes. Infectious causes have been ruled out by negative U/A
and chest CT. Seizure is very unlikely, given the closed eyes,
lack of eye/head deviation, absence of motor activity, and
absence of post-ictal state. The episodes are also too long in
duration to suggest seizure. However, if he continues to have
frequent episodes, it may be worthwhile to get an EEG to capture
a spell. Otherwise, EEG could be considered non-urgently.
Vascular issues are also very low probability, given that he is
lying in bed during the events, has a normal blood pressure, and
has no other abnormalities suggesting brainstem localization on
exam (other than anisocoria, but normal EOMs). Medications may
be a cause, especially the Lyrica or Neurontin. It would be
useful in the setting of these events to hold all sedating
medications (Neurontin and Lyrica), or at least to decrease the
dose.
[**6-5**]: Normal EEG in the waking and drowsy states. There were no
focal abnormalities or epileptiform features.
Neurontin and Lyrica discontinued based on recommendations per
neurology. Patient also felt that Neurontin and Lyrica were not
helping with his shingles and he preferred to discontinue these
medications. Pt did not have any issues after he stopped
Neurontin and Lyrica.
[**6-7**] POD#7: Pt doing well clinically tolerating a regular diet,
ambulating and pain well controlled. Incision C/D/I. Pt
discharged to home and is to follow up with Dr. [**Last Name (STitle) 468**] and
Neurology in [**3-2**] weeks.
Medications on Admission:
toprol, accupril, lyrica, neurontin
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
3. Quinapril 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
for 2 weeks.
Disp:*25 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Pancreatic Head Mass
Post-op Unresponsive episodes x 3
Discharge Condition:
Good
A+O x 3
Tolerating diet
Pain controlled
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomitting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomitting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
=
=
=
=
=
================================================================
Please resume all regular home medications and take any new meds
as ordered. Do not take your Neurontin or Lyrica. Discuss with
your PCP if there is a need to restart these meds. Discuss your
unresponsive episodes with your PCP before considering
restarting these medications.
.
Continue to ambulate several times per day.
.
It is OK to shower, no tub baths. [**Date Range **] incision dry and keep
clean and dry.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 468**] in [**3-2**] weeks. Call ([**Telephone/Fax (1) 27734**] to schedule an appointment.
Please follow-up with Neurology in [**3-2**] weeks. Call ([**Telephone/Fax (1) 8951**] to schedule an appointment.
Please follow-up with your PCP [**Last Name (NamePattern4) **] 2 weeks re: your medications.
Do not restart Neurontin or Lyrica without talking to your PCP.
Completed by:[**2148-6-7**]
|
[
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"198.5",
"576.2",
"V45.73",
"998.11",
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] |
icd9cm
|
[
[
[]
]
] |
[
"51.22",
"51.37",
"54.59",
"52.11"
] |
icd9pcs
|
[
[
[]
]
] |
6242, 6248
|
2681, 5568
|
333, 403
|
6347, 6394
|
1727, 2658
|
7847, 8288
|
1223, 1312
|
5654, 6219
|
6269, 6326
|
5594, 5631
|
6418, 7824
|
1327, 1708
|
273, 295
|
431, 981
|
1003, 1121
|
1137, 1207
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,420
| 162,635
|
22270
|
Discharge summary
|
report
|
Admission Date: [**2132-1-27**] Discharge Date: [**2132-2-2**]
Date of Birth: [**2065-1-28**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
cerebellar hemorrhage
Major Surgical or Invasive Procedure:
Suboccipital Craniotomy
History of Present Illness:
66yo M with h/o HTN presents with sudden onset dizziness
followed by vomiting and loss of consciousness found to have 3.8
x 2.6cm R cerebellar hemorrhage with mass effect on 4th vent
with small SDH and SAH on tentorium. Pt was sitting down for
morning prayers and developed acute dizziness at 10:30am. It did
not resolve and pt then developed nausea and vomiting. He tilted
to the floor and was did not comprehend or respond to verbal
commands. Taken to [**Hospital3 417**] Hospital. SBP's there were
170's. Labs at OSH notable for INR 1.1, PTT 30, Platelets of
128. Given etomidate, lidocaine, succinylcholine and intubated,
transferred to [**Hospital1 18**] on propofol for further care.
Past Medical History:
Three prior strokes- unclear symptoms per discussion with his
sons. Told one of them was "brainstem" ? residual R sided
weakness.
Hypertension
Hyperlipidemia
CAD- s/p cath at [**Hospital1 18**]
Social History:
SH: retired, lives with one of his sons, co-owns a [**Name (NI) 58048**] Donut
shop with his sons, never [**Name2 (NI) 1818**], no ETOH.
Family History:
FH: unavailable.
Physical Exam:
On admission:
PHYSICAL EXAM: on propofol
T 97.8, BP 153/93, HR 57, R 14 on CMV, 100% intubated FiO2 0.4
Gen- critically ill, off propofol x 10 minutes prior to exam.
HEENT: NCAT, MMM (intubated), anicteric sclera
Neck: no carotid bruits, no nuchal rigidity
CV- RRR, no MRG
Pulm- CTA B
Abd- soft, nd, BS+, no organomegaly
Extrem- no CCE
Neurologic Exam:
MS- briefly opens eyes to voice, localizes sternal rub with left
arm, follows command briefly such as "wiggle your toes, squeeze
my hands"
CN- PERRL 3-->2mm sluggish, intact but sluggish oculocephalics,
intact corneals bilaterally, face symmetric, intact gag.
Motor- withdraws each limb to noxious stim L > R.
Sensation- intact to noxious
Reflexes- 3+ [**Hospital1 **], tri, brachiorad, patellars, 2+ ankles
Plantar response extensor bilaterally
Upon Discharge: Awake, sl. lethargic, PERRL, opens eyes
Spontaneously, MAE spontaneously. Able to vebalize how he is
feeling otherwise not overly interactive.
Wound:Small amount of drainage on inferior portion however was
oversewn with sutures.
Pertinent Results:
[**2132-1-27**] 01:50PM BLOOD WBC-11.5* RBC-4.52* Hgb-13.9* Hct-38.6*
MCV-85 MCH-30.7 MCHC-35.9* RDW-13.8 Plt Ct-128*
[**2132-1-27**] 01:50PM BLOOD PT-13.4 PTT-28.0 INR(PT)-1.2*
[**2132-1-27**] 01:50PM BLOOD UreaN-10 Creat-0.9 Na-140 K-3.3 Cl-104
HCO3-24 AnGap-15
[**2132-2-1**] 06:20AM BLOOD WBC-8.3 RBC-4.14* Hgb-12.8* Hct-36.4*
MCV-88 MCH-30.9 MCHC-35.1* RDW-13.7 Plt Ct-179
[**2132-2-1**] 06:20AM BLOOD PT-12.8 INR(PT)-1.1
[**2132-2-1**] 06:20AM BLOOD Glucose-95 UreaN-15 Creat-0.9 Na-146*
K-3.0* Cl-107 HCO3-25 AnGap-17
[**2132-2-1**] 06:20AM BLOOD Calcium-8.7 Phos-2.8 Mg-2.2
[**1-27**] Head CT IMPRESSION:
1. Slight interval increase in size of posterior fossa
intraparenchymal
hemorrhage when compared to outside imaging in conjunction with
slightly
increased mass effect on the fourth ventricle and increased size
to the
lateral ventricle likely related to component of
non-communicating
hydrocephalus. The hemorrhage could be primary from
hypertension. However, differential diagnosis includes
underlying neoplasm.
2. Extensive periventricular white matter hypoattenuating
changes likely
related to chronic small vessel disease.
[**2-1**] Head CT IMPRESSION:
1. Status post suboccipital craniotomy with persistent
hemorrhage and
pneumocephalus in the right cerebellar resection bed. No new
intracranial
hemorrhage.
2. No significant change in ventriculomegaly, status post
ventriculostomy
catheter removal.
Brief Hospital Course:
Pt was taken to the OR on [**1-27**] for a suboccipital craniotomy. He
tolerated the procedure well and was admitted to the ICU. There
he was extubated and then transferred to the SDU on [**1-30**]. He
continued to improve and he began taking PO's and tolerating
well. On [**1-30**] he had scant amount of drainage out of inferior
aspect of wound and was started on ancef which he will continue
for another 7 days. He was afebrile and dropping WBC. His blood
pressure was also an issue trending into the 170-180's, his BP
meds were increased and SBP trended down to 150's. His
lisinopril may be titrated further as needed. PRN Hydralazine
also effective. He was seen by PT and accepted to rehab.
Medications on Admission:
Aspirin 325mg daily
Antihypertensives (sons unsure of dosages)
Discharge Medications:
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
R cerebellar hemorrhage
Discharge Condition:
Neurologically stable
Discharge Instructions:
Followup Instructions:
|
[
"V45.82",
"414.01",
"348.4",
"401.9",
"431",
"331.4",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"01.39",
"02.2"
] |
icd9pcs
|
[
[
[]
]
] |
4859, 4931
|
4025, 4722
|
338, 364
|
4999, 5023
|
2580, 4002
|
5073, 5073
|
1473, 1492
|
4836, 4836
|
4952, 4978
|
4748, 4812
|
5048, 5048
|
1536, 1844
|
277, 300
|
2329, 2561
|
392, 1084
|
1521, 1521
|
1861, 2313
|
1106, 1302
|
1318, 1457
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,546
| 176,128
|
49854
|
Discharge summary
|
report
|
Admission Date: [**2107-5-2**] Discharge Date: [**2107-5-27**]
Date of Birth: [**2037-10-1**] Sex: F
Service: NEUROLOGY
Allergies:
Depakote / Iodine; Iodine Containing / Erythromycin Base /
Tegretol / Demerol / Morphine
Attending:[**First Name3 (LF) 11291**]
Chief Complaint:
Increased seizure frequency to [**5-2**] sz/day with increased
coughing episodes
Major Surgical or Invasive Procedure:
Right temporal lobe cyst fenestration to the
posterior fossa and placement of Rickham reservoir with
catheter in the cyst cavity
History of Present Illness:
The pt is a 69yo F, who has PMH of seizure, who presented with
the CC of cough and increasing frequency of seizure.
She was in her USOH until [**2105-12-26**] when she cought a cold, which
progressed to bronchitis. Her cold got better in a week, leaving
the cough with yellow sputum. She lost her voice for a month,
and was diagnosed with fungal infection of esophagus and vocal
cord. Her cough once got better (though it did not disappear)
in
summer [**2106**], with the anti-fungus medication, which she took
from
[**2106-8-27**] to [**2107-3-27**]. Her cough exacerbated in [**2107-2-27**]. Lying back
makes this dry cough worse and does wake her up at night. It
gets
worse from morning towards afternoon, but it is basically
consistant for all the day. It is alleviated by albuterol nebs,
but comes back after a while.
The pt also complained of the increasing frequency of seizure,
from once/year to 4-6times/day since last month. Her husband
described that it starts in Lt side getting stiff, and then the
Rt side gets stiff. It is resolved by Rameron in few minutes
but
repeats 4-6 times in 4 hours. Pt and her husband stated that
she
can hear but cannot respond, and that the is tired but not
confused after the seizures.
The cough and seizure are associated with 8/10 bitemporal
throbbing HA, which is alleviated by tylenol.
ROS found pain in leg and fall from her bed 2-3 weeks ago, which
made a bruise on her leg.
Denied weight change, fever, chills, sweats, night sweats, chest
pain, abd pain, diarrhea or change in urination.
Past Medical History:
1) Seizure d/o s/p R temporal lobectomy with multiple admissions
for sz
2) [**Doctor Last Name 1193**]-Chiari malformation s/p tonsillectomy [**2087**]
3) R temporal lobectomy
4) CAD with MI s/p PTCA [**2085**]
5) Asthma
6) Hemorrhoids
7) Fibromyalgia
8) Depression
) S/P cholecystectomy
) S/P TAH
Social History:
Pt lives with her husband and brother. She smoked 2ppd x 20yrs
and quit 18yrs ago. No etoh.
Family History:
Mother died of MI at 72. Father died of interstitial fibrosis
at 80.
Physical Exam:
Exam:
T 97.9 BP 119/64 HR 85 RR 18 O2Sat 97%(RA)
Gen: Lying in bed, NAD
HEENT: NC/AT, conjunctivae pink, sclerae non icteric, moist oral
mucosa
Neck: No tenderness to palpation, normal ROM, supple, no carotid
or vertebral bruit, thyroid mass(assymetric to Rt)
CV: RRR, nl. S1 and S2, no S3 or S4, no murmurs/gallops/rubs
Lung: B/l coarse crackles worse in Rt
aBd: +BS soft, nontender, distended, no bruit, no masses, no
organomegaly
ext: nl. turgor, pitting edema in both legs, no
cyanosis/clubbing, good peripheral pulses at radial and dorsalis
pedis
Neurologic examination:
MS:
General: alert, awake, normal affect, co-operative
Orientation: oriented to person, place, date
Attention: follows simple/complex commands.
Speech/[**Doctor Last Name **]: fluent, but has difficulty speaking with the cough
Memory: Registers [**3-29**] and Recalls [**3-29**] at 5 min
Calculations: 14+38=52
L/R confusion: Touches left thumb to right ear
CN:
I: not tested
II,III: VFF to confrontation, PERRL 4mm to 2mm, fundi normal
III,IV,VI: EOMI, no ptosis, end-gazed nystagmus on Rt
V: sensation intact V1-V3 to LT
VII: asymmetrical face, weak on Lt, orbicular oculi / ,
orbicularis oris /
VIII: hears finger rub bilaterally
IX,X: palate elevates symmetrically, uvula midline
[**Doctor First Name 81**]: SCM/trapezeii [**5-31**] bilaterally
XII: tongue protrudes midline, no dysarthria
Motor: Normal bulk and tone; resting tremor in Rt hand,
asterixis
or myoclonus. No pronator drift.
Delt [**Hospital1 **] Tri WE FE Grip IO IP Quad Hamst DF [**Last Name (un) 938**]
PF
C5 C6 C7 C6 C7 C8/T1 T1 L2 L3 L4-S1 L4 L5
S1/S2
L 5 5 5 5 5 5 5 5 5 5 5
5 5
R 5 5 5 5 5 5 5 5 5 5 5
5 5
Reflex: No clonus, no pathological reflexes(Babinski, [**Last Name (un) 9301**],
Hoffmans)
[**Hospital1 **] Tri Bra Pat An Plantar
C5 C7 C6 L4 S1 CST
L 1 1 1 0 0 Flexor
R 1 1 1 0 0 Flexor
Sensation: Intact to light touch, pinprick, vibration and
proprioception throughout. No extinction to DSS.
Coordination: finger-nose-finger normal, heel to shin normal,
RAMs normal.
Gait: Narrow based, steady.
Romberg: Negative
Pertinent Results:
[**2107-5-2**] 03:58PM URINE HOURS-RANDOM
[**2107-5-2**] 03:58PM URINE GR HOLD-HOLD
[**2107-5-2**] 03:40PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.006
[**2107-5-2**] 03:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2107-5-2**] 12:50PM GLUCOSE-90 UREA N-11 CREAT-1.2* SODIUM-136
POTASSIUM-4.3 CHLORIDE-104 TOTAL CO2-22 ANION GAP-14
[**2107-5-2**] 12:50PM estGFR-Using this
[**2107-5-2**] 12:50PM CALCIUM-9.1 PHOSPHATE-3.7 MAGNESIUM-2.3
[**2107-5-2**] 12:50PM WBC-6.4 RBC-4.08* HGB-13.7 HCT-39.6 MCV-97
MCH-33.6* MCHC-34.7 RDW-13.5
[**2107-5-2**] 12:50PM NEUTS-71.1* LYMPHS-18.5 MONOS-6.4 EOS-3.0
BASOS-1.0
[**2107-5-2**] 12:50PM PLT COUNT-270
Brief Hospital Course:
69 y/o RHF with R Temporal Epilepsy s/p R temporal lobectomy,
[**Doctor Last Name 1193**] Chiari s/p tonsillectomy who presented with increasing
cough. She was on EEEG-LTM. The coughs were associated with R
temporal spikes in EEG. She was also having seizures which
consisted of left side stiffening and shaking. Patient underwent
drainage of right temporal cystic area & placement of reservoir
in R temporal lobe on [**5-13**]. Seizures accociated with cough
decreased significantly. She continues to have seizures 1-2 per
day whose semiology can be partial complex with left sided jerks
or episodes in which she would "freeze". Patient was febrile for
5 days after surgery; CSF collected from shunt from reservoir
showed WBC 800 RBC 2800 with 82% eosinophils. Eosinophilia and
fever prompted a broad infectious work-up as per ID
recommendation. Patient was started empirically on vancomycin,
ceftazidine which were stopped on [**2107-5-26**] as patient was
afebrile and cultures were negative. Serologies for toxoplasma,
RPR, cryptococcal were negative. EBV PCR, TB PCR from CSF.
[**Location (un) **], cysticercosis, trichinella, LCMV antibodies are
pending.
In summary:
SEIZURES: Patient has a baseline [**5-1**] seizures per day. Semiology
can be cough, left side jerks or "freezing episodes". Coushing
seizures improved significantly after neurosurgical procedure as
above
**SEIZURES SHOULD BE TREATED WITH ATIVAN 1-2MG AT REHAB IF THEY
LAST LONGER THAN 5 MINUTES OR SHE HAS MORE THAN 2 SEIZURES
WITHIN ONE HOUR.
Continue AEM as per prescriptions including topamax , lamictal,
gabapentin.
ID: Patient has been afebrile for more than 72 hours; off
antibiotics since [**2107-5-26**]. She should have Serologies for
toxoplasma, RPR, cryptococcal were negative. EBV PCR, TB PCR
from CSF. [**Location (un) **], cysticercosis, trichinella, LCMV antibodies
are pending and should be followed-up in next appointment. The
fever etiology is mostly likely non-infectious but a reaction to
the neurosurgical procedure: placement of Rickham reservoir with
catheter in the cyst cavity.
Medications on Admission:
Fosamax 70mg 1tab weekly
Lamictal 200mg 3tab daily
Nevrontin 300mg 4tab daily
Lipitor 10mg 1tab daily
Remeron 30mg 1/2tab daily
Topamax 25mg 4tab daily
Lasix 20mg 1tab daily
Rasperadal 3mg 1/2tab daily
Dulcolax stool softener 100mg 4 daily
Slow Fe Iron 2 daily
Multi Vitamin 1 daily
Lorazepam 1mg 2tab daily
Albuterol nebs
Discharge Medications:
1. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QWED (every
Wednesday).
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Risperidone 0.5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
6. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
7. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as
needed for cough and comfort.
9. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed.
10. Lorazepam 2 mg/mL Syringe Sig: One (1) Injection Q5 MIN PRN
() as needed for seizures.
11. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
12. Lamotrigine 100 mg Tablet Sig: 3.5 Tablets PO BID (2 times a
day).
13. Polyethylene Glycol 3350 100 % Powder Sig: One (1) PO DAILY
(Daily).
14. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: One
(1) Tablet PO Q6H (every 6 hours) as needed for headache.
15. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
16. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
17. Acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal Q6H (every 6 hours) as needed for fever.
18. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO BID (2 times a day) as needed.
19. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
20. Docusate Sodium 100 mg Capsule Sig: [**1-28**] Capsules PO TID (3
times a day).
21. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
22. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q6 (): Taper
0.5mg/per every 3 days until patient takes 2mg daily.
23. Topiramate 50 mg Tablet Sig: 2 and 1/2tab Tablets PO BID (2
times a day).
24. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1)
Injection Q8H (every 8 hours) as needed for nausea.
25. Hydralazine 20 mg/mL Solution Sig: One (1) Injection Q6H
(every 6 hours) as needed for for SBP>160.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Epilepsy
Right Tempotal Lobectomy
-now s/p Right temporal lobe cyst fenestration to the
posterior fossa and placement of Rickham reservoir with
catheter in the cyst cavity
Discharge Condition:
Stable; patient still has [**1-28**] seizures per day after procedure.
Neuro exam: alert and oriented, speech is fluent, comphehension
is intact, mild left sided weakness UMN pattern
Discharge Instructions:
You were admitted with increasing seizure frequency, left sided
jerking and cough, some of which was found to be seizures. You
had a brain surgery to decompress the cystic area that was in
the temporal side of your brain. The coughing seizures improved
significantly; although you still have some of the other
seizures. You should continue to take your seizures medications
as per the prescriptions.
If you have more seizures than what you usually have, you should
contact your doctor.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 5285**]
Date/Time:[**2107-8-25**] 1:00
DO NOT HESITATE TO CALL IF THE APPOITMENT IS NEEDED EARLIER THAN
THAT
Completed by:[**2107-5-27**]
|
[
"519.19",
"311",
"V45.82",
"493.90",
"518.81",
"455.8",
"401.9",
"349.89",
"780.62",
"288.3",
"530.81",
"414.01",
"338.19",
"345.80",
"348.0",
"338.29"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.59",
"38.93",
"03.09"
] |
icd9pcs
|
[
[
[]
]
] |
10431, 10528
|
5712, 7793
|
431, 562
|
10744, 10929
|
4939, 5689
|
11463, 11710
|
2585, 2656
|
8173, 10408
|
10549, 10723
|
7819, 8150
|
10953, 11440
|
2671, 3224
|
311, 393
|
590, 2136
|
3248, 4920
|
2158, 2457
|
2473, 2569
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,330
| 139,040
|
40103
|
Discharge summary
|
report
|
Admission Date: [**2161-12-6**] Discharge Date: [**2161-12-9**]
Date of Birth: [**2079-7-11**] Sex: F
Service: MEDICINE
Allergies:
Enalapril
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
Hematuria
Major Surgical or Invasive Procedure:
3-Way Foley Placement for continuous bladder irrigation.
History of Present Illness:
82-year-old woman with history of ovarian cancer originally
diagnosed in [**2148**] s/p recurrence with metastatic spread to the
bladder in [**2160**], off chemotherapy since [**2161-5-2**], who presented
yesterday to [**Hospital3 26615**] Hospital with abdominal discomfort and
hematuria for 2 months. She had been taking oxycodone at home
but was unable to control the pain with this. Per ED report, she
was found at the OSH to pass large clots from the urethra. She
underwent a CT scan prior to transfer that showed tumor invasion
into both ureters, with bilateral hydronephrosis and invasion
into the bladder. Additionally at the OSH, she spiked a fever to
103, and she was treated empirically with Zosyn. She received 1u
of PRBCs and she was then transferred to [**Hospital1 18**] for urologic
evaluation for nephrostomy tube placement.
In the [**Hospital1 18**] ED, her initial vitals were T 101, HR 96, BP 89/50,
RR 17, and oxygen saturation of 95% on RA. Labs were notable for
hematocrit of 26.5 (up from 22.5 at [**Hospital3 26615**] prior to the
blood transfusion), with INR 1.1 and normal platelets. White
count was 5.9 with 14% bandemia. The patient was bolused with 2L
of intravenous saline for systolic blood pressure in the 80s.
She was transfused a second unit of packed red cells, with a
third unit reportedly waiting to be hung prior to admission. She
was making dark red urine. Urology was not called. Three
peripheral IVs were placed - a central line was not felt to be
necessary. Vitals at time of admission were BP 83/47, RR 24, HR
83, saturation 98% RA.
Of note, in the [**Hospital1 18**] ED the patient's code status was confirmed
to be DNR/DNI.
Past Medical History:
1. Ovarian cancer diagnosed originally in [**2148**], s/p surgery at
[**Hospital1 2177**], treatment then through [**Company 2860**], with recurrence of cancer with
metastatic spread to the bladder in [**2160**], off chemotherapy since
[**2161-5-2**]
2. Polio at age 28
3. Coronary artery disease
4. Multiple sclerosis, now wheelchair-bound
5. Remote history of breast cancer
Social History:
Lives in [**Location 5028**] with husband. Wheelchair-bound due to MS.
Family History:
Non-contributory.
Physical Exam:
Admission Exam:
Vitals: BP 88/57, HR 68, RR 14, sat 100% 2L
General: cachectic, elderly-appearing woman in no distress
Neck: supple, supraclavicular wasting
Heart: regular rate, systolic murmur [**3-7**] radiating to left
axilla
Lungs: clear bilaterally anterior fields
Abdomen: diffuse abdominal tenderness, greatest in the
epigastrium, hypoactive bowel sounds
Urogenital: foley catheter in place with dark red liquid output
Extremities: 2+ pitting edema bilaterally to knees
Pertinent Results:
Admission Results:
[**2161-12-6**] 02:55AM BLOOD WBC-5.9 RBC-3.06* Hgb-8.7* Hct-26.5*
MCV-87 MCH-28.5 MCHC-32.9 RDW-14.7 Plt Ct-234
[**2161-12-6**] 02:55AM BLOOD Neuts-84* Bands-14* Lymphs-1* Monos-1*
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2161-12-6**] 02:55AM BLOOD PT-13.3 PTT-25.5 INR(PT)-1.1
[**2161-12-6**] 02:55AM BLOOD Glucose-103* UreaN-31* Creat-1.2* Na-139
K-3.6 Cl-105 HCO3-23 AnGap-15
[**2161-12-6**] 08:55AM BLOOD ALT-19 AST-34 LD(LDH)-207 AlkPhos-41
TotBili-0.9
[**2161-12-6**] 08:55AM BLOOD Calcium-8.7 Phos-3.7 Mg-1.7
[**2161-12-6**] 03:26PM BLOOD Lactate-2.4*
CT scan abdomen-pelvis with contrast ([**2161-12-5**]):
1. Increase in size of the metastatic ovarian tumor in the right
anterolateral aspect of the bladder wall which extends into the
bladder lumen.
2. Large hematoma within the bladder.
3. Significant increase in the bilateral hydroureter and
hydronephrosis, secondary to obstruction.
4. Perinephric fluic seen bilaterally secondary to forniceal
rupture.
5. Possible mesenteric implants of tumor.
6. Cholelithiasis.
7. Status post previous lymph node dissection.
CXR ([**2161-12-6**]):
Small bilateral pleural effusions with moderate cardiomegaly. No
pneumonia.
Brief Hospital Course:
82-year-old woman with history of metastatic ovarian cancer who
presented with worsening abdominal pain and hematuria with
imaging suggestive of tumor invasion into bilateral ureters and
bladder.
# Sepsis: The patient presented with hypotension, fevers, and a
bandemia of 14%, lactate of 2.4 and acute renal failure which
were all consistent with sepis. White count bumped from 5.9 to
20.2 the day of admission. A CXR was performed that did not show
a pneumonia. Blood and urine cultures were performed. The
patient received 2 liters of normal saline and 2 units of packed
red cells in the emergency department. Upon arrival to the ICU
the patient received an additional 2 liters of normal saline.
Intravenous fluids were provided to maintain a MAP > 60 mm Hg.
Vancomycin and Zosyn were started empirically for broad coverage
initially while blood and urine cultures were awaiting return.
The patient remained afebrile and normotensive overnight and was
felt appropriate to transfer to the medicine service. The
patient's renal failure improved significantly after intravenous
fluids and chronic bladder irrigation. As cultures remained
negative throughout the hospitalization, her antibiotics were
discontinued on [**2161-12-8**].
.
# Hematuria: The patient had reportedly bloody urine on arrival
to the ED. The most likely etiology was considered to be from
tumor invasion into her urologic tract. Urology was consulted
after the patient arrived in the ICU and placed a 3-way foley
for chronic bladder irrigation. The patient received continuous
bladder irrigation while in the ICU and her hematuria slowly
subsided but she continued to pass clots through the foley.
Hematocrits were monitored closely with a transfusion goal of
maintaining her hematocrit of 25 and she was transfused one unit
of packed red blood cells on [**2161-12-8**].
.
# Metastatic Ovarian Cancer: Patient had known metastatic
ovarian cancer with spread to the bladder and bilateral ureters,
as described on imaging from [**Hospital3 26615**] Hospital. Urology was
consulted as per above. The patient's outpatient oncologist was
contact[**Name (NI) **] regarding the ultimate treatment plan. She
subsequently met with the [**Hospital1 18**] palliative care team and
decision was made to transition to home hospice care. I called
her primary MD to let him know, and am awaiting a call back.
.
# History of Coronary Disease: The patient's statin was held on
arrival to the ICU. As well, her metoprolol and nitrate were
held due to her hypotension at time of admission. These
medicines were reintroduced as her clinical status improved -
see below.
.
# Anemia - As above
.
# Code status - DNR/DNI. The patient met with the palliative
care team during her admission and decision made to transition
to home hospice care.
Medications on Admission:
1. Klonopin 0.5 mg once daily as needed.
2. Metoprolol succinate 50 mg once daily.
3. Simvastatin 40 mg once daily.
5. Isosorbide 30 mg twice daily.
Discharge Medications:
1. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2
times a day) as needed for Constipation.
Disp:*250 mL* Refills:*0*
2. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for Pain or fever.
Disp:*60 Tablet(s)* Refills:*0*
3. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*0*
4. oxycodone 5 mg Tablet Sig: 2-3 Tablets PO every 4-6 hours as
needed for pain.
Disp:*90 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Hospice of the [**Hospital3 **]
Discharge Diagnosis:
Hematuria
Ovarian cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
see below
Followup Instructions:
with hospice care at home
|
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"413.9",
"584.9",
"414.00",
"V10.3",
"593.5"
] |
icd9cm
|
[
[
[]
]
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[
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icd9pcs
|
[
[
[]
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|
4295, 7091
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280, 338
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7930, 7930
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3075, 4272
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8072, 8100
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7290, 7776
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8038, 8049
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2577, 3056
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231, 242
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366, 2039
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7945, 8014
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2061, 2438
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2454, 2527
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,434
| 103,381
|
44579
|
Discharge summary
|
report
|
Admission Date: [**2125-1-31**] Discharge Date: [**2125-2-10**]
Date of Birth: [**2069-12-22**] Sex: M
Service: SURGERY
Allergies:
Skelaxin / Flexeril
Attending:[**First Name3 (LF) 1390**]
Chief Complaint:
Trauma: Fall
R posterior rib fxs [**3-26**]
R lateral rib fxs [**6-25**]
pulmonary contusion
Major Surgical or Invasive Procedure:
s/p VATS & rib plating [**2125-2-5**]
thoracic epidural [**2125-2-1**], d/c [**2-4**]
History of Present Illness:
55 year old male who complains of chest pain. This patient was 5
feet up on a ladder sawing off a 200 pound tree branch which
swung from exporting rope striking him in the right chest. It
knocked him off the ladder. There was a documented LOC. He went
to [**Hospital6 3105**] where imaging showed multiple rib
fractures on the right, 7 through 9 with a suspected flail
segment, a pulmonary contusion, and a pleural effusion on the
right. There was no pneumothorax. Because of all of these
findings, he was sent to [**Hospital1 **] for further
evaluation and treatment. He has had CT scans read by attending
radiologist of his brain, cervical spine, and torso. The
injuries above are the only injuries that were found.
Past Medical History:
PMH: sleep apnea, hypothyroidism, depression, ADHD
PSH: tonsillectomy, perianal surgery for wart removal
Social History:
former smoker (quit 5 yrs ago), no illicit drugs
Family History:
non-contributory
Physical Exam:
PHYSICAL EXAMINATION: upon admission
Temp: 98.7 HR: 96 BP: 123/103 Resp: 19 O(2)Sat: 97-100% on
3 L Normal
Constitutional: Comfortable boarded and collared with a GCS
of 15.
On the triage sheet, there was an O2 sat of 93%, but all of
the O2 sats I saw, and I watched him for several minutes now
have all been 97% and above.
HEENT: Extraocular muscles intact, with both pupils being 3
mm and briskly constricting to light
There is no C-spine tenderness. Given his awake mental
status, his negative C-spine CT scan, we cleared his
cervical spine.
Chest: He has tenderness in the right chest wall. Breath
sounds are bilaterally symmetrical
Cardiovascular: Normal first and second heart sounds
without murmur
Abdominal: Soft, Nontender and specifically no right upper
quadrant tenderness
Extr/Back: All 4 extremities move normally without pain or
long bone findings.
His back is negative.
Neuro: Speech fluent with no lateralizing or localizing
motor findings
Psych: Normal mood, Normal mentation
Pertinent Results:
[**2125-2-8**] 06:00AM BLOOD WBC-4.2 RBC-3.32* Hgb-10.4* Hct-29.2*
MCV-88 MCH-31.5 MCHC-35.8* RDW-15.1 Plt Ct-187
[**2125-2-7**] 02:11AM BLOOD WBC-5.8 RBC-3.05* Hgb-9.8* Hct-26.8*
MCV-88 MCH-32.1* MCHC-36.5* RDW-14.3 Plt Ct-159
[**2125-2-8**] 06:00AM BLOOD Plt Ct-187
[**2125-2-7**] 02:11AM BLOOD Plt Ct-159
[**2125-2-8**] 06:00AM BLOOD Glucose-104* UreaN-15 Creat-1.0 Na-138
K-3.7 Cl-101 HCO3-30 AnGap-11
[**2125-2-7**] 03:19PM BLOOD Glucose-114* UreaN-16 Creat-0.9 Na-136
K-3.3 Cl-97 HCO3-36* AnGap-6*
[**2125-2-4**] 02:53PM BLOOD CK(CPK)-239
[**2125-2-4**] 10:45PM BLOOD CK-MB-7 cTropnT-<0.01
[**2125-2-4**] 02:53PM BLOOD CK-MB-5 cTropnT-<0.01
[**2125-2-4**] 04:29AM BLOOD CK-MB-5 cTropnT-<0.01
[**2125-2-8**] 06:00AM BLOOD Calcium-8.7 Phos-3.7 Mg-2.4
[**2125-2-5**] 03:00PM BLOOD Glucose-132* Lactate-0.7 Na-133 K-4.1
[**2125-2-6**] 01:46AM BLOOD freeCa-1.13
[**2125-1-31**]: chest x-ray:
IMPRESSION: Elevated right hemidiaphragm with tiny right pleural
effusion,
atelectasis and several displaced right rib fractures, but no
pneumothorax.
Please refer to CT for further details.
[**2125-2-1**]: chest x-ray:
IMPRESSION:
1) Fractures are in closer approximation with no pneumothorax.
2) Increased right basilar atelectasis with small right pleural
effusion.
Right hemidiaphragm is stably elevated.
[**2125-2-2**]: right shoulder x-ray:
No acute bony injury. Mild degenerative changes of the AC joint.
[**2125-2-4**]: CTA chest:
IMPRESSION: Flail chest with contiguous segmental fractures of
the right
8th-10th ribs and subsequent development of a large hemothorax
since four
days prior, now with compressive atelectasis without evidence of
pneumothorax.
No evidence of pulmonary embolism.
[**2125-2-4**]: chest x-ray:
Right chest tube remains in place with its tip at the apex.
There is
persistent elevation of the right hemidiaphragm with patchy
opacity at the
right base which either reflects loculated pleural fluid within
the horizontal fissure or could represent an evolving pneumonia.
Clinical correlation is advised. The left lung remains grossly
clear. No pneumothorax is seen. No evidence of pulmonary edema.
Overall cardiac and mediastinal contours are stable
[**2125-2-4**]: chest x-ray:
1. Interval placement of a right internal jugular central line
which has its tip in the distal SVC at the cavoatrial junction.
Right chest tube remains unchanged in position. Endotracheal
tube and nasogastric tube also unchanged; however, the
nasogastric tube has its side port near the gastroesophageal
junction.
2. Cardiac and mediastinal contours are stable. Left lung
demonstrates
slightly improved aeration at the left base with residual patchy
atelectasis.
There is also patchy atelectasis at the right base with an
associated layering effusion. No large pneumothorax is seen;
however, the ability to detect a pneumothorax on a supine
radiograph is diminished. Several right-sided anterolateral rib
fractures are again identified.
[**2125-2-7**]: chest x-ray:
IMPRESSION: Enlarging moderate to large right pneumothorax
sufficient to
shift mediastinum contralaterally, but not to displace the right
hemidiaphragm
[**2125-2-8**]: chest x-ray:
IMPRESSION: Increasing size in right pneumothorax.
Time Taken Not Noted Log-In Date/Time: [**2125-2-4**] 8:38 pm
SPUTUM
**FINAL REPORT [**2125-2-6**]**
GRAM STAIN (Final [**2125-2-4**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2125-2-6**]):
SPARSE GROWTH Commensal Respiratory Flora.
HAEMOPHILUS INFLUENZAE, BETA-LACTAMASE NEGATIVE. HEAVY
GROWTH.
Beta-lactamse negative: presumptively sensitive to
ampicillin.
Confirmation should be requested in cases of treatment
failure in
life-threatening infections..
Brief Hospital Course:
55 year old gentleman admitted to the acute care service after
falling off a ladder while cutting a branch. He sustained loss
of consciousness as a result of the fall. He was taken to an
outside hospital where on imaging he was found to have multiple
rib fractures on the right, 7 through 9 with a likely flail
segment, a pulmonary contusion, and a pleural effusion on the
right. He was transferred here for further management. He was
admitted to the intensive care unit for observation. During this
time, he had an epidural catheter placed for management of his
rib pain. This was discontinued in 48 hours and he was
transitioned to PCA. His vital signs and respiratory status
remained stable and he was transferred to the surgical floor on
HD #3.
While on the floor, he had a late presentation right-sided
hemothorax which required emergent chest tube placement and
transfer back to the ICU. A CTA of the chest was done which
showed a flail chest with contiguous segmental fractures of the
right
8th-10th ribs and subsequent development of a large hemothorax
with compressive atelectasis without evidence of pneumothorax.
His epidural catheter was replaced and he required neosynephrine
for blood pressure support. He was intubation for increased
respiratory distress. He was bronched and started on
vancomycin, cefepime, and ciprofloxacin for hospital acquired
pneumonia. The thoracic service was consulted on HD #5 for
possible rib plating to help facilitate his pulmonary status.
He was taken to the operating room on HD #6 where he underwent a
right thoracotomy and evacuation of hemothorax. At this time,he
also had an internal rib fixation of ribs #7, 8, and 9.
His operative course was stable with a EBL of 100cc. He did
require additional PRBC during the procedure. He was bronched at
the completion of the procedure and transferred back to the
intensive care unit. He was extubated on POD #1. His hemodynamic
status was labile after the procedure requiring additional
fluid, albumin, and lasix. On POD #2, his pneumothorax was
enlarged, the chest repositioned, and it was placed to wall
suction with improvement of the pnemothorax. He was introduced
to clear liquids with advancment to a regular diet.
He was transferred to the surgical floor on POD #2. He was
started on cefepime for a sputum culture which grew H.Flu. His
vital signs and pulmonary status were closely monitored. A
chest x-ray showed a decrease in the size of the pneumothorax
and the chest tube was discontinued on POD # 3. Post chest-tube
removal x-ray showed a large right pneumothorax which is
unchanged from prior films. He was breathing comfortably with an
oxygen saturation of 97% on room air. His cefepime was switched
to cefepoxidime for completion of a 10 day course. During his
hospital stay, he ws evaluted by occupational therapy because
of his +LOC during the accident. They recommended follow-up with
cognitive neurology to re-evaluate him.
His vital signs are stable and he is afebrile. He is tolerating
a regular diet. His white blood cell count is normalized and
his hematorcrit is stable. He is preparing for discharge home
with follow up with the Thoracic service and with cognitive
neurology.
Medications on Admission:
citalopram 20, adderall 40'', levothyroxine 250, atarax 25-50
daily
Discharge Medications:
1. levothyroxine 125 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Colace 50 mg Capsule Sig: One (1) Capsule PO twice a day:
hold for loose stool.
3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
4. gabapentin 400 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
5. citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
6. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain: may cause drowsiness, avoid driving
while on this medication.
Disp:*40 Tablet(s)* Refills:*0*
7. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
8. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
Disp:*20 Tablet(s)* Refills:*0*
9. amphetamine-dextroamphetamine 5 mg Tablet Sig: Four (4)
Tablet PO BID (2 times a day).
10. cefpodoxime 200 mg Tablet Sig: Two (2) Tablet PO every
twelve (12) hours for 6 days.
Disp:*24 Tablet(s)* Refills:*0*
11. ibuprofen 400 mg Tablet Sig: 1-2 Tablets PO Q8H (every 8
hours) as needed for pain: please take with food.
Discharge Disposition:
Home
Discharge Diagnosis:
Trauma: fall
R posterior rib fxs [**3-26**]
R lateral rib fxs [**6-25**]
pulmonary contusion
flail chest
Discharge Condition:
..
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital after you fell off a ladder
while cutting a tree branch. You sustained rib fractures and a
bruise to your lungs. You were taken to the operating room for a
stabilization of your rib fractures. You also had a collection
of fluid in your lungs for which a chest tube was placed. The
chest tube has been removed and your respiratory status is
slowly getting better. You are preparing for discharge home
with the following instructions:
Because you had rib fractures, please follow:
* Your injury caused right sided [**3-26**] rib fractures which can
cause severe pain and subsequently cause you to take shallow
breaths because of the pain.
* You should take your pain medication as directed to stay
ahead of the pain otherwise you won't be able to take deep
breaths. If the pain medication is too sedating take half the
dose and notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to
hold against your chest and guard your rib cage while coughing
and deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non steroidal antiinflammatory drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs ( crepitus ).
Followup Instructions:
Name: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 95463**],MD
Specialty: Internal Medicine
When: Wednesday [**2-14**] at 11:30am
Location: [**Location (un) **] FAMILY MEDICINE, P.C.
Address: [**Location (un) 86867**], STE G06, [**Hospital1 **],[**Numeric Identifier 26407**]
Phone: [**Telephone/Fax (1) 45479**]
Name: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD
Specialty: Cognitive Neurology
Location: [**Hospital1 18**] - COGNITIVE NEUROLOGY UNIT
Address: [**Location (un) **], KS 257, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 1690**]
We are working on a follow up appointment with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] in the Neurology department within a month to follow
up on your head injury. You will be called at home with the
appointment. If you have not heard within 2 business days or
have questions, please call the number listed above.
Department: THORACIC SURGERY/CHEST DISEASE
When: TUESDAY [**2125-3-6**] at 3:30 PM
With: [**Name6 (MD) 1532**] [**Name8 (MD) 1533**], MD [**0-0-**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Please arrive to this appointment at 2pm to have a chest xray
done. You will see the doctor at 3:30pm.
Completed by:[**2125-2-10**]
|
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53,836
| 155,531
|
51986
|
Discharge summary
|
report
|
Admission Date: [**2111-2-18**] Discharge Date: [**2111-2-24**]
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
RUQ pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is an 86 year old spanish speaking woman with a PMH
significant for atrial fibrillation (on coumadin), CKD (Cr [**1-4**]
1.5), systolic CHF (EF 10%), DMII, UTIs, HTN, colon cancer s/p
colectomy, depression and dementia who presents with RUQ pain
that started today. She was evaluated at her nursing home where
there was concern for a possible biliary process. Per her
daughter who was with her earlier today the patient was close to
her baseline mental status.
.
In the ED, initial vs were: 97.6 105 86/52 16 96% RA. Her exam
was notable for tender RUQ with guarding. SBP remained in 80s
to 90s. Her labs were notable for luekocytosis 15 with 85%
polys, no bands, elevated Cr 2.2, mildly elevated AP and AST
(159, 106), and lactate 3.4, glucose 67. Her UA was notable for
bacturia, pyuria, and leuks. A KUB was done that did not show
obstruction (my read) and CT abdomen/pelvis was notable for
bilateral perinephric stranding and fluid and no gallbladder
visualized. Patient was given 20mg prednisone, flagyl and cipro
for concern of gallbladder process, and 1amp D50 for
hypoglycemia. She received a total of 1L NS in addition to the
fluids in her antibiotics. On discussion with health care
proxy, patient remains DNR/DNI and does not desire invasive
measures such as central line and pressors. Vital signs on
transfer were T 96.8, BP 89/56, HR 90, RR 21, O2 sat 100% RA.
.
Of note, she was recently discharged after hospitalization at
[**Hospital1 18**] [**Date range (1) 107620**] for hypoxia and altered mental status. She
had an echo done significant for presumed ischemic
cardiomyopathy with an EF 10% and bivent failure. She improved
with diuresis and treatment for a pneumonia w/ levaquin.
.
On the floor, the patient was having RUQ pain, but easily
drifted off to sleep. She denied any cough, chest pain, nausea,
vomiting, diarrhea, fevers, or chills.
Past Medical History:
- Afib onCoumadin
- systolic CHF: [**First Name8 (NamePattern2) **] [**Hospital1 **] echo [**10-3**] EF 20%
- DM2 (hga1c 7.6 [**10-3**])
- CRF (creat 1.8-2.2)
- mild dementia
- depression
- GERD
- HTN
- venous insufficiency
- h/o of colon cancer, s/p colectomy
Social History:
Lives at [**Hospital3 1186**], denies smoking, alcohol and drugs.
Family History:
non contributory
Physical Exam:
Vitals: T: 95.7 BP: 95/62 P: 93 R: 17 O2: 97% RA
General: Elderly female, drowsy but easily arousable, no acute
distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation anteriorly, no wheezes, rales, or
ronchi
CV: Irregularly irregular, no murmurs, rubs, gallops
Abdomen: Decreased BS, soft, TTP in the RUQ, no rebound or
guarding.
GU: + foley
Ext: cool, pulses not appreciated, 1+ edema bilaterally
Neuro: Oriented to self. Moves all extremities. Cranial nerves
II-XII grossly intact.
Pertinent Results:
Admission Labs
[**2111-2-18**] 06:00PM GLUCOSE-67* UREA N-60* CREAT-2.0* SODIUM-138
POTASSIUM-4.6 CHLORIDE-98 TOTAL CO2-26 ANION GAP-19
[**2111-2-18**] 06:00PM PH-7.43 COMMENTS-GREEN TOP
[**2111-2-18**] 06:00PM GLUCOSE-73 LACTATE-3.4* NA+-140 K+-4.9
CL--95* TCO2-29
[**2111-2-18**] 06:00PM HGB-12.4 calcHCT-37
[**2111-2-18**] 06:00PM freeCa-1.04*
.
[**2111-2-18**] 06:00PM WBC-15.3* RBC-4.00* HGB-11.6* HCT-36.0 MCV-90
MCH-29.0 MCHC-32.2 RDW-17.5*
[**2111-2-18**] 06:00PM NEUTS-84* BANDS-0 LYMPHS-12* MONOS-4 EOS-0
BASOS-0
[**2111-2-18**] 06:00PM PLT COUNT-220
.
ALT(SGPT)-40 AST(SGOT)-106* ALK PHOS-159* TOT BILI-1.1
LIPASE-28
Albumin 3.3* CALCIUM-8.6 PHOSPHATE-3.7 MAGNESIUM-2.1
.
[**2111-2-18**] 06:40PM URINE COLOR-Amber APPEAR-Cloudy SP [**Last Name (un) 155**]-1.016
[**2111-2-18**] 06:40PM URINE BLOOD-TR NITRITE-NEG PROTEIN-75
GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-1 PH-5.0 LEUK-MOD
[**2111-2-18**] 06:40PM URINE RBC-[**6-4**]* WBC-21-50* BACTERIA-MANY
YEAST-NONE EPI-[**6-4**]
.
Microbiology:
Urine Cx [**2-18**] contaminated
Blood cx [**2-18**] No growth to date
Imaging:
CXR: [**2-20**]
RUQ US: IMPRESSION: No cholelithiasis or secondary signs of
cholecystitis to explain the patient's right upper quadrant
pain. The gallbladder is small, possibly normal anatomy in this
patient, though this should be correlated for possible history
of previous partial cholecystectomy.
.
CT abdomen [**2-18**]: IMPRESSION:
1. Perinephric stranding and perinephric fluid, nonspecific,
though
correlation clinically and with laboratory data for underlying
infection.
2. Cardiomegaly with diffuse body wall edema.
.
Discharge labs:
[**2111-2-23**] 05:35AM BLOOD WBC-5.9 RBC-3.91* Hgb-11.7* Hct-35.3*
MCV-90 MCH-29.9 MCHC-33.0 RDW-16.7* Plt Ct-225
[**2111-2-24**] 05:40AM BLOOD PT-16.9* INR(PT)-1.5*
[**2111-2-24**] 05:40AM BLOOD Glucose-94 UreaN-46* Creat-1.4* Na-139
K-3.6 Cl-100 HCO3-31 AnGap-12
Brief Hospital Course:
1. Pyelonephritis complicated by sepsis, requiring ICU
admission:
Ms [**Known lastname **] was admitted to the MICU with concern for biliary
process given leukocytosis and worsening RUQ pain. UA showed
significant pyuria and bacteria and CT abdomen was suggestive of
perinerphric stranding; no biliary abnormalities were
visualized. A presumptive diagnosis of pyelonephritis was made.
Given her history of recurrent UTIs, she was started
empirically on IV meropenem. Although UA was positive, her
urine culture was negative. Day 1 of meropenem was [**2-19**]; we
decided to treat her for a fourteen day course despite negative
cultures given frequency of recurrent UTIs per outside hospital
report and perinephric stranding seen on CT; last day of
meropenem will be [**2111-3-4**].
.
2. Acute renal failure, with chronic kidney disease, stage II:
Her creatinine was noted to be elevated (baseline is 1.5) with
her creatinine near 2.3, thought to be secondary to poor forward
flow. Her EF is only 10% and so to improve perfusion to her
kidney, we initiated diuresis with lasix with a goal of -500 mLs
- 1 L. Her creatinine improved mildly to 2.1 with lasix; she
was transitioned to PO bumetanide as per her home regimen of 4
mg [**Hospital1 **]. We held her ACE inhibitor secondary to her acute on
chronic renal failure. It will be started at discharge at a
lower dose.
.
3. Atrial fibrillatoin with poor rate control, subtherapeutic
INR:
She continued to be in atrial fibrillation; her metoprolol was
titrated up for rate control. Her INR was subtherapeutic and
she was started on IV heparin on [**2-20**] in addition to her
coumadin dose of 3.5 mg daily. She remained poorly rate
controlled and was eventually started on metoprolol 50 mg q6 and
diltiazem 30 mg po qid. She will be transitioned to daily
formulations on discharge. She should have daily pulse checks
for bradycardia, although there were no abnormalities on
telemetry.
.
4. Diabetes mellitus, type II, controlled:
Her metformin was held in the setting of renal failure; she
covered on an insulin sliding scale.
.
5. Dementia: mild. No evidence of acute delirium.
.
Disposition: after discussion with her nurse practitioner at
her nursing home, and her family, she was discharged back to the
[**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] with goal of transitioning to comfort measures.
Her heparin drip was stopped at discharge.
Medications on Admission:
Citalopram 20 mg daily
Lisinopril 5 mg daily
Coumadin previously 4mg daily, current dose unknown
Metformin 500 [**Hospital1 **]
Omeprazole 20 mg daily
Aspirin 81 mg daily
Multivitamin
Senna 8.6 mg [**Hospital1 **]
Docusate Sodium 100 mg [**Hospital1 **]
Atorvastatin 40 mg daily
Bumetanide 4 mg [**Hospital1 **] (per cardiology note [**1-19**], increased from 4
mg daily)
Metoprolol Succinate 100 mg daily
Insulin Glargine 100 unit/mL 6 units Subcutaneous at bedtime.
Discharge Medications:
1. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Toprol XL 200 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day: hold for sbp <
100.
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4
PM: Adjust by INR.
7. Meropenem 500 mg Recon Soln Sig: Five Hundred (500) mg
Intravenous Q12H (every 12 hours) for 8 days: Last day [**3-4**].
8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Bumetanide 2 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
11. Insulin Lispro 100 unit/mL Solution Sig: Six (6) units
Subcutaneous at bedtime.
12. Novolog 100 unit/mL Solution Sig: sliding scale
Subcutaneous QAC and QHS.
13. Diltiazem HCl 120 mg Capsule, Sust. Release 24 hr Sig: One
(1) Capsule, Sust. Release 24 hr PO at bedtime: hold for sbp <
100.
14. Sodium Chloride 0.9 % 0.9 % Syringe Sig: Ten (10) ML
Injection Q8H (every 8 hours) as needed for line flush.
15. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush.
16. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day.
17. Fleet Enema 19-7 gram/118 mL Enema Sig: One (1) enema Rectal
once a day as needed for constipation.
18. Dulcolax 10 mg Suppository Sig: One (1) suppository Rectal
once a day as needed for constipation.
19. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day:
hold for sbp < 100.
20. Outpatient Lab Work
INR [**2-25**] then as by INR.
Discharge Disposition:
Extended Care
Facility:
[**Last Name (un) **] house
Discharge Diagnosis:
Pyelonephritis
Sepsis with organ dysfunction
Chronic systolic CHF without acute exacerbation
Hypertension
Diabetes mellitus, type II , controlled, without complications
Atrial fibrillation
GERD
Chronic kidney disease, stage III, with acute renal failure
Dementia, chronic
Discharge Condition:
Mental Status: Confused - sometimes
Level of Consciousness: Lethargic but arousable
Activity Status: Bedbound
Discharge Instructions:
You were admitted with right sided abdominal pain, and were
found to have a kidney infection. You improved with
antibiotics. Your heart rate was high and we changed your
medications to control it. We also restarted your blood
thinning medication for your irregular heart rate.
.
Medication changes:
Coumadin as per INR, Dosing recently: 2/26 3/5 mg, no dose
[**2-21**], [**2-22**] 5 mg, [**2-23**] 4 mg. INR 1.5
Toprol increased to 200 mg daily.
Diltiazem 120 mg daily added.
Lisinopril decreased to 2.5 mg daily.
Meropenem through [**3-4**] for pyelonephritis.
.
Repeat INR [**2-25**]. Follow every other day while on antibiotics.
Followup Instructions:
Your nurse [**First Name8 (NamePattern2) 107621**] [**Last Name (Titles) 107622**] will see you once you return to
the nursing home.
.
Department: CARDIAC SERVICES
When: TUESDAY [**2111-4-21**] at 1:30 PM
With: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], NP [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"V10.05",
"584.9",
"403.90",
"038.9",
"590.80",
"428.0",
"530.81",
"V58.61",
"585.2",
"427.31",
"250.00",
"995.92",
"294.8",
"428.22"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
9870, 9924
|
5079, 7524
|
228, 234
|
10240, 10240
|
3134, 4773
|
11039, 11498
|
2525, 2543
|
8043, 9847
|
9945, 10219
|
7550, 8020
|
10375, 10657
|
4789, 5056
|
2558, 3115
|
10677, 11016
|
180, 190
|
262, 2141
|
10255, 10351
|
2163, 2425
|
2441, 2509
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,928
| 155,418
|
52463
|
Discharge summary
|
report
|
Admission Date: [**2123-12-8**] Discharge Date: [**2123-12-16**]
Date of Birth: [**2045-6-5**] Sex: F
Service: SURGERY
Allergies:
Keflex
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
colonoscopy
History of Present Illness:
Ms. [**Known lastname 108376**] is a 78 y.o. F with hx of CAD s/p recent
admissions for CHF, afib on coumadin- who presented with BRBPR
which began at 3pm on [**12-8**]. Poor historian- hx provided by
husband/daughter. She had 1-2 episodes at home and an additional
episode of red blood with clots in the ER. She asserts mild LH
today, but no SOB/CP. No abdominal pain/N/V. Pt had been
complaining of fatigue and poor appetite for the 2 weeks
following her last admission on [**2127-11-23**] for CHF. Denies any
NSAID use, no additional meds.
Past Medical History:
Diabetes Type 2 on insulin--last A1C unknown
Atrial fibrillation
CAD s/p stent to RCA in [**2104**]
Acute and Chronic Diastolic CHF (EF unknown)
HTN
Pulmonary HTN
Dyslipidemia
Hypothyroidism (s/p thyroidectomy?)
Breast CA s/p b/l mastectomies and tamoxifen (Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2036**])
s/p breast reconstruction
COPD
Thrombocytopenia
Recent ICU admission [**10/2123**] at OSH with staph aureus bacteremia
Infected 3rd left toe [**10/2123**]
.
Cardiologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 108377**]
PCP: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 4768**] [**Last Name (NamePattern1) 5456**]
Social History:
Social history is significant for the absence of current tobacco
use; she quit smoking in [**2106**]. There is no history of alcohol
abuse. Patient lives with her husband; she used to work in a
candy factory. She currently uses a walker and has home PT and
[**Year (4 digits) 269**].
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
On admission:
afebrile, 90/40 HR 79
Appears pale, alert and talkative, but poor short term recall of
events
MM slightly dry
Lungs clear
Irregular, [**2-23**] SM at LLSB
Abdomen soft, dark red blood on rectal exam
Pertinent Results:
[**2123-12-8**] 09:23PM HCT-20.9*
Brief Hospital Course:
Pt was admitted to the ICU on [**12-8**] and was kept NPO. She was
initially transfused 5 units of PRBCs, and 4 units of FFP. She
had a bleeding scan that was positive.
On [**12-9**] she had a mesenteric angio which showed no active
extravasation, neovascularity, or signs of angiodysplasia in the
[**Female First Name (un) 899**] and SMA territories. She was given proplex & Vit K and was
transfused 1 more unit RBC for Hct 25.2-->29.5, INR 1.5.
The patient was kept NPO and her hct was closely followed until
she went for colonoscopy on [**12-14**] which showed with numerous
diverticuli, 2 AVMs, one treated with APC. Her diet was advanced
until she was ultimately tolerating a regular diet.
She was restarted on her plavix prior to discharge as well as
aspirin 81 mg but told to NOT restart coumadin at this time. At
discharge the patient was hemodynamically stable without melena
and with a hct of 30.
Medications on Admission:
asa 325mg daily, plavix 75mg daily, coumadin 6mg hs,
digoxin, advair, levothyroxine, lopressor, lisinopril, lasix,
insulin, protonix 40 daily, lipitor
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
2. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*2*
4. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Primary:
low GI bleed
Secondary:
CAD s/p RCA stend
afib
thrombocytopenia
IDDM
COPD
Discharge Condition:
Good. hct 30
Discharge Instructions:
You came to the hospital because you were having bleeding from
your GI tract. While you were here, you had treatments and
medications to help stop your bleeding.
Please continue your previous home medications except for the
follow two changes:
DO NOT take coumadin. Take only ASPIRIN 81 mg daily. (DO NOT
take your previous dose of 325 mg daily.)
Please return to the ER if you notice any red bloodly bowel
movements, black or tarry stool, lightheadedness, confusion,
chest pain or shortness of breath.
Followup Instructions:
Please follow up with your primary care doctor within the next
week.
Please follow up with Dr. [**Last Name (STitle) **] in [**1-19**] weeks.
|
[
"401.9",
"V58.67",
"428.0",
"428.32",
"V58.61",
"427.31",
"287.5",
"496",
"569.85",
"V45.82",
"250.80",
"569.0",
"562.10",
"416.8",
"244.9",
"V10.3",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"48.36",
"99.07",
"45.43",
"88.47"
] |
icd9pcs
|
[
[
[]
]
] |
4024, 4073
|
2314, 3226
|
272, 286
|
4201, 4216
|
2254, 2291
|
4770, 4916
|
1920, 2002
|
3428, 4001
|
4094, 4180
|
3252, 3405
|
4240, 4747
|
2017, 2017
|
227, 234
|
314, 860
|
2032, 2235
|
882, 1602
|
1618, 1904
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,530
| 129,819
|
10308
|
Discharge summary
|
report
|
Admission Date: [**2155-4-7**] Discharge Date: [**2155-4-15**]
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 14964**]
Chief Complaint:
worsening chest pain and shortness of breath
Major Surgical or Invasive Procedure:
Coronary artery bypass graft x 2/Aortic valve replacement [**4-7**]
History of Present Illness:
Mr. [**Known lastname **] is an 85 yo gentleman who has a known cardiac
history and has had a h/o worsening chest pain and shortness of
breath. He had an echocardiogram which showed an EF 40-45% and
severe aortic stenosis. He underwent cardiac catheterization
which showed an 80% LAD lesion, chronically occluded RCA,
anneurysmal mid LCX w/50% lesion. He was refered to Dr.
[**Last Name (STitle) 70**] for surgical treatment.
Past Medical History:
s/p MI [**2130**]
AS
h/o prostate CA s/p brachytherapy and hormone treatment
hyperlipidemia
HTN
PAF
h/o rectal bleeding s/p cauterization
cholelithiasis
s/p AAA repair '[**45**]
s/p bilateral hernia repair
s/p R lung surgery
CRI
chronic lung disease
Pertinent Results:
[**2155-4-15**] 06:20AM BLOOD WBC-8.0 RBC-3.35* Hgb-10.3* Hct-31.0*
MCV-93 MCH-30.7 MCHC-33.1 RDW-13.0 Plt Ct-201
[**2155-4-15**] 06:20AM BLOOD Plt Ct-201
[**2155-4-15**] 06:20AM BLOOD PT-19.0* INR(PT)-2.3
[**2155-4-15**] 09:50AM BLOOD Glucose-118* UreaN-18 Creat-1.6* Na-137
K-5.1 Cl-98 HCO3-29 AnGap-15
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to [**Hospital1 18**] on [**4-7**] and taken to the
operating room with Dr. [**Last Name (STitle) 70**] for a CABGx2 and AVR w/25mm
pericardial valve. Please see operative note for full details.
He was transfered to the ICU in stable condition. He was weaned
and extubated from mechanical ventillation on POD#1 without
difficulty. He was transfered to the regular part of the
hospital on POD#2, where he began working with physical therapy.
He developed atrial fibrillation on POD#2 with well controlled
rate and hemodynamically stable. He was started on heparin and
coumadin for anticoagulation on POD#5. On POD#7 he was cleared
for discharge to home by physical therapy and on POD#8 he was
discharged.
Medications on Admission:
lasix 40mg q M-W-F
Klorcon 10mEq q M-W-F
Pepcid 40mg qd
colexa 10mg qd
metoprolol 50mg [**Hospital1 **]
lipitor 20mg qd
aspirin 325mg qd
flovent 110mcg inhaler [**Hospital1 **]
atrovent inhaler tid
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 canister* Refills:*0*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
5. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
Disp:*1 canister* Refills:*0*
6. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
8. Lipitor 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
9. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day).
Disp:*1 tube* Refills:*0*
10. Celexa 10 mg Tablet Sig: One (1) Tablet PO once a day.
Tablet(s)
11. Warfarin Sodium 1 mg Tablet Sig: Five (5) Tablet PO once a
day: Take 5 mg on [**3-18**].
MD to dose daily.
Disp:*150 Tablet(s)* Refills:*2*
12. Lasix 40 mg Tablet Sig: One (1) Tablet PO q M-W-F.
Disp:*30 Tablet(s)* Refills:*0*
13. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
One (1) Capsule, Sustained Release PO q M-W-F.
Disp:*30 Capsule, Sustained Release(s)* Refills:*2*
14. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day: as
directed for goal INR 2.0-2.5.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 2203**] VNA
Discharge Diagnosis:
Coronary artery disease.
Aortic stenosis.
Hyperlipidemia.
Atrial fibrillation.
Chronic renal insufficiency
Discharge Condition:
Good.
Discharge Instructions:
Shower daily and wash incisions with soap and water. Rinse
well. Do not apply any creams, lotions, powders, or ointments.
No bathing in tub or swimming.
No heavy lifting, greater than 10 pounds.
No driving for 6 weeks.
Followup Instructions:
Make follow-appointment with Dr. [**Last Name (STitle) 70**] in [**4-30**] weeks.
Make follow-up appointment with Dr. [**First Name (STitle) **] in [**1-26**] weeks.
Completed by:[**2155-4-16**]
|
[
"272.4",
"424.1",
"593.9",
"412",
"414.01",
"V10.46",
"427.31",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.22",
"36.15",
"39.61",
"36.11"
] |
icd9pcs
|
[
[
[]
]
] |
4266, 4325
|
1460, 2209
|
313, 382
|
4476, 4483
|
1131, 1437
|
4752, 4949
|
2457, 4243
|
4346, 4455
|
2235, 2434
|
4507, 4729
|
229, 275
|
410, 839
|
861, 1112
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,159
| 181,374
|
27384
|
Discharge summary
|
report
|
Admission Date: [**2134-4-5**] Discharge Date: [**2134-5-7**]
Date of Birth: [**2065-5-25**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest Pain/ Indigestion
Major Surgical or Invasive Procedure:
off pump CABG X 2 (LIMA > LAD, SVG > OM) on [**2134-4-12**]
History of Present Illness:
68 yo male with PMH DM2, HTN, Hyperlipidemia, CKD recent
admission to OSH w/CHF exacerbation ([**2134-3-28**]), was readmitted to
OSH today with N/V/CP, which pt described as indigestion. Found
to have a new LBBB. Cardiac enzymes were positive (peak: CK 404,
mb 46, index 11, tn T 0.46)). Of note, adenosine myoview from
last admission showed inferior wall defect; at that time, pt
refused adenosine stress portion. Cath showed 40-50% left main,
70-80% mid LAD, 90% prox LCx, occluded RCA. Pt evaluated for
CABG.
Past Medical History:
Diabetes Mellitus, Hypertension, Hyperlipidemia, Chronic Renal
Insufficiency, Depression, Interstitial Lung Disease
Social History:
widowed. Has one son. Quit smoking 15 years ago; 12.5 pk-yr hx.
Rare etoh
Family History:
Mother died in 50s of CAD; had DM2. Father died of alcoholic
liver cirrhosis. One sister passed away with lung cancer.
Physical Exam:
VS: p89 (80-113), 115/49 (115-160s/49-79), rr18, 91% 2L
Gen: Overweight, sedated gentleman, lying in bed post sheath
pull, drowsy but arousable.
HEENT: PEERL, EOMI, sclera anicteric. MMM.
Neck: JVD difficult to assess. + bruit Right, absent on Left
Lungs: CTA anteriorly.
CV: Regular with no MRG appreciated
Abd: obese, soft, NT, ND.
Ext: no edema. 1+ DP and PT pulses bilaterally.
Pertinent Results:
Carotid ultrasound [**4-6**]: <40% on right, 40-59% on left, normal
vertebral arteries
CXR [**2134-4-6**]: Mild congestive heart failure: increased
interstitial prominence consistent with mild CHF.
ECHO [**2134-4-6**]: EF 30-35%. The left atrium is moderately dilated.
There is mild symmetric left ventricular hypertrophy. Overall
left ventricular systolic function is moderately depressed.
Resting regional wall motion abnormalities include akinesis of
the basal and mid inferior, basal inferoseptal wall akinesis
with inferolateral and basal lateral wall hypokinesis. No aortic
regurgitation is seen. Moderate (2+) mitral regurgitation is
seen..
Renal Ultrasound [**2134-4-6**]: right kidney measures 9.6cm and left
kidney measures 12.9 cm. No hydronephrosis.
Headt CT [**4-30**]: New hypodensity in left temporal lobe,
representing acute left MCA infarction with small amount of
hemorrhage, with mass effect.
[**2134-4-5**] 07:20PM BLOOD WBC-14.2* RBC-4.13* Hgb-11.2* Hct-34.6*
MCV-84 MCH-27.1 MCHC-32.4 RDW-15.3 Plt Ct-393
[**2134-5-3**] 09:40AM BLOOD WBC-12.8* RBC-4.26* Hgb-11.6* Hct-37.5*
MCV-88 MCH-27.2 MCHC-30.9* RDW-16.0* Plt Ct-547*
[**2134-4-5**] 07:20PM BLOOD PT-14.6* PTT-76.0* INR(PT)-1.3*
[**2134-5-1**] 03:01AM BLOOD PT-16.1* INR(PT)-1.5*
[**2134-4-5**] 07:20PM BLOOD Glucose-228* UreaN-72* Creat-2.1* Na-136
K-3.6 Cl-101 HCO3-23 AnGap-16
[**2134-5-3**] 09:40AM BLOOD Glucose-147* UreaN-23* Creat-1.5* Na-145
K-4.3 Cl-112* HCO3-21* AnGap-16
[**2134-5-1**] 03:01AM BLOOD Calcium-8.3* Phos-3.1 Mg-1.9
[**2134-5-6**] 01:10PM BLOOD WBC-11.4* RBC-4.49* Hgb-12.2* Hct-38.8*
MCV-87 MCH-27.1 MCHC-31.4 RDW-16.6* Plt Ct-453*
[**2134-5-4**] 07:00AM BLOOD UreaN-21* Creat-1.5* K-4.5
[**2134-5-3**] 09:40AM BLOOD Glucose-147* UreaN-23* Creat-1.5* Na-145
K-4.3 Cl-112* HCO3-21* AnGap-16
Brief Hospital Course:
As mentioned in the HPI, Mr. [**Known lastname **] was transferred from OSH after
being ruled in for a myocardial infarction. He underwent a
cardiac catheterization which revealed three vessel coronary
artery disease. He underwent usual pre-operative work-up along
with carotid u/s, echocardiogram, and pulmonary function tests.
Renal was consulted secondary to his h/o renal insufficiency and
possible contrast nephropathy. Over the next several days he
underwent above test and renal continued to evaluate and surgery
was delayed pending creatinine to decrease. He was brought to
the operating room on [**2134-4-12**] where he underwent a off-pump
coronary artery bypass graft x 2. Please see operative report
for surgical details. Surgery was uneventful and he was
transferred in stable condition to the CSRU for invasive
monitoring. He remained intubated for several days and unable to
wean off sedation secondary to patient becoming restless and
agitated. He also remained on multiple pressors and was started
on amiodarone for atrial fibrillation on post-op day three. His
WBC was elevated and Vancomycin was continued and he was started
on ceftriaxone. Multiple cultures were taken (urine, sputum,
blood, stool) throughout post-op course. Chest tubes and
epicardial pacing wires were removed per protocol. On post-op
day three he underwent a head CT to evaluate for a stroke which
showed no evidence of intracranial hemorrhage or shift of
normally midline structures. Neurology and psychology were
consulted. Felt agitation was related to delerium. On post-op
day five he had another head CT secondary to continued agitation
when weaned from sedation and failure to respond to
stimuli/followe commands. CT again revealed no CVA. He was
eventually weaned off all pressors and was started on beta
blockers and diuretics. On post-op day six a Dobbhoff feeding
tube was placed. It was found on post-op day eight the feeding
tube was in mid-esophagus and eventually [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 28075**]-[**Doctor First Name 1557**]
feeding tube was placed via fluoro. Finally on this day sedation
was weaned, he made more purposeful movements and was extubated.
Following extubation though he had more agitation events and
wasn't following commnds. Over the next several days he remained
stable, still was agitated at times but was more alert and
oriented. He did require a patient observer throughout post-op
course. Post-op day nine he had a speech and swallow study. He
started to tolerate liquids by mouth and his diet was slowly
advanced. On post-op day fourteen he appeared to be improving
and was finally transferred to the cardaic surgery step down
floor. But on post-op day fifteen he was transferred back to the
CSRU following patient found to be disoriented, lethargic w/
flat affect. He also developed aphasia and right side
hemiparesis. Head CT was performed which again revealed no CVA.
Blood culture taken on this day revealed staphylococcus coag
negative bacteria. His mental status appeared to be improving on
post-op day fifteen. He underwent another head CT on post-op day
seventeen which revealed a new hypodensity in left temporal
lobe, representing acute left MCA infarction with small amount
of hemorrhage, with mass effect. Carotid u/s was performed which
revealed 40-59% stenosis in both [**Country **] and [**Doctor First Name 3098**]. He also had an
EEG done which suggests deep midline subcortical dysfunction
consistent with a mild encephalopathy and superimposed fast
activity which is suggestive of a medication effect. He remained
stable though, slowly improving and was eventually transferred
back to the cardaic surgery step down floor on post-op day
nineteen. On post-op day twenty-one a PICC line was placed for
long-term total parenteral nutrition. Physical therapy followed
patient during post-op course for strength and mobility. On
post-op day twenty-two Mr. [**Known lastname **] aphasia was still present but
slightly improving. Hecontinued to improve and was discharged to
rehab facility on post-op day 25.
Medications on Admission:
Medications on Transfer:
Isosorbide mononitrate SR 30mg qd
Folic acid 1mgd qd
Lisinopril 40mg qd
Fluoxetine 20mg qd
Potassium 20meq qd
Lithium 300mg qd
Ativan 1mg qhs
Spiriva qd
Lipitor 20mg qd
Zetia 10mg qd
Insulin
Maalox
Nitro sl
Plavix 300mg x1 ([**4-5**])
Asa 325mg x1 ([**4-5**])
heparin 6000U IV bolus ([**4-5**])
.
Home Meds:
1. Atenolol/chlorathiadone 50/25 qd
2. Folic acid 1mg qd
3. Fluoxetine 20mg qd
4. Lisinopril 40mg qd
5. Avandia 4mg qd
6. Metformin 1000mg [**Hospital1 **]
7. Vytorin 10/40 qd
8 Lithium 300mg qd
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q4H (every 4 hours).
3. Metoprolol Tartrate 25 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. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day.
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Dipyridamole-Aspirin 200-25 mg Cap, Multiphasic Release 12 HR
Sig: One (1) Cap PO BID (2 times a day).
9. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours).
10. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 5 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Coronary Artery Disease s/p Off-Pump Coronary Artery Bypass
Graft x 2
Post-op CVA
Post-op Delerium
Post-op Bacteremia
PMH: Diabetes Mellitus, Hypertension, Hyperlipidemia, Chronic
Renal Insufficiency, Depression, Interstitial Lung Disease
Discharge Condition:
good
Discharge Instructions:
no lifting > 10 # for 10 weeks
no creams, lotions, or ointments to any incisons
no driving for 1 month
may shower, no bathing or swimming for 1 month
please call office if you develop a fever or notice drainage
from any incision
Followup Instructions:
with Dr. [**Last Name (STitle) 1860**] (renal medicine) [**Telephone/Fax (1) 60**] upon discharge from
rehab, will need MRI of kidneys
with Dr. [**Last Name (STitle) **] in [**12-25**] weeks
with Dr. [**Last Name (STitle) 5686**] upon discahrge from rehab
with Dr. [**Last Name (STitle) 48918**] upon discharge from rehab
Completed by:[**2134-5-7**]
|
[
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"293.0",
"414.01",
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"349.82",
"438.11",
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"584.5",
"427.31",
"311",
"515",
"793.5",
"583.81",
"041.10",
"434.11",
"440.0",
"518.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"36.15",
"00.17",
"37.22",
"99.04",
"96.6",
"88.72",
"38.93",
"88.56",
"36.11"
] |
icd9pcs
|
[
[
[]
]
] |
9171, 9250
|
3547, 7631
|
343, 404
|
9532, 9538
|
1729, 3524
|
9815, 10167
|
1192, 1312
|
8209, 9148
|
9271, 9511
|
7657, 7657
|
9562, 9792
|
1327, 1710
|
280, 305
|
432, 946
|
7682, 8186
|
968, 1085
|
1101, 1176
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,046
| 165,079
|
9301
|
Discharge summary
|
report
|
Admission Date: [**2113-12-6**] Discharge Date: [**2113-12-8**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Diarrhea/Hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **] year old male with DM, CKD, CAD, CHF (EF 25%) p/w acute on
chronic renal failure and hypotension (SBP 50s). He was being
diuresed with Lasix 100 mg PO BID and zaroxolyn 5 mg PO BID at
[**Hospital 100**] Rehab for CHF exacerbation with good urine output for 1.5
weeks, but was noted to have rising creatinine starting [**12-1**]
(2.0), which was up to 4.2 on [**2113-12-5**]. He also has had waxing
and [**Doctor Last Name 688**] mental status x 1 week, different from his normal
clear MS per his son. [**Name (NI) 8389**] was placed the day prior to
admission and the patient had only about 75ml of urine despite
an 800cc fluid challenge. A left midline was also placed on
[**2113-12-5**]. He was given an additional 250cc fluid with no
response. He was transferred to [**Hospital1 18**] for further w/u of renal
failure.
Of note, he completed a course of Levofloxacin on [**2113-12-2**] for a
RLL Pna. He was noted to have loose stool on [**12-4**], with
negative Cdiff toxin on [**2113-12-4**].
Upon arrival to [**Hospital1 18**] ed, vitals were T98.7 BP 50s/palp, HR 62
RR 17, 91% 6L NC. Per [**Hospital 100**] Rehab his baseline BP is 120/60.
A fresh foley was placed in the ED and about 700-800cc bloody
urine returned. U/A was postive for blood and moderate leuks.
He received 1.5L NS and started on dopamine via a PICC line. He
received a dose of vanco and zosyn to cover broadly for sepsis.
He was sent for CT abdomen with oral contrast prior to
admission to MICU.
Past Medical History:
DM2
CKD, baseline cr 1.6
CHF (EF 25%) [**8-/2113**])
CAD, with at least 5 stents (done in [**State 108**])
PPM since [**2105**] for sick sinus syndrome
Restrictive lung dz (recent dx at HebReb), on 2L NC
Pneumonia (last [**11/2113**])
R cataract surgery.
Remote hemorrhoid surgery
s/p CCY
Chronic LBP
Constipation
melanoma resection.
h/o clear cell carcinoma upper lip
Morbid obesity
h/o fractured left shoulder with pin
Social History:
Living at [**Hospital 31844**] rehab since [**2113-10-5**] when not able to
care for self any longer at [**Hospital3 **]. Was walking with
walker x 2 yrs, but not as much lately (no more than 20 steps at
[**Hospital1 1501**]). Longtime smoker, 50-70 pack years, quit 48 yrs ago.
Family History:
non-contributory
Physical Exam:
VS T96.3 BP 123/68, HR 64, RR 24 96% NRB
Gen: arouses to voice, follows some commands
HEENT: NC/AT, OP dry, could not assess neck veins [**1-6**] body
habitus
Lungs: bibasilar crackles [**12-7**] way up
CV: RRR, nl S1S2, no M/R/G
Abd: +BS, soft, ND/NT
GU: foley with some blood around meatus
Ext: trace LE edema, 1+ upper ext edema
Neuro: arouses to voice, opens eyes on command.
Pertinent Results:
Labs:
WBC 19.9 N:80 Band:6 L:5 M:9 E:0 Bas:0
HGB 12.9
HCT 39.0
PLT 276
PT: 15.2 PTT: 36.5 INR: 1.3
Lactate 1.6
Na 136
K 4.5
Cl 88
HCO3 36
BUN 85
Cr 4.6
Glu 191
U/A:
mod leuks, large blood, neg nitr
>50 RBCs, 0 WBC, many bacteria, 0 epis
Studies:
CXR [**2113-12-6**]: Mild CHF; Despite the given history, a right-sided
PICC is not seen.
Abd x-ray [**2113-12-6**]: Non-obstructive bowel gas pattern with
moderately dilated stomach.
CT abd w/oral contrast only, [**2113-12-6**]:
1. Nonspecific inflammatory stranding and fascial thickening
around the right kidney and proximal right ureter without
hydronephrosis or stones. Assessment for underlying infection
or urothelial mass is significantly limited without IV contrast,
and cannot be excluded.
2. Bilateral renal cysts.
3. Marked prostatic enlargement with evidence of chronic
bladder outlet obstruction including bladder wall thickening and
trabeculation. Assessment for underlying bladder wall mass is
limited without IV contrast and given the decompressed state of
the bladder.
4. Consolidation at the visualized lung bases, left greater than
right, concerning for pneumonia/aspiration.
5. Lipoma along the proximal right femoral metadiaphysis
Micro
Stool, Cdiff [**2113-12-4**] - negative
Blood cultures [**2113-12-6**] - pending
Urine culture [**2113-12-6**] -
PROTEUS MIRABILIS. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PROTEUS MIRABILIS
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- 32 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 8 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ 8 I
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- 32 I
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ 2 S
TRIMETHOPRIM/SULFA---- =>16 R
Brief Hospital Course:
[**Age over 90 **] y.o. man with CAD, CHF, DM, p/w hypotension and acute on
chronic renal failure.
Hypotension: The patients hypotension was originally thought
most likely secondary to sepsis. He was started on
vanco/cefepime/flagyl. Suspected sources were urosepsis given
retained urine (and positive UA) or colitis (cdiff) given recent
abx and diarrhea. The patient was hydrated and briefly on
dopamine for hypotension. This was quickly weaned off and the
patient was volume resusitated. His urine eventually grew
Proteus sensitive to ceftriaxone (see results section for full
sensitivies). His vancomycin was discontinued. He remains on
flagyl for now until stool cultures are able to be sent (did not
have BM while at [**Hospital1 18**]).
Acute on chronic renal failure: Baseline cr 1.6. The patient
was admitted with a creatinine of 4.6. He was likely pre-renal
secondary over diuresis while at rehab and infection
(urosepsis). The patient creatinine was trending down at the
time of discharge after volume resusitation.
Urinary Retention: The patient had urinary retention at the time
of admission and needed a foley placed. His prostate was noted
to be large on CT abdomen. A foley was kept in at the time fo
discharge. He was started on proscar and will need follow up in
the [**Hospital 159**] Clinic in [**12-6**] weeks.
Altered mental status: likely multifactorial, including
infection, toxic metabolic (uremia). Was slowly improving at
the time of discharge.
CHF, ef 25%: Per [**Hospital1 1501**] records, dry weight around 260-264 lbs.
Admission wt 255. Bibasilar crackles are likely chronic. His
carvedilol, lisinopril, lasix, and metolazone were held on this
admission because of his hypotension. These should all be added
back as tolerated.
Medications on Admission:
ASA 325 mg daily
Carvedilol 12.5mg PO BID
Lisinopril 2.5mg PO Daily
Celexa 20mg PO daily
Metolazone 5mg PO BID
Clonazepam 0.5mg QHS (stopped [**2113-11-30**])
Lasix 100mg PO BID (stopped [**2113-12-4**])
Insulin 70/30 12 units daily at 0730
Colace 250mg PO daily
Senna 2 tabs PO QHS
Sorbitol soln 70%, give 30ML PO BID
RISS
Tylenol 975mg TID at 0800, 1200, 1800
Nystatin cream [**Hospital1 **] to groin
Duoderm and Senicare to sacrum
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime as
needed.
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Celexa 20 mg Tablet Sig: One (1) Tablet PO once a day.
4. Ceftriaxone-Dextrose (Iso-osm) 1 gram/50 mL Piggyback Sig:
One (1) Intravenous Q24H (every 24 hours) for 10 days: day 1 =
[**2113-12-6**].
5. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig:
Five Hundred (500) mg Intravenous Q8H (every 8 hours) for 14
days: day 1 = [**2113-12-6**].
6. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Colace 100 mg Capsule Sig: 2.5 Capsules PO once a day.
8. insulin 70/30 Sig: Twelve (12) units once a day.
9. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours.
10. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Urosepsis - Proteus
Hypotension
Urinary retention
Discharge Condition:
Stable
Discharge Instructions:
You were admitted to the hospital with low blood pressure and a
urinary tract infection. We treated you with IV fluids and
antibiotics. You may also have an infection of your colon
called c diff so we are presumptively treating you with an
antibiotic for this infection.
At the time of admission you were found to have urinary
retention so a foley catether had to be placed. This is likely
because your prostate is enlarged. You will need to see a
urologist in the next few weeks for follow up. I have made you
an appointment with Dr [**Last Name (STitle) 3748**] on [**12-28**].
We did not give you your carvedilol, lisinopril, lasix, and
metolazone during this admission because of his hypotension.
These should all be added back as tolerated by your doctor.
Followup Instructions:
-- I have made you an appointment with urology (Dr [**Last Name (STitle) 3748**] on
[**12-28**] at 7:30am. His office is located on the [**Location (un) 470**]
of the [**Hospital Ward Name 23**] Building. The phone number is [**Telephone/Fax (1) 164**] in
case you need to change the appointment.
--Please follow up with your primary care doctor in the next few
weeks.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
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icd9cm
|
[
[
[]
]
] |
[
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icd9pcs
|
[
[
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8219, 8285
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290, 296
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8379, 8388
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3025, 5084
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2591, 2609
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324, 1832
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,391
| 152,271
|
20514+57167
|
Discharge summary
|
report+addendum
|
Admission Date: [**2142-6-10**] Discharge Date: [**2142-6-23**]
Date of Birth: [**2076-8-1**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
[**Date range (1) 54890**] intubation
[**6-14**]- L-IJ Quinton line for temp HD
[**6-13**]- placement of R-IJ Cordis w/ PA catheter
[**6-12**]- PICC line placement
[**6-11**]- Cardiac catheterization
History of Present Illness:
Mr [**Known lastname 17029**] 65 year old man with past medical history
significant for hypertension, hyperlipidemia, coronary artery
disease s/p CABG and recent PTCA with BMS to D1 [**2142-3-19**], CHF
(EF 40%) presenting with worsening difficulty breathing for the
past 3 days.
.
Patient reports worsening difficulty breathing for the past 3
days. He has been residing in rehab facility after recent TMA of
Right foot for non healing diabetic foot ulcer. Patient
describes shortness of breath with exertion (transfering to and
from wheelchair) that was at its worse today, and was associated
with chest burning which lasted one hour. Patient denies any
frank pain, arm / neck / jaw pain or tingling, did not
experience palpitations or syncope / presyncope/
lightheadedness.
.
Per Transfer note, pt coplained of shortness of breath and chest
pain at rehab facility. Pt given SL Nitro with good effect,
however with new recurrent episode shortly thereafter EMS was
called and patient trasnferred to [**Hospital1 18**] for evaluation.
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, palpitations, syncope or
presyncope.
.
In the ED: 0 98.8 80 179/54 100% ? NC. Patients ECG obtained and
concerning given worsened ST elevations in setting of LBBB. Code
stemi called, patient given 40mg lasix IV, 1 inch nitro paste,
Heparin bolus given only 6K, integrilin bolus 18, 600 plavix
load, aspirin 324mg more given. He was guaiac negative. After
evaluation by cardiology fellow, clinical presentation felt to
be more suggestive of volume overload and hyperkalemia. Code
stemi cancelled, patient admitted to [**Hospital1 1516**] service for futher
managment.
.
At time of transfer, VS HR 72 118/42 21 4L NC 95%. Patient
remained chest pain free while in the ED, no urine output was
recorded.
Past Medical History:
CAD s/p 4 MI's ([**2125**], [**2134**], [**2142**])
Diabetes mellitus type II
Neuropathy
Retinopathy
diabetic foot ulcer
PVD
Hypertension
Hyperlipidemia
GERD
Depression
h/o alcoholism- stopped drinking 25 years ago
? ischemic colitis per OMR
Right fem-DP, L fem-[**Doctor Last Name **] with stents bilaterally
3 vessel CABG,
? history of partial colectomy from ischemic colitis
(looks like appendectomy on CT scan)
s/p amputation of 2nd left toe
Social History:
Retired automechanic. No current alcohol or tobacco. Prior
smoker: 80 pack-years, quit in [**2125**] after first MI per OMR.
Previous alcoholism- no alcohol for 25+ years.
Family History:
Mother with breast cancer at 54. Father with alcohol abuse,
multisystem organ failure at 77.
Physical Exam:
VS - 98.6 158/50 72 95% 3L NC
Gen: WDWN middle aged male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with JVP of 18 cm.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, soft I/VI systolic crescendo murmur at RUSB. No S3 or S4.
Chest: Decrased air movement, bilateral crackles at bases.
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits.
Ext: RLE with dressing that is clean, dry, intact, 1+ pitting
edema.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
Labs on admission:
[**2142-6-10**] 09:42PM cTropnT-0.05*
[**2142-6-10**] 09:42PM CK-MB-3
Micro:
[**2142-6-12**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL INPATIENT
GRAM STAIN (Final [**2142-6-13**]):
[**12-10**] PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final [**2142-6-15**]):
MODERATE GROWTH Commensal Respiratory Flora.
Imaging:
C Cath ([**2142-6-11**]):
COMMENTS:
1. Coronary angiography in this left-dominant system revealed
diffuse
coronary artery disease. The LMCA was a small caliber vessel
without
disease. The LAD had 60-70% calcified stenoses of the proximal
section,
as well as the diagonal branch, and was occluded after the
mid-section.
The LCX had sequential stenoses of the proximal and distal LCX,
with
occluded OM1 and OM2 branches, and total occlusion after the
distal LCX.
The RCA was a non-dominant vessel with sequential 80% stenoses.
2. Selective graft venography revealed a widely patent SVG-PDA
and LPL
graft. The SVG-OM1 graft had a 30-40% stenosis in the mid-SVG,
and was
patent to the OM1 branch.
3. Selective graft arteriography revealed a widely patent
LIMA-LAD
graft.
4. Resting hemodynamics revealed elevated right- and left-sided
filling
pressures, with mean RA pressure of 15 mmHg, and mean PCW
pressure of 30
mmHg. The wedge tracing was notable for a prominant v-wave with
pressure of 51 mmHg, consistent with possible mitral
regurgitation.
There was mild pulmonary hypertension with mean PA pressure of
38 mmHg,
and mild systemic hypertension, with SBP of 140mmHg. The
cardiac output
was normal at 5.1 L/min. There was no aortic stenosis detected
by
pullback technique.
5. Nonselective left subclavian injection revealed a 70%
stenosis of the
proximal left subclavian artery, with a 45 mmHg pressure drop
across the
stenotic lesion.
FINAL DIAGNOSIS:
1. Diffuse coronary artery disease.
2. Elevated left- and right-sided filling pressures.
3. Mild pulmonary and systemic hypertension.
4. Subclavian stenosis.
CXR ([**2142-6-10**]):
IMPRESSION: Cardiomegaly, bilateral airspace opacity, right
greater than
left, concerning for pulmonary edema with bilateral pleural
effusions, also greater on the right.
Echo ([**2142-6-12**]):
The left atrium is moderately dilated. There is mild symmetric
left ventricular hypertrophy. The left ventricular cavity is
mildly dilated. LV systolic function appears
moderately-to-severelydepressed (ejection fraction 30 percent)
secondary to akinesis of the posterior wall and hypokinesis of
the inferior septum, anterior free wall, and apex. Tissue
Doppler imaging suggests an increased left ventricular filling
pressure (PCWP>18mmHg). Right ventricular chamber size and free
wall motion are normal. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Moderate (2+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. Moderate [2+]
tricuspid regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
A possible discontinuity in the myocardium between the inferior
and posterior wall at the basal level is seen. The discontinuity
occurs where normal inferior wall meets akinetic posterior wall.
This could represent a contained pseudoaneurysm of the left
ventricle. This finding was present on the prior study.
Compared with the findings of the prior study (images reviewed)
of [**2142-5-1**], the mitral regurgitation is increased.
CT Chest ([**2142-6-13**]):
IMPRESSION:
1. Severe coronary artery atherosclerosis. Anemia.
2. Likely asymmetric pulmonary edema. Contribution of drug
reaction, for
example amiodarone toxicity, pulmonary hemorrhage or aspiration
cannot be
assessed in the setting of cardiac decompensation.
3. Asbestos-related pleural plaques. Basal rounded atelectasis,
greater on
the right, stable for three years.
4. Mild-to-moderate emphysema apical predominant.
Abd Ultrasound ([**2142-6-14**]):
IMPRESSION:
1. No hydronephrosis.
2. Normal liver Doppler.
3. No extra- or intra-hepatic biliary duct dilatation.
CT A/P ([**2142-6-14**]):
1. No evidence of retroperitoneal hemorrhage or hemorrhage in
the left groin (the site of recent catheterization).
2. New bilateral basal consolidations, likely relate to
aspiration.
3. Small amount of simple ascites, new since prior study.
4. Extensive atherosclerotic disease.
Gallbladder U/S ([**2142-6-17**]):
1. No evidence of acute cholecystitis or intra- or extra-hepatic
biliary
ductal dilation.
2. A echogenic focus in the gallbladder neck measuring 1.2 cm,
could either represent a polyp, adherent sludge or a
non-calcified stone. Follow-up evaluation upon resolution of
acute symptoms is recommended.
CXR ([**2142-6-19**]):
AP single view of the chest has been obtained with patient
sitting
semi-upright position. Available for comparison is a preceding
similar study dated [**2142-6-17**]. During the two days examination
interval, the patient has been extubated. Comparison of heart
size obtained in portable AP position suggests mild regression
of cardiac enlargement. This is also supported by the less
marked perivascular haze previously noted in the pulmonary
circulation. Although the diaphragmatic contours are now again
visible, although blunting of the lateral pleural sinuses
persists, indicating some remaining pleural effusion. Previously
described left internal jugular approach central venous line as
well as a similar right-sided line persist. The latter still
carrying the Swan-Ganz catheter seen to reach the central
portion of the right PA. No evidence of pneumothorax or newly
developed discrete pulmonary parenchymal infiltrates that would
indicate the presence of pneumonia in this patient with
leukocytosis.
Brief Hospital Course:
** PATIENT WAS DISCHARGED AGAINST MEDICAL ADVICE ON [**2142-6-23**] **
Mr. [**Known lastname 17029**] is a 65 year-old man with CAD s/p previous CABG
who was admitted w/ shortness of breath, transferred to the CCU
for SOB and hypoxia.
1. HYPOXIC RESPIRATORY FAILURE- This was likely exacerbated in
the setting of pulmonary edema with possible superimposed
infection. Volume overload and newly diagnosed mitral
regurgitation also contributed to difficulty breathing. Pt was
intubated on [**6-12**] for increasing respiratory distress. He was
treated with an 8-day course of vanc/cefepime for aspiration
pneumonia. He was initially diuresed with lasix boluses and
lasix drip, but due to poor urine output and increasing
creatinine, drip was discontinued. On [**6-13**], diurses with lasix
boluses and metolazone was initiated and renal was consulted,
who recommended starting CVVH. On [**6-14**], pt started diuresis with
CVVHD for pulmonary edema in setting of worsening MR. CVVH was
continued until [**6-18**]. Pt was extubated on [**6-17**], without
complications. In the setting of aggressive diuresis, pt's
respiratory status continued to improved and he was called-out
to the floor on [**6-21**]. Pt was comfortable on room air, prior to
discharge when he chose to be released AGAINST MEDICAL ADVICE on
[**2142-6-23**].
2. ACUTE ON CHRONIC SYSTOLIC HEART FAILURE: Patient was
clinically volume overloaded and cardiac catheterization showed
evidence of new MR (but patent grafts). Patient had little
diuresis with IV lasix on the general medical floors, and was
transfered to the CCU due to increasing oxygen requirement. He
required intubation in the setting of aspiration while on
facemask, with desaturation to 70%. While intubated, he had
little output to lasix, and required CVVH for a net of [**11-27**]
liters off. As he approached the euvolemic state, he was
successfully extubated. He was maintained on beta blocker,
plavix, and statin. ACEi was not started given ARF, but should
be considered in future. Optimized afterload reduction in
setting of new MR [**First Name (Titles) 151**] [**Last Name (Titles) **].
3. ACUTE ON CHRONIC RENAL FAILURE: This was likely in setting of
poor forward flow (Fe Urea 16%) s/p CVVH. Electrolytes
acceptable, volume status much improved and appeared to be
euvolemic on exam. Pt's urine output improved. CVVH continued
until [**6-18**] and pt underwent hemodialysis on [**6-19**]. His creatinine
trended downwards without the need for regular hemodyalysis.
Patient LEFT AGAINST MEDICAL ADVICE on [**6-23**] before further
parameters could be discussed.
4. ATRIAL FLUTTER: Patient demonstrated new slow aflutter in the
CCU. He underwent bedside cardioversion on [**6-15**] and converted to
normal sinus rhythm. For rate control, beta blocker and
amiodarone were initiated. Initially he was maintained on
heparin gtt which was later transitioned to coumadin.
5. HYPERTENSION: Pt was continued on [**Month/Year (2) **]/ metoprolol.
Optimized with goal SBP??????s 100-110??????s and HR 60??????s. Of note,
patient had left-sided subclavian stenosis (proximal LIMA) with
disparate blood pressure in upper extremities. [**Month (only) 116**] consider
intervention for subclavian stenosis as outpatient (not done as
inpatient in cath given the dye load and renal failure)
6. TRANSAMINITIS: Pt's LFTs were consistent with cholestatic
picture- he had a negative RUQ U/S and CT initially, but repeat
RUQ showed a questionable stone in the gallbladder neck vs
echogenic focus, but this was non- obstructing. There could be
some component of congestion, but could be also medication
effect from Statin or Zosyn. Atorvastatin was decreased from
80mg to 40mg daily and initial zosyn for hospital-acquired
pneumonia coverage was changed to cefepime. LFT's were carefully
monitored throughout hospital course and trended downward.
7. ANEMIA: Unclear etiology. There were no signs of active
bleeding on exam. His Hct increased appropriately after 4 units
PRBC transfusion. Pt underwent abdominal CT on [**6-14**] to rule-out
retroperitoneal bleed given recent catheterization on [**6-11**].
There was no evidence of RP bleed on CT. His hemolysis labs were
negative. His blood pressures and HCTs remained stable
throughout the remainder of his hospital course and he did not
require further blood transfusions.
8. Diabetes mellitus type II: insulin was continued per
outpatient regimen
9. Diabetic foot ulcer: s/p R- TMA. Incision was clean, no
evidence of infection at this time, sutures intact. Seen by
vascular surgery as inpatient, who recommended outpatient
follow-up.
Medications on Admission:
# Atorvastatin 40 mg Tablet Daily.
# Clopidogrel 75 mg Tablet Daily.
# Aspirin 325 mg Tablet Daily.
# [**Month/Year (2) 23928**] 10 mg Daily.
# Metoprolol Tartrate 50 mg 2 times a day.
.
# Lorazepam 0.5 mg every 4 hours as needed for anxiety.
# Sertraline 100 mg Daily.
# Temazepam 15 mg Capsule PO HS as needed for insomnia.
.
# Heparin (Porcine) 5,000 TID (3 times a day).
# Acetaminophen 325 mg for pain, fever.
# Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed for pain.
# Ranitidine HCl 150 mg Tablet
.
# Humalog Sliding Scale
# NPH Insulin
- 20 Units AM, and 24 Units PM
# Humalog
- 10 units with breakfast, 12 units with dinner
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. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for anxiety.
5. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
Disp:*30 Tablet(s)* Refills:*2*
8. Outpatient Lab Work
Please check LFT's, INR on tuesday [**6-26**] with results to Dr.
[**Last Name (STitle) 35501**]
9. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
10. 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:*2*
11. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
12. NPH Insulin Human Recomb 100 unit/mL Suspension Sig: as
directed units Subcutaneous twice a day: 20 units in the morning
and 24 units in the evening.
13. Insulin Lispro 100 unit/mL Solution Sig: as directed units
Subcutaneous twice a day: 10 units with breakfast, 12 units with
dinner.
Discharge Disposition:
Home with Service
Discharge Diagnosis:
Acute on chronic systolic congestive heart Failure
Acute Renal Failure
Diabetes Mellitus Type 2
AFlutter
Discharge Condition:
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You had trouble breathing and some chest pain. You were
transferred here and found to have a heart attack. You had a
cardiac catheterization which showed your arteries are open but
you have a blockage in your subclavian vein. You developed
congestive heart failure and acute renal failure which is now
resolved. You received antibiotics for pneumonia. You also now
have a heart rhythm called aflutter which is not dangerous but
does put you at risk for a stroke. WE have made the following
medication changes:
1. Start amiodarone 200mg daily to treat the aflutter and
control your heart rate
2. Start coumadin to thin your blood and prevent blood clots and
strokes. You will need to check your coumadin level (INR) on
Tuesday at Dr.[**Name (NI) 54891**] office and they will tell you how much
coumadin to take from now on.
3. change the metoprolol 50mg twice daily to "Toprol" 50mg once
daily, this is the long acting form of metoprolol
4. stop taking Percocet
5. Stop taking Temazepam, take Trazadone instead to sleep.
6. stop taking [**Name (NI) 23928**] and take lisinopril 5mg daily instead
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Primary Care:
[**Last Name (LF) **],[**First Name3 (LF) **] A. Phone: [**Telephone/Fax (1) 54889**] Date/time: Tuesday [**6-26**] at
1:15pm.
.
Cardiology:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 37559**] Phone: ([**2142**] Date/Time: Please call the
office when you get home and make an appt in 5 days of your
discharge from the hospital. Also, if you would like you can
see Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at the [**Hospital3 **] ([**Telephone/Fax (1) 9410**], he is a
cardiologist and you have seen him once in the past.
Completed by:[**2142-6-23**] Name: [**Known lastname 10264**],[**Known firstname **] A. Unit No: [**Numeric Identifier 10265**]
Admission Date: [**2142-6-10**] Discharge Date: [**2142-6-23**]
Date of Birth: [**2076-8-1**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4473**]
Addendum:
The patient did not have a STEMI during this admission as there
were no documented ST elevations on his EKGs. It is likely he
had an NSTEMI as cardiac enzymes were elevated; however there
are many reasons cardiac enzymes can be elevated such as demand
ischemia from hypoxia. The patient may have had an underlying
infectious process consistent with pneumonia, but this was
difficult to tease out radiographically and clinically, in the
setting of his underlying volume overload from acute mitral
regurgitation. He was treated with the appropriate antibiotic
course to cover pneumonia, but his difficulty breathing was
multifactorial.
Discharge Disposition:
Home with Service
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4474**] MD [**MD Number(1) 4475**]
Completed by:[**2142-7-9**]
|
[
"250.60",
"V58.67",
"585.9",
"357.2",
"362.01",
"518.81",
"507.0",
"414.01",
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"276.7",
"410.71",
"311",
"428.0",
"447.1",
"V45.82",
"403.90",
"486",
"424.0",
"443.9",
"285.9",
"530.81",
"276.1",
"412",
"584.5",
"416.8",
"V15.82",
"427.32",
"V45.81",
"428.23"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.64",
"37.23",
"38.93",
"99.20",
"39.95",
"99.61",
"88.56",
"38.95",
"96.04",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
20091, 20266
|
10246, 14869
|
333, 535
|
17081, 17198
|
4223, 4228
|
18432, 20068
|
3422, 3517
|
15597, 16890
|
16953, 17060
|
14895, 15574
|
6230, 10223
|
17222, 17713
|
3532, 4204
|
17733, 18409
|
274, 295
|
563, 2746
|
4242, 6213
|
2768, 3216
|
3232, 3406
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,580
| 187,272
|
44648
|
Discharge summary
|
report
|
Admission Date: [**2168-5-23**] Discharge Date: [**2168-5-26**]
Date of Birth: [**2085-2-23**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Hemodialysis
History of Present Illness:
This is an 83-year-old Rusian-speaking gentleman with multiple
problems including CAD s/p CABG, ischemic cardiomyopathy with
systolic and diastolic heart failure (EF 40%), CKD stage V on
HD, [**First Name3 (LF) **] sinus syndrome s/p pacemaker, s/p CVA with residual
left facial droop and RLE weakness, DMII, recent admission to
[**Hospital1 112**] for LLE transmetatarsal amputation who presents with acute
dyspnea. Started mid-morning, VNA noted patient was dyspnic,
called EMS, enroute became acutely worse. Noted to be hypoxic to
mid-80's in triage. Similar episode of dyspnea during recent
hospitalization that resolved after HD.
.
Patient reports not feeling well on morning of admission. He
says his blood pressures were low in the 80s/40s and his sugars
were low at 85. He had [**Location (un) 2452**] juice, pickles and some other food
and then had an episode of nausea and vomiting. He called his
VNA who evaluated him and felt that he sounded crackly on exam
and sent to the ED. He reports some chest pressure and shortness
of breath. He denies cough, abdominal pain, diarrhea, urinary
symptoms (patient makes little urine at baseline).
.
In the ED, initial VS were 38 84% and was in respiratory
distress. Exam was significant for RLL crackles. Labs were
significant for WBC count of 23.7 with 93% neutrophils (no
bands), K of 6.1, lactate of 2.6. ECG showed paced rhythm
without peaked T waves. CXR showed findings consistent with
volume overload. Patient was given levofloxacin and cefepime for
possible pneumonia. He was then admitted to the MICU for
further care given hypoxia and need for dialysis.
.
On arrival to the MICU, patient felt continued shortness of
breath and chest pressure. He was given antibiotics and
dialyzed and breathing improved.
Past Medical History:
-Ischemic cardiomyopathy with chronic systolic and diastolic
heart failure (lTTE [**11/2167**] LVEF 40%, LV inferior hypokinesis,
mild MR, borderline, pulm HTN)
- Coronary artery disease, s/p CABG x3 [**2151**]
- Hypertension.
- Severe PAD/PVD s/p left femorotibial bypass, recent left TMA,
prior right TMA
- Hypothyroidism.
- Diabetes mellitus type II
- Chronic kidney disease stage V on HD
- Kidney stones.
- Spinal stenosis.
- Pulmonary nodules on CT.
- Multiple pneumonias.
- GI bleed ([**2161**], [**2162**])
- [**Year (4 digits) **] Sinus Syndrome, s/p A-V pacer
- Anemia of chronic disease
- CVA in [**2146**] with residual left facial droop and right leg
weakness
Social History:
Russian-speaking only. He is a widower who lives alone. Uses a
wheelchair. He emigrated from [**Location (un) 3155**] in [**2147**]. He has a
30-pack-year smoking history, quit 25-years-ago. Denies alcohol
use.
Family History:
Mother: hypertension.
Father: died at age 46 in [**Country 532**].
Sister: hypertension and a [**Last Name **] problem.
[**Name (NI) **] [**Name2 (NI) 499**] cancer or gastric cancer in his family history.
Daughter and grandson also have chronic anemia.
Physical Exam:
Admission exam:
Vitals: 115/48 60 28 100% NRB
General: Alert, oriented, in some respiratory distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP elevated to angle of the jaw while at 45
degrees, no cervical LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops. L. IJ dialysis catheter in place.
Lungs: Bibasilar crackles, no wheezes
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, bilateral distal foot amputations with wound vac in
place over LLE. pulses dopplerable. New fistula thrill noted in
LUE. LUE radial pulse dopplerable with cool fingers on left. RUE
with palpable pulse. no LE edema
Neuro: CNII-XII intact, 5/5 strength upper extremities and LLE.
4/5 strength in RLE.
Skin: ecchymosis noted over both arms
Discharge exam:
Vitals: T 97.5 BP 112/56 64 18 100% RA
General: Alert, oriented, in some respiratory distress
HEENT: MMM, OP clear
Neck: supple, no JVD
CV: RRR, normal S1 + S2, no m/r/g. Left IJ dialysis catheter in
place.
Lungs: Bibasilar crackles, no wheezes, mild decreased breath
sounds on left side
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, bilateral distal foot amputations. Well-healed wound
on LLE. New fistula thrill noted in LUE. Cool fingers on left
with weak radial pulse. RUE with palpable pulse. no LE edema
Neuro: CNII-XII intact, 5/5 strength upper extremities and LLE.
4/5 strength in RLE.
Skin: ecchymosis noted over both arms
Pertinent Results:
Admission labs:
[**2168-5-23**] 01:30PM WBC-23.7*# RBC-3.31* HGB-9.2* HCT-31.5*
MCV-95 MCH-28.0 MCHC-29.3* RDW-18.6*
[**2168-5-23**] 01:30PM NEUTS-93.4* LYMPHS-4.3* MONOS-2.0 EOS-0.2
BASOS-0.1
[**2168-5-23**] 01:30PM PLT COUNT-453*#
[**2168-5-23**] 01:30PM GLUCOSE-183* UREA N-43* CREAT-5.4*#
SODIUM-133 POTASSIUM-6.1* CHLORIDE-97 TOTAL CO2-17* ANION
GAP-25*
[**2168-5-23**] 01:39PM LACTATE-2.6*
[**2168-5-23**] 04:30PM CALCIUM-7.8* PHOSPHATE-5.6*# MAGNESIUM-2.2
[**2168-5-23**] 01:30PM cTropnT-0.44* proBNP-[**Numeric Identifier 95565**]*
[**2168-5-23**] 05:58PM TYPE-[**Last Name (un) **] PO2-18* PCO2-38 PH-7.49* TOTAL
CO2-30 BASE XS-4
[**2168-5-23**] 05:58PM LACTATE-2.1*
[**2168-5-23**] 08:15PM CK-MB-2 cTropnT-0.53*
[**2168-5-23**] 08:15PM CK(CPK)-36*
Discharge lab:
[**2168-5-26**] 04:53AM BLOOD WBC-8.1# RBC-3.33* Hgb-9.4* Hct-32.5*
MCV-97 MCH-28.2 MCHC-29.0* RDW-19.3* Plt Ct-326
[**2168-5-26**] 04:53AM BLOOD Plt Ct-326
[**2168-5-26**] 04:53AM BLOOD
[**2168-5-26**] 04:53AM BLOOD Glucose-76 UreaN-19 Creat-3.0* Na-136
K-3.6 Cl-93* HCO3-32 AnGap-15
[**2168-5-26**] 04:53AM BLOOD Calcium-7.9* Phos-3.6 Mg-2.1
CXR [**2168-5-23**]:
Evaluation of the patient with CAD, end-stage renal
disease on hemodialysis with dyspnea.
Portable AP radiograph of the chest was reviewed in comparison
to [**2168-5-23**] obtained at 1:32 p.m.
Since the prior study no substantial change has been
demonstrated in the
cardiomediastinal silhouette, position of pacemaker leads and
hemodialysis catheter as well as small bilateral pleural
effusion. Right upper lobe opacity is slightly more conspicuous
on the current study but that might be due to interval
improvement in the right lower lobe opacity as overall
improvement of the aeration of the right lung is noted. There
is no pneumothorax.
.
ECHO [**2168-5-24**]:
There is mild symmetric left ventricular hypertrophy. LV
systolic function appears depressed with lateral hypokinesis and
probable anterior hypokinesis but views are suboptimal for
assessment of regional wall motion (estimated ejection fraction
?35-40%). Right ventricular chamber size is normal. The aortic
valve leaflets are mildly thickened (?#). The aortic valve is
not well seen. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild to moderate ([**1-11**]+) 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 at least mild pulmonary
artery systolic hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2167-11-27**],
findings are probably similar although studies are technically
suboptimal for comparison. The tricuspid regurgitant peak
gradient is slightly lower than in the previous study but may be
underestimated.
Brief Hospital Course:
This is an 83-year-old gentleman with multiple medical problems
including CAD, ischemic cardiomyopathy, s/p CVA, CKD stage V on
HD, [**Year (4 digits) **] sinus s/p pacemaker, DM II, and recent left TMA
amputation who presents with acute dyspnea found to be volume
overloaded on exam and with leukocytosis.
.
# DYSPNEA/HYPOXIA: Likely in the setting of flash pulmonary
edema (due to dietary indiscretion and volume overload) and
pneumonia. Patient was emergently dialyzed upon arrival in the
MICU and hypoxia improved. Also given broad spectrum
antibiotics in setting of RLL infiltrate and meeting SIRS
criteria. A TTE was ordered to evaluate for interval silent
ischemia that may have caused worsening of CHF; this was
unchanged from prior. His symptoms improved with extra fluid
removal from HD. At discharge he is satting at 100% on RA
without SOB and he remained afebrile with downtrending WBC. We
switched his antibiotics to levofloxacin for another 4 days
through [**2168-5-30**] to complete a course for HCAP.
# COLD LUE: Distal left UE was cold, numb, and tender. Likely
steal syndrome from recently placed AV fistula. Not a surgical
emergency per transplant surgery. No need for LUE U/S. Will have
outpatent follow up with Dr. [**Last Name (STitle) **] on [**2168-5-27**] at [**Hospital1 112**].
# CKD stage V on HD [**2-11**] DIABETIC NEPHROPATHY: Renal team was
consulted and he underwent emergent HD as noted above. Continue
HD M,W,F. Continued nephrocaps and midodrine.
.
# ELEVATED TROPONINS: this was likely demand ischemia in the
setting of dyspnea with inability to clear troponins because of
ESRD. CK-MBs were normal. ECHO unchanged from prior.
.
# RECENT LLE TMA: Patient was evaluated by vascular surgery.
Dressing changes as per nursing. Wound vac was removed.
.
# CAD s/p CABG, PVD: stable: Continued ASA, plavix, statin,
beta blocker
.
# PAROXYSMAL AFIB: Patient was continued amiodarone and
aspirin. He has refused coumadin in the past.
.
# DMII: Home lantus was changed to 15units QHS (instead of
25units QHS) due to relative hypoglycemia. A sliding scale was
continued.
.
# HYPOTHYROIDISM: Synthroid was continued.
.
Patient was confirmed full code during this admission. Contact
is daughter: ([**Name (NI) **]) [**Telephone/Fax (1) 95566**].
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Amiodarone 200 mg PO DAILY
2. Atorvastatin 40 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. Polyethylene Glycol Dose is Unknown PO DAILY:PRN
constipation
5. Pantoprazole 40 mg PO Q24H
6. Levothyroxine Sodium 100 mcg PO DAILY
7. Nephrocaps 1 CAP PO DAILY
8. Glargine 25 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
9. Metoprolol Succinate XL 25 mg PO DAILY
Hold if SBP < 100 or HR < 60. On dialysis day take this after
dialysis
10. Midodrine 2.5 mg PO PRE HD
Take this each time before your dialysis
11. Albuterol Dose is Unknown PO TID
12. OxycoDONE (Immediate Release) Dose is Unknown PO Frequency
is Unknown
13. Aspirin
Discharge Medications:
1. Amiodarone 200 mg PO DAILY
2. Atorvastatin 40 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. Glargine 25 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
5. Levothyroxine Sodium 100 mcg PO DAILY
6. Hydrocortisone (Rectal) 2.5% Cream 1 Appl PR QD Hemorrhoids
RX *hydrocortisone-pramox-E-pram#1 2.5 %-1 %-1 % once a day Disp
#*1 Kit Refills:*0
7. Levofloxacin 250 mg PO DAILY Duration: 4 Days
Through [**2168-5-30**].
RX *levofloxacin 250 mg once a day Disp #*4 Tablet Refills:*0
8. Pantoprazole 40 mg PO Q24H
9. Nephrocaps 1 CAP PO DAILY
10. Metoprolol Succinate XL 25 mg PO DAILY
Hold if SBP < 100 or HR < 60. On dialysis day take this after
dialysis
11. Polyethylene Glycol 17 g PO DAILY:PRN constipation
12. Aspirin 81 mg PO DAILY
13. Midodrine 2.5 mg PO PRE HD
Take this each time before your dialysis
14. Heparin 5000 UNIT SC TID
15. Sarna Lotion 1 Appl TP QID:PRN Itchiness
16. Docusate Sodium 100 mg PO BID
17. Vitamin D 50,000 UNIT PO 1X/WEEK ([**Doctor First Name **])
Discharge Disposition:
Extended Care
Facility:
[**Hospital 4542**] Rehabilitation and Nursing of [**Location (un) 38**]
Discharge Diagnosis:
Primary diagnosis:
acute on chronic systolic and diastolic [**Hospital 1902**]
health care associated pneumonia
Secondary diagnoses:
LUE vascular steal syndrome
CKD stage V on HD
HTN
DM II
CAD s/p CABG x3 [**2151**]
[**Year (4 digits) **] Sinus Syndrome s/p AV pacemaker
severe PVD s/p bilateral TMA (most recently left, [**2168-4-10**])
hypothyroidism
anemia of chronic 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.
Discharge Instructions:
Dear Mr. [**Known lastname 95557**],
It was a pleasure taking care of you at [**Hospital1 18**]. You were admitted
to the hospital because you had shortness of breath. The cause
of your shortness of breath was due to fluid accumulation and
infection in your lung. You were treated with antibiotics.
Extra fluid was removed from hemodialysis. Your symptoms
subsequently improved. After discharge from the hospital, please
weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs. Please avoid food with high salt content.
.
The following changes were made to your medications:
--Start taking Levofloxacin (antibiotic) 250mg once a day for
the next 4 days through
--Lantus 15 units QHS (instead of 25 units) for DM
Followup Instructions:
Name: Dr [**First Name8 (NamePattern2) 1692**] [**Last Name (NamePattern1) **]
Location: [**Hospital1 112**]-Vascular & Endovascular Surgery
Address: [**First Name8 (NamePattern2) **] [**Hospital Ward Name 23**] 2 Clinic A, [**Location (un) 86**], MA Phone:
[**0-0-**]
Appt: Tomorrow, [**5-27**] at 9:30am
Department: CARDIAC SERVICES
When: MONDAY [**2168-8-22**] at 11:20 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
|
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"428.43",
"518.82",
"V45.01",
"V17.49",
"995.90",
"585.6",
"403.91",
"428.0",
"438.89",
"V12.72",
"250.40",
"443.9",
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] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
11928, 12027
|
7838, 10127
|
311, 325
|
12451, 12451
|
4897, 4897
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13397, 14119
|
3067, 3322
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10916, 11905
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12048, 12048
|
10153, 10893
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12627, 13374
|
3337, 4169
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12182, 12430
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4185, 4878
|
264, 273
|
353, 2126
|
4913, 7815
|
12067, 12161
|
12466, 12603
|
2148, 2821
|
2837, 3051
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,412
| 114,483
|
14731
|
Discharge summary
|
report
|
Admission Date: [**2195-2-19**] Discharge Date: [**2195-3-1**]
Date of Birth: [**2130-7-6**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 338**]
Chief Complaint:
Respiratory distress
Major Surgical or Invasive Procedure:
None
History of Present Illness:
64yo M with peripheral vascular disease (s/p left AKA),
hypertension, hyperlipidemia, chronic obstructive pulmonary
disease, and right deep venous thrombosis transferred from [**Hospital **]. He was at home and fell out of his wheelchair yesterday,
and couldn't get off the floor. Denies head trauma. Was taken to
[**Hospital3 **] and evaluated, then pt asked to be transferred here
because he has gotten most of his care here.
.
Prior to arrival, the patient got solumedrol and levofloxacin at
[**Hospital3 **] hospital. He got vanc and flagyl here. In our ED, he
was noted to have cough, wheezes, and bruises. He was found to
be hypoxic to 86% on RA on arrival, which improved to 99% on 4L
after nebs. VBG was 7/26/63/22. CXR showed possible left sided
pneumonia, but CT abdomen showed a left base pneumonia. The
abdominal CT also showed a large hematoma consistent with his
exam and history of falls. Though his creatinine was elevated,
the ED considered a CTA to rule out PE in the setting of a
positive D-dimer at [**Hospital3 **]; then considered a VQ scan but the
decision was made to defer these studies to the floor team. He
also had an elevated troponin of 0.05 and CK of 2935 (MB 24,
index 0.8) and was given aspirin. Cards was notified, but the
decision for official consult was deferred to floor team. The
patient was admitted to the MICU due to "tenuous respiratory
status". He is DNR/DNI.
Past Medical History:
1. History of seizure disorder, type unknown.
2. History of hypertension.
3. Chronic obstructive pulmonary disease.
4. History of left deep vein thrombosis.
5. History of peptic ulcer disease with gastrointestinal
bleed.
6. Remote history of osteoarthritis.
7. History of fracture of the left elbow.
8. Methicillin resistant Staphylococcus aureus infections in
[**2190-6-7**].
9. Vancomycin resistant enterococcus in [**2190-9-7**].
10. History of Clostridium difficile in [**2190-5-8**].
11. History of peripheral vascular disease, status post left
external iliac stenting in [**2189-12-8**].
Social History:
Lives at home alone in [**Location (un) 5110**]. No ETOH, tabacco x 40 years
currently 2 packs per day.
Family History:
Mother died of cancer, unknown which type or age at death.
Father died of MI in his 80s. Pt. has two brothers amd two
sisters.
Physical Exam:
V: T96.7 P62 BP 100/65 sat 92-95% 3LNC
Gen: sleepy but arousable. Gutteral voice difficult to
understand at times. No respiratory distress.
HEENT: right pupil reactive, left surgical. eyes disconjucate at
rest with right eye lateral deviated, but conjugate to movement
Neck: no JDV
Resp: wheezes diffusely with inspiration and expiration
CV: RRR nl s1s2 no MGR
Chest: left ecchymosis over chest above nipple, 10 cm in
diameter, well demarcated
Abd: ecchymotic, purple, with firm area left side. +BS nontender
Ext: left leg s/p AKA. small scab over [**Last Name (LF) **], [**First Name3 (LF) **] erythema.
right leg with erythema lower area, not warm, with some anterior
tibial ulcer 2 cm, and scab over medial malleolus (3 cm) without
drainage
Neuro: oriented to place, person, date
Pertinent Results:
[**2195-2-27**] 06:05AM BLOOD WBC-12.7* RBC-3.01* Hgb-9.7* Hct-29.0*
MCV-96 MCH-32.4* MCHC-33.6 RDW-15.9* Plt Ct-433
[**2195-2-26**] 05:38AM BLOOD Neuts-78.1* Lymphs-10.0* Monos-6.2
Eos-5.3* Baso-0.4
[**2195-2-26**] 05:38AM BLOOD Hypochr-3+ Anisocy-1+ Macrocy-3+
[**2195-2-27**] 06:05AM BLOOD PT-15.4* INR(PT)-1.4*
[**2195-2-21**] 06:20AM BLOOD ESR-40*
[**2195-2-27**] 06:05AM BLOOD Glucose-96 UreaN-31* Creat-1.0 Na-140
K-3.5 Cl-97 HCO3-35* AnGap-12
[**2195-2-20**] 03:20AM BLOOD CK(CPK)-2717*
[**2195-2-19**] 06:37PM BLOOD CK(CPK)-2208*
[**2195-2-19**] 01:32PM BLOOD CK(CPK)-2489*
[**2195-2-19**] 05:35AM BLOOD ALT-38 AST-85* CK(CPK)-2935* AlkPhos-128*
Amylase-29 TotBili-0.7
[**2195-2-19**] 05:35AM BLOOD Lipase-19
[**2195-2-24**] 06:15AM BLOOD proBNP-802*
[**2195-2-20**] 03:20AM BLOOD CK-MB-18* MB Indx-0.7 cTropnT-<0.01
[**2195-2-19**] 06:37PM BLOOD CK-MB-15* MB Indx-0.7 cTropnT-<0.01
[**2195-2-19**] 01:32PM BLOOD CK-MB-18* MB Indx-0.7 cTropnT-0.03*
[**2195-2-23**] 06:00AM BLOOD Calcium-8.7 Phos-2.7 Mg-2.2
[**2195-2-24**] 06:15AM BLOOD Triglyc-148 HDL-56 CHOL/HD-2.8 LDLcalc-71
[**2195-2-21**] 06:20AM BLOOD CRP-102.9*
[**2195-2-27**] 06:05AM BLOOD Vanco-25.6*
[**2195-2-24**] 06:15AM BLOOD Phenyto-4.0*
Brief Hospital Course:
A/P: 64M with history of PVD and COPD presents s/p fall with
COPD exacerbation, PNA, and RLE cellulitis/vascular insuficiency
who expired in the MICU.
#) COPD exacerbation +/- PNA - Admitted to ICU for O2sat in the
80's on room air but mid 90's on 3L NC. Pt neg for influenza.
Started on Levofloxacin for COPD exacerbation and a question of
retrocardiac opacity on CXR. Also started on Nebulizers and
Prednisone IV then tapered to 60mg PO. Following stabilization
in the MICU, his floor course was marked by waxing and [**Doctor Last Name 688**]
respiratory status with O2sats ranging from 88-96% on a
significant O2 requirement (3-4L, patient is not on oxygen at
home). He recieved a 7 day course of Levofloxacin and 6 days of
Prednisone 60mg. He benefited from Chest PT and clearance of
secretions with improved clinical exam and O2sats. His O2sats
were thought to be lowered in his digits by the presence of
significant PVD and forehead O2sats were obtained showing better
saturation. Given waxing and [**Doctor Last Name 688**] respiratory status and
O2sats, a repeat CXR was performed which was essentially
unchanged and did not reveal any acute cardiopulmonary process.
A Chest CT was also performed to r/o any evidence of mucus plug
and showed tracheobronchomalacia, collapse of the LLL concerning
for PE, and R pericardic triangular opacity. The patient was
started on Heparin IV drip and given NaHCO3 in D5W and a CTA was
obtain that showed no PE. Subsequently, patient's sats dropped
to 83 % on 4 L. He was given nebs and the 96% on 4L but sats
dropped to 85% on 4L again and Bp dropped to 90s systolic.
Patient was disoriented and denied any complaints VBG
7.36/86/47. He was transferred to the ICU for further management
where his respiratory status continued to worsen. Diuresis was
attempted with lasix but the pt did not have much UOP. O2 sats
were lowered to the low 90's given pt's somnolence and concern
for CO2 retention, but he continued to remain somnolent. He
became diaphoretic and tachycardic and was started on BiPAP.
Multiple ABG's were attempted but only venous blood was
obtained. His family was notified that his clinical status was
declining and they felt that he would only want intubation if it
would be a quick turn around. However, given his poor lung
function it was felt that the pt's course on the ventilator
would likely be long. His family felt he would not want this,
and thus the pt was made CMO. He expired a few hours later.
.
#) RLE pain/erythema: There was a 1.5x1.5 inch circular scabbed
ulcer involving the medial malleolus with surrounding erythema.
The patient stated that he had had the ulcer for approximately
2-4 weeks. The foot was thought to be cold on exam in the MICU
and he did not have a DPP pulse by doppler u/s. He remained
afebrile throughout his course and was start4d on Vancomycin due
to concern for cellulitis and his history of MRSA cellulitis.
Given his severe PVD, vascular insufficiency was also a
potential cause of the pain, erythema, and ulcer formation.
Vascular surgery was consulted and they performed a RLE
arteriogram revealing severe vascular insufficiency. Vein
mappping of the upper extremities was performed and a candidate
graft from the left upper extremity was identified. Per vascular
surgery, the wound care included dry dressing changes with
accuzyme QD.
.
#) Elevated troponin/CK - CK elevation most likely from fall.
Trop more likely from renal insufficiency. EKG without acute
changes. Assymptomatic.
.
#) Renal failure - He presented with a creatinine of 1.6 which
trended down to his baseline of 0.8 during his course.
.
#) Frequent falls with hematoma - Could be from seizures or
baseline immobility. Denies loss of consciousness but somnolent
on admission. Dilantin level low, however patient says that he
has not had seizures in years and did not appear post-icatl
during intial evaluation. His home dose of AEDs was continued.
.
#) PVD with edema: Continued ASA. Consulted vascular surgery as
above.
.
#) HTN - Continued metoprolol with adeuqate control. Was held
for pharmacologic stress echo testing.
.
#) GI - Patient did not have any stools during his floor course
while on narcotics and was started on an aggressive bowel
regimen.
Medications on Admission:
Magnesium Oxide 400 mg PO BID
Atorvastatin 10 mg PO DAILY
Amlodipine 5 mg PO DAILY
Ipratropium Bromide 0.02 % Solution Sig: 1-2 puffs Inhalation
Q6H (every 6 hours) as needed for COPD.
Pantoprazole 40 mg PO Q24H
Docusate Sodium 100 mg PO BID
Ibuprofen 400 mg PO Q8H prn
Phenytoin Sodium Extended 300 mg PO BID
Metoprolol 75mg PO
Furosemide 80 mg PO DAILY
Folic Acid 1 mg Tablet PO DAILY
Aspirin 325 mg po qd
Discharge Disposition:
Extended Care
Discharge Diagnosis:
COPD Exacerbation
Pneumonia
Right Leg cellulitis/vascular insufficiency
Discharge Condition:
expired.
Discharge Instructions:
pt expired.
Followup Instructions:
pt expired.
|
[
"440.23",
"401.9",
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"V49.76",
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"428.0",
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] |
icd9cm
|
[
[
[]
]
] |
[
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icd9pcs
|
[
[
[]
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9370, 9385
|
4676, 8911
|
290, 296
|
9501, 9511
|
3438, 4653
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9571, 9585
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2487, 2617
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230, 252
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324, 1730
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2364, 2471
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
83,497
| 132,356
|
29144
|
Discharge summary
|
report
|
Admission Date: [**2150-2-13**] Discharge Date: [**2150-2-18**]
Date of Birth: [**2083-11-10**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Jaundice
Major Surgical or Invasive Procedure:
[**2-14**] ERCP
History of Present Illness:
Mr. [**Known lastname 70132**] is a 66 year old man with a history of alcoholic
cirrhosis. He presented to his PCP with painless jaundice and
malaise. 4 days prior to arrival, patient noted insidious onset
of fatigue. He also noted some loose dark stool. The next day
he noted he was jaundiced with nausea/chills and lip cracking.
He denied any abdominal pain, fevers. He did note low urine
output, dizziness on standing. He gradually felt better, but an
orthpedic surgeon friend urged him to see his PCP. [**Name10 (NameIs) **] saw his
PCP today, who referred him to the [**Hospital3 **] ED There labs
demonstrated Cr 5.3, Total Bili 11.9, Direct Bili 10.2, Alk
Phos 141, ALT 124, AST 30. WBC 11.79 Hct 37.0 Plt 114. RUQ U/S
showed portal vein thrombosis, CBD dilatation 9mm. He was given
cipro/flagyl for ? cholangitis, IV protonix. Transferred to
[**Hospital1 18**] for consideration of ERCP.
On arrival to the ED T 97.2 HR 57 BP 95/56 RR 15 SpO2 95%/RA.
On exam, he was jaundiced, but otherwise well. ERCP consulted,
recommended MRCP. Admitted to [**Hospital Unit Name 153**] for observation, possible
ERCP. VS on transfer BP 86/43, HR 57, RR 15, SpO2 100/ra. On
arrival to the ED, he is comfortable and has no 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:
1. Alcoholic cirrhosis. He has been sober for eight years.
2. History of hepatic encephalopathy, well-maintained on
lactulose.
3. History of ulcers per EGD in [**2144-8-25**].
4. History of left bundle branch block.
5. History of hyperlipidemia.
Social History:
Per OMR, retired from the [**Company 2318**] in [**2143**], where he worked in
management construction for 26 years. Also says he worked as a
NFL football coach for the [**Location (un) 5622**] Eagles. Has a long term
partner, [**Name (NI) **] [**Name (NI) 17**], and 6 children. Formerly a heavy weekend
drinker. Does not smoke or use other illicits
Family History:
Father died of MI, mother died of "old age"
Physical Exam:
ON ADMISSION (To [**Hospital Unit Name 153**]):
General: obese middle aged man, appears stated age, no acute
distress
HEENT: PERRL, + Scleral icteris, MMM, oropharynx clear
Neck: supple, JVP not elevated
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
ON DISCHARGE:
Vitals: 99.3, 116/56, 68, 20, 97% RA
General: Obese, not markedly jaundiced today, alert, oriented,
no acute distress
HEENT: Sclera icteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally except for right
basilar rales, no wheezes, ronchi
CV: Regular rate, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: obese, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
LABS:
On admission:
[**2150-2-13**] 07:55PM BLOOD WBC-8.0 RBC-3.34* Hgb-11.5* Hct-32.1*
MCV-96 MCH-34.4* MCHC-35.8* RDW-13.2 Plt Ct-108*
[**2150-2-13**] 07:55PM BLOOD Neuts-82* Bands-0 Lymphs-7* Monos-9 Eos-2
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2150-2-13**] 07:55PM BLOOD PT-13.6* PTT-28.6 INR(PT)-1.3*
[**2150-2-13**] 07:55PM BLOOD Glucose-120* UreaN-89* Creat-4.5*#
Na-129* K-3.2* Cl-97 HCO3-20* AnGap-15
[**2150-2-13**] 07:55PM BLOOD ALT-91* AST-16 TotBili-9.7*
[**2150-2-13**] 07:55PM BLOOD Lipase-122*
[**2150-2-13**] 07:55PM BLOOD Calcium-8.3* Mg-2.1
[**2150-2-13**] 08:39PM BLOOD Lactate-1.7
[**2-13**] Urine Culture Negative
[**2-13**] Blood Culture Negative
IMAGING:
[**2-14**] CXR:
Low lung volumes with crowding of the pulmonary vasculature and
no focal
airspace consolidation to suggest pneumonia. No pleural
effusions or
pneumothoraces. Overall cardiac and mediastinal contours are
likely stable
given differences in technique and positioning between studies.
[**2-14**] ERCP:
Esophagus: Limited exam of the esophagus was normal
Stomach: Limited exam of the stomach was normal
Duodenum: Limited exam of the duodenum was normal
Major Papilla: Normal major papilla
Cannulation: Cannulation of the biliary duct was successful and
deep with a sphincterotome after a guidewire was placed.
Contrast medium was injected resulting in complete
opacification.
Biliary Tree Fluoroscopic Interpretation: A single 8 mm round
stone that was causing partial obstruction was seen at the
distal common bile duct. A sphincterotomy was performed in the
12 o'clock position using a sphincterotome over an existing
guidewire. Balloon sweep was performed, but the stone was unable
to be successfully extracted given hard consistency and size. A
7cm by 10FR plastic biliary stent was placed successfully.
Excellent drainage of bile was seen post-deployment.
[**2150-2-18**] MRI Abdomen
1. Subacute thrombus in the portal venous system, occluding the
right main,
anterior, and posterior portal veins with partial flow still
demonstrated
within the main and left portal veins. Non-occlusive thrombus is
also present
in the left and main portal veins.
2. Cirrhosis with sequela of portal hypertension, including
extensive
retroperitoneal varices, recanalized paraumbilical vein, and
splenomegaly.
3. Trace perihepatic ascites and small bilateral pleural
effusions.
On Discharge:
[**2150-2-18**] 05:20AM BLOOD WBC-7.4 RBC-2.80* Hgb-9.4* Hct-27.9*
MCV-100* MCH-33.6* MCHC-33.8 RDW-14.0 Plt Ct-147*
[**2150-2-18**] 05:20AM BLOOD PT-17.3* PTT-32.6 INR(PT)-1.6*
[**2150-2-18**] 05:20AM BLOOD Glucose-90 UreaN-19 Creat-1.1 Na-140
K-3.7 Cl-109* HCO3-24 AnGap-11
[**2150-2-18**] 05:20AM BLOOD ALT-27 AST-26 LD(LDH)-161 AlkPhos-86
TotBili-3.2*
[**2150-2-18**] 05:20AM BLOOD Albumin-3.2* Calcium-7.7* Phos-3.0 Mg-1.7
Brief Hospital Course:
Mr. [**Known lastname 70132**] is a 66 year old man with alcoholic cirrhosis who
presented with new onset jaundice, a biliary stone, and a portal
vein thrombus.
.
# Early cholangitis: Mr. [**Known lastname 70132**] had an obstructing stone on
ERCP. It could not be removed, but was stented. He was started
on cipro and flagyl for concern of cholangitis. He did not have
any documented fevers. However, was hypotensive on admission.
Therefore, he was placed in the ICU. Once he stabilized, he was
transferred to the floor. His LFT's trended down throughout the
admission. He will return in one month for a repeat ERCP. He
will complete a seven day course of ciprofloxacin and flagyl.
# Acute renal failure: Creatinine elevated to 4.5 on admission
from a baseline of around 1.1 (per OMR labs 11/[**2149**]). Most
likely pre-renal given low urinary sodium. His creatinine
trended down with aggressive IV fluids and albumin. His
diuretics were initially held. They were to be restarted
following discharge. He had repeat labs to be scheduled
following discharge.
# Portal Vein Thombosis: A portal vein thrombus was seen on a
RUQ ultrasound performed at an outside hospital. This was
confirmed with an MRI. He was started on enoxaparin and warfarin
three days following ERCP. He was scheduled for an INR check two
days following discharge. His PCP was [**Name (NI) 653**] and agreed to
monitor his INR. Mr. [**Known lastname 70133**] hepatology team followed him in
the hospital.
.
# Alcoholic Cirrhosis: He was continued on home nadolol and
lactulose.
.
# HSV: He developed several perioral lesions consistent with
HSV. He was started on acyclovir.
Medications on Admission:
(Confirmed with patient):
- furosemide 20 mg once a day
- Enulose as needed for constipation
- lisinopril 10 mg daily
- nadolol 20 mg daily,
- Protonix 40 mg once a day
- rifaximin 200 mg two tablets three times a day
- calcium and vitamin D
Discharge Medications:
1. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed for constipation.
2. nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 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. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) for 2 days.
Disp:*7 Tablet(s)* Refills:*0*
6. enoxaparin 120 mg/0.8 mL Syringe Sig: One Hundred-Eighteen
(118) mg Subcutaneous [**Hospital1 **] (2 times a day) for 7 days: Please
follow instructions from your PCP about dose adjustments.
Disp:*14 syringes* Refills:*0*
7. warfarin 2.5 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4
PM.
Disp:*60 Tablet(s)* Refills:*0*
8. Outpatient Lab Work
Please draw INR, chem-7 on [**2150-2-20**]. Please fax results to Dr.
[**Last Name (STitle) 4829**]. Fax [**Telephone/Fax (1) 70134**]. Phone number [**Telephone/Fax (1) 26774**].
9. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
10. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 2
days.
Disp:*4 Tablet(s)* Refills:*0*
11. metronidazole 500 mg Tablet Sig: One (1) Tablet PO twice a
day for 2 days.
Disp:*4 Tablet(s)* Refills:*0*
12. lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
Primary diagnoses:
- Choledocholithiasis
- Possible cholangitis
- Portal vein thrombosis
- Acute kidney injury ([**Last Name (un) **])
Secondary diagnosis:
- Alcohol induced cirrhosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure taking care of you at [**Hospital1 18**]. You were admitted
from [**Hospital6 **] for a procedure to place a stent in
your bile duct. You had a stone in one of your ducts which was
causing you to experience fatigue, jaundice and nausea/chills.
Following your procedure, you improved signifcantly.
An ultrasound performed at [**Hospital6 **] showed the
presence of a clot in your portal vein (a vein that supplies the
liver). After consulting with your Gastroenterologist, Dr. [**Last Name (STitle) 497**]
- we sent you for an MRI scan which confirmed the presence of a
clot. You will need to take a blood thinning medication to treat
this. This medication is called warfarin or coumadin. Since
this takes time to become effective, we have started you on
another medication at the same time called lovenox or
enoxaparin. You will need regular blood tests to assess the
efficiency of your warfarin and determine how long to be on
Lovenox.
Please note:
1) We have made several follow-up appointments for you as noted
below.
2) We have [**Last Name (STitle) 653**] your primary care physician (PCP) who will
follow-up with you on your warfarin and Lovenox medication.
3) We have added a new medication to your current regimen,
called acyclovir for the rash around your mouth. You will take
this for two more days.
4) We added two antibiotics, ciprofloxacin and metronidazole,
for two more days.
It is very important to follow the instructions for being on
warfarin. Please see the information that we gave you for more
information.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] P.
Location: [**Hospital **] MEDICAL ASSOCIATES
Address: [**Apartment Address(1) 33524**], [**Hospital1 **],[**Numeric Identifier 4293**]
Phone: [**Telephone/Fax (1) 26774**]
*Please contact your primary care physician to book [**Name Initial (PRE) **] follow up
appointment for your hospitalization. It is recommended you
follow up within 2 weeks.
Department: TRANSPLANT
When: WEDNESDAY [**2150-3-4**] at 10:20 AM
With: TRANSPLANT [**Hospital 1389**] CLINIC [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
You will have a repeat procedure (ERCP) in one month. The ERCP
office will call you to schedule a repeat procedure. If you have
any questions, the phone number is [**Telephone/Fax (1) 2799**].
|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,039
| 165,913
|
38494+58221
|
Discharge summary
|
report+addendum
|
Admission Date: [**2129-6-25**] Discharge Date: [**2129-7-5**]
Date of Birth: [**2077-8-8**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Lipitor
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
51yoM well known to cardiac surgery service. Discharged to rehab
1 day prior to readmission. Temp to 101.5 at rehab facility and
patient
transferred to local hospital for further evaluation.
Transferred to [**Hospital1 18**] ER. In ER, patient with Temp of 101.1 and
hypotensive. Pancultured and started on vancomycin and zosyn.
Still with secretions.
Major Surgical or Invasive Procedure:
none this admission
History of Present Illness:
History of Present Illness:
51 y/o male s/p emergent coronary artery bypass grafting x4 on
intra-aortic balloon pump of the left internal mammary artery to
left anterior descending coronary; reverse saphenous vein single
graft from aorta to the first diagonal coronary; reverse
saphenous vein single graft from aorta to first obtuse marginal
coronary; as well as reverse saphenous vein single graft from
aorta to posterior descending coronary artery on [**6-5**] and
trach/peg on [**6-17**] who was transferred to rehab facility
yesterday. Temp to 101.5 at rehab facility and patient
transferred to local hospital for further evaluation.
Transferred to [**Hospital1 18**] ER. In ER, patient with Temp of 101.1 and
hypotensive. Pancultured and started on vancomycin and zosyn.
Still with secretions.
Past Medical History:
Emergent Coronary bypass grafting [**6-5**] w/Intra Aortic ballon
pump preoperatively
Post-operative CVA
LV thrombus
lower extremity DVT
Diabetes Mellitus
fatty liver
DM
Social History:
Occupation:computer tech analyst
Tobacco:denies
ETOH:social
Family History:
noncontributory
Physical Exam:
Admission:
Pulse: Resp:18 O2 sat: 99 on 4 L
B/P Right:80/50 Left:82/50
Height:70" Weight:220#
General:lying in bed tachypneic, will not answer questions
Skin: Dry [x] intact []macular rash w/scabs from itching dorsum
hands
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally []few rhonchi
Heart: RRR [x] Irregular [] Murmur
Chest - wound without sign of infection and stable
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]peg in place without evidence of infection
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x]
Neuro: will not answer questions, CN seem to be intact, moves
all
extremities
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:none Left:none
Pertinent Results:
Admission:
[**2129-6-24**] 03:26AM PT-29.2* PTT-30.8 INR(PT)-2.9*
[**2129-6-24**] 03:26AM PLT COUNT-431
[**2129-6-24**] 03:26AM WBC-12.6* RBC-3.61* HGB-10.5* HCT-30.8*
MCV-85 MCH-29.1 MCHC-34.2 RDW-13.9
[**2129-6-24**] 03:26AM CALCIUM-9.4 PHOSPHATE-5.0* MAGNESIUM-2.2
[**2129-6-24**] 03:26AM GLUCOSE-111* UREA N-28* CREAT-0.8 SODIUM-137
POTASSIUM-4.0 CHLORIDE-94* TOTAL CO2-32 ANION GAP-15
[**2129-6-25**] 03:30AM URINE RBC->50 WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-0-2
[**2129-6-25**] 03:30AM URINE BLOOD-LGE NITRITE-NEG PROTEIN-25
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
Discharge:
[**2129-7-5**] 02:36AM BLOOD WBC-7.0 RBC-4.04* Hgb-11.6* Hct-33.9*
MCV-84 MCH-28.7 MCHC-34.2 RDW-15.1 Plt Ct-427
[**2129-7-5**] 06:41AM BLOOD PT-28.1* PTT-31.6 INR(PT)-2.8*
[**2129-7-5**] 02:36AM BLOOD Glucose-115* UreaN-21* Creat-0.8 Na-141
K-4.5 Cl-103 HCO3-29 AnGap-14
[**2129-6-28**] 03:03AM BLOOD ALT-24 AST-31 LD(LDH)-200 AlkPhos-111
Amylase-61 TotBili-0.3
[**2129-7-5**] 02:36AM BLOOD Mg-2.5
-------------------
[**2129-6-25**] 8:57 am Mini-BAL
**FINAL REPORT [**2129-6-27**]**
GRAM STAIN (Final [**2129-6-25**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2129-6-27**]): NO GROWTH.
[**2129-6-25**] 7:56 pm CATHETER TIP-IV Source: midline Rt arm .
**FINAL REPORT [**2129-6-27**]**
WOUND CULTURE (Final [**2129-6-27**]): No significant growth.
CHEST PORT. LINE PLACEMENT [**2129-6-29**] Clip # [**Clip Number (Radiology) 85649**]
Final Report
HISTORY: 51-year-old male with left-sided PICC.
FINDINGS: There has been interval removal of the right-sided
PICC line and
interval placement of a left-sided PICC. The left-sided PICC tip
is in the
right atrium, approximately 4 cm beyond the cavoatrial junction.
Midline
sternotomy wires are intact. The mediastinal contours are
unchanged. The
heart is enlarged. There is no large pleural effusion or
pneumothorax. IMPRESSION: Left PICC tip in right atrium, 4 cm
beyond cavoatrial junction. These findings were discussed with
[**Doctor First Name **], the IV nurse, at the time of dictation.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**]
Approved: WED [**2129-6-29**] 10:22 PM
Radiology Report CT CHEST W/O CONTRAST Study Date of [**2129-6-25**]
8:55 AM
REASON FOR THIS EXAMINATION: secretions with fevers - r/o
infiltrate
Final Report:
There is geographic ground-glass opacity seen in the basal
segments of the
right lower lobe (4:129). Elsewhere, other than minimal
dependent
atelectasis, the lungs are clear, without further focal
consolidations. There is no cavitary lung lesion identified.
There is a small simple left pleural effusion. There is no
pneumothorax.
There is a tracheostomy tube in standard position. The airways
are patent to the subsegmental level, without endobronchial
lesions or appreciable
endobronchial secretions.
There is a right-sided PICC, which terminates in the superior
vena cava.
Postoperative changes in the mediastinum following CABG are
noted. Median
sternotomy wires appear intact. There are numerous surgical
clips. There is no pericardial effusion. The aorta is normal in
caliber and configuration.
The main pulmonary artery is normal in caliber. Scattered
prominent
mediastinal lymph nodes are noted, possibly reactive.
In the visualized portion of the upper abdomen, there is no
acute abnormality identified. There is no adrenal nodule or
mass. There are no contour altering hepatic or renal masses in
the visualized portion of the liver and kidneys.
BONE WINDOWS:
There are no suspicious lytic or sclerotic osseous lesions.
Minimal height
loss is noted at multiple mid thoracic vertebral bodies, of
uncertain
chronicity. No acute fracture lines are identified.
IMPRESSION:
1. Focal ground-glass opacities in the right lower lobe. While
this may
reflect infectious or inflammatory etiologies, including
possible aspiration, the isolated nature and clinical history
favors pneumonia.
2. Small left pleural effusion.
3. Expected postoperative changes status post CABG, without
pericardial
effusion, mediastinal hematoma, or other evidence of
complication.
4. Prominent mediastinal nodes, likely reactive.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 1507**]
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
Left Ventricle - Ejection Fraction: <= 25% >= 55%
Findings
LEFT VENTRICLE: Normal LV wall thickness. Dilated LV cavity.
Severely depressed LVEF.
MITRAL VALVE: Normal mitral valve leaflets.
PERICARDIUM: Small pericardial effusion. No echocardiographic
signs of tamponade.
GENERAL COMMENTS: Suboptimal image quality - poor apical views.
Suboptimal image quality - poor subcostal views.
Conclusions
Suboptimal technical quality due to poor apical and subcostal
images.
Left ventricular wall thicknesses are normal. The left
ventricular cavity is dilated with severe systolic dysfunction.
The mitral valve leaflets are structurally normal. There is a
small pericardial effusion inferolateral to the left ventricle
without evidence of hemodynamic compromise.
Compared with the prior study (images reviewed) of [**2129-6-8**], a
very small inferolateral pericardial effusion is now identified.
Left ventricular systolic function is similar.
Electronically signed by [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4083**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2129-6-25**] 16:02
Brief Hospital Course:
Mr [**Known lastname **] was readmitted to [**Hospital1 18**] after a very short stay at
rehabilitation for fever.
He was started on broad spectrum antibiotics for presumed
aspiration pneumonia.
A fever workup was completed and his PICC was changed. Although
the patient had copious secretions all cultures returned
negative.
The infectious disease and neurology services were reconsulted
to assist with care.
He was noted to have guiac positive stool-felt to be gastritis
he was started on a proton pump inhibitor and transfused with
two units of packed red blood cells. His hematocrit remianed
stable from this point on.
He was also re-evaluated for a Passy-Muir valve which he used
intermittently.
Otherwise he continued to receive supportive care, the remainder
of his hospital care was uneventful.
Medications on Admission:
1. Acetaminophen 325-650 mg Q4H as needed for temperature >38.0.
2. Magnesium Hydroxide (30) ML PO DAILY (Daily) as needed for
constipation.
3. Aspirin 81 mg PO DAILY (Daily).
4. Docusate Sodium 100 mg [**Hospital1 **] (2 times a day).
5. Nystatin 100,000 unit/mL Suspension (5) ML QID
6. Simvastatin 20 mg DAILY (Daily).
7. Warfarin 1 mg Tablet [**Hospital1 **]: MD to dose Tablet PO DAILY (Daily):
PAF/Thromboembolic event, INR goal 2-3.0.
8. Scopolamine Base 1.5 mg Patch (1) Patch 72 hr Transdermal
DAILY (Daily).
9. Carvedilol 3.125 mg [**Hospital1 **] (2 times a day).
10. Olanzapine 2.5 mg HS (at bedtime) as needed for aggitation.
11. Furosemide 40 mg DAILY
13. Bisacodyl 10 mg Suppository HS as needed for constipation.
14. Albuterol Sulfate Q6H (every 6 hours).
15. Ipratropium Bromide Q6H (every 6 hours).
16. Chlorhexidine Gluconate 0.12 % Mouthwash [**Hospital1 **] (2 times a
day).
17. Amiodarone 200 mg DAILY
18. Tamsulosin 0.4 mg HS (at bedtime).
19. Ranitidine HCl 15 mg/mL Syrup [**Hospital1 **]: One (1) PO DAILY
20. Insulin Regular Human 100 unit/mL (3 mL) Insulin Pen [**Hospital1 **]:
One (1) Subcutaneous every six (6) hours: per SS protocol.
21. Lantus 100 unit/mL Cartridge [**Hospital1 **]: As directed Subcutaneous
twice a day.
22. 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. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: Ten (10) cc PO BID (2
times a day) as needed for constipation.
3. Simvastatin 10 mg Tablet [**Hospital1 **]: Twenty (20) mg PO DAILY
(Daily).
4. Warfarin 1 mg Tablet [**Hospital1 **]: as directed Tablet PO Once Daily at
4 PM: Target INR 2-2.5.
5. Amiodarone 200 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
6. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr [**Hospital1 **]: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime) as needed for
---.
7. Nystatin 100,000 unit/mL Suspension [**Hospital1 **]: Five (5) ML PO TID
(3 times a day).
8. Insulin Glargine 100 unit/mL Solution [**Hospital1 **]: Fifty (50) units
Subcutaneous Q breakfast & Q dinner.
9. Insulin Regular Human 100 unit/mL Cartridge [**Hospital1 **]: sliding
scale u Injection four times a day.
10. Bisacodyl 10 mg Suppository [**Hospital1 **]: One (1) Suppository Rectal
DAILY (Daily).
11. Magnesium Hydroxide 400 mg/5 mL Suspension [**Hospital1 **]: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation .
12. Metronidazole 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q8H
(every 8 hours) for 7 days.
13. Ipratropium Bromide 17 mcg/Actuation HFA Aerosol Inhaler
[**Hospital1 **]: Four (4) Puff Inhalation Q6H (every 6 hours) as needed for
wheezing.
14. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Hospital1 **]:
Four (4) Puff Inhalation Q6H (every 6 hours) as needed for
wheezing.
15. Carvedilol 3.125 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2
times a day): hold for HR<60
SBP<90.
16. Ferrous Sulfate 300 mg (60 mg Iron) Tablet [**Hospital1 **]: One (1)
Tablet PO BID (2 times a day).
17. Ascorbic Acid 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2
times a day).
18. Folic Acid 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
19. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
20. Levofloxacin 250 mg Tablet [**Hospital1 **]: Three (3) Tablet PO Q24H
(every 24 hours) for 7 days.
21. Prevacid SoluTab 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One
(1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] twice a day.
22. Warfarin 2 mg Tablet [**Last Name (STitle) **]: One (1) mg PO once for 1 doses:
[**6-5**] dose.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
Bronchiectasis
CABG x4, [**2129-6-5**], postop EF 30%
post-op embolic CVA
post-op DVT
G-tube [**6-2**]
tracheostomy [**6-2**]
DM
fatty liver
Discharge Condition:
Deconditioned
Moves all extermities
left lid drooping but can open to command-disconjugate gaze
Trach collar
PEG feeding tube
Voids spontaneously
Discharge Instructions:
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 until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**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:[**2129-7-11**] 1:00
Neurologist: [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**], MD Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2129-7-29**] 12:00
Please call to schedule appointments with your:
Primary Care Doctor 1-2 weeks after discharge from
rehabilitation
Cardiologist Dr [**Last Name (STitle) 39975**] in [**12-25**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication LV thrombus/Atrial
Fibrillation
Goal INR 2.5
First draw [**7-6**]
Completed by:[**2129-7-5**] Name: [**Known lastname 13578**],[**Known firstname 1516**] Unit No: [**Numeric Identifier 13579**]
Admission Date: [**2129-6-25**] Discharge Date: [**2129-7-5**]
Date of Birth: [**2077-8-8**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Lipitor
Attending:[**First Name3 (LF) 1543**]
Addendum:
It should be noted that the patient was discharged to Northeast
Reabilitation in [**Hospital1 2314**], NH
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1933**]
[**First Name11 (Name Pattern1) 33**] [**Last Name (NamePattern4) 1544**] MD [**MD Number(2) 1545**]
Completed by:[**2129-7-5**]
|
[
"V12.51",
"410.72",
"V58.61",
"V45.81",
"427.31",
"285.9",
"V44.0",
"494.0",
"250.00",
"V44.1",
"438.13",
"112.0",
"293.0",
"425.4",
"571.8",
"507.0",
"438.84"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"33.24",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
15841, 16046
|
8591, 9396
|
624, 646
|
13526, 13674
|
2690, 5240
|
14536, 15818
|
1763, 1780
|
10872, 13271
|
13362, 13505
|
9422, 10849
|
13698, 14513
|
1795, 2671
|
232, 586
|
5269, 8568
|
702, 1476
|
1498, 1669
|
1685, 1747
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,385
| 131,665
|
5423
|
Discharge summary
|
report
|
Admission Date: [**2125-6-14**] Discharge Date: [**2125-6-18**]
Date of Birth: [**2048-1-7**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
chills
Major Surgical or Invasive Procedure:
Right IJ CVL
History of Present Illness:
77 Spanish speaking F with past medical history of diabetes,
hypertension presents with 8 hours of shaking chills. Patient
denies all other symptoms, except malaise, which she describes
as inability to get out of bed since 4 pm the day prior to
presentation. No CP, cough, dyspnea, nausea, vomiting, headace,
photophobia, neck stiffness, confusion, dysuria, rash, sick
contacts, vaginal discharge. Pt describes normal bowel
movements. No recent trauma. No new medications. Chronic Low
back pain on NSAIDS.
.
In ED, T 104, BP 142/80 but repeat decreased to systolic 80s, HR
96 initially, blood cultures x 2 sent and patient given 1 g
Tylenol, 500 IV levofoxacin, 500 mg IV flagyl. Lactate initially
3.8, decreased to 2.7 now 1.1. A CT scan of her abdomen was
performed out of concern for LLQ tenderness and ?
diverticulitis. CT abd/pelivs with contrast showed no abscess,
diverticulitis, or peri-nephric fat stranding. Stayed in ED
overnight and received 4.5 L of IVF with 600 cc UOP since 10 am
(urinated once without recording)with SBP still 80s with MAPs
50s, HR 90s but on beta blocker, and T still 102.2 rectally,
Sats decreased from 98% RA to 94% 3L. RIJ with SVO2 monitor
placed in ED with initial SVO2 30 by ABG and on machine 90s, CVP
8, then ?16, then [**11-10**]. Levo/Flagyl changed to Zosyn. MICU
consulted for evaluation.
Past Medical History:
DMII
HTN
s/p ventral hernia repair [**6-2**] c/b colonic ileus
LBP
Social History:
lives with her husband and daughter; denies tob, etOH, IVDA
Family History:
noncontributory
Physical Exam:
T 102 rectal BP 88/50 with MAP 60 P95 R 20 Sat 92% 3L
Gen: spanish speaking only, A+O x3, NAD
HEENT: PERRL, EOMI, OP clear with MM slightly dry
Neck: supple, NT, JVP diff to assess
Pulm: +bibasilar crackles
CV: RRR, no m/r/g
Abd: s/nt/nd +BS
Ext: 1+ pitting edema BLE, +2 DP pulses bilat
Pertinent Results:
CXR no infiltrate
EKG old LBBB, NSR 89 bpm, new TWI V1-V3 when compared to prior
[**2125-6-14**] 11:32PM LACTATE-0.5
[**2125-6-14**] 11:16PM GLUCOSE-141* POTASSIUM-4.9
[**2125-6-14**] 11:16PM MAGNESIUM-3.0*
[**2125-6-14**] 11:16PM CORTISOL-29.8*
[**2125-6-14**] 11:16PM WBC-13.9* RBC-2.79* HGB-8.5* HCT-25.8* MCV-93
MCH-30.4 MCHC-32.8 RDW-14.8
[**2125-6-14**] 11:16PM PLT COUNT-327
[**2125-6-14**] 09:40PM CORTISOL-24.3*
[**2125-6-14**] 06:09PM TYPE-MIX TEMP-37.9 PH-7.39
[**2125-6-14**] 06:09PM LACTATE-1.2
[**2125-6-14**] 06:09PM HGB-9.1* calcHCT-27 O2 SAT-78
[**2125-6-14**] 06:09PM freeCa-1.18
[**2125-6-14**] 06:00PM CORTISOL-12.2
[**2125-6-14**] 04:40PM COMMENTS-GREEN TOP
[**2125-6-14**] 04:40PM LACTATE-1.4
[**2125-6-14**] 04:30PM GLUCOSE-154* UREA N-10 CREAT-0.8 SODIUM-140
POTASSIUM-3.6 CHLORIDE-114* TOTAL CO2-20* ANION GAP-10
[**2125-6-14**] 04:30PM ALT(SGPT)-22 AST(SGOT)-19 ALK PHOS-67
AMYLASE-11 TOT BILI-0.3
[**2125-6-14**] 04:30PM ALBUMIN-2.4* CALCIUM-8.1* PHOSPHATE-2.5*
MAGNESIUM-1.4*
[**2125-6-14**] 04:30PM CORTISOL-13.1
[**2125-6-14**] 04:30PM CRP-18.7*
[**2125-6-14**] 04:30PM WBC-13.3*# RBC-2.71*# HGB-8.3*# HCT-25.6*#
MCV-95 MCH-30.5 MCHC-32.2 RDW-15.1
[**2125-6-14**] 04:30PM NEUTS-88.9* BANDS-0 LYMPHS-8.4* MONOS-2.6
EOS-0.2 BASOS-0
[**2125-6-14**] 04:30PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-OCCASIONAL
[**2125-6-14**] 04:30PM PLT SMR-NORMAL PLT COUNT-314
[**2125-6-14**] 04:30PM PT-12.1 PTT-27.0 INR(PT)-1.0
[**2125-6-14**] 03:50PM TYPE-MIX PO2-33* PCO2-34* PH-7.42 TOTAL
CO2-23 BASE XS--2
[**2125-6-14**] 03:18PM %HbA1c-9.9* [Hgb]-DONE [A1c]-DONE
[**2125-6-14**] 02:35PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-TR
[**2125-6-14**] 03:15AM URINE RBC-0-2 WBC-21-50* BACTERIA-MANY
YEAST-NONE EPI-0-2
[**2125-6-14**] 01:55AM COMMENTS-GREEN TOP
[**2125-6-14**] 01:55AM LACTATE-3.8*
[**2125-6-14**] 01:45AM GLUCOSE-255* UREA N-17 CREAT-1.1 SODIUM-134
POTASSIUM-5.6* CHLORIDE-98 TOTAL CO2-23 ANION GAP-19
[**2125-6-14**] 01:45AM CK(CPK)-73
[**2125-6-14**] 01:45AM ALT(SGPT)-32 AST(SGOT)-49* ALK PHOS-101
AMYLASE-17 TOT BILI-0.4
[**2125-6-14**] 01:45AM LIPASE-23
[**2125-6-14**] 01:45AM CK-MB-1 cTropnT-<0.01
[**2125-6-14**] 01:45AM ALBUMIN-3.3* CALCIUM-10.1 PHOSPHATE-2.8
MAGNESIUM-1.8
[**2125-6-14**] 01:45AM CORTISOL-24.5*
[**2125-6-14**] 01:45AM WBC-7.8 RBC-3.69* HGB-11.2* HCT-34.9* MCV-95
MCH-30.5 MCHC-32.1 RDW-15.0
[**2125-6-14**] 01:45AM NEUTS-88.9* BANDS-0 LYMPHS-9.4* MONOS-0.7*
EOS-1.0 BASOS-0.1
[**2125-6-14**] 01:45AM HYPOCHROM-1+ ANISOCYT-NORMAL POIKILOCY-NORMAL
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL
[**2125-6-14**] 01:45AM PLT COUNT-402
Brief Hospital Course:
1) Gram negative sepsis: Likely urinary source given positive UA
and EColi in blood cultures. She was admitted to the MICU due
to hypotension despite aggressive IVF hydration. In the MICU
she continued to be hydrated with IVFs and never required
vasopressors. A Cortisol stimulation test was done and was
appropriate. On HOD#2, [**2-2**] blood cxs grew GNRs. She was
initially continued on Zosyn pending speciation and
sensitivities. She was then called out to the floor as her
blood pressure had stabilized and she was asymptomatic. On the
floors, she had low grade temperatures (99-100) for another day.
The culture results revealed E-coli sensitive to Levaquin and
ceftriaxone. She was initially changed to IV ceftriaxone and
surveillance cultures were sent. The following day, she was
afebrile and she was changed to PO Levaquin. The cultures
remained negative and she was discharged home to complete a 10
day course.
2)DM-2 - Initially her oral hypoglycemics were held but were
restarted prior to discharge when she was tolerating a normal
diet.
3) HTN: Her antihypertensives were held initially due to low
blood pressure and were reinstated slowly once she stabilized.
She was discharged on her home dose atenolol 100mg daily, but
her norvasc was discontinued as her blood pressure was well
controlled on the bblocker alone.
4) Anemia: Her HCT was in 30s at admission as well as one year
ago. After IVF hydration her HCT ranged from 25-28. She was
guiaic negative and B12, folate, TSH levels were normal. Her
iron level was low/normal. She will need an outpatient work-up
for this anemia, including a colonoscopy.
5) A pancreatic hypodensity was found incidentally on CT scan.
Amylase and Lipase levels were normal. An outpatient MRI was
recommended.
Medications on Admission:
Lipitor 10 mg daily
Glipizide 5 mg [**Hospital1 **]
Avandia 4 mg daily
Atenolol 100 mg daily
Lasix 40 mg daily
Norvasc 10 mg daily
Diclofenac 75 mg daily
Tylenol #3 prn
Discharge Medications:
1. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
2. Atenolol 100 mg Tablet Sig: One (1) Tablet PO once a day.
3. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
4. Rosiglitazone Maleate 4 mg Tablet Sig: One (1) Tablet PO once
a day.
5. Glipizide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
UTI
Gram negative Sepsis likely secondary to urinary source
DM
Anemia
Pancreatic hypodensity
Discharge Condition:
good
Discharge Instructions:
Please seek medical attention if you experience chest pain,
shortness of breath, lightheadedness or other concerning
symptoms.
During this hospital course, a irregularity was found in the
pancreas. Please discuss with Dr [**Last Name (STitle) 20670**] about scheduling an
MRI to better evaluate this finding.
You should also discuss with Dr [**Last Name (STitle) 20670**] scheduling a
colonoscopy.
Followup Instructions:
Follow up with [**Last Name (LF) **],[**First Name3 (LF) **] M. [**Telephone/Fax (1) 21993**] Monday 6/27th at
8:15am
|
[
"599.0",
"995.91",
"401.9",
"577.8",
"038.42",
"285.9",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
7494, 7551
|
5022, 6797
|
320, 335
|
7688, 7694
|
2225, 4999
|
8143, 8264
|
1884, 1901
|
7017, 7471
|
7572, 7667
|
6823, 6994
|
7718, 8120
|
1916, 2206
|
274, 282
|
363, 1700
|
1722, 1791
|
1807, 1868
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,573
| 117,657
|
47818
|
Discharge summary
|
report
|
Admission Date: [**2139-5-13**] Discharge Date: [**2139-5-17**]
Date of Birth: [**2066-4-30**] Sex: M
Service: MEDICINE
Allergies:
Amoxicillin
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
DOE
Major Surgical or Invasive Procedure:
Cardiac Catheterization s/t stent placement to ramus and LIMA
anastamosis
Swan [**Last Name (un) 26645**] Catheter Placement
History of Present Illness:
73YO male with hx CAD s/p CABG with redo [**2120**], CHF with EF 30%,
afib, DM, CRI, PVD who has recent [**Hospital1 18**] stay last month for
decompensated heart failure and ARF that required CCU stay for
tailored therapy and CVVH presents today with worsening DOE. Pt
reports that he has been working with [**Hospital 1902**] clinic to try to
manage his weight gain of 11 lbs since being discharged on
[**2139-4-18**]. His metolazone has been tepered off and his lasix was
increased to 120mg QAM/ 80mg QPM (from 80mg [**Hospital1 **]). He reports
increased DOE today during his work as an [**Doctor Last Name **] at [**Hospital1 778**]. This
worsened to the point that he got SOB walking across a room. He
had some transient chest tightness that was relieved with rest
but no ongoing chest pain. He has chronic non-productive cough,
no fever. He has marked increase in his LE edema in past [**1-26**]
weeks, L>R per baseline. He had a stress test just 4 days ago
that showed defects and is aware that cath is planned for him in
the near future. He has no ongoing SOB currently. He notes easy
fatiguability but - n/v, abd pain. dizziness, LH. -PND,
-orthopnea. He uses 2 pillows at night.
Past Medical History:
CAD (CABG [**2109**] AND [**2120**])
CHF w/ EF 30%, diastolic dysfx
- recent admit with CCU transfer for tailored therapy [**3-30**]. The
patient had a Swan line placed and initially was maintained on
dopamine and vasopressin. His wedge was 33, PAP 63/29, cardiac
output 4.4, cardiac index 2.07. Numbers improved when placed on
Milrinone. He ultimately required CVVH due to severe volume
overload. He was stabilized and transferred back to a floor
where he was maintained on Lasix and metolazone with good urine
output and faily stable renal
function.
AF (dating back to [**2134**])
DM (HBA1c [**2138**] = 7.5)
CRI
GERD
PUD
gout
claudication
s/p CCY
s/p cataract [**Doctor First Name **] [**1-30**]
s/p back surgery
Social History:
Pt is a retired electrial engineer for Ratheon. Currently works
as [**Doctor Last Name **] at [**Hospital1 778**]. lives w/ wife, daughter and
granddaughter in [**Name (NI) 8242**]. Quit tobacco >15 years ago; 50 pk-yr
history.
Social EtOH (2 drinks/week), no illicits. Wife is HCP. Daughter
is cardiac nurse.
Family History:
Noncontributory.
Physical Exam:
Gen: pleasant, comfortable, mild SOB
VS: 98.0 67 94/31 17 100%
HEENT: EOMI, anicteric, mild sclerae injection, MMM
Neck: supple, JVP at 11-12, no LAD
lungs: left basilar rales otherwise CTA bilaterally
heart: irregular, HSM across precordium greatest at LSB
abd; soft NT ND -h/s megaly, midline hernia with scar
ext: 3+ edema bilaterally but L>R (pt states chronic)
neuro: CN intact, A&OX3
Pertinent Results:
[**2139-5-13**] 11:00PM CK(CPK)-81
[**2139-5-13**] 11:00PM CK-MB-NotDone cTropnT-0.44*
[**2139-5-13**] 04:19PM CK(CPK)-106
[**2139-5-13**] 04:19PM CK-MB-12* MB INDX-11.3* cTropnT-0.52*
[**2139-5-13**] 04:19PM PT-21.2* PTT-37.4* INR(PT)-2.1*
[**2139-5-13**] 02:00PM PT-42.4* PTT-44.4* INR(PT)-4.8*
[**2139-5-13**] 01:20PM CK(CPK)-117
[**2139-5-13**] 01:20PM CK-MB-15* MB INDX-12.8* cTropnT-0.48*
[**2139-5-13**] 01:20PM PT-40.1* PTT-39.8* INR(PT)-4.5*
[**2139-5-13**] 08:50AM GLUCOSE-137* UREA N-115* CREAT-2.7*
SODIUM-137 POTASSIUM-3.2* CHLORIDE-96 TOTAL CO2-26 ANION GAP-18
[**2139-5-13**] 08:50AM CK(CPK)-120
[**2139-5-13**] 08:50AM CK-MB-16* MB INDX-13.3* cTropnT-0.40*
[**2139-5-13**] 08:50AM PLT COUNT-104*
[**2139-5-13**] 08:50AM PT-45.6* PTT-40.8* INR(PT)-5.3*
[**2139-5-13**] 07:01AM URINE HOURS-RANDOM UREA N-521 CREAT-69
SODIUM-63 albumin-2.9 alb/CREA-42.0*
[**2139-5-13**] 07:01AM URINE OSMOLAL-373
[**2139-5-13**] 07:01AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.010
[**2139-5-13**] 07:01AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2139-5-12**] 10:15PM GLUCOSE-274* UREA N-119* CREAT-3.0*
SODIUM-134 POTASSIUM-4.3 CHLORIDE-92* TOTAL CO2-28 ANION GAP-18
[**2139-5-12**] 10:15PM ALT(SGPT)-24 AST(SGOT)-22 LD(LDH)-208
CK(CPK)-93 ALK PHOS-144* TOT BILI-0.4
[**2139-5-12**] 10:15PM cTropnT-0.08*
[**2139-5-12**] 10:15PM CK-MB-NotDone proBNP-5593*
[**2139-5-12**] 10:15PM ALBUMIN-3.8
[**2139-5-12**] 10:15PM DIGOXIN-1.5
[**2139-5-12**] 10:15PM WBC-7.5 RBC-3.18* HGB-10.5* HCT-30.9* MCV-97
MCH-32.9* MCHC-33.9 RDW-15.8*
[**2139-5-12**] 10:15PM NEUTS-82.5* LYMPHS-10.5* MONOS-5.6 EOS-0.8
BASOS-0.5
[**2139-5-12**] 10:15PM MACROCYT-1+
[**2139-5-12**] 10:15PM PLT COUNT-114*
[**2139-5-12**] 10:15PM PT-49.7* PTT-41.4* INR(PT)-5.9*
[**2139-5-12**] 01:15PM UREA N-108* CREAT-2.8* SODIUM-137
POTASSIUM-3.8 CHLORIDE-93* TOTAL CO2-29 ANION GAP-19
[**2139-5-12**] 01:15PM MAGNESIUM-2.0
[**2139-5-12**] 01:15PM DIGOXIN-1.7
[**2139-5-12**] 01:15PM WBC-7.5 RBC-3.18* HGB-10.5* HCT-31.0* MCV-97
MCH-33.0* MCHC-33.9 RDW-16.0*
[**2139-5-12**] 01:15PM PLT COUNT-134*
[**2139-5-12**] 01:15PM PT-43.2* INR(PT)-4.9*
.
[**2139-5-12**] CXR:
1. Mild pulmonary edema.
2. Left lower lobe patchy atelectasis versus pneumonia.
.
[**2139-5-12**] EKG
Atrial fibrillation with a controlled ventricular response.
Since the previous
tracing of [**2138-4-6**] the rate has decreased. ST-T wave
abnormalities are more
marked. Clinical correlation is suggested
.
[**2139-5-14**]
BRIEF HISTORY: 73 year old male with ischemic cardiomyopathy
(EF 20%)
referred for cardiac catheterization for non-ST elevation MI. HI
last
catheterization was on [**2131-4-12**] that showed left dominant system
with
patent LMCA and ramus only, otherwise occluded LAD, LCX, and
RCA. The
LIMA-LAD, SVG-OM, and SVG-PDA were all patent.
INDICATIONS FOR CATHETERIZATION:
Coronary artery disease, Canadian Heart Class II, stable.
Prior CABG
[**2109**] & [**2120**].
PROCEDURE:
Right Heart Catheterization: was performed by percutaneous entry
of the
right femoral vein, using a 7 French pulmonary wedge pressure
catheter,
advanced to the PCW position through an 8 French introducing
sheath.
Cardiac output was measured by the Fick method.
Left Heart Catheterization: was performed by percutaneous entry
of the
right femoral artery, using a 5 French angled pigtail catheter,
advanced
to the left ventricle through a 5 French introducing sheath.
Coronary Angiography: was performed in multiple projections
using a 5
French JL4 and a 5 French JR4 catheter, with manual contrast
injections.
Graft Angiography: of 2 saphenous vein bypass grafts was
performed using
a 5 French right [**Last Name (un) 2699**] catheter, with manual contrast
injections.
Arterial Conduit Angiography: of a left internal mammary artery
graft
was performed using a preformed [**Female First Name (un) 899**] catheter, with manual
contrast
injections.
Percutaneous coronary revascularization was performed using
placement of
drug-eluting stent(s).
Percutaneous coronary revascularization of an additional vessel
was
performed using placement of drug-eluting stent(s).
Conscious Sedation: was provided with appropriate monitoring
performed by
a member of the nursing staff.
HEMODYNAMICS RESULTS BODY SURFACE AREA: 2.02 m2
HEMOGLOBIN: 10.2 gms %
FICK
**PRESSURES
RIGHT ATRIUM {a/v/m} 22/24/21
RIGHT VENTRICLE {s/ed} 67/22
PULMONARY ARTERY {s/d/m} 64/30/40
PULMONARY WEDGE {a/v/m} 33/36/30
AORTA {s/d/m} 119/50/64
**CARDIAC OUTPUT
HEART RATE {beats/min} 53
RHYTHM SINUS
O2 CONS. IND {ml/min/m2} 125
A-V O2 DIFFERENCE {ml/ltr} 55
CARD. OP/IND FICK {l/mn/m2} 4.6/2.3
**RESISTANCES
SYSTEMIC VASC. RESISTANCE 748
PULMONARY VASC. RESISTANCE 174
**% SATURATION DATA (NL)
PA MAIN 58
AO 98
**ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM
**RIGHT CORONARY
1) PROXIMAL RCA DISCRETE 70
2) MID RCA DISCRETE 70
2A) ACUTE MARGINAL NORMAL
3) DISTAL RCA NORMAL
**ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM
**LEFT CORONARY
5) LEFT MAIN NORMAL
6) PROXIMAL LAD DISCRETE 100
11) INTERMEDIUS DISCRETE 90
12) PROXIMAL CX DISCRETE 100
**ARTERIOGRAPHY RESULTS TO SEGMENTS MORPHOLOGY % STENOSIS
LOCATION
**BYPASS GRAFT
28) SVBG #1 17 NORMAL
29) SVBG #2 14 DISCRETE 100
32) LIMA 7 NORMAL
COMMENTS:
1. Selective coronary angiogrraphy of this left dominant system
revealed
severe native three vessel coronary artery disease. The LMCA was
patent.
The LAD, LCX, and RCA all had proximal occlusion. The ramus
intermedius
was the only remaining native vessel supplying the left
ventricle with
proximal 80% stenosis.
2. Selective vein graft angiography demonstrated patent SVG-PDA
with 80%
stenosis in jump segment to the posterolateral branch. SVG to OM
was not
visualized and presumed to be occluded.
3. Selective arterial conduit angiography revealed patent
LIMA-LAD with
90% distal anastomosis stenosis.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Patent LIMA-LAD.
3. Patent SVG-PDA.
.
[**2139-5-14**] CXR
INDICATION: Swan-Ganz catheter placement.
A Swan-Ganz catheter is present, with the tip making an abrupt
rightward turn in the expected location of the junction of the
main pulmonary artery and its bifurcation into the left and
right pulmonary arteries. The acuity of the angle of the turn is
greater than expected and the catheter could potentially be
slightly coiled on itself at the tip. There is no pneumothorax.
Cardiac and mediastinal contours are stable allowing for
positional differences. There has been interval worsening of a
pattern of perihilar haziness and interstitial opacities
suggesting worsening pulmonary edema. A small left pleural
effusion is noted. Right costophrenic angle has been excluded
from the study and cannot be assessed.
.
[**2139-5-16**] CXR
INDICATION: 72-year-old man with CHF.
COMMENTS: Portable erect AP radiograph of the chest is reviewed,
and compared with the previous study of [**2139-5-14**].
The patient has prior CABG and median sternotomy. The Swan-Ganz
catheter has been removed. No pneumothorax is identified.
The previously identified congestive heart failure has been
improving. There is small bilateral pleural effusion and
bibasilar patchy atelectasis.
.
[**2139-5-17**] CXR
COMMENTS: Portable erect AP radiograph of the chest is reviewed,
and compared with the previous study of yesterday.
The previously identified mild congestive heart failure has been
resolving. The heart is normal in size. The patient has prior
CABG and median sternotomy. No pneumothorax is identified.
.
Brief Hospital Course:
73M s/p CABG x 2, CHF EF 20%, AFIB, DM2, abnormal MIBI, p/w
worsening SOB/DOE, noted to have NSTEMI via markers. He was
admitted to the medical service on [**2139-5-13**] for decompensated
heart failure, NSTEMI and abnormal MIBI. He had INR reversed in
preparation for c. cath and renal consulted for possible CVVH.
At cardiac cath a cypher stent was deployed to the Ramus
(3.0x13) and to the LIMA anastomosis (2.5x13). Patient was then
transferred to the CCU for further monitoring and diuretic
therapy. HD notable for elevated wedge to 29. He was diuresed
with lasix 60mm iv, fluid restricted. Beta blocker held d/t HR,
ACE I held d/t renal insufficiency. HCT 25 and recieved 2 units
PRBC's without complications, lasix IV in between units.
Patient was tranferred back to floor where he was stable and
asymptomatic, breathing comfortably. He had no chest pain or
recurrence of SOB, and he was continued on ASA, avorvastatin,
plavix, BB until discharge. No ACE I was prescribed given CRI,
and the decision to start this medication will be decided by Dr.
[**First Name (STitle) 437**] as an outpatient. He resumed lasix, standing, at 80 mg PO
BID and required no prn doses. An ECHO is planned as an
outpatient to see if EF has improved now that he is s/p
intervention.
.
Patient is chronically in Afib and coumadin was held
(supratherapeutic) for cardiac cath. He was restarted on
coumadin after cath, and no heparin bridge was used. Digoxin
was held d/t elevated level of 1.6, and he is due to restart
this medication on the day after discharge, per Dr. [**First Name (STitle) 437**], every
other day.
.
Diabetes was well controlled with FSQID, diabetic diet, RISS.
Held glyburide d/t renal failure, but this was restarted on
discharge as patient was back to baseline.
.
Developed acute on chronic renal failure (2.8 from baseline
~1.8), likely secondary to decompensated heart failure and poor
forward flow. Renal function improved with diuresis. Renal
team followed patient and decided CVVH was not necessary during
this admission. Cr returned to baseline of 2.0 by discharge.
EPO continued.
.
Medications on Admission:
1. Vitamin E 400 unit Capsule Sig: One (1) Capsule PO DAILY
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
3. Ferrous Sulfate 325 (65) mg Tab QD
4. Epoetin Alfa 4,000 unit/mL QMOWEFR (Monday
-Wednesday-Friday).
5. Aspirin 81 mg Tablet QD
6. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID
7. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY
8. Nexium 40 mg Capsule, QD
9. Magnesium Oxide 400 mg Tablet Sig: Two (2) Tablet PO BID *
10 Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day.
11 Glyburide 1.25 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Medications:
1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Epoetin Alfa 4,000 unit/mL Solution Sig: 4000 (4000) units/mL
Injection QMOWEFR (Monday -Wednesday-Friday).
3. Vitamin E 400 unit Capsule Sig: One (1) Capsule PO DAILY
(Daily).
4. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*8*
7. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
8. Glyburide 1.25 mg Tablet Sig: One (1) Tablet PO once a day.
9. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
11. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO QOD: Every
other day.
12. Magnesium Oxide 400 mg Tablet Sig: Two (2) Tablet PO twice a
day.
13. Coreg 6.25 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Congestive Heart Failure
Non ST elevation myocardial infarction
Atrial fibrillation
Acute on Chronic renal insufficiency
Discharge Condition:
Good. Patient ambulating without shortness of breath. No chest
pain. Feels well.
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1 liter
Please note the following changes in your medications:
1) Plavix 75 mg PO QD to prevent clots after stent placement
2) Coreg 6.25 mg PO BID to help with blood pressure and cardiac
function
3) Increase ASA to 162 mg PO QD from 81 mg PO QD
4) Digoxin has been changed from 125mcg every day to 125mcg
every other day
Followup Instructions:
Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 3512**] Date/Time:[**2139-5-25**]
10:00
Provider: [**Name10 (NameIs) **],[**First Name3 (LF) **] [**Location (un) 2788**] CARDIOLOGY-PRIVATE
Date/Time:[**2139-5-26**] 8:30
Provider: [**Name10 (NameIs) **],[**First Name3 (LF) **] [**Location (un) 2788**] CARDIOLOGY-PRIVATE
Date/Time:[**2139-8-4**] 11:00
|
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"414.01",
"530.81",
"V45.81",
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] |
icd9cm
|
[
[
[]
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[
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"99.20",
"36.07",
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icd9pcs
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|
2387, 2700
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,035
| 119,860
|
18022
|
Discharge summary
|
report
|
Admission Date: [**2155-3-4**] Discharge Date: [**2155-4-8**]
Date of Birth: [**2089-12-13**] Sex: F
Service: SURGERY
Allergies:
Erythromycin Base / Indomethacin / Actonel / Reglan
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
Headache
fever, headache, neck pain and altered mental status for four
days
Major Surgical or Invasive Procedure:
[**2155-3-11**] Exploratory laparotomy, evacuation of intra-
abdominal blood, exploration of retroperitoneal hematoma,
left salpingo-oophorectomy.
[**2155-3-12**] Left iliolumbar artery coil/gelfoam
[**2155-3-25**] Deployment of a 6 mm x 18 mm [**Month/Day/Year 18979**] stent in the main
hepatic artery.
Joint aspiration
Bronch
History of Present Illness:
The patient is a 65 yo woman with h/o DM2, ESRD, AFib on
coumadin, and nonalcoholic steatohepatitis s/p liver and kidney
transplant in [**2153**], on cellcept/prograf, and prednisone taper
(for gout flare), who presents with a four-day history of fever
(tmax 101 at home), headache, neck pain, and confusion. She
reportedly presented to [**Hospital 5871**] Hospital yesterday with similar
complaints and was found to have a WBC of 21. It was thought
that this was secondary to her steroids, so she was discharged
home. She then presented back to [**Hospital 5871**] Hospital today with
similar complaints, but at this time she had meningismus. She
was given Ceftriaxone 1g and Vancomycin (at 3:25pm), and was
transferred to [**Hospital1 18**] for further evaluation.
.
In the ED, the patient's initial VS were T 101.2, P 76, BP
126/60, R 18, O2 99% on 4L. She was unable to have a LP because
her INR was 2.7, and there was concern that her picture was more
consistent with an epidural abscess. Neurology was consulted,
who recommended LP after INR reversal. Neurosurgery was then
C/S, who recommended CT spine with contrast, as a MRI cannot be
performed because of her pacemaker. She was given another 1 g of
CTX, Ampicillin, Acyclovir, and Decadron 10 mg in the ED. Her
mental status began to decline and she was thus admitted to the
MICU for further evaluation. At the time of transfer, her VS
were 76, 147/59, 17, 96% on 2L.
.
On the floor, she continues to have [**8-17**] HA, described as sharp,
pounding, constant, and diffuse, as well as stiff neck. Denies
photophobia, visual changes, nausea, vomiting, rash. No recent
travel; last trip was to [**State 3908**] in [**Month (only) **] to visit her son.
[**Name (NI) **] known tick exposures.
.
Review of systems:
(+) Per HPI
(-) Denies night sweats, recent weight loss or gain. Denies
sinus tenderness, rhinorrhea or congestion. Denies 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:
- Diabetes Mellitus Type 2, on Insulin, c/b retinopathy,
nephropathy, and neuropathy
- Dyslipidemia
- Hypertension
- Atrial fibrillation, on coumadin
- High-degree AV block, s/p PPM [**2154-2-5**] ([**Company 1543**] Sensia DDD
pacemaker), now pacer dependent
- Diastolic heart failure, NYHA II-[**Last Name (LF) 1105**], [**First Name3 (LF) **] >65% on TTE [**1-/2154**]
- Calcific aortic stenosis, moderate (area 1.0-1.2cm2) on TTE
[**1-/2154**]
- Moderate mitral annular calcification and mitral regurgitation
- Mild tricuspid regurgitation
- Moderate pulmonary hypertension
.
- End-stage renal disease, [**3-12**] diabetes & contrast-induced
nephropathy, s/p cadaveric transplant [**2153-7-21**]
- Non-alcoholic steato-hepatitis cirrhosis (Stage IV, Grade 2),
c/b portal HTN, ascites, encephalopathy, grade I-II esophageal
varices s/p banding s/p TIPS [**8-/2152**], s/p OLTx [**2153-7-21**]
- saphenous vein interposition graft repair of the hepatic
artery and harvesting of the left saphenous vein graft [**2154-3-14**],
Hepatic artery s/p stent [**2154-4-25**]
- s/p VATS decortication [**11/2153**]
- Splenic vein thrombosis, on coumadin
- Anemia
- Thrombocytopenia
- h/o C.diff
- h/o Seizures
-headaches ? [**3-12**] occipital neuralgia
- Meningioma, small left frontal lobe
- GERD
- OSA has CPAP at home but does not use
- Cervical DJD
- Dermoid cyst
- Right adrenal mass
-osteoporosis
- Recurrent MDR UTI (ESBL Klebsiella)
- Status post cholecystectomy followed by tubal ligation
- Status post left oopherectomy
- Status post appendectomy
- ? Restless legs syndrome
Social History:
Widowed, lives in [**Hospital3 **] facility in [**Hospital1 6930**] MA. Has 4
children, 3 in MA, one in [**State 3908**]. Smoking: None; EtOH: Never;
Illicits: None.
Family History:
Mother and Father with CAD. Father with stroke at 90. No other
family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
Admission Labs
Vitals: BP:141/52 P:76 R:18 O2:96% RA
General: Alert, oriented x3, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: stiff, tender to palpation, unable to touch chin to chest
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, systolic murmur
(old per patient)
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. No rash or petechiae. There are some excoriated red
lesions on the R shoulder, but these appear to be secondary to
scratching.
Neuro: AOx3 ("[**Hospital3 **], [**2155-2-8**]"), moving all extremities,
strength 4/5, sensation intact throughout. CN 2-12 intact.
Negative Kernig/Brudzinski signs. Baseline intention tremor but
no asterixis.
Pertinent Results:
Admission Labs
[**2155-3-4**] 07:38PM BLOOD WBC-19.2* RBC-3.57* Hgb-10.6* Hct-31.6*
MCV-89# MCH-29.8 MCHC-33.7 RDW-17.5* Plt Ct-479*
[**2155-3-4**] 07:38PM BLOOD Neuts-88.8* Lymphs-5.6* Monos-5.4 Eos-0.1
Baso-0.1
[**2155-3-4**] 07:38PM BLOOD PT-27.9* PTT-35.8* INR(PT)-2.7*
[**2155-3-4**] 07:38PM BLOOD Glucose-105* UreaN-28* Creat-1.4* Na-141
K-3.6 Cl-99 HCO3-31 AnGap-15
[**2155-3-5**] 05:16AM BLOOD ALT-27 AST-29 LD(LDH)-278* AlkPhos-178*
TotBili-0.5
[**2155-3-4**] 07:38PM BLOOD Calcium-8.6 Phos-4.4 Mg-1.7
[**2155-3-5**] 05:16AM BLOOD tacroFK-12.6
[**2155-3-4**] 07:55PM BLOOD Lactate-1.2
.
Pertinent Reports
CT Spine with contrast ([**2155-3-4**]): No evidence of abscess on
noncontrast CT. Note that this study has low sensitivity for
infection. If the patient cannot undergo MR imaging, a contrast
CT may be the next best alternative, although far less useful
for detecting intraspinal infection.
.
[**2155-3-5**] 10:30AM CEREBROSPINAL FLUID (CSF) WBC-9 RBC-438*
Polys-89 Lymphs-10 Monos-1
[**2155-3-5**] 10:30AM CEREBROSPINAL FLUID (CSF) WBC-4 RBC-1125*
Polys-93 Lymphs-5 Monos-2
[**2155-3-5**] 10:30AM CEREBROSPINAL FLUID (CSF) TotProt-28 Glucose-93
[**2155-4-8**] 05:21AM BLOOD WBC-25.0* RBC-2.96* Hgb-9.3* Hct-28.3*
MCV-96 MCH-31.5 MCHC-33.0 RDW-18.0* Plt Ct-941*
[**2155-4-4**] 06:00AM BLOOD PT-12.6 PTT-32.9 INR(PT)-1.1
[**2155-4-7**] 05:33AM BLOOD Glucose-77 UreaN-96* Creat-1.1 Na-136
K-4.1 Cl-101 HCO3-27 AnGap-12
[**2155-4-8**] 05:21AM BLOOD Glucose-92 UreaN-90* Creat-1.0 Na-136
K-4.3 Cl-99 HCO3-27 AnGap-14
[**2155-4-7**] 05:33AM BLOOD ALT-45* AST-30 AlkPhos-250* TotBili-1.8*
DirBili-1.1* IndBili-0.7
[**2155-4-8**] 05:21AM BLOOD Albumin-3.0* Calcium-8.7 Phos-3.7 Mg-2.6
[**2155-4-2**] 09:00AM BLOOD Vanco-5.5*
Brief Hospital Course:
65 year old female with extensive medical history including DM,
ESRD, AFib on coumadin, and nonalcoholic steatohepatitis s/p
liver and kidney transplant, on immunosuppression, who presented
with fever, headache, neck pain and altered mental status for
four days. She was initially admitted to the medical service for
management. Symptoms were concerning for meningitis versus
epidural abscess. Empiric antibiotic therapy was initiated which
included vancomycin, ceftriaxone, ampicillin and acyclovir along
with a 4 day course of dexamethasone to be completed which
completed on [**3-8**]. CT neck did not show epidural abscess while
CT head at outside hospital was negative for acute intracranial
process. LP obtained 20 hours out from presentation showed few
WBC ([**5-17**]), RBC (diluting from tube 1 to 4) with normal protein
and glucose. Neurology and infectious disease were consulted
and suggested continuing current care. She was clinically doing
well with no fever, improved mental status and mild headache and
neck pain so she was transferred to the floor for further workup
and evaluation. Antibiotics were discontinued per ID
recommendations. She remained afebrile and symptoms improved.
There was concern that her symptoms are related to bad
arthritis. Flexion/Extension X-ray of the neck showed no
evidence of subluxation. She continued to have tenderness to
the left of her vertebrae at the level of C5. Etiology was
unclear, but it did not seem to be infectious.
.
Creatinine of 1.4 on admission with baseline of 1.0. Improved
to 1.3 with intravenous fluids. She then developed a new oxygen
requirement and CXR showed some concern for vascular congestion
and fluid overload. She was diuresed aggressively and her
creatinine rose to 1.6. Clinical exam and urine lytes showed a
pre-renal picture and the patient's lasix was temporarily held
and she was given IV fluids. Creatinine 1.1 and she was
restarted on her home dose lasix.
INR was elevated as she had been on coumadin for atrial
fibrillation and splenic vein thrombosis. FFP was given for
lumbar punction. INR dropped below 2 and a heparin drip was
started pending decision for any invasive procedures. Once this
was determined her coumadin was restarted and she was being
bridged with Lovenox. Lost IV access and was switched to LMWH
bridge. INR trended up above 2 and her LMWH was discontinued. .
Gout - continue allopurinol 200mg daily; When dexamethasone was
disconitnued, pt gout flared up again. She was started on a
prednisone taper and then the renal attending decided that given
she has been on multiple pred tapers in the past, she may
benefit from colchicine therapy while her allopurinol is being
titrated up. She was started on colchicine and rheumatology was
consulted.
.
Transplant surgery was consulted on [**3-11**] for severe abd pain and
hypotension. She was taken to the OR on [**3-11**] for exploratory
laparotomy, evacuation of intra-abdominal blood, exploration of
retroperitoneal hematoma,and left salpingo-oophorectomy for
retroperitoneal bleed. Surgeon was Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]. Please
refrer to operative note for futher details. Postop, she was
transferred to the SICU intubated. SICU course was notable for
volume overload requiring diuresis and CVVHD for
ultrafiltration. On [**3-18**], an abd CT was done to evaluate for
repeat bleeding. A small right abdominal wall fluid collection
was noted. There was mild interval increase in the size of a
left iliopsoas retroperitoneal hematoma. No further intervention
was done.
She experienced ATN related to contrast nephrophathy. ATN
gradually resolved and CVVHD was stopped. Creatinine slowly
improved.
She required bronchoscopy with BAL which was negative. Once
volume status improved she was weaned and extubated.
LFTs increased and liver duplex was done concerning for impaired
hepatic artery flow. CTA was done noting concerns for hepatic
artery stenosis. On [**3-25**], IR performed an angiogram via the
right common femoral artery placing a 6 mm x 18 mm [**First Name8 (NamePattern2) 18979**] [**Last Name (un) 2435**]
in the main hepatic artery. She exerienced a right groin
hematoma at the groin site, but right leg CSM was intact. Once
HCTs were stable, Aspirin and plavix were started. No coumadin
was indicated.
Also, while in the SICU, she had RUE weakness and was noted to
have significant pain in wrists and ankle. Rheumatology tapped
the right wrist noting crystals consistent with gout. A head CT
was negative for mass or bleed. Steroid taper was started on
[**4-2**] consisting of 30mg x3 days then 20mg x3 days then 10mg x 3
days then resumption of home dose of prednisone 2.5mg qd for
transplant immunosuppession along with cellcept and prograf.
Rheumatology recommended holding off on previous allopurinol for
several weeks to prevent flare up of gout. Gout symptoms were
dramatically resolved at time of discharge. She will require a
rheumatology f/u as an outpatient in a couple of weeks.
Overall, the remainder of the hospital stay was uncomplicated.
While in the SICU, she was confused and delerious. This
improved. Psyche was consulted given h/o bipolar illness.
Ariprazole 5mg daily was increased to [**Hospital1 **] on [**4-4**]. She required
rare doses of intermittent ativan 0.5mg for anxiety.
Given h/o diastolic heart failure previous home dose of lasix
120 mg po qam was initiated on [**4-7**]. Carvedilol and valsartan
were continued. Atrial fibrillation: Coumadin was discontinued
and the plan was to not resume this.
Seizure disorder - cont
She continued on keppra 500mg [**Hospital1 **]. She did not experience any
seizures during this hospital stay. Depression - continue home
aripiprazole, desvenlafaxine, trazodone.
Primary biliary cirrhosis - continue ursodiol 300mg [**Hospital1 **]. this
was not an active issue during this hospitalization.
Given prolonged hospital course and poor appetite and intake,
post pyloric tube feeds were started in the SICU and continued
during the hospital stay. She tolerated Novasource renal with
beneprotein, 21 gm/day at 40ml/hour continuous.
Physical therapy worked with her and was able to get her OOB to
the chair. Rehab was recommended. Rehab screen was persued and a
bed became available on [**4-8**]. She will transfer there today.
Medications on Admission:
Acyclovir 700 mg IV Q12H
Ampicillin 2 g IV Q6H
CeftriaXONE 2 gm IV Q12H
Vancomycin 1000 mg IV Q 24H
Dexamethasone 10 mg IV Q6H
Sulfameth/Trimethoprim SS 1 TAB PO/NG DAILY
.
Mycophenolate Mofetil 500 mg PO BID
Tacrolimus 2 mg PO Q12H
.
Allopurinol 100 mg PO/NG DAILY
Insulin sc (per Insulin Flowsheet)
Aripiprazole 5 mg PO/NG DAILY
LeVETiracetam 500 mg PO/NG [**Hospital1 **]
Atorvastatin 10 mg PO/NG DAILY
Carvedilol 25 mg PO/NG [**Hospital1 **]
OxycoDONE (Immediate Release) 5 mg PO/NG Q4H:PRN pain
Senna 1 TAB PO/NG [**Hospital1 **]
Ursodiol 300 mg PO BID
Docusate Sodium (Liquid) 100 mg PO BID
Docusate Sodium 100 mg PO BID
Valsartan 160 mg PO/NG DAILY
Ferrous Sulfate 325 mg PO/NG DAILY
Venlafaxine XR 112.5 mg PO DAILY
Furosemide 120 mg PO/NG QAM
traZODONE 100 mg PO/NG HS
Furosemide 80 mg PO/NG QPM
Discharge Medications:
1. glucagon (human recombinant) 1 mg Recon Soln [**Hospital1 **]: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
2. miconazole nitrate 2 % Powder [**Hospital1 **]: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
3. carvedilol 12.5 mg Tablet [**Hospital1 **]: Two (2) Tablet PO BID (2 times
a day).
4. heparin (porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1) ml
Injection TID (3 times a day).
5. desvenlafaxine 50 mg Tablet Extended Release 24 hr [**Hospital1 **]: One
(1) Tablet Extended Release 24 hr PO daily ().
6. oxycodone 5 mg Tablet [**Hospital1 **]: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
7. clopidogrel 75 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
8. aspirin 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
9. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
10. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Last Name (STitle) **]: One (1) neb Inhalation Q6H (every 6 hours) as
needed for shortness of breath/wheezing.
11. ipratropium bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) neb
Inhalation Q6H (every 6 hours) as needed for shortness of
breath/wheezing.
12. amlodipine 5 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY (Daily).
13. prednisone 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily)
for 3 days: [**Date range (1) 9237**] then decrease to 2.5mg qd.
14. aripiprazole 5 mg Tablet [**Date range (1) **]: One (1) Tablet PO BID (2 times
a day).
15. furosemide 40 mg Tablet [**Date range (1) **]: Three (3) Tablet PO DAILY
(Daily).
16. ursodiol 300 mg Capsule [**Date range (1) **]: One (1) Capsule PO BID (2 times
a day).
17. omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Date range (1) **]: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
18. prednisone 2.5 mg Tablet [**Date range (1) **]: One (1) Tablet PO DAILY
(Daily): start [**4-11**].
19. lorazepam 0.5 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO BID (2 times
a day) as needed for anxiety.
20. sulfamethoxazole-trimethoprim 400-80 mg Tablet [**Month/Day (4) **]: One (1)
Tablet PO DAILY (Daily): pcp [**Name Initial (PRE) 1102**].
21. levetiracetam 500 mg Tablet [**Name Initial (PRE) **]: One (1) Tablet PO BID (2
times a day).
22. mycophenolate mofetil 500 mg Tablet [**Name Initial (PRE) **]: One (1) Tablet PO
BID (2 times a day).
23. tacrolimus 1 mg Capsule [**Name Initial (PRE) **]: One (1) Capsule PO Q12H (every
12 hours): trough levels every Monday and Thursday am.
24. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
25. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
26. insulin glargine 100 unit/mL Solution [**Name Initial (PRE) **]: Thirty (30) units
Subcutaneous twice a day: Am and HS.
27. insulin regular human 100 unit/mL Solution [**Name Initial (PRE) **]: follow
printed sliding scale units Injection four times a day.
28. Outpatient Lab Work
Every Monday and Thursday for CBC, chem 10, alt, ast, alk phos,
t.bili, albumin, trough prograf level and ua
fax to [**Telephone/Fax (1) 697**] [**Hospital1 18**] Transplant Coordinator
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital - [**Hospital1 8**]
Discharge Diagnosis:
h/o liver/kidney transplant
retroperitoneal hematoma
hepatic artery stenosis, stented
ATN, resolved
Fluid overload, resolved
gout flare
h/o bipolar, anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You will be transferred to [**Hospital3 **]
[**Hospital1 18**] transplant office [**Telephone/Fax (1) 673**] should be called if the
following are noted:
fever, chills, nausea, vomiting, inability to take any
medications, increased abdominal pain/distension, jaundice,
joint pain/swelling/redness or any concerns
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. phone: [**Telephone/Fax (1) 673**] [**2155-4-16**] at
3:20
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2155-5-15**] 8:30
Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2155-8-27**]
9:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4450**], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2155-8-27**] 10:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2155-4-8**]
|
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"584.9",
"401.9",
"428.32",
"041.3",
"396.2",
"790.92",
"250.50",
"357.2",
"416.8",
"362.01",
"428.0",
"620.2",
"997.79",
"785.59",
"296.50",
"272.4",
"427.31",
"V45.01",
"568.81",
"250.60",
"E947.8",
"V58.67",
"721.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"39.79",
"00.40",
"39.95",
"39.50",
"96.6",
"03.31",
"38.95",
"39.90",
"00.45",
"96.72",
"65.49",
"88.42",
"81.91",
"88.47",
"38.97",
"99.15",
"33.24",
"54.0"
] |
icd9pcs
|
[
[
[]
]
] |
18150, 18221
|
7582, 13959
|
385, 718
|
18422, 18422
|
5825, 7559
|
19024, 19719
|
4733, 4908
|
14815, 18127
|
18242, 18401
|
13985, 14792
|
18598, 19001
|
4923, 5806
|
2516, 2931
|
270, 347
|
746, 2497
|
18437, 18574
|
2953, 4533
|
4549, 4717
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,946
| 140,734
|
5697
|
Discharge summary
|
report
|
Admission Date: [**2127-11-18**] Discharge Date: [**2127-11-25**]
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides) / Penicillins
Attending:[**First Name3 (LF) 134**]
Chief Complaint:
Second Degree Atrioventricular block
Atrial Perforation
Major Surgical or Invasive Procedure:
Pacemaker insertion
Pericardiocentesis
Pulmonary artery catheter insertion
Femoral Venous Central Line
History of Present Illness:
89yo F w PMH HTN and osteoporosis presents to CCU with atrial
perforation and tamponade secondary to pacemaker lead placement.
Pt presented to her PCP's office for preoperative evaluation for
cataract surgery and found to be bradycardic to high 30's with
2nd degree heart block. Pt was sent to [**Hospital1 18**] emergency for
further evaluation and sent for stat EP consultation and
pacemaker was placed. RV lead was placed without difficulty.
Cephalic vein required dilation to pass RA lead. RA lead
required multiple attempts to capture, once captured lead was
screwed into place and pt became hypotensive to SBP 50's. Given
fluids and dopamine was started, emergent echo showed moderate
pericardial effusion. PA catheter introduced and
pericardiocentesis revealed equilibration of PA and pericaridial
pressures. Pericardial catheter drained 300ml of blood with
stabilization of systemic blood pressures. Patient was weaned
from dopamine and transferred to the CCU for further monitoring.
.
ROS: per Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1007**] (PMD). Slight DOE, no palpitations,
no dizziness or LH, no HA, N/V, denied CP, SOB.
Past Medical History:
HTN
Osteoporosis
Shoulder arthritis
.
PsurgHx: none
Social History:
widowed, lives alone, but actively cares for her mentally
disable daughter who also lives alone nearby. Retired from
substitue teaching about 1 year ago. Son in the area is HCP. [**Name (NI) **]
ETOH, tobacco, or Illicits.
Physical Exam:
T 95.1, BP 123/65, HR 70, R15, 100% on 100% FIO2
Gen: Critically ill elderly female, intubated and sedated.
HEENT: MMM, PERRL, no exudates
NECK: no cervical LAD, unable to assess for carotid bruit on
vent
CHEST: L pectoralis bandage CDI, no hematoma, coarse transmitted
upperairway sounds, breath sounds heard bilaterally in all lung
fields
HEART: normal s1 and s2, High pitched crescendo-decrescendo [**4-14**]
SEM loudest at RUSB, no Rubs or gallops. pericardial catheter
lateral to xiphoid process draining small amounts of blood.
Abd: Soft, ND, BS+, non-pulsatile, no Masses, no HSM.
Extrem: warm, well-perfused, 2+ DP, PT pulses, no CCE.
Pertinent Results:
[**2127-11-18**] 01:00PM PLT COUNT-204
[**2127-11-18**] 01:00PM WBC-6.5 RBC-3.90* HGB-12.8 HCT-36.6 MCV-94
MCH-33.0* MCHC-35.1* RDW-14.0
[**2127-11-18**] 01:00PM T4-7.4
[**2127-11-18**] 01:00PM TSH-4.7*
[**2127-11-18**] 01:00PM cTropnT-<0.01
[**2127-11-18**] 01:00PM GLUCOSE-92 UREA N-31* CREAT-1.3* SODIUM-139
POTASSIUM-4.2 CHLORIDE-101 TOTAL CO2-25 ANION GAP-17
[**2127-11-18**] 07:32PM TYPE-ART TEMP-34.3 RATES-12/0 TIDAL VOL-450
PEEP-0 O2-100 PO2-206* PCO2-33* PH-7.36 TOTAL CO2-19* BASE XS--5
AADO2-503 REQ O2-81 -ASSIST/CON INTUBATED-INTUBATED
LYME SEROLOGY (Final [**2127-11-20**]):
NO ANTIBODY TO B. BURGDORFERI DETECTED BY EIA.
Reference Range: No antibody detected.
Negative results do not rule out B. burgdorferi infection.
Patients
in early stages of infection or on antibiotic therapy may
not produce
detectable levels of antibody. Patients with clinical
history and/or
symptoms suggestive of lyme disease should be retested in
[**3-14**] weeks.
[**2127-11-21**] 05:45AM BLOOD Glucose-97 UreaN-21* Creat-1.2* Na-136
K-3.6 Cl-104 HCO3-23 AnGap-13
Data: hct 34.2 from 36 in ED, WBC 9.5, Plts 237, Na 131, K 4.5,
CL 101, HCO3 25 BUN 31, Creat 1.3,
ABG 7.36/33/220/19 on 100% FiO2
.
EKG's:
1) [**2127-11-18**] (from PMD's office) Sinus rhythm with 2:1 AV block
at rate 40 bpm. normal axis. no ST segment changes, no LVH.
2) Old EKG ([**2124**])- NSR 55, normal intervals, no Q-waves, no ST
changes.
3) EKG on admit to CCU- A-V paced at 70 bpm.
.
.
CXR:
1)AP-portable- in ED- no acute cardiopulm process, new
cardiomegaly.
2)AP-portable- in CCU-
left-sided pacemaker with leads in the right atrium and right
ventricle. A pericardial drain is seen entering from the left,
terminating around the area of the mid left main stem bronchus.
IMPRESSION: No definite pneumothorax is seen on this supine
view. There is fullness of the hila, which may be due to
vascular fullness. Blunting of the right costophrenic angle is
identified, which probably represents scarring on this supine
view. There is atelectasis of the left costophrenic angle. Again
no definite evidence of pneumothorax on this view; if
pneumothorax is
clinically suspected, a right-side decubitus film may be
obtained.
3) ? R hilar fullness larger from previous- will require CT with
contrast, no-angio, follow-up.
CT CHEST, [**2127-11-19**]
INDICATION: Pacemaker insertion complicated by right atrial
perforation and tamponade. Right hilar fullness on previous
chest x-ray.
COMPARISON: Chest radiograph, [**2127-11-18**] which described
right hilar fullness. No prior chest CTs.
Multidetector CT of the chest was performed following
intravenous administration of 65 cc of Optiray. Images were
presented for display in the axial plane at 5 mm and 1 mm
collimation.
There is no right hilar mass. The observed hilar fullness on the
prior chest radiograph was likely due to a combination of
prominent pulmonary vasculature and patient rotation. The heart
is mildly enlarged. A small pericardial effusion is present with
relatively high attenuation values of 60. Small-to-moderate
bilateral dependent pleural effusions with simple fluid
attenuation are present with adjacent basilar atelectasis. A
pericardial drain is present, coursing from an inferoposterior
approach inferiorly to an anteromedial approach superiorly with
the tip terminating anterior to the ascending aorta and main
pulmonary artery in the superoanterior pericardial space.
Coronary artery calcifications are present. A permanent
pacemaker is present with leads in the right atrium and right
ventricle.
In the imaged portion of the upper abdomen, the left adrenal
gland is mildly enlarged, but maintains a normal adrenal shape.
Diffuse vascular calcifications are present in the abdominal
aorta extending into the proximal renal arteries. The remaining
imaged portion of the upper abdomen is unremarkable on this
examination that was not specifically tailored for evaluating
the abdominal organs. One additional finding is dependent sludge
within the gallbladder.
Endotracheal tube is present, terminating several centimeters
above the carina. With the exception of basilar atelectasis
adjacent to pleural effusions, the lungs are well expanded and
grossly clear except for scattered areas of discoid atelectasis
or linear scarring.
CORONAL REFORMATION IMAGES: These images confirm the presence of
bilateral pleural effusions and a small pericardial effusion.
Note is also made of soft tissue stranding within the
mediastinal fat and small mediastinal lymph nodes.
Degenerative changes are present within the spine.
Finally, calcification of the aortic valve is also noted.
IMPRESSION:
1. No right hilar mass. Observed finding on recent chest
radiograph was due to prominent pulmonary vasculature
accentuated by patient rotation.
2. Small high attenuation pericardial effusion, likely due to
hemopericardium related to provided history of right atrial
perforation following pacemaker insertion.
3. Small-to-moderate dependent bilateral pleural effusions with
adjacent atelectasis.
CT HEAD W/O CONTRAST [**2127-11-20**] 8:18 AM
FINDINGS: There is no intracranial hemorrhage. There is no
midline shift, mass effect, or hydrocephalus. The [**Doctor Last Name 352**]-white
matter differentiation is preserved. There are areas of
periventricular white matter hypodensity, most consistent with
chronic microvascular ischemic changes. There are no fractures.
Incidental note is made of air-fluid levels around the
visualized paranasal sinuses which would be consistent with the
patient's recent intubation.
IMPRESSION: No intracranial hemorrhage or mass effect.
[**2127-11-25**] ECHOCARDIOGRAM:
Conclusions:
The left atrium is mildly dilated. 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 three severely
thickened/calcified aortic valve leaflets. There is moderate
aortic valve
stenosis. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Moderate (2+) mitral
regurgitation is seen. Moderate [2+] tricuspid regurgitation is
seen. There is mild pulmonary artery systolic hypertension.
There is a trivial/physiologic pericardial effusion.
IMPRESSION: No pericardial effusion. Preserved biventricular
systolic
function. Moderate aortic stenosis. Moderate mitral
regurgitation. Moderate tricuspid regurgitation. Mild pulmonary
hypertension.
Compared with the prior study (images reviewed) of [**2127-11-19**],
more
significant tricuspid regurgitation is identified. The other
findings appear similar.
Brief Hospital Course:
89yo F with new 2:1 AV block s/p pacemaker insertion complicated
by atrial perforation and tamponade. Pt was intubated and
sedated for 24hours with minimal output from her pericardial
drain. She was extubated on hospital day #2, pericardial drain
and central lines were removed. Following extubation the pt had
a period of marked short term memory impairment and difficulty
with naming common objects. A Head CT scan obtained was negative
for any acute process. The patient's mental status improved over
the next few days, but marked short term memory deficit
persisted. The patient developed atrial fibrillation and
underwent two separate attempts at DC cardioversion, but
reverted to afib within 24hours. She was started on full dose
aspirin therapy, but not anticoagulated due to her recent atrial
perforation. Repeat echocardiogram revealed resolution of the
pericardial effusion. She is scheduled to follow up with
electrophysiology for her pacemaker and new onset atrial
fibrillation in one week. The patient was seen by PT and OT
prior to discharge and recommended home PT. She was also given
an appointment to see Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in behavioral neurology
for evaluation of her likely underlying dementia.
1) Cardiac:
Left Ventricular Function-
tamponade physiology secondary to hemopericardium resolved s/p
pericardial drain placement. Hyperdynamic LV fx EF > 75%, murmur
suggestive of AS with suboptimal ECHO evaluation. Moderate AS on
repeat echo evaluation with severe calcification of aortic and
tricuspid leaflets. Resolution of pericardial effusion.
Preserved LVEF >55%. We re-started her hydrochlorothiazide,
added lisinopril to reach goal SBP < 130.
.
Rhythm-
Presented with 2:1 AV block likely related to intrinsic disease
of the conduction pathway, fibrosis, sclerosis secondary to
Lev's disease. At time of presentation the patient was
symptomatic only with exertion. No known ischemic disease. She
was given a DDI pacemaker in the EP lab with the complication
described above. New onset afib with RVR in EP lab, DC
cardioversion to sinus, reverted to afib < 24hrs later. Started
amiodarone- baseline LFT's and TFT's were within normal limits.
The patient will need PFT's scheduled as an outpatient should
amiodarone therapy continue. A second trial of DC cardioversion
for new onset afib maintain sinus rhythm for 24hours. She is
scheduled to follow up with electrophysiology in one week for
determination if long term anticoagulation is warranted.
.
Valves-
The patient was moderate to severe aortic stenosis by
echocardiogram. Severe valvular calcification. Her valvular
disease should be followed closely as an outpatient should she
become symptomatic.
.
2) Pulmonary-
CT chest was obtained to evaluate R hilar fullness found on
x-ray film. CT chest was unremarkable- full findings above. Pt
developed a mild cough productive of clear sputum (prior to
initiation of ACE inhibitor), repeated CXR evaluations revealed
small bilateral pleural effusions. These were likely
transudative and she was gently diuresed with a single dose of
lasix. She did not develop signs of symptoms consistent with
pneumonia.
.
3) Heme-
She was transfused 2units of red blood cells on admission to the
CCU for low hematocrit and peri-procedure blood loss. Her
hematocrit was stable thereafter until dishcarge.
.
4) Renal-
Serum creatinine on admission 1.3, flucated 1.1-1.3 during
admission. Likely age related reduction in GFR in absence of
other known renal disease. Calculated Creatinine clearance was
33.4.
.
5) [**Name (NI) 22744**]
Pt was intubated and sedated. There was however a brief period
of hypotension in the EP lab to SBP 50's related to tamponade
physiology. As patient's mental status improved following
extubation her underlying short term memory deficit persisted.
She has short term memory deficits at baseline per son and PCP.
[**Name10 (NameIs) **] was started on Aspirin 325mg daily. She was schedulred to
see Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in Behavioral Neurology Friday [**1-16**] at
8:30am, [**Hospital Ward Name 860**] [**Location (un) **] rm 253. For eval of dementia, may
need carotid doppler studies at discretion of Dr. [**Last Name (STitle) **]. The
patient was advised to avoid driving until evaluated by Dr.
[**Last Name (STitle) **] and was agreeable.
.
6) Endocrine-
Elevated TSH, normal T4. ? subclinical hypothyroid- consider
anti TPO antibodies for further work-up as outpatient.
.
PCP: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1007**] ([**Hospital1 18**])
Contact: [**Name (NI) **] [**Name (NI) 3094**] [**Name (NI) 6330**] [**Telephone/Fax (1) 22745**](home),
[**Telephone/Fax (1) 22746**](cell)
Medications on Admission:
Hydrochlorothiazide 25mg PO daily
Alendronate
Discharge Medications:
1. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*90 Tablet(s)* Refills:*2*
3. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Amiodarone 400 mg Tablet Sig: One (1) Tablet PO once a day
for 2 months.
Disp:*60 Tablet(s)* Refills:*0*
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*30 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Primary:
2:1 AV block
Pericardial tamponade
Atrial fibrillation
.
Secondary:
Hypertension
Discharge Condition:
Good
Discharge Instructions:
You were found to have a conduction abnormality within your
heart requiring a pacemaker to be placed. During placement of
the pacemaker you developed bleeding around your heart and
required a drain to be placed. After removal of the drain your
heart developed an irregular rhythm called atrial fibrillation.
You received a shock to get your heart out of atrial
fibrillation, but you returned to atrial fibrillation one day
later.
.
It is important that you take all of your medications as
prescribed. We have added several new medications for your
heart. Amiodarone is for your heart rhythm, Aspirin to prevent
blood clots, lisinopril for your blood pressure, in addition to
continuing your hydrochlorothiazide and fosamax as you were
before being admitted to the hospital.
.
Call Dr. [**Last Name (STitle) 1007**] or 911 if you should experience any chest pain or
pressure, dizziness, racing heart beat or palpitations, profuse
sweating, nausea or vomiting, worsening cough or shortness of
breath. High fevers or shaking chills.
Followup Instructions:
You have the following appointments:
.
You have an appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] of Behavioral
Neurology on Friday, [**1-16**] at 8:30am, at the [**Hospital1 **] [**Last Name (Titles) 22747**] [**Location 860**] Building, [**Location (un) **], [**Apartment Address(1) **].
.
[**Hospital **] Clinic (cardiology [**Hospital 22748**] CLINIC') Phone:[**Telephone/Fax (1) 59**]
Date/Time:[**2127-12-1**] 11:30
.
Provider: [**Last Name (NamePattern4) **]. [**First Name11 (Name Pattern1) 275**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], Electrophysiology Lab
Phone:[**Telephone/Fax (1) 2934**] Date/Time:[**2127-12-4**] 3:00
.
Cardiology will setup Pulmonary Function Tests at your followup
appointment since you will be on amiodarone for the atrial
fibrillation.
|
[
"998.2",
"396.2",
"401.9",
"511.9",
"426.13",
"285.1",
"733.00",
"397.0",
"423.0",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.72",
"37.0",
"38.93",
"37.83",
"99.04",
"00.17",
"89.64"
] |
icd9pcs
|
[
[
[]
]
] |
14694, 14743
|
9273, 14061
|
300, 404
|
14877, 14884
|
2591, 9250
|
15962, 16801
|
14157, 14671
|
14764, 14856
|
14087, 14134
|
14908, 15939
|
1927, 2572
|
204, 262
|
432, 1596
|
1618, 1672
|
1688, 1912
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,152
| 178,873
|
33090
|
Discharge summary
|
report
|
Admission Date: [**2110-3-16**] Discharge Date: [**2110-3-31**]
Date of Birth: [**2049-10-26**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 473**]
Chief Complaint:
Abdominal Pain
Acute gallstone pancreatitis
Major Surgical or Invasive Procedure:
ERCP
History of Present Illness:
This is a 60 year old male who presented to [**Hospital 1562**] Hosp. on
[**2110-3-15**] with increasing abdominal pain. On the morning of
admission he noted abdominal discomfort following a meal that
developed into severe epigastric, non-radiating, sharp, buring
pain accomplanied by nausea and vomiting. He was taken to the
[**Hospital1 1562**] ED where he was afebrile and his admission labs were
notable for WBC 20.1 Amylase 4094 Lipase 3000 AST 288 ALT 188.
An abdominal CT showed diffuse pancreatic enlargement with
surrounding inflammation, multiple gallstones, no CBD
dilatation, no signs of obstruction and no free air. While
admitted to [**Hospital1 1562**] his enzymes and WBC began to trend down
while his K+
increased to 8 from 3.6. On [**3-16**] he was transferred to [**Hospital1 18**]
surgical ICU. His last BM was the AM of [**3-16**], described as dark
brown, and his last emesis was on arrival at [**Hospital1 18**].
Past Medical History:
PMH: CAD, DMII, HTN, Hyperlipidemia, CRI ([**Date range (1) 76919**] dialysis),
suicide attempt (antifreeze)
PSH:
-colectomy for diverticulitis w/ ostomy s/p revision and
takedown
approx 8y ago.
-ventral hernia repair with mesh
-L knee repair
-L shoulder repair
-back surgery
Social History:
lives with wife at home. Retired town administrator, non-smoker,
rare EtOH
Family History:
non contributory
Physical Exam:
VS:98.7 123 115/76 19 93%2L nc
Gen: lying in bed, mildly lethargic but responsive and
appropriate, NAD
CV:tachycardic regular S1 S2
Pulm: CTA B, no wheeze or rales
Abd: soft, distended, tympanitic, focally tender epigastrically
and LLQ. No rebound or guarding. Midline scar. LLQ transverse
scar. Supraumbilical transverse scar.
Extr: w,w-p, no edema
Skin: no jaundice
Pertinent Results:
[**2110-3-16**] 11:12PM BLOOD WBC-11.4* RBC-4.89 Hgb-14.6 Hct-42.6
MCV-87 MCH-29.9 MCHC-34.4 RDW-14.0 Plt Ct-188
[**2110-3-18**] 06:05AM BLOOD WBC-8.1 RBC-3.96* Hgb-11.9* Hct-34.5*
MCV-87 MCH-30.1 MCHC-34.6 RDW-14.9 Plt Ct-160
[**2110-3-17**] 03:39AM BLOOD Glucose-237* UreaN-54* Creat-3.1* Na-146*
K-4.8 Cl-114* HCO3-22 AnGap-15
[**2110-3-18**] 06:05AM BLOOD Glucose-190* UreaN-59* Creat-2.6* Na-147*
K-4.3 Cl-115* HCO3-20* AnGap-16
[**2110-3-18**] 06:05AM BLOOD ALT-77* AST-57* AlkPhos-33* Amylase-562*
TotBili-2.5*
[**2110-3-16**] 11:12PM BLOOD ALT-178* AST-153* AlkPhos-36*
Amylase-979* TotBili-2.6*
[**2110-3-18**] 06:05AM BLOOD Lipase-565*
[**2110-3-16**] 11:12PM BLOOD Lipase-1892*
[**2110-3-18**] 06:05AM BLOOD Calcium-6.9* Phos-2.7 Mg-2.1
[**2110-3-17**] 11:49AM BLOOD %HbA1c-8.6*
.
ABDOMEN U.S. (COMPLETE STUDY) [**2110-3-17**] 3:55 PM
IMPRESSION: Limited study, cholelithiasis and biliary sludge. No
acute cholecystitis is evident. No ascites.
.
Brief Hospital Course:
This is a 60 year old man admitted directly from outside
hospital with acute
pancreatitis.
Acute necrotizing gallstone pancreatitis: He was NPO with IV
fluid resuscitation. His pain was adequately controlled. He had
a Foley in order to closely watch his fluid balance.
.
He had a RUQ U/S on HD 3 and this showed cholelithiasis and
biliary sludge. No acute cholecystitis is evident.
.
A CXR was done on HD 3 and showed Free air under the
hemidiaphragms. A CT abd showed extensive emphysematous
pancreatic necrosis of the neck, body and tail of the pancreas
with multiple fluid collections along the greater curvature of
the stomach. Infected necrotizing pancreatitis cannot be
excluded. Significant amount of free intraperitoneal air. This
is likely related extension of retroperitoneal air into the
peritoneal cavity as there is no extravasation of oral contrast
that would document bowel perforation. However, bowel
perforation cannot be excluded.
.
He went to the OR on [**2110-3-18**] for a necrosectomy. He was admitted
to the ICU on pressre support and broad spectrum antibiotics.
.
He self-extubated on POD 1. He was stable and transferred to the
floor on POD 2.
His incision had some spotty drainage along the right side. He
had JP drains x [**Street Address(2) 76920**]. JP#3 was removed on POD#11, as the
output was <10cc/day.
.
On POD 8, he went for CT guided drainage of necrotic debris and
fluid from the pancreatic bed. A 14 French pigtail drain was
placed and 20cc of brownish fluid and debris was aspirated.
Cultures had no growth.
.
JPs #1 and 2 and the pigtail drain were left in place upon
discharge, with VNA to provide home care.
FEN: He was started on TPN while NPO. He was started on clears
on POD 6
He was tolerating regular food by POD#9 and the TPN was weaned
off.
Hyperglycemia: His blood sugars were elevated and a HbA1C was
8.6. [**Last Name (un) **] was consulted for blood glucose control. He was
started on Lantus and a humalog sliding scale and his blood
sugars were under control upon discharge. He will follow up as
an outpatient.
Chest Pain: On the morning of POD 7, he complained of chest
pain. He was worked up with EKG, CXR, cardiac enzymes and was
ruled out for a MI. He received ASA, Morphine and his pain
resolved.
Post-op blood loss anemia: He received 2 units of PRBC on POD 8
for a HCT of 22.9, with appropriate rise in HCT to 28.3.
Post-op Delirium: He had mental status change on POD 4. A head
CT revealed no acute intracranial abnormalities or hemorrhage
identified. He had a sitter at the bed-side. His mental status
continued to slowly improve to baseline at discharge.
Acute on chronic renal failure (CRI): His Cr at admission was
3.3. After IVF, his Cr returned to his baseline.
Pt was discharged on POD#12 with VNA for diabetic
teaching/monitoring and drain and incision care, to follow up
with Dr. [**Last Name (STitle) 468**] in 2 weeks.
Medications on Admission:
metoprolol 50mg',zoloft 50mg', lisinopril 20mg', tricor 145mg',
vytorin 10/80mg', omeprazole20mg', ASA 81mg', trazodone QHS
Discharge Medications:
1. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
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. Diltiazem HCl 60 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
Disp:*240 Tablet(s)* Refills:*2*
6. Amylase-Lipase-Protease 20,000-4,500- 25,000 unit Capsule,
Delayed Release(E.C.) Sig: One (1) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
Disp:*90 Cap(s)* Refills:*2*
7. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed.
Disp:*40 Tablet(s)* Refills:*0*
8. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO
Daily ().
9. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
13. Insulin Glargine 300 unit/3 mL Insulin Pen Sig: Sixty (60)
units Subcutaneous With breakfast.
Disp:*qs ml* Refills:*2*
14. Humalog 100 unit/mL Solution Sig: 10-40 units Subcutaneous
four times a day: Pt has instructions for sliding scale.
Disp:*qs ml* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
VNA of Central & [**Hospital3 29991**] [**Hospital3 **]
Discharge Diagnosis:
Acute gallstone pancreatitis
Necrotizing Pancreatitis
post-op hyperglycemia
post-op delerium
post-op blood loss anemia
Discharge Condition:
good
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting, diarrhea
or other reasons.
* Signs of dehydration include dry mouth, rapid heartbeat or
feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
.
* Please resume all regular home medications and take any new
meds
as ordered.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
* Continue to increase activity daily
* No heavy lifting (>[**11-26**] lbs) for 6 weeks.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 468**] in 2 weeks. His office should
get in touch with you regarding the time for your appointment,
likely [**2110-4-14**]. [**Telephone/Fax (1) 2835**]
|
[
"574.20",
"038.9",
"552.9",
"568.0",
"584.9",
"567.22",
"995.92",
"585.9",
"250.00",
"577.0",
"285.9",
"293.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"99.15",
"54.91",
"54.19",
"54.59",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
7713, 7799
|
3148, 6049
|
358, 365
|
7962, 7969
|
2165, 3125
|
9426, 9630
|
1740, 1758
|
6223, 7690
|
7820, 7941
|
6075, 6200
|
7993, 9403
|
1773, 2146
|
275, 320
|
393, 1331
|
1353, 1631
|
1647, 1724
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,900
| 134,824
|
30745
|
Discharge summary
|
report
|
Admission Date: [**2176-5-25**] Discharge Date: [**2176-6-4**]
Date of Birth: [**2096-7-10**] Sex: F
Service: MEDICINE
Allergies:
Cortisone
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Pneumonia and hypoxia from outside hospital
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt is a 79 year old woman with sub acute pulmonary process who
was transferred from [**Hospital3 **] with hypoxia and Afib with
RVR. She presented to [**Hospital1 **] on [**5-13**] with 2 weeks of cough and
hemoptysis but subtherapeutic on coumadin. Chest x-rays showed
bilateral upper lobe opacities and despite being afebrile she
was started on ceftr/azithro then transitioned to levo/oxac for
presummed pna. She had no improvement and on [**5-22**] underwent
VATS. She was seen by ID at [**Hospital1 **] on [**5-24**] who felt this was
less likely an infectious process. ABG was 7.28/69/84/32 94% on
4LNC.
.
VATS on [**5-22**] at [**Hospital1 **] showed pan-pneumonia and acute
fibroblasts, likely diagnosis of BOOP. Per medical reports and
family patient has had subacute respiratory process since
1/[**2175**]. She had progressive DOE with decrease in functional
status at home. On all accounts she denied accompanying symptoms
such as cough, fever, chills. She was hospitalized on [**4-12**] at
[**Hospital1 **] with transfer to [**Hospital1 18**] on [**2176-5-25**] for afib with RVR, but
was also treated with cef/azithro/prednisone without improvement
during her [**Hospital1 **] course. At [**Hospital1 **] pt had a high res chest CT which
showed nonspecific interstitial pneumonitis and bilateral
ground-glass opacities in the dependent portions. She was not
discharged on Coumadin as both patient and family refused.
.
Past Medical History:
- atrial fibrillation: paroxysmal x 3-4 years, now with RVR
- hyperlipidemia
- COPD
- breast CA: s/p lumpectomy and radiation
- colon CA: s/p resection [**2163**]
- OA right knee
- anxiety
- GERD
- s/p splenectomy
- s/p CCY
- s/p appendectomy
Social History:
Social history is significant for the absence of current tobacco
use; she smoked 40 pack-years but quit years ago. There is no
history of alcohol abuse. She lives in [**Hospital1 **] with her husband.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
ADMISSION PE:
VS: 97.4F ax HR 107 afib, BP 149/59, RR 18, 93% 6L
General: Elderly, lethargic woman responds to simple commands,
but unable to stay awake to communicate
HEENT: PERRL, sluggish, dry mucous membranes
Neck: supple
Chest: crackles throughout all lung fields, left sided
subclavian with minimal erythema surrounding line
Cardiac:
ABD: soft, diffusely tender, no guarding/rebound,
Extremities: 1+ non pitting edema in LE, no c/c
D/C PE:
VS:
General: AAO x 3, NAD, responds to commands
HEENT: OP clear, No LAD
Pulm: scattered wheezes, with good air movement b/l
Cardiac: irregularly irregular, no murmurs/rubs/gallops
Abd: soft, NT/ND, + BS all four quadrants
Extremities: edema in b/l feet, +1 DPs
Pertinent Results:
[**2176-5-25**] WBC-9.6 RBC-3.36* HGB-10.0* HCT-30.8* MCV-91# MCH-29.7
MCHC-32.5 RDW-15.8* PLT COUNT-407
[**2176-5-25**] NEUTS-91* BANDS-0 LYMPHS-7* MONOS-2 EOS-0 BASOS-0
ATYPS-0 METAS-0 MYELOS-0
[**2176-5-25**] GLUCOSE-178* UREA N-14 CREAT-0.8 SODIUM-133
POTASSIUM-5.3* CHLORIDE-96 TOTAL CO2-32 ANION GAP-10
[**2176-5-25**] ALBUMIN-2.6* CALCIUM-8.9 PHOSPHATE-3.6 MAGNESIUM-2.3
[**2176-5-25**] PT-15.0* PTT-32.9 INR(PT)-1.4*
[**2176-5-25**] LACTATE-1.1
[**2176-5-25**] TYPE-ART TEMP-37.4 PO2-65* PCO2-75* PH-7.27* TOTAL
CO2-36* BASE XS-4 INTUBATED-NOT INTUBA
[**2176-5-25**] SED RATE-91* CRP-129.4*
[**2176-5-25**] [**Doctor First Name **]-POSITIVE TITER-1:40
[**2176-5-25**] calTIBC-224 VIT B12-758 FOLATE-7.1 FERRITIN-487*
TRF-172* IRON-16*
.
.
CXR [**5-25**]
- Airspace disease in right upper lobe consistent with
consolidation.
- Diffuse increase in interstitial lung markings, which may be
due to
underlying fibrotic change
- Left retrocardiac opacity which may represent atelectasis/
consolidation.
.
Chest CT [**2176-5-25**]
Increase over 5 weeks in multifocal pulmonary consolidation and
peribronchial infiltration, upper lobe predominance, bilateral
pleural effusion and mediastinal adenopathy. Simple explanations
such as severe atypical pneumonia and congestive heart failure
can account for all findings, but given the history of
progressive respiratory compromise over six months, more unusual
such conditions such as DIP, COP, and CEP and non-Hodgkin's
lymphoma should be entertained.
.
VATS pathology from OSH [**5-22**]:
Active interstitial fibrosing process, occuring in background of
mild-mod chronic inflammation and patchy areas of organizing
intra-alveolar material s/of hyaline membranes. c/w
acute/subacute organizing interstitial fibrosing pneumonitis. no
granulomas/giant cells. AFB and fungal neg. no malignancy.
.
CT Head [**2176-5-25**]
No acute IC hemorrhage
Brief Hospital Course:
Assessment and Plan: 79 F with subacute respiratory process
since [**11/2175**] with progressive DOE and hypoxia.
.
# BOOP: Patient had hypoxia to 70s at OSH. VATS done with
acute/subacute pneumonitis. Patient has a distant but
significant smoking history and was on COPD regimen at home,
PFTs obstructive without vasodilator response. ABG shows
subacute/chronic co2 retention based on pH. ANCA, ACE, IGE
negative. [**Doctor First Name **] + at 1:80 and 1:40 diffuse. ESR and CRP elevated.
Patient has had several courses of both abx and steroids in the
last few months with no improvement. Not likely CAP, less likely
OI from steroids (aspergil, PCP). Patient with mostly negative
panel from prior (except [**Doctor First Name **] and ESR). She was transferred to
the [**Hospital1 18**] MICU on [**5-25**]. In the MICU, she was on venturi mask and
was intially on IV steroids then transitioned to PO steroids.
Her hypoxemia improved marginally. She was transferred to the
floor for further work up and management. Review of the OSH
pathology slides with [**Hospital1 18**] pathologists lead to the new
diagnosis of BOOP. It is unclear if anything triggered this
process (infection or drug effect). She was continued on high
dose (Prednisone 60 mg daily) steroids and will be discharged on
this dose. Pulmonary followed her here and will see her for
outpatient followup. Also seen on review of the pathology
slides were microthrombi within the pulmonary vasculature.
Extensive discussion was had with the patient and her family
regarding this feature of the pathology regarding restart of
Coumadin, which was recommended given her AFib and this new
information. At this time the patient and family do not wish
her to be on Coumadin at this time. The risks and benefits of
Coumadin therapy were discussed and the family felt that the
risks outweighed the benefits at this time. While on the floor,
pt had episodes of desaturation to the 60-70's which responded
to nebs and oxygen.
.
# Afib: She was rate control with diltiazem drip in the MICU;
following transfer to the floor oral diltiazem was progressively
increased for improved rate control. Her heart rate was in the
90's - 110 range. Anticoagulation with Coumadin was initially
held in light of hemoptysis; see above for further discussion of
Coumadin use in this patient. Pt is currently rate controlled
on Diltiazem and low dose metoprolol.
.
# Anxiety: Patient on prn xanax at home. This was initially
held for concerns of altered mental status. She was restarted
on a PRN basis as she improved.
.
# Steroid therapy: She was placed on an insulin sliding scale
with reasonable control of glucose. A small dose of glargine
insulin was also added. The patient has no history of DM.
Also, given high dose steroids, she was placed on a PPI, calcium
and vitamin D, and Bactrim three times weekly for PCP
[**Name Initial (PRE) 1102**].
.
#Hyperkalemia: likely nutritional, potassium has been high, has
been getting kayexalate. Potassium was trending down during
discharge. Continue Kayexalate at rehab until level is 4.5,
continue to check potassium daily. Nutrition recommeded low
potassium diet.
Medications on Admission:
Albuterol
Home medications:
Atrovent
xanax
robitussin with codeine
digoxin
cardizem
advair
lopressor
spiriva
coumadin
.
Meds on transfer from OSH:
levaquin 500mg QD
oxacillin 1g Q6
solumedrol 125mg Q6h
advair 250/50
albuterol
atrovent
Spiriva 1 puff
diltiazem gtt
ativan 0.25 Q3/prn
xanax 0.25 [**Hospital1 **] PO
diflucan 100mg QD
nystatin S&S
Digoxin 0.125mg
dilaudid 0.5-1mg Q2-3
colace 100mg [**Hospital1 **]
coumadin 1mg QD
FeSo4
tylenol
Zofran
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
2. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO twice a
day.
3. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Inhalation Q4H (every 4 hours).
4. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
5. Acetaminophen 160 mg/5 mL Solution Sig: [**9-14**] mL PO Q6H
(every 6 hours) as needed for fever or pain.
6. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day) as needed.
9. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
10. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) as needed for anxiety.
11. Diltiazem HCl 60 mg Tablet Sig: Two (2) Tablet PO QID (4
times a day).
12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
13. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO QMOWEFR (Monday -Wednesday-Friday).
14. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
15. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous DAILY (Daily) as needed.
16. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
17. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**11-28**] Sprays Nasal
QID (4 times a day) as needed for dry nose.
18. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
19. kayexalate
Please give 30 ml of Kayexalate per day, once a day until
potassium is less than 4.5. Then continue to monitor potassium
once a day
20. insulin sliding scale
Please see attached Insulin sliding scale.
21. Ondansetron HCl 2 mg/mL Solution Sig: [**11-28**] Intravenous three
times a day as needed for nausea.
22. Vitamin D 400 unit Capsule Sig: One (1) Capsule PO once a
day.
23. picc line
Please continue PICC line care. D/C PICC line when patient is
discharged.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 671**] [**Hospital 4094**] Hospital
Discharge Diagnosis:
Primary: BOOP with hypercarbic respiratory failure
Secondary: atrial fibrillation with RVR, hyperkalemia, anemia,
COPD
Discharge Condition:
Stable
Discharge Instructions:
You have been diagnosed with BOOP. You should continue taking
your medications, including your prednisone at the recommended
doses and use oxygen at all times.
.
Please take all of your medications as scheduled and keep all of
your appointments with your doctors.
.
Please return to the hospital if you are experiencing worsening
shortness of breath, chest pain, palpitations, coughing up
blood, or any new symptoms that you are concerned about.
Followup Instructions:
Please make an appointment to followup with your PCP, [**Last Name (NamePattern4) **].
[**Last Name (STitle) 18323**], in 1 to 2 weeks. Please call [**Telephone/Fax (1) 18325**] to set up
this appointment.
.
Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION
BILLING Date/Time:[**2176-6-24**] 4:00
.
Provider: [**Name10 (NameIs) 1571**] BREATHING TESTS Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2176-6-24**] 3:40
.
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) 2515**] & DR. [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2176-6-24**] 4:00, please come to appointment at 3:30 pm
|
[
"496",
"530.81",
"272.4",
"518.84",
"V10.05",
"285.29",
"276.7",
"V10.3",
"516.8",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10901, 10975
|
5027, 8199
|
312, 318
|
11138, 11147
|
3112, 5004
|
11642, 12331
|
2282, 2365
|
8700, 10878
|
10996, 11117
|
8225, 8235
|
11171, 11619
|
2380, 3093
|
8253, 8677
|
229, 274
|
346, 1780
|
1802, 2047
|
2063, 2266
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,770
| 142,833
|
45462
|
Discharge summary
|
report
|
Admission Date: [**2126-12-12**] Discharge Date: [**2126-12-25**]
Date of Birth: [**2048-4-18**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins / Morphine
Attending:[**Last Name (NamePattern1) 1561**]
Chief Complaint:
Esophageal perforation
Major Surgical or Invasive Procedure:
Thoracentesis with pig tail placement x2 - bilaterally
History of Present Illness:
Pt came in for his routine esophageal dilation for strictures as
he had been having for 20+ years. Had perforation during last
procedure of his esophagus.
Family declined surgery and pt was amde DNR.
Past Medical History:
GERD, esophageal ring at 33cm s/p q6mo dilations since [**2118**], CAD
s/p MI '[**21**] and cardiac cath w [**Year (2 digits) **] [**Last Name (LF) **], [**First Name3 (LF) **] 55%, rheumatoid
arthritis, COPD w FEV1 29%, s/p oropharyngeal CA resection 198
Physical Exam:
On discharge:
AAOx3, NAD
RRR
Lungs with coarse BS B/L
abd is soft NT/ND
no c/c/e
Pertinent Results:
RADIOLOGY Final Report
CT CHEST W&W/O C [**2126-12-12**] 5:37 PM
Reason: eval ptx, esoph injury
Field of view: 36
[**Hospital 93**] MEDICAL CONDITION:
78 year old man with esoph dilation, now c free air under
diaphragm
REASON FOR THIS EXAMINATION:
eval ptx, esoph injury
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 78-year-old man with esophageal dilatation of free
air under diaphragms. Evaluate for pneumothorax or esophageal
injury.
IMPRESSION:
1. Posterior mediastinal emphysema centered around the esophagus
after attempted dilatation of esophageal stricture, highly
suggestive of esophageal perforation. No extravasation of orally
instilled contrast material. No pneumothorax or free intra-
abdominal air.
2. Right lower lobe consolidative process suspicious for
pneumonia. Associated small bilateral pleural effusions.
3. Calcified pleural plaques bilaterally suggestive of prior
asbestos exposure.
4. Left lower lobe nodule. A followup CT and 3-6 months is
recommended to assess for resolution/stability.
5. Hypoattenuating lesions in the right kidney, most of which
are too small to characterize. Ultrasound could be performed for
further evaluation.
6. Cholelithiasis without evidence of cholecystitis.
7. Calcified granulomas in the liver indicating prior
granulomatous disease.
8. Hypoenhancing lesion with peripheral contrast puddling in
segment V of the liver most likely representing hemangioma.
Additional hypoenhancing lesion in segment VIII of the liver,
incompletely characterized. These lesions should be further
assessed with ultrasound or MRI.
9. Multiple thoracic wedge compression fractures, stable
compared to prior plain radiographs.
10. Small bilateral pleural effusions.
Date: [**2126-12-20**]
PROCEDURE: Laparotomy and gastrostomy tube and jejunostomy
tube placement.
Brief Hospital Course:
Pt returned to the ED s/p esophageal dilatation with chest pain
and SOB. CT showed evidence of esophageal perforation. He was
paleced on broad spectrum emperic antibiotics -vanco, levo,
fluc, flagyl [**Date range (1) 97009**]/07. He was intubated and taken to the OR
where a 1 cm tear was found approx 33 cm down the esophagus. At
this time there was a family meeting where they decided to not
go ahead with definitive repair and to make him DNR. He was
taken to the SICU intubated and on pressors. Pressors were
weaned off and he extubated without difficulty. On [**12-16**] he had
R sided u/s guided R pleural drainage yielding 900 cc of fluid.
The next day he had the same done on the L side with 850 of
drainage. On [**12-20**] he had a laparotomy with G and J tube
placement. He also had respiratory difficulties on the floor
which may been due to narcotic pain med administered which
warranted a transfer to the CSRU. Pt recovered w/ narcan and non
invasive resp support. On [**12-21**] the R pigtail was d/c'd and on [**12-23**]
the L pigtail was d/c'd without complications. On [**12-23**] he was in
good condition for transfered back to the floor. He completed
his antibiotic course and has remianed afebrile. He is working
w/PT but remains deconditioned and requires ongoing rehab. His
tube feeds were advanced to goal.
Medications on Admission:
albuterol, advair, spiriva, Plavix 75', aspirin 325', Lipitor
10', Toprol 25', lisinopril 5', Imdur 30', omeprazole 20',
Enbrel 50 mg weekly
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal Q4-6H (every 4 to 6 hours) as needed.
3. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
dissolve and give via j-tube.
6. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
7. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed.
8. Zantac 150 EFFERdose 150 mg Tablet, Effervescent Sig: One (1)
Tablet, Effervescent PO twice a day: dissolve and give
via-j-tube.
9. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day): disslove and give via j-tube.
10. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) ml PO BID (2
times a day).
11. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed.
12. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
GERD, esophageal ring at 33cm s/p dilation q6mos since [**2118**],
CAD, s/p MI, cardiac cath w/ left circ [**Last Name (LF) **], [**First Name3 (LF) **] 55%, RA, COPD
w/ FEV1 29%, oropharyngeal ca s/p
Esophageal perforation
Discharge Condition:
deconditioned
Discharge Instructions:
Please call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 170**] if you have
fever >101,chills, chest pain, shortness of breath.
Any problems related to your feeding tube.
keep the gastric tube to gravity until your appointment with Dr.
[**Last Name (STitle) **].
Followup Instructions:
You have an appointment with Dr.[**Name (NI) 2347**] office on
thursday [**2127-1-2**] 10:30am in the [**Hospital Ward Name **] clinical center [**Location (un) 8939**]. Please report to the [**Location (un) **] radiology at 10am for a
chest XRAY prior to your appointment. ([**Telephone/Fax (1) 1504**]
bring G-tube out put totals with you to your appointment.
Completed by:[**2126-12-25**]
|
[
"998.2",
"496",
"511.9",
"414.01",
"412",
"518.5",
"V15.3",
"530.81",
"530.3",
"V10.02",
"V45.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.6",
"42.23",
"34.91",
"99.15",
"38.93",
"34.09",
"96.71",
"43.19",
"46.39"
] |
icd9pcs
|
[
[
[]
]
] |
5662, 5728
|
2875, 4215
|
322, 379
|
5996, 6012
|
1007, 1127
|
6331, 6725
|
4406, 5639
|
1164, 1232
|
5749, 5975
|
4241, 4383
|
6036, 6308
|
903, 903
|
917, 985
|
260, 284
|
1261, 2852
|
407, 609
|
631, 888
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,873
| 141,490
|
3479
|
Discharge summary
|
report
|
Admission Date: [**2149-5-1**] Discharge Date: [**2149-5-7**]
Service: MEDICINE
Allergies:
Levofloxacin / Codeine
Attending:[**First Name3 (LF) 358**]
Chief Complaint:
hypoxia
Major Surgical or Invasive Procedure:
PICC Line placement
History of Present Illness:
86 year old woman with history of CAD s/p CABG, HTN, rheumatoid
arthritis, COPD, DM2 presenting with hypoxia and hypotension.
The patient was referred in the [**Hospital1 18**] after developing new onset
shortness of breath at her [**Hospital1 1501**]. She was found to be very
congested and non-productive cough. O2sat was found to be 83% RA
with improvement to 96% on 2L. Vitals were 98.1 79 82/52 22
and fingerstick was 116. She received albuterol and atrovent
prior to transfer.
Of note she was just discharged on [**2149-4-29**] from [**Hospital1 18**] following
an admission for RLL pneumonia. She was discharged to complete
a 10 day course of vancomycin/cefepime via a PICC line. At the
[**Hospital1 1501**] she was feeling improved with increasing energy and
participating in her activities of bingo and other social
gatherings.
In the ED her initial vitals were 101.2 86 88/40 21 99% NRB.
Her CXR was notable for persistent opacities in the RLL with
worsening pulmonary edema. She was hypoxic with response to NRB
then titrate down to venti-mask. Her blood pressure initially
was in the 90s then trended down requiring levophed infusion via
her PICC line. She received 1.5L of NS. Lactate remained normal.
She received vanc/zosyn.
Past Medical History:
- Coronary artery disease s/p CABG x3 ([**11/2141**])
- Hypertension
- Atrial fibrillation
- Hyperlipidemia
- Rheumatoid arthritis
- COPD
- Type two diabetes mellitus
- GERD
- Paraesophageal hernia repair ([**5-13**])
- Upper GI Bleed secondary to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] tear ([**8-14**])
Social History:
Patient lives alone at the nursing home. She has 4 children some
living in the area, 1 living in [**Doctor First Name **]. She previously worked
in a store. She denies tobacco use for 40 yrs, but previously
smoked 4 PPD. She drinks <1 drink ETOH/month, but previously
said that she "enjoyed her beer" when she was younger. She
denies any illicit drug use.
Functional status: She is able to ambulate with a walker. She is
able to eat unassisted, but has nursing help for showers,
sometime getting dressed, and other aspects of daily living.
Family History:
Mother died in her 60's of a MI.
Father died in his 80's of Liver cancer
Patient has 9 siblings, who have histories of lung cancer and
MI.
Physical Exam:
AF, VSS, on 2L nasal canula
General Appearance: cachectic, NAD
Eyes / Conjunctiva: PERRL, Conjunctiva pale
Head, Ears, Nose, Throat: Poor dentition, temporal wasting, dry
op
Lymphatic: Cervical WNL
Cardiovascular: regular III/VI holosystolic at LLSB
Respiratory / Chest: sparse anterior rales
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: no edema, muscle wasting, ankle contractures
Musculoskeletal: Muscle wasting
Skin: Cool, multiple ecchymoses B arms/legs
Neurologic: Attentive, Follows simple commands, Responds to:
Verbal stimuli, Oriented to person
Lines: PICC In place right arm
Pertinent Results:
Admission Labs:
-------------
[**2149-5-1**] 07:45PM WBC-7.9 RBC-2.80* HGB-8.3* HCT-25.8* MCV-92
MCH-29.6 MCHC-32.1 RDW-18.3*
[**2149-5-1**] 07:45PM NEUTS-78.6* LYMPHS-14.9* MONOS-4.5 EOS-1.5
BASOS-0.3
[**2149-5-1**] 07:45PM GLUCOSE-106* UREA N-21* CREAT-0.9 SODIUM-140
POTASSIUM-3.7 CHLORIDE-103 TOTAL CO2-31 ANION GAP-10
[**2149-5-1**] 08:10PM URINE RBC-0-2 WBC->50 BACTERIA-FEW YEAST-NONE
EPI-0-2
[**2149-5-1**] 08:10PM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2149-5-1**] 07:50PM LACTATE-1.0\
CXR [**5-1**]
---------
FINDINGS: Single bedside AP examination labeled "upright" with
lordotic positioning is compared with recent examinations dated
[**4-25**] and [**2149-4-23**]. The patient is status post median sternotomy
and CABG with six intact sternal cerclage wires, as before.
There is cardiomegaly with pulmonary vascular congestion,
interstitial edema and bilateral pleural effusions, representing
CHF, worse since [**4-23**]. There is persistent focal airspace
opacity involving the right lung base, also more confluent over
the series of studies, likely representing pneumonic
consolidation; no new airspace process is seen elsewhere. There
has been interval placement of a right subclavian PICC with its
tip in the proximal SVC. Atherosclerotic changes involving the
thoracic aorta are redemonstrated.
IMPRESSION:
1. Persistent confluent airspace process involving the right
lung base, likely representing pneumonic consolidation.
2. CHF with interstitial edema and bilateral pleural effusions,
worse since [**4-23**].
==============
Discharge Labs:
c.diff negative x1, second pending
[**2149-5-5**] 06:45AM BLOOD WBC-19.9*# RBC-3.61* Hgb-10.7* Hct-33.9*
MCV-94 MCH-29.6 MCHC-31.6 RDW-18.2* Plt Ct-269
[**2149-5-5**] 12:19PM BLOOD WBC-20.3* RBC-3.11* Hgb-9.4* Hct-29.9*
MCV-96 MCH-30.1 MCHC-31.3 RDW-17.5* Plt Ct-247
[**2149-5-6**] 05:05AM BLOOD WBC-12.7* RBC-2.58* Hgb-7.8* Hct-24.8*
MCV-96 MCH-30.4 MCHC-31.7 RDW-17.3* Plt Ct-221
[**2149-5-1**] 07:45PM BLOOD PT-15.0* PTT-29.6 INR(PT)-1.3*
[**2149-5-6**] 05:05AM BLOOD Glucose-104 UreaN-21* Creat-0.8 Na-149*
K-2.9* Cl-113* HCO3-30 AnGap-9
[**2149-5-5**] 06:45AM BLOOD Glucose-86 UreaN-17 Creat-0.9 Na-145
K-3.5 Cl-104 HCO3-28 AnGap-17
[**2149-5-2**] 03:47AM BLOOD CK-MB-4 cTropnT-0.07*
[**2149-5-1**] 07:45PM BLOOD cTropnT-0.08*
[**2149-5-5**] 06:45AM BLOOD Calcium-8.8 Phos-4.1 Mg-2.2
[**2149-5-1**] 07:50PM BLOOD Lactate-1.0
[**2149-5-5**] 12:57PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.011
[**2149-5-5**] 12:57PM URINE Blood-TR Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR
[**2149-5-5**] 12:57PM URINE RBC-3* WBC-18* Bacteri-MOD Yeast-NONE
Epi-1 TransE-1
URINE CULTURE (Final [**2149-5-2**]):
YEAST. >100,000 ORGANISMS/ML..
Brief Hospital Course:
86 year old woman with hx of CAD s/p CABG, biventricular CHF,
COPD, DM2 who presented with acute hypoxia and hypotension.
Hypoxia secondary to Aspiration Pneumonia: Likely multifactorial
with residual pneumonia +/- additional aspiration with
co-incident pulmonary edema (potentially capillary leak from
UTI). Patient presented on day 8 of 10 of health-care associated
pneumonia therapy. In the ICU, the patient's vanc/cefepime
outpatient tx was changed to vanco/zosyn for HAP. She received
seven additional days of IV abx as an inpatient here. Her
oxygen requirement improved throughout her stay. Speech/swallow
evaluation consisitent with moderate dysphagia. Family does not
wish to pursue restricted diet or PEG placement (see below for
hospice/comfort measures discussion).
Hypotension: ICU team thought likely related to infection in
patient with poor cardiac reserve (biV dysfunction). After
speaking with the family, it was realized that the patient's two
arms had significant differences in her BP. Her right arm BP is
significantly higher, and more consistent with the BP in her
cuff. She was weaned off pressors and did not require any
further pressors or fluid boluses. At the time of discharge
from the ICU, the patient was hemodynamically stable. Her HCT
remained stable.
Delirium: After transfer to the floor, the patient was noted to
be muttering that she was very frightened repeatedly and refused
to interact with her famil;y or medical staff. The following
day, she was more interactive but not verbal. Psychiatry
evaluated the patient and was concerned for delirium versus
catatonia. The patient was deemed not to have capacity at that
tiem and per the strong wishes of her HCP, the patient's code
status was changed to DNR/DNI on [**2149-5-4**]. Her mental status
improved throughout her stay, although she remained
intermittently disoriented/delerious.
Anemia: Normocytic anemia with elevated RDW but with no evidence
of acute blood loss or hemolysis. Her HCT remained stable.
COPD: stable; continued bronchodilators.
Biventricular ischemic CHF: currently intra-vascularly wet given
edema in legs and pulmonary edema in setting of likely
infection. no evidence of an ischemic event and CE unremarkable.
Cardiac enzymes were flat. She was continued on digoxin and
aspirin. Her b-blocker was held initially. She was also
continued on her statin.
Diabetes mellitus type 2: currently well controlled. continued
regular insulin sliding scale.
Rheumatoid Arthritis: continue home regimen with therapies
directed at chronic neck pain.
Hospice/Comfort measures -- Palliative care was consulted given
patient's poor functional status and numerous recent admissions.
They decided, consistent with Ms. [**Known lastname 16013**] previous
conversations, that she would not want aggressive care and
recurrent hospitalizations. She had previously expressed wishes
to be DNR/DNI, and her son/granddaughters agreed. Additionally,
they want to pursue hospice care at her skilled nursing
facility, avoid future hospitalizations, and focus on comfort
care only. Antibiotics were discontinued after a seven day
course. All unnecessary medications were discontinued,
including simvastatin, aspirin, insulin, ppi, plaquenil. She
continues to recieve oral and IV morphine for pain (neck/hips).
Even with known risk for aspiration, she will continue to eat or
drink what she desires. Cardiac medications were continued to
avoid symptomatic palpatations.
Contacts: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 16014**] (grand-daughter/co-HCP) [**Telephone/Fax (1) 16015**], cell
[**Telephone/Fax (1) 16016**]
Medications on Admission:
Simvastatin 40 mg DAILY
Lidocaine 5 %(700 mg/patch) DAILY
Hydroxychloroquine 200 mg [**Hospital1 **]
Sulfasalazine 500 mg [**Hospital1 **]
Aspirin 325 mg DAILY
Docusate Sodium 100 mg [**Hospital1 **]
Guaifenesin 100 mg/5 mL 5-10 MLs PO Q6H
Cholecalciferol (Vitamin D3) 800 unit DAILY
Ipratropium Bromide Neb Q6H:prn
Furosemide 60 mg DAILY
Metoprolol Tartrate 25 mg [**Hospital1 **]
Ferrous Sulfate 325 mg DAILY
Albuterol Sulfate Neb Q6h:prn
Oxycodone 5-10 mg Q4H:prn
Acetaminophen 325-650 mg Q4H:prn
Pregabalin 150 mg [**Hospital1 **]
Baclofen 10 mg Q12H
Cefepime 2 gram q24 (ending [**2149-5-3**])
Vancomycin 500 mg Q 12H (ending [**2149-5-3**])
Prilosec OTC 20 mg daily
Digoxin 125 mcg daily
Imdur 30 mg daily
Insulin Sliding scale
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
3. Baclofen 10 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
4. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
5. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) Inhalation Q6H (every 6 hours) as needed for shortness
of breath or wheezing.
6. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Morphine Concentrate 20 mg/mL Solution Sig: 5-10 mg PO Q4H
(every 4 hours) as needed for pain/grimacing.
8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
9. [**Hospital **]
Hospice consultation, hospice physician to assume care.
10. Morphine 10 mg/mL Solution Sig: 0.5-1 mg Intravenous every
four (4) hours as needed for pain: breakthrough or if unable to
take po.
11. Ativan 2 mg/mL Solution Sig: 0.5-1 mg Injection every four
(4) hours as needed for agitation/anxiety.
Discharge Disposition:
Extended Care
Facility:
Meadowbrook - [**Location (un) 2624**]
Discharge Diagnosis:
Hypoxia
Aspiration Pneumonia
Pulmonary Edema
Delirium
Discharge Condition:
Vital Signs Stable, bed bound, intermittently somnolent,
cachectic, PICC in place.
Discharge Instructions:
You were hospitalized with aspiration pneumonia. You completed
seven days of IV antibiotics. You will be discharged to a
nursing facility with hospice care. Please call your primary
physician with concerns or questions.
Followup Instructions:
Please discuss care with your hospice providers.
|
[
"507.0",
"250.00",
"530.81",
"496",
"280.9",
"428.0",
"714.0",
"V45.81",
"427.31",
"428.21",
"401.9",
"293.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11702, 11767
|
6113, 9770
|
235, 256
|
11865, 11950
|
3245, 3245
|
12222, 12274
|
2465, 2605
|
10554, 11679
|
11788, 11844
|
9796, 10531
|
11974, 12199
|
4889, 6090
|
2620, 3226
|
188, 197
|
284, 1534
|
3261, 4873
|
1556, 1890
|
1906, 2449
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,386
| 196,951
|
10150+56112
|
Discharge summary
|
report+addendum
|
Admission Date: [**2137-2-25**] Discharge Date: [**2137-3-7**]
Date of Birth: [**2072-5-17**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1148**]
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
PEJ tube replacement by IR
History of Present Illness:
This is a 64 y/o NH patient with chronic, indwelling foley,
mental retardation, recurrent osteomyelitis of thoracic spine
s/p fusion [**2136**], recurrent UTIs, DM, HTN, who presented from
nursing home with fever to 101.5 and increased leukocytosis
(14.3). Patient unable to provide a review of systems.
.
ED course: Temp on arrival was 99.2 in triage, 104 rectally in
ED, elevated Lactate 2.5, K was 6.5. For elevated K, patient
received calcium gluconate 2 amps, sodium bicarb 1 amp IV x 1, 1
amp of D50, regular insulin 10U IV x 1, Tylenol 650mg PR. Given
her fever, she received levaquin 500mg IV x1 and vancomycin 1g
IV times one. ECG showed sinus tachycardia at 121.
Past Medical History:
.
- h/o Osteomyelitis T6-T8 with cord compression: s/p T6-7
corpectomy with T5-8 strut graft/fusion on [**2136-10-19**], s/p T3-L3
fusion w/bone graft on [**2136-11-2**], on long-term nafcillin
- h/o MSSA epidural abscesses from L4-brain: s/p multiple
drainages during prior admissions
- h/o ATN requiring HD, now with CRI (recent baseline 1.2-1.4)
- anemia likley [**2-22**] ACD, on epo (recent baseline hct 26-28)
- h/o upper GIB (no recent scopes in OMR)
- COPD
- h/o transudative pleural effusion
- h/o sepsis
- h/o drug resistant acinetobacter from sputum cx (sensitive to
tobramycin)
- h/o VRE UTI
- h/o resp failure: s/p trach and PEG [**2136-11-9**], continues to
require vent at rehab
- persistent diarrhea (C.diff negative)
- Mental retardation
- DVT [**1-/2130**]
- NIDDM
- Obesity
- Sciatica
- Hypertension
- Hypercholesterolemia
- Anxiety
- Psoriasis
- Paroxysmal A. fib
- cholelithiasis
.
Social History:
Prev lived in apt with 24 hour caregiver. [**Name (NI) **] term boyfriend.
Prev worked part time. Guardian is [**Name (NI) 402**] [**Name (NI) 33801**] [**Telephone/Fax (1) 33802**].
In past year since getting sick has been in group home and then
[**Hospital1 1501**].
Family History:
Pt unable to provide
Physical Exam:
T 97.8 BP 103/60 HR 106-115 RR 18 99%RA
Gen: alert, NAD
HEENT: PERRL. Does not follow commands. Dysmorphic facial
features. Dry MM. Fissured tongue. Dry cracked lips
Neck: Thick neck. supple. No LAD.
CV: RRR Nl S1, S2, No m/g/r appreciated
RR: coarse otherwise clear
Abd: soft, NT, ND, NABS. obese, NABS. No r/g.
Ext: Trace b/l LE.
Skin: Erythematous sacral decub. R heel ulcer. Neither
infectious appearing
Neuro: alert, answers questions but unclear if appropriate,
moves extremities but not to command.
Pertinent Results:
[**2137-2-25**] 10:50PM SED RATE-120*
[**2137-2-25**] 10:50PM PLT COUNT-315
[**2137-2-25**] 10:50PM ANISOCYT-1+ MACROCYT-1+
[**2137-2-25**] 10:50PM NEUTS-83.0* LYMPHS-12.2* MONOS-4.0 EOS-0.5
BASOS-0.4
[**2137-2-25**] 10:50PM WBC-16.5*# RBC-3.51*# HGB-11.5*# HCT-33.8*#
MCV-96 MCH-32.7* MCHC-34.0 RDW-16.3*
[**2137-2-25**] 10:50PM GLUCOSE-359* UREA N-106* CREAT-1.8*
SODIUM-153* POTASSIUM-5.1 CHLORIDE-119* TOTAL CO2-17* ANION
GAP-22*
[**2137-2-25**] 10:51PM LACTATE-2.5* K+-6.5*
[**2137-2-25**] 11:50PM URINE AMORPH-MOD CA OXAL-FEW
[**2137-2-25**] 11:50PM URINE GRANULAR-[**3-25**]*
[**2137-2-25**] 11:50PM URINE RBC-0-2 WBC->50 BACTERIA-MANY YEAST-NONE
EPI-0
.
[**2137-2-26**] CXR: FINDINGS: AP single view of the chest obtained with
patient in supine position is analyzed in direct comparison with
a similar preceding study obtained three hours earlier during
the same date. The right subclavian approach central venous line
has now been repositioned and its termination point is overlying
the SVC at the level of the carina. It is partially obscured by
the orthopedic hardware, but the position is now deemed to be
correct. No pneumothorax has developed and no other
placement-related complication is identified. Lungs remain
unchanged without evidence of CHF or acute infiltrates
.
[**2137-2-27**] CT abd/pelvis: IMPRESSION:
1. No convincing evidence of rectovesicular fistula. 2.
Nonspecific wall thickening of the distal colon and rectum is
suggestive of a focal colitis.
3. Cholelithiasis without cholecystitis.
4. Small left-sided pleural effusion with associated
atelectasis.
5. Foci of air within the bladder lumen, likely intraluminal.
However, a focus of intramural air cannot be entirely excluded.
If the patient appears toxic consider emphysematous cystitis
.
URINE CULTURE (Final [**2137-2-27**]):
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH FECAL
CONTAMINATION
Blood cultures [**2137-2-25**], 8 bottles: no growth
Stool c diff positive
Brief Hospital Course:
Impression/Plan: 64 yo F w/ NH patient with chronic, indwelling
foley, mental retardation, recurrent osteomyelitis of thoracic
spine s/p fusion [**2136**], recurrent UTIs, DM, HTN, who presented
from nursing home with fever to 101.5 and urine c/w UTI. In the
MICU the patient req. pressors for blood pressure support, CVL
and Art line placed. Pressors off in less than 24 hours.
Transfused 2 unit pRBC.
.
# Fever: Most likely secondary to UTI in patient with chronic
indwelling foley plus found to have c difficile. She also has a
history of chronic osteomyelitis and should be on chronic
suppressive therapy. Her urine grew mixed flora so she was
covered for other organisms that she previously was infected
with including VRE and Enterobacter, sensitive to daptomycin and
imipenem, respectively. She received 10 days of treatment.
During her prior hospitalization, she was noted to be "rigid"
when on linezolid, thus we avoided this antibiotic and covered
vRE with daptomycin. Foley was also replaced during this
hospital stay.
-finished 10 days daptomycin/imipenem today. Start
dicloxacillin now for lifelong suppression osteomyelitis.
-follow up appointment in [**Hospital **] clinic
-patient should get trial of foley removal in future and see if
can void on own.
.
#Clostridium difficile colitis: Colitis seen on CT scan abd and
stool positive for c diff. Started on flagyl and stool is
slowly improving in consistency. Has rectal tube in place to
protect decubitus ulcers.
-should get 14 days more of flagyl
-remove rectal tube in next few days as output slows and more
formed
.
# Anion gap acidosis: Positive ketones with hyperglycemia, most
likely DKA in face of sepsis. Improved and closed with IV
hydration and insulin drip.
.
# Non-anion gap metabolic acidosis: Most likely from diarrhea.
Improved with less output. Should repeat in 1 week to follow up
resolution with improvement in diarrhea.
.
#. Abdominal pain: Chronic in nature, no clear source of pain.
Decreasing hematocrit in setting of [**Month (only) **] Hct concerning for
retroperitoneal bleed, no evidence on CT abdomen of bleed.
.
# Acute renal failure: Improved to baseline Cr 0.9 with IV fluid
hydration, likely prerenal.
.
# Hypertension: Hold metoprolol for now
.
# NIDDM: Required insulin drip on admission but only needed diet
control with occasional sliding scale insulin after. Continue
to follow.
.
# Decubitus ulcers: Seen by wound care and plastics while here.
Patient will need continued [**Hospital1 **] wet to dry dressing changes (and
should get pain medication prior to changes) and frequent
turning. Did not need debridement at this time. Should be
followed carefully by wound care specialist as outpatient.
.
# FEN: Continued to use PEJ tube which required replacement on
[**2137-3-4**] by IR and was working at time of discharge. Seen by
swallow therapy and found to be safe to take thin liquids and
ground solids with assistance. Can give diabetic diet with such
consistency and continue to see if can transition back to more
full diet support orally.
.
# Anxiety: Patient appears to have a lot of anxiety and may have
had some mild delirium while in hospital. Very talkative and
interactive by time of discharge but quick to cry or become
frustrated. Seen by psych who agreed with continued buspar and
to use seroquel prn additional anxiety.
.
# Leg pain: Continued wound care. Patient should get follow up
with podiatry arranged. Cont gabapentin and ultram..
.
# Access: Patient has R TLC in place at time of discharge in
case access needed. Should remove in next 5 days.
.
# Contacts: HCP [**Name (NI) 402**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 33801**], guardian, cell phone
[**Telephone/Fax (1) 33803**]. Second [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 17**] [**Last Name (NamePattern1) 33892**] LICSW [**Telephone/Fax (1) 33893**]
cell.
Medications on Admission:
TF through PEG, flush 200 cc free water q6h
Chronic indwelling foley
Multivitamin
Zantac 150mg po/ng qdaily
Levothyroxine 200mcg po qdaily
Vitamin B12 100mcg po daily
Vitamin C 500mg daily
Neurontin 200mg po tid
Buspar 10mg po daily
Hep SQ 5000 U TID
Lipitor 10mg po daily
Metoprolol tartate 25mg po daily
Humulin sliding scale
Dulcolax 10mg pr prn constipation
Albuterol nebs prn wheezing
Atrovent nebs prn wheezing
Ativan 1mg prn anxiety
Tylenol 650mg po q4-6h prn
Ultram 50mg po q6h prn pain
Discharge Medications:
1. Dicloxacillin 500 mg Capsule [**Telephone/Fax (1) **]: One (1) Capsule PO three
times a day.
Disp:*90 Capsule(s)* Refills:*2*
2. Hexavitamin Tablet [**Telephone/Fax (1) **]: One (1) Cap PO DAILY (Daily).
3. Ranitidine HCl 150 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO DAILY
(Daily).
4. Levothyroxine 100 mcg Tablet [**Telephone/Fax (1) **]: Two (2) Tablet PO DAILY
(Daily).
5. Cyanocobalamin 100 mcg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO DAILY
(Daily).
6. Ascorbic Acid 500 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO DAILY
(Daily).
7. Gabapentin 100 mg Capsule [**Telephone/Fax (1) **]: Two (2) Capsule PO TID (3
times a day).
8. Buspirone 5 mg Tablet [**Telephone/Fax (1) **]: Two (2) Tablet PO DAILY (Daily).
9. Bisacodyl 10 mg Suppository [**Telephone/Fax (1) **]: One (1) Suppository Rectal
HS (at bedtime) as needed.
10. Heparin (Porcine) 5,000 unit/mL Solution [**Telephone/Fax (1) **]: One (1)
Injection TID (3 times a day).
11. Insulin Lispro (Human) 100 unit/mL Solution [**Telephone/Fax (1) **]: One (1)
Subcutaneous ASDIR (AS DIRECTED).
12. Toprol XL 25 mg Tablet Sustained Release 24HR [**Telephone/Fax (1) **]: One (1)
Tablet Sustained Release 24HR PO once a day.
13. Tramadol 50 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO QID (4 times a
day).
14. Metronidazole 500 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO TID (3
times a day) for 14 days.
15. Miconazole Nitrate 2 % Powder [**Telephone/Fax (1) **]: One (1) Appl Topical TID
(3 times a day) as needed.
16. Acetaminophen 325 mg Tablet [**Telephone/Fax (1) **]: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
17. Zinc Sulfate 220 (50) mg Capsule [**Telephone/Fax (1) **]: One (1) Capsule PO PRN
(as needed) for 14 days.
18. Quetiapine 25 mg Tablet [**Telephone/Fax (1) **]: 0.5 Tablet PO Q6H (every 6
hours) as needed for anxiety.
19. Heparin Lock Flush (Porcine) 100 unit/mL Syringe [**Telephone/Fax (1) **]: One
(1) ML Intravenous DAILY (Daily) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
UTI, urosepsis
Clostridium difficile colitis
DKA
Decubitis ulcers
Anxiety disorder
Delirium
Type 2 Diabetes
Discharge Condition:
Good
Discharge Instructions:
Please continue medications as outlined. Please call your
doctor if you develop fevers, chills, worsening diarrhea,
worsening of your wounds.
Followup Instructions:
You have an appointment to follow in in [**Hospital **] clinic with Dr. [**Last Name (STitle) 3394**]
on [**4-2**] @ 9:30am. You can reach her clinic at:
[**Telephone/Fax (1) 457**].
.
If you continue to have worsening problems with the wound on
your backside, you may follow up in plastic surgery clinic.
call [**Telephone/Fax (1) 4652**] for an appointment.
.
Please make a follow up appointment with your primary care
doctor, [**Telephone/Fax (1) **] [**Doctor Last Name 5404**] [**Telephone/Fax (1) 33894**] within a few weeks after
discharge from [**Hospital1 **].
.
Please make a follow up appointment with your podiatrist in the
next 3 weeks to evaluate your foot care.
Name: [**Known lastname 5916**],[**Known firstname **] Unit No: [**Numeric Identifier 5917**]
Admission Date: [**2137-2-25**] Discharge Date: [**2137-3-7**]
Date of Birth: [**2072-5-17**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 803**]
Addendum:
Chest Pain: On day of discharge patient mentioned some
substernal pain. Occurred when lying in bed and resolved with
1mg morphine. Hard to obtain clear EKG because of movement but
no acute EKG changes seen. Cardiac enymes times two were sent
and not significantly elevated (CK-MG normal, trop 0.1). This
should be monitored as outpatient but no evidence acute coronary
event here.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 14**] & Rehab Center - [**Hospital1 15**]
[**First Name11 (Name Pattern1) 153**] [**Last Name (NamePattern1) 811**] MD [**MD Number(2) 812**]
Completed by:[**2137-3-7**]
|
[
"585.9",
"599.0",
"707.03",
"785.52",
"250.12",
"707.07",
"995.92",
"730.18",
"403.90",
"285.21",
"584.9",
"996.64",
"038.9",
"008.45",
"496",
"319",
"V55.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"97.03",
"38.93",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
13154, 13392
|
4825, 8730
|
277, 305
|
11526, 11533
|
2804, 4802
|
11725, 13131
|
2239, 2262
|
9275, 11272
|
11395, 11505
|
8756, 9252
|
11557, 11702
|
2277, 2785
|
232, 239
|
333, 1007
|
1029, 1933
|
1949, 2223
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,464
| 176,530
|
37319
|
Discharge summary
|
report
|
Admission Date: [**2119-1-29**] Discharge Date: [**2119-2-8**]
Date of Birth: [**2096-8-29**] Sex: M
Service: NEUROSURGERY
Allergies:
Chocolate Flavor
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
"worst headache of life"
Major Surgical or Invasive Procedure:
Angiogram [**2119-1-29**] Acomm aneurysm coiling
EVD placement [**2119-1-29**]
History of Present Illness:
22 year old man woken from sleep with worst headache of
life, nausea and vomiting. Pain is [**10-22**], bifrontal. Presented
to
OSH where he was found to have SAH. Transferred by [**Location (un) **] for
neurosurgical care. Of note, patient reports intermittant
headaches over the past several days. +photophobia, neck pain,
visual changes.
Past Medical History:
none
Social History:
lives with sister. works in garment industry. smokes
approx 1 cig/day. No EtOH. Denies drugs.
Family History:
NC
Physical Exam:
T: 98.8 BP: 152/77 HR: 104 R: 16 O2Sats: 100%RA
Gen: WD/WN, uncomfortable lying down
HEENT: Pupils: 2mm, nonreactive b/l EOMs: full
Neck: Supple, tender ROM
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round, non reactive to light,
2mm bilaterally.
III, IV, VI: Extraocular movements intact bilaterally.
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 [**5-17**] throughout. No pronator drift
Sensation: Intact to light touch bilaterally.
Coordination: normal on finger-nose-finger
Upon discharge pt was intact.
Pertinent Results:
CTA HEAD W&W/O C & RECONS [**2119-1-29**]
Extensive bilateral subarachnoid hemorrhage as described in
detail above.
There is also evidence of intraventricular hemorrhage with small
amount of
blood in the occipital ventricular horns.
Interval enlargement of the third and lateral ventricles,
concerning for
hydrocephalus.
CTA demonstrates 6 x 5 x 4-mm aneurysm apparently arising from
the anterior communicating artery complex with no evidence of
vasospasm.
Hypoplasia of the A1 segment on the left, apparently both
anterior cerebral arteries are filling from the right. There is
patency of the left posterior communicating artery. Mild
bilateral ethmoidal mucosal thickening is identified.
CT HEAD W/O CONTRAST [**2119-1-29**]
1. Marked decreased size of the ventricles compared to prior
study. There is effacement of the perimesencephalic cisterns,
ambient cisterns concerning for uncal herniation.
2. Decreased size of the ventricles, concerning for over
shunting.
3. Stable appearance to diffuse subarachnoid hemorrhage without
areas of new hemorrhage.
4. No evidence for acute infarct.
5. Stable opacification of the paranasal sinuses and nasal
passages.
CTA 1.20 Head
Status post coiling of an anterior communicating artery
aneurysm. Given
beam hardening artifact, it is difficult to preclude the
possibility of subtle residual aneurysm, although no large
residual aneurysm is identified.
2. Stable right posterior communicating artery aneurysm,
projecting
inferiorly from the origin of the posterior communicating
artery.
3. Possible subtle decreased CBF and CBV in the superior aspect
of the left frontal lobe which given the lack of a corresponding
finding on the MTT map is likely artifactual in nature. No
definite evidence of vasospasm is identified.
CTA [**2-6**] Head
IMPRESSION:
1. Stable mild, intracranial arterial spasm.
2. Resolution of prior subarachnoid hemorrhage.
3. Unchanged right posterior communicating artery aneurysm.
Brief Hospital Course:
22 y/o M presents after being awaken by the worst headache of
life. Patient also presented with nause and vomiting. Head CT
reveals significant SAH and CTA confirmed aneurysmal source of
bleed. Angiogram revealed ACOMM aneurysm which was ruptured and
PCOMM aneurysm. Acomm aneurysm was coiled and PCOMM will be
coiled at a later date. Patient remains nonfocal. EVD was placed
at time of angiogram for hydrocephalus and is at 20 and open. On
[**1-31**], patient pulled EVD out due to agitation. He was monitored
closely and he remained neurologically stable thus no EVD was
placed again. Because his neuro exam remained stable and his
repeat CTA showed no evidence of vasospasm, the patient was
transferred to the neuro step down unit on [**2-4**].
The patient was transferred to the floor shortly thereafter in
which he had an uneventful stay and was discharged home after
being cleared by PT/OT.
Medications on Admission:
none
Discharge Medications:
1. Nimodipine 30 mg Capsule Sig: Two (2) Capsule PO Q4H (every 4
hours) for 11 days.
Disp:*132 Capsule(s)* Refills:*0*
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: One
(1) Tablet PO Q6H (every 6 hours) as needed for headache.
Disp:*120 Tablet(s)* Refills:*2*
4. Hydromorphone 4 mg Tablet Sig: 0.5-1 Tablet PO Q3H (every 3
hours) as needed for pain: Please only take for breakthrough
Headache.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
SAH, Acomm and Pcomm aneurysm
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
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.
?????? 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
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:
You will need to follow-up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] 1 month with an
MRI/A
Please call Takeisha at [**Telephone/Fax (1) 4296**] to make this appointment.
Completed by:[**2119-2-19**]
|
[
"331.4",
"780.1",
"430",
"305.1",
"437.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.75",
"02.2",
"88.41"
] |
icd9pcs
|
[
[
[]
]
] |
5581, 5587
|
4100, 4999
|
303, 384
|
5661, 5661
|
2117, 4077
|
7716, 7940
|
912, 917
|
5055, 5558
|
5608, 5640
|
5025, 5032
|
5806, 6775
|
6801, 7693
|
932, 1197
|
239, 265
|
412, 755
|
1449, 2098
|
5675, 5782
|
777, 784
|
800, 896
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,632
| 183,202
|
50465
|
Discharge summary
|
report
|
Admission Date: [**2100-12-29**] Discharge Date: [**2101-1-3**]
Date of Birth: [**2051-4-14**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Sulfasalazine / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 64**]
Chief Complaint:
Right Hip pain
Major Surgical or Invasive Procedure:
Revision Right Total Hip Arthroplasty [**2100-12-29**]
History of Present Illness:
49 yo M with worsening Right hip pain. The right leg is getting
shorter and more painful and more incapacitating. We repeated
radiographs today and most definitely the previously noted
failed right acetabulum is migrating more medial to the point
that there is just a wisp of bone covering the medial
quadrilateral plate. The cup is completely vertical and now
presenting almost in direct visual line to the column of the
beam
indicating that of course it completely has lost all its
fixation. This is a very difficult situation and we will
attempt
to reconstruct him again. He had problems with progressive
osteoporosis. His most recent bone mineral density studies by
[**First Name8 (NamePattern2) 1312**] [**Last Name (NamePattern1) **] demonstrates that his T-scores however are by WHO
characterization certainly normal. So I would certainly feel
that he is not osteoporotic now we have these studies available.
His T-score of the left forearm was 2.6, his AP spine was -0.2.
We are going to go forward with the following options. We
believe that the femoral component is solid. He will need a
transtrochanteric approach, lateral, and once the cup is easily
removed the options would include morselized bone grafting into
the protrusio defect with either a large hemispherical perhaps
dual geometry cup implanted if we are able to get a reasonable
rim fit. If the rim fit is not possible even with jumbo sizes,
then we would have additional options of bone graft
morselization/impaction grafting into the defect with cementing
of the cup into the graft bed and additional screw fixation
through the multiple holes of the hemispherical cup. If that
appears to be inadequate intraoperative trialing, then
morselized
bone grafting with a gap cup construct or other cage such as [**Initials (NamePattern4) **]
[**Last Name (NamePattern4) **]-[**Doctor Last Name **] and a cemented cup, would be reasonable also.
Certainly constraint liners are to be avoided given the tenuous
nature of the implantation fixation nicks that we might expect
on
the acetabulum side. The defect does not appear to be amenable
to oblong bilobed cup. Reestablishment of the hip center and
lateralization will be important for stability. He has a
significant leg length discrepancy now and it will be quite hard
to get them to match and he would run the risk of a sciatic
nerve
palsy when we lengthen him. Offset cups, liners and 10-degree
and 20-degree hooded liners need to be available as inventory on
that day as well. Additional considerations that I have
discussed with him are that in order to get past the problem of
progressive acetabulum cup loosening, a jumbo unipolar head is
an
option. All would depend on how much contact area the
endo-prosthetic head would get on the superior bone and rim of
the acetabulum. If it tends to seat deeply back in to the
protrusio area, it may just continue to migrate medially in
which
case little would have been accomplished. It just will not be
possible until we are actually in there and can assess the full
nature of the defect that we will know the best surgical
options.
Finally, he understands that this quality of bone loss that he
has may ultimately even require an allograft hemipelvis segment
but those would be considered very much a salvage and are
certainly problem[**Name (NI) 115**] in their own right for long-term
stability.
I think it will take a good three and a half to four hours of
surgery. We asked the patient to donate 2 units of blood for
this extensive procedure. He understands that in no way can we
guarantee the longevity, leg-length equality, etc. with this
complex problem that he has. I have discussed all of these
risks
and benefits with him. He would like to proceed and we will
forward the surgical booking forms for him.
Past Medical History:
1. In [**2073**] (question [**2076**]) cervical laminectomy by Dr.
[**Last Name (STitle) 105136**].
2. In [**2078**] L4-L5 ruptured disc with surgery by Dr. [**Last Name (STitle) 105136**].
3. In [**2083**] he had an ependymoma from C5 through C7 and had
surgery by Dr. [**Last Name (STitle) 56743**] at [**Hospital1 112**].
4. In [**2085**] he had bilateral THR by Dr. [**Last Name (STitle) 105137**] at [**Hospital **]
Hospital. The reason for this was AVM.
5. In [**2090**] he had right shoulder replacement by Dr. [**Last Name (STitle) 105137**],
also for AVM. In [**2097**] left hip revision.
6. In [**5-/2098**] right hip revision by Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 3419**] at NEBH.
7. The patient also has HTN but is presently not on meds for
this. He has no history of PUD, IBD, Crohn's disease, prostate
problems, psoriasis, asthma, heart disease.
8. GERD
9. multiple episodes of MRSA cellulitis/abscess on his right
arm.
10. leg edema s/p hip revision in [**2097**]/[**2098**]
Social History:
nonsmoker, no ETOH, other drugs. lives with father, sister, and
nephew, on disability, walks at baseline with walker.
Family History:
Diabetes Mellitus
Physical Exam:
Afebrile VSS, A/Ox3
LCTA bilaterally
RRR
ABD soft, NTND, +BS
BLE fully NVI distally with 2+ DP pulses and full strength
throughout
Painful and limited ROM of R hip
Pertinent Results:
[**2100-12-31**] 05:00AM BLOOD WBC-8.2 RBC-2.90* Hgb-8.2* Hct-24.1*
MCV-83 MCH-28.5 MCHC-34.2 RDW-14.1 Plt Ct-331
[**2100-12-30**] 03:37PM BLOOD Hct-28.4*
[**2100-12-30**] 06:46AM BLOOD WBC-8.6 RBC-2.41* Hgb-6.6* Hct-20.1*
MCV-84 MCH-27.6 MCHC-33.0 RDW-13.8 Plt Ct-324
[**2100-12-30**] 03:35AM BLOOD WBC-10.4 RBC-3.04*# Hgb-8.4* Hct-25.0*#
MCV-82 MCH-27.5 MCHC-33.5 RDW-13.8 Plt Ct-409
[**2100-12-29**] 09:01PM BLOOD WBC-15.3*# RBC-4.17* Hgb-11.1* Hct-34.5*
MCV-83 MCH-26.7* MCHC-32.2 RDW-14.0 Plt Ct-525*
[**2100-12-31**] 05:00AM BLOOD Plt Ct-331
[**2100-12-31**] 05:00AM BLOOD Glucose-129* UreaN-10 Creat-0.6 Na-137
K-4.6 Cl-105 HCO3-31 AnGap-6*
[**2100-12-30**] 03:35AM BLOOD Glucose-137* UreaN-10 Creat-0.7 Na-133
K-5.3* Cl-103 HCO3-26 AnGap-9
[**2100-12-31**] 05:00AM BLOOD Calcium-8.4 Phos-2.9 Mg-2.2
[**2100-12-30**] 05:53AM BLOOD Cortsol-23.5*
[**2100-12-29**] 06:00PM BLOOD Glucose-145* Lactate-1.5 Na-134* K-4.2
Cl-99* calHCO3-26
[**2100-12-29**] 06:00PM BLOOD Hgb-10.4* calcHCT-31
[**12-31**] XR R Hip:
AP pelvis and two dedicated views of the right hip are compared
to [**2100-12-29**], and demonstrate no change in right bipolar
hemiarthroplasty. Cement has been inserted in the acetabular
protrusio defect and the acetabular component has been upsized
and is well positioned within the new acetabulum, and the
femoral component is well covered.
There is a minimally displaced fracture through the greater
trochanter, not well previously demonstrated. Skin staples are
again noted.
The appearance of the left total hip arthroplasty is unchanged,
with partial uncovering of the femoral component and mild
vertical tilt of acetabular component, both unchanged.
Degenerative changes are present in the lower lumbar spine. Gas
filled bowel loops are partially visualized.
IMPRESSION: No change from prior, status post right acetabular
protrusio repair, bilateral hip arthroplasty, and right greater
trochanter fracture, not previously well demonstrated.
Brief Hospital Course:
The patient was admitted on [**2100-12-29**] and taken to the operating
room by Dr. [**Last Name (STitle) **] where the patient underwent complex revision
right hiptotal joint arthroplasty. The procedure was well
tolerated there were no complications. Please see the separately
dictated operative report for details regarding the surgery. The
patient was subsequently transferred to the post-anesthesia care
unit in stable condition and transferred to the ICU later that
evening for monitoring due to 1L blood loss and 2u PRBC and 800
cell [**Doctor Last Name 10105**] given in the OR.
Overnight, the patient was placed on a PCA for pain control. IV
antibiotics were continued for 24 hours postoperatively for
prophylaxis. Lovenox was started the morning of POD#1 for DVT
prophylaxis. The patient did get transfused 2U PRBCs for
hypotension and anemia in the ICU on POD 1 and was given
hydrocortisone with resolution of hypotension and was
transferred to the floor on POD 1 PM without event
On postoperative day 1, the drain was removed without incident.
The patient was weaned off of the PCA onto oral pain
medications.
On postoperative day 2, the Foley catheter was removed without
incident. The surgical dressing was also removed, and the
surgical incision was found to be clean, dry, and intact without
erythema nor purulent drainage.
During the hospital course the patient was seen daily by
physical therapy. Labs were checked both post-operatively and
throughout the hospital course and repleted accordingly. The
patient was tolerating regular diet and otherwise feeling well.
Prior to discharge the patient was afebrile with stable vital
signs. Hematocrit was stable and pain was adequately controlled
on a PO regimen. The operative extremity was neurovascularly
intact and the wound was benign. Pt was made PWB with crutches
x6wks.
On POD#4 the patient was ready for discharge to home or rehab in
a stable condition.
Medications on Admission:
Fentanyl 75q72h, folate, lasix 40', ?librium 300'?, MTX 20'qMon,
olmesartan 20', oxycontin 15'', KCL 10', prednisone 5'
Discharge Medications:
1. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4-6H () as needed.
Disp:*70 Tablet(s)* Refills:*0*
2. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) syringe
Subcutaneous Q24H (every 24 hours) for 18 days: Take x 3weeks
then Aspirin 325mg po qd x additional 3 weeks then DC blood
thinners.
Disp:*18 syringe* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Fentanyl 75 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
7. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: One
(1) Capsule, Sustained Release PO DAILY (Daily).
8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Failed previous revision Right Total Hip Arthroplasty
Discharge Condition:
Good
Discharge Instructions:
Please seek medical attention if you have any nausea, vomiting,
fever greater than 101.5, chest pain, shortness of breath,
increased pain/redness/drainage from your incision site,
numbness/tingling, or any other concerning symptoms.
Take all medications as prescribed and resume home medications,
please take a stool softener if taking narcotic pain
medications, please taper down pain medication use as tolerated.
No driving nor operating heavy machinery while using narcotic
pain medications.
ANTICOAGULATION: Take lovenox injections (40mg) once a day x 3
weeks and then take aspirin 325 mg [**Hospital1 **] x 3 weeks. [**Month (only) 116**]
discontinue all blood
thinners 6 weeks post-operatively.
WOUND CARE: Keep your incision clean and dry. Okay to shower
after POD#5 but do not tub-bath or submerge your incision.
Please place a dry sterile dressing to the wound each day if
there is drainage, leave it open to air. Check wound regularly
for signs of infection such as redness or thick yellow drainage.
Staples will be removed at the first post-op visit.
ACTIVITY: Partial weight bearing to operative leg, posterior hip
precautions at all times. No strenuous exercise or heavy lifting
until follow up appointment, at least.
VNA (after home): Home PT/OT, dressing changes as instructed,
and wound checks
Physical Therapy:
ACTIVITY: Partial weight bearing to operative leg, posterior
hip precautions at all times with crutches x 6wks. No strenuous
exercise or heavy lifting until follow up appointment, at least.
Treatments Frequency:
ANTICOAGULATION: Take lovenox injections (40mg) once a day x 3
weeks and then take aspirin 325 mg [**Hospital1 **] x 3 weeks. [**Month (only) 116**]
discontinue all blood
thinners 6 weeks post-operatively.
WOUND CARE: Keep your incision clean and dry. Okay to shower
after POD#5 but do not tub-bath or submerge your incision.
Please place a dry sterile dressing to the wound each day if
there is drainage, leave it open to air. Check wound regularly
for signs of infection such as redness or thick yellow drainage.
Staples will be removed at the first post-op visit.
VNA (after home): Home PT/OT, dressing changes as instructed,
and wound checks
Please call Dr. [**Last Name (STitle) 67**] office to confirm your follow-up
appointment for within 10-14 days of surgery.
Followup Instructions:
Please call Dr. [**Last Name (STitle) 67**] office to confirm your follow-up
appointment for within 10-14 days of surgery.
Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2101-1-12**] 10:10
Provider: [**Last Name (NamePattern4) **]. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2101-1-12**] 10:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10486**], MD Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2101-1-14**] 3:10
Completed by:[**2101-1-3**]
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5419, 5438
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63,471
| 110,580
|
41842
|
Discharge summary
|
report
|
Admission Date: [**2162-3-23**] Discharge Date: [**2162-4-6**]
Date of Birth: [**2106-9-19**] Sex: F
Service: MEDICINE
Allergies:
Librium
Attending:[**First Name3 (LF) 12174**]
Chief Complaint:
Hematemesis, Encephalopathy
Major Surgical or Invasive Procedure:
Feeding Tube Placement
Intubation
EGD
History of Present Illness:
55-year-old female with alcohol cirrhosis with ?esophageal
varices (last variceal bleed 6 years ago) presenting from OSH
with hematemesis. Pt states that she has been drinking heavily
recently due to recent life stressors, about a quart of vodka
daily. Last drink at 7pm on [**2162-3-22**]. Had 3 episodes of
hematemesis yesterday morning; could not quantify amount. Also
noted dark stools for the last three days. Denies abdominal
pain or diarrhea. She was seen at [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] where she had two
more episodes of hematemesis. She received 1unit PRBC, zofran
iv 8mg, and was placed on octreotide gtt. She was transferred
here because endoscopy suite was not available until 7AM.
In the ED, initial VS were: 98.4 100 167/71 16 96% 2L nc. Hct
was 39. INR 1.3. Serum etoh level 16. GI was called who
stated that they would perform EGD in AM. She was given 1g
ceftriaxone and placed on protonix and octreotide gtts. She
received 1L IVFs. She remained hemodynamically stable, mildly
hypertensive. She had another episode of emesis 150cc in ED of
frank blood. Vitals on transfer: 96 169/70 21 94%RA.
Past Medical History:
1. Major Depression
2. Alcoholic dependance
3. Post traumatic stress disorder
4. H/o pancreatitis
5. Hypertension
6. Alcoholic cirrhosis
Social History:
Lives alone in subsidized housing in [**Hospital1 1562**]. 20 year history
of alcoholism. States that she was sober for 6 weeks in [**Month (only) **]-[**Month (only) **]
[**2161**] but recently struggled with several tragedies (death of
close friend, separation of oldest son from his wife, another
close friend involved in [**Name (NI) 8751**]) and has relapsed. Drinks about a
quart of vodka daily. Reports hx of DTs previously when
withdrawing. Has three children; son and daughter live nearby
but oldest son is in [**Name (NI) 4565**]. Has 25 pack year history;
curently smoking about 1ppd. Remote hx of cocaine and IVDU,
none recently.
Family History:
- Mother: died lung CA > 60yo, alcoholism, ? psychiatric illness
- Father: 76, alive & well, no h/o heart disease, cancer,
diabetes
- 4 Siblings; 3 are alcoholics
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: 98.6 166/67 107 22 95%3L
General: Alert, oriented x 3, no acute distress
HEENT: Sclera anicteric, dry MM, erythema of posterior
oropharynx, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Mildly tachycardic, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema; no asterixis
Neuro: CNII-XII intact
DISCHARGE EXAM:
98.5, 117/42, 77, 18, 96% RA
NAD, AOx3, slightly slowed mentation
Anicteric, Dobhoff in place
Heart: RRR, no MRG
Lungs: scattered crackles, no consolidations or wheezes
Abd: soft, obese, nontender, no fluid appreciated
Exdt: trace edema
Neuro: no asterixis, nonfocal
Pertinent Results:
ADMISSION LABS
[**2162-3-23**] 03:54AM BLOOD Hgb-12.8 calcHCT-38
[**2162-3-23**] 03:40AM BLOOD ASA-NEG Ethanol-16* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2162-3-23**] 03:40AM BLOOD Albumin-3.8 Calcium-8.5 Phos-2.7 Mg-1.7
[**2162-3-23**] 03:40AM BLOOD ALT-34 AST-93* AlkPhos-153* TotBili-1.7*
[**2162-3-23**] 03:40AM BLOOD cTropnT-<0.01
[**2162-3-23**] 03:40AM BLOOD Lipase-44
[**2162-3-23**] 03:40AM BLOOD Glucose-300* UreaN-19 Creat-0.6 Na-141
K-4.9 Cl-103 HCO3-27 AnGap-16
[**2162-3-23**] 03:40AM BLOOD PT-14.2* PTT-32.2 INR(PT)-1.3*
[**2162-3-23**] 03:40AM BLOOD Plt Ct-101*
[**2162-3-23**] 03:40AM BLOOD Neuts-69.8 Lymphs-19.4 Monos-7.6 Eos-2.3
Baso-0.9
[**2162-3-23**] 03:40AM BLOOD WBC-7.5 RBC-3.86* Hgb-12.6 Hct-39.2
MCV-101* MCH-32.6* MCHC-32.1 RDW-16.9* Plt Ct-101*
Micro:
- Ucx (5/8,14,16): neg
- Bcx (5/14,15,16): NGTD
- Cdiff ([**4-1**]): neg
Studies:
- Head CT ([**3-31**]): IMPRESSION: No acute intracranial process;
bifrontal cortical atrophy.
- RUQ U/S with Dopplers ([**3-31**]):
IMPRESSION:
-> No portal vein thrombus identified. Reversed flow is
again seen in the main, right and left portal veins.
-> The liver is very heterogeneous and nodular.
Ultrasound cannot
exclude an underlying liver mass. A CT is recommended for
further evaluation of the hepatic architecture.
-> Cholelithiasis. No biliary dilatation seen.
- Bilateral LE U/S ([**4-1**]):
IMPRESSION: Negative study for bilateral lower extremity deep
vein
thrombosis.
DISCHARGE LABS:
[**2162-4-5**] 06:05AM BLOOD WBC-6.9 RBC-2.47* Hgb-7.7* Hct-25.6*
MCV-104* MCH-31.3 MCHC-30.2* RDW-17.3* Plt Ct-79*
[**2162-4-5**] 06:05AM BLOOD PT-14.2* PTT-33.3 INR(PT)-1.3*
[**2162-4-5**] 06:05AM BLOOD Glucose-227* UreaN-15 Creat-0.5 Na-133
K-4.1 Cl-103 HCO3-22 AnGap-12
[**2162-4-5**] 06:05AM BLOOD ALT-37 AST-85* AlkPhos-146* TotBili-2.0*
[**2162-4-5**] 06:05AM BLOOD Calcium-8.3* Phos-2.4* Mg-2.1
Brief Hospital Course:
55-year-old female with alcohol cirrhosis with known varices
(last variceal bleed 6 years ago) presenting from OSH with
hematemesis. Hospital course complicated by significant
encephalopathy.
1. Hematemesis: Pt with several episodes of hematemesis at home
and at OSH. She has been prescribed propranolol but was not been
taking this consistently at home. Hct on admission was stable
at 39. She was initially placed on IV PPI gtt and IV
octreotide. Initially, she was intubated for EGD which showed
varices at lower third of esophagus that was ligated as well as
varices at GE junction and fundus and portal gastropathy. She
did not have further episodes of hematemesis during hospital
stay and Hct remained stable. She completed a 7 day course of
ABX for infection prophylaxis. She was started on nadolol for
her varices. She should have repeat EGD as outpatient.
2. ST elevations: After being intubated for planned EGD, patient
had ST elevations on telemetry. 12 lead EKG revealed ST
elevations were in leads I/AVL with reciprocal depressions in
AVF/III. She was seen urgently by cardiology and taken to
cardiac catheterization which revealed clean coronaries. The
likely diagnosis was coronary vasospasm. TTE showed EF > 75%,
mild symmetric left ventricular hypertrophy with preserved
global and regional biventricular systolic function. No
pathologic valvular abnormality seen. No further cardiac
complications during admission.
3. Altered Mental Status: Initially was admitted to the MICU for
GI bleeding reasons, but was sent to floor on [**3-29**]. However,
readmitted to the MICU on morning of [**3-31**] for worsening mental
status. Infection was ruled out. The patient's decompensation
was likely due to holding of lactulose, polypharmacy, and GI
bleed. CXR, LE U/S, Head CT, RUQ U/S were all unrevealing for
cause of AMS and all cultures of blood/urine were negative. She
was not placed on antibiotics and slowly cleared with aggressive
lactulose. At discharge, she is alert and oriented x 3.
4. Alcoholic cirrhosis with alcoholic hepatitis: Pt with
alcoholic cirrhosis that decompensated due to GI bleed and
continued alcohol/drug use. Her bili started to trend up,
peaking at 4.4 on [**3-31**]. She was not started on steroids due to
GI bleed. A biopsy was not done. The patient was treated with
aggressive nutrition and her bilirubin trended down on
discharge.
5. Polysubstance abuse: Pt had active alcohol abuse. Urine tox
was also positive for methadone and benzos. She was seen by
social work and addictions consult. She was started on MVI,
thiamine, and folic acid. She initially had significant alcohol
withdrawal and required high doses of IV ativan and haloperidol
that was eventually weaned. The patient had family support
throughout her hospital stay.
6. COPD: Pt with questionable hx of COPD. Currently smokes
1ppd, on nicotine patch. She was continued on albuterol and
advair inhalers.
7. Depression: Pt with severe depression, particularly in
setting of recent life tragedies. Her home psych meds were held
in the setting of confusion, and only duloxetine and seroquel
have been restarted prior to discharge. The patient will need
psychiatry follow-up after discharge for management and
uptitration of her medications. She reports also taking 100mg
Zoloft daily and 50mg [**Hospital1 **] of Topamax.
8. Vaginal pruritis: Patient complained of vaginal discomfort on
day of discharge and was started on empiric treatment for
candidiasis with intravaginal Miconazole cream.
9. Hyperglycemia: Patient had elevated blood sugars requiring
glargine and insulin sliding scale while in the hospital. This
should be further evaluated by her PCP at discharge and workup
for possible underlying diabetes should be done.
TRANSITIONAL ISSUES:
- Continue 7 day course of intravaginal miconazole
- Slowly restart psychiatric medications as above, patient
reports her psychiatrist is Dr. [**Last Name (STitle) 90873**] ([**Telephone/Fax (1) 90874**]
- Titrate lactulose to achieve 3 bowel movements daily
Medications on Admission:
Medications: (has not been taking consistently)
1. topiramate 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
2. sertraline 100 mg Tablet Sig: 1 Tablet PO at bedtime.
3. prazosin 5 mg Capsule Sig: One (1) Capsule PO QHS (once a day
(at bedtime)).
4. propranolol 10 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
5. risperidone 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): 9a, 9p.
6. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Seroquel 100 mg Tablet Sig: 2.5 Tablets PO at bedtime.
8. dextroamphetamine 10 mg Tablet Sig: Three (3) Tablet PO twice
a day.
9. duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO QAM (once a day (in the
morning)).
10. lactulose 10 gram/15 mL Solution Sig: Two (2) tablespoons PO
four times a day: to maintain [**1-17**] BMs daily.
11. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
[**11-16**] Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
12. Advair Diskus 250-50 mcg/dose Disk with Device Sig: One (1)
puff Inhalation twice a day.
Discharge Medications:
1. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
2. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) puff Inhalation [**Hospital1 **] (2 times a day).
3. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q8H PRN ()
as needed for pain.
8. nadolol 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
9. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. phenol 1.4 % Aerosol, Spray Sig: One (1) Spray Mucous
membrane Q4H (every 4 hours) as needed for sore throat.
11. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
12. duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
13. quetiapine 100 mg Tablet Sig: 2.5 Tablets PO QHS (once a day
(at bedtime)).
14. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
15. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
16. miconazole nitrate 2 % Cream Sig: One (1) Appl Vaginal HS
(at bedtime) for 7 days: start date [**4-6**].
17. insulin glargine 100 unit/mL Solution Sig: Five (5) units
Subcutaneous at bedtime.
18. Humalog insulin sliding scale
Please continue Humalog insulin sliding scale.
19. Lidocaine Viscous 2 % Solution Sig: Five (5) milliliters
Mucous membrane every 4-6 hours as needed for sore throat.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
Alcoholic Cirrhosis
Upper GI bleed
Encephalopathy
Poor Nutrition
Discharge Condition:
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Mental Status: Clear and coherent.
Discharge Instructions:
You were admitted to the hospital with GI bleeding and confusion
due to buildup of chemicals related to your liver disease. You
were initially stabilized in the ICU where an endoscopy was
performed and a vessel was banded in the esophagus. You
continued to have confusion, which slowly resolved as your liver
improved. You required a feeding tube to help with your
nutrition as your liver recovers. You will be discharged to
rehab.
You must refrain from any further substance abuse or your liver
will get more sick and you may die. Please take your medications
as prescribed. Please make all of your follow-up appointments.
Your medication list will be sent with you to rehab.
Followup Instructions:
Department: LIVER CENTER
When: MONDAY [**2162-5-10**] at 11:50 AM
With: [**Name6 (MD) 1382**] [**Name8 (MD) 1383**], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
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"456.0",
"305.40",
"112.1",
"269.8",
"571.1",
"291.0",
"572.2",
"537.89",
"311"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"45.13",
"88.56",
"37.22",
"96.71",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
12329, 12401
|
5358, 6810
|
296, 336
|
12510, 12632
|
3420, 4914
|
13396, 13675
|
2376, 2541
|
10550, 12306
|
12422, 12489
|
9423, 10527
|
12693, 13373
|
4931, 5335
|
2556, 3117
|
3133, 3401
|
9137, 9397
|
229, 258
|
364, 1532
|
12647, 12669
|
1554, 1693
|
1709, 2360
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,526
| 130,736
|
16587
|
Discharge summary
|
report
|
Admission Date: [**2145-12-8**] Discharge Date: [**2146-1-3**]
Date of Birth: [**2089-8-6**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 56 year old
male with past medical history significant for hypertension
who fell from a height of approximately 15 feet at a
construction site. He had a loss of consciousness and was
evaluated at an outside hospital and found to have no
sensation or movement from the waist down. [**Location (un) 2611**] coma
scale was 15 and he complained of chest and wrist pain. He
was hemodynamically stable throughout his evaluation on
transport and he arrived at [**Hospital6 2018**] with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 2611**] coma scale of 15, decreased sensation
below the knee on the left and below the mid calf on the
right with complaint of right chest pain and wrist pain as
well as shortness of breath. He was transferred on
intravenous steroid, spine protocol.
PAST MEDICAL HISTORY: Hypertension, scoliosis.
PAST SURGICAL HISTORY: None.
MEDICATIONS ON ADMISSION: Atenolol 100 mg q.d.; Zoloft 100
mg q.d.; Triamterene and Hydrochlorothiazide 50/25 q. day;
potassium supplement, acetaminophen 81 mg q. day, and
Pulmicort.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: The patient was awake, alert with
[**Location (un) 2611**] coma scale of 15, temperature 36.2, blood pressure
150/palpable, heartrate 96. Head, eyes, ears, nose and
throat, pupils were equally round and reactive to light.
Tympanic membranes were clear bilaterally. He was
normocephalic, atraumatic. His trachea was midline and no
jugulovenous distension. His chest was stable with decreased
breathsounds at the apex on the right but otherwise clear to
auscultation bilaterally. Heart was regular rate and rhythm,
no murmurs. Abdomen was soft, nontender, nondistended.
Pelvis was stable. Rectal examination, no tone, normal
prostate. Extremities, no sensation on the left from the
knee distally and on the right from mid calf distally. No
movement bilaterally of the lower extremities. Bilateral
upper extremities, neurovascularly intact. Right wrist
laceration, pulses 2+ peripheral pulses.
LABORATORY DATA: On admission complete blood count white
count 17.4, hematocrit 38.4, platelets 289, PT 13.3, PTT
22.1, INR 1.2. Chemistries, sodium 142, potassium 2.9,
chloride 106, bicarbonate 24, glucose 208, BUN 18, creatinine
1.1, lactaid 4.5, fibrinogen level 177. Urinalysis with
small amount of blood and protein. Serum toxicology was
negative, urine was positive for opiates. Films done on
admission, chest x-ray showed positive right pulmonary
contusion, rib fractures, T3 through T7, no pneumothorax, no
hemothorax, mediastinum within normal limits. Severe
thoracic scoliosis. Pelvis no fractures. Right wrist forearm
films were negative for fracture. Computerized tomography
scan of the head showed no bleed, shift, soft tissue swelling
or fractures. Computerized tomography scan of the spine
showed no fractures. Computerized tomography scan of the
chest showed no fracture, no pneumothorax, mediastinum
normal, right scapular fracture. Computerized tomography
scan of the abdomen and pelvis, L1, L2 fracture with
posterior displacement, cord compression and a T12 anterior
body fracture.
HOSPITAL COURSE: The patient was admitted to the Trauma
Intensive Care Unit and Neurosurgery consult was obtained and
the patient was continued on Solu-Medrol 5.4 mg/kg/hour for
23 hours.
Initial neurological examination reveals the patient was
alert and oriented times three, conversant, speech fluent,
moving upper extremity through full range of motion with good
strength, sensation, right wrist in Ace wrap with splint.
Absent rectal tone, absent sensation to light touch and
pinprick from right knee down and from approximately 4 cm
above the left knee down. Motor and minimal flicker movement
of bilateral iliopsoas muscles and quadriceps but not able to
lift leg or knee off of bed. No movement of feet or toes
bilaterally. Deep tendon reflexes absent in the lower
extremities. Plantar reflex was absent. Magnetic resonance
imaging scan of the lumbar spine was obtained, acute
compression deformity of L1 with retropulsion with a fracture
fragment to the canal and anterior wedging due to the
fracture seen at L1, compression of the conus was also seen.
Inversion recovery images revealed narrow edema within T11,
T12, L1 and L5 levels. There was also suggestion of possible
contusion or edema present within the conus. In addition
there was compression of the conus by the retropulsed
fracture of L1. The overall examination was limited
secondary to motion artifact. Upon admission the patient was
made NPO. With the use of Solu-Medrol, confusion was
continued. The cervical collar was left in place. He was
limited to lying flat on his back and the neurological checks
q. 1 hour and log-roll precautions. Anesthesia was consulted
with possible epidural for pain control of the scapular and
rib fractures, but secondary to his neurological deficits it
was decided not to place the catheter, instead a rib block
with .1% Bupivacaine was done with minimal pain relief. On
hospital day #2 the patient's neurological examination was
slightly improved with increased iliopsoas strength to 2 out
of 5 and increased quadriceps strength, able to lift against
gravity, although the sensory examination had not changed.
The patient's cervical spine was cleared clinically and with
negative films and the cervical collar was removed. An
orthopedic consult was obtained on hospital day #1 for
recommendations on the scapular fracture and the clavicular
fracture. Their recommendations were for nonoperative
treatment and just making the right upper extremity
nonweightbearing on SICU day #3. The patient's oxygen
saturations went down to the 80s when he was off
nonrebreather face mask. He had obvious reduction with
excursion, repairing of the flare segment, but peak generous
title volumes on the left. The chest x-ray that day showed a
right-sided effusion with multiple rib fractures, so a 36
French right-sided chest tube was placed for evacuation of
the hemothorax with immediate 200 cc out of the chest tube.
The patient's hematocrit on SICU day #3 was 32, which was
down from a initial hematocrit of 38. The drop in hematocrit
was likely from hemothorax and possibly from retroperitoneal
bleeding from his fractures. A Dobbhoff tube was placed
under fluoroscopy as well as a right internal jugular placed.
Total parenteral nutrition was started. Because of the
patient's fever, temperature maximum of 38.4, and elevated
amylase of 909 it was decided to obtain an abdominal
computerized tomography scan, looking for possible small
bowel injury. The computerized tomography scan showed no
evidence of pancreatic injury and again showed the L1, L2
burst fracture with multiple rib fractures and no evidence of
bowel injury. The patient also received bilateral lower
extremity duplex dopplers that were negative for deep vein
thrombosis. On SICU day #4 the patient received 3 units of
packed red blood cells secondary to a hematocrit of 26, again
likely secondary to retroperitoneal bleed and seeing as how
the abdominal computerized tomography scan was negative for
any visceral injury the patient was also started on CPAP to
improve oxygenation. The patient was also changed from
Lopressor to Labetalol for his cardiac protection as well as
blood pressure control. Over the past couple of days the
patient had been noted to be slightly confused with
agitation. The patient was given Ativan for the agitation
with adequate control as well as Haldol for the delirium.
The patient was taken to the Operating Room on SICU day #6.
Dr. [**Last Name (STitle) 1327**] performed a retroperitoneal and one vertebrectomy
with stabilization from T12 to L2. There was estimated blood
loss of 1700 cc, 4 units of packed red blood cells were
given. The urine output was 550 during the procedure. The
patient was taken to the Trauma SICU in stable condition. On
postoperative day #1 chest x-ray showed continued right
pleural effusion and the left chest tube output had been 150
cc over the past 24 hours and the right chest tube output was
the same over 24 hours. Perioperative Ancef was continued.
On SICU #7, a second right chest tube was placed. The
Labetalol was discontinued. Subcutaneous heparin was started
and total parenteral nutrition was started. TLSO brace was
applied and needed to be on the patient when the bed is above
30 degrees and one unit of packed red blood cells were given
for a hematocrit of less than 30. On SICU day #8,
postoperative day #3 the right chest tube was discontinued.
The patient was also pancultured for spike in temperature to
102.6. The patient continued the Ativan 1 mg q. 8. On SICU
day #9, postoperative day #3 the patient received chest
computerized tomography scan secondary to the fevers and
continued right pleural effusion. The computerized
tomography scan was read as having a slight interval
improvement in the aeration of the majority of the right lung
though dependent and progressive atelectasis persisted,
particularly at the right lung base interval. There was
development of small patchy opacity in the right middle lobe
which could reflect an early infiltrate, persistent bilateral
pleural effusions which were small, but right greater than
left and multiple fractures including both clavicles and ribs
1 through 8 on the right. The patient had been started
empirically on Vancomycin and Zosyn that day. On SICU day
#11, the patient with increasing agitation and was given
Propofol prn. The patient had an increase in secretions
necessitating vigorous suctioning. Vancomycin was started on
SICU day #13 secondary to fever and positive blood cultures
growing gram positive cocci and a new central venous line and
arterial line were placed.
The patient's other major issues, neurologically very
agitated necessitating Ativan, Haldol and Morphine was given
for pain. While the patient was still on the vent with CPAP
with pressure support of 10 and positive end-expiratory
pressure 10, at 40% oxygen with pO2 of 86, left-sided chest
tube was also discontinued at this time. The patient also
received his lower extremity duplex doppler which was
negative for deep vein thrombosis and he was continued on
subcutaneous heparin and pneumo boots. On SICU day #14 the
patient received a bronchoscopy secondary to increased
secretions. Sputum cultures from the 2nd were growing out
coagulase positive Staphylococcus. Sensitivities were still
pending at that point so Vancomycin was continued. Epogen
was also started secondary to a hematocrit of 27 without
increase. On SICU day #15 Lovenox was started for deep vein
thrombosis prophylaxis, okayed by Neurosurgery. Tube feeds
were at 30 cc/hr and total parenteral nutrition was at 41
cc/hr. Standing Haldol was increased secondary to increased
confusion and delirium. On SICU day #17, a computerized
tomography scan of the chest was obtained because of
continued fevers and for assessment of possible fluid
collections as well as sign of infection. The computerized
tomography scan was limited secondary to artifact from the
hardware of T12 to L2, but there was no evidence of discrete
fluid collection, abscess and there were just small
effusions. The prolonged course of ventilator support, being
intubated, the patient was extubated on SICU day #17. TLS
films were obtained showing hardware intact and stable
position. Bowel gas pattern was consistent with ileus. The
left internal jugular was discontinued secondary to positive
cultures and Zoloft was started which was now one of the
patient's outpatient medications. On SICU day #18,
computerized tomography scan of the head was obtained
secondary to mental status changes and showed no evidence of
intracranial hemorrhage. Propofol was given for sedation and
an nasogastric tube was placed to suction secondary to
episodes of emesis. On SICU day #19 the patient was noted to
have profuse diarrhea which necessitated a rectal tube and
p.o. Flagyl was started empirically and Clostridium difficile
toxins were sent. Also the patient had abdominal pain with
massive distention and a right upper quadrant ultrasound was
performed and showed dilated gallbladder filled with sludge
but no other findings to suggest acute cholecystitis. On
SICU day #20, the patient had PICC line placed. Haldol was
given for his mental status changes of confusion and
disorientation and then actually the Haldol was discontinued
secondary to worsening of symptoms with the Haldol.
Vancomycin was continued day #9 of #10 and Flagyl was day #3.
The patient was transferred to the floor on SICU day #21,
stable respiratory-wise, NPO with total parenteral nutrition.
His hematocrit was 29 and stable and he continued to have
fever at 38.2. He was on Vancomycin and Flagyl. Chest x-ray
done showed no change from the previous. A neurology consult
was obtained secondary to his continued confusion. They had
a very broad differential for the confusion including
possible trauma-related brain injury and also delirium
secondary to sedation or metabolic causes or infection and
electrolyte abnormalities. They suggested getting an
magnetic resonance imaging scan of the cervical spine and
brain as well as magnetic resonance angiography of the head
and neck, to send for liver function tests and ammonia levels
and to give Thiamine and hold sedation if possible, as well
as to maintain a well lit room and have digital clock and
calender. Magnetic resonance angiography showed probable
tiny left cerebral chronic infarct. No flow was seen within
the left vertebral artery possibly due to hypoplasia and
termination in the left pica or possibly occlusion. Further
assessment is not possible without dedicated magnetic
resonance angiography imaging. There is no evidence of acute
cerebral or cerebellar infarction. Diffuse degenerative
disease of the cervical spine without evidence of acute
injury is noted. The patient was also noted to have
difficulty swallowing medications and a swallow evaluation
was obtained. The patient's bedside swallow evaluation, the
patient had no overt signs of aspiration. He had struggling
posture and red face after swallowing which may indicate
silent aspiration and a video swallow was performed and
showed overall functional swallow ability with only minimal
pharyngeal residue that cleared with acute repeat swallow.
No aspiration or penetration was noted. The patient was
initiated on a regular diet. Over the next few days, the
patient's confusion seemed to improve every day as per the
Trauma Team as well as his wife who was seeing him on a daily
basis. Total parenteral nutrition was continued because of
minimal p.o. but p.o. intake was being encouraged. The rest
of the [**Hospital 228**] hospital stay was uneventful. The PICC line
was discontinued on hospital day #24 and after adequate p.o.
intake and the patient was being discharged to rehabilitation
on [**2146-1-3**] with discharge diagnosis of partial
spinal cord injury at the level of T12 status post trauma
with L1 fracture status post L1, L2 fixation. The patient is
alert and oriented times three on discharge. The patient
continues to have no movement below the knees. Physical
therapy and occupational therapy consultation is seeing the
patient. The patient benefited greatly from transfer to
rehabilitation with continuing physical therapy and
occupational therapy.
DISCHARGE MEDICATIONS:
1. Metoprolol 75 mg p.o. b.i.d., hold for systolic blood
pressure less than 100, heartrate less than 55
2. Sertraline 100 mg p.o. q.d.
3. Clonidine TTS one patch q. week on Saturday
4. 30 mg subcutaneous q. 12
5. Epoetin 40,000 units subcutaneous once a week on Tuesday
6. Albuterol ipratropium 1 to 2 puffs inhaler q. 4 prn
7. Albuterol 1 to 2 puffs q. 6 prn
8. Tylenol 325 to 650 mg p.o. q. 4-6 hours prn
9. Dulcolax 10 mg p.o. p.r. q.d. prn
10. Colace 100 mg p.o. b.i.d.
FOLLOW UP: The patient is to follow up with Dr. [**Last Name (STitle) 1327**] of
Neurosurgery.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**], M.D. [**MD Number(1) 521**]
Dictated By:[**Last Name (NamePattern1) 7241**]
MEDQUIST36
D: [**2146-1-2**] 17:23
T: [**2146-1-2**] 17:39
JOB#: [**Job Number **]
|
[
"806.4",
"807.06",
"996.62",
"560.1",
"805.2",
"707.0",
"860.2",
"291.0",
"482.41"
] |
icd9cm
|
[
[
[]
]
] |
[
"77.99",
"03.53",
"34.04",
"84.51",
"99.15",
"96.72",
"96.04",
"81.06",
"04.81",
"38.93",
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
15611, 16100
|
1075, 1271
|
3329, 15588
|
1041, 1048
|
16112, 16469
|
1294, 3311
|
158, 968
|
991, 1017
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,883
| 191,833
|
49328
|
Discharge summary
|
report
|
Admission Date: [**2107-5-7**] Discharge Date: [**2107-5-23**]
Service: MEDICINE
Allergies:
Univasc
Attending:[**First Name3 (LF) 2932**]
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
Exploratory laparotomy
Bilateral salpingo-oophorectomy
History of Present Illness:
[**Age over 90 **] yo G6P2 woman, with hx of CAD s/p IMI, breast CA s/p
mastectomy, and known right adnexal mass, who presented to the
ED with RLQ abdominal pain that had been intermittent for 2
weeks, but worsened over the course of the day prior to
admission. It was not associated with nausea, vomiting, fevers,
or chills. She also notes no flatus/bowel movements x2d. 20
pound weight loss in mid [**2105**]-mid [**2106**]. Of note, she has a known
large ovarian mass for which she has refused surgery in the
past.
ROS: + productive cough, no CP/SOB/palp. No GU complaints: mild
inc urinary freq, otherwise no dysuria/hematuria.
Past Medical History:
1. Coronary artery disease, status post MI in [**2070**].
2. Hypertension.
3. Breast cancer [**2061**], status post right radical mastectomy.
4. Ovarian cancer.
5. Iron deficiency anemia, baseline hct 36-39
6. Diverticulosis.
7. Carpal tunnel syndrome.
8. Osteoarthritis.
9. Chronic Renal Insufficiency (baseline 1.5-1.7 --> GFR
30cc/min)
Social History:
She is widowed and lives alone. Able to take care of self
overall: ambulant, toileting, dress. No history of alcohol use.
She smokes two packs per week for over sixty years. >120 pkyr
hx. Has several children, all except one lives in state.
Family History:
Mother lived to age [**Age over 90 **]. Otherwise unknown.
Physical Exam:
Physical exam on admission:
T: 99.8 BP: 152/70 P: 74 RR: 16 O2 sats: 98%RA
Gen: comfortable, nad
HEENT: nc/at, mmm
Neck: supple, no [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) **]: RRR, +sys murmur best heard over LUSB
Resp: CTAB
Abd: distended, well healed scar over abd, soft, pelvic mass
palpable, tender over RLQ and suprapubis
Ext: NE/no calf tenderness
Neuro: grossly wnl
Pertinent Results:
Laboratory studies on admission:
[**2107-5-7**]
WBC-16.2 HGB-11.3 HCT-33.7 MCV-86 RDW-13.7 PLT COUNT-190
NEUTS-83.7* LYMPHS-10.6* MONOS-5.3 EOS-0.2 BASOS-0.2
GLUCOSE-109* UREA N-27* CREAT-1.7* SODIUM-130* POTASSIUM-4.3
CHLORIDE-98 TOTAL CO2-26
PT-27.4* PTT-36.2* INR(PT)-2.8*
Laboratory studies on discharge:
[**2107-5-23**]
wbc 6.7 3.59* hgb 10.0* HCT31.4
INR 2.2
glucose 148, BUN 18, Cr 1.4, Na 140, K 4, Cl 103
Radiology
[**5-7**] Abd/pelvic CT: Interim development of mildly dilated small
bowel loops and air fluid levels, with air and stool seen
throughout the colon. No clear transition point is identified.
The findings are suggestive of partial small-bowel obstruction.
Ascites fluid may be slightly increased from the prior study.
Unchanged partially cystic and solid pelvic mass concerning for
an ovarian neoplasm. Patchy opacities of the left lung base may
reflect pneumonia versus atelectasis. This finding is new from
the prior exam. Atherosclerosis of the abdominal aorta and
branches. The mesenteric vessels are not well evaluated without
IV contrast.
[**5-14**] Renal scan: The tracer was administered intravenously. Flow
was obtained and dynamic images were then obtained for 40
minutes. The images demonstrate delayed concentration in both
kidneys. The right kidney is malrotated and there may be pooling
in the right renal pelvis, or this could be related to kidney
position. There is filling of the bladder. No tracer
extravasation is seen. No evidence of ureteral leak. Findings
consistent with renal parenchymal abnormality such as acute
tubular necrosis.
[**5-14**] Renal U/S: The right and left kidneys measure 8.7 and 9.5 cm
respectively without hydronephrosis nor focal lesions. There are
bilateral pleural effusions and ascites.
[**5-16**] CT Head: No intracranial mass lesion, hydrocephalus, shift
of normal midline structures, major or minor vascular
territorial infarct is apparent. The density values of brain
parenchyma within normal limits. Surrounding osseous and soft
tissue structures are unremarkable.
[**5-17**] KUB: Residual contrast material, presumably from the CT
study of [**2107-5-7**] is seen at the hepatic flexure, the splenic
flexure, and the distal sigmoid/rectum. Multiple staples project
over the left lower quadrant. No air-fluid levels or distended
loops of bowel are present. There are marked degenerative
changes of the lower lumbar spine. There is moderate-severe
joint space narrowing at the right hip.
[**5-19**] right arm ultrasound: Nonocclusive right internal jugular
vein thrombus. Probable right axillary lymphocele
[**5-21**] CXR: One portable view. Comparison with the previous study
done [**2107-5-16**]. There is interval improvement in pulmonary
vascular congestion and small bilateral pleural effusions. The
heart appears large and the aorta is tortuous and calcified as
before. Degenerative arthritic changes are again noted in the
right shoulder joint.
Pathology
[**5-13**]:
Left ovary and fallopian tube (A-D): Ovary with serous cyst
adenofibroma, 0.5cm, and endosalpingiosis. Fallopian tube, no
diagnostic abnormalities recognized (additional levels were
examined).
Right ovary and fallopian tube (E-R): Endometrial
adenocarcinoma, grade I, arising in a serous cystadenofibroma
Histologic Type: Endometrioid, carcinoma, G1: well
differentiated. Washings/cytology: Negative.
Primary Tumor TNM (FIGO): pT1a (IA): Tumor limited to 1 ovary;
capsule intact, no tumor on ovarian surface. No malignant cells
in ascites or peritoneal washings.
Regional Lymph Nodes: pNX: Cannot be assessed.
Lymph Nodes: None submitted.
Distant metastasis: pMX: Cannot be assessed.
Venous/lymphatic vessel invasion (V/L): Absent.
Comments: Thrombus of hilar vessels and hemorrhagic infarction
of tumor consistent with torsion.
vessels are not well evaluated without IV contrast.
Brief Hospital Course:
In brief, Ms [**Known lastname 65453**] was [**Age over 90 **] yo G6P2 woman, with hx of CAD s/p
IMI, breast CA s/p mastectomy, and known right adnexal mass who
presented to the ED on [**2107-5-7**] with RLQ abd pain. Initially
there was concern for partial SBO possibly from ovarian mass.
1) Ovarian Mass/small bowel obstruction While patient was on
medicine team there was a discussion with team and pallative
care to undergo surgery to treat possible bowel obstruction. The
patient and family initially did not want surgery given high
surgical risk, however later changed their decision after felt
removal of ovarian mass would improve pain symptoms. Patient
underwent ex-lap on [**2107-5-13**] and was found to have R ovarian mass
with torsion. Both her ovaries and tubes were removed.
Intra-operatively, there was no clear evidence of bowel
obstruction; it was felt that her ovary, which was now removed,
may have been causing a physical obstruction. Her diet was
advanced and she did not have further evidence of bowel
obstruction. The surgical pathology was consistent with Grade I
endometrial carcinoma. No malignant cells in ascites or
peritoneal washings. She will follow-up with Dr. [**Last Name (STitle) 2028**] 3 weeks
following discharge to discuss further management/treatment.
2) Renal failure: Post-operatively, her creatinine rose to 1.6.
Renal scan was not consistent with ureteral leak and renal
ultrasound was without evidence of obstruction. It was felt that
she likely had ATN related to surgery. Her creatinine on
discharge was 1.4; this should be closely monitored as an
outpatient to ensure downward trend.
3) Postoperative Delerium: This was likely related to
anesthesia/hospital-indiced delirium. She gradually improved
with zyprexa qhs and prn. There was no evidence of concurrent
infection.
4) Catheter Associated DVT: The patient developed RUE swelling;
U/S showed clot in RIJ from RIJ line (subsequently removed). She
was continued on anticoagulation.
5) HTN: The patient was restarted on beta-blocker, nifedipine
(titrated up), valsartan, and Nitropatch with good control
6) Atrial fibrillation: She was continued on metoprolol as
above. Her INR will need to be closely monitored as an
outpatient and coumadin dose titrated as needed for an INR [**3-12**].
Full code
Medications on Admission:
ATENOLOL 50 MG--One by mouth every day
COLACE 100 mg--1 capsule(s) by mouth once a day
COUMADIN 3 mg--will hold per Dr. [**Last Name (STitle) **]
DULCOLAX 5 mg--1 tablet(s) by mouth qd prn no bm
MINITRAN 0.1MG/HR--Apply to chest each day, off at bedtime
NIFEDIPINE ER 30MG--Take one by mouth every day
NITROGLYCERIN 400 MCG (1/150 GR)--One under the tongue as needed
for chest pain
PERCOCET 5 mg-325 mg--0.5-1 tablet(s) by mouth qd prn pain
VALSARTAN 40MG--One every day
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
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. Valsartan 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
6. Minitran 0.1 mg/hr Patch 24 hr Sig: One (1) patch Transdermal
once a day: apply in am, off in bedtime
to start [**5-23**] if BP still not controlled.
7. Coumadin 3 mg Tablet Sig: One (1) Tablet PO once a day:
titrate to INR [**3-12**].
8. Nitroglycerin 0.1 mg/hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal Q24H (every 24 hours): apply to chest each day, off
@ night .
9. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO QHS (once a day (at bedtime)).
10. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) as needed for agitation.
11. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours) as needed for pain.
12. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Primary
1. Endometrial Carcinoma with torsion
2. Postoperative Delerium, resolving
3. Anemia, NOS
4. Catheter Associated DVT
5. Partial Small Bowel Obstruction, resolved
Secondary: Hypertension, Atrial Fibrillation
Discharge Condition:
stable
Discharge Instructions:
Please contact Dr. [**Last Name (STitle) 2028**] or Dr. [**Last Name (STitle) **] should you develop any
fevers, chills, sweats, nausea, vomiting, abdominal pain, or any
other complaints.
Followup Instructions:
1) Primary Care
Provider: [**First Name4 (NamePattern1) 247**] [**Last Name (NamePattern1) 248**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2107-6-9**] 11:20
2) Gynecology: Please schedule an appointment with Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2028**] ([**Telephone/Fax (1) 5777**]) to be seen within 3 weeks for
post-operative follow-up
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2937**]
Completed by:[**2107-5-23**]
|
[
"564.00",
"486",
"293.9",
"280.9",
"414.01",
"272.4",
"997.5",
"182.0",
"V10.3",
"276.51",
"584.5",
"733.00",
"427.31",
"E879.8",
"403.90",
"585.9",
"453.40",
"276.6",
"412",
"V58.61",
"620.5",
"996.74",
"220",
"276.2",
"560.9",
"E878.6",
"496"
] |
icd9cm
|
[
[
[]
]
] |
[
"46.82",
"96.38",
"99.04",
"65.61"
] |
icd9pcs
|
[
[
[]
]
] |
10020, 10090
|
5949, 8259
|
229, 286
|
10354, 10363
|
2075, 2094
|
10599, 11130
|
1588, 1648
|
8781, 9997
|
10111, 10333
|
8285, 8758
|
10387, 10576
|
1663, 1677
|
2385, 3848
|
175, 191
|
314, 949
|
3857, 5926
|
2108, 2371
|
971, 1311
|
1327, 1572
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,270
| 193,405
|
36072
|
Discharge summary
|
report
|
Admission Date: [**2152-11-18**] Discharge Date: [**2152-12-5**]
Date of Birth: [**2069-10-14**] Sex: M
Service: NEUROSURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
Skull fx with IPH
Major Surgical or Invasive Procedure:
None
History of Present Illness:
83 yo male s/p fall from standing while sweeping snow. INtubated
in field taken to outside hospital and transfered here without
films. Now found with nondisplaced fkull fracture and ICH.
Past Medical History:
Brain tumor, HTN, pacemaker
Social History:
Lives with________
Family History:
Unknown
Physical Exam:
BP:135 /70 HR:65 R 15 O2Sats:100
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: L5+ R4+ minimally reactive, lac with soft tissue
edema on
left side resolving
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: lethargic, opens eyes to voice only. Has not
followed commands.
Orientation: Non communicative
Language: nonverbal
minimal spontaneous movements
Brief Hospital Course:
Mr [**Known lastname 81837**] was admitted to the SICU for close observation of
neurological changes. On admission he was seen by ENT for facial
fx and epistaxis who packed his nose. He was followed with
serial crits due to his continued epistaxis. Follow up CT showed
evolution of the SAH blood and contusion. On his exam he
followed commands on left and withdrew the on the right. Due to
his age, poor exam and extent of blood it was decided he should
have a PEG and trach which was done on [**11-21**]. EP consulted due
to his pacemaker which was found to be normal however he had new
A-Fib for which he was started on cardiazem drip. Mr [**Known lastname 81837**]
was transferred to floor on [**11-22**]. Patient spiked to T 105.3 o/n
of [**11-21**], and started on cipro on [**11-22**], and meropenem added on
[**11-23**] for suspected sinusitis. Since then, patient has continued
to be febrile, and remained hemodynamically stable.
Neurologically he had a poor exam of no commands, + eye
openings, localized on left and plegic on right.
ID was involved on [**11-28**] they broadened his antibiotic coverage
to Vanco and Meropenum the only positive culture was
ACINETOBACTER from his sputum. On [**11-30**] he was made DNR/DNI and
his Vancomycin dose was decreased due to an elevated level of
23.9. On [**12-1**] vancomycin level was decreased to 14.8. After a
family meeting the patient was made CMO. He is pending transfer
from Step down to the Floor and screened for hospice care. His
condition remains unchanged with no clinical improvement. Family
has remained active with his care and all planning.
Medications on Admission:
Esinopril
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4H (every 4 hours) as needed. ML(s)
2. Ibuprofen 100 mg/5 mL Suspension Sig: One (1) PO Q8H (every
8 hours) as needed for fever.
3. Scopolamine Base 1.5 mg Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal EVERY 3 DAYS (Every 3 Days).
4. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic Q4H
(every 4 hours).
5. Morphine 2 mg/mL Syringe Sig: One (1) Injection Q4HRS; PRN
as needed for discomfort; RR>12.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 7661**] Nursing
Discharge Diagnosis:
Nondisplaced skull fracture
SubDural hematoma
Left temporal Intraparanchymal hemorrhage (non surgical)
Scattered sub arachnoid hemorrhages (non surgical)
Discharge Condition:
none
Discharge Instructions:
General Instructions
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
Followup Instructions:
Follow-Up Appointment Instructions: Feel free to call with any
questions. Dr.[**Name (NI) 4674**] office [**Telephone/Fax (1) 1669**]
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2152-12-5**]
|
[
"276.51",
"518.81",
"E880.9",
"V45.01",
"707.03",
"473.9",
"801.26",
"401.9",
"707.21",
"V46.11",
"E849.0",
"427.31",
"366.9",
"802.4",
"427.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"43.11",
"99.04",
"31.1",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
3305, 3364
|
1126, 2741
|
316, 322
|
3562, 3569
|
4140, 4400
|
642, 651
|
2801, 3282
|
3385, 3541
|
2767, 2778
|
3593, 4117
|
666, 940
|
259, 278
|
350, 539
|
955, 1103
|
561, 590
|
606, 626
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,153
| 108,222
|
26014
|
Discharge summary
|
report
|
Admission Date: [**2176-11-15**] Discharge Date: [**2176-11-21**]
Date of Birth: [**2147-12-18**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
seizure
Major Surgical or Invasive Procedure:
Placement of PICC line
History of Present Illness:
28-year-old Spanish speaking male with a history of etoh abuse
and multiple past seizures for which he was hospitalized at [**Hospital1 2177**]
and [**Hospital1 336**]. He drinks ~l L of vodka/day and has currently has
been abstinant for 2 days until today when he was found down
with emesis and question of seizure. He has had seizures
previously and has been in and out of detox facilities. He does
not recall the events that lead up to him being found down. He
has been having some visual hallucinations recently - seeing men
who are not actually present. He was tremulous and anxious on
admission, and was also complaining of some epigastric pain
without nausea. He has not had any black or bloody stools. He
denies having diarrhea.
ROS: no HA, no cough, no sob, no neck stiffness or photophobia.
+ diffuse body pain/soreness
Past Medical History:
Alcohol abuse
Suspected previousl alcohol withdrawal seziures
Social History:
daily etoh use of one liter of vodka a day
denies other drug use/tobacco
Family History:
unknown
Physical Exam:
PE: vs t 100, bp 140/90, HR 84, RR 16 100%ra
gen: nad, alert and lucid
heent: mild abrasion to face
cvs rrr
resp cta B
abd soft, mild diffuse tenderness
ext no [**Location (un) **]
neuro: no evidence of FND, cn 2-12 intact, moving all 4 limbs.
Pertinent Results:
CXR: Mild pulmonary edema is present accompanied by stable mild
cardiomegaly and progressive mediastinal vascular engorgement.
More focal peribronchial opacification in the right lower lung
could represent a very early pneumonia. There is no
pneumothorax or more than a small right pleural effusion. Tip of
the right PIC line passes as far as the SVC, but the tip is
indistinct, perhaps at the level of the upper right atrium.
[**2176-11-20**] 04:14AM BLOOD WBC-6.4 RBC-3.39* Hgb-11.2* Hct-31.9*
MCV-94 MCH-33.1* MCHC-35.2* RDW-15.7* Plt Ct-190
[**2176-11-20**] 04:14AM BLOOD PT-12.5 PTT-27.5 INR(PT)-1.0
[**2176-11-20**] 04:14AM BLOOD Glucose-84 UreaN-3* Creat-0.7 Na-143
K-3.5 Cl-107 HCO3-24 AnGap-16
[**2176-11-17**] 10:20PM BLOOD ALT-45* AST-142* LD(LDH)-802*
CK(CPK)-4138* AlkPhos-49 Amylase-88 TotBili-1.0
[**2176-11-18**] 02:46PM BLOOD ALT-37 AST-82* LD(LDH)-539* CK(CPK)-2499*
AlkPhos-42 TotBili-0.5
[**2176-11-20**] 04:14AM BLOOD ALT-30 AST-41* CK(CPK)-927* AlkPhos-50
TotBili-0.4
[**2176-11-17**] 10:20PM BLOOD Lipase-137*
[**2176-11-17**] 03:27AM BLOOD CK-MB-22* MB Indx-1.7 cTropnT-<0.01
[**2176-11-17**] 05:46AM BLOOD calTIBC-355 Ferritn-149 TRF-273
[**2176-11-20**] 04:14AM BLOOD VitB12-611 Folate-13.6
[**2176-11-15**] 05:45PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Brief Hospital Course:
Over Mr. [**Known lastname 64626**] first 24 hours, he experienced worsening
withdrawal symptoms. He repeatedly removed his IV, and was
demanding very high levels of BZs and constant 1:1 observation.
he was transferred to the [**Hospital Unit Name 153**] for closer observation.
In the [**Hospital Unit Name 153**], Mr. [**Known lastname 13216**] required very high levels of valium
(1500mg over 12 hours), plus ativan, haldol, and versed to
control symptoms per CIWA scale. Elevated AG to 22, attempted to
minimize midazolam and lorazepam since propylene glycol solvent
likely etiology of AG-metabolic acidosis. No urine ketones.
Eventually achieved adquate control of sx's on versed drip, with
monitored daily QTc. Considered starting phenobarb 30mg q6h if
sx's not controlled, but did not have to do so. BZ weaned to
off.
Mr. [**Known lastname 13216**] also was febrile to max 101.8F. CXR showed possible
early RLL PNA. Suspect aspiration as etiology. Was coughing up
brown sputum. Normal wbc, but had pancytopenia, most likely [**1-3**]
marrow suppression [**1-3**] EtOH. Started on 7-day course levo and
flagyl, and was ultimately d/c'ed to complete this course.
PICC line placed. Started on clears on [**11-19**], advanced to
regular diet. Also had evidence of some rhabdo with elevated
CKs, normal trops. Trended down with aggressive hydration.
Creatinine transiently bumpted to 1.3, probably [**1-3**] propylene
glycol or rhabdo, which resolved.
Pt continued to have mild abdominal pain. On PPI, antiemetics.
LFTs elevated, likely fatty liver, which resolved. Guaiac
negative.
Derm consulted for numerous nits visible in scalp and groin
hair. Lice also seen on scalp and groin hair as well as on
clothing in patient's bag. Was treated with Lindane shampoo to
hair-bearing areas - scalp, axilla and groin for two days in a
row, and Lindane lotion applied to. Above regimen was to be
repeated in one week, and he was d/c'ed with the Lindane shampoo
and lotion.
Mr. [**Known lastname 13216**] was transferred to the floor after BZ drips were
tapered to off. He did well on the floor over the next 24 hours,
and did not require any treatment per CIWA scale. He was seen by
case management and social work, and set up to receive free
medications. He was offered lodging at [**Hospital1 **] shelter, but
deferred. He was discharged with multivitamins, the remainder of
his antibiotic course, PPI, Lindane shampoo and lotion, and
contact information for several shelters and substance abuse
centers.
Medications on Admission:
none
Discharge Medications:
1. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 3 days: Last dose [**2176-11-24**].
Disp:*3 Tablet(s)* Refills:*0*
2. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q 8H
(Every 8 Hours) for 3 days: Last dose [**2176-11-24**].
Disp:*9 Tablet(s)* Refills:*0*
3. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Lindane 1 % Shampoo Sig: One (1) application Topical once a
day for 2 doses: Use Lindane shampoo to hair-bearing areas -
scalp, axilla and groin - leave on for 5 minutes daily before
rinsing off, use for two days in a row. Do not apply to
eyelashes if nits become evident here - can simply apply
vaseline to the eyelashes.
.
Disp:*1 bottle* Refills:*0*
8. Lindane 1 % Lotion Sig: One (1) application Topical once a
day for 2 doses: Use Lindane lotion to body - apply, leave on
for eight hours, then wash off.
.
Disp:*1 bottle* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Alcohol withdrawal
Discharge Condition:
Good. No evidence of withdrawal symptoms, off all withdrawal
meds.
Discharge Instructions:
You have been diagnosed with alcohol withdrawal. You were
treated with medicines to ease your withdrawal. You were also
diagnosed with a possible pneumonia. You are being given three
days more of antibiotics, and should take these medicines as
prescribed.
You also were diagnosed with lice. You were treated with Lindane
shampoo and lotion. It is important that you use these again on
[**11-26**] and [**11-27**] as prescribed.
It is very important for you to cut down on your alcohol intake.
Some resources are listed below. If you feel as though you are
having withdrawal symptoms again, you should return to the ED.
Followup Instructions:
The number for Alcoholics Anonymous in [**Location (un) 86**] is [**Telephone/Fax (1) 11418**].
There is also a Spanish-speaking Alcoholics Anonymous group in
[**Location (un) **], and they can be contact[**Name (NI) **] at [**Telephone/Fax (1) 64627**].
If you reconsider living at [**Hospital1 **] shelter, their phone number
is [**Telephone/Fax (1) 14771**].
|
[
"291.0",
"458.9",
"276.0",
"284.8",
"790.99",
"276.2",
"507.0",
"728.88",
"289.9",
"780.39",
"305.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"94.62",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
6928, 6934
|
3036, 5544
|
324, 348
|
6997, 7066
|
1694, 3013
|
7734, 8099
|
1406, 1415
|
5599, 6905
|
6955, 6976
|
5570, 5576
|
7090, 7711
|
1430, 1675
|
277, 286
|
376, 1215
|
1237, 1300
|
1316, 1390
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,892
| 101,386
|
668
|
Discharge summary
|
report
|
Admission Date: [**2137-12-25**] Discharge Date: [**2138-1-1**]
Date of Birth: [**2090-7-30**] Sex: F
Service: MEDICINE
Allergies:
Morphine / Iodine; Iodine Containing
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
abdominal pain, nausea and vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: Patient is a 47-year-old female with h/o metastatic breast
cancer to the liver and bone (currently on treatment with
Navelbine), h/o pancreatitis secondary to hypertriglyceridemia
who presents with nausea, vomiting and abdominal pain. States
she woke up this AM with severe, diffuse abdominal pain
radiating across the front of her abdomen. No radiation to her
back. Pain was [**11-4**] and assoicated with frequent emesis.
Patient immediately came to the ER. Denies fevers of chills. No
diarrhea or constipation. Last BM was last night. Last treatment
with navelbine was one week ago. Patient says she was febrile to
101.3 two days ago, was seen in ER for backpain but no new
fractures were seen on MRI. Was sent home after bcx were drawn
for close follow-up with heme/onc. Blood cultures show NGTD.
.
In ER patient was given IV dilaudid and phenergan without much
improvement in nausea or pain. She was afebrile with nl HR. She
was given 3 L NS. Amylase was 406, lipase 1191, WBC 30.5.
Abdominal CT was done and showed acute pancreatitis with
extensive inflammatory stranding surrounding the entire pancreas
without focal fluid collections. Increased mets in liver were
seen and stable lytic and sclerotic bone lesions were also
noted.
.
Currently patient is in severe pain and having episodes of
emesis. She feels dizzy with some numbness in nose and
fingertips. Husband states that she has had some peripheral
neuropathy for chemo, but she states this is a different
feeling.
Past Medical History:
Past Medical History:
Metastatic Breast ca- undergone chemo w/ adriamycin/cytoxan,
then taxol. Also with 5FU/leukovorin and Zometa. Currently on
therapy with Navelbine
s/p radiation to the T4 region for mets this year
s/p ccy
h/o ovarian clot- requiring coumadin, was post Taxol therapy
hypertrigylceridemia
pancreatitis in [**2130**]. Had elevated triglycerides at that time
and told it was genetic.
Social History:
Social History:
Married with 3 children. Denies any T/A/D
Used to drink occasiounally
Family History:
Family History:
Aunt with breast cancer on father's side. Mother with bladder
cancer. Uncle with unknown cancer.
Physical Exam:
Tc 100.0 BP 122/74 P 102 R 22 O2 sat 96% RA
Gen: A& O x3 in severe pain and having episodes of emesis
HEENT: MMM, anicteric sclera, patient is able to feel me
touching her face, even though she feels it is numb
Neck: supple
Cardio: tachycardic with regular rhythm, nl S1 S2, no m/r/g
Pulm: few crackles at bases and scattered expiratory wheezes but
moving air well
Abd: soft, distended, pain on light palpation diffusely,
hypoactive; BS in all 4 quadrants; no bruising seen on abd or
flank
Ext: no edema; 2+ PT pulses, warm extremities
Neuro: A& O x3
muscle strength grossly intact in all four extremities
patient does not feel light touch in her fingertips bilaterally
but is able to move her fingers. Extremities are warm.
Pertinent Results:
[**2137-12-25**] 12:54PM BLOOD WBC-30.5*# RBC-UNABLE TO Hgb-12.6
Hct-30.0* MCV-UNABLE TO MCH-UNABLE TO MCHC-UNABLE TO
RDW-UNABLE TO Plt Ct-206
[**2137-12-26**] 05:01AM BLOOD WBC-32.1* RBC-4.01* Hgb-12.7 Hct-34.3*
MCV-85 MCH-31.5 MCHC-37.0* RDW-18.7* Plt Ct-172
[**2137-12-26**] 09:01AM BLOOD WBC-24.4* RBC-3.60* Hgb-11.3* Hct-30.9*
MCV-86 MCH-31.3 MCHC-36.5* RDW-18.9* Plt Ct-139*
[**2137-12-25**] 12:54PM BLOOD Neuts-53 Bands-31* Lymphs-4* Monos-4
Eos-0 Baso-0 Atyps-0 Metas-3* Myelos-5* NRBC-1*
[**2137-12-26**] 05:01AM BLOOD Neuts-67 Bands-16* Lymphs-5* Monos-3
Eos-0 Baso-1 Atyps-0 Metas-5* Myelos-3*
[**2137-12-25**] 12:54PM BLOOD PT-12.7 PTT-22.6 INR(PT)-1.1
[**2137-12-26**] 05:01AM BLOOD PT-13.7* PTT-23.5 INR(PT)-1.3
[**2137-12-25**] 12:54PM BLOOD Glucose-107* UreaN-9 Creat-0.7 Na-141
K-3.5 Cl-105 HCO3-22 AnGap-18
[**2137-12-26**] 05:01AM BLOOD Glucose-133* UreaN-7 Creat-0.6 Na-137
K-3.1* Cl-102 HCO3-20* AnGap-18
[**2137-12-26**] 09:01AM BLOOD Glucose-123* UreaN-8 Creat-0.6 Na-136
K-2.9* Cl-106 HCO3-21* AnGap-12
[**2137-12-25**] 12:54PM BLOOD ALT-38 AST-40 LD(LDH)-809* AlkPhos-124*
Amylase-406* TotBili-0.6
[**2137-12-26**] 05:01AM BLOOD ALT-25 AST-31 Amylase-205* TotBili-1.0
[**2137-12-25**] 12:54PM BLOOD Lipase-1191*
[**2137-12-26**] 05:01AM BLOOD Lipase-437*
[**2137-12-26**] 09:01AM BLOOD Calcium-7.1* Phos-1.9* Mg-1.3*
[**2137-12-26**] 05:01AM BLOOD Calcium-7.1* Phos-2.2* Mg-1.3*
[**2137-12-25**] 12:54PM BLOOD Calcium-9.2 Cholest-375*
[**2137-12-25**] 12:54PM BLOOD Triglyc-2736* HDL-39 CHOL/HD-9.6
LDLmeas-PND
[**2137-12-26**] 10:32AM BLOOD Lactate-1.5 K-2.6*
[**2137-12-25**] 02:12PM BLOOD Lactate-1.2
[**2137-12-26**] 10:32AM BLOOD freeCa-1.08*
[**2138-1-1**] 03:11AM BLOOD WBC-11.8* RBC-2.84* Hgb-8.6* Hct-24.8*
MCV-88 MCH-30.3 MCHC-34.6 RDW-18.2* Plt Ct-238
[**2138-1-1**] 03:11AM BLOOD Amylase-96
[**2138-1-1**] 03:11AM BLOOD Lipase-126*
.
CXR [**2137-12-25**]:
No airspace consolidations or pleural effusions are identified.
However, increased vascular markings and peripheral interstitial
lines suggest tiny degree of fluid overload. Some of this
appearance is enhanced by lower lung volumes. The right
hemidiaphragm continues to be slightly elevated. The tip of a
right central venous catheter overlies the right atrium. No
pneumothorax. No pleural effusions. The cardiac and mediastinal
contours are unchanged.
.
Abd CT [**2137-12-24**]:
1. Acute pancreatitis with extensive inflammatory stranding
surrounding the entire pancreas without focal fluid collections,
pseudocyst, splenic vein thrombosis or splenic artery aneurysm.
2. Slight interval increase in the size of the multiple liver
metastatic lesions.
3. Stable mixed lytic and sclerotic bone lesions.
.
Abd CT [**12-30**]:
IMPRESSION:
1. Interval development of left-sided pleural effusion with
associated atelectasis and interval increase in degree of
peripancreatic stranding and effusion with no evidence of
pancreatic necrosis. No evidence of retroperitoneal hemorrhage.
No pseudoaneurysm identified in the pancreatic bed.
2. Unchanged appearance of multiple hepatic lesions.
3. Interval apparent development of a right-sided 4.5 cm adnexal
cyst.
.
Bcx [**12-25**], [**12-26**]: no growth
Ucx [**12-28**]: no growth
Stool c. diff [**12-28**], [**12-29**]: no growth
Brief Hospital Course:
47-year-old female with h/o metastatic breast cancer to the
liver and bone, currently on treatment with Navelbine and h/o
pancreatitis secondary to hypertriglyceridemia who presented
with nausea, vomiting and abdominal pain which appeared
secondary to acute pancreatitis.
.
*Acute Pancreatitis: Patient presented with severe abdominal
pain,nausea and vomiting. In the ER she was given IV dilaudid
and phenergan without much improvement in nausea or pain. She
was afebrile with a nl HR. Amylase was 406, lipase 1191 and WBC
30.5. Abdominal CT was done and showed acute pancreatitis with
extensive inflammatory stranding surrounding the entire pancreas
without focal fluid collections. Increased mets in the liver
were seen and stable lytic and sclerotic bone lesions were also
noted. Her pancreatitis was likely secondary to
hypertriglyceridemia (Trig 2736), but could have been secondary
to Navelbine treatment. Patient had an initial admission
[**Last Name (un) 5063**] score of 2. She was given 3L of NS in the ER.
After admission, she received aggressive IVF hydration,
dilaudid PCA for pain control and anti-emetics. She was given 2
L NS at 200 cc/hr initially. When her hct was found to be
higher, it suggested her fluid requirement was not being met so
her fluids were increased to 500cc/hr. Her calcium dropped to
7.1 on [**2137-12-26**] and her K+ to 2.6. Her pain was not well
controlled on the PCA and she had continued N/V. She was
transferred to the MICU for monitoring. She was empirically
started on flugyl and cipro for high fevers, but there was no CT
evidence of necrotizing pacnreatitis. In the ICU she had close
electrolyte monitoring and received IVFs. Her dilaudid PCA was
changed to fentanyl. Her N/V and pain improved and WBC trended
down. Repeat abd CT was done on [**12-30**] and showed interval
developement of left sidedd pleural effusion and increase in
degree of peripanreatic stranding and effusion with no evidence
of necrosis. While the CT showed more stranding, the patient
improved clinically. Her diet was advanced and she was started
on Tricor for her hypertriglyceridemia. Her amylase, lipase,
WBC and triglycerides trended down over her stay. She was
discharged home in stable condition.
.
* Diarrhea: She developed diarrhea in the MICU which improved
after arrival to the floor. 2 sets of c. diff toxin were
negative.
.
*h/o metastatic breast CA: Patient had known metastatic breast
cancer and was being treated with Navelbine as an outpatient.
Her abdominal CT showed increased liver mets. Her cancer care
was deferred to her outpatient doctors.
.
*H/o ovarian clot: Patient had a known ovarian clot for which
she was on coumadin . Coumadin was initially held out of concern
that she might require surgery. It was re-started upon
discharge.
Medications on Admission:
Navelbine
Ativan prn
Coumadin 1mg QD
Neurontin 300 HS
Oxycontin 80mg [**Hospital1 **]
Vocodin prn
Recently on Neulasta for neutropenia, last dose 1 week ago
Protonix qd
Zofran prn
.
Discharge Medications:
1. Prochlorperazine 10 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for nausea.
Disp:*40 Tablet(s)* Refills:*0*
2. Zofran 4 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours.
Disp:*40 Tablet(s)* Refills:*2*
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours) for
2 weeks.
Disp:*28 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. OxyContin 40 mg Tablet Sustained Release 12HR Sig: One (1)
Tablet Sustained Release 12HR PO twice a day for 1 months.
Disp:*60 Tablet Sustained Release 12HR(s)* Refills:*0*
5. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO
QD ().
Disp:*30 Tablet(s)* Refills:*1*
6. Diphenoxylate-Atropine 2.5-0.025 mg Tablet Sig: 1-2 Tablets
PO Q8H (every 8 hours) as needed for diarrhea for 1 weeks.
Disp:*40 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Acute pancreatitis
Hypertriglicidemia
Metastatic Breast Cancer
Discharge Condition:
Stable
Discharge Instructions:
You were admitted to the hospital with Acute Pancreatitis.
Please return to the hospital if you develop shortness of
breath, chest pain or severe nausea/vomiting/diarrhea. If you
are unable to eat or drink fluid due to nausea and vomiting
please return to the hospital. Please call your doctor if you
have any questions about your symptoms.
You should advance your diet slowly. Concentrate on taking in
fluids and then bland foods such as rice, bread, and fruits such
as bananas. Please take medications as prescribed.
Followup Instructions:
Please call your PCP [**Last Name (NamePattern4) **] [**Telephone/Fax (1) 2936**] to make a follow-up
appointment for next week.
|
[
"V10.3",
"272.1",
"276.50",
"285.9",
"577.0",
"197.7",
"198.5",
"276.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
10483, 10489
|
6570, 9372
|
332, 339
|
10596, 10605
|
3277, 6547
|
11172, 11304
|
2417, 2516
|
9605, 10460
|
10510, 10575
|
9398, 9582
|
10629, 11149
|
2531, 3258
|
257, 294
|
368, 1855
|
1900, 2281
|
2313, 2385
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,220
| 134,568
|
35732
|
Discharge summary
|
report
|
Admission Date: [**2189-6-7**] Discharge Date: [**2189-6-24**]
Date of Birth: [**2133-6-4**] Sex: M
Service: SURGERY
Allergies:
Bactrim
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
abdominal pain, nausea and vomiting
Major Surgical or Invasive Procedure:
none
History of Present Illness:
56 y/o male presents with epigastric abdominal pain. Sharp,
constant, [**6-30**] severity. Associated with nausea and vomiting.
Had just had a yogurt prior to episode but does not attribute to
postprandial pain. Has not attempted PO since then but feels
thirsty. No diarrhea or constipation. No fevers or
chills. Just completed course of antibiotics for bronchitis.
Past Medical History:
Prior episode pancreatitis- admitted to OSH ~1yr prior
Hematoma/mass in head of pancreas- size decreeased at last
imaging.\
-DMII, dx [**2187-10-22**]
-Low back pain with an L5 herniated disc.
-History of melanoma, with subsequent follow-up with no
recurrence.
Social History:
He works with a software business company. He lives at home
with his children. He does not smoke, and drinks occasionally
five to six glasses of alcohol a week. He denies any history of
IV drug abuse.
Family History:
no biliary or pancreatic disease
Physical Exam:
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: +BS, soft, non tender, non distended, no palbable masses
Ext: No LE edema, LE warm and well perfused
Pertinent Results:
LABS AT ADMISSION:
[**2189-6-6**] 10:00PM BLOOD WBC-21.5* RBC-5.39 Hgb-16.2 Hct-46.9
MCV-87 MCH-30.0 MCHC-34.5 RDW-13.9 Plt Ct-410
[**2189-6-6**] 10:00PM BLOOD Glucose-352* UreaN-15 Creat-0.9 Na-140
K-4.2 Cl-105 HCO3-20* AnGap-19
[**2189-6-6**] 10:00PM BLOOD ALT-222* AST-246* LD(LDH)-329* AlkPhos-82
TotBili-1.5
[**2189-6-6**] 10:00PM BLOOD Lipase-1556*
[**2189-6-7**] 07:25AM BLOOD Calcium-8.0* Phos-3.7 Mg-1.9 Cholest-115
[**2189-6-7**] 07:25AM BLOOD Triglyc-44 HDL-71 CHOL/HD-1.6 LDLcalc-35
LABS AT DISCHARGE:
[**2189-6-24**] 06:12AM BLOOD WBC-15.2* RBC-3.24* Hgb-9.5* Hct-27.7*
MCV-85 MCH-29.2 MCHC-34.2 RDW-14.1 Plt Ct-452*
[**2189-6-24**] 06:12AM BLOOD Glucose-153* UreaN-15 Creat-0.8 Na-133
K-4.6 Cl-99 HCO3-25 AnGap-14
[**2189-6-18**] 03:29AM BLOOD ALT-53* AST-39 LD(LDH)-495* AlkPhos-159*
Amylase-29 TotBili-1.5
[**2189-6-18**] 03:29AM BLOOD Lipase-15
[**2189-6-24**] 06:12AM BLOOD Calcium-8.0* Phos-4.4 Mg-2.2
Brief Hospital Course:
The patient was admitted on [**6-7**] for acute abdominal pain,
nausea and vomiting. A CT scan performed in the ED showed:
"Extensive pancreatitis with findings consistent with
hypoenhancement of the head, uncinate and a portion of the body
of the pancreas. This is concerning for necrotizing
pancreatitis. Adjacent extensive edema of the duodenum". Lipase:
1556.
The patient was admitted to the ICU.
Neurologic: pain was controlled with dilaudid PCA. On HD2 the
patient became very agitated and combative overnight (likely DT)
needing restraints. CIWA scale was started. He continued to
require significant amounts of benzodiazepines until HD7. A head
CT was obtained to r/o intracranial pathologic processes as a
cause for waxing and [**Doctor Last Name 688**] responsiveness, which was negative.
His mental status kept improving throughout his hostpital stay.
By HD 14 he was able to be transferred to the floor.
Cardiovascular: HTN, controlled with metoprolol 20 mg Q4H,
clonidine patch 0.2mg and enalapril. Had 3 episodes of SVT which
resolved with adenosine and carotid massage. He remained stable
from the cardiovascular point of view for the rest of his
hospital stay.
Pulmonary: on HD3 the patient's O2 requirements increased and a
CXR showed small lung volumes and b/l pleural effusions which
remained unchanged on his f/u CXR on HD5. ABG showed mixed
respiratory/metabolic acidosis. His pulmonary function
subsequently improved and he was weaned off O2.
GI/Abdomen: the patient was made NPO with strict bowel rest. TPN
was started on HD4. The patient experienced diarrhea and stool
Cx were sent and came back negative for O/P and C.diff. A RUQ US
was performed on HD3 and was negative for cholecystitis.
CT scan on HD9 showed: "Interval new non-occlusive thrombus in
the main portal vein, and splenic vein". The patient was
therefore started on a heparin drip.
Nutrition: the patient was made NPO with strict bowel rest. Diet
was advanced when the patient's mental status cleared and his
abdominal pain subsided.
Renal: a foley was placed on HD1 to allow monitoring of urine
output. Required D5W boluses to maintain normonatremia. His
foley was d/c'd on HD12 and the patient was able to void.
Endocrine: Type II DM at baseline, was put on ISS [**First Name8 (NamePattern2) **] [**Last Name (un) **]
recs.
ID: developed bandemia and fever on HD6, BCx were sent,
meropenem was started. On HD8 vanc/cipro/zosyn were started for
HAP. His BCx were repeatedly negative.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home with VNA for INR
and BG monitoring. A follow up appointment with his PCP was
scheduled for INR check and coumadin dosing. He will follow up
with Dr. [**Last Name (STitle) **] in 2 weeks. The patient is currently beeing
followed by [**Last Name (un) **] for DM management. The patient received
discharge teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan.
Medications on Admission:
Lisinopril 2.5mg, glipizide 2.5mg, metformin 1000mg
[**Hospital1 **]
Discharge Medications:
1. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
2. Glipizide 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
3. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
4. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4
PM.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
necrotizing pancreatitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**3-30**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Followup Instructions:
Please follow up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 81268**] (Nurse for Dr. [**Last Name (STitle) 28261**] on
[**2189-6-29**] at 09:00 am.
.
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2189-7-10**] 9:45
.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2832**], MD Phone:[**Telephone/Fax (1) 1231**] Date/Time: [**2189-7-10**]
11:15
.
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2190-2-19**] 10:00
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2832**], MD Phone:[**Telephone/Fax (1) 1231**]
Date/Time:[**2190-2-19**] 11:00 [**Hospital Ward Name 23**] 3, [**Hospital Ward Name **]
Completed by:[**2189-6-25**]
|
[
"511.9",
"452",
"250.00",
"486",
"518.0",
"518.82",
"577.0",
"V10.82",
"291.0",
"427.0",
"305.00",
"289.59",
"401.1",
"780.60",
"276.4",
"288.66"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"38.91",
"99.15",
"94.62"
] |
icd9pcs
|
[
[
[]
]
] |
6345, 6416
|
2478, 5610
|
300, 307
|
6485, 6485
|
1532, 2028
|
7240, 8011
|
1232, 1267
|
5730, 6322
|
6437, 6464
|
5636, 5707
|
6636, 7217
|
1282, 1513
|
225, 262
|
2047, 2455
|
335, 709
|
6500, 6612
|
731, 994
|
1010, 1216
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,104
| 131,802
|
48976+59128
|
Discharge summary
|
report+addendum
|
Admission Date: [**2180-2-18**] Discharge Date: [**2180-2-21**]
Date of Birth: [**2100-6-12**] Sex: F
Service: MEDICINE
Allergies:
Percocet
Attending:[**First Name3 (LF) 7055**]
Chief Complaint:
Transferred from [**Hospital 47**] hospital for balloon pericardiotomy
Major Surgical or Invasive Procedure:
balloon pericardiotomy
History of Present Illness:
Patient is a 75 yo woman with PMH of Lung cancer
(adenocarcinoma) diagnosed in [**2176**], on maintenance XRT and
chemotherapy, history of HTN, diastolic dysfunction, and CRI who
presents from [**Hospital 47**] hospital with newly noted pericardial
effusion for balloon pericardiotomy. Patient states that she was
feeling in her USOH until 2 weeks prior to presentation at
[**Hospital 47**] hospital, when began feeling sick with cough,
described as dry cough productive of only scant amounts of
yellow sputum. Per patient, has cough at baseline productive of
white, foamy sputum, from her lung ca, but this cough was
different. Over the next 2 weeks, her cough progressed, was
associated with fever to around 100 on-and-off, SOB with
exertion, and on day of presentation to [**Location (un) 47**], had episode
of nausea and vomiting. 2 days PTA, she started on doxycycline
prescribed by her outpatient physician, [**Name10 (NameIs) **] improvement and
in fact worsening of her symptoms. She denies any orthopnea,
PND, LE swelling, change in weight, palpitations,
lightheadedness/dizziness, change in bowel habits, urinary
symptoms during this time.
.
On presentation to the OSH on [**2180-2-12**], patient was found to be
hypoxic, requiring oxygen through nasal cannula. During
[**Hospital 228**] hospital course at [**Location (un) 47**], she had an admission
CXR demonstrating large RUL and RML consolidation, mass like
lesion in R hilum c/w pneumonia, ?post-obstructive, ?recurrent
ca. Patient was treated with azithromycin and clindamycin.
Patient also had ECHO done in the ED that demonstrated small
pericardial effusion of 1.1 cm, no evidence of tamponade. Follow
up ECHO 5 days after admission demonstrated increase of her
pericardial effusion, still no evidence of tamponade, and
therefore patient was transferred for balloon pericardiotomy.
Hospital course otherwise notable for transfusion of 2 units
pRBC that brought her Hct from 26-> 30.2. Patient was also noted
at one point to be hypoglycemic with FSBS=36 for unknown reasons
- resolved with D50, and subsequently had normal FSBS. Patient
also had episode of desaturation to 80's, which resolved with
administration of 20mg IV lasix.
.
Currently, post-balloon pericardiotomy, patient feels well.
Denies any chest pain/pressure, shortness of [**Last Name (LF) 1440**], [**First Name3 (LF) 691**] other
complaints at this time.
Past Medical History:
1.) Lung cancer (adenocarcinoma) - diagnosed in [**2176**], currently
on maintenance XRT and chemotherapy
2.) HTN
3.) Diastolic heart failure (cath in [**2176**] w/ elevated filling
pressures - RA 19, PA 52/26, mean PCWP 26)
4.) CRI (?baseline Cr=1.8-2.2)
Last cardiac cath in [**2176**] w/ clean coronary arteries
Social History:
Lives with son in [**Name (NI) 47**], MA, used to smoke, quit 25 years
ago, rare EtOH, no drug use.
Family History:
NC
Physical Exam:
Vitals - HR 82, BP 121/60, RR 27, O2 96% on 0.5L NC
General - awake, alert, oriented, NAD
HEENT - PERRL, dry MM
Neck - JVD at approximately 7cm
CVS - RRR, nl S1,S2, no M/R/G
Chest - pericardial drain in place, drainage bag w/
approximately 75cc serosanguinous drainage
Lungs - scattered wheezes diffusely, decreased BS at lateral
bases b/l
Abd - obese, soft, non-tender, +BS
Groin - R groin w/ bandage in place, some sanguinous staining of
bandage site, tender to palpation, no noted hematoma
Ext - 2+ DP pulses b/l, no LE edema b/l
Pertinent Results:
[**2180-2-18**] 04:25PM BLOOD WBC-8.3 RBC-3.88* Hgb-9.8* Hct-31.6*
MCV-82# MCH-25.3*# MCHC-31.0 RDW-19.0* Plt Ct-582*#
[**2180-2-19**] 05:40AM BLOOD WBC-7.2 RBC-3.85* Hgb-9.6* Hct-31.4*
MCV-81* MCH-25.0* MCHC-30.7* RDW-18.9* Plt Ct-585*
[**2180-2-18**] 04:25PM BLOOD Neuts-90.7* Lymphs-4.4* Monos-3.3 Eos-1.4
Baso-0.3
[**2180-2-18**] 04:25PM BLOOD PT-14.9* PTT-36.2* INR(PT)-1.3*
[**2180-2-18**] 11:40AM BLOOD Glucose-79 UreaN-60* Creat-2.4* Na-137
K-6.0* Cl-101 HCO3-24 AnGap-18
[**2180-2-19**] 05:40AM BLOOD Glucose-99 UreaN-57* Creat-2.3* Na-140
K-5.1 Cl-103 HCO3-25 AnGap-17
[**2180-2-19**] 08:53PM BLOOD Glucose-150* UreaN-59* Creat-2.2* Na-134
K-4.3 Cl-100 HCO3-23 AnGap-15
[**2180-2-18**] 04:25PM BLOOD ALT-123* AST-76* LD(LDH)-278*
AlkPhos-148* TotBili-0.6
[**2180-2-19**] 05:40AM BLOOD ALT-92* AST-54* LD(LDH)-247 AlkPhos-141*
TotBili-0.5
[**2180-2-19**] 05:40AM BLOOD Albumin-3.1* Calcium-9.4 Phos-4.2 Mg-2.1
[**2180-2-19**] 05:40AM BLOOD HBsAg-PND HBsAb-PND HBcAb-PND IgM HAV-PND
[**2180-2-19**] 05:40AM BLOOD HCV Ab-PND
.
CXR [**2-18**]: IMPRESSION:
Interval development of marked right-sided upper lung volume
loss. At least partial obstruction of the right upper and right
middle lobe bronchi is not excluded.
Airspace opacity, most evident in the left mid and lower lung
zones, with left-sided small pleural effusion. The findings
represent mild pulmonary edema.
Pericardial drain projecting over the cardiac apex.
These findings would all be better assessed with
contrast-enhanced CT examination of the chest.
.
Echo [**2-18**]: Conclusions:
1. The left atrium is normal in size.
2.There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%).
3.Right ventricular chamber size is normal. Right ventricular
systolic
function is normal.
4.The aortic valve leaflets are mildly thickened. No aortic
regurgitation is seen.
5.The mitral valve leaflets are structurally normal. No mitral
regurgitation is seen.
6.Moderate [2+] tricuspid regurgitation is seen.
7.There is mild pulmonary artery systolic hypertension.
8.There is a large circumferential pericardial effusion. There
are no
echocardiographic signs of tamponade.
.
Echo [**2-18**]: Conclusions:
1. Overall left ventricular systolic function is normal
(LVEF>55%).
2.There is a trivial/physiologic pericardial effusion.
Brief Hospital Course:
75 yo woman with PMH of lung cancer, diastolic dysfxn, CRI, who
presented with pericardial effusion for pericaricentesis and
pericardiotomy.
.
# Pericardial effusion:
pt had successful balloon pericardiotomy performed, 300cc
removed during procedure, 300cc additionally via drain, this was
kept in place until output was < 500cc/8hr and removed on [**2-19**],
repeat echo prior to removal showed trace effusion remaining.
The fluid was serosanguinous, labs showed [**Numeric Identifier 102834**] RBCs, 3000
WBCs, 85 polys, 11 lymps, 2 monos, 1 eo, 1 macro. Cytology
pending at time of discharge, although most likely cause felt to
be malignancy given hx of lung CA. Pt received 1 dose of Kefzol
after procedure.
.
# Cardiac:
A. Coronaries: Patient without evidence of ischemic heart
disease, last cath per OSH records in [**2176**] w/ clean coronary
arteries, no signs/sxs of ischemic heart disease currently.
.
B. Pump: Patient w/ hx of diastolic heart failure, on lasix 40mg
PO QD as outpt. Currently appears euvolemic. Continued regular
dose lasix and spironolactone.
.
C. Rhythm: patient initially in NSR, on [**2-19**] she developed sinus
tachycardia - ? [**1-13**] infection vs pericardial irritation. Pt
thereafter was noted to have periods of tachycardia up to 130s
with underlying atrial tachycardial/multifocal atrial
tachycardia. She was additionally noted to have episodes of
AVNRT with well visualized retrograde p waves. Her electrolytes
were within normal limits. Her metoprolol was increased to 67.5
TID, and may need to be titrated further. Overnight [**2-19**] she
continued having episode of tachycardia to 120s, BP stable,
asymptomatic, resolving spontaneously.
.
# Pneumonia: Per patient, c/o cough and fever on presentation to
OSH. Per OSH records, ? RUL and RML pna on CXR c/w possible
post-obstructive pna. Was treated w/ azithromycin (started [**2-12**])
and clindamycin (started [**2-13**]) at OSH. On presentation, got
repeat CXR that demonstrated severe consolidation of RUL, RML,
upper part of RLL. Chest CT performed at OSH, so not repeated
here, but this was presumed to be post-obstructive pna. Pt was
placed on clindamycin 300mg q6hr, levofloxacin 250mg q24hr.
.
# Hx lung ca: Patient with hx lung ca (adenocarcinoma) diagnosed
in [**2176**], currently on maintenance XRT and chemo (tarceva).
Likely cancer recurrence as etiology of pericardial effusion as
above, and w/ CXR findings from OSH and here, and references to
Chest CT findings from OSH. Continued tarceva. Plan to:
- f/u cytology of pericardial effusion
.
# Resp: Patient w/ no documented hx of COPD. However + wheezes
on exam, and per OSH records, receiving albuterol/atrovent nebs
PRN. Continued atrovent nebs PRN, oxygenation remained stable
of 2L NC.
.
# CRI: Pt w/ hx of CRI, unknown baseline Cr, ?1.8-2.2. On
admission, Cr=2.4, trended down to baseline of 2.2, rec'd one
addition dose of 20mg lasix for period of shortness of [**Year (4 digits) 1440**],
but otherwise continued previous doses of lasix/spironolactone.
.
# Transaminitis: On admission, pt noted to have elevated
transaminases (AST 76, ALT 123, Alk Phos 148, LDH 278). T. bili
WNL. Abd exam non-tender. Noted to be trending down. Possible
[**1-13**] congestion vs lung mets, hepatitis panel sent, pending at
time of discharge. Consider abdominal CT if they trend up.
.
# HTN: On atenolol 100mg qd as outpt. Pt was placed on
metoprolol during admission to allow for better titration in
face of arrhythmias. Would not restart atenolol in face of
renal insufficiency, would favor toprol XL.
.
# FEN: Cardiac diet
.
# PPX: VD boots, Protonix (outpt med), bowel regimen
.
# Access: Midline placed [**2180-2-18**] for ongoing antibiotics
.
# Code status: Full
.
# Communication: Son, [**Name (NI) **], ([**Telephone/Fax (1) 102835**]
Medications on Admission:
lasix 40 qd
spironolactone 25 qd
atenolol 100mg qd
tarceva 100mg qd
azithromycin 250mg qd
clindamycin 300mg q8hr
protonix 40mg qd
albuterol/atrovent nebs
Discharge Medications:
1. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Tarceva 100 mg Tablet Sig: One (1) Tablet PO QD ().
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q4H (every 4 hours) as needed.
7. Clindamycin HCl 150 mg Capsule Sig: Two (2) Capsule PO Q6H
(every 6 hours).
8. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
9. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO 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. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL
Injection TID (3 times a day).
12. Metoprolol Tartrate 25 mg Tablet Sig: 2.5 Tablets PO TID (3
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] - [**Location (un) 47**]
Discharge Diagnosis:
Primary:
Pericardial effusion
Post-obstructive pneumonia
Secondary:
Lung CA
Narrow complex tachycardia
Discharge Condition:
fair
Discharge Instructions:
Please follow up with your primary care doctor as needed. Take
your medications as prescribed. Continue your antibiotics as
recommended by your doctors.
Followup Instructions:
Follow up with your primary care doctor as needed
Completed by:[**2180-2-20**] Name: [**Known lastname 400**],[**Known firstname 16611**] Unit No: [**Numeric Identifier 16612**]
Admission Date: [**2180-2-18**] Discharge Date: [**2180-2-21**]
Date of Birth: [**2100-6-12**] Sex: F
Service: MEDICINE
Allergies:
Percocet
Attending:[**First Name3 (LF) 3753**]
Addendum:
On day prior to discharge, the patient developed bursts of
junctional tachycardia and multifocal atrial tachycardia. Given
her COPD and tachycardia, she was switched from metoprolol 62.5
[**Hospital1 **] to diltiazem 30 mg QID. She tolerated this well without
repeat occurences of her tachycardia.
Patient had a repeat echocardiogram prior to transfer back to
[**Location (un) 4887**] to ensure no re-accumulation of her pericardial
effusion. ECHO demonstrated trivial pericardial effusion,
confirming no re-accumulation.
Pericardial effusion studies noted in discharge summary -
cytology pending at time of transfer.p
She was transferred, to the service of Dr. [**Last Name (STitle) 13747**], back to
[**Location (un) 4887**] to complete IV antibiotics course for
post-obstructive pneumonia and for further monitoring.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 2057**] - [**Location (un) 4887**]
[**First Name11 (Name Pattern1) 399**] [**Last Name (NamePattern4) 3754**] MD [**MD Number(1) 3755**]
Completed by:[**2180-2-21**]
|
[
"585.9",
"251.2",
"428.0",
"428.32",
"401.9",
"V10.11",
"485",
"427.89",
"198.89",
"397.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.12",
"37.0",
"37.21",
"88.55"
] |
icd9pcs
|
[
[
[]
]
] |
12958, 13192
|
6242, 10048
|
340, 364
|
11477, 11484
|
3829, 6219
|
11687, 12935
|
3257, 3261
|
10252, 11240
|
11352, 11456
|
10074, 10229
|
11508, 11664
|
3276, 3810
|
230, 302
|
392, 2785
|
2807, 3124
|
3140, 3241
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,061
| 124,972
|
36739
|
Discharge summary
|
report
|
Admission Date: [**2179-8-2**] Discharge Date: [**2179-8-11**]
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
shortness of breath and dizziness
Major Surgical or Invasive Procedure:
[**2179-8-5**] Aortic valve replacement with 21 mm [**Doctor Last Name **] Magna aortic
valve bioprosthesis.
Full left-sided Maze procedure with [**Company 1543**] Gemini S
system and Cardioblate pen with resection of left atrial
appendage.
Epiaortic duplex
History of Present Illness:
84 year old female that presented to outpatient clinic with SOB
and dizziness. Sent via ambulance to [**Hospital 5279**] hospital ER for
evaluation. Confirmed rapid atrial fibrillation of unknown
duration due to no previous medical evaluations. Echocardiogram
revealed severe aortic steonsis and underwent cardiac
catherization that revealed no coronary artery disease. She was
transferred for surgical evaluation.
Past Medical History:
no previous history
Social History:
retired
Lives alone
Spends summer in NH and [**Doctor Last Name 6165**] in FL
Tobacco: denies
ETOH: denies
Family History:
noncontributory
Physical Exam:
Physical Exam
Pulse: Resp: O2 sat: 72 afib/flutter
B/P Right: 134/74 Left:
Height: 5'1" Weight:65.7
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]- Edentulous
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [] Irregular [x] Murmur- III/VI
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x]
Neuro: Grossly intact
Pulses:
Femoral Right: cath site w/ hematoma Left:+2
DP Right: +2 Left:+2
PT [**Name (NI) 167**]: +2 Left:+2
Radial Right: +2 Left:+2
Carotid Bruit right bruit- radiating Aortic murmur Right:
+2 Left:+2
Pertinent Results:
[**2179-8-10**] 04:00AM BLOOD WBC-9.6 RBC-2.67* Hgb-8.5* Hct-25.9*
MCV-97 MCH-31.9 MCHC-32.9 RDW-13.9 Plt Ct-186
[**2179-8-2**] 05:44PM BLOOD WBC-8.4 RBC-4.21 Hgb-13.4 Hct-39.9 MCV-95
MCH-31.8 MCHC-33.6 RDW-14.2 Plt Ct-151
[**2179-8-10**] 04:00AM BLOOD PT-15.2* PTT-27.7 INR(PT)-1.3*
[**2179-8-3**] 07:08PM BLOOD PT-12.8 PTT-61.7* INR(PT)-1.1
[**2179-8-10**] 04:00AM BLOOD Glucose-156* UreaN-31* Creat-1.1 Na-139
K-4.0 Cl-104 HCO3-26 AnGap-13
[**2179-8-2**] 05:44PM BLOOD Glucose-108* UreaN-11 Creat-0.8 Na-142
K-3.9 Cl-106 HCO3-28 AnGap-12
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 83062**], [**Known firstname 12739**] [**Hospital1 18**] [**Numeric Identifier 83063**] (Complete)
Done [**2179-8-5**] at 2:41:16 PM 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: [**2094-8-4**]
Age (years): 84 F Hgt (in): 62
BP (mm Hg): 190/100 Wgt (lb): 130
HR (bpm): 82 BSA (m2): 1.59 m2
Indication: Aortic valve disease. Atrial fibrillation.
ICD-9 Codes: 402.90, 427.31, 440.0, 424.1, 424.0, 424.2
Test Information
Date/Time: [**2179-8-5**] at 14:41 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Name8 (MD) 22194**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2009AW000-0:00 Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Four Chamber Length: 4.7 cm <= 5.2 cm
Left Atrium - Peak Pulm Vein S: 0.3 m/s
Left Atrium - Peak Pulm Vein D: 0.6 m/s
Left Ventricle - Septal Wall Thickness: 1.0 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 0.8 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 2.8 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 2.0 cm
Left Ventricle - Fractional Shortening: 0.29 >= 0.29
Left Ventricle - Ejection Fraction: 50% to 55% >= 55%
Aorta - Sinus Level: 2.6 cm <= 3.6 cm
Aorta - Ascending: 3.1 cm <= 3.4 cm
Aortic Valve - Mean Gradient: 21 mm Hg
Aortic Valve - LVOT diam: 1.6 cm
Aortic Valve - Valve Area: *0.6 cm2 >= 3.0 cm2
Mitral Valve - MVA (P [**2-12**] T): 3.6 cm2
Mitral Valve - E Wave: 1.0 m/sec
Mitral Valve - E Wave deceleration time: 212 ms 140-250 ms
Findings
[**2179-8-9**] Internal billing status corrected. No changes made in
findings. WJM
LEFT ATRIUM: Normal LA and RA cavity sizes.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal
interatrial septum. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Normal LV wall thickness and cavity size.
Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending aorta diameter. Simple atheroma in
ascending aorta. Complex (mobile) atheroma in the aortic arch.
Focal calcifications in aortic arch. Normal descending aorta
diameter. Complex (mobile) atheroma in the descending aorta.
AORTIC VALVE: Severely thickened/deformed aortic valve leaflets.
Critical AS (area <0.8cm2). Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MS.
Mild (1+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR. Normal
main PA.
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. See Conclusions for post-bypass data
Conclusions
The left atrium and right atrium are normal in cavity size. 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 normal (LVEF >55%). Right
ventricular chamber size and free wall motion are normal. There
is a (mobile) atheroma in the aortic arch. Epiaortic Scan shows
clean site for insertion of aortic cannula and application of
cross clamp. There are simple atheroma in the ascending aorta.
The aortic valve leaflets are severely thickened/deformed. There
is critical aortic valve stenosis (valve area 0.6 cm2). Trace
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild (1+) mitral regurgitation is seen. There
is no pericardial effusion.
POST-BYPASS: Aortic Valve prosthesis in place with mean gradient
14 mmHg. Small paravalvular leak which resolved with protamine.
Preserved LV function. Mild Mitral regurgitation remains. Aortic
contours intact. Remaining exam is unchanged. All findings
dicussed with surgeons at the time of the exam.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2179-8-9**] 18:49
Brief Hospital Course:
Transferred in [**8-2**] and underwent preoperative evaluation.. On
[**8-5**] she was taken to the operating room and underwent Aortic
Valve Replacement, MAZE, and Left Atrial Appendage ligation. See
operative report for further details She received vancomycin for
perioperative antibiotics since she was in the hospital
preoperatively She was transferred to the intensive care unit
for hemodynamic management. She awoke neurologically intact and
was extubated without difficulty. Beta-blocker and diuretic was
initiated. On post operative day two she became confused and
agitated, narcotic medications were stopped. She was treated
with haldol for the confusion with improvement. Coumadin was
started due to MAZE and LAA ligation. Physical therapy worked
with her on strength and mobility. She continued to improve and
was transfer to the floor on post operative day four. Cipro was
started for urinary tract infection due to + leuks on
urinalysis. She continued to progress and was ready for
discharge to rehab ([**First Name8 (NamePattern2) **] [**Doctor First Name **] in [**Location (un) **] NH) on
postoperative day six.
Coumadin received 3mg [**8-7**], 5mg [**8-8**], [**8-9**], [**8-10**] INR increased
from 1.3 to 2.3 no coumadin [**8-11**] with lab check at rehab on [**8-12**],
increase most likely due to cipro that was started for UTI which
treatment is complete. If INR 2.5 or less resume coumadin at
4mg daily with INR checks three times a week until on steady
dose
Medications on Admission:
None
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day): 12.5 mg three times a day.
5. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily).
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day: goal
INR 2.0-2.5 please check INR [**8-12**] prior to dose and then 3x/week
until on steady dose
.
8. Ferrous Gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Discharge Disposition:
Extended Care
Facility:
TBA
Discharge Diagnosis:
Aortic stenosis s/p avr
Atrial fibrillation s/p MAZE and LAA ligation
Confusion
Discharge Condition:
Good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming for 1 month
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**]
PT/INR for coumadin dosing - s/p MAZE and LAA ligation, goal INR
2.0-2.5 please check PT/INR three times a week until on steady
dose
Followup Instructions:
Dr.[**Last Name (STitle) 914**] in 2 weeks ([**Telephone/Fax (1) 170**]) please call for appointment
Dr [**Last Name (STitle) 83064**] in 6 week ([**Telephone/Fax (1) 83065**]) please call for
appointment
Dr [**Last Name (STitle) 39975**] in 4 weeks please call for appointment
PT/INR for coumadin dosing - s/p MAZE and LAA ligation, goal INR
2.0-2.5 please check PT/INR three times a week until on steady
dose
Completed by:[**2179-8-11**]
|
[
"427.31",
"396.2",
"416.8",
"293.0",
"429.3",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.36",
"39.61",
"35.21"
] |
icd9pcs
|
[
[
[]
]
] |
9369, 9399
|
6930, 8422
|
300, 572
|
9523, 9530
|
1959, 6907
|
10187, 10630
|
1202, 1219
|
8477, 9346
|
9420, 9502
|
8448, 8454
|
9554, 10164
|
1234, 1940
|
227, 262
|
600, 1018
|
1040, 1061
|
1077, 1186
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,493
| 127,985
|
34855
|
Discharge summary
|
report
|
Admission Date: [**2172-10-30**] Discharge Date: [**2172-11-13**]
Date of Birth: [**2115-3-25**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
s/p Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
57 yo male transferred from a referring hospital s/p fall 9 days
prior to his presentation to [**Hospital1 18**] Emergency room with a Grade
IV splenic laceration. Upon arrival to the [**Hospital 48825**] hospital his
HCT was 21 and he and hypotensive; he was subsequently
intubated.
Past Medical History:
HTN, Cirrhosis (Child's B), ETOH abuse
Social History:
+EtOH
Family History:
Noncontributory
Pertinent Results:
[**2172-10-30**] 11:44PM GLUCOSE-113* UREA N-29* CREAT-0.7 SODIUM-138
POTASSIUM-2.7* CHLORIDE-107 TOTAL CO2-23 ANION GAP-11
[**2172-10-30**] 11:44PM CK(CPK)-571*
[**2172-10-30**] 11:44PM CALCIUM-6.7* PHOSPHATE-3.7 MAGNESIUM-2.2
[**2172-10-30**] 11:44PM WBC-18.8* RBC-2.96* HGB-9.1* HCT-26.5* MCV-90
MCH-30.8 MCHC-34.4 RDW-17.3*
[**2172-10-30**] 11:44PM PLT COUNT-497*
[**2172-10-30**] 09:20PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-POS barbitrt-NEG tricyclic-NEG
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW
Plt Ct
[**2172-11-10**] 05:11AM 11.0 3.47* 10.6* 31.1* 90 30.4 33.9
14.2 463*
[**2172-10-30**] CT Chest/Abdomen
IMPRESSION:
1. High-grade splenic laceration with massive hemoperitoneum. No
definite
active extravasation, however, cannot be completely excluded. A
repeat triple
phase study through the abdomen or angiography is recommended if
clinically
indicated.
2. Striated nephrogram, bilaterally suggestive of ATN.
3. Bilateral pleural effusions and associated compressive
atelectasis.
Consolidations in the dependent portions of both lower lobes and
right middle
lobe may represent aspiration pneumonia.
4. Cholelithiasis.
5. Endotracheal tube at 3 cm above the carina. Repositioning is
recommended.
[**2172-11-13**]
IMPRESSION: PA and lateral chest compared to [**11-8**] and 20.
Left subclavian line has been removed since [**11-9**]. No
catheter fragment
is identified. Left lower lobe atelectasis has improved, small
bilateral
pleural effusions, left greater than right, also decreased.
Heart size
normal. No pneumothorax. Upper lungs grossly clear.
Brief Hospital Course:
He was admitted to the Trauma Service and taken to the Trauma
ICU where he remained for several days sedated and vented. He
required transfusion with packed cells for an admission HCT of
24 as he was hypotensive. His most recent HCT is 31 as of [**11-10**].
He was noted to have an elevated WBC while in the ICU and
underwent a BAL which did eventually grow MRSA; he was treated
with a course of Vancomycin. He also became hypernatremic during
his ICU course which was treated with scheduled free water
boluses that were given via NG for which he was already
receiving also received tube feedings through. This also did
resolve and his last Na was 139 on [**11-10**].
He was eventually extubated and was transferred to the regular
nursing unit where he continued to progress. There was
discussion regarding whether to vaccinate given his spleen
injury; a smear for [**Location (un) **]-Jolly bodies was obtained and was
negative and so vaccination was not required. His diet was
advanced and he is tolerating this without any difficulties.
There are no pain control issues at this time.
He continues to require supplemental oxygen as he desaturates
with ambulation. He was evaluated by Physical therapy and is
being recommended for rehab after his acute hospital stay.
Social work was consulted for coping and also because of alcohol
associated with his injury.
Medications on Admission:
Atenolol, HCTZ, Flomax
Discharge Medications:
1. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
2. Quetiapine 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
3. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
4. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q4H (every 4 hours) as needed for shortness of breath
or wheezing.
5. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day) as needed for shortness of
breath or wheezing.
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML's
Injection TID (3 times a day).
8. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
11. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for pain.
12. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day) as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1970**] - [**Hospital1 1559**]
Discharge Diagnosis:
s/p Fall
Grade IV splenic laceration
Acute blood loss anemia
Discharge Condition:
Hemodynamically stable, tolerating regular diet, pain adequately
controlled.
Discharge Instructions:
AVOID any contact sports or any other activiyt that may cause
injury to your abdominal area becasue of your spleen injury.
It is important that if you become suddenly weak, dizzy or
lightheaded and there is a sudden and significant drop in your
blood pressure from baseline that you return to the Emergency
room immediately as this may be a sign that you are having
bleeding from your spleen.
Followup Instructions:
Follow up in 2 weeks, in clinic with Dr. [**Last Name (STitle) **], Trauma surgery
call [**Telephone/Fax (1) 6429**] for an appointment.
Completed by:[**2172-11-13**]
|
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"865.04",
"291.0",
"E888.1",
"041.12",
"707.05",
"707.21",
"E849.0",
"458.8"
] |
icd9cm
|
[
[
[]
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] |
[
"57.94",
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"38.91",
"96.6",
"88.01",
"88.47",
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"87.03",
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"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
5019, 5089
|
2432, 3798
|
324, 330
|
5193, 5271
|
782, 2409
|
5713, 5881
|
746, 763
|
3871, 4996
|
5110, 5172
|
3824, 3848
|
5295, 5690
|
276, 286
|
358, 645
|
667, 707
|
723, 730
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,411
| 128,795
|
4921
|
Discharge summary
|
report
|
Admission Date: [**2164-9-13**] Discharge Date: [**2164-9-24**]
Service: [**Hospital Unit Name 196**]
Allergies:
Penicillins
Attending:[**First Name3 (LF) 9569**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization with intervention.
History of Present Illness:
83yo female with known CAD (s/p MI in '70s and cath x7), HTN,
Afib, CHF (EF 35%), [**Hospital 5550**] transferred from OSH for cardiac
catheterization.
Pt has been in usual state of health until 2 months previous
to admission when pt had a CVA resulting in a 2 month
hospitalization at [**Hospital1 1474**]. Pt was subsequently transferred to
Life Care NH for rehab where she developed severe diarrhea and
dehydration. Pt was transferred back to [**Hospital1 1474**] where she was
tx'd with flagyl for C.diff. While being transferred from
[**Hospital1 1474**] to rehab pt experienced brief episode of chest
tightness.
Pt reports onset of sub sternal chest tightness while being
transferred from [**Hospital 1474**] hospital to rehab center. Chest
tightness was unlike any other chest pain or GERD sx experienced
previously and did not radiate to any other location. Lasted
less than 1 min and resolved with rest (no medical
intervention). Chest tightness was associated with SOB and
sensation of "panic" or inability to breath, but no diaphoresis,
n/v, lightheadedness, faintness. Pt does admit to night sweats
but this has been ongoing for some time now and has been
atributed to CML and CLL. Pt also admits to stable [**1-24**] pillow
orthopnea that has not changed recently. Pt deneis PND, DOE.
.
ROS: 7 Bm last night within 12 hours (less watery)
.
Transfered from MICU on [**9-20**]:
Pt transfered to ICU post cath with GIB. EGD neg. Found to have
small sigmoid ulcer and internal hemorroids. HCT stable over 24
hours after transfused 2 units. Pt has no complaints of CP/SOB.
Diarrhea has greatly improved.
Past Medical History:
-CAD
-HTN
-CVA with residual left sided weakness
-Chronic Afib
-CHF (EF 35% by ETT MIBI on [**4-24**] at [**Hospital1 1474**])
-GERD
-CLL
-CML
-?DM?
Social History:
Pt is from [**Country 3587**] and only speaks portugese.
Pt denies tobacco, alcohol or illicit drug use.
Family History:
[**Name (NI) 2280**] - pt is only one with heart disease, stroke,
blood clots in family.
Physical Exam:
PE:
VS: BP: 161/48 HR: 43 afib RR: 12 SaO2: 100% on 3L
Gen: elderly woman lying in bed at 30 degrees in no acute
distress, only speaks Portugese, but speaking in complete
sentences.
HEENT: L surgical pupil with whitish "cloud" in superior nasal
region (10 o'clock). R pupil round, responsive to light, oral
pharynx clear, mmm, dentures in both upper and lower jaw.
Neck: no JVP appreciate, asymmetric prominent carotid pulse at
base of left neck with positive bruit
CV: irregularly irregular, S1, S2, no murmurs, rubs, gallops
Chest: CTA bilaterally
Abd: soft, NT, ND, BS+
Back: no CVA tenderness
Buttocks: 3 pressure ulcers in midline sacral region (largest is
4cm x 1cm stage II, with smaller ones approximately 2cm x 2cm
and 2cm x 1cm stage II ulcers). Tender to palpation.
Vaginal exam: white ulcers at 6 o'clock with ?irregular borders
(limited by pt's pain/intolerance of exam).
Ext: pigmentation of skin laterally on leg up to knees (as per
daughter due to allergic rxn from 3 years ago, is improving), no
clubbing, cyanosis, edema
Neuro: A+O x3, CN II-XII grossly intact.
Strength: Right UE [**4-25**] with Left UE [**3-26**], Right LE [**4-25**] with Left
LE [**3-26**]
Pertinent Results:
[**2164-9-13**] 08:55AM INR(PT)-1.0
[**2164-9-13**] 04:14PM PLT COUNT-446*#
[**2164-9-13**] 06:00PM DIGOXIN-0.6*
[**2164-9-13**] 10:03PM PLT COUNT-445*
[**2164-9-13**] 10:03PM CK-MB-NotDone
[**2164-9-13**] 10:03PM CK(CPK)-27
[**2164-9-13**] 10:03PM POTASSIUM-3.5
ELECTROCARDIOGRAM PERFORMED ON: [**2164-9-13**]
Atrial fibrillation with well controlled ventricular response
Left axis deviation - possible left anterior fascicular block
Left ventricular hypertrophy
Diffuse nonspecific ST-T wave abnormalities
Since previous tracing of [**2157-12-19**], atrial fibrillation is new
ELECTROCARDIOGRAM PERFORMED ON: [**2164-9-19**]
Sinus rhythm. Compared to the previous tracing of [**2164-9-18**] atrial
fibrillation
with a rapid ventricular response persist as do the ischemic
appearing
ST-T wave abnormalities in leads I and aVL. The T wave
inversions recorded on
the tracing of [**2164-9-16**] can now be compared with the current ECG
showing less
prominent T wave inversions in leads V2-V6 but without
diagnostic interim
change. Clinical correlation is suggested.
Cath:
FINAL DIAGNOSIS:
1. Severe single vessel coronary artery disease status post PTCA
and
stenting of the RCA.
2. Moderate two vessel coronary artery disease involving the LAD
and
LCX.
3. Moderate left ventricular systolic dysfunction.
4. Severe central hypertension.
COMMENTS:
1. Coronary angiography of this right dominant system revealed
moderate
two vessel disease and severe single vessel disease. The left
main
coronary artery demonstrated an ostial 40% stenosis. The LAD
contained
a 40% stenosis in the mid vessel and mild luminal irregularities
throughout. The LCX demonstrated moderate diffuse disease in the
mid
vessel. The OMB revealed diffuse disease. The RCA contained
moderate
diffuse throughout with 90% tandem stenoses in the mid vessel
and a long
90% stenosis in the proximal PDA.
2. Limited resting hemodynamics were performed upon entry. Left
sided
filling pressures were mildly elevated (LVEDP was 20 mm Hg).
Severe
central hypertension was noted (aortic pressure was 200/90 mm
Hg).
There was no significant gradient across the aortic valve upon
pullback
of the catheter from the left ventricle to the ascending aorta.
3. Left ventriculography revealed a contrast calculated ejection
fraction of 38%. Inferior akinesis and anterolateral hypokinesis
were
noted. Moderate mitral regurgitation was noted.
4. Successful placement of overlapping 2.5 x 28 Cypher
drug-eluting
stent (DES) and 2.5 x 23 mm Cypher DES in the proximal to
mid-RCA,
postdilated most proximally with a 3.5 mm balloon and in the
midvessel
with a 2.75 mm balloon. Final angiography demonstrated no
residual
stenosis, no angiographically apparent dissection, and normal
flow (See
PTCA Comments).
5. Successful placement of overlapping 2.5 x 8 mm Cypher DES and
2.5 x
28 mm Cypher DES. Final angiography demonstrated no residual
stenosis,
no angiographically apparent dissection, and normal flow (See
PTCA
Comments).
Colonoscopy:
Impressions: Grade 1 internal hemorrhoids
Ulcer in the cecum
Otherwise normal Colonoscopy to cecum
Recommendations: No lesions that would account for hematochezia
were localized. Would reccomend push enteroscopy.
EGD:
Normal EGD to second part of the duodenum
Brief Hospital Course:
Ms. [**Known lastname 1001**] is a 83yo woman with h/o CLL/CAD/AF admitted on [**9-13**]
from OSH for CP/ROMI, transferred for elective cath. Her cath
on [**2164-9-13**] revealed severe 1vCAD s/p PTCA and stenting of the
RCA. Was placed on 18 hours of Integrillen and Plavix 150mg po
qd (double the dose as patient has ASA allergy). Patient off
Coumadin for AF. On 9/27am patient had 5 episodes of BRBPR. Was
orthostatic on exam 175 SBP flat--->76 SBP standing. HCT still
35 but no time for hemodilution. Patient taken for EGD--> normal
with mild gastritis. Family reports no h/o GIB with normal
C-Scope ~1 years ago. Pt transferred to the MICU on [**9-17**] for
stablization, and colonscopy revealed small sigmoid ulcer and
hemorroids. Pt given 3 units of PRBC with improvement of Hct
from 28 to 33.5. Pt transferred back to floor on [**9-20**], and her
hematocrit and vital signs remained stable until discharge on
[**9-24**]. Aside from the GI bleed, her hosital course was
complicated by a mulit-drug resistent proteus urinary tract
infection, being treated treated with oral cefpodoxime with
improvment of symptoms.
GIB: d/t sigmoid ulcer +/- hemorroids in setting of aggressive
antiplatelet therapy. Colonoscopy showed only small,
non-bleeding sigmoid ulcer, some internal hemorrhoid. Push
enteroscopy (to assess small bowel) was within normal limits. As
per GI, bleeding likely secondary to small ulcer/hemorrhoids in
setting of high-dose antiplatelet therapy. Serial hematocrits
continue to be checked for stability. Plavix was decreased to
75mg qd from 150mg (pt has apirin allergy), and Coumadin was
held, to be restarted on [**9-27**]. She is on a proton pump
inhibitor 2x's/day.
Coronaries: s/p cath with intervention of RCA. Given GIB,
metoprolol and lisinopril initially held but were restarted as
bp tolerated. Can titrate up metoprolol to 50mg [**Hospital1 **] as
tolerated. Cont Statin 80mg QHS, Cholestyramine 4g once daily,
decreased Plavix to 75 qd (pt with ASA allergy).
Rhythm: Chronic AF. Continue rate control with digoxin and
metoprolol. Holding coumadin until [**9-27**] given GI bleed. ECG
with small persistent inferior ST elevation, asymptomatic.
Ectopy on tele, and lytes were continuously repleted.
Pump: last EF 55% with HTN. Pt monitored for fluiod overload
given receiving blood products and fluids, without any signs of
overload.
CLL: Continue hydroxyurea and allopurinol, outpt heme f/u
Diarrhea at OSH: 2 c diff negative during admission. Pt was
continued on OSH vancomycin regimen po 125 qid prophylactically.
14 day course (unitl [**9-27**])
UTI: Multidrug resistent proteus: Started on Levo, then
Aztreonam, then d/c'd on or cefpodoxime for 8 more days. Pt's
symptoms were resolving on discharge.
Stage II sacral decubiti: Barrier protection and wound care qd,
duoderm.
Vaginal ulcer: Unlikely pressure ulcer, outpt gyne for biopsy.
Hyperpigmented rash across body: may need outpt derm follow-up.
Prophylaxis: C diff precautions, bowel regimen, protonix, pain
Code:FULL
Communicate w/family
Medications on Admission:
Hydroxyurea 500mg every other day
Allopurinol 150mg once daily
Digoxin 0.125mg QHS
Lisinopril 10mg once daily
Atenolol 25mg [**Hospital1 **]
Lipitor 10mg once daily
Protonix 40mg once daily
Vancomycin 250mg Q6hours
After transfer from ED these meds added:
Cholestyramine 4 g QD
Simvastatin 40 mg
Atenolol D/c'd, started lopressor 50 [**Hospital1 **]
Plavix 150mg QD
All:
-PCN (sulfas)
-Lasix?, ASA? Flagyl? (all given at previous hosptial without
problem)
Discharge Medications:
1. Hydroxyurea 500 mg Capsule Sig: One (1) Capsule PO EVERY
OTHER DAY. ().
2. Allopurinol 100 mg Tablet Sig: 1.5 Tablets PO QD (once a
day).
3. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO QD (once a
day).
4. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)).
5. Cholestyramine 4 g Packet Sig: One (1) Packet PO QD (once a
day).
6. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
8. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
9. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO QD (once a
day).
Disp:*60 Tablet(s)* Refills:*2*
10. Vancomycin HCl 10 g Recon Soln Sig: One [**Age over 90 **]y Five
(125) mG Recon Soln Intravenous Q6H (every 6 hours) for 6 days:
TAKE FOR 6 DAYS AFTER DISCHARGE.
11. Warfarin Sodium 3 mg Tablet Sig: One (1) Tablet PO at
bedtime: Start taking this medication 3 days after you leave the
hospital, ([**2164-9-27**]), as directed by your doctor. .
Disp:*30 Tablet(s)* Refills:*2*
12. Cefpodoxime Proxetil 200 mg Tablet Sig: One (1) Tablet PO
Q12H (every 12 hours) for 8 days: take until [**2164-10-1**].
Disp:*16 Tablet(s)* Refills:*0*
13. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours) as needed for itching prevention for 10
days: take as needed 30minutes before your antibiotic
cefpodoxime to prevent itching.
Disp:*20 Capsule(s)* Refills:*0*
14. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 tablets Tablets PO
twice a day: Take 1.5 tablets (37.5mg) twice daily. Tablet(s)
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
CAD
thrombocytosis
CML/CLL
GERD
anemia due to blood loss
vaginal ulceration
sacral decubiti
rash
anxiety
chronic atrial fibrillation
hypertension
Discharge Condition:
Fair
Discharge Instructions:
Please take all of your medications. Please follow up with your
doctors.
YOU MUST take plavix 75mg daily for life or unless your
cardiologist says it is okay to change this recommendation. He
may increase the dose.
Call your doctor if you have bright red blood from your rectum,
chest pain, shortness of breath, pain with urination.
Followup Instructions:
Primary Care: Please follow up with your PCP [**Name Initial (PRE) 176**] 2 weeks of
discharge. If you need a new primary care doctor call
[**Telephone/Fax (1) 250**] to get an appointment here at [**Company 191**] [**Hospital Ward Name 23**] center.
Cardiology: Please follow up with your cardiologist within 2
months of discharge. If you need a new cardiologist call
[**Telephone/Fax (1) 62**] for an appointment here with Dr. [**Last Name (STitle) 7047**] or someone
else if you like.
Continue taking vancomycin the antibiotic that treats c.diffile
dirarrhea, for 6 days after discharge. See a gastroenterologist
if it recurs.
You have an ulcer in your vaginal region, you need to see the
gynecologists for this, call [**Telephone/Fax (1) 5777**] if you want to see one
at [**Hospital1 18**].
Talk with your primary care doctor about the rash on your body
and to see if undergoing allergy testing would benefit you. You
may not have a true allergy to lasix/furosemide or aspirin and
taking these medications would help your heart greatly.
Talk with your doctors about [**Name5 (PTitle) 20483**] [**Name5 (PTitle) **] echocardiogram of your
heart in the next month to evaluate its function
Restart Coumadin 3mg daily on [**2164-9-27**] as directed by your
doctor.
Continue taking your antibiotic for a multi-drug resistent
proteus urinary tract infection for 8 more days.
Provider: [**Name10 (NameIs) 20484**],[**Name11 (NameIs) 20485**] [**Name12 (NameIs) **] appointment should be in 2
weeks
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 3183**] Follow-up appointment
should be in 2 months
|
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|
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icd9pcs
|
[
[
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] |
12129, 12226
|
6867, 9932
|
250, 295
|
12416, 12422
|
3580, 4667
|
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2263, 2354
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|
200, 212
|
323, 1951
|
1973, 2124
|
2140, 2247
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,481
| 145,846
|
44200
|
Discharge summary
|
report
|
Admission Date: [**2101-7-19**] Discharge Date: [**2101-7-24**]
Date of Birth: [**2057-11-8**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Amoxicillin / E-Mycin / Latex / Ondansetron /
Vancomycin / Levofloxacin / Zofran / Phenergan / Dilaudid /
Ceftriaxone / Sulfamethoxazole/Trimethoprim / Voriconazole /
Fluconazole / Caspofungin / Doxycycline / Propranolol /
Neurontin / Azithromycin / Xopenex Hfa / Optiray 300 / Ketorolac
Attending:[**First Name3 (LF) 1242**]
Chief Complaint:
elective admission for vancomycin desensitization
Major Surgical or Invasive Procedure:
Vancomycin desensitization
History of Present Illness:
42F with a history of recurrent pyelonephitis and multiple drug
sensitivities who was directly admitted to the [**Hospital Unit Name 153**] for
vancomycin desensitization for an Enterococcal UTI. She reports
that starting approximately a week ago she began having urinary
frequency and malaise consistent with past UTIs. About 5 days
ago she was seen in [**Company 191**]. A UA at that time was bland, but grew
Enterococcus spp. She continued to feel unwell and began to
develop fevers and chills. By Monday she was starting to have L
CVA tenderness. She was again seen in [**Company 191**]. Her UA remained
notable for 1WBC and 3 RBC and her UCx grew Enterococcus. She
continued to feel increasingly unwell and was seen today by her
PCP. [**Name10 (NameIs) **] had significant L CVAT and urinary frequency as well as
chills and subjective fevers. Her PCP was concerned about her
progressive pyelonephritis and arranged admission directly from
clinic. Of note, the patient has significant phlebitis with PIVs
and is a difficult access, so it was decided that the antibiotic
regimen with the least frequent dosing would be advantegeous for
her clinically. Ultimately it was decided that she should be
directly admitted to the [**Hospital Unit Name 153**] for vancomycin desensitization and
then treatment for 10 to 14 days with [**Hospital1 **] vancomycin over QID
ampicillin.
.
In the [**Hospital Unit Name 153**] she has significant L CVAT and subjective fevers.
She received an IV infusion of morphine sulphate and promptly
had a reaction to with with hives speading up her arm. She
received diphenhydramine 25mg IV and betamethasone TP for this
and felt better. Pharmacy was consulted and given the [**Hospital1 112**]
protocol for vancomycin desensitization to use over the [**Hospital1 18**]
protocol as she has tolerated the [**Hospital1 112**] protocols better in the
past.
Past Medical History:
# Multiple drug allergies including likely [**Initials (NamePattern4) 22721**] [**Last Name (NamePattern4) **]
Syndrome associated with fluconazole desensitization. Also,
severe phlebitis with PICCs, milder phlebitis with conventional
IV catheters if left indwelling
# CVID - monthly IVIG
# History of recurrent pyelonephritis
# autonomic neuropathy - on IVIG primarily for neuropathy but
also CVID.
# esophageal dysmotility
# oral/genital ulcers ? Behcet's
# colonic inertia s/p subtotal colectomy at [**Hospital3 14659**] in [**2093**]
# atrophic vaginitis with recurrent yeast infections
# sleep disorder characterized by non-REM narcolepsy, restless
leg
syndrome, and periodic leg movements
Social History:
The patient was [**Name Initial (MD) **] GI NP at [**Hospital1 18**]. She has been on disability for
2 years. She lives alone in the [**Hospital3 4414**]. No tobacoo, alcohol
and illict drugs.
Family History:
Mother with ovarian cancer and history of DVT.
Physical Exam:
Physical Exam:
VS: T: 97.1, BP: 112/78, P: 75, R: 18, O2sat: 100% RA.
GEN: pleasant conversant woman in no acute distress
HEENT: moist mucus membranes, no oral ulcers
Neck: supple, no lymphadenopathy
CV: RRR, S1, S2, no murmurs/rubs/gallops
PULM: clear to auscultation b/l, no wheezes/rales/rhonchi
ABD: BS+, soft, NTND, no masses or HSM, + left sided CVA
tenderness
LIMBS: no clubbing, cyanosis or edema
SKIN: mild erythema near R arm IV site
Pertinent Results:
On Admission:
CBC: WBC-6.1, Hgb-13.9, Hct-41.5, Plt Ct-267
Coags: PT-12.6 PTT-27.1 INR(PT)-1.1
Chemistry: Glucose-81 UreaN-10 Creat-0.9 Na-137 K-4.1 Cl-101
HCO3-30 AnGap-10
LFTs: ALT-14 AST-19 LD(LDH)-123 AlkPhos-50 TotBili-0.4
On Discharge:
Hct-38.3
CBC: WBC-6.8, Hgb-12.1, Hct-35.4, Plt Ct-214
Coags: PT-11.3 PTT-25.7 INR(PT)-0.9
Chemistry: Glucose-97 UreaN-11 Creat-1.2* Na-140 K-4.2 Cl-106
HCO3-29 AnGap-9
Calcium-9.1 Phos-4.1 Mg-2.0
Vanco-24.4*
Imaging:
[**7-20**] CT Abdomen/Pelvis:
IMPRESSION:
1. Few liver hypodensities are unchanged in size from [**2100-2-23**].
2. Kidneys are symmetric without stones or hydronephrosis. No
perinephric
abscess is noted.
[**7-19**] CXR:
FINDINGS: As compared to the previous radiograph, there is no
relevant
change. Normal appearance of the lung parenchyma, no focal
parenchymal
opacity suggesting pneumonia. No pleural effusions. No pulmonary
edema.
Normal size of the cardiac silhouette, normal appearance of the
hilar and
mediastinal contours.
Brief Hospital Course:
Ms. [**Known lastname 94828**] is a 42F with a history of recurrent pyelonephitis and
multiple drug sensitivities who was directly admitted to the
[**Hospital Unit Name 153**] for vancomycin desensitization for an Enterococcal UTI.
Ultimately it was decided that she should be directly admitted
to the [**Hospital Unit Name 153**] for vancomycin desensitization and then treatment
for 10 to 14 days with [**Hospital1 **] vancomycin over QID ampicillin.
.
1. Enterococcus UTI: Sensitive to ampicillin and vancomycin.
Given the need for a 14 day course, the patient cannot
conveniently manage multiple daily [**Hospital1 4319**] of ampicillin, so she
will have to use vancomycin. Her allergist, Dr. [**First Name8 (NamePattern2) 21734**] [**Last Name (NamePattern1) **]
at [**Hospital1 112**] ([**Telephone/Fax (1) 21743**]) has forwarded a desensitization protocol
for vancomycin for her. The protocol was completed, and the
patient will remain on IV Vancomycin [**Hospital1 **]. Given difficult
logistics of administering vancomycin at q 12 hr dosing and need
for inpatient admission for administration over the weekend, she
was admitted for inpt stay through the weekend. Her CT Abdomen
showed no hydronephrosis and no perinephric
abscess.
.
Throughout the hospitalization her symptoms improved. Her flank
pain lessened and she remained afebrile. On the day of
discharge the patient developed temperature of 100.1. She was
asymptomatic, and generally looked well. Urine and blood
cultures were sent and she was sent home with instructions to
monitor her temperature every six hours. Ms. [**Known lastname 94828**] will
continue to receive vancomycin treatment at her outpatient
[**Known lastname **] unit.
.
2. Elevated creatinine: During the hospitalization, Ms. [**Known lastname 94829**]
creatinine increased from 0.8 to 1.2. This occurred the day
after she had an episode of diarrhea and was likely
multifactorial secondary to both dehydration due to the diarrhea
and from the vancomycin. She received several fluid boluses.
She was sent home with instructions to have her creatinine
re-checked at her [**Known lastname **] unit on [**7-25**].
.
3. Diarrhea: Ms. [**Known lastname 94828**] had several episodes of diarrhea during
her admission. C. Diff was sent and was negative. Her symptoms
improved prior to discharge.
.
4. CVID: Ms. [**Known lastname 94828**] was scheduled for [**Known lastname **] on [**2101-7-20**]. Held
secondary to infection.
Medications on Admission:
- Esomeprazole 20mg PO BID
- Ferumoxytol (Feraheme) 510 mg/17 mL x [**6-28**] and [**7-5**]
- Lorazepam 0.5mg PO Q6H PRN
- Methylphenidate 36mg PO daily
- Sucralfate 1g TP PRN for oral and genital ulcers
Discharge Medications:
1. Clobetasol 0.05 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
2. Vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) gram
Intravenous Q 12H (Every 12 Hours) for 10-14 days days: Please
follow-up wtih [**First Name8 (NamePattern2) **] [**Doctor Last Name **] to determine antibiotic time course.
Disp:*1000 ml* Refills:*10*
3. Outpatient Lab Work
BUN and Cr, [**2101-7-25**], fax results to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Company 191**]
[**Telephone/Fax (1) 16804**]
4. Esomeprazole Magnesium 20 mg Capsule, Delayed Release(E.C.)
Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day.
5. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours.
6. Methylphenidate 36 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO once a day.
7. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO once a day as
needed for ulcers: prn for oral and genital ulcers, .
8. EpiPen 0.3 mg/0.3 mL Pen Injector Sig: One (1) Intramuscular
prn as needed for allergy symptoms.
Discharge Disposition:
Home
Discharge Diagnosis:
Pyelonephritis
Vancomycin allergy s/p desensitization
Acute Renal Failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure to participate in your care Ms. [**Known lastname 94828**]. You
were admitted to the intensive care unit for desensitization to
Vancomycin for treatment of pyelonephritis. You were
successfully desensitized and were transferred to the floor. We
continued to treat your infection with Vancomycin and your
symptoms improved. You will continue to receive treatment at
your outpatient [**Known lastname **] unit starting Monday [**7-25**].
You will have your kidney functionr rechecked tomorrow at the
[**Month (only) **] unit. Please drink lots of fluids to keep well
hydrated.
Check your temp at home every 6 hours for the next 2 days if you
have a fever (>100.4) contact Dr. [**Last Name (STitle) **] or her coverage or come
to the ER.
We made the following changes to your medications:
1. Added Vancomycin 1000 mg IV every 12 hours (at [**Last Name (STitle) **]
unit)
Please see below for your follow-up appointments.
Followup Instructions:
Department: INFUSION/[**Last Name (STitle) 1248**] UNIT
When: MONDAY [**2101-7-25**] at 7:15 AM [**Telephone/Fax (1) 14067**]
Building: GZ [**Hospital Ward Name **] BUILDING (FELBEERG/[**Hospital Ward Name **] COMPLEX) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
Department: INFUSION/[**Location (un) 1248**] UNIT
When: MONDAY [**2101-7-25**] at 4:30 PM [**Telephone/Fax (1) 14067**]
Building: GZ [**Hospital Ward Name **] BUILDING (FELBEERG/[**Hospital Ward Name **] COMPLEX) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
Department: INFUSION/[**Location (un) 1248**] UNIT
When: TUESDAY [**2101-7-26**] at 7:15 AM [**Telephone/Fax (1) 14067**]
Building: GZ [**Hospital Ward Name **] BUILDING (FELBEERG/[**Hospital Ward Name **] COMPLEX) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
|
[
"787.91",
"V07.1",
"337.9",
"599.70",
"136.1",
"E930.9",
"E849.8",
"590.00",
"584.9",
"041.04"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.12"
] |
icd9pcs
|
[
[
[]
]
] |
8849, 8855
|
5045, 7515
|
612, 640
|
8973, 8973
|
4024, 4024
|
10093, 10938
|
3497, 3545
|
7769, 8826
|
8876, 8952
|
7541, 7746
|
9124, 9906
|
3575, 4005
|
4269, 5022
|
9935, 10070
|
523, 574
|
668, 2550
|
4039, 4254
|
8988, 9100
|
2572, 3270
|
3286, 3481
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,495
| 188,823
|
34124
|
Discharge summary
|
report
|
Admission Date: [**2117-6-26**] Discharge Date: [**2117-7-2**]
Date of Birth: [**2043-8-17**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Mental Status Changes
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a 73 yo woman with PMH of brain tumor s/p VP shunt
[**2101**], near deafness, hypothyroid and colon CA last year who
presented to [**Hospital1 **] ED with mental status changes.
Past Medical History:
1. Brain Tumor: [**2101**]. Apparently benign per daughter but was
irradiated anyways (?). had severe loss of hearing and
imbalance
following that. Had Shunt placed that in conjunction with tumor
treatment and has never had complications.
2. Colon Ca diagnosed 1 yr ago.
3. Hypothyroidism
Social History:
no tobacco, social ETOH
Family History:
non-contributory
Physical Exam:
On Admission:
Exam:
T- 100.6/100.6 BP- 107-154/65-83 HR- 64 RR- 21 O2Sat 99 %
RA
Gen: Lying in bed, NAD
HEENT: evidence of old crani at right posteroir region with bony
abnormalities, dry oral mucosa with large brown mucous at back
of
oropharynx
Neck: No tenderness to palpation, normal ROM, supple, no carotid
or vertebral bruit
Back: No point tenderness or erythema
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally, but shallow breaths
aBd: +BS soft, nontender
ext: no edema
Neurologic examination:
Mental status: Has just received 2mg Ativan IV about 2-3 hours
ago. Has eyes closed, does not move spontaneously. Groans to
noxious stim and moves x 4 but not antigravity. No major
asymetries. Does not follow any midline or appendicular
commands.
Cranial Nerves:
Pupils equally round and reactive to light, 3 to 2 mm
bilaterally. Blinks to threat bilaterally. Extraocular movements
intact bilaterally with spontaneous roving movements. Sensation
Grimace symmetric. No gag. Tongue midline.
Motor:
Normal bulk bilaterally. Tone paratonic throughout. No observed
myoclonus or tremor
Withdraws to noxious stim x 4 antigravity with no asymetries.
Sensation: withdraws x 4
Reflexes:
+2 and symmetric throughout BUE. 2 knees. 1+ ankles.
Toes up bilaterally
Coordination: cannot assess
Pertinent Results:
MRA([**6-26**]):IMPRESSION: No significant new interval change in the
previously described subdural hematomas and subarachnoid
hemorrhage. There is no evidence of diffusion abnormalities or
acute ischemic changes. Diffuse leptomeningeal enhancement,
likely related with the recent fractures and subdural hematomas.
Hyperintensity areas noted on FLAIR located in the subcortical
white matter and basal ganglia consistent with chronic lacunar
ischemic changes and small- vessel disease. The shunt catheter
is unchanged in position with the tip near to the foramen of
[**Location (un) 9700**]. There is no evidence of hydrocephalus. Right occipital
burr hole.
CT([**6-26**]):IMPRESSION:
1. Slight interval increase in size of subdural hemorrhage in
the inferior left frontal lobe, with minimal edema and mass
effect on regional sulci. Otherwise, little interval change in
the bilateral convexity subdural hemorrhages, and bilateral
subarachnoid blood.
2. Unchanged position of shunt catheter, with collapsed
ventricles which may reflect intracranial hypotension or
overshunting.
Brief Hospital Course:
Patient is a 73 yo woman with PMH of brain tumor s/p VP shunt
[**2101**], near deafness, hypothyroid and colon CA last year who
presented to [**Hospital1 **] ED yesterday at 2300 with mental status
changes. According to the daughter, the patient has in town
from
[**Location (un) 14336**] for the alst 2 weeks visiting for a graduation. Last
night she had had 3 glasses of wine the of her MS changes. Last
night during the graduation party said that she was feeling
tired and that she was going to go upstairs to go to bed. About
an hour later, she came down the stares and had notable face/eye
trauma as if she had fallen. Her speech was dysarthric and she
was mumbling. She said "I don't know what happened" and could
not give explanation. Taken to ED. She was found to have
bilateral SDH L >R and was transferred here. Here in the ICU,
would open eyes and intermittently seemed to follow commands.
She is very hard of hearing per daughter and nearly deaf. She
was noted by ICU team to be moving x 4 but not speaking, and
sleepy.
She was obeserved in the ICU for 24 hours, and started on
Folate, Thiamine, and Dilantin prophylactically. Subsequent CT
scans revealved stability of SDH, and no worsening such to
indicate surgical evacuation. Given her medical history a
MRI/MRA was obtained(results included previously in this
summary). Patient had inquired about receving her ongoing care
in her come country of [**Country 6607**]. Discharge planning has been
moving toward that goal. She has a neurologist who follows her
in [**Country 6607**], Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4553**]. This is acceptable per Dr.
[**Last Name (STitle) **], and case managment has been working with the daughter to
make arrangements to this effect. Physical therapy has
continued to work with the patient in-house pending the
finalization of these plans.
The PT and OT felt that she did not require rehab but that she
did need continued therapy after discharge. The patient will be
discharged with the plan to go back home to [**Country 6607**] with home PT
and OT services.
Medications on Admission:
Lipitor, Colace, levoxyl 50 mcg dialy, Aggrenox 1 [**Hospital1 **], protonix
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed.
2. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Home PT
This patient requires home physical therapy as recommended by
the inpatient therapists at [**Hospital1 1170**].
4. Home OT
This patient requires home occupational therapy as recommended
by the inpatient therapists at [**Hospital1 1170**].
5. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
6. Dilantin Extended 100 mg Capsule Sig: One (1) Capsule PO
three times a day.
Disp:*90 Capsule(s)* Refills:*0*
7. Medications
Please resume all home medications except for Aggrenox.
Discharge Disposition:
Home With Service
Facility:
Pts PCP will set up services in [**Country 6607**].
Discharge Diagnosis:
Bilateral SDH, SAH, s/p fall
Conjunctivitis
Discharge Condition:
Stable
Discharge Instructions:
General Instructions
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? If you have been prescribed an anti-seizure medicine, take it
as prescribed and follow up with laboratory blood drawing as
ordered.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion, lethargy or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
Followup Instructions:
Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in [**7-4**] weeks.
You will need a CT scan of the brain without contrast.
You may follow up with your own physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4553**]
in [**Country 6607**] for your convenience if it is too difficult to come
back to the U.S.
Completed by:[**2117-7-2**]
|
[
"V45.2",
"E888.9",
"V10.05",
"244.9",
"348.8",
"348.30",
"V15.3",
"852.20",
"852.00",
"784.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
6346, 6428
|
3433, 5545
|
340, 347
|
6516, 6525
|
2331, 3410
|
7560, 8017
|
939, 957
|
5672, 6323
|
6449, 6495
|
5571, 5649
|
6549, 7537
|
972, 972
|
279, 302
|
375, 566
|
1786, 2312
|
986, 1494
|
1533, 1770
|
1518, 1518
|
588, 882
|
898, 923
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,937
| 174,041
|
29784
|
Discharge summary
|
report
|
Admission Date: [**2133-3-31**] Discharge Date: [**2133-5-21**]
Date of Birth: [**2092-7-8**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 398**]
Chief Complaint:
Respiratory failure
Major Surgical or Invasive Procedure:
Right subclavian central line.
Intubation.
History of Present Illness:
40 y/o male with a h/o IPF, s/p B/L lung tx [**2128**], h/o recurrent
pneumonia, chronic rejection and obliterative bronchiolitis,
polymiositis, recent hospitalization for acute on chronic
respiratory
failure and multilobar pneumonia requiring chest tubes and PEJ
placement by IR (discharged on [**2133-2-26**]) and recent admission for
PEJ tube blockage and resp distress (discharged on [**2133-3-4**]) who
presented with acidemia, hypercarbia, and hypoxia at rehab
(7.28/96/63 initially).
.
In the [**Name (NI) **], pt had initial ABG 7.12/151/217 on FiO2%:40;
Rate:/32; TV:300; PEEP:9; Mode:AC. Pt received vanc/ceftaz,
solumedrol 125mg, and sodium bicarbonate 50mEq x2, Ativan, as
well as versed, fentanyl, and propofol. He was reportedly
afebrile. A right femoral line and A-line was placed. Transplant
surgery was called, but did not consult as pt is not followed
here for his lung transplant.
Past Medical History:
Chronic resp failure/ vent dependent since [**2132-2-3**]
Chronic bronchitis
Status post bilateral lung tranplant in [**2128**] [**3-6**] idiopathic
pulmonary fibrosis complicated by chronic rejection and frequent
aspiration pneumonia
idiopathic pulmonary fibrosis since [**2122**]
status post tracheostomy placement in [**2132-2-3**]
esophageal dysmotility
GERD
HTN
Paroxysmal atrial fibrillation
hyperlipidemia
DM II
sacral decubitus ulcer now healed
severe anxiety
depression
anemia of chronic disease
pancreatitis
chronic renal insufficiency
Social History:
Lives at [**Hospital 671**] Rehab, wife is supportive. Has two sons. [**Name (NI) **]
drinking, smoking, drug use.
Family History:
NC
Physical Exam:
Vitals: T 97.3 BP 140/70 HR 93 RR 30 O2 100%
Vent: AC TV 280 R 28 FIO2 0.5 PEEP 5
Gen: pt ventilated, sedated and paralyzed, diaphoretic
HEENT: MMM, PERRL, sclera anicteric
Neck: no JVD, cervical [**Doctor First Name **], thyroidmegaly
Cardio: RRR, ? systolic M, no rubs/gallops
Resp: course breath sounds b/l R>L. no wheezes
Abd: soft, NT, ND, no HSM, + PEJ tube with dressing c/d/i
Ext: no c/c/e, 1+ DP pulses
Neuro: pt sedated and paralyzed.
Pertinent Results:
Numerous lab and imaging studies were obtained during this
greater than 6 week hospital stay. Please check the record for
individual test results.
Brief Hospital Course:
Unfortunately Mr. [**Known lastname **] did not survive this hospitalization.
During his hospitalization he suffered from:
Worsening lung graft regection.
Severe hypercarbic respiratory failure.
Circulatory collapse.
Renal Failure due to chronic exposure to FK506 and/or
circulatory collapse- the patient was briefly on CVVHD.
Herepes Zoster re-credescence.
Positive beta glucan indicative of disseminated fungal
infection.
Proteus and Acinetobacter PNA.
Ultimately the patient succumbed to circulatory collapse in the
setting of overwhelming organ failure and infection as detailed
above. After the patient's death his family requested a post
mortem examination.
Medications on Admission:
Novolin SS
Albuterol Six Puff Inhalation Q4H prn.
Ipratropium Bromide Six (6) Puff Q4H prn.
Nexium 20mg qd
Bactrim DS (0.5 tabs?) qd
Mycophenolate Mofetil 1000 mg PO BID
Atorvastatin 10 mg PO DAILY
Clonazepam 0.5 mg PO QHS
Quetiapine 50 mg PO BID
Prednisone 10 mg DAILY
Docusate Sodium 50 mg PO BID
Zolpidem 5 mg PO HS
Metoprolol Tartrate 100 mg PO TID
HCTZ 25 mg one PO Daily
Tacrolimus 9 mg PO BID
Lovenox 40mg qd
Acetaminophen 1000mg qid prn
Aranesp 40mcg SC qfri
Celexa 40mg qd
Senna qhs
kayexalate 30gm x 2 (today only)
.
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Death
Discharge Condition:
Deceased
Discharge Instructions:
None
Followup Instructions:
NOne
Completed by:[**2133-5-31**]
|
[
"E933.1",
"E878.0",
"403.91",
"276.2",
"996.84",
"584.5",
"482.83",
"285.1",
"053.9",
"427.31",
"515",
"530.81",
"428.0",
"599.0",
"707.03",
"276.0",
"518.84",
"V44.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"96.6",
"38.93",
"38.91",
"38.95",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
3957, 3966
|
2684, 3350
|
333, 378
|
4015, 4025
|
2512, 2661
|
4078, 4113
|
2027, 2031
|
3928, 3934
|
3987, 3994
|
3376, 3905
|
4049, 4055
|
2046, 2493
|
274, 295
|
406, 1308
|
1330, 1878
|
1894, 2011
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,645
| 119,101
|
31992
|
Discharge summary
|
report
|
Admission Date: [**2184-7-6**] Discharge Date: [**2184-7-10**]
Date of Birth: [**2117-1-12**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
recurrent angina
Major Surgical or Invasive Procedure:
[**2184-7-6**] CABG x3 (LIMA to LAD, SVG to DIAG, SVG to PDA)
History of Present Illness:
This 67 year old white male with with a history of coronary
artery diseasepresented with recurrent exertional angina. A
nuclear stress test was inconclusive for ischemia.
Catheterization revealed severe double vessel disease and he was
referred for revascularization.
Past Medical History:
Hypertension
Hyperlipidemia
Anxiety
Social History:
Significant for the absence of current tobacco use. Consumes
approximately [**2-17**] alcoholic beverages per day.
Family History:
non contributory
Physical Exam:
Admission:
Pulse:51 Resp:14 O2 sat: 98% RA
B/P Right:143/81 Left:153/81
Height:5'7" Weight:180 LBS
General:
Skin: Warm, dry no C/C/E
HEENT: NCAT. PERRLA, EOMI, Sclera anicteric, OP benign
Neck: Supple, Full ROM, No JVD
Chest: Lungs clear bilaterally
Heart: RRR, N1 S1-S2, No murmur, rub or gallop
Abdomen: Soft, nontender, nondistended, normoactive bowels
sounds.
Extremities: Warm, well-perfused, No Edema
Varicosities: None noted on standing
Neuro: A+Ox3, gait steady, no focal deficits
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: None appreciated Left: None
appreciated
Pertinent Results:
Conclusions
PRE-BYPASS:
The left atrium and right atrium are normal in cavity size. No
spontaneous echo contrast or thrombus is seen in the body of the
left atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. No atrial septal defect is seen
by 2D or color Doppler.
Left ventricular wall thicknesses and cavity size are normal.
The left ventricular cavity size is normal. Overall left
ventricular systolic function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
The ascending, transverse and descending thoracic aorta are
normal in diameter and free of atherosclerotic plaque to 40 cm
from the incisors.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic regurgitation. There is no
aortic valve stenosis. No aortic regurgitation is seen.
The mitral valve appears structurally normal with trivial mitral
regurgitation. No mitral regurgitation is seen. There is no
pericardial effusion.
Dr. [**Last Name (STitle) **] was notified in person of the results on [**Known lastname **] 11AM.
POST-BYPASS:
Preserved biventricular systolic function. LVEF 55%.
Intact thoracic aorta.
Minimal MR [**First Name (Titles) **] [**Last Name (Titles) **].
Electronically signed by [**Name6 (MD) 3892**] [**Name8 (MD) 3893**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2184-7-6**] 14:43
?????? [**2178**] CareGroup IS. All rights reserved.
[**2184-7-8**] 05:35AM BLOOD WBC-9.6 RBC-3.26* Hgb-10.0* Hct-29.4*
MCV-90 MCH-30.8 MCHC-34.2 RDW-13.7 Plt Ct-141*
[**2184-7-8**] 05:35AM BLOOD Glucose-121* UreaN-17 Creat-1.0 Na-137
K-4.1 Cl-103 HCO3-27 AnGap-11
Brief Hospital Course:
He was admitted on [**7-6**] and underwent revascularization by Dr.
[**Last Name (STitle) **]. Please see operative note for deatils. He transferred
to the CVICU in stable condition on low dose phenylephrine and
Propofol drips. Hemodynamicaly he remained stable and these
were weaned off the night of surgery, he weaned from the
ventilator and was extubated. Beta blockade was resumed and
diuresis begun.
He transferred to the floor on POD 1. CTs were removed on POD 2
and temporary pacing wires on POD 3. Physical therapy worked
with him and he progressed adequately. He was prepared for
discharge.
Medications, restrictions and followup were discussed with him
prior to his discharge. All wounds were clean and healing well
and he was eating a solid diet.
He was encouraged to continue an aggressive bowel regimen while
on narcotics.
Medications on Admission:
plavix 75 mg daily ( LD [**6-16**])
folic acid 1 mg [**Hospital1 **]
viagra 100 mg once prn
simvastatin 40 mg daily
valsartan 80 mg daily
ECASA 325 mg daily
B complex vitamin cap daily
glucoamine /chondroitin 3X (750 mg/600mg) [**Hospital1 **]
MVI daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours) for
2 weeks.
Disp:*14 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
6. Acetaminophen 650 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain for 4 weeks.
Disp:*50 Tablet(s)* Refills:*0*
8. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
9. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 7
days.
Disp:*7 Tablet(s)* Refills:*2*
10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 7
days.
Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
VNA of [**Doctor Last Name **]
Discharge Diagnosis:
coronary artery disease
s/p coronary artery bypass grafts
s/p coronary stenting [**2182**]
Hypertension
hyperlipidemia
osteoarthritis
anxiety
gastric reflux
Discharge Condition:
good
Discharge Instructions:
no lotions, creams or powders on any incision
shower daily and pat incisions dry
no driving for one month AND off all narcotics
call for fever greater than 100.5, redness, drainage, or weight
gain of 2 pounds in 2 days or 5 lbs in 1 week
no lifting greater than 10 pounds for 10 weeks
Followup Instructions:
see Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] [**Doctor Last Name **] in [**1-16**] weeks([**Telephone/Fax (1) 3070**])
see Dr. [**Last Name (STitle) **] in [**2-17**] weeks
see Dr. [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**])
please call forappointments.
[**Hospital Ward Name 121**] 6 wound clinic in 2 weeks
Completed by:[**2184-7-10**]
|
[
"300.00",
"413.9",
"530.81",
"414.01",
"272.4",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.12",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
5781, 5842
|
3387, 4234
|
337, 401
|
6043, 6050
|
1685, 3364
|
6383, 6808
|
909, 927
|
4540, 5758
|
5863, 6022
|
4260, 4517
|
6074, 6360
|
942, 1666
|
281, 299
|
429, 700
|
722, 760
|
776, 893
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,548
| 139,257
|
7753
|
Discharge summary
|
report
|
Admission Date: [**2192-1-24**] Discharge Date: [**2192-1-29**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Doctor First Name 3290**]
Chief Complaint:
Fevers, cough, sob.
Major Surgical or Invasive Procedure:
1. Thoracentesis [**2192-1-26**]
History of Present Illness:
This is a [**Age over 90 **] year old man with PMH significant for multiple
hospitalizations for PNA, CAD status post CABG [**9-/2184**], no caths
in our system, Peripheral arterial disease,
Chronic kidney disease, baseline creatinine 1.0-1.3,HTN, GERD,
VitB12 deficiency, history of mild COPD, presented to ED with
fevers, and weakness.
.
Per patient and wife, patient had a fever of 37.5 at home 3 days
PTA, and they called Dr. [**Last Name (STitle) **], who is patient's pulmonologist.
He prescribed azithromycin for 3 days. Over the past sevearal
days patient has been feeling tired, but has been able to get up
for his usual morning walks. This morning he had a fever of 38.5
as well as chills, which promoted a visit to the emergency room.
On arrival to [**Last Name (LF) **], [**First Name3 (LF) **] report, he came in in severe resp distress
tachypneic to 30-40, with PNA, got antibiotics and steroids and
started improving. Now 95% on 5L, tachypneic in 30s, HR in 110.
In the ED, initial VS were: 100.4 108 136/67 18 100%. He was
noted to be tachypneic. He was given Levofloxacin, Ceftriaxone,
Tylenol, Albuterol/Ipratropium NEBs, Methylprednisolone.
On arrival to the MICU, patient was coughing, was arousable and
answered questions, was alert to name, hospital, but did not
know the year, appeared sleepy, and only said "[**2180**]".
Past Medical History:
Multiple Hospitalizations for Pneumonia
CAD status post CABG [**9-/2184**], no caths in our system
Peripheral arterial disease
Chronic kidney disease, baseline creatinine 1.0-1.3
Hypertension
GERD
Vitamin B12 deficiency
History of abnormal CXR
Dyslipidemia
COPD
Social History:
Married, lives with wife. Lives in [**Hospital3 **] facility.
Has VNA services. Uses wheelchair to get around. Remote [**Hospital3 1818**]
(quit in [**2140**]), daily small glass of wine. No narcotic use.
Family History:
No history of pulmonary issues in family.
Physical Exam:
Admission:
Vitals: T: 96.7 BP: 130/52 P: 78 R: 22 O2: 94% on 2L NC
GENERAL: Elderly [**Male First Name (un) 4746**] in NAD. Unable to answer orientation
questions, however A+Ox1 in the ED per report. No central or
peripheral cyanosis; no jaundice/pallor. Not using accessory mm
to breath
HEENT: NCAT. Sclera anicteric.
NECK: Supple; No JVD,
CARDIAC: RRR, nl S1,S2, no r/g noted (possible grade II/IV
holosystolic murmur heard throughout precordium, but difficult
to differentiate from breath sounds)
LUNGS: Good air flow, end expiratory wheezes bases>mid lung
fields, no obvious crackles.
ABDOMEN: Soft, NTND.
EXTREMITIES: No cyanosis, clubbing. Trace edema. WWP. 1+ distal
pulses.
Discharge Physical:
Afebrile, RR 20 O2 sat 96% on 2LNC
GENERAL: Elderly [**Male First Name (un) 4746**] in NAD. [**Male First Name (un) 595**]-speaking only. Able to
communicate with interpreter and family. Hard of hearing (must
speak loudly)
HEENT: NCAT. Sclera anicteric.
NECK: Supple; No JVD
CARDIAC: RRR, nl S1,S2, 2/6 systolic murmur LUSB, difficult to
appreciate with patient talking
LUNGS: no use of accessory muscles, occasional end expiratory
wheezes, crackles right>L
ABDOMEN: NABS, Soft, NTND, no rebound or guarding.
EXTREMITIES: No cyanosis, clubbing. Trace edema. WWP. 1+ distal
pulses.
Pertinent Results:
Admission Labs:
[**2192-1-24**] 08:52PM BLOOD WBC-19.1* RBC-4.41* Hgb-12.6* Hct-38.8*
MCV-88 MCH-28.7 MCHC-32.6 RDW-13.7 Plt Ct-425#
[**2192-1-24**] 08:52PM BLOOD Neuts-85.2* Lymphs-10.8* Monos-2.8
Eos-0.9 Baso-0.3
[**2192-1-24**] 09:10PM BLOOD PT-11.3 PTT-30.8 INR(PT)-1.0
[**2192-1-24**] 09:10PM BLOOD Glucose-199* UreaN-23* Creat-1.4* Na-134
K-4.9 Cl-99 HCO3-24 AnGap-16
[**2192-1-24**] 09:10PM BLOOD cTropnT-<0.01 proBNP-1395*
[**2192-1-25**] 05:22AM BLOOD D-Dimer-3549*
[**2192-1-24**] 09:00PM BLOOD Lactate-2.1* K-5.9*
CBC trend:
[**2192-1-24**] 08:52PM BLOOD WBC-19.1* RBC-4.41* Hgb-12.6* Hct-38.8*
MCV-88 MCH-28.7 MCHC-32.6 RDW-13.7 Plt Ct-425#
[**2192-1-25**] 05:22AM BLOOD WBC-25.7* RBC-4.10* Hgb-11.5* Hct-37.2*
MCV-91 MCH-28.1 MCHC-30.9* RDW-13.2 Plt Ct-331
[**2192-1-26**] 07:45AM BLOOD WBC-31.7* RBC-4.06* Hgb-11.3* Hct-35.8*
MCV-88 MCH-27.9 MCHC-31.6 RDW-13.8 Plt Ct-368
[**2192-1-27**] 06:50AM BLOOD WBC-25.0* RBC-4.40* Hgb-12.2* Hct-38.1*
MCV-87 MCH-27.7 MCHC-32.0 RDW-13.8 Plt Ct-374
[**2192-1-28**] 06:50AM BLOOD WBC-15.3* RBC-3.90* Hgb-10.9* Hct-34.2*
MCV-88 MCH-28.1 MCHC-32.0 RDW-13.9 Plt Ct-286
Discharge Labs:
[**2192-1-28**] 06:50AM BLOOD WBC-15.3* RBC-3.90* Hgb-10.9* Hct-34.2*
MCV-88 MCH-28.1 MCHC-32.0 RDW-13.9 Plt Ct-286
[**2192-1-28**] 06:50AM BLOOD Glucose-147* UreaN-27* Creat-1.1 Na-137
K-4.1 Cl-106 HCO3-21* AnGap-14
Microbiology:
Blood cultures [**2192-1-24**] pending at time of discharge
[**2192-1-25**] 1:00 am Influenza A/B by DFA
Source: Nasopharyngeal swab.
**FINAL REPORT [**2192-1-25**]**
DIRECT INFLUENZA A ANTIGEN TEST (Final [**2192-1-25**]):
Negative for Influenza A.
DIRECT INFLUENZA B ANTIGEN TEST (Final [**2192-1-25**]):
Negative for Influenza B.
MRSA SCREEN (Final [**2192-1-27**]): No MRSA isolated.
[**2192-1-26**] 12:44 pm PLEURAL FLUID PLEURAL FLUID.
GRAM STAIN (Final [**2192-1-26**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Final [**2192-1-28**]):
DUE TO LABORATORY ERROR, UNABLE TO PROCESS.
ANAEROBES ARE SCREENED FOR IN THE FLUID CULTURE.
TEST CANCELLED, PATIENT CREDITED.
ACID FAST SMEAR (Final [**2192-1-27**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
Legionella Urinary Antigen (Final [**2192-1-27**]):
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
Studies:
CXR [**2192-1-24**]
PORTABLE UPRIGHT AP VIEW OF THE CHEST: The patient is status
post median
sternotomy and CABG. Evaluation of the cardiac silhouette size
is difficult due to the presence of a chronic, moderate-to-large
left pleural effusion, which appears slightly increased in size
when compared to prior study. There is persistent left basilar
opacification, likely reflecting compressive atelectasis. The
right lung demonstrates mild atelectasis at the lung base, but
is otherwise clear. No pneumothorax is identified. There is no
pulmonary vascular congestion. The aorta remains tortuous and
calcified.
IMPRESSION: Moderate-to-large chronic left pleural effusion,
slightly
increased compared to the prior study with persistent left
basilar
opacification, likely reflecting compressive atelectasis, though
infection
cannot be completely excluded.
CXR [**2192-1-26**]:
FINDINGS: Sternotomy wires are unchanged. The heart and
mediastinal contours are within normal limits and stable. There
has been interval decrease in a left-sided pleural effusion with
some persisting left basilar atelectasis. The right lung is
clear. A line between the posterior aspects of the left third
and fourth rib space is more compatible with a skin fold rather
than the visceral pleura of the lung, so pneumothorax is not
favored. However, given the recent instrumentation, if growing
clinical concern for pneumothorax exists, short-interval
followup may be considered.
LENI [**2192-1-25**]:
IMPRESSION: No evidence of deep vein thrombosis in either leg.
Brief Hospital Course:
Brief Course:
Mr. [**Known lastname 28109**] is a [**Age over 90 **] year old man with PMH significant for
multiple hospitalizations for PNA, CAD status post CABG [**9-/2184**],
peripheral arterial disease, chronic kidney disease, baseline
creatinine 1.0-1.3, HTN, GERD, VitB12 deficiency, history of
mild COPD, presented to ED with fevers, and weakness as well as
SOB. He was initially in respiratory distress in monitored in
the ICU overnight. He was quickly transitioned to the medicine
floor and on nasal cannula. He was treated for
community-acquired pneumonia, and he clinically improved. He was
discharged to rehabilitation.
Active issues:
#. Fevers, cough: Likely secondary to community acquired
pneumonia. On admission patient had cough, fevers, elevated WBC.
CXR unchanged from prior and still showed pleural effusions.
Etiolgy was likely bacterial vs viral pneumonia. He was treated
with Ceftriaxone/Levaquin to cover for CAP in ICU setting. He
was given albuterol/Ipratropium standing NEBS. Suspicion low for
PE, d-dimer was elevated but LENIs were negative. He was treated
empirically with Tamiflu initially but discontinued once DFA
negative. He had a thoracentesis on [**1-26**] that was exudative by
light's criteria, though culture and gram stain were negative.
He was continued on Levofloxacin on the floors and continued to
improve. He was discharged on planned 10 day course of
Levofloxacin. He required 2L NC on discharge (sats 96%), which
should be weaned as able on at rehab. If he was unable to be
weaned to room air after treatment for pneumonia, recommend
consideration of gentle diuresis (pt received fluids while
admitted and lasix initially held).
# Acute on chronic renal failure: Baseline Cr 1.1-1.3, up to
1.4, improved with fluids to 1.1 on day prior to discharge,
therefore likely pre-renal. His lasix was initially held, and
restarted the day prior to discharge.
# Aspiration: Pt found to be aspirating on bedside evaluation
with speech and swallow. Aspiration precautions were maintained.
Recommend that patient have formal video swallow after
resolution of his pneumonia.
Inactive issues:
#. Type 2 diabetes: He has a slowly rising hemoglobin A1c (7.8
from 6/[**2191**]). Had been diet controlled until [**Month (only) **] of last
year. He was written for an insulin sliding scale while on the
medical floors, and required around 8 units Humalog daily for BG
high 100s-200. Pt will require follow-up with this PCP, [**Name10 (NameIs) **] if
he continues to have elevated BG may require oral medications.
This was not started in house given concern for hypoglycemia in
this patient with significant coronary artery disease.
# CAD status post CABG [**9-/2184**]: Continued on home ASA. No longer
on statin.
# HTN: Continued on amlodipine. His lasix was restarted at 10mg
daily the day prior to discharge (held briefly given pre-renal
ARF as discussed above).
# GERD: Pt was changed from prilosec to lansoprazole for ease of
taking given aspiration as discussed above.
# Vitamin B12 deficinecy: Continued home Vitamin B12.
Transitional care:
1. CODE: DNR/DNI
2. Contact:
dtr ([**Name2 (NI) **]) 1 ([**Telephone/Fax (1) 28112**], ([**Telephone/Fax (1) 28113**] dtr speaks english.
Also Wife ([**Telephone/Fax (1) 28114**]. Grandson [**Name (NI) 2491**] [**Telephone/Fax (1) 28115**].
3. Pending studies:
Blood cultures from [**1-24**] pending at time of discharge
Final pleural fluid culture [**1-26**]
4. Follow-up:
Pulmonology
Recommend video swallow after treatment for pneumonia
Will need assistance with making PCP [**Name9 (PRE) 702**] after discharge
Recommend repeat labs for CBC, chem 7 2-3 days after discharge
for assessment of improving WBC count, and monitoring renal
function
Medications on Admission:
-Amlodipine 5mg PO daily
-Aspirin 81mg PO daily
-Fluticasone, 2 sprays in each nostril daily (**Last filled in
[**Month (only) 956**])
-Furosemide 10mg daily
-Ipratropium-albuterol 0.5 mg-3 mg (2.5 mg base)/3 mL Solution
for Nebulization; 1 neb QID prn SOB (**last filled in [**Month (only) **])
-Omeprazole 20mg PO daily
-Tamsulosin 0.4mg PO qPM
-Calcium citrate-Vitamin D3 (200mg-125u); 1 tab PO BID
-Vitamin B12 1,000 units PO daily
-Simethicone 80mg PO BID prn gassiness (chew one 20minutes
before
eating)
Discharge Medications:
1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Month (only) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. senna 8.6 mg Tablet [**Month (only) **]: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
3. docusate sodium 50 mg/5 mL Liquid [**Month (only) **]: One (1) PO BID (2
times a day).
4. aspirin 81 mg Tablet, Chewable [**Month (only) **]: One (1) Tablet, Chewable
PO DAILY (Daily).
5. amlodipine 5 mg Tablet [**Month (only) **]: One (1) Tablet PO DAILY (Daily):
HOLD if SBP<100.
6. furosemide 20 mg Tablet [**Month (only) **]: 0.5 Tablet PO once a day: hold
if SBP<100.
7. ipratropium bromide 0.02 % Solution [**Month (only) **]: One (1) neb
Inhalation Q6H (every 6 hours): during the day, HOLD at night.
8. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Month (only) **]: One (1) neb Inhalation Q4H (every 4 hours):
only during the day, HOLD at night.
9. Vitamin B-12 1,000 mcg Tablet [**Month (only) **]: One (1) Tablet PO once a
day.
10. calcium citrate-vitamin D3 200-125 mg-unit Tablet [**Month (only) **]: One
(1) Tablet PO twice a day.
11. tamsulosin 0.4 mg Capsule, Ext Release 24 hr [**Month (only) **]: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime): HOLD for SBP<100.
12. simethicone 80 mg Tablet [**Month (only) **]: One (1) Tablet PO twice a day
as needed for gas.
13. levofloxacin 500 mg Tablet [**Month (only) **]: One (1) Tablet PO Q24H
(every 24 hours) for 5 days: to be completed on [**2192-2-3**].
14. heparin (porcine) 5,000 unit/mL Solution [**Date Range **]: 5000 (5000)
units Injection TID (3 times a day): if not ambulating.
15. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
16. guaifenesin 100 mg/5 mL Syrup [**Last Name (STitle) **]: Ten (10) ML PO Q6H (every
6 hours).
17. insulin lispro 100 unit/mL Cartridge [**Last Name (STitle) **]: per sliding scale
units Subcutaneous QACHS: recommend ISS if needed:
for breakfast, lunch, dinner, recommend starting at BG 151-200 2
units, increasing by 2 units for every 50 BG; for bedtime scale,
start at BG 201, 2 units, increasing by 1 unit for every
increase in BG of 50.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
Primary:
1. Community-acquired pneumonia
2. Aspiration
Secondary:
1. Coronary artery disease
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:
Dr. [**Last Name (STitle) **]. [**Known lastname 28109**],
It was a pleasure taking care of you during this admission. You
were admitted with fevers and shortness of breath. You were
initially in the ICU, but moved to the medicine floors shortly
thereafter. You were placed on antibiotics and you improved. You
were seen by the speech specialists, and you were found to be
aspirating, so you were placed on a special diet. You will
benefit from further evaluation with a video swallow after your
pneumonia improves.
The following medications were changed during this
hospitalization:
1. START Levofloxacin 500mg by mouth for 5 more days (to be
completed [**2192-2-3**])
2. START Guaifenesin 10 mL by mouth every 6 hours until cough
improves
3. START Insulin per sliding scale while at rehab (only during
the day, may hold at night)
4. Take Albuterol nebulizer 1 neb every 4 hours until your
breathing improves (only during the day, may hold at night)
5. Take Ipratropium nebulizer 1 neb every 6 hours until your
breathing improves (you can then change back to as needed)
6. CHANGE the medication Omeprazole 20mg daily to Lansoprazole
30mg daily
7. START Docusate sodium twice daily for constipation
8. TAKE Bisacodyl and senna as needed for constipation
You were found to have Type 2 Diabetes earlier this year with
your primary doctor. You have not yet been started on oral
medications for this. In the hospital we had you on a gentle
insulin sliding scale for high blood sugars, but you required
only small doses. If your blood sugars continue to be high, you
may need to start a medication for this. Please discuss this
further with your primary doctor at your follow-up appointment.
Please continue the other medications you were taking prior to
this admission.
Followup Instructions:
Please follow-up with the following appointments:
We cannot schedule primary care appointments when you go to
rehab. Please call your doctor, Dr. [**Last Name (STitle) **], at [**Telephone/Fax (1) 250**]
when you are discharged from rehabilitation. The speech
therapists recommended that you have a video swallow evaluation
when you are discharged. Please discuss this with him if this is
not done at rehab.
Department: PULMONARY FUNCTION LAB
When: THURSDAY [**2192-3-1**] at 2:40 PM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: MEDICAL SPECIALTIES
When: THURSDAY [**2192-3-1**] at 3:00 PM
With: [**Name6 (MD) 610**] [**Name8 (MD) **] RN/DR. [**Last Name (STitle) 611**] [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Name: [**Last Name (LF) **], [**Name8 (MD) **] MD
Location: [**Hospital1 **]
INTERVENTIONAL PULMONARY
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 3020**]
**We are working on a follow up appointment with Dr. [**Last Name (STitle) **]
within 2-4 weeks. You will be called at home with the
appointment. If you have not heard from the office within 2 days
or have any questions, please call the number above.**
Completed by:[**2192-1-29**]
|
[
"250.00",
"496",
"414.00",
"585.9",
"V49.86",
"V45.81",
"511.9",
"V46.3",
"266.2",
"443.9",
"403.90",
"584.9",
"V15.82",
"530.81",
"486",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
14352, 14437
|
7783, 8416
|
272, 307
|
14574, 14574
|
3578, 3578
|
16545, 18032
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2214, 2258
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14458, 14553
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11547, 12059
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14751, 16522
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4714, 5731
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2273, 3559
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6101, 7760
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213, 234
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8432, 9897
|
335, 1685
|
9915, 11521
|
3594, 4698
|
14589, 14727
|
1707, 1971
|
1987, 2198
|
5763, 6064
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,575
| 137,042
|
46980
|
Discharge summary
|
report
|
Admission Date: [**2103-10-31**] Discharge Date: [**2103-11-2**]
Date of Birth: [**2040-2-24**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5266**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
63 yo F w/ Hx of COPD FEV1 1.13 p/w dyspnea. Her symptoms
gradually started last week with gradually increasing dyspnea.
She lost her home O2 3L NC one year ago [**12-18**] insurance problems.
This morning her dyspnea got acutely worse when she got into the
shower. She denies recent wt. gain, complains of orthopnea which
is unchanged and she says is c/w her sleep apnea. She has a
cough productive of light brown sputum which is baseline, denies
rhinorrhea and sick contacts or fevers but has had chills. She
has been using her albuterol 2-3x/day. In the ED she was
initially placed on BIpap and she ripped it off and refused to
put it back on.
In the ED, initial VS: 79, 149/110, 30, 95% 6L
ROS: Denies fever, night sweats, headache, , rhinorrhea,
congestion, sore throat, cough, shortness of breath, chest pain,
abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR,
melena, hematochezia, dysuria, hematuria.
Past Medical History:
HTN
CHF.
Cardiovascular procedures/symptoms: echo w/low EF 25-30%, 42% by
cath [**3-20**], has chronic LE swelling
COPD.
pulmonary nodules and lymphadenopathy on CT
Diabetes.
hypercholesterolemia
GERD that she reports is better since partial colectomy
RA X 15 years but no flares recently
reports LBP for many reasons including weight but also reports
OA
Social History:
TOB [**1-17**] ppd X 30 years. Denies etoh, illicits. Lives with son.
Family History:
NC
Physical Exam:
(Per Admitting Resident)
Vitals - T:98.7 BP: 154/85 HR: 85 RR: 14 02 sat: 95% on 2L NC
GENERAL: a/ox3, pleasant, conversant, speaking in complete
sentences
CARDIAC: RRR, distant heart sounds
LUNG: diffuse wheezing and prolonged expiratory phase. No
crackles
ABDOMEN: soft, NT, ND, BS+
EXT: 2+ pitting edema to midtibia
Pertinent Results:
Admission Labs
[**2103-10-31**] 06:19PM BLOOD WBC-7.9 RBC-4.32 Hgb-13.8 Hct-40.3 MCV-93
MCH-32.0 MCHC-34.3 RDW-14.7 Plt Ct-231
[**2103-10-31**] 06:19PM BLOOD Neuts-76.4* Lymphs-17.5* Monos-4.1
Eos-1.2 Baso-0.8
[**2103-10-31**] 06:19PM BLOOD Glucose-108* UreaN-10 Creat-0.6 Na-142
K-3.7 Cl-102 HCO3-33* AnGap-11
[**2103-10-31**] 06:19PM BLOOD CK(CPK)-139
[**2103-10-31**] 06:19PM BLOOD cTropnT-<0.01 proBNP-424*
[**2103-10-31**] 06:19PM BLOOD Calcium-8.9 Phos-2.8# Mg-2.3
[**2103-10-31**] 06:44PM BLOOD Lactate-1.4
Discharge Labs
[**2103-11-2**] 07:22AM BLOOD WBC-10.0 RBC-3.96* Hgb-12.6 Hct-37.3
MCV-94 MCH-31.7 MCHC-33.7 RDW-14.8 Plt Ct-226
[**2103-11-2**] 07:22AM BLOOD Glucose-106* UreaN-13 Creat-0.5 Na-145
K-3.5 Cl-104 HCO3-32 AnGap-13
[**2103-11-2**] 07:22AM BLOOD Calcium-8.8 Phos-3.5 Mg-2.2
Microbiology
DIRECT INFLUENZA A ANTIGEN TEST (Final [**2103-11-1**]): Negative for
Influenza A.
DIRECT INFLUENZA B ANTIGEN TEST (Final [**2103-11-1**]): Negative for
Influenza B.
Blood Cx ([**2103-10-31**]) x 2 - Pending, with no growth to date.
Radiology
CXR - AP view of the chest obtained. Heart is enlarged. Lungs
appear clear, though underpenetrated technique does limit
evaluation somewhat. No large effusion or pneumothorax is seen.
Mediastinal contour is normal. Bones appear intact.
Brief Hospital Course:
# COPD Exacerbation - In the MICU, the patient was given
prednisone, ceftriaxone/azithromycin, lasix 20 mg IV and nebs.
Her dyspnea greatly improved with this therapy. Given that
there was no infiltrate on CXR and her lack of fever, the
ceftriazone was discontinued. A flu swab was sent and was
negative. On transfer to the floor, the patient stated that her
dyspnea had improved. The patient was noted to desat to the
mid-80's with ambultation (on room air). Therefore, at
discharge, she was given a prescription for home oxygen. She
was also discharged to complete a prednisone burst and a 5-day
course of azithromycin.
# CHF - The patient's BNP was elevated on admission. However,
she had not gained any weight recently and there was no
pulmonary edema on CXR. She was given 20 mg IV lasix in the
MICU and diuresed well. She was then maintained on her home PO
lasix regimen.
# GERD - The patient was continued on her omeprazole.
# Hyperlipidemia - The patient was continued on her
atorvastatin.
# RA - The patient was continued on her hydroxychloroquine while
in-house. She was also continued on her leflunomide and
methotrexate at discharge.
#HTN - The patient was continued on her home lisinopril,
amlodipine, and metoprolol.
Medications on Admission:
-Albuterol Sulfate 90 mcg HFA 2 puffs inh 2-3 times a day
-Amlodipine 5 mg Tablet once a day
-Atorvastatin 80 mg Tablet at bedtime
-Bupropion HCl 100 mg Tablet 1 once a day (not currently taking)
-Fluticasone-Salmeterol 500 mcg-50 mcgone inhalation twice daily
-Folic Acid 1 mg Tablet 1 Tablet(s) by mouth once a day
-Furosemide 20 mg Tablet once a day
-Hydrocodone-Acetaminophen two times a day as needed for pain
-Hydroxychloroquine 200 mg 1 by mouth twice a day
-Leflunomide 20 mg Tablet 1 Tablet(s) by mouth once a day
-Lisinopril 20 mg Tablet 1 Tablet(s) by mouth twice a day
-Methotrexate 7.5mg Qweek
-Metoprolol Tartrate 50 mg by mouth twice a day
-Omeprazole 20 mg Capsule, 1 Capsule(s) by mouth once a day
-Prednisone 1 mg Tablet 4 Tablet(s) by mouth once a day (not
currently taking)
-Tiotropium Bromide 18 mcg Capsule, inhaled once a day
-Tramadol [Ultram] 50 mg Tablet 2 Tablet(s) by mouth tid prn
-Varenicline [Chantix] Dose Pack (not currently taking)
-Zolpidem 5 mg Tablet bedtime (not currently taking)
Discharge Medications:
1. Home Oxygen
Oxygen at 3 liters continuously.
Diagnosis: COPD
Pulse dose for portability.
2. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) puffs Inhalation three times a day as needed for
shortness of breath or wheezing.
3. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1) Tablet
PO twice a day as needed for pain.
9. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
10. Leflunomide 20 mg Tablet Sig: One (1) Tablet PO once a day.
11. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
12. Methotrexate (Anti-Rheumatic) 2.5 mg Tablets, Dose Pack Sig:
Three (3) Tablets, Dose Pack PO once a week.
13. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
14. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
15. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
16. Tramadol 50 mg Tablet Sig: Two (2) Tablet PO three times a
day as needed for pain.
17. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 3 days.
Disp:*3 Tablet(s)* Refills:*0*
18. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
for 3 days.
Disp:*6 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Primary
- COPD Exacerbation
Discharge Condition:
Afebrile, hemodynamically stable.
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent; Desats to Mid 80's on
room air with ambulation
Discharge Instructions:
You presented to the emergency department with shortness of
breath. You were given nebs, diuretics, and steroids. You were
also initially started on broad antibiotics to treat for a
possible pneumonia. Your chest x-ray did not show signs of
infection, and it was felt that your symptoms were due to a COPD
exacerbation. At that point, your antibiotics were narrowed.
Of note, you were also tested for influenza while you were in
the hospital, and you were found to not have influenza.
Changes to your medications:
-START Prednisone 40 mg daily for 3 more days.
-START Azithromycin 250 mg daily for 3 more days.
-There were no other changes to your medications.
You should also quit smoking. Quitting smoking will prevent
many negative effects on your health.
It was a pleasure taking part in your medical care.
Followup Instructions:
You should follow-up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 5263**], on Monday
[**2103-11-12**]. You can call her office at [**Telephone/Fax (1) 250**] to set up
this appointment.
You also have the following follow-up appointments:
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2103-11-23**] 11:40
Provider: [**First Name11 (Name Pattern1) 1569**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2103-11-23**] 12:00
|
[
"272.4",
"491.21",
"V46.2",
"530.81",
"714.0",
"401.9",
"327.23",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7494, 7565
|
3442, 4689
|
324, 331
|
7637, 7671
|
2124, 3419
|
8707, 8948
|
1766, 1770
|
5758, 7471
|
7586, 7616
|
4715, 5735
|
7864, 8354
|
1785, 2105
|
8973, 9280
|
8383, 8684
|
277, 286
|
359, 1285
|
7685, 7840
|
1307, 1663
|
1679, 1750
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,718
| 144,533
|
44874
|
Discharge summary
|
report
|
Admission Date: [**2202-6-6**] Discharge Date: [**2202-7-19**]
Date of Birth: [**2162-8-15**] Sex: M
Service: MEDICINE
Allergies:
Betadine / Iodine; Iodine Containing / Compazine / Keflex /
Zosyn / Heparin Agents
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
Blocked port a catheter, Urinary tract infection.
Major Surgical or Invasive Procedure:
Removal and replacement of blocked port-a catheter.
Surgical Incision and Drainage
History of Present Illness:
39 y.o. man with paraplegia and multiple medical problems well
known to [**Hospital1 18**] s/p recent discharge from neurology admitted with
"clogged port a cath" for a few days. Currently requiring IV
abx for recurrent UTI's which are sensitive to Tobramycin and
Gentimycin only. Denies symptoms: cough, fever, shortness of
breath, unusually high colostomy or urinary output. Denies
headaches, changes in mentation, or neck pain. He does endorse
some blood at his colostomy site, now resolved and not in his
stool. States that he requires port acath for fluid boluses.
States he has "ulcer on my back/buttocks" Does complain of
stomach pain specifically near suprapubic cath. Recently
completed course of Merepenim and Tobramycin for UTI on [**2202-5-25**]
but subsequent follow-up culture was positive. Started on
course of gentamycin. Tried TPA in the ED without result.
Patient also received 6 mg Dilaudid in the ED.
with port a cath for periodic fluid boluses for hypotension and
Is. Now presents with blocked port a cath. Recently completed
course of meropenem and tobramycin for pseudomonal UTI.
Reportedly ua was repeated and was still found to have evidence
of infection therefore a course of gentamycin was intitiated.
He states that his last dose of gent was
He currently denies complaints and has no localizing symptoms.
Past Medical History:
Paraplegia s/p MVA C6C7
Chronic sacral decubitus ulcer
s/p renal tx [**2181**]
h/o frequent recurrent UTIs resistant to everything except
gentamycin and tobramycin
s/p MI [**2188**] 2' to cocaine
Chronic Osteomyelitis
s/p R BKA, multiple amps of b/l distal fingers
s/p diverting colostomy
autonomic dysreflexia
depression
Social History:
Denies alcohol, quit tobacco [**2185**], denies IVDA. no cocaine since
MI in [**2188**]; Lives at rehab facility: [**Hospital3 672**] Hospital.
Family History:
N/A
Physical Exam:
VS: 97.6 105/56 60 16 94% RA
Gen: obese caucasian man lying in bed, periodically
hittinghimself
HEENT:AT, NC, EOMI
CV: RRR, NL S1, S2, No M/R/G
Pulm: CTAB but exam limited by patient's limited mobility
Abd: soft, obese, non-tender, non-distended, + bowel sounds,
colostomy on lower left side
Ext: R BKA, multiple auto-amputations of his distal fingers.
Neuro: A & O
Pertinent Results:
[**2202-6-8**] 09:46PM BLOOD PT-12.2 PTT-28.7 INR(PT)-1.0
[**2202-6-8**] 09:46PM BLOOD Plt Ct-286
[**2202-6-8**] 09:46PM BLOOD Glucose-114* UreaN-14 Creat-0.5 Na-144
K-3.8 Cl-107 HCO3-30* AnGap-11
[**2202-6-16**] 03:37AM BLOOD Calcium-9.4Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2202-7-19**] 06:27AM 9.6 3.61* 9.6* 31.5* 87 26.5* 30.4* 16.8*
259
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2202-7-19**] 11:45AM 12.6 28.3 1.1
[**2202-7-19**] 06:27AM 259
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2202-7-19**] 06:27AM 112* 25* 0.4* 140 4.8 103 36*1 6*
1 NOTE UPDATED REFERENCE RANGE AS OF [**2202-6-11**]
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
[**2202-7-19**] 01:38AM 9*1
TROUGH VANCOMYCIN
1 VERIFIED BY REPLICATE ANALYSIS
CPK ISOENZYMES CK-MB cTropnT
[**2202-7-19**] 01:38AM NotDone1
TROUGH VANCOMYCIN
1 NotDone
CK-MB NOT PERFORMED, TOTAL CK < 100
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2202-7-19**] 06:27AM 9.0 1.8* 1.6
ANTIBIOTICS Vanco
[**2202-7-19**] 01:38AM 19.7*
TROUGH VANCOMYCIN
AP CXR [**2202-7-19**]: Portable erect AP radiograph of the chest is
reviewed, and compared to the previous study of [**2202-7-12**].
There is continued mild cardiomegaly. There is improving left
lower lobe patchy atelectasis. The lungs are clear otherwise.
Again, note is made of biapical thickening. The left subclavian
IV catheter terminates in the SVC. No pneumothorax is
identified.
Continued mild cardiomegaly. Otherwise, no active lung disease.
DR. [**First Name (STitle) 7204**] [**Name (STitle) 7205**]
Approved: MON [**2202-7-19**] 9:52 AM
CT ABD/Pelvis: [**2202-7-19**]:PERLIM READ BY RADIOLOGY: No recollection
of fluid s/p I and D on [**2202-7-17**]. Lung bases clear.
Brief Hospital Course:
Mr. [**Known lastname 11679**] was admitted with a block port a catheter which was
being used for IV gentamycin to treat a reported urinary tract
infection which was diagnosed at [**Hospital3 672**] Hospital. He
has a history of recurrent Pseudomonas urinary tract infections
which are resistant to all antibiotics except Tobramycin and
Gentamycin. He recently completed a course of meropenem and
tobramycin for pseudomonal UTI. A repeat urinalysis was still
found to have evidence of infection and a course of gentamycin
was intitiated. Patient subsequrntly developed a RUQ fluid
collestion, and urosepsis.
1. port a cath: Mr. [**Known lastname 11679**] has had 6 port-a catheters, the last
five of which were placed by surgery. The catheter was flushed
with t-pa at the rehabilitation hospital where Mr. [**Known lastname 11679**] lives
with no improvement. The catheter was flushed with normal
saline by the IV team but they were unable to pass sufficient
saline to warrant an attempt to flush with t-pa. Patient was
seen by surgery to evaluate the [**Doctor First Name **], and for new port a catheter
placement. Vein mapping and venous ultrasound were performed,
and a new port a cath placed [**6-8**]. He was started on warfarin
with a gola INR [**1-14**] to be contiunued for 3 months. Pt has
allergy to heparin and can not have hep flushes.
.
2. Urinary tract infection: The patient has a history of chronic
infections with pseudomonas and Morganella morganii. It is
unclear if this is actually a recurrent problem or if the
patient is colonized. Patient reported increasing abdominal
pain on [**2202-6-17**]. CT abd/pelvis did not show any acute pathology.
Patient has completed 14d of tobramyacin. Subsequently on
[**2202-7-12**], patient developed hypotension and transient hypoxia.
Hypotension persisted after treatment with 2L NS, and treatment
with dilaudid (? Narcotic effect). This occurred in setting of
bladder catheter flushing. Patient's Urine Culture and blood
cultures were drawn and paitient was started on broad spectrum
antibiotics as well as stress dose steroids. Patint was taken to
the MICU (See MICU course below) and his urine Ux grew
Morganella. Patient started promptly dcd from ICU and will
continue on Meropenum, Levofloxacin, Vancomycin and Flagyl for a
total of 14 days, as well as a steroid taper.
.
3. Chronic sacral decubitus ulcer: a chronic problem for this
patient given his paraplegia. He arrived being treated with
twice daily irrigations and dressing changes with xeroform
adhesive. Regular positional changes were ordered and special
matress was ordered.
4. Autonomic dysreflexia: The patient is known to have wide
swings in blood pressure secondary to this disorder. as
mentioned above, his blood pressure seems to respond most
efefctively to IV fluid boluses, which is one of the reasons why
regular reliable IV access is so important for this patient. He
required several NS fluid boluses during his stay for
hypotension.
.
5. Abdominal pain - Pt had persistant RLQ pain during his
hospital stay. Patient had a a drain placed in the RUQ for
fluid collection noted on CT the abdomen. On [**2202-7-8**], this
drain was discontineud. Subsequently, patient had recollection
of RUQ fluid and underwent surgical I and D on [**2202-7-17**]. Repeat CT
on [**2202-7-19**] (Perlim read) revealed no recollection offluid.
.
6.Anemia - Chronic in nature. Ferritin low and tarted on oral
iron supplements. Stool remained guiac negative.
7. Left arm swelling - Resolved issue. Surgery had been
consulted. U/S was negative for clot. Cath is still patent.
likley [**1-13**] new port. Arm does not appear swollen today.
.
8. Scrotal Lac-scrotum lacerated by attending during
examination- s/p suturing by [**Month/Day (2) 159**]. NO current issues
.
9. FEN - house diet
.
10. PPx: bowel regimen, PPI, fondaparinux
.
11. Access: left port-o-cath
.
12. Communication: patient and his parents
.
13. Full Code
.
14. Renal Transplant: Patient maintained on Azothioprine
.
15. Constipation: Patient maintained n aggressive bowel regimen
including Lactulose
.
16. Pain: Patient with significant RUQ pain in setting of I and
D of RUQ fluid collection. He has been managed and stable on
dilaudid. This should be continued and tapered as pain improves.
.
17. CP: During his stay, patient had episode of pleuritic CP. He
was ruled out for MI with cardiac enzymes that were negative
times 3, negative VQ scan for PE, Negative LE dopplers. Patient
was imperically treated with levofloxacin for small RLL
infiltrate. His CP abated.
MICU COURSE-patient transferred on [**2202-7-12**]:
On the day of MICU transfer he was found to be hypothermic iwth
T 95.4 ax, hypotensive with BP 75/45, and hypoxic with O2 sat
85% on 6Lnc, complaining of headache, dizziness, and [**9-20**]
abdominal pain. ABG 7.39/52/66 on 4Lnc. He was given 2L NS and
treated with hydrocortisone, 0.1mg naloxone, and given doses of
vancomycin, levofloxacin, and metronidazole. BP improved to
110s/60s, HR remained in 70s, and oxygenation stabilized in 90%s
on NRB. He was noted to be more lethargic, but remained
arousable to verbal and pain stimuli, and oriented when aroused.
Currently he complains of fatigue but denies headache, chest
pain, and shortness of breath. Still with abdominal pain [**8-21**],
and back pain that is unchanged from baseline.
Pt kept on levo/flagyl/vanco as on floor. repeat abd ct showed
persisent abd wall fluid collection, decision was to watch as
fever/wbc; if spikes or increased pain, will repeat drainage for
micro data.
Briefly, this is a 39yoM with h/o parplegia s/p MVC, autonomic
dysregulation, s/p renal transplant on immunosuppressives,
chronic sacral decubitus ulcers, and frequent drug-resistant
UTI's, transferred to MICU from our service on [**7-12**] with
hypotension and hypoxia.
.
Patient was initially admitted to [**Hospital1 18**] [**2202-6-6**] with port-o-cath
thrombosis; port resited [**2202-6-8**]. He subsequently developed
abdominal pain and was diagnosed with abdominal wall fluid
collection, and underwent surgical drainage by IR. Fluid was
purulant but without growth on micro. Hospital course has been
complicated by recurrent UTI for which the patient recently
completed a two week course of tobramycin, and replacement of
urostomy tube by [**Month/Day/Year 159**]. He is also being treated for a left
lower lobe pneumonia with levofloxacin. On [**2202-7-9**] he complained
of chest pain. He ruled out for acute MI; V/Q scan was low
probability PE, and bilateral LENIs negative for DVT. On [**2202-7-10**]
he was on Fondaparinux and warfarin for thrombosis and h/o HIT,
which was diagnosed at OSH.
.
On the day of MICU transfer he was found to be hypothermic with
T 95.4 ax, hypotensive with BP 75/45, and hypoxic with O2 sat
85% on 6Lnc, complaining of headache, dizziness, and [**9-20**]
abdominal pain. ABG 7.39/52/66 on 4Lnc. He was given 2L NS and
treated with hydrocortisone, 0.1mg naloxone, and given doses of
vancomycin, levofloxacin, and metronidazole. BP improved to
110s/60s, HR remained in 70s, and oxygenation stabilized in 90%s
on NRB. He was noted to be more lethargic, but remained
arousable to verbal and pain stimuli, and oriented when aroused.
His BP again dropped into the 80s, and at this point pt was
tranferred to MICU
.
In the MICU, patient felt likely have sepsis from urinary source
and UCx eventually grew Morgenalla. Patient continued on Vanco,
Levo, Flagyl, and Meropenum, as well steroid taper. These were
to be continued on the floor.
Medications on Admission:
Buspirone 10 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
Percocet 1-2 tabs po q4hrs prn
Promethazine prn
Dilaudid 4 mg IV bid
Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Lamotrigine 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Senna, lactulose, doucusate sodium
Baclofen 10 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Nicotine 2 mg Gum Sig: One (1) Gum Buccal Q1H (every hour) as
needed.
reglan
Azathioprine 50 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Zolpidem Tartrate 5 mg Tablet Sig: 1-2 Tablets PO HS (at
bedtime) as needed.
Gentamycin IV
Discharge Medications:
1. Hydromorphone 2 mg/mL Syringe Sig: 3-5 mg Injection Q3-4H
(Every 3 to 4 Hours) as needed for pain: hold for sedation or RR
< 12
wean as tolerated.
2. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed.
3. Buspirone 10 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
4. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed.
5. Baclofen 10 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
6. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
7. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Nicotine 2 mg Gum Sig: One (1) Gum Buccal Q1H (every hour) as
needed.
9. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
10. Vitamin E 400 unit Capsule Sig: One (1) Capsule PO DAILY
(Daily).
11. Azathioprine 50 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
12. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
13. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
14. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed.
15. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO BID (2 times a day).
16. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID
(2 times a day).
17. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed.
18. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 10 days.
19. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
20. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
21. Ascorbic Acid 250 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
22. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
23. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
24. Fondaparinux Sodium 7.5 mg/0.6 mL Syringe Sig: One (1)
injection Subcutaneous DAILY (Daily): give till INR [**1-14**] on
coumadin.
25. Warfarin Sodium 2 mg Tablet Sig: One (1) Tablet PO QHS (once
a day (at bedtime)).
26. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
27. Promethazine 25 mg/mL Solution Sig: One (1) injection
Injection Q6H (every 6 hours) as needed for nausea.
28. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
dose Intravenous Q 12H (Every 12 Hours) for 10 days.
29. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a
day for 10 days.
30. Meropenem 1 g Recon Soln Sig: One (1) Recon Soln Intravenous
Q8H (every 8 hours) for 10 days.
31. Hydrocortisone Sod Succinate 100 mg/2 mL Recon Soln Sig:
Fifty (50) mg Injection Q 12 HR () for 1 days: stop on [**2202-7-20**].
32. Hydrocortisone Sod Succinate 100 mg/2 mL Recon Soln Sig:
Forty (40) mg Injection Q 12 HR () for 2 doses: give on [**2202-7-21**].
33. Hydrocortisone Sod Succinate 100 mg/2 mL Recon Soln Sig:
Thirty (30) mg Injection Q 12 HR () for 2 doses: give on
[**2202-7-22**].
34. Hydrocortisone Sod Succinate 100 mg/2 mL Recon Soln Sig:
Twenty (20) mg Injection twice a day for 2 doses: give on
[**2202-7-23**].
35. Prednisone 10 mg Tablet Sig: as directed Tablet PO as
directed on taper below: 60mg prednisone [**7-24**]/-[**7-26**], 50mg
Prednisone [**Date range (1) 57944**], 40mg perdnisone [**Date range (1) 59676**], 30mg prednisone
[**Date range (1) 95998**], 20mg Prednisone [**Date range (1) 49941**], 10mg prednisone [**Date range (1) 47964**],
7.5mg prednisone [**Date range (1) 95999**], 5mg prednisone from [**8-14**] onwards.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 672**] Hospital
Discharge Diagnosis:
1. Blocked port-a catheter.
2. Surgical removal and replacement of port-a catheter.
3. Abdominal pain - s/p drain placement and I and D
Discharge Condition:
Stable
Discharge Instructions:
Please take all medications as directed.
Return if you feel chest pain, shortness of breath, decreased
urination or any other concerning symptoms.
Followup Instructions:
PCP:
[**Name10 (NameIs) 96000**],[**Name11 (NameIs) 96001**] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 96002**] at next available
appointment
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
Completed by:[**2202-7-19**]
|
[
"996.1",
"038.8",
"707.03",
"255.4",
"E928.9",
"E929.0",
"V49.62",
"344.1",
"878.2",
"682.2",
"337.3",
"595.2",
"453.8",
"278.00",
"V49.75",
"V44.3",
"V58.65",
"280.9",
"996.81",
"707.8",
"996.65",
"041.7",
"486",
"907.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.04",
"99.04",
"54.0",
"86.05",
"38.93",
"61.41"
] |
icd9pcs
|
[
[
[]
]
] |
16908, 16963
|
4669, 12217
|
391, 476
|
17146, 17154
|
2782, 4646
|
17350, 17662
|
2375, 2380
|
13134, 16885
|
16984, 17125
|
12243, 13111
|
17178, 17327
|
2395, 2763
|
302, 353
|
504, 1852
|
1874, 2197
|
2213, 2359
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,672
| 129,060
|
14789
|
Discharge summary
|
report
|
Admission Date: [**2180-5-9**] Discharge Date: [**2180-5-15**]
Date of Birth: [**2122-9-3**] Sex: M
Service: Cardiac Surgery
CHIEF COMPLAINT: Chief complaint was worsening exertional
angina.
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 43481**] is a 57-year-old
male with a history of diabetes, hypertension, and high
cholesterol who was transferred from an outside hospital to
the Cardiology Service after having a catheterization that
showed severe left main disease. He has been having
squeezing middle/substernal chest pain with
moderate-to-severe exertion for the last three months (for
example, when he was mowing the lawn). This is associated
with shortness of breath and bilateral arm tingling. He
denies any diaphoresis, palpitations, lightheadedness, or
nausea and vomiting, and his pain is relieved by rest. He
also denies having shortness of breath at other times and
denies orthopnea, paroxysmal nocturnal dyspnea, or peripheral
edema.
He was evaluated at [**Hospital 1474**] Hospital on [**5-5**] and had a
positive exercise treadmill test and was referred to [**Hospital1 1444**] for cardiac catheterization.
His catheterization demonstrated an 80% middle and distal
lesion of his left main, 50% middle lesion in the left
anterior descending artery at the level of the diagonal, some
minimal luminal irregularities of the left circumflex, and
diffuse disease of the right coronary artery. His ejection
fraction was approximately 60%.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Hypercholesterolemia.
3. Diabetes mellitus.
4. Status post pilonidal cyst removal.
MEDICATIONS ON ADMISSION:
1. Aspirin 325 mg p.o. q.d.
2. Lopid 1200 mg p.o. b.i.d.
3. Accupril 80 mg p.o. q.d.
4. Glyburide 5 mg p.o. q.d.
5. Protonix 40 mg p.o. q.d.
6. Atenolol 50 mg p.o. q.d.
7. Imdur 30 mg p.o. q.d.
8. Hydrochlorothiazide 25 mg p.o. q.d.
ALLERGIES: The patient is not allergic to any medications.
FAMILY HISTORY: He has a positive history of coronary
artery disease with his father having a myocardial infarction
at the age of 40.
SOCIAL HISTORY: He is married. He lives in [**Location 5165**]. He
quit smoking 10 years ago.
PHYSICAL EXAMINATION ON PRESENTATION: On physical
examination his temperature was 97.9, blood pressure was
117/55, pulse of 53, respiratory rate of 18, oxygen
saturation of 97% on room air. In general, he was in no
acute distress. On cardiovascular examination, there was
jugular venous distention. Heart had a regular rate and
rhythm without murmurs, rubs or gallops. On pulmonary
examination he had diminished breath sounds anterolaterally
bilaterally. The abdomen was obese, soft, and nontender,
with bowel sounds present. His extremities revealed his
groin was without bruit.
HOSPITAL COURSE: Due to the patient's severe left main
disease, he was referred to Cardiothoracic Surgery for
operative intervention.
On [**2180-5-10**], the patient had coronary artery bypass graft
times three. He had a left internal mammary artery to the
left anterior descending artery and a sequential saphenous
vein graft to first obtuse marginal and second obtuse
marginal. His procedure itself was unremarkable.
Postoperatively, he was taken to the Cardiac Surgery
Intensive Care Unit.
Overnight, he was extubated without incident. He required a
Neo-Synephrine drip through the night, but on the first
postoperative day he was weaned from that and started on
Lopressor. He did spike a temperature to 102.3 degrees on
the night of his operation. He was pan-cultured for this and
started on intravenous vancomycin that was continued for
several days until his cultures proved to be negative.
On the first postoperative day, he was transferred to the
floor. There, his chest tube and Foley catheter were both
removed. The following day, his pacemaker wires were also
removed. He continued with low-grade temperatures to
approximately 100.3, but all of his culture results remained
negative. He worked with Physical Therapy on the floor, and
by the fifth postoperative day was doing rather well. At
this time all of his cultures did indeed prove to be
negative, and his antibiotics were discontinued.
On [**2180-5-15**] the patient was able to do a level V
physical therapy by ascending a flight of stairs, and the
determination was made that he would be safe to be discharged
to home.
DISCHARGE FOLLOWUP: He was instructed to follow up with his
primary care physician (Dr. [**Last Name (STitle) **] in approximately two
weeks. In addition, he was to follow up with Dr. [**Last Name (STitle) 70**]
in six weeks.
DISCHARGE STATUS: The patient was discharged to home.
MEDICATIONS ON DISCHARGE:
1. Lopressor 12.5 mg p.o. b.i.d.
2. Glyburide 5 mg p.o. q.d.
3. Protonix 40 mg p.o. q.d.
4. Lopid 1200 mg p.o. b.i.d.
5. Lasix 20 mg p.o. b.i.d. (times seven days).
6. Potassium chloride 20 mEq p.o. b.i.d. (times seven days).
7. Aspirin 325 mg p.o. q.d.
8. Colace 100 mg p.o. b.i.d.
9. Percocet one to two tablets p.o. q.4-6h. p.r.n.
DISCHARGE DIAGNOSES:
1. Coronary artery disease and left main disease.
2. Now status post coronary artery bypass graft times three.
3. Hypertension; controlled.
4. Non-insulin-dependent diabetes; controlled.
5. Hypercholesterolemia.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 9638**]
MEDQUIST36
D: [**2180-5-15**] 13:53
T: [**2180-5-17**] 12:47
JOB#: [**Job Number **]
|
[
"780.57",
"401.9",
"413.9",
"V17.3",
"780.6",
"250.00",
"998.89",
"414.01",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"36.12",
"88.56",
"39.61",
"89.68",
"36.15",
"88.53"
] |
icd9pcs
|
[
[
[]
]
] |
1959, 2078
|
5047, 5563
|
4682, 5026
|
1638, 1941
|
2782, 4370
|
160, 210
|
4392, 4656
|
239, 1482
|
1504, 1612
|
2095, 2764
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,718
| 121,066
|
7788
|
Discharge summary
|
report
|
Admission Date: [**2121-10-13**] Discharge Date: [**2121-11-14**]
Date of Birth: [**2075-7-7**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Excedrin Sinus / Lipitor
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Dyspnea on exertion, fatigue
Major Surgical or Invasive Procedure:
[**2121-10-15**] AVR([**Street Address(2) 17167**]. [**Male First Name (un) 923**] Regent valve)/MVR(26mm [**Doctor Last Name 405**]
Band)/TVR(28mm [**Doctor Last Name 405**] Band)
[**2121-10-30**] Right-sided evacuation of hemothorax and clotted
blood, Partial pulmonary decortication, and multiple intercostal
rib blocks
[**2121-11-4**] Exploraotry Laparotomy
History of Present Illness:
Mrs. [**Known lastname **] is a 46 year old female who underwent prior coronary
artery bypass grafting in [**2118**] for left main disease. Surgery
was done at [**Hospital3 28188**] center in [**Hospital1 1559**]. Her
postoperative course was complicated by hepatic failure with
coma x 5 weeks. The patient has since that time been
experiencing increasing shortness of breath and chest pressure
associated with dizziness and mild orthopnea. A transesophageal
echocardiogram done in [**2120-12-28**] showed an ejection fraction
of 60 percent, 3+ aortic insufficiency, [**1-30**]+ mitral
regurgitation and a normal aorta. She on a subsequent
catheterization in [**2121-3-28**] was found to have a patent
saphenous vein graft to the left anterior descending as well as
the OM, with moderate to severe aortic insufficiency and
moderate mitral regurgitation. Additionally, the patient had
carotid studies that showed no significant stenosis. She was
admitted to [**Hospital1 69**] for anticipated
aortic valve replacement with +/- mitral valve repair or
replacement and a re-do sternotomy.
Of note, patient was originally admitted in [**2121-5-28**]. The
operation however was postponed secondary to hyponatremia and
mental status changes. Since that time, outpatient evaluation
was performed. A liver ultrasound was normal and biopsy in
[**2121-7-28**] found no evidence of cirrhosis.
Past Medical History:
Aortic and Mitral Valve Regurgitation, Coronary Artery Disease -
s/p CABG in [**2118**], Peripheral Vascular Disease - partial right
iliac occlusion, Hyponatremia, Non-Hodgkins Lymphoma with prior
Radiation, Fibromyalgia, Cervical carcinoma, History of Hip
Necrosis, Hypertension, Hypercholesterolemia, Barrett's
esophagus with Gastroesophageal reflux disease, History of
gastrointestinal bleed, History of bone marrow transplantation,
Status post appendectomy, Status post hysterectomy,
Hypothyroidism, Asthma, Sleep apnea on CPAP, Status post femoral
thrombectomy, Raynaud syndrome, Restless Leg Syndrome
Social History:
The patient is currently disabled. She lives with her
16-year-old daughter in [**Name (NI) 11333**], Mass. She had a recent clearing
by dentistry for surgery. She smoked one pack per day for 30
years. She stopped drinking about 5 years ago. She admitted to
drinking one pint of [**First Name8 (NamePattern2) **] [**Initials (NamePattern4) 28189**] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **]. She used cocaine as a
teenager but denied IV drug use.
Family History:
Both grandparents had coronary artery disease.
Physical Exam:
Vitals: T 95.0, BP 131/64, HR 75, RR 20, SAT 96% RA
General: well developed female in no acute distress
HEENT: oropharynx benign, PERRL, EOMI
Neck: supple, no JVD, carotids 2+ without bruits
Heart: regular rate, 3/6 systolic ejection murmur
Lungs: clear bilaterally
Abdomen: soft, nontender, nondistended, normoactive bowel sounds
Ext: warm, no edema
Pulses: 2+ distally
Neuro: alert and oriented, CN2-12 grossly intact, no focal
deficits noted
Pertinent Results:
[**2121-11-14**] 06:00AM BLOOD WBC-7.9 RBC-3.21* Hgb-9.2* Hct-27.3*
MCV-85 MCH-28.6 MCHC-33.6 RDW-20.6* Plt Ct-314
[**2121-11-14**] 06:00AM BLOOD PT-21.2* PTT-34.0 INR(PT)-3.2
[**2121-11-14**] 06:00AM BLOOD Glucose-90 UreaN-5* Creat-0.5 Na-135
K-4.5 Cl-100 HCO3-26 AnGap-14
Brief Hospital Course:
Outside evaluation for her hyponatremia was unrevealing. Mrs.
[**Known lastname **] was therefore admitted and underwent routine preoperative
evaluation. Sodium at time of admission was 125. Workup was
otherwise unremarkable and she was cleared for surgery. On
[**10-15**], she was taken to the operating room. An
intraoperative TEE revealed moderate to severe tricuspid
regurgitation in addition to her known aortic and mitral valve
insufficiency. As a result, she required an aortic valve
replacement, along with mitral and tricuspid valve repairs - see
operative note for details. Following the operation, she was
brought to the CSRU in stable condition. Her discharge summary
will now be broken down by systems:
CARDIAC: Early postop, she initially required multiple inotropes
to maintain adequate hemodynamics. Concomitantly noted to have
paroxsymal atrial fibrillation which was treated with Amiodarone
and low dose beta blockade. She also experienced periods of
junctional tachycardia. Over her hospital stay, beta blockade
was slowly advanced as tolerated. She remained mostly in a
normal sinus rhythm. Given her mechanical aortic valve, she was
maintained on Heparin with transition to Warfarin. Goal INR is
between 3-3.5
PULMONARY: She had a prolonged intubation secondary to labile
hemodynamics. First extubation trial on [**10-22**] failed,
requiring reintubation. Gradually tolerated pressure support
ventilation and was successfully extubated on [**10-25**]. Due
to a persistent right pleural effusion, a chest tube was placed
on [**10-27**]. There was minimal drainage which consistented
mostly of old blood. Given concern for loculation, the thoracic
service was consulted for VATS procedure. A chest CT was
obtained and significant for large partially loculated right
hemothorax. On [**10-30**], a right sided VATS was performed
along with bronchoscopy. There were no signs of active bleeding,
the hemothorax was drained without complication and the lung
expanded well at end of the operation. Additional chest tubes
were placed. She was followed by serial chest x-rays and the
chest tubes were eventually removed without complication.
VASCULAR: On [**11-4**], she experienced acute abdominal pain
and near syncopal episode while attempting a bowel movement. She
developed acute respiratory distress and required reintubation.
She concomitantly became hypotensive and was noted to have an
extreme drop in hematocrit, as low as 15%. Multiple blood
products were given. Inotropic support was required and she was
brought emergently to the operating room where she was noted to
have a retroperitoneal bleed secondary to a bleeding branch of
the external iliac artery. Once this artery was identified, it
was ligated with surgical clips. The remainder of the
retroperitoneum was examined and found to be free of areas of
bleeding. There was no active abdominal pathology.
GASTROINTESTINAL: LFTs remained essentially normal throughout
her hospital stay. Underwent exploratory laparotomy for an acute
abdomen - see above. A JP drain was placed at the time of
surgery and eventually removed without complication.
RENAL: Initially very fluid overloaded and placed on Lasix drip.
She was gradually transitioned to PO Lasix. Throughout her
hospital stay, her renal function remained stable and she
maintained adequate urine output.
NEUROLOGY: Initially had a prolonged sedation secondary to
cardiac and pulmonary issues. Once awake, she remained
neurologically intact. She suffers from chronic pain. A Fentanyl
patch was utilized with supplemental pain medications prn.
INFECTIOUS DISEASE: Initially febrile without signs of
infection. Fevers gradually resolved. She went on to experience
an acute leukocytosis during acute abdomen/retroperitoneal bleed
episode. White count peaked to 27K at that time. She was
temporarily put on broad spectrum antibiotics for concern for
hollow organ rupture. Antibiotics were eventually discontinued.
NUTRITION: Intermittently required tube feedings. Once clinical
stablized, her diet was advanced and she tolerated PO's without
difficulty.
OTHER: Once clinically stable, she worked daily with physical
therapy to regain strength and mobility.
She was discharged to home in stable condition on POD#30.
Medications on Admission:
Pepcid 40 qd, Seroquel, Quinine 260 qd, Lisinopril 5 qd, Celexa
5 10 qd, Synthroid 25 qd, Zetia 10 qd, Flovent MDI, Atrovent
MDI, Albuterol MDI, Combivent MDI, Ativan, Lopressor 50 [**Hospital1 **],
Fentanyl patch, Prilosec 60 qd
Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*2*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) as needed.
4. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
5. Levothyroxine Sodium 25 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
6. Fentanyl 50 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
7. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q4H (every 4 hours) as needed.
8. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. 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*
10. 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*
11. Coumadin 6 mg Tablet Sig: One (1) Tablet PO once a day for 3
days: Take as directed by Dr. [**Last Name (STitle) 16528**] for INR goal of
[**2-27**].5.
Disp:*30 Tablet(s)* Refills:*0*
12. Zetia 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
13. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1)
Tablet PO Q4-6H (every 4 to 6 hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Aortic, Mitral and Tricuspid Regurgitation, Postoperative
Hemothorax, Postoperative Retroperitoneal Bleed, Postoperative
Atrial Fibrillation, Coronary Artery Disease - s/p CABG in [**2118**],
Lymphoma with prior Radiation, Fibromyalgia, Cervical carcinoma,
History of Hip, Hypertension, Hypercholesterolemia, History of
gastrointestinal bleed, History of bone marrow transplant,
Status post appendectomy, Status post hysterectomy,
Hypothyroidism, Sleep apnea on CPAP, Status post femoral
thrombectomy, Raynaud syndrome
Discharge Condition:
Good
Discharge Instructions:
Patient may shower, no baths. No lotions, creams or ointments to
incisions. No driving or heavy lifting until follow up with
cardiac surgeon. Call if you experience shortness of breath,
excessive weight gain or fevers.
Followup Instructions:
Dr. [**Last Name (STitle) 1290**] in 4 weeks - call for appt
Local PCP, [**Name10 (NameIs) 28190**] [**Name Initial (NameIs) **] [**Last Name (NamePattern4) 16528**] in [**12-29**] weeks - call for appt
Local cardiologist, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**1-30**] weeks - call for appt
Completed by:[**2121-11-14**]
|
[
"998.11",
"398.91",
"244.9",
"998.12",
"427.31",
"397.0",
"396.3",
"496",
"V15.3",
"518.5",
"V10.79",
"997.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"99.04",
"35.33",
"34.09",
"89.60",
"38.93",
"96.72",
"34.51",
"54.95",
"34.04",
"39.61",
"99.07",
"35.22",
"04.81",
"38.86",
"54.19",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
10142, 10191
|
4057, 8314
|
321, 685
|
10754, 10761
|
3759, 4034
|
11028, 11385
|
3230, 3279
|
8594, 10119
|
10212, 10733
|
8340, 8571
|
10785, 11005
|
3294, 3740
|
253, 283
|
713, 2097
|
2119, 2728
|
2744, 3214
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,007
| 134,806
|
23953
|
Discharge summary
|
report
|
Admission Date: [**2192-2-26**] Discharge Date: [**2192-3-1**]
Service: MEDICINE
Allergies:
Penicillins / Naprosyn / Minipress / Nsaids
Attending:[**First Name3 (LF) 7055**]
Chief Complaint:
transferred from outside hospital for cardiac catherization
Major Surgical or Invasive Procedure:
cardiac catherization with drug eluting stent to right coronary
artery
History of Present Illness:
84 year old female,history hypertension presented to outside
hospital with 2 day history of fall/syncope in the setting
feeling weak. At the outside hospital, her head CT was negative
for acute bleed but positive for chronic small vessel changes.
Her lab chemistry was within normal range. Of note, she was
found to have +U/A, and was started on levaquin for presumed
UTI. She was admitted overnite to the outside hospital for
observation and was found on telemetry to have concerning
changes. Her routine EKG on the morning of [**2-26**]
elevation of III, F, and ST depression over L, somewhat more
prominent. Her first set of cardiac enzymes at the outside
hospital showed troponin of 0.28 that trended down to 0.17. Her
3rd set of enzymes (first set of enzymes here ) was negative.
SHe denies any chest pain, shortness of breath, and nausea at
the outside hospital and here. She was evaluated by the
cardiology fellow who transfered her from OSH to here to be
cathed.
Past Medical History:
Spinal stenosis
Hypertension
TIA
s/p bilateral knee surgery
Social History:
lives alone by herself
Family History:
non-contributory
Physical Exam:
Exam on admission:
BP 120/70 P 80 R 14 O2 95% on RA
Gen: NAD, [**Last Name (un) 1425**], somewhat frail-appearing
Neck: NO JVD, supple
CV: RRR, no m/r/g appreciated
Chest: CTAB
Abd: S, NT/ND +BS
Ext: cool, + 1- +2 DP, shinny skin, no edema, old [**Doctor First Name **] scar over
bilaterally knees
Neuro: A+ O X 3, motor and sensory grossly intact
Pertinent Results:
[**2192-2-29**] 06:30AM BLOOD WBC-11.9* RBC-4.19* Hgb-12.2 Hct-35.4*
MCV-85 MCH-29.2 MCHC-34.5 RDW-13.2 Plt Ct-353
[**2192-2-28**] 06:10AM BLOOD WBC-14.0* RBC-4.08* Hgb-12.1 Hct-34.5*
MCV-85 MCH-29.8 MCHC-35.1* RDW-13.3 Plt Ct-280
[**2192-2-27**] 08:55PM BLOOD WBC-14.0* RBC-4.29 Hgb-12.7 Hct-36.4
MCV-85 MCH-29.6 MCHC-34.8 RDW-13.2 Plt Ct-280
[**2192-2-28**] 06:10AM BLOOD Plt Ct-280
[**2192-2-28**] 06:10AM BLOOD PT-14.9* PTT-33.2 INR(PT)-1.4
[**2192-2-27**] 09:29AM BLOOD Plt Ct-259
[**2192-2-27**] 09:29AM BLOOD PT-14.7* PTT-30.3 INR(PT)-1.4
[**2192-2-29**] 06:30AM BLOOD Glucose-85 UreaN-10 Creat-0.6 Na-134
K-4.4 Cl-102 HCO3-22 AnGap-14
[**2192-2-28**] 06:10AM BLOOD Glucose-79 UreaN-11 Creat-0.6 Na-132*
K-4.2 Cl-104 HCO3-19* AnGap-13
[**2192-2-27**] 09:29AM BLOOD ALT-12 AST-18 LD(LDH)-196 CK(CPK)-42
AlkPhos-118* TotBili-0.8
[**2192-2-29**] 06:30AM BLOOD Calcium-8.1* Phos-3.0 Mg-1.7
[**2192-2-28**] 06:10AM BLOOD Calcium-8.0* Phos-2.9 Mg-1.7
...
ECHO ([**2-27**])
1. Left ventricular wall thickness, cavity size, and systolic
function are normal (LVEF>55%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded.
2. The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Mild (1+) aortic regurgitation is
seen.
3. The mitral valve leaflets are mildly thickened. There is
severe mitral
annular calcification. Mild (1+) mitral regurgitation is seen.
..
Carotid U/S ([**2-27**]):Minimal plaque with bilateral less than 40%
carotid stenosis.
..
Cath ([**2-26**])
1. Selective coronary angiography of this right dominant system
revealed
two vessel coronary disease. The LMCA was without flow limiting
disease. The LAD contained a focal 80% lesion involving the
bifurcation
of a large D1. The LCX was without angiographically apparent
disease.
The RCA contained a discrete 95% lesion mid vessel.
2. Limited resting hemodynamics revealed a central aortic
pressure of
140/60.
3. Successful PTCA/stenting of the mid RCA with a 3.0x16mm Taxus
DES,
postdilated to 3.5mm. Final angiography revealed no residual
stenosis,
no dissection and TIMI-3 flow ( see PTCA comments).
4. Left ventriculography was not performed.
..
CT head ([**2-26**]): neg acute bleed
..
CT abd/pelvis ([**2-26**]):
1) Diffuse swelling of the muscles and other soft tissues in the
right groin and thigh, consistent with bleeding status post
right common femoral artery puncture. No focal measurable
hematoma collection. No evidence of retroperitoneal hematoma.
2) Anasarca.
3) Right renal cyst.
Ultrasound of RLE ([**3-1**]): demonstrated Deep Venous Thrombosis of
R common femoral vein.
Brief Hospital Course:
The patient was admitted and underwent cath that showed the
above. She received stents. She experienced a vagal symptoms
after having the sheaths pulled. She received phenergan and
experienced EPS-like symptoms, acute mental status change and
hypotension stabilized with IV fluids and brief infusion of
dopamine. She was transferred to the CCU for observation
overnite for concerning of hematoma bleed/retroperitoneal
bleed/head bleed. Her head CT was negative bleed. Her carotid
ultrasound showed minimal plaques disease. Her abdominal CT did
not show any retroperitoneal bleed and no significant bleed
around the right groin site. Her hct dropped from 36 to 31 and
was given 2 unit of pRBC. She also had a cardiac ECHO on [**2-26**]
that did not show any pericardial effusion. Her hct stabilized
to 34-36 afterward. Her mental status also cleared up from [**2-26**]
to [**2-27**]. She was subsequently transferred from CCU to cardiac
step-down on [**2-27**] for continue medical management.
The patient had stent to RCA but had a complex LAD lesion at
bifurcation with D1 that was not intervened upon. There was
consideration given to performing P-MIBI on patient during
admission to assess extent of LAD ischemia. However, patient was
hesitant to undergo repeat cardiac catheterization and and no
symptoms of ischemia during remainder of hospital stay.
Therefore, the MIBI was deferred. If she has symptoms she could
be stressed as outpatient to evaluate LAD lesion.
She was optimized in terms of her blood pressure medications.
She was evaluated by physical therapy who felt that she needs to
go to rehab for further optimization.
On [**3-1**] the patient was noted to have edema of the R leg.
US of the leg demonstrated DVT of the right common femoral vein.
She denied any chest pain, shortness of breath. Her vital signs
remained normal and stable. She was started on Lovenox 50 mg SQ
[**Hospital1 **] and Warfarin 4 mg PO QD to target INR of 2.0 for 6 months.
She is to go to rehab on aspirin, plavix along with other blood
pressure medications and a statin medication.
Given that patient has history of diverticulosis and falls and
she is now on multiple antiplatelet agents and coumadin, her INR
and HCT need to be followed closely as an outpatient.
Medications on Admission:
asa 325
levaquin 250 daily
accupril 10 daily
atenolol 50 daily
hctz 25 daily
KCL MVI
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
3. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. 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*
5. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
6. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
8. Enoxaparin 50 mg SQ [**Hospital1 **] until INR reaches 2.0
9. Warfarin 4 mg PO QAM to target INR 2.0 for 6 months
Discharge Disposition:
Extended Care
Facility:
[**Hospital 66**] Rehab & Nursing Center - [**Hospital1 392**]
Discharge Diagnosis:
Primary
CAD
Secondary
Hypertension
Discharge Condition:
stable
Discharge Instructions:
please take your medications, including aspirin and plavix.
please call your doctor or 911 if you experience chest pain or
shortness of breath
Followup Instructions:
please call your primary care physician for followup in 2 weeks.
please call for appointment with cardiology to see Dr. [**Last Name (STitle) **]
in [**2-29**] weeks. He can call Dr. [**Last Name (STitle) 7047**] here at [**Hospital1 18**] for more
information about your cardiac catheterization here at [**Hospital1 18**].
|
[
"410.31",
"427.89",
"780.2",
"285.1",
"997.1",
"724.00",
"414.01",
"998.12",
"V12.59",
"715.90",
"562.10",
"401.9",
"787.01",
"V43.65",
"453.40"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"99.20",
"99.04",
"36.01",
"88.56",
"36.07"
] |
icd9pcs
|
[
[
[]
]
] |
7899, 7988
|
4593, 6857
|
310, 383
|
8067, 8075
|
1927, 4570
|
8268, 8596
|
1525, 1543
|
6993, 7876
|
8009, 8046
|
6883, 6970
|
8099, 8245
|
1558, 1563
|
211, 272
|
411, 1385
|
1577, 1908
|
1407, 1469
|
1485, 1509
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,630
| 191,470
|
13360
|
Discharge summary
|
report
|
Admission Date: [**2151-7-13**] Discharge Date: [**2151-7-28**]
Date of Birth: [**2078-11-27**] Sex: F
Service: CSU
CHIEF COMPLAINT: Ms. [**Known lastname 40614**] is a postoperative admission
admitted to the directly to the Operating Room for an aortic
valve replacement as well as a root replacement. Her chief
complaint upon assessment at the hospital was increasing
shortness of breath and dyspnea on exertion with occasional
shortness of breath at rest.
HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 40614**] is a 72 year-old
woman followed with serial echocardiograms for many years
with an increasing shortness of breath in the past three to
six months. A CAT scan done in [**2137**] showed a dilated aorta.
She has been followed since that time. Cardiac
catheterization done in [**2151-1-21**] showed normal
coronaries with severe aortic insufficiency and severe aortic
root dilatation. Echocardiogram done in [**2150-12-21**]
showed 3 to 4 plus aortic insufficiency as well as an aortic
stenosis with a peak gradient of 42 as well as dilated
ascending aorta.
PAST MEDICAL HISTORY: Hypertension.
Osteoarthritis of both knees.
Obesity.
Hypercholesterolemia.
Bilateral cataracts.
Renal calculi.
Chelation therapy in [**2142**] for unknown reason.
Depression.
Bilateral lower extremity varicosities.
PAST SURGICAL HISTORY: Bilateral total hip replacement.
Right urolithotomy.
Total abdominal hysterectomy.
MEDICATIONS:
1. Aspirin 81 mg po q.d.
2. Cozaar 100 mg q.d.
3. methdilazine q.d.
4. Lipitor no dose.
5. Amoxicillin prn for any dental work.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: Mother died at 90 of old age. Father died
at 72 of Parkinson's disease. She is currently living alone
and is retired. Denies tobacco use. One glass of wine per
day. No other recreational drug use.
PHYSICAL EXAMINATION: Heart rate 77. Blood pressure 132/76
. Height 5'3". Weight 182 pounds. General obese, pleasant
woman slightly short of breath. Skin no obvious lesions.
HEENT pupils are equal, round and reactive to light.
Extraocular movements intact. Neck is supple with enlarged
pulsatile carotid on the right. Chest is clear to
auscultation on the left with basilar crackles on the right.
Cardiovascular regular rate and rhythm. S1 and S2 with 4/6
systolic ejection murmur throughout. Abdomen is soft, obese,
nontender, nondistended with positive bowel sounds. No
hepatosplenomegaly. No costovertebral angle tenderness.
Extremities are warm and well perfuse with no clubbing,
cyanosis or edema, bilateral varicosities noted left greater
then right. Pulses femoral 1 plus bilaterally. Dorsalis
pedis pulses 2 plus bilaterally. Posterior tibial pulses 2
plus bilaterally and radial is 2 plus on the right.
LABORATORIES ON ADMISSION: White blood cell count 6.3,
hematocrit 35.6, platelets 213, sodium 140, potassium 3.9,
BUN 20, creatinine 0.7, glucose 119. Chest x-ray showed
cardiomegaly. Preoperatively the patient also had a carotid
ultrasound that showed no significant atherosclerotic plaque
or stenoses. She had a CT of the chest and abdomen, which
showed a 7 cm fusiform ascending aortic aneurysm,
nephrolithiasis without evidence of obstruction and
cholelithiasis.
HOSPITAL COURSE: As stated previously the patient was
admitted directly to the Operating Room on [**2151-7-13**]. At that
time she underwent Bentall procedure with a number 21
homograft and number 26 gel weave, hemi arch repair
proximally. Please see the Operating Room report for full
details. In summary, the patient's cardiopulmonary bypass
time was 220 minuets with cross clamp time of 188 minutes and
circ arrest time of 14 minutes. She tolerated the operation
well and was transferred from the Operating Room to the
Cardiothoracic Intensive Care Unit. At the time of transfer
the patient had Phenylephrine at 0.2 mics per kilogram per
minute and Propofol at 20 mics per kilogram per minute. She
was in sinus rhythm at 100 beats per minute with a mean
arterial pressure of 70 and a CVP of 5. The patient did well
on the immediate postoperative period, however, she was very
agitated and tachypneic upon reversing her anesthesia and we
were unable to extubate her on the day of surgery. On
postoperative day one the patient remained hemodynamically
stable. She was started on Apresodex in an attempt to wean
from the ventilator and successfully weaned and extubated
with a Apresodex infusion. Following extubation her Swan-
Ganz catheter was discontinued. She remained in the
Cardiothoracic Intensive Care Unit for hemodynamic control.
On postoperative day two the patient continued to do well.
She was hemodynamically stable. Her chest tubes were removed
and she was transferred to the floor for continued
postoperative care and rehabilitation. On postoperative day
three the patient continued to do well. Her temporary pacing
wires were removed and her activity level was advanced with
the assistance of the nursing staff and physical therapy
staff. Over the next several days the patient remained on
the floor, slowly advancing in her activity level. On
postoperative day five the patient was noted to be increasing
tachycardic. She continued to be monitored closely. On the
evening of postoperative day five the patient had increasing
ectopy and ultimately went into an atrial fibrillation
following which she became dyspneic. At that time she was
transferred from the floor to the Cardiothoracic Intensive
Care Unit for closer hemodynamic monitoring and to be begun
on intravenous beta blockade as well as ultimately a trial of
Diltiazem. Following which the patient became despite her
atrial fibrillation and dyspnea the patient continued to
mentate and make adequate amounts of urine. On postoperative
day six in the Intensive Care Unit the patient was started on
an Amiodarone drip. She had an echocardiogram done that
showed a pericardial effusion without signs of tamponade.
She also had a chest x-ray, which showed a left sided
effusion. Chest tube was placed to drain the pleural
effusion and the patient was begun on a Neo-Synephrine drip
to support her blood pressure. Additionally the Cardiology
Service was consulted.
Following morning a repeat echocardiogram showed continued
pericardial effusion with increasing signs of tamponade. At
that time interventional cardiology was consulted and the
patient was brought to the cardiac catheterization laboratory
in attempt to drain the pericardial effusion. That attempt,
however, was not successful and the patient was transferred
from the cardiac catheterization laboratory to the Operating
Room at which time she underwent drainage of her pericardial
effusion through a sternal incision. Please see the full
Operating Room report for full details. In summary, the
patient tolerated the drainage of her pericardial effusion
and was transferred from the Operating Room back to the
Cardiothoracic Intensive Care Unit. The patient did well in
the immediate postoperative period. She was continued on her
Amiodarone drip as well as a Propofol drip to keep her
sedated throughout the course of the night. On the morning
of postoperative day one from her pericardial drainage the
patient's sedation was discontinued. She was successfully
weaned from the ventilator and extubated. Prior to extubation
the patient underwent DC cardioversion successfully to a
sinus rhythm. The patient remained hemodynamically stable.
On postoperative day eight from the Bentall and two from her
pericardial drainage the patient had gone back into an atrial
fibrillation. She remained on her Amiodarone drip and was
off and Neo-synephrine drip to support her blood pressure.
She therefore remained in the Cardiothoracic Intensive Care
Unit during this period. Later in the day the patient
spontaneously converted to a sinus rhythm with a heart rate
in 60s following which her Amiodarone drip was discontinued
and she was placed on oral Amiodarone as well as Metoprolol.
On postoperative day nine the patient continued to progress
slowly and on postoperative day ten the patient's chest tubes
and central line were discontinued as well as her Foley
catheter and she was again transferred to the floor for
continuing postoperative care. Over the next several days on
the floor the patient had an uneventful hospital course. Her
activity level was gradually increased with the assistance of
the nursing staff and physical therapy. She remained
hemodynamically stable. She was gradually diuresed and her
beta blockade increased as tolerated by her blood pressure
and on postoperative day 15 it was decided that the patient
was stable and ready to be transferred to rehabilitation.
At this time the patient's physical examination is vital
signs temperature 97, heart rate 67, sinus rhythm, blood
pressure 117/81, respiratory rate 18, O2 sat 94 percent on
room air. Weight preoperatively is 82 kilograms, at
discharge it is 88.6 kilograms. Laboratory data at discharge
white blood cell count 10.9, hematocrit 29.7, platelets 342,
sodium 135, potassium 4.3, chloride 96, CO2 29, BUN 15,
creatinine 0.6, glucose 110. Neurological alert and oriented
times three, moves all extremities, follows commands,
nonfocal examination. Respiratory diminished in the bases,
otherwise clear. Cardiovascular regular rate and rhythm. S1
and S2. Incision with staples open to air clean and dry.
Abdomen is soft, nontender with normoactive bowel sounds.
Extremities are warm and well perfuse with 1 to 2 plus edema
bilaterally.
DISCHARGE MEDICATIONS:
1. Aspirin 325 q.d.
2. Ranitidine 75 b.i.d.
3. Colace 100 b.i.d.
4. Lasix 20 mg b.i.d. times two weeks and then q.d.
5. Amiodarone 400 mg po b.i.d. times one week and then 400 mg
q.d. times one week and then 200 mg q.d.
6. Lopressor 25 mg b.i.d.
7. Percocet 5/325 one to two tablets q 4 hours prn.
8. Tylenol 650 mg q 6 hours prn.
CONDITION ON DISCHARGE: Good.
DISCHARGE DIAGNOSES: Status post Bentall with a number 21
homograft and hemi arch repair proximally with a number 26
gel weave.
Status post pericardial effusion requiring drainage.
Atrial fibrillation.
Hypertension.
Hypercholesterolemia.
Nephrolithiasis.
Osteoarthritis bilaterally.
Bilateral cataracts.
Depression.
Bilateral total hip replacements.
Right ureteral lithotomy.
Total abdominal hysterectomy.
DI[**Last Name (STitle) 408**]E STATUS: The patient is to be discharged to
rehabilitation. She is to have follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
two to three weeks following her discharge from
rehabilitation and follow up with Dr. [**Last Name (Prefixes) **] in four
weeks.
[**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**]
Dictated By:[**Last Name (NamePattern4) 1718**]
MEDQUIST36
D: [**2151-7-28**] 11:29:12
T: [**2151-7-28**] 12:22:33
Job#: [**Job Number **]
|
[
"997.1",
"592.0",
"441.2",
"427.31",
"278.00",
"423.0",
"424.1",
"401.9",
"V43.64"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.69",
"34.09",
"37.21",
"99.29",
"34.03",
"37.0",
"39.64",
"38.45",
"39.61",
"35.21",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
1656, 1859
|
9960, 10931
|
9570, 9906
|
3276, 9547
|
1372, 1639
|
1882, 2799
|
155, 483
|
512, 1101
|
2814, 3258
|
1124, 1348
|
9931, 9938
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,134
| 168,518
|
36925
|
Discharge summary
|
report
|
Admission Date: [**2198-6-12**] Discharge Date: [**2198-6-18**]
Date of Birth: [**2116-8-13**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
Chest pain and dyspnea
Major Surgical or Invasive Procedure:
Cardiac Cath
IABP placement and removal
History of Present Illness:
81 year old man with HTN, PUD, DM and CRI presented on [**2198-6-11**] to
[**Hospital3 **] with progressive shortness of breath, epigastric
fullness, chest pain and dysuria. His EKG showed Q waves V1-4
and STD laterally and initial Troponin-I was 0.85, which
subsequently bumped to 70.93 on next draw and then trended down
to 55.28 prior to transfer to [**Hospital1 18**]. His CXR and exam were also
found to be consistent with pulmonary edema (pt O2 sat 95% 3L)
and pt was diuresed with 40 mg IV Lasix. He was noted to have a
UTI (+ E.Coli with unknown antimicrobial sensitivities) and
treated with a dose of 500 mg IV Levoquin (remained afebrile).
Also, his Cr on admission 2.5 (recent baseline apparently 1.6)
with a K 6.9. These were treated with Kayexalate, insulin,
calcium gluoncate and Lasix. The pt's home ACEi was held and his
repeat SCr this morning was 2.1.
.
Pt was reportedly loaded with 600 mg clopidogrel and started on
heparing and nitroglycerin gtts. Arrangments were made for
transfer to [**Hospital1 18**] for cardiac catheterization.
.
On arrival to [**Hospital1 18**], the patient was comfortable with stable
vitals, but was noted to have persistent wet crackles on lung
exam with a 4L NC oxygen requirement. Repeat CE were CK: 459
MB:19 MBI:4.1 Trop-T:5.27. As the nitro infusion rate was very
low, this was stopped and he was continued on heparin.
Integrelin was not started due to renal failure.
.
After several hours on the floor, the patient reported
experiencing recurrent [**2-13**] right chest pain (achy, pressure
sensation) while eating. This pain was identical to this
discomfort that caused him to present initially. An ECG was
remarkable for new 2 mm STE in V1 and 1 mm STE in V2, as well as
new inferior Q waves. A nitroglycerin gtt was restarted with
rapid resolution in the patient's symptoms. Repeat ECG once pain
free was remarkable for a new RBBB. Given the patient's
recurrent CP and dynamic ECG changes he was transferred to the
CCU for ongoing monitoring.
REVIEW OF SYSTEMS: current
Cardiac:
(+)ve: None
(-)ve: chest pain, dyspnea on exertion, paroxysmal nocturnal
dyspnea, orthopnea, ankle edema, palpitations, syncope,
presyncope
General:
(+)ve: Difficulty hearing
(-)ve: fevers, chills, rigors, dysuria, hematuria, myalgias,
joint pains, cough, hemoptysis, black stools, red stools,
exertional buttock pain, calf pain
Past Medical History:
Cardiac Risk Factors:
(+)ve Diabetes (Last recorded Hgb A1C = 8.1% [**11/2197**])
(+)ve Hypertension
(-)ve Dyslipidemia
.
Cardiac History:
CABG: None
Percutaneous coronary intervention: None
Pacemaker/ICD: None
.
Other Past History:
1) Peripheral vascular disease
2) CKD with baseline CR of 1.5
3) Chronic lower extremity edema
4) ? BPH (patient on doxazosin as outpatient and presented to
OSH with urinary retension)
Social History:
The pt is retired from the army. He lives at home with his wife
and son. [**Name (NI) **] under 3 pack years of tobacco use. Denies EtOH.
Family History:
The patient's father died at 69 from his first MI. The pt's
mother died in her 50's from non-alcoholic cirrhosis. The
patient has two brothers and one sister who underwent CABG in
their 50s. There is a strong FH of smoking and lung cancer.
Physical Exam:
Gen: Thin, elderly male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with flat neck veins.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Few bibasilar crackles,
no wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits.
Ext: No C/C/E. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
.
Pulses:
Right: Carotid 2+ Femoral 2+ DP 1+
Left: Carotid 2+ Femoral 2+ DP 1+
Pertinent Results:
[**2198-6-12**] 05:04PM BLOOD WBC-14.6* RBC-3.89* Hgb-11.4* Hct-32.4*
MCV-83 MCH-29.2 MCHC-35.2* RDW-13.1 Plt Ct-369
[**2198-6-12**] 05:04PM BLOOD PT-16.0* PTT-46.5* INR(PT)-1.4*
[**2198-6-12**] 05:04PM BLOOD Glucose-146* UreaN-58* Creat-2.0* Na-139
K-3.7 Cl-98 HCO3-27 AnGap-18
[**2198-6-13**] 10:30AM BLOOD ALT-32 AST-45* CK(CPK)-170 AlkPhos-63
Amylase-44 DirBili-0.1
[**2198-6-13**] 05:31AM BLOOD Calcium-9.0 Phos-3.6 Mg-2.2 Iron-34*
Cholest-91
[**2198-6-13**] 05:31AM BLOOD Triglyc-135 HDL-25 CHOL/HD-3.6 LDLcalc-39
[**2198-6-12**] 05:04PM BLOOD %HbA1c-6.9*
[**2198-6-13**] 05:31AM BLOOD calTIBC-234* Ferritn-157 TRF-180*
[**2198-6-13**] 10:30AM BLOOD VitB12-196*
[**2198-6-12**] 05:04PM BLOOD CK-MB-19* MB Indx-4.1 cTropnT-5.27*
[**2198-6-12**] 09:38PM BLOOD CK-MB-15* MB Indx-4.3 cTropnT-4.20*
proBNP-[**Numeric Identifier **]*
[**2198-6-12**] 09:38PM BLOOD CK-MB-14* MB Indx-4.3 cTropnT-4.15*
proBNP-[**Numeric Identifier **]*
[**2198-6-13**] 05:31AM BLOOD CK-MB-10 MB Indx-4.8 cTropnT-3.52*
proBNP-[**Numeric Identifier **]*
[**2198-6-13**] 10:30AM BLOOD cTropnT-2.87*
[**2198-6-13**] 07:04PM BLOOD CK-MB-6
[**2198-6-14**] 08:00PM BLOOD CK-MB-5
[**2198-6-15**] 04:24AM BLOOD CK-MB-7
[**2198-6-12**] 05:04PM BLOOD CK(CPK)-459*
[**2198-6-12**] 09:38PM BLOOD CK(CPK)-345*
[**2198-6-12**] 09:38PM BLOOD CK(CPK)-327*
[**2198-6-13**] 05:31AM BLOOD CK(CPK)-210*
[**2198-6-13**] 07:04PM BLOOD CK(CPK)-143
[**2198-6-14**] 08:00PM BLOOD CK(CPK)-112
[**2198-6-15**] 04:24AM BLOOD CK(CPK)-130
[**2198-6-13**] 03:25PM URINE CastHy-0-2
[**2198-6-13**] 03:25PM URINE RBC-[**6-13**]* WBC-21-50* Bacteri-MOD
Yeast-NONE Epi-0
[**2198-6-13**] 03:25PM URINE Blood-LG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD
[**2198-6-13**] 03:25PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.018
URINE CULTURE (Final [**2198-6-14**]): NO GROWTH.
OSH Urine Culture: E. Coli pansensitive
ECG:
Sinus tachycardia. Left axis deviation. Late R wave progression.
Predominantly anterolateral ST-T wave abnormalities. Low
precordial
QRS voltage. No previous tracing available for comparison.
Clinical
correlation is suggested.
[**6-13**] Cardiac Cath
COMMENTS:
1. Selective coronary angiography in this right dominanat system
revealed severe LM and 3 vessel coronary artery disease. The
LMCA had
diffues 90% stenosis involving the proximal LAD. Poor distal
filling of
the LAD was noted with R to L collaterals. The LCX was noted to
have
poor filling with one reasonable sized OM with a diffuse 80%
proximal
stenosis. The RCA was a large vessel with a proximal PDA 70%
stenosis in
a notably small vessel. The RPL had a 60% stenosis.
2. Resting hemodynamics revealed normal systemic blood pressure.
There
was elevated right sided filling pressures with RVEDP of 16
mmHg. There
were elevated estimated left sided filling pressures with mean
PCWP of
18 mmHg. There was mild pulmonary hypertension with PASP of 30
mmHg.
3. Successful IABP placement.
FINAL DIAGNOSIS:
1. Left main and Three vessel coronary artery disease.
2. Successful IABP placement.
[**6-14**] Cardiac Cath
COMMENTS:
1. Selective coronary angiography revealed 3 vessel coronary
artery
disease. The LMCA had a 90% stenosis. The proximal LAD had a 90%
stenosis and was diffusely diseased distally. The LCX was
diffusely
disease and the OM2 had an 80% mid vessel stenosis. The RCA was
not
engaged.
2. Limited resting hemodynamics revealed normal systemic
pressures with
good diastolic augmentation from the IABP.
3. Left ventriculography was deferred.
4. Successful PTCA and stenting of the LMCA with a 3.0 x 28 mm
XIENCE
DES which was post dilated with a 4.0 x 12 mm NC balloon at 14
ATM.
Final angiography revealed no residual stenosis in the stent, no
dissection and TIMI III flow. (See PTCA comments)
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Successful stenting of the LMCA.
[**6-13**] TTE
Left ventricular wall thicknesses and cavity size are normal. No
masses or thrombi are seen in the left ventricle. Overall left
ventricular systolic function is severely depressed (LVEF= 25-30
%) with globbal hypokinesis and regioanl akinesis of the
inferior wall, distal septum and apex (multivessel CAD?). RV
with borderline normal free wall function. 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. The tricuspid
valve leaflets are mildly thickened. There is mild pulmonary
artery systolic hypertension. There is a small pericardial
effusion. There are no echocardiographic signs of tamponade.
Carotid U/S
IMPRESSION: Mild plaque in the internal carotid arteries
bilaterally with
less than 40% stenosis on both sides. This is a baseline
examination at the
[**Hospital1 18**].
Brief Hospital Course:
[**2198-6-15**]:
- balloon pump removed at 14:30, will need groin check
- I/O (goal 500-1000cc): 4:30pm +622, gave 20mg IV lasix.
- Urine lytes...
[**2198-6-14**]:
-Successful cath w/ placement of left main stent
-IABP remained in o/n, hep gtt restarted
-unremarkable post cath check
-
[**2198-6-13**]:
- [**Hospital3 **] U/A: yellow, turbid, SG 1.011, -glucose,
-bili, -ketones, blood large, pH5.5, protein 300, urobilinogen
0.2, -nitrite, large leuk esterase, few squamous epi, TNTC WBC,
[**10-17**] RBC, 2+ bacteria. Growing E.Coli 100,000 CFU/mL,
pansensitive. Record is in chart.
- U/A: cont to be dirty
- Echo: LVEF= 25-30 % with globbal hypokinesis and regioanl
akinesis of the inferior wall, distal septum and apex. RV with
borderline normal free wall function. No AS/AR, no MVP. 1+ MR,
Mild pulmonary HTN. Small pericardial effusion, no echo signs of
tamponade.
- Carotid U/S: <40% bilaterally
- Iron studies: Fe 34, ferritin 157, TIBC 234, TRF 180. Thought
mildy iron deficient. Started iron 325mg daily, and guiac stools
x3
- lipid panel: total chol 91, HDL 25, LDL 39
- HbA1c: 6.9%
- labs ordered for AM per CT [**Doctor First Name **]: albumin, LFTs, T+C
- EKG: unchanged
- CT surgery will take in morning.
- became nauseated w/ K replacement, vomit x1, compazine x1
[**2198-6-12**]:
Repeat CE trending down: CK:327 MB:14 MBI:4.3 Trop-T:4.15
81 yo male with history of HTN and diabetes who presented to OSH
with SOB/CP found to have [**Hospital 39700**] transferred to [**Hospital1 18**] for
cardiac cath and to CCU for ongoing monitoring in setting of
recurrent CP and new RBBB.
.
#. CAD: Patient was found to have an NSTEMI at an OSH. He was
transferred to [**Hospital1 18**] for cardiac cath and further monitoring.
His EKG showed Q waves V1-4 and STD laterally and initial
Troponin-I was 0.85, which subsequently bumped to 70.93 on next
draw and then trended down to 55.28 prior to transfer to [**Hospital1 18**].
.
Pt was reportedly loaded with 600 mg clopidogrel and started on
heparin and nitroglycerin gtts. On arrival to [**Hospital1 18**], the patient
was comfortable with stable vitals, but was noted to have
persistent wet crackles on lung exam with a 4L NC oxygen
requirement. Repeat CE were CK: 459 MB:19 MBI:4.1 Trop-T:5.27.
As the nitro infusion rate was very low, this was stopped and he
was continued on heparin. Integrelin was not started due to
renal failure.
.
After several hours on the floor, the patient reported
experiencing recurrent [**2-13**] right chest pain (achy, pressure
sensation) while eating. This pain was identical to this
discomfort that caused him to present initially. An ECG was
remarkable for new 2 mm STE in V1 and 1 mm STE in V2, as well as
new inferior Q waves. A nitroglycerin gtt was restarted with
rapid resolution in the patient's symptoms. Repeat ECG once pain
free was remarkable for a new RBBB. Given the patient's
recurrent CP and dynamic ECG changes he was transferred to the
CCU for ongoing monitoring.
Pt with multiple risk factors for CAD, including HTN and
diabetes. The patient underwent cardiac cath on that showed
severe LM and 3 vessel coronary artery disease. The LMCA had
diffues 90% stenosis involving the proximal LAD, OM with a
diffuse 80% proximal stenosis. The RCA was a large vessel with a
proximal PDA 70% stenosis and RPL with 60% stenosis.
Additionally, an IABP was successfully placed. Given the
patient's disease a discussion occured regarding CABG, but the
patient declined surgery and opted for stenting. The patient
then underwent successful stenting of his LMCA with a 3.0 x 28
mm DES on [**2198-6-14**]. The patient tolerated the procedure well and
his IABP was weaned and successfully removed on [**6-15**]. The
patient remained chest pain free. He was continued on aspirin,
plavix, metoprolol, and atorvastatin. His ACE-I was held
secondary to his renal failure.
#. Pump: At the OSH the patient's CXR and exam were consistent
with pulmonary edema (pt O2 sat 95% 3L) and pt was diuresed with
40 mg IV Lasix. Pt initially with evidence of mild failure on
exam by report, although in the CCU the patient appeared
improved. The patient was on Lasix as an outpatient. An ECHO
performed on [**6-13**] showed EF 25-30% with global hypokinesis and
regioanl akinesis of the inferior wall, distal septum and apex.
Likely suspect ischemia as major contributing etiology to his
failure. The patient was given lasix 20mg IV for diuresis and
restarted on his home dose of 40mg po.
#. Rhythm: NSR per OSH EKGs, with RBBB initally on ECG. On
repeat [**6-14**] the bundle branch had resolved.
#. [**Last Name (un) **] on CKD: By report pt had some urinary retention at OSH
and improved s/p Foley catheter placement. Also, his Cr on
admission 2.5 (recent baseline apparently 1.6) with a K 6.9.
These were treated with Kayexalate, insulin, calcium gluoncate
and Lasix at the OSH. The pt's home ACEi was held and his repeat
SCr this morning was 2.1. The patient's creatine did trend up to
2.3 after his two cardiac catheterizations. Prior to each
procedure he was given mucomyst and pre-cath hydration. His
ACE-I was held secondary to his rising creatinine. On discharge
hos creatine was improving and was 2.0 on discharge.
.
#. Urinary Tract Infection: At the OSH he was noted to have a
UTI (+ E.Coli that was pansensitive). He was treated at the OSH
with a dose of 500 mg IV Levoquin. He reamined afebrile. On
admission he was treated with Ciprofloxacin 500 mg Q24H x 6 days
(total 7 day course). His repeat urine culture here was no
growth.
.
#. Urinary Retention: The patient was found to have retention at
the OSH and foley catheter was placed. During his admission his
foley was removed, but the patient was unable to void. A foley
was placed again and speaking with Urology recommended leaving
the foley in place for 1 week with urology follow-up as an
outpatient. He was arranged with outpatient follow-up on [**6-21**].
He was also restarted on doxazosin.
#. GERD: Was on PPI at home and at OSH. Due to interaction with
clopidogrel he was changed to H2 blocker (Ranitidine 150 mg
[**Hospital1 **]).
.
#. Diabetes: His home medications of metformin, glimepiride,
rosiglitazone were held. He was continued on ISS and diabetic
diet. He was discharged on his home regimen.
.
# Anemia: The patient was found to be iron deficient and low
B12. He was started on iron supplements and given an IM dose of
Vit B12. His Hct remained stable and discharge Hct was 28.4.
He did not receive blood products durng his admission.
Medications on Admission:
Metformin 500mg [**Hospital1 **]
Nadolol 80mg daily
Glimeperide 4mg BS <140
Glimeperide 8mg BS >140
Lasix 40mg daily
KChlor 20mg daily
Quinapril 20mg daily
Avandia 50mg daily
Doxazosin 4mg qHS
Omeprazole 20mg daily
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. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*30 Tablet(s)* Refills:*0*
6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
Disp:*30 Tablet(s)* Refills:*2*
7. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
10. Glimepiride 4 mg Tablet Sig: One (1) Tablet PO once a day.
11. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
12. Rosiglitazone Oral
13. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Primary:
NSTEMI
UTI
Urinary Retention
Secondary:
CRI
Anemia
Discharge Condition:
stable, ambulating with walker, foley in place
Discharge Instructions:
It was a pleasure taking care of you while you were in the
hospital. You were admitted to [**Hospital1 18**] because of a heart attack.
You underwent intervention and got a stent to your heart. You
also had a balloon pump in place to help your heart pump, this
was removed without complications. You were also treated for a
urinary tract infection with antibiotics.
You also had difficulty urinating and a foley catheter was
placed. This should remain inplace until you follow-up with
your Urology appointment below.
Please follow the medications prescribed below.
1) START metoprolol 25mg twice a day
2) START plavix 75mg daily
3) START atorvastatin 80mg daily
4) START Ferrous Sulfate 325mg daily
5) START Aspirin 325mg daily
6) CONT lasix 40mg daily
7) STOP omeprazole and START famotidine 20mg daily
8) START docusate and senna for bowel regimen if needed
9) START Doxazosin 4mg daily at night
Please follow up with the appointments below.
Please call your PCP or go to the ED if you experience chest
pain, palpitations, shortness of breath, nausea, vomiting,
fevers, chills, or other concerning symptoms.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction:
Followup Instructions:
Appointment #1
MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7986**], NP
Specialty: Urology
Date and time: [**6-21**] at 9:30am
Location: [**Hospital Ward Name 23**] Clinical Center, [**Location (un) 470**]
Phone number: [**Telephone/Fax (1) 164**]
Special instructions if applicable: for Foley Catheter removal
Appointment #2
MD: Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Specialty: Cardilogy
Date and time: [**7-10**] at 10:20am
Location: [**Hospital Ward Name 23**] [**Location (un) 436**]
Phone number: [**Telephone/Fax (1) 62**]
Special instructions if applicable:
Appointment #3
MD: Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 15942**]
Specialty: Primary Care
Date and time: [**7-2**] at 11:30am
Location: [**Street Address(2) 14226**], [**Location (un) 5110**]
Phone number: [**Telephone/Fax (1) 60570**]
Completed by:[**2198-6-18**]
|
[
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"403.91",
"599.0",
"E849.7",
"584.9",
"585.6",
"996.72",
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"458.29",
"428.33",
"E879.0",
"414.01",
"427.89",
"428.0",
"041.4",
"280.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.61",
"88.56",
"36.07",
"97.44",
"00.45",
"00.66",
"00.40",
"37.23"
] |
icd9pcs
|
[
[
[]
]
] |
17373, 17424
|
9354, 15877
|
338, 380
|
17529, 17578
|
4439, 7419
|
18864, 19777
|
3389, 3630
|
16143, 17350
|
17445, 17508
|
15903, 16120
|
8261, 9331
|
17602, 18841
|
3645, 4420
|
2428, 2776
|
276, 300
|
408, 2409
|
2798, 3218
|
3234, 3373
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,232
| 188,942
|
52430
|
Discharge summary
|
report
|
Admission Date: [**2182-9-23**] Discharge Date: [**2182-10-3**]
HISTORY OF PRESENT ILLNESS: This is a 77-year-old man with
history of end stage renal disease on hemodialysis,
hypertension, non insulin dependent diabetes mellitus, PVD,
admitted day #4 postoperatively for elective L4,5 lumbar
His operation was uncomplicated, however, he had a presumed
aspiration day #1 postoperatively which led to respiratory
distress, unresponsiveness requiring intubation and he was
transferred to SICU. Bronchoscopy was performed on [**2182-9-24**]
with finding consistent with bleeding from ETT trauma and
positive evidence of food in lower airway consistent with
aspiration. ENT consult noted no significant laceration,
patient's SICU course was notable for extubation on [**9-25**], he
continued hemodialysis per renal team and unexplained
hypotension despite increased fluid volume. Cortisol
stimulation test was done today which was normal. The
patient had swallowing evaluation which he failed during the
SICU stay. The patient was transferred to medical service on
[**2182-9-27**] for further management.
PAST MEDICAL HISTORY: End stage renal disease, non-insulin
dependent diabetes mellitus, hypercholesterolemia, peripheral
vascular disease, status post right fem tib bypass, status
post right toe amputation, pulmonary nodule awaiting biopsy,
LBP, L4,L5 stenosis, status post L4,L5 decompressive
laminectomy on [**2182-9-23**], glaucoma, hypertension, atrial
fibrillation, positive PPD.
MEDICATIONS ON TRANSFER: Insulin sliding scale, Xalatan
0.005% GTT q d, Alphagan 0.2% GTT [**Hospital1 **], Neurontin 200 mg po
bid, Prandin 0.25 mg po if blood sugar below 150, Coreg 6.25
mg po q d, Cosopt GTT [**Hospital1 **], Lipitor 5 mg po q d, Nephrocaps
one tablet po q d, Prozac 20 mg po q d, Phos-Lo 667 mg po
tid, Zantac 50 mg IV q 24 hours, Dilaudid 1-2 mg IV q 4 hours
prn, Albuterol nebulizers q 4 hours prn.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient denies alcohol or smoking
history. Lives with his wife.
PHYSICAL EXAMINATION: On admission patient is afebrile,
blood pressure 120/60, heart rate 62, respiratory rate 16, O2
saturation 96 on two liters. The patient is with no acute
distress, alert and oriented times three. HEENT: Pupils are
equal, round, and reactive to light and accommodation,
oropharynx clear, mucus membranes dry. Neck, no jugulovenous
distension. Lungs, rales at the left base, expiratory
rhonchi, otherwise clear to auscultation. Cardiovascular,
irregular irregular, no audible murmurs. Abdomen soft, non
distended, nontender with positive bowel sounds. Extremities
without edema and palpable pulsations bilaterally. Right
second toe status post amputation. Skin reveals two skin
ulcers with clean dressing, two dry necrotic toe like small
ulcers on each foot.
HOSPITAL COURSE: This is a 77-year-old man who was admitted
for decompressive laminectomy L4,L5, who developed
postoperative day #1 aspiration resulting in respiratory
distress requiring transient intubation, who was initially
hospitalized on SICU and then transferred to medicine for
further management for dysphagia.
1. Pulmonary: The patient developed aspiration
postoperative day #1 which led into aspiration/chemical
pneumonitis. His treatment consisted of oxygen through nasal
cannula but patient was not on antibiotics since he remained
afebrile throughout the course of hospitalization. Three
days post aspiration patient did not require any
supplementary oxygen and his lung exam significantly
improved.
2. Dysphagia: The patient developed severe dysphagia
postoperatively, failed three swallowing video studies for
solid and liquid food. Initially NG tube was inserted with
nutritional supplement feeding. He had PEG placement
inserted on [**2182-10-2**] without complications. During
endoscopic evaluation there were several ulcers found in his
stomach which were biopsied but the results of biopsy are
pending on the date of discharge. The patient was seen by a
nutrition consult and feeding through the PEG was recommended
and patient started this on [**10-3**], one day after PEG was
placed. He also received TPN through IV line for several
days prior to PEG placement. He will continue on Protonix
and additional studies such as H. pylori antibody was sent
which results are still pending during discharge. If this
result is positive, patient should be treated with
antibiotics since this could be cause for his findings during
endoscopy.
The cause of his severe dysphagia was believed to be due to
mechanical cause and patient might be evaluated in several
months with additional swallowing study.
Renal, patient has end stage renal disease on hemodialysis,
continued hemodialysis during hospitalization without
complications.
LABORATORY DATA: White blood count on discharge 8.1,
hematocrit 31.4, hemoglobin 10.1, platelet count 370,000, PT
12.8, PTT 32.5, INR 1.1, glucose 144, BUN 43, creatinine 6.3,
sodium 140, potassium 4.4, chloride 105, CO2 24, liver
function tests within normal limits, albumin 2.6, calcium
8.6, phosphorus 5.6, magnesium 2.5, free calcium 1.16.
Swallowing study revealed aspiration involving thick as well
as thin barium, no cough reflex was elicited. EKG revealed
sinus rhythm, borderline first degree AV block, left atrial
abnormality. Biopsies from the stomach ulcer are still
pending on the day of discharge.
DISCHARGE DIAGNOSIS:
1. Status post L4,L5 laminectomy.
2. Aspiration pneumonia.
3. Dysphagia, status post PEG placement on [**10-2**].
4. ESRD on hemodialysis.
5. Non-insulin dependent diabetes mellitus.
6. Peripheral vascular disease.
7. Hypertension.
8. Glaucoma.
DISCHARGE MEDICATIONS: Nepro 10 cc per hour, could be
advanced by 10 cc q 6-8 hours (go 40 units per hour),
Protonix 40 mg through PEG tube [**Hospital1 **], Pilocarpine 4% one drop
OU [**Hospital1 **], Albuterol nebulizers four puffs q 4 hours prn,
Phos-Lo 6.7 mg po tid, Prozac 20 mg q d, Xalatan 0.005% GTT
[**Hospital1 **], Alphagan 0.2% GTT [**Hospital1 **], SSRI, Coreg 6.25 mg q d,
Nephrocaps one tablet q d, Neurontin 200 mg [**Hospital1 **], Lipitor 5 mg
q d.
The patient will be discharged in stable condition to
[**Hospital6 85**].
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-207
Dictated By:[**Last Name (NamePattern1) 6063**]
MEDQUIST36
D: [**2182-10-3**] 08:59
T: [**2182-10-3**] 09:28
JOB#: [**Job Number 108341**]
|
[
"724.02",
"496",
"272.0",
"250.40",
"518.5",
"997.3",
"440.20",
"403.91",
"507.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"39.95",
"03.09",
"43.11",
"96.6",
"96.71",
"33.23"
] |
icd9pcs
|
[
[
[]
]
] |
5723, 6484
|
5445, 5699
|
2863, 5424
|
2077, 2845
|
104, 1118
|
1531, 1967
|
1141, 1505
|
1984, 2054
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
43,520
| 124,085
|
45962
|
Discharge summary
|
report
|
Admission Date: [**2186-11-24**] Discharge Date: [**2186-11-28**]
Date of Birth: [**2108-3-6**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Accupril / Celebrex
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
"spitting up dark vomit"
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname **] is a 78y/o lady with dementia, HTN, SLE on
Prednisone/Plaquenil, [**Known lastname 2091**] stage IV (baseline Cr 1.5), amyloid
angiopathy with recent ICH who presents from nursing home due to
hematemesis.
.
She is a resident at [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **]; at her baseline she is
disoriented and does not speak very much, though she can answer
questions appropriately. She has had a complicated recent course
including hospitalizations x2 at [**Hospital1 2177**] over the past month for
multiple intracerebral hemorrhages/hemorrhagic strokes. It was
felt that these strokes were related to hypertension and amyloid
angiopathy. Goal SBP has been less than 150. Prior to her recent
hospitalization she reportedly fell, was on the ground for a
prolonged amount of time, and was also noted to be "spitting up
dark vomit."
.
On the day of presentation she reported "burning" but did not
elaborate when asked. She had a BP 200/100. Vomited dark
brown/marroon vomit and the paramedics were called. En route,
she again vomited maroon emesis.
.
She was recently admitted to [**Hospital1 2177**] in [**Month (only) 216**] for a cerebellar ICH,
and again on [**11-21**] for lethargy/somnolence. CT scan of the head
revealed a new left posterior temporal lobe intraparenchymal
hemorrhage without mass effect. No MRI done due to agitation.
BP controlled and she was subsequently discharged. Of note, she
had a few runs of SVT there that were beta blocker responsive.
.
In the ED, initial VS: T98.3, HR 108, BP 171/120, RR 18, POx
100% 3L NC. Labs notable for Hct 47.3 (at baseline), Cr 1.8 (at
baseline), lipase slightly elevated at 111. She had no more
episodes of emesis after arrival. NG lavage mstly clear with
some maroon sediment and coffee ground emesis. She had PIVx2
placed, was started on normal saline @150cc/hr, Pantoprazole 80
mg IV bolus then drip at 8mg/hr. Her SBP was noted to be >180;
she was given Diltiazem 10mg IV given recent ICH. She was
admitted to Medicine for management of upper GI bleed. VS prior
to transfer were: T98.4, HR74, BP156/78, RR16, POx98%RA.
.
This morning on the medicine floor, she had no further episodes
of hematemesis or coffee grounds. Repeat HCT to 43 this AM. She
was noted to be hypertensive to 200-210 systolic. The stroke
team was involved given the finding of ?ICH on CT head. After
obtaining [**Hospital1 2177**] records, teams were reassured that imaging
abnormalities were present during most recent admission a few
days ago. Strict BP control recommended, along with MRI. She
got hydralazine 10mg IV x2 which brought BP down to 160s. She
then developed SVT with rates to 160s that was initially
responsive to vagal maneuvers but eventually required lopressor
5mg IV x2. She retained hemodynamic stability throughout these
episodes.
.
Upon arrival to the MICU, she complains of no pain but resists
continued questioning, getting somewhat irritated with physical
exam as well. Denies abdominal pain, N/V/D, bloody emesis, chest
pain, SOB. No further ROS could be elicited.
Past Medical History:
- intracerebral hemorrhages, involved the left cerebellar and
right parietal lobes
- dementia
- [**Hospital1 2091**] IV, baseline Cr 1.5-1.8
- HTN
- SLE
- DM2
- DJD, knees
- acute gout flare, on prednisone taper
- rotator cuff surgery
- patient has had most of her care at [**Hospital1 2177**]
Social History:
Widowed, now at [**First Name4 (NamePattern1) 1785**] [**Last Name (NamePattern1) **]. Never smoker. No alcohol. Never
drugs.
Family History:
non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - Temp 96.1F, BP 182/91, HR 80, R 18, O2-sat 98% RA
GENERAL - elderly lady in NAD
HEENT - EOMI, sclerae anicteric, dry MM, OP clear
NECK - no JVD, no carotid bruits
LUNGS - CTA bilaterally
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - (+) bowel sounds; no tenderness to palpation in any
quadrant; no rebound
RECTAL: deferred; was guaiac negative in the ED
EXTREMITIES - warm, no edema, 2+ DP pulses bilaterally
NEURO - awake, oriented to self only.
Smile reveals very mild flattening of left nasolabial fold and
very mild down-turning of left mouth.
Sensation to light touch intact V1-V3.
Can keep eyes closed when attempted to force open.
Tongue is midline.
Normal muscle bulk and tone.
Sensation to light touch grossly intact throughout.
Right hand finger-to-nose test is slow/deliberate with hesitancy
as approaches target; left hand is even more inaccurate
Slow alternating movements of hands in lap; cannot perform task
faster.
LEs with 4+/5 strength of hip flexion and toe dorsi/plantar
flexion.
UEs with 5/5 flexion/extension at elbow.
Oriented to self only. When asked if this might be a restaurant
or school or hospital or apartment, she says, "I'm, I think it
is a sool, shool, a shool."
Two minutes after telling her where she is, when asked if she
remembers which hospital this is she does not remember.
DISCHARGE PHYSICAL EXAM:
VS: 96.8 128/76 68 18 96%RA
Exam is otherwise unchanged
Pertinent Results:
LABS:
On admission:
[**2186-11-23**] 09:30PM BLOOD WBC-10.3 RBC-5.43* Hgb-15.6 Hct-47.3
MCV-87 MCH-28.8 MCHC-33.1 RDW-14.1 Plt Ct-270
[**2186-11-23**] 09:30PM BLOOD Neuts-86* Bands-0 Lymphs-11* Monos-3
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2186-11-23**] 09:30PM BLOOD PT-12.4 PTT-23.9 INR(PT)-1.0
[**2186-11-23**] 09:30PM BLOOD Glucose-208* UreaN-31* Creat-1.8* Na-144
K-4.2 Cl-104 HCO3-24 AnGap-20
[**2186-11-23**] 09:30PM BLOOD ALT-25 AST-27 AlkPhos-76 TotBili-0.2
[**2186-11-23**] 09:30PM BLOOD Lipase-111*
[**2186-11-23**] 09:30PM BLOOD Albumin-4.4 Calcium-10.6* Phos-3.1 Mg-1.8
On discharge:
[**2186-11-28**] 07:00AM BLOOD WBC-8.4 RBC-5.07 Hgb-14.7 Hct-44.1 MCV-87
MCH-29.1 MCHC-33.4 RDW-13.9 Plt Ct-229
[**2186-11-28**] 07:00AM BLOOD Plt Ct-229
[**2186-11-28**] 07:00AM BLOOD Glucose-139* UreaN-35* Creat-1.6* Na-140
K-4.3 Cl-104 HCO3-25 AnGap-15
[**2186-11-27**] 07:05AM BLOOD ALT-17 AST-16 LD(LDH)-252* AlkPhos-50
TotBili-0.4
[**2186-11-28**] 07:00AM BLOOD Calcium-9.5 Phos-3.7 Mg-2.1
IMAGING:
[**11-24**] CT head:
IMPRESSION:
1. New hyperdense focus within the left parietal lobe may
represent new
hemorrhagic stroke versus hemorrhagic tumor versus a focus of
hemorrhage.
Additional low-attenuating region within the right parietal and
iso- to
hyperdense focus within the left cerebellar region may
correspond to patient's history of hemorrhagic stroke. Overall,
findings may suggest an embolic phenomenon; however, correlation
with clinical history is recommended.
NOTE ADDED AT ATTENDING REVIEW: The hemorrhagic lesions in the
left cerebellar hemisphere and left parietal lobe might
represent hemorrhagic infarctions, however, the possibility of
neoplasms should be considered. The hypodense right parietal
mass with a thin hyperdense rim would be an unusual appearance
for infarction, acute or chronic, and the possibility of
neoplasm should be strongly considered. Given these findings, an
MR with contrast is recommended to pursue the possibility than
one or more of the lesions may be due to a malignancy, such as
metastatic disease.
After discussion by Dr. [**Last Name (STitle) **] with Dr. [**Last Name (STitle) 7886**] of Stroke
Neurology, at 10:30 am on [**2186-11-24**] by telephone, it appears
these lesions were pursued with CT as well as MR [**First Name (Titles) 151**] [**Last Name (Titles) **]
enhancement during a recent evaluation at [**Hospital6 **].
These studies are not available for comparison at this time, but
apparently reports interepreted the lesions described above as
benign hemorrhages. As discussed with Dr. [**Last Name (STitle) 7886**], the best
approach may be to obtain these studies and compare them to the
current examination. If this is not possible, then it would be
best to obtain an MR [**First Name (Titles) 151**] [**Last Name (Titles) **] when the patient's renal
function will permit this.
[**11-25**] CXR: In comparison with study of [**2184-2-14**], there is little
overall
change. No evidence of acute cardiopulmonary disease.
Specifically, the left base appears clear.
Brief Hospital Course:
78 year old female with dementia, HTN, SLE on
Prednisone/Plaquenil, [**Date Range 2091**] stage IV (baseline Cr 1.8) and amyloid
angiopathy with recent ICH who presented from nursing home due
to hematemesis on [**2186-11-24**] noted to have hypertensive
emergency, recent bleeds on head CT unchanged. She was
transferred briefly to the ICU for careful neuro checks,
frequent blood pressure monitoring, management of SVT (see
below), but was stable for transfer back to the floor within 1
day. Non-emergenct EGD showed no active bleeding, only candidal
esophagitis. Please see below for more details on each hospital
problem.
.
ACTIVE PROBLEMS:
# AMYLOID ANGIOPATHY/ICH: Given hypertensive urgency in the ED
with recent ICH, stat head CT obtained when she arrived on the
floor. The CT showed multiple sites of bleed, initially
concerning for acute new hemorrhage. She was evaluated
emergently by the Neuro Stroke service, who reviewed reports
from her OSH CT and MRI the previous week were obtained and it
was decided that what we were seeing was more likely due to
older bleeds. They recommended conservative managment with
aggressive control of BP, with goal BP <140/90. She was started
on metoprolol for blood pressure control (as well as prevention
of SVT- see below) and restarted on home dose of felodipine.
She will be continued on these two medications at discharge.
Good blood pressure control will be of paramount importance in
preventing new intracranial bleeds, so this is something that
should continued to be monitored frequently (at least every 8
hours) at her rehab facility.
.
# MAROON EMESIS: Hct at baseline on admission, NG lavage in ED
showed mostly clear fluid with some dark sediment. Made NPO and
started PPI IV. Repeat hematocrits showed no clinically
significant drop, and she hemodynamically stable with no
recurrence of hematemesis. EGD on [**2186-11-27**] revealed esophageal
candidiasis, likely as a result of her high dose prednisone
(even though this was started just 1 week ago). No other signs
to point to underlying immunodeficiency, however it would not be
unreasonable to order an HIV test as an outpatient, will defer
to outpatient PCP. [**Name10 (NameIs) **] was started on fluconazole 200 mg qday
for a planned 3 week course (from [**Date range (1) 97861**]). LFTs sent at
the initiation of therapy to establish a baseline (normal).
Continued on omeprazole 20 mg for additional gastric protection
on discharge. A biopsy of the candidal plaques as taken, so this
will need to be followed up as an outpatient.
.
# SUPRAVENTRICULAR TACHYCARDIA: Placed on telemetry on arrival
given concern for GI bleed, noted to have short runs of narrow
complex tachycardia which initially self-resolved on the morning
of admission. Then went into another run of SVT (appeared to be
AVNRT) to the 160s which was sustained. Attempted carotid
massage and vagal maneuvers, then metoprolol 5 mg IV x2 with
minimal response (rate decreased to 130s). She was then
transferred to the ICU for higher level of nursing care, and her
SVT broke while en route, converting back to sinus rhythm in the
80s. She was started on metoprolol for rate control. She
remained on telemetry throughout her stay and did not have a
recurrence.
.
#. DEMENTIA/DELIRIUM: Per daughter, pt is forgetful at
baseline, usually oriented to herself but not time or place.
She appeared to be baseline mental status throughout most of her
stay, but she was at times somewhat agitated. Likely a degree
of acute delirium, given her illness and frequent transfers
between floors. Her medication list from [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] listed
seroquel 12.5 mg [**Hospital1 **] as one of her outpatient medications, so
she was started on this dose of seroquel with PRN haloperidol.
Her agitation was decreased with this medications, but she was
somewhat sleepy. She seemed to do better with a decreased dose
of 6.25 mg qHS, with additional 6.25 mg PRN (never needed to be
given this). She is being discharged on this decreased dose of
seroquel.
.
# HYPERNATREMIA: Na elevated to 146 on admission, likely due to
poor PO intake in the setting of dementia. Improved after
getting boluses of D5W, unlikely to have contributed to her
mental status.
.
# HYPERTENSION: BP control as above.
.
INACTIVE PROBLEMS:
#. [**Name2 (NI) 2091**]: Cr 1.7, remained within recent range through her
hospitalization. She was also continued on her calcitriol.
.
#. SLE, gout: Continued on outpatient doses of plaquenil and
allopurinol. She also came in on Prednisone for gout flare, and
supposedly this was to be tapered, but have not been able to
touch base with the PCP on this. Will send her back to [**First Name4 (NamePattern1) 1188**]
[**Last Name (NamePattern1) **] on a taper over 6 days. She will be covered with sliding
scale insulin for steroid-induced hyperglycemia during these 6
days.
.
TRANSITIONAL ISSUES:
- Amyloid angiopathy: will need very tight control of her BP
with checks every 8 hours at her ECF. Does not need repeat
imaging unless clinical status changes
- Esophageal candiasis: given 3 week course of fluconazole,
should have LFTs checked and consider HIV test as screen for
causes of immunosuppression
- Follow up biopsy of esophagus
DNR/DNI throughout hospital stay, confirmed w daughter/HCP
[**Name (NI) **]
Outstanding tests:
Esophageal biopsy [**11-27**] - returned consistent with candidal
esophagitis.
Medications on Admission:
- prednisone 40 mg PO daily (being tapered)
- hydrochloroquine 200 mg PO BID
- felodipine 10 mg PO daily
- allopurinol 150 mg PO daily
- seroquel 12.5 mg PO daily
- prilosec 20 mg PO daily
- calcitriol 0.25 mcg PO daily
- folic acid 1 mg PO daily
- colace 100 mg PO BID
- Tylenol PRN
- Senna PRN
- Miralax PRN
Discharge Medications:
1. prednisone 10 mg Tablet Sig: Three (3) Tablet PO once a day
for 2 days.
2. prednisone 10 mg Tablet Sig: Two (2) Tablet PO once a day for
2 days.
3. prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day for
2 days.
4. hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. felodipine 10 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO once a day.
6. allopurinol 300 mg Tablet Sig: 0.5 Tablet(s) (150 mg) PO once
a day.
7. quetiapine 25 mg Tablet Sig: 0.25 Tablet PO qHS (bedtime),
may repeat x1 as needed.
8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
10. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain/fever.
13. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day): Please hold for SBP<100 or HR<60
.
14. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day.
15. insulin lispro 100 unit/mL Solution Sig: per sliding scale
Subcutaneous four times a day for 6 days: Sliding scale:
200-250 1 unit, 251-300 2 units, 301-350 3 units, 351-400 4
units.
16. fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 3 weeks: Please stop on [**12-18**] .
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] - [**Location (un) 538**]
Discharge Diagnosis:
Hypertensive urgency
Esophageal candidiasis
Amyloid angiopathy with h/o intracranial hemorrhage
Supraventricular tachycardia
Chronic kidney disease
Hypernatremia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. [**Known lastname **],
It was a pleasure to take care of you at [**Hospital1 18**]. You were
admitted to the hospital after you vomited some blood. We
looked down your throat with a camera, and we did not see any
bleeding but did find that you have a thrush infection of your
throat. We are prescibing you a 3 week course of a medicine
called fluconazole to help treat this.
We did a CT scan of your head and found that the bleeding from
your strokes looks stable. Because of your high blood pressure,
you are at an increased risk to bleed again. It is very
important that you continue taking your blood pressure medicines
and have your blood pressure checked regularly to make sure that
it does not get too high again.
Changes to your medications:
START fluconazole 200 mg daily for 3 weeks (until [**12-18**])
START metoprolol 25 mg three times a day
DECREASE prednisone to 30 mg for 2 days, then 20 mg for 2 days,
then 10 mg for 2 days, then stop
START insulin sliding scale four times a day (can stop when done
with prednisone taper)
Followup Instructions:
Please follow up with the on-staff doctor [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **]
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23,349
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Discharge summary
|
report
|
Admission Date: [**2176-2-16**] Discharge Date: [**2176-2-22**]
Service: MEDICINE
Allergies:
Nsaids
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
found down, SAH
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname **] is a [**Age over 90 **]yo woman with poorly controlled HTN
(baseline 160s per PCP), h/o paroxysmal atrial tach,
hypothyroidism, moderate dementia who was found down at NH today
in her own urine. Pt does not recall falling, does not recall
any symptoms prior to fall. Does not recall whether she hit her
head. She was brought to the ER where she was found to be
hypertensive with BP 222/111, to have no bruises or stigmata of
fall. According to her brother she was only mildly off her
baseline mental status in the ER.
.
Head CT done due to fall showed small parietal SAH. She was seen
by neurosurgery and neurology who recommended BP control, no
antiepileptics given small size of SAH, and repeat head CT in
the AM. She was started on a nitroglycerin drip with goal SBP
<165. She was given one dose of hydralazine and aspirin x 1. EKG
showed prominent T waves but when repeated several times over
several hours showed no evolution. She denied chest pain,
shortness of breath but did contain of some dizziness and
unsteady gait. She also reported a feeling like something was in
her throat and she had to clear her throat although no itching,
no difficulty breathing. She was seen putting her finger in her
mouth and possibly touching near her uvula.
.
She was admitted to the ICU for blood pressure control and
monitoring. On arrival to the ICU she was found to be
disoriented, attempting to crawl out of bed, refusing to
cooperate or to answer questions. She repeatedly clears her
thorat and says she feels like something is "cack there." She
denies all other complaints and does not let me complete ROS as
she no longer wishes to cooperate.
.
Paperwork from her home facility states that her blood pressure
medications are typically taken at 8am, although we do not have
dispense records to confirm that she received these today. Notes
that her BP at 9:30am was 160/80, however she then fell and
after the fall it was 190/90.
.
Past Medical History:
Dementia
HTN - baseline sbp 160s per pcp
paroxysmal atrial tachycardia
Hypothyroidism s/p resection of funcitoning goiter
s/p R hip replacement
L hip ORIF
Social History:
Lives at Nursing Home. uanble to elicit further history.
Family History:
unable to elicit
Physical Exam:
T 98.7 HR 76, BP 165/64, 94% on RA
Gen: attempting to climb out of bed, refusing to answer
questions, insisting on going home, does not know where she is,
refuses to tell me her name, repeatedly clearing her throat
HEENT: surgical pupils, MM moist, uvula notably injected and
edematous although not obstructing airway
Cor: RRR, s1s2, no murmur
Pulm: CTAB, limited cooperation
Abd: distended, soft, NT, +BS
Ext: no edema, w/w/p
Neuro: pt not following commands at present however by report in
ER she had 5/5 strength throughout and was intact to light
touch.
Pertinent Results:
remarkable for WBC 15.9, 6% bands, 86% polys; CK 1182->1250, MB
18->14; trop 0.08->0.03, MB index 1.5->1.1. creatinine 1.2 (at
last check 1.6).
.
Studies:
EKG: NSR at 60, nl axis, nl intervals, tall T waves, persistent
on repeat EKG. no ST changes, no Q waves, no TWI.
CXR: No radiographic evidence of traumatic injury.
.
CT head:
A tiny amount of subarachnoid blood is seen within a single
right
parietal focus. No additional intra- or extra-axial hemorrhage
is seen. There is no mass effect or shift of normally midline
structures. Small lacunar infarcts are noted within the left
coronal radiata and bilateral external capsules. The [**Doctor Last Name 352**]-white
matter differentiation is preserved. The visualized paranasal
sinuses and mastoid air cells are clear. No fractures are
identified. The bones of the skull are diffusely demineralized.
IMPRESSION: Small right parietal subarachnoid hemorrhage.
Brief Hospital Course:
[**Age over 90 **]yo woman with paroxysmal atrial tachycardia, hypothyroidism
poorly controlled HTN wtih baseline sbp 160s presented s/p
unwitnessed fall found in urine with new small SAH on head CT
and BP 222/111 on arrival to ER.
.
# Subarachnoid hemorrhage. The patient was admitted after a fall
and was found on CT head to have a small SAH. It is not clear if
this was due to hypertension (on admission approximately
200/100) or fall (NO stigmata of head trauma). The patient was
seen by neurosurgery and neurology in the ED. She was managed
medically with bp control. Without mass effect or ongoing
bleeding, the patient was not given seizure prophylaxis. The
patient had a repeat CT scan the following morning after
overnight ICU monitoring that revealed no change in the SAH. The
patient requires ongoing blood pressure control with target
130-160/70-80. The patient should avoid blood thinning
medications such as aspirin and heparin products until her SAH
resolves.
.
# HTN. The patient presented with marked hypertensive urgency.
She initially was placed on a labetolol drip. After confirmation
of her home meds, these were re-instituted. She continued to
have periods of elevated blood pressure (up to 190 systolic) for
which she received intermittent hydralazine. Her amlodipine was
upregulated with much improved control over the 24 hours prior
to discharge.
.
# Mechanical fall vs. syncope. The patient was a poor historian
and her fall was unwitnessed, though she was found in her own
urine. The patient was maintained on tele without event. She had
no EKG changes. She had a cardiac enzyme elevation on admission
though these trended downwards. Echo revealed mild AS and no
other mechanical explanation for her fall. Carotid ultrasound
showed some bilateral plaque without hemodynamically significant
stenosis on preliminary read. The patient had an EEG with some
signs of frontal cortical irritability likely secondary to the
SAH though no signs of seizure activity. Repeat EEG showed
slowing at the right parietal lobe again consistent with SAH and
no other concerning activity.
.
# Altered mental status. The patient is known to have baseline
'moderate' dementia. The patinet's brother and son described her
baseline mental status as poorly oriented to place and time. The
patient had waxing and [**Doctor Last Name 688**] consciousness/orientation
consistent with sundowning. She had no signs of infection, a
post-ictal state to explain her symptoms. Her TSH was in normal
limits. This almost certainly represents baseline dementia
exacerbated by sundowning in an elderly woman in a new
environment with loss of orienting cues. The patient
intermittently required haldol and disintegrating olanzapine
tabs at times of agitation.
.
# Hypothyroidism. TSH normal. Continued on home synthroid.
.
# Code status: DNR/DNI
.
# Communication: [**Name (NI) **] [**Name (NI) **], brother and HCP (c) [**Telephone/Fax (1) 107869**],
(h) [**Telephone/Fax (1) 107870**] (w) [**Telephone/Fax (1) 107871**]. PCP [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 140**] [**Last Name (NamePattern1) 141**]
[**Telephone/Fax (1) **].
.
Medications on Admission:
Levoxyl 75mcg po qday
Dyazide (hydrochlorothiazide/triamterene) 1 cap po qday
ECAsa 81mg po qday
Atenolol 25mg po qday
Avapro (irbesartan) 150mg po qday
Lipitor 10mg po qday
Ca + Vit D (citracal) 2 tabs qday
folgard 2.2mg po qday
Discharge Medications:
1. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Atorvastatin 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
4. Citracal + D 250-200 mg-unit Tablet Sig: Two (2) Tablet PO
once a day.
5. Irbesartan 150 mg Tablet Sig: One (1) Tablet PO qday ().
6. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO BID (2 times a day) as needed for Agitation.
8. Triamterene-Hydrochlorothiazid 37.5-25 mg Capsule Sig: One
(1) Cap PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] of [**Location (un) 55**]
Discharge Diagnosis:
Fall
Stable subarachnoid hemorrhage
Hypertensive urgency
.
Hypothyroidism
Dementia
Discharge Condition:
Stable.
Discharge Instructions:
You were admitted because of a fall. Work-up was negative for a
cardiac or neurologic explanation for your fall. It is likely
that you had a mechanical fall.
.
You were found to have a small, stable bleed around your brain.
This may be due to extremely high blood pressure or from your
fall. You do not have any signs of ongoing bleeding. Please take
all of your blood pressure medications. Your target blood
pressure is systolic 130-160, diastolic 70-80.
.
You had episodes of confusion, agitation and disorientation
while in the hospital. This is in part due to baseline dementia.
Your dementia was exacerbated by new surroundings and loss of
orienting cues.
.
Follow-up with Dr. [**Last Name (STitle) 141**].
.
Take all medications as prescribed.
.
Call your doctor or return to the hospital for any new or
worsening dizziness, lightheadedness, blurred vision, nausea,
vomiting, severe headache, falls, chest pain or other concerning
symptoms.
Followup Instructions:
Dr. [**Last Name (STitle) 141**] [**2176-3-31**] 09:45AM
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
|
[
"584.9",
"276.52",
"403.90",
"585.9",
"276.1",
"E888.9",
"427.0",
"294.8",
"244.0",
"852.01"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8105, 8177
|
4041, 7191
|
229, 236
|
8304, 8314
|
3103, 3425
|
9309, 9490
|
2491, 2509
|
7472, 8082
|
8198, 8283
|
7217, 7449
|
8338, 9286
|
2524, 3084
|
174, 191
|
264, 2222
|
3434, 4018
|
2244, 2401
|
2417, 2475
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,213
| 121,563
|
5492
|
Discharge summary
|
report
|
Admission Date: [**2115-2-20**] Discharge Date: [**2115-2-25**]
Date of Birth: [**2047-10-12**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Iodine; Iodine Containing / Penicillins / Sulfa (Sulfonamides) /
Ciprofloxacin
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Aortic Aneurysm
Major Surgical or Invasive Procedure:
[**2115-2-20**] Endovascular Stenting of Thoracic Aortic Aneurysm
History of Present Illness:
Mr. [**Known lastname **] is a 67 year old male with a complicated past medical
history. He has a known history of thoracic aortic aneurysm and
has been followed by Dr. [**Last Name (STitle) **] with serial CT scans. His most
recent CTA was on [**2115-1-29**] showed a saccular aneurysm in the
thoracic aorta measuring 54 x 60 millimeters. Given the
dimensions, he was referred for surgical intervention. With
regards to symptoms, he reports occasional chest discomfort
which will intermittently radiate to his left arm.
Past Medical History:
Possible silent MI (per patient report)
CAD s/p multiple prior PTCA's
[**2099**] CABG x 4([**Hospital6 22197**] Center)
[**2108**] s/p pacemaker for bradycardic arrhythmias
Hypertension
CRF on dialysis x two years (M/W/F @ [**Location (un) 22201**] dialysis center-
[**Telephone/Fax (1) 22202**]. Access is via a right upper loop
COPD
[**11-23**] s/p repair of infrarenal AAA with a 20mm tubular graft
(Dr.
[**Last Name (STitle) **]
Renal stones/renal cysts
Stable left adrenal adenoma by CT
[**2106**] s/p gastric bypass and cholecystectomy with multiple
complications including wound dehiscence, DVT/PE s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 260**]
filter placement, pseudomonal sepsis requiring tracheostomy.
Ventral hernia repair per records in CCC (patient denies)
[**2107**]: removal of a fatty tumor from abdomen
Hx of remote GIB, s/p treatment for H. Pylori
[**2107**] VRE UTI
Depression/Anxiety
Hx of prior ETOH abuse and prior withdrawal. Patient quit heavy
drinking 2 years ago.
[**2107**] right ankle arthrodesis and tendon release with left ankle
Achilles tendon lengthening
[**2107**]: right foot subtalar fusion, s/p removal of infected
hardware
Right second toe amputation, after a traumatic accident
Left ankle surgery
Restless leg syndrome
Social History:
Patient is married. His wife [**Name (NI) 22203**] will
accompany him to the hospital. They have four children.
Patient sells plumbing and heating products.
Family History:
Father with CAD in his late 50's. Brother also has "heart
problems".
Pertinent Results:
[**2115-2-20**] 10:53AM BLOOD WBC-8.3 RBC-3.91* Hgb-12.6* Hct-38.3*
MCV-98 MCH-32.2* MCHC-32.9 RDW-20.4* Plt Ct-102*
[**2115-2-25**] 09:20AM BLOOD WBC-10.0 RBC-2.81* Hgb-9.3* Hct-28.3*
MCV-101* MCH-33.0* MCHC-32.8 RDW-22.3* Plt Ct-141*
[**2115-2-20**] 05:42PM BLOOD UreaN-29* Creat-4.6*# Cl-99 HCO3-28
[**2115-2-21**] 02:06AM BLOOD Glucose-156* UreaN-32* Creat-5.3* Na-137
K-4.2 Cl-96 HCO3-28 AnGap-17
[**2115-2-22**] 02:09AM BLOOD Glucose-81 UreaN-40* Creat-6.9*# Na-132*
K-4.9 Cl-90* HCO3-24 AnGap-23*
[**2115-2-22**] 11:12AM BLOOD Glucose-93 Na-131* K-6.6* Cl-92* HCO3-24
AnGap-22*
[**2115-2-23**] 11:20AM BLOOD Glucose-116* UreaN-28* Creat-5.7*# Na-136
K-3.8 Cl-94* HCO3-25 AnGap-21*
[**2115-2-25**] 09:20AM BLOOD Glucose-104 UreaN-62* Creat-8.2*# Na-129*
K-4.4 Cl-90* HCO3-21* AnGap-22*
[**2115-2-24**] Chest CTA: 1. Status post interval placement of a
descending thoracic aortic stent, which is well positioned.
Possible small area of leak in the lower thoracic aorta into the
aneurysm sac as described, recommend close interval followup
with a normal dose pre-contrast imaging to better define this
area.
[**2115-2-25**] Chest x-ray: Comparison is made with the prior chest
x-ray of [**2115-2-20**]. There has been some improvement in
the degree of failure. Mild upper zone redistribution is still
present and a small left effusion is seen but the interstitial
edema present on the prior chest x ray has resolved.
Brief Hospital Course:
Mr. [**Known lastname **] was admitted and underwent elective repair of his
descending thoracic aortic aneurysm. For surgical details,
please see seperate dictated operative note. Following the
operation, he was brought to the CSRU for invasive monitoring.
Initially hypertensive, he initially required intravenous
Labetolol and Nipride. The renal service was also consulted to
manage his normal dialysis schedule. His preoperative
medications were resumed. He gradually weaned from intravenous
therapy. He maintained stable hemodynamics and transferred to
the SDU for further care and recovery. A postoperative chest CTA
was notable for a possible small area of leak in the lower
thoracic aorta into the aneurysm sac. The chest CTA was reviewed
by both Drs. [**Last Name (STitle) **] and [**Name5 (PTitle) 914**]. The rest of his postoperative
course was uneventful. He was medically cleared for discharge
and will follow up with Dr. [**Last Name (STitle) **] in approximately one month.
Medications on Admission:
see below
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(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. 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. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
5. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
Disp:*30 Tablet(s)* Refills:*2*
6. Chlorpromazine 25 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
Disp:*120 Tablet(s)* Refills:*2*
7. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): Also take 4 at bedtime.
Disp:*180 Tablet(s)* Refills:*2*
8. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
9. Diphenoxylate-Atropine 2.5-0.025 mg Tablet Sig: One (1)
Tablet PO Q6H (every 6 hours).
Disp:*120 Tablet(s)* Refills:*2*
10. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*0*
12. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*180 Capsule(s)* Refills:*2*
13. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
14. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO Q SUN ().
Disp:*4 Tablet(s)* Refills:*2*
15. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
Disp:*30 Tablet(s)* Refills:*0*
16. Cholestyramine-Sucrose 4 g Packet Sig: One (1) Packet PO BID
(2 times a day).
Disp:*60 Packet(s)* Refills:*2*
17. Zinc Sulfate 220 (50) mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
18. Loperamide 2 mg Capsule Sig: Two (2) Capsule PO QHS (once a
day (at bedtime)).
Disp:*60 Capsule(s)* Refills:*2*
19. Simethicone 80 mg Tablet, Chewable Sig: 0.5 Tablet, Chewable
PO QID (4 times a day).
Disp:*60 Tablet, Chewable(s)* Refills:*2*
20. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
VNA of [**Location (un) 22201**]
Discharge Diagnosis:
Thoracic aortic aneurysm - s/p Endovascular Stenting
Discharge Condition:
Good.
Discharge Instructions:
Follow medications on discharge instructions.
Call our office with temp.>101.5, drainage from groin wounds.
Followup Instructions:
Make an appointment with Dr. [**Last Name (STitle) 914**] for 3 months.
CTA of torso in 3 months.
Make an appointment with Dr. [**Last Name (STitle) 3407**] for 1 month.
Completed by:[**2115-2-27**]
|
[
"V45.01",
"496",
"227.0",
"403.91",
"V45.81",
"585.6",
"441.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.73",
"88.44",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
7503, 7566
|
4011, 5001
|
361, 428
|
7663, 7671
|
2565, 3988
|
7827, 8028
|
2476, 2546
|
5061, 7480
|
7587, 7642
|
5027, 5038
|
7695, 7804
|
306, 323
|
456, 978
|
1000, 2285
|
2301, 2460
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,884
| 188,585
|
31739
|
Discharge summary
|
report
|
Admission Date: [**2140-10-18**] Discharge Date: [**2140-10-24**]
Service: CARDIOTHORACIC
Allergies:
Diovan
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
SOB, respiratory distress
Major Surgical or Invasive Procedure:
[**10-18**] AVR (tissue)
History of Present Illness:
85 yo F who presented to PSH with SOB and respiratory distress,
was intubated and transferred to [**Hospital1 18**] on [**2140-10-7**]. Echo here
showed severe AS, 2+MR.
Past Medical History:
H/o of mild AS: Aortic valve area is estimated to be 1.5 cm sq.
Mean pressure gradient is 20 mmHg and maximum pressure gradient
is 28 mmHg on ECHO in [**2136**]. ECHO from [**6-/2140**] AS with 0.7cm2,
peak gradient 76 and mean 49 mmHg.
Osteoporosis
HTN
Hypercholesterolemia
DM 2
Paget's disease
S/p PCM, DDD, for bradycardia
Anemia, unclear baseline, Vit B12 def
Breast cancer, s/p L mastectomy and chest radiation
S/p R hip fracture and L knee fracture in the 60s and 70s
Social History:
Social history is significant for the absence of current or
prior tobacco use. There is no history of alcohol abuse.
Family History:
There is no family history of premature coronary artery disease
or sudden death. Mother had angina in her 60s and a stroke in
her 70s. Son with DM2.
Physical Exam:
deferred on admission.
Pertinent Results:
[**2140-10-23**] 10:20AM BLOOD WBC-10.5 RBC-3.87* Hgb-12.4 Hct-34.9*
MCV-90 MCH-32.1* MCHC-35.7* RDW-15.3 Plt Ct-289
[**2140-10-23**] 10:20AM BLOOD Plt Ct-289
[**2140-10-19**] 02:00AM BLOOD PT-16.0* PTT-33.1 INR(PT)-1.5*
[**2140-10-23**] 10:20AM BLOOD UreaN-21* Creat-1.1 K-3.4
Brief Hospital Course:
She was taken to the operating room on [**10-18**] where she underwent
an AVR. She was transferred to the ICU in critical but stable
condition. She was extubated on POD #1. She was transferred to
the floor on POD #2. She did well postoperatively and was ready
for discharge to rehab on POD #5.
Medications on Admission:
Aspirin 325', Lipitor 80', Metoprolol 12.5'', Glyburide 10'',
Levothyroxine 150', Folic Acid 1'
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Levothyroxine 50 mcg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
6. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day).
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
8. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Tablet(s)
10. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
11. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Two (2) Capsule, Sustained Release PO Q12H (every 12 hours).
12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] Of [**Location (un) 620**]
Discharge Diagnosis:
AS,
Osteoporosis, HTN, Hypercholesterolemia, DM, Paget's disease,
S/p PCM, DDD, Anemia, Vit B12 def, Breast cancer, s/p L
mastectomy XRT, S/p R hip fx and L knee fx
Discharge Condition:
Good.
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions, creams or powders to incisions.
No lifting more than 10 pounds or driving until follow up with
surgeon.
Followup Instructions:
Dr. [**Last Name (STitle) 911**] 2 weeks
Dr. [**Last Name (STitle) **] 4 weeks
Completed by:[**2140-10-24**]
|
[
"V15.3",
"731.0",
"V10.3",
"515",
"401.9",
"V45.01",
"398.91",
"414.01",
"396.2",
"733.00",
"250.00",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.21",
"99.04",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
3047, 3124
|
1635, 1930
|
248, 275
|
3333, 3341
|
1333, 1612
|
3640, 3751
|
1124, 1275
|
2076, 3024
|
3145, 3312
|
1956, 2053
|
3365, 3617
|
1290, 1314
|
183, 210
|
303, 474
|
496, 972
|
988, 1107
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,081
| 134,455
|
49847
|
Discharge summary
|
report
|
Admission Date: [**2122-6-8**] Discharge Date: [**2122-6-12**]
Date of Birth: [**2052-9-15**] Sex: M
Service: MEDICINE
Allergies:
Sporanox / Ace Inhibitors / Penicillins
Attending:[**First Name3 (LF) 398**]
Chief Complaint:
angioedema
Major Surgical or Invasive Procedure:
nasopharyngeal intubation
History of Present Illness:
69-year-old gentleman with a history of FSGS, who is status
post DCD renal transplant on [**2121-5-7**], recent
hospitalization for influenza A, CHF (EF=25-30%), presenting
with angioedema and difficulty breathing. As per pt's wife, he
started with swelling of his right cheek about 1-2 weeks ago; he
was seen by his PCP who suspected angioedema and started him on
prednisone/benadryl (4-d course). Wife reports some improvement
with this treatment. A day after this, he started to have pain
in his tooth (left upper molar), was seen by his dentist, and
started on penicillin for ?infection (with recommendation to see
oral surgeon). On day of admission, pt reports swelling of his
tongue, and his wife brought him to the [**Name (NI) **] at [**Name (NI) 620**]. There, he
was given solumedrol and benadryl, transferred here for further
care. He was dysarthric on presentation but in no respiratory
distress (stable vitals). He was seen by ENT, and airway was
thought to be adequate. He was continued on decadron and
benadryl, H2 blocker. On reevaluation by ENT, he was found to
have swelling of supraglottic area and tongue, and he was
brought to the OR for fiberoptic nasotracheal intubation. He was
brought to the ICU after this for further mgt.
.
Pt was started on Lisinopril many months ago; dose was recently
increased (last 1-2 months) to 5 mg. He was recently started on
Fe gluconate, and took some tussin over the weekend (also recent
PCN). Wife reports that he had some URI sx but no f/c/n/v. Pt
has also had diarrhea. On arrival to the ICU, he was intubated
and sedated.
Past Medical History:
1. ESRD [**2-12**] FSGS, s/p DCD transplant [**2121-5-7**]
2. CHF, EF=25-30%
Past Medical History:
3. CABG x 4 in [**5-13**]; SVG to OM, SVG to PDA, LIMA to LAD
4. Hypertension
5. History of zoster
6. Gout
7. History of left basal cell cancer.
8. History of right thumb loss from a chainsaw accident.
Social History:
He lives with his wife. [**Name (NI) **] retired as a
physiologist at [**Hospital **] Medical School. He says he still smokes
five cigarettes per day. He rarely drinks alcohol and does not
use any drugs and does not use any herbal medicines (history of
heavier etoh use).
.
Family History:
His parents are both deceased, his father from stroke, his
mother from unknown cancer. He has one sister who is ruled out
as a potential donor because of kidney disease and one brother
who has cardiac disease. He does have two children in early 40s,
one of whom would potentially be a donor.
Physical Exam:
VS: 97.0 140/49 55 14 98%
AC, 600/14, 40% FiO2, PEEP=5, PIP=20, Plat=16
Gen: intubated, sedated, responds to voice
HEENT: PERRL, with swelling of tongue, unable to visualize OP
Neck: no stridor; some fullness of anterior neck
Lungs: CTA bilat on anterior exam
CV: [**Last Name (LF) 8450**], [**First Name3 (LF) **] s1/s2, no m/r/g
Abd: soft, protuberant, nt/nd, can palpate kidney on right side
Extr: no c/c/e, 1+ DP bilat; with graft/fistula in left arm; som
exposed graft (non-erythematous)
.
Pertinent Results:
CXR: no evidence of pneumonia or CHF
Brief Hospital Course:
69 yo male, h/o ESRD, CHF, presenting with angioedema after
recent increase in dose of ACE-I, s/p OR intubation for airway
protection
.
1. Angioedema - pt was intubated ENT in the OR under direct
visualization for airway protection. This was thought to be
most likely related to ACE-I, a reaction that can present at any
time during treatment course. He was started on IV decadron,
broad anti-histamines. Although penicillin was felt to be less
likely, he was switched to clindamycin for treatment of the oral
infection.
Pt was ventilated without difficulty, release of pressure cuff
revealed progressively improved cuff leak. Pt was extubated
succesfully and re-evaluation by ENT revealed improved swelling.
.
2. ESRD: Cr was monitored, found to be stable.
- continued [**Last Name (un) **], cellcept for immunosupression, rapamycin level
found to be 5.7
- continued bactrim for infectious prophylaxis.
- PTH found to be elevated and Vitamin D nl at 21.
- noted to have exposed Left upper extremity graft, transplant
surgery [**Name (NI) 653**], will see patient as outpatient for elective
revision.
.
3. CAD: continued ASA, pt initially tahycardic, however then
developed asymptomatic bradycardia to 50's, so metoprolol was
held. This resolved spontaneously and metoprolol was restarted
at home dose without redevelopment of bradycardia.
.
4. CHF, systolic: euvolemic, no need for diuresis during his
stay.
.
5. Hyponatremia - noted to develop hyponatremia with Na to 126,
urime osm 592, appears euvolemic, likely [**2-12**] SIADH. Stopped IVF
fluids, improved with fluid restriction.
.
6. Anemia - pt noted to have decrease in HCT from 29.9 to 25, no
evidence of active bleeding. Iron studies were consistent with
anemia of chronic disease.
6. PPX: SQ hep, H2 blocker, bowel meds
.
7. Code: FULL
.
8. Communication: wife, [**Name (NI) **]
Medications on Admission:
Cellcept [**Pager number **] mg [**Hospital1 **]
Rapamune 1 mg daily
Bacrtrim SS daily
Protonix 40 mg
Neurontin 400 mg [**Hospital1 **]
Metoprolol 150 mg [**Hospital1 **]
Norvasc 5 mg
Lisinopril 5 mg
Elavil 10 mg
Lipitor 20 mg
ASA 81 mg
Epogen
Fe gluconate
Duragesic patch
.
ALL: Sporanox: hives, no swelling or anaphylaxis
ACE-Inhibitors: angioedema
Discharge Medications:
1. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
3. Sirolimus 1 mg Tablet Sig: Two (2) Tablet PO QMOWEFR (Monday
-Wednesday-Friday).
4. Sirolimus 1 mg Tablet Sig: One (1) Tablet PO TUES, THURS,
SAT, SUN ().
5. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Metoprolol Tartrate 50 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
8. Clindamycin HCl 300 mg Capsule Sig: One (1) Capsule PO every
six (6) hours for 4 days.
Disp:*16 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Angioedema
.
Secondary:
ESRD [**2-12**] FSGS s/p cadeveric transplant [**2121-5-7**]
CHF
CAD s/p CABG [**2119**]
HTN
Gout
Discharge Condition:
Extubated, with stable respiratory status, angioedema resolved.
Discharge Instructions:
Take medications as prescribed. You should not take your
lisinopril any longer, at least until you follow up with Dr.
[**Last Name (STitle) **]. This follow up appointment should be set up within the
next 1-2 weeks.
.
You will need to make an outpatient appointment with surgery for
a revision of your fistula in the left arm. Call the number
provided for this.
.
Please see your dentist within the next week for treatment of
your tooth. Continue the antibiotic Clindamycin as directed.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **] next week.
.
Follow up with Transplant surgery in the next 1 month to arrange
for revision of your fistula.
.
Follow up with your dentist within the next 1 week for
management of your tooth fracture.
Completed by:[**2122-7-17**]
|
[
"V42.0",
"786.1",
"E942.9",
"276.1",
"995.1",
"428.0",
"274.9",
"401.9",
"V45.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71",
"31.42"
] |
icd9pcs
|
[
[
[]
]
] |
6558, 6564
|
3472, 5322
|
309, 336
|
6739, 6805
|
3411, 3449
|
7341, 7618
|
2583, 2879
|
5723, 6535
|
6585, 6718
|
5348, 5700
|
6829, 7318
|
2894, 3392
|
259, 271
|
365, 1949
|
2070, 2274
|
2290, 2567
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,539
| 120,164
|
42743
|
Discharge summary
|
report
|
Admission Date: [**2110-3-4**] Discharge Date: [**2110-3-10**]
Date of Birth: [**2041-1-1**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Sulfa(Sulfonamide Antibiotics) / Methotrexate
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2110-3-6**] - Coronary artery bypass grafting to four vessels. Left
internal mammary artery to left anterior descending artery,
Saphenous vein graft (SVG) to left posterior descending artery,
SVG->Diagonal artery, SVG->Obtuse marginal artery)
History of Present Illness:
69 year old male seen by his PCP for worsening dyspnea on
exertion. Stress test showed ST depressions in the inferolateral
leads. He was referred to MWMC for cardiac cath. Cath revealed
multivessel severe coronary artery disease. He was transferred
to the [**Hospital1 18**] for evaluation of coronary revascularization.
Past Medical History:
Hypertension
Hyperlipidemia
MV prolapse
TIA '[**09**]-no residual
Psoriatic arthritis
Shingles
Lyme disease
RBBB/LAFB
Heartburn
Social History:
Last Dental Exam:edentulous
Lives with:wife
Contact: Phone #
Occupation:works as supervisor in credit collections dept.
Cigarettes: Smoked no [] yes [x] last cigarette >10yo Hx:
Other Tobacco use:
ETOH: < 1 drink/week [] [**2-18**] drinks/week [x] >8 drinks/week []
Illicit drug use
Family History:
Brother (+)CABG at age 69yo. father (+)MI 40s.
Physical Exam:
Pulse: 85 Resp: 20 O2 sat:100%RA
B/P 137/92
Height: 5'7.5" Weight:198LB
General:A&Ox3, NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI []
Neck: Supple [x] Full ROM []
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema [] _____
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right:2+ Left:2+
DP Right: Left:
PT [**Name (NI) 167**]: 2+ Left:
Radial Right: 2+ Left:2+
Carotid Bruit -none Right:2+ Left:2+
Pertinent Results:
[**2110-3-4**] Carotid U/S: There is mild homogeneous calcified plaque
at the carotid bifurcations bilaterally, but no evidence of a
hemodynamically significant stenosis. Flow in the vertebral
arteries is prograde.
.
[**2110-3-6**] ECHO PRE-CPB: The left atrium is mildly dilated. No
spontaneous echo contrast is seen in the left atrial appendage.
No atrial septal defect is seen by 2D or color Doppler. There is
mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%). The right ventricular
cavity is mildly dilated with normal free wall contractility.
The ascending aorta is mildly dilated. There are simple atheroma
in the descending thoracic aorta. No thoracic aortic dissection
is seen. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic stenosis. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild to moderate ([**1-13**]+) mitral regurgitation
is seen. Dr. [**Last Name (STitle) **] was notified in person of the results at
time of study.
POST-CPB: The left ventricular systolic function remains normal,
estimated EF>55%. The RV systolic function remains normal. The
mitral regurgitation remains mild to moderate. Other valve
function remains unchanged. There is no evidence of dissection.
.
[**2110-3-9**] Chest X-ray: A tiny pneumothorax suggested on the films
dated [**2110-3-8**] at 10 a.m. is not distinctly visualized on the
current exam and has likely resolved. No other evidence for
pneumothorax is identified. There are small bilateral effusions
seen posteriorly and slight blunting of the right costophrenic
angle. There is minimal plate-like atelectasis and some patchy
retrocardiac density, which has improved in the interim. Minimal
plate-like atelectasis at the left base is new.
Cardiomediastinal silhouette is prominent, but slightly
improved. Sternotomy wires and mediastinal clips noted. There
is upper zone re-distribution, without other evidence of CHF.
.
[**2110-3-4**] 05:43PM BLOOD WBC-5.9 RBC-4.30* Hgb-13.6* Hct-37.7*
MCV-88 MCH-31.7 MCHC-36.1* RDW-12.9 Plt Ct-192
[**2110-3-9**] 06:30AM BLOOD WBC-8.2 RBC-3.26* Hgb-10.4* Hct-29.1*
MCV-89 MCH-31.9 MCHC-35.7* RDW-13.4 Plt Ct-131*
[**2110-3-4**] 05:43PM BLOOD PT-11.5 PTT-31.2 INR(PT)-1.1
[**2110-3-6**] 02:59PM BLOOD PT-12.4 PTT-33.8 INR(PT)-1.1
[**2110-3-4**] 05:43PM BLOOD Glucose-114* UreaN-19 Creat-0.9 Na-137
K-3.8 Cl-103 HCO3-24 AnGap-14
[**2110-3-10**] 04:30AM BLOOD Glucose-103* UreaN-22* Creat-0.9 Na-137
K-3.9 Cl-100 HCO3-29 AnGap-12
[**2110-3-4**] 05:43PM BLOOD ALT-21 AST-24 LD(LDH)-149 AlkPhos-51
Amylase-53 TotBili-0.4
[**2110-3-4**] 05:43PM BLOOD %HbA1c-5.8 eAG-120
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2110-3-4**] for further
management of his coronary artery disease. He was worked-up in
the usual preoperative manner including a carotid ultrasound
which showed no evidence of a hemodynamically significant
stenosis. Heparin was started given his significant disease and
coronary anatomy. On [**2110-3-6**] Mr. [**Known lastname **] was taken to the
operating room where he underwent coronary artery bypass
grafting to four vessels. Please see operative note for details.
Postoperatively he was taken to the intensive care unit for
monitoring. Over the next several hours, he awoke neurologically
intact and was extubated. He remained on Neo through POD #1 this
was weaned off by POD#2 and he was started on low dose
lopressor. He transferred to floor for further care. Chest tubes
and epicardial pacing wires were removed per protocol. While on
the telemetry floor he continued to make good progress and
worked with physical therapy for strength and mobility. On
post-op day four he was discharged home with VNA services with
the appropriate medications and follow-up appointments.
Medications on Admission:
ASA 81mg daily
Lisinopril-Hydrochlorothiazide 20/12.5mg daily
Cyclobenzaprine HCL 5mg daily
Doxazosin 2mg daily
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
4. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
5. furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
6. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO Q12H (every 12 hours)
for 2 weeks.
Disp:*28 Tablet, ER Particles/Crystals(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
Coronary artery disease s/p Coronary artery bypass graft x 4
Past medical history:
Hypertension
Hyperlipidemia
MV prolapse
TIA '[**09**]-no residual
Psoriatic arthritis
Shingles
Lyme disease
RBBB/LAFB
Heartburn
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage.
Edema +1
Discharge Instructions:
1) Please shower daily including washing incisions gently with
mild soap, no baths or swimming until cleared by surgeon. Look
at your incisions daily for redness or drainage.
2) Please NO lotions, cream, powder, or ointments to incisions.
3) Each morning you should weigh yourself and then in the
evening take your temperature, these should be written down on
the chart provided.
4) No driving for approximately one month and while taking
narcotics. Driving will be discussed at follow up appointment
with surgeon when you will likely be cleared to drive.
5) No lifting more than 10 pounds for 10 weeks
6) Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] [**2110-4-9**] @1pm
Cardiologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 31888**] [**2110-3-31**] 11:30am
Wound check : [**2110-3-18**] @ 10am
Please call to schedule appointments with your
Primary Care Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) **] in [**4-17**] 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:[**2110-3-10**]
|
[
"496",
"696.0",
"426.52",
"424.0",
"458.29",
"428.0",
"403.90",
"V12.72",
"428.32",
"V15.82",
"585.9",
"V17.3",
"285.9",
"272.4",
"V12.54",
"414.01",
"715.36",
"V45.79"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.13",
"39.61",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
7055, 7114
|
4895, 6049
|
330, 577
|
7368, 7576
|
2127, 4872
|
8464, 9069
|
1416, 1464
|
6211, 7032
|
7135, 7196
|
6075, 6188
|
7600, 8441
|
1479, 2108
|
271, 292
|
605, 927
|
7218, 7347
|
1094, 1400
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,236
| 167,863
|
52420
|
Discharge summary
|
report
|
Admission Date: [**2194-3-24**] Discharge Date: [**2194-4-8**]
Date of Birth: [**2112-2-19**] Sex: F
Service: MEDICINE
Allergies:
Belladonna Alkaloids
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Diarrhea with fever & tachycardia
Major Surgical or Invasive Procedure:
blood transfusion
History of Present Illness:
An 82 year old [**First Name3 (LF) 595**] speaking woman recently discharged from
[**Hospital Ward Name 516**] for PNA returns with 3 days of diarrhea complicated
by tachycardia and fever as measured by her daughter/VNA. This
history is obtained from the patient's daughter and review of
medical records as communication with the patient is difficult
secondary to language and hearing difficulties.
.
BRIEF SUMMARY OF RECENT HOSPITALIZATION [**Date range (1) 108333**]:
The patient presented with hypoxic/hypercapnic respiratory
failure due to PNA with effusions attributed to diastolic heart
failure. She was admitted to the [**Hospital Unit Name 153**] and started on
Levoflox/Vanc to finish a 10 day Levofloxacin only course. The
patient experienced ? AMS but head CT was negative. Patient was
continued on Lovenox for chronic DVT h/o PE. Her cr remained at
1.8-2.4 during this admission. She developed a new wound
possibly from plexipulses and required extensive wound care for
multiple wounds. She was made DNR/DNI. The patient was D/C'd
home without mention of diarrhea.
.
Per the daughter, [**Name (NI) 108329**], the patient developed diarrhea during
her recent hospitalization that has persisted since discharge.
The patient had a "tought day" with some agitation and apparent
discomfort with breathing. The patient was eating but
"everything she ate caused loose stools" different from her
regular Crohn's flares. When [**Name (NI) 108329**] noted tachycardia and fever
accompanying the loose, yellow non-bloody stools with an
increasing O2 requirement, the patient was brought into the ED
.
In the ED, VS: 99.2 BP 103/53 HR 110, RR 24, 100% on 3L. Exam
revealed crackles and decreased BS. EKG showing RBBB with old
TWI in 3, sinus tach. CXR: resolving PNA. Received Vanco 1g &
fluids in ED.
.
On arrival to the floor, the patient is laying in bed and
reports that she is "fine." She complains of generalized chronic
weakness and has pain during wound dressing changes. Her
daughter relayed the history as above. The patient has a cough
productive of green sputum once on arrival. She has R sided
tremor.
.
ROS:
Significant for easy bruising, long standing vision & hearing
loss,
Denies headache, cough (except for above), SOB, chest pain,
abdominal pain, hematochezia, melena
Past Medical History:
PAST MEDICAL HISTORY:
-Anemia [**3-3**] CRI, chronic disease
-MDS dx 3 yrs ago
-Crohn's disease
-CAD s/p NSTEMI '[**89**]
-CRI w baseline Cr 1.5-1.8
-BL DVTs and saddle embolus in [**2190**], previously on warfarin now
on Lovenox
-Chronic BL LE edema
-Breast cancer s/p lumpectomy & XRT
-GERD
-Intracranial bleed and fx after pedestrian vs car 20 yrs ago
-Cataracts
-Venous stasis dermatitis
-Tinea pedis
-?Arrhythmia unspecified which daughter says is tx with
metoprolol
-dHF with EF 60-70%
.
PAST SURGICAL HISTORY:
-CCY 10 yrs ago
-Lumpectomy 13 yrs ago
Social History:
Married; lives with her husband who is demented, her daughter
[**Name (NI) 108329**], [**Name2 (NI) 108330**] husband and 6 [**Name2 (NI) **] granddaughter. Presently in
temporary housing while awaiting renovations on their [**Last Name (un) **]
which was damaged during a fire last winter. [**Last Name (un) 108329**] is the
caretaker for both of her parents. [**Last Name (un) 108329**] very stressed and
overwhelmed. Her mother-in-law in [**Name (NI) 4565**] died this past
month which required her husband to leave for [**Name (NI) 4565**]. She is
in the midst of trying to place her father in nursing care
facility and is quite guilty about this decision. Ms. [**Known lastname 108328**] [**Last Name (Titles) 108331**]y recieves near daily RN visits from Suburban Home Care.
[**Last Name (Titles) 108329**] is reliant on "sitters" to bring her mother to
appointments.
Family History:
non-contributory
Physical Exam:
VS: T BP 95/32 P 32 R 32 96% 3L
General: somnolent, but wakes to voice and responds to
questions; daughter at bedside
[**Name (NI) 4459**]: PERRL, NC/AT, conjunctival pallor, anicteric
Neck: no JVD appreciated
Lungs: bilaterla crackles while sitting up in bed
Cardiac: RRR, S1 S2, 2/6 SEM best at LUSB,
Abdomen: soft, non-tender, non-distended, +BS throughout
Extrem: [**3-4**]+ gross bilateral edema R>>L; dry dressings to both
legs, several healing skin tears over upper and lower
extremities
.
Pertinent Results:
[**2194-3-24**] 11:00PM GLUCOSE-105 UREA N-34* CREAT-2.5* SODIUM-136
POTASSIUM-4.7 CHLORIDE-98 TOTAL CO2-33* ANION GAP-10
[**2194-3-24**] 11:00PM CK(CPK)-11*
[**2194-3-24**] 11:00PM CK-MB-NotDone cTropnT-0.07*
[**2194-3-24**] 11:00PM ALBUMIN-3.1* CALCIUM-7.8* PHOSPHATE-4.3
MAGNESIUM-1.5*
[**2194-3-24**] 04:15PM URINE HOURS-RANDOM UREA N-317 CREAT-58
SODIUM-77
[**2194-3-24**] 04:15PM URINE UHOLD-HOLD
[**2194-3-24**] 04:15PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.009
[**2194-3-24**] 04:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-TR
[**2194-3-24**] 04:15PM URINE RBC-0-2 WBC-3 BACTERIA-OCC YEAST-NONE
EPI-0
[**2194-3-24**] 02:18PM LACTATE-1.5
[**2194-3-24**] 01:10PM GLUCOSE-88 UREA N-29* CREAT-2.4* SODIUM-139
POTASSIUM-4.7 CHLORIDE-99 TOTAL CO2-34* ANION GAP-11
[**2194-3-24**] 01:10PM estGFR-Using this
[**2194-3-24**] 01:10PM LD(LDH)-238 CK(CPK)-20*
[**2194-3-24**] 01:10PM cTropnT-0.07*
[**2194-3-24**] 01:10PM CK-MB-NotDone proBNP-1643*
[**2194-3-24**] 01:10PM CALCIUM-8.0* PHOSPHATE-3.2 MAGNESIUM-1.6
[**2194-3-24**] 01:10PM WBC-17.4*# RBC-2.68* HGB-9.9* HCT-30.9*
MCV-115* MCH-37.0* MCHC-32.1 RDW-19.3*
[**2194-3-24**] 01:10PM NEUTS-89.6* LYMPHS-7.1* MONOS-2.6 EOS-0.4
BASOS-0.3
[**2194-3-24**] 01:10PM HYPOCHROM-1+ ANISOCYT-2+ POIKILOCY-1+
MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-1+
SCHISTOCY-OCCASIONAL STIPPLED-OCCASIONAL
[**2194-3-24**] 01:10PM PLT COUNT-133*
[**2194-3-24**] 01:10PM PT-12.3 PTT-29.7 INR(PT)-1.0
[**2194-4-8**] 05:56AM BLOOD Plt Smr-LOW Plt Ct-82*
[**2194-4-8**] 05:56AM BLOOD WBC-11.8* RBC-2.86* Hgb-9.6* Hct-29.5*
MCV-103* MCH-33.7* MCHC-32.6 RDW-18.8* Plt Ct-82*
[**2194-4-8**] 05:56AM BLOOD Glucose-110* UreaN-67* Creat-2.5* Na-143
K-5.2* Cl-109* HCO3-27 AnGap-12
[**2194-4-8**] 05:56AM BLOOD Calcium-7.9* Phos-3.9 Mg-1.6
MICROBIOLOGY:
MRSA negative
C.diff negative x2
IMAGING:
[**2194-4-7**] CXR: IMPRESSION:
1. New mild-to-moderate right pleural effusion.
2. Persistent moderate left pleural effusion and dense
retrocardiac opacity
which may represent left lower lobe collapse or, less likely,
consolidation.
[**2194-4-2**] UPPER EXT U/S: IMPRESSION:
1. No left upper extremity DVT.
2. Left thyroid cyst.
Brief Hospital Course:
An 82 year old lady with multiple medical problems recently
discharged for PNA presents with 3 days of diarrhea accompanied
by tachycardia & fever with concern for new left pneumonia
despite levaquin therapy. Her exam and appearance is concerning
for respiratory distress.
.
1) Pneumonia: The patient was found to have a new left sided
pneumonia, retrocardiac opacity and L pleural effusion on CXR
from either new process or aspiration. On admission to the
medicine service she was found to be in hypoxic/hypercarbic
respiratory failure and was transferred to the ICU. She was
started on vancomycin/zosyn 2 week course, albuterol and
ipratropium neb treatments and supplemental oxygen. IV fluids
were administered for her acute on chronic CKD (see below) which
may have lead to some pulmonary edema. Sputum culture was done
but did not reveal the source of her pneumonia. She completed
the course and her oxygen requirements improved. Lasix was held
in the setting of her ATN thus some fluid overload may be
present, and prior to discharge she was slowly restarted on
lasix for diuresis. She remained afebrile for the length of her
admission. Prior to discharge a repeat chest xray showed a
stable left-sided pleural effusion, new small right sided
pleural effusion (thought to be secondary to holding lasix for
hypotension for over a week), and stable retrocardiac opacity.
The patient was discharged on 2.5-3L of oxygen, with
saturdations 90-93%.
.
2) Diarrhea: This may have been the cause to the patient's
volume loss, leading to hypotension and eventually to ATN. While
initially guaiaic negative, it was felt to be due to antibiotic
use, infectious or Crohn's flare. She was c.diff negative x2.
Her poor po intake began to improve and her diarrhea, while
intermittent continued to be an issue. In the setting of
thrombocytopenia she had loose guaiac positive, dark/tarry
stools. It was unclear if this was a [**Name (NI) 4522**] flare of small
bleed from anticoagulation (on heparin at the time) or
thrombocytopenia. She was started on pulse dose steroids and
tapered down to prednisone 60mg daily. She is currently on a
taper. The GI service was consulted and felt that flexible
sigmoidoscopy may help elucidate whether there is new dysplasia
or worsening of her Crohn's. The patient's daughter and HCT did
not feel her mother could tolerate a procedure at this time and
opted for medical management. It remains unclear what caused her
diarrhea but it was encouraged that she maintain a lactose-free
diet as this was felt to exacerbate the issue. She will continue
her prednisone taper while at rehabilitation. She has a
follow-up appointment with Dr.[**Last Name (STitle) 3708**] after discharge. Given she
has been on steroids for many years, calcium and vitamin D
therapy was initiated during this hospitalization.
.
3) Diastolic Heart Failure: Her most recent echo suggests
hyperdynamic stiff ventricle as supported by elevated BNP, EF
70-80%. However this was done in the setting of what appeared to
be septic physiology. Her lasix and metoprolol were held on
admission for hypotension and renal failure. Lasix was restarted
prior to discharge for diuresis and improve her respiratory
status. Metoprolol should be restarted when appropriate, given
she is on a prednisone taper. Prior to discharge a transthoracic
echo was performed so that it can be used for comparison in the
future. The results will be pending after discharge and should
be followed-up at next PCP [**Name Initial (PRE) **]. Her weight on discharge was
77.8kg.
.
4) ATN/CKD: Patient at last discharge with creatinine of 2.4.
She was felt to be pre-renal given the diarrhea, which was
likely responsible for her elevated troponin on this admission.
Her creatinine rose to peak at 4.4. The nephrology service was
consulted and upon evaluation of her labs felt this was
consistent with ATN. Witholding lasix and gentle diuresis, the
patient's renal function improved. Her medications were renally
dosed and nephrotoxins avoided where possible. Urine output
improved and creatinine trended down to 2.5 prior to discharge
to rehabilitation.
.
5) Crohn's Disease: Initially the patient was continued on
prednisone 18mg daily as per her home regimen. However with
hypotension and respiratory failure, she was started on stress
dose regimen which was eventually tapered. She was switched from
IV to po prednisone and is currently on a long taper. As above,
she has an appointment with Dr. [**Last Name (STitle) 3708**] as an outpatient. She will
continue on prednisone, mesalamine and cipro twice daily to
prevent a flare.
.
6) MDS and Related Anemia: The patient is known to have chronic
anemia secondary to both MDS and CKD. She is followed as an
outpatient by hematology and received weekly Epogen treatment
prior to her multiple admission. She was transfused several
times for hematocrit of 25. Prior to discharge she was also
given a one-time dose of 10,000U Epogen (slightly hypertensive
at the time, did not give full 40,000U dose). She has follow-up
with Dr.[**Last Name (STitle) **] in clinic to evaluate whether she should be
restarted on her Epogen treatments.
.
7) DVT/PE: Patient had chronic DVT/PE in the past for which she
was on lovenox, which was initially continued. In the setting of
acute renal failure she was switched to heparin for
approximately 2 days at which point her thrombocytopenia became
significantly worse (plt 49 at lowest). HIT antibodies were sent
and were negative. She was also found to have guaiac + stools
and tarry loose stools at times. Given her risk of bleeding
(anemia, thrombocytopenia) it was felt the risk of
anticoagulation was greater than the benefit, despite her
underlying PE/DVT history. The issue of anticoagulation should
be readdressed once her more pressing issues, namely
intermittent bloody stools and thrombocytopenia are resolved.
Lovenox was not restarted prior to discharge. Pneumoboot was
applied to the left arm once her skin and edema had healed.
Given her extensive upper extremity swelling of the L arm, an
upper extremity US was done to r/o DVT which was negative. Of
note, a thyroid cyst was identified on this study, which it
appears has been seen on prior imaging but should be further
evaluated if concerns arise in the future.
.
8) Hemorrhagic bullae s/p rupture: Much of this is likely due to
her years of steroid use. She has a variety of wounds from a
recent hospitalizations. Both wound care consult and vascular
surgery were asked to comment and felt surgical intervention or
debridement were not warranted, but good wound care and close
monitoring should be instituted. The patients legs were wrapped
daily, adaptec applied to wounds, and lotion applied to decrease
the risk of further skin tears. With time the swelling in her
arms and legs decreased, however her skin is very delicate and
good wound care practices need to be followed.
.
9) GERD: In the setting of guaiac positive stools she was
switched from omeprazole to protonix IV for two days while
concern for active bleed was ruled out. Once stable, she was
restarted on omeprazole 20mg twice daily.
.
10) Osteoporosis: Calcium and vitamin D were continued during
admission.
.
11) Nutrition: The patient has very poor appetite. She was NPO
for several days, and when she would eat, her diarrhea would
recur. Her diet was switched to lactose free and high calorie
supplements were provided.
.
12) Code: the patient's daughter and health care proxy confirmed
code as DNR/DNI
Medications on Admission:
-Ciprofloxacin 250 mg [**Hospital1 **]: "Crohn's Ppx"
-Mesalamine 400mg 3 tab TID (pt usually only takes 3 tab QDAY)
-Prednisone 18 mg QDAY
-Omeprazole 20mg [**Hospital1 **]
-Metoprolol 12.5 mg QDAY
-Furosemide 10mg QOD
-Epogen 40,000 units QWEEK
-Lovenox 80mg syringe/70 units QDAY
-Alendronate 70mg QSATURDAY
-Calcium carbonate 500mg TID
-Folic acid 1 mg QDAY
-Vitamin B12 1cc QMONTH
-Vitamin D3 400 unit [**Unit Number **] tab QDAY
-APAP 500mg [**1-31**] tab QID PRN
-Albuterol 2.5mg neb QID PRN
-Camphor-Menthol 0.5-0.5 % Lotion TID PRN
-Triamcinolone cream PRN
-Miconazole cream PRN
Discharge Medications:
1. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for Pain.
2. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
3. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Three
(3) Tablet, Delayed Release (E.C.) PO BID (2 times a day).
4. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day).
5. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
6. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q2H (every 2 hours) as
needed for dyspnea.
8. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-31**] Sprays Nasal
TID (3 times a day) as needed.
9. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours).
12. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed for diarrhea.
13. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2)
Tablet, Chewable PO TID (3 times a day).
14. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic
DAILY (Daily).
15. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-31**]
Drops Ophthalmic PRN (as needed).
16. Prednisone 20 mg Tablet Sig: taper as below Tablet PO DAILY
(Daily): 60mg (3 tabs) daily for 4 days (start [**2194-4-8**]).
40mg (2 tabs) daily for 4 days.
20mg (1 tab) daily for 4 days .
17. Furosemide 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1643**] center
Discharge Diagnosis:
Primary:
Pneumonia
Acute Tubular Necrosis of the kidney
Secondary:
Thrombocytopenia
Anemia
MDS
Discharge Condition:
hemodynamically stable and afebrile, 92% on 3L
Discharge Instructions:
You were admitted to the hospital for diarrhea and pneumonia.
You were found to be hypotensive (low blood pressure) and have
respiratory failure which required you to be admitted to the
ICU. You were treated with IV fluids and antibiotics. You
completed a two week course of antibiotics for your pneumonia.
For your diarrhea you were given pulse dose steroids and are now
on a taper of prednisone. Since you had bowel movements that
were positive for blood (guaiac positive) and your platelet
count became very low, your anticoagulation was stopped. Your
lasix was initially held as you were found to be in renal
failure, which is now resolving. Please make sure to discuss
with your doctor when it is appropriate for you to restart your
metoprolol and lovenox.
The following changes were made to your medications:
Your lovenox has been stopped.
Your metoprolol is being held- speak to your doctor to determine
when it is ok to restart this medication.
Calcium, vitamin D have been added to your regimen.
If you experience any shortness of breath, chest pains,
abdominal pains, fevers or chills, or any other concerning
symptoms please call your doctor or return to the emergency
room.
Followup Instructions:
Please make sure to follow-up with:
Primary care doctor: Dr.[**Last Name (STitle) 3357**] ([**Telephone/Fax (1) 4606**]on Thursday [**4-10**]
at 5:45pm
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7290**], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2194-4-24**]
10:20
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 647**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2194-4-29**] 3:30
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3014**], RN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2194-4-29**]
3:30
|
[
"518.81",
"V10.3",
"276.7",
"428.0",
"682.6",
"428.32",
"414.01",
"511.9",
"584.5",
"555.9",
"787.91",
"530.81",
"238.75",
"585.5",
"733.00",
"709.8",
"285.21",
"507.0",
"V12.51",
"V58.61",
"412"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
16855, 16909
|
6999, 14500
|
313, 333
|
17049, 17098
|
4689, 6976
|
18335, 18940
|
4137, 4156
|
15139, 16832
|
16930, 17028
|
14526, 15116
|
17122, 18312
|
3189, 3230
|
4171, 4670
|
240, 275
|
361, 2650
|
2694, 3166
|
3246, 4121
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,503
| 123,311
|
40842
|
Discharge summary
|
report
|
Admission Date: [**2194-5-6**] Discharge Date: [**2194-5-12**]
Date of Birth: [**2152-7-6**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
chset pressure
Major Surgical or Invasive Procedure:
coronary artery bypass grafting LIMA-LAD, RIMA-PDA, SVG-OM,
SVG-DG
History of Present Illness:
41 year old male who complains of
several months of worsening chest pressure with exertion. No
nausea or vomiting or diaphoresis. No shortness of breath or
fevers or chills or cough. Stress test performed today and was
positive for cardiac ischemia. Sent to the ED for admission for
cardiac catheterization. He was found to have coronary artery
disease upon cardiac catheterization and is now being referred
to
cardiac surgery for revascularization.
Past Medical History:
borderline hypertension
Social History:
Race:Caucasian
Last Dental Exam:2 years ago
Lives with:Wife and 2 daughters (8 months and 2 yrs old)
Occupation:managment at Stop and Shop Distribution
Tobacco:denies
ETOH:rare
Family History:
Family History:Father s/p MI at age 42, s/p CABG in 50's
Physical Exam:
Pulse:54 Resp:12 O2 sat:98/RA
B/P Right:119/72 Left: 118/68
Height:5'[**93**]" Weight:181 lbs
General: awake alert oriented
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
Extremities: Warm [x], well-perfused [x]
no Edema no Varicosities
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+
Pt is right handed; cath was done via R radial artery;
[**Doctor Last Name 6237**] test: delayed filling on the left; more rapid filling on
the left.
Carotid Bruit Right: no Left: no
Pertinent Results:
ECHO:
Pre CPB:
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium or left atrial appendage.
No atrial septal defect is seen by 2D or color Doppler.
Left ventricular wall thicknesses are normal. The left
ventricular cavity is mildly dilated. Overall left ventricular
systolic function is normal (LVEF>55%).
Tissue Doppler imaging suggests a normal left ventricular
filling pressure (PCWP<12mmHg).
There are simple atheroma in the descending thoracic aorta.
There are three aortic valve leaflets. There is no aortic valve
stenosis. No aortic regurgitation is seen.
Mild (1+) mitral regurgitation is seen.
Dr. [**Last Name (STitle) **] was notified in person of the results.
Post CPB:
The patient is being A-paced on a phenylephrine infusion.
The biventricular sytoic function is preserved.
There is mild MR.
The visible contours of the thoracic aorta are intact.
Brief Hospital Course:
The patient was admitted to the hospital and brought to the
operating room on [**2194-5-8**] where the patient underwent coronary
artery bypass graft x 4 (see operative note for details).
Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. POD 1 found the
patient extubated, alert and oriented and breathing comfortably.
The patient was neurologically intact and hemodynamically
stable on no inotropic or vasopressor support. Beta blocker was
initiated and the patient was gently diuresed toward the
preoperative weight. Unable to initiate cardiazem for RIMA graft
due to borderline low blood pressure while on low dose
lopressor. The patient was transferred to the telemetry floor
for further recovery. Chest tubes and pacing wires were
discontinued per protocol without complication. The patient was
evaluated by the physical therapy service for assistance with
strength and mobility. By the time of discharge on POD #4 the
patient was ambulating freely, the wound was healing and pain
was controlled with oral analgesics. The patient was discharged
home on POD# 4 in good condition with appropriate follow up
instructions.
Medications on Admission:
aspirin
Discharge Medications:
1. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule 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).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Lasix 20 mg Tablet Sig: Two (2) Tablet PO once a day for 7
days.
Disp:*14 Tablet(s)* Refills:*0*
6. potassium chloride 20 mEq Packet Sig: Two (2) Packet PO once
a day for 7 days.
Disp:*14 Packet(s)* Refills:*0*
7. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*70 Tablet(s)* Refills:*0*
8. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
Disp:*45 Tablet(s)* Refills:*2*
9. Motrin 600 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for pain.
Disp:*90 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
vns of greater RI 6 [**Location (un) **] valleyplace
Discharge Diagnosis:
coronary artery disease
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Edema; trace
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, 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 will need the following appointments:
Wound Check at Cardiac Surgery Office [**Telephone/Fax (1) 170**] within one
week, office will call with appointment
Surgeon Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**], office will call with
appointment
Cardiologist's office will call with appointment date to see you
within 2 weeks.
Please call to schedule the following:
Primary Care Dr. [**First Name8 (NamePattern2) 1439**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 89215**] to be seen in [**3-18**]
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:[**2194-5-12**]
|
[
"411.1",
"458.29",
"401.9",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"38.93",
"39.61",
"88.56",
"36.16",
"36.12"
] |
icd9pcs
|
[
[
[]
]
] |
5268, 5351
|
2926, 4165
|
323, 392
|
5419, 5597
|
2011, 2713
|
6386, 7109
|
1145, 1189
|
4223, 5245
|
5372, 5398
|
4191, 4200
|
5621, 6363
|
1204, 1992
|
269, 285
|
420, 872
|
894, 919
|
935, 1114
|
2723, 2903
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,272
| 196,156
|
25255+24683
|
Discharge summary
|
report+report
|
Admission Date: [**2195-9-8**] Discharge Date: [**2195-9-14**]
Service: VSU
CHIEF COMPLAINT: Non healing Achilles tendon ulceration.
HISTORY OF PRESENT ILLNESS: This is a [**Age over 90 **]-year-old female who
presented to [**Hospital3 **] [**Location (un) 620**] with a right pressure
ulceration at the area of the Achilles tendon and an anterior
tibial lesion at the distal third of the tibia secondary to
trauma suffered on [**5-13**]. The patient is baseline demented,
communication is difficult, and information was obtained from
the family. The patient now is admitted for definitive
treatment of her right leg and Achilles tendon ulcerations.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: Corgard 20 mg daily, vancomycin,
Megace 400 mg daily and Synthroid 70 mcg daily.
PAST ILLNESSES: Hypertension, history of DVT in [**2193**],
hypothyroidism supplemented, dementia, hyponatremia, history
of dehydration, history of acute renal failure, history of
coronary artery disease, history of osteoarthritis status
post partial hip arthroplasty, questionable right hip,
history of hernia status post hernia repair.
PHYSICAL EXAMINATION: General appearance is disoriented,
demented, elderly female. HEENT exam was unremarkable. Heart
is a regular rate and rhythm without murmur, gallop or rub.
Chest is clear to auscultation bilaterally. Abdominal exam is
unremarkable. Extremity exam - right distal leg has ischemic
changes with posterior Achilles ulceration and an anterior
tibial ulceration, full-thickness. The right DP is
nonpalpable and non Dopplerable.
HOSPITAL COURSE: The patient was admitted to the vascular
service for definitive treatment of her leg ulceration. Her
admitting white count was 13.7, hematocrit 33.4, BUN 16,
creatinine 0.8, K of 3.4, which was repleted. The patient was
begun on vancomycin, levofloxacin and Flagyl. The patient was
determined non revascularable. The patient was prepared for a
right above-knee amputation which she underwent on [**2195-9-10**] without complications. She was evaluated prior to
discharge by our speech and swallow service to determine
adequacy of swallowing and presence of aspiration. They felt
there were no signs of aspiration on her bedside swallowing
evaluation. She appeared safe to eat a diet of pureed foods
and to drink thin liquids. Medications would be safest if
crushed and given in apple sauce or in liquid form. From
speaking with the family, this is what the patient had been
on prior to transfer to our institution. She was also begun
on Boost t.i.d. Her postoperative course was unremarkable.
Initial dressings were removed on postoperative day 2. The
wound was clean, dry and intact, well-approximated without
erythema or ischemic changes. The patient was transfused 2
units of packed red cells postoperatively for a hematocrit of
26. The patient's hemoglobin A1c was 6.6, TSH 1.5, T4 of 5.0.
A total iron binding capacity was 130 and a TRF was 100. The
patient was returned to [**Location 1036**] in stable condition.
Wound care is dry, sterile dressing changed daily and protect
wound from excoriation and soiling. The patient should follow
up with Dr. [**Last Name (STitle) **] in 3 weeks for skin clip removal.
DISCHARGE MEDICATIONS: Levothyroxine 75 mcg daily, nadolol
20 mg daily, morphine 2 mg subcutaneously q.4h. p.r.n. as
needed, Megace 400 mg daily, calcium carbonate 1000 mg b.i.d.
DISCHARGE DIAGNOSES: Right Achilles tendon ulceration
secondary to trauma, right anterior tibial distal ulceration
secondary to trauma, history of hypertension, controlled,
history of dementia, history of osteoarthritis status post
right hip arthroplasty, history of DVT in [**2193**], history of
dehydration, history of acute renal failure, history of
coronary artery disease status post right AKA on [**2195-9-10**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(2) 6039**]
Dictated By:[**Last Name (NamePattern1) 2382**]
MEDQUIST36
D: [**2195-9-14**] 08:16:29
T: [**2195-9-14**] 08:41:54
Job#: [**Job Number 63228**]
Admission Date: [**2195-9-14**] Discharge Date: [**2195-9-26**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
[**Age over 90 **]F s/p recent right AKA, who presents with fever, UTI and
dyspnea.
Major Surgical or Invasive Procedure:
G tube placement
History of Present Illness:
Transferred from rehab for fevers to 101, dyspnea.
Past Medical History:
HTN, DVT,CRI, Hypothyriod,CAD,OA, severe dementia
Social History:
in nursing home since discharge from [**Hospital1 18**]
Family History:
daughter [**Name (NI) **] is HCP
Physical Exam:
T 101 62 90/60
not oriented
RRR
lungs CTA B
soft nontender
Right AKA site w/o cellulitis or fluctuance
Pertinent Results:
on admission:
WBC 25
U/A: +bacteria, +WBC
C diff+ x1
RUE US: near occlusive subclavian DVT
Brief Hospital Course:
[**9-14**]: admitted with UTI to [**Hospital Ward Name **] 9. also worrisome for failure
to thrive, which calorie counts confirmed.
[**9-21**]: per g-j tube placed in IR.
[**9-23**]: transferred to ICU setting for respiratory failure & was
intubated.
[**9-25**]: extubated after family meeting opting to make patient
DNR/DNI. transferred to floor & diuresed.
[**9-26**]: respiratory failure led to ms [**Known lastname 62288**]' death. see event
note. family, attending & admitting notified.
Medications on Admission:
Cogard 20', megace 400', synthriod 75', CaCO3 100q12
Discharge Medications:
na
Discharge Disposition:
Expired
Discharge Diagnosis:
HTN,
CRI,
Hypothyriod,
CAD,
OA,
severe dementia,
UTI,
pneumonia,
right SCV deep vein thrombosis
Discharge Condition:
deceased
Discharge Instructions:
na
Followup Instructions:
na
Completed by:[**2195-9-26**]
|
[
"008.45",
"996.74",
"250.00",
"428.0",
"041.3",
"995.92",
"599.0",
"038.9",
"294.8",
"783.7",
"453.8",
"584.9",
"401.9",
"507.0",
"244.9",
"518.81",
"V49.76",
"427.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"44.32",
"96.71",
"00.17",
"96.04",
"38.93",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
5639, 5648
|
5008, 5509
|
4454, 4472
|
5787, 5797
|
4890, 4890
|
5848, 5881
|
4714, 4748
|
3437, 4314
|
5612, 5616
|
5669, 5766
|
5535, 5589
|
1617, 3234
|
5821, 5825
|
4763, 4871
|
1176, 1599
|
4331, 4416
|
4500, 4552
|
4905, 4985
|
4574, 4625
|
4641, 4698
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,227
| 153,316
|
7750
|
Discharge summary
|
report
|
Admission Date: [**2113-11-12**] Discharge Date: [**2113-11-19**]
Date of Birth: [**2068-3-20**] Sex: F
Service: MEDICINE
Allergies:
Ibuprofen / Aspirin / Penicillins / Vitamin B Complex / Latex
Attending:[**First Name3 (LF) 4282**]
Chief Complaint:
difficulty swallowing, hypotension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms [**Known lastname **] is a 45 yo woman with h/o breast cancer, infiltrating
lobular carcinoma, metastatic to liver, bone who last chemo was
carboplatin on [**2113-11-9**]. The patient reports that she has been
having difficulty swallowing and oral pain over the last several
days. She has only been able to tolerate minimal po due to her
pain. Her pain was initially caused her to have difficulty
swallowing solids, but has progressed to liquids. Due to her
poor intake she feels she has been dehydrated. She took some
dilaudid with some pain relief.
.
In the ED VS: 96.8 103 94/67 20 97%RA. She had white plaques
noted in her oropharynx consistent with candidiasis. She was
given nystatin swish&swallow, fluconazole 200mg and 1mg dilaudid
IV for pain. The patient's SBP were in the high 70s, bolused
with 3L, now in 90s. No pulsus paradoxus. Was somnolent,
maintaining airway. Was very icteric on exam with abdominal
distention in absence of pain. Elevated LFTs, Tbili, u/s
without cholecystitis. Has 16g and portacath. Admitted to [**Hospital Unit Name 153**]
in setting of hypotension and altered mental status.
.
On arrival to ICU pt is somnolent, but arousable, ROS limited,
admits to odynophagia and some abdominal discomfort as well as
feeling groggy. Denies fevers, cough, leg pain, shortness of
breath, constipation, last BM yesterday. Per sisters, pt had
been having some dysphagia with spitting/vomiting x 1 week and a
cough. No fever. No AMS at home. Took 2mg dilaudid pill at
home and 1mg dilaudid in ED, she is now more sedated to them.
Past Medical History:
Dx [**2108**] with infiltrating lobular carcinoma grade II with
extensive ductal carcinoma and lymphovascular invasion. She had
local excision followed by left total mastectomy, completed
dose-dense CA followed by taxol & then followed by tamoxifen.
She was admitted to [**Hospital1 18**] from [**2112-10-12**] to [**2112-10-25**] for right
leg swelling & pain & was found to have a right lower ext DVT &
extensive metastatic lesions of the [**Last Name (un) **] & femurs. She was
treated with radiation therapy inpatient with improvement of
pain. She received pamidronate on [**10-14**]. She was evaluated by
[**Month/Day (4) **] & given wait bearing instruction & discharged to rehab.
She started her first cycle of navelbine on [**2112-11-17**]. She was
also admitted in [**11-21**] for hypercalcemia and [**Doctor First Name **] that was
treated with iv fluid. Had another admission [**12-23**] for
hypercalcemia. Admission [**Date range (1) 17957**] for elevated transaminitis
likely due to liver metastatasis and edema for which her
diuretics were adjusted.
.
Tx history:
[**2109-3-22**] Dose dense AC
[**2109-5-24**] Dose dense Taxol switched to weekly Taxol d/t peripheral
neuropathy [**2109-6-21**] to [**2109-7-26**]
[**2112-10-14**] to [**2112-10-20**] XRT to pelvis for bony lesions
[**2112-12-29**] started Taxotere/Avastin inpatient
[**2113-1-21**]- left femur surgery after fall at home
[**2113-1-26**] Resume Taxotere without Avastin
[**2113-2-23**] Avastin readed to Taxotere/Avastin regimen
[**2113-9-14**] Doxil for disease progression (10/01,10/08,10/15,[**10-12**])
[**2113-11-2**] CARBOplatin ([**2113-11-2**], [**2113-11-9**], [**2113-11-16**])
.
PAST MEDICAL HISTORY:
DVT
Migraines
Social History:
She lives with her 8 year old son [**Name (NI) **] along with mother and
sisters living close by. Denies smoking or alcohol use. She
worked as a librarian at the State House. Has [**Location (un) 5700**] Chair car
to assist into house, HHA 5 days/wk, home OT/PT, as well has
medical equiptment. Uses a wheelchair and walker to ambulate
Family History:
Family: No hx ovarian or breast ca
Physical Exam:
T=AF BP=89-109/56-68 HR=69-102 RR=15 O2=100% RA
.
.
PHYSICAL EXAM
GENERAL: Somnolent, snoring, but arousable. NAD. Weeping
anasarca.
HEENT: Normocephalic, atraumatic. Deeply icteric sclera.
Impressive oral thrush. Neck supple, no LAD.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**].
LUNGS: CTAB, good air movement biaterally. Decreased at bases.
ABDOMEN: Distended. Mild tympany. Hypoactive BS. Non-tender.
No rebound or guarding.
EXTREMITIES: 3+ pitting edema to hip. Port-a-cath right chest
wall c/d/i.
SKIN: No rashes/lesions, ecchymoses.
NEURO: Somnolent but arousable, oriented, responding
appropriately. EOMI, pupils constricted, but constrict
symmetrically. Moving all extremities, responding to commands,
grip strength 5/5. Unable to cooperate with exam for asterixes.
Pertinent Results:
[**2113-11-12**] Abd u/s prelim read:
1. Collapsed GB. CBD 2mm. No acute cholecystitis.
2. Multiple hepatic focal hypodensities, compatible with known
liver mets.
3. Right hydronephrosis.
4. Moderate amount of ascites.
.
CT chest/abd/pelvis [**2113-10-27**]
IMPRESSION:
1. New bilateral pleural effusions and intra-abdominal ascites.
2. Multiple metastatic foci within the liver with new nodularity
and shrunken appearance of the liver which can be seen with
pseudocirrhosis.
3. Cholelithiasis.
4. Stable right-sided hydronephrosis and right renal cyst.
5. Right adnexal mass, not significantly changed when compared
to prior exam. DDX includes drop met to the ovary. Pelvic
ultrasound recommended.
6. Progression of diffuse osseous metastases including new
compression fractures of the thoracolumbar spine.
7. Asymmetric breast tissue within the right breast. Correlation
with
mammogram is recommended.
Brief Hospital Course:
45 year old female with breast cancer with metastases to bone
and liver who presented with dysphagia and hypotension.
#. Hypotension: She was admitted with hypotension that was felt
to be dehydration and hypovolemia in the setting of poor PO
intake with dysphagia, hypercalcemia, diuretic use, high BUN/cr
ratio and hyponatremia. Her hypotension was stabilized with
IVF, 4L at admission to [**Hospital Unit Name 153**], however volume status was
constantly difficult due to poor UOP and tachycardia with
peripheral anasarca suggesting poor intravascular volume. Her
BPs however remained stable after the first 12-24 hours of
admission. She was given albumin temporarily as an attempt to
increase her intravascular volume. This intervention helped
urine output but did not have an effect on her persistent
tachycardia. She was also temporarily given Vanc/Zosyn due to
concern for sepsis as a possible contributor but she had no
other signs of infection other than hypotension and when her
cultures were negative, all antibiotics were discontinued.
#. Altered mental status: She was admitted with altered mental
status in the setting of dilaudid use and hypotension. There
was also some concern for hepatic encephalopathy as she had some
asterixis on exam and elevated LFTs. Her mental status quickly
improved with increased blood pressure and holding Dilaudid. A
head CT was considered to evaluate for metastatic disease,
however it was felt that patient's renal function was not
adequate for contrast administration and that this was not an
acute need to determine medical management.
#. Dysphagia: She was immunocopromised on chemotherapy and
steroids with concurrent liver failure. She had white plaques
in oropharynx suggestive of thrush, and was started on
fluconazole 200mg daily for 21 days. She also had a positive
viral load for CMV and was treated for CMV esophagitis with
ganciclovir for a [**2-17**] week course.
#. Hypercalcemia: This has been a recurrent problem for this
patient with widely metastatic cancer. Her corrected Ca was
11.6 on admission, which is only mildly elevated for this
patient, who has been admitted with a Ca as high as 19 in the
past. It decreased to 9s with IVF.
#. Liver failure - She has known extensive liver metastases.
She also had no evidence of biliary obstruction on ultrasound.
She also has very poor synthetic function with a low albumin and
elevated coags. It was felt that her liver disease was a result
of her metastases.
#. Breast cancer: She was seen by her outpatient oncologist,
Dr. [**Last Name (STitle) 2036**] while in the MICU. She was also given stress dose
steroids for 3 days at 3 times the usual dose starting on [**11-13**]
given likely adrenal suppression.
#. Elevated Coags: It was felt that her elevated coags were due
to decreased synthetic function in the liver. DIC labs were
normal. Lovenox Factor Xa level was also appropriate at 0.88.
She was also given vitamin K due to a GI bleed.
#. GI Bleed: She had one episode of bright red blood per rectum
on [**2113-11-14**] and remained hemodynamically stable with a stable
hematocrit after the bleed. She continued to have some black
stools. She was given vitamin K for an elevated INR and her
Lovenox was held.
#. DVT: She has a lower extremity DVT for which she is on
Lovenox. This was held in the setting of a GI bleed.
Patient and health care proxy decided to convert goals of care
to comfort measures only on [**2113-11-16**], and patient passed away
peacefully while on morphine drip on [**2113-11-19**] at 1250.
Medications on Admission:
Dexamethasone 4 mg daily
Lovenox 100 mg daily
Lasix 40 mg daily (?)
Spironolactone 100mg daily
Zofran 8mg q8 prn
Tylenol prn
Benadryl prn
Hydromorphone 2mg PRN
Discharge Medications:
expired
Discharge Disposition:
Home With Service
Facility:
Good [**Hospital 3005**] Hospice
Discharge Diagnosis:
Metastatic Breast Cancer
End Stage Liver Disease
Candidal Esophagitis
Gastrointestinal bleed
Anemia
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
|
[
"V58.61",
"530.10",
"785.0",
"338.3",
"591",
"286.7",
"285.9",
"346.90",
"528.00",
"174.8",
"275.42",
"528.09",
"198.5",
"787.20",
"112.0",
"576.2",
"782.3",
"V87.41",
"780.09",
"572.8",
"276.1",
"078.5",
"V15.3",
"572.2",
"458.9",
"198.7",
"V66.7",
"453.51",
"197.7",
"578.1",
"E933.1"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9708, 9771
|
5894, 6960
|
359, 365
|
9915, 9925
|
4965, 5871
|
9981, 9991
|
4058, 4094
|
9676, 9685
|
9792, 9894
|
9490, 9653
|
9949, 9958
|
4109, 4946
|
285, 321
|
393, 1956
|
6975, 9464
|
3672, 3688
|
3704, 4042
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,900
| 115,281
|
12072
|
Discharge summary
|
report
|
Admission Date: [**2203-10-26**] Discharge Date: [**2203-10-31**]
Date of Birth: [**2133-2-23**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
exertional chest pain
Major Surgical or Invasive Procedure:
[**2203-10-26**]
1. Re-do sternotomy.
2. Re-do coronary artery bypass graft x2: Saphenous vein
graft to left anterior descending artery and saphenous
vein graft to obtuse marginal.
3. Endoscopic harvesting of the long saphenous vein.
History of Present Illness:
70M was diagnosed with rectal cancer
in [**2202-12-30**]. He received chemotherapy and radiation in
[**Month (only) 404**]-[**2203-3-31**] and underwent an open proctosigmoidectomy
with
diverting loop ileostomy [**2203-6-29**]. A cardiac catheterization was
done at [**Hospital1 18**] on [**2203-6-24**] prior to his surgery. This was notable
for a patent SVG to RCA, occluded SVG to OM, and LIMA, and
severe
proximal LAD and LCX disease. PCI was deferred at that time due
to urgency of his surgery and the need to be off ASA and Plavix
prior to surgery. He will be having ileostomy reversal sometime
in the near future.
Since surgery, he has started to experience chest pain with
exertion, e.g. walking or taking out garbage. He had a stress
test in [**Month (only) **] at Dr.[**Name (NI) 31668**] office that was notable for EKG
changes. On cardiac catheterization, he was found to have total
occlusion in LIMA and heavily calcified LAD. He is now being
referred to cardiac surgery for redo-CABG.
Past Medical History:
Diabetes type II
Hyperlipidemia
CAD s/p MI/CABG [**2193**]
Carotid disease
Rectal cancer s/p resection and cyber knife radiation (finished
[**8-15**])
C spine injury [**3-3**] fall at work [**2198**] s/p repair
[**Doctor Last Name **] [**Location (un) 2452**] exposure
Past Surgical History:
right carotid endarterectomy [**2196**]
proctosigmoidectomy, diverting loop ileostomy [**2203-6-29**]
cholecystectomy
placement of left portacath
Past Cardiac Procedures:
Surgery: CABG (LIMA to LAD, SVG to OM, and SVG to PDA)
Date: [**2193-4-17**] with Dr. [**Last Name (STitle) 2230**]
Social History:
Lives with: wife
Contact: [**Name (NI) **] (Wife) Phone #[**Telephone/Fax (1) 37867**], cell # [**Telephone/Fax (1) 37868**]
Occupation: Retired air force and postal service
Cigarettes: Smoked no [] yes [x]Hx: quit [**2180**]
Other Tobacco use: denies
ETOH: < 1 drink/week [x] [**3-8**] drinks/week [] >8 drinks/week []
Illicit drug use: denies
Family History:
Mother died from heart disease at age 67
Physical Exam:
Pulse: 94 Resp: 16 O2 sat: 98/RA
B/P Right: Left: 130/76
Height: 5'8" Weight: 183 lbs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [] EOMI [x]
Neck: Supple [x] Full ROM []
Chest: Lungs clear bilaterally [x], well healed midline
sternotomy incision
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel
sounds+
[+], well healed midline incision, ileostomy pink w/ gas + stool
in bag
Extremities: Warm [x], well-perfused [x] Edema [] _____, LLE
with well healed SVG harvest site
Varicosities: None [x]
Neuro: Grossly intact []
Pulses:
Femoral Right: Left:
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: 2+ Left: 2+
Carotid Bruit Right: none Left: none
Pertinent Results:
Conclusions
PRE-CPB:
No spontaneous echo contrast is seen in the left atrial
appendage.
A tiny patent foramen ovale is present. A left-to-right shunt
across the interatrial septum is seen at rest.
Overall left ventricular systolic function is mildly depressed
(LVEF= 40 - 45 %). with mild global free wall hypokinesis.
The ascending aorta is mildly dilated.
There are simple atheroma in the descending thoracic aorta.
The aortic valve leaflets (3) are mildly thickened and
hypo-motile. There is mild aortic valve stenosis (valve area
1.2-1.9cm2). No aortic regurgitation is seen.
The mitral valve leaflets are moderately thickened. Physiologic
mitral regurgitation is seen (within normal limits). There is no
pericardial effusion.
Intra-op the patient's RV was cut by the sternotomy saw, causing
early move onto fem-fem bypass. Then several episodes of Vfib
occurred, and air was found in the LV cavity.
Post-CPB:
The patient is in SR, on an infusion of epinephrine.
Biventricular systolic fxn is worse, with EF now 30 - 35%.
Inferior wall and inferior septum are hypokinetic.
MR remains trace. No AI. Aorta intact.
Discussed with Dr [**First Name (STitle) **] in the OR.
.
[**2203-10-31**] 08:05AM BLOOD Hct-27.2*
[**2203-10-30**] 06:05AM BLOOD WBC-8.0 RBC-2.90* Hgb-8.0* Hct-24.2*
MCV-84 MCH-27.4 MCHC-32.9 RDW-16.3* Plt Ct-227#
[**2203-10-29**] 06:00AM BLOOD WBC-8.2 RBC-2.83* Hgb-8.0* Hct-23.7*
MCV-84 MCH-28.2 MCHC-33.7 RDW-16.1* Plt Ct-149*
[**2203-10-31**] 08:05AM BLOOD UreaN-21* Creat-1.0 Na-141 K-4.7 Cl-103
[**2203-10-30**] 06:05AM BLOOD Glucose-139* UreaN-17 Creat-0.8 Na-140
K-4.2 Cl-103 HCO3-28 AnGap-13
[**2203-10-29**] 06:00AM BLOOD Glucose-108* UreaN-17 Creat-0.8 Na-140
K-4.1 Cl-105 HCO3-26 AnGap-13
[**2203-10-28**] 03:55AM BLOOD Glucose-164* UreaN-13 Creat-1.0 Na-138
K-4.0 Cl-103 HCO3-29 AnGap-10
Brief Hospital Course:
The patient was brought to the Operating Room on [**2203-10-26**] where
the patient underwent redo sternotomy, CABG x 2 with Dr. [**First Name (STitle) **].
Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. He remained
intubated overnight and on Nitro for hypertension. This was
weaned and POD 1 found the patient 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. The patient
was transferred to the telemetry floor for further recovery.
Chest tubes and pacing wires were discontinued without
complication. The patient was evaluated by the physical therapy
service for assistance with strength and mobility. By the time
of discharge on POD 5 the patient was ambulating freely, the
[**First Name (STitle) **] was healing and pain was controlled with oral analgesics.
The patient was discharged home with VNA in good condition with
appropriate follow up instructions.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Gabapentin 400 mg PO TID
2. Clopidogrel 75 mg PO DAILY
3. GlipiZIDE 10 mg PO BID
4. Lisinopril 40 mg PO DAILY
5. MetFORMIN (Glucophage) 1500 mg PO DAILY
6. Metoprolol Succinate XL 50 mg PO DAILY
7. Oxycodone-Acetaminophen (5mg-325mg) [**1-31**] TAB PO Q4H:PRN pain
8. Rosuvastatin Calcium 10 mg PO DAILY
9. Tamsulosin 0.4 mg PO HS
10. Aspirin 81 mg PO DAILY
11. Ferrous Sulfate 325 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Ferrous Sulfate 325 mg PO DAILY
4. Gabapentin 400 mg PO TID
5. GlipiZIDE 10 mg PO BID
6. MetFORMIN (Glucophage) 1500 mg PO DAILY
7. Oxycodone-Acetaminophen (5mg-325mg) [**1-31**] TAB PO Q4H:PRN pain
8. Rosuvastatin Calcium 10 mg PO DAILY
9. Tamsulosin 0.4 mg PO HS
10. Metoprolol Tartrate 75 mg PO TID
Hold for HR < 55 or SBP < 90 and call medical provider.
[**Last Name (NamePattern4) 9641**] *metoprolol tartrate 50 mg 1.5 tablet(s) by mouth three times
a day Disp #*150 Tablet Refills:*0
11. Furosemide 20 mg PO DAILY Duration: 7 Days
RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*7 Tablet
Refills:*0
12. Potassium Chloride 20 mEq PO DAILY Duration: 7 Days
RX *potassium chloride [Klor-Con] 20 mEq 1 packet by mouth daily
Disp #*7 Packet Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Diabetes type II
Hyperlipidemia
CAD s/p MI/CABG [**2193**]
Carotid disease
Rectal cancer s/p resection and cyber knife radiation (finished
[**8-15**])
C spine injury [**3-3**] fall at work [**2198**] s/p repair
[**Doctor Last Name **] [**Location (un) 2452**] exposure
Past Surgical History:
right carotid endarterectomy [**2196**]
proctosigmoidectomy, diverting loop ileostomy [**2203-6-29**]
cholecystectomy
placement of left portacath
Past Cardiac Procedures:
Surgery: CABG (LIMA to LAD, SVG to OM, and SVG to PDA)
Date: [**2193-4-17**] with Dr. [**Last Name (STitle) 2230**]
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
no edema
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:
The cardiac surgery office will call you with the following
appointments:
[**Telephone/Fax (1) 409**] Check at Cardiac Surgery Office [**Telephone/Fax (1) 170**]
Surgeon Dr. [**First Name (STitle) **] [**Telephone/Fax (1) 170**]
Cardiologist/PCP: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] [**Telephone/Fax (1) 16827**]
**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:[**2203-10-31**]
|
[
"272.4",
"285.9",
"V44.2",
"250.00",
"414.02",
"V10.06",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.12",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
7894, 7943
|
5308, 6505
|
334, 579
|
8566, 8731
|
3463, 5285
|
9519, 10141
|
2592, 2635
|
7049, 7871
|
7964, 8233
|
6531, 7026
|
8755, 9496
|
8256, 8545
|
2650, 3444
|
272, 296
|
607, 1609
|
1631, 1900
|
2228, 2576
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,668
| 163,150
|
4178
|
Discharge summary
|
report
|
Admission Date: [**2148-7-29**] Discharge Date: [**2148-8-11**]
Date of Birth: [**2067-7-11**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Codeine / Talwin / Demerol / Valium / Aspirin /
Oxycodone/Aspirin / Oxycodone Hcl/Acetaminophen
Attending:[**Last Name (NamePattern1) 1171**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Cardiac catheterization
Aortic valvuloplasty
History of Present Illness:
Ms. [**Known lastname **] is an 81 year old woman with history of aortic
stenosis (valve area 0.8-1.0 cm2 in [**12-19**]), CHF (diastolic- EF
60%), AF on coumadin, COPD, and RA/SLE who presented to
cardiology clinic today with progressive SOB. Patient saw her
outpatient cardiologist Dr. [**Last Name (STitle) **] the morning of admission for
follow up of her chronic conditions. She describes increased
palpitations and shortness of breath in the past several weeks.
She denies associated chest pain but does note some dizziness on
moving from lying to sitting or sitting to standing. Notes
palpitations are less severe than those she has had with AF in
the past. Denies syncope and pre-syncope.
.
Daughter notes that the patient has more chronically been
suffering from SOB, worsening over the 6 month to one year. She
was hospitalized in [**2147-12-12**] and went to rehab, at which time
she was put on home oxygen - 3L - and spiriva and advair were
added to regimen. Her daughter and home health aide note that
she has had new SOB with small movements- moving from bed to her
wheelchair or moving from her chair to the comode. As recently
as a year and a half ago they report she was able to walk up a
few stairs. Patient and daughter deny increase in lower leg
edema, but report worsened orthopnea (sleeps in hospital bed at
about 45 degrees with 2-3 pillows) and PND. Report chronic
cough, productive of white phlegm. No hemoptysis. Deny fevers,
chills, nausea, vomiting, and diarrhea.
.
On review of systems, she denies any prior history of stroke,
MI, TIA, deep venous thrombosis, pulmonary embolism, bleeding at
the time of surgery, black stools or red stools. He denies
recent fevers, chills or rigors. He denies exertional buttock or
calf pain. She does note chronic myalgias and joint pains. All
of the other review of systems were negative.
Past Medical History:
# Aortic stenosis - valve area area 0.8-1.0cm2 [**12-19**]
# CHF (diastolic - EF of 60%)
# Atrial fibrillation - on warfarin
# Rheumatoid arthritis - on prednisone
# s/p femur fx [**8-16**]
# s/p femur nail [**12-19**]
# s/p R hip replacement [**2142**]
# s/p right shoulder replacement date unknown
# s/p R BKA [**2144-10-28**]
# RA/SLE/positive [**Doctor First Name **] antibody - on chronic prednisone
# COPD
# osteoporosis
# venous stasis
# peripheral neuropathy
# h/o Clostridium difficile in the past
# spinal stenosis
# SBO
# PVD s/p Left AT angioplasty [**4-18**]
Social History:
Patient lives at home with 24 hr aide 5 days a week
with children rotating over weekends. Uses walker to ambulate to
wheelchair. Remote tobacco use. No alcohol use.
Family History:
Mother - liver cancer, father - CVA
Physical Exam:
On Admission:
VS - 97.6 140/76 96 22 96% on 3L
Gen: obese elderly woman sitting up in bed at nearly 90 degrees,
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 at 45 degrees 5 cm below ear.
CV: irregular, normal S1, S2. III/VI systolic murmur at RUSB. No
r/g.
Chest: Resp were effortful on oxygen, but minimal accessory
muscle use. Poor air movement with crackles in the bases b/l. No
wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits.
Ext: R LE is s/p BKA. No clubbing, but bluish coloring to
fingers, good capillary refill and skin turgor. 1+ pitting edema
in LLE 3/4 up calf.
Skin: Central posterior fat at level of shoulders. No stasis
dermatitis. Multiple old ecchymoses on arms. Healed wound on
anterior L LE. Paper thin skin.
.
Pulses:
Left: Carotid 2+ DP 2+ PT 2+
On discharge:
98.1 143/60 92 22 95% on 2L
Gen: obese elderly woman sitting up in bed at 45 degrees, NAD.
Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP 2 cm above clavicle.
CV: irregular, normal S1, S2. III/VI systolic murmur at RUSB. No
r/g.
Chest: No use of accessory muscles. Poor air movement with
coarse crackles b/l. No wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness.
Ext: R LE is s/p BKA. 1+ pitting edema in LLE 3/4 up calf.
Skin: Central posterior fat at level of shoulders. No stasis
dermatitis. Multiple old ecchymoses on arms. Healed wound on
anterior L LE. Paper thin skin.
Pertinent Results:
[**2148-7-29**] 06:55PM GLUCOSE-181* UREA N-30* CREAT-1.2* SODIUM-140
POTASSIUM-4.7 CHLORIDE-94* TOTAL CO2-36* ANION GAP-15
[**2148-7-29**] 06:55PM proBNP-1665*
[**2148-7-29**] 06:55PM WBC-12.1* RBC-4.19* HGB-12.1 HCT-38.2 MCV-91
MCH-28.9 MCHC-31.7 RDW-16.1*
[**2148-7-29**] 06:55PM PT-18.0* PTT-30.5 INR(PT)-1.6*
[**2148-7-31**] 06:15 CK MB 2 TnT <0.011 CK 21
[**2148-8-1**] INR (PT) 1.8
Urine Legionella negative.
[**8-3**] Blood cultures = No growth x2
[**8-2**] Urine culture- GRAM POSITIVE BACTERIA. 10,000-100,000
ORGANISMS/ML. Alpha hemolytic colonies consistent with alpha
streptococcus or Lactobacillus sp.
[**7-30**] Urine culture- No growth.
.
[**7-29**] EKG - Baseline artifact. Atrial fibrillation with
controlled ventricular response. T wave abnormalities. Since the
previous tracing of [**2148-1-5**] the rate has decreased.
.
[**7-31**] EKG - Atrial fibrillation with rapid ventricular response.
Diffuse non-specific ST-T wave change. Compared to the previous
tracing of [**2148-7-29**] no diagnostic interim change.
.
[**7-29**] CXR - Comparison made with a radiograph dated [**2146-10-5**]. Mild
cardiomegaly, a diaphragmatic hernia containing small bowel and
a moderate thoracic spine kyphosis are stable findings. Left
lower lobe atelectasis and a small left lower lobe effusion have
progressed slightly since the previous radiograph. There is no
evidence of pulmonary edema.
.
[**7-30**] LENI (Left)- No evidence of DVT of the left lower
extremity.
.
[**7-30**] Echo - The left atrium is markedly dilated. The right
atrium is markedly dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity is
unusually small. Left ventricular systolic function is
hyperdynamic (EF>75%). Right ventricular chamber size and free
wall motion are normal. The ascending aorta is mildly dilated.
The aortic valve leaflets are severely thickened/deformed. There
is severe aortic valve stenosis (valve area 0.8 square cm). Mild
(1+) aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. There is
severe mitral annular calcification. 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. Moderate [2+]
tricuspid regurgitation is seen. There is no pericardial
effusion.
.
[**2148-8-1**] Cardiac Cath (prelim): 1. Coronary angiography in this
right dominant system demonstrated no angiographically apparent
disease in the LMCA, LAD, LCx, or RCA. 2. Resting hemodynamics
revealed elevated right and left sided filling pressures with
RVEDP 16 mmHg and LVEDP 30 mmHg. There was mild pulmonary
arterial hypertension with PASP 42 mmHg. The cardiac index was
preserved at 2.0 L/min/m2. The systemic [**Month/Day/Year 1106**] resistance was
mildly elevated at 1667 dyn-sec/cm5 with normal pulmonary
[**Month/Day/Year 1106**] resistance. There was systemic arterial normotension.
3. At baseline, there was a 45 mmHg gradient across the aortic
valve with a calculated valve area of 0.61 cm2. Following three
inflations of a 20 mm Tyshak baloon during rapid right
ventricular pacing, the mean pressure gradient diminished to 25
mmHg with a calculated aortic valve area of 0.88 cm2.
[**2148-8-2**] CXR- There is a new right lower lobe opacity consistent
with volume loss and associated infiltrate. Left hemidiaphragm
continues to be elevated with associated volume loss and
effusion.
[**2148-8-5**] CXR- Cardiomediastinal contours are similar in
appearance. Left
hemidiaphragm remains markedly elevated with adjacent left
basilar
atelectasis. Small left and moderate right pleural effusion
appears similar to the recent study. Overall, no substantial
change allowing for positional differences between the exams.
[**2148-8-6**] CXR- Severe cardiomegaly, mild pulmonary edema which is
a new finding.
[**2148-8-7**] EKG- Atrial fibrillation. Occasional ventricular
premature beats. Compared to the previous tracing of [**2148-8-6**]
ectopy is new.
[**2148-8-10**] Shoulder XR- There is no evidence of fracture or
dislocation. Moderate degenerative changes are in the AC joint.
Moderate-to-severe degenerative changes are in the glenohumeral
joint. There are no soft tissue calcifications.
Brief Hospital Course:
Ms. [**Known lastname **] is an 81 year old woman with multiple medical
problems including severe AS (valve area 0.8-1.0 cm2 in [**12-19**]),
AF on coumadin, COPD, and diastolic CHF who was admitted from
cardiology clinic today with progressive shortness of breath.
Her hospital course by problem is as follows:
.
# Leukocytosis/Pneumonia- Had baseline leukocytosis of 12 to 13
during hospitalization. Was elevated to 17.9 -> now approx.
15.0-20.0. She has remained afebrile, lung exam non-focal, with
only a slight clinical productive cough. Could also be related
to her chronic steroid use but there are concerns for a
developing PNA.Urine. blood, and sputum cultures are pending
with no growth to date. Legionella urine antigen was nagetive.
Vancomycin and Cefepime was renally dosed and in the absence of
signs of significant infection and with a downtrending WBC
count, she was changed to oral cefpodoxime and levofloxacin on
[**2148-8-7**] to complete an 8 day course of antibiotics.
.
#. Acute on chronic diastolic CHF exacerbation- Patient has
known history of diastolic CHF with EF of 60% on echo in [**Month (only) **]
[**2147**]. On admission, patient's exam was significant for several
clinical indices of cardiac failure with blateral crackles on
auscultation, elevated JVP and LE edema. She was initialy
diuresed with IV furosemide and then a furosemide infusion and
her volume status improved. She was switched to PO lasix and
maintained stable weights. She was given a low salt diet and
fluid restricted to 1500 mL, with strict monitoring of her
weights and Is/Os. Echo showed hyperdynamic systolic function w/
EF 75% and severe AS (valve area 0.8 cm2). She underwent cardiac
catheterization which showed moderately severe diastolic
dysfunction, clean coronaries and severe AS (valve area 0.61
cm2). Her home Toprol XL was converted to metoprolol tartrate
and was uptitrated to 100 mg PO BID. Following aortic
valvuloplasty, she required further furosemide whilst her renal
function was cautiously monitored. She became hypotensive and
oliguric and required transfer to the CCU (see below). While she
was in the CCU, her volume status was carefully monitored and
she was initially bolused with small amounts of fluid, at which
point her urine output improved. She then showed signs of volume
overload with worsening dyspnea and required gentle diuresis
with lasix. She was transitioned to her home dose of lasix (40
mg PO qAM; 80 mg PO qPM) and remained euvolemic. She was
discharged on this regimen.
.
#. Hypotension- Patient became hypotensive and oliguric with
lasix diuresis and was transferred to the CCU. She was felt to
be overdiuresed and was bolused with fluid; beta blocker was
held. CXR was concerning for pneumonia. She was started on
empiric coverage with vancomycin and cefepime and blood cultures
were sent which ultimately returned negative. She also received
stress dose steroids as there was some thought that she might
have adrenal insufficiency with her chronic steroids. She
responded well to the boluses, and ended up needing a little
diuresis to get her closer to euvolemia. The stress dose
steroids were discontinued and she was put back on her home
regimen.
.
#. Aortic stenosis- Patient has a known history of severe AS on
echo in [**2147-12-12**] with valve area of 0.8-1.0cm2 and was admitted
from clinic with concern that this has worsened in the 6 months
given her decline in functional status and severe shortness of
breath. Echo showed stable to slight worsening of AS w/ valve
area of 0.8 cm2, but increased gradient (61 mmHg, previously 44
in [**Month (only) **]). Cardiac catheterization was performed and showed valve
area of 0.61 and mean gradient of 45.4 mmHg. She under went
aortic valvuloplasty with 3 balloon inflations and after the
procedure her mean gradient had improved to 24.5 mmHg and her
aortic valve was appx 0.88 cm2. The procedure was without
complications.
.
#. Atrial fibrillation- Patient has a known history of AF, and
remained in AF with rate in the 70s to 80s on telemetry for most
of her hospitalization. Her rate crept up into the 90s, and her
metoprolol was uptitrated for better control. At the time of
discharge she was receiving 100 mg PO BID. Patient was on
coumadin for anticoagulation at home. During hospitalization,
coumadin was held and she was kept on heparin in anticipation of
her cardiac catheterization. She was restarted on coumadin on
[**8-5**] on her home dose and became supratherapeutic. Coumadin was
held once more and was 2.4 on discharge. She was discharged with
instructions to stop taking her coumadin and take plavix 75
daily as she has an aspirin allergy until she follows up with
Dr. [**Last Name (STitle) **]. On day of discharge, her HR was in the 90s
despite being on metoprolol 100 mg [**Hospital1 **]- this may be secondary to
her use of albuterol nebulizer treatments. We instructed the
patient to limit her use of these treatments to 1-2 times per
day. We did not further uptitrate her beta blocker, but would
consider perhaps adding on a calcium channel blocker in the
outpatient setting should her pressures tolerate it.
.
#. COPD- Patient has a history of COPD and has been on 3L home
oxygen and standing advair and spiriva since [**Month (only) 956**]. She has a
chronic cough productive of white phlegm and is dyspnic with any
exertion. Patient is not wheezing but had generally poor air
entry on examination. CXR was similar to previous. We therefore
continued her home spiriva and in addition she received regular
albuterol and ipratropium nebulisers at q4 intervals. She was
maintained on oxygen 3L via nasal cannulae, with goal sats in
the mid 90s. Following 2 days of stress dose methylprednisolone,
she was continued on her home prednisone 10mg daily. She was
discharged with ipratroprium and albuterol nebulizer treatments
and her home tiotroprium.
.
#. Chest tightness- Patient reports has history of chest
tightness at home, at rest, usually while sleeping, lasting a
couple of minutes and usually relieved with deep breathing. Had
a brief episode on [**8-5**], with no new ECG changes and negative
cardiac enzymes and was felt to be non-cardiac and potentially
anxiety-related.
.
#. Left calf pain- Patient complained of new posterior left calf
pain on palpation on [**7-30**]. On exam, firm and TTP. LENI study was
negative.
.
#. Leukocytosis/Pneumonia- Patient had baseline leukocytosis of
12 to 13 on admission which was attributed to her home steroid
use. WBCs bumped to 17.9. She remained afebrile, with a
non-focal lung exam, with only a slight clinical productive
cough. CXR was concerning for a possible RLL pneumonia or
atelectasis, she was commenced on IV cefepime and vancomycin on
[**8-3**] as per the HAP policy. She remained afebrile and
antibiotics were changed to oral levofloxacin and cefpodoxime on
[**8-7**] to complete an 8 day course. Vancomycin was dropped as MRSA
pneumonia was believed unlikely in the setting of her clinical
presentation. UA, UCx and legionalla UAg were negative and blood
cultures showed no growth.
.
#. RA/SLE- chronic issue. Continued on her home prednisone 10 mg
daily with 2 days of stress dose IV methylprednisolone and was
changed back to her home regimen on resolution of her
hypotension.
.
#. Osteoporosis- No active issues. Patient was continued on her
home calcium and vitamin D.
.
#. Neuropathic pain- No active issues. Was continued on her home
gabapentin.
.
#. Shoulder pain- Patient complained of some left shoulder pain
while in the CCU. There was no point tenderness on examination
and motion was intact. Shoulder films should no fractures or
dislocations. Patient had some relief of symptoms with daily
lidocaine patches.
.
#. Goals of Care- Patient was DNR/DNI for this hospitalization.
Palliative care was consulted to discuss goals of care with the
patient (see OMR note). The patient is not ready to initiate
hospice at this time and would like to be hospitalized should it
be necessary in the future. Palliative care recommended
continued discussions with her cardiologist and PCP regarding
when it might be appropriate to stop hospitalization and focus
on comfort/hospice, as well as efforts to streamline the
patient's medication list.
Medications on Admission:
BRIMONIDINE [ALPHAGAN P] - (Prescribed by Other Provider) - 0.15
% Drops - 1 drop OD twice a day
DORZOLAMIDE-TIMOLOL [COSOPT] - (Prescribed by Other Provider) -
0.5 %-2 % Drops - 1 drop OD twice a day
FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 250 mcg-50 mcg/Dose
Disk
with Device - 1 puff(s) inhaled twice a day for copd
FUROSEMIDE - 40 mg Tablet - 2 Tablet(s) by mouth qam, 1 qpm
edema, chf
GABAPENTIN - 100 mg Capsule - 2 Capsule(s) by mouth at bedtime
for chronic pain,
INHALATIONAL SPACING DEVICE [AEROCHAMBER] - Inhaler - use with
inhaler
LATANOPROST [XALATAN] - (Prescribed by Other Provider) - 0.005 %
Drops - 1 to right eye at night only
METOPROLOL SUCCINATE - 50 mg Tablet Sustained Release 24 hr - 2
and [**1-13**] Tablet(s) by mouth daily
NYSTATIN - 100,000 unit/gram Powder - apply twice a day affected
area, rash
OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule,
Delayed Release(E.C.)(s) by mouth once a day as needed for gerd
POTASSIUM CHLORIDE [KLOR-CON M20] - 20 mEq Tab Sust.Rel.
Particle/Crystal - 1 Tab(s) by mouth once a day for potassium
supplement
PREDNISONE - 10 mg Tablet - 1 Tablet(s) by mouth once a day RA
PT/INR - - [**2143-12-18**] per Drs. [**Name5 (PTitle) **]
[**Name5 (PTitle) 18188**] - 25 mg Tablet - 1 Tablet(s) by mouth daily
TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - 18 mcg Capsule,
w/Inhalation Device - 1 puff(s) inhaled once a day copd
TRIAMCINOLONE ACETONIDE - 0.1 % Cream - apply twice a day
affected area
WARFARIN - 2 mg Tablet - [**1-13**] Tablet(s) by mouth once a day ut
dict afib
CALCIUM CARBONATE-VITAMIN D3 [CALCIUM 600 + D(3)] - 600-125
mg-unit Tablet - 1 Tablet(s) by mouth twice a day
DOCUSATE SODIUM - 100 mg Capsule - 2 Capsule(s) by mouth QAM, 1
qpm as needed for constipation
GUAIFENESIN [MUCINEX] - 1,200 mg Tab, Multiphasic Release 12 hr
-
1 Tab(s) by mouth twice a day for copd
MULTIVITAMIN - Tablet - 1 Tablet(s) by mouth once a day
prevention
SENNOSIDES [SENOKOT] - 8.6 mg Tablet - 1 Tablet(s) by mouth
twice
a day as needed for constipation
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] [**Location (un) 269**]
Discharge Diagnosis:
Primary:
Acute on chronic diastolic heart failure
Aortic stenosis
COPD
Secondary:
Atrial fibrillation
Rheumatoid arthritis/SLE
Osteoporosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Completed by:[**2148-8-11**]
|
[
"424.1",
"427.31",
"733.00",
"V58.61",
"V43.61",
"428.0",
"V58.65",
"V43.64",
"428.33",
"486",
"496",
"458.29",
"729.5",
"710.0",
"V49.75",
"714.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.96",
"37.23",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
19558, 19635
|
9248, 17480
|
398, 445
|
19820, 19820
|
4900, 9225
|
3123, 3160
|
19656, 19799
|
17506, 19535
|
3175, 3175
|
4172, 4881
|
339, 360
|
473, 2328
|
3189, 4158
|
19835, 20001
|
2350, 2924
|
2940, 3107
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,446
| 187,001
|
45181
|
Discharge summary
|
report
|
Admission Date: [**2187-5-10**] Discharge Date: [**2187-5-23**]
Date of Birth: [**2118-9-17**] Sex: F
Service: MEDICINE
Allergies:
Bactrim / Percocet / Vicodin
Attending:[**First Name3 (LF) 1845**]
Chief Complaint:
Weakness/fatigue
Major Surgical or Invasive Procedure:
Parathyroidectomy
History of Present Illness:
68 y/o female with systolic CHF (EF 35% in [**2187-1-12**]), atrial
fibrillation (on coumadin), known parathyroid adenoma who
presented with hypercalcemia and urinary tract infection, found
to be weak as according to VNA. Generally denies physical
complaints besides general weakness and mild chronic dyspnea.
Denies loss of consciousness, fevers, chills, sweats, pain
anywhere in her body, dysuria, hematuria, abdominal or flank
pain. She does report that her urine has been dark lately.
.
In the ED, initial VS: 97.6-72-150/90-16-96% RA. Labs notable
for calcium 12.5 and INR 3.4. Patient was given cipro and normal
saline. ECG revealed AFib, RSR' RBBB no change from prior.
Currently, the patient is no acute distress, and states "I hope
you can fix me." Denies all symptoms, laying comfortably in bed.
.
Of note, patient was recently hospitalized on [**4-22**] for new LE
edema. Chronic dyspnea was stable. She was discharged on
furosemide 40 mg PO daily the following day.
.
ROS: As per HPI.
Past Medical History:
1. Hypercalcemia, secondary to primary hyperparathyroidism with
right lower pole parathyroid adenoma.
2. Multinodular goiter.
3. Adrenal adenoma.
4. Osteoporosis.
5. Unclear systemic, rheumatologic, neurologic, hematologic
disorder, previously diagnosed as possible inclusion body
myositis.
6. Pulmonary embolus, recurrent thrombosis with recent event
[**2183-12-12**].
7. Hypertension.
8. Hypercholesterolemia.
9. Cardiomyopathy with inferior wall hypokinesis by echo and
possible old myocardial infarction.
10. Peripheral vascular disease with left femoral artery
stenosis status post bypass in [**2168**].
12. History of pulmonary edema.
13. Dermatofibromas with blanching papules on the face.
14. History of keloid scar formation.
15. History of seizure disorder of unknown etiology.
16. Gastroesophageal reflux syndrome.
17. Gastrointestinal bleeding on Coumadin.
18. Moderate to severe restrictive lung disease with possible
neuromuscular origin.
Social History:
Lives at home, alone. Retired secretary. Denies current or past
tobacco or alcohol intake.
Family History:
Mother had [**Name (NI) 2481**] disease. Father died at 99 and did not
have any known medical problems.
Physical Exam:
Vitals - T:97.1 BP:138/94 HR:74 RR:18 02 sat:98% RA
GENERAL: NAD. Lying comfortably in bed. Speaking in complete
sentences.
HEENT: MMM. No chvostek sign. No conjunctival icterus,
injection or pallor. EOMI, PERRLA. OP clear, no hyperemia or
tonsillar exudate. No cervical LAD or appreciable JVD
CARDIAC: Irregularly irregular. Normal S1/S2. No murmurs/rubs
appreciated
LUNG: CTAB. No wheeze or crackles. Good inspiratory effort.
ABDOMEN: Soft, NT/ND. NABSx4. No organomegaly or pulsatile
masses. No rebound tenderness or guarding.
EXT: WWP. No cyanosis or edema. 2+ symmetric radial/DP/PT
pulses
NEURO: AAOx3. Speech fluent, thought process clear. [**4-16**]
strength throughout, upper and lower extrem's, proximally and
distally. Sensation grossly intact throughout. CN II-XII grossly
intact.
DERM: +Keloid on chest
Pertinent Results:
Admission labs:
[**2187-5-10**] 02:50PM BLOOD WBC-7.0 RBC-4.80 Hgb-14.1 Hct-46.1 MCV-96
MCH-29.3 MCHC-30.5* RDW-14.5 Plt Ct-267
[**2187-5-10**] 02:50PM BLOOD Neuts-69.3 Lymphs-22.0 Monos-6.8 Eos-0.9
Baso-1.0
[**2187-5-10**] 02:50PM BLOOD PT-33.2* PTT-38.0* INR(PT)-3.4*
[**2187-5-10**] 02:50PM BLOOD Glucose-99 UreaN-17 Creat-0.8 Na-143
K-4.2 Cl-104 HCO3-31 AnGap-12
[**2187-5-10**] 02:50PM BLOOD Calcium-12.5* Phos-2.9 Mg-2.4
[**2187-5-11**] 06:25AM BLOOD VitB12-636
[**2187-5-11**] 06:25AM BLOOD Digoxin-0.3*
[**2187-5-10**] 02:35PM URINE Color-Amber Appear-Clear Sp [**Last Name (un) **]-1.019
[**2187-5-10**] 02:35PM URINE Blood-NEG Nitrite-NEG Protein-25
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-4* pH-6.5 Leuks-NEG
[**2187-5-10**] 02:35PM URINE RBC-0-2 WBC-6* Bacteri-OCC Yeast-NONE
Epi-2
[**2187-5-10**] 02:35PM URINE CastGr-<1 CastHy-2*
Blood gas:
[**2187-5-11**] 07:09AM BLOOD pH-7.38
[**2187-5-17**] 10:56AM BLOOD Type-[**Last Name (un) **] pH-7.33*
[**2187-5-17**] 02:52PM BLOOD Type-ART pO2-114* pCO2-63* pH-7.30*
calTCO2-32* Base XS-2
[**2187-5-17**] 02:52PM BLOOD Glucose-106* Lactate-1.1 Na-139 K-4.0
Cl-96*
[**2187-5-17**] 02:52PM BLOOD freeCa-1.36*
PTH:
[**2187-5-16**] 11:31AM BLOOD PTH-141*
[**2187-5-16**] 01:05PM BLOOD PTH-20
MICRO:
[**5-11**] UCx: Negative
[**5-11**] RPR: Non-reactive
[**5-17**] Blood culture: Negative x2
STUDIES:
-[**5-10**] ECG: Artifact is present. Atrial fibrillation with a
controlled ventricular response. Right bundle-branch block.
There are non-diagnostic Q waves in the lateral leads.
Non-specific ST-T wave changes. Compared to the previous tracing
the rate is faster.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
76 0 138 362/390 0 -19 151
-[**5-10**] CXR: Massive cardiomegaly, stable from prior exam. No
overt failure
or infiltrate identified.
-[**5-16**] PATHOLOGY PARATHYROID: Pending at time of discharge
-[**5-17**] Portable CXR: 1. moderate pericardial effusion.
2. Mild pulmonary edema.
3. Left lower lobe consolidation which might represent
atelectasis or
pneumonia.Post-operative aspiration pneumonia is possible and
folow-up chest x-ray with short interval is recommended.
- [**5-18**] TTE:
The left atrium is dilated. The right atrium is moderately
dilated. The estimated right atrial pressure is 10-20mmHg. Left
ventricular wall thicknesses are normal. The left ventricular
cavity size is normal. Overall left ventricular systolic
function is mildly depressed (LVEF= 45 %) secondary to
hypokinesis of the inferior septum and inferior free wall. The
right ventricular cavity is markedly dilated with severe global
free wall hypokinesis. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. The mitral valve
leaflets are mildly thickened. There is mild mitral valve
prolapse. Mild to moderate ([**1-13**]+) mitral regurgitation is seen.
The tricuspid valve leaflets are mildly thickened. Moderate [2+]
tricuspid regurgitation is seen. There is
mild-to-moderatepulmonary artery systolic hypertension. There is
a small pericardial effusion. There are no echocardiographic
signs of tamponade.
Compared with the findings of the prior study (images reviewed)
of [**2187-1-19**], the findings are similar.
[**5-18**] Renal ultrasound:
CONCLUSION: Normal renal ultrasound.
Brief Hospital Course:
# Weakness: This was Ms. [**Known lastname **] main complaint at time of
admission and throughout her hospital stay. This was
mutlifactorial, initially due to hypercalcemia, with components
related to deconditioning and then post-operative state as
discussed below. At time of discharge, she reported that her
weakness had improved. She worked with physical therapy and will
continue to do so on an outpatient basis. Throughout her stay,
she had no focal complaints or deficits. B12 was normal, and an
RPR non-reactive.
.
# Hyperparathyroidism: Patient's hypercalcemia was initially
treated medically. Given her symptoms and social concerns, she
remained monitored in the hospital and underwent
parathyroidectomy on [**2187-5-16**] (details in operative report).
Endocrinology followed during her stay, with careful monitoring
of calcium/phosphorous levels post-operatively.
She was discharged on 1500 mg of calcium carbonate TID, 0.25 mg
of calcitriol, and 800 units of vitamin D daily, as well as her
home dose of furosemide. She will follow up with endocrinology
within one week of discharge.
.
# Atrial fibrillation: Patient has a history of a pulmonary
embolism in [**12/2183**] as well as atrial fibrillation for which she
was on warfarin. Her INR was initially supratherapeutic. Her
warfarin was held for surgery and resumed post-operatively. She
will follow up with the [**Hospital3 **] at discharge. Her
digoxin and carvediolol were continued, however several days
after surgery she was noted to have rapid ventricular response
when exerting herself with rates to 130-140 (70-80 at rest),
without symptoms. Her carvedilol was titrated up to 12.5 mg
twice a day with improvement in her heart rate; improved
conditioning also reduced the degree of rapid ventricular
response that was observed.
.
# Hypotension, somnolence, oliguria: Post-operatively after
returning to the floor, patient was noted to be more somnolent,
hypotensive with systolic blood pressure in the 70's-80's, and
hypoxic. She was given intravenous fluids, and after a chest
x-ray was completed that was concerning for pulmonary edema, was
transferred to the ICU for closer monitoring. An ABG completed
demonstrated hypercapnia. In the MICU, a transthoracic echo was
completed that was without change from prior. Infectious work-up
was unrevealing, and cortisol level was not consistent with
adrenal insufficiency. Her mental status returned to baseline,
and her anti-hypertensives were held. Her urine output also
returned to [**Location 213**]. It was felt that her hypotension was likely
due to poor PO intake surrounding her surgery, in addition to
receiving her usual home medications. Her hypercapnia was felt
to be a combination of her baseline restrictive lung disease, as
well as some worsening secondary to pain medications. After
transfer back to the floor, her anti-hypertensives were slowly
reintroduced, and intravenous fluids were discontinued. At time
of discharge, she actually remained mildly hypertensive with
systolic blood pressure of 140-150.
.
# Systolic congestive heart failure: Repeat echocardiogram as
noted above, overall unchanged. Her home regimen of furosemide,
enalapril, and carvediolol was continued, with increase in
carvedilol as noted above. She appeared euvolemic at time of
discharge with clear lung exam and no oxygen requirement.
.
# Osteoporosis: Continued calcium carbonate, vitamin D as above.
.
# Hypercholesterolemia: The patient was continued on her home
statin
.
# CODE: The patient was confirmed full code on admission
.
# Discharge: Patient was discharged home with VNA and home PT
services. Her son accompanied her home. PCP and endocrinology
[**Name9 (PRE) 702**] were arranged.
Medications on Admission:
-Carvedilol 3.125 PO BID
-Clonazepam 1 mg PO daily
-Digoxin 125 mcg tab PO daily
-Enalapril 5 mg PO daily
-Pravastatin 20 mg PO daily
-Warfarin 5 mg PO daily
-Cholecalciferol 800 units PO daily
-MVI PO daily
-Furosemide 40 mg PO daily
Discharge Medications:
1. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
4. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
[**Name9 (PRE) **]:*30 Capsule(s)* Refills:*0*
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: Three (3)
Tablet, Chewable PO Q 8H (Every 8 Hours): New Medication.
[**Name9 (PRE) **]:*360 Tablet, Chewable(s)* Refills:*2*
6. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO [**Name9 (PRE) 766**],
Wednesday, [**Name9 (PRE) 2974**]: Or as directed by [**Hospital 197**] Clinic.
7. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
9. Enalapril Maleate 5 mg Tablet Sig: One (1) Tablet PO once a
day.
10. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO once a day.
11. Outpatient Lab Work
- Please have INR/PT/PTT checked on [**5-24**] or [**5-25**] as directed by
and results sent to [**Company 191**] coumadin clinic.
12. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO twice a
day.
[**Company **]:*60 Tablet(s)* Refills:*0*
13. Warfarin 2.5 mg Tablet Sig: Two (2) Tablet PO Tuesday,
Thursday, Saturday, Sunday.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary diagnosis:
- Hypercalcemia
Secondary diagnoses:
- Parathyroid adenoma
- Systolic congestive heart failure
- Atrial fibrillation
- Multinodular goiter
- Osteoporosis
- Peripheral vascular disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. [**Known lastname **],
You were admitted to the hospital when you were found to be more
short of breath and weak, by your visiting nurse. It was
discovered that you had a high calcium level. You were kept in
the hospital until your parathyroidectomy. After your surgery,
you transiently had low blood pressure, however no serious
reason for this was discovered, and your blood pressure returned
to normal after getting intravenous fluids.
The following changes were made to your medications:
- CALCIUM CARBONATE: STARTED 1500 mg every 8 hours
- CALCITRIOL: STARTED 0.25 mg daily
- CARVEDILOL: INCREASED to 12.5 mg twice a day
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Department: [**Hospital3 249**]
When: TUESDAY [**2187-5-29**] at 2:20 PM
With: [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1849**], M.D. [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: MEDICAL SPECIALTIES
When: WEDNESDAY [**2187-5-30**] at 1:20 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2164**], MD [**Telephone/Fax (1) 1803**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"252.01",
"428.0",
"255.41",
"788.5",
"733.00",
"275.42",
"458.29",
"518.89",
"440.20",
"518.81",
"425.4",
"V12.51",
"428.22",
"227.1",
"276.52",
"276.2",
"359.71",
"427.31",
"272.4",
"241.1",
"V58.61",
"216.9",
"227.0",
"401.9",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"38.93",
"06.89"
] |
icd9pcs
|
[
[
[]
]
] |
12000, 12057
|
6711, 10420
|
307, 326
|
12304, 12304
|
3417, 3417
|
13200, 13861
|
2455, 2560
|
10705, 11977
|
12078, 12078
|
10446, 10682
|
12455, 13177
|
2575, 3398
|
12134, 12283
|
250, 269
|
354, 1355
|
3433, 6688
|
12097, 12113
|
12319, 12431
|
1377, 2331
|
2347, 2439
|
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